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1.  A prospective cohort study of stroke mortality and arsenic in drinking water in Bangladeshi adults 
BMC Public Health  2014;14:174.
Arsenic in drinking water causes increased coronary artery disease (CAD) and death from CAD, but its association with stroke is not known.
Prospective cohort study with arsenic exposure measured in well water at baseline. 61074 men and women aged 18 years or older on January 2003 were enrolled in 2003. The cohort was actively followed for an average of 7 years (421,754 person-years) through December 2010. Based on arsenic concentration the population was categorized in three groups and stroke mortality HR was compared to the referent. The risk of stroke mortality Hazard Ratio (HR) and 95% Confidence Interval was calculated in relation to arsenic exposure was estimated by Cox proportional hazard models with adjustment for potential confounders.
A total of 1033 people died from stroke during the follow-up period, accounting for 23% of the total deaths. Multivariable adjusted HRs (95% confidence interval) for stroke for well water arsenic concentrations <10, 10-49, and ≥50 μg/L were 1.0 (reference), 1.20 (0.92 to 1.57), and 1.35 (1.04 to 1.75) respectively (Ptrend=0.00058). For men, multivariable adjusted HRs (95%) for well water arsenic concentrations <10, 10-49, and ≥50 μg/L were 1.0 (reference), 1.12 (0.78 to 1.60), and 1.07 (0.75 to 1.51) respectively (Ptrend=0.45) and for women 1.0 (reference),1.31 (0.87 to 1.98), and 1.72 (1.15 to 2.57) respectively (Ptrend=0.00004).
The result suggests that arsenic exposure was associated with increased stroke mortality risk in this population, and was more significant in women compared to men.
PMCID: PMC3943382  PMID: 24548416
2.  A snapshot of the prevalence of physical activity amongst older, community dwelling people in Victoria, Australia: patterns across the 'young-old' and 'old-old' 
BMC Geriatrics  2007;7:4.
Physical activity has a range of health benefits for older people. The aim of this study was to determine physical activity prevalence and attitudes amongst respondents to a trial screening survey.
A cross-sectional survey was conducted. Subjects were community dwelling older people aged ≥ 65 years, recruited via general practices in Victoria, Australia. Participants completed a mailed screening tool containing the Geriatric Depression Scale, the Active Australia survey and the Physical Activity Readiness Questionnaire.
Of 330 participants, 20% were ≥ 80 years. Activity levels were similar to those reported in population studies. The proportion of participants reporting physical activity was greatest for the walking category, but decreased across categories of physical activity intensity. The oldest-old were represented at all physical activity intensity levels. Over half reported exercising at levels that, according to national criteria are, 'sufficient to attain health benefit'. A greater proportion of participants aged 85 years and older were unaware of key physical activity messages, compared to participants aged less than 85 years.
Most population surveys do not provide details of older people across age categories. This survey provided information on the physical activity of people up to 91 years old. Physical activity promotion strategies should be tailored according to the individual's needs. A better understanding of the determinants of physical activity behaviour amongst older sub-groups is needed to tailor and target physical activity promotion strategies and programs to maximise physical activity related health outcomes for older people.
PMCID: PMC1828159  PMID: 17316454
3.  Low Micronutrient Levels as a Predictor of Incident Disability in Older Women 
Archives of internal medicine  2006;166(21):2335-2340.
The role of nutritional status in the disablement process is still unclear. The objective of this study was to assess whether low concentrations of nutrients predict the development and course of disability.
Longitudinal study including community-dwelling women 65 years or older enrolled in the Women’s Health and Aging Study I. In total, 643 women were assessed prospectively at 6-month intervals from 1992 to 1995.
Incidence rates of disability in activities of daily living (ADLs) during 3 years of follow-up. Incidence rates in the lowest quartile of each selected nutrient were compared with those in the upper quartiles. The hazard ratios were estimated from Cox models adjusted for potential confounders. Women in the lowest quartile of serum concentrations of vitamin B6 (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.03–1.67), vitamin B12 (HR, 1.40; 95% CI, 1.12–1.74), and selenium (HR, 1.38; 95% CI, 1.12–1.71) had significantly higher risk of disability in ADLs during 3 years of follow-up compared with women in the upper 3 quartiles.
Low serum concentrations of vitamins B6 and B12 and selenium predict subsequent disability in ADLs in older women living in the community. Nutritional status is one of the key factors to be considered in the development of strategies aimed at preventing or delaying the disablement process.
PMCID: PMC2645646  PMID: 17130386
4.  Respiratory symptoms in older people and their association with mortality 
Thorax  2005;60(4):331-334.
Methods: A total of 14 458 people aged 75 years and over participating in a trial of health screening of older people in general practice answered questions on three respiratory symptoms: cough, sputum production, and wheeze. The association of symptoms with mortality was examined for all cause and respiratory causes of death taking account of potential confounders.
Results: Coughing up phlegm in winter mornings had a prevalence of 27.0% (95% confidence interval (CI) 26.8 to 27.2). Those with this symptom had an adjusted hazard ratio for all cause mortality of 1.35 (95% CI 1.21 to 1.50), p<0.001 and for respiratory specific mortality of 2.01 (95% CI 1.66 to 2.41), p<0.001. Phlegm at any time of the day in winter had a prevalence of 16.5% (95% CI 16.3 to 16.7) with hazard ratios for all cause and respiratory specific mortality of 1.28 (95% CI 1.15 to 1.42) and 2.28 (95% CI 1.92 to 2.70), p<0.001. Wheeze or whistling from the chest had a prevalence of 14.3% (95% CI 14.1 to 14.5) with hazard ratios of 1.45 (95% CI 1.31 to 1.61) and 2.86 (95% CI 2.45 to 3.35), p<0.001.
Conclusions: The prevalence of respiratory symptoms is widespread among elderly people and their presence is a strong predictor of mortality.
PMCID: PMC1747384  PMID: 15790990
5.  Frequency of Attendance at Religious Services and Mortality in a U.S. National Cohort 
Annals of epidemiology  2008;18(2):124-129.
Few nationally representative cohort studies have appeared on frequency of attendance at religious services and mortality. We test the hypothesis that > weekly attendance compared with nonattendance at religious services is associated with lower probability of future mortality in such a study.
Data were analyzed from a longitudinal follow-up study of 8450 American men and women age 40 years and older who were examined from 1988 to 1994 and followed an average of 8.5 years. Measurements at baseline included self-reported frequency of attendance at religious services, sociodemographics, and health, physical and biochemical measurements.
Death during follow-up occurred in 2058. After adjusting for confounding by baseline sociodemographics and health status, the hazards ratios (95% confidence limits) were never 1.00 (reference); < weekly 0.89 (0.75–1.04), p = 0.15; weekly 0.82 (0.71–0.94) p = 0.005; and > weekly attenders 0.70 (0.59–0.83), p < 0.001. Mediators, including health behaviors and inflammation, explained part of the association.
In a nationwide cohort of Americans, predominantly Christians, analyses demonstrated a lower risk of death independent of confounders among those reporting religious attendance at least weekly compared to never. The association was substantially mediated by health behaviors and other risk factors.
PMCID: PMC2659561  PMID: 18083539
Aging; Cultural Factors; Epidemiologic Methods; Mortality; Religion; Spirituality
6.  Traditional Risk Factors Alone Could Not Explain the Excess Mortality in Patients With Diabetes 
Diabetes Care  2012;35(12):2503-2509.
Individuals with diabetes have an excess mortality compared with people without diabetes. This study used a national cohort of older Spanish adults to identify possible factors explaining the relation between diabetes and excess mortality.
A cohort of 4,008 people ≥60 years of age was selected in 2000–2001 and followed prospectively until 2008. At baseline, data were collected on diabetes and major risk factors for mortality: social network, diet, physical activity and other lifestyle factors, obesity, hypertension, dyslipidemia, and previous cardiovascular disease and cancer. Analyses were conducted with Cox regression with progressive adjustment for mortality risk factors.
In the study cohort, 667 people had diabetes. A total of 972 deaths occurred during follow-up. The hazard ratio (HR) and 95% CI for mortality in diabetic versus nondiabetic subjects, adjusted for age, marital status, education level, social class, medical consultation, and treatment with statins, angiotensin II antagonists, or aspirin, was 1.40 (1.11–1.76) in men and 1.70 (1.37–2.10) in women. Adjustment for additional risk factors produced little change in the HR. After adjustment for all risk factors, including cardiovascular disease and cancer, the mortality HR in diabetic versus nondiabetic individuals was 1.43 (1.12–1.82) in men and 1.67 (1.34–2.08) in women. The inclusion of lifestyles and diseases occurring during follow-up also produced little change in the relation between diabetes and mortality.
The excess risk of mortality in diabetic versus nondiabetic individuals cannot be explained by mortality risk factors or by the presence of cardiovascular disease or cancer.
PMCID: PMC3507605  PMID: 22875228
7.  Diabetes severity and the role of leisure time physical exercise on cardiovascular mortality: the Nord-Trøndelag Health study (HUNT), Norway 
Physical activity has been associated with lower cardiovascular mortality in people with diabetes, but how diabetes severity influence this association has not been extensively studied.
We prospectively examined the joint association of diabetes severity, measured as medical treatment status and disease duration, and physical exercise with cardiovascular mortality. A total of 56,170 people were followed up for 24 years through the Norwegian Cause of Death Registry. Cox proportional adjusted hazard ratios (HRs) with 95% confidence intervals (CI) were estimated.
Overall, 7,723 people died from cardiovascular disease during the follow-up. Compared to the reference group of inactive people without diabetes, people with diabetes who reported no medical treatment had a hazard ratio (HR) of 1.65 (95% CI: 1.34, 2.03) if they were inactive and a HR of 0.99 (95% CI: 0.68, 1.45) if they reported ≥2.0 hours physical exercise per week. Among people who received oral hypoglycemic drugs or insulin, the corresponding comparison gave HRs of 2.46 (95% CI: 2.08-2.92) and 1.58 (95% CI: 1.21, 2.05), respectively.
The data suggest a more favourable effect of exercise in people with diabetes who used medication than in those who did not, suggesting that physical exercise should be encouraged as a therapeutic measure additional to medical treatment.
PMCID: PMC3680183  PMID: 23738538
Diabetes severity; Leisure time physical exercise; Cardiovascular mortality; Epidemiology
8.  Even low level of physical activity is associated with reduced mortality among people with metabolic syndrome, a population based study (the HUNT 2 study, Norway) 
BMC Medicine  2011;9:109.
Low levels of physical activity may increase the risk of developing metabolic syndrome, a cluster of metabolic factors that are associated with the risk of premature death. It has been suggested that physical activity may reduce the impact of factors associated with metabolic syndrome, but it is not known whether physical activity may reduce mortality in people with metabolic syndrome.
In a prospective study of 50,339 people, 13,449 had metabolic syndrome at baseline and were followed up for ten years to assess cause-specific mortality. The population was divided into two age groups: those younger than 65 years of age and those older than age 65. Information on their physical activity levels was collected at baseline.
Metabolic syndrome was associated with higher mortality from all causes (hazard ratio (HR) 1.35, 95% confidence interval (95% CI) 1.20 to 1.52) and from cardiovascular causes (HR 1.78, 95% CI 1.39 to 2.29) in people younger than 65 years old than among other populations. In older people, there was no overall association of metabolic syndrome with mortality. People with metabolic syndrome who reported high levels of physical activity at baseline were at a reduced risk of death from all causes compared to those who reported no physical activity, both in the younger age group (HR 0.52, 95% CI 0.37 to 0.73) and in the older age group (HR 0.59, 95% CI 0.47 to 0.74).
Among people with metabolic syndrome, physical activity was associated with reduced mortality from all causes and from cardiovascular causes. Compared to inactivity, even low levels of physical activity were associated with reduced mortality.
PMCID: PMC3193808  PMID: 21958416
metabolic syndrome; physical activity; mortality
9.  Health, cognitive, and psychosocial factors as predictors of mortality in an elderly community sample 
STUDY OBJECTIVE: To examine whether cognitive and psychosocial factors predict mortality once physical health is controlled. DESIGN: A prospective study of community dwelling elderly. Mortality was assessed over a period of 3-4 years after the baseline assessment of predictors. The data were analysed using the Cox proportional hazards model. SETTING: Canberra and Queanbeyan, Australia. PARTICIPANTS: A sample of 897 people aged 70 or over and living in the community, drawn from the compulsory electoral roll. RESULTS: For the sample as a whole, the significant predictors of mortality were male sex, poor physical health, poor cognitive functioning, and low neuroticism. Men had an adjusted relative risk of mortality of 2.5 compared with women. For the male sub-sample, poor self rated health and a poor performance on a speeded cognitive task were significant predictors, while for women, greater disability, low systolic blood pressure, and a low score on a dementia screening test were the strongest predictors. CONCLUSIONS: Mortality was predicted by physical ill health and poor cognitive functioning. Psychosocial factors such as socioeconomic status, psychiatric symptoms, and social support did not add to the prediction of mortality, once sex, physical health, and cognitive functioning were controlled. Mortality among men was more than twice that of women, even when adjusted for other predictors.
PMCID: PMC1756829  PMID: 10396468
10.  Translating a Community-Based Motivational Support Program to Increase Physical Activity Among Older Adults With Diabetes at Community Clinics: A Pilot Study of Physical Activity for a Lifetime of Success (PALS) 
Preventing Chronic Disease  2007;5(1):A18.
Regular physical activity is an important goal for elders with chronic health conditions.
This report describes Physical Activity for a Lifetime of Success (PALS), an attempt to translate a motivational support program for physical activity, Active Choices, for use by a group of diverse, low-income, community-dwelling elders with diabetes.
PALS linked physical activity assessment and brief counseling by primary care providers with a structured referral to a community-based motivational telephone support program delivered by older adult volunteers. People with diabetes aged 65 years or older who were receiving care at two community clinics were randomized to receive either immediate or delayed intervention. The main intended outcome measure was physical activity level; the secondary outcome measure was mean hemoglobin A1c.
One-third of those offered referral to the PALS program in the clinic setting declined. Another 44% subsequently declined enrollment or were unreachable by the support center. Only 14 (21%) of those offered referral enrolled in the program. Among these 14, the percentage who were sufficiently active was higher at follow-up than at enrollment, though not significantly so. Using an intent-to-treat analysis, which included all randomized clinic patients, we found no significant change in mean hemoglobin A1c for the intervention group compared with controls.
A community-based referral and support program to increase physical activity among elderly, ethnically diverse, low-income people with diabetes, many of whom are not English-speaking, may be thwarted by unforeseen barriers. Those who enroll and participate in the PALS program appear to increase their level of physical activity.
PMCID: PMC2248781  PMID: 18082007
11.  The Impact of Age on Mortality, Impairment, and Disability among Adults with Acute Traumatic Spinal Cord Injury 
Journal of Neurotrauma  2009;26(10):1707-1717.
Given the potential effects of age on mortality, impairment, and disability among individuals with traumatic spinal cord injury [(SCI), we examined these issues using a large, prospectively accrued clinical database. This study includes all patients who were enrolled in the Third National Spinal Cord Injury Study (NASCIS 3). Motor, sensory, and pain outcomes were assessed using NASCIS scores. Functional outcome was evaluated using the Functional Independence Measure (FIM). Data analyses included regression models adjusted for major potential confounders (i.e., sex, ethnicity, Glasgow Coma Scale [GCS] score, blood alcohol concentration on admission, drug protocol, cause, and level and severity of SCI). Mortality rates among older people (≥65 years) were significantly greater than those of younger individuals at 6 weeks, at 6 months, and at 1 year following SCI (38.6% versus 3.1%; p < 0.0001). Among survivors, age was not significantly correlated with motor recovery or change in pain scores in the acute and chronic stages after SCI based on regression analyses adjusted for major confounders. However, older individuals experienced greater functional deficit (based on FIM scores) than younger individuals, despite experiencing similar rates of sensorimotor recovery (based on NASCIS scores). Our results suggest that older individuals have a substantially increased mortality rate during the first year following traumatic SCI in comparison with younger patients. Among survivors, the potential of older patients with SCI to neurologically improve within the first year post-injury does not appear to translate into similar functional recovery compared to that seen in younger individuals. Given this fact, rehabilitation protocols that are more focused on functional recovery may reduce disability among older people with acute traumatic SCI.
PMCID: PMC2822797  PMID: 19413491
aging; functional recovery; mortality; motor recovery; spinal cord injury
12.  Digestive symptoms in older adults: Prevalence and associations with institutionalization and mortality 
Digestive symptoms are common in adults. However, little is known about their prevalence in older adults and the association of digestive symptoms with institutionalization and mortality in community-dwelling older adults.
To determine the prevalence of digestive symptoms among older adults in Canada and whether they are associated with increased risk of institutionalization and mortality, independent of the effect of potential confounders.
The present study was a secondary analysis of data collected from community-dwelling participants 65 years of age and older in the Canadian Study of Health and Aging. Measures incuded age, sex, presence of digestive symptoms, cognition, impairment in activities of daily living (ADL) and self-reported health. Outcome measures included death or institutionalization over the 10 years of follow-up.
Digestive symptoms were found in 2288 (25.6%) of the 8949 subjects. Those with digestive symptoms were older, with a mean difference in age of six months (P=0.007). Digestive symptoms were more common among women (28.4%) than men (20.3%), among individuals with poor self-reported health and those with an increased number of impairments in their ADLs (P<0.001). The presence of digestive symptoms was associated with higher mortality (HR 1.15 [95% CI 1.05 to 1.25] adjusted for age, sex, cognitive function and ADL impairment); however, this association was not statistically significant after adjusting for self-reported health.
Although digestive symptoms were associated with increased mortality independent of age and sex, cognition and function, this association was largely explained by poor self-assessed health. Digestive symptoms were not associated with institutionalization
PMCID: PMC3551561  PMID: 23248787
Activities of daily living; Aged; Digestive symptoms; Epidemiology; Institutionalization; Mortality
13.  Self-reported medication side effects in an older cohort living independently in the community - the Melbourne Longitudinal Study on Healthy Ageing (MELSHA): cross-sectional analysis of prevalence and risk factors 
BMC Geriatrics  2010;10:37.
Medication side effects are an important cause of morbidity, mortality and costs in older people. The aim of our study was to examine prevalence and risk factors for self-reported medication side effects in an older cohort living independently in the community.
The Melbourne Longitudinal Study on Healthy Ageing (MELSHA), collected information on those aged 65 years or older living independently in the community and commenced in 1994. Data on medication side effects was collected from the baseline cohort (n = 1000) in face-to-face baseline interviews in 1994 and analysed as cross-sectional data. Risk factors examined were: socio-demographics, health status and medical conditions; medication use and health service factors. Analysis included univariate logistic regression to estimate unadjusted risk and multivariate logistic regression analysis to assess confounding and estimate adjusted risk.
Self-reported medication side effects were reported by approximately 6.7% (67/1000) of the entire baseline MELSHA cohort, and by 8.5% (65/761) of those on medication. Identified risk factors were increased education level, co-morbidities and health service factors including recency of visiting the pharmacist, attending younger doctors, and their doctor's awareness of their medications. The greatest increase in risk for medication side effects was associated with liver problems and their doctor's awareness of their medications. Aging and gender were not risk factors.
Prevalence of self-reported medication side effects was comparable with that reported in adults attending General Practices in a primary care setting in Australia. The prevalence and identified risk factors provide further insight and opportunity to develop strategies to address the problem of medication side effects in older people living independently in the community setting.
PMCID: PMC2897784  PMID: 20537140
14.  Whole grain, cereal fiber, bran, and germ intake and the risks of all-cause and CVD-specific mortality among women with type 2 diabetes 
Circulation  2010;121(20):2162-2168.
Although whole grain consumption has been associated with a lower risk of cardiovascular diseases (CVD) and mortality in the general population, the association of whole grain with mortality in diabetic patients remain to be determined. This study investigated whole grain and its components cereal fiber, bran and germ in relation to all-cause and CVD-specific mortality in patients with type 2 diabetes.
Methods and Results
We followed 7,822 US women with type 2 diabetes in the Nurses’ Health Study (NHS). Dietary intakes and potential confounders were assessed with regularly administered questionnaires. We documented 852 all-cause deaths and 295 CVD-deaths during up to 26 years of follow-up. After adjustment for age, the highest versus the lowest fifth of intakes of whole grain, cereal fiber, bran, and germ were associated with 16–31% lower all-cause mortality. After further adjustment for lifestyle and dietary risk factors, only the association for bran intake remained significant (P for trend = 0.01). The multivariate relative risks (RRs) across the fifths of bran intake were 1.0 (reference), 0.94 (0.75–1.18), 0.80 (0.64–1.01), 0.82 (0.65–1.04), and 0.72 (0.56–0.92). Similarly, bran intake was inversely associated with CVD-specific mortality (P for trend = 0.04). The RRs across the fifths of bran intake were 1.0 (reference), 0.95 (0.66–1.38), 0.80 (0.55–1.16), 0.76 (0.51–1.14), and 0.65 (0.43–0.99). Similar results were observed for added bran alone.
Whole grain and bran intakes were associated with reduced all-cause and CVD-specific mortality in women with diabetes. These findings suggest a potential benefit of whole grain intake in reducing mortality and cardiovascular risk in diabetic patients.
PMCID: PMC2886277  PMID: 20458012
Cardiovascular diseases; mortality; diabetes mellitus; whole grain; bran
15.  Self-reported chronic pain is associated with physical performance in older people leaving aged care rehabilitation 
The impact of pain on the physical performance of patients in aged care rehabilitation is not known. The study sought to assess 1) the prevalence of pain in older people being discharged from inpatient rehabilitation; 2) the association between self-reported pain and physical performance in people being discharged from inpatient rehabilitation; and 3) the association between self-reported pain and physical performance in this population, after adjusting for potential confounding factors.
This was an observational cross-sectional study of 420 older people at two inpatient aged care rehabilitation units. Physical performance was assessed using the Lower Limb Summary Performance Score. Pain was assessed with questions about the extent to which participants were troubled by pain, the duration of symptoms, and the impact of chronic pain on everyday activity. Depression and the number of comorbidities were assessed by questionnaire and medical file audit. Cognition was assessed with the Mini-Mental State Examination.
Thirty percent of participants reported chronic pain (pain lasting more than 3 months), and 17% reported that this pain interfered with daily activities to a moderate or greater extent. Chronic pain (P=0.013) and chronic pain affecting daily activities (P<0.001) were associated with a poorer Lower Limb Summary Performance Score. The relationship between chronic pain affecting daily activities and Lower Limb Summary Performance Score remained significant (P=0.001) after adjusting for depression, age, comorbidities, and Mini-Mental State Examination score. This model explained 10% of the variability in physical performance.
One-third of participants reported chronic pain, and close to one-fifth reported that this pain interfered with daily activities. Chronic pain was associated with impaired physical performance, and this relationship persisted after adjusting for likely confounding factors.
PMCID: PMC3921084  PMID: 24523583
pain; older people; physical performance; rehabilitation
16.  Social Determinants of Active Aging: Differences in Mortality and the Loss of Healthy Life between Different Income Levels among Older Japanese in the AGES Cohort Study 
We examined the relationship between income, mortality, and loss of years of healthy life in a sample of older persons in Japan. We analyzed 22,829 persons aged 65 or older who were functionally independent at baseline as a part of the Aichi Gerontological Evaluation Study (AGES). Two outcome measures were adopted, mortality and loss of healthy life. Independent variables were income level and age. The occurrence of mortality and need for care during these 1,461 days were tracked. Cox regressions were used to calculate the hazard ratio for mortality and loss of healthy life by income level. We found that people with lower incomes were more likely than those with higher incomes to report worse health. For the overall sample, using the governmental administrative data, the hazard ratios of mortality and loss of healthy life-years comparing the lowest to the highest income level were 3.50 for men and 2.48 for women for mortality and 3.71 for men and 2.27 for women for loss of healthy life. When only those who responded to questions about income on the mail survey were included in the analysis, the relationships became weaker and lost statistical significance.
PMCID: PMC3458408  PMID: 23028385
17.  The predictive value of self assessed general, physical, and mental health on functional decline and mortality in older adults 
OBJECTIVE—To examine the extent to which older people's self assessments of general health, physical health, and mental health predict functional decline and mortality.
DESIGN—The study uses population-based secondary data from the US Longitudinal Study of Aging (LSOA).
PARTICIPANTS—A total of 7527 persons aged 70 years or above living in the community.
METHODS—Eight different measures on self reported general, physical, and mental health were used. Change in functional status was measured using a composite index of ADLs and IADLs over a period of six years. Duration of survival was calculated over a period of seven years. Adjusting for age and gender, multiple logistic regression was used in analysing functional decline, and Cox proportional hazard model, for mortality. Then all of the self assessed health measures were incorporated into the final model—controlling for baseline sociodemographic characteristics, functional status, disease/conditions, and use of health and social services—to assess the independent contribution of each measure in predicting future health outcomes.
MAIN RESULTS—Overall, older people's self assessed general, physical, and mental health were predictive of functional decline and mortality. In multivariate analyses, older people who assessed their global health, self care ability, and physical activity less favourably were more likely to experience poor health outcomes. Gender disparity, however, was observed with poor global health affecting functional decline in men only. Self care ability was predictive of functioning in women only, whereas it was predictive of mortality in men only.
CONCLUSIONS—Self assessed global health, as well as, specific dimensions of health act as significant, independent predictors of functioning and mortality in a community dwelling older people.

Keywords: age; self assessed health; functional status; mortality
PMCID: PMC1731623  PMID: 10715745
18.  Diet Quality Is Associated with All-Cause Mortality in Adults Aged 65 Years and Older123 
The Journal of Nutrition  2011;142(2):320-325.
Diet quality indices assess compliance with dietary guidelines and represent a measure of healthy dietary patterns. Few studies have compared different approaches to assessing diet quality in the same cohort. Our analysis was based on 972 participants of the British Diet and Nutrition Survey of people aged 65 y and older in 1994/1995 and who were followed-up for mortality status until 2008. Dietary intake was measured via a 4-d weighed food record. Three measures of diet quality were used: the Healthy Diet Score (HDS), the Recommended Food Score (RFS), and the Mediterranean Diet Score (MDS). HR for all-cause mortality were obtained using Cox regression adjusted for age, sex, energy intake, social class, region, smoking, physical activity, and BMI. After adjustment for confounders, the MDS was significantly associated with mortality [highest vs. lowest quartile; HR = 0.78 (95% CI = 0.62–0.98)]. Similarly, the RFS was also associated with mortality [HR = 0.67 (95 % CI = 0.52–0.86)]; however, there were no significant associations for the HDS [HR = 0.99 (95% CI = 0.79–1.24)]. The HDS was not a predictor of mortality is this population, whereas the RFS and the MDS were both associated with all-cause mortality. Simple measures of diet quality using food-based indicators can be useful predictors of longevity.
PMCID: PMC3593296  PMID: 22190031
19.  Lipid-lowering treatment to the end? A review of observational studies and RCTs on cholesterol and mortality in 80+-year olds 
Age and Ageing  2010;39(6):674-680.
People aged 80 or older are the fastest growing population in high-income countries. One of the most common causes of death among the elderly is the cardiovascular disease (CVD). Lipid-lowering treatment is common, e.g. one-third of 75–84-year-old Swedes are treated with statins [ 3]. The assumption that hypercholesterolaemia is a risk factor at the highest ages seems to be based on extrapolation from younger adults. A review of observational studies shows a trend where all-cause mortality was highest when total cholesterol (TC) was lowest (‘a reverse J-shaped’ association between TC and all-cause mortality). Low TC (<5.5 mmol/l) is associated with the highest mortality rate in 80+-year olds. No clear optimal level of TC was identified. A review of the few randomised controlled trials including 80+-year olds did not provide evidence of an effect of lipid-lowering treatment on total mortality in 80+-year-old people. There is not sufficient data to recommend anything regarding initiation or continuation of lipid-lowering treatment for the population aged 80+, with known CVD, and it is even possible that statins may increase all-cause mortality in this group of elderly individuals without CVD.
PMCID: PMC2956535  PMID: 20952373
cholesterol; aged; 80+-year olds; lipid-lowering treatment and all-cause mortality; elderly
20.  Incidence and prognosis of ischaemic heart disease with respect to marital status and social class. A national record linkage study. 
Increased mortality from ischaemic heart disease (IHD) has been found in previous studies among divorced, widowed, and unskilled middle-aged Finnish men. In this study all cases of IHD in men aged 40-64 during 1972 were analysed by linking death certificates and hospital records (7499 cases with 3136 deaths). Age-adjusted incidence, mortality, and survival rates of the first and third year were calculated by marital status and social class. The highest mortality rate was found among unskilled workers, the highest incidence among widowers and those in the lower professional classes, and the lowest survival rate among divorcees, single persons, and unskilled workers. The ratio of mortality by marital status (1.77) was in part due to survival (ratio 1.44) and in part due to incidence (ratio 1.32). The ratio of mortality by social class (1.44) seemed to be due more to differences in incidence (ratio 1.36) than to differences in survival (ratio 1.18). The distribution of conventional risk factors of IHD by marital status and social class seems to explain only part of the mortality differences.
PMCID: PMC1052155  PMID: 7328378
21.  Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study 
Objective To test the hypothesis that people taking anxiolytic and hypnotic drugs are at increased risk of premature mortality, using primary care prescription records and after adjusting for a wide range of potential confounders.
Design Retrospective cohort study.
Setting 273 UK primary care practices contributing data to the General Practice Research Database.
Participants 34 727 patients aged 16 years and older first prescribed anxiolytic or hypnotic drugs, or both, between 1998 and 2001, and 69 418 patients with no prescriptions for such drugs (controls) matched by age, sex, and practice. Patients were followed-up for a mean of 7.6 years (range 0.1-13.4 years).
Main outcome All cause mortality ascertained from practice records.
Results Physical and psychiatric comorbidities and prescribing of non-study drugs were significantly more prevalent among those prescribed study drugs than among controls. The age adjusted hazard ratio for mortality during the whole follow-up period for use of any study drug in the first year after recruitment was 3.46 (95% confidence interval 3.34 to 3.59) and 3.32 (3.19 to 3.45) after adjusting for other potential confounders. Dose-response associations were found for all three classes of study drugs (benzodiazepines, Z drugs (zaleplon, zolpidem, and zopiclone), and other drugs). After excluding deaths in the first year, there were approximately four excess deaths linked to drug use per 100 people followed for an average of 7.6 years after their first prescription.
Conclusions In this large cohort of patients attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.
PMCID: PMC3959619  PMID: 24647164
22.  Physical activity and risk of ischemic stroke in the Northern Manhattan Study 
Neurology  2009;73(21):1774-1779.
It is controversial whether physical activity is protective against first stroke among older persons. We sought to examine whether physical activity, as measured by intensity of exercise and energy expended, is protective against ischemic stroke.
The Northern Manhattan Study is a prospective cohort study in older, urban-dwelling, multiethnic, stroke-free individuals. Baseline measures of leisure-time physical activity were collected via in-person questionnaires. Cox proportional hazards models were constructed to examine whether energy expended and intensity of physical activity were associated with the risk of incident ischemic stroke.
Physical inactivity was present in 40.5% of the cohort. Over a median follow-up of 9.1 years, there were 238 incident ischemic strokes. Moderate- to heavy-intensity physical activity was associated with a lower risk of ischemic stroke (adjusted hazard ratio [HR] 0.65, 95% confidence interval [0.44–0.98]). Engaging in any physical activity vs none (adjusted HR 1.16, 95% CI 0.88–1.51) and energy expended in kcal/wk (adjusted HR per 500-unit increase 1.01, 95% CI 0.99–1.03) were not associated with ischemic stroke risk. There was an interaction of sex with intensity of physical activity (p = 0.04), such that moderate to heavy activity was protective against ischemic stroke in men (adjusted HR 0.37, 95% CI 0.18–0.78), but not in women (adjusted HR 0.92, 95% CI 0.57–1.50).
Moderate- to heavy-intensity physical activity, but not energy expended, is protective against risk of ischemic stroke independent of other stroke risk factors in men in our cohort. Engaging in moderate to heavy physical activities may be an important component of primary prevention strategies aimed at reducing stroke risk.
= confidence interval;
= hazard ratio;
= metabolic equivalents.
PMCID: PMC2788811  PMID: 19933979
23.  Age-related impairments of mobility associated with cobalt and other heavy metals: Data from NHANES 1999-2004 
Exposure to heavy metals can promote oxidative stress and damage to cellular components, and may accelerate age-related disease and disability.. Physical mobility is a validated biomarker of age-related disability and is predictive of hospitalization and mortality.
To examine associations between selected heavy metals and impaired lower limb mobility in a representative older human population.
Data for 1615 adults aged ≥60 years from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004 were used to identify associations between urinary concentrations of 10 metals with self-reported and measured walking impairments (at p<0.01). Models were adjusted for confounding factors, including smoking.
In models adjusted for age, sex and ethnicity, elevated levels of cadmium, cobalt and uranium were associated with impairment of the ability to walk a quarter mile. In fully adjusted models, cobalt was the only metal that remained associated: the odds ratio for reporting walking problems with a 1-unit increase in logged cobalt concentration (μg L-1) was 1.43 (95% CI 1.12 to 1.84). Cobalt was also the only metal associated with an increased measured time to walk a 20 foot course (p=0.008). In analyses of disease categories to explain the mobility finding, cobalt was associated with physician diagnosed arthritis (1-unit increase OR=1.22 (95% CI 1.00 to 1.49, p=0.045).
Low level cobalt exposure, assessed through urinary concentrations of this essential heavy metal may be a risk factor for age-related physical impairments. Independent replication is needed to confirm this association.
PMCID: PMC3404487  PMID: 19199147
Cobalt; aging; NHANES; arthritis; gait speed
24.  Prevalence of sarcopenia in community-dwelling older people in the UK using the European Working Group on Sarcopenia in Older People (EWGSOP) definition: findings from the Hertfordshire Cohort Study (HCS) 
Age and Ageing  2013;42(3):378-384.
Introduction: sarcopenia is associated with adverse health outcomes. The aim of this study was to describe the prevalence of sarcopenia in community-dwelling older people in the UK using the European Working Group on Sarcopenia in Older People (EWGSOP) consensus definition.
Methods: we applied the EWGSOP definition to 103 community-dwelling men participating in the Hertfordshire Sarcopenia Study (HSS) using both the lowest third of dual-energy X-ray absorptiometry (DXA) lean mass (LM) and the lowest third of skin-fold-based fat-free mass (FFM) as markers of low muscle mass. We also used the FFM approach among 765 male and 1,022 female participants in the Hertfordshire Cohort Study (HCS). Body size, physical performance and self-reported health were compared in participants with and without sarcopenia.
Results: the prevalence of sarcopenia in HSS men (mean age 73 years) was 6.8% and 7.8% when using the lowest third of DXA LM and FFM, respectively. DXA LM and FFM were highly correlated (0.91, P < 0.001). The prevalence of sarcopenia among the HCS men and women (mean age 67 years) was 4.6% and 7.9%, respectively. HSS and HCS participants with sarcopenia were shorter, weighed less and had worse physical performance. HCS men and women with sarcopenia had poorer self-reported general health and physical functioning scores.
Conclusions: this is one of the first studies to describe the prevalence of sarcopenia in UK community-dwelling older people. The EWGSOP consensus definition was of practical use for sarcopenia case finding. The next step is to use this consensus definition in other ageing cohorts and among older people in a range of health-care settings.
PMCID: PMC3633365  PMID: 23384705
sarcopenia; prevalence; EWGSOP consensus definition; muscle mass; fat-free mass; grip strength; gait speed; older people
25.  Risk factors among elderly for short term deaths related to high levels of air pollution 
Background: Air pollution has been linked to increased rates of mortality, but little is known about individual characteristics related to the increase in risk.
Aims: To examine short term effects of air pollution on daily mortality in elderly people in Bordeaux and compare characteristics of subjects ⩾65 years old who died with levels of particulate air pollution.
Methods: Daily mortality data from Bordeaux were used to determine the core model of mortality for the period 1988–97. The air pollution indicator was regressed on the core model of mortality, allowing control of the main effect modifiers and confounding factors of air pollution on the same day. The residual series of this regression model was classified from the lowest to the highest to determine "low level days" and "high level days". A sample of 1469 elderly people in a French cohort study were studied.
Results: From 1988 to 1997, 543 subjects died; 55 deaths were during days with low air pollution and 51 during days with high air pollution. Only gender differed significantly according to both types of days, with a proportion of women significantly higher in high air pollution days than men. After adjustment for smoking habits, the odds ratio was 5.2 for women.
Conclusion: The risk of mortality between women and men was determined on days with "high air pollution levels" above the 50–90th centiles compared to below the 10th centile. No clear pattern was observed between days with low levels of air pollution and the different centiles of exposure.
PMCID: PMC1740638  PMID: 12937192

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