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OBJECTIVE: To assess the value of using frailty measures in primary care for predicting death, nursing home transfer (NHT) and hospital admission. DESIGN: Cohort study. SETTING AND PARTICIPANTS: All 380 people, mean age 88.4, living in the community and receiving home-based primary geriatric care from one practice in Victoria, Canada. INTERVENTIONS/MEASUREMENTS: A 60 min baseline assessment which included: Clinical Frailty Scale (CFS), EuroQol EQ-5D-5L (EQ-5D), EuroQol Visual Analogue Scale (EQ-VAS) and Gait Speed (Gaitspeed). OUTCOMES: Death, NHT and hospital admission. RESULTS: During 18 months of follow-up, there were 39 (10.3%) deaths, 48 (12.6%) NHTs and 93 (24.5%) individuals admitted to hospital. All three outcomes were predicted by: CFS Level 6+7/4+5 (HR death 5.92, 95% CI 3.12 to 11.22, NHT 6.00, 95% CI 3.37 to 10.66 and hospital admission 2.92, 95% CI 1.93 to 4.40); EQ-5D Quintile 1/Quintile 5 (death 6.26, 95% CI 2.11 to 18.62; NHT 3.18, 95% CI 1.29 to 7.82 and hospital admission 2.94, 95% CI 1.47 to 5.87); EQ-VAS Q1/Q5 (death 7.0, 95% CI 2.34 to 20.93; NHT 3.38, 95% CI 1.22 to 9.35 and hospital admission 6.69, 95% CI 3.20 to 13.99) and Gaitspeed (death 5.87, 95% CI 1.78 to 19.34; NHT 8.51, 95% CI 3.18 to 22.79 and hospital admission 11.05, 95% CI 5.45 to 22.40). Medical diagnoses, multiple comorbidities and polypharmacy were weaker predictors of these outcomes. Cox regression analyses showed CFS (adjusted HR 2.88, 95% CI 1.23 to 6.68), EQ-VAS (0.96, 95% CI 0.93 to 0.98), estimated glomerular filtration rate (0.97, 95% CI 0.95 to 1.00) and haemoglobin (0.97, 95% CI 0.94 to 0.99) were independently associated with death. Gaitspeed (0.13, 95% CI 0.03 to 0.57), Geriatric Depression Scale (1.39, 95% CI 1.07 to 1.82) and dementia diagnosis (4.61, 95% CI 1.86 to 11.44) were associated with NHT. Only CFS (1.75, 95% CI 1.21 to 2.51) and EQ-VAS (0.98, 95% CI 0.96 to 0.99) were associated with hospital admission. No other diagnoses, polypharmacy nor multiple comorbidities predicted these outcomes. CONCLUSIONS: For elderly people, standardised simple measures of frailty and health status were stronger predictors of death, NHT and hospital admission than medical diagnoses. Consideration should be given to adding these measures into usual medical care for this age group.

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BACKGROUND: The association between interstitial lung disease (ILD) and selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors (SSRI/SNRI) has been previously described in published case reports. However, its prevalence may be more common than expected. We examined the association between SSRI/SNRI usage and presence of ILD and or bronchiectasis (ILD/B) in an elderly population. METHODS: We conducted a retrospective case series and case-control study involving all 296 eligible elderly patients in one primary care geriatric practice in Victoria, BC, Canada. Cases required the presence of ILD/B on computed tomography (CT) or chest X-ray (CXR). Cases were excluded if they had other causes for ILD/B on CXR or CT such as exposure to known pneumotoxic drugs, metastatic cancer, rheumatoid lung disease, sarcoidosis, previous pulmonary tuberculosis, or pneumoconiosis. Data were abstracted from the patients' medical record. The exposure variable was standardized cumulative person-month (p-m) dose of SSRI/SNRI. The study was approved by the Clinical Research Ethics Board of University of British Columbia with a waiver of informed consent. RESULTS: A total of 12 cases and 273 controls were identified. Their mean ages were 89.0 and 88.7 years, respectively (p=0.862). A total of 10/12 cases and 99/273 controls were exposed to SSRI/SNRI. The odds ratio was 8.79, 95% confidence interval 2.40-32.23 (p=0.001). The median p-m exposure to SSRI/SNRI was 110.0 months for cases and 29.5 for controls (p=0.003). CONCLUSION: SSRIs and SNRIs were significantly associated with the risk of ILD/B in this elderly population. Because of their widespread usage, further studies should be done to validate these findings. Prescribers should cautiously monitor patients for development of insidious pulmonary symptoms when these drugs are used.

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OBJECTIVE: To determine if the modified mini-mental state examination (3MS) predicts functional status and if any effect on function is observed within the normal range of cognition. DESIGN: Cohort study. SETTING: Community-dwelling older adults in the Canadian province of Manitoba sampled in 1991 and followed in 1996. PARTICIPANTS: Baseline sample of 1751 adults aged 65+ from a representative registry. Five years later, 1028 participants remained in the community and had no missing data. MEASUREMENTS: The 3MS, age, gender, education, living arrangements, self-rated health, and depressive symptoms were self-reported. Functional status was assessed using the Older Americans Resource Survey, which was dichotomized into no/mild disability versus moderate/severe disability. RESULTS: Baseline 3MS score predicted baseline functional status. This effect was a gradient across the entire 3MS score, extending into the normal range with no apparent threshold. In logistic regression models, the unadjusted odds ratio (OR, 95% confidence interval) for the association of 3MS score with disability was 0.94 (0.93, 0.95); the adjusted OR was 0.96 (0.95, 0.98) in models including age, gender, education, and other covariates. Baseline 3MS score also predicted functional status 5 years later: The unadjusted OR for disability was 0.94 (0.92, 0.95); the adjusted OR was 0.97 (0.95, 0.99). Again, the risk of functional impairment at time 2 was a gradient effect, extending into the normal range of baseline 3MS score. CONCLUSIONS: The 3MS predicts functional decline, and this effect is a gradient effect. These results support the hypothesis that cognition is a continuum in risk.

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OBJECTIVE: To determine if one of Hippocrates' aphorisms, identifying good cognition and good appetite as two prognostic factors, predicts death in community living older adults in the modern era. DESIGN: Secondary analysis of an existing population based cohort study. SETTING: Manitoba Study of Health and Aging. PARTICIPANTS: 1751 community living adults aged more than 65 enrolled in the Manitoba Study of Health and Aging in 1991 and followed over five years. MAIN OUTCOME MEASURE: Time to death. METHODS: We recreated the hippocratic prognosticator using an item that measures appetite drawn from the Center for Epidemiologic Studies-depression subscale, and the mini-mental state examination, with a score of >25 being considered as normal. People with normal cognition and appetite were compared with those with either poor cognition or poor appetite. We constructed Cox regression models, adjusted for age, sex, education, and functional status. RESULTS: The prognostic aphorism predicted death, with an unadjusted hazard ratio of 2.37 (95% confidence interval 1.93 to 2.88) and a hazard ratio of 1.71 (1.37 to 2.12) adjusted for age, sex, and education. Both poor appetite and poor cognition predicted death. The sensitivity and specificity were not, however, sufficient for the measure to be used alone. CONCLUSION: An aphorism devised by Hippocrates millennia ago can predict death in the modern era.

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BACKGROUND: THE OBJECTIVES ARE TO DETERMINE IF: 1) accepting disability as a part of aging is associated with frailty; and 2) accepting disability is associated with becoming frail over a five-year period. METHODS: Secondary analysis of a prospective cohort study of 1,751 community-dwelling adults aged 65+. Participants were asked to rate their agreement with the statement: "When you reach my age, you have to accept a fair degree of discomfort and physical disability" on a five-point scale. Frailty was categorized as not frail or frail. The sample was re-interviewed five years later. RESULTS: The mean age was 75.5 years, 62.3% were women, and the mean education was 10.2 years. Accepting disability as a part of aging was strongly associated with frailty at time 1; the unadjusted Odds Ratio (OR) and 95% confidence interval (CI) was 1.47 (1.25, 1.72) and this association persisted after adjusting for confounding factors. Accepting disability was also associated with becoming frail; the unadjusted OR and 95% CI was 1.51 (1.20, 1.90), and this association also persisted after adjusting for potential confounding factors. CONCLUSIONS: Accepting disability as a part of aging is associated with being frail and becoming frail.

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This study sought to determine (1) if measures of social position are associated with frailty; (2) if any observed association between social position and frailty is a threshold or gradient effect; and (3) if any observed association is independent of possible confounders. Data were drawn from a sample of 1,751 community-dwelling adults, aged 65 and older, living in the Canadian province of Manitoba in 1991. Education, self-reported income adequacy, and self-reported income satisfaction were used as measures of social position. Frailty was graded based on functional loss, cognition, and urinary incontinence. Multivariate regression analyses revealed, after adjusting for possible confounding factors, that all measures of social position were strongly associated with frailty in a gradient, rather than a threshold, manner. We conclude that social gradients for frailty are present in older adults, although a causal mechanism is not yet clear.

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BACKGROUND: Frailty may be associated with reduced life satisfaction (LS). The objectives of this paper are to determine if (1) frailty is associated with LS in community-dwelling older adults in cross-sectional analyses; (2) frailty predicts LS five years later; and (3) specific domains of LS are preferentially associated with frailty. METHODS: This paper presents analysis of an existing population-based cohort study of 1,751 persons aged 65+ who were assessed in 1991, with follow-up five years later. LS was measured using the terrible-delightful scale, which measures overall LS and LS in specific domains. Frailty was measured using the Brief Frailty Instrument. Analyses were adjusted for age, gender, education, and marital status. RESULTS: Frailty was associated with overall LS at time 1 and predicted overall LS at time 2. This was seen in unadjusted analyses and after adjusting for confounding factors. Frailty was associated with all domains of LS at time 1, and predicted LS at time 2 in all domains except housing and self-esteem. However, the effect was stronger for LS with health than with other domains for both times 1 and 2. CONCLUSIONS: Frailty is associated with LS, and the effect is strongest for LS with health.

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OBJECTIVES: 1. To determine if Self-Rated Health (SRH) predicts dementia over a five period in cognitively intact older adults, and in older adults with Cognitive Impairment, No Dementia (CIND); and 2. To determine if different methods of eliciting SRH (age-referenced (AR) versus unreferenced) yield similar results. DESIGN: Prospective cohort. POPULATION: 1468 cognitively intact adults and 94 older adults with CIND aged 65+ living in the community, followed over five years. MEASURES: Age, gender, education, subjective memory loss, depressive symptoms, functional status, cognition, SRH and AR-SRH were all measured; dementia was diagnosed on clinical examination. Those with abnormal cognition not meeting criteria for dementia were diagnosed with CIND. RESULTS: In those who were cognitively intact at time 1, and had good SRH: 69.4% were intact; 6.0% had CIND; 6.9% had dementia, and 17.7% had died at time 2, while in those with poor SRH: 44.9% were intact, 11.1% had CIND, 9.1% had dementia, and 34.8% had died (p<0.001, chi-square test). In multinomial regression models SRH predicted dementia and death. In those with CIND at time 1 and good SRH: 2.3% were intact: 18.6% had CIND; 34.9% had dementia and 44.2% had died at time 2, while in those with poor SRH: 4.8% were intact, 31.0% had CIND, 19.0% had dementia, and 43.6% had died (p=0.30, chi-square test). In multinomial regression models, this was not significant. AR-SRH analyses were similar. CONCLUSIONS: In cognitively intact older adults SRH predicts dementia. In older adults with CIND, SRH does not predict dementia.

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BACKGROUND: Frailty and depressive symptoms are common issues facing older adults and may be associated. OBJECTIVES: To determine if: (i) depressive symptoms are associated with frailty; (ii) there is a gradient in this effect across the range of depressive symptoms; and (iii) the association between depressive symptoms and frailty is specific to particular types of depressive symptoms (positive affect, negative affect, somatic complaints, and interpersonal relations). METHOD: Secondary analysis of an existing population-based study was conducted. POPULATION: In 1991, 1751 community-living adults aged 65+ years were interviewed. MEASURES: Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression (CES-D) scale. Frailty was graded from 0 (no frailty) to 3 (moderate/severe frailty). Age, gender, education, marital status, self-rated health, and the number of comorbid conditions were self-reported. ANALYSES: Logistic regression models were constructed with the outcome of no frailty/urinary incontinence only versus frailty. RESULTS: Depressive symptoms were strongly associated with frailty, and there was a gradient effect across the entire range of the CES-D scale. The odds ratio and 95% confidence interval was 1.08 (1.06, 1.09) per point of the CES-D in unadjusted models. After potential confounding factors were adjusted, the adjusted odds ratio (95% confidence interval) was 1.03 (1.01, 1.05). Positive affect, negative affect, and somatic complaints were all associated with frailty, whereas interpersonal relations were not associated with frailty. CONCLUSIONS: Depressive symptoms are associated with frailty. Clinicians should consider assessing frail older adults for the presence of depression.

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We analysed a prospective cohort study to determine (1) if self-rated health (SRH) predicts mortality in older adults with and without depressive symptoms, and (2) to determine if there is an interaction between SRH and depressive symptoms on mortality. We followed 1,751 community-dwelling adults aged 65 and older over five years. Measurements included age, gender, education, the Center for Epidemiological Studies-Depression (CES-D), SRH, the Modified Mini-Mental State Examination (3MS), and the Older Americans Resource Survey (OARS). Our outcome measure was time to death. Analyses were conducted in those with, and those without, depressive symptoms. We constructed Cox regression models with an interaction term for the CES-D and SRH. The hazard ratio (HR) for mortality was 1.63 for those with depressive symptoms; it was 1.68 for those without. No significant interaction was found between depressive symptoms and SRH for mortality.

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BACKGROUND: Quality of life in dementia has been studied in clinical settings. There is less population-based research on life satisfaction and cognition. OBJECTIVES: (1) To compare the overall life satisfaction (LS), LS with material circumstances (LS (material)), and LS with social circumstances (LS (social)) of older adults with no cognitive impairment, with cognitive impairment no dementia (CIND), and with dementia; (2) To examine the effect of cognition on LS across a broad spectrum of cognition; and (3) To explore the effect of factors such as depressive symptoms, functional impairment, education, and social support. POPULATION: 1620 community-dwelling older adults with a mini-mental state examination (MMSE) score > 10, sampled from a representative list were interviewed. MEASURES: Age, gender, education, social networks, and social supports were all self-reported. The MMSE, the Centre for Epidemiologic Studies-Depression (CES-D), and the Older Americans Resource Survey (OARS) were used. Dementia was diagnosed by clinical examination using DSM-IIIR criteria. LS was measured using the Terrible-Delightful Scale. Factor analysis identified two factors: LS (material), and LS (social). A global item measuring overall LS was also used. RESULTS: Those with dementia and CIND had lower LS than those with normal cognition, but the effect was relatively small. There was a gradient in LS which extended into the normal range of cognition. Depressive symptoms and functional status were strongly associated with LS. CONCLUSIONS: Cognition is associated with LS, but the effect is fairly small. Most older adults are satisfied with life.

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CONTEXT: Depressive symptoms are common in older persons, and may predict mortality. OBJECTIVES: To determine: (1) If depressive symptoms predict mortality; (2) If there is a gradient in this effect; and (3) Which depressive factors predict mortality. POPULATION: In 1991-1992, 1751 community-dwelling older persons, sampled from a population-based registry, were interviewed. MEASURES: The Center for Epidemiologic Studies - Depression (CES-D), age, gender, the Modified Mini-Mental State Examination, self-rated health, and functional status. OUTCOME MEASURE: Time to death. ANALYSIS: Those scoring 16+ on the CES-D were considered depressed. To determine if a gradient was present, the CES-D was treated as a continuous variable. Four depressive factors from the CES-D (depressed affect, positive affect, somatic, and interpersonal) were analyzed. Cox regression models were constructed. RESULTS: The mortality in those with depressive symptoms was higher in those without depressive symptoms (Hazard Ratio of 1.71, p < 0.001, Log rank test). In multivariable models, this association was no longer significant after accounting for self-rated health and functional status. There was a gradient in risk of mortality across the range of the CES-D. Somatic factors, depressed affect, and positive affect were all associated with mortality in bivariate analyses, but not in multivariable models adjusting for functional status. Interpersonal factors were not associated with mortality. CONCLUSIONS: Depressive symptoms predict mortality in older persons.

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OBJECTIVES: To determine if marital status is associated with depressive symptoms in men and women, and to determine if partner satisfaction is associated with depressive symptoms. METHODS: Community-dwelling adults (n = 1751) aged 65 years and older were sampled from a representative population-based registry. Age, sex, education, and marital status were self-reported. Satisfaction with living partner was assessed with an item from the terrible-delightful scale. The Center for Epidemiologic Studies-Depression was used to assess depressive symptoms, with a score of 15 or more indicating depressive symptoms. RESULTS: Only 3% of the sample were dissatisfied with their living partner, and those who were dissatisfied with their living partner had higher levels of depressive symptoms. Proportions of men with depressive symptoms were: 20.6% for never married; 19.2% for separated or divorced; 17.3% for widowed; 7.3% for married (satisfied); and 38.1% for married (dissatisfied) (chi square = 32.98, df = 4, P < 0.001). In women, the results were different: 11.8% for never married; 23.1% for separated or divorced; 15.4% for widowed; 14.4% for married (satisfied); and 41.9% for married (dissatisfied) (chi square = 18.33, df = 4, P < 0.001). In logistic regression models, a significant interaction term was seen for Marital status Sex. In stratified models, adjusting for age and education, an effect of marital status was seen in men, but not in women. CONCLUSIONS: The effects of marriage on depressive symptoms in men and women may be different, with lower levels of depressive symptoms in married men, compared with unmarried men, but similar rates in married women, compared with unmarried women. Dissatisfaction with their partner was uncommon, but highly associated with depressive symptoms.

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OBJECTIVE: To determine if a single-item measure of depression predicts mortality over 5 years. DESIGN: Secondary analysis of a population-based cohort study. SETTING: Province of Manitoba. PARTICIPANTS: A total of 1751 community-dwelling adults aged 65 years or older. MAIN OUTCOME MEASURES: Self-reported depression; age, sex, education, functional status, and cognition; death over 5 years. Depression was measured with 1 item drawn from the Center for Epidemiologic Studies Depression (CES-D) scale: "I felt depressed." Bivariate and multivariate analyses were conducted. RESULTS: Those with self-reported depression had a 5-year mortality of 30.2% versus 19.7% in those without self-reported depression (P < .001, chi2). This association persisted after adjustment for age, sex, education, functional status, and cognition: adjusted odds ratio for mortality 1.35 (95% confidence interval 1.03 to 1.76). Among those with cognitive impairment, however, neither the CES-D scale nor the single-item measure predicted mortality. CONCLUSION: A simple measure of depression drawn from the CES-D predicts mortality among cognitively intact community-dwelling older adults, but not among cognitively impaired older adults. Further study is needed in order to determine the usefulness of this question in clinical practice.

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OBJECTIVES: Alcohol misuse in seniors has been studied in clinical samples and in small communities, but relatively few studies are population-based. Objectives are: (1) to describe the characteristics of seniors who score 1 or more on the CAGE (Cut down; Annoyed; Guilty; Eye-opener) questionnaire of alcohol problems; (2) to determine if depressive symptoms are associated with alcohol misuse after accounting for other factors. METHODS: Cross-sectional study of community-dwelling older people (65+ years) sampled from a representative population registry in Manitoba, Canada. Participants were initially interviewed in 1991-1992 and reinterviewed in 1996-1997. Data from Time 2 were used; 1,028 persons were included in the analyses. Sociodemographic characteristics, the CAGE questionnaire, Activities of Daily Living (ADLs) and instrumental ADLs (IADLs), the Center for Epidemiologic Studies-Depression (CES-D) scale and the Mini-Mental State Examination (MMSE) were assessed by trained interviewers. RESULTS: Males were more likely to score positive on the CAGE questionnaire. After adjusting for gender, age, and education, there was a strong association between depressive symptoms and alcohol misuse. Poor self-rated health and impairments in IADLs were also associated with alcohol misuse. CONCLUSIONS: Male gender, depressive symptoms, and poor functional status were associated with alcohol misuse in this population-based study. Attention to depressive symptoms and functional status may be important in the care of seniors with alcohol misuse. Alternatively, physicians should enquire about alcohol use in seniors with functional impairment or depressive symptoms.

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BACKGROUND AND PURPOSE: Empirical studies to clarify the outcomes in Vascular Cognitive Impairment (VCI) are needed. We compared cognitive, functional, and behavioural outcomes in patients with VCI to patients with no cognitive impairment (NCI), and Alzheimer's disease (AD). METHODS: Secondary analysis of the Consortium to Investigate Vascular Impairment of Cognition (CIVIC), a multi-centre Canadian memory clinic 30-month cohort study. RESULTS: Of 1347 patients, 938 were eligible for follow-up, of whom 239 (24.5%) were lost and 29 (3%) had died. Of the remaining 697 patients, 125 had NCI, 229 had VCI, and 343 had AD at baseline. Compared to people with NCI, of whom 20-40% showed progression based on cognitive and functional measures, those with VCI were more likely to progress (50-65%), as were people with AD (50-80%) (p<0.01). More people with VCI showed progression of affective symptoms (30%) than those with NCI (12%) or AD (15% p<0.01). Progression of impaired judgment (rated clinically) in VCI (15%) was similar to AD (11%) but more common than in NCI (4%, p<0.01). CONCLUSIONS: Most people with VCI show readily detectable progression by 30 months. Depressive symptoms were more common and more progressive in VCI than in Alzheimer's disease, whereas clinical evidence of progressive executive dysfunction was common in both AD and VCI.

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BACKGROUND AND PURPOSE: There is a need for empirical studies to define criteria for vascular cognitive impairment (VCI) subtypes. In this paper, we report the predictive validity of a subtype classification scheme based on clinical and radiographic features. METHODS: Nine Canadian memory clinics participated in the Consortium to Investigate Vascular Impairment of Cognition. This cohort consisted of 1347 patients, of whom 324 had VCI, and was followed for up to 30 months. RESULTS: Clinical and neuroimaging features defined three subtypes: vascular cognitive impairment, no dementia, (n=97), vascular dementia (n=101) and mixed neurodegenerative/vascular dementia (n=126). Any ischemic lesion on neuroimaging increased the odds (odds ratio=9.31; 95% confidence interval 6.46, 13.39) of a VCI diagnosis. No VCI subtype, however, was associated with a specific neuroimaging abnormality. Compared to those with no cognitive impairment, patients with each VCI subtype had higher rates of death and institutionalization (hazard ratio for combined adverse events=6.08, p<0.001). CONCLUSIONS: Both clinical features and radiographic features help establish a diagnosis of VCI. The outcomes of VCI subtypes, however, are more strongly associated with clinical features than with radiographic ones.

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BACKGROUND: Depressive symptoms are common in seniors and may predict dementia. The objective of this study was to evaluate multiple measures of depressive symptoms to determine whether they predict subsequent Alzheimer's disease (AD) or dementia. METHODS: This population-based cohort study with 5-year follow-up included 766 community-dwelling seniors (ages 65+ years) in Manitoba, Canada. Measurements considered were the Center for Epidemiologic Studies Depression (CES-D) scale, participant-reported medical history, and duration of depression. RESULTS: Total CES-D score was a significant predictor of AD and dementia when categorized as a dichotomous variable according to the cutoff scores of 16 and 17; a CES-D cutoff of 21 was a significant predictor of AD and a marginally significant predictor of dementia. When analyzed as a continuous variable, CES-D score was marginally predictive of AD and dementia. Neither participant-reported history of depression nor participant-reported duration of depression was significant in predicting AD or dementia. CONCLUSION: Because depressive symptoms as measured by the CES-D predict the development of AD and dementia over 5 years, clinicians should monitor their older patients with these symptoms for signs of cognitive impairment.

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