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Background: Very late-onset (aged ≥ 60 years) schizophrenia-like psychosis (VLOSLP) occurs frequently but no placebo-controlled, randomised trials have assessed the efficacy or risks of antipsychotic treatment. Most patients are not prescribed treatment., Objectives: The study investigated whether or not low-dose amisulpride is superior to placebo in reducing psychosis symptoms over 12 weeks and if any benefit is maintained by continuing treatment thereafter. Treatment safety and cost-effectiveness were also investigated., Design: Three-arm, parallel-group, placebo-controlled, double-blind, randomised controlled trial. Participants who received at least one dose of study treatment were included in the intention-to-treat analyses., Setting: Secondary care specialist old age psychiatry services in 25 NHS mental health trusts in England and Scotland., Participants: Patients meeting diagnostic criteria for VLOSLP and scoring > 30 points on the Brief Psychiatric Rating Scale (BPRS)., Intervention: Participants were randomly assigned to three arms in a two-stage trial: (1) 100 mg of amisulpride in both stages, (2) amisulpride then placebo and (3) placebo then amisulpride. Treatment duration was 12 weeks in stage 1 and 24 weeks (later reduced to 12) in stage 2. Participants, investigators and outcome assessors were blind to treatment allocation., Main Outcome Measures: Primary outcomes were psychosis symptoms assessed by the BPRS and trial treatment discontinuation for non-efficacy. Secondary outcomes were extrapyramidal symptoms measured with the Simpson-Angus Scale, quality of life measured with the World Health Organization's quality-of-life scale, and cost-effectiveness measured with NHS, social care and carer work loss costs and EuroQol-5 Dimensions., Results: A total of 101 participants were randomised. Ninety-two (91%) participants took the trial medication, 59 (64%) completed stage 1 and 33 (56%) completed stage 2 treatment. Despite suboptimal compliance, improvements in BPRS scores at 12 weeks were 7.7 points (95% CI 3.8 to 11.5 points) greater with amisulpride than with placebo (11.9 vs. 4.2 points; p  = 0.0002). In stage 2, BPRS scores improved by 1.1 point in those who continued with amisulpride but deteriorated by 5.2 points in those who switched from amisulpride to placebo, a difference of 6.3 points (95% CI 0.9 to 11.7 points; p  = 0.024). Fewer participants allocated to the amisulpride group stopped treatment because of non-efficacy in stages 1 ( p  = 0.01) and 2 ( p  = 0.031). The number of patients stopping because of extrapyramidal symptoms and other side effects did not differ significantly between groups. Amisulpride treatment in the base-case analyses was associated with non-significant reductions in combined NHS, social care and unpaid carer costs and non-significant reductions in quality-adjusted life-years (QALYs) in both stages. Including patients who were intensive users of inpatient services in sensitivity analyses did not change the QALY result but resulted in placebo dominance in stage 1 and significant reductions in NHS/social care (95% CI -£8923 to -£122) and societal costs (95% CI -£8985 to -£153) for those continuing with amisulpride., Limitations: The original recruitment target of 300 participants was not achieved and compliance with trial medication was highly variable., Conclusions: Low-dose amisulpride is effective and well tolerated as a treatment for VLOSLP, with benefits maintained by prolonging treatment. Potential adverse events include clinically significant extrapyramidal symptoms and falls., Future Work: Trials should examine the longer-term effectiveness and safety of antipsychotic treatment in this patient group, and assess interventions to improve their appreciation of potential benefits of antipsychotic treatment and compliance with prescribed medication., Trial Registration: Current Controlled Trials ISRCTN45593573 and EudraCT2010-022184-35., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 67. See the NIHR Journals Library website for further project information., Competing Interests: Robert Howard reports membership of the Heath Technology Assessment (HTA) Commissioning Board. Peter Bentham reports grants from the HTA programme during the course of this study. Craig Ritchie reports grants and personal fees from Merck Sharp & Dohme Ltd (Kenilworth, NJ, USA), personal fees from Pfizer Inc. (New York City, NY, USA), Eisai Co. Ltd (Tokyo, Japan), Actinogen (Sydney, NSW, Australia), Kyowa Hakko Kirin (Tokyo, Japan), Eli Lilly and Company (Indianapolis, IN, USA), and F. Hoffmann-La Roche AG (Basel, Switzerland), grants from Biogen Inc. (Cambridge, MA, USA) and grants and non-financial support from Janssen EMEA (Beerse, Belgium) and Takeda Pharmaceutical Company Ltd (Osaka, Japan) during the conduct of the study. Craig Ritchie was also the co-coordinator and academic lead for the European Prevention of Alzheimer’s Dementia (EPAD) project, which has numerous commercial partners in keeping with the mechanisms of the European Union’s Innovative Medicine’s Initiative [i.e. Janssen, Eisai Co. Ltd, Pfizer, Eli Lilly and Company, Roche Diagnostics (Risch-Rotkreuz, Switzerland), Boehringher Ingelheim GmbH (Ingelheim am Rhein, Germany), Novartis International AG (Basel, Switzerland), AC Immune SA (Lausanne, Switzerland), IXICO (London, UK), Aridhia (Glasgow, UK), Amgen Inc. (Thousand Oaks, CA, USA), Berry Consultants (Abingdon, UK), H. Lundbeck A/S (Copenhagen, Denmark), Sanofi SA (Paris, France), IQVIA (formerly Quintiles IMS Holdings, Inc.) (Durham, NC, USA) and Takeda Pharmaceutical Company]. Andrew Sommerlad reports grants from the Wellcome Trust outside the submitted work. Ramin Nilforooshan reports personal fees from Eli Lilly and Company and non-financial support from Janssen outside the submitted work. Martin Knapp reports grants from Merck Sharp & Dohme outside the submitted work.

Objectives: We used logistic regression to investigate whether health literacy and cognitive ability independently predicted whether participants have ever smoked and, in ever smokers, whether participants still smoked nowadays., Design: Cross-sectional study., Setting: This study used data from Wave 2 (2004-05) of the English Longitudinal Study of Ageing, which is a cohort study of adults who live in England and who, at baseline, were aged 50 years and older., Participants: 8734 (mean age=65.31 years, SD=10.18) English Longitudinal Study of Ageing participants who answered questions about their current and past smoking status, and completed cognitive ability and health literacy tests at Wave 2., Primary and Secondary Outcome Measures: The primary outcome measures were whether participants reported ever smoking at Wave 2 and whether ever smokers reported still smoking at Wave 2., Results: In models adjusting for age, sex, age left full-time education and occupational social class, limited health literacy (OR=1.096, 95% CI 0.988 to 1.216) and higher general cognitive ability (OR=1.000, 95% CI 0.945 to 1.057) were not associated with reporting ever smoking. In ever smokers, limited compared with adequate health literacy was associated with greater odds of being a current smoker (OR=1.194, 95% CI 1.034 to 1.378) and a 1 SD higher general cognitive ability score was associated with reduced odds of being a current smoker (OR=0.878, 95% CI 0.810 to 0.951), when adjusting for age, sex, age left full-time education and occupational social class., Conclusions: When adjusting for education and occupation variables, this study found that health literacy and cognitive ability were independently associated with whether ever smokers continued to smoke nowadays, but not with whether participants had ever smoked., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: Assistive technology and telecare (ATT) are relatively new ways of delivering care and support to people with social care needs. It is claimed that ATT reduces the need for community care, prevents unnecessary hospital admission, and delays or prevents admission into residential or nursing care. The current economic situation in England has renewed interest in ATT instead of community care packages. However, at present, the evidence base to support claims about the impact and effectiveness of ATT is limited, despite its potential to mitigate the high financial cost of caring for people with dementia and the social and psychological cost to unpaid carers., Method/design: ATTILA (Assistive Technology and Telecare to maintain Independent Living At Home for People with Dementia) is a pragmatic, multi-centre, randomised controlled trial over 104 weeks that compares outcomes for people with dementia who receive ATT and those who receive equivalent community services but not ATT. The study hypothesis is that fewer people in the ATT group will go into institutional care over the 4-year period for which the study is funded. The study aims to recruit 500 participants, living in community settings, with dementia or significant cognitive impairment, who have recently been referred to social services.Primary outcome measures are time in days from randomisation to institutionalisation and cost effectiveness. Secondary outcomes are caregiver burden, health-related quality of life in carers, number and severity of serious adverse events, and data on acceptability, applicability and reliability of ATT intervention packages. Assessments will be undertaken in weeks 0 (baseline), 12, 24, 52 and 104 or until institutionalisation or withdrawal of the participant from the trial., Discussion: In a time of financial austerity, CASSRs in England are increasingly turning to ATT in the belief that it will deliver good outcomes for less money. There is an absence of robust evidence for the cost-effectiveness and benefit of using assistive technology and telecare. The ATTILA trial meets a pressing need for robust, generalisable evidence to either justify continuing investment or reappraise the appropriate scale of ATT use., Trial Registration: Current Controlled Trials ISRCTN86537017.

A retrospective study of the results of dipstick testing and microscopical examination of urine from 10 050 men undergoing health screening showed a prevalence of occult haematuria of 2.5%. Those patients with occult haematuria who were resident in the United Kingdom and registered with a general practitioner were identified and a questionnaire sent to their general practitioners asking what further investigations had been performed. The response rate was 92% (152/165 inquiries). Fifty nine general practitioners (39%) had not instigated any investigations. Among the 76 patients who underwent some further investigations abnormalities were found in 21 (28%); and among those fully investigated by examination of midstream urine, intravenous urography, and cystoscopy abnormalities were found in 12(50%). These included bladder neoplasms (two; one in a patient aged 37), epithelial dysplasia (one), staghorn calculi (one), and chronic reflux nephropathy (one). It is proposed that occult haematuria should be fully investigated regardless of the age of the patient.