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COGNITIVE decline in old age is common and is strongly associated with increased risk of cognitive impairment, Alzheimer’s disease, dementia, and death (1–5). With the U.S. population getting older, this problem of decline in cognitive function is expected to increase in future, underscoring the need to identify substrates contributing to cognitive decline and strategies to reduce their impact. Physical disability is one such adverse health condition that may be related to cognitive decline in older persons through neurodegenerative processes. Some studies have shown a relationship between self-reported physical disability and cognitive function (6,7), whereas others do not (8,9). In addition to physical disability, common chronic health conditions, such as diabetes (10,11) and pulmonary disease (12–15), and general indicators of demographic and anthropometric variables, such as education (16–18) and body mass index (19,20) have been shown to be associated with late-life cognitive decline. The relationship between physical disability and cognitive function is not well established, and understanding this association is likely to require a thorough understanding of the temporal course of change in cognitive function with respect to the temporal change in physical disability. Previous research either used a set cutoff point to define cognitive decline or focused on the relationship between baseline physical disability and cognitive decline. However, physical disability is a dynamic process that can be defined in terms of transitions and progression toward more severe disability. In this article, we focus on one transition defined by the onset of physical disability and severity of physical disability at the time of reported onset. Many previous studies have been limited in their ability to study temporal change in cognitive function in terms of temporal changes in physical disability due the insufficient longitudinal data. This study examines change in cognitive function before and after onset of disability in older persons using data from the Chicago Health and Aging Project (21) to test the hypothesis that onset of physical disability is associated with an increased rate of cognitive decline. Participants were 6,678 older residents of a geographically defined neighborhood in Chicago. During a mean of 12.6 years of observation of participants not disabled at baseline, cognitive function was assessed 2–6 times at 3-year intervals and their difficulties with activities of daily living (ADL) and instrumental activities of daily living (IADL) were ascertained at the same time. We used mixed-effects change point regression models to test the hypothesis that cognitive decline accelerates after onset of ADL and IADL disability.

Disability is generally seen as the outcome of multiple comorbid chronic conditions that affect people as they age and represents the cumulative impact of age-related conditions on a person’s ability to maintain essential activities of daily living (ADL (1)). This conceptualization has resulted in two basic approaches to investigating disability and its determinants. The first approach has emphasized maintenance of independence in the ability to live in the community or to perform basic self-care tasks. The second approach has focused on late-life disability as a progressive process that can be linked to the gradual increase in organ system pathologies and chronic disease processes (2). Disability is a complex process with factors that influence transitions into a disabled state and factors that influence progression toward more severe levels of disability. The theoretical models of disability suggest that age-related transitions and progressive changes occur at various stages in the degenerative aging process (3,4). On the biological aspect of disability, pathology has to accumulate to a sufficient degree to produce organ dysfunction and impairment, which is often a function of age; impairment in one or multiple organs or domains has to reach a certain level of severity in order to produce functional limitations (5,6). Moreover, changes throughout this process may also be conceptualized as age-related transitions from nondisabled to disable state followed by progressive change in the number of functional limitations. Few investigations to date have captured and systematically examined these two aspects of the disability process simultaneously (7,8). In addition, with the exception of specific demographic characteristics, such as sex and race (9), previous research has tended to consider the influence of risk factors for disability transitions or progression as age invariant, that is, the magnitude of the association between a specific risk factor and changes in disability status as constant across age (10). However, age-related degenerative transitions provide important clinical and pathological changes in the health status of older adults. Thus, in this study, we propose a two-part regression approach to model transitions to disability and progression of disability simultaneously to see if certain risk factors differentially affect transitions and progression. In addition, instead of modeling incident disability as a function of time since baseline, we model onset as age at first occurrence of disability. This allows us to more specifically characterize the influence of age on the relationship between risk factor and onset of disability. In this investigation, we focus on two well-known determinants of aging-related disability: cognitive function and physical (or motor) function. Poor cognitive function is generally seen as a strong risk factor for late-life disability (11–14), although its potential differential impact on onset or progression has not been studied previously. Similarly, physical function is another well-established predictor of changes in disability status in older age, with better physical function being associated with lower risk of disability (15,16). In addition to these two factors, gender, race, education, body mass index, and history of chronic health conditions may influence the risk of disability among older adults (17–19) and need to be adjusted for in analyses. Therefore, in this article, we will study the role of cognitive and physical functions on the age at onset and progression after onset of disability among older adults after adjusting for above-described confounders.

Objective: To test the hypothesis that hospitalization in old age is associated with subsequent cognitive decline. Methods: As part of a longitudinal population-based cohort study, 1,870 older residents of an urban community were interviewed at 3-year intervals for up to 12 years. The interview included a set of brief cognitive tests from which measures of global cognition, episodic memory, and executive function were derived. Information about hospitalization during the observation period was obtained from Medicare records. Results: During a mean of 9.3 years, 1,335 of 1,870 persons (71.4%) were hospitalized at least once. In a mixed-effects model adjusted for age, sex, race, and education, the global cognitive score declined a mean of 0.031 unit per year before the first hospitalization compared with 0.075 unit per year thereafter, a more than 2.4-fold increase. The posthospital acceleration in cognitive decline was also evident on measures of episodic memory (3.3-fold increase) and executive function (1.7-fold increase). The rate of cognitive decline after hospitalization was not related to the level of cognitive function at study entry ( r = 0.01, p = 0.88) but was moderately correlated with rate of cognitive decline before hospitalization ( r = 0.55, p = 0.021). More severe illness, longer hospital stay, and older age were each associated with faster cognitive decline after hospitalization but did not eliminate the effect of hospitalization. Conclusion: In old age, cognitive functioning tends to decline substantially after hospitalization even after controlling for illness severity and prehospital cognitive decline.

Self-neglect is the behavior of an elderly person that threatens his or her own health and safety, and it is associated with increased morbidity and mortality. Although report of self-neglect is more common among black older adults, the racial/ethnic differences in mortality remain unclear.The Chicago Healthy Aging Project is a population-based cohort study conducted from 1993 to 2005. A subset of these participants were suspected to self-neglect and were reported to a social services agency. Mortality was ascertained during follow-up and from the National Death Index. Cox proportional hazards models were used to assess the mortality risk.In the total cohort, there were 5,963 black and 3,475 white older adults, and of these, 1,479 were reported for self-neglect (21.7% in black and 5.3% in white older adults). In multivariable analyses with extensive adjustments, the interaction term indicated that impact of self-neglect on mortality was significantly stronger in black than in white older adults (parameter estimate, 0.54, SE, 0.14, p.001). This difference persisted over time. In race/ethnicity-stratified analyses, at 6 months after report of self-neglect, the hazard ratio for black older adults was 5.00 (95% confidence interval, 4.47-5.59) and for white older adults was 2.75 (95% confidence interval, 2.19-3.44). At 3 years after report, the hazard ratios were 2.61 (95% confidence interval, 2.25-3.04) and 1.47 (95% confidence interval, 1.10-1.96) for black older adults and white older adults, respectively.Future studies are needed to qualify the casual mechanisms between self-neglect and mortality in black and white older adults in order to devise targeted prevention and intervention strategies.

Objectives: To examine the role of neighborhood social conditions and walking in community-dwelling older adults. Methods: A multi-level analysis of data from 4,317 older adults (mean age = 74.5; 73% black) from a geographically-defined urban community. Participants completed structured interviews including 14 questions on neighborhood conditions and self-reported walking. The neighborhood questions were summarized into individual-level measures of perceived neighborhood social cohesion and disorder. These measures were aggregated by neighborhood to construct neighborhood-level measures of social cohesion and disorder. Results: Neighborhood-level disorder, but not social cohesion, was significantly associated with walking, independent individual-level neighborhood perceptions and other correlates of walking. Further adjustment for race weakened this association to a marginally significant level. Discussion: Neighborhood conditions may shape walking behavior in older adults, especially conditions that reflect physical neglect or social threat. Promotion of walking behavior in older adults may require improvement of the safety and upkeep of the neighborhood environment.

Plans are underway in Nevada to conduct a comprehenive, statewide initiative that will identify people at risk for ementia, Alzheimer’s disease (AD), or other memory disrders. The Nevada Vital Aging (NVA) Initiative will enroll s many as 12,000 volunteers older than 45 years in Nevada uring the next 5 years for the long-term exploration of actors that lead to memory problems ranging from mild emory loss to dementia. At a September 2006 think tank orkshop convened by Keep Memory Alive, the foundation or the Lou Ruvo Brain Institute of Las Vegas, Nevada, a roup of researchers and clinicians who specialize in AD or n conducting large-scale observational trials met to begin esigning the Initiative, which is expected to begin enrollng volunteers in the summer of 2007. Spearheading this Initiative is Zaven S. Khachaturian, hD, former Director of the Office of Alzheimer’s Disease esearch at the National Institutes of Health and now the resident and chief executive officer of Keep Memory live. Leon Thal, MD, and Lewis Kuller, MD, DrPH, o-chair the initiative. Thal heads the Alzheimer’s Disease esearch Center at the University of California, San Diego; uller is a professor of epidemiology at the University of ittsburgh Graduate School of Public Health. Other particpants at the workshop included Keith Bowman, MD, John reitner, MD, MPH, Denis Evans, MD, Lindsey Farrer, hD, Richard Frank, MD, Walter Kukull, PhD, Javier Nito, MD, PhD, Ronald Petersen, PhD, MD, Mark Sager, D, and Paul Scherr, PhD, DSc. These scientists and cliicians will form the core advisory group for the Initiative. lso participating in the workshop were John A. McDonald

We examined the relation of early life socioeconomic circumstances to cognition in older residents of a biracial urban community. Participants had brief cognitive testing three times at approximately 3-year intervals. At baseline, information about early life household and county socioeconomic level was collected. In mixed-effects models adjusted for age, sex, race, and education, both early life household and county socioeconomic levels were positively associated with baseline level of cognition but unrelated to cognitive decline. The results suggest that socioeconomic conditions in early life are associated with level of cognitive function in old age but not with rate of cognitive decline.

Objective: To examine the relation of blood pressure (BP) to subsequent decline in cognitive function among persons age 65 or over. Methods: All persons age 65 or over in a geographically defined community were invited to participate in a longitudinal study of problems of the elderly. Interviews were conducted in the participants’ homes and included two BP measures and four tests of cognitive function. Follow-up interviews 3 and 6 years after baseline repeated the cognitive function tests. These analyses included 4,284 individuals who had baseline and at least one follow-up measure of cognitive function. The average of z scores of the individual cognitive function tests was used as a global measure of cognitive function. Results: In random effects analyses controlling for age, sex, education, and race, there was no significant linear association of either systolic or diastolic BP with 6-year change in global cognitive function score. There was no significant curvilinear association with systolic BP. In tests for a curvilinear association with diastolic BP, there was a suggestion of increased decline among those with low or high diastolic BP ( p = 0.03 for the quadratic diastolic term). At baseline, 50% of participants took some type of medication affecting BP. Conclusion: In this community population where BP treatment was common, there was no association of either high systolic or high diastolic BP at the beginning of the observation interval with 6-year cognitive decline.

BACKGROUND Loss in physical function is indicative of deterioration in physiological health that may also be associated with deterioration in neurological health. The objective of this study was to examine whether the onset of functional limitations and their severity is associated with increases in cognitive decline among older adults. METHODS The study sample consists of 3825 (65% African Americans and 53% females) participants over the age of 65 with no functional limitations. Cognitive function was assessed using a standardized global cognitive score, and functional limitations using a summary measure of 8 Rosow-Breslau and Nagi limitations (ROS-B/Nagi). Cognitive decline before and after the onset of limitations were analyzed using a linear piecewise change point model. RESULTS During follow-up, 2682 (70%) participants reported limitations in ROS-B/Nagi measure. The rate of cognitive decline was 0.053-units per year before any limitations, and increased to 0.069-units per year after one or more limitations in ROS-B/Nagi measure. This was about 30% (95% Confidence Interval [CI]: 18 - 42%) increase in the rate of cognitive decline comparing before and after the onset of limitations in ROS-B/Nagi measure. Also, higher number of limitations in ROS-B/Nagi measure at the time of onset was associated with faster cognitive decline. CONCLUSIONS The rate of cognitive decline was significantly higher following functional limitations. This study suggests that self-reported measures of functional limitations may serve as an important marker of cognitive decline.

ObjectiveTo assess the burden of mortality attributable to Alzheimer disease (AD) dementia in the United States.MethodsData came from 2,566 persons aged 65 years and older (mean 78.1 years) without dementia at baseline from 2 cohort studies of aging with identical annual diagnostic assessments of dementia. Because both studies require organ donation, ascertainment of mortality was complete and dates of death accurate. Mortality hazard ratios (HRs) after incident AD dementia were estimated per 10-year age strata from proportional hazards models. Population attributable risk percentage was derived to estimate excess mortality after a diagnosis of AD dementia. The number of excess deaths attributable to AD dementia in the United States was then estimated.ResultsOver an average of 8 years, 559 participants (21.8%) without dementia at baseline developed AD dementia and 1,090 (42.4%) died. Median time from AD dementia diagnosis to death was 3.8 years. The mortality HR for AD dementia was 4.30 (confidence interval = 3.33, 5.58) for ages 75-84 years and 2.77 (confidence interval = 2.37, 3.23) for ages 85 years and older (too few deaths after AD dementia in ages 65-74 were available to estimate HR). Population attributable risk percentage was 37.0% for ages 75-84 and 35.8% for ages 85 and older. An estimated 503,400 deaths in Americans aged 75 years and older were attributable to AD dementia in 2010.ConclusionsA larger number of deaths are attributable to AD dementia in the United States each year than the number (

Background Alzheimer's disease (AD) profoundly affects the end-of-life experience. Yet, counts of deaths attributable to AD understate this burden of AD in the population. Therefore, we estimated the annual number of deaths in the United States among older adults with AD from 2010 to 2050. Methods We calculated probabilities of AD incidence and mortality from a longitudinal population-based study of 10,802 participants. From this population, 1913 previously disease-free individuals, selected via stratified random sampling, underwent 2577 detailed clinical evaluations. Over the course of follow-up, 990 participants died. We computed age-, sex-, race-, and education-specific AD incidences and education-adjusted AD mortality proportions specific to age, sex, and race group. We then combined these probabilities with US-wide census, education, and mortality data. Results In 2010, approximately 600,000 deaths occurred among individuals aged 65 years or older with AD, comprising 32% of all older adult deaths. By 2050, this number is projected to be 1.6 million, 43% of all older adult deaths. Conclusion Individuals with AD comprise a substantial number of older adult deaths in the United States, a number expected to rise considerably in coming decades.

A large proportion of people with Alzheimer's disease (AD) are women; however, it is not clear whether this is due to higher risk of disease or solely to the larger number of women alive at ages when AD is common. Beginning in 1982, two stratified random samples of people aged > or =65 years in East Boston, Massachusetts underwent detailed, structured clinical evaluation for prevalent (467 people) and incident (642 people from a cohort previously ascertained to be disease-free) probable AD. The prevalence sample was followed for mortality for up to 11 years (through December 1992). The age-specific incidence of AD did not differ significantly by sex (for men vs. women, odds ratio = 0.92; 95% confidence interval (CI): 0.51, 1.67). Controlled for age, prevalence also did not differ significantly by sex (for men vs. women, odds ratio = 1.29; 95% CI: 0.67, 2.48). The increase in risk of mortality due to AD did not vary by sex. The odds ratio for women with AD compared with women without AD was 2.07 (95% CI: 1.21, 3.56). For men, the odds ratio was 2.22 (95% CI: 1.02, 4.81). These findings suggest that the excess number of women with AD is due to the longer life expectancy of women rather than sex-specific risk factors for the disease.

Patterns of cognitive activity, and their relation to cognitive function, were examined in a geographically defined, biracial population of persons aged 65 years and older. Persons (N = 6,162) were given cognitive performance tests and interviewed about their participation in common cognitive activities, like reading a newspaper. Overall, more frequent participation in cognitive activities was associated with younger age, more education, higher family income, female gender, and White race; participation in activities judged to be more cognitively intense was not strongly related to age, but was associated with more education, higher family income, male gender, and White race. Substantial heterogeneity in activity patterns remained after accounting for demographic factors, however. In an analysis controlling for demographic variables, level of cognitive function on performance tests was positively related to composite measures of the frequency and intensity of cognitive activity. Longitudinal studies are needed to assess the relation of cognitive activity patterns to stability and change in cognitive function in older persons.

Purpose: Risk factors, natural history, consequences, therapeutic responses and costs are all likely related to type of urinary incontinence, for example stress or urge. Yet few epidemiologic type specific data are available and only 1 study has been validated urodynamically. We compare the accuracy of a typical questionnaire used in a large epidemiologic study with the criterion standard of multichannel video urodynamic testing.Materials and Methods: The questionnaire was administered before urodynamic testing to 132 subjects 65 years old or older, of whom 80% were women, all were mobile and none was severely demented. Responses to questionnaire items were compared to the criterion standard, singly and in combination, using a total of 4 a priori and post hoc strategies, including a computerized regression tree program.Results: Overall, no analytic strategy correctly classified more than 67% of patients and none accurately classified even a single type of incontinence, including stress incontinenc...

We considered whether general practitioners should examine all older patients over a certain age for cognitive impairment in screening for early dementia. We invited presentations from key experts, selectively reviewed the literature, and developed a consensus statement. The efficacy of and benefits from unselective use of cognitive testing and informant questionnaires for detecting early dementia in older patients attending general practice are limited. Positive predictive values of cognitive screening for dementia are less than 50%, even for older patient populations. Higher values may be obtained by testing patients who have a relevant history of cognitive or functional decline. Whatever procedures are adopted for screening older general practice attenders for cognitive impairment or early dementia, investigation is still required into the relative merits of different health professionals performing the screening, the positive and negative effects on patients and their families, and the cost-benefit ratio. The majority view of workshop participants was that cognitive testing should occur for older patients when there is a reason to suspect dementia. Testing may occur in an individual considered to be at risk because of an informant history of cognitive or functional decline, clinical observation, or, sometimes, very old age. No single instrument for cognitive screening is suitable for global use. Screening programs must be supported by training and supplemented by education for professionals and families in management of dementia.

Objective: To assess the relations of 3 measures of socioeconomic status (education, occupational prestige, and income) to risk of incident clinically diagnosed Alzheimer disease (AD). Design: Cohort study with an average observation of 4.3 years. Setting: East Boston, Mass, a geographically defined community. Participants: A stratified random sample of 642 community residents 65 years of age and older who were free of AD at baseline. Main Outcome Measure: Clinical diagnosis of probable AD according to standard criteria, using structured uniform evaluation. Results: The relations of the 3 measures of socioeconomic status to risk of disease were assessed using logistic regression analyses. In individual analyses, fewer years of formal schooling, lower income, and lower occupational status each predicted risk of incident AD; risk of disease decreased by approximately 17% for each year of education. In an analysis including all 3 measures, the effect of education on risk for disease remained approximately the same, but the effects of the other 2 measures were somewhat less and did not attain formal statistical significance, compared with separate analysis of each measure. Conclusions: Markers of lower socioeconomic status predict risk of developing incident AD. The mechanism of this relation is uncertain, but the possibility that it reflects unidentified and potentially reversible risk factors for the disease deserves careful investigation.

Objectives: To provide updated estimates of Alzheimer disease (AD) dementia prevalence in the United States from 2010 through 2050. Methods: Probabilities of AD dementia incidence were calculated from a longitudinal, population-based study including substantial numbers of both black and white participants. Incidence probabilities for single year of age, race, and level of education were calculated using weighted logistic regression and AD dementia diagnosis from 2,577 detailed clinical evaluations of 1,913 people obtained from stratified random samples of previously disease-free individuals in a population of 10,800. These were combined with US mortality, education, and new US Census Bureau estimates of current and future population to estimate current and future numbers of people with AD dementia in the United States. Results: We estimated that in 2010, there were 4.7 million individuals aged 65 years or older with AD dementia (95% confidence interval [CI] = 4.0–5.5). Of these, 0.7 million (95% CI = 0.4–0.9) were between 65 and 74 years, 2.3 million were between 75 and 84 years (95% CI = 1.7–2.9), and 1.8 million were 85 years or older (95% CI = 1.4–2.2). The total number of people with AD dementia in 2050 is projected to be 13.8 million, with 7.0 million aged 85 years or older. Conclusion: The number of people in the United States with AD dementia will increase dramatically in the next 40 years unless preventive measures are developed.

OBJECTIVE: The goal of this study was to estimate the prevalence and correlates of difficulty holding urine among a population of community-dwelling older people. DESIGN: Population-based cross-sectional study. SUBJECTS: A population census identified all residents aged 65 years and older residing in East Boston, Massachusetts, in 1982. MEASURES: Data collected via in-home interviews were used to estimate the prevalence of difficulty holding urine and to provide information regarding potential correlates of urinary difficulty. RESULTS: Of the 3809 study participants (85% response rate), 28% reported having “difficulty holding urine until they can get to a toilet” at least some of the time, and 8% reported difficulty “most” or “all of the time.” Difficulty was associated with age and sex; 44% of women and 34% of men reported some difficulty (P < .001), and 9% of women and 6% of men (P < .001) reported difficulty most or all of the time. For respondents aged 65 to 74 years, 40% reported some difficulty, compared with 47% of those aged 85 and older (Ptrend < .001); difficulty most or all of the time was reported by 6% of those aged 65 to 74 and 12% of those aged 85 and older (Ptrend < .001). Difficulty holding urine was associated with important health and functional measures including depression, stroke, chronic cough, night awakening, fecal incontinence, problems with activities of daily living, decreased frequency and ease in getting out of the house, and poor self-perception of health. CONCLUSIONS: Difficulty holding urine is a prevalent condition among older people living in the community and is associated highly with a number of health conditions and functional problems.

Objective: Virtually all estimates of the prevalence and incidence of incontinence in the community rely on self-reported continence status. The goal of this study was to assess the reliability of this measure in older adults. Design: Telephone interviews administered approximately 2 weeks apart. Setting: Community-based congregate living facility. Participants: A convenience sample of approximately 100 residents was contacted by letter; 48 of 51 (94%) who indicated their willingness to participate were interviewed. They included eight men and 40 women >70 years old (79% >80 years old), virtually all of whom were independent in basic ADLs and 83% of whom reported their health as good or excellent. Measurement: Responses to a structured questionnaire. Main Results: The prevalence of urinary incontinence was 40% at baseline and 44% on re-interview; the prevalence of fecal incontinence was 17% on both occasions. All Spearman correlations for items related to urinary incontinence characteristics were between .80 and .86, except for a question related to stress incontinence (r = .62); correlations for fecal incontinence were .67–.69. Conclusion: Prevalence estimates of incontinence are stable over a 2-week period. However, the variability of individual responses, while relatively low, was within the range previously reported for estimates of incidence and remission rates of incontinence in community-dwelling elderly. This, variability should be taken into consideration when interpreting previous studies and designing future ones.

This article sought to determine the extent to which the number of self-reported mentally unhealthy days (MUDs) in the past 30 days estimates depressive symptoms in older adults. The sample of 4,321 community-dwelling residents aged 65 and above originated from an ongoing population-based study of older Blacks and Whites. Participants’ data from 1993 through 2005 included the single MUD question and questions from the Center for Epidemiologic Studies Short Depression Scale (CES-D). Fourteen percent of participants had four or more depressive symptoms at baseline; of these, only 52% reported one or more MUD. Thirty-eight percent of those with one or more MUDs had four or more depressive symptoms. The results illustrate an interesting association regarding the measurements of two distinct, but related, mental health constructs. Although the number of MUDs was associated with having more depressive symptoms over time, the single-question MUD measure does not fully capture depressive symptomatology.

To determine whether smoking habits and alcohol consumption are related to changes in cognitive function, the authors conducted a prospective, community-based study of persons aged 65 years and over in East Boston, Massachusetts. In 1982 and again in 1985, the subjects were given three brief tests of cognitive function: immediate memory, digit span, and a mental status questionnaire, which primarily assessed orientation. The 1,201 individuals who performed well in 1982 were included in linear regression analyses of 3-year change in performance, adjusted for age, sex, education, and income. Relative to nonsmoking, current smoking, past smoking, and pack-years were not significantly related to change in immediate memory. None was significantly related to change in orientation. Only pack-years was significantly related to normal change score in digit span (normal change score change per unit of predictor = 0.001, 95% confidence interval 0.0003-0.002). Low-to-moderate alcohol consumption during the month preceding baseline testing was not significantly related to a subsequent 3-year change in performance in two of the three tests. However, people who consumed a very small amount of alcohol had a normal change score that was 0.088 (95% confidence interval 0.015-0.160) better for digit span than did nondrinkers. This study provides evidence that the reported levels of smoking and alcohol use among older persons are not consistent or substantial predictors of the longitudinal change in cognitive function observed in a community.

In a community population of persons over the age of 65, cognitive function was assessed using brief performance tests on two occasions 3 years apart. Those with fewer years of formal education consistently had greater declines in cognitive function, independently of age, birthplace, language of interview, occupation, and income. These prospective findings suggest that low educational attainment or a correlate predicts cognitive decline. It is not clear, however, whether this relation represents a direct effect of education on future cognition, whether education might be related to occurrence of a disease leading to cognitive decline in older persons, or whether education might be a surrogate for some variable not included in the study.

This report examines the relation of upper and lower extremity motor performance to functional impairment among 371 persons with probable Alzheimer’s disease (AD). Cognitive and motor performance tests were administered at 6-month intervals for up to 4 years. Motor performance was assessed using 3 lower extremity tests and 2 upper extremity tests. Functional impairment was measured at 3-month intervals using caregiver ratings of impairments in activities of daily living, mobility, and range of motion. Both lower and upper extremity performance were inversely related to functional impairments on all 3 scales (all Ps < .001), after controlling for age, sex, and level of cognitive impairment. This suggests that motor performance contributes to functional impairments in AD, independent of cognitive impairment. It is important to preserve motor performance in individuals with AD because it influences physical function throughout the course of the disease.

Risk of dementia and Alzheimer disease (AD) in old age is reduced in persons with higher levels of educational attainment compared to those with lower levels.1–4 This finding is due in part to the well-established correlation of education with cognitive test performance at all ages. Thus, persons with more schooling, relative to those with less, are likely to begin old age at a higher level of cognitive function and so would need to experience more cognitive decline before reaching a level of impairment meeting dementia criteria. Another way in which education might influence risk of dementia is by a correlation with late life cognitive decline, the primary clinical manifestation of AD. Consistent with this idea, several studies have reported an association of higher educational attainment with reduced cognitive decline.5–23 However, this research is mostly based on change between two measurement points. Although this approach can provide an estimate of rate of change in cognitive function, it has a fundamental limitation: even with statistical adjustments, change in function between two time points is hard to securely distinguish from level of function at either point.24 This limitation is especially telling when the predictor of interest is highly correlated with the outcome as in the present case. Importantly, therefore, such studies are not well positioned to separate the estimate of education’s correlation with cognitive decline from its strong correlation with level of cognition. Assessment of cognition at three or more points in time permits separation of initial level of cognition from rate of change, but fewer of these studies have been published and their findings on the relation of higher educational attainment to cognitive decline have been mixed.12,17,19,21,25–28 Other factors may be contributing to this inconsistency. For example, education has been quantified in different ways (e.g., categorically vs continuously, linearly vs nonlinearly) and its association with cognitive decline may be modified by other variables (e.g., preexisting cognitive impairment, practice effects, race/ethnicity). In the present study, we test the hypothesis that higher level of education is associated with reduced rate of cognitive decline in old age using data from the Chicago Health and Aging Project, a longitudinal population-based study of aging and AD. Participants are more than 6,000 older African American and white residents of a community on the south side of Chicago. At approximately 3-year intervals for up to 14 years, they completed four brief tests of cognitive performance from which a previously established composite measure of global cognition was derived. We used mixed-effects models to characterize person-specific paths of cognitive change and to test the relation of education to initial level of cognition and annual rate of change. In subsequent analyses, we examined other socioeconomic indicators and tested whether the association of education with change in cognitive function was modified by race, cognitive impairment, or repeated exposure to the cognitive tests.

Clinical case-control studies of the relation between blood pressure and cognitive function have generally found lower function among hypertensives. Most of these studies were small and incompletely controlled for confounders. Two population-based studies have yielded conflicting results. This study examines cognitive function over the entire range of blood pressure in a defined elderly population. A questionnaire administered in the home to 3,809 persons aged greater than or equal to 65 years in East Boston, Massachusetts, in 1982 and 1983 contained four brief cognitive tests: immediate memory, delayed memory, a mental status questionnaire, and digit span. In linear regression analyses adjusting for age, sex, and education, the direction of the association was not consistent among the tests. An increase in diastolic pressure of 10 mmHg was associated with an increase of 1.0 in percentile scores on the immediate memory test (95% confidence interval (CI) -0.04 to 1.9); with an increase of 1.1 in percentile scores on the delayed memory test (95% CI -0.1 to 2.3); with a decrease of -0.8 in percentile scores on the mental status questionnaire (95% CI -1.8 to 0.2); and with a decrease of -0.9 in percentile scores on the attention test (95% CI -1.5 to -0.2). These results suggest that blood pressure is not a substantial contributor to cognitive status in the elderly.

Blood pressure was assessed between 1981 and 1983 in all persons over age 65 years in three communities (East Boston, Massachusetts; New Haven, Connecticut; and Iowa and Washington countries, Iowa), and cause-specific mortality was monitored annually over the subsequent 5 years as part of the National Institute on Aging-sponsored Established Populations for Epidemiologic Studies of the Elderly. Each community had 80% or more participation: in East Boston, 3,809 persons with 903 deaths, in New Haven, 2,812 persons with 804 deaths, and in Iowa, 3,673 persons with 763 deaths. At 2 years, odds of death from all causes were higher in the low (less than 130 mmHg) than the middle (130-159 mmHg) systolic blood pressure group for persons aged 65-79 years in all three populations. By 5 years, cardiovascular death increased with increasing systolic pressure in all three communities and reached significance in Iowa. Cancer death was highest in the low systolic pressure stratum in all three centers. All-cause, cardiovascular death, and cancer mortality was highest in the low (less than 75 mmHg) diastolic blood pressure group in East Boston, even at 5 years. Blood pressures obtained 9 years earlier in 2,079 (68%) of the East Boston participants showed a significantly higher risk of cardiovascular death with increasing systolic pressure and no relation between diastolic pressure and mortality risk. In the elderly, excess mortality at lower levels of blood pressure during early follow-up may in part be due to the effects of illness and disability present at baseline. This may obscure the usual rise in mortality with increasing systolic pressure. There is no consistent relation between diastolic pressure and mortality.

During a population survey in 1982-1983 among all community-dwelling elderly aged 65 years and over in East Boston, Massachusetts, measurements of peak expiratory flow rate using the mini-Wright peak flow meter were made on 3,582 participants (80% of those eligible). The average peak flow rate was 315 liters/minute, and a measure of peak flow rate adjusted for age, sex, height, and weight was computed. This was a highly significant (p less than 0.0001) predictor of 5-year total mortality, whose ascertainment was virtually complete. The relative risk was 1.27 (95 percent confidence interval 1.19-1.36) per 100 liters/minute decrease in peak flow rate, using a proportional hazards model including terms for age, sex, and smoking. There was no apparent modification of the effect of this measure in various categories of smoking, with relative risks of 1.24 for nonsmokers, 1.29 for ex-smokers, and 1.26 for current smokers. This finding also persisted after adjustments for other covariates, including respiratory symptoms such as cough, phlegm, and wheeze; cardiovascular risk factors such as history of myocardial infarction and stroke; and systolic and diastolic blood pressures; socioeconomic status; scores on simple tests of cognitive function; measures of physical activity and functional ability; and self-assessed state of health. In a stepwise model including all of these variables, the relative risk was 1.16 (p less than 0.0001) per 100 liters/minute decrease in peak flow rate, indicating that peak flow rate is a strong independent predictor of total mortality in the elderly.

Two brief screening tests, the Short Portable Mental Status Questionnaire (SPMSQ) and the East Boston Memory Test (EBMT), were included in a population questionnaire administered to 3,811 persons 65 years of age and older. A detailed clinical evaluation was then administered to 467 persons (drawn from high, medium and low performers on the EBMT) to determine who was cognitively impaired and the disorders that were responsible for that cognitive impairment. The results showed that the EBMT was better at enriching the population of the poor performance group with persons who had Alzheimer's disease (AD). It had a lower refusal rate among non-proxy respondents: 2% for the EMBT versus 9% for the SPMSQ. The sensitivity and positive predictive value were also higher for the EBMT than the SPMSQ when the diagnosis of interest was AD. However, there were persons with AD in all strata of performance on both the EBMT and the SPMSQ, emphasizing the importance of selecting persons from all performance strata in multistage community studies of AD.

Measures of physical performance were used in intact and community populations. We examined upper and lower extremity physical performance tests among people with Alzheimer's disease.A total of 367 persons with probable Alzheimer's disease, recruited from an Alzheimer's disease diagnostic center, were given three tests of lower extremity function and two tests of upper extremity function at 6 month intervals for up to 4 years. Gender, race, age and Mini-Mental State Examination (MMSE) score at baseline were used to predict subsequent decline in composite scores of lower and upper extremity function.At baseline, older age and lower MMSE scores were associated with lower scores on both lower and upper extremity function. Males performed better at baseline on lower extremity tests only. For each point higher on MMSE, a person declined 0.023 Standard Unit (SU) less per year (p = 0.0001) on lower extremity tests and declined 0.019 SU less per year (p0.0001) on upper extremity tests.Physical performance was measured across a range of disease severities and declined over time. Lower cognitive score at baseline predicted faster decline in both lower and upper extremity function. Demographic heterogeneity in decline suggests other predictors may identify factors protective against physical decline.

Background: Frequent cognitive activity in old age has been associated with reduced risk of Alzheimer disease (AD), but the basis of the association is uncertain. Methods: More than 700 old people underwent annual clinical evaluations for up to 5 years. At baseline, they rated current and past frequency of cognitive activity with the current activity measure administered annually thereafter. Those who died underwent a uniform postmortem examination of the brain. Amyloid burden, density of tangles, and presence of Lewy bodies were assessed in eight brain regions and the number of chronic cerebral infarctions was noted. Results: During follow-up, 90 people developed AD. More frequent participation in cognitive activity was associated with reduced incidence of AD (HR 0.58; 95% CI: 0.44, 0.77); a cognitively inactive person (score 2.2, 10th percentile) was 2.6 times more likely to develop AD than a cognitively active person (score 4.0, 90th percentile). The association remained after controlling for past cognitive activity, lifespan socioeconomic status, current social and physical activity, and low baseline cognitive function. Frequent cognitive activity was also associated with reduced incidence of mild cognitive impairment and less rapid decline in cognitive function. Among 102 persons who died and had a brain autopsy, neither global nor regionally specific measures of neuropathology were related to level of cognitive activity before the study, at study onset, or during the course of the study. Conclusion: Level of cognitively stimulating activity in old age is related to risk of developing

Very little information exists on racial differences in quality of life among older adults. In this paper, we examine black–white differences in health-related quality of life (HRQOL) and identify factors that may account for these differences. The participants were 5,986 community-dwelling persons age 65+ (62% black at baseline) from the Chicago Health and Aging Project. Poor HRQOL was defined as having 14 or more self-reported physically or mentally unhealthy days over the past 30 days. A higher proportion of blacks (11.0%) than whites (9.7%) reported poor HRQOL. After adjusting for age and sex, blacks had increased odds of reporting poor HRQOL compared with whites (odds ratio [OR] = 1.72; 95% CI: 1.50–1.98). The black–white differences in HRQOL tended to increase with age (p < 0.05) and were greater among females (p < 0.05). Lifetime socioeconomic status, summary measures of medical conditions, and cognitive function accounted for most of the black–white difference (OR = 1.06; 95% CI: 0.89–1.27). Our results suggest that racial differences in HRQOL are associated with the combined effects of social disadvantage, poor physical health, and lower cognitive function.

The authors examined the relation of early life socioeconomic status to incident Alzheimer’s disease (AD), level of cognition and rate of cognitive decline in old age. For up to 10 years, 859 older Catholic clergy members without dementia at baseline completed annual clinical evaluations as part of the Religious Orders Study. The evaluations included clinical classification of AD and detailed cognitive testing. At baseline, indicators of early life household socioeconomic level (e.g., parental education) and the county of birth were ascertained. Socioeconomic features of the birth county (e.g., literacy rate) were estimated with data from the 1920 US Census. Composite measures of early life household and community socioeconomic level were developed. In analyses that controlled for age, sex and education, higher household and community socioeconomic levels in early life were associated with higher level of cognition in late life but not with risk of AD or rate of cognitive decline. The results suggest that early life socioeconomic level is related to level of cognition in late life but not to rate of cognitive decline or risk of AD.

Deficiencies in folate and vitamin B12 have been associated with neurodegenerative disease.To examine the association between rates of age-related cognitive change and dietary intakes of folate and vitamin B12.Prospective study performed from 1993 to 2002.Geographically defined biracial community in Chicago, Ill.A total of 3718 residents, 65 years and older, who completed 2 to 3 cognitive assessments and a food frequency questionnaire.Change in cognitive function measured at baseline and 3-year and 6-year follow-ups, using the average z score of 4 tests: the East Boston Tests of immediate and delayed recall, the Mini-Mental State Examination, and the Symbol Digit Modalities Test.High folate intake was associated with a faster rate of cognitive decline in mixed models adjusted for multiple risk factors. The rate of cognitive decline among persons in the top fifth of total folate intake (median, 742 microg/d) was more than twice that of those in the lowest fifth of intake (median, 186 microg/d), a statistically significant difference of 0.02 standardized unit per year (P = .002). A faster rate of cognitive decline was also associated with high folate intake from food (P for trend = .04) and with folate vitamin supplementation of more than 400 microg/d compared with nonusers (beta = -.03, P.001). High total B12 intake was associated with slower cognitive decline only among the oldest participants.High intake of folate may be associated with cognitive decline in older persons. These unexpected findings call for further study of the cognitive implications of high levels of dietary folate in older populations.

Background High intake of vitamin E from food (tocopherol), but not from supplements (which usually contain alpha-tocopherol), is inversely associated with Alzheimer disease. Objective We examined whether food intakes of vitamin E, alpha-tocopherol equivalents (a measure of the relative biologic activity of tocopherols and tocotrienols), or individual tocopherols would protect against incident Alzheimer disease and cognitive decline over 6 y in participants of the Chicago Health and Aging Project. Design The 1993-2002 study of community residents aged >or=65 y included the administration of 4 cognitive tests and clinical evaluations for Alzheimer disease. Dietary assessment was by food-frequency questionnaire. Results Tocopherol intake from food was related to the 4-y incidence of Alzheimer disease determined by logistic regression in 1041 participants who were clinically evaluated (n=162 incident cases) and to change in a global cognitive score determined by mixed models in 3718 participants. Higher intakes of vitamin E (relative risk: 0.74 per 5 mg/d increase; 95% CI: 0.62, 0.88) and alpha-tocopherol equivalents (relative risk: 0.56 per 5 mg/d increase; 95% CI: 0.32, 0.98) were associated with a reduced incidence of Alzheimer disease in separate multiple-adjusted models that included intakes of saturated and trans fats and docosahexaenoic acid. alpha- and gamma-Tocopherol had independent associations. In separate mixed models, a slower rate of cognitive decline was associated with intakes of vitamin E, alpha-tocopherol equivalents, and alpha- and gamma-tocopherols. Conclusion The results suggest that various tocopherol forms rather than alpha- tocopherol alone may be important in the vitamin E protective association with Alzheimer disease.

State-specific estimates of1 urrent and future prevalence of Alzheimer disease (AD) are necessary for state planning because states vary greatly in population age structures, which determine disease prevalence.1 We calculated prevalence rates using AD incidence estimates from a population study2 of a geographically defined biracial (black and white) community of Chicago, National Center for Health Statistics data,3 and US Census Bureau Data. We used data from the 2000 census4 for 2000 estimates and state-specific mortality and population projections5 corresponding to middle-series estimates for the national population for future years. This approach is similar to that used for previous estimates and projections of nationwide prevalence of AD.6,7⇓ Current numbers of people with AD in each state depend strongly on total population size and proportion of the population affected. The latter, in turn, depends on the proportion of the total population in older age groups. Of seven states with ≥200,000 persons affected by AD …

We examined whether or not blood pressure is related to cognitive function in a cross-sectional study of a biracial community of 5,816 persons aged 65 years and older. Blood pressure had a curvilinear association with cognitive performance in linear regression models adjusted for age, sex, race and education. Scores were lower by 2–5 percentiles at 100 mm Hg systolic pressure compared to scores at the mean of 140 mm Hg and lower by

Alzheimer disease will affect increasing numbers of people as baby boomers (persons born between 1946 and 1964) age. This work reports projections of the incidence of Alzheimer disease(AD) that will occur among older Americans in the future. Education adjusted age-specific incidence rates of clinically diagnosed probable AD were obtained from stratified random samples of residents 65 years of age and older in a geographically defined community. These rates were applied to U.S. Census Bureau projections of the total U.S. population by age and sex to estimate the number of people newly affected each year. The annual number of incident cases is expected to more than double by the midpoint of the twenty-first century: from 377,000 (95% confidence interval = 159,000-595,000) in 1995 to 959,000 (95% confidence interval = 140,000-1,778,000) in 2050. The proportion of new onset cases who are age 85 or older will increase from 40% in 1995 to 62% in 2050 when the youngest of the baby boomers will attain that age. Without progress in preventing or delaying onset of Alzheimer disease, both the number of people with Alzheimer disease and the proportion of the total population affected will increase substantially.

OBJECTIVES: To examine the prevalence of informal caregiving and demographic factors associated with caregiving time in older community residents and compare caregiving prevalence and time spent providing care by black and white residents. DESIGN: A cross-sectional, population-based study. SETTING: The study was conducted as part of the Chicago Health and Aging Project (CHAP) in a geographically defined community of black and white residents aged 65 and older. PARTICIPANTS: Participants were 5924 community residents (61.4% black; 38.6% white) who answered questions about informal caregiving responsibilities during a structured interview about a broad range of health and social factors. METHODS: Data were collected during an in-home interview. Multiple logistic and linear regression models were used to examine the association between caregiving and race, gender, age, marital status, and education. RESULTS: More than 16% of residents had provided care to others during the previous 12 months, and 10.3% were currently providing care. Compared with whites, blacks were 30% more likely to be caregivers, spent almost 13 more hours each week in caregiving activities, and were more likely to assist friends. The probability of caregiving increased significantly with age for married persons, decreased with age for unmarried persons, and was lower for men compared with women. The time spent providing care each week increased significantly with age for married persons and did not differ between men and women. CONCLUSIONS: Although physicians and other healthcare providers typically view older people as the recipients of informal care, individuals older than age 65 provide a substantial amount of care to others with health problems and disability. Most research has focused on the needs of young and middle-aged caregivers, and little is known about the needs of these older caregivers. Future research should use sampling strategies that provide adequate numbers of white and non-white participants for meaningful comparisons. This will permit identification of racial and cultural differences in caregiving so that interventions can be tailored to specific groups.

Background. The relation of blood pressure to Alzheimer’s disease (AD) is complex because both an association of high blood pressure with increased risk of the disease and lower blood pressure as a consequence of the disease are possible. Methods. We examined the cross-sectional association of blood pressure and AD in the Chicago Health and Aging Project (CHAP), a study of a geographically defined, biracial community. After in-home interviews with 6,162 residents $ 65 years, a stratified random sample of 729 participants was clinically evaluated; 709 had blood pressures measured, and 243 were diagnosed with AD. Results. In logistic regression models adjusted for age, sex, education, and race there was no association between blood pressure measured as a continuous variable and Alzheimer’s disease. In categorical analyses, however, prevalence of Alzheimer’s disease was significantly higher among persons with low systolic pressure ( , 130 mmHg) compared with the referent group of 130‐139 mmHg (odds ratio [OR] 5 2.2, 95% confidence interval [CI]: 1.2,4.1), and with low diastolic pressure ( , 70 mmHg) compared to the referent of 70‐79 mmHg (OR 5 1.8, 95% CI: 1.1,3.1). High systolic and diastolic categories were not statistically different from the referent group, although there was some evidence that the associations differed by race. The odds ratios changed little with further adjustment for apolipoprotein E genotype, antihypertensive medications, body mass, stroke, diabetes, and heart disease. Conclusion. These findings are consistent with previous studies showing associations between low blood pressure and AD, but longitudinal studies are needed to characterize cause-and-effect associations.

Oxidative stress may play a role in neurologic disease. The present study examined the relation between use of vitamin E and vitamin C and incident Alzheimer disease in a prospective study of 633 persons 65 years and older. A stratified random sample was selected from a disease-free population. At baseline, all vitamin supplements taken in the previous 2 weeks were identified by direct inspection. After an average follow-up period of 4.3 years, 91 of the sample participants with vitamin information met accepted criteria for the clinical diagnosis of Alzheimer disease. None of the 27 vitamin E supplement users had Alzheimer disease compared with 3.9 predicted based on the crude observed incidence among nonusers (p = 0.04) and 2.5 predicted based on age, sex, years of education, and length of follow-up interval (p = 0.23). None of the 23 vitamin C supplement users had Alzheimer disease compared with 3.3 predicted based on the crude observed incidence among nonusers (p = 0.10) and 3.2 predicted adjusted for age, sex, education, and follow-up interval (p = 0.04). There was no relation between Alzheimer disease and use of multivitamins. These data suggest that use of the higher-dose vitamin E and vitamin C supplements may lower the risk of Alzheimer disease.

Weight loss among older people, often due to conditions such as cancer and heart disease, has been associated with increased risks of disability and mortality.1 Alzheimer's disease may be a more important source of weight loss than previously recognised, and we examined this issue in a community sample of older adults from a population based, longitudinal study. We collected data during five annual structured clinical evaluations of subjects from a stratified random sample of the population aged 65 years and older of East Boston, Massachusetts, a geographically defined community. We measured weight and height, with participants wearing light clothing, without shoes. Body mass index (weight (kg)/height (m)2) was used to standardise weight for height. Of the 467 clinical evaluation subjects, 338 survived and underwent follow up assessments and 280 (83%) had two or more weight measurements. We diagnosed Alzheimer's disease on the basis …

• The association between findings on the neurologic examination and the clinical diagnosis of Alzheimer's disease was investigated among 467 individuals from a geographically defined community population. Participants were selected by stratified random sampling based on their memory performance in a population survey of community residents 65 years of age and older. Each participant underwent a structured medical, psychiatric, neurologic, and neuropsychologic examination. Of the 467 persons examined there were 134 cases of probable Alzheimer's disease and 167 control subjects. Multiple logistic regression analysis was used to estimate the degree to which the presence of each of several neurologic examination findings affected the age- and sex-adjusted relative odds of having clinically diagnosed Alzheimer's disease. The most striking associations with the diagnosis of Alzheimer's disease were seen with various measures of extrapyramidal dysfunction. These increased relative odds were not markedly affected by excluding from the analysis cases with severe cognitive impairment. The results suggest that involvement of the extrapyramidal system is a common finding in Alzheimer's disease.

Author(s): Scherr, PA; LaCroix, AZ; Wallace, RB; Berkman, L; Curb, JD; Cornoni-Huntley, J; Evans, DA; Hennekens, CH | Abstract: ObjectiveTo determine whether there is a relationship of low to moderate alcohol consumption with cardiovascular mortality in the elderly.DesignProspective cohort studies with 5-year mortality follow-up.SettingThree populations of community-dwelling elders.ParticipantsPopulation-based cohorts of men and women, aged 65 or older, in three populations. Subjects with prior myocardial infarction, stroke, or cancer, as well as those lacking alcohol consumption data, were excluded from statistical analyses leaving 2,694 subjects in East Boston, Massachusetts, 2,293 subjects in Iowa, and 1,904 subjects in New Haven, Connecticut.Main outcome measurementsAlcohol consumption, total mortality, cardiovascular mortality, and cancer mortality.ResultsLow to moderate alcohol consumption was associated with statistically significant lowered total as well as cardiovascular mortality in East Boston and New Haven. The relative risks of total mortality for low to moderate consumers of alcohol compared to those consuming no alcohol in the previous year were 0.7 (95% CI 0.6-0.8) in East Boston and 0.6 (95% CI 0.5-0.8) in New Haven. For cardiovascular mortality, the RRs were 0.6 in East Boston and 0.5 in New Haven (95% CI's exclude null). These results persisted after control for potential confounding variables. In Iowa, there were no significant differences in total or cardiovascular mortality according to alcohol consumption patterns. For cancer mortality, there were no significant associations with alcohol consumption in any of the three populations.ConclusionsThese data suggest that the relationship of low to moderate alcohol consumption with reduced total and cardiovascular mortality, which are well documented in middle age, also occur in older populations.

Epidemiologic studies are often designed to severe several purposes. The complex sampling plans necessary to ensure an adequate number of cases, a similar age distribution among cases and controls, or other important design constraints for comparative studies may make the additional goal of estimating prevalence in the population or in important subgroups difficult to attain with existing computer software, which typically assumes simple random sample selection. We consider here various methods for estimating overall and subgroup prevalence from complex samples, including crude prevalences, direct standardization of prevalences, and standardization using logistic regression to smooth the sampling group prevalences. We illustrate these methods using a complex sample to estimate the prevalence of Alzheimer's disease in an urban community. A simulation study under various models in this setting is also described. We conclude that the use of logistic regression to smooth sampling group prevalences before standardization is an effective method for estimation of overall prevalence, provided that the adequacy of fit of a logistic model is carefully checked.

The authors examined the effects of smoking and alcohol use in a prospective community-based study of incident Alzheimer's disease. Two in-home interviews of the total elderly population of East Boston, Massachusetts, conducted in 1982 and 1985 were used to sample individuals for clinical evaluation for Alzheimer's disease. A total of 513 persons underwent detailed clinical evaluation including neurologic, neuropsychologic, and psychiatric evaluation to diagnose Alzheimer's disease. In weighted logistic regression controlled for age, sex, and education, the estimated odds ratio of Alzheimer's disease was 0.7 (95% confidence interval 0.3-1.4) for ever smokers compared with never smokers. For 40 pack-years of smoking, the odds ratio of Alzheimer's disease was 0.8 (95% confidence interval 0.6-1.1). Consumption of 1 oz (30 ml) of alcohol per day was associated with an odds ratio of 1.1 (95% confidence interval 0.8-1.5). These results suggest that recent mild-to-moderate consumption of alcohol is not substantially related to incidence of Alzheimer's disease and that smoking does not increase risk of the disease.

A random sample of 467 persons over age 65 years from the population of an urban US community, stratified by age, sex, and performance on a brief memory test, underwent clinical evaluation for dementing illness in 1982-1984. Of these persons, 134 had probable Alzheimer's disease, 166 had possible Alzheimer's disease, and 167 had no evidence of Alzheimer's disease. Over a median follow-up period of 4.9 years following evaluation, 165 (35%) died. Overall, persons with probable Alzheimer's disease had a relative risk of death 1.44 (95% confidence interval (Cl) 1.05-1.96) times that of the unaffected. Level of cognitive impairment and the presence of cachexia upon physical examination both strongly and independently modified risk of death. Among those with probable Alzheimer's disease, mortality for those with mild or moderate cognitive impairment and no evidence of cachexia was comparable to that of the unaffected. However, among those with probable Alzheimer's disease and either severe cognitive impairment or cachexia, the risk of death was substantially higher. Persons with probable Alzheimer's disease who had both severe cognitive impairment and clear cachexia had a risk of death 4.60 (95% Cl 1.63-13.1) times that of unaffected persons.

BackgroundAlthough cigarette smoking is the leading avoidable cause of premature death in middle age, some have claimed that no association is present among older persons.MethodsWe prospectively examined the relation of cigarette-smoking habits with mortality from all causes, cardiovascular causes, and cancer among 7178 persons 65 years of age or older without a history of myocardial infarction, stroke, or cancer who lived in one of three communities: East Boston, Massachusetts; Iowa and Washington counties, Iowa; and New Haven, Connecticut. At the time of the initial interview, prevalence rates of smoking in the three communities ranged from 5.2 to 17.8 percent among women and from 14.2 to 25.8 percent among men. During five years of follow-up there were 1442 deaths, 729 due to cardiovascular disease and 316 due to cancer.ResultsIn both sexes, rates of total mortality among current smokers were twice what they were among participants who had never smoked. Relative risks, as adjusted for age and community, were 2.1 among the men (95 percent confidence interval, 1.7 to 2.7) and 1.8 among the women (95 percent confidence interval, 1.4 to 2.4). Current smokers had higher rates of cardiovascular mortality than those who had never smoked (as adjusted for age and community, the relative risk was 2.0 [95 percent confidence interval, 1.4 to 2.9] among the men and 1.6 [95 percent confidence interval, 1.1 to 2.3] among the women), as well as increased rates of cancer mortality (relative risk, 2.4 [95 percent confidence interval, 1.4 to 4.1] among the men and 2.4 [95 percent confidence interval, 1.4 to 3.9] among the women). In both sexes, former smokers had rates of cardiovascular mortality similar to those of the participants who had never smoked, regardless of age at cessation, whereas the rates for all cancers, as well as smoking-related cancers, remained elevated among men who had once smoked.ConclusionsOur prospective findings indicate that the mortality hazards of smoking extend well into later life, and suggest that cessation will continue to improve life expectancy in older people.

Self reported physical function was assessed in telephone interviews approximately 3 weeks apart for a sample of 193 persons aged 69 or older. Three measures of physical function were used: a modified Activities of Daily Living scale, three items proposed by Rosow and Breslau, and five items from among those used by Nagi. Agreement between first and second interviews was very good; most subjects reported no impairment in function at either interview. Among those who reported some impairment, the degree of limitation within the specific activities reported as limited and the total number of activities with any degree of limitation agreed exactly for most and within one level for almost all subjects. There was no evidence to suggest that age or cognitive impairment affected the variability of the responses, and reported declines and improvements in function were about equally common.