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Age and Ageing is now inviting papers on healthcare improvement for older people. In this article we outline the nature and scope of healthcare improvement and reference improvement models and the tools and methods of improvement science. We emphasise the issues of sustainability, including scale and spread; evaluation – including associated ethical consideration and the involvement of patients and the public in healthcare improvement and associated research. Throughout we refer to resources the authors have found useful in their own work, and provide a bibliography of sources and web-links which will provide essential guidance and support for potential contributors to this new category of submission to Age and Ageing. [ABSTRACT FROM AUTHOR]

As people age they are at increased risk of cardiovascular disease, the leading cause of mortality and morbidity worldwide. Understanding cardiovascular ageing is essential to preserving healthy ageing and preventing serious health outcomes. This collection of papers published in Age and Ageing since 2011 cover key themes in cardiovascular ageing, with a separate collection on stroke and atrial fibrillation planned. Treating high blood pressure remains important as people age and reduces strokes and heart attacks. That said, a more personalised approach to blood pressure may be even more important as people age to lower blood pressure to tight targets where appropriate but avoid overtreatment in vulnerable groups. As people age, more people experience blood pressure drops on standing (orthostatic hypotension), particularly as they become frail. This can predispose them to falls. The papers in this collection provide an insight into blood pressure and orthostatic hypotension. They highlight areas for further research to understand blood pressure changes and management in the ageing population. Inpatient clinical care of older people with heart attacks differs from younger people in UK national audit data. People aged over 80 had improved outcomes in survival after heart attack over time, but had lower rates of specialist input from cardiology compared with younger people. This may partly reflect different clinical presentations, with heart attacks occurring in the context of other health conditions, frailty and multimorbidity. The care and outcomes of acute and chronic cardiovascular disease are impacted by the frailty and health status of an individual at baseline. The research included in this collection reinforces the wide variations in the ageing population and the necessity to focus on the individual needs and priorities, and provide a person-centred multidisciplinary approach to care. [ABSTRACT FROM AUTHOR]

Background Older people are often explicitly or implicitly excluded from research, in particular clinical trials. This means that study findings may not be applicable to them, or that older people may not be offered treatments due to an absence of evidence. Aims The aim of this work was to develop recommendations to guide all research relevant to older people. Methods A diverse stakeholder group identified barriers and solutions to including older people in research. In parallel, a rapid literature review of published papers was undertaken to identify existing papers on the inclusion of older people in research. The findings were synthesised and mapped onto a socio-ecological model. From the synthesis we identified themes that were developed into initial recommendations that were iteratively refined with the stakeholder group. Results A range of individual, interpersonal, organisational, community and policy factors impact on the inclusion of older people in research. A total of 14 recommendations were developed such as removing upper age limits and comorbidity exclusions, involving older people, advocates and health and social care professionals with expertise in ageing in designing the research, and considering flexible or alternative approaches to data collection to maximise opportunities for participation. We also developed four questions that may guide those developing, reviewing and funding research that is inclusive of older people. Conclusion Our recommendations provide up to date, practical advice on ways to improve the inclusion of older people in health and care research. [ABSTRACT FROM AUTHOR]

With an increase in the ageing population, there is a rise in the burden of cardiovascular disease. Age and Ageing have compiled collections of their key cardiovascular themed papers. The first Age and Ageing Cardiovascular Collection focussed on blood pressure, coronary heart disease and heart failure. In this second collection, publications since 2011 were selected with emphasis on atrial fibrillation, transient ischaemic attack (TIA) and stroke. The prevalence of TIA and stroke increases as people get older. In this commentary we summarise studies published in Age and Ageing that bring to the fore the need for a multidisciplinary, person-centred approach to care, conscientious identification of risk factors and their management and prevention strategies, which will inform policy ultimately reducing the burden of cost placed by stroke care on healthcare financing. Read the latest Cardiovascular Collection here. [ABSTRACT FROM AUTHOR]

Introduction the COVID-19 pandemic poses a high risk to older people. The aim of this article is to provide a rapid overview of the COVID-19 literature, with a specific focus on older adults. We frame our findings within an overview of the disease and have also evaluated the inclusion of older people within forthcoming clinical trials. Methods we searched PubMed and bioRxiv/medRxiv to identify English language papers describing the testing, treatment and prognosis of COVID-19. PubMed and bioRxiv/medRxiv searches took place on 20 and 24 March 2020, respectively. Results screening of over 1,100 peer-reviewed and pre-print papers yielded n  = 22 on COVID-19 testing, n  = 15 on treatment and n  = 13 on prognosis. Viral polymerase chain reaction (PCR) and serology are the mainstays of testing, but a positive diagnosis may be increasingly supported by radiological findings. The current evidence for the effectiveness of antiviral, corticosteroid and immunotherapies is inconclusive, although trial data are largely based on younger people. In addition to age, male gender and comorbidities, specific laboratory and radiology findings are important prognostic factors. Evidence suggests that social distancing policies could have important negative consequences, particularly if in place for an extended period. Conclusion given the established association between increasing age and poor prognosis in COVID-19, we anticipate that this rapid review of the current and emergent evidence might form a basis on which future work can be established. Exclusion of older people, particularly those with comorbidities, from clinical trials is well recognised and is potentially being perpetuated in the field of current COVID-19 research. [ABSTRACT FROM AUTHOR]

Background older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014–2017) since NELA was established. Methods patient-level data were populated from the NELA data set years 1–4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation. Results in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P  < 0.001) and 90-day mortality (20.4 versus 7.2%, P  < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P  < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P  < 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1–4 (8.5 to 16.5%, P  < 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35–0.42, P  < 0.001; 90-day OR 0.6, CI 0.56–0.65, P  < 0.001). Conclusions older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input. [ABSTRACT FROM AUTHOR]

Background Currently, 1 in 10 people diagnosed with dementia in Ireland are aged under 65, this is termed "Younger Onset Dementia" (YOD). Though small in numbers these figures (4000 people) are increasing, and important differences exist between people diagnosed with (PwYOD) and those diagnosed with later onset dementia (LOD). As dementia is normally associated with advancing age, clinicians are not always on the alert for its diagnosis in younger people. Diagnosing YOD can be especially challenging since presentation may be atypical and there is a lack of clinical ownership in this area. Methods A structured literature review was conducted to identify optimum models of diagnostic processes and pathways for PwYOD. Two research questions were addressed: (i) what models for the diagnosis of PwYOD exist nationally and internationally, and what evidence supports these and (ii) what are the differences between diagnostic processes and pathways for PwYOD compared with PwLOD. A systematic search strategy was devised to identify all relevant scientific papers. Key databases were used, supplemented by grey literature searches. A narrative synthesis approach was undertaken to assess the literature identified. Results Pathways and processes to the diagnosis of YOD are unclear and complex and compared with LOD, diagnosis takes more time. PwYOD are more likely to have multiple referrals to different specialists, have their memory and cognitive complaints misattributed to other factors such as depression and experience longer delays in obtaining a diagnosis. Conclusion Few evidence-based best-practice models or guidelines for the diagnosis of YOD exist internationally. Increased awareness of the signs and symptoms of YOD among all healthcare professionals is necessary. There is a need for improved linkages to be developed between Geriatric Medicine, Neurology, Psychiatry, and Primary Care services and in certain instances for suspected cases of YOD to be referred to neurology-led memory clinics. [ABSTRACT FROM AUTHOR]

Background: the complex management for patients presenting to hospital with vertebral fragility fractures provides justification for the development of specific services for them. A systematic review was undertaken to determine the incidence of hospital admission, patient characteristics and health outcomes of vertebral fragility fracture patients to inform the development of such a service. Methods: non-randomised studies of vertebral fragility fracture in hospital were included. Searches were conducted using electronic databases and citation searching of the included papers. Results: a total of 19 studies were included. The incidence of hospital admission varied from 2.8 to 19.3 per 10,000/year. The average patient age was 81 years, the majority having presented with a fall. A diagnosis of osteoporosis or previous fragility fracture was reported in around one-third of patients. Most patients (75% men and 78% women) had five or more copathologies. Most patients were managed non-operatively with a median hospital length of stay of 10 days. One-third of patients were started on osteoporosis treatment. Inpatient and 1-year mortality was between 0.9 and 3.5%, and 20 and 27%, respectively, between 34 and 50% were discharged from hospital to a care facility. Many patients were more dependent with activities of daily living on discharge compared to their pre-admission level. Older age and increasing comorbidities was associated with longer hospital stay and higher mortality. Conclusion: these findings indicate that specific hospital services for patients with vertebral fragility fractures should take into consideration local hospitalisation rates for the condition, and should be multifaceted-providing access to diagnostic, therapeutic, surgical and rehabilitation interventions. [ABSTRACT FROM AUTHOR]

Background Following hip fracture surgery, patients from residential care are frequently excluded from inpatient rehabilitation. We aimed to assess the impact of place of residence and other factors such as frailty on rehabilitation outcomes after hip fracture surgery. Methods Retrospective cohort study. Outcome measures included Functional Independence Measure efficiency, discharge destination and recovery of pre-fracture mobility. Univariable and multivariable linear or logistic regression analyses were performed. Setting One general rehabilitation and two geriatric evaluation and management wards in a large public tertiary teaching hospital. Participants A total of 844 patients who underwent inpatient rehabilitation after hip fracture surgery from 2010 to 2018. Results There were 139 (16%) patients from residential care. Being from residential care was not an independent predictor of poor outcomes. Premorbid frailty (Clinical Frailty Scale) was the strongest independent predictor of poorer Functional Independence Measure efficiency, inability to recover pre-fracture mobility and return to community dwelling. Dementia and delirium were also independently predictive of poor outcomes across all measures. Age > 90 years was independently predictive of inability to recover pre-fracture mobility and return to community dwelling. Conclusion Being from residential care is not independently associated with poor outcomes following inpatient rehabilitation after hip fracture surgery and should not be the basis for excluding these patients from rehabilitation. Major predictors of poorer outcomes include premorbid frailty, dementia, delirium and age > 90 years. If able and motivated, those with potentially reversible functional limitations should be given the opportunity to participate in inpatient rehabilitation as even small gains can have a significant impact on quality of life. [ABSTRACT FROM AUTHOR]

Background: concern over the sustainability of the National Health Service (NHS) is often focussed on rising numbers of hospital admissions, particularly among older people. Hospital admissions are enumerated routinely by the Hospital Episode Statistics (HES) Service, but published data do not allow individual-level service use to be explored. This study linked information on Hertfordshire Cohort Study (HCS) participants with HES inpatient data, with the objective of describing patterns and predictors of admissions among individuals.Methods: 2,997 community-dwelling men and women aged 59–73 years completed a baseline HCS assessment between 1998 and 2004; HES and mortality data to 31 March 2010 were linked with the HCS database. This paper describes patterns of hospital use among the cohort at both the admission and individual person level.Results: the cohort experienced 8,741 admissions; rates were 391 per 1,000 person-years among men (95% CI: 380, 402) and 327 among women (95% CI: 316, 338), P < 0.0001 for gender difference. A total of 1,187 men (75%) and 981 women (69%) were admitted to hospital at least once; among these, median numbers of admissions were 3 in men (inter-quartile range, (IQR): 1, 6) and 2 in women (IQR: 1, 5). Forty-eight percent of those ever admitted had experienced an emergency admission and 70% had been admitted overnight.Discussion: It is possible to link routinely collected HES data with detailed information from a cohort study. Hospital admission is common among community-dwelling ‘young-old’ men and women. These linked datasets will facilitate research into lifecourse determinants of hospital admission and inform strategies to manage demand on the NHS. [ABSTRACT FROM AUTHOR]

Objective To develop a prognostic model of 1-year mortality for individuals aged 65+ presenting at the emergency department (ED) with a fall based on health care spending patterns to guide clinical decision-making. Design Population-based cohort study (n  = 35,997) included with a fall in 2013 and followed 1 year. Methods Health care spending indicators (dynamical indicators of resilience, DIORs) 2 years before admission were evaluated as potential predictors, along with age, sex and other clinical and sociodemographic covariates. Multivariable logistic regression models were developed and internally validated (10-fold cross-validation). Performance was assessed via discrimination (area under the receiver operating characteristic curve, AUC), Brier scores, calibration and decision curve analysis. Results The AUC of age and sex for mortality was 72.5% [95% confidence interval 71.8 to 73.2]. The best model included age, sex, number of medications and health care spending DIORs. It exhibited high discrimination (AUC: 81.1 [80.5 to 81.6]), good calibration and potential clinical benefit for various threshold probabilities. Overall, health care spending patterns improved predictive accuracy the most while also exhibiting superior performance and clinical benefit. Conclusions Patterns of health care spending have the potential to significantly improve assessments on who is at high risk of dying following admission to the ED with a fall. The proposed methodology can assist in predicting the prognosis of fallers, emphasising the added predictive value of longitudinal health-related information next to clinical and sociodemographic predictors. [ABSTRACT FROM AUTHOR]

Background The label 'faller' and the associated stigma may reduce healthcare-seeking behaviours. However, falls are not inevitably progressive and many drivers are modifiable. This observational study described the 8-year longitudinal trajectories of self-reported falls in The Irish Longitudinal Study on Ageing (TILDA) and studied associations with factors, including mobility, cognition, orthostatic hypotension (OH), fear of falling (FOF) and use of antihypertensive and antidepressant medications. Methods Participants aged ≥50 years at each wave were categorised by whether they averaged ≥2 falls in the previous year (recurrent fallers) or not (≤1 fall). Next-wave transition probabilities were estimated with multi-state models. Results 8,157 (54.2% female) participants were included, of whom 586 reported ≥2 falls at Wave 1. Those reporting ≥2 falls in the past year had a 63% probability of moving to the more favourable state of ≤1 fall. Those reporting ≤1 fall had a 2% probability of transitioning to ≥2 falls. Besides older age and higher number of chronic conditions, factors that increased the risk of transitioning from ≤1 fall to ≥2 falls were lower Montreal Cognitive Assessment score, FOF and taking antidepressants. Conversely, male sex, higher timed up and go time, the presence of OH and being on antidepressants reduced the probability of improving from ≥2 falls to ≤1 fall. Conclusion The majority of recurrent fallers experienced favourable transitions. Improvements in cognitive and psychological status, psychotropic prescribing, mobility and OH may help improve trajectories. Findings may help combat stigma associated with falling and promote preventative healthcare-seeking behaviours. [ABSTRACT FROM AUTHOR]

Background dementia may increase care home residents' risk of COVID-19, but there is a lack of evidence on this effect and on interactions with individual and care home-level factors. Methods we created a national cross-sectional retrospective cohort of care home residents in Wales for 1 September to 31 December 2020. Risk factors were analysed using multi-level logistic regression to model the likelihood of SARS-CoV-2 infection and mortality. Results the cohort included 9,571 individuals in 673 homes. Dementia was diagnosed in 5,647 individuals (59%); 1,488 (15.5%) individuals tested positive for SARS-CoV-2. We estimated the effects of age, dementia, frailty, care home size, proportion of residents with dementia, nursing and dementia services, communal space and region. The final model included the proportion of residents with dementia (OR for positive test 4.54 (95% CIs 1.55–13.27) where 75% of residents had dementia compared to no residents with dementia) and frailty (OR 1.29 (95% CIs 1.05–1.59) for severe frailty compared with no frailty). Analysis suggested 76% of the variation was due to setting rather than individual factors. Additional analysis suggested severe frailty and proportion of residents with dementia was associated with all-cause mortality, as was dementia diagnosis. Mortality analyses were challenging to interpret. Discussion whilst individual frailty increased the risk of COVID-19 infection, dementia was a risk factor at care home but not individual level. These findings suggest whole-setting interventions, particularly in homes with high proportions of residents with dementia and including those with low/no individual risk factors may reduce the impact of COVID-19. [ABSTRACT FROM AUTHOR]

Background Sarcoidosis is a multi-system disorder with an increasing propensity to present in older patients. Diagnostic uncertainty is common and understandable given the higher prevalence of co-morbidities in older patients and broad differential for multi-system clinical presentations. Excluding malignancy and infection with a high degree of certainty is challenging and may require repeated confirmatory investigation where the diagnosis remains in doubt. Summary of main findings There are a paucity of studies examining late-onset sarcoidosis. Female predominance, pulmonary, ocular, skin and systemic symptoms are common, while more classical presentations such as Lofgren's syndrome are uncommon. Positivity rates of biopsies vary between studies; however, targeted biopsies of accessible sites with organ involvement are the most successful. Therapeutic management is directed at reducing inflammation, and thereby reducing symptom burden, improving quality of life and avoiding progression of organ damage. While most older patients will require corticosteroid therapy, they are also more prone to developing adverse effects. Most older patients will experience a clinical remission; however, the risk of developing chronic sarcoidosis and organ damage is higher compared with younger counterparts. Patients with evidence of pulmonary fibrosis and pulmonary hypertension are at particular risk. Impact on clinical practice Health care providers who care for older adults should be aware of the increasing prevalence of late-onset sarcoidosis and consider the diagnosis in those who present with otherwise unexplained systemic symptoms, thoracic abnormalities on imaging and/or evidence of other organ involvement. Earlier diagnosis and therapeutic intervention to halt the development of pulmonary fibrosis and pulmonary hypertension and monitoring for treatment-related adverse effects will confer a mortality benefit. [ABSTRACT FROM AUTHOR]

In the past, illness and dependence were viewed as inevitable consequences of old age. Now, we understand that there is a difference between age (the passing of chronological time) and ageing (the increased risk of adverse outcomes over time). Over the last 50 years, 'frailty' research has established that ageing is heterogeneous, variable and malleable. Significant advances have been made in frailty measurement (description of clinical features and development of clinical models), mechanisms (insights into pathogenesis) and management (development of interventions to reduce and/or prevent progression). Subsequently, the concept of frailty has informed health policy and clinical practice and started to change perceptions of older age held by the general public and the health sector. Here, we overview key achievements in frailty research and clinical practice and highlight the considerable number of known unknowns that may be addressed in the future. [ABSTRACT FROM AUTHOR]

Introduction multimorbidity has become an increasingly important issue for many populations around the world, including Canada. The objectives of this study were to estimate the prevalence of multimorbidity at first follow-up and to identify factors associated with multimorbidity using data from the Canadian Longitudinal Study on Aging (CLSA). Methods this study included 27,701 community-dwelling participants in the first follow-up of the CLSA. Multimorbidity was operationalised using two definitions (Public Health and Primary Care), as well as the cut-points of two or more chronic conditions (MM2+) and three or more chronic conditions (MM3+). The prevalence of multimorbidity was calculated at first follow-up and multivariable regression models were used to identify correlates of multimorbidity occurrence. Results the prevalence of multimorbidity at first follow-up was 32.3% among males and 39.3% among females when using the MM2+ Public Health definition, whereas the prevalence was 67.2% among males and 75.8% among females when using the MM2+ Primary Care definition. Older age, lower alcohol consumption, lower physical activity levels, dissatisfaction with sleep quality, dissatisfaction with life and experiencing social limitations due to health conditions were significantly associated with increased odds of multimorbidity for both males and females, regardless of the definition of multimorbidity used. Conclusion various sociodemographic, behavioural and psychosocial factors are associated with multimorbidity. Future research should continue to examine how the prevalence of multimorbidity changes with time and how these changes may be related to specific risk factors. This future research should be supplemented with studies examining the longitudinal impacts of multimorbidity over time. [ABSTRACT FROM AUTHOR]

Background physical functioning impairment is common among persons with cognitive impairment, but little is known about physical functioning trajectories across the US population or how trajectories may differ among persons with dementia and mild cognitive impairment (MCI). Objective to examine trajectories of physical functioning among persons with MCI and dementia in the USA. Design we used data from the National Health and Aging Trends study (NHATS) 2011–18. Physical functioning was assessed using the NHATS Expanded Short Physical Performance Battery. Participants the 661 individuals with MCI and 980 individuals with dementia were included in this study. Methods we applied group-based trajectory models to identify latent groups and estimate their trajectories. Multinomial logistic regressions were applied to examine relationships between sociodemographic and health characteristics and trajectory group memberships. Results both MCI- and dementia-specific trajectories differed at baseline levels and declined at varying rates across groups. Approximately, 78.43% of persons with MCI were in trajectories with a moderate rate of decline, with only 9.75% in a trajectory with good physical function and 11.82% with poor physical function without as much change over time. Among persons with dementia, approximately 81.4% experienced moderate or fast declines, and 18.52% with virtually no functional ability remained at this same low level. Worse physical functioning trajectories were found among persons who were females, Blacks, with at least four comorbidities, and among persons who had a low socioeconomic status. Conclusions persons with both dementia and MCI experienced steady declines in physical functioning. Socioeconomically disadvantaged groups have worse physical functioning trajectories. [ABSTRACT FROM AUTHOR]

Background: little is known about changes in the quality of medical care for older adults over time.Objective: to assess changes in technical quality of care over 6 years, and associations with participants' characteristics.Design: a national cohort survey covering RAND Corporation-derived quality indicators (QIs) in face-to-face structured interviews in participants' households.Participants: a total of 5,114 people aged 50 or more in four waves of the English Longitudinal Study of Ageing.Methods: the percentage achievement of 24 QIs in 10 general medical and geriatric clinical conditions was calculated for each time point, and associations with participants' characteristics were estimated using logistic regression.Results: participants were eligible for 21,220 QIs. QI achievement for geriatric conditions (cataract, falls, osteoarthritis and osteoporosis) was 41% [95% confidence interval (CI): 38–44] in 2004–05 and 38% (36–39) in 2010–11. Achievement for general medical conditions (depression, diabetes mellitus, hypertension, ischaemic heart disease, pain and cerebrovascular disease) improved from 75% (73–77) in 2004–05 to 80% (79–82) in 2010–11. Achievement ranged from 89% for cerebrovascular disease to 34% for osteoarthritis. Overall achievement was lower for participants who were men, wealthier, infrequent alcohol drinkers, not obese and living alone.Conclusion: substantial system-level shortfalls in quality of care for geriatric conditions persisted over 6 years, with relatively small and inconsistent variations in quality by participants' characteristics. The relative lack of variation by participants' characteristics suggests that quality improvement interventions may be more effective when directed at healthcare delivery systems rather than individuals. [ABSTRACT FROM AUTHOR]

Background people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs). Objective to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings. Design nationwide cohort study using administrative database. Setting French community and nursing-home residents. Subjects incident ADRS people identified in 2012, who died up to 31 December 2017. Methods we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models. Results 62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities. Conclusions Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities. [ABSTRACT FROM AUTHOR]

Objective to develop a user-friendly prediction tool of 1-year mortality for patients with hip fracture, in order to guide clinicians and patients on appropriate targeted preventive measures. Design population-based cohort study from 2011 to 2017 using nationwide data from the Danish Hip Fracture Registry. Subjects a total of 28,791 patients age 65 and above undergoing surgery for a first-time hip fracture. Methods patient-related prognostic factors at the time of admission were assessed as potential predictors: Nursing home residency, comorbidity (Charlson Comorbidity Index [CCI] Score), frailty (Hospital Frailty Risk Score), basic mobility (Cumulated Ambulation Score), atrial fibrillation, fracture type, body mass index (BMI), age and sex. Association with 1-year mortality examined by determining the cumulative incidence, applying univariable logistic regression and assessing discrimination (area under the receiver operating characteristics curve [AUROC]). The final model (logistic regression) was utilised on a development cohort (70% of patients). Discrimination and calibration were assessed on the validation cohort (remaining 30% of patients). Results all predictors showed an association with 1-year mortality, but discrimination was moderate. The final model included nursing home residency, CCI Score, Cumulated Ambulation Score, BMI and age. It had an acceptable discrimination (AUROC 0.74) and calibration, and predicted 1-year mortality risk spanning from 5 to 91% depending on the combination of predictors in the individual patient. Conclusions using information obtainable at the time of admission, 1-year mortality among patients with hip fracture can be predicted. We present a user-friendly chart for daily clinical practice and provide new insight regarding the interplay between prognostic factors. [ABSTRACT FROM AUTHOR]

Background: the World Health Organization estimates that more than one billion of the world's population are disabled. Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability among the elderly in low-income countries. The aim of this study was to accurately document the prevalence of disability in those aged 70 years and over in a community-based setting in sub-Saharan Africa.Methods: we performed a community-based study of people aged 70 years and over in Hai, Tanzania. Participants underwent disability assessment using the culturally non-specific Barthel index (BI), and also clinical assessment for neurological disorders and memory problems.Results: in 2,232 participants, the age-adjusted prevalence of severe disability (BI < 15) was 3.7% (95% CI: 2.9–4.5) and the age-adjusted prevalence of moderate disability (BI: 15–18) was 6.2% [95% confidence interval (CI): 5.2–7.2]. Increasing age, female gender, memory problems and the presence of neurological disorders were all independent predictors of the presence of disability.Conclusion: in this study, the average disability level was lower than seen in most high-income countries. This may reflect increased mortality from disabling disease in low-income countries. Disability is likely to increase as the population of low-income countries ages and disease survival improves. [ABSTRACT FROM AUTHOR]

Background systemic inflammation appears to play an important role in the pathogenesis and expression of Alzheimer's disease and other dementias. Previous research has found that elevated levels of serum C-reactive protein (CRP) is associated with poorer cognitive functioning and increased risk for dementia. However, most studies are limited by single CRP measurements, which fail to capture long-term inflammatory exposures or dynamic changes in inflammation and cognition which may occur across repeated measurements. Methods using data from 3,563 older adults aged 65–101 from the Health and Retirement Study, we examined bivariate changes in CRP and cognition measured repeatedly over a 10-year follow-up. Bivariate multilevel models estimated the effect of time-varying CRP on cognition among cognitively healthy older adults and in a subset of 427 participants who reported incident dementia onset during the follow-up period. Results in cognitively healthy participants, CRP was associated with lower level of cognitive functioning, but not rate of change over time. This effect was significant in participants under 80 years of age (b  = −0.09, standard error (SE) = 0.05, P  = 0.04), but not in older participants. In participants with incident dementia, those with higher CRP experienced smaller rates of cognitive decline, leading up to dementia diagnosis. Conclusions elevated levels of CRP predict poorer cognition and increased dementia risk in cognitively healthy adults under the age of 80. Conversely, increased CRP may confer protective effects on cognition in the prodromal stage of dementia. [ABSTRACT FROM AUTHOR]

Background after hospitalisation for cardiac disease, older patients are at high risk of readmission and death. Objective the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality. Design single-blind, randomised clinical trial. Setting the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge. Subjects cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months. Methods the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months. Results in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P  = 0.253). The study was discontinued prematurely due to implementation activities in usual care. Conclusion in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months. Trial registration Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169 [ABSTRACT FROM AUTHOR]

Background older patients with hip fractures are arbitrarily classified as octogenarians, nonagenarians and centenarians. We have designed this study to quantify in-hospital mortality and complications among each of these groups. We hypothesised that the associations between age and in-hospital mortality and complications are continuously increasing, and that these risks increase rapidly when patients reach a certain age. Methods this research is a retrospective cohort study using nationwide database between 2010 and 2018. Patients undergoing hip fracture surgery, and aged 60 or older, were included. The associations between patient age, in-hospital mortality and complications were visualised using the restricted cubic spline models, and were analysed employing multivariable regression models. Then, octogenarians, nonagenarians and centenarians were compared. Results among a total of 565,950 patients, 48.7% (n  = 275,775) were octogenarians, 23.0% (n  = 129,937) were nonagenarians and 0.7% (n  = 4,093) were centenarians. The models presented three types of association between age, in-hospital mortality and complications: (i) a continuous increase (mortality and respiratory complications); (ii) a mild increase followed by a steep rise (intensive care unit admission, heart failure, renal failure and surgical site hematoma) and (iii) a steep increase followed by a limited change (coronary heart disease, stroke and pulmonary embolisms). Conclusion we identified three types of association between age and clinical outcomes. Patients aged 85–90 may constitute the upper threshold for age categorisations, because the risk of in-hospital complications changed dramatically at that stage. This information can improve clinical awareness of various complications and support collective decision-making. [ABSTRACT FROM AUTHOR]

Background despite rapid population ageing, few studies have investigated frailty in older people in sub-Saharan Africa. We tested a cumulative deficit frailty index in a population of older people from rural South Africa. Methods analysis of cross-sectional data from the Health and Ageing in Africa: Longitudinal Studies of an INDEPTH Community (HAALSI) study. We used self-reported diagnoses, symptoms, activities of daily living, objective physiological indices and blood tests to calculate a 32-variable cumulative deficit frailty index. We fitted Cox proportional hazards models to test associations between frailty category and all-cause mortality. We tested the discriminant ability of the frailty index to predict one-year mortality alone and in addition to age and sex. Results in total 3,989 participants were included in the analysis, mean age 61 years (standard deviation 13); 2,175 (54.5%) were women. The median frailty index was 0.13 (interquartile range 0.09–0.19); Using population-specific cutoffs, 557 (14.0%) had moderate frailty and 263 (6.6%) had severe frailty. All-cause mortality risk was related to frailty severity independent of age and sex (hazard ratio per 0.01 increase in frailty index: 1.06 [95% confidence interval 1.04–1.07]). The frailty index alone showed moderate discrimination for one-year mortality: c-statistic 0.68–0.76; combining the frailty index with age and sex improved performance (c-statistic 0.77–0.81). Conclusion frailty measured by cumulative deficits is common and predicts mortality in a rural population of older South Africans. The number of measures needed may limit utility in resource-poor settings. [ABSTRACT FROM AUTHOR]

Background frailty shows an upward trajectory with age, and higher levels increase the risk of mortality. However, it is less known whether the shape of frailty trajectories differs by age at death or whether the rate of change in frailty is associated with mortality. Objectives to assess population frailty trajectories by age at death and to analyse whether the current level of the frailty index (FI) i.e. the most recent measurement or the person-specific rate of change is more predictive of mortality. Methods 3,689 individuals from three population-based cohorts with up to 15 repeated measurements of the Rockwood frailty index were analysed. The FI trajectories were assessed by stratifying the sample into four age-at-death groups: <70, 70–80, 80–90 and >90 years. Generalised survival models were used in the survival analysis. Results the FI trajectories by age at death showed that those who died at <70 years had a steadily increasing trajectory throughout the 40 years before death, whereas those who died at the oldest ages only accrued deficits from age ~75 onwards. Higher level of FI was independently associated with increased risk of mortality (hazard ratio 1.68, 95% confidence interval 1.47–1.91), whereas the rate of change was no longer significant after accounting for the current FI level. The effect of the FI level did not weaken with time elapsed since the last measurement. Conclusions Frailty trajectories differ as a function of age-at-death category. The current level of FI is a stronger marker for risk stratification than the rate of change. [ABSTRACT FROM AUTHOR]

Background Delirium is an underdiagnosed and possibly preventable complication in acute stroke and is linked to poor outcome. Neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, is also associated with poor outcome after acute ischemic stroke. Aim To determine whether NLR is a predictor of post-stroke delirium (PSD). Methods We reviewed the UZ Brussel stroke database and included 514 patients with acute ischemic stroke within 24 hours from stroke onset between February 2009 and December 2014. The presence of delirium was evaluated by two raters based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, using a retrospective chart review method. When no consensus was reached, a third evaluator was consulted. Patients were divided into two groups: those who developed delirium within the first week after stroke onset (n  = 201; 39%) and those who did not (n  = 313; 61%). Receiver operating characteristics (ROC) and multiple logistic regression analysis (MLRA) were used to identify predictors of PSD. Results MLRA showed that NLR (odds ratio (OR) 1.14; 95% confidence interval (CI) 1.04–1.26), age (OR 1.05; 95% CI 1.03–1.07), National Institutes of Health Stroke Scale (NIHSS; OR 1.14; 95% CI 1.10–1.18), premorbid modified Rankin Scale (mRS) (OR 1.35; 95% CI 1.05–1.74) and premorbid cognitive dysfunction (OR 3.16; 95% CI 1.26–7.92) predicted PSD. ROC curve of a prediction model including NLR, age, NIHSS and premorbid cognitive dysfunction showed an area under the curve of 0.84 (95% CI = 0.81–0.88). Conclusions Besides age, stroke severity, premorbid mRS and cognitive impairment, NLR is a predictor of PSD, even independent of the development of pneumonia or urinary tract infection. [ABSTRACT FROM AUTHOR]

Background The objectives were to assess the excess deaths among Nursing Home (NH) residents during the first wave of the COVID-19 pandemic, to determine their part in the total excess deaths and whether there was a mortality displacement. Methods We studied a cohort of 494,753 adults in 6,515 NHs in France exposed to COVID-19 pandemic (from 1 March to 31 May 2020) and compared with the 2014–2019 cohorts using data from the French National Health Data System. The main outcome was death. Excess deaths and standardized mortality ratios (SMRs) were estimated. Result There were 13,505 excess deaths. Mortality increased by 43% (SMR: 1.43). The mortality excess was higher among males than females (SMR: 1.51 and 1.38) and decreased with increasing age (SMRs in females: 1.61 in the 60–74 age group, 1.58 for 75–84, 1.41 for 85–94 and 1.31 for 95 or over; males: SMRs: 1.59 for 60–74, 1.69 for 75–84, 1.47 for 85–94 and 1.41 for 95 or over). No mortality displacement effect was observed up until 30 August 2020. By extrapolating to all NH residents nationally (N  = 570,003), we estimated that they accounted for 51% of the general population excess deaths (N  = 15,114 out of 29,563). Conclusion NH residents accounted for half of the total excess deaths in France during the first wave of the COVID-19 pandemic. The excess death rate was higher among males than females and among younger than older residents. [ABSTRACT FROM AUTHOR]

Background weight loss is commonly observed with ageing. We explored the trajectory of body mass index (BMI) and two proxies of muscle mass—calf circumference (CC) and mid-arm circumference (MAC)—and identified their determinants. Methods within the SNAC-K cohort, 2,155 dementia-free participants aged ≥60 years were followed over 15 years. BMI, CC and MAC were measured at baseline and follow-ups. Baseline sociodemographic and lifestyle factors were collected through interviews. Diabetes and vascular disorders were diagnosed by physicians through clinical examination and medical records. Data were analysed using linear mixed-effect models stratified by age (younger-old [<78 years] vs. older-old [≥78 years]). Results over the 15-year follow-up, BMI remained stable among participants aged 60 years at baseline (β slope = 0.009 [95% confidence interval −0.006 to 0.024], P  = 0.234) and declined significantly among those aged ≥66 years, while CC and MAC declined significantly across all age groups. The decline over 15 years in BMI, CC and MAC separately was 0.435 kg/m2, 1.110 cm and 1.455 cm in the younger-old and was 3.480 kg/m2, 3.405 cm and 3.390 cm in the older-old. In younger-old adults, higher education was associated with slower declines in all three measures, while vascular disorders and diabetes were associated with faster declines. In older-old adults, vigorous physical activity slowed declines in BMI and CC, while vascular disorders accelerated declines in BMI and MAC. Conclusions CC and MAC declined earlier and more steeply than BMI. Cardiometabolic disorders accelerated such declines, while higher education and physical activity could counteract those declines. [ABSTRACT FROM AUTHOR]

Background Critical care demand for older people is increasing. However, there is scarce population-based information about the use of life-support measures such as invasive mechanical ventilation (IMV) in this population segment. Objective To examine the characteristics and recent trends of IMV for older adults. Methods Retrospective cohort study on IMV in adults ≥65 years using the 2004–15 Spanish national hospital discharge database. Primary outcomes were incidence, inhospital mortality and resource utilization. Trends were assessed for average annual percentage change in rates using joinpoint regression models. Results 233,038 cases were identified representing 1.27% of all-cause hospitalizations and a crude incidence of 248 cases/100,000 older adult population. Mean age was 75 years, 62% were men and 70% had comorbidities. Inhospital mortality was 48%. Across all ages, about 80% of survivors were discharged home. Incidence rates of IMV remained roughly unchanged over time with an average annual change of −0.2% (95% confidence interval (CI): −0.9, 0.6). Inhospital mortality decreased an annual average of −0.7% (95% CI: −0.5, −1.0), a trend detected across age groups and most clinical strata. Further, there was a 3.4% (95% CI: 3.0, 3.8) annual increase in the proportion of adults aged ≥80 years, an age group that showed higher mortality risk, lower frequency of prolonged IMV, shorter hospital stays and lower costs. Conclusions Overall rates of IMV remained roughly stable among older adults, while inhospital mortality showed a decreasing trend. There was a notable increase in adults aged ≥80 years, a group with high mortality and lower associated hospital resource use. [ABSTRACT FROM AUTHOR]

Background Nursing homes for older adults have concentrated large numbers of severe cases and deaths for coronavirus disease 2019 (COVID-19). Methods Point seroprevalence study of nursing homes to describe the demography and characteristic of severe acute respiratory syndrome by coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG)-positive residents and staff. Results Clinical information and blood samples were available for 9,332 residents (mean age 86.7 ± 8.1 years, 76.4% women) and 10,614 staff (mean age 45.6 ± 11.5, 86.2% women). Up to 84.4% of residents had frailty, 84.9% co-morbidity and 69.3% cognitive impairment; 65.2% of workers were health-aides. COVID-19 seroprevalence was 55.4% (95% confidence interval (CI), 54.4–56.4) for older adults and 31.5% (30.6–32.4) for staff. In multivariable analysis, frailty of residents was related with seropositivity (odds ratio (OR): 1.19, P  = 0.02). In the case of staff, age > 50 years (2.10, P  < 0.001), obesity (1.19, P  = 0.01), being a health-aide (1.94, P  < 0.001), working in a center with high seroprevalence in residents (3.49, P  < 0.001) and contact with external cases of COVID-19 (1.52, P  < 0.001) were factors associated with seropositivity. Past symptoms of COVID-19 were good predictors of seropositivity for residents (5.41, P  < 0.001) and staff (2.52, P  < 0.001). Conclusions Level of dependency influences risk of COVID-19 among residents. Individual and work factors, contacts outside the nursing home are associated with COVID-19 exposure in staff members. It is key to strengthen control measures to prevent the introduction of COVID-19 into care facilities from the community. [ABSTRACT FROM AUTHOR]

Background Previous studies have demonstrated an association between gait speed and cognitive function. However, the relationship between balance and cognition remains less well explored. This study examined the cross-sectional and longitudinal relationship of balance and cognitive decline in older adults. Methods A cohort of 4,811 adults, aged ≥65 years, participating in the Cardiovascular Health Study was followed for 6 years. Modified Mini-Mental State Examination (3MSE) and Digit Symbol Substitution Test (DSST) were used to measure cognition. Tandem balance measures were used to evaluate balance. Regression models were adjusted for demographics, behavioural and disease factors. Results Worse balance was independently associated with worse cognition in cross-sectional analysis. Longitudinally, participants aged ≥76 years with poorer balance had a faster rate of decline after adjustment for co-variates: −0.97 points faster decline in 3MSE per year (95% confidence interval (CI): −1.32, −0.63) compared to the participants with good balance. There was no association of balance and change in 3MSE among adults aged <76 years (P value for balance and age interaction < 0.0001). DSST scores reflected −0.21 (95% CI: −0.37, −0.05) points greater decline when adjusted for co-variates. In Cox proportional hazard models, participants with worse balance had a higher risk of being cognitively impaired over the 6 years of follow-up visits (adjusted HR:1.72, 95% CI: 1.30, 2.29). Conclusions Future studies should evaluate standing balance as a potential screening technique to identify individuals at risk of cognitive decline. Furthermore, a better understanding of the pathophysiological link between balance and cognition may inform strategies to prevent cognitive decline. [ABSTRACT FROM AUTHOR]

Background We examined the associations between dual impairments in visual and hearing acuity and aging-related cognitive decline. Methods This was a longitudinal study of adults who had visual and hearing acuity and cognitive function assessed in 1992–1996 and were followed for up to 24 years (mean = 7.3 years), with up to five additional cognitive assessments. Visual impairment was defined as vision worse than 20/40, hearing impairment as pure-tone average thresholds >25 dB. Associations were tested using linear mixed-effects regressions. Results Of 1,383 participants, 293 had visual impairment, 990 had a hearing impairment and 251 had both deficits. In fully adjusted models, low visual acuity was associated with poorer Mini-Mental State Examination (MMSE; β = −0.29) and Trail-Making Test Part B (Trails B; β = 13.22) performance, and with faster declines in MMSE (β = −0.12) and Trails B (β = 1.84). The combination of low visual and low hearing acuity was associated with poorer MMSE (β = −0.44) and Trails B (β = 11.20) scores, and with faster declines in MMSE (β = −0.19), Trails B (β = 3.50), and Verbal Fluency Test (VFT; β = −0.14) performance. Associations were similar in men and women. Conclusion Impairments in both vision and hearing are associated with a more rapid decline in cognitive function with aging. [ABSTRACT FROM AUTHOR]

Introduction Hyponatraemia is associated with increased morbidity and mortality; the aetiology and outcomes of hyponatraemia in older patients have not been defined in prospective studies. Methods A single-centre 9-month prospective observational study in which clinical outcomes in hospitalised patients ≥ 65 years (older patients with hyponatraemia (OP-HN)) and those <65 years (young patients with hyponatraemia (YP-HN)) with hyponatraemia were analysed, and compared with eunatraemic controls (older patients with normonatraemia (OP-NN) and young patients with normonatraemia (YP-NN)). Results In total, 1,321 episodes of hyponatraemia in 1,086 patients were included; 437 YP-HN, median age 54 years (IQR 44,60) and 884 OP-HN, median age 77 years (IQR 71,82). A total of 1,120 consecutive eunatraemic control patients were simultaneously recruited; 690 OP-NN, median age 77 years (IQR 71,83) and 430 YP-NN, median age 52 years (IQR 41,58). Euvolaemic hyponatraemia was the commonest cause of hyponatraemia in both age groups (48% in YP-HN and 46% in OP-HN). Sixty-two percent of OP-HN received hyponatraemia-directed treatment within the initial 48 h, compared with 55% of YP-HN, P  = 0.01. Despite the greater treatment rates in OP-HN, younger patients were 24% more likely to be discharged with normal plasma sodium concentration (pNa) compared with older patients, relative risk (RR) 1.24 (95% confidence interval (CI) 1.12–1.37), P  < 0.001. Using OP-NN as the reference group, the RR of in-hospital death in OP-HN was 2.15 (95% CI 1.3–3.56), P  = 0.002. Using YP-NN as the reference group, the RR of in-hospital death in YP-HN was 4.34 (95% CI 1.98–9.56), P  < 0.001. Conclusion Despite greater rates of HN-targeted treatment, the risk of in-hospital death is increased in older hyponatraemic patients compared with older eunatraemic controls. The impact of hyponatraemia on mortality is even greater in younger patients. [ABSTRACT FROM AUTHOR]

Introduction Increased mortality has been demonstrated in older adults with coronavirus disease 2019 (COVID-19), but the effect of frailty has been unclear. Methods This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS) and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results Data from 5,711 patients from 55 hospitals in 12 countries were included (median age 74, interquartile range [IQR] 54–83; 55.2% male). The risk of death increased independently with increasing age (>80 versus 18–49: hazard ratio [HR] 3.57, confidence interval [CI] 2.54–5.02), frailty (CFS 8 versus 1–3: HR 3.03, CI 2.29–4.00) inflammation, renal disease, cardiovascular disease and cancer, but not delirium. Age, frailty (CFS 7 versus 1–3: odds ratio 7.00, CI 5.27–9.32), delirium, dementia and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusion Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age. [ABSTRACT FROM AUTHOR]

Background the ongoing growing and ageing population is associated with an increase in older patients suffering a stroke. We aimed to assess the current profile of these patients in a population-based setting. Methods all patients with acute stroke were prospectively identified among residents of Dijon, France, between 2013 and 2017, using a population-based registry. Characteristics and early outcome of patients were compared according to age groups. Results 1,288 stroke cases were recorded (median age: 81.1 years, interquartile range: 66.1–86.7, 54% women). Patients aged 75–85 years and those >85 years accounted for 27.6 and 33.9% of overall cases. Increasing age was associated with a greater prevalence of vascular risk factors, pre-existing cognitive impairment and handicap, higher initial severity, more frequent cardioembolic ischemic stroke, post-stroke pulmonary infection and delirium. Only 41% of patients aged 75–85 years and 18% of those aged >85 years had a good early recovery. Compared with patients aged <75 years, patients aged 75–85 years [adjusted odds ratio (OR) = 2.61; 95% confidence interval (CI): 1.74–3.93, P  < 0.001] and those aged >85 years (adjusted OR = 7.18; 95% CI: 4.58–11.3, P  < 0.001) had an increased risk of poor post-stroke functional outcome. Among survivors, the proportion of patients discharged to home was 60% in age group <75 years, compared with 49% in patients aged 75–85 years and 29% in those aged >85 years. Thirty per cent of patients >85 years old required a long-term care institution. Conclusion the increasing burden of stroke in older people has major implications for future treatment strategies and need for dedicated care facilities. [ABSTRACT FROM AUTHOR]

Background Adherence to healthy lifestyles/behaviours promotes healthy ageing. However, little is known about whether age, sex and/or race/ethnicity moderate associations of lifestyle/behavioural factors with relative telomere length (RTL), a potential biomarker of ageing. Methods We included 749 midlife to older non-Hispanic White (n  = 254), Black (n  = 248) and Hispanic (n  = 247) US participants [mean (standard deviation) age = 69.3 (7.2) years; women: 50.5%]. We extracted genomic DNA from peripheral leucocytes. RTL was assayed using real-time quantitative polymerase chain reaction. Multivariable regression was used to examine associations between lifestyle/behavioural exposures (i.e. physical activity, alcohol consumption, smoking and depression) with RTL. Results Increasing chronological age was associated with shorter RTL (P  < 0.01). Higher physical activity was associated with longer RTL (P -trend = 0.03); daily versus never/rare alcohol consumption and 30+ versus <5 smoking pack-year were associated with shorter RTLs (P -trend = 0.02). Associations varied significantly by sex and race/ethnicity. The association between physical activity and longer RTL appeared strongest among non-Hispanic Whites (P -interaction = 0.01). Compared to men, women had stronger associations between heavy smoking and shorter RTLs (P -interaction = 0.03). Light/moderate alcohol consumption (monthly/weekly) was associated with longer RTL among non-Hispanic Whites, while daily consumption was related to shorter RTLs among Blacks and Hispanics (P -interactions < 0.01). Associations of daily alcohol and heavy smoking with shorter RTLs were particularly apparent among Black women. Conclusion We observed novel variations by sex and race/ethnicity in associations between lifestyle/behavioural factors and RTL. Further work is needed to replicate these findings and to address potential public health implications for modifying strategies by sex or across racial/ethnic groups to optimise lifestyles/behaviours for healthy ageing. [ABSTRACT FROM AUTHOR]

Background the coronavirus disease 2019 (COVID-19) is characterized by poor outcomes and mortality, particularly in older patients. Methods post hoc analysis of the international, multicentre, 'real-world' HOPE COVID-19 registry. All patients aged ≥65 years hospitalised for COVID-19 were selected. Epidemiological, clinical, analytical and outcome data were obtained. A comparative study between two age subgroups, 65–74 and ≥75 years, was performed. The primary endpoint was all cause in-hospital mortality. Results about, 1,520 patients aged ≥65 years (60.3% male, median age of 76 [IQR 71–83] years) were included. Comorbidities such as hypertension (69.2%), dyslipidaemia (48.6%), cardiovascular diseases (any chronic heart disease in 38.4% and cerebrovascular disease in 12.5%), and chronic lung disease (25.3%) were prevalent, and 49.6% were on ACEI/ARBs. Patients aged 75 years and older suffered more in-hospital complications (respiratory failure, heart failure, renal failure, sepsis) and a significantly higher mortality (18.4 vs. 48.2%, P < 0.001), but fewer admissions to intensive care units (11.2 vs. 4.8%). In the overall cohort, multivariable analysis demonstrated age ≥75 (OR 3.54), chronic kidney disease (OR 3.36), dementia (OR 8.06), peripheral oxygen saturation at admission <92% (OR 5.85), severe lymphopenia (<500/mm3) (OR 3.36) and qSOFA (Quick Sequential Organ Failure Assessment Score) >1 (OR 8.31) to be independent predictors of mortality. Conclusion patients aged ≥65 years hospitalised for COVID-19 had high rates of in-hospital complications and mortality, especially among patients 75 years or older. Age ≥75 years, dementia, peripheral oxygen saturation <92%, severe lymphopenia and qSOFA scale >1 were independent predictors of mortality in this population. [ABSTRACT FROM AUTHOR]

Background Hypoglycaemia during hospital admission is associated with poor outcomes including increased length of stay. In this study, we compared the incidence of inpatient hypoglycaemia and length of stays among people of three age groups: ≤65 years, 65–80 years and >80 years old. Methods The study was conducted using a 4-year electronic patient record dataset from Oxford University Hospitals NHS Foundation Trust. The dataset contains hospital admission data for people with diabetes. We analysed the blood glucose (BG) measurements and identified all level 1 (BG <4 mmol/l) and level 2 (BG <3 mmol/l) hypoglycaemic episodes. We compared the length of stays between different age groups and with different levels of hypoglycaemia. Results We analysed data obtained from 17,658 inpatients with diabetes who underwent 32,758 hospital admissions. The length of stays for admissions with no hypoglycaemia were 3[1,6], 3[1,8] and 4[2,11] (median[interquartile range]) days for age groups ≤65 years, 65–80 years and >80 years, respectively. These were statistically significantly lower (P  < 0.01 for all pairwise comparisons) than the length of stays for admissions with level 1 hypoglycaemia, which were 6[3,13], 10[5,20] and 12[6,22] days, and level 2 hypoglycaemia, which were 7[3,14], 11[5,24] and 13[6,24] days. Conclusions In all age groups, admissions with either level 1 or level 2 hypoglycaemia were associated with an increased length of stay. However, in both the older groups, the length of stay increments were much higher (double) than the younger counterparts. The clinical consequences of hypoglycaemia were more severe in older people compared with the younger population. [ABSTRACT FROM AUTHOR]

Background little is known about the relationship between multimorbidity and social care use (also known as long-term care). The aim of this study was to assess the relationship between receipt of formal social care services and multimorbidity. Methods this retrospective data linkage, observational study included all individuals over the age of 65 in the population of Scotland in financial years 2014–15 and 2015–16 (n  = 975,265). The main outcome was receipt of social care measured by presence in the Scottish Social Care Survey. Logistic regression models were used to assess the influence of multimorbidity, age, sex and socioeconomic position on the outcome reporting average marginal effects (AME). Findings 93.3% of those receiving social care had multimorbidity, 16.2% of those with multimorbidity received social care compared with 3.7% of those without. The strongest magnitudes of AME for receiving social care were seen for age and multimorbidity (respectively, 50 and 18% increased probability comparing oldest to youngest and most severe multimorbidity to none). A 5.5% increased probability of receiving social care was observed for the most-deprived compared with the least-deprived. Interpretation higher levels of social care receipt are observed in those with increasing age, severe multimorbidity and living in more deprived areas. Multimorbidity does not fully moderate the relationship between social care receipt and either age or deprivation. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID-19) has been particularly severe on older people. Past coronavirus epidemics namely Severe Acute Respiratory Syndrome and the Middle East Respiratory Syndrome have also been severe on older people. These epidemics lasted for only a limited period, however, and have proven short lived in the memories of both the public and public health systems. No lessons were learnt to mitigate the impact of future epidemics of such nature, on older people. This complacency we feel has claimed the lives of many older people during the current COVID-19 global epidemic. The nature of risks associated with acquiring infections and associated mortality among older people in respiratory epidemic situations are varied and of serious concern. Our commentary identifies demographic, biological, behavioural, social and healthcare-related determinants, which increase the vulnerability of older people to respiratory epidemics. We acknowledge that these determinants will likely vary between older people in high- and low-middle income countries. Notwithstanding these variations, we call for urgent action to mitigate the impact of epidemics on older people and preserve their health and dignity. Intersectoral programmes that recognise the special needs of older people and in unique contexts such as care homes must be developed and implemented, with the full participation and agreement of older people. COVID-19 has created upheaval, challenging humanity and threatening the lives, rights, and well-being of older people. We must ensure that we remain an age-friendly society and make the world a better place for all including older people. [ABSTRACT FROM AUTHOR]

Background despite unique gender patterns of suicide among older people in rural China, research addressing this issue is scarce. This study aims to clarify the gender-specific risk factors of late-life suicide in rural China. Methods the study included 242 persons (51% male) aged 60 and above who had committed suicide between June 2014 and September 2015 in the rural areas of three provinces of China. Using 1:1 matched case-control design, 242 living controls matched in age, gender and neighbourhood were randomly selected. Psychological autopsy interviews and psychological assessments were conducted with two informants for each suicide and living control, respectively. Results men used alcohol before suicide more than women (12.6 versus 4.7%, P  < 0.05). There was no gender difference in suicide method, suicide intent and previous attempts. Univariate analysis showed that married status, mental disorder, depressive symptoms, hopelessness, impulsivity, loneliness, social support, family function and quality of life were associated with suicide in both genders. For men, other risk factors were chronic physical illness and functions of daily living. Variables remaining in the multivariable model for both men and women were depressive symptoms and hopelessness. Discussion depression and hopelessness are the two major risk factors for suicide among both older men and woman in rural China. Suicide prevention programmes focusing on depression and hopelessness in this population are indicated. Also needed are continued efforts to develop and refined gender-specialised strategies to identify high-risk individuals or groups and to enhance targeted support in the rural community. [ABSTRACT FROM AUTHOR]

Background we project incidence and prevalence of stroke in the UK and associated costs to society to 2035. We include future costs of health care, social care, unpaid care and lost productivity, drawing on recent estimates that there are almost 1 million people living with stroke and the current cost of their care is £26 billion. Methods we developed a model to produce projections, building on earlier work to estimate the costs of stroke care by age, gender and other characteristics. Our cell-based simulation model uses the 2014-based Office for National Statistics population projections; future trends in incidence and prevalence rates of stroke derived from an expert consultation exercise; and data from the Office for Budget Responsibility on expected future changes in productivity and average earnings. Results between 2015 and 2035, the number of strokes in the UK per year is projected to increase by 60% and the number of stroke survivors is projected to more than double. Under current patterns of care, the societal cost is projected to almost treble in constant prices over the period. The greatest increase is projected to be in social care costs—both public and private—which we anticipate will rise by as much as 250% between 2015 and 2035. Conclusion the costs of stroke care in the UK are expected to rise rapidly over the next two decades unless measures to prevent strokes and to reduce the disabling effects of strokes can be successfully developed and implemented. [ABSTRACT FROM AUTHOR]

Background the increasing number of multimorbid older people places high demands on future health care systems. To inform the discussion on how to structure future care strategies, we aimed to describe the temporal relationship between admission, and morbidity and mortality in nursing home residents. Methods data on 5,179 older individuals admitted to 94 Danish nursing homes in 12 municipalities during 2015–2017 were linked to the nationwide Danish health registries to retrieve information on the temporal relation between nursing home admission and morbidity and mortality. Results at the time of nursing home admission, the majority were women (63%). Male residents were younger than women (median 82 vs 85 years) and had a higher prevalence of comorbidities (median Charlson score 2 vs 1 among women). The median survival after nursing home admission was 25.8 months, with the 3-year survival being 37%. Three-year survival was lower among men (29 vs 43% among women) and among the oldest residents (23% among those aged ≥90 years vs 64% among individuals ≤65 years). In addition to age and sex, predictors of mortality included hospitalisations prior to nursing home admission and a high burden of comorbidity. The rate of hospitalisations, primarily for reasons related to frailty, increased substantially during the 9 months prior to nursing home admission. Conclusion we provide detailed information on differences in morbidity and mortality across age span and sex at the time of nursing home admission, thereby contributing to the ongoing discussion of how to structure the future health care system. [ABSTRACT FROM AUTHOR]

Objective to evaluate the association between first- and second-eye cataract surgery and motor vehicle crashes for older drivers and the associated costs to the community. Design retrospective population-based cohort study. Subjects a total of 2,849 drivers aged 60 years and older who had undergone both first- and second-eye cataract surgery were involved in 3,113 motor vehicle crashes as drivers during the study period. Methods de-identified data were obtained using the Western Australian Data Linkage System from 1 January 2003 to 31 December 2015. Poisson regression analysis based on Generalised Estimating Equations was undertaken to compare the frequency of crashes in the year before first eye cataract surgery, between first and second eye surgery and 1 year after second eye surgery. Results first eye cataract surgery was associated with a significant 61% reduction in crash frequency (P < 0.001) and second eye surgery was associated with a significant 23% reduction in crashes (P < 0.001), compared to the year before first eye cataract surgery after accounting for age, gender, marital status, accessibility, socio-economic status, driving exposure and comorbidities. The estimated cost savings from the reduction in crashes in the year after second eye cataract surgery compared to the year before first eye cataract surgery was $14.9 million. Conclusions first- and second-eye cataract surgery were associated with a significant reduction in motor vehicle crashes, with first eye surgery having the greatest impact. These results provide encouragement for the timely provision of first- and second-eye cataract surgery for older drivers. [ABSTRACT FROM AUTHOR]

Objective to evaluate the association between first- and second-eye cataract surgery and motor vehicle crashes for older drivers and the associated costs to the community. Design retrospective population-based cohort study. Subjects a total of 2,849 drivers aged 60 years and older who had undergone both first- and second-eye cataract surgery were involved in 3,113 motor vehicle crashes as drivers during the study period. Methods de-identified data were obtained using the Western Australian Data Linkage System from 1 January 2003 to 31 December 2015. Poisson regression analysis based on Generalised Estimating Equations was undertaken to compare the frequency of crashes in the year before first eye cataract surgery, between first and second eye surgery and 1 year after second eye surgery. Results first eye cataract surgery was associated with a significant 61% reduction in crash frequency (P < 0.001) and second eye surgery was associated with a significant 23% reduction in crashes (P < 0.001), compared to the year before first eye cataract surgery after accounting for age, gender, marital status, accessibility, socio-economic status, driving exposure and comorbidities. The estimated cost savings from the reduction in crashes in the year after second eye cataract surgery compared to the year before first eye cataract surgery was $14.9 million. Conclusions first- and second-eye cataract surgery were associated with a significant reduction in motor vehicle crashes, with first eye surgery having the greatest impact. These results provide encouragement for the timely provision of first- and second-eye cataract surgery for older drivers. [ABSTRACT FROM AUTHOR]

Background loneliness has an adverse effect on health and well-being, and is common at older ages. Evidence that it is a risk factor for care home admission is sparse. Objective to investigate the association between loneliness and care home admission. Setting English Longitudinal Study of Ageing (ELSA). Participants two-hundred fifty-four individuals across seven waves (2002–15) of ELSA who moved into care homes were age, sex matched to four randomly selected individuals who remained in the community. Methods logistic regression models examined associations between loneliness, socio-demographic factors, functional status and health on moving into care homes. Results loneliness (measured by the University of California, Los Angeles (UCLA) Loneliness Scale and a single-item question from the Center for Epidemiological Studies Depression Scale (CES-D)) was associated with moving into a care home (CES-D OR 2.13, 95% CI 1.43–3.17, P = 0.0002, UCLA OR 1.81, 95% CI 1.01–3.27, P = 0.05). The association persisted after adjusting for established predictors (age, sex, social isolation, depression, memory problems including diagnosis of Alzheimer's disease, disability, long-term physical health and wealth). The impact of loneliness (measured by CES-D) on admission accounted for a population attributable fraction of 19.9% (95% CI 7.8–30.4%). Conclusions loneliness conveys an independent risk of care home admission that, unlike other risk factors, may be amenable to modification. Tackling loneliness amongst older adults may be a way of enhancing wellbeing and delaying or reducing the demand for institutional care. [ABSTRACT FROM AUTHOR]

Background age-specific mortality reduction has been accompanied by a decrease in the prevalence of some diseases and an increase in others. Whether populations are becoming ‘healthier’ depends on which aspect of health is being considered. Frailty has been proposed as an integrative measure to quantify health status. Objective to investigate changes in the near-term lethality of frailty before and after a 20-year interval using the frailty index (FI), a summary of age-related health deficit accumulation. Design baseline data from the Cognitive Function and Ageing Studies (CFAS) in 1991 (n = 7,635) and 2011 (n = 7,762). Setting three geographically distinct UK centres (Newcastle, Cambridgeshire and Nottingham). Subjects individuals aged 65 and over (both institutionalised and community-living). Methods a 30-item frailty score was used, which includes morbidities, risk factors and subjective measures of disability. Missing items were imputed using multiple imputations by chained equations. Binomial regression was used to investigate the relationship between frailty, age, sex and cohort. Two-year mortality was modelled using logistic regression. Results mean frailty was slightly higher in CFAS II (0.19, 95% confidence interval (CI): 0.19–0.20) than CFAS I (0.18, 95% CI: 0.17–0.18). Two-year mortality in CFAS I was higher than in CFAS II (odds ratio (OR) = 1.16, 95% CI: 1.03–1.30). The association between frailty and 2-year mortality was non-linear with an OR of ~1.6 for each 0.10 increment in the FI. Conclusions the relationship between frailty and mortality did not significantly differ across the studies. Severe frailty as an indicator of mortality is shown to be a stable construct. [ABSTRACT FROM AUTHOR]

Background: there is evidence suggesting that several chronic diseases have their origins in utero and that development taking place during sensitive periods may affect the aging process. We investigated whether early life determinants would be associated with frailty in old age. Methods: at a mean age of 71 years, 1,078 participants belonging to the Helsinki Birth Cohort Study were assessed for frailty according to the Fried frailty criteria. Early life measurements (birth weight, length, mother body mass index [BMI] and parity) were obtained from birth, child welfare and school health records. Multinomial regression analysis was used to assess the association between early life determinants and frailty in old age. Results: weight, length and BMI at birth were all inversely associated with frailty in old age. A 1 kg increase in birth weight was associated with a lower relative risk ratio (RRR) of frailty (age and sex-adjusted RRR = 0.40, 95% CI: 0.19, 0.82) compared to non-frailty. Associations persisted after adjusting for several confounding factors. Compared to cohort members in the upper middle class, those who as adults worked as manual workers or belonged to the lower middle class, were at an increased risk of frailty. Conclusions: those who were small at birth were at an increased risk of developing frailty in old age, suggesting that frailty is at least partly programmed in early life. A less privileged socioeconomic status in adulthood was associated with an increased risk of frailty in old age. [ABSTRACT FROM AUTHOR]

Objectives: to determine whether pain increases the risk of developing the frailty phenotype and whether frailty increases the risk of developing chronic or intrusive pain, using longitudinal data. Design/Setting: longitudinal data from the Concord Health and Ageing in Men Project (CHAMP), a prospective population based cohort study. Participants: a total of 1,705 men aged 70 years or older, living in an urban area of New South Wales, Australia. Measurements: data on the presence of chronic pain (daily pain for at least 3 months), intrusive pain (pain causing moderate to severe interference with activities) and the criteria for the Cardiovascular Health Study (CHS) frailty phenotype were collected in three waves, from January 2005 to October 2013. Data on age, living arrangements, education, smoking status, alcohol consumption, body mass index, comorbidities, cognitive function, depressive symptoms and history of vertebral or hip fracture were also collected and included as covariates in the analyses. Results: a total of 1,705 participants were included at baseline, of whom 1,332 provided data at the 2-year follow-up and 940 at the 5-year follow-up. Non-frail (robust and pre-frail) men who reported chronic pain were 1.60 (95% confidence interval (CI): 1.02-2.51, P = 0.039) times more likely to develop frailty at follow-up, compared to those with no pain. Intrusive pain did not significantly increase the risk of future frailty. Likewise, the frailty status was not associated with future chronic or intrusive pain in the adjusted analysis. Conclusions: the presence of chronic pain increases the risk of developing the frailty phenotype in community-dwelling older men. [ABSTRACT FROM AUTHOR]