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Background dehydration is associated with significant adverse outcomes in older people despite being largely preventable and treatable. Little research has focused on the views of community-dwelling older people on hydration, healthy drinking and the perceived importance of drinking well in later life. Objectives to understand community-dwelling older people and informal carers’ views on hydration in later life and how older people can be supported to drink well. Methods qualitative study using interviews and a focus group exploring hydration and nutrition in later life (24 older people at risk of malnutrition and dehydration, 9 informal carers) and thematic analysis. Results this article presents the findings on hydration alone. Four themes are presented: perceptions of healthy drinking, barriers to and facilitators of drinking in later life and supporting older people to drink well. The perceived importance of adequate hydration in later life was polarised. Concerns about urinary incontinence and knowledge gaps were significant barriers. Consideration of individual taste preference and functional capacity acted as facilitators. Distinct habitual drinking patterns with medications and meals exist within individuals. Many relied on thirst at other times or when fluid demands are greater (such as hot weather), a known unreliable prompt in later life. Conclusions older people could be supported to drink well by building upon existing habitual drinking patterns. Primary care and public health should consider individual barriers, facilitators and tailored education. A multidisciplinary approach to promote hydration should be incorporated into care for older people with more complex needs.

Objectives To explore cross-sectional and longitudinal relationships between self-reported hearing and vision impairments and self-rated health, quality of life (QoL) and depressive symptoms at 4-year follow-up. Study design The study involved cross-sectional and longitudinal analyses with 4-year follow-up using data from the English Longitudinal Study of Ageing. Methods Community-dwelling adults (n = 3931) aged ≥50 years from the English Longitudinal Study of Ageing participated in this study. Self-reported hearing and vision were defined as good or poor. Self-rated health was treated as a dichotomous variable (good and poor health). QoL was based on the 19-item Critical Appraisal Skills Programme and treated as a continuous variable (score 0–57). Depressive symptoms were assessed using the eight-item Center for Epidemiologic Studies Depression Scale (CES-D8) and defined as CES-D≥3. Relationships between sensory impairments and self-rated health and depressive symptoms were analysed using logistic regression. Linear regression was used to assess the relationships between sensory impairments and QoL. Results In cross-sectional analyses, both self-reported hearing and vision impairment were positively associated with all outcomes assessed. In longitudinal analyses, self-reported poor hearing and vision were associated with increased risks of poor self-rated health (hearing: odds ratio [OR] 1.65, 95% confidence interval [CI] 1.32, 2.05; vision: OR 1.57, 95% CI 1.16, 2.12) and depressive symptoms (hearing: OR 1.35, 95% CI 1.07, 1.71; vision: OR 1.44, 95% CI 1.09, 1.90) after adjustment for sociodemographic and lifestyle factors, chronic illness, mobility limitations and cognition. Poor hearing and poor vision were not associated with reduced QoL after adjustment for covariates. Conclusions The findings stress the importance of identifying and addressing sensory impairments in older adults to improve their health and well-being.

Older adults are a highly heterogeneous group with variable health and functional life courses. Frailty has received increasing scientific attention as a potential explanation of the health diversity of older adults. The frailty phenotype and the Frailty Index are the most frequently used frailty definitions, but recently new frailty definitions that are more practical have been advocated. Prevalence of frailty among the community-dwelling population aged 65 years and older is ~10% but varies depending on which frailty definitions are used. The mean prevalence of frailty gradually increases with age, but the individual’s frailty level can be improved. Older adults, especially frail older adults, form the main users of medical and social care services. However, current health care systems are not well prepared to deal with the chronic and complex medical needs of frail older patients. In this context, frailty is potentially a perfect fit as a risk stratification paradigm. The evidence from frailty studies has not yet been fully translated into clinical practice and health care policy making. Successful implementation would improve quality of care and promote healthy aging as well as diminish the impact of aging on health care systems and strengthen their sustainability. At present, however, there is no effective treatment for frailty and the most effective intervention is not yet known. Based on currently available evidence, multi-domain intervention trials, including exercise component, especially multicomponent exercise, which includes resistance training, seem to be promising. The current challenges in frailty research include the lack of an international standard definition of frailty, further understanding of interventions to reverse frailty, the best timing for intervention, and education/training of health care professionals. The hazards of stigmatization should also be considered. If these concerns are properly addressed, widespread application of public health approaches will be possible, including screening, identification, and treatment of frailty, resulting in better care and healthier aging for older people.

Objective: To investigate the influence of single and dual sensory impairments prospectively on cognition in adults aged ⩾50 years. Method: Community-dwelling English adults ( n = 4,621) were followed up from 2008 to 2014. Self-reported hearing and vision were collected in 2008. Change in cognitive performance on working memory and executive function between 2008 and 2014 was evaluated. Results: Compared with good hearing and good vision, respectively, poor hearing and poor vision were associated with worse cognitive function (hearing: unstandardized coefficient B = 0.83, 95% Confidence Interval [CI] = [0.29, 1.37]; vision: B = 1.61, 95% CI = [0.92, 2.29] adjusted for age, sex, baseline cognition). Compared with no sensory impairment, dual sensory impairment was associated with worse cognition ( B = 2.30, 95% CI = [1.21, 3.39] adjusted for age, sex, baseline cognition). All associations remained after further adjustment for sociodemographic characteristics, lifestyle factors, chronic conditions, falls, mobility, depression, and lack of companionship. Discussion: The findings are important as age-related sensory impairments are often preventable or modifiable, which may prevent or delay cognitive impairment.

Mild frailty is common in later life, increasing the risk of hospitalisation, loss of independence and premature death. Targeted health promotion services may reduce adverse outcomes and increase quality of life; however, effective, well-developed theory-based interventions are lacking. We aimed to explore perceptions of health promotion behaviours undertaken by older people with mild frailty, barriers and facilitators to engagement, and identify potential components for new home-based health promotion services. We carried out 17 semi-structured qualitative interviews and six focus groups with 53 stakeholders, including 14 mildly frail older people, 12 family carers, 19 community health and social care professionals, and 8 homecare workers, in one urban and one semi-rural area of England. Transcripts were thematically analysed. Older people with mild frailty reported engaging in a variety of lifestyle behaviours to promote health and well-being. Key barriers or facilitators to engaging in these included transport, knowledge of local services, social support and acceptance of personal limitations. Older people, carers and professionals agreed that any new service should address social networks and mobility and tailor other content to each individual. Services should aim to increase motivation through focussing on independence and facilitate older people to continue carrying out behaviours that improve their well-being, as well as provide information, motivation, psychological support and practical support. Stakeholders agreed services should be delivered over a sustained period by trained non-specialist workers. New services including these components are likely to be acceptable to older people with mild frailty.

Introduction: The growing number of older adults with multiple needs increases the pressure to reform existing healthcare systems. Integrated care may be part of such reforms. The aim of this systematic review was to identify important patient-related outcomes of integrated care provided to older adults. Methods: A systematic search of 5 databases to identify studies comprising older adults assessing hospital admission, length of hospital stay, hospital readmission, patient satisfaction and mortality in integrated care settings. Retrieved literature was analysed employing a narrative synthesis. Results: Twelve studies were included (2 randomised controlled trials, 7 quasi-experimental design, 2 comparison studies, 1 survey evaluation). Five studies investigated patient satisfaction, 9 hospital admission, 7 length of stay, 3 readmission and 5 mortality. Findings show that integrated care tends to have a positive impact on hospital admission rates, some positive impact on length of stay and possibly also on readmission and patient satisfaction but not on mortality. Conclusions: Integrated care may reduce hospital admission rates and lengths of hospital stay. However due to lack of robust findings, the effectiveness of integrated care on patient-related outcomes in later life remain largely unknown. Further research is needed to establish the effect of integrated care on these patient-related outcomes. Prospero registration number: CRD42018110491.

Background: While malnutrition is an important cause of morbidity and mortality in older people, it is commonly under-recognised. We know little on the views of community-dwelling older people and their carers regarding the management of malnutrition. The aim of the study was: (a) to explore views and dietary practices of older people at risk of malnutrition and their carers, (b) to identify gaps in knowledge, barriers and facilitators to healthy eating in later life, (c) to explore potential interventions for malnutrition in primary care. Methods: A qualitative study was performed using semi-structured interviews with participants recruited from four general practices and a carers&rsquo, focus group in London. Community-dwelling people aged &ge, 75, identified as malnourished or at risk of malnutrition (n = 24), and informal carers of older people (n = 9) were interviewed. Data were analysed using thematic analysis. Results: Older people at risk of malnutrition rarely recognise appetite or weight loss as a problem. Commonly held perceptions include that being thin is healthy and &lsquo, snacking&rsquo, is unhealthy. Changes in household composition, physical or mental health conditions and cognitive impairment can lead to inadequate food intake. Most carers demonstrate an awareness of malnutrition, but also a lack of knowledge of what constitutes a nutritious diet. Although older people rarely seek any help, most would value advice from their GP/practice nurse, a dietitian or another trained professional. Conclusion: Older people at risk of malnutrition and their carers lack knowledge on nutritional requirements in later life but are receptive to intervention. Training for health professionals in delivering tailored dietary advice should be considered.

Background Older people living in deprived areas, from black and minority ethnic groups (BME) or aged over 85 years (oldest old) are recognised as ‘hard to reach’. Engaging these groups in health promotion is of particular importance when seeking to target those who may benefit the most and to reduce health inequalities. This study aimed to explore what influences them practicing health promotion and elicit the views of cross-sector professionals with experiences of working with ‘hard to reach’ older people, to help inform best practice on engagement. Methods ‘Hard to reach’ older people were recruited through primary care by approaching those not attending for preventative healthcare, and via day centres. Nineteen participated in an interview (n = 15) or focus group (n = 4); including some overlaps: 17 were from a deprived area, 12 from BME groups, and five were oldest old. Cross-sector health promotion professionals across England with experience of health promotion with older people were identified through online searches and snowball sampling. A total of 31 of these 44 professionals completed an online survey including open questions on barriers and facilitators to uptake in these groups. Thematic analysis was used to develop a framework of higher and lower level themes. Interpretations were discussed and agreed within the team. Results Older people’s motivation to stay healthy and independent reflected their everyday behaviour including practicing activities to feel or stay well, level of social engagement, and enthusiasm for and belief in health promotion. All of the oldest old reported trying to live healthily, often facilitated by others, yet sometimes being restricted due to poor health. Most older people from BME groups reported a strong wish to remain independent which was often positively influenced by their social network. Older people living in deprived areas reported reluctance to undertake health promotion activities, conveyed apathy and reported little social interaction. Cross-sector health professionals consistently reported similar themes as the older people, reinforcing the views of the older people through examples. Conclusions The study shows some shared themes across the three ‘hard-to-reach’ groups but also some distinct differences, suggesting that a carefully outlined strategy should be considered to reach successfully the group targeted. Electronic supplementary material The online version of this article (10.1186/s12889-019-6911-1) contains supplementary material, which is available to authorized users.

A recent systematic review and meta-analysis study suggested that higher alcohol consumption is associated with lower risks for frailty. However the apparent protective effect may not be true because of some limitations. Therefore we further explored potential linear and non-linear associations using a two-stage dose-response meta-analysis. Restricted cubic splines were applied with three fixed knots at percentiles (10%, 50%, and 90%). A two-stage dose-response meta-analysis showed a significant non-linear association (p for non-linearity < 0.001); incident frailty risk decreased until around 15 g/day of alcohol consumption and increased thereafter. This suggests that while moderate alcohol consumption is associated with a lower risk of frailty, at higher consumption levels this apparent protect effect is lost. Given these findings, non-linear associations should be considered in future research on alcohol and frailty.

Importance Sensory acuity tends to decrease with age, but little is known about the relationship between having multiple sensory impairments and well-being in later life. Objective To examine associations between concurrent multisensory impairments and aspects of well-being and mental health, namely quality of life and depressive symptoms. Design, Setting, and Participants Cross-sectional analysis of participants in the English Longitudinal Study of Aging wave 8 (May 2016 to June 2017). This is a representative sample of free-living English individuals 52 years and older. Analysis began April 2018. Main Outcomes and Measures Linear and logistic regression models were used to assess the association of self-reported concurrent impairments in hearing, vision, smell, and taste with quality of life (0-57 on the 19-item CASP-19 scale; Control, Autonomy, Self-realization and Pleasure) and depressive symptoms (≥4 items on the 8-item Centre for Epidemiologic Study Depression Scale). Results Using a representative sample of 6147 individuals, 52% (weighted) were women (n = 3455; unweighted, 56%) and the mean (95% CI) age was 66.6 (66.2-67.0) years. Multiple sensory impairments were associated with poorer quality of life and greater odds of depressive symptoms after adjustment for sociodemographic characteristics, lifestyle factors, chronic conditions, and cognitive function. Compared with no sensory impairment, quality of life decreased linearly as the number of senses impaired increased, with individuals reporting 3 to 4 sensory impairments displaying the poorest quality of life (−4.68; 95% CI, −6.13 to −3.23 points on the CASP-19 scale). Similarly, odds of depressive symptoms increased linearly as the number of impairments increased. Individuals with 3 to 4 senses impaired had more than a 3-fold risk of depressive symptoms (odds ratio, 3.36; 95% CI, 2.28-4.96). Conclusions and Relevance In this cross-sectional study, concurrent sensory impairments were associated with poorer quality of life and increased risks of depressive symptoms. Therefore, assessing and managing sensory impairments could help improve older adults’ well-being.

Alcohol consumption is a common modifiable lifestyle factor. Alcohol may be a risk factor for frailty, however, there is limited evidence in the literature.The objectives of this study were to examine the association of alcohol consumption with the risk of incident frailty.This is a prospective panel study of 2544 community-dwelling people aged 60 years and older in England. Frailty status defined by frailty phenotype criteria was measured at baseline and 4 years later. Participants free of frailty at baseline were divided into 5 groups based on quantity of self-reported alcohol consumption per week with cut-points at 0, 7, 14, and 21 UK units per week. Adjusted odds ratios (OR) were calculated for incident frailty according to the alcohol consumption using logistic regression models.Compared with the low consumption group (0 and ≤7 units per week), incident frailty risk over 4 years was significantly higher among nondrinkers [OR 1.71, 95% confidence interval (CI) 1.12‒2.60, P value = .01], after controlling for sociodemographic confounders. In a supplementary analysis this became nonsignificant after further adjustment for baseline health status. Heavy drinkers (21 units per week) had a significantly lower incident frailty risk (unadjusted OR 0.45, 95% CI 0.27‒0.75, P .01), which became nonsignificant on adjustment for sociodemographic factors (OR 0.64, 95% CI 0.37‒1.13, P = .12).We found that nondrinkers were more likely than those with low alcohol consumption to develop frailty, but this appeared to be explained by poorer baseline health status. No evidence was found for an association between high levels of alcohol consumption and becoming frail. Future studies with information on life-course history of alcohol use, especially for those classified as nondrinkers in old age, are warranted.

BackgroundMild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression.Objectives(1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT).DesignEvidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation.Intervention developmentTwo systematic reviews (including systematic searches of 14 databases and registries, 1990–2016 and 1980–2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65–94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the ‘HomeHealth’ intervention in collaboration with older people and multidisciplinary stakeholders. ‘HomeHealth’ comprised 3–6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation.Feasibility RCTSingle-blind RCT, individually randomised to ‘HomeHealth’ or treatment as usual (TAU).SettingCommunity settings in London and Hertfordshire, UK.ParticipantsA total of 51 community-dwelling adults aged ≥ 65 years with mild frailty.Main outcome measuresFeasibility – recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs.ResultsWe successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68;p = 0.004), better grip strength (+6.48 kg;p = 0.02), reduced psychological distress (12-item General Health Questionnaire –3.92;p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding.ConclusionsEvidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible.Future workA large, definitive RCT of the HomeHealth service is warranted.Study registrationThis study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information.

BACKGROUND: Frailty is a state of increased vulnerability to poor resolution of homeostasis as a consequence of age-related decreased physiological reserves. Although physical frailty and cognitive impairment have been shown to be associated, evidence on the prevalence of frailty in Alzheimer’s disease is scarce. OBJECTIVE: To conduct a systematic review on the prevalence of frailty and to combine the data to synthesize the pooled prevalence of physical frailty among patients with Alzheimer’s disease. METHOD: Five electronic databases (Embase, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library) were searched for studies providing cross-sectional data on physical frailty among patients with Alzheimer’s disease published from 2000 to January 2016. RESULTS: Of 2,564 studies identified through the systematic review, five studies incorporating 534 patients with Alzheimer’s disease were included for the meta-analysis. The prevalence of frailty varied with a wide range from 11.1% to 50.0% and the pooled prevalence was 31.9% (five studies, 95% confidence interval (CI)=15.7%-48.5%) . The high degree of heterogeneity was observed in all analyses publication bias was detected. CONCLUSION: The current study showed that frailty is highly prevalent in older patients with Alzheimer’s disease in the community with the pooled prevalence of 31.9%. The true prevalence may be much higher given that end-stage patients may not be included. This information is important for clinicians and researchers.

BACKGROUND: smoking is the single most preventable cause of morbidity and mortality. The evidence on independent associations between smoking in later life and incident frailty is scarce. OBJECTIVES: to examine the effect of current smoking in older people on the risk of developing frailty, controlling for important confounders. METHODS: we used data of 2,542 community-dwelling older people aged ≥60 years in England. Participants were classified as current smokers or non-smokers. Frailty was defined using modified Fried criteria. Multivariable logistic regression models were used to examine risk of 4-year incident frailty in current smokers compared with non-smokers, adjusted for demographic, socioeconomic and health variables. RESULTS: of 2,542 participants, 261 and 2,281 were current smokers and non-smokers, respectively. The current smokers were significantly frailer, younger, with lower BMI, less educated, less wealthy and lonelier compared with non-smokers at baseline. In multivariable logistic regression models adjusting for age and gender, current smokers were twice as likely to develop frailty compared with non-smokers (odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.39–3.39, P = 0.001). The association is attenuated largely by controlling for socioeconomic status. Smoking remains significantly associated with incident frailty in fully adjusted models including age, gender, socioeconomic status, alcohol use, cognitive function and loneliness (OR = 1.60, 95% CI = 1.02–2.51, P = 0.04). The relationship is however attenuated when taking account of non-response bias through multiple imputation. CONCLUSIONS: current smokers compared with non-smokers were significantly more likely to develop frailty over 4 years among community-dwelling older people. Given that smoking is a modifiable lifestyle factor, smoking cessation may potentially prevent or delay developing frailty, even in old age.

Plain English Summary A one day public engagement workshop was held to focus on the priorities of older people about research and practice in health and social care. Seventy-five older people from the general public and a variety of backgrounds attended this event to share their views and discuss what should be prioritised. The main aim of this workshop was to identify and prioritise issues that are important to older people that would benefit from further research, as well as create an environment for older people to share ideas and problems related to these important issues. Key priorities brought up by participants included loneliness and isolation, support and training for professional and family carers, post-surgical care, negative perceptions of older people and inequalities related to public services and healthcare. Participants further suggested older people should be actively involved in all stages of the research process. Abstract As the world’s population ages, there is an increasing need for research that addresses the priorities of older people. A public engagement workshop focusing on the priorities of older people for research and practice in health and social care was attended by seventy-five people aged 70 years and above in London, United Kingdom (UK). The workshop aimed to identify and prioritise issues important to older people that would benefit from further research and act as a platform to promote sharing of ideas and problems related to these important issues. Key priorities emerged including loneliness and isolation, support and training for professional and family carers, post-surgical care, negative perceptions of older people and inequalities related to public services and healthcare. Participants further suggested older people should be actively involved in all stages of the research process.

Background: Hearing and vision problems are common in older adults. We investigated the association of self-reported sensory impairment with lifestyle factors, chronic conditions, physical functioning, quality of life and social interaction. / Methods: A population-based cross-sectional study of participants of the British Regional Heart Study aged 63–85 years. / Results: A total of 3981 men (82% response rate) provided data. Twenty-seven per cent (n = 1074) reported hearing impairment including being able to hear with aid (n = 482), being unable to hear (no aid) (n = 424) and being unable to hear despite aid (n = 168). Three per cent (n = 124) reported vision impairment. Not being able to hear, irrespective of use of hearing aid, was associated with poor quality of life, poor social interaction and poor physical functioning. Men who could not hear despite hearing aid were more likely to report coronary heart disease (CHD) [age-adjusted odds ratios (ORs) 1.89 (95% confidence interval 1.36–2.63)]. Vision impairment was associated with symptoms of CHD including breathlessness [OR 2.06 (1.38–3.06)] and chest pain [OR 1.58 (1.07–2.35)]. Vision impairment was also associated with poor quality of life, poor social interaction and poor physical functioning. / Conclusions: Sensory impairment is associated with poor physical functioning, poor health and poor social interaction in older men. Further research is warranted on pathways underlying these associations.

Background Older people living in deprived areas, from black and minority ethnic groups, and aged over 85 years are often considered hard-to-reach. This qualitative study aimed to explore their views on health promotion services, with a view to help inform best practice on engagement. Methods Older people were recruited through primary care and community-based groups. 19 participated in an interview (n=15) or focus group (n=4); including some overlaps, 16 were from a deprived area, 12 were in black and ethnic minority groups, and 5 were aged 85 years or older. Cross-sector professionals across England with experience of working with one or more of the groups were identified with online searches and snowball sampling. 31 of 44 professionals completed an online survey. Thematic analysis was used to develop a framework of higher and lower level themes. Interpretations were discussed and agreed within the team. Findings Older people from all hard-to-reach groups described some health-promoting activities they practised themselves, including lifelong lifestyle approaches, with a focus on maintaining independence. All groups reported cost and access considerations as barriers to participation in health promotion. Among older people in deprived areas, facilitators included monetary incentives and interventions held locally or accessible through free transport. Barriers included reluctance to seek medical help, mistrust of professionals, and negative social relationships with other participants. Professionals' successful strategies targeting this group included personalised health education focusing on their interests and engaging local services, community, peers, and family. Older people from black and ethnic minority groups reported that social opportunities and peer support facilitated engagement. Barriers focused on cultural and language differences. These barriers were also reported by professionals who reported culture-specific, tailored information alongside good relationships with community groups and families as important. For the oldest-old, home visits were popular. Poor health and lack of interest in health promotion were major barriers. Face-to-face contact and involving individuals from an early stage were reported as successful strategies by professionals. Interpretation This is one of few studies conducted in England investigating views of both hard-to-reach older people and professionals working with them. Study limitations include selection bias because only those interested responded. Specific facilitators and barriers identified by older people and professionals may shape best practice on increasing engagement with health promotion services for hard-to-reach groups. Funding National Institute for Health Research (NIHR). AL is funded by the NIHR School for Public Health Research.

Background Age-related vision impairment has been associated with comorbidities, current disability, and poor quality of life. However, it is unclear whether vision impairment is associated with increasing future frailty, further affecting ability to live independently. We investigated the association of poor vision with incident pre-frailty and frailty. Methods 2836 men and women aged 60 years or more with data on vision (self-reported vision problems) and frailty status (Fried phenotype) from the nationally representative English Longitudinal Study of Ageing were followed up for 4 years for pre-frailty and frailty between 2004 and 2008. Frailty was defined according to number of Fried phenotype components present (slow walking, weak grip, self-reported exhaustion, weight loss, low physical activity) as non-frail (0 components), pre-frail (1–2), and frail (≥3). Participants non-frail at baseline were followed up for incident pre-frailty and frailty. Participants pre-frail at baseline were followed up for incident frailty. Findings At baseline, 1396 participants (49%) were non-frail, 1178 (42%) pre-frail, and 262 (9%) frail. At follow-up, there were 367 new cases of pre-frailty and frailty among those non-frail at baseline, and 133 new cases of frailty among those pre-frail at baseline. Cross-sectional analysis showed an association between vision impairment and frailty (age-adjusted and sex-adjusted odds ratio 2·53, 95% CI 1·95–3·30; p Interpretation Older adults who experience poor vision and are not frail have double the risk of becoming pre-frail or frail over 4 years. Public health interventions aiming to identify and actively manage vision impairment might prevent frailty. Funding AEML is funded by the National Institute for Health Research School for Public Health Research (509546). LAC is funded by the British Heart Foundation (RG/10/001/28296) and the Medical Research Council (RG71546). SER is funded by a UK Medical Research Council fellowship (G1002391).