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Few studies have comprehensively described changes in blood biomarkers of the physiological responses underlying sarcopenia reduction associated with lifestyle interventions. In this study, we performed secondary analyses of data in a randomized controlled trial of multi-domain lifestyle interventions (6-month duration physical exercise, nutritional enrichment, cognitive training, combination and standard care control) among 246 community-dwelling pre-frail and frail elderly, aged ≥65 years, with and without sarcopenia. Appendicular lean mass (ALM), lower limb strength, gait speed, and blood levels of markers of muscle metabolism, inflammation, anti-oxidation, anabolic hormone regulation, insulin signaling, tissue oxygenation were measured at baseline, 3-month and 6-month post-intervention. Multi-domain interventions were associated with significant (p < 0.001) reduction of sarcopenia at 3-month and 6-month post-intervention, improved gait speed, enhanced lower limb strength, and were equally evident among sarcopenic participants who were slower at baseline than non-sarcopenic participants. Active intervention was associated with significantly reduced inflammation levels. Sarcopenia status and reduction were associated with blood biomarkers related to muscle metabolism, steroid hormone regulation, insulin-leptin signaling, and tissue oxygenation. Physical, nutritional and cognitive intervention was associated with measures of sarcopenia reduction, together with changes in circulating biomarkers of anabolic and catabolic metabolism underlying sarcopenia.

Key Points Question How is an active lifestyle intervention associated with improvement in muscle mass and function among frail older persons with sarcopenia? Findings In this secondary analysis of a randomized clinical trial of physical, nutritional, cognitive, or combined interventions among 92 community dwelling at-risk frail adults aged 65 years and older with sarcopenia, the intervention was associated with a significant reduction in sarcopenia and improved muscle mass and strength and gait speed at 3 months and 6 months. Sarcopenia reversal was more likely to happen in men, younger individuals, and those with higher baseline lean muscle mass. Meaning These findings suggest that multidomain lifestyle interventions may be effective in reversing sarcopenia and improving muscle mass and function in community-dwelling at-risk frail older adults., This secondary analysis of a randomized clinical trial examines the association of a 6-month multidomain active lifestyle intervention with sarcopenia among elderly participants in Singapore., Importance There is little understanding of the outcomes associated with active lifestyle interventions for sarcopenia among older persons. Objective To determine the association of 6-month multidomain lifestyle interventions (physical exercise, nutritional enhancement, cognitive training, combined treatment, and standard care) with change in sarcopenia status and physical function among adults 65 years and older. Design, Setting, and Participants Post hoc secondary analysis of a parallel-group randomized clinical trial conducted from September 1, 2012, to September 1, 2014, at community centers providing services to elderly individuals in Singapore. Participants included a subsample of 92 community-dwelling prefrail or frail older persons with sarcopenia aged 65 years and older. Data were analyzed from June 1, 2017, to January 1, 2018. Interventions The 5 intervention groups were a 6-month duration of physical exercise that included resistance and balance training, nutritional enhancement with a commercial oral nutrition supplement formula, cognitive training, a combination of the preceding 3 interventions, and standard care (control). Main Outcomes and Measures Primary outcomes were changes in sarcopenia status and its components, appendicular skeletal muscle index (ASMI), knee extension strength (KES), and gait speed (GS) at 3 months and 6 months following the intervention. Sarcopenia was defined as the presence of both low ASMI and low KES and/or GS. Results In 92 participants with sarcopenia, the mean (SD) age was 70.0 (4.7) years and 59 (64.1%) were female. Seventy-eight participants received active interventions and 14 received standard care. Of 92 total participants, the number who remained sarcopenic was reduced to 48 (of 73) after 3 months and 51 (of 75) after 6 months of intervention, indicating that 25 of 92 participants (27.2%) experienced sarcopenia reduction at 3 months and 24 of 92 (26.1%) had sarcopenia reduction at 6 months. Low KES was present in 88 of 92 patients (95.6%), and low GS in 30 of 92 patients (32.6%) at baseline. Among the components of sarcopenia, GS had the greatest change associated with active interventions, with 22 of 30 participants (73.3%) free of low GS at 6 months; in comparison, 17 of 88 participants (19.3%) were free of low KES at 6 months and 7 of 92 participants (7.6%) were free of low ASMI at 6 months. Men experienced greater reduction in sarcopenia than women (χ2 = 5.925; P = .02), as did those with younger age (t = −2.078; P = .04) or higher ASMI (mean [SD] ASMI, 5.74 [0.77] vs 5.14 [0.77] kg/m2; P = .002). Participants in the active intervention group experienced statistically significant decreases in sarcopenia score and its components at 3 months and 6 months from baseline (F = 14.138; P

Background Cognitive, physical, and nutritional interventions may produce different cognitive effects for different groups of older persons. We investigated simultaneously the cognitive outcomes of cognitive, physical, and nutritional interventions singly and in combinations in older persons with the physical frailty phenotype at particular risk of cognitive decline. Method Pre-frail and frail participants were randomly allocated to 24 weeks nutritional supplementation (N = 49), physical training (N = 48), cognitive training (N = 50), combination intervention (N = 49), or usual care control (N = 50). Cognitive domain and global functions were assessed at baseline (0M), 6 month (6M), and 12 month (12M). Results The control group showed declines in z-scores (from -0.100 to -0.244) of all domains. The cognitive training compared to control group showed the greatest increase in global cognition at 6M (0.094 vs -0.174, p = .006) and 12M (0.099 vs -0.142, p = .002), immediate memory at 6M (0.164 vs -0.211, p = .010) and 12M (0.182 vs -0.142, p = .040), delayed memory at 6M (p = .010), and attention at 6M (p = .025). Nutritional intervention showed benefits at 6M for immediate memory (p = .028) and delayed memory (p = .024), but physical training showed no positive effects. The combination group showed the greatest increase for visuospatial construction at 6M (0.215 vs -0.141, p = .010) and 12M (0.166 vs -0.180, p = .016), and for global cognition at 12M (p = .016) and language at 12M (p = .023). Conclusion Among frail older persons, cognitive training conferred the greatest cognitive benefits. Nutritional and physical interventions singly were associated with modest short-term or no cognitive benefits, but their combined effects on visuospatial construction should be further investigated.

Research on long-term exposure to electromagnetic fields on cognition is lacking. We investigated the associations between frequent digital mobile phone use and global and domain-specific cognitive changes in older persons, a vulnerable group experiencing age-associated cognitive decline. We assessed 871 non-demented Chinese participants in the Singapore Longitudinal Ageing Studies cohort on the frequency of digital mobile phone use, neurocognitive performance and confounding variables at baseline, and neurocognitive performance at the 4-year follow-up. Findings showed that digital mobile phone users were typically self-selected to possess characteristics favoring better cognitive functioning and concomitantly demonstrate better performance on cognitive tasks. There was evidently no significant deleterious effect of digital mobile phone use on cognitive functioning in older people. Findings suggest, however, that digital mobile phone use may have an independent facilitating effect on global and executive functioning. Bioelectromagnetics 33:176–185, 2012. © 2011 Wiley Periodicals, Inc.

Background The relationships between blood pressure and depression are unclear. There are inconsistent reports of an association between low blood pressure and depressive symptoms. Methods In a population-based sample of 2611 Chinese older adults aged 55 years and above, including participants with treated (n=1088), untreated (n=545), or no hypertension (n=978), depressive symptoms were determined by the 15-item Geriatric Depression Scale (≥5), and current systolic blood pressure and diastolic blood pressure measurements were used to classify participants into high, normal, and low blood pressure groups. Estimates of association were adjusted for confounding by use of antihypertensive and depressogenic drugs and other covariables in hierarchical regression analyses. Results Systolic blood pressure and diastolic blood pressure were negatively associated with Geriatric Depression Scale scores, independent of other variables. Low systolic blood pressure (odds ratio [OR] 1.54; 95% confidence interval [CI], 1.07-2.22), low diastolic blood pressure (OR 1.67; 95% CI, 0.98-2.85), and low systolic blood pressure or diastolic blood pressure (or both) (OR 1.55; 95% CI, 1.10-2.19) were independently associated with depressive symptoms. The associations with depressive symptoms were particularly observed for low systolic blood pressure (OR 2.13; 95% CI, 1.13-4.03) among treated hypertensive participants, and low diastolic blood pressure (OR 2.42; 95% CI, 1.26-4.68) among untreated or nonhypertensive participants. Conclusion Low blood pressure was independently associated with depressive symptoms in both older subjects who were treated for hypertension and those who were not.

Background: The Frontal Assessment Battery (FAB) has been shown to be useful in evaluating frontal dysfunction. There is a paucity of studies validating cutoffs in the early cognitive impairment. We aim to validate the Chinese FAB in Asian subjects with mild cognitive impairment (MCI) and early dementia. Methods: Eighty subjects with MCI and mild dementia and 100 cognitively healthy community subjects were studied. ROC analysis was done to determine the Chinese FAB’s optimal cutoff scores for age- and education-adjusted subgroups. Results: Chinese FAB scores were significantly lower in early cognitive impairment compared with cognitively normal controls. The optimal cutoff score was 12/13 (sensitivity 92%, specificity 78.7%). A similar cutoff score was obtained following age-adjustment and for subjects with Conclusion: The education-adjusted Chinese FAB has good diagnostic performance, which can supplement the MMSE in early cognitive impairment evaluation with construct differences observed between the Chinese FAB and MMSE.

SummaryObjectivesDepression occurs commonly among patients with COPD, but the independent association of depression and COPD and the effect of depression on COPD outcomes are not well established.MethodA population sample of 2402 Chinese aged ≥55 with and without COPD (characteristic symptoms of chronic cough, sputum or breathlessness and airflow obstruction and FEV1/FVC

Objectives To investigate whether the effect of depressive symptoms on the risk of cognitive decline and incident cognitive impairment (CI) in cognitively well-functioning older persons differed between men and women and whether sex differences in cerebrovascular factors might explain this. Design Prospective cohort study. Setting General community. Participants One thousand four hundred eighty-seven well-functioning Chinese older adults (Mini-Mental State Examination (MMSE) score > or =24) assessed at baseline for the presence of depressive symptoms (Geriatric Depression Scale score > or =5), and covariates (age, apolipoprotein E epsilon4, education, smoking, alcohol drinking, and vascular risk factors and diseases). Main outcome measures Incident CI and change in MMSE were assessed at 2-year follow-up. Results In the whole sample, participants with depression showed significantly more incident CI than those without (5.7% vs 2.6%, P=.04; adjusted odds ratio (OR)=2.29, 95% confidence interval (CI)=1.05-5.00. Significantly higher OR was observed only in men (OR=4.75, 95% CI=1.22-18.5) and not for women (OR=1.29). There was a correspondingly greater rate of cognitive decline in participants with depressive symptoms that was observed to be marked only in men and not in women. The association was accentuated in subgroups with hypertension or vascular factors, but the sex differences in association were consistently observed. Conclusion The association between depressive symptoms and risk of cognitive decline was observed only in men and was not explained by sex differences in vascular factors. The comorbid presence of underlying cerebral vascular pathology or multi-infarct disease was possibly not a mediating factor but might amplify the process of cognitive decline.

OBJECTIVES: To investigate the independent associations between folate, B12, and homocysteine levels and depressive symptoms in older adults. DESIGN: Cross-sectional study. SETTING: Resident population in southeast Singapore. PARTICIPANTS: Six hundred sixty-nine community-living noninstitutionalized Chinese adults aged 55 and older. MEASUREMENTS: Laboratory values of folate, vitamin B12, and homocysteine were examined for their independent relationships with depressive symptoms (Geriatric Depression Scale (GDS) score ≥5). RESULTS: Respondents with depression (n=178) had lower mean serum folate concentrations (21.5 nmol/L) than those without (n=491, 24.0 nmol/L, P=.04). There was a linear relationship between descending quartiles of folate concentrations and increasing odds of association with depressive symptoms, independent of other risk factors (demographic, psychosocial, alcohol and smoking, chronic morbidity, functional status, nutritional risk, albumin, anemia, depression-inducing medications, use of antidepressants and vitamin supplements), including B12 and homocysteine (P for trend=.02). The odds ratio (OR) of association between low folate (lowest quartile

Objectives To examine the association between serum albumin and cognitive impairment and decline in community-living older adults. Designs Population-based cohort study, followed up to 2 years; serum albumin, apolipoprotein E (APOE)-epsilon4, and cognitive impairment measured at baseline and cognitive decline (> or =2-point drop in Mini-Mental State Examination (MMSE) score). Odds ratios were controlled for age, sex, education, medical comorbidity, hypertension, diabetes mellitus, cardiac disease, stroke, smoking, alcohol drinking, depression, APOE-epsilon4, nutritional status, body mass index, anemia, glomerular filtration rate, and baseline MMSE. Settings Local area whole population. Participants One thousand six hundred sixty-four Chinese older adults aged 55 and older. Results The mean age of the cohort was 66.0+/-7.3, 65% were women, mean serum albumin was 42.3+/-3.1 g/L, and mean MMSE score was 27.2+/-3.2. Lower albumin tertile was associated with greater risk of cognitive impairment in cross-sectional analysis (low, odds ratio (OR)=2.30, 95% confidence interval (CI)=1.31-4.03); medium, OR=1.59, 95% CI=0.88-2.88) versus high (P for trend=.002); and with cognitive decline in longitudinal analyses: low, OR=1.73, 95% CI=1.18-2.55; medium, OR=1.32, 95% CI=0.89-1.95, vs high (P for trend=.004). In cognitively unimpaired respondents at baseline (MMSE> or =24), similar associations with cognitive decline were observed (P for trends Conclusion Low albumin was an independent risk marker for cognitive decline in community-living older adults.

Objectives: to examine the relationships between serum albumin, haemoglobin and body mass index (BMI) with cognitive performance among community-living older adults. Method: design—population-based cross-sectional study; setting—local community in Southeast Region of Singapore; subjects—Chinese older adults aged 55 and above (N = 2, 550); measurements—serum albumin, haemoglobin, BMI and Mini-Mental State Examination (MMSE). Results: in multivariable analyses controlling for gender, age, education and vascular risk factors, low albumin in the bottom quintile (OR 2.04; 95% CI 1.22–3.41) and low haemoglobin in the bottom quintile (OR 1.56; 95% CI 1.00–2.47) and low BMI with chronic comorbidity (OR 1.73; 95%CI 1.02–2.95) were independently associated with poor cognitive performance (MMSE ≤ 23). Among cognitively intact respondents (MMSE ≥ 24), albumin concentration showed a significant inverse linear relationship with MMSE scores (P for trend =0.002). Conclusion: low albumin, low haemoglobin and low BMI (in the presence of chronic comorbidity) are independently associated with poor cognitive performance in community-living older adults.

Objective: Few studies have explored the relationship between orthostatic hypotension (OH) and cognition. The aim of this study was to examine the association of OH with cognitive impairment and decline in a cohort of Chinese elderly, and its effect modification by blood pressure (BP) status at baseline. Method: Among 2,321 community-living older adults, free of cardiovascular disease and stroke, baseline BP measurements were used to determine the presence of OH and categorize participants as hypotensives, normotensives or hypertensives. The Mini-Mental State Examination (MMSE) was used to assess cognitive impairment (MMSE score Results: Mean age of the subjects was 65.5 years and 381 (16.6%) showed OH. OH was not associated with cognitive impairment overall. However, among hypotensives, OH increased the odds of cognitive impairment (OR = 4.1, 95% CI = 1.11–15.1), while hypertensives with OH showed reduced odds of cognitive impairment (OR = 0.48, 95% CI = 0.26–0.90). Among cognitively intact participants, OH was not associated with cognitive decline overall or in BP subgroups. Conclusion: The increased risk of cognitive impairment in hypotensives with OH suggests that hypotension with OH may be an early comorbid marker of a primary incipient dementia.

Objectives: To make comparative estimates of prevalence of late-life functional disability, examine sociodemographic and health correlates, investigate sex and ethnic differences, and estimate population attributable risk of modifiable risk factors. Design: Population-based survey. Setting: Multiethnic population of Singapore (3 million residents). Participants: Noninstitutionalized Chinese, Malay, and Indian people aged 60 and older (N=1,079) Measurements: Functional disability was defined as needing help in at least one basic activity of daily living (ADL) task in the 10 items of the Barthel Index. Five basic ADLs (eating, bathing, dressing, transferring, toileting) were used to compare prevalence with those reported from other national surveys and with reported past prevalence within the country. Results: The prevalence of disability in at least one of five ADL items (6.6% in those aged≥65) appeared lower than elsewhere, including China, but higher than reported past prevalence within the country. Functional disability on at least one of the 10 ADL items was independently associated with female sex, Indian ethnicity, older age, poor self-rated health, specific chronic diseases, cognitive impairment, sensory impairment, and living with others. The population attributable risks for leading modifiable factors were arthritis (12%) and cognitive impairment (14%). Conclusion: Lower prevalence of functional disability accompanies rapid aging and health transition in Singapore than in other countries but higher prevalence than reported past prevalence within the country. Associations with sociodemographic and health-related factors were consistent with Western studies, including unexplained sex and ethnic differences.

ObjectiveA limited but growing body of evidence supports a significant role of antioxidant and anti-inflammatory micronutrients in pulmonary health. We investigated the associations of dietary and supplemental intakes of vitamins A, C, E and D, Se and n-3 PUFA with pulmonary function in a population-based study.DesignPopulation-based, cross-sectional study and data analysis of fruits and vegetables, dairy products and fish, vitamins A, C, E and D, Se and n-3 PUFA supplemental intakes, pulmonary risk factors and spirometry.SubjectsChinese older adults (n 2478) aged 55 years and above in the Singapore Longitudinal Ageing Studies.ResultsIn multiple regression models that controlled simultaneously for gender, age, height, smoking, occupational exposure and history of asthma/chronic obstructive pulmonary disease, BMI, physical activity, and in the presence of other nutrient variables, daily supplementary vitamins A/C/E (b = 0·044, se = 0·022, P = 0·04), dietary fish intake at least thrice weekly (b = 0·058, se = 0·016, P < 0·0001) and daily supplementary n-3 PUFA (b = 0·068, se = 0·032, P = 0·034) were individually associated with forced expiratory volume in the first second. Supplemental n-3 PUFA was also positively associated with forced vital capacity (b = 0·091, se = 0·045, P = 0·045). No significant association with daily dairy product intake, vitamin D or Se supplements was observed.ConclusionsThe findings support the roles of antioxidant vitamins and n-3 PUFA in the pulmonary health of older persons.

BACKGROUND: Research on the effects of dietary nutrients on respiratory health in human populations have not investigated curcumin, a potent anti-oxidant and anti-inflammatory compound present principally in turmeric used in large amounts in Asian curry meals. OBJECTIVES: To examine the association of curry intake with pulmonary function among smokers and non-smokers. DESIGN: The frequency of curry intake, respiratory risk factors and spirometry were measured in a population-based study of 2,478 Chinese older adults aged 55 and above in the Singapore Longitudinal Ageing Studies. RESULTS: Curry intake (at least once monthly) was significantly associated with better FEV(1) (b = 0.045±0.018, p = 0.011) and FEV(1)/FVC (b = 1.14±0.52, p = 0.029) in multivariate analyses that controlled simultaneously for gender, age, height, height-squared, smoking, occupational exposure and asthma/COPD history and other dietary or supplementary intakes. Increasing levels of curry intake ('never or rarely', 'occasional', 'often', 'very often') were associated with higher mean adjusted FEV(1) (p for linear trend = 0.001) and FEV(1)/FVC% (p for linear trend = 0.048). Significant effect modifications were observed for FEV(1) (curry* smoking interaction, p = 0.028) and FEV(1)/FVC% (curry*smoking interaction, p = 0.05). There were significantly larger differences in FEV(1) and FEV(1)/FVC% between curry intake and non-curry intake especially among current and past smokers. The mean adjusted FEV(1) associated with curry intake was 9.2% higher among current smokers, 10.3% higher among past smokers, and 1.5% higher among non-smokers. CONCLUSION: The possible role of curcumins in protecting the pulmonary function of smokers should be investigated in further clinical studies.

Background It is important to establish whether frailty among older individuals is reversible with nutritional, physical, or cognitive interventions, singly or in combination. We compared the effects of 6-month-duration interventions with nutritional supplementation, physical training, cognitive training, and combination treatment vs control in reducing frailty among community-dwelling prefrail and frail older persons. Methods We conducted a parallel group, randomized controlled trial in community-living prefrail and frail old adults in Singapore. The participants' mean age was 70.0 years, and 61.4% (n = 151) were female. Five different 6-month interventions included nutritional supplementation (n = 49), cognitive training (n = 50), physical training (n = 48), combination treatment (n = 49), and usual care control (n = 50). Frailty score, body mass index, knee extension strength, gait speed, energy/vitality, and physical activity levels and secondary outcomes (activities of daily living dependency, hospitalization, and falls) were assessed at 0 months, 3 months, 6 months, and 12 months. Results Frailty score and status over 12 months were reduced in all groups, including control (15%), but were significantly higher (35.6% to 47.8%) in the nutritional (odds ratio [OR] 2.98), cognition (OR 2.89), and physical (OR 4.05) and combination (OR 5.00) intervention groups. Beneficial effects were observed at 3 months and 6 months, and persisted at 12 months. Improvements in physical frailty domains (associated with interventions) were most evident for knee strength (physical, cognitive, and combination treatment), physical activity (nutritional intervention), gait speed (physical intervention), and energy (combination intervention). There were no major differences with respect to the small numbers of secondary outcomes. Conclusions Physical, nutritional, and cognitive interventional approaches were effective in reversing frailty among community-living older persons.

To determine the association between long chain omega-3 polyunsaturated fatty acid (n-3 PUFA) supplements intake and cognitive decline in an older Chinese population.Prospective cohort study.The Singapore Longitudinal Aging Studies (SLAS), a community-based study in urban region of Singapore.1,475 Chinese adults aged ≥ 55 years.Omega-3 PUFA supplements intake and Mini-Mental State Examination (MMSE) were assessed at baseline. MMSE was re-assessed at a median of 1.5 years after baseline and cognitive decline was defined as at least 2-points drop in MMSE score from baseline to follow-up. Odds ratios (ORs) of association between n-3 PUFA supplements intake and cognitive decline were calculated in logistic regression models controlling for baseline confounding variables.Daily n-3 PUFA supplements intake was significantly (p=0.024) associated with lower risk of cognitive decline (OR=0.37, 95% C.I. 0.16-0.87) after controlling for age, gender, education, number of medical comorbidity, the presence of vascular risk factors/diseases, smoking, alcohol drinking, depression, APOE e4 allele carrier status, nutritional status, level of leisure activities, baseline MMSE and length of follow-up. The association remained significant (p=0.015) after excluding participants with baseline cognitive impairment (MMSE24), diabetes, stroke, and cardiac diseases (OR=0.23, 95% C.I. 0.07-0.75). No statistically significant association (OR=1.02, 95% C.I. 0.81-1.27) of fish consumption with cognitive decline was found.Daily n-3 PUFA supplements consumption was independently associated with less cognitive decline in elderly Chinese.

Few studies have evaluated the validation of 15-item Geriatric Depression Scale (GDS-15) in a heterogeneous population with different age, ethnicity and comorbidities of elderly users of social services in the community.To assess the criterion validity and reliability of the GDS-15 and its equivalence across different gender, age groups, ethnicity and different comorbidities in community living elderly and nursing homes residents.A validation sample of non-demented 4253 elderly (ageor = 60 years), who regularly use community based care corner, senior activity center, day care center, sheltered homes and nursing homes were interviewed using the GDS-15. Structured clinical interview (SCID) was used to make DSM-IV diagnosis of major depressive disorder (MDD).The overall sensitivity and specificity were 0.97 and 0.95, respectively (area under curve, AUC was 0.98). The overall Cronbach's alpha was 0.80, and intraclass coefficient of test--retest reliability over 2 weeks was 0.83 and inter-rater reliability was 0.94 (intra-class) and 0.99 (Cohen's kappa). Although some items in the GDS-15 appeared to be biased by gender, age and ethnicity, there were no clinically significant differences in test performance among different age, gender, ethnicity and comorbidities at cutoff of 4/5.The GDS-15 was a reliable and valid screening for MDD across different age, gender, ethnicity and chronic illness status in the community and social service setting.

To investigate the independent associations between folate, B12, and homocysteine levels and depressive symptoms in older adults.Cross-sectional study.Resident population in southeast Singapore.Six hundred sixty-nine community-living noninstitutionalized Chinese adults aged 55 and older.Laboratory values of folate, vitamin B12, and homocysteine were examined for their independent relationships with depressive symptoms (Geriatric Depression Scale (GDS) scoreor =5).Respondents with depression (n=178) had lower mean serum folate concentrations (21.5 nmol/L) than those without (n=491, 24.0 nmol/L, P=.04). There was a linear relationship between descending quartiles of folate concentrations and increasing odds of association with depressive symptoms, independent of other risk factors (demographic, psychosocial, alcohol and smoking, chronic morbidity, functional status, nutritional risk, albumin, anemia, depression-inducing medications, use of antidepressants and vitamin supplements), including B12 and homocysteine (P for trend=.02). The odds ratio (OR) of association between low folate (lowest quartile:14.6 nmol/L) and depressive symptoms independent of other risk factors, including homocysteine and B12, was 1.72 (95% confidence interval (CI)=1.11-2.66). Vitamin B12 across a range of values did not show a linear association, but B12 deficiency (180 pmol/L) appeared to be significantly associated with depressive symptoms (OR=2.68, 95% CI=1.20-6.00), independent of folate and homocysteine.Decreasing and low levels of serum folate and deficient levels of B12 were associated with greater risk of depressive symptoms in older Chinese adults.

Objective: to examine the effect of late life engagement in continued work involvement or volunteer activities during retirement on mental well-being. Methods: two waves of data from the Singapore Longitudinal Ageing Studies were analyzed for 2,716 Singaporeans aged 55 or above at baseline and 1,754 at 2-year follow-up. Trained research nurses interviewed participants (non-volunteering retiree, volunteering retiree, and working seniors) on mental health status (geriatric depression scale, Mini Mental State Examination, positive mental wellbeing and life satisfaction). Results: about 88% of seniors were retired (78% non-volunteering, 10% volunteering) and 12% were still working in paid employment or business. At baseline and 2 year follow up, and regardless of physical health status, volunteering retirees and working seniors gave significantly better MMSE cognitive performance scores, fewer depressive symptoms, and better mental well-being and life satisfaction than non-volunteering retirees. Conclusion: the results of this study suggest that continued work involvement or volunteerism provides opportunities for social interaction and engagement and may be associated with enhanced mental well-being. Future research should clarify which specific aspects of volunteerism are related to long-term mental well-being.

To investigate whether the effect of depressive symptoms on the risk of cognitive decline and incident cognitive impairment (CI) in cognitively well-functioning older persons differed between men and women and whether sex differences in cerebrovascular factors might explain this.Prospective cohort study.General community.One thousand four hundred eighty-seven well-functioning Chinese older adults (Mini-Mental State Examination (MMSE) scoreor =24) assessed at baseline for the presence of depressive symptoms (Geriatric Depression Scale scoreor =5), and covariates (age, apolipoprotein E epsilon4, education, smoking, alcohol drinking, and vascular risk factors and diseases).Incident CI and change in MMSE were assessed at 2-year follow-up.In the whole sample, participants with depression showed significantly more incident CI than those without (5.7% vs 2.6%, P=.04; adjusted odds ratio (OR)=2.29, 95% confidence interval (CI)=1.05-5.00. Significantly higher OR was observed only in men (OR=4.75, 95% CI=1.22-18.5) and not for women (OR=1.29). There was a correspondingly greater rate of cognitive decline in participants with depressive symptoms that was observed to be marked only in men and not in women. The association was accentuated in subgroups with hypertension or vascular factors, but the sex differences in association were consistently observed.The association between depressive symptoms and risk of cognitive decline was observed only in men and was not explained by sex differences in vascular factors. The comorbid presence of underlying cerebral vascular pathology or multi-infarct disease was possibly not a mediating factor but might amplify the process of cognitive decline.

Background . The precise relationship between depression and cognitive decline in older adults is unclear. We investigated the infl uence of apolipoprotein E (APOE)- e 4 genotype in modulating the effect of depressive symptoms on cognitive decline. Methods . Prospective cohort study of 1,487 cognitively high-functioning Chinese older adults. Depressive symptoms (Geriatric Depression Scale score ≥ 5) and Mini-Mental State Examination (MMSE) were assessed at baseline, and cognitive decline (at least 1-point drop in MMSE) at 1 – 2 years after baseline. Results. There was no signifi cant difference in cognitive decline between depressed (32.9%) and nondepressed (31.5%) participants in the whole sample or among non – APOE- e 4 carriers. Among APOE- e 4 carriers, depressed participants showed more cognitive decline (40.0%) than their nondepressed counterparts (28.6%), odds ratio = 2.89, 95% confi dence interval: 1.03 – 8.12; p = .04, after controlling for age, gender, education, vascular risk factors/events, smoking, alcohol drinking, physical functioning, subjective memory complaint, length of follow-up, and baseline MMSE scores ( p for interaction = .03). Conclusions. Our study suggests that the presence of the APOE- e 4 allele signifi cantly enhanced the risk of cognitive decline associated with depressive symptoms. This fi nding should be independently replicated in future studies .

To examine the association between serum albumin and cognitive impairment and decline in community-living older adults.Population-based cohort study, followed up to 2 years; serum albumin, apolipoprotein E (APOE)-epsilon4, and cognitive impairment measured at baseline and cognitive decline (or =2-point drop in Mini-Mental State Examination (MMSE) score). Odds ratios were controlled for age, sex, education, medical comorbidity, hypertension, diabetes mellitus, cardiac disease, stroke, smoking, alcohol drinking, depression, APOE-epsilon4, nutritional status, body mass index, anemia, glomerular filtration rate, and baseline MMSE.Local area whole population.One thousand six hundred sixty-four Chinese older adults aged 55 and older.The mean age of the cohort was 66.0+/-7.3, 65% were women, mean serum albumin was 42.3+/-3.1 g/L, and mean MMSE score was 27.2+/-3.2. Lower albumin tertile was associated with greater risk of cognitive impairment in cross-sectional analysis (low, odds ratio (OR)=2.30, 95% confidence interval (CI)=1.31-4.03); medium, OR=1.59, 95% CI=0.88-2.88) versus high (P for trend=.002); and with cognitive decline in longitudinal analyses: low, OR=1.73, 95% CI=1.18-2.55; medium, OR=1.32, 95% CI=0.89-1.95, vs high (P for trend=.004). In cognitively unimpaired respondents at baseline (MMSEor =24), similar associations with cognitive decline were observed (P for trends.002). APOE-epsilon4 appeared to modify the association, due mainly to low rates of cognitive decline in subjects with the APOE-epsilon4 allele and high albumin.Low albumin was an independent risk marker for cognitive decline in community-living older adults.

Background: Laboratory research suggests that tea has potential neuro-cognitive protective effects, but this is not established in humans. Methods: Among community-living Chinese older adults aged 55 in the Singapore Longitudinal Aging Studies (SLAS) cohort, we measured tea consumption at baseline, and Mini Mental State Examination (MMSE) at baseline and 1 to 2 years later. Cognitive impairment was defined as MMSE 23, cognitive decline as MMSE drop 1 point. We performed cross-sectional analysis on baseline data of 2501 participants, and longitudinal analysis on 1438 cognitively intact participants. Odds ratio (OR) of association were calculated in logistic regression models that adjusted for potential confounders. Results: Total tea intake was significantly associated with lower prevalence of cognitive impairment, independent of other risk factors. Compared with those who never or rarely drink teas, the OR for low, medium and high levels of tea intake was 0.54 (95% CI: 0.39-0.76), 0.48 (95% CI: 0.30-0.78) and 0.38 (95% CI: 0.14-1.00) respectively (P for tend 0.001). For cognitive decline, the corresponding OR was 0.76 (95% CI: 0.56-1.02), 0.74 (95% CI: 0.52-1.04) and 0.64 (95% CI: 0.36-1.12), (P for tend 0.037). Both black and green teas were associated with lower prevalence of cognitive impairment in cross-sectional analysis, but only black tea was associated with lower risk of cognitive decline. In contrast, no association between coffee intake and cognitive status was found. Conclusions: Regular tea consumption was associated with lower risks of cognitive impairment and decline.

To determine the association of the metabolic syndrome (MS) with cognitive decline in a Chinese older population.In a prospective cohort study of 1,352 community-living Chinese older adults without cognitive impairment (Mini Mental State Examination, MMSE24) and without cardiovascular disease and stroke, the authors assessed baseline MS (defined according to International Diabetic Federation Criteria). Cognitive decline was predefined as at least 2-point drop in MMSE score at follow-up 1-2 years after baseline assessment.MS was present in 26.3% of the participants at baseline and was significantly associated with the risk of cognitive decline (odds ratio, 1.42: confidence interval, 1.01-1.98), after controlling for potential confounding by age, gender, education, smoking, alcohol drinking, depressive symptoms, APOE-e4 status, level of leisure activities, baseline MMSE, and length of follow-up.The MS was associated with increased risk of cognitive decline in Chinese older adults.

Background The Geriatric Depression Scale (GDS) is widely used for screening and assessment of major depressive disorder (MDD). Screening scales are often culture-specific and should be evaluated for item response bias (synonymously differential item functioning, DIF) before use in clinical practice and research in a different population. In this study, we examined DIF associated with age, gender, ethnicity and chronic illness in a heterogeneous Asian population in Singapore. Methods The GDS-15 and Structured Clinical Interview for DSM-IV diagnosis of MDD were independently administered by interviewers on 4253 non-institutionalized community living elderly subjects aged 60 years and above who were users of social service agencies. Multiple Indicator Multiple Cause latent variable modelling was used to identify DIF. Results We found evidence of significant DIF associated with age, gender, ethnicity and chronic illness for 8 items: dropped many activities and interests, afraid something bad is going to happen, prefer staying home to going out, more problems with memory than most, think it is (not) wonderful to be alive, feel pretty worthless, feel (not) full of energy, feel that situation is hopeless. Limitations The smaller number of minority Indian and Malay subjects and the self-report of chronic medical illnesses. Conclusions In a heterogeneous mix of respondents in Singapore, eight items of the GDS-15 showed DIF for age, gender, ethnicity and chronic illness. The awareness and identification of DIF in the GDS-15 provides a rational basis for its use in diverse population groups and guiding the derivation of abbreviated scales.

Background/Aims: Clock Drawing Tests are commonly used for cognitive screening, but their clinical utility has not yet been studied in Chinese Singaporeans. We examined the usefulness of a Clock Drawing Test, CLOX, in detecting dementia in our population and explored its performance in the dementia subtypes, Alzheimer’s disease (AD), and the vascular composite group (VCG) of AD with cerebrovascular disease and vascular dementia. Method: CLOX was administered to 73 subjects (49.3%) with dementia and 75 healthy controls (50.7%). Receiver operating characteristic analysis determined the diagnostic accuracy and optimal cut-off scores, stratified by education. Analysis of Variance was used to compare CLOX scores between AD and VCG. Results: The diagnostic accuracy (area under the curve) was 84 and 85% for CLOX1 and CLOX2, respectively. Cut-offs at 10 for CLOX1 and 12 for CLOX2 yielded sensitivities of 75.3 and 75%, and specificities of 76 and 80%, respectively. The mean CLOX1 but not CLOX2 scores for AD (8.1) and VCG (5.5) remained significantly different (p = 0.002) after adjustment for the covariates age, gender, education, MMSE and dementia stage. Conclusion: Our results support CLOX as a valid cognitive screen in Singaporean Chinese with adequate psychometric properties. In addition, CLOX may aid as an adjunct in differentiating AD from dementia with a vascular element, e.g. AD with cerebrovascular disease and vascular dementia.

Background. We sought to assess the validity of the physical and cognitive domains of Lawton and Brody’s Instrumental Activities of Daily Living (IADL) scale and its cross-cultural applicability across ethnic groups in an Asian population of community-living older adults. Methods. Using data from a random population sample of noninstitutionalized Chinese, Malay, and Indian older adults 60 years old and older in Singapore (N ¼ 1072), we modeled the dimensional structure of the 8-item IADL Scale using exploratory and confirmatory factor analyses, and assessed its convergent and divergent validity using known group differences and strengths of association. Results. Factor analyses yielded two strong and reliable factors representing underlying physical and cognitive dimensions of IADL. The validity of the model was supported by the pattern of associations of the IADL with age, gender, education, self-reported health status, hospitalization, physical comorbidities, dementia and depression, and Mini-Mental State Examination (MMSE) scores. Notably, cognitive IADL showed a greater total effect on MMSE cognitive performance score than did physical IADL, with the effect of physical IADL on MMSE score mostly explained by cognitive IADL. Reasonably good cross-cultural validity was demonstrated among Chinese, Malays, and Indians, with strongest validity for Indians. Conclusion. The eight-item IADL Scale has physical and cognitive domains and is cross-culturally applicable. The cognitive IADL domain taps a set of activities directly related to cognitive functioning.

To make comparative estimates of prevalence of late-life functional disability, examine sociodemographic and health correlates, investigate sex and ethnic differences, and estimate population attributable risk of modifiable risk factors.Population-based survey.Multiethnic population of Singapore (3 million residents).Noninstitutionalized Chinese, Malay, and Indian people aged 60 and older (N=1,079)Functional disability was defined as needing help in at least one basic activity of daily living (ADL) task in the 10 items of the Barthel Index. Five basic ADLs (eating, bathing, dressing, transferring, toileting) were used to compare prevalence with those reported from other national surveys and with reported past prevalence within the country.The prevalence of disability in at least one of five ADL items (6.6% in those agedor = 65) appeared lower than elsewhere, including China, but higher than reported past prevalence within the country. Functional disability on at least one of the 10 ADL items was independently associated with female sex, Indian ethnicity, older age, poor self-rated health, specific chronic diseases, cognitive impairment, sensory impairment, and living with others. The population attributable risks for leading modifiable factors were arthritis (12%) and cognitive impairment (14%).Lower prevalence of functional disability accompanies rapid aging and health transition in Singapore than in other countries but higher prevalence than reported past prevalence within the country. Associations with sociodemographic and health-related factors were consistent with Western studies, including unexplained sex and ethnic differences.

Objective Item response bias (also called differential item functioning, DIF) in Instrumental Activities of Daily Living (IADL) occurs when members of different groups possessing the same disability level do not have the same probability of responding positively for a given item(s). This study aimed to identify the extent of DIF by gender, age, ethnicity, and dementia groups in IADL estimates in Asian (Chinese, Malays, and Indian) elderly subjects. Methods Data of 1,072 noninstitutionalized elderly subjects were analyzed using Multiple-Indicator Multiple-Cause (MIMIC) latent variable modeling. Results Given the same functional level, older elderly were less likely to report needing help with preparing meals; men were more likely to report needing help with preparing meals, doing laundry, and taking medication; Malays and demented elderly were more likely to report needing help with using the telephone. The impact of DIF on group differences in cognitive IADL was highest for ethnicity (58%), followed by gender (50%), and dementia (23%); whereas 92% and 5% of group differences in physical IADL were for gender and age, respectively. Conclusion Item-response bias in IADL scale by gender, age, ethnicity, and dementia should be considered in direct comparisons of disability status among population groups.

Background Depressive symptoms are common among patients with chronic obstructive pulmonary disease (COPD), but depression’s impact on COPD outcomes has not been fully investigated. We evaluated the impact of comorbid depression on mortality, hospital readmission, smoking behavior, respiratory symptom burden, and physical and social functioning in patients with COPD. Methods In this prospective cohort study, 376 consecutive patients with COPD hospitalized for acute exacerbation were followed up for 1 year. The independent associations of baseline comorbid depression (designated as a Hospital Anxiety and Depression Scale score of ≥8) with mortality, hospital readmission, length of stay, persistent smoking, and quality of life (determined by responses to the St George Respiratory Questionnaire) were evaluated after adjusting for potential confounders. Results The prevalence of depression at admission was 44.4%. The median follow-up duration was 369 days, during which 57 patients (15.2%) died, and 202 (53.7%) were readmitted at least once. Multivariate analyses showed that depression was significantly associated with mortality (hazard ratio, 1.93; 95% confidence interval, 1.04-3.58), longer index stay (mean, 1.1 more days;P = .02) and total stay (mean, 3.0 more days;P = .047), persistent smoking at 6 months (odds ratio, 2.30; 95% confidence interval, 1.17-4.52), and 12% to 37% worse symptoms, activities, and impact subscale scores and total score on the St George Respiratory Questionnaire at the index hospitalization and 1 year later, even after controlling for chronicity and severity of COPD, comorbidities, and behavioral, psychosocial, and socioeconomic variables. Conclusions Comorbid depressive symptoms in patients with COPD are associated with poorer survival, longer hospitalization stay, persistent smoking, increased symptom burden, and poorer physical and social functioning. Interventions that reduce depressive symptoms may potentially affect COPD outcomes.

Background: Laboratory research suggests that tea has potential neurocognitive protective effects, but this is not established in humans. Objective: We aimed to examine the relation between tea intake and cognitive impairment and decline. Design: Among community-living Chinese adults aged ≥55 y in the Singapore Longitudinal Ageing Studies cohort, we measured tea consumption at baseline and administered the Mini-Mental State Examination (MMSE) at baseline and 1-2 y later. Cognitive impairment was defined as an MMSE score ≤23 and cognitive decline as a drop in MMSE score of ≥1 point. We performed cross-sectional analysis of baseline data from 2501 participants and longitudinal analysis of data from 1438 cognitively intact participants. Odds ratios (ORs) of association were calculated in logistic regression models that adjusted for potential confounders. Results: Total tea intake was significantly associated with a lower prevalence of cognitive impairment, independent of other risk factors. Compared with the ORs for rare or no tea intake, the ORs for low, medium, and high levels of tea intake were 0.56 (95% CI: 0.40, 0.78), 0.45 (95% CI: 0.27, 0.72), and 0.37 (95% CI: 0.14, 0.98), respectively (P for trend < 0.001). For cognitive decline, the corresponding ORs were 0.74 (95% CI: 0.54, 1.00), 0.78 (95% CI: 0.55, 1.11), and 0.57 (95% CI: 0.32, 1.03), respectively (P for trend = 0.042). These effects were most evident for black (fermented) and oolong (semi-fermented) teas, the predominant types consumed by this population. In contrast, no association between coffee intake and cognitive status was found. Conclusion: Regular tea consumption was associated with lower risks of cognitive impairment and decline.

Background The relations of elevated homocysteine, low folate, and vitamin B-12 with cognitive performance in nondemented elderly are not well established. Limited research data suggest differential effects of homocysteine and folate on specific cognitive domains. Objective The aim was to examine the independent associations of homocysteine, folate, and vitamin B-12 with cognitive performance in high-functioning elderly Chinese. Design Homocysteine, folate, and vitamin B-12 concentrations were measured in fasting blood samples of 451 Chinese aged >or=55 y with Mini-Mental State Examination scores >or=24 and who were considered fully independent based on Activities of Daily Living score. Cognitive functions were assessed by a neuropsychological test battery. Independent associations (standardized beta) were determined in multiple linear regression models that simultaneously controlled for potential confounders. Results Log-transformed homocysteine was inversely associated with performance on Block Design (beta = -0.319, P = 0.006) and the written Symbol Digit Modality Test (beta = -0.129, P = 0.031). Log-transformed folate was significantly associated with Rey Auditory Verbal Learning Test delayed recall (beta = 0.139, P = 0.010), verbal learning (beta = 0.112, P = 0.038), percentage of forgetting (beta = -0.139, P = 0.013), and the Categorical Verbal Fluency test (beta = 0.104, P = 0.042). Vitamin B-12 was not significantly associated with any cognitive test score. Conclusions In this high-functioning elderly Chinese population, elevated homocysteine is associated with deficits in constructional ability and processing speed and folate is associated with measures of episodic memory and language. Our results provide support for differential effects of homocysteine and folate on specific cognitive functions.