Showing papers in "Age and Ageing in 2019"

Sarcopenia: Revised European consensus on definition and diagnosis

Abstract: Background in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings. Objectives to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia. Recommendations sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia. Conclusions EWGSOP2's updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems.

Erratum: Sarcopenia: Revised European consensus on definition and diagnosis (Age and Ageing DOI: 10.1093/ageing/afy169)

Abstract: In the original version of the above paper there was an error in Table 3, which shows the recommended cut-off points for ASM/height2 in women. The cut-off point was given as <6.0 kg/m2, but the correct value is <5.5 kg/m2. This has now been corrected online. The authors wish to apologise for this error.

The prevalence of sarcopenia in community-dwelling older adults, an exploration of differences between studies and within definitions: a systematic review and meta-analyses.

Abstract: Background sarcopenia in ageing is a progressive decrease in muscle mass, strength and/or physical function. This review aims to summarise the definitions of sarcopenia in community-dwelling older adults and explore similarities and differences in prevalence estimates by definition. Methods a systematic review was conducted to identify articles which estimated sarcopenia prevalence in older populations using search terms for sarcopenia and muscle mass. Overall prevalence for each sarcopenia definition was estimated stratified by sex and ethnicity. Secondary analyses explored differences between studies and within definitions, including participant age, muscle mass measurement techniques and thresholds for muscle mass and gait speed. Results in 109 included articles, eight definitions of sarcopenia were identified. The lowest pooled prevalence estimates came from the European Working Group on Sarcopenia/Asian Working Group on Sarcopenia (12.9%, 95% confidence interval: 9.9-15.9%), International Working Group on Sarcopenia (9.9%, 3.2-16.6%) and Foundation for the National Institutes of Health (18.6%, 11.8-25.5%) definitions. The highest prevalence estimates were for the appendicular lean mass (ALM)/weight (40.4%, 19.5-61.2%), ALM/height (30.4%, 20.4-40.3%), ALM regressed on height and weight (30.4%, 20.4-40.3%) and ALM / body mass index (24.2%, 18.3-30.1%) definitions. Within definitions, the age of study participants and the muscle mass cut points used were substantive sources of between-study differences. Conclusion estimates of sarcopenia prevalence vary from 9.9 to 40.4%, depending on the definition used. Significant differences in prevalence exist within definitions across populations. This lack of agreement between definitions needs to be better understood before sarcopenia can be appropriately used in a clinical context.

Intraventricular haemorrhage and seizures in a patient with dementia: a case of chronic neurobrucellosis.

Abstract: Brucellosis is the most commonly reported zoonosis. Nervous system participation can occur at any stage of the disease either in acute or subacute or chronic form. Isolated nervous system involvement or neurobrucellosis is a relatively rare form of the disease. We describe an unusual case of an older patient with dementia with recent onset of seizures in the context of primary isolated intraventricular haemorrhage, diagnosed as chronic neurobrucellosis.

Frailty predicts mortality in all emergency surgical admissions regardless of age. An observational study.

Abstract: Background frail patients in any age group are more likely to die than those that are not frail. We aimed to evaluate the impact of frailty on clinical mortality, readmission rate and length of stay for emergency surgical patients of all ages. Methods a multi-centre prospective cohort study was conducted on adult admissions to acute surgical units. Every patient presenting as a surgical emergency to secondary care, regardless of whether they ultimately underwent a surgical procedure was included. The study was carried out during 2015 and 2016. Frailty was defined using the 7-point Clinical Frailty Scale. The primary outcome was mortality at Day 90. Secondary outcomes included: mortality at Day 30, length of stay and readmission within a Day 30 period. Results the cohort included 2,279 patients (median age 54 years [IQR 36–72]; 56% female). Frailty was documented in patients of all ages: 1% in the under 40’s to 45% of those aged 80+. We found that each incremental step of worsening frailty was associated with an 80% increase in mortality at Day 90 (OR 1.80, 95% CI: 1.61–2.01) supporting a linear dose–response relationship. In addition, the most frail patients were increasingly likely to stay in hospital longer, be readmitted within 30 days, and die within 30 days. Conclusions worsening frailty at any age is associated with significantly poorer patient outcomes, including mortality in unselected acute surgical admissions. Assessment of frailty should be integrated into emergency surgical practice to allow prognostication and implementation of strategies to improve outcomes.

Consequences of applying the new EWGSOP2 guideline instead of the former EWGSOP guideline for sarcopenia case finding in older patients

Abstract: INTRODUCTION we examined the consequences of applying the new EWGSOP2 algorithm for sarcopenia screening instead of the former EWGSOP algorithm (EWGSOP1) in geriatric inpatients. METHODS the dataset of our formerly published Sarcopenia in Geriatric Elderly (SAGE) study includes 144 geriatric inpatients (86 women, 58 men, mean age 80.7±5.6 years) with measurements of gait speed, handgrip strength and appendicular muscle mass by dual x-ray absorptiometry (DXA). We analysed the agreement between EWGSOP and EWGSOP2 algorithms in identifying patients as sarcopenic/non-sarcopenic. Differences in the distribution sarcopenic vs. non-sarcopenic were assessed by Chi²-test. RESULTS sarcopenia prevalence according to EWGSOP1 (41 (27.7%)) was significantly higher than with EWGSOP2 (26(18.1%), p<0.05). The sex-specific sarcopenia prevalence was 22.1% (EWGSOP1) and 17.4% (EWGSOP2), respectively, for women (difference not significant) and 37.9% vs. 19.4% for men (p<0.05%). The overall agreement in classifying subjects as sarcopenic/non-sarcopenic was 81.25% (81.4% for women, 81.0% for men). However, among the 41 sarcopenia cases identified by EWGSOP1, only 20 (48.8%) were diagnosed with sarcopenia by EWGSOP2 (9/19 w (47.4%), 11/22 m (50.0%)). Ten of 19 women (52.6%) and 11 of 22 men (50.0%) diagnosed with sarcopenia by EWGSOP1 were missed by EWGSOP2, while 6 of 15 women (40.0%) and 0 of 11 men (0.0%) were newly diagnosed. DISCUSSION there is a substantial mismatch in sarcopenia case finding according to EWGSOP1 and EWGSOP2. The overall prevalence and the number of men diagnosed with sarcopenia are significantly lower in EWGSOP2. While the absolute number of women identified as sarcopenic remains relatively constant, the overlap of individual cases between the two definitions is low.

Management of atrial fibrillation for older people with frailty: a systematic review and meta-analysis.

Abstract: Background despite a large and growing population of older people with frailty and atrial fibrillation (AF), there is a lack of guidance on optimal AF management in this high-risk group. Objective to synthesise the existing evidence base on the association between frailty, AF and clinical outcomes. Methods a systematic review of studies examining the association between validated measures of frailty, AF and clinical outcomes, and meta-analysis of the association between frailty and oral anticoagulation (OAC) prescription. Results twenty studies (30,883 patients) were included, all observational. Fifteen were in hospital, four in the community, one in nursing care. Risk of bias was low-to-moderate. AF prevalence was 3%-38%. In people with AF, frailty was associated with increased stroke incidence, all-cause mortality, symptom severity and length of hospital stay.Meta-analysis of six studies showed frailty was associated with decreased OAC prescription at hospital admission (pooled adjusted OR 0.45 [95%CI 0.22-0.93], three studies), but not at discharge (pooled adjusted OR 0.40 [95%CI 0.13-1.23], three studies). A community-based study showed increased OAC prescription associated with frailty (OR 2.33 [95%CI 1.03-5.23]). Conclusion frailty is common, and associated with adverse clinical outcomes in patients with AF. There is evidence of an association between frailty status and OAC prescription, with different direction of effect in community compared with hospital cohorts. Despite the majority of care for older people being provided in the community, there is a lack of evidence on the association between frailty, AF, anticoagulation and clinical outcomes to guide optimal care in this setting.

The impact of comorbidity on the quality of life of people with dementia: findings from the IDEAL study.

Abstract: Background The aim was to investigate the comorbidity profile of people with dementia and examine the associations between severity of comorbidity, health-related quality of life (HRQoL) and quality of life (QoL). Methods The improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort consisted of 1,547 people diagnosed with dementia who provided information on the number and type of comorbid conditions. Participants also provided ratings of their health-related and dementia-specific QoL. Results The majority of the sample were living with more than one chronic condition. Hypertension was commonly reported and frequently combined with connective tissue disease, diabetes and depression. The number of comorbid conditions was associated with low QoL scores, and those with severe comorbidity (≥5 conditions) showed the greatest impact on their well-being. Conclusions Comorbidity is an important risk factor for poor QoL and health status in people with dementia. Greater recognition of the nature and impact of comorbidity is needed to inform support and interventions for people with dementia and a multidisciplinary approach to care provision is recommended.

Effects of exercise and nutrition supplementation in community-dwelling older Chinese people with sarcopenia: a randomized controlled trial.

Abstract: Background Limited trials examining the effect of exercise and nutrition supplementation in older people with sarcopenia are available. Objectives to assess the impact of resistance exercise program targeting muscle strength and power with and without nutrition supplementation on gait speed, body composition, physical function and quality of life. Methods this trial randomized 113 community-dwelling older Chinese adults aged ≥65 and with sarcopenia defined using the Asian Criteria into one of the three groups: exercise program alone, combined-exercise program and nutrition supplement or waitlist control. The exercise program consisted of 90-min group training twice weekly and one-home session weekly for 12 weeks. Participants in the combined group were additionally asked to consume nutrition supplement twice daily for 12 weeks. Both groups were encouraged to keep home exercise after intervention period for another 12 weeks to detect sustained effect. The primary outcome was gait speed. Results at 12 and 24 weeks, gait speed did not differ significantly between groups. Significant improvement in leg extension, and five-chair stand test occurred in both intervention groups that persisted to 24 weeks. Physical Activity Scale for the Elderly improved in both intervention groups that persisted until 24 weeks only in the combined group. Lower limb muscle and appendicular skeletal muscle mass increased significantly in the combined group but the increase was not sustained to 24 weeks. Conclusion the exercise program with and without nutrition supplementation had no significant effect on the primary outcome of gait speed but improved the secondary outcomes of strength and the five-chair stand test in community-dwelling Chinese sarcopenic older adults. Clinicaltrials.gov identifier NCT02374268.

Prevalence of sarcopenia in community-dwelling older adults using the definition of the European Working Group on Sarcopenia in Older People 2: findings from the Korean Frailty and Aging Cohort Study.

Abstract: Background in October 2018, the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) updated their original definition of sarcopenia to reflect the scientific and clinical evidence that has accumulated over the last decade. Objective to determine the prevalence of sarcopenia in a large group of community-dwelling older adults using the EWGSOP2 definition and algorithm. Design a cross-sectional study. Setting the nationwide Korean Frailty and Aging Cohort Study (KFACS). Subjects a total of 2,099 ambulatory community-dwelling older adults, aged 70-84 years (mean age, 75.9 ± 4.0 years; 49.8% women) who were enrolled in the KFACS. Methods physical function was assessed by handgrip strength, usual gait speed, the five-times-sit-to-stand test, the timed up-and-go test, and the Short Physical Performance Battery. Appendicular skeletal muscle mass (ASM) was measured by dual-energy X-ray absorptiometry. Results according to the criteria of the EWGSOP2, the sarcopenia indicators of combined low muscle strength and low muscle quantity were present in 4.6-14.5% of men and 6.7-14.4% of women. The severe sarcopenia indicators of combined low muscle strength, low muscle quantity and low physical performance were present in 0.3-2.2% of men and 0.2-6.2% of women. Using the clinical algorithm with SARC-F as a screening tool, the prevalence of probable sarcopenia (2.2%), confirmed sarcopenia (1.4%) and severe sarcopenia (0.8%) was low. Conclusions the prevalence of sarcopenia among community-dwelling older individuals varied depending on which components of the revised EWGSOP2 definition were used, such as the tools used to measure muscle strength and the ASM indicators for low muscle mass.

Efficacy and safety of empagliflozin in older patients in the EMPA-REG OUTCOME® trial

Abstract: OBJECTIVE The risks of cardio-renal complications of diabetes increase with age. In the EMPA-REG OUTCOME® trial, empagliflozin reduced cardiovascular (CV) mortality by 38% in patients with type 2 diabetes (T2D) and CV disease. Here we compare outcomes with empagliflozin in older patients in EMPA-REG OUTCOME. METHODS Patients with T2D and CV disease were randomised to empagliflozin 10 or 25 mg, or placebo plus standard of care. In post hoc analyses, risks of 3-point major adverse CV events (3P-MACE: composite of CV death, non-fatal myocardial infarction (MI) or non-fatal stroke), CV death, hospitalisation for heart failure, all-cause mortality, all-cause hospitalisation and incident/worsening nephropathy were evaluated for empagliflozin versus placebo by baseline age (<65, 65 to <75, ≥75 years). Adverse events (AEs) were analysed descriptively. RESULTS Effect of empagliflozin on all outcomes was consistent across age categories (P ≥ 0.05 for interactions) except 3P-MACE. The 3P-MACE hazard ratios (HRs) were 1.04 (95% confidence interval [CI] 0.84, 1.29), 0.74 (0.58, 0.93) and 0.68 (0.46, 1.00) in patients aged <65, 65 to <75, and ≥75 years, respectively (P = 0.047 for treatment-by-age group interaction). Corresponding CV death HRs were 0.72 (95% CI 0.52, 1.01), 0.54 (0.37, 0.79) and 0.55 (0.32, 0.94), respectively (P = 0.484 for treatment-by-age group interaction). Across age categories, empagliflozin AEs reflected its known safety profile. Rates of bone fractures, renal AEs and diabetic ketoacidosis were similar between empagliflozin and placebo across age categories. CONCLUSIONS In the EMPA-REG OUTCOME trial, empagliflozin reduced risks of CV mortality, heart failure and renal outcomes, supporting its cardio-renal benefits in older patients.

The impact of frailty on healthcare resource use: a longitudinal analysis using the Clinical Practice Research Datalink in England

Abstract: Background routine frailty identification and management is national policy in England, but there remains a lack of evidence on the impact of frailty on healthcare resource use. We evaluated the impact of frailty on the use and costs of general practice and hospital care. Methods retrospective longitudinal analysis using linked routine primary care records for 95,863 patients aged 65-95 years registered with 125 UK general practices between 2003 and 2014. Baseline frailty was measured using the electronic Frailty Index (eFI) and classified in four categories (non, mild, moderate, severe). Negative binomial regressions and ordinary least squares regressions with multilevel mixed effects were applied on the use and costs of general practice and hospital care. Results compared with non-frail status, annual general practitioner consultation incidence rate ratios (IRRs) were 1.24 (95% CI: 1.21-1.27) for mild, 1.41 (95% CI: 1.35-1.47) for moderate, and 1.52 (95% CI: 1.42-1.62) for severe frailty. For emergency hospital admissions, the respective IRRs were 1.64 (95% CI 1.60-1.68), 2.45 (95% CI 2.37-2.53) and 3.16 (95% CI: 3.00-3.33). Compared with non-frail people the IRR for inpatient days was 7.26 (95% CI 6.61-7.97) for severe frailty. Using 2013/14 reference costs, extra annual cost to the healthcare system per person was £561.05 for mild, £1,208.60 for moderate and £2,108.20 for severe frailty. This equates to a total additional cost of £5.8 billion per year across the UK. Conclusions increasing frailty is associated with substantial increases in healthcare costs, driven by increased hospital admissions, longer inpatient stay, and increased general practice consultations.

Convergent validity of the electronic frailty index

Abstract: Background: the electronic frailty index (eFI) has been developed and validated using routine primary care electronic health record data. The focus of the original big data study was on predictive validity as a form of criterion validation. Convergent validity is a subtype of construct validity and considered a core component of the validity of a test. Objective: to investigate convergent validity between the eFI and research standard frailty measures. Design: cross-sectional validation study using data from the Community Ageing Research 75+ (CARE 75+) cohort. Setting: multi-site UK community-based cohort study. Subjects: three hundred fifty-three community-dwelling older people (median age 80 years, IQR 77–84), excluding care home residents and people in the terminal stage of life. Median eFI score of participants was 0.22 (IQR 0.14–0.31). Methods: convergent validities between the eFI and: a research standard frailty index (FI); the phenotype model of frailty; Clinical Frailty Scale (CFS) and Edmonton Frail Scale were assessed using scatter plots and Spearman’s rank tests to estimate correlation coefficients (Spearman’s rho, ρ) and 95% confidence intervals. Results: results indicate strong correlation between the eFI and both the research standard FI (ρ = 0.68, 95% CI 0.62–0.74) and Edmonton Frail Scale (ρ = 0.63, 95% CI 0.57–0.69). There was evidence for moderate correlation between the eFI and both the CFS (ρ = 0.59, 95% CI 0.49–0.65) and phenotype model (ρ = 0.51, 95% CI 0.42–0.59). Conclusions: This study provides evidence for convergent validity of the eFI, a core component of test validity.

Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2.

Abstract: BACKGROUND Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) criteria were developed in 2017 to assist physicians with deprescribing decisions in older people approaching end-of-life. Updating was required to make the tool more practical, patient-centred and complete. METHODS a thorough literature review was conducted to, first, devise a practical method for identifying older people who are likely to be approaching end-of-life, and second, reassess and update the existing deprescribing criteria. An eight-member panel with a wide-ranging experience in geriatric pharmacotherapy reviewed a new draft of STOPPFrail and were invited to propose new deprescribing criteria. STOPPFrail version 2 was then validated using Delphi consensus methodology. RESULTS STOPPFrail version 2 emphasises the importance of shared decision-making in the deprescribing process. A new method for identifying older people who are likely to be approaching end-of-life is included along with 25 deprescribing criteria. Guidance relating to the deprescribing of antihypertensive therapies, anti-anginal medications and vitamin D preparations comprises the new criteria. CONCLUSIONS STOPPFrail criteria have been updated to assist physicians in efforts to reduce drug-related morbidity and burden for their frailest older patients. Version 2 is based on an up-to-date literature review and consensus validation by a panel of experts.

Understanding and improving multidisciplinary team working in geriatric medicine

Abstract: Geriatric medicine is a speciality that has historically relied on team working to best serve patients. The nature of frailty in older people means that people present with numerous comorbidities, which in turn require a team-based approach to be managed, including allied health professionals, social work and nursing alongside medicine. The 'engine room' of the speciality has thus for many years been the multidisciplinary team (MDT) meeting-something other specialities have discovered only recently. Yet, rather paradoxically, the speciality has been slow compared to others (e.g. trauma, surgery, cancer) to reflect more formally on how team working can be enhanced, trained and supported in geriatric teams. This paper is a reflective review, grounded on our respective expertise in geriatric medicine and improvement science, on practice and its changing patterns within geriatric medicine, and the role of MDTs within it (Part 1). It offers a perspective from behavioural safety science, which has been studying team-working in healthcare for the last 20 years (Part 2) and concludes with practical suggestions, based on evidence, on how to integrate evidence and best practice into modern geriatric medicine-to address current and future challenges (Part 3).

The Scottish Intercollegiate Guidelines Network: risk reduction and management of delirium.

Abstract: Clinical and research interest in delirium has been rising over the last 15 years. The Scottish Intercollegiate Guidelines Network (SIGN) publication on delirium is a state-of-the-art synthesis of the field, and the first UK guideline since 2010. There is new guidance around delirium detection, particularly in recommending the 4 'A's Test (4AT). The 4AT has the advantage of being brief, embeds and operationalises cognitive testing, and is scalable with little training. The guidelines highlight the importance of non-pharmacological management for all hospital presentations involving the spectrum of cognitive disorders (delirium, dementia but at risk of delirium, delirium superimposed on dementia). Pharmacotherapy has a minimal role, but specific indications (e.g. intractable distress) are discussed. Advances in delirium research, education and policy, have come together with steady changes in the sociocultural context in which healthcare systems look after older people with cognitive impairment. However, there remains a gap between desired and actual clinical practice, one which might be bridged by re-engaging with compassionate, patient-centred care. In this respect, these SIGN guidelines offer a key resource.

Frailty and co-morbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England.

Abstract: Background: frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations. Objectives: to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of comorbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI). Design: observational study. Setting: primary care in England. Subjects: all adult patients diagnosed with HF in primary care between 2010 and 2013. Methods: we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis. Results: of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, comorbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85. Conclusions: this study suggests that frailty has predictive power beyond its comorbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.

The association of grip strength with health outcomes does not differ if grip strength is used in absolute or relative terms: a prospective cohort study.

Abstract: Background: higher grip strength is associated with better health outcomes. The optimal way to report grip strength (i.e. absolute vs. relative) for prediction, however, remains to be established. Methods: in participants (aged 37–73 at baseline) from the UK Biobank, we examined the associations of grip strength, expressed in absolute terms (kilograms) and relative to anthropometric variables, with mortality and disease incidence, after exclusion of the first 2 years of follow-up, and compared risk predictions scores of handgrip strength when differentially expressed. Results: of the 356 721 participants included in the analysis 6,234 died (1.7%) and 4,523 developed CVD (1.3%) over a mean follow-up of 5.0 years (ranging from 3.3 to 7.8) for mortality and 4.1 years (ranging from 2.4 to 7.0) for disease incidence data. As expected, baseline higher grip strength was associated with lower risk of all-cause and cause specific mortality and incidence. These associations did not meaningfully differ when grip-strength was expressed in absolute terms, vs. relative to height, weight, fat-free mass, BMI, fat-free mass index and fat-free mass, or as z-scores. Similarly the different ways of expressing grip strength had little effect on the ability of grip strength to improve risk prediction, based on C-index change, of an office-based risk score. Conclusions: the ability of grip strength to predict mortality is not altered by changing how it is expressed.

External validation of the electronic Frailty Index using the population of Wales within the Secure Anonymised Information Linkage Databank.

Abstract: BACKGROUND frailty has major implications for health and social care services internationally. The development, validation and national implementation of the electronic Frailty Index (eFI) using routine primary care data has enabled change in the care of older people living with frailty in England. AIMS to externally validate the eFI in Wales and assess new frailty-related outcomes. STUDY DESIGN AND SETTING retrospective cohort study using the Secure Anonymised Information Linkage (SAIL) Databank, comprising 469,000 people aged 65-95, registered with a SAIL contributing general practice on 1 January 2010. METHODS four categories (fit; mild; moderate and severe) of frailty were constructed using recognised cut points from the eFI. We calculated adjusted hazard ratios (HRs) from Cox regression models for validation of existing outcomes: 1-, 3- and 5-year mortality, hospitalisation, and care home admission for validation. We also analysed, as novel outcomes, 1-year mortality following hospitalisation and frailty transition times. RESULTS HR trends for the validation outcomes in SAIL followed the original results from ResearchOne and THIN databases. Relative to the fit category, adjusted HRs in SAIL (95% CI) for 1-year mortality following hospitalisation were 1.05 (95% CI 1.03-1.08) for mild frailty, 1.24 (95% CI 1.21-1.28) for moderate frailty and 1.51 (95% CI 1.45-1.57) for severe frailty. The median time (lower and upper quartile) between frailty categories was 2,165 days (lower and upper quartiles: 1,510 and 2,831) from fit to mild, 1,155 days (lower and upper quartiles: 756 and 1,610) from mild to moderate and 898 days (lower and upper quartiles: 584 and 1,275) from moderate to severe. CONCLUSIONS further validation of the eFI showed robust predictive validity and utility for new outcomes.

Drinking in later life: a systematic review and thematic synthesis of qualitative studies exploring older people's perceptions and experiences.

Abstract: Background - Alcohol presents risks to the health of older adults at levels that may have been 'safer' earlier in life. Moderate drinking is associated with some health benefits, and can play a positive role in older people's social lives. To support healthy ageing, we must understand older people's views with regards to their drinking. This study aims to synthesise qualitative evidence exploring the perceptions and experiences of alcohol use by adults aged 50 years and over. Methods- A pre-specified search strategy was applied to Medline, PsychINFO, Scopus, Applied Social Sciences Index and Abstracts and Cumulative Index to Nursing and Allied Health Literature databases from starting dates. Grey literature, relevant journals, references and citations of included articles were searched. Two independent reviewers sifted articles and assessed study quality. Principles of thematic analysis were applied to synthesise the findings from included studies. Results- Of 2,056 unique articles identified, 25 articles met inclusion criteria. Four themes explained study findings: routines and rituals of older people's drinking; self-image as a responsible drinker; perceptions of alcohol and the ageing body; and older people's access to alcohol. Differences between gender, countries and social patterns are highlighted. Conclusions- Older people perceive themselves as controlled and responsible drinkers. They may not recognise risks associated with alcohol, but appreciate its role in sustaining social and leisure activities important to health and well-being in later life. These are important considerations for intervention development. Drinking is routinised across the life course and may be difficult to change in retirement.

Fluctuations in frailty among older adults.

Abstract: BACKGROUND frailty fluctuations, that is, within-person up and down deviations from individual long-term frailty index trajectories represent a hitherto both conceptually and empirically untapped facet of frailty among older adults. OBJECTIVE to assess the size of frailty fluctuations in old age and their association with frailty levels, frailty growth as well as sex and socio-economic position. METHODS a total of 18,704 biannual observations from 4,514 community-dwelling older adults (65+) in 10 European countries over 12 years from the Survey of Health, Ageing and Retirement in Europe (SHARE) were analysed. A frailty index was constructed based on 50 items. Long-term frailty trajectories and fluctuations were modelled simultaneously using Bayesian mixed-effects location-scale regression models. RESULTS frailty index fluctuations were non-negligible among older adults, amounting to 0.04/0.05 FI or 2.0/2.5 health deficits on average. 30% of fluctuations were between 0.04 and 0.1 FI (2 and 5 health deficits) and 8% were larger than 0.1 FI (5 health deficits). Fluctuations increased with age and frailty levels, and were higher among women, those with low socio-economic position (education) and individuals who died during follow-up. CONCLUSIONS frailty index fluctuations refer to instabilities in an older person's health status and represent a hitherto untapped but relevant aspect of vulnerability in old age. Future analysis of frailty fluctuations should be based on a larger number of repeated observations with shorter time intervals.

New versus old guidelines for sarcopenia classification: What is the impact on prevalence and health outcomes?

Abstract: Introduction: recently, the European Working Group on Sarcopenia in Older People (EWGSOP) established a new operational definition and cut-off points for sarcopenia. The aim of this study was, therefore, to compare the prevalence of sarcopenia and its associations with different health outcomes using the old (EWGSOP1) and new (EWGSOP2) definitions of sarcopenia in the UK Biobank cohort. Methods: sarcopenia was defined as low grip strength plus low muscle mass. Using both EWGSOP cut-off points, we created specific sarcopenia variables. Prevalence of sarcopenia derived using both EWGSOP definitions was calculated and compared as well as prospective health outcomes including all-cause mortality as well as incidence and mortality from cardiovascular disease (CVD), respiratory disease and chronic obstructive pulmonary disease (COPD). Results: the prevalence of sarcopenia based on the EWGSOP1 and EWGSOP2 classifications were 8.14 and 0.36%, respectively. Sarcopenia defined by EWGSOP1 was associated with a higher risk of respiratory disease and COPD as well as mortality from all-cause, CVD and respiratory diseases. However, only respiratory incidence remained associated with sarcopenia when EWGSOP2 was used (HR: 1.32 [95% CI: 1.05–1.66]). Moreover, although individuals classified as sarcopenic using both classifications had the highest risk of all-cause mortality and respiratory disease, those with sarcopenia based on EWGSOP1 only experienced a more extensive range of poorer health outcomes. Conclusion: in comparison with EWGSOP1, the new classification (EWGSOP2) produced a lower estimate of sarcopenia prevalence and fewer associations with adverse health outcomes. Although these associations were higher, many become non-significant.

Impact of sarcopenia on 1-year mortality in older patients with cancer

Abstract: Objectives: sarcopenia is common especially in hospitalised older populations. The aim of this study was to assess the prevalence of sarcopenia, defined as low skeletal mass and muscle strength, and its impact on 1-year mortality in older patients with cancer. Methods: skeletal muscle mass was estimated using bioelectric impedance analysis and related to height2 (SMI; Janssen et al. 2002). Grip strength was measured with the JAMAR dynamometer and the cut-offs suggested by the European Sarcopenia and 1-year mortality in cancer 413 Downloaded from https://academic.oup.com/ageing/article-abstract/48/3/413/5272750 by Universite de Geneve user on 26 November 2019 Working Group on Sarcopenia in Older People (EWGSOP) were applied. One-year mortality was assessed by telephone follow-up and the local cancer death registry. Results: of the 439 consecutively recruited cancer patients (60–95 years; 43.5% women), 119 (27.1%) had sarcopenia. Of the patients with sarcopenia, 62 (52.5%) died within 1 year after study entry compared to 108 (35.1%) patients who did not have sarcopenia (P = 0.001). In a stepwise, forward Cox proportional hazards analysis, sarcopenia (HR = 1.53; 95% CI: 1.034–2.250; P < 0.05), advanced disease (HR = 1.87; 95% CI: 1.228–2.847; P < 0.05), number of drugs/day (HR = 1.11; 95% CI: 1.057–1.170; P < 0.001), tumour diagnosis (overall P < 0.05) and Karnofsky index (HR = 0.98, 95% CI: 0.963–0.995; P < 0.05) associated with 1-year mortality risk. The factors sex, age, co-morbidities and involuntary 6-month weight loss ≥5% were insignificant. Conclusions: sarcopenia was present in 27.1% of older patients with cancer and was independently associated with 1-year mortality. The fact that sarcopenia was nearly as predictive for 1-year mortality as an advanced disease stage underlines the importance of preservation of muscle mass and function as a potential target of intervention in older patients with cancer.

Chronic conditions and multimorbidity in population aged 90 years and over: associations with mortality and long-term care admission.

Abstract: Background prevalence of many chronic conditions is rising in the aging population worldwide. However, the long-term impact of these conditions and multimorbidity on other health outcomes in very old age is rarely studied. Methods the data were based on four waves of the Vitality 90+ Study conducted in 2001, 2003, 2007 and 2010. Associations of chronic conditions and multimorbidity with mortality were analysed in a total sample of 2,862 people aged over 90, and associations with long-term care (LTC) admission in a subsample of 1,954 participants living at home in baseline. Risk of death and LTC admission were assessed with Cox and competing risks regression with time-dependent covariates. Population attributable fractions (PAF) for mortality and LTC admission were calculated for chronic conditions based on the regression models. Results heart disease, diabetes and dementia predicted mortality in men and women. In addition, depression was associated with increased mortality in women. Parkinson's disease, dementia and hip fracture predicted LTC admission in women. Multimorbidity increased the risk of death and LTC admission in women but not in men. For both genders, dementia had the highest PAF for mortality and LTC admission. Conclusion heart disease and diabetes are still important predictors of mortality in very old age. However, the role of dementia is pronounced in this age group. Of the studied conditions, dementia is the main contributor both to mortality and LTC admission. Multimorbidity has predictive value concerning both mortality and LTC admission, at least in oldest old women.

Can comprehensive geriatric assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings

Abstract: Introduction the aim of this study was to design an approach to improving care for frail older patients in hospital services where comprehensive geriatric assessment (CGA) was not part of the clinical tradition. Methods the intervention was based on the principles of CGA, using quality improvement methodology to embed care processes. Qualitative methods and coproduction were used to inform development of the intervention, which was directed towards the health care professionals involved in peri-operative/surgical cancer care pathways in two large UK teaching hospitals. A formative, qualitative evaluation was undertaken; data collection and analysis were guided by normalisation process theory. Results the clinicians involved agreed to use the toolkit, identifying potential benefits including improved surgical decision making and delivery of interventions pre-operatively. However, sites concluded that pre-operative assessment was not the best place for CGA, and at the end of the 12-month trial, implementation was still nascent. Efforts competed against the dominance of national time-limited targets, and concerns relating to patients' immediate treatment and recovery. Some participants involved in the peri-operative pathway felt that CGA required ongoing specialist input from geriatricians, but it was not clear that this was sustainable. Conclusions clinical toolkits designed to empower non-geriatric teams to deliver CGA were received with initial enthusiasm, but did not fully achieve their stated aims due to the need for an extended period of service development with geriatrician support, competing priorities, and divergent views about appropriate professional domains.

The prevalence of non-communicable disease in older people in prison: a systematic review and meta-analysis.

Abstract: Background people in prison often experience poor health. Those aged 50 and over are the fastest growing age-group in prison and present particular challenges to criminal justice systems around the world. Non-communicable diseases (NCDs) account for two-thirds of deaths globally and no estimate of the prevalence of NCDs in this vulnerable population exists. Methods we searched PubMed, Medline, CINAHL, EMBASE and Global Health databases to identify original research papers that met our pre-defined inclusion criteria. No date or language restrictions were applied. Two authors undertook full-text screening as well as quality assessment and data extraction for all included studies. A random effects model was used to calculate pooled prevalence of any disease that was reported in two or more articles. Results the initial search identified 2,712 articles. 119 underwent full-text screening with 26 meeting the inclusion criteria. This provided prevalence data on 28 NCDs in 93,862 individuals from prisons in 11 countries. Pooled prevalence for the most significant NCDs was a follows; cancer 8% (95% CI 6-10%), cardiovascular disease 38% (95% CI 33-42%), hypertension 39% (95% CI 32-47%), diabetes 14% (95% CI 12-16%), COPD prevalence estimates ranged from 4% to 18%. Heterogeneity across studies was high. Conclusions those in prison over 50 years of age experience a high burden of NCDs which is often higher than younger prison and age-matched community peers. This health inequality is influenced by lifestyle, environmental and societal factors. Prison services should be adapted to serve the needs of this growing population.

Is the association between blood pressure and mortality in older adults different with frailty? A systematic review and meta-analysis.

Abstract: Objective: To investigate whether the association between blood pressure and clinical outcomes is different in older adults with and without frailty, using observational studies. Methods: MEDLINE, EMBASE, and CINAHL were searched from 1st January 2000 to 13th June 2018. Prospero CRD42017081635. We included all observational studies reporting clinical outcomes in older adults with an average age over 65 years living in the community with and without treatment that measured blood pressure and frailty using validated methods. Two independent reviewers evaluated study quality and risk of bias using the ROBANS tool. We used generic inverse variance modelling to pool risks of all-cause mortality adjusted for age and sex. Results: Nine observational studies involving 21,906 older adults were included, comparing all-cause mortality over a mean of six years. Fixed effects meta-analysis of six studies demonstrated that in people with frailty, there was no mortality difference associated with systolic blood pressure 140 mm Hg (HR 1.02, 95% CI 0.90 to 1.16). In the absence of frailty, systolic blood pressure 140 mm Hg (HR 0.86, 95% CI 0.77 to 0.96). Conclusions: Evidence from observational studies demonstrates no mortality difference for older people with frailty whose systolic blood pressure is 140 mm Hg. Current evidence fails to capture the complexities of blood pressure measurement, and the association with non-fatal outcomes.

Psychological correlates of multimorbidity and disability accumulation in older adults

Abstract: Background/objectives attitudes toward life and health are emerging as important psychological contributors to health heterogeneity in ageing. We aimed to explore whether different psychological factors were associated with the rate of chronic disease and disability accumulation over time. Design population-based cohort study between 2001 and 2010. Setting Swedish National study on aging and care in Kungsholmen. Subjects adults aged 60 and older (N = 2293). Methods linear mixed models were employed to study the association of life satisfaction, health outlook, resistance to illness, sickness orientation, and health worry with the rate of accumulation of chronic diseases and impaired basic and instrumental activities of daily living. Models were adjusted for demographic, clinical, social, personality and lifestyle factors. Analyses were repeated after excluding individuals with multimorbidity or disability at baseline. Results high life satisfaction and positive health outlook were consistently associated with a lower rate of accumulation and progression of multimorbidity (β -0.064 95% confidence interval [CI] -0.116, -0.011; β -0.065 95% CI -0.121, -0.008, respectively) and disability (β -0.063 95% CI -0.098, -0.028; β -0.042 95% CI -0.079, -0.004, respectively) over time. This was true even for people without multimorbidity or disability at baseline and after adjusting for all covariates. Conclusions positive attitudes toward life in general and health in particular may be especially important in old age, when the cumulative effects of biological and environmental deficits lead to accelerated health decline. These findings should encourage researchers to use measures of psychological well-being to better understand the multifactorial and diverse process of ageing.

Comparison between multicomponent and simultaneous dual-task exercise interventions in long-term nursing home residents: the Ageing-ONDUAL-TASK randomized controlled study.

Abstract: BACKGROUND the potential benefits of dual-task interventions on older adults living in long-term nursing homes (LTNHs) from a multidimensional perspective are unknown. We sought to determine whether the addition of simultaneous cognitive training to a multicomponent exercise program offers further benefits to dual-task, physical and cognitive performance, psycho-affective status, quality of life and frailty in LTNH residents. Design: a single-blind randomized controlled trial. SETTING nine LTNHs in Gipuzkoa, Spain. SUBJECTS 85 men and women (ACTRN12618000536268). METHODS participants were randomly assigned to a multicomponent or dual-task training group. The multicomponent group performed two sessions per week of individualized and progressive strength and balance exercises for 3 months. The dual-task group performed simultaneous cognitive tasks to the same tasks as in the multicomponent group. Gait speed under single- and dual-task conditions, physical and cognitive performance, psycho-affective status, quality of life and frailty were measured at baseline and after 3 months of intervention. RESULTS both groups showed clinically significant improvements on gait performance under single- and dual-task conditions and on the short physical performance battery (P 0.05). Only the multicomponent group significantly improved quality of life, and reduced anxiety and Fried frailty score (P < 0.05). No group-by-time interactions were found except for the chair-stand test in favour of the multicomponent group (P < 0.05). CONCLUSIONS the addition of simultaneous cognitive training does not seem to offer significantly greater benefits to the evaluated multicomponent exercise program in older adults living in LTNHs.