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OBJECTIVE To evaluate the role of PhA in diabetes in a large population of older adults with a high prevalence of diabetes in order to gain new insights on the potential diagnostic and prognostic role of PhA in individuals with diabetes. DESIGN Cross-sectional study. SETTING Teaching Hospital. PARTICIPANTS 1085 individuals aged 55 years or over. MEASUREMENTS Phase Angle was obtained using bioimpedance analysis with the Bodystat QuadScan® 4000. Diabetes mellitus was considered present with fasting hyperglycaemia (serum fasting glucose >6.66 mmol/l), HbA1c > 42 mmol/mol (6.1%), or self-reported Diabetes or the consumption of glucose-lowering agents. RESULTS The mean age of the (standard deviation) of the 1,085 participants was 68.11 (7.12) years and 60.7% were women. Among male participants, individuals with PhA within the lowest quartile (PhA ≤4.9) were significantly more likely to have diabetes mellitus [odds Ratio (95% confidence interval, CI), 2.02 (1.17-3.47)] following adjustments for age, body mass index and other comorbidities. The above relationship was attenuated following further adjustment hypoglycaemic medications. Men on oral hypoglycaemic agents had significantly reduced PhA [mean difference (95% CI), -0.44 (-0.67 to -0.22)]. No significant relationship between PhA and diabetes existed among women. CONCLUSION The association between lower PhA (≤4.9) in men aged 55 and over and diabetes which is accounted for by oral hypoglycaemic agents. The mechanisms underlying this relationship remain unclear. This relationship should also be evaluated further to determine the potential of PhA as a prognostic tool for diabetes.

Background Prolonged life expectancy is associated with increased prevalence of chronic diseases. The aim of this study was to determine the different disability trajectories for the top ten leading causes of death in Taiwan . Methods A total of 2,431 participants aged 50–96 in 1996 from the Taiwan longitudinal study on aging (TLSA) who died from 1996 to 2016 were analyzed. Integration of Cause of Death Data and TLSA helped sort out participants who had died from the ten leading causes of death. The level of physical disability was evaluated with the Activities of Daily Living Scale (ADLs), ranging from 0 to 6 points, in 1996, 1999, 2003, 2007, and 2011. A multilevel model was used to investigate the levels and rates of change in disability development before death. Results The outcome of the research showed that the earliest group to experience physical limitation was individuals living with diabetes. The groups with the highest ADL scores were participants with diabetes, cerebrovascular disease, and hypertension-related diseases. Most groups reach ADL scores ≥ 1 (mild-level) during 4–6 years before death except chronic hepatitis and cirrhosis and injury. Conclusions People who had died from the ten leading causes of death experienced different disability trajectories before death. The trajectory of the participants who had died from diabetes showed a unique pattern with the earliest occurrence and more severe deterioration in terms of development of disabilities. Disability trajectories provide a prediction of survival status for middle-aged and older adults associated with the ten leading causes of death.

Introduction Osteoarthritis (OA) is a major cause of physical impairment in older persons. Few studies have determined the relationship between the presence of OA and frailty. We evaluated the prospective relationship between knee pain and frailty in a Malaysian longitudinal cohort. Method Data from Malaysian Elders Longitudinal Research (MELoR) study were utilised. Baseline data were obtained from home-based computer-assisted questionnaires and hospital-based health-checks from 2013–2015. The presence of knee pain was determined with the single question, ‘do you have pain in your knee(s)?’. Frailty status was determined at follow-up in 2019 using SARC-F. Results Data from 1,226 individuals, mean age (SD) = 68.97 (7.48), range = 54–97 years and 56.6% women at baseline, were included. 408 (33.3%) had knee pain. Individuals with knee pain were significantly more likely to be female (66.2% vs 51.8%, p Conclusion Knee pain was associated with an increased risk of frailty with 5-years follow-up in an urban population in Kuala Lumpur. More detailed evaluation using imaging and clinical diagnosis of osteoarthritis is now indicated. Future studies should also seek to identify modifiable risk factors for the development of frailty in individuals with knee OA and develop strategies to prevent frailty.

Objective: Alzheimer’s disease (AD), the commonest form of dementia which is characterized by progressive decline in cognitive function, can only be definitively diagnosed after death. Although bio...

Parkinson's disease (PD) is the second most common neurodegenerative disease. The etiology of PD remains an enigma with no available disease modifying treatment or cure. Pharmacological compensation is the only quality of life improving treatments available. Endogenous dopaminergic neuroregeneration has recently been considered a plausible therapeutic strategy for PD. However, researchers have to first decipher the complexity of adult endogenous neuroregeneration. This raises the need of animal models to understand the underlying molecular basis. Mammalian models with highly conserved genetic homology might aid researchers to identify specific molecular mechanisms. However, the scarcity of adult neuroregeneration potential in mammals obfuscates such investigations. Nowadays, non-mammalian models are gaining popularity due to their explicit ability to neuroregenerate naturally without the need of external enhancements, yet these non-mammals have a much diverse gene homology that critical molecular signals might not be conserved across species. The present review highlights the advantages and disadvantages of both mammalian and non-mammalian animal models that can be essentially used to study the potential of endogenous DpN regeneration against PD.

To palliate suffering, understanding the circumstances leading to suffering and its amelioration could be helpful. Our study aimed to explore contributing and relieving factors of suffering in palliative care. Adult palliative care stage III or IV cancer in-patients were recruited from University of Malaya Medical Centre. Participants recorded their overall suffering score from 0 to 10 three times daily, followed by descriptions of their contributing and relieving factors. Factors of suffering were thematically analysed with NVIVO. Descriptive data were analysed with SPSS. 108 patients participated. The most common contributing factor of suffering was health factor (96.3%), followed by healthcare factor (78.7%), psychological factor (63.0%) and community factor (20.4%). The most common relieving factor was health factor (88.9%), followed by psychological factor (78.7%), community factor (75.9%) and healthcare factor (70.4%). Self-reported assessment of suffering offers a rapid approach to detect bothering issues that require immediate attention and further in-depth exploration.

BackgroundThe ageing skin is more susceptible to pruritic dermatoses, which are associated with adverse psychosocial effects and reduced quality of life among older adults. This cross-sectional study aimed to identify the burden of pruritus and factors associated with its presence and severity among older adults recruited to the Malaysian Elders Longitudinal Research study.MethodsSeven hundred seventy individuals aged 55 years (lower age limit) and above were interviewed as to whether they experienced pruritus during the preceding week and the locations involved if present. The association between generalised pruritus, sleep quality, and major systemic risk factors were explored.Results5.97% of respondents reported generalised pruritus. Generalised pruritus was associated with poorer sleep quality, with Pittsburgh Sleep Quality Index score above 6. Mean haemoglobin level was lower in subjects with generalised pruritus (13.14 g/dL) but there was no significant difference in the frequency of generalised pruritus and severe generalized pruritus between subjects with clinically defined anaemia. Also, there were no significant associations between other major systemic risk factors and generalised pruritus in this population-based study. There was no association between generalised pruritus with depression, anxiety or stress.ConclusionThe negative effect of pruritus on sleep quality suggests a possible deleterious effect of pruritus on health and quality of life. Further prospective research on the longer-term effects of pruritus on health status is now warranted.(222 words)

The current evidence on the relationship between a higher body mass index (BMI) and falls in older adults is conflicting. This study, therefore, evaluated the relationship between BMI and falls and explored underlying mechanisms for this relationship. Data from 1,340 individuals from the Malaysian Elders Longitudinal Research study, obtained through home-based computer-assisted interviews and followed by hospital-based health checks, were utilized. A history of the presence of falls in the previous 12 months was obtained. The presence of at least one fall in the past 12 months was associated with a higher BMI (odds ratio = 1.03, 95% confidence interval [1.01, 1.06]). The relationship between a higher BMI and falls was, however, attenuated by a lower percentage of lean body mass, which accounted for 69% of the total effect of BMI on the risk of falls. Future studies should now investigate this aforementioned relationship prospectively.

Background Age is an established risk factor for poor outcomes in individuals with influenza‐related illness, and data on its influence on clinical presentations and outcomes in the South‐East Asian settings are scarce. The aim of this study was to determine the above among adults with influenza‐related upper respiratory tract infection at a teaching hospital in Malaysia. Methods A retrospective case‐note analysis was conducted on a cohort of 3935 patients attending primary care at the University Malaya Medical Centre, Malaysia from February 2012 till May 2014 with URTI symptoms. Demographics, clinical characteristics, medical and vaccination history were obtained from electronic medical records, and mortality data from the National Registration Department. Comparisons were made between those aged

Several studies have been suggested that immunity plays a part in neurodevelopment and schizophrenia pathogenesis. Early age of onset in schizophrenia is associated with genetic factors which affect neurodevelopment. This study aims to identify immune abnormalities associated with neurodevelopmental impairments in early-onset schizophrenia (EOS) and adult-onset schizophrenia (AOS) patients. We determined the plasma levels of six cytokines (IL-1β, IL-4, IL-6, IL-10, IL-12 and TNF-α) in schizophrenia patients and healthy controls. Measurements included neurological soft signs (NSS) to distinguish and subgroup those with neurodevelopmental impairments. The study included 210 schizophrenia patients, which were divided into 84 EOS and 126 AOS patients, as well as 122 healthy controls. We observed significant differences in levels of IL-4, IL-6 and IL-10 between EOS and AOS patients. The results demonstrated the area under ROC curve (AUC) of the IL-4 in EOS and healthy controls was 0.81. Moreover, these results indicated that AUC of the IL-4 and the combination of IL-4, IL-6 and IL-12 in EOS with NSS and healthy controls were 0.91 and 0.95. These cytokines are altered in EOS and schizophrenia patients with neurodevelopmental impairments and demonstrated good classification abilities. These findings manifested that both pro- and anti-inflammatory cytokines are contributed to the clinical and pathophysiological features of schizophrenia. Future works are expected to explore potential genetic effectors and predictors as well as therapeutic directions in personalized medicine for early-onset schizophrenia.

Introduction Patient safety, such as inpatient falls, is a global problem, accounting for increasing compensation costs from our healthcare facilities. The aim of this study was to evaluate the patient safety culture among healthcare providers. Method An online survey was developed within the hospital staff portal at the University of Malaya Medical Centre, with a dialogue box appearing on the launching of the portal website inviting the members of staff to participate in the survey. The survey contained a safety assessment questionnaire (SAQ) which measures the patient safety culture. The SAQ consists of 36 items measuring the six domains: teamwork climate, job satisfaction, safety climate, stress recognition, working conditions, and perception of management. Each domain is assigned a percentage score, and comparisons of scores according to healthcare disciplines were then made. Results 5275 (80%) responded to the online SAQ which was sent out to all 6562 healthcare professionals employed, by the hospital. The teamwork and safety climate was poor among supporting staff, with scores of 56.7 and 59.8 respectively. Job satisfaction (62.9), perception of ward management (56.8), and hospital management (53.2), and working conditions (44.7) were less among the clinicians. Stress recognition (36.5) was in alarmingly low among the nurses. Conclusion A comprehensive unit-based safety programme will be conducted in response to the SAQ findings, and should incorporate objective falls the outcome in order to convince the hospital hierarchy of the need for urgent solutions to lower the rates of inpatient falls.

Introduction Previous studies have found that older adults with osteoarthritis (OA) were more likely to fall. However, the role of inflammation in OA severity, impaired physical function and increased risk of fall remains unclear. Therefore, the aim of this study is to explore the association between the inflammatory biomarkers and OA severity. Method This is a cross sectional case-control study which includes 69 individuals aged 55y recruited from orthopaedic clinics, geriatric clinics, primary care and senior citizen groups. Demographic characteristics, medical history, lifestyle factors, Knee Injury and Osteoarthritis Outcome Scores (Koos) were obtained through computer-assisted questionnaires and physical performance were measured. Blood samples were drawn after an overnight fast for a routine laboratory panel. The 20 inflammatory markers were measured and quantified using validated enzyme linked immunosorbent assays included TGFA, IFNG, IL1ra, IL1A, IL1B, IL2, IL3, IL4, IL5, IL6, IL7, IL8, IL9, IL10, IL12P40, IL12P70, IL13, IL15, IL17A and TNFA. Results Of the 69 participants, mean (SD) age being 66.67 (7.605) and 71% women, 18 (26.1%) reported severe, 13(18.8%) moderate, 20 (29.0%) mild and 18 (26.1%) no OA, women. Significant differences in BMI (p-value Conclusion More research is needed to see whether this applies to a bigger population and more detailed research needs to be done in regards to TGF-A, IL-6 and IL-8 which shows promise as a severity biomarker for osteoarthritis.

Background One in three older adults fall each year leading to increased disability, hospitalizations and mortality. Recent studies suggested an increased risk of falls among obese individuals which may correlate with increased rates of falls hospitalizations. However, there is not much information supporting the hypothesis that obesity may influence the risk of falls related hospitalizations. Aims To prospectively investigate whether body mass index (BMI) is a predictor for falls hospitalization by age group in the population of the EPIC-Norfolk Study. Methods Body height and weight were measured at baseline and BMI calculated. Falls hospitalization status over 20 years’ follow-up was ascertained using data linkage with centralized NHS records. Participants were categorized into the four BMI groups: underweight (BMI Results Data from 25636 individuals, (54.7%) women and (45.3%) men, mean age 59.2 ± 9.3 years, were included. For individuals within the under 55-year age group at baseline, individuals who were overweight (HR = 1.25; 95% CI= 1.01-1.56) and obese (HR = 1.54; 95% CI= 1.17-1.81) were at higher risk of falls hospitalization compared with those with normal BMI. As for individuals aged ≥ 65 years at recruitment, individuals who were obese were less likely to be hospitalized after a fall (HR = 0.85; 95% CI= 0.74 – 0.97) compared to those with normal BMI. Conclusions The relationship between obesity and falls hospitalization over 20 years differed between those aged

Background Diabetes mellitus (DM) is a highly prevalent NCD affecting 20-30% of worldwide population with a rapidly rising prevalence in LMICs. It has been suggested that DM is one of the important risk factors for falls in older people attributed to complications. However, only a handful studies has evaluated the mechanisms of falls in diabetes. Aim To determine the potential mediating factors for falls individuals with diabetes mellitus Methods Cross-sectional analysis was conducted using the Malaysian Elders Longitudinal Study (MELoR) first wave data. The MELoR study recruited Klang Valley residents aged >55 years. DM was defined as fasting hyperglycaemia (serum fasting glucose > 6.66 mmol/l) or HbA1c > 42 mmol/mol (6.1%) or self-reported diabetes by participants or consumption of hypoglycaemic medications. Falls were identified by enquiring about the presence of fall in the past 12 months. Physical measurements obtained were hand grip strength (HGS), timed-up-and-go (TUG) and functional reach. Result Of 1579 participants, mean (SD) age 68.85 (7.48) years and 901 (57.1%) female, DM was present in 796 (50.4%) participants while 363 (22.9%) had falls in the past 12months. DM was associated with 35% of increased odds of falls compared to those without DM (odds ratio (95% CI)= 1.35 (1.07-1.71)). The association was remained significant after adjustment of demographic differences, body mass index and TUG. The associations were, however, attenuated after the inclusion of HGS in the model. Conclusion Weaker HGS appeared to account for the increased risk of falls in individuals aged 55 ears and above with DM. Reduced HGS is a marker including in the frailty phenotype. It is unclear why HGS rather than TUG, which is a composite measure of gait speed, lower limb girdle and dynamic balance mediated the relationship. A prospective study is required to determine the temporal relation between HGS and falls in diabetes.

Background Cross-sectional studies linking the association between obesity and falls are limited and their results are somewhat conflicting. The inconsistent evidence between obesity and falls could be explained by the utilization of different measures of obesity including BMI, WC, waist hip ratio (WHR) and percentage body fat (%BF) in different studies. Aims To examine the prospective association between various measures of obesity and falls among community-dwelling older adults. Methods We utilized data from the wave 1 and wave 2 of the Malaysian Elder’s Longitudinal Research Study (MELoR). Basic demographic characteristics, medical history, lifestyle factors and falls history in preceding 12 months was recorded by computer assisted questionnaire in participant’s home while anthropometric measurements, body composition assessments and physical performance were collected at the hospital during a hospital check-up at baseline. The main exposure variables were increased body mass index (BMI), waist circumference (WC), waist hip ratio (WHR) and percentage body fat (%BF) and the main outcome was self-report falls in the preceding 12 months at time of follow-up. Results Among 746 participants at baseline and follow-up (mean age 68.9 ± 7.3 years, old, 56.7% women), 150(20.1%) individuals had ≥1 time of fall at follow-up. No differences in mean age and proportion of men and women among fallers and non-fallers. However, fallers were found to have higher WHR, lower percentage muscle mass and performed poorer in physical performance (p-value Conclusions In conclusion, our findings suggest that WHR is the measure of adiposity most likely to differentiate fallers from non-fallers prospectively. Future studies should evaluate the mechanisms underlying the increased risk of falls associated with increased WHR.

Introduction Recent studies identified a relationship between gait difficulties and risk of developing dementia, a condition now termed motoric cognitive risk. We interrogated a clinical dataset to determine the relationship between cognitive assessment scores and physical performance scores to identify the strength of association between these two types of measures. Methods Consecutive patients referred to the falls and syncope service and the University of Malaya Medical Centre were recruited. The cognitive function of consenting individuals was assessed using the Montreal Cognitive Assessment (MoCA) and Visual Cognitive Assessment Tool (VCAT). Physical performance was assessed using hand grip strength (HGS), timed-up-and-go (TUG) and functional reach (FR). Results One hundred and forty-seven individuals, mean age (standard deviation,SD)=76.1 (7.8) years, 85 (58%) women were included. The mean (SD) for right and left HGS, FR and TUG scores for the overall population were 19.1 (7.0)kg, 19.0 (12.1)kg, 28.9 (39.7)cm, TUG 19.2 (11.0)s respectively. The mean MoCA and VCAT scores were 21.1 (7.1) and 20.3 (6.3) respectively. Right HGS correlated moderately with MoCA (r=0.367) and VCAT scores (r=0.397). Left HGS had a weak to moderate correlation with MoCA (r=0.281) and VCAT (0.271). FR, however, was not correlated with either MoCA (r=0.073) and VCAT (0.020). TUG scores were moderately negatively correlated with MoCA (-0.3206) but weakly correlated with VCAT (-0.175) Conclusion Our evaluation of the relationship between cognitive scores and physical performance in a falls and syncope clinic setting found that a relationship exists between muscle strength measured with grip strength and composite assessment of gait and balance using the TUG. Dynamic balance measured with functional reach, however, was not associated with cognitive function. Future studies will need to identify the possible mechanisms linking cognitive function with strength and gait in order to establish cognitive function as a modifiable risk factor for falls in older adults.

The Malaysian Elders Longitudinal Research (MELoR) study found 1 in 4 residents aged 65 years and over living in the Klang Valley of Malaysia fall at least once a year in their survey conducted between 2013 and 2015. Recent figures obtained from the First Older Persons’ National Health and Morbidity Survey conducted in 2018 revealed that 15% of Malaysians aged 60 years and over fall at least once a year. In a 10-year follow-up study involving 200 individuals who presented to the emergency department over a six-month period in 2002, 22% were no longer alive at one year, and 80% had died at 10 years. Older age, indoor falls, subsequent hospital admission and functional impairment predicted death at one year. Cross-sectional data from MELoR revealed ethnic differences in fall prevalence, with the ethnic Indians more likely to report falls in the past 12 months compared to the ethnic Malays. Independent risk factors for falls identified from MELoR were urinary incontinence, reduced grip strength, hearing impairment, comorbidities and reducing walking speed. The ethnic differences in falls in our population remain unexplained. Lifestyle and cultural practices may well be the underlying rationale, but genetic influences cannot currently be ruled out. The results of a randomized controlled trial on multifactorial interventions, the Malaysian Falls Assessment and Intervention Trial (MyFAIT), was published last year. Mo differences in falls outcomes with an individualized multifactorial intervention were observed, despite improvements in physical performance and psychological status in the intervention group compared to the control group. The research group has now secured two-year funding to evaluate post-fall behavior in our setting in the Life After Falls (LiAF) study. In addition, dissemination and upskilling efforts are underway through training workshops, formation of the Malaysian Falls Network (MyFalls) and collaborations with the private sector to increase awareness on falls and increase fall prevention efforts throughout the country.

Objective: The aim of this review was to determine the contents and parameters of self‐management education programs (SMEPs) for older adults with knee osteoarthritis (KOA). Methods: A systematic electronic literature search (Scopus, MEDLINE, ProQuest, CINAHL, Cochrane and a grey literature specific site through Google Scholar) was undertaken between March and May 2018 (search updated in June 2019). Studies were selected based on predetermined criteria. Data relating to the contents and parameters of the SMEP were extracted and collated. Results: A total of 11 experimental studies met the inclusion criteria. Overall quality of the selected studies was good. The contents used for SMEP in older adults with KOA were information and management of KOA, healthy lifestyle and additional management strategies for KOA. The parameters used were face‐to‐face sessions led by health professionals and were chiefly group‐based. Conclusion: This review comprehensively summarises the structure of multifaceted SMEP for people with KOA, which could be used to inform clinical practice and future research. Refereed/Peer-reviewed

Introduction Older persons with diabetes are at an increased risk of falls leading to fractures, head injuries and disability. Objective To evaluate the potential relationship between falls and diabetes in older persons and identify differences in risk factors for falls among older persons with and without diabetes using the first wave dataset of the Malaysian Elders Longitudinal Research (MELoR) study. Methodology Community dwelling adults aged ≥ 55 years were selected through stratified random sampling from three parliamentary constituencies in greater Kuala Lumpur. Baseline data was obtained through computer-assisted, home-based interviews. Presence of falls was established by enquiring about falls in the preceding 12 months. Diabetes was defined as self-reported, physician-diagnosed diabetes, diabetes medication use and a HbA1c of ≥ 6.3%. Results Diabetes was present in 44.4% of the overall 1610 participants. The prevalence for fall among older diabetics was 25.6%. Recurrent falls (odds ratio (OR) 1.65; 95% confidence interval (CI) 1.06 - 2.57) was more common among diabetics. Following adjustment for potential confounders, osteoporosis (OR 2.58; 95% CI 1.31 - 5.08) and dizziness (OR 1.50; 95% CI 1.01 - 2.23) were independent risk factors for falls. Better instrumental activities of daily living scores were protective against falls (OR 0.75; 95% CI 0.58 - 0.97). Conclusion The presence of osteoporosis and dizziness was associated with increased risk of falls among older diabetics. These findings will need to be confirmed in future prospective follow-up of this cohort.

Few studies to date have evaluated dementia care in Malaysia, and the focus of studies has primarily been on epidemiological and laboratory research. In this study, we aimed to identify potential challenges for the delivery of dementia care in Malaysia and priorities for research and enhancing existing dementia care. This study used thematic analysis to evaluate the open and focus group workshop discussions guided by semi-structured questions. Triangulation of the collected data (sticky notes, collated field notes, and transcripts of discussions) was achieved through stakeholder consensus agreement during a workshop held in 2017. Five main themes as priorities for dementia care were identified: (1) availability of a valued multi-disciplinary care service, (2) accessibility of training to provide awareness, (3) the functionality of the governance in establishing regulation and policy to empower care services, (4) perceived availability and accessibility of research data, and (5) influence of cultural uniqueness. The findings of this study seek to enhance existing dementia care in Malaysia but have potential application for other low and middle-income countries with a similar social and health care set up. The constructed relationship between themes also tries to tackle the challenges in a more efficient and effective manner, as none of these aforementioned issues are standalone challenges. In addition, we demonstrated how a carefully constructed workshop with defined aims and objectives can provide a useful analysis tool to evaluate health and social care challenges in a multidisciplinary forum.

This study assesses the impact of a decrease in air quality and the risk of hospital admissions to a public hospital for chronic respiratory diseases for residents of Petaling Jaya, a city in the Greater Kuala Lumpur area in Malaysia. Data on hospital admissions for asthma, bronchitis, emphysema and other chronic obstructive pulmonary disease, weather conditions and the Malaysian Air Pollution Index, a composite indicator of air quality, were collated. An unconstrained distributed lag model to obtain risk of hospitalization for a 10 μg/m3 increase in the API. The lag cumulative effect for a 10 μg/m3 increase in the API was calculated to test for harvesting in the short term. Findings indicate that after an initial decrease in admissions (days 3 and 4), admissions increased again at day 7 and 8 and this relationship was significant. We therefore conclude that a 10 μg/m3 increase has a greater effect on admissions for respiratory health in the short term than a harvesting effect alone would suggest. These results suggest that while air quality is improving in the Greater Kuala Lumpur area, no level of air pollution can be deemed safe.

Background: The number of people living with dementia worldwide is increasing, particularly in low- and middle-income countries (LMICs) where little is known about existing post-diagnostic care and support. This study aimed to better understand healthcare provision for people living with dementia in Malaysia, and to identify priorities for providing timely, quality, and accessible care and support to all.Methods: This is a qualitative interview study on care providers and facilitators (health and community care professionals, paid carers, traditional medicine practitioners, faith healers, community leaders, non-governmental organisations). A topic guide, piloted in Malaysia and peer reviewed by all LMIC partners, elicited the understanding of dementia and dementia care and barriers and facilitators to care for people living with dementia and carers, and perceptions of key priorities for developing efficient, feasible, and sustainable dementia care pathways. Verbatim transcription of audio-recorded interviews was followed by iterative, thematic data analysis.Results: Twenty interviews were conducted (11 healthcare professionals, 4 traditional medicine practitioners, and 5 social support providers). The findings indicate that dementia care and support services exist in Malaysia, but that they are not fully utilised because of variations in infrastructure and facilities across the country. Despite a locally recognised pathway of care being available in an urban area, people with dementia still present to the healthcare system with advanced disease. The interviewees linked this to a public perception that symptoms of dementia, in particular, are normal sequelae of ageing. Earlier detection of dementia is commonly opportunistic when patients present to GPs, government clinic staff, and general physicians with other ailments. Dementia may only be identified by practitioners who have some specialist interest or expertise in it. Workforce factors that hindered early identification and management of dementia included lack of specialists, overburdened clinics, and limited knowledge of dementia and training in guideline use. Post-diagnostic social care was reported to be largely the domain of families, but additional community-based support was reported to be available in some areas. Raising awareness for both the public and medical professionals, prevention, and more support from the government are seen as key priorities to improve dementia management.Conclusions: This qualitative study provides novel insight into the availability, delivery, and use of post-diagnostic care and support in Malaysia from the perspective of care providers. The respondents in this study perceived that while there was a provision for dementia care in the hospital and community settings, the different care sectors are largely unaware of the services each provides. Future work should explore how care provision across different service sectors and providers can be supported to better facilitate patient access and referral between primary, secondary, and social care. The importance of supporting families to understand dementia and its progression, and strategies to help them care for relatives was emphasised. There is also a need for broad workforce training and development, at both the postgraduate and undergraduate levels, as well as improved general awareness in the community to encourage earlier help-seeking for symptoms of dementia. This will enable the use of preventive strategies and access to specialist services to optimise care and quality of life for people living with dementia in Malaysia.

Early-onset schizophrenia (EOS) may have stronger familial aggregation and a more severe outcome than adult-onset schizophrenia (AOS). MicroRNA (miRNA) takes on dual roles as a genetic and epigenetic modulator, which may mediate the influence of genetic risk. Neurological soft signs (NSS) are neurological abnormalities that may be intermediate phenotypes or endophenotypes for schizophrenia. Our previous study found poorer performance on NSS tests from patients with EOS and their unaffected first-degree relatives. Thus, we aimed to identify a set of aberrant neurodevelopmental-related miRNAs that could serve as potential biomarkers for EOS or schizophrenia with NSS. This study included 215 schizophrenia patients (104 EOS and 111 AOS), 72 unaffected first-degree relatives, 31 patients with bipolar disorder, and 100 healthy controls. Differential expression analysis revealed that miR-137, miR-34b, and miR-34c were significantly up-regulated in patients with schizophrenia and their unaffected first-degree relatives compared to healthy controls. Receiver operating characteristic (ROC) analysis showed that the miR-137 expression signature could be used to discriminate between patients with EOS and healthy controls (AUC = 0.911). Additionally, miR-34b had the highest ability to discriminate between EOS and AOS (AUC = 0.810), which may indicate different aetiological pathways to disease onset. Moreover, miR-137 dysregulation was correlated with almost all NSS subscales (i.e., sensory integration, motor sequencing, etc.) and, when EOS patients with NSS, miR-137 expression discriminated these patients from healthy controls to a greater extent (AUC = 0.957). These findings support the potential for neurodevelopmental-related miRNAs to be used as indicators of vulnerability to EOS.

Background: Acute cholangitis (AC) is a common emergency with a significant mortality risk. The Tokyo Guidelines (TG) provide recommendations for diagnosis, severity stratification, and management of AC. However, validation of the TG remains poor. This study aims to validate TG07, TG13, and TG18 criteria and identify predictors of in-hospital mortality in patients with AC. Methods: This is a retrospective audit of patients with a discharge diagnosis of AC in the year 2016. Demographic, clinical, investigation, management and mortality data were documented. We performed a multinomial logistic regression analysis with stepwise variable selection to identify severity predictors for in-hospital mortality. Results: Two hundred sixty-two patients with a median age of 75.9 years (IQR 64.8–82.8) years were included for analysis. TG13/TG18 diagnostic criteria were more sensitive than TG07 diagnostic criteria (85.1 vs. 75.2%; p < 0.006). The majority of the patients (n = 178; 67.9%) presented with abdominal pain, pyrexia (n = 156; 59.5%), and vomiting (n = 123; 46.9%). Blood cultures were positive in 95 (36.3%) patients, and 79 (83.2%) patients had monomicrobial growth. The 30-day, 90-day, and in-hospital mortality numbers were 3 (1.1%), 11 (4.2%), and 15 (5.7%), respectively. In multivariate analysis, type 2 diabetes mellitus (OR = 12.531; 95% CI 0.354–116.015; p = 0.026), systolic blood pressure p = 0.041), Glasgow coma score p = 0.019), and malignancy (OR = 14.135; 95% CI 1.017–196.394; p = 0.049) predicted in-hospital mortality. Conclusion: TG13/18 diagnostic criteria are more sensitive than TG07 diagnostic criteria. Type 2 diabetes mellitus, systolic blood pressure

BackgroundThe 2013 Malaysian Clinical Practice Guidelines on the Management of Osteoarthritis (OA) recommend a linear step-up approach to manage knee OA. However, patients with knee OA often require a multimodal approach to address OA-related pain symptoms and functional limitations. This consensus aimed to provide doctors with an updated set of evidence-based, clinical experience-guided recommendations to manage knee OA.MethodsA multi-speciality expert panel consisting of nine Malaysian physicians from different healthcare settings who manage a diverse OA patient population was convened. Using a combination of the ADAPTE process and modified Delphi method, the panel reviewed current evidence on the management of knee OA and synthesised a set of nine recommendations on the management of knee OA, supported by an algorithm that summarises the consensus’ core messages.ResultsA multimodal intervention strategy is the mainstay of OA management and the choice of any single or multimodal intervention may vary over the course of the disease. Overall, a non-pharmacological core treatment set of patient education, weight loss and exercise is recommended for all patients. When pharmacotherapy is indicated, symptomatic slow-acting drugs for osteoarthritis are recommended at the early stage of disease, and they can be paired with physical therapy as background treatment. Concurrent advanced pharmacotherapy that includes non-steroidal anti-inflammatory drugs, intraarticular injections and short-term weak opioids can be considered if patients do not respond sufficiently to background treatment. Patients with severe symptomatic knee OA should be considered for knee replacement surgery. Management should begin with specific treatments with the least systemic exposure or toxicity, and the choice of treatment should be determined as a shared decision between patients and their team of healthcare providers.ConclusionsThis consensus presents nine recommendations that advocate an algorithmic approach in the management of patients living with knee OA. They are applicable to patients receiving treatment from primary to tertiary care providers in Malaysia as well as other countries.

Background Cardiovascular problems such as orthostatic hypotension are common risk factors for falls in older persons. Arterial stiffness has been suggested as the key determinant of cardiovascular risk. Published evidence to support the assumption on the associations between arterial stiffness parameters and falls remains limited. Aim To determine the association between arterial stiffness and falls in older people. Methods This was a cross-sectional analysis of MELoR first wave data. Of 446 participants included, 103 reported at least one falls in the past 12 months. The assessment of arterial pulse wave components was performed by non-invasive applanation tonometry of radial artery a SphygmoCor device (AtCor Medical, Sydney, Australia). Result Participants with mean age 68.28 (7.28) and 60% female were included in this study. Fallers showed significant higher central arterial pressure percentage at heart rate 75bpm compared to the non-fallers [mean (SD): 16.61 (8.16) vs 14.79 (6.89), p=0.026]. The association remained significant after adjustment for age and hypertension. In addition, peripheral diastolic pressure in fallers was significantly lower than non-fallers (p-value=0.049). Conclusion Augmented index at the heart rate of 75bpm was associated with falls in older people. Thus, this study suggests that this parameter could be the determinants in assessing risk of falls. A prospective study is therefore recommended to determine temporal associations between arterial stiffness and falls.

Background and purpose Poor quality of life (QoL) is a well-recognized consequence after stroke. Quality of life is influenced by a complex interaction between personal and environmental factors. Most previous investigations of the QoL after stroke have focused on personal factors, for example, physical deficits directly resulting from stroke. The influence of environmental factors, including social participation, is relatively understudied partly due to its high variation across different sociocultural contexts. The purpose of this study was to investigate the determinants of QoL among older adults with stroke living in an urban area of a developing country. Methods This cross-sectional observational study included 75 older adults who were at least 3 months poststroke and 50 age-matched healthy controls. Depressive symptoms were quantified using the World Health Organization Quality of Life Brief version (WHOQoL-BREF). Physical function was examined using Functional Ambulation Category, grip strength, 5 times Sit-to-Stand test, and Box and Block tests. The Montreal Cognitive Assessment and visual-manual reaction time were used to index cognitive function. Depressive symptom was quantified using the Patient Health Questionnaire-9. The Barthel Index and Fatigue Severity Scale were used to quantify activity limitation. Social participation and environmental participation were assessed using the Assessment of Life Habit and Craig Hospital Inventory of Environment Factors, respectively. Linear stepwise regression models were used to determine explanators for WHOQoL-BREF domain scores. Results Individuals with stroke demonstrated significantly worse QoL on all WHOQoL-BREF domains compared with healthy controls. Stroke was a strong determinant for QoL and explained 16% to 43% of variances. Adding other outcome measures significantly improved the robustness of the models (R change = 12%-32%). The physical, psychological, social, and environmental domains of WHOQoL-BREF were all explained by the LIFE-H scores (β = -10.58, -3.37, 4.24, -5.35, respectively), while psychological, social, and environmental domains were explained by Montreal Cognitive Assessment scores (β = .47, 0.78, 0.54, respectively). Conclusion Social participation and cognition were strong determinants of QoL among urban-dwelling older adults with stroke. Social and recreational activities and cognitive rehabilitation should therefore be evaluated as potential strategies to improve the well-being of older adults affected by stroke.

To evaluate the relationship between waist-to-hip ratio and fall-related outcomes in community-dwelling individuals aged 55 years and above. A higher waist-to-hip ratio remained independently associated with increased risk of falls compared to those with a lower waist-to-hip ratio. Waist-to-hip ratio should be measured when assessing fall risk in adults aged 55 years and above. To evaluate the relationship between waist-to-hip ratio (WHR) and fall-related outcomes in community-dwelling individuals aged 55 and above. Cross-sectional data obtained from the first wave of the Malaysian Elders Longitudinal Research (MELoR) study were utilized for this study. Participants aged 55 years and over were recruited using simple random sampling from the electoral rolls of three local parliamentary constituencies. Socio-demographics, falls history and medical history were obtained through home-based computer-assisted interviews while anthropometric measurements, including WHR, and physical performance were obtained during hospital-based health checks. WHR was categorized into three arbitrary categories stratified by gender. Data on both falls and WHR were available for 1335 participants, mean age ± standard deviation (SD) = 68.4 ± 7.1 years. Logistic regression analyses using dummy variables revealed that individuals within the higher WHR group were significantly more likely to report a history of fall in the preceding 12 months {adjusted odds ratio (aOR) [95% confidence interval (CI)] = 1.78 (1.18–2.67)}, fear of falling [aOR (95% CI) = 1.58 (1.08–2.32)], impaired timed-up-and-go [2.14 (1.44–3.17)] and reduced functional reach [1.68 (1.18–2.38)] compared to those with lower WHR. A higher WHR remained independently associated with increased risk of falls compared to those with lower WHR after additional adjustment for fear of falling and functional performance. Our finding suggests WHR as an independent risk factor for higher risk of fall which may indicate body shape as a potentially modifiable risk factor for falls in adults in aged 55 years and over.

Knee osteoarthritis (OA) is a prevalent chronic disorder in the older population. While timely management is important to minimize the consequences of knee OA, information on the utilization of healthcare services among this population remains limited. Therefore, the objectives of this study were to determine the healthcare utilization and its associated factors in older persons with knee OA. Cross-sectional data from 1073 participants aged 60 years and above from the Malaysian Elders Longitudinal Research (MELoR) study were included. The utilization rate of healthcare services was quantified. Factors related to the utilization of healthcare services were determined using logistic regression analysis. Healthcare utilization among participants with knee OA was significantly higher than those without knee OA (p &lt, 0.01). Outpatient usage was higher (p &lt, 0.01) in comparison to inpatient and pharmacotherapy. Being married and having an income were significantly associated with seeking outpatient care (OR: 11.136, 95% CI: 1.73–52.82, p &lt, 0.01) and pharmacotherapy (OR: 10.439, 95% CI: 1.187–91.812, p &lt, 0.05), while females were less likely to utilize inpatient care services (OR: 0.126, 95% CI: 0.021–0.746, p &lt, 0.05). The higher rate of healthcare utilization among older persons with knee OA indicates the increased healthcare needs of this population, who are commonly assumed to suffer from a benign disease.

Background Since 2014, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) algorithm for the management of knee osteoarthritis (OA) is available worldwide. Aim Based on this document, a Southeast Asia Working Group (SEAWG) wished to see how the new ESCEO algorithm developed in 2019 was perceived by Southeast Asian experts and how it was integrated into their clinical practice. Methods A SEAWG was set up between members of the international ESCEO task force and a group of Southeast Asian experts. Results Non-pharmacological management should always be combined with pharmacological management. In step 1, symptomatic slow-acting drugs for osteoarthritis are the main background therapy, for which high-quality evidence is available only for the formulations of patented crystalline glucosamine sulfate and chondroitin sulfate. In step 2, oral NSAIDs are a useful option, considering the cardiovascular/renal/gastrointestinal profiles of the individual patient. Intra-articular hyaluronic acid and corticosteroids are a possible alternative to oral NSAIDs, but limited evidence is available. If steps 1 and 2 do not give adequate relief of symptoms, tramadol can be used, but its safety is debated. In general, the indications of the ESCEO algorithm are important in Southeast Asian countries, but the reimbursement criteria of local health systems are an important aspect for adherence to the ESCEO algorithm. Conclusion This guidance provides evidence-based and easy-to-follow advice on how to establish a treatment algorithm in knee OA, for practical implementation in clinical practice in Southeast Asian countries.

While metabolic syndrome, falls, and frailty are common health issues among older adults which are likely to be related, the potential interplay between these three conditions has not previously been investigated. We investigated the relationship between metabolic syndrome with falls, and the role of frailty markers in this potential relationship, among community-dwelling older adults.Data from the first wave Malaysian Elders Longitudinal Research (MELoR) study comprising urban dwellers aged 55 years and above were utilized. Twelve-month fall histories were established during home-based, computer-assisted interviews which physical performance, anthropometric and laboratory measures were obtained during a hospital-based health check. Gait speed, exhaustion, weakness, and weight loss were employed as frailty markers.Data were available for 1415 participants, mean age of 68.56 ± 7.26 years, 57.2% women. Falls and metabolic syndrome were present in 22.8% and 44.2%, respectively. After adjusting for age, sex, and multiple comorbidities, metabolic syndrome was significantly associated with falls in the sample population [odds ratio (OR): 1.33, 95% confidence interval (CI): 1.03; 1.72]. This relationship was attenuated by the presence of slow gait speed, but not exhaustion, weakness, or weight loss.Metabolic syndrome was independently associated with falls among older adults, and this relationship was accounted for by the presence of slow gait speed. Future studies should determine the value of screening for frailty and falls with gait speed in older adults with metabolic syndrome as a potential fall prevention measure.

Reduced peak expiratory flow is a common physiological change in older individuals and age is an important predictor for sarcopenia. We analyzed nationwide survey data to determine the relationship between peak expiratory flow rate and sarcopenia in older Indonesians. Community-dwelling Indonesian individuals aged ≥60 years (n = 2422; mean age = 67.21 y) from the fifth-wave data of the Indonesian Family Life Survey was selected. Sarcopenia was diagnosed based on handgrip strength, gait speed, and appendicular skeletal muscle mass measurements. Peak expiratory flow rates (PEFRs) were categorized according to their percentage of predicted flow rates as 80%. Confounders previously determined to be associated with sarcopenia occurrence were included. Sarcopenia prevalence was 50.25%. After adjustment for confounders, PEFRs of 80%. Poor lung function was independently associated with sarcopenia occurrence. Future studies should explore the usefulness of PEFR as a risk factor of sarcopenia.

Background Early mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery initiatives. Objectives The primary objective was to increase postoperative day (POD) 2 mobilisation rate from 23% to 75% in patients undergoing elective major hepatopancreatobiliary (HPB) surgery within 6 months. Methods We report a multidisciplinary team clinical practice improvement project (CPIP) to improve postoperative mobilisation of patients undergoing elective major HPB surgery. We identified the common barriers to mobilisation and analysed using the fishbone or cause-and-effect diagram and Pareto chart. A series of Plan–Do–Study–Act cycles followed this. We tracked the rate of early mobilisation and mean distance walked. In the post hoc analysis, we examined the potential cost savings based on reduced hospital length of stay. Results Mobilisation rate on POD 2 following elective major HPB surgery improved from 23% to 78.9%, and this sustained at 6 months after the CPIP. Wound pain was the most common reason for failure to ambulate on POD 2. Hospital length of stay reduced from a median of 8 days to 6 days with an estimated cost saving of S$2228 per hospital stay. Conclusion Multidisciplinary quality improvement intervention effort resulted in an improved POD 2 mobilisation rate for patients who underwent elective major HPB surgery. This observed outcome was sustained at 6 months after completion of the CPIP with potential cost savings.

AIM Dementia is the major cause of disability among older persons and leading physical and psychological sequelae for both the person living with dementia (PLwD) and their caregivers. The aim of this study was to determine the prevalence of dementia in Malaysia and identify the factors influencing quality of life (QoL) of caregivers of PLwD. METHODS A nationwide survey was conducted among individuals aged ≥60 years. Cognition was assessed with the Identification and Intervention for Dementia in Elderly Africans (IDEA) tool. QoL of older caregivers was assessed using the Control, Autonomy, Self-Realization and Pleasure (CASP-19) questionnaire. RESULTS The prevalence of dementia among older adults aged ≥60 years in Malaysia was found to be 8.5%. The prevalence was found to be higher among females, those with no formal education and those in rural areas in Malaysia. The mean QoL of family caregivers of PLwD was significantly lower than the caregivers of older adults without dementia were (P

The incidence of nonmelanoma skin cancer (NMSC) has been increasing worldwide. Most studies have highlighted the importance of cancer-associated fibroblasts (CAFs) in NMSC progression. However much less is known about the communication between normal fibroblasts and epithelia; disruption of this communication affects tumor initiation and the latency period in the emergence of tumors. Delineating the mechanism that mediates this epithelial-mesenchymal communication in NMSC could identify more effective targeted therapies. The nuclear receptor PPARβ/δ in fibroblasts has been shown to modulate adjacent epithelial cell behavior, however, its role in skin tumorigenesis remains unknown. Using chemically induced skin carcinogenesis, we showed that FSPCre-Pparb/dex4 mice, whose Pparb/d gene was selectively deleted in fibroblasts, had delayed emergence and reduced tumor burden compared with control mice (Pparb/dfl/fl). However, FSPCre-Pparb/dex4-derived tumors showed increased proliferation, with no difference in differentiation, suggesting delayed tumor initiation. Network analysis revealed a link between dermal Pparb/d and TGF-β1 with epidermal NRF2 and Nox4. In vitro investigations showed that PPARβ/δ deficiency in fibroblasts increased epidermal Nox4-derived H2O2 production, which triggered an NRF2-mediated antioxidant response. We further showed that H2O2 upregulated NRF2 mRNA via the B-Raf-MEK1/2 pathway. The enhanced NRF2 response altered the activities of PTEN, Src, and AKT. In vivo, we detected the differential phosphorylation profiles of B-Raf, MEK1/2, PTEN, Src, and AKT in the vehicle-treated and chemically treated epidermis of FSPCre-Pparb/dex4 mice compared with that in Pparb/dfl/fl mice, prior to the first appearance of tumors in Pparb/dfl/fl. Our study revealed a role for fibroblast PPARβ/δ in the epithelial-mesenchymal communication involved in cellular redox homeostasis. Ministry of Education (MOE) Accepted version This research/project is supported by Start-Up Grant (M4082040) and Ministry of Education, Singapore, under Academic Research Fund Tier 1 (2017-T1-002-103) to NST, (2015-T1-001-034) to WW and Start-Up Grant from the Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore to WW and XW; the Région Midi-Pyrénées through the Chaire d’Excellence Pierre de Fermat and the Bonizzi-Theler-Stiftung to WW; SERB-DST, Govt. of India funded Ramanujan Fellowship Grant (SB/S2/RJN-087/2014) to MP

Background While anticholinergic use is associated with stroke, dementia and mortality, few have evaluated its potential link with falls. To determine the relationship between anticholinergic cognitive burden (ACB) and falls over five years using the Malaysian Elders Longitudinal Research (MELoR). Methods Community-dwelling adults aged 55 years and over were recruited through electoral roll sampling. Data obtained at baseline and follow-up (FU) at two and five years were included. Falls in the preceding 12 months were recorded. Results Of the 1499 individuals (mean (SD) age= 68.9(7.5) yrs and 53.3% female) with information on baseline ACB exposure, 575(38.4%) had ACB scores of 1-2 and 117(7.8%) had ACB scores ≥ 3 . Differences in age, ethnicity, smoking status, diabetes, hypertension, cardiovascular disease, arthritis and education existed between ACB groups. Fall occurrence differed between ACB groups at recruitment (p = 0.004) and 2-year FU (p = 0.001) but not at 5-year FU (p = 0.053). Logistic regression revealed an independent association between ACB 1-2 and falls at baseline (odds ratio, OR (95% confidence interval, CI) =1.412(1.035-1.926)) and ACB ≥ 3 and falls at 2-yr FU (OR (95%CI) =2.098(1.032-4.263)) following adjustment for confounders. Conclusion Low level exposure to drugs with anticholinergic properties was associated cross-sectionally with falls, while exposure to higher levels were prospectively associated with falls at 2-year but not at 5-year FU. Future studies should determine whether avoidance of drugs with anticholinergic effects will lead to reduction in falls.

Objectives: While the negative impact of falls in older persons has been recognized, the association between knee pains and falls remains inconclusive due to underreporting and undertreatment of knee pain. This study was conducted to evaluate the relationship between knee pain and knee pain severity with falls risk and to further determine factors which influence this potential relationship. Design: This was cross-sectional study from the Malaysian Elders Longitudinal Research (MELoR) study. Setting: Urban community dwellers in a middle-income South East Asian country. Participants: One thousand two hundred twelve of a representative sample of community dwelling older persons aged 55 years and older. Outcome measures: Falls in the preceding 12 months and knee pain were collected during a home-based computer-assisted interview. Physical and functional performance were measured using the Timed Up and Go test and the Katz and Lawton scales, respectively. Psychological status was determined using the Depression Anxiety and Stress Scale (DASS-21). Results: Of the 1,212 participants included in this analysis, knee pain was present in 402 (33.17%) individuals (124 (30.85%) mild, 210 (52.24%) moderate, 68 (16.92%) severe). The presence of knee pain was associated with increased risk of falls [odds Ratio, OR(95% confidence interval, CI): 1.81 (1.37–2.38)]. Severe knee pain was an independent predictor for falls after adjustment for functional impairment and psychological status. Mild, moderate, and severe knee pain had a specific indirect effect on falls through reducing functional impairment, which in turn increases their psychological concern. Conclusion: Future studies should explore this relationship prospectively and evaluate whether interventions which alleviate psychological concerns and improve function will reduce falls risk in those with mild to moderate knee pain.

Aim To determine the association between vitamin D and knee pain among participants of the Malaysian Elders Longitudinal Research (MELoR) study. Method This was a cross-sectional study from the MELoR study consisting of a representative group of 1011 community-dwelling older persons (57% female), mean age 86.5 (54-94) years; 313 were Malays, 367 Chinese and 330 Indians. Participants were asked if they had knee pain. Levels of serum 25-hydroxy cholecalciferol (25-[OH]D), an indicator of vitamin D status, were measured using routine laboratory techniques. Results In unadjusted analysis, presence of knee pain was significantly associated with vitamin D deficiency (odds ratio [OR] 1.42; 95% confidence interval (CI) 1.08-1.85, P 0.011). Vitamin D levels were significantly associated with ethnicity differences where Malays (OR 7.08; 95% CI 4.94-10.15) and Indians (OR 6.10; 95% CI 4.28-9.71) have lower levels of vitamin D compared to Chinese. Subsequent multivariate analysis revealed that the association between vitamin D deficiency and knee pain was confounded by ethnic differences. Conclusion A previous study suggested that vitamin D deficiency was associated with knee pain. This relationship was reproduced in our study, but we further established that the association was explained by ethnic variations. As vitamin D status is dependent on skin tone, diet and sunlight exposure, which are all effected by ethnicity, future studies are now required to determine whether a true relationship exists between vitamin D and knee pain.

Objectives To examine the cross‐sectional and longitudinal relationships between elder abuse and neglect (EAN) and chronic pain in rural older Malaysians. Design Two‐year prospective cohort study. Setting Kuala Pilah, a district in Negeri Sembilan approximately 100 km from the capital city, Kuala Lumpur. Participants Community‐dwelling older adults aged 60 and older. Using a multistage cluster sampling strategy, 1,927 respondents were recruited and assessed at baseline, of whom 1,189 were re‐assessed 2 years later. Measures EAN was determined using the modified Conflict Tactic Scale, and chronic pain was assessed through self‐report using validated questions. Results The prevalence of chronic pain was 20.4%. Cross‐sectional results revealed 8 variables significantly associated with chronic pain—age, education, income, comorbidities, self‐rated health, depression, gait speed, and EAN. Abused elderly adults were 1.52 times as likely to have chronic pain (odds ratio=1.52, 95% confidence interval (CI)=1.03–2.27), although longitudinal analyses showed no relationship between EAN and risk of chronic pain (risk ratio=1.14, 95% CI=0.81–1.60). This lack of causal link was consistent when comparing analysis with complete cases with that of imputed data. Conclusion Our findings indicate no temporal relationship between EAN and chronic pain but indicated cross‐sectional associations between the two. This might indicate that, although EAN does not lead to chronic pain, individuals with greater physical limitations are more vulnerable to abuse. Our study also shows the importance of cohort design in determining causal relationships between EAN and potentially linked health outcomes.

37 Background: Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) is a multidisciplinary survivorship care model launched at the National Cancer Centre Singapore (NCCS) in 2019. ACCESS employs routine distress and problem screening to triage cancer patients with varying care needs and complexities for tailored care. Here, we described the study design to evaluate ACCESS, and reported the baseline characteristics of our study cohort to characterize the profile of prospective target recipients of the new care model. Methods: A cluster randomized controlled trial was initiated to assess the effectiveness of ACCESS on quality of life and symptom burden, with each cluster unit defined at the oncologist level. Clusters were randomized in a 1:1 ratio to receive ACCESS or usual care. Eligible patients were ≥21 years, newly diagnosed with breast or gynecological cancer, and receiving follow-up care in NCCS. Patients were followed up for one year and patient-reported outcomes were collected every three months using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Rotterdam Symptom Checklist. Results: By May 2021, 91 patients and 89 patients in the usual care and ACCESS arm were recruited, respectively. Both groups (usual care vs. ACCESS) had comparable mean age (56.2±10.9 vs. 56.2±10.7, P = 0.998) and racial composition (P = 0.760). Employment status was similar in both arms (48.4% vs. 56.2% employed, P = 0.293) and most patients were covered by health insurance (89.8% vs. 88.1%, P = 0.920). At baseline, patients in both arms had comparable mean quality of life scores (65.1±19.8 vs. 66.9±17.6, P = 0.51) and reported high physical, role, emotional, cognitive, and social functioning levels (all mean scores > 70). No statistically significant differences in physical symptom and psychological distress levels were observed. Prevalent symptoms reported included fatigue (82.4% vs. 71.9%), pain (68.1% vs. 55.1%), and insomnia (57.1% vs. 55.1%). Almost half of the cohort reported financial difficulties (45.1% vs. 46.1%). Conclusions: Comparable baseline characteristics suggested the absence of systematic differences in care needs and demand among patients cared by different oncologists. Despite high functioning statuses at baseline, participants reported impaired quality of life with active physical and financial problems. These results support our hypothesis that routine screening would be valuable to identify such problems promptly for management via standardized care pathways. Results from this ongoing trial will determine the effectiveness of ACCESS on quality of life and functional recovery through treatment and survivorship. Clinical trial information: NCT04014309.

Introduction Pancreaticoduodenectomy is technically challenging with high risk of major morbidity. Morbidity is associated with patient comorbidities and reduced functional reserves. Prehabilitation aims to restore and enhance physiologic function with intent to reduce post-operative morbidity, and improve clinical outcomes. This study aims to compare the impact of an outpatient prehabilitation program (PP) in patients undergoing elective pancreaticoduodenectomy versus standard care (SC). Methods This is a prospective cohort study comparing patients who underwent PP versus SC prior to elective pancreaticoduodenectomy from January 2016 to December 2020. The PP includes dietician, physiotherapist, case manager and anaesthesia services. Outcomes evaluated include post-operative morbidity, length of stay and 30-day mortality. Results Fifty (68.5%) and 23 (31.5%) patients with median age of 65 years (interquartile range [IQR], 58-71 years) received PP and SC respectively. Sixty (82.2%), four (5.5%), and nine (12.3%) patients underwent open, laparoscopic surgery, and laparoscopic surgery with open conversion respectively. Ductal adenocarcinoma was the most common histology (50.7%). Patient demographics were comparable between both groups. Length of stay (days) (PP: 12.5 [IQR 9-17.3], SC: 10 [IQR 8-16]; p = 0.162), overall morbidity (PP: n = 28/50 [56.0%]; SC: n = 11/23 [47.8%]; p = 0.516), postoperative pancreatic fistula (PP: n = 12/50 [24.0%], SC: n = 3/23 [13.0%]; p = 0.289), intra-abdominal collection (PP: n = 11/50 [22.0%], SC: 6/23 [26.1%], p = 0.701) and delayed gastric emptying (PP: n = 4/50 [8.0%], SC: 3/23 [13.0%], p = 0.501) were similar. Overall 30-day readmission rate was 24.7% (n = 18) and 30-day mortality was 1.4% (n = 1). Conclusions Prehabilitation for patients undergoing pancreaticoduodenectomy did not improve post-operative outcomes, possibly due to selection bias. Exercise program compliance, functional capacity and quality of life should be assessed for future studies evaluating prehabilitation programs.

The approach to correlate frailty status with potential biomarkers has been generating increasing interest. However, there is currently no standardised definition or agreed biomarker for frailty. Hence, we conducted a systematic review on biomarkers evaluated in the published literature in relation to existing accepted measurements of frailty. The databases PUBMED, EMBASE, Web of Science and Science Direct were searched systematically for articles published from 2009 until July 2017. We included studies on frailty and associated biomarkers among individuals aged 65 years and older. Articles were reviewed by two reviewers independently. We identified 486 titles with 40 papers retained for final review after removal of duplicates and exclusion after the title, abstract and full-text review stages. Large variations in frailty measures and reported biomarkers were present in the published literature. Twenty-six articles recruited subjects from community-dwelling older individuals and 33 used the Fried's criteria. Of 11 studies, which evaluated Interleukin-6 (IL-6) against the Fried criteria, nine studies showed significant associations. Nearly all studies evaluating tumour necrosis factor-α, fibrinogen and C-reactive protein against Fried and Rockwood phenotypes showed positive associations. A large number of protein, nutritional, endocrine and genetic markers have been found to be associated with frailty defined with Fried, Rockwood and several other criteria, but only in isolated studies. The identification of potential biomarkers should be conducted with detailed knowledge of potential mechanistic pathways. It is likely that concurrent usage of clinical and biomarkers will be the favoured approach to the identification and management of frailty in the near future.

Sumaiyah Mat,1 Chin Teck Ng,1–3 Farhana Fadzil,4 Faizatul Izza Rozalli,4 Maw Pin Tan1,5 1Ageing and Age-Associated Disorders Research Group, University of Malaya, Kuala Lumpur, Malaysia; 2Department of Rheumatology and Immunology, Singapore General Hospital, 3Duke-NUS Medical School, National University Singapore, Singapore; 4Department of Radiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 5Geriatric Division, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia Abstract: The purpose of this study was to investigate the role of fear of falling (FoF) and psychological symptoms in explaining the relationship between osteoarthritis (OA) symptom severity and falls. Individuals aged ≥65 years with ≥2 falls or ≥1 injurious fall over the past 12 months were included in the falls group, while volunteers aged ≥65 years with no history of falls over 12 months were recruited as controls. The presence of lower extremity OA was determined radiologically and clinically. Severity of symptoms was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. FoF and psychological status were measured with the shortened version of the Falls Efficacy Scale-International and the 21-item Depression, Anxiety and Stress Scale (DASS-21), respectively. Of 389 (229 fallers, 160 non-fallers) potential participants, mean (SD) age: 73.74 (6.60) years, 141 had clinical OA and 171 had radiological OA. Fallers with both radiological OA and clinical OA had significantly higher FoF and DASS-21 scores than non-fallers. FoF was significantly positively correlated with symptom severity in fallers and non-fallers with radiological and clinical OA. Depression, anxiety, and stress scores were only significantly correlated with symptom severity among fallers but not non-fallers in both clinical and radiological OA. The relationship between mild symptoms and reduced risk of falls compared to no symptoms in those with radiological OA was attenuated by increased anxiety. The increased falls risk associated with severe symptoms compared to mild symptoms in clinical OA was attenuated by FoF. FoF may, therefore, be a potentially modifiable risk factor for OA-associated falls which could be considered in future intervention studies. Keywords: falls, fear of falling, osteoarthritis, psychological status, aged

To pilot two new cognitive screening tools for use in an urban Malaysian population and to compare their criterion validity against a gold standard, the well-established Mini-Mental State Examination (MMSE).The IDEA cognitive screen, Picture-based Memory Impairment Scale (PMIS), and MMSE were administered to a convenience sample of elderly (≥ 65 years) from the community and outpatient clinics at an urban teaching hospital. Consensus diagnosis was performed by two geriatricians blinded to PMIS and IDEA cognitive screen scores using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) clinical criteria. The MMSE performance was used as a reference.The study enrolled 66 participants, with a median age of 78.5 years (interquartile range [IQR], 72.5-83.0) years and 11.0 median years of education (IQR, 9.0-13.0). Forty-three (65.2%) were female, and 32 (48.4%) were Chinese. The area under the receiver operating characteristic (AUROC) curve values were .962 (IDEA cognitive screen), .970 (PMIS), and .935 (MMSE). The optimal cutoff values for sensitivity and specificity were: IDEA cognitive screen: ≤ 11, 90.9% and 89.7%; PMIS: ≤ 6, 97.3% and 69.0%; and MMSE: ≤ 23, 84.6% and 76.0%. Although the sample size was small, multivariable logistic regression modelling suggested that all three screen scores did not appear to be educationally biased.The IDEA and PMIS tools are potentially valid screening tools for dementia in urban Malaysia, and perform at least as well as the MMSE. Further work on larger representative, cohorts is needed to further assess the psychometric properties.Study provides alternative screening tools for dementia for both non-specialists and specialists.

The rapid increase in the older population has made age-related diseases like Alzheimer's disease (AD) a global concern. Given that there is still no cure for this neurodegenerative disease, the drastic growth in the number of susceptible individuals represents a major emerging threat to public health. The poor understanding of the mechanisms underlying AD is deemed the greatest stumbling block against progress in definitive diagnosis and management of this disease. There is a dire need for biomarkers that can facilitate early diagnosis, classification, prognosis, and treatment response. Efforts have been directed toward discovery of reliable and distinctive AD biomarkers but with very little success. With the recent emergence of high-throughput technology that is able to collect and catalogue vast datasets of small metabolites, metabolomics offers hope for a better understanding of AD and subsequent identification of biomarkers. This review article highlights the potential of using multiple metabolomics platforms as useful means in uncovering AD biomarkers from body fluids. © 2017 Wiley Periodicals, Inc.

Background As cancer mortality rates improve in Singapore, there is an increasing need to improve the transition to posttreatment survivorship care. This study aimed to evaluate the effectiveness of a psychoeducation group (PEG) intervention program compared with usual care to reduce distress for physical symptom and psychological aspects in Asian breast cancer survivors who have completed adjuvant chemotherapy. Methods This was a randomized, controlled trial comprising 72 Asian early stage breast cancer survivors who were randomized into the PEG (n = 34) or the control (n = 38) arm. The participants in the PEG arm underwent a weekly multidisciplinary PEG program delivered in a group format over 3 weeks coupled with cultural adaptation. Both arms were assessed at baseline and 2 months after intervention using the Rotterdam Symptom Checklist, Beck Anxiety Inventory, and EORTC QLQ-C30. A satisfaction questionnaire was also conducted among those survivors who have participated in the PEG program. Effective sizes were calculated using Cohen d. Results The mean age ± SD of all participants was 53.0 ± 8.9 years, with the majority being Chinese (84.7%) and Malay (6.9%), and clinical characteristics were well balanced in both arms. Compared to the control arm, the PEG arm showed a significantly greater reduction in physical symptom distress (d = 0.76, P = .01) and fatigue (d = 0.49, P = .04). The 82.4% of the participants in the intervention group responded to the satisfaction questionnaire, and the majority (92.9%) agreed that the overall duration of the PEG intervention program was appropriate. Conclusions A culturally adapted PEG program was effective in reducing physical symptom distress in Asian breast cancer survivors. (ClinicalTrials.gov: NCT02600299)