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Introduction: exposure to air pollution has been shown to increase risk of inflammatory processes and risk of cardiovascular mortality. Such exposure may therefore also be a risk factor for cognitive impairment/dementia. Method: a systematic review of the literature was conducted with databases searched using keywords for air pollution, cognitive decline and dementia. All identified abstracts and potentially relevant articles were double read. For those papers meeting the inclusion criteria, summary tables were prepared and papers quality assessed. Results: from 1,551 abstracts identified, 10 articles were retrieved of which two were rejected. Of the eight remaining six reported prevalent cognitive assessment with historical pollution exposure and two incident cognitive decline, also with historical pollution exposure. In general, an association was reported between exposure and poorer prevalent measures of cognitive function. Data were mixed for incident cognitive decline with one study finding an association and the other not. Reports were limited by a lack of detailed reporting, use of proxy measures of pollution exposure and a lack of clarity regarding cognitive testing methodology and analysis. Conclusion: this systematic review highlights that there is some evidence of a potential association between air pollution and subsequent cognitive decline. Further work is clearly required and longitudinal analysis of ongoing cohort studies or new research would add much needed clarity to this area. [ABSTRACT FROM AUTHOR]

Background: the care of older people with dementia is often complicated by physical comorbidity and polypharmacy, but the extent and patterns of these have not been well described. This paper reports analysis of these factors within a large, cross-sectional primary care data set. Methods: data were extracted for 291,169 people aged 65 years or older registered with 314 general practices in the UK, of whom 10,258 had an electronically recorded dementia diagnosis. Differences in the number and type of 32 physical conditions and the number of repeat prescriptions in those with and without dementia were examined. Age-gender standardised rates were used to calculate odds ratios (ORs) of physical comorbidity and polypharmacy. Results: people with dementia, after controlling for age and sex, had on average more physical conditions than controls (mean number of conditions 2.9 versus 2.4; P < 0.001) and were on more repeat medication (mean number of repeats 5.4 versus 4.2; P < 0.001). Those with dementia were more likely to have 5 or more physical conditions (age-sex standardised OR [sOR] 1.42, 95% confidence interval (CI) 1.35-1.50; P < 0.001) and were also more likely to be on 5 or more (sOR 1.46; 95% CI 1.40-1.52; P < 0.001) or 10 or more repeat prescriptions (sOR 2.01; 95% CI 1.90-2.12; P < 0.001). Conclusions: people with dementia have a higher burden of comorbid physical disease and polypharmacy than those without dementia, even after accounting for age and sex differences. Such complex needs require an integrated response from general health professionals and multidisciplinary dementia specialists. [ABSTRACT FROM AUTHOR]

Background: an increased mortality rate among patients admitted to hospital at weekends has been found in many studies, and this 'weekend effect' has been used to justify major health service reorganisation. Most studies have used routine administrative data to adjust for potential confounding factors, and are unable to measure differences in illness severity due to the tendency of patients with milder symptoms to stay home at weekends. We set out to estimate the importance of such unmeasured 'confounding by severity', using data from a hospital stroke register. Methods: all suspected acute stroke admissions in Gateshead were prospectively registered over a period of 14.3 years, including information on premorbid factors, measures of stroke severity and survival to hospital discharge. We examined whether each factor differed between weekday and weekend admissions, then used logistic regression to estimate the main contributors to variation in mortality rates. Results: stroke severity, measured by the Scandinavian Stroke Scale (SSS), was significantly greater among weekend admissions and strongly associated with mortality, and after adjustment for SSS score in logistic regression, the weekend effect completely disappeared. By contrast, most indicators of pre-stroke function, comorbidity or stroke type did not differ between weekday and weekend admissions, although some of them had prognostic significance. Conclusions: the sorts of factors measurable in administrative databases only account for a small part of the prognostically important differences in case-mix between weekday and weekend stroke admissions. While increasing weekend staffing might improve adherence to care standards, evidence that it could save lives is unreliable. [ABSTRACT FROM AUTHOR]

Objectives: although melatonin prescribing in England has been increasing in recent years, there have been no large scale studies on the safety of melatonin compared to other medical treatments for insomnia. The primary aim of this study was to examine the association between exposure to melatonin, hypnotic benzodiazepines (temazepam, nitrazepam) or Z-drugs (zolpidem, zopiclone) and fracture risk. Design: retrospective cohort study. Setting: 309 general practices contributing to The Health Improvement Network (THIN) between 2008 and 2013. Participants: 1,377 patients aged 45 years and older prescribed melatonin; 880 patients prescribed hypnotic benzodiazepines; 1,148 patients prescribed Z-drugs and 2,752 unexposed controls matched by age, gender and practice. Main outcome: fracture following prescription of study drugs ascertained from practice records. Results: the unadjusted hazard ratios for fracture during the follow-up period were 1.90 (95% CI 1.41-2.57) for melatonin, 1.70 (95% CI 1.18-2.46) for hypnotic benzodiazepines and 2.03 (95% CI 1.45-2.84) for Z-drugs. After adjustment for 26 cov-ariates, the hazard ratios were 1.44 (95% CI 1.01-2.04) for melatonin, 1.26 (95% CI 0.82-1.92) for hypnotic benzodiazepines and 1.52 (95% CI 1.04-2.23) for Z-drugs. Only patients with three or more melatonin prescriptions had elevated risk. The mean time to fracture was 1.04 years and there was no significant difference in mean time to fracture between the cohorts. Conclusions: in this large cohort of patients attending UK primary care, prescriptions for melatonin and Z-drugs were associated with a significantly increased risk of fracture. With the use of melatonin increasing steadily overtime, this study adds to the literature on the safety profile of this drug. [ABSTRACT FROM AUTHOR]

Background: the apolipoprotein (APOE) e4 locus is a genetic risk factor for dementia. Carriers ofthe e4 allele may be more vulnerable to conditions that are independent risk factors for cognitive decline, such as cardiometabolic diseases. Objective: we tested whether any association with APOE e4 status on cognitive ability was larger in older ages or in those with cardiometabolic diseases. Subjects: UK Biobank includes over 500,000 middle- and older aged adults who have undergone detailed medical and cognitive phenotypic assessment. Around 150,000 currently have genetic data. We examined 111,739 participants with complete genetic and cognitive data. Methods: baseline cognitive data relating to information processing speed, memory and reasoning were used. We tested for interactions with age and with the presence versus absence of type 2 diabetes (T2D), coronary artery disease (CAD) and hypertension. Results: in several instances, APOE e4 dosage interacted with older age and disease presence to affect cognitive scores. When adjusted for potentially confounding variables, there was no APOE e4 effect on the outcome variables. Conclusions: future research in large independent cohorts should continue to investigate this important question, which has potential implications for aetiology related to dementia and cognitive impairment. [ABSTRACT FROM AUTHOR]

Background: delirium and dementia are common in the general hospital, being present in nearly 50% of older unselected admissions to hospital. Cognitive impairment is a risk factor for delirium, but the prevalence of previously undiagnosed cognitive impairment (dementia or mild cognitive impairment) in patients with delirium is unknown. Methods: we performed a prospective cohort study of people over 70 years admitted to hospital with delirium to establish the prevalence of previously unrecognised prior cognitive impairment. Delirium was diagnosed at baseline using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Mild cognitive impairment and dementia were diagnosed 3 months following recruitment in survivors using the International Working Group on Mild Cognitive Impairment criteria and DSM- IV criteria, respectively. Results: delirium was identified in 17.9% of older patients, and 82 participants with delirium were assessed at 3 months: 5 (6%) had persistent delirium, 14 (17%) had mild cognitive impairment and 47 (57%) had dementia. In 17 participants with prior dementia and 14 with prior mild cognitive impairment, the diagnosis had been unrecognised, amounting to 31/82 (38%) of all patients with delirium having some form of previously undiagnosed cognitive impairment. Conclusion: given that over 1/3 of older patients with delirium were found to have a previously undiagnosed cognitive impairment, the development and evaluation of services to follow-up and manage patients with delirium are warranted. [ABSTRACT FROM AUTHOR]

Background: UK National Dementia Strategies prioritise fair access to dementia treatments for the whole population. We investigated for the first time inequalities in NHS national dementia prescribing and how they have varied between UK countries and over time. Method: we investigated the association between Townsend deprivation score and anti-dementia drug prescribing in 77,045 dementia patients from UK primary care records from 2002 to 2013. Results: we included 77,045 patients with recorded dementia diagnosis or anti-dementia drug prescription. Least deprived patients were 25% more likely to be initiated on anti-dementia drugs than the most deprived (adjusted incidence rate ratio 1.25, 95% confidence interval 1.19-1.31). This was driven by data from English practices where prescribing rates were consistently lower in more deprived patients compared with Scotland, Northern Ireland and Wales, where prescribing was not related to deprivation quintile. Compared with English practices, anti-dementia medication was prescribed more often in Northern Irish (1.81, 1.41-2.34) and less in Welsh practices (0.68, 0.55-0.82), with a trend towards more prescribing in Scottish practices (1.14, 0.98-1.32). Drug initiation rates were also higher in younger people and men. Conclusion: four years after the English National Dementia Strategy, there is no evidence that the Strategy's key objective of reducing treatment inequalities is being achieved. Higher overall anti-dementia drug prescribing in Scottish and Northern Irish practices, and differing clinical guidelines in Scotland from other UK countries might explain greater equality in prescribing in these countries. Strategies to offer treatment to more deprived people with dementia in England are needed. [ABSTRACT FROM AUTHOR]

Introduction: age-related demographic change is not being matched by a growth in relevant undergraduate medical education, in particular communication skills pertinent to elderly patients. To address this, a workshop for medical students focusing on important communication skills techniques for interacting with patients with dementia was designed by clinicians from the Geriatric, General Practice and Psychiatry departments at the University of Oxford. Methods: one hundred and forty-four first-year clinical students (Year 4 of the 6-year course; Year 2 of the 4-year graduate-entry course) attended the teaching. One hundred and twenty-nine students returned feedback forms with 104 forms matched for individual performance before and after the session. Feedback forms assessed student-perceived confidence in communicating with patients with dementia before and after the session using a 4-point Likert scale with corresponding numerical value (low (1), medium (2), high (3), very high (4)). Results: using the Wilcoxon Signed-Rank Test on the 104 matched forms, student-perceived confidence was higher post-teaching intervention (median = 2.75) than pre-intervention (median = 1.50). This difference was statistically significant with large effect size, Z = -8.47, P< 0.001, r = -0.59. Free-text comments focused on non-verbal communication skills teaching, suggesting that these sessions were most beneficial for topics hardest to teach in lecture-based approaches. Conclusion: the teaching aimed to promote patient-centred care and multidisciplinary collaborative practice, encourage student self-reflection and peer-assisted education and provide insight into the needs of patients with dementia. Student feedback indicated that these objectives had been met. This easily replicable teaching method provides a simple means of improving communication skills. [ABSTRACT FROM AUTHOR]

Background: the objective of the study was to estimate and compare the incidence rates of ischaemic and haemorrhagic stroke and seizure among cohorts with and without Alzheimer's disease (AD) dementia. Methods: we conducted a retrospective cohort study using electronic medical records (EMRs) from primary care practices that participated in The Health Improvement Network (THIN) in the United Kingdom from 1 January 1990 to 31 July 2009. For each AD-dementia patient, we selected one general population control patient without AD-dementia matched to one AD-dementia patient on year of birth, sex and physician practice. Findings: the AD-dementia cohorts were 68% female and averaged 80 years of age at the start of follow-up. Populations for analysis included 19,902 AD-dementia and matched non-AD-dementia patients with no history of stroke at baseline in which 790 incident cases of stroke occurred, and similarly, 22,084 AD-dementia and matched patients with no history of seizure at baseline in which 286 cases of seizure occurred. After adjusting for risk factors for each outcome, hazard ratios comparing AD-dementia with non-AD-dementia patients indicated higher rates among AD-dementia patients for stroke (HR = 1.29, 95% CI 1.11, 1.50) and seizure (HR = 5.31, 95% CI 3.97, 7.10). For stroke and seizure, the incidence rate ratios comparing AD-dementia patients with non-AD-dementia controls were greatest for the younger age groups. AD-dementia was observed to be a risk factor for both haemorrhagic stroke and seizures. Increasing age was associated with a decrease in relative risk and an increase in absolute risk. [ABSTRACT FROM AUTHOR]

Background: studies have raised concerns that medications with anticholinergic property have potential adverse effects on health outcomes.Objectives: the objective of this study is to examine the prospective relationships between total anticholinergic burden (ACB) from medications and mortality, and cardiovascular disease (CVD) in a general population.Design: observational study.Setting: community cohort.Subjects: we examined data collected from 21,636 men and women without cancer at the baseline who participated in a baseline survey 1993–97 in the European Prospective Investigation into Cancer (EPIC)-Norfolk. They were followed until 2009/11.Methods: we performed Cox-proportional hazards models to determine the associations between total ACB and the subsequent risk of all-cause mortality and incident CVD during the follow-up.Results: there were a total of 4,342 people died and 7,328 had an incident CVD during the study follow-up (total person years = 322,321 years for mortality and 244,119 years for CVD event). Compared with people with no anticholinergic burden (ACB = 0), people with total ACB ≥3 from medications had hazards ratios of 1.83 (1.53, 2.20) and 2.17 (1.87, 2.52) for mortality and CVD incidence outcomes, respectively, after adjusting for potential confounders. Repeating the analyses after excluding people with prevalent illnesses, and events occurring within the first 2 years of follow-up, only slightly attenuated the results.Conclusion: there appear to be a class effect as well as dose–response relationship between the ACB and both outcomes. Future research should focus on understanding the relationship between ACB and mortality, and cardiovascular disease and possibly minimising ACB load where feasible. [ABSTRACT FROM PUBLISHER]