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Background: Frailty and multimorbidity are independent prognostic factors for mortality, but their interaction has not been fully explored. We investigated the importance of multimorbidity patterns in older adults with the same level of frailty phenotype.Methods: In a cohort of 7,197 community-dwelling adults aged 65 years and older, physical frailty status (robust, pre-frail, frail) was defined using shrinking, exhaustion, inactivity, slowness, and weakness. Latent class analysis was used to identify individuals with multimorbidity patterns based on 10 self-reported chronic conditions. We estimated hazard ratios (HR) and incidence rate differences (IRDs) for mortality comparing multimorbidity patterns within each frailty state.Results: Five multimorbidity classes were identified: minimal disease (24.7%), cardiovascular disease (29.0%), osteoarticular disease (27.3%), neuropsychiatric disease (8.9%), and high multisystem morbidity (10.0%). Within each frailty state, the mortality rate per 1,000 person-years over 4 years was greatest in the neuropsychiatric class and lowest in the minimal disease class: robust (56.3 vs 15.7; HR, 2.11 [95% CI: 1.05, 4.21]; IRD, 24.1 [95% CI: -11.2, 59.3]), pre-frail (85.3 vs 40.4; HR, 1.74 [95% CI: 1.28, 2.37]; IRD, 27.1 [95% CI: 7.6, 46.7]), and frail (218.1 vs 96.4; HR, 2.05 [95% CI: 1.36, 3.10]; IRD, 108.4 [95% CI: 65.0, 151.9]). Although HRs did not vary widely by frailty, the excess number of deaths, as reflected by IRDs, increased with greater frailty level.Conclusions: Considering both multimorbidity patterns and frailty is important for identifying older adults at greater risk of mortality. Of the five patterns identified, the neuropsychiatric class was associated with lower survival across all frailty levels. [ABSTRACT FROM AUTHOR]

Background: Disability in activities of daily living (ADLs) is a dynamic process and transitions among different disability states are common. However, little is known about factors affecting recovery from disability. We examined the association between frailty and recovery from disability among nondisabled community-dwelling elders.Methods: We studied 1,023 adults from the Cardiovascular Health Study (CHS) and 685 adults from the Health and Retirement Study (HRS), who were ≥65 years and had incident disability, defined as having difficulty in ≥1 ADL (dressing, eating, toileting, bathing, transferring, walking across a room). Disability recovery was defined as having no difficulty in any ADLs. Frailty was assessed by slowness, weakness, exhaustion, inactivity, and shrinking. Persons were classified as "nonfrail" (0 criteria), "prefrail" (1-2 criteria), or "frail" (3-5 criteria).Results: In total, 539 (52.7%) CHS participants recovered from disability within 1 year. Almost two-thirds of nonfrail persons recovered, while less than two-fifths of the frail recovered. In the HRS, 234 (34.2%) participants recovered from disability within 2 years. Approximately half of the nonfrail recovered, while less than one-fifth of the frail recovered. After adjustment, prefrail and frail CHS participants were 16% and 36% less likely to recover than the nonfrail, respectively. In the HRS, frail persons had a 41% lower likelihood of recovery than the nonfrail.Conclusions: Frailty is an independent predictor of poor recovery from disability among nondisabled older adults. These findings validate frailty as a marker of decreased resilience and may offer opportunities for individualized interventions and geriatric care based on frailty assessment. [ABSTRACT FROM AUTHOR]

The US population aged 90 years or more is growing rapidly, and there are limited data on their health. The Cardiovascular Health Study is a prospective study of black and white adults aged ≥65 years recruited in 2 waves (1989–1990 and 1992–1993) from Medicare eligibility lists in Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania. We created a synthetic cohort of the 1,889 participants who had reached age 90 years at baseline or during follow-up through July 16, 2015. Participants entered the cohort at 90 years of age, and we evaluated their changes in health after age 90 years (median duration of follow-up, 3 years (interquartile range, 1.3–5)). Measures of health included cardiovascular events, cognitive function, depressive symptoms, prescription medications, self-rated health, and functional status. The mortality rate was high: 19.0 per 100 person-years (95% confidence interval : 17.8, 20.3) in women and 20.9 per 100 person-years (95% confidence interval: 19.2, 22.8) in men. Cognitive function and all measures of functional status declined with age; these changes were similar by sex. When we isolated period effects, we found that medication use increased over time. These estimates can help inform future research and can help health-care systems meet the needs of this growing population. [ABSTRACT FROM AUTHOR]

Introduction: Brachial flow-mediated dilation (FMD) is a physiologic measure of endothelial function. We determined the prospective association of brachial FMD with incident dementia among older adults.Methods: We included 2777 Cardiovascular Health Study participants who underwent brachial FMD measurement. Incident dementia was ascertained by medication use, International Classification of Diseases-9 codes, requirement for a proxy, and death certificates and calibrated to gold-standard assessments performed in a subset of the cohort.Results: Mean participant age at time of brachial FMD measurement was 77.9 years. We identified 1650 incident dementia cases (median follow-up=10.5 y). After adjusting for age, race, sex, education, clinic site, and baseline arterial diameter, risk of dementia for participants in the highest quartile of percent brachial FMD did not differ from those in lowest quartile (hazard ratio=0.89, 95% confidence interval: 0.77, 1.03).Conclusions: Brachial FMD, measured late in life, is not associated with an increased risk of incident dementia. [ABSTRACT FROM AUTHOR]

BACKGROUND While changes in blood pressure (BP) are independently associated with cardiovascular events, less is known about the association between changes in BP and subsequent changes in renal function in adults with an estimated glomerular filtration rate (eGFR) of >60 ml/min/1.73 m2. METHODS The present study included 3,920 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) study who had ≥2 BP measurements during the first 5 years of MESA and had eGFR measurements at both year 5 and 10. Change in BP was estimated as the annualized slope of BP between year 0 and 5 based on linear mixed models (mean number of measurements = 4.0). Participants were then grouped into 1 of 3 categories based on the distribution of systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) change (top 20%, middle 21–79%, bottom 20%). We calculated eGFR from cystatin C (ml/min/1.73 m2), estimated annual change in eGFR (ml/min/1.73 m2/year), and defined rapid kidney function decline as a >30% decrease in eGFR from year 5 to 10. We used multivariable logistic regression adjusting for year 0 demographic and clinical characteristics, including eGFR and BP, to determine associations of BP change with rapid kidney function decline. RESULTS Median age was 59 [interquartile range (IQR): 52, 67] and median eGFR at year 0 was 95.5 (IQR: 81.7, 105.9) ml/min/1.73 m2. Median SBP at year 0 was 111, 121, and 147 mm Hg for increasing, stable, and decreasing SBP change, respectively. Increasing SBP and widening PP change were each associated with higher odds of rapid kidney function decline compared with stable SBP and PP groups, respectively [odds ratio, OR 1.7 (95% confidence interval, CI 1.3, 2.4) for SBP; OR 1.4 (95% CI 1.1, 1.9) for PP]. Decreasing SBP was associated with rapid kidney function decline after adjusting for all covariates except for year 0 BP [OR 1.4 (95% CI 1.0, 1.8)], but this association was no longer statistically significant after adjustment for year 0 BP. There were no significant associations between DBP change and rapid decline in the fully adjusted models. Similar findings were seen with annual change in eGFR. CONCLUSIONS Increasing SBP and widening PP over time were associated with greater risk for accelerated kidney function decline even at BP levels below established hypertension thresholds. [ABSTRACT FROM AUTHOR]

Purpose:We applied cluster analysis to identify discrete patterns of concomitant responses of systolic (SBP), diastolic (DBP) and pulse pressure (PP) during intensive BP lowering; and to evaluate their clinical relevance and association with risk of mortality, major vascular events (MVEs), and stroke. Material and methods:We used an unsupervised cluster procedure to identify distinct patterns of BP change during the first 9 months of anti-hypertensive therapy intensification among 1,331 participants in the Secondary Prevention of Small Subcortical Strokes Trial who were previously randomized to lower BP target (SBP < 130 mm Hg) after lacunar stroke. Results:The cluster procedure partitioned participants into three groups in the lower SBP target arm, persons with: 1) mildly elevated baseline SBP and minimal visit-to-visit BP variability (mild reducers); 2) moderately elevated baseline SBP and moderate visit-to-visit BP variability (moderate reducers); and 3) very elevated baseline SBP with very large visit-to-visit BP variability during intensification (large reducers). In the lower SBP target group, moderate reducers had a higher risk of death (adjusted HR 1.6 [95% CI 1.0–2.7]), MVE (adjusted HR 2.1 [95% CI 1.4–3.2]), and stroke (adjusted HR 2.6[95% CI 1.7–4.1]) compared to mild reducers. Large reducers had the highest risk of death (adjusted HR 2.3 [95% CI 1.2–4.4]), but risk of MVE (HR = 1.7 [95%CI 0.9–3.1]) and stroke (HR = 1.6 [95%CI: 0.8–3.5]) were not statistically significantly different compared to mild reducers. Conclusions:Among persons with prior lacunar stroke, baseline BP levels, and BP variability in the setting of intensive BP lowering can identify discrete groups of persons at higher risk of adverse outcomes. [ABSTRACT FROM PUBLISHER]

Background: Incident disability rates enable the comparison of risk across populations. Understanding these by age, sex, and race is important for planning for the care of older adults and targeting prevention.Methods: We calculated incident disability rates among older adults in the Cardiovascular Health Study, a study of 5,888 older adults aged ≥ 65 years over 6 years of follow-up. Disability was defined in the following two ways: (i) self-report of disability (severe difficulty or inability) in any of six Activities of Daily Living (ADL), and (ii) mobility difficulty (any difficulty walking half a mile or climbing 10 steps). Incident disability rates were calculated as events per 100 person years for age, gender, and race groups.Results: The incidence of ADL disability, and mobility difficulty were 2.7 (2.5-2.8), and 9.8 (9.4-10.3) events per 100 person years. Women, older participants, and blacks had higher rates in both domains.Conclusion: Incidence rates are considerably different based on the domain examined as well as age, race, and gender composition of the population. Prevention efforts should focus on high risk populations and attempt to ameliorate factors that increase risk in these groups. [ABSTRACT FROM AUTHOR]

Background: The theoretical conditions under which causal estimates can be derived from observational data are challenging to achieve in the real world. Applied examples can help elucidate the practical limitations of methods to estimate randomized-controlled trial effects from observational data.Methods: We used six methods with varying design and analytic features to compare the 5-year risk of incident myocardial infarction among statin users and non-users, and used non-cardiovascular mortality as a negative control outcome. Design features included restriction to a statin-eligible population and new users only; analytic features included multivariable adjustment and propensity score matching.Results: We used data from 5294 participants in the Cardiovascular Health Study from 1989 to 2004. For non-cardiovascular mortality, most methods produced protective estimates with confidence intervals that crossed the null. The hazard ratio (HR) was 0.92, 95% confidence interval: 0.58, 1.46 using propensity score matching among eligible new users. For myocardial infarction, all estimates were strongly protective; the propensity score-matched analysis among eligible new users resulted in a HR of 0.55 (0.29, 1.05)-a much stronger association than observed in randomized controlled trials.Conclusions: In designs that compare active treatment with non-treated participants to evaluate effectiveness, methods to address bias in observational data may be limited in real-world settings by residual bias. [ABSTRACT FROM AUTHOR]

Objectives Research has demonstrated that the association between high blood pressure and outcomes is attenuated among older adults with functional limitations, compared with healthier elders. However, it is not known whether these patterns vary by racial/ethnic group. We evaluated race/ethnicity-specific patterns of effect modification in the association between blood pressure and incident cardiovascular disease (CVD) by functional status. Setting We used data from the Multi-Ethnic Study of Atherosclerosis (2002-2004, with an average of 8.8 years of follow-up for incident CVD). We assessed effect modification of systolic blood pressure and cardiovascular outcomes by self-reported physical limitations and by age. Participants The study included 6117 participants (aged 46 to 87; 40% white, 27% black, 22% Hispanic and 12% Chinese) who did not have CVD at the second study examination (when self-reported physical limitations were assessed). Outcome measures Incident CVD was defined as an incident myocardial infarction, coronary revascularisation, resuscitated cardiac arrest, angina, stroke (fatal or nonfatal) or death from CVD. Results We observed weaker associations between systolic blood pressure (SBP) and CVD among white adults with physical limitations (incident rate ratio (IRR) per 10 mm Hg higher SBP: 1.09 (95% CI 0.99 to 1.20)) than those without physical limitations (IRR 1.29 (1.19, 1.40); P value for interaction <0.01). We found a similar pattern among black adults. Poor precision among the estimates for Hispanic or Chinese participants limited the findings in these groups. The attenuated associations were consistent across both multiplicative and additive scales, though physical limitations showed clearer patterns than age on an additive scale. Conclusion Attenuated associations between high blood pressure and incident CVD were observed for blacks and whites with poor function, though small sample sizes remain a limitation for identifying differences among Hispanic or Chinese participants. Identifying the characteristics that distinguish those in whom higher SBP is associated with less risk of morbidity or mortality may inform our understanding of the consequences of hypertension among older adults. [ABSTRACT FROM AUTHOR]

Background: Frailty is an age-related clinical syndrome of decreased resilience to stressors and is associated with numerous adverse outcomes. Although there is preponderance of literature on frailty in developed countries, limited investigations have been conducted in less developed regions including China-a country that has the world's largest aging population. We examined frailty prevalence in China by sociodemographics and geographic region, and investigated correlates of frailty.Methods: Participants were 5,301 adults aged ≥60 years from the China Health and Retirement Longitudinal Study. Frailty was identified by the validated physical frailty phenotype (PFP) scale. We estimated frailty prevalence in the overall sample and by sociodemographics. We identified age-adjusted frailty prevalence by geographical region. Bivariate associations of frailty with health and function measures were evaluated by chi-squared test and analysis of variance.Results: We found 7.0% of adults aged 60 years or older were frail. Frailty is more prevalent at advanced ages, among women, and persons with low education. Age-adjusted frailty prevalence ranged from 3.3% in the Southeast and the Northeast to 9.1% in the Northwest, and was more than 1.5 times higher in rural versus urban areas. Frail versus nonfrail persons had higher prevalence of comorbidities, falls, disability, and functional limitation.Conclusions: We demonstrated the utility of the PFP scale in identifying frail Chinese elders, and found substantial sociodemographic and regional disparities in frailty prevalence. The PFP scale may be incorporated into clinical practice in China to identify the most vulnerable elders to reduce morbidity, prevent disability, and enable more efficient use of health care resources. [ABSTRACT FROM AUTHOR]

Background: Comorbidity indices that are based on clinically recognized disease do not capture the full spectrum of health. The Healthy Aging Index (HAI) was recently developed to describe a wider range of health and disease across multiple organ systems. We characterized the distribution of a modified HAI (mHAI) by sociodemographics in a representative sample of the U.S. population. We also examined the association of the mHAI with mortality across individuals with different levels of clinically recognizable comorbidities.Methods: Data are from the National Health and Nutrition Examination Survey (1999-2000, 2001-2002) on 2,451 adults aged 60 years or older. Five mHAI components (systolic blood pressure, Digit Symbol Substitution Test, cystatin C, glucose, and respiratory problems) were scored 0 (healthiest), 1, or 2 (unhealthiest) by sex-specific tertiles or clinically relevant cutoffs and summed to construct the mHAI.Results: The mean mHAI score was 4.3; 20.6% had a score of 0-2. 33.2% had a score of 3-4, 31.0% had a score of 5-6, and 15.2% had a score of 7-10. Mean mHAI scores were lower in adults who were younger, non-Hispanic whites, more educated, and married/living with partner. After multivariate adjustment, per unit higher of the mHAI was associated with higher all-cause mortality (HR = 1.19, 95% CI = 1.11-1.27) and higher cardiovascular mortality (HR = 1.23, 95% CI = 1.11-1.35). Within each comorbidity category (0, 1, 2, 3, 4+), the mHAI was still widely distributed and further stratified mortality.Conclusions: Substantial variation exists in the mHAI across sociodemographic subgroups. The mHAI could provide incremental value for mortality risk prediction beyond clinically diagnosed chronic diseases among elders. [ABSTRACT FROM AUTHOR]

Background: Walking speed is associated with functional status and all-cause mortality. Yet the relationship between walking speed and stroke, also a leading cause of disability, remains poorly understood, especially in older Latino adults who suffer from a significant burden of stroke.Methods: A total of 1,486 stroke-free participants from the Sacramento Area Latino Study on Aging, aged 60 and older at baseline in 1998-1999, were followed annually through 2010. Participants reported their usual walking speed outdoors which was classified into slow, medium, or fast. We also assessed timed tandem walk ability (unable or eight or more errors vs less than eight errors). We ascertained three incident stroke endpoints: total stroke, nonfatal stroke, and fatal stroke. Using Cox proportional hazards models, we estimated hazard ratios (HRs) for stroke at different walking speed and timed tandem walk categories.Results: Over an average of 6 years of follow-up (SD = 2.8), the incidence rate of total strokes was 23.2/1,000 person-years for slow walkers compared to 15.6/1,000 person-years for medium walkers, and 7.6/1,000 person-years for fast walkers. In Cox models adjusted for sociodemographics, cardiovascular risk, cognition and functional status, and self-rated health, the hazard of total stroke was 31% lower for medium walkers (HR: 0.69, 95% confidence interval [CI]: 0.47, 1.02) and 56% lower for fast walkers (HR: 0.44, 95% CI: 0.24, 0.82) compared with slow walkers. We found similar associations with timed tandem walk ability (fully adjusted HR: 0.66, 95% CI: 0.45, 0.98).Conclusions: Our findings suggest perceived walking speed captures more than self-rated health alone and is a strong risk factor for stroke risk in Latino older adults. [ABSTRACT FROM AUTHOR]

BACKGROUND: Level of blood pressure (BP) is strongly associated with cardiovascular (CV) events and mortality. However, it is questionable whether mean BP can fully capture BP-related vascular risk. Increasing attention has been given to the value of visit-to-visit BP variability. METHODS: We examined the association of visit-to-visit BP variability with mortality, incident myocardial infarction (MI), and incident stroke among 1,877 well-functioning elders in the Health, Aging, and Body Composition Study. We defined visit-to-visit diastolic BP (DBP) and systolic BP (SBP) variability as the root-mean-square error of person-specific linear regression of BP as a function of time. Alternatively, we counted the number of considerable BP increases and decreases (separately; 10 mm Hg for DBP and 20 mm Hg for SBP) between consecutive visits for each individual. RESULTS: Over an average follow-up of 8.5 years, 623 deaths (207 from CV disease), 153 MIs, and 156 strokes occurred. The median visit-to-visit DBP and SBP variability was 4.96 mmHg and 8.53 mmHg, respectively. After multivariable adjustment, visit-to-visit DBP variability was related to higher all-cause (hazard ratio (HR) = 1.18 per 1 SD, 95% confidence interval (CI) = 1.01-1.37) and CV mortality (HR = 1.35, 95% CI = 1.05-1.73). Additionally, individuals having more considerable decreases of DBP (=10mm Hg between 2 consecutive visits) had higher risk of allcause (HR = 1.13, 95% CI = 0.99-1.28) and CV mortality (HR = 1.30, 95% CI = 1.05-1.61); considerable increases of SBP (=20 mm Hg) were associated with higher risk of all-cause (HR = 1.18, 95% CI = 1.03-1.36) and CV mortality (HR = 1.37, 95% CI = 1.08-1.74). CONCLUSIONS: Visit-to-visit DBP variability and considerable changes in DBP and SBP were risk factors for mortality in the elderly. [ABSTRACT FROM AUTHOR]

Background: The present study aimed to (i) evaluate previous observations that the association of blood pressure (BP) with outcomes varies by gait speed and (ii) evaluate the association of subsequent changes in BP and cardiovascular risk.Methods: Participants included 2,669 adults aged 70-79 years in the Health, Aging, and Body Composition (Health ABC) study. Gait speed was dichotomized at ≥1.0 m/s over a 20-m test at baseline. BP was measured at baseline, and changes in BP over 5 years were evaluated using (i) population-based trajectory models and (ii) intraindividual mean and slope.Results: Over a mean of 10 years, there were 1,366 deaths, 336 first myocardial infarctions, and 295 first strokes. There was a differential pattern of association between baseline systolic BP and diastolic BP and outcomes among brisk and moderate speed walkers. For example, the association between higher diastolic BP and mortality was in the protective direction for moderate speed walkers (hazard ratio = 0.75; 95% confidence interval: 0.63, 0.91) per 10 mmHg higher, whereas it was null in brisk walkers (hazard ratio = 1.05; 95% confidence interval: 0.98, 1.11), p value for interaction .01. The 5-year population-based trajectories did not add important information beyond baseline BP. Individual slopes in both systolic BP and diastolic BP did not appear to have important associations with the outcomes.Conclusions: In this study, we found that the overall level of BP was associated with myocardial infarction, stroke, and death, and this association differed by baseline gait speed, whereas changes in BP were not associated with these outcomes. [ABSTRACT FROM AUTHOR]