Background

Previous research regarding anxiety as a predictor of future cognitive decline in older adults is limited and inconsistent. We examined the independent relationship between anxiety symptoms and subsequent cognitive decline.

Methods

We included 2,818 community-dwelling older men (mean age = 76.1, SD ±5.3 years) who were followed on an average for 3.4 years. We assessed anxiety symptoms at baseline using the Goldberg Anxiety Scale (GAS; range = 0-9). We assessed cognitive function at baseline and at two subsequent visits using the Modified Mini-Mental State Examination (3MS; global cognition) and the Trails B test (executive function).

Results

At baseline, there were 690 (24%) men with mild anxiety symptoms (GAS 1-4) and 226 (8%) men with moderate/severe symptoms (GAS 5-9). Men with anxiety symptoms were more likely to have depressed mood, poor sleep, more chronic medical conditions, and more impairment in activities of daily living compared to those with no anxiety symptoms. Compared to those with no anxiety symptoms at baseline, men with any anxiety symptoms were more likely to have substantial worsening in Trails B completion time (OR = 1.56, 95% CI 1.19, 2.05). The association was attenuated after adjusting for potential confounders, including depression and poor sleep, but remained significant (OR = 1.40, 95% CI 1.04, 1.88).

Conclusion

In cognitively healthy older men, mild anxiety symptoms may potentially predict future decline in executive functioning. Anxiety is likely a manifestation of an underlying neurodegenerative process rather than a cause.

Introduction

We examined whether statins are associated with better cerebral white (WM) and gray matter (GM) indices in community-dwelling elders.

Methods

In 295 older adults, we compared white matter hyperintensities (WMH) on brain magnetic resonance imaging and, total WM fractional anisotropy (FA) and GM mean diffusivity (MD) on diffusion tensor imaging, of Alzheimer's disease (AD) relevant regions in statin-exposed and statin-unexposed participants stratified by Modified Mini-Mental Status Examination (3MS) score.

Results

There was no overall effect of statin exposure on cerebral structural indices. The interaction between statin exposure and 3MS was significant for total-WMH and WM FA (both P < .05) but not GM MD. In the lowest 3MS tertile (mean: 86), statin-exposed individuals had lower total-WMH and higher WM FA (P = .005 and P = .044) and FA of tracts linked to clinical AD (P-value range= .005-.04) despite statistical adjustments. These differences were not significant in the two higher 3MS tertiles.

Discussion

Statins may benefit WM in older adults vulnerable to dementia.

Objectives

To determine whether benzodiazepine use is associated with incident disability in mobility and activities of daily living (ADLs) in older individuals.

Design

A prospective cohort study.

Setting

Four sites of the Established Populations for Epidemiologic Studies of the Elderly.

Participants

This study included 9,093 subjects (aged > or =65) who were not disabled in mobility or ADLs at baseline.

Measurements

Mobility disability was defined as inability to walk half a mile or climb one flight of stairs. ADL disability was defined as inability to perform one or more basic ADLs (bathing, eating, dressing, transferring from a bed to a chair, using the toilet, or walking across a small room). Trained interviewers assessed outcomes annually.

Results

At baseline, 5.5% of subjects reported benzodiazepine use. In multivariable models, benzodiazepine users were 1.23 times as likely as nonusers (95% confidence interval (CI) = 1.09-1.39) to develop mobility disability and 1.28 times as likely (95% CI = 1.09-1.52) to develop ADL disability. Risk for incident mobility was increased with short- (hazard ratio (HR) = 1.27, 95% CI = 1.08-1.50) and long-acting benzodiazepines (HR = 1.20, 95% CI = 1.03-1.39) and no use. Risk for ADL disability was greater with short- (HR = 1.58, 95% CI = 1.25-2.01) but not long-acting (HR = 1.11, 95% CI = 0.89-1.39) agents than for no use.

Conclusion

Older adults taking benzodiazepines have a greater risk for incident mobility and ADL disability. Use of short-acting agents does not appear to confer any safety benefits over long-acting agents.

Background

Gait speed decline, an early marker of functional impairment, is a sensitive predictor of adverse health outcomes in older adults. The effect of potentially inappropriate medications, including drug-disease and drug-drug interactions, on gait speed decline is not well known.

Objective

The aim of this study was to determine if drug interactions impair functional status as measured by gait speed.

Methods

The sample included 2402 older adults with medication and gait speed data from the Health, Aging and Body Composition study. The independent variable was the frequency of drug-disease and/or drug-drug interactions at baseline and 3 additional years. The main outcome was a clinically meaningful gait speed decline of ≥0.1 m/s the year following drug interaction assessment. Adjusted odds ratios and 95 % confidence intervals (CIs) were calculated using multivariate generalized estimating equations for both the overall sample and a sample stratified by gait speed at time of drug interaction assessment.

Results

The prevalence of drug-disease and drug-drug interactions ranged from 7.6 to 9.3 and 10.5 to 12.3 %, respectively, with few participants (3.8-5.7 %) having multiple drug interactions. At least 22 % of participants had a gait speed decline of ≥0.1 m/s annually. Drug interactions were not significantly associated with gait speed decline overall or in the stratified sample of fast walkers. There was some evidence, however, that drug interactions increased the risk of gait speed decline among those participants with slower gait speeds, though p values did not reach statistical significance (adjusted odds ratio 1.22; 95 % CIs 0.96-1.56; p = 0.11). Moreover, a marginally significant dose-response relationship was seen with multiple drug interactions and gait speed decline (adjusted odds ratio 1.40; 95 % CIs 0.95-2.04; p = 0.08).

Conclusions

Drug interactions may increase the likelihood of gait speed decline among older adults with evidence of preexisting debility. Future studies should focus on frail elders with less physiological reserve who may be more susceptible to the harms associated with potentially inappropriate medications.

Objectives

Research is limited and findings conflict regarding anxiety as a predictor of future cognitive decline in the oldest old persons. We examined the relationship between levels of and changes in anxiety symptoms, and subsequent dementia and mild cognitive impairment (MCI) in the oldest old women.

Method

We conducted secondary analyses of data collected from 1425 community-dwelling women (mean age = 82.8, SD ±3.1 years) followed on average for five years. The Goldberg Anxiety Scale was used to assess anxiety symptoms at baseline, and an expert clinical panel adjudicated dementia and MCI at follow-up. Participants with probable cognitive impairment at baseline were excluded.

Results

At baseline, 190 (13%) women had moderate/severe anxiety symptoms and 403 (28%) had mild anxiety symptoms. Compared with those with no anxiety symptoms at baseline, women with mild anxiety symptoms were more likely to develop dementia at follow-up (multivariable-adjusted odds ratio = 1.66, 95% confidence interval 1.12-2.45). No significant association was observed between anxiety symptoms and MCI.

Conclusion

In the oldest old women, our findings suggest that mild anxiety symptoms may predict future risk of dementia, but not MCI. Future studies should explore potential biological mechanisms underlying associations of anxiety with cognitive impairment.

Background

Medication complexity is a large determinant of adherence. Few studies have explored the relationship between cognitive impairment and medication complexity.

Objective

To evaluate whether cognitive impairment is associated with medication complexity for prescription and over-the-counter (OTC) medications.

Methods

In this cross-sectional analysis, we studied the association between cognitive impairment and the complexity of prescription and OTC drug regimens. Baseline participants were from the Health, Aging and Body Composition study, consisting of 3075 well-functioning 70- to 79-year-old black and white men and women. Cognitive impairment was defined by having a Modified Mini-Mental State Examination score <80. The complexity of prescription and OTC (including supplements/herbals) medications was assessed using a modified version of the Medication Regimen Complexity Index (mMRCI). The mMRCI score increases with complexity of dosage forms, number of medications, pill burden, and nondaily dosing.

Results

The mean (SD) age was 74 (2.9) years (n = 3055; 52% female, 41% black). The median prescription mMRCI score was 6 (range 0-66). The median OTC mMRCI score was 4 (range 0-71). Adjusting for health status, demographics, and access to care, medication complexity was lower in participants with cognitive impairment for prescription (adjusted RR 0.89; 95% CI 0.80 to 0.99) and OTC medications (adjusted RR 0.76; 95% CI 0.64 to 0.93) compared to those without cognitive impairment. The number of prescription medications was not different, but the number of OTC drugs was lower for those with cognitive impairment.

Conclusions

In this cohort of well-functioning older adults, those with cognitive impairment had lower prescription complexity due to less-complex dosage forms, pill burden, or daily dosing. OTC complexity was also lower, primarily due to a lower number of OTC drugs. The results of this study show that further research on medication complexity and adherence and health outcomes in cognitively impaired individuals is warranted.

Background

Older blacks are less likely to receive guideline-recommended antilipemic therapy and achieve lipid control than older whites because, in part, of out-of-pocket costs. We sought to determine whether racial differences in antilipemic use and lipid control narrowed after Medicare Part D's implementation.

Methods

This before-after study included 1,091 black and white adults 70 years or older with coronary heart disease and/or diabetes mellitus from the Health Aging and Body Composition Study. Primary outcomes were antilipemic use and low-density lipoprotein cholesterol control. Key independent variables were race, time (pre-Part D vs post-Part D), and their interaction.

Results

Before Part D, fewer blacks than whites reported taking an antilipemic (32.70% vs 49.35%), and this difference was sustained after Part D (blacks 48.30% vs whites 64.57%). Multivariable generalized estimating equations confirmed no post-Part D change in racial differences in antilipemic use (adjusted ratio of the odds ratio 1.07, 95% CI 0.79-1.45). Compared with whites, more blacks had poor lipid control both before Part D (24.30% vs 12.36%, respectively) and after Part D (24.46% vs 13.72%, respectively), with no post-Part D change in racial differences in lipid control (adjusted ratio of the odds ratio 0.82, 95% CI 0.51-1.33).

Conclusion

Although antilipemic use increased after Medicare Part D for both races, this policy change was associated with a change neither in lipid control for either racial group nor in the racial differences in antilipemic use or lipid control.

Background

Information about the prevalence and correlates of self-reported medication nonadherence using multiple measures in older adults with chronic cardiovascular conditions is needed.

Objective

To examine the prevalence and correlates of self-reported medication nonadherence among community-dwelling elders with chronic cardiovascular conditions.

Methods

Participants (n = 897) included members from the Health, Aging and Body Composition Study with coronary heart disease, diabetes mellitus, and/or hypertension at Year 10. Self-reported nonadherence was measured by the 4-item Morisky Medication Adherence Scale (MMAS-4) and 2-item cost-related nonadherence (CRN-2) scale at Year 11. Factors (demographic, health status, and access to care) were examined for association with the MMAS-4 and then for association with the CRN-2 scale.

Results

Nonadherence per the MMAS-4 and CRN-2 scale was reported by 40.7% and 7.7% of participants, respectively, with little overlap (3.7%). Multivariable logistic regression analyses found that black race was significantly associated with nonadherence per the MMAS-4 (P = 0.002) and the CRN-2 scale (P = 0.005). Other correlates of nonadherence per the MMAS-4 (with independent associations) included having cancer (P = 0.04), a history of falls (P = 0.02), sleep disturbances (P = 0.04) and having a hospitalization in the previous 6 months (P = 0.005). Conversely, being unmarried (P = 0.049), having worse self-reported health (P = 0.04) and needs being poorly met by income (P = 0.02) showed significant independent associations with nonadherence per the CRN-2 scale.

Conclusions

Self-reported medication nonadherence was common in older adults with chronic cardiovascular conditions and only one factor - race - was associated with both types. The research implication of this finding is that it highlights the need to measure both types of self-reported nonadherence in older adults. Moreover, the administration of these quick measures in the clinical setting should help identify specific actions such as patient education or greater use of generic medications or pill boxes that may address barriers to medication nonadherence.

Background

Use of central nervous system (CNS) active medications may increase the risk for fractures. Prior studies are limited by incomplete control of confounders.

Methods

To determine whether use of CNS active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics, increases fracture risk in elderly, community-dwelling women, we examined use of these 4 categories of medications in a cohort of 8127 older women and followed the participants prospectively for incident nonspine fractures, including hip fractures. Current use of CNS active medications was assessed by interview with verification of use from containers between 1992 and 1994 and between 1995 and 1996. Use was coded as a time-dependent variable. Incident nonspine fractures occurring after the initial medication assessment until May 31, 1999, were confirmed by radiographic reports.

Results

During an average follow-up of 4.8 years, 1256 women (15%) experienced at least one nonspine fracture, including 288 (4%) with first hip fractures. Compared with nonusers, women taking narcotics (multivariate hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.06-1.83) and those taking antidepressants (multivariate HR, 1.25; 95% CI, 0.99-1.58) had increases in the risks for any nonspine fractures. Women taking tricyclic antidepressants and those using selective serotonin reuptake inhibitors (SSRIs) had similar fracture rates. There were no independent associations between benzodiazepine use or anticonvulsant use and risk for nonspine fracture. Women taking antidepressants compared with nonusers had a 1.7-fold increase in the risk for hip fracture (multivariate HR, 1.65; 95% CI, 1.05-2.57). We did not observe independent associations between use of any of the other 3 classes of CNS active medications and risk of hip fracture.

Conclusions

Community-dwelling older women taking narcotics have an increased risk for any nonspine fracture, and those taking antidepressants have a greater risk for nonspine fractures, including hip fracture. Rates of fracture were similar in women taking tricyclic antidepressants and those using SSRIs. Benzodiazepine use and anticonvulsant use were not independently associated with an increased risk of nonspine fractures, including hip fracture.

Background

Although it is generally accepted that anticholinergic use may lead to a fall, results from studies assessing the association between anticholinergic use and falls are mixed. In addition, direct evidence of an association between use of anticholinergic medications and recurrent falls among community-dwelling elders is not available.

Objective

To assess the association between anticholinergic use across multiple anticholinergic subclasses, including over-the-counter medications, and recurrent falls.

Methods

This was a longitudinal analysis of 2948 participants, with data collected via interview at year 1 from the Health, Aging and Body Composition study and followed through year 7 (1997-2004). Self-reported use of anticholinergic medication was identified at years 1, 2, 3, 5, and 6 as defined by the list from the 2015 American Geriatrics Society Beers Criteria. Dosage and duration were also examined. The main outcome was recurrent falls (≥2) in an ensuing 12-month period from each medication data collection.

Results

Using multivariable generalized estimating equation models, controlling for demographic, health status/behaviors, and access-to-care factors, a 34% increase in likelihood of recurrent falls in anticholinergic users (adjusted odds ratio = 1.34; 95% CI = 0.93-1.93) was observed, but the results were not statistically significant; similar results were found with higher doses and longer duration of use.

Conclusion

Increased point estimates suggest an association of anticholinergic use with recurrent falls, but the associations did not reach statistical significance. Future studies are needed for more definitive evidence and to examine other measures of anticholinergic burden and associations with more intermediate adverse effects such as cognitive function.