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Abstract: The need for home care services is expanding around the world with increased attention to the resources required to produce them. To assist decision making, there is a need to assess the cost-effectiveness of alternative programs within home care. Electronic searches were performed in five databases (before February 2020) identifying 3292 potentially relevant studies that assessed new or enhanced home care interventions compared with usual care for adults with an accompanying economic evaluation. From these, 133 articles were selected for full-text screening; 17 met the inclusion criteria and were analyzed. Six main areas of research were identified including the following: alternative nursing care (n = 4), interdisciplinary care coordination (n = 4), fall prevention (n = 4), telemedicine/remote monitoring (n = 2), restorative/reablement care (n = 2), and one multifactorial undernutrition intervention study. Risk of bias was found to be high/weak (n = 7) or have some concerns/moderate (n = 6) rating, in addition to inconsistent reporting of important information required for economic evaluations. Both health and cost outcomes had mixed results. Cost-effective interventions were found in two areas including alternative nursing care and reablement/restorative care. Clinicians and decision makers are encouraged to carefully evaluate the quality of the studies because of issues with risk of bias and incomplete reporting of economic outcomes., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Behavioral economic (BE) approaches to understanding and reducing risky drinking among college students are well established, but little is known about the generalizability of prior findings to peers who currently are not traditional college students and are more difficult to reach for assessment and intervention. This cross-sectional survey investigated whether drinking practices and negative consequences were associated with greater alcohol demand, alcohol reward value, and delay discounting in this target population. Method: Community-dwelling emerging adult drinkers aged 21 to 29 ( N = 357) were recruited using Respondent-Driven Sampling adapted to a digital platform ( M age = 23.6 years, 64% women). Peers recruited peers in an iterative fashion. Participants completed a web-based survey of drinking practices, negative alcohol-related consequences, and BE measures of alcohol demand, alcohol reward value, and delay discounting. Results: Regression analyses supported the study hypotheses. Higher alcohol demand (intensity and elasticity) predicted higher drinks per drinking day, more past-month drinking days, and more negative consequences. Higher alcohol reward value (discretionary alcohol spending and alcohol-involved activities) and stronger preference for sooner smaller versus later larger rewards predicted select drinking risk variables in the hypothesized direction ( p < .05). Conclusions: BE risk characteristics were generalized to community-dwelling emerging adult risky drinkers, with the most consistent associations found between alcohol demand and drinking risk measures. The findings lay a foundation for extending successful BE interventions with college drinkers to this underserved population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Abstract: The purpose of this study was to determine predictors of pain severity among older United States (US) adults with pain.This cross-sectional, retrospective study utilized 2017 Medical Expenditure Panel Survey data. Eligible participants were alive for the calendar year, aged ≥50 years, and reported pain in the past 4 weeks. Hierarchical logistic regression models, adjusting for the survey design, were used to identify significant predictors of pain severity (i.e., extreme/quite a bit or moderate/little pain).An estimated 14,250,534 adults aged ≥50 with pain reported extreme/quite a bit of pain. Many variables were associated with extreme/quite a bit of pain, including: age 50 to 64 vs ≥65 years (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [95% CI] = 1.22-1.82); males vs females (AOR = 0.80, 95% CI = 0.67-0.95); white race vs others (AOR = 0.75, 95% CI = 0.61-0.92); married vs other marital status (AOR = 1.31, 95% CI = 1.08-1.57); income <200% vs ≥200% federal poverty level (AOR = 1.30, 95% CI = 1.06-1.60); employed vs unemployed (AOR = 0.47, 95% CI = 0.37-0.60); limitation vs no limitation (AOR = 2.64, 95% CI = 2.09-3.33); 0, 1, 3, or 4 vs ≥5 chronic conditions (AOR ranged from 0.39 for 0 conditions to 0.77 for 4 conditions); excellent/very good or good vs fair/poor perceived physical health status (AOR ranged from 0.28 for excellent/very good to 0.40 for good); smokers vs non-smokers (AOR = 1.56, 95% CI = 1.27-1.93); exercise versus no exercise (AOR = 0.74, 95% CI = 0.62-0.88); and South vs West census region (AOR = 1.34, 95% CI = 1.04-1.74).This study found several characteristics could predict pain severity among older US adults who reported extreme/quite a bit of pain. These characteristics may guide specific areas of focus to improve patients' pain management., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To determine the willingness-to-pay (WTP) of family caregivers to learn care strategies for persons living with dementia (PLwD)., Design: Randomized clinical trial., Setting: Community-dwelling PLwD and their caregivers (dyads) in Maryland and Washington, DC., Participants: 250 dyads., Intervention: Tailored Activity Program (TAP) compared to attention control. TAP provides activities tailored to the PLwD and instructs caregivers in their use., Measurement: At baseline, 3 and 6 months, caregivers were asked their WTP per session for an 8-session 3-month in-home nonpharmacologic intervention to address behavioral symptoms and functional dependence., Results: At baseline, 3 and 6 months, caregivers assigned to TAP were willing to pay $26.10/session (95%CI:$20.42, $33.00), $28.70 (95%CI:$19.73, $39.30), and $22.79 (95%CI: $16.64, $30.09), respectively; attention control caregivers were willing to pay $37.90/session (95%CI: $27.10, $52.02), $30.92 (95%CI: $23.44, $40.94), $27.44 (95%CI: $20.82, $35.34), respectively. The difference in baseline to 3 and 6 months change in WTP between TAP and the attention control was $9.58 (95%CI: -$5.00, $25.47) and $7.15 (95%CI: -$5.72, $21.81). The difference between TAP and attention control in change in the proportion of caregivers willing to pay something from baseline to 3 and 6 months was -12% (95%CI: -28%, -5%) and -7% (95%CI:-25%, -11%), respectively. The difference in change in WTP, among caregivers willing to pay something, between TAP and attention control from baseline to 3 and 6 months was $17.93 (95%CI: $0.22, $38.30) and $11.81 (95%CI: -$2.57, $28.17)., Conclusions: Family caregivers are willing to pay more for an intervention immediately following participation in a program similar to which they were asked to value.

This study aimed to investigate the impact of food insecurity and poor nutrient intake on the psychological health of middle-aged and older adults during the COVID-19 pandemic. A sub-sample of 535 individuals aged 52 years and above, from the earlier cohort and interventional studies ( n = 4) from four selected states in Peninsular Malaysia, were recruited during the COVID-19 outbreak (April to June 2020). Telephone interviews were conducted by trained interviewers with a health sciences background to obtain participants' information on health status, physical activity, food security, and psychological health (General Health Questionnaire-12; normal and psychological distress). Univariate analyses were performed for each variable, followed by a logistic regression analysis using SPSS Statistics version 25.0. Results revealed food insecurity (OR = 17.06, 95% CI: 8.24-35.32, p < 0.001), low protein (OR = 0.981, 95% CI: 0.965-0.998, p < 0.05), and fiber intakes (OR = 0.822, 95% CI: 0.695-0.972, p < 0.05) were found to be significant factors associated with the psychological distress group after adjusting for confounding factors. The findings suggested that food insecurity and insufficiencies of protein and fiber intakes heightened the psychological distress during the COVID-19 pandemic. Optimal nutrition is vital to ensure the physical and psychological health of the older population, specifically during the current pandemic.

Background: Understanding the changes of unmet need in dementia may enable effective targeting of help and allow people to stay in their homes longer., Objective: We investigated changes in unmet need and functioning over a 4-year period and the role of socio-demographic factors in these changes among people with dementia., Methods: 234 community-dwelling people with dementia at baseline were studied in three consecutive waves (four years) of the English Longitudinal Study of Ageing (ELSA). Unmet needs (self/informant-reported limitations for which no help was received) and functional limitations (self/informant-reported difficulties in activities/instrumental activities of daily living and mobility) were modelled with latent growth curves. Sex, age, partnership, and socioeconomic status at baseline were used as predictors. Admission to a care home was an additional outcome., Results: Unmet needs increased over time, especially among those who initially had more functional limitations. Unmet needs contributed to faster decline in functional capability, except among those with many limitations initially. The major driver of increased unmet needs was not having a partner (direct effect). Age, sex, and wealth contributed indirectly via the initial level of functional limitations and/or unmet need. Those with several functional limitations but few unmet needs were most likely to move to a care home., Conclusion: Unmet need increases over time in those with dementia with mitigating effects of having a partner and initial levels of functioning. Meeting needs at early stages of dementia, especially for those living alone and when functional limitations are low may help slow functional decline.

This study is on the effects of spousal loss among older adults who continue to live independently after bereavement. Little longitudinal studies focus on this group, which is of special interest, since in many countries, care policy and system reform are aimed at increasing independent living among older adults. Using longitudinal data from a Dutch public data repository, we investigate the effects of spousal loss on psychological well-being, perceived quality of life, and (indication of) yearly health-care costs. Of the respondents who had a spouse and were living independently ( N  = 9,400) at baseline, the majority had not lost their spouse after 12 months ( T 12, n  = 9,150), but 2.7% ( n  = 250) had lost their spouse and still lived independently. We compared both groups using multivariate regression (ordinary least squares) analyses. The results show that spousal loss significantly lowers scores on psychological well-being and perceived quality of life, but we found no effect on health-care costs.

Background: Alzheimer's Disease is the most common cause of dementia, affecting memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks. AD is predicted to increase healthcare spending and costs associated with formal and informal caregiving. The aim of this study was to identify and quantify the contribution of the different cost components associated with AD., Methods: A structured literature review was conducted to identify studies reporting the economic burden of Alzheimer`s Disease beyond the healthcare setting. The search was conducted in Medline, Embase and EconLit and limited to studies published in the last 10 years. For each identified cost component, frequency weighted mean costs were calculated across countries to estimate the percentage contribution of each component by care setting and disease severity. Results obtained by each costing approach were also compared., Results: For community-dwelling adults, the percentage of healthcare, social care and indirect costs to total costs were 13.9%, 17.4% and 68.7%, respectively. The percentage of costs varied by disease severity with 26.0% and 10.4% of costs spent on healthcare for mild and severe disease, respectively. The proportion of total spending on indirect costs changed from 60.7% to 72.5% as disease progressed. For those in residential care, the contribution of each cost component was similar between moderate and severe disease. Social care accounted on average for 85.9% of total costs., Conclusion: The contribution of healthcare costs to the overall burden was not negligible; but was generally exceeded by social and informal care costs., Competing Interests: The authors report no further conflicts of interest in relation to the work described here.

Importance: Falls and osteoporosis share the potential clinical end point of fractures among older patients. To date, few fall prevention guidelines incorporate screening for osteoporosis to reduce fall-related fractures., Objective: To assess the cost-effectiveness of screening for osteoporosis using dual-energy x-ray absorptiometry (DXA) followed by osteoporosis treatment in older men with a history of falls., Design, Setting, and Participants: In this economic evaluation, a Markov model was developed to simulate the incidence of major osteoporotic fractures in a hypothetical cohort of community-dwelling men aged 65 years who had fallen at least once in the past year. Data sources included literature published from January 1, 1946, to July 31, 2020. The model adopted a societal perspective, a lifetime horizon, a 1-year cycle length, and a discount rate of 3% per year for both health benefits and costs. The analysis was designed and conducted from October 1, 2019, to September 30, 2020., Interventions: Screening with DXA followed by treatment for men diagnosed with osteoporosis compared with usual care., Main Outcomes and Measures: Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained., Results: Among the hypothetical cohort of men aged 65 years, the screening strategy had an ICER of $33 169/QALY gained and was preferred over usual care at the willingness-to-pay threshold of $100 000/QALY gained. The number needed to screen to prevent 1 hip fracture was 1876; to prevent 1 major osteoporotic fracture, 746. The screening strategy would become more effective and less costly than usual care for men 77 years and older. The ICER for the screening strategy did not substantially change across a wide range of assumptions tested in all other deterministic sensitivity analyses. At a willingness-to-pay threshold of $50 000/QALY gained, screening was cost-effective in 56.0% of simulations; at $100 000/QALY gained, 90.8% of simulations; and at $200 000/QALY gained, 99.6% of simulations., Conclusions and Relevance: These findings suggest that for older men who have fallen at least once in the past year, screening with DXA followed by treatment for those diagnosed with osteoporosis is a cost-effective use of resources. Fall history could be a useful cue to trigger assessment for osteoporosis in men.

This article explores innovative applications of sharing economy services that have the potential to support a population aging in place, especially the "oldest old," aged 85 and older, and their caregivers. A mixed-methods study conducted by the MIT AgeLab examined perceptions of and experiences with sharing economy services, ultimately finding opportunities and barriers to use. Thus, although sharing economy services have potential to support aging in place, to do so successfully will require reconstructing how older adults, family caregivers, aging service professionals, gerontology educators, and gerontology students conceptualize and deliver care to an aging population. We suggest examples for gerontology educators to integrate into their classrooms to further cultivate an appreciation among students of multiple approaches to intervention, including those that leverage sharing economy and technology-enabled platforms to support older adults and their caregivers.

Background/objectives: Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking., Design: Retrospective cohort study using the National Inpatient Sample from 2012 to 2016., Setting: U.S. acute care hospitals., Participants: A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia., Measurements: Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs., Results: The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community., Conclusion: The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020., (© 2020 The American Geriatrics Society.)

While we know that living alone is often associated with greater risk of financial hardship, we have limited knowledge on the possible link between the availability of public support and independent living. We use data from the 2014 Health and Retirement Study and the 2011-2015 Survey of Health, Ageing and Retirement in Europe to compare income and wealth profiles of the population aged 60 and above who are living alone in the United States and 19 European countries. We find that the likelihood of living alone is higher in generous welfare states, with social support and spending both positively associated with living alone. The relationship between personal resources and living alone has a smaller positive gradient in countries with robust welfare systems. The lack of adequate public support in less generous welfare states may constrain the ability of many low-income older adults without a partner to continue living independently.

Objectives: Older adults are often prescribed potentially inappropriate medications associated with adverse health outcomes and increased health services utilization. Developing Pharmacist-led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly (D-PRESCRIBE), a pragmatic randomized clinical trial, demonstrated how a community pharmacist-led evidence-based educational intervention successfully empowered community-dwelling older adults and their physicians to reduce chronic use of inappropriate medications. The objective of this study was to evaluate the cost-effectiveness of the D-PRESCRIBE intervention for discontinuing nonsteroidal anti-inflammatory drugs (NSAIDs)., Design: Cost-effectiveness analysis., Setting: Canada., Participants: Community-dwelling adults aged 65 years and older., Measurements: Decision analysis combining decision tree and Markov state transition modeling was developed to estimate the cost-effectiveness of D-PRESCRIBE (NSAIDs) compared with usual care from a Canadian healthcare system perspective with a time horizon of 1 year. Data from the D-PRESCRIBE trial and published literature were used to calculate effectiveness, utilities, and costs. Reference case and scenario analyses were conducted using probabilistic modeling. Sensitivity analyses assessed the robustness of the reference case model., Results: D-PRESCRIBE (NSAIDs) was less costly (-$1008.61) and more effective (.11 quality-adjusted life-years [QALYs]) than usual care and was the dominant strategy. At willingness-to-pay thresholds of $50 000 per QALY and $100 000 per QALY, D-PRESCRIBE (NSAIDs) incurred a positive incremental net benefit compared with usual care, suggesting it is cost-effective. Compared with the reference case, scenario analyses gave comparable QALYs with modest variation in cost estimates., Conclusion: For community-dwelling older adults, D-PRESCRIBE (NSAIDs) provides greater benefits at lower system costs, making it a compelling strategy to reduce the use and harms associated with chronic NSAID consumption. Our findings support reimbursing community pharmacists' clinical professional services for deprescribing inappropriate NSAIDs in community-dwelling older adults. J Am Geriatr Soc 68:1090-1097, 2020., (© 2020 The American Geriatrics Society.)

We consider a demand response program in which a block of apartments receive a discount from their electricity supplier if they ensure that their aggregate load from air conditioning does not exceed a predetermined threshold. The goal of the participants is to obtain the discount, while ensuring that their individual temperature preferences are also satisfied. As such, the apartments need to collectively optimise their use of air conditioning so as to satisfy these constraints and minimise their costs. Given an optimal cooling profile that secures the discount, the problem that the apartments face then is to divide the total discounted cost in a fair way. To achieve this, we take a coalitional game approach and propose the use of the Shapley value from cooperative game theory, which is the normative payoff division mechanism that offers a unique set of desirable fairness properties. However, applying the Shapley value in this setting presents a novel computational challenge. This is because its calculation requires, as input, the cost of every subset of apartments, which means solving an exponential number of collective optimisations, each of which is a computationally intensive problem. To address this, we propose solving the optimisation problem of each subset suboptimally, to allow for acceptable solutions that require less computation. We show that, due to the linearity property of the Shapley value, if suboptimal costs are used rather than optimal ones, the division of the discount will be fair in the following sense: each apartment is fairly "rewarded" for its contribution to the optimal cost and, at the same time, is fairly "penalised" for its contribution to the discrepancy between the suboptimal and the optimal costs. Importantly, this is achieved without requiring the optimal solutions., Competing Interests: The authors have declared that no competing interests exist.

Background: The current trends of unhealthy lifestyle behaviors in underserved communities are disturbing. Thus, effective health promotion strategies constitute an unmet need., Objectives: The purpose of this study was to assess the impact of 2 different lifestyle interventions on parents/caregivers of children attending preschools in a socioeconomically disadvantaged community., Methods: The FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health) study is a cluster-randomized trial involving 15 Head Start preschools in Harlem, New York. Schools, and their children's parents/caregivers, were randomized to receive either an "individual-focused" or "peer-to-peer-based" lifestyle intervention program for 12 months or control. The primary outcome was the change from baseline to 12 months in a composite health score related to blood pressure, exercise, weight, alimentation, and tobacco (Fuster-BEWAT Score [FBS]), ranging from 0 to 15 (ideal health = 15). To assess the sustainability of the intervention, this study evaluated the change of FBS at 24 months. Main pre-specified secondary outcomes included changes in FBS subcomponents and the effect of the knowledge of presence of atherosclerosis as assessed by bilateral carotid/femoral vascular ultrasound. Mixed-effects models were used to test for intervention effects., Results: A total of 635 parents/caregivers were enrolled: mean age 38 ± 11 years, 83% women, 57% Hispanic/Latino, 31% African American, and a baseline FBS of 9.3 ± 2.4 points. The mean within-group change in FBS from baseline to 12 months was ∼0.20 points in all groups, with no overall between-group differences. However, high-adherence participants to the intervention exhibited a greater change in FBS than their low-adherence counterparts: 0.30 points (95% confidence interval: 0.03 to 0.57; p = 0.027) versus 0.00 points (95% confidence interval: -0.43 to 0.43; p = 1.0), respectively. Furthermore, the knowledge by the participant of the presence of atherosclerosis significantly boosted the intervention effects. Similar results were sustained at 24 months., Conclusions: Although overall significant differences were not observed between intervention and control groups, the FAMILIA trial highlights that high adherence rates to lifestyle interventions may improve health outcomes. It also suggests a potential contributory role of the presentation of atherosclerosis pictures, providing helpful information to improve future lifestyle interventions in adults., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: As the Japanese population ages, caring for people with Alzheimer's disease (AD) dementia is becoming a major socioeconomic issue., Objective: To determine the contribution of patient and caregiver costs to total societal costs associated with AD dementia., Methods: Baseline data was used from the longitudinal, observational GERAS-J study. Using the Mini-Mental State Examination (MMSE) score, patients routinely visiting memory clinics were stratified into three groups based on AD severity. Health care resource utilizationwas recorded using the Resource Utilization in Dementia questionnaire. Total monthly societal costs were estimated using Japan-specific unit costs of services and products (patient direct health care use, patient social care use, and informal caregiving time). Uncertainty around mean costs was estimated using bootstrapping methods., Results: Overall, 553 community-dwelling patients withADdementia (28.3% mild[MMSE21-26], 37.8% moderate[MMSE 15-20], and 34.0% moderately severe/severe [MMSE < 14]) and their caregivers were enrolled. Patient characteristics were: mean age 80.3 years, 72.7% female, and 13.6% living alone. Caregiver characteristics were: mean age 62.1 years, 70.7% female, 78.8% living with patient, 49.0% child of patient, and 39.2% sole caregiver. Total monthly societal costs of AD dementia (Japanese yen) were: 158,454 (mild), 211,301 (moderate), and 294,224 (moderately severe/severe). Informal caregiving costs comprised over 50% of total costs., Conclusion: Baseline results of GERAS-J showed that total monthly societal costs associated with AD dementia increased with AD severity. Caregiver-related costs were the largest cost component. Interventions are needed to decrease informal costs and decrease caregiver burden.

Background: Memory services often see people with early stage dementia who are largely independent and able to participate in community activities but who run the risk of reducing activities and social networks. PRIDE is a self-management intervention designed to promote living well and enhance independence for people with mild dementia. This study aims to examine the feasibility of conducting a definitive randomised trial comparing the clinical and cost-effectiveness of the PRIDE intervention offered in addition to usual care or with usual care alone., Methods/design: PRIDE is a parallel, two-arm, multicentre, feasibility, randomised controlled trial (RCT). Eligible participants aged 18 or over who have mild dementia (defined as a score of 0.5 or 1 on the Clinical Dementia Rating Scale) who can participate in the intervention and provide informed consent will be randomised (1:1) to treatment with the PRIDE intervention delivered in addition to usual care, or usual care only. Participants will be followed-up at 3 and 6 month's post-randomisation. There will be an option for a supporter to join each participant. Each supporter will be provided with questionnaires at baseline and follow-ups at 3 to 6 months. Embedded qualitative research with both participants and supporters will explore their perspectives on the intervention investigating a range of themes including acceptability and barriers and facilitators to delivery and participation. The feasibility of conducting a full RCT associated with participant recruitment and follow-up of both conditions, intervention delivery including the recruitment, training, retention of PRIDE trained facilitators, clinical outcomes, intervention and resource use costs and the acceptability of the intervention and study related procedures will be examined., Discussion: This study will assess whether a definitive randomised trial comparing the clinical and cost-effectiveness of whether the PRIDE intervention offered in addition to usual care is feasible in comparison to usual care alone, and if so, will provide data to inform the design and conduct of a future trial., Trial Registration: ISRCTN, ISRCTN11288961, registered on 23 October 2019, http://www.isrctn.com/ISRCTN12345678 Protocol V2.1 dated 19 June 2019.

Background: Instrumental Activities of Daily Living (IADL) is an indicator of whether a community-dwelling elderly can live independently. IADL decline was reported to be associated with aging and depression. The present study aimed to investigate whether the association between IADL decline and depressive symptoms differs with aging, using two age groups of community-dwelling Japanese elderly in their 70s and 80s., Methods: We conducted longitudinal analysis among participants in their 70s and 80s at the baseline from Septuagenarians, Octogenarians, Nonagenarians Investigation with Centenarians (SONIC) study. IADL was assessed by The Tokyo Metropolitan Institute of Gerontology (TMIG) index of competence. As a main predictor, depressive symptoms were measured by the five-item version of the Geriatrics Depression Scale (GDS-5). As possible confounders, we considered cognitive function, body mass index, solitary living, education, economic status, medical history of stroke and heart disease, hypertension, dyslipidemia, diabetes, and sex. We obtained odds ratios (ORs) of IADL decline for having depressive symptoms in each age group (70s/80s) and tested interactions between depressive symptoms and age groups in relation to IADL decline in 3 years by logistic regression. Additionally, to confirm age group differences, we conducted multiple group analysis., Results: There were 559 participants in their 70s and 519 in their 80s. Compared to participants without depressive symptoms, those with depressive symptoms had higher OR of IADL decline in 70s (OR [95% CI] = 2.33 [1.13, 4.78]), but not in 80s (OR [95% CI] = 0.85 [0.46, 1.53]). There were significant interactions between depressive symptoms and age groups in relation to IADL decline (p-value = 0.03). Multiple group analyses showed differences between the age groups by Akaike information criterion (AIC), and ORs (95%CI) decline for depressive symptoms was 2.33 (1.14, 4.77) in 70s and 0.85 (0.47, 1.54) in 80s., Conclusion: The association of depressive symptoms and IADL decline during the 3 years was significantly different between the 70s and 80s age groups, and significant association was found only in people in their 70s. Detecting depressive symptoms may be a key for preventing IADL decline in people in their 70s and not for those in their 80s.

Background: Demographic changes combined with costly technological progress put a financial strain on the healthcare sector in the industrialized world. Hence, there is a constant need to develop new cost-effective treatment procedures in order to optimize the use of available resources. As a response, the concept of a Mobile Geriatric Team (MGT) has emerged not only nationally but also internationally during the last decade; however, scientific evaluation of this initiative has been very scarce. Thus, the objective of this study was to perform a mixed methods analysis, including a prospective, controlled and randomized quantitative evaluation, in combination with an interview-based qualitative assessment, to measure the effectiveness and user satisfaction of MGT., Materials and Methods: Community-dwelling, frail elderly people were randomized to an intervention group (n=31, mean age 84) and a control group (n=31, mean age 86). A two-year retrospective quantitative data collection and a prospective one-year follow-up on healthcare utilization were combined with qualitative interviews. Non-parametric statistics and difference-in-difference (DiD) analyses were applied to the quantitative data. Qualitative data were analyzed using content analysis., Results: No significant group differences in healthcare utilization were found before inclusion. Post intervention, primary care contact (including MGTs) increased for the MGT group. Inpatient care decreased dramatically for both groups. Hence, the increase in primary care contact for MGT patients was not accompanied by a reduction in inpatient care compared to the control group. Utilization of non-primary care was lower (p< 0.01) post-intervention in both groups., Conclusion: There appears to be a "natural" variation in healthcare needs over time among frail elderly people. Hence, it is vital to perform open, controlled clinical studies in tandem with the implementation of new caregiving strategies. The MGT initiative was clearly appreciated but did not fully achieve the desired reduction in healthcare utilization in this study., Trial Registration: Retrospectively registered 09/10/2018, ClinicalTrials.gov ID NCT03662945., Competing Interests: The authors report no conflicts of interest in this work., (© 2019 Fristedt et al.)

Objective: The objective of this scoping review is to describe the available evidence reporting out-of-pocket expenses for aging-in-place for frail older people and their caregivers., Introduction: There has been an increased focus on supporting frail older people to live in the community, rather than in costly long-term residential care. The out-of-pocket expenses associated with supporting older people with frailty to remain in their homes and communities contribute to caregiver burden and can influence decisions about where to live., Inclusion Criteria: This scoping review will consider literature on community-dwelling older people 60 years and older who have been identified as frail. Research and policy papers that report the out-of-pocket expenses incurred by older people with frailty or by their family or friend caregivers to support aging well at home will be included. Studies in English will be considered with no date restriction., Methods: The search strategy aims to find both published and unpublished literature (e.g. policy papers, theses and dissertations). Search databases include CINAHL, PubMed, Scopus, Embase, PsycINFO, Sociological Abstracts, and Public Affairs Index, as well as databases of unpublished sources. The language will be limited to English or French. Title and abstract screening, as well as full-text screening, will be completed by two reviewers. Data will be charted to describe the body of literature focusing on elements such as type of literature, methods used, setting and out-of-pocket expenses. Data will be presented graphically when possible, and accompanied by a narrative that describes the characteristics of the body of literature.

Background: Older people with a low social position are at higher risk of poor health outcomes compared to those with a higher social position. Whether lower social position also increases the risk of geriatric syndromes (GSs) remains to be determined. This study investigates the association of social position with GSs among older community-dwellers., Methods: Three consecutive population-based health surveys in 2006, 2010 and 2014 among older community-dwellers (age 65-84 years) in Stockholm County were combined (n = 17,612) and linked with Swedish administrative registry information. Social position was assessed using registry information (i.e. education, country of origin and civil status) and by self-reports (i.e. type of housing and financial stress). GSs were assessed by self-reports of the following conditions: insomnia, urinary incontinence, functional decline, falls, depressive disorder, hearing or vision problems. Binomial logistic regression analyses were used to estimate the association between social position and GSs after adjusting for age, sex, health status, health behavior and social stress., Results: The prevalence of GSs was 70.0%, but varied across GSs and ranged from 1.9% for depression to 39.1% for insomnia. Living in rented accommodation, being born outside the Nordic countries, being widowed or divorced were associated with GS presence. Financial stress was most strongly associated with GSs (adjusted odds ratio, 2.59; 95% CI, 2.13-3.15)., Conclusion: GSs are highly prevalent among older Swedish community-dwellers with wide variations across syndromes and strong association with all measures of social position, most strikingly that of experiencing financial stress.

Background: Limited attention has been paid to an association between food environment and household economic resources related to food expenditure in food-insecure seniors. The aim of the study was to investigate the relationship between factors of economic resource, food environment, and food insecurity in single seniors residing in rural areas of South Korea., Methods: A cross-sectional study was conducted in 170 single senior households aged 65 years or over residing in rural areas. Face-to-face interviews were performed to collect data on demographic characteristics, household economic resources/expenditure, food environmental factors, and food insecurity., Results: Among economic resources, generally limited food expenditures due to housing fees and heating costs during the winter were positively related to food insecurity. Among food environmental factors, food accessibility at community level such as food stores located far from home and inconvenient bus routes was related to food insecurity. The most explainable economic and food environment factors related to food insecurity by stepwise logistic regression analysis were the percentage of total expenditure on housing fee (OR = 1.021, 95% CI: 1.008-1.034), foods purchasing at super supermarket (OR = 0.398, 95% CI: 0.166-0.951), having difficulties in food purchasing due to food stores being located far from home (OR = 14.487, 95% CI: 5.139-40.842) and inconvenient bus routes (OR = 0.083, 95% CI: 0.015-0.460)., Conclusion: Inadequate community food environment as well as limited household food resources were an important risk factor for food insecurity in Korean single rural seniors. Findings of this study could help us better understand how characteristics of household food resources and community food environment can serve as barriers or facilitators of food security among single older adults residing in rural areas.

Objectives: Depressive symptoms can be both a cause and a consequence of functional limitations and medical conditions. Our objectives were to determine the association of depressive symptoms with subsequent total healthcare costs in older women after accounting for functional limitations and multimorbidity., Design: Prospective cohort study (Study of Osteoporotic Fractures [SOF])., Setting: Four US sites., Participants: A total of 2508 community-dwelling women (mean age = 79.4 years) participating in the SOF year 10 (Y10) examination linked with their Medicare claims data., Measurements: At Y10, depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS) and functional limitations were assessed by number (range = 0-5) of impairments in performing instrumental activities of daily living. Multimorbidity was ascertained by the Elixhauser method using claims data for the 12 months preceding the Y10 examination. Total direct healthcare costs, outpatient costs, acute hospital stays, and skilled nursing facility during the 12 months following the Y10 examination were ascertained from claims data., Results: Annualized mean (SD) total healthcare costs were $4654 ($9075) in those with little or no depressive symptoms (GDS score = 0-1), $7871 ($14 534) in those with mild depressive symptoms (GDS score = 2-5), and $9010 ($15 578) in those with moderate to severe depressive symptoms (GDS score = 6 or more). After adjustment for age, site, self-reported functional limitations, and multimorbidity, the magnitudes of these incremental costs were partially attenuated (cost ratio = 1.34 [95% confidence interval {CI} = 1.14-1.59] for those with mild depressive symptoms, and cost ratio = 1.29 [95% CI = 0.99-1.69] for those with moderate to severe depressive symptoms vs women with little or no depressive symptoms)., Conclusion: Depressive symptoms were associated with higher subsequent healthcare costs attributable, in part, to greater functional limitations and multimorbidity among those with symptoms. Importantly, even mild depressive symptoms were associated with higher healthcare costs. J Am Geriatr Soc 67:1596-1603, 2019., (© 2019 The American Geriatrics Society.)

Objectives: We studied the determinants of high healthcare costs (highest decile of hospital care and medication costs) and cost trajectories among all community-dwellers with clinically verified Alzheimer's disease (AD), diagnosed during 2005-2011 in Finland ( N  = 70,531). Methods: The analyses were done separately for hospital care costs, medication costs and total healthcare costs that were calculated for each 6-month period from 5 years before to 3 years after AD diagnosis. Results: Total healthcare costs were driven mainly by hospital care costs. The definition of "high-cost person" was time-dependent as 63% belonged to the highest 10% at some timepoint during the study period and six distinct cost trajectories were identified. Strokes, cardiovascular diseases, fractures and mental and behavioural disorders were most strongly associated with high hospital care costs. Conclusions: Although persons with AD are often collectively considered as expensive patient group, there is large temporal and inter-individual variation in belonging to the highest decile of hospitalization and/or medication costs. It would be important to assess whether hospitalization rate could be decreased by, e.g., comprehensive outpatient care with more efficient management of comorbidities. In addition, other interventions that could decrease hospitalization rate in persons with dementia should be studied further in this context. Key messages Persons with AD had large individual fluctuation in hospital care costs and medication costs over time. Hospital care costs were considerably larger than medication costs, with fractures, cardiovascular diseases and mental and behavioural disorders being the key predictors. Antidementia medication was associated with lower hospital care costs.

Objectives: To determine the effect of home-based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long-term institutionalization (LTI)., Design: Case-cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks., Setting: Three IAH-participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC., Participants: HBPC integrated with long-term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home-qualified (IAH-Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC., Intervention: HBPC integrated with LTSS under IAH demonstration incentives., Measurements: Measurements include LTI rate and mortality rates, community survival, and LTSS costs., Results: The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH-Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home- and community-based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed-to-expected ratio = .88 [.68-1.09]). LTI-free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH-q participants in NHATS., Conclusion: HBPC integrated with long-term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs., (© 2019 The American Geriatrics Society.)

Background: Identifying factors that affect variation in health care spending among older adults with disability may reveal opportunities to better address their care needs while offsetting excess spending., Objective: To quantify differences in total Medicare spending among older adults with disability by whether they experience negative consequences due to inadequate support with household activities, mobility, or self-care., Design: Observational study of in-person interviews and linked Medicare claims., Setting: United States, 2015., Participants: 3716 community-living older adults who participated in the 2015 NHATS (National Health and Aging Trends Study) and survived for 12 months., Measurements: Total Medicare spending by spending quartile in multivariable regression models that adjusted for individual characteristics., Results: Negative consequences were experienced by 18.3% of participants with disability in household activities, 25.6% with mobility disability, and 20.0% with self-care disability. Median Medicare spending was higher for those who experienced negative consequences due to household ($4866 vs. $4095), mobility ($7266 vs. $4115), and self-care ($10 935 vs. $4436) disability versus those who did not. In regression-adjusted analyses, median spending did not differ appreciably for participants who experienced negative consequences in household activities ($338 [95% CI, -$768 to $1444]), but was higher for those with mobility ($2309 [CI, $208 to $4409]) and self-care ($3187 [CI, $432 to $5942]) disability. In the bottom-spending quartile, differences were observed for self-care only ($1460 [CI, $358 to $2561]). No differences were observed in the top quartile., Limitation: This observational study could not establish causality., Conclusion: Inadequate support for mobility and self-care is associated with higher Medicare spending, especially in the middle and lower ends of the spending distribution. Better support for the care needs of older adults with disability could offset some Medicare spending., Primary Funding Source: The Commonwealth Fund.

People living with serious illness, including multiple chronic conditions and conditions that limit the ability to perform everyday activities, prefer to receive care in their home or their community rather than in an institutional health care setting. This month's DataGraphic highlights the workforce that cares for these people in the home and community, including the characteristics of this workforce and the costs of such care.

Study Design: Observational study., Objectives: To determine the prevalence, predictors, and consequences of self-reported service needs among community-dwelling persons with SCI., Setting: Community-based, Switzerland., Methods: Participants were 490 people who took part in the health services module of the Swiss Spinal Cord Injury Cohort Study (SwiSCI) 2012 community survey. We determined the prevalence of 20 service needs and the extent to which they were unmet. Predictors and consequences of service needs were examined with multiple regression analyses., Results: High-prevalence needs (e.g., general health care, accessible housing) exhibited a high level of fulfillment. Conversely, less prevalent service needs (e.g., peer support, support for family caregivers) showed lower levels of fulfillment. Across three specific service domains (peer support, support for family caregivers, sports activities), lower household income predicted most consistently a higher likelihood of unmet needs. The total number of expressed needs was higher in non-Swiss nationals, persons with complete para- or tetraplegia and lower income individuals. Being female, French language region and lower household income predicted more total unmet needs. Increased expressed and unmet service needs were associated with lower life satisfaction., Conclusions: Service needs with a high prevalence seem to be adequately met by the current service provision system. However, rehabilitation professionals should remain alert to clients' specific and cumulative unmet needs, in particular with respect to less common ones, and their impact on successful community reintegration and life satisfaction.

Background: Although China is undergoing rapid economic development, it is facing an ageing population. No data exists on malnutrition risks of older adults in an affluent Chinese society. The aim of this study is to examine these risks and identify their associated factors among home-living older Chinese adults in Hong Kong., Methods: This is a cross-sectional study, to which home-living subjects aged 60 or above were recruited, between May and September 2017, from a non-governmental community organisation located in three different districts of Hong Kong. Nutritional status was assessed by the Mini Nutritional Assessment (MNA), and its associated factors examined included socio-demographic characteristics, lifestyle, health status and diet. Multivariable logistic regression analysis was performed to identify factors associated with malnutrition risks (MNA < 24)., Results: Six hundred thirteen subjects (mean age: 78.5 ± 7.4; 54.0% females) completed the survey. Nearly 30% (n = 179) were at risk of malnutrition. By multivariable logistic regression, subjects (1) whose vision was only fair or unclear, (2) with poor usual appetite and (3) with main meal skipping behaviour had significantly higher malnutrition risk (all p < 0.05)., Conclusions: In this affluent Chinese society, the malnutrition risk in older adults is close to the global average, which is a matter for much concern. Interventions are therefore warranted that target vulnerable groups with poor vision, appetite, and meal skipping behaviour., Trial Registration: Not applicable.

Guided by resource dependence theory, this mixed-methods study examined organizational characteristics contributing to the perceived sustainability of Villages, a rapidly proliferating grassroots approach for promoting social participation and service access for community-dwelling older adults. Surveys conducted with leaders of 86% of Villages in the United States in 2012 found that higher predicted confidence in their Village's 10-year survival was associated with greater financial reserves, human resources, number of Village members, formal policies and procedures, and formal collaboration agreements. Respondents' explanations of their confidence ratings revealed additional themes of organizational leadership and perceived community need. Member resource inputs were not found to be as salient for Village leaders' perceptions of sustainability as was anticipated given the Village model's emphasis on consumer involvement. Despite the lack of longitudinal prospective data, study findings suggest potential limitations of consumer-driven organizational models such as Villages, including the need for a more stable resource base.

Objectives: To examine the costs of caring for community-dwelling patients with Alzheimer's disease (AD) dementia in relation to the time to institutionalisation., Methods: GERAS was a prospective, non-interventional cohort study in community-dwelling patients with AD dementia and their caregivers in three European countries. Using identified factors associated with time to institutionalisation, models were developed to estimate the time to institutionalisation for all patients. Estimates of monthly total societal costs, patient healthcare costs and total patient costs (healthcare and social care together) prior to institutionalisation were developed as a function of the time to institutionalisation., Results: Of the 1495 patients assessed at baseline, 307 (20.5%) were institutionalised over 36 months. Disease severity at baseline [based on Mini-Mental State Examination (MMSE) scores] was associated with risk of being institutionalised during follow up (p < 0.001). Having a non-spousal informal caregiver was associated with a faster time to institutionalisation (944 fewer days versus having a spousal caregiver), as was each one-point worsening in baseline score of MMSE, instrumental activities of daily living and behavioural disturbance (67, 50 and 30 fewer days, respectively). Total societal costs, total patient costs and, to a lesser extent, patient healthcare-only costs were associated with time to institutionalisation. In the 5 years pre-institutionalisation, monthly total societal costs increased by more than £1000 (€1166 equivalent for 2010) from £1900 to £3160 and monthly total patient costs almost doubled from £770 to £1529., Conclusions: Total societal costs and total patient costs rise steeply as community-dwelling patients with AD dementia approach institutionalisation.

We investigated correlates of sedentary behavior (SB) among community-dwelling adults with elevated anxiety symptoms in six low- and middle-income countries (LMICs). Cross-sectional data from the World Health Organization's Study on Global Ageing and Adult Health (2007-2010) were analyzed. Associations between SB levels and the correlates were examined using multivariable linear and logistic regressions. Out of 42,469 individuals aged ≥ 18 years, there were 2630 participants with anxiety (47.6 ± 16.5 years; 66.6% female). Correlates significantly associated with being sedentary ≥ 8 h/day were being male, older age, a lower income, never married (vs. married/cohabiting), being unemployed, poor self-related health, alcohol consumption, and less social cohesion (highest quartile vs. lowest). Disability and bodily pain were associated with more time spent (min/day) sedentary. Future intervention research should target the risk groups based on identified sociodemographic correlates. Also, whether the promotion of social cohesion increases the efficacy of public health initiatives should be examined with prospective data., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Physical activity is linked to benefits such as increased physical fitness, cognition, emotional and social functioning, general health and well-being in older people. Some evidence suggests that this also applies to people living with dementia. However, it can be harder for them to perform physical activities, due to several barriers, such as issues with orientation and balance problems. A relatively new type of physical activity called exergaming may help them overcome these barriers. Exergaming is "physical exercise interactively combined with cognitive stimulation in a gaming environment". The aim of our study is to evaluate the effectiveness and cost-effectiveness of exergaming compared to regular activities in people living with dementia, who attend day-care centres. Additionally, we want to investigate whether the exergaming activity for the person living with dementia, also (indirectly) affects the informal caregiver, as well as which facilitators and barriers to implementation of exergames for this target group exist., Methods: A cluster Randomized Controlled Trial (RCT), with economic and process evaluations alongside will be carried out. In the Netherlands, 24 day-care centres are randomized in the experimental or control group. The study group will consist of 224 dyads (community-dwelling participants with dementia and their informal caregivers), who are interviewed at baseline, and at 3 and 6 months of follow-up. The participant with dementia has to visit the day-care centre for at least two days per week, have a diagnosis of mild to moderate dementia and have an informal caregiver present, who is willing to participate. Societal cost data will be collected during interviews, using healthcare utilization diaries, and from day-care centres. The process evaluation will only involve the experimental group, and will include an online survey, qualitative interviews and focus groups., Discussion: This study will contribute to the evidence base that more effective exercise among people with dementia will result in positive effects on their wellbeing and quality of life. This will motivate people with dementia to be physically active. We also envision that there might be a positive effect on the burden of care experienced by their informal caregivers., Trial Registration: This trial was registered at the Netherlands Trial Register (NTR) on December 10, 2015 (number: NTR5537 ), this publication is based on protocol amendment number 01, issue date 28 December 2018. This includes all items from the World Health Organization Trial Registration Data Set [see Additional file 1].

Background: Higher-level functional capacity is crucial component for independent living in later life. We used repeated-measures analysis to identify aging trajectories in higher-level functional capacity. We then determined whether these trajectories were associated with all-cause mortality and examined differences in medical and long-term care costs between trajectories among community-dwelling older Japanese., Methods: 2,675 adults aged 65-90 years participated in annual geriatric health assessments and biennial health monitoring surveys during the period from October 2001 through August 2011. The average number of follow-up assessments was 4.0, and the total number of observations was 10,609. Higher-level functional capacity, which correspond to the fourth and fifth sublevels of Lawton's hierarchical model, was assessed with the Tokyo Metropolitan Institute of Gerontology-Index of Competence (TMIG-IC)., Results: We identified four distinct trajectory patterns (high-stable, late-onset decreasing, early-onset decreasing, and low-decreasing) on the TMIG-IC through age 65-90 years. As compared with the high-stable trajectory group, participants in the late-onset decreasing, early-onset decreasing, and low-decreasing TMIG-IC trajectory groups had adjusted hazard ratios for mortality of 1.22 (95% confidence interval: 1.01-1.47), 1.90 (1.53-2.36), and 2.87 (2.14-3.84), respectively. Participants with high-stable and late-onset decreasing higher-level functional capacity trajectories had lower mean monthly medical costs and long-term care costs. In contrast, mean total costs were higher for those with low-decreasing trajectories, after excluding the large increase in such costs at the end of life., Conclusions: People with a low-decreasing aging trajectory in higher-level functional capacity had higher risks of death and had high monthly total costs.

Objective: To perform a cost-effectiveness analysis of a multifactorial, tailored intervention to reduce falls among a heterogeneous group of high-risk elderly people., Design: Randomized control trial., Settings: Communities., Participants: Adults aged at least 65 years (N=354) seen at the emergency department (ED) for a fall or fall-related injury and discharged home., Interventions: The intervention group received a tailored program of physical therapy focused on progressive training in strength, balance, and gait for a period of 3 months. They also received screening and referrals for low vision, polypharmacy, and environmental hazards. The Short Physical Performance Battery (SPPB) test was assessed at regular intervals to allocate participants into either a home-based or group center-based program. The control group received usual care prescribed by a physician and educational materials on falls prevention., Main Outcome Measures: The incremental cost-effectiveness ratio (ICER) over the 9-month study period based on intervention costs and utility in terms of quality-adjusted life years (QALYs) calculated from EuroQol-5D scores., Results: The ICER was 120,667 Singapore dollars (S$) per QALY gained (S$362/0.003 QALYs), above benchmark values (S$70,000). However, the intervention was more effective and cost-saving among those with SPPB scores of greater than 6 at baseline, higher cognitive function, better vision and no more than 1 fall in the preceding 6 months. The intervention was also cost-effective among those with 0-1 critical comorbidities (S$22,646/QALY)., Conclusion: The intervention was, overall, not cost-effective, compared to usual care. However, the program was cost-effective among healthier subgroups, and even potentially cost-saving among individuals with sufficient reserve to benefit., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

There is a lack of multinational research investigating the association between sleep problems and sedentary behaviour. In this study, we investigated the relationship between the time spent sedentary during waking hours and sleep problems in six low- and middle-income countries. Cross-sectional, community-based data from the Study on Global Ageing and Adult Health survey were analysed. Adjusted logistic regression analyses were undertaken to explore the relationship between self-reported sleep problems (such as difficulties falling asleep, waking up frequently during the night or waking up too early in the morning) in the last 30 days and self-reported sedentary time (categorized as <4, 4 to <8, 8 to <11 or ≥11 hr/day). Among 42,489 individuals aged ≥18 years (mean age=43.8 ± 14.4 years; 50.1% women), those who were sedentary for 8 to <11 hr/day (n = 2,782) and ≥11 hr/day (n = 674) had a 1.61 (95% confidence interval =1.03-2.50) and 1.75 (95% confidence interval =1.17-2.62) times higher odds of having sleep problems, respectively, compared with those being sedentary for less than 4 hr per day (n = 24,637). The strongest associations were observed among those aged 50-64 years. The observed associations were independent of a wide range of sociodemographic factors, physical and mental health conditions and physical activity behaviour. Considering the social and occupational costs of sleep problems, it is important that future longitudinal research should consider the directionality of the data., (© 2018 European Sleep Research Society.)

Background: Most people prefer to "age in place" and to remain in their homes for as long as possible even in case they require long-term care. While informal care is projected to decrease in Germany, the use of home- and community-based services (HCBS) can be expected to increase in the future. Preference-based data on aspects of HCBS is needed to optimize person-centered care., Objective: To investigate preferences for home- and community-based long-term care services packages., Design: Discrete choice experiment conducted in mailed survey., Setting and Participants: Randomly selected sample of the general population aged 45-64 years in Germany (n = 1.209)., Main Variables Studied: Preferences and marginal willingness to pay (WTP) for HCBS were assessed with respect to five HCBS attributes (with 2-4 levels): care time per day, service level of the HCBS provider, quality of care, number of different caregivers per month, co-payment., Results: Quality of care was the most important attribute to respondents and small teams of regular caregivers (1-2) were preferred over larger teams. Yet, an extended range of services of the HCBS provider was not preferred over a more narrow range. WTP per hour of HCBS was €8.98., Conclusions: Our findings on preferences for HCBS in the general population in Germany add to the growing international evidence of preferences for LTC. In light of the great importance of high care quality to respondents, reimbursement for services by HCBS providers could be more strongly linked to the quality of services.

Aims: To estimate the health service use and direct healthcare costs attributable to diabetes using best available data and methods., Methods: A nationally representative sample of adults aged ≥50 years was analysed (n=8107). Health service use in the previous 12 months included the number of general practitioner visits, outpatient department visits, hospital admissions, and accident and emergency department attendances. Multivariable negative binomial regression was used to estimate the associations between diabetes and frequency of visits. Average marginal effects were applied to unit costs for each health service and extrapolated to the total population, calculating the incremental costs associated with diabetes., Results: The prevalence of diabetes was 8.0% (95% CI: 7.4, 8.6). In fully adjusted models, diabetes was associated with additional health service use. Compared to those without diabetes, people with diabetes have, on average, 1.49 (95% CI: 1.10, 1.88) additional general practitioner visits annually. Diabetes was associated with an 87% increase in outpatient visits, a 52% increase in hospital admissions and a 33% increase in accident and emergency department attendances (P<0.001). The incremental cost of this additional service use, nationally, is an estimated €88,894,421 annually, with hospital admissions accounting for 67% of these costs., Conclusion: Using robust methods, we identified substantially increased service use attributable to diabetes across the health system. Our findings highlight the urgent need to invest in the prevention and management of diabetes., (© 2018 Diabetes UK.)

ABSTRACTGiven the urgency of finding cost-effective and innovative solutions to providing community services for aging in place, novel solutions that take advantage of existing infrastructure are clearly needed. In this sequential mixed-method study, we chose to explore the role that nursing homes could play in offering services to a non-traditional target population, namely seniors with loss of independence living in the community. Forty-two (n = 42) nursing homes in the province of New Brunswick completed an online survey, and 10 agreed to participate in face-to-face interviews. Results show that 100 per cent of participants agreed that nursing homes could offer services to seniors in their communities for aging in place. Results suggest that nursing homes are cost-effective, innovative solutions for aging in place.

Background: According to the principles of Reablement, home care services are meant to be goal-oriented, holistic and person-centred taking into account the capabilities and opportunities of older adults. However, home care services traditionally focus on doing things for older adults rather than with them. To implement Reablement in practice, the 'Stay Active at Home' programme was developed. It is assumed that the programme leads to a reduction in sedentary behaviour in older adults and consequently more cost-effective outcomes in terms of their health and wellbeing. However, this has yet to be proven., Methods/ Design: A two-group cluster randomised controlled trial with 12 months follow-up will be conducted. Ten nursing teams will be selected, pre-stratified on working area and randomised into an intervention group ('Stay Active at Home') or control group (no training). All nurses of the participating teams are eligible to participate in the study. Older adults and, if applicable, their domestic support workers (DSWs) will be allocated to the intervention or control group as well, based on the allocation of the nursing team. Older adults are eligible to participate, if they: 1) receive homecare services by the selected teams; and 2) are 65 years or older. Older adults will be excluded if they: 1) are terminally ill or bedbound; 2) have serious cognitive or psychological problems; or 3) are unable to communicate in Dutch. DSWs are eligible to participate if they provide services to clients who fulfil the eligibility criteria for older adults. The study consists of an effect evaluation (primary outcome: sedentary behaviour in older adults), an economic evaluation and a process evaluation. Data for the effect and economic evaluation will be collected at baseline and 6 and/or 12 months after baseline using performance-based and self-reported measures. In addition, data from client records will be extracted. A mixed-methods design will be applied for the process evaluation, collecting data of older adults and professionals throughout the study period., Discussion: This study will result in evidence about the effectiveness, cost-effectiveness and feasibility of the 'Stay Active at Home' programme., Trial Registration: ClinicalTrials.gov: NCT03293303 , registered on 20 September 2017.

Purpose: Among others, the German National Prevention Conference recently recommended the provision of preventive options for elderly to maintain their independent living. Because a home safety assessment and modification program (HSM) has shown to be effective in avoiding falls and risk of falling in elderly, the aim of this analysis was to evaluate the cost-effectiveness of HSM in patients aged ≥ 80 years who receive non-institutionalized long-term care., Methods: In order to reflect quality-adjusted life years (QALYs) and costs resulting from HSM, a Markov-model with a time horizon of 20 years was performed from the perspective of the German statutory health insurance (SHI) and statutory long-term care insurance (LCI). The model assumed that HSM reduces fall-related hip fractures in accordance with the reduction of the rate of falls. Data was obtained from public databases and from various literature searches. The robustness of the results was assessed in deterministic and probabilistic sensitivity analyses., Results: In women, the incremental cost-effectiveness ratio of HSM compared to no prevention was €9580 per QALY, while in men, it was €57,589. For the German SHI/LCI, in total, the provision of HSM to patients ≥ 80 years who receive non-institutionalized long-term care would result in annual costs of €7.7 million. The results were robust in several sensitivity analyses., Conclusions: Provided that the rate of falls is a valid surrogate endpoint for the rate of fall-related hip fractures, HSM could be a promising approach for investments in preventive options targeting the reduction of fall-related fractures in elderly women.

Objectives: To provide a comprehensive overview of economic evaluations of falls prevention programs and to evaluate the methodology and quality of these studies., Design: Systematic review of economic evaluations on falls prevention programs., Setting: Studies (N=31) of community-dwelling older adults (n=25), of older adults living in residential care facilities (n=3), and of both populations (n=3) published before May 2017., Participants: Adults aged 60 and older., Measurements: Information on study characteristics and health economics was collected. Study quality was appraised using the 20-item Consensus on Health Economic Criteria., Results: Economic evaluations of falls prevention through exercise (n = 9), home assessment (n = 6), medication adjustment (n = 4), multifactorial programs (n = 11), and various other programs (n = 13) were identified. Approximately two-thirds of all reported incremental cost-effectiveness ratios (ICERs) with quality-adjusted life-years (QALYs) as outcome were below the willingness-to-pay threshold of $50,000 per QALY. All studies on home assessment and medication adjustment programs reported favorable ICERs, whereas the results of studies on exercise and multifactorial programs were inconsistent. The overall methodological quality of the studies was good, although there was variation between studies., Conclusion: The majority of the reported ICERs indicated that falls prevention programs were cost-effective, but methodological differences between studies hampered direct comparison of the cost-effectiveness of program types. The results imply that investing in falls prevention programs for adults aged 60 and older is cost-effective. Home assessment programs (ICERs < $40,000/QALY) were the most cost-effective type of program for community-dwelling older adults, and medication adjustment programs (ICERs < $13,000/QALY) were the most cost-effective type of program for older adults living in a residential care facility. J Am Geriatr Soc 66:2197-2204, 2018., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Introduction and Aims: Adolescent alcohol consumption and associated harms are significant public health issues in Australia. One strategy to reduce this problem is restricting alcohol supply to adolescents below age 18. To ensure compliance with laws that forbid underage alcohol sales, effective monitoring systems that operate across a range of settings, including sporting clubs, are required. This study investigated compliance with regulations requiring proof of age identification and refusal of underage alcohol sales in community sporting clubs., Design and Methods: Compliance with alcohol sales laws was monitored using a male confederate that appeared under 18 who attempted to purchase alcohol at community sporting clubs in two regional areas of Victoria, Australia during the 2016-2017 sporting seasons., Results: Purchase observations were completed at 43 clubs (observations could not be conducted at 14 clubs); alcohol was purchased at 41 (95%) clubs. Four (9%) clubs asked the confederate-purchaser to provide identification of age-in two instances the purchaser was not sold alcohol and in two instances was sold alcohol after not showing identification. Rates of compliance with proof of age identification and alcohol sales did not vary according to staff- and club-related variables., Discussion and Conclusions: This study indicates the need for more rigorous enforcement of alcohol sales regulations in community sporting clubs. Community health agencies could work with sporting clubs to assist them to improve compliance with alcohol sales regulations and to provide information on the significant role clubs play in shaping the adolescent alcohol culture., (© 2018 Australasian Professional Society on Alcohol and other Drugs.)

At any age, the pursuit of a good life is easier in a physical environment that promotes health, supports activities important to self-fulfillment, and facilitates connections to the larger community. In old age, the home and neighborhood environments are particularly important: they are the locations where older people spend most their time, and they can have a great impact on independence, social connection, feelings of self-worth, and physical and emotional well-being. Within the urban planning field, home and neighborhood characteristics are important dimensions of debates about the measurement of human progress and quality of life, particularly as an alternative to purely economic measures. They are also key issues in public health, particularly as they relate to physical, social, and mental well-being. Here, we focus on how to improve the fit of environments for people as they age., (© 2018 The Hastings Center.)

The consideration of diverse family factors on parents' acceptance of behavioral parent training (BPT) components aids in the development and delivery of culturally sensitive parenting programs. Perceptions of acceptability are particularly important to investigate among low-income and racial-minority families, as they are less likely to engage in nonadapted BPT programs. Therefore, the current study examines the synergistic effects of race and income on mothers' acceptance of five common child management methods relevant to BPT. The relationship between mothers' acceptability ratings and self-reported parenting practices was also explored. Participants were 106 White and Black mothers from different income levels who completed measures related to the acceptability of response cost, positive reinforcement, time-out, spanking, and medication. The results indicated that mothers from varying backgrounds differed in their acceptance of child management methods, particularly with regard to corporal punishment. Additionally, a relationship was found between parents' acceptability ratings and their self-reported parenting behavior. The findings support the consideration of parents' perceptions of child discipline methods when recommending and delivering BPT programs to diverse parents., (Copyright © 2018. Published by Elsevier Ltd.)

Inspired by poet J.L. Borges's intimations on acceptance, this commentary highlights the eviction of an older woman and her kitten from an affordable independent living facility as representing exclusionary practices and policies that compromise the ability for some lower-income older adults to age-in-place. Even as efforts to promote aging-in-place have prioritized housing as a key need, and public health evidence suggests benefits from animal companionship later in life, there is a shortage of social and other types of affordable housing in Canada and elsewhere that allows older adult tenants to reside independently with companion animals. Within the private housing market, however, companion animals may be leveraged as a marketing tactic, with 'pets' being welcomed into rental arrangements. In light of this means-patterned discrepancy, this commentary troubles the persistent undervaluing of human-animal relationships that exists at policy and practice levels. Furthermore, banning companion animals from affordable housing subsumes an accepted yet insidious practise of regulating the lives of older adults who have not achieved idealized conceptions of responsible aging, including home ownership. We draw these two concerns together by advocating for adequate provision of affordable housing opportunities where lower-income older adults may be granted the choice to establish a home that includes a companion animal as they age-in-place.

Background: Poverty increases the risk of contracting infectious diseases and therefore exposure to antibiotics. Yet there is lacking evidence on the relationship between income and non-income dimensions of poverty and antimicrobial resistance. Investigating such relationship would strengthen antimicrobial stewardship interventions., Methods: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Ovid, MEDLINE, EMBASE, Scopus, CINAHL, PsychINFO, EBSCO, HMIC, and Web of Science databases were searched in October 2016. Prospective and retrospective studies reporting on income or non-income dimensions of poverty and their influence on colonisation or infection with antimicrobial-resistant organisms were retrieved. Study quality was assessed with the Integrated quality criteria for review of multiple study designs (ICROMS) tool., Results: Nineteen articles were reviewed. Crowding and homelessness were associated with antimicrobial resistance in community and hospital patients. In high-income countries, low income was associated with Streptococcus pneumoniae and Acinetobacter baumannii resistance and a seven-fold higher infection rate. In low-income countries the findings on this relation were contradictory. Lack of education was linked to resistant S. pneumoniae and Escherichia coli. Two papers explored the relation between water and sanitation and antimicrobial resistance in low-income settings., Conclusions: Despite methodological limitations, the results suggest that addressing social determinants of poverty worldwide remains a crucial yet neglected step towards preventing antimicrobial resistance.

Background: A major challenge in primary healthcare is the substantial increase in the proportion of frail community-dwelling older persons with long-term conditions and multiple complex needs. Consequently, a fundamental transformation of current models of primary care by means of implementing proactive integrated care is necessary. Therefore, an understanding of the effects of integrated primary care approaches and underlying mechanisms is essential. This article presents the design of a theory-based evaluation of an integrated primary care approach to improve well-being among frail community-living older adults, which is called "Finding and Follow-up of Frail older persons" (FFF). First, we present a theoretical model to facilitate a sound theory-guided evaluation of integrated primary care approaches for frail community-dwelling older people. The model incorporates interrelated elements of integrated primary care approaches (e.g. proactive case finding and self-management support). Efforts to improve primary care should integrate these promising components to assure productive patient-professional interactions and to improve well-being. Moreover, cognitive and behavioral components of healthcare professionals and patients are assumed to be important. Second, we present the design of the study to evaluate the FFF approach which consists of the following key components: (1) proactive case finding, (2) case management, (3) medication review, (4) self-management support, and (5) working in multidisciplinary care teams., Methods: The longitudinal evaluation study has a matched quasi-experimental design with one pretest and one posttest (12 month follow-up) and is conducted in the Netherlands between 2014 and 2017. Both quantitative and qualitative methods are used to evaluate effectiveness, processes, and cost-effectiveness. In total, 250 frail older persons (75 years and older) of 11 GP (general practitioner) practices that implemented the FFF approach are compared with 250 frail older patients of 4 GP practices providing care as usual. In addition, data are collected from healthcare professionals. Outcome measures are based on our theoretical model., Discussion: The proposed evaluation study will reveal insight into the (cost)effectiveness and underlying mechanisms of the proactive integrated primary care approach FFF. A major strength of the study is the comprehensive evaluation based on a theoretical framework. The quasi-experimental design presents some challenges.

Purpose: The purpose of this pilot study was to determine the effectiveness and costs of the occupation-based practice for community dwelling frail elderly., Design: Pilot pre-post design without a control group., Setting: A care management center involving 37 local elderly., Subject: The final analysis included 26 frail elderly in a community dwelling center., Intervention: The intervention was occupation-based practice involving setting of client-centered goals, observation of real living situations, and provision of advice on the individual problem of real occupation., Outcome: The outcome was the Frenchay Activities Index (FAI), which is used to evaluate the instrumental activities of daily living (IADL). Additionally, the frequency, duration, and cost of the intervention were calculated., Results: Regarding the FAI score before and after the interventions, there were significant improvements in all items except work ( P <0.05, effect size [r]: 0.67-0.93). A total of 15 people out of 26 (57.7%) showed improvement in activities of daily living. The frequency of interventions was 3.7 (95% confidence interval [CI]: 2.83-4.48), and the duration was 7.4 weeks (95% CI: 5.27-9.42). The average intervention cost was $258 (95% CI: 200.4-317.4)., Conclusion: The results of this study showed that occupation-based practice has a potential to improve IADL in frail elderly, with low frequency of intervention, within a short-term, and direct cost reduction. We believe that this pilot study will contribute to future clinical studies for frail elderly, and the findings can be easily applied to daily clinical intervention. A well-designed prospective randomized-controlled trial is necessary to verify these results., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: Increased out-of-pocket health-care expenditures may exert budget pressure on low-income households that leads to food insecurity. The objective of the present study was to examine whether older adults with higher chronic disease burden are at increased risk of food insecurity., Design: Secondary analysis of the 2013 Health and Retirement Study (HRS) Health Care and Nutrition Study (HCNS) linked to the 2012 nationally representative HRS., Setting: USA., Subjects: Respondents of the 2013 HRS HCNS with household incomes <300 % of the federal poverty line (n 3552). Chronic disease burden was categorized by number of concurrent chronic conditions (0-1, 2-4, ≥5 conditions), with multiple chronic conditions (MCC) defined as ≥2 conditions., Results: The prevalence of food insecurity was 27·8 %. Compared with those having 0-1 conditions, respondents with MCC were significantly more likely to report food insecurity, with the adjusted odds ratio for those with 2-4 conditions being 2·12 (95 % CI 1·45, 3·09) and for those with ≥5 conditions being 3·64 (95 % CI 2·47, 5·37)., Conclusions: A heavy chronic disease burden likely exerts substantial pressure on the household budgets of older adults, creating an increased risk for food insecurity. Given the high prevalence of food insecurity among older adults, screening those with MCC for food insecurity in the clinical setting may be warranted in order to refer to community food resources.