Faculty Bibliography

BACKGROUND: Physical disability is increasingly recognized as an adverse health consequence of type 2 diabetes in older adults. We studied the effect of diabetes on disability in middle-aged and older adults to: 1) characterize the association of diabetes with physical disability in middle-aged adults, and 2) determine the extent to which the effect of diabetes is explained by related covariates in either or both age groups. METHODS: We used data from two parallel national panel studies of middle-aged and older adults to study the effect of self-reported diabetes at baseline on disability 2 years later, adjusting for baseline covariates. RESULTS: Diabetes was strongly associated with subsequent physical disability (measured by a composite variable combining activities of daily living, mobility, and strength tasks) in middle-aged and older adults. Controlling for socioeconomic characteristics and common diabetes-related and unrelated comorbidities and conditions reduced the diabetes effect substantially, but it remained a significant predictor of disability in both groups. CONCLUSIONS: Our analyses demonstrated that disability is an important diabetes-related health outcome in middle-aged and older adults that should be prevented or mitigated through appropriate diabetes management.

OBJECTIVES: To determine whether obesity is associated with the frailty phenotype and, if so, whether comorbid conditions or inflammatory markers explain this association. DESIGN: Cross-sectional analysis of baseline data from the Women's Health and Aging Studies I (1992) and II (1994), complementary population-based studies. SETTING: Twelve contiguous ZIP code areas in Baltimore, Maryland. PARTICIPANTS: Five hundred ninety-nine community-dwelling women aged 70 to 79 with a body mass index (BMI) greater than 18.5 kg/m(2). MEASUREMENTS: The dependent variables were the frailty syndrome, including prefrailty, defined as presence of one or two of five frailty indicators (weakness, slowness, weight loss, low physical activity, exhaustion), and frailty, defined as three or more indicators. Independent variables included BMI, categorized using World Health Organization criteria as normal (18.5 to <25 kg/m(2)), overweight (25 to <30 kg/m(2)), and obese (>/=30 kg/m(2)); chronic diseases; C-reactive protein; and serum carotenoids. RESULTS: Being overweight was significantly associated with prefrailty, and obesity was associated with prefrailty and frailty. In all frail women, regardless of BMI group, a similar pattern of three defining frailty indicators was found: slowness, weakness, and low activity (with the addition of weight loss in the normal weight group.) In multinomial regression models, obesity was significantly associated with prefrailty (odds ratio (OR)=2.23, 95% confidence interval (CI)=1.29-3.84) and frailty (OR=3.52, 95% CI=1.34-9.13), even when controlling for covariates. CONCLUSION: Obesity is associated with the frailty syndrome in older women in cross-sectional data. This association remains significant even when multiple conditions associated with frailty are considered. Prospective studies are needed to confirm this finding.

OBJECTIVE: Those aged <65 in nursing homes (NHs) are substantially different from elderly residents. This study uses data gathered from the Resident Assessment Instrument's Minimum Data Set (MDS) to describe these relatively rare residents. STUDY DESIGN AND SETTING: The study uses MDS assessments of close to three-quarter million residents in nine states from 1994 to 1996. Residents are described within chronological age group (0-4, 5-14, etc.). Factor analysis is used to develop diagnostic clusters, and the prevalence of these clusters, functional problems, other conditions, and treatments is described for each group. RESULTS: Thirteen diagnostic clusters describe nearly 85% of all NH residents and highlight differences between age groups. Pediatric residents are substantially more physically and cognitively impaired than young adult residents, and have the highest case mix burden of care. The youngest population primarily has diagnoses related to mental retardation and developmental disabilities, young adults have the highest prevalence of hemi- and quadriplegia, while older residents are typified by increasing prevalence of neurological diagnoses. CONCLUSION: This study offers an initial description of NH residents <65. The prevalence of residents with unique conditions may suggest the need to modify the MDS assessment instrument.

BACKGROUND: Microalbuminuria is a risk factor for coronary heart disease (CHD). It occurs most commonly in the settings of diabetes and hypertension. The mechanisms by which it increases CHD risk are uncertain. METHODS: We examined the cross-sectional association of microalbuminuria with a broad range of CHD risk factors in 3 groups of adults aged 65 years or older with and without microalbuminuria: those with (1) no diabetes or hypertension (n = 1,098), (2) hypertension only (n = 1,450), and (3) diabetes with or without hypertension (n = 465). RESULTS: Three factors were related to microalbuminuria in all 3 groups: age, elevated systolic blood pressure, and markers of systemic inflammation. In patients with neither diabetes nor hypertension, increasing C-reactive protein levels were associated with microalbuminuria (odds ratio per 1-mg/L increase, 1.46; 95% confidence interval [CI], 1.15 to 1.84). Among those with diabetes, an increase in white blood cell (WBC) count was associated with microalbuminuria (odds ratio per 1,000-cell/mL increase, 2.57; 95% CI, 1.12 to 5.89). Among those with hypertension, an increase in WBC count (odds ratio per 1,000-cell/mL increase, 1.83; 95% CI, 1.04 to 3.23) and fibrinogen level (odds ratio per 10-mg/dL increase, 1.02; 95% CI, 1.00 to 1.05) were significantly associated with microalbuminuria. In all 3 groups, prevalent CHD was related to an elevated WBC count. In none of the 3 groups was brachial artery reactivity to ischemia, an in vivo marker of endothelial function, related to microalbuminuria. CONCLUSION: Microalbuminuria is associated with age, systolic blood pressure, and markers of inflammation. These associations reflect potential mechanisms by which microalbuminuria is related to CHD risk.

PURPOSE: To identify pattern(s) of disability related to diabetes in older women and to determine the extent to which disability is mediated by selected diabetes complications. METHODS: Cross-sectional analysis of data from a population-based study composed of a representative sample of 3570 noninstitutionalized women aged 65 years and older living in the Baltimore metropolitan area who agreed to be screened for the Women's Health and Aging Study. RESULTS: 483 (13.5%) of the women reported physician-diagnosed diabetes. Compared to women without diabetes, women with diabetes were significantly more likely to report difficulty in 14 of 15 daily tasks, including walking 2-3 blocks, lifting 10 pounds, using the telephone, and bathing (range of odds ratios [OR] 1.5-2.8; all p <.01). After adjustment for age, race, and marital status, women with diabetes were about twice as likely to report difficulty in any one of four functioning groups (mobility, upper extremity, higher functioning tasks, or self-care) (OR 2.2; 95% confidence interval [CI] 1.8-2.7), and over three times as likely to report difficulty in a group combining higher functioning and self-care tasks (OR 3.2; 95% CI 2.4-4.1). Adjustment for self-reported heart disease, stroke, high blood pressure, and visual problems did not attenuate these associations. CONCLUSIONS: Diabetes is strongly associated with a wide range of disabilities in older women. This association does not appear to be mediated by prevalent diabetes complications and risks, heart disease, high blood pressure, stroke, or eye disease. Other complications of diabetes (e.g., neuropathy, peripheral vascular disease) may mediate diabetes-associated disability in older adults.

BACKGROUND AND AIMS: Oxidative stress may play a role in the pathogenesis of sarcopenia, and the relationship between dietary antioxidants and sarcopenia needs further elucidation. The aim was to determine whether dietary carotenoids and alpha-tocopherol are associated with sarcopenia, as indicated by low grip, hip, and knee strength. METHODS: Cross-sectional analyses were conducted on 669 non-disabled to severely disabled community-dwelling women aged 70 to 79 who participated in the Women's Health and Aging Studies. Plasma carotenoids and alpha-tocopherol were measured. Grip, hip, and knee strength were measured, and low strength was defined as the lowest tertile of each strength measure. RESULTS: Higher plasma concentrations of alpha-carotene, beta-carotene, beta-cryptoxanthin, and lutein/zeaxanthin were associated with reduced risk of low grip, hip, and knee strength. After adjusting for potential confounding factors such as age, race, smoking, cardiovascular disease, arthritis, and plasma interleukin-6 concentrations, there was an independent association for women in the highest compared with the lowest quartile of total carotenoids with low grip strength [Odds Ratios (OR) 0.34, 95% Confidence Interval (CI) 0.20-0.59], low hip strength (OR 0.28, 95% CI 0.16-0.48), and low knee strength (OR 0.45, 95% CI 0.27-0.75), and there was an independent association for women in the highest compared with the lowest quartile of alpha-tocopherol with low grip strength (OR 0.44, 95% CI 0.24-0.78) and low knee strength (OR 0.52, 95% CI 0.29-0.95). CONCLUSIONS: Higher carotenoid and alpha-tocopherol status were independently associated with higher strength measures. These data support the hypothesis that oxidative stress is associated with sarcopenia in older adults, but further longitudinal and interventional studies are needed to establish causality.

This research aimed to chart the trajectories of functional status in old age in Japan and to assess how self-rated health and cognitive functioning differentiate these trajectories and account for interpersonal differences. Data came from a 5-wave panel study of a national sample of 2,200 Japanese older adults between 1987 and 1999. The sample as a whole showed an accelerated increase in functional limitations with age. approximated by a quadratic function. More important, 3 major trajectories of functional change were identified: (a) minimal functional decrement, (b) early onset of functional impairment. and (c) late onset of functional impairment. These findings may serve as useful benchmarks for observations derived from other developed nations.

OBJECTIVES: To determine how baseline functional status affects health outcomes in older adults with diabetes mellitus (DM). DESIGN: Nationally representative cross-sectional and longitudinal health interview survey. SETTING: Waves I (1993) and II (1995) of the Assets and Health Dynamics of the Oldest Old Survey (AHEAD) in the United States. PARTICIPANTS: AHEAD respondents aged 70 and older (n = 7,447, including 995 with DM). MEASUREMENTS: At baseline, the entire sample was divided into three groups: high-functioning group, defined as having no physical limitations or instrumental activities of daily living/activities of daily living (IADL/ADL) disabilities (39%); low-functioning group, having three or more limitations or IADL/ADL disabilities (24%); and intermediate-functioning group, those in the middle (36%). Older adults with and without DM, within each of the functioning groups, were compared at 2-year follow-up with respect to demographic characteristics, weight/body mass index, baseline and incident chronic diseases and conditions, and follow-up functioning. RESULTS: Of people aged 70 and older, 28% with DM and 41% without were high functioning; 38% with DM and 22% without were low functioning (both P <.001). High-functioning people with DM remained high functioning at 2 years but had a significantly higher incidence of heart disease and mortality than high-functioning people without DM. Low-functioning people with DM were significantly more likely to have vascular comorbidities at baseline than low-functioning people without DM, but their 2-year outcomes were similar. The intermediate-functioning group showed the most differences between those with and without DM; those with DM were significantly (P <.01) more likely to have baseline vascular disease, low cognitive performance, increased incident vascular disease, and significantly worse 2-year functioning and to have experienced falls (P <.001). CONCLUSION: Differences in baseline functional status in older adults with DM were associated with outcome differences. High-functioning older people with DM tended to remain high functioning but demonstrated significantly higher incidence of heart disease and mortality than those without DM, whereas low-functioning people with and without DM had similar outcomes. However, intermediate-functioning older diabetics had worse health and functioning outcomes than a similarly impaired group without DM. DM management adjusted to functional status can potentially address the most-relevant outcomes in the heterogeneous older population with DM.

The number of patients in nursing homes with severe cognitive impairment (SCI) is growing. The authors compared the characteristics and 6-month outcomes of a sample of nursing home residents with SCI to those of other residents. This cross-sectional and 6-month follow-up study used data from pooled 1990 and 1993 cohorts in the Resident Assessment Instrument Evaluation Study. The authors compared baseline characteristics of residents with SCI (n = 1304) with all others and evaluated 6-month improvement and associated factors in the SCI group. SCI residents had poorer nutrition and lower frequencies of most symptoms and chronic diseases. Fourteen percent showed 6-month cognitive improvement, associated with higher baseline function, antidepressant medication, and recent falls. Nursing home residents with SCI had possible underrecognition of medical problems and poor nutritional status. Measured improvement may indicate possible misclassification for some residents and potential for improvement for others.

OBJECTIVE: Older patients with diabetes are more likely to have a higher prevalence of multiple risk factors for physical disability, as a result of diabetic complications. We evaluated the pace of decline in lower-extremity function and the risk for progression of disability in older women with diabetes. RESEARCH DESIGN AND METHODS: We conducted a 3-year longitudinal cohort study of a random sample of 729 physically impaired older women (age > or =65 years) living in the community (Baltimore, MD). Diabetes was ascertained by standard criteria. Self-reported functional status and objective performance measures were assessed at baseline and over six semiannual follow-up visits. RESULTS: The baseline prevalence of diabetes was 14.4%. After adjustment for age and compared with women without diabetes, those with diabetes had an RR of 1.8 (95% CI 1.3-2.5) for incident mobility disability and 1.6 (1.2-2.1) for incident activity of daily living disability. The increased incidence of new disability associated with diabetes was paralleled by a greater decline in objective measures of lower-extremity function. Adjustment for multiple risk factors for disability did not significantly attenuate the risk for disability associated with diabetes. CONCLUSIONS: In older patients, impaired lower-extremity function is a long-term diabetic complication. Comprehensive assessment of older diabetic patients should include a standardized evaluation of lower-extremity performance.