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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 defining features of the COVID-19 pandemic in many countries were the tragic extent to which care home residents were affected and the difficulty in preventing the introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was the transfer of patients from hospitals that were experiencing high levels of nosocomial events. Methods we tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period from March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in case rates following exposure to a hospital discharge using multi-level hierarchical logistic regression and a novel stochastic Hawkes process outbreak model. Findings in regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI: 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated that approximately 1.8% of hospital discharged patients may have been infected. Interpretation there is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients and action taken within care homes following transfer all may have contributed to the mitigation. The precise key transmission routes from the community remain to be quantified. [ABSTRACT FROM AUTHOR]

Background Weak grip strength is associated with a range of adverse health outcomes and an accelerated decline in grip strength confers an even greater risk. The factors associated with change in grip strength in mid-life remain to be fully determined. Methods We used data from 44,315 UK Biobank participants who had grip strength measured at baseline (2006-10) and a subsequent visit approximately nine years later. At baseline, participants' long-term conditions (LTCs) were categorised against a hierarchy, with multimorbidity characterised by the number of LTC categories. Lifestyle factors were assessed. Change in grip strength was grouped into four patterns: decline, stable low, stable high or reference (no change or increase) and used as the outcome in multinomial logistic regression. Results Most LTC categories were associated with adverse patterns of change in grip strength (stable low and/or decline): for example, musculoskeletal/trauma conditions were associated with an increased risk of the stable low pattern (Relative Risk Ratio [RRR] = 1.63; 95% confidence interval [CI]: 1.49-1.79). Multimorbidity and lifestyle factors had independent associations with grip strength change. Those with 3+ categories of LTCs were more likely to experience decline in grip strength (RRR = 1.18; 95% CI: 1.08-1.28) compared to those with none. Low physical activity was associated with adverse patterns of grip strength, while raised body mass index (BMI) had divergent associations. Conclusions Individuals living with multimorbidity and those with lifestyle risk factors such as low physical activity are at increased risk of low muscle strength and the loss of strength over time. [ABSTRACT FROM AUTHOR]

Background Frailty assessment using the Clinical Frailty Scale (CFS) has been mandated for older people admitted to English major trauma centres (MTC) since April 2019. Little evidence is available as to CFS-associated outcomes in the trauma population. Objective To investigate post-injury outcomes stratified by the CFS. Methods A single centre prospective observational cohort study was undertaken. CFS was prospectively assigned to patients ≥ 65 years old admitted to the MTC over a 5-month period. Primary outcome was 30-day post-injury mortality. Secondary outcomes were length of hospital stay, complications and discharge level of care. Results In 300 patients median age was 82; 146 (47%) were frail (CFS 5–9) and 28 (9.3%) severely frail (CFS 7–9). Frail patients had lower injury severity scores (median 9 vs 16) but greater 30-day mortality (CFS 5–6 odds ratio (OR) 5.68; P  < 0.01; CFS 7–9 OR 10.38; P  < 0.01). Frailty was associated with delirium (29.5% vs 17.5%; P  = 0.02), but not complication rate (50.7% vs 41.6%; P  = 0.20) or length of hospital stay (13 vs 11 days; P  = 0.35). Mild to moderate frailty was associated with increased care level at discharge (OR 2.31; P  < 0.01). Conclusions Frailty is an independent predictor of 30-day mortality, inpatient delirium and increased care level at discharge in older people experiencing trauma. CFS can therefore be used to identify those at risk of poor outcome who may benefit from comprehensive geriatric review, validating its inclusion in the 2019 best practice tariff for major trauma. [ABSTRACT FROM AUTHOR]

Objective To determine whether mobilisation timing was associated with the cumulative incidence of hospital discharge by 30 days after hip fracture surgery, accounting for potential confounders and the competing risk of in-hospital death. Method We examined data for 135,105 patients 60 years or older who underwent surgery for nonpathological first hip fracture between 1 January 2014 and 31 December 2016 in any hospital in England or Wales. We tested whether the cumulative incidences of discharge differed between those mobilised early (within 36 h of surgery) and those mobilised late, accounting for potential confounders and the competing risk of in-hospital death. Results A total of 106,722 (79%) of patients first mobilised early. The average rate of discharge was 39.2 (95% CI 38.9–39.5) per 1,000 patient days, varying from 43.1 (95% CI 42.8–43.5) among those who mobilised early to 27.0 (95% CI 26.6–27.5) among those who mobilised late, accounting for the competing risk of death. By 30-day postoperatively, the crude and adjusted odds ratios of discharge were 2.36 (95% CI 2.29–2.43) and 2.08 (95% CI 2.00–2.16), respectively, among those who first mobilised early compared with those who mobilised late, accounting for the competing risk of death. Conclusion Early mobilisation led to a 2-fold increase in the adjusted odds of discharge by 30-day postoperatively. We recommend inclusion of mobilisation within 36 h of surgery as a new UK Best Practice Tariff to help reduce delays to mobilisation currently experienced by one-fifth of patients surgically treated for hip fracture. [ABSTRACT FROM AUTHOR]

Background To guide decision-making about driving ability, some patients with Parkinson's disease (PD) undergo specialist driving assessment. However, decisions about driving safety in most patients need to be made without this definitive test. There is no consensus on what predicts unsafe driving in PD nor a validated prediction tool to guide clinician decision-making and the need to refer for further assessment. Objectives To describe the characteristics of patients with PD assessed at a Driving Mobility Centre and investigate factors that predict driving assessment outcome. Methods Retrospective cohort study of patients with PD assessed between 2012 and 2016. Descriptive analyses and logistic models to determine factors predicting a negative outcome. Results There were 86 assessments of patients with PD. The mean age was 70 years (±9.2), 86% were male, median disease duration 7 years (interquartile range 5–12.5 years) and 59% were referred by the Driver and Vehicle Licensing Agency. In total, 62% had a negative 'not drive' outcome. The Rookwood Driving Battery (RDB), depth of vision deficit, usual driving frequency, age, duration license held and response time were all predictors in univariable analysis. The RDB was the best predictor of assessment failure, conditional on other variables in a backward stepwise model (odds ratio 1.29; 95% confidence interval 1.05, 1.60; P  = 0.015). Conclusions This is the first study to describe patients with PD undergoing driving assessments in the UK. In this population, RDB performance was the best predictor of outcome. Future prospective studies are required to better determine predictors of driving ability to guide development of prediction tools for implementation into clinical practice. [ABSTRACT FROM AUTHOR]

Background: kidney function declines in older adults and physical activity levels are low. We investigated whether higher levels of physical activity and lower levels of sedentary behaviour were associated with lower odds of low kidney function in older men. Methods: cross-sectional study of 1,352 men from the British Regional Heart Study, mean (standard deviation) age 78.5 (4.6) year. Physical activity and sedentary behaviour were measured using Actigraph GT3X accelerometers. Kidney function was measured by estimated Glomerular filtration rate (eGFR) using the chronic kidney disease-EPI creatinine-cystatin equation. Associations between physical (in)activity and kidney function were investigated using regression models. Results: higher levels of physical activity and lower levels of sedentary behaviour were associated with reduced odds ratios (ORs) for lower eGFR (<45 versus ≥45 ml/min per 1.73 m²) after adjustment for covariates. Each additional 1,000 steps, 30 min of light physical activity and 10 min of moderate/vigorous physical activity per day were associated with a lower Objectively measured physical activity and kidney function in older men odds (95% confidence interval (CI)) of a low eGFR; OR 0.81 (0.73, 0.91), OR 0.87 (0.78, 0.97) and OR 0.84 (0.76, 0.92), respectively. Each additional 30 min of sedentary behaviour per day was associated with a higher odds of a low eGFR (1.16 95% CI 1.06, 1.27). Associations between moderate/vigorous physical activity and lower kidney function persisted after adjustment for light physical activity or sedentary behaviour. Conclusion: physical activity is associated with kidney function in older men and could be of public health importance in this group who are at increased risk of poor kidney function and low physical activity. More evidence is needed on whether the association is causal. [ABSTRACT FROM AUTHOR]

Background: recognition of prevalent delirium and prediction of incident delirium may be difficult at first assessment. We therefore aimed to validate a pragmatic delirium susceptibility (for any, prevalent and incident delirium) score for use in front-line clinical practice in a consecutive cohort of older acute medicine patients. Methods: consecutive patients aged ≥65 years over two 8-week periods (2010-12) were screened prospectively for delirium using the Confusion Assessment Method (CAM), and delirium was diagnosed using the DSM IV criteria. The delirium susceptibility score was the sum of weighted risk factors derived using pooled data from UK-NICE guidelines: age >80 = 2, cognitive impairment (cognitive score below cut-off/dementia) = 2, severe illness (systemic inflammatory response syndrome) = 1, infection = 1, visual impairment = 1. Score reliability was determined by the area under the receiver operating curve (AUC). Results: among 308 consecutive patients aged ≥65 years (mean age/SD = 81/8 years, 164 (54%) female), AUC was 0.78 (95% CI 0.71-0.84) for any delirium; 0.71 (0.64-0.79), for prevalent delirium; 0.81 (0.70-0.92), for incident delirium; odds ratios (ORs) for risk score 5-7 versus <2 were 17.9 (5.4-60.0), P < 0.0001 for any delirium, 8.1 (2.2-29.7), P = 0.002 for prevalent delirium, and 25.0 (3.0-208.9) P = 0.003 for incident delirium, with corresponding relative risks of 5.4, 4.7 and 13. Higher risk scores were associated with frailty markers, increased care needs and poor outcomes. Conclusions: the externally derived delirium susceptibility score reliably identified prevalent and incident delirium using clinical data routinely available at initial patient assessment and might therefore aid recognition of vulnerability in acute medical admissions early in the acute care pathway. [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]

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: advance care planning (ACP) is a process to establish an individual's preference for care in the future; few UK studies have been conducted to ascertain public attitudes towards ACP. Objective: the aim of this study was to assess the attitudes of older people in East Midlands through the development and administration of a survey. Design: the survey questionnaire was developed on the basis of a literature review, exploratory focus groups with older adults and expert advisor input. The final questions were then re-tested with lay volunteers. Setting: thirteen general practices were enrolled to send out surveys to potential participants aged 65 or older. There were no additional inclusion or exclusion criteria for participants. Methods: simple descriptive statistics were used to describe the responses and regression analyses were used to evaluate which items predicted responses to key outcomes. Results: of the 5,375 (34%) community-dwelling older peoples, 1,823 returned questionnaires. Seventeen per cent of respondents had prepared an ACP document; of whom, 4% had completed an Advance Decision to Refuse Treatment (ADRT). Five per cent of respondents stated that they had been offered an opportunity to talk about ACP. Predictors of completing an ACP document included: being offered the opportunity to discuss ACP, older age, better physical function and male gender. Levels of trust were higher for families than for professionals. One-third of the respondents would be interested in talking about ACP if sessions were available. Conclusion: although a third of the respondents were in favour of discussing ACP if the opportunity was available with their GP, only a relative minority (17%) had actively engaged. Preferences were for informal discussions with family rather than professionals. [ABSTRACT FROM AUTHOR]

Objective: to develop and validate a prediction model for incident locomotor disability after 7 years in older adults.Setting: prospective British cohort studies: British Women's Heart and Health Study (BWHHS) for development and the English Longitudinal Study of Ageing (ELSA) for validation.Subjects: community-dwelling older adults.Methods: multivariable logistic regression models after selection of predictors with backward elimination. Model performance was assessed using metrics of discrimination and calibration. Models were internally and externally validated.Results: locomotor disability was reported in BWHHS by 861 of 1,786 (48%) women after 7 years. Age, a history of arthritis and low physical activity levels were the most important predictors of locomotor disability. Models using routine measures as predictors had satisfactory calibration and discrimination (c-index 0.73). Addition of 31 blood markers did not increase the predictive performance. External validation in ELSA showed reduced discrimination (c-index 0.65) and an underestimation of disability risks. A web-based calculator for locomotor disability is available (http://www.sealedenvelope.com/trials/bwhhsmodel/).Conclusions: we developed and externally validated a prediction model for incident locomotor disability in older adults based on routine measures available to general practitioners, patients and public health workers, and showed an adequate discrimination. Addition of blood markers from major biological pathways did not improve the performance of the model. Further replication in additional data sets may lead to further enhancement of the current model. [ABSTRACT FROM PUBLISHER]

Background: evidence on the long-term natural history, predictors and outcomes of anxiety after stroke is insufficient to inform effective interventions. This study estimates within 10 years of stroke: (i) the incidence, cumulative incidence, prevalence, and time of onset of anxiety. (ii) Predictors of anxiety and its association with depression. (iii) The association between anxiety 3 months after stroke and mortality, stroke recurrence, disability, cognitive impairment and quality of life (QoL) at follow-up.Methods: data from the South London Stroke Register (1995–2010). Patients were assessed at the time of the stroke, at 3 months, 1 year and then annually for up to 10 years. Baseline data included socio-demographics and stroke severity. Follow-up data included assessments for anxiety and depression (hospital anxiety and depression scale), disability, cognition and QoL. Multivariate regression was used to investigate predictors and associated outcomes of anxiety.Results: incidence of anxiety up to 10 years ranged from 17 to 24%. Cumulative incidence: 57%. Prevalence range: 32–38%. Amongst patients with anxiety, 58% were anxious at 3 months. 57–73% of patients with anxiety had co-morbid depression. Predictors of anxiety included age under 65, female gender, inability to work, depression treatment, smoking and stroke severity. Anxiety at 3 months was associated with lower QoL at follow-up.Conclusions: anxiety is a frequent problem affecting stroke survivors in the long term. Clinicians should pay attention to patients at risk of anxiety since it is associated with lower QoL and depression. [ABSTRACT FROM AUTHOR]