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Background The association between dietary protein intake and the risk of mortality is still controversial. The present study aimed to examine the associations between dietary total, animal and plant protein intake and all-cause and cause-specific mortality. Methods Community-dwelling men aged ≥ 70 years were recruited from local government areas surrounding Concord Hospital in Sydney, New South Wales for the Concord Health and Ageing in Men Project (CHAMP). The research dietitian administered a standardised validated diet history questionnaire to capture baseline dietary intake. In total, 794 men participated in a detailed diet history interview at the third wave. Adequacy of protein intake was assessed by comparing participant intake with the Nutrient Reference Values. Total protein intake was categorised into quintiles. Sources of protein were also captured. Mortality was ascertained through the New South Wales death registry. Cox proportional hazard models were used to assess the association between dietary total, animal and plant protein intake and risk of mortality. Results The mean age of the CHAMP men was 81 years. In total, 162 men died during a median follow-up of 3.7 years. Of these, 54 (33.3%) and 49 (30.2%) men died due to cancer and cardiovascular disease, respectively. There were U-shaped associations between protein intake and all-cause and cancer mortality. In multiple adjusted analysis, the second (hazard ratio [HR] = 0.38; 95% confidence interval [CI] = 0.18-0.82) and third (HR = 0.36; 95% CI = 0.16-0.82) quintiles of protein intakes were significantly associated with reduced risk of all-cause and only second quintile (HR = 0.47; 95% CI = 0.10-0.93) of protein intake was significantly associated with cancer mortality. Each serve increase in animal protein was significantly associated with 12% (HR = 1.12; 95% CI = 1.00-1.26) and 23% (HR = 1.23; 95% CI = 1.02-1.49) increased risk of all-cause mortality and cancer mortality respectively. Conversely, each serve increase in plant protein intake was significantly associated with 25% (HR = 0.75; 95% CI 0.61-0.92) and 28% (HR = 0.72; 95% CI = 0.53-0.97) reduced risk of all-cause and cancer mortality, respectively. No such associations were observed for cardiovascular disease mortality. Conclusions Both second and third quintiles of total protein intake were associated with reduced all-cause and cancer mortality. Plant protein was inversely associated with all-cause and cancer mortality, whereas animal protein intake was positively associated with mortality.

Objective:Inadequate nutrient intakes have been linked with poor dentition in older adults. The aim of this study was to investigate the associations between the composition of functional tooth units (FTU) and nutrient intakes in older men.Design:A cross-sectional study with a standardised validated diet history assessment and comprehensive oral health assessments. FTU were categorised by dentition type: (i) Group A (Natural FTU Only), (ii) Group B (Natural and Replaced FTU) and (iii) Group C (No Natural FTU). Attainment of nutrient reference values (NRV) for sixteen micronutrients was incorporated into a micronutrient risk variable, dichotomised ‘good’ (≥ 12) or ‘poor’ (≤ 11), and for seven macronutrients into a macronutrient risk variable, dichotomised ‘good’ (≥ 5) or ‘poor’ (≤ 4).Setting:Subjects selected from the local Sydney geographical areas.Participants:Community-dwelling older men (n 608).Results:32 % (n 197) of participants were categorised as Group A, 27 % (n 167) as Group B and 40 % (n 244) as Group C. In adjusted logistic regression analysis, being in Group C, compared with Group A, was associated with intakes below NRV recommendations for fibre (OR: 2·30, 95 % CI 1·30, 4·05). Adjusted analysis also showed that men in Group C, compared with Group A, were more likely to have poor intake of macronutrients (OR: 2·00, 95 % CI 1·01, 3·94).Conclusions:Our study shows statistically significant associations between the composition of FTU and poor macronutrient intakes. Maintaining natural pairs of occluding FTU may be important for attaining adequate nutrient intakes in older men.

Deprescribing is the systematic process of discontinuing drugs when harms outweigh the benefits. We conducted semistructured telephone interviews with 22 general practitioners (GPs) who had prescribed or deprescribed opioids in patients with chronic noncancer pain within the past 6 months to investigate the barriers and facilitators to deprescribing opioid analgesics in patients with chronic noncancer pain. We also explored GPs' perspectives on the available resources to assist them with opioid deprescribing. Interviews were audio-recorded, transcribed verbatim, and then coded using an iterative process until data saturation reached. The thematic analysis process identified themes, first as concepts, and then refined to overarching themes after the merging of similar subthemes. Themes exploring barriers to deprescribing highlighted the difficulties GPs face while considering patient factors and varying prescribing practices within the confines of the health system. Patient motivation and doctor-patient rapport were central factors to facilitate deprescribing and GPs considered the most important deprescribing resource to be a multidisciplinary network of clinicians to support themselves and their patients. Therefore, although GPs emphasised the importance of deprescribing opioid analgesics, they also expressed many barriers relating to managing complex pain conditions, patient factors, and varying prescribing practices between clinicians. Some of these barriers could be mitigated by GPs having time and resources to educate and build rapport with their patients. This suggests the need for further development of multimodal resources and improved support through the public health system to enable GPs to prioritise patient-centred care.

Background Unintended weight loss and the reduction in appetite are common phenomenon among older people. Reduced appetite has been linked to medication related reductions in saliva production, reduced taste ability and poor oral health. Poor appetite can result in reduced nutrient intake ensuing weight loss. It is possible that poor appetite is a mediating step on the causal pathway between oral health and weight loss. This study investigates whether poor oral health and loss of appetite are related to weight loss. Methods This is an observational study where data were obtained from the Concord Health and Ageing in Men Project (CHAMP). Information on socio-demographics, appetite and health related behavior was collected by self-completed questionnaire. Intraoral assessment was conducted by calibrated oral health therapists. Height and weight were measured by trained staff. Regression analysis investigated associations between oral health and appetite as risk factors for weight loss. Results Participants included 542 community dwelling older males. 99 older men (18.3%) experienced 5% or more weight loss over 3 years. Men who lost weight from baseline had lower BMI and lower body weight, had higher prevalence of frailty and depression, reported poorer appetite, and had fewer teeth (13.8 ± 9.5) than those who did not lose weight (16.3 ± 9.3). Before adjustment, the prevalence ratio (PR) for weight loss was 1.76 (95% Confidence Interval (CI), 1.19–2.59) for participants with 0–19 natural teeth present compared to those with 20 or more teeth. When adding appetite and other variables to the model, the PR for number of teeth and weight loss was unchanged: 1.78 (95% CI, 1.06–3.00). The mediation analysis showed that the indirect effect of appetite on the association between number of natural teeth on weight loss was not found to be significant. Conclusion This study found that number of natural teeth present and appetite are independently related to weight change among elderly men in Australia. Tooth loss can increase the risk of swallowing difficulty leading to change in food preference, avoidance of foods and a decrease in energy intake. Our study showed the importance of oral health interventions to encourage maintenance of 20 or more natural teeth in older people.

The role of antioxidant intake in cardiovascular disease remains inconclusive. This study evaluates the association between antioxidant intake and the risk of major adverse cardiovascular events (MACE) among older Australian men.794 men aged ≥75 years participated in the 3rd wave of the Concord Health and Ageing in Men Project. Dietary adequacy of antioxidant intake was assessed by comparing participants' intake of vitamins A, E, C and zinc to the Nutrient Reference Values (NRV) for Australia. Attainment of NRVs of antioxidants was categorised into a dichotomised variable 'inadequate' (meeting≤2 of 4 antioxidants) or 'adequate' (meeting≥3 of 4 antioxidants). The usage of antioxidant supplements was assessed. The outcome measure was MACE. The composite MACE endpoint was defined as having one of the following: death, myocardial infarction, ischemic stroke, congestive cardiac failure (CCF), and revascularization during the period of observation. There was no significant association between dietary (HR: 1.03, 95% CI: 0.71, 1.48) or supplemental antioxidant intake (HR: 1.10, 95% CI: 0.75, 1.63) and overall MACE. However, a significant association was observed between inadequate antioxidant intake and CCF (HR: 1.32; 95% CI: 1.16, 1.50). The lowest quartile of zinc intake (11.00 mg/d) was significantly associated with CCF (HR 2.36; 95% CI: 1.04, 5.34). None of the other antioxidants were significantly associated with CCF or other MACE components.Inadequate dietary antioxidant intake, particularly zinc, is associated with increased risk of CCF in older Australian men but not associated with overall MACE.

BACKGROUND/OBJECTIVES To compare the Australian Dietary Guideline Index (DGI-2013) and the Pyramid-based Mediterranean Diet Score (pyrMDS) as measures of diet quality in an ethnically diverse group of older men. SUBJECTS/METHODS Seven hundred and ninety-four older men aged ≥75 participated in wave 3 (2012-2013) of the Concord Health and Ageing in Men Project. Dietary intake was assessed using a validated diet history questionnaire. Ethnicity was based on self-reported country of birth and categorised as Australian-born (418 men), Italian or Greek migrants (188), and other migrants (188). Incident cardiovascular outcomes until March 2018 were measured using the composite of major adverse cardiovascular events (MACE), which comprises all-cause mortality, acute myocardial infarction, congestive cardiac failure, coronary revascularisation and/or ischaemic stroke. Ability to predict incident cardiovascular outcomes and all-cause mortality were compared between standardised DGI-2013 pyrMDS scores by comparison of hazard ratios, discrimination (Harrell's C-statistic) and calibration (calibration plots). RESULTS Italian and Greek migrant men had significantly lower DGI-2013 scores (91.7 vs. 93.9; p = 0.01) but significantly higher pyrMDS scores (8.8 vs. 8.2; p

Although characteristic changes in amino acid concentrations occur in obesity and sarcopenia, amino acids concentrations have not been reported in sarcopenic obesity. We studied n = 831 men aged 75 years and older from the 5-year follow-up of the Concord Health and Ageing in Men Project. Sarcopenia was defined using the Foundation of the National Institutes of Health criteria and obesity was defined as >30% fat mass. There were 31 men (3.7%) who had sarcopenic obesity. Branched chain amino acids were elevated in the obese (but not sarcopenic) group (n = 348) but reduced in both the sarcopenic (but not obese) (n = 44) and the sarcopenic obese groups. Apart from this, most of the amino acid concentrations were between those for the obese and the sarcopenic groups. Yet despite low concentrations of branched chain amino acids, the sarcopenic obese group had indications of insulin resistance and diabetes mellitus (fasting glucose and insulin concentrations, homeostatic model assessment, and percentage of participants taking diabetes medications) that were similar to the obese group. In summary, sarcopenic obese participants did not have a unique amino acid signature. In obesity, elevated branched chain amino acids are not a prerequisite for insulin resistance and diabetes if obesity is associated with sarcopenia.

Pregabalin has become widely used as an alternative to opioids in treating certain types of chronic non-cancer pain, but few studies have examined its clinical efficacy outside trials. We address this gap by examining the utilization, correlates and clinical outcomes of pregabalin use among an Australian community-based cohort of people prescribed opioids for chronic non-cancer pain. Through a five-year prospective cohort study (n = 1514) we examined associations between pregabalin use and pain severity and interference, mental health, opioid dose and past month use of ambulance and emergency department services. We used fixed-effects regression models to examine within-participant differences, and random-effects regression models to examine within and between participant differences in clinical outcomes. In an analysis of cases with complete data over five-years (n = 896), the prevalence of pregabalin use ranged from 16% at cohort entry to 29% at 36- and 48-months, and 46% reported pregabalin use at any time during the five years.. Pregabalin use was associated with greater pain severity and interference and greater use of high-risk opioid doses (>90 oral morphine equivalents/day). Pregabalin use was not associated with changes in mental health symptoms, ambulance, or emergency department attendance in the fixed or random effects models. Pregabalin use was common, but for most people use was not associated with clinically meaningful improvements in pain or functioning.

High-impact physical activities with bone strains of high magnitude and frequency may benefit bone health. This study aimed to investigate the longitudinal associations between changes in loading intensities and application rates, estimated from self-reported physical activity, with bone mineral density (BMD) changes over 5 years and also with incident falls over 2 years and long-term incident fractures in community-dwelling older men. A total of 1599 men (mean age 76.8 ± 5.4 years) from the Concord Health and Aging in Men Project (CHAMP) were assessed at baseline (2005-2007) and at 2- and 5-year follow-up. At each time point, hip and lumbar spine BMD were measured by dual-energy X-ray absorptiometry, and physical activity energy expenditure over the past week was self-reported via the Physical Activity Scale for the Elderly (PASE) questionnaire. Sum effective load ratings (ELRs) and peak force were estimated from the PASE questionnaire, reflecting the total and highest loading intensity and application rate of physical activities, respectively. Participants were contacted every 4 months over 2 years to self-report falls and over 6.0 ± 2.2 years for fractures. Hip fractures were ascertained by data linkage for 8.9 ± 3.6 years. Compared with sum ELR and PASE scores, peak force demonstrated the greatest standardized effect size for BMD maintenance at the spine (β = 9.77 mg/cm2 ), total hip (β = 14.14 mg/cm2 ), and femoral neck (β = 13.72 mg/cm2 ) after adjustment for covariates, including PASE components (all p

Objective To assess the associations between nutrient intake and dietary patterns with different sarcopenia definitions in older men. Design Cross-sectional study. Setting Sarcopenia was defined using the Foundation for the National Institutes of Health (FNIH), the European Working Group on Sarcopenia in Older People (EWGSOP) and the European Working Group on Sarcopenia in Older People 2 (EWGSOP2). Dietary adequacy of fourteen nutrients was assessed by comparing participants' intakes with the Nutrient Reference Values (NRV). Attainment of NRV for nutrients was incorporated into a variable 'poor' (meeting ≤ 9) v. 'good' (meeting ≥ 10) using the cut-point method. Also, two different dietary patterns, monounsaturated:saturated fat and n-6:n-3 fatty acids ratio and individual nutrients were used as predictor variables. Participants A total of 794 men aged ≥75 years participated in this study. Results The prevalence of sarcopenia by the FNIH, EWGSOP and EWGSOP2 definitions was 12·9 %, 12·9 % and 19·6 %, respectively. With the adjustment, poor nutrient intake was significantly associated with FNIH-defined sarcopenia (OR: 2·07 (95 % CI 1·16, 3·67)), but not with EWGSOP and EWGSPOP2 definitions. The lowest and second-lowest quartiles of protein, Mg and Ca and the lowest quartiles of n-6 PUFA and n-3 PUFA intakes were significantly associated with FNIH-defined sarcopenia. Each unit decrease in n-6:n-3 ratio was significantly associated with a 9 % increased risk of FNIH-defined sarcopenia (OR: 1·09 (95 % CI 1·04, 1·16)). Conclusions Inadequate intakes of nutrients are associated with FNIH-defined sarcopenia in older men, but not with the other two sarcopenia definitions. Further studies are required to understand these relationships.

Across the world, pain treatment centres have closed their doors. Because of the COVID-19 pandemic, healthcare providers are abruptly changing their care delivery to protect patients and staff from infection and to reallocate resource towards the greatest acute needs. Elective, routine, and nonemergency casework has stopped in secondary and tertiary centres, while in primary care, patients are requested to stay away or “socially distance,” and in residential care facilities and hospices, strict isolation and separation protocols have been introduced. Before the COVID-19 pandemic, telemedicine and eHealth approaches were being developed and tested in a gradual fashion with many studies focusing on lessons learned and barriers to using digital solutions.3,37,39,51 Overnight, however, treating or supporting people with non-urgent and long-term conditions at a distance from healthcare providers has become imperative. These immediate changes are happening across healthcare systems. Telemedicine is being used to demand-manage the flow of patients with respiratory distress accessing emergency departments25; video consultation is being introduced in multiple settings23; and using social media is being discussed positively for its potential to direct people to trusted resources, to counteract misinformation, and to provide psychological first aid.36 Pain management providers face the challenge of delivering face-to-face service through different modes. Fortunately, there is a rich stream of research and clinical experience in the use of different technological solutions. Table ​Table11 provides a summary of the definitions and terminology in use. Table 1 Definitions and terminology used in remotely supported pain management.

Background Several studies have examined the relationship between cognition and oral health in older populations. To further understand this relationship, we examined the associations between cognitive function, chewing capacity and the number of teeth present in community-dwelling older males in Australia. Methods Data were obtained from cross-sectional analysis of fourth wave of the Concord Health and Ageing in Men Project (CHAMP). Participants were 369 community-dwelling males aged 78 years or over. Cognitive function was measured utilising the Mini-Mental State Examination (MMSE). Chewing capacity was determined on ability to chew food items of different textures, and oral health data were collected. Ordinal regression was used to analyse associations between MMSE (four categories) and chewing capacity and number of natural teeth present. Results Overall, 67.5% of participants reported that they could chew all 11 listed food items. Participants with fewer than 20 teeth were statistically significantly more likely to have cognitive impairment (unadjusted odds ratio (OR) 1.87; 95% confidence interval (CI) 1.25-2.79, adjusted OR 1.62; 95% CI 1.07-2.43). Participants with limited chewing capacity were also more likely to have cognitive impairment (unadjusted OR 1.91; 95% CI 1.25-2.94, adjusted OR 1.61; 95% CI 1.03-2.49). Conclusions This study suggests either that older men with fewer than 20 natural teeth and those with limited chewing capacity are more likely to have an associated cognitive impairment or that those with cognitive impairment are more likely to have fewer teeth and limited chewing capacity. Further longitudinal studies should clarify these relationships.

Objectives The types of medical conditions leading to hospitalization in frail older people have not been investigated. The objectives were to evaluate associations between frailty and (a) risk of all-cause and cause-specific hospitalization, and (b) rate of all-cause and cause-specific hospitalizations. Design, Setting and Participants Community-dwelling men aged 70+ years in the Concord Health and Ageing in Men Project (CHAMP) were assessed for frailty at baseline (2005–2007, n=1705). Measurements Frailty was determined by both the Fried frailty phenotype (FP) and the Rockwood frailty index (FI). Non-elective and elective hospitalization data were accessed from the New South Wales (NSW) Admitted Patient Data Collection and mortality from the NSW Deaths Registry for the period 2005–2017. Causes of hospitalization were categorized using ICD-10 classification of principal diagnoses based on organ system involved into 14 major categories. Results Nearly 80% of CHAMP men had at least one non-elective hospitalization and 63% had an elective hospitalization over a 9-year follow-up. Men with FP frailty were twice as likely to have a non-elective hospitalization (HR: 1.98, 95%CI: 1.61–2.44) and a greater number of non-elective hospitalizations (IRR: 1.44, 95%CI: 1.22-1.70). Similar relationships were found between FI frailty and non-elective hospitalizations. Men with frailty (either FP or FI) were more likely to have at least one non-elective hospitalization for 13 of the 14 cause-related admissions. In contrast, frailty was only associated with 3 cause-related elective hospitalizations. Men with frailty were also more likely to have an increased number of non-elective hospitalizations for all 14 causes, but only for 6 causes of elective hospitalizations. Conclusions Our findings suggest frailty increases the risk and number of non-elective hospitalizations in older men for a wide range of cause. Strategies on early identification of frailty, followed by appropriate preventative strategies to lower the risk of non-elective hospital admissions are warranted.

Objective To determine, in a population based linked data study, the relationship between peri-operative multiple complications and longer term outcomes, specifically the combined outcome of two year amputation or death, after lower limb revascularisation for peripheral artery disease (PAD). Methods State wide health administrative data and death records were probabilistically linked for all patients who had lower limb artery surgery between 2010 and 2012 in New South Wales, Australia. Multivariable Cox regression modelled the impact of medical and surgical complications on the combined outcome of amputation or death two years after discharge. Results Open surgery was performed on 3004 patients (26.7%), and endovascular on 8263 (73.3%). Of the 10 971 patients discharged alive, 3747 (34.1%) experienced at least one complication, and 2113 (19.3%) had multiple complications. Older patients, those with high comorbidity scores, or those with chronic limb threatening ischaemia were at increased risk of multiple complications. After adjusting for procedure type, patients with multiple complications experienced more than three times the hazard ratio (HR) of amputation or death two years after the procedure than those without complications (adjusted HR 3.4, 95% confidence interval 3.1–3.7), and increasing complications progressively multiplied the risk. In particular, non-surgical complications such as stroke, acute renal failure, delirium, and cardiac events were associated with the highest rates of two year amputation or death. Conclusion Multiple complications after surgery for lower limb PAD carried a compounding risk of reduced long term amputation free survival. Patients experiencing at least one complication form a high risk group that requires increased attention to prevent the potential development of further complications.

Background The relations between diet, chronic inflammation, and musculoskeletal health are unclear, especially among older men. Objective This study aimed to determine associations of the Dietary Inflammatory Index (DII) with inflammatory biomarkers, musculoskeletal health, and falls risk in community-dwelling older men. Methods The cross-sectional analysis included 794 community-dwelling men, mean age 81.1 ± 4.5 y, who participated in the 5-y follow-up of the Concord Health and Aging in Men Project. Of these, 616 were seen again 3 y later for the longitudinal analysis. Energy-adjusted DII (E-DII) was calculated from a validated diet history questionnaire. Bone mineral density (BMD) was measured using DXA. Twenty-four inflammatory biomarkers were analyzed. Incident falls over 3 y were determined through telephone interviews every 4 mo. Multiple regression, linear mixed effects models, negative binomial regression, and mediation analysis were utilized in this study. Results A higher E-DII score (indicating a more proinflammatory diet) was associated with higher concentrations of IL-6 (β: 0.028 pg/mL; 95% CI: 0.003, 0.053), IL-7 (β: 0.020 pg/mL; 95% CI: 0.002, 0.037), and TNF-α (β: 0.027 pg/mL; 95% CI: 0.003, 0.051). A higher E-DII score was also associated with lower appendicular lean mass adjusted for BMI (ALMBMI) (β: -0.006 kg/m2; 95% CI: -0.010, -0.001). For every unit increase in E-DII (range: -4.91 to +3.66 units), incident falls rates increased by 13% (incidence rate ratio: 1.13; 95% CI: 1.05, 1.21) over 3 y. Mediation analysis showed that the association between E-DII and 3-y incident falls was influenced by the concentrations of IL-7 by 24%. There was no association between E-DII and BMD. Conclusions Consumption of a proinflammatory diet was associated with increased concentrations of IL-6, IL-7, and TNF-α; increased falls risk; and lower ALMBMI in community-dwelling older men. The association between incident falls and E-DII was partly mediated by concentrations of IL-7.

The President of the International Association for the Study of Pain (IASP) established a Taskforce on Cannabis and Cannabinoid Analgesia, to systematically examine the evidence on (i) analgesic pharmacology of cannabinoids and preclinical evidence on their efficacy in animal models of injury-related or pathological persistent pain, (ii) the clinical efficacy of cannabis, cannabinoids and cannabis-based medicines (CBM) for pain, (iii) harms related to long-term use of cannabinoids, as well as (iv) societal issues and policy implications related to the use of these compounds for pain management. Here, we summarize key knowledge gaps identified in the Taskforce outputs and propose a research agenda for generating high-quality evidence on the topic. The systematic assessment of preclinical and clinical literature identified gaps in rigor of study design and reporting across the translational spectrum. We provide recommendations to improve the quality, rigor, transparency, and reproducibility of preclinical and clinical research on cannabis and cannabinoids for pain, as well as for the conduct of systematic reviews on the topic. Gaps related to comprehensive understanding of the endocannabinoid system and cannabinoid pharmacology, including pharmacokinetics and drug formulation aspects, are discussed. We outline key areas where high quality clinical trials with cannabinoids are needed. Important remaining questions about long-term and short-term safety of cannabis and cannabinoids are emphasized. Finally, regulatory, societal and policy challenges associated with medicinal and non-medicinal use of cannabis are highlighted, with recommendations for improving patient safety and reducing societal harms in the context of pain management.

OBJECTIVES: Mediterranean dietary patterns may exert favorable effects on various health conditions. This study aimed to determine associations of adherence to Mediterranean diet with circulating cytokine levels, musculoskeletal health and incident falls in community-dwelling older men. METHODS: Seven hundred ninety-four (794) community-dwelling men with mean age 81.1 ± 4.5 years, who participated in the five-year follow-up of the Concord Health and Ageing in Men Project (CHAMP) were included in the cross-sectional analysis, and 616 attended follow-up three years later. Adherence to Mediterranean diet was assessed using MEDI-LITE (literature-derived Mediterranean diet) score which was derived using a validated diet history questionnaire. Twenty-four evaluable circulating cytokines were analyzed using Bio-Plex Pro Human Cytokine 27-plex Assay kit. Appendicular lean mass (ALM) and bone mineral density (BMD) were measured using dual-energy x-ray absorptiometry (DXA). Three-year changes in gait speed and hand grip strength were assessed by walking a 6-meter course and using a dynamometer respectively. Incident falls over three years were determined through telephone interviews every four months. RESULTS: A higher MEDI-LITE score, indicating greater adherence to Mediterranean diet, was associated with higher appendicular lean mass adjusted for body mass index (ALM(BMI)) (β: 0.004 kg/kg/m(2); 95% CI: 0.000, 0.008), and lower serum interleukin-7 (IL-7) (β: −0.017 pg/mL; 95% CI: −0.031, −0.003), and incident falls rates (IRR: 0.94; 95% CI: 0.89, 0.99). Higher consumption of monounsaturated fatty acids (IRR: 0.76; 95% CI: 0.59, 0.98) and monounsaturated fatty acids to saturated fatty acids ratio (IRR: 0.72; 95% CI: 0.57, 0.90) were associated with 24%, and 28% lower falls risk in older men respectively. MEDI-LITE scores were not associated with bone mineral density or physical function parameters. CONCLUSIONS: Adherence to a Mediterranean diet is associated with higher ALM(BMI), lower levels of serum IL-7, and fewer falls in community-dwelling older men. Monounsaturated and saturated fatty acids were the most important contributors to the association between Mediterranean diet and falls risk. FUNDING SOURCES: The CHAMP study is funded by the National Health and Medical Research Council of Australia, and the Ageing and Alzheimer's Institute.

ObjectiveLow levels of total cholesterol (TC) are associated with adverse outcomes in older populations. Whether this phenomenon is independent of statin use is unknown. We investigated the association between low TC levels and long-term major adverse cardiovascular events (MACE) in a prospective study of men aged ≥70 years without ischaemic heart disease (IHD) and whether this was influenced by statin use.MethodsThe CHAMP (Concord Health and Ageing in Men Project) cohort is a prospective cohort study of community-dwelling men aged ≥70 years. The relationship between TC and long-term MACE was analysed using Cox-regression modelling adjusted for comorbidities and stratified by statin use.ResultsThe study cohort comprised 1289 men (mean (±SD) age, 77.0±5.5 years; mean follow-up, 6.4±2.7 years). Decreasing TC level was associated with increased comorbidity burden, frailty and MACE (linear trend pConclusionLow TC is associated with increased risk of MACE in older men without IHD who are not taking statin therapy but not in those on statins.

Background The Concord Health and Ageing in Men Project (CHAMP) is a cohort study of the health of a representative sample of older Australian men. The aim of this paper is to describe the oral health behaviours and dental service use of CHAMP participants and explore associations between oral health behaviours with and general health status. Method Information collected related to socio‐demographics, general health, oral health service‐use and oral health behaviours. Key general health conditions were ascertained from the health questionnaire and included physical capacity and cognitive status. Results Fifty‐seven percent of the men reported visiting a dental provider at least once or more a year and 56.7% did so for a “dental check‐up”. Of those with some natural teeth, 59.3% claimed to brush their teeth at least twice or more a day. Most men (96%) used a standard fluoride toothpaste. Few participants used dental floss, tooth picks or mouth‐rinses to supplement oral hygiene. Cognitive status and self‐rated general health were associated with dental visiting patterns and toothbrushing behaviour. Conclusions Most older men in CHAMP perform favourable oral health behaviours. Smoking behaviour is associated with less favourable dental visiting patterns, and cognitive status with toothbrushing behaviour. NHMRC, Sydney Medical School Foundation, Ageing and Alzheimer's Institute

Background while both negative and positive impacts of caregiving on health have been reported, findings regarding caregiver’s mortality may be biased by the lack of consideration of changes in their health and caregiving status during follow-up. This study examines the impact of caregiving on the risk of death in older men, allowing for caregiving-transition by individuals and adjusting for changes over time in their health status. Methods data from 1639 men age ≥70 years old from the Concord Health and Ageing in Men Project (CHAMP) were collected between baseline (2005–07), 2-year and 5-year follow-up and linked to death records up to 30 September 2015. A time-varying Cox proportional hazards model was used to examine the risk of death from caregiving between 2005 and 2015, adjusting for baseline education, history of myocardial infarction, congestive heart failure, and risk factors which may change over time (age, income, self-rated overall health, number of morbidities, physical disability, depression and anxiety). Results the average follow-up was 7.39 years (SD = 2.95) with 495 deaths observed. There was no significant difference in all-cause mortality between caregivers and non-caregivers in the multivariable model (HR: 0.95, 95% CI: 0.67–1.32, P = 0.73). Conclusions this study addressed the dynamic caregiving role and covariates which has been rarely considered in the literature. While there is concern that when older people take on a caring role their health suffers, we found no difference in mortality between older male caregivers and non-caregivers when we accounted for transitions in their caregiving status. NHMRC and Ageing and Alzheimer’s Institute, Australia

Normative data for chronic pain questionnaires are essential to the interpretation of aggregate scores on these questionnaires, for both clinical trials and clinical practice. In this study, we summarised data from 13,343 heterogeneous patients on several commonly used pain questionnaires that were routinely collected from 36 pain clinics in Australia and New Zealand as part of the electronic Persistent Pain Outcomes Collaboration (ePPOC) including the Brief Pain Inventory (BPI); the Depression Anxiety and Stress Scales (DASS); the Pain Self-Efficacy Questionnaire (PSEQ); and the Pain Catastrophizing Scale (PCS). The data are presented as summarised normative data, broken down by demographic (age, sex, work status, etc) and pain site/medical variables. The mean BPI severity score was 6.4 (moderate-severe), and mean interference score was 7.0. The mean DASS depression score was 20.2 (moderate-severe), mean DASS anxiety was 14.0 (moderate), and mean DASS stress was 21.0 (moderate). The mean PCS scores were 10.0, 5.9, 14.1, and 29.8 for rumination, magnification, helplessness, and total, respectively. The mean PSEQ score was 20.7. Men had slightly worse scores than women on some scales. Scores tended to worsen with age until 31 to 50 years, after which they improved. Scores were worse for those who had a greater number of pain sites, were unemployed, were injury compensation cases, or whose triggering event was a motor vehicle accident or injury at work or home. These results and comparisons with data on the same measures from other countries, as well as their uses in both clinical practice and clinical trials, are discussed.

To summarize the current understanding of the global burden of musculoskeletal pain–related conditions, consider the process of evidence generation and the steps to generate global pain estimates, identify key gaps in our understanding, and propose an agenda to address these gaps, we performed a narrative review. In the 2010 Global Burden of Disease Study (GBD), which broadened the scope of musculoskeletal conditions that were included over previous rounds, low back pain imposed the highest disability burden of all specific conditions assessed, and subsequent GBD reports further reinforce the size of this burden. Over the past decade, the GBD has produced compelling evidence of the leading contribution of musculoskeletal pain conditions to the global burden of disability, but this has not translated into global health policy initiatives. However, system- and service-level responses to the disease burden persist across high-, middle-, and low-income settings. There is a mismatch between the burden of musculoskeletal pain conditions and appropriate health policy response and planning internationally that can be addressed with an integrated research and policy agenda.

Background Assessing perceived needs for dental treatment is important in understanding and predicting people's health behaviours. The purpose of this study is to examine older men's perceptions regarding dental treatment needs, and to investigate the disparity between perceived needs and the actual oral health of a population of community-dwelling older Australians. Methods Using cross-sectional data from the 4th wave of the Concord Health and Ageing in Men Project, logistic regression analysis of perceived needs for dental treatment was conducted for 596 men aged 78 and over, with functional tooth units (FTUs), number of decayed tooth surfaces, and periodontitis as independent variables. Results Thirty-six percent (n = 216) of the participants believed they required some form of dental treatment. The remaining participants did not perceive a need for treatment, yet 65.3% objectively required prosthodontic or restorative care. The regression model showed men with lower FTUs were significantly more likely to report a perceived need for dental treatment than those with 12 FTUs [0-6 FTUs: adjusted odds ratio (OR) 2.58, 95% CI 1.28-5.20; 7-11 FTUs: adjusted OR 2.43, 95% CI 1.16-5.10]. However, neither the number of decayed tooth surfaces nor the existence of periodontitis was associated with perceived dental treatment needs. Conclusions Most older men viewed their oral health positively, and the majority of those with objectively assessed needs, did not perceive themselves as requiring dental treatment. Loss of FTUs appears to alert participants to seek treatment, but not the presence of dental caries or periodontitis.

Objective Chronic pain and cardiovascular disease (CVD) have a high disease burden. This research aimed to understand whether Australian primary health networks (PHNs) are recognising the need for the prevention of these conditions by investigating what local health and service issues have been identified. Methods Separate sets of needs assessments were analysed for chronic pain and CVD for all 31 PHNs using a document analysis approach. Framework analysis was undertaken to ascertain the types of health and service issues, prevention-related issues and supporting data sources identified, as well as to quantify the number of PHNs identifying these issues. Results Fewer PHNs identified health issues for chronic pain (n = 13) compared with CVD (n = 30), with the most common being disease prevalence and burden supported by National Health Survey data. Service issues were identified by fewer than half the PHNs (n = 13 for each disease), which were largely informed by stakeholder consultation and related to service integration, service accessibility and health professional training. Prevention-related issues were frequently identified for CVD (n = 26), but not chronic pain (n = 3). Conclusions This paper highlights the need for a greater focus on chronic pain- and CVD-related issues by PHNs. This could be supported nationally by recognising chronic pain and risk factors in national datasets and PHN performance frameworks, and locally via greater stakeholder consultation to inform PHN population health planning. What is known about the topic? Chronic pain and CVD are the two leading causes of total disease burden in Australia. PHNs are well positioned to address prevention locally through population health planning, supporting primary healthcare providers, health care integration and coordination and commissioning necessary services. What does this paper add? This paper highlights gaps in data availability, the proportion of PHNs identifying local service issues for both chronic pain and CVD and health- and prevention-related issues for chronic pain. What are the implications for practitioners? Although PHNs are constrained by government priorities and funding, greater stakeholder consultation is one potentially promising strategy to overcome local data gaps to identifying and prioritising chronic pain and CVD prevention.

Background The association between socioeconomic position (SEP) and health is well-established. However, the association between SEP and healthy ageing as a multidimensional construct is unclear. Methods We conducted a systematic review of peer-reviewed cross-sectional and longitudinal studies on the associations between SEP and multidimensional healthy ageing measures. Studies were identified from a systematic search across major electronic databases from inception to February 2021. Results Fourthy-five articles met inclusion criteria (26 cross-sectional and 19 longitudinal studies). There was no consistency in method of operationalizing healthy ageing across studies, domains included in the healthy ageing measures, or in the definition and number of levels of SEP indicators. Overall, regardless of heterogeneity between studies, a positive association between educational level (85.0 % of studies) and income/wealth (81.4 % of studies) and healthy ageing was evident. Regarding occupational position, evidence from 11 studies was inconclusive. The number of studies including home ownership, parenteral SEP, or composite SEP scores was insufficient to be able to draw a conclusion. Conclusions There is evidence that socioeconomic inequalities, as assessed by educational level and income/wealth, are associated with healthy ageing. These findings, and the broader evidence base on SEP and healthy ageing, highlight the importance of addressing inequality through integrated health and social policies and strategies.

Objective To investigate the association between home ownership and health in older men. Methods Cross-sectional analysis of 909 community-dwelling Australian men (mean age: 81.3 ± 4.6) from the Concord Health and Ageing in Men Project (CHAMP, 2012-2013). We considered self-rated health, frailty status, multimorbidity, and anxiety and depressive symptoms which identify different dimensions of health. Results Most participants were owner-occupiers (89.7%). In age- and country of birth-adjusted analyses, not being an owner-occupier was associated with an increased likelihood of depressive symptoms [prevalence ratio: 1.82, 95% confidence intervals 1.17 to 2.84]. There were no associations between home ownership and other health conditions. Conclusion Lack of home ownership was associated with a higher prevalence of depressive symptoms, largely explained by poorer social support. Thus, targeting mental health programs at older divorced or separated men who do not own their own home could be an appropriate community-based intervention.

Deprescribing opioids has been identified as an intervention to mitigate opioid harm; however, it is often challenging to implement interventions and communicate deprescribing decisions to consumers. The development of opioid deprescribing guidelines may provide guidance and support on when and how to reduce or cease opioids in routine care. This study aimed to explore the perspectives of opioid consumers on opioid deprescribing and determine factors to be considered in the development of opioid deprescribing guidelines. A purposive sample of 20 consumers using opioids for pain was recruited. Semistructured interviews were conducted, audio recorded, and transcribed verbatim. Inductive thematic analysis was undertaken, followed by a framework analysis informed by Bandura's Social Cognitive Theory. Behavioral, cognitive, and environmental factors influence consumers' attitudes and actions regarding opioid deprescribing. Significant barriers to opioid deprescribing were identified, including fears of pain and withdrawal effects, opioid-related stigma, and perceived inadequacies of the healthcare system. Improved communication between healthcare professionals and consumers regarding expectations of deprescribing and goals of care, as well as the provision of greater opportunities for consumer engagement in decision making were identified as avenues to improve the success of opioid deprescribing. For opioid deprescribing guidelines to be effective and achieve the intended goal of optimizing opioid use, consumers need to feel empowered to engage in opioid reduction or cessation. The findings of this study may facilitate a patient-centred approach for practitioners and guideline developers in creating recommendations and interventions to enable opioid deprescribing through targeting behavioral change.

Background Type 2 diabetes mellitus (T2DM) increases falls and fracture risk. Our objective was to compare incidence and risk factors for falls and fractures in community-dwelling older men with and without T2DM. Methods A total of 1705 men (471 with T2DM; 1234 without T2DM) aged ≥70 years were assessed at baseline. Men were contacted every 4 months for 6.0 ± 2.2 years to ascertain incident falls and fractures, with the latter being confirmed by radiographic reports. Hip fractures were ascertained via data linkage (follow-up: 8.8 ± 3.6 years). Risk factors for falls and fractures included physical activity and function, body composition, medications, and vision measures. Results Men with T2DM had similar fall (incident rate ratio [IRR]: 0.92 [95% confidence interval {CI}: 0.70, 1.12], n = 1246) and fracture rates (hazard ratio [HR]: 0.86 [95% CI: 0.56, 1.32], n = 1326) compared to men without T2DM after adjustment for significant risk factors. In men with T2DM, depression (IRR: 1.87 [95% CI: 1.05, 3.34], n = 333), sulphonylurea usage (IRR: 2.07 [95% CI: 1.30, 3.27]) and a greater number of prescription medications (IRR: 1.13 [95% CI: 1.03, 1.24]) were independently associated with increased fall rates, and higher total hip bone mineral density was independently associated with lower fracture rates (HR: 0.63 [95% CI: 0.47, 0.86], n = 351). Interaction terms demonstrated that better contrast sensitivity was independently associated with lower fracture rates (HR: 0.14 [95% CI: 0.02, 0.87]) in men with T2DM compared to men without T2DM. Conclusion Fall and fracture rates were similar in men with and without T2DM after adjusting for significant risk factors. Vision assessments including contrast sensitivity measures may improve fracture prediction in older men with T2DM.

Objectives:To examine changes in micronutrient intake over 3 years and identify any associations between socio-economic, health, lifestyle and meal-related factors and these changes in micronutrient intakes among older men.Design:Prospective study.Setting:Dietary adequacy of individual micronutrient was compared to the estimated average requirement of the nutrient reference values (NRV). Attainment of the NRV for twelve micronutrients was incorporated into a dichotomised variable ‘not meeting’ (meeting ≤ 6) or ‘meeting’ (meeting ≥ 7) and categorised into four categories to assess change in micronutrient intake over 3 years. The multinomial logistic regression analyses were conducted to model predictors of changes in micronutrient intake.Participants:Seven hundred and ninety-four men participated in a detailed diet history interview at the third wave (baseline nutrition) and 718 men participated at the fourth wave (3-year follow-up).Results:The mean age was 81 years (range 75–99 years). Median intakes of the majority of micronutrients decreased significantly over a 3-year follow-up. Inadequacy of the NRV for thiamine, dietary folate, Zn, Mg, Ca and I were significantly increased at a 3-year follow-up than baseline nutrition. The incidence of inadequate micronutrient intake was 21 % and remained inadequate micronutrient intake was 16·4 % at 3-year follow-up. Changes in micronutrient intakes were significantly associated with participants born in the UK and Italy, low levels of physical activity, having ≥2 medical conditions and used meal services.Conclusions:Micronutrient intake decreases with age in older men. Our results suggest that strategies to improve some of the suboptimal micronutrient intakes might need to be developed and implemented for older men.

Background Socioeconomic status (SES) has been suggested as a risk factor for falls but the few prospective studies to test this have had mixed results. We evaluated the prospective association between SES and falls in the Concord Health and Ageing in Men Project (CHAMP). Methods CHAMP is a population-based prospective cohort study of men aged ≥70 years in Sydney, Australia. Incident falls were ascertained by triannual telephone calls for up to 4 years. SES was assessed with 4 indicators (education, occupation, source of income, home ownership) and cumulative SES score. We tested for interaction between SES indicators and country of birth and conducted stratified analyses. Results We evaluated 1624 men (mean age: 77.3 ± 5.4 years). During a mean ± SD follow-up of 42.6 ± 8.7 months, 766 (47%) participants reported ≥1 incident falls. In nonstratified analyses, there were no associations between SES indicators and falls. In stratified analyses, falls rates were higher among Australian-born men with less formal education (incidence rate ratio [IRR] 1.66, 95% confidence interval [CI] 1.16–2.37, compared with those with more education) and those with low occupational position (1.45; 1.09–1.93). However, among men born in non-main English-speaking countries the rate of falls was lower among those with low educational level and no associations were evident for occupational position. Conclusions Lower educational level and occupational position predicted a higher falls rate in Australian-born men; the opposite relationship was evident for educational level among migrants born in non-main English-speaking countries. Further studies should test these relationships in different populations and settings and evaluate targeted interventions.

Background Conflicting evidence exists regarding the association of socioeconomic status (SES) with mortality among older people and little is known about the mechanisms underlying this association. We investigated the association of SES with mortality among older Australian men. We also investigated potential mediating effects of health-related behaviours in SES-mortality associations. Methods We used data from a prospective population-based cohort (the Concord Health and Aging in Men Project), in Sydney, Australia. The main outcomes were all-cause and cause-specific mortality. Educational attainment, occupational position, source of income, housing tenure, and a cumulative SES score were assessed at baseline. Longitudinally assessed alcohol consumption, smoking, physical activity, and body mass index were investigated as potential mediators. Associations were quantified using Cox regression. Results We evaluated 1527 men (mean age: 77.4 ± 5.5 years). During a mean follow-up time of 9.0 years, 783 deaths occurred. For deaths from all causes, the adjusted hazard ratio (HR) for the lowest tertile of cumulative SES score versus the highest tertile was 1.44 (95% CI 1.21 to 1.70); the corresponding sub-HRs were 1.35 (0.96 to 1.89) for cardiovascular disease (CVD) mortality; 1.58 (1.15 to 2.18) for cancer mortality, and 1.86 (1.36 to 2.56) for non-CVD, non-cancer mortality. SES-mortality associations were attenuated by 11–25% after adjustment for mediating health-related behaviours. Conclusion Low SES is associated with increased mortality in older Australian men and health-related behaviours accounted for less than one-fourth of these associations. Further research is needed to fully understand the mechanisms underlying SES inequalities in mortality among older people.

The growing demand for improved pain treatments together with expanding legalization of, and access to, cannabinoids, cannabis, and cannabis-based medicines has intensified the focus on risk-benefit considerations in pain management. Given limited harms data from analgesic clinical trials, we conducted an overview of systematic reviews focused on all harms possibly relevant to patients receiving cannabinoids for pain management. This PROSPERO-registered, PRISMA-compliant systematic overview identified 79 reviews, encompassing over 2200 individual reports about psychiatric and psychosocial harms, cognitive/behavioral effects, motor vehicle accidents, cardiovascular, respiratory, cancer-related, maternal/fetal, and general harms. Reviews, and their included studies, were of variable quality. Available evidence suggests variable associations between cannabis exposure (ranging from monthly to daily use based largely on self-report) and psychosis, motor vehicle accidents, respiratory problems, and other harms. Most evidence comes from settings other than that of pain management (eg, nonmedicinal and experimental) but does signal a need for caution and more robust harms evaluation in future studies. Given partial overlap between patients receiving cannabinoids for pain management and individuals using cannabinoids for other reasons, lessons from the crisis of oversupply and overuse of opioids in some parts of the world emphasize the need to broadly consider harms evidence from real-world settings. The advancement of research on cannabinoid harms will serve to guide optimal approaches to the use of cannabinoids for pain management. In the meantime, this evidence should be carefully examined when making risk-benefit considerations about the use of cannabinoids, cannabis, and cannabis-based medicine for chronic pain.

Background Among older people, the extent to which psychosocial factors explain socioeconomic inequalities in mortality is debated. We aimed to investigate the potential mediating effect of psychosocial factors on socioeconomic inequalities in mortality. Methods We used data from a prospective population-based cohort (the Concord Health and Ageing in Men Project; baseline recruitment in 2005–2007), in Sydney, Australia. The main outcomes were all-cause and cause-specific mortality. Socioeconomic status (SES; educational attainment, occupational position, source of income, housing tenure, and a cumulative SES score) was assessed at baseline. Measures of structural and functional social support, as well as depressive and anxiety symptoms were assessed three times during follow-ups. Associations were quantified using Cox regression. Mediation was calculated using “change-in-estimate method”. Results 1522 men (mean age at baseline: 77·4 ± 5·5 years) were included in the analyses with a mean (SD) follow-up time of 9·0 (3·6) years for all-cause and 8·0 (2·8) years for cause-specific mortality. At baseline, psychosocial measures displayed marked social patterning. Being unmarried, living alone, low social interactions, and elevated depressive symptoms were associated with higher risk of all-cause and cardiovascular disease (CVD) mortality. Psychosocial factors explained 35% of SES inequalities in all-cause mortality, 29% in CVD mortality, 12% in cancer mortality, and 39% in non-CVD, non-cancer mortality. Conclusion Psychosocial factors may account for up to one-third of SES inequalities in deaths from all and specific causes (except cancer mortality). Our findings suggest that interventional studies targeting social relationships and/or psychological distress in older men aiming to reduce socioeconomic inequalities in mortality are warranted.

Pain is a growing public health issue worldwide, but there is limited population-based evidence in low- and middle-income country settings. Using nationwide Indonesian Family Life Survey (IFLS) data in 2007 and 2014, this research sets out to investigate the associations between changes in pain status between two time points and its impact on functional health outcomes among middle-aged and older adults in Indonesia. Analyses focused on 7936 adults aged 50 years and older in 2014 who responded to both waves. Functional health was assessed using a composite score of functional limitations (range 20&ndash, 100), representing difficulty in performing activities of daily living, and grip strength (kilograms). Multivariate linear regression models were used to analyse associations between pain measured in 2007 and 2014 and functional health in 2014. Severe pain in the latest wave of IFLS was associated with older age, female, lower education, having chronic conditions or depressive symptoms. Notably, those who reported &lsquo, low&ndash, medium&rsquo, pain in 2007 and &lsquo, severe&rsquo, pain in 2014 belonged to the most vulnerable group with worst functional health outcomes (4.96 points higher limitation scores and 1.17 kg weaker average grip strength). Findings have implications for public health policy in monitoring and management of pain including related co-morbidities as an increasingly critical component of population ageing.

Background & aims Mediterranean dietary patterns may exert favourable effects on various health conditions. This study aimed to determine associations of adherence to Mediterranean diet as well as its components, with circulating cytokine levels, musculoskeletal health and incident falls in community-dwelling older men. Methods Seven hundred ninety-four (794) community-dwelling men with mean age 81.1 ± 4.5 years, who participated in the five-year follow-up of the Concord Health and Ageing in Men Project (CHAMP) were included in the cross-sectional analysis, and 616 attended follow-up three years later. Adherence to Mediterranean diet was assessed using MEDI-LITE (literature-derived Mediterranean diet) score which was obtained using a validated diet history questionnaire. Twenty-four evaluable circulating cytokines were analyzed using Bio-Plex Pro Human Cytokine 27-plex Assay kit. Appendicular lean mass (ALM) and bone mineral density (BMD) were measured using dual-energy x-ray absorptiometry (DXA). Three-year changes in gait speed and hand grip strength were assessed by walking a 6-m course and using a dynamometer respectively and analyzed using linear mixed-effects models. Incident falls over three years were determined through telephone interviews every four months. Multivariable linear regression was utilized to determine the cross-sectional associations between MEDI-LITE scores and circulating cytokines, bone mineral density, ALM, and ALMBMI. Linear mixed-effects models were performed to estimate associations between MEDI-LITE scores and three-year change in hand grip strength and gait speed while negative binomial regression was applied to estimate associations between MEDI-LITE scores and three-year incident falls as well as associations between each MEDI-LITE component and three-year incident falls. Adjustments for multiple comparisons were performed using Benjamini-Hochberg adjustment for multiple testing. Results A higher MEDI-LITE score, indicating greater adherence to Mediterranean diet, was associated with higher appendicular lean mass adjusted for body mass index (ALMBMI) (β: 0.004 kg; 95% CI: 0.000, 0.008), and lower incident falls rates (IRR: 0.94; 95% CI: 0.89, 0.99). Higher consumption of monounsaturated fatty acids (IRR: 0.76; 95% CI: 0.59, 0.98) and monounsaturated fatty acids to saturated fatty acids ratio (IRR: 0.72; 95% CI: 0.57, 0.90) were associated with 24%, and 28% lower falls risk in older men respectively. MEDI-LITE scores were not associated with BMD or physical function parameters. Conclusions Adherence to a Mediterranean diet is associated with higher ALMBMI, and fewer falls in community-dwelling older men. Monounsaturated and saturated fatty acids were the most important contributors to the association between Mediterranean diet and falls risk.

Frailty may explain why some older patients having vascular surgery are at high risk of adverse outcomes. The Hospital Frailty Risk Score (HFRS) has been designed specifically for use with administrative data and has three categories of frailty risk (low, intermediate and high). The aim of this study was to evaluate the HFRS in predicting mortality, and hospital use in older patients undergoing vascular surgery.Routinely collected hospital data linked to death records were analysed for all patients aged 75 years or older who had undergone either endovascular or open vascular surgery between 2010 and 2012 in New South Wales, Australia. Multilevel logistic regression models were used to compare outcomes adjusted for patient and procedural factors, with and without frailty.Some 9752 patients were identified, of whom 1719 (17·6 per cent) had a high-risk HFRS. Patients in the high-risk frailty category had an adjusted odds ratio for death by 30 days after surgery of 4·15 (95 per cent c.i. 2·99 to 5·76) compared with those in the low-risk frailty category, and a similarly increased odds of death by 2 years (odds ratio 4·27, 3·69 to 4·95). Adding the HFRS to a model adjusted for age, sex, co-morbidity score, socioeconomic status, previous hospitalization and vascular procedure type improved the prediction of 2-year mortality and prolonged hospital stay, but there was minimal improvement for 30-day mortality and readmission.Adjusting for the HFRS in addition to other patient and procedural risk factors provided greater discrimination of outcomes in this cohort of older patients undergoing vascular surgery.La fragilidad puede explicar por qué algunos pacientes de edad avanzada que se someten a cirugía vascular tienen un alto riesgo de sufrir resultados adversos. La puntuación de riesgo de fragilidad hospitalaria (Hospital Frailty Risk Score, HFRS) está diseñada específicamente para ser usada con datos administrativos y presenta tres categorías de riesgo de fragilidad (bajo, intermedio y alto). El objetivo de este estudio fue evaluar la HFRS para predecir la mortalidad y su utilización en el hospital en pacientes de edad avanzada sometidos a cirugía vascular. MÉTODOS: Se analizaron los datos hospitalarios recogidos de forma rutinaria y que se relacionaron con los registros de defunción correspondientes a todos los pacientes de 75 o más años que se habían sometido a cirugía endovascular o vascular abierta, entre 2010-2012, en Nueva Gales del Sur, Australia. Se utilizaron modelos de regresión logística multinivel para comparar los resultados ajustados por factores relativos al paciente y al procedimiento, con y sin fragilidad.Se identificaron 9.752 pacientes, un 18% de los cuales tenían una puntuación del HFRS alta. Los pacientes en la categoría de fragilidad alta en comparación con los pacientes en la categoría de fragilidad baja presentaron una probabilidad ajustada de mortalidad a los 30 días (razón de oportunidades, odds ratio, OR) de 4,1 (i.c. del 95% 3,0-5,8) y una probabilidad de mortalidad a los 2 años similar (OR 4,3, i.c. del 95% 3,7-5,0). Añadiendo la HFRS a un modelo ajustado por edad., sexo, puntuación de comorbilidad, categoría socioeconómico, hospitalización previa y tipo de cirugía vascular aumentó la predicción de la mortalidad a los 2 años y la prolongación de la estancia hospitalaria, pero mejoró mínimamente la predicción de la mortalidad a los 30 días y de reingreso. CONCLUSIÓN: En esta cohorte de pacientes mayores sometidos a cirugía vascular, ajustar por la HFRS, además de por otros factores de riesgo relacionados con el paciente y el procedimiento quirúrgico, proporcionó una mayor discriminación de los resultados.

The aim of this scoping review was to identify initiatives focused on the secondary prevention and management of chronic pain in Australian primary care to understand options available to Primary Health Networks and to identify evidence gaps. The Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Cochrane databases, as well as relevant websites, were searched for eligible records published from 2007 to 2018. Initiative characteristics and outcomes evaluated were extracted and synthesised. In all, 84 initiatives from 167 published and grey literature records were identified, including: (1) consumer initiatives that aimed to improve access to multidisciplinary care, health literacy and care navigation (n=56); (2) health professional capacity building initiatives that aimed to ensure health professionals are skilled and provide best-practice evidence-based care (n=21); and (3) quality improvement and health system support initiatives (n=7). Evidence gaps were found relating to initiatives addressing the secondary prevention of chronic pain, those targeting vulnerable and regional populations, health professional capacity building initiatives for all primary health care providers and quality improvement and system support initiatives. Addressing evidence gaps related to effectiveness, cost-effectiveness and implementation should be the focus for future chronic pain initiatives in primary care settings.

APOE genotype has been associated with various age-related outcomes including Alzheimer’s disease, frailty, and mortality. In this study, the relationship between health, particularly cognitive function, and APOE was investigated in older men from the Concord Health and Ageing in Men Project (n = 1,616; age 76.9 ± 5.5 years [range 70–97 years]; Australia). Baseline characteristics and survival up to 12 years were determined. Frailty was measured using Cardiovascular Health study (CHS) criteria and Rockwood frailty index, and cognition using Mini-Mental State Examination (MMSE) and Addenbrookes Cognitive Examination. APOE ε4 was less common in the oldest men and those born in Mediterranean countries. APOE ε2 was beneficially associated with cholesterol, creatinine, gamma-glutamyl transaminase, glucose, and HDL cholesterol while APOE ε4 was adversely associated with cholesterol and albumin. APOE ε4 was associated with a clinical diagnosis of Alzheimer’s disease when adjusted for age and region of birth (ε4 homozygotes Odds ratio (OR) 7.0; ε4 heterozygotes OR 2.4, p < .05), and APOE ε2 had a small positive association with cognition. On multivariate regression, overall cognitive function in the entire cohort was associated with age, country of birth, education, and frailty (all p < .001). APOE was not associated with frailty or survival. In conclusion, age and region of birth influenced distribution of APOE genotype in older men. Although APOE ε4 was associated with Alzheimer’s disease, overall cognitive function in the cohort was associated more strongly with frailty than APOE genotype.

BackgroundChronic prescription opioid use is a major international public health issue associated with significant harms, including increased risk of hospitalisation, morbidity and death. Guidance for healthcare professionals on when and how to deprescribe or reduce opioids is required. A key step for guideline development for deprescribing pharmacotherapy is to understand the perspectives of stakeholders. The aim of this study was to explore the perspectives of healthcare professional stakeholders on the challenges associated with opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines.MethodsA qualitative study was undertaken with a purposive sample of healthcare professionals including prescribers, pharmacists and nurses. An initial cohort of participants was identified at the 2018 Australian Deprescribing Network annual meeting and two focus groups were conducted (n=20). Individual interviews were conducted with a further 11 healthcare professionals. Focus groups and interviews were audio-recorded and transcribed verbatim. Data underwent inductive thematic analysis using a phenomenological perspective.ResultsHealthcare professionals viewed opioid deprescribing as a challenge and identified several key barriers to deprescribing in clinical practice. Medication, patient, prescriber and health system level challenges were identified. Participants requested evidence-based guidance on the withdrawal of opioid therapies and suggested that prospective opioid deprescribing guidelines require a multitarget, multimodal intervention strategy that addresses patient psychosocial factors and incorporates behavioural change techniques.ConclusionOpioid deprescribing was perceived as a complex and challenging practice with continued prescribing the default behaviour. Evidence-based opioid deprescribing guidelines may be a valuable resource for clinicians to support clinical decision-making and reduce suboptimal opioid use.

Population Comprehensive evaluation of chronic pain in older adults is multifaceted. Objective and Methods Research on chronic pain in older adults needs to be guided by sound conceptual models. The purpose of this paper is to describe an adaptation of the Biopsychosocial Model (BPS) of Chronic Pain for older adults. The extant literature was reviewed, and selected research findings that provide the empiric foundation for this adaptation of the BPS model of chronic pain are summarized. The paper concludes with a discussion of specific recommendations for how this adapted model can be used to guide future research. Conclusions This adaptation of the BPS model of chronic pain for older adults provides a comprehensive framework to guide future research in this vulnerable population.

Objectives Overuse of prescription opioid analgesics is a major international public health problem. The objectives of this review are to i) investigate guideline recommendations on opioid deprescribing in people with non-cancer pain, ii) compare these recommendations across international guidelines, and iii) rate the risk of bias of the guidelines. Methods We searched electronic databases from inception to December 2018 for opioid guidelines containing recommendations to deprescribe (taper or stop) the use of prescription opioid analgesics in people with chronic non-cancer pain. There was no language or publication restriction. We also consulted experts and performed citation tracking. Screening and data extraction were conducted by two independent reviewers following standard methodology, and the risk of bias was assessed using the AGREE II tool. The outcomes, i) when to deprescribe, ii) how to deprescribe, iii) managing withdrawal symptoms, iv) additional support during the deprescribing process, v) monitoring outcomes and vi) deprescribing in patients with co-prescription of sedatives, were presented descriptively. Results The search resulted in 2905 unique references and 7 included guidelines: 4 from America, 1 from Australia, 1 from Canada and 1 from Germany. All deprescribing recommendations were embedded within prescribing guidelines rather than presented in a standalone deprescribing guideline. In general, guidelines scored well in all risk of bias domains on AGREE II except for applicability (limited information on guideline monitoring or auditing). We are currently finalising data interpretation; preliminary results are presented below. For when to deprescribe, all 7 guidelines recommended deprescribing in cases where benefits were outweighed by harms, and in pregnant women or those at a higher risk (e.g. substance use disorder). One guideline made specific recommendations on post-surgical patients. For how to deprescribe, some guidelines recommended a tapering plan at the time of opioid initiation, and gave guidance on the speed of tapering but this varied between 5% to 25% per week in different clinical situations and between guidelines. Two guidelines did not provide specific recommendations on managing withdrawal symptoms, while other guidelines recommended patient and family education, a slower taper, and specific medicines to manage symptoms such as nausea. For additional support, one guideline provided no recommendations but the most common support recommended by other guidelines included mental health support, multidisciplinary team involvement (e.g. for non-pharmacological pain management and pharmacy) and pain or addiction specialists. Recommendations on outcome monitoring varied between guidelines. Some recommended regular monitoring, and some recommended pausing or discontinuing the deprescribing process if appropriate (e.g. substantial increase in pain). Four guidelines made specific recommendations on co-prescription with sedatives, all recommending against the concurrent use of these medicines and for the gradual tapering of both medicines. Conclusions Opioid deprescribing recommendations are being made in opioid prescribing guidelines. In general there is consistency in when and how to deprescribe, but fewer recommendations are offered on managing withdrawal symptoms, outcome monitoring and co-prescription with sedatives.

Objectives Misuse and abuse of opioids is a major international public health problem leading to harms including increased risk of hospitalization, morbidity and death. Overtreatment with opioids contributes to misuse and has been documented in the USA, Australia and other countries. In order for health professionals to manage opioid overtreatment, guidance on when and how to deprescribe or reduce opioids is required. A key step for guideline development is to understand the perspectives of stakeholders. The aim of this study was to explore the perspectives of Australian deprescribing experts regarding opioid deprescribing practices. Method A purposive sample of deprescribing experts (including prescribers, pharmacists, researchers and policymakers) were identified for recruitment at the 2018 Australian Deprescribing Network annual meeting. Focus groups were conducted, audio recorded, transcribed verbatim, and entered into QSR NVivo 11 for coding.Inductive thematic analysis using a phenomenological perspective was completed, following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results Two focus groups (n= 20 participants) were conducted in December, 2018. A central theme identified in the focus groups was that opioid deprescribing was considered more challenging than deprescribing of other medicines due to additional user and prescriber-level barriers, including barriers at the organizational and system levels. Addiction was seen as a key barrier due to the intrinsic properties of opioids and that opioid users may be using opioids other than for physical analgesia. Prescribers were perceived to be hesitant to initiate deprescribing due to concerns of user resistance, potentially affecting the therapeutic relationship. This is of concern as medicines of high addictive potential may result in reduced user desire to request cessation. The opioid deprescribing process is considered a time-intensive activity without system-level incentives or clear guidance. Desirable elements for opioid deprescribing guidelines were consideration of psychosocial factors including; opioid phobia, stigma, shared decision making and vulnerable patient populations. Although specialist multidisciplinary care was seen as an enabler, accessibility was poor due to lengthy wait times for referral. Potential strategies to reduce opioid overtreatment could include patient education on the nature of pain and alternatives to opioids as well as targeting routine opioid prescribing in the acute care setting due overdiagnosis of anticipated pain as well as lack of planning of opioid tapering or cessation. Conclusions Opioid deprescribing was perceived by deprescribing experts as a complex, challenging practice with continued overtreatment the default behavior for both prescribers and opioid users. Consequently, prescribers are hesitant to initiate deprescribing activity. Efforts to reduce opioid overtreatment would require development of guidelines with the inclusion of psychosocial factors with a multi-target, multi-modal intervention strategy that incorporates behavioral change techniques.

Aim The aim of the present longitudinal study of community-dwelling older men was to examine the association between cognitive status at baseline, and falls, fractures and bone loss over time. Methods In the Concord Health and Aging in Men Project, 1705 community-dwelling men aged 70-97 years had detailed baseline clinical assessment of cognitive status (dementia, mild cognitive impairment [MCI] and normal cognition), as well as depression, physical activity, neuromuscular function, health status, sociodemographics, comorbidities, medication use and serum 25 hydroxyvitamin D, 1,25 dihydroxyvitamin D and parathyroid hormone levels. During a mean follow-up period of 6 years, participants were contacted 4-monthly to ascertain incident falls and fractures, the latter being confirmed by radiographic reports. Bone mineral density was measured by dual X-ray absorptiometry at multiple time-points. Results At baseline, 120 men were assessed to have MCI and 93 men to have dementia. Over time, there were 162 first incident fractures, including 43 hip and 32 vertebral fractures. In univariate models, baseline dementia, but not MCI, predicted an increased incidence of hip fracture (HR 6.95, 95% CI 3.47-13.96), but not vertebral (HR 2.26, 95% CI 0.79-6.46) or non-hip non-vertebral fracture (HR 0.73, 95% CI 0.27-1.99). The strong risk of hip fractures associated with dementia remained after accounting for potential confounders (HR 4.44, 95% CI 1.97-9.98). In multivariate analyses, dementia (incidence rate ratio 2.26, 95% CI 1.70-2.99), but not MCI, was associated with an increased risk of falls compared with normal cognition. There was no association between baseline dementia and change in bone mineral density. Conclusions Older men with dementia, but not MCI, have a greater tendency to fall and sustain hip fractures, but not any other types of fractures. Geriatr Gerontol Int 2018; 18: 1479-1484.

Purpose: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. Methods: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative’s mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. Results: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. Conclusion: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.]

Background Musculoskeletal (MSK) conditions are common and the biggest global cause of physical disability. The objective of the current study was to estimate the population prevalence of MSK-related pain using a standardized global MSK survey module for the first time. Methods A MSK survey module was constructed by the Global Alliance for Musculoskeletal Health Surveillance Taskforce and the Global Burden of Disease MSK Expert Group. The MSK module was included in the 2015 Solomon Islands Demographic and Health Survey. The sampling design was a two-stage stratified, nationally representative sample of households. Results A total of 9214 participants aged 15–49 years were included in the analysis. The age-standardized four-week prevalence of activity-limiting low back pain, neck pain, and hip and/or knee pain was 16.8, 8.9, and 10.8%, respectively. Prevalence tended to increase with age, and be higher in those with lower levels of education. Conclusions Prevalence of activity-limited pain was high in all measured MSK sites. This indicates an important public health issue for the Solomon Islands that needs to be addressed. Efforts should be underpinned by integration with strategies for other non-communicable diseases, aging, disability, and rehabilitation, and with other sectors such as social services, education, industry, and agriculture. Primary prevention strategies and strategies aimed at self-management are likely to have the greatest and most cost-effective impact. Electronic supplementary material The online version of this article (10.1186/s12891-018-2198-0) contains supplementary material, which is available to authorized users.