Showing papers in "Age and Ageing in 2020"

Ageism and COVID-19: what does our society's response say about us?

Abstract: The goal of this commentary is to highlight the ageism that has emerged during the COVID-19 pandemic. Over 20 international researchers in the field of ageing have contributed to this document. This commentary discusses how older people are misrepresented and undervalued in the current public discourse surrounding the pandemic. It points to issues in documenting the deaths of older adults, the lack of preparation for such a crisis in long-term care homes, how some 'protective' policies can be considered patronising and how the initial perception of the public was that the virus was really an older adult problem. This commentary also calls attention to important intergenerational solidarity that has occurred during this crisis to ensure support and social-inclusion of older adults, even at a distance. Our hope is that with this commentary we can contribute to the discourse on older adults during this pandemic and diminish the ageist attitudes that have circulated.

COVID-19 in older people: a rapid clinical review.

Abstract: Introduction the COVID-19 pandemic poses a high risk to older people. The aim of this article is to provide a rapid overview of the COVID-19 literature, with a specific focus on older adults. We frame our findings within an overview of the disease and have also evaluated the inclusion of older people within forthcoming clinical trials. Methods we searched PubMed and bioRxiv/medRxiv to identify English language papers describing the testing, treatment and prognosis of COVID-19. PubMed and bioRxiv/medRxiv searches took place on 20 and 24 March 2020, respectively. Results screening of over 1,100 peer-reviewed and pre-print papers yielded n = 22 on COVID-19 testing, n = 15 on treatment and n = 13 on prognosis. Viral polymerase chain reaction (PCR) and serology are the mainstays of testing, but a positive diagnosis may be increasingly supported by radiological findings. The current evidence for the effectiveness of antiviral, corticosteroid and immunotherapies is inconclusive, although trial data are largely based on younger people. In addition to age, male gender and comorbidities, specific laboratory and radiology findings are important prognostic factors. Evidence suggests that social distancing policies could have important negative consequences, particularly if in place for an extended period. Conclusion given the established association between increasing age and poor prognosis in COVID-19, we anticipate that this rapid review of the current and emergent evidence might form a basis on which future work can be established. Exclusion of older people, particularly those with comorbidities, from clinical trials is well recognised and is potentially being perpetuated in the field of current COVID-19 research.

Commentary: COVID in care homes-challenges and dilemmas in healthcare delivery.

Abstract: The COVID-19 pandemic has disproportionately affected care home residents internationally, with 19-72% of COVID-19 deaths occurring in care homes. COVID-19 presents atypically in care home residents and up to 56% of residents may test positive whilst pre-symptomatic. In this article, we provide a commentary on challenges and dilemmas identified in the response to COVID-19 for care homes and their residents. We highlight the low sensitivity of polymerase chain reaction testing and the difficulties this poses for blanket screening and isolation of residents. We discuss quarantine of residents and the potential harms associated with this. Personal protective equipment supply for care homes during the pandemic has been suboptimal and we suggest that better integration of procurement and supply is required. Advance care planning has been challenged by the pandemic and there is a need to for healthcare staff to provide support to care homes with this. Finally, we discuss measures to implement augmented care in care homes, including treatment with oxygen and subcutaneous fluids, and the frameworks which will be required if these are to be sustainable. All of these challenges must be met by healthcare, social care and government agencies if care home residents and staff are to be physically and psychologically supported during this time of crisis for care homes.

The COVID-19 rehabilitation pandemic

Abstract: The coronavirus disease 2019 (COVID-19) pandemic and the response to the pandemic are combining to produce a tidal wave of need for rehabilitation. Rehabilitation will be needed for survivors of COVID-19, many of whom are older, with underlying health problems. In addition, rehabilitation will be needed for those who have become deconditioned as a result of movement restrictions, social isolation, and inability to access healthcare for pre-existing or new non-COVID-19 illnesses. Delivering rehabilitation in the same way as before the pandemic will not be practical, nor will this approach meet the likely scale of need for rehabilitation. This commentary reviews the likely rehabilitation needs of older people both with and without COVID-19 and discusses how strategies to deliver effective rehabilitation at scale can be designed and implemented in a world living with COVID-19.

Delirium: a missing piece in the COVID-19 pandemic puzzle.

Abstract: • Older people are most vulnerable to severe COVID-19 infections and mortality. • Current guidance for diagnosis does not routinely include delirium, which may lead to under-detection of COVID19. • The care home population is particularly at risk, as failure to promptly detect COVID-19 may lead to outbreaks. • Non-pharmacological approaches to management of delirium may be more difficult to implement but remain the priority.

The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study.

Abstract: INTRODUCTION: Delirium is associated with a wide range of adverse patient safety outcomes, yet it remains consistently under-diagnosed. We undertook a systematic review of studies describing delirium in adult medical patients in secondary care. We investigated if changes in healthcare complexity were associated with trends in reported delirium over the last four decades. METHODS: We used identical criteria to a previous systematic review, only including studies using internationally accepted diagnostic criteria for delirium (the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases). Estimates were pooled across studies using random effects meta-analysis, and we estimated temporal changes using meta-regression. We investigated publication bias with funnel plots. RESULTS: We identified 15 further studies to add to 18 studies from the original review. Overall delirium occurrence was 23% (95% CI 19-26%) (33 studies) though this varied according to diagnostic criteria used (highest in DSM-IV, lowest in DSM-5). There was no change from 1980 to 2019, nor was case-mix (average age of sample, proportion with dementia) different. Overall, risk of bias was moderate or low, though there was evidence of increasing publication bias over time. DISCUSSION: The incidence and prevalence of delirium in hospitals appears to be stable, though publication bias may have masked true changes. Nonetheless, delirium remains a challenging and urgent priority for clinical diagnosis and care pathways.

Association of frailty with mortality in older inpatients with Covid-19: a cohort study.

Abstract: Background COVID-19 has disproportionately affected older people. Objective The objective of this paper to investigate whether frailty is associated with all-cause mortality in older hospital inpatients, with COVID-19. Design Cohort study. Setting Secondary care acute hospital. Participants Participants included are 677 consecutive inpatients aged 65 years and over. Methods Cox proportional hazards models were used to examine the association of frailty with mortality. Frailty was assessed at baseline, according to the Clinical Frailty Scale (CFS), where higher categories indicate worse frailty. Analyses were adjusted for age, sex, deprivation, ethnicity, previous admissions and acute illness severity. Results Six hundred and sixty-four patients were classified according to CFS. Two hundred and seventy-one died, during a mean follow-up of 34.3 days. Worse frailty at baseline was associated with increased mortality risk, even after full adjustment (P = 0.004). Patients with CFS 4 and CFS 5 had non-significant increased mortality risks, compared to those with CFS 1-3. Patients with CFS 6 had a 2.13-fold (95% CI 1.34-3.38) and those with CFS 7-9 had a 1.79-fold (95% CI 1.12-2.88) increased mortality risk, compared to those with CFS 1-3 (P = 0.001 and 0.016, respectively). Older age, male sex and acute illness severity were also associated with increased mortality risk. Conclusions Frailty is associated with all-cause mortality risk in older inpatients with COVID-19.

Research with older people in a world with COVID-19: identification of current and future priorities, challenges and opportunities.

Abstract: Older people are disproportionately affected by the COVID-19 pandemic, which has had a profound impact on research as well as clinical service delivery This commentary identifies key challenges and opportunities in continuing to conduct research with and for older people, both during and after the current pandemic It shares opinions from responders to an international survey, a range of academic authors and opinions from specialist societies Priorities in COVID-19 research include its specific presentation in older people, consequences for physical, cognitive and psychological health, treatments and vaccines, rehabilitation, supporting care homes more effectively, the impact of social distancing, lockdown policies and system reconfiguration to provide best health and social care for older people COVID-19 research needs to be inclusive, particularly involving older people living with frailty, cognitive impairment or multimorbidity, and those living in care homes Non-COVID-19 related research for older people remains of critical importance and must not be neglected in the rush to study the pandemic Profound changes are required in the way that we design and deliver research for older people in a world where movement and face-to-face contact are restricted, but we also highlight new opportunities such as the ability to collaborate more widely and to design and deliver research efficiently at scale and speed

Atypical presentation of COVID-19 in a frail older person.

Abstract: Common symptoms of pandemic coronavirus disease (COVID-19) include fever and cough. We describe a 94-year-old man with well-controlled schizoaffective disorder, who presented with non-specific and atypical symptoms: delirium, low-grade pyrexia and abdominal pain. He was given antibiotics for infection of unknown source, subsequently refined to treatment for community-acquired pneumonia. Despite active treatment, he deteriorated with oxygen desaturation and tachypnoea. A repeat chest X-ray showed widespread opacification. A postmortem throat swab identified COVID-19 infection. He was treated in three wards over 5 days with no infection control precautions. This has implications for the screening, assessment and isolation of frail older people to COVID-specific clinical facilities and highlights the potential for spread among healthcare professionals and other patients.

Frailty in the face of COVID-19.

Abstract: 1Centre for Health Services Research, The University of Queensland, Brisbane, Australia 2Department of Medicine and Aged Care, @AgeMelbourne, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia 3Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands 4Kolling Institute,Northern Clinical School,Faculty of Medicine and Health,The University of Sydney and Royal North Shore Hospital, Australia 5Centre for Education and Research on Ageing, Faculty of Medicine and Health, University of Sydney, Australia 6University of Western Australia, Perth, Australia 7Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health Authority, Halifax, Nova Scotia, Canada

The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine.

Abstract: Background we investigated whether two frailty tools predicted mortality among emergency department (ED) patients referred to internal medicine and how the level of illness acuity influenced any association between frailty and mortality. Methods two tools, embedded in a Comprehensive Geriatric Assessment (CGA), were the clinical frailty scale (CFS) and a 57-item deficit accumulation frailty index (FI-CGA). Illness acuity was assessed using the Canadian Triage and Acuity Scale (CTAS). We examined all-cause 30-day and 6-month mortality and time to death. Results in 808 ED patients (mean age ± SD 80.8 ± 8.8, 54.4% female), the mean FI-CGA score was 0.44 ± 0.14, and the CFS was 5.6 ± 1.6. A minority (307; 38%) were classified as having high acuity (CTAS: 1-2). The 30-day mortality rate was 17%; this increased to 34% at 6 months. Compared to well patients with low acuity, the risk of 30-day mortality was 22.5 times (95% CI: 9.35-62.12) higher for severely frail patients with high acuity; 53% of people with very severe frailty (CFS = 8) and high acuity died within 30 days. When acuity was low, the risk for 30-day mortality was significantly higher only among those with very high levels of frailty (CFS 7-9, FI-CGA > 0.5). When acuity was high, even lower levels of frailty (CFS 5-6, FI-CGA 0.4-0.5) were associated with higher 30-day mortality. Conclusions across levels of frailty, higher acuity increased mortality risk. When acuity was low, the risk was significant only when the degree of frailty was high, whereas when acuity was high, even lower levels of frailty were associated with greater mortality risk.

The impact of delirium on outcomes for older adults hospitalised with COVID-19.

Abstract: Introduction Delirium is a frequent condition in hospitalized older patients and it usually has a negative prognostic value. A direct effect of SARS-COV-2 on the central nervous system (CNS) has been hypothesized. Objective To evaluate the presence of delirium in older patients admitted for a suspected diagnosis of COVID-19 and its impact on in-hospital mortality. Setting and subjects 91 patients, aged 70-years and older, admitted to an acute geriatric ward in Northern Italy from March 8th to April 17th, 2020. Methods COVID-19 cases were confirmed by reverse transcriptase-polymerase chain reaction assay for SARS-Cov-2 RNA from nasal and pharyngeal swabs. Delirium was diagnosed by two geriatricians according to the Diagnostic and Statistical Manual of Mental Disorders V (DMS V) criteria. The number of chronic diseases was calculated among a pre-defined list of 60. The pre-disease Clinical Frailty Scale (CFS) was assessed at hospital admission. Results Of the total sample, 39 patients died, 49 were discharged and 3 were transferred to ICU. Twenty-five patients (27.5%) had delirium. Seventy-two percent of patients with delirium died during hospitalization compared to 31.8% of those without delirium. In a multivariate logistic regression model adjusted for potential confounders, patients with delirium were four times more likely to die during hospital stay compared to those without delirium (OR = 3.98;95%CI = 1.05-17.28; p = 0.047). Conclusions Delirium is common in older patients with COVID-19 and strongly associated with in-hospital mortality. Regardless of causation, either due to a direct effect of SARS-COV-2 on the CNS or to a multifactorial cause, delirium should be interpreted as an alarming prognostic indicator in older people.

Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity.

Abstract: BACKGROUND medication-related problems occur frequently when older patients are discharged from hospital. Interventions to support medication use have been developed; however, their effectiveness in older populations are unknown. This review evaluates interventions that support successful transitions of care through enhanced medication continuity. METHODS a database search for randomised controlled trials was conducted. Selection criteria included mean participant age of 65 years and older, intervention delivered during hospital stay or following recent discharge and including activities that support medication continuity. Primary outcome of interest was hospital readmission. Secondary outcomes related to the safe use of medication and quality of life. Outcomes were pooled by random-effects meta-analysis where possible. RESULTS twenty-four studies (total participants = 17,664) describing activities delivered at multiple time points were included. Interventions that bridged the transition for up to 90 days were more likely to support successful transitions. The meta-analysis, stratified by intervention component, demonstrated that self-management activities (RR 0.81 [0.74, 0.89]), telephone follow-up (RR 0.84 [0.73, 0.97]) and medication reconciliation (RR 0.88 [0.81, 0.96]) were statistically associated with reduced hospital readmissions. CONCLUSION our results suggest that interventions that best support older patients' medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self-management, telephone follow-up and medication reconciliation activities were most likely to be effective; however, further research needs to identify how to meaningfully engage with patients and caregivers to best support post-discharge medication continuity. Limitations included high subjectivity of intervention coding, study heterogeneity and resource restrictions.

Estimated societal costs of stroke in the UK based on a discrete event simulation

Abstract: Background There around 100,000 new stroke cases and over a million people living with its consequences annually in the United Kingdom (UK). This has large impacts on health and social care, unpaid carers and lost productivity. We aimed to estimate associated costs. Methods We estimated 2014/15 annual mean cost per person and aggregate UK cost of stroke for individuals aged ≥40 from a societal perspective. Health and social care costs in the first and subsequent years after stroke were estimated from discrete event simulation modelling, with probability of progression and length of receipt of different health and social care services obtained from routine registry and audit data. Unpaid care hours and lost productivity were obtained from trial data. UK unit costs were applied to estimate mean costs. Epidemiological estimates of stroke incidence and prevalence were then applied to estimate aggregate costs for the UK. Results Mean cost of new-onset stroke is £45,409 (95% CI 42,054-48,763) in the first year after stroke and £24,778 (20,234-29,322) in subsequent years. Aggregate societal cost of stroke is £26 billion per year, including £8.6 billion for NHS and social care. The largest component of total cost was unpaid care (61%) and, given high survival, £20.6 billion related to ongoing care. Conclusion The estimated aggregate cost of stroke substantially exceeds previous UK estimates. Since most of the cost is attributed to unpaid care, interventions aimed at rehabilitation and reducing new and recurrent stroke are likely to yield substantial benefits to carers and cost savings to society.

What is the prevalence of loneliness amongst older people living in residential and nursing care homes? A systematic review and meta-analysis.

Abstract: Background the number of older people living in residential and nursing care homes is rising. Loneliness is a major problem for older people, but little is known about the prevalence of loneliness amongst older people living in care homes. Aim to undertake a systematic review of literature on the prevalence of moderate and severe loneliness amongst older people living in residential and nursing care homes. Design we systematically reviewed the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, Embase, Scopus, Cochrane and Allied and Complementary Medicine Database (AMED) from inception to January 2019. We included all studies reporting data on the prevalence of loneliness amongst older people living in care homes. A random-effects meta-analysis was conducted on all eligible data. Results a total of 13 articles were included, representing 5,115 participants (age range of 55–102 years, mean age 83.5 years, 68% female). There was a significant variation between studies in estimates of prevalence. The prevalence of moderate loneliness ranged from 31 to 100%, and the prevalence of severe loneliness ranged from 9 to 81%. The estimated mean prevalence of ‘moderate loneliness’ was 61% (95% confidence interval (CI): 0.41, 0.80). The estimated mean prevalence of ‘severe loneliness’ was 35% (95% CI: 0.14, 0.60). Conclusion the prevalence of both moderate loneliness and severe loneliness amongst care home residents is high enough to warrant concern. However, the significant variation in prevalence estimates warrants further research. Future studies should identify which interventions can address loneliness and promote meaningful social engagement to enhance quality of life in care homes.

Loneliness as a mediator of the impact of social isolation on cognitive functioning of Chinese older adults.

Abstract: Background and objective older adults have increased risk of social isolation, loneliness and cognitive functioning impairment, but the relationships among these factors are not conclusive. We investigated the potential mediation mechanism of loneliness on the association between social isolation and cognitive functioning among Chinese older adults within their cultural context. Design secondary analysis of the baseline wave (2011-12) of the harmonised China Health and Retirement Longitudinal Study. Setting and subjects community-dwelling older adults in China (N = 7,410 participants aged 60-101 years). Methods we applied a multiple indicator multiple cause approach to determine whether the construct of social isolation is well defined by four indicators (social activity engagement, weekly adult children contact, caregiving for grandchildren and living alone) and used structural equation modelling to examine the direct and indirect effects among variables of interest. Results the results demonstrated that social activity engagement, weekly adult children contact and caregiving for grandchildren were significantly related to social isolation (β = -0.26 to -0.28) (Living alone was fixed to 1 for model identification.) The indirect effect of social isolation on cognitive functioning through loneliness was significant (β = -0.15), indicating loneliness was an important mediator. However, the direct effect of social isolation on cognitive functioning also remained significant (β = -0.83), suggesting a partial mediation effect. Conclusions our study highlights the mediation role of loneliness in the relationship between social isolation and cognitive functioning among Chinese older adults. The findings support the beneficial effects of maintaining social relations and coping with feelings of loneliness on older adults' cognitive functioning.

Virtual geriatric clinics and the COVID-19 catalyst: a rapid review.

Abstract: Background During the current COVID-19 health crisis virtual geriatric clinics have become increasingly utilised to complete outpatient consultations, although concerns exist about feasibility of such virtual consultations for older people. The aim of this rapid review is to describe the satisfaction, clinic productivity, clinical benefit, and costs associated with the virtual geriatric clinic model of care. Methods A rapid review of PubMed, MEDLINE and CINAHL databases was conducted up to April 2020. Two independent reviewers extracted the information. Four subdomains were focused on: satisfaction with the virtual geriatric clinic, clinic productivity, clinical benefit to patients, costs and any challenges associated with the virtual clinic process. Results Nine studies with 975 patients met our inclusion criteria. All were observational studies. Seven studies reported patients were satisfied with the virtual geriatric clinic model of care. Productivity outcomes included reports of cost-effectiveness, savings on transport, and improved waiting list metrics. Clinical benefits included successful polypharmacy reviews, and reductions in acute hospitalisation rates. Varying challenges were reported for both clinicians and patients in eight of the nine studies. Hearing impairments and difficulty with technology added to anxieties experienced by patients. Physicians missed the added value of a thorough physical examination and had concerns about confidentiality. Conclusion Virtual geriatric clinics demonstrate evidence of productivity, benefit to patients, cost effectiveness and patient satisfaction with the treatment provided. In the current suboptimal pandemic climate, virtual geriatric clinics may allow Geriatricians to continue to provide an outpatient service, despite the encountered inherent challenges.

Prevention of adverse drug reactions in hospitalized older patients with multi-morbidity and polypharmacy : the SENATOR∗ randomized controlled clinical trial

Abstract: Background: Multi-morbidity and polypharmacy increase the risk of non-trivial adverse drug reactions (ADRs) in older people during hospitalization. Despite this, there are no established interventions for hospital-acquired ADR prevention. Methods: We undertook a pragmatic, multi-national, parallel arm prospective randomized open-label, blinded endpoint (PROBE) controlled trial enrolling patients at six European medical centres. We randomized 1,537 older medical and surgical patients with multi-morbidity and polypharmacy on admission in a 1:1 ratio to SENATOR software-guided medication optimization plus standard care (intervention, n= 772, mean number of daily medications= 9.34) or standard care alone (control, n= 765, mean number of daily medications= 9.23) using block randomization stratified by site and admission type. Attending clinicians in the intervention arm received SENATOR-generated advice at a single time point with recommendations they could choose to adopt or not. The primary endpoint was occurrence of probable or certain ADRs within 14 days of randomization. Secondary endpoints were primary endpoint derivatives; tertiary endpoints included all-cause mortality, re-hospitalization, composite healthcare utilization and health-related quality of life. Results: For the primary endpoint, there was no difference between the intervention and control groups (24.5 vs. 24.8%; OR 0.98; 95% CI 0.77-1.24; P = 0.88). Similarly, with secondary and tertiary endpoints, there were no significant differences. Among attending clinicians in the intervention group, implementation of SENATOR software-generated medication advice points was poor (similar to 15%). Conclusions: In this trial, uptake of software-generated medication advice to minimize ADRs was poor and did not reduce ADR incidence during index hospitalization.

New horizons in appetite and the anorexia of ageing

Abstract: Appetite drives essential oral nutritional intake. Its regulation is complex, influenced by physiology, hedonism (the reward of eating) and learning from external cues within a person's society and culture. Appetite loss is common in the older population and not always attributable to medical conditions or treatment. Although the physiological basis of the anorexia of ageing (loss of appetite due to the ageing process) has been established, the effect of ageing on hedonism and external cues, which may be equally important, is less well understood. The anorexia of ageing is associated with reductions in dietary diversity and oral intake, and increased risk of malnutrition, sarcopenia and frailty. Early identification of poor appetite could allow timely intervention before weight loss occurs. There is no standardised tool for assessing appetite in clinical settings at present but the 4-item Simplified Nutritional Appetite Questionnaire (SNAQ) has the potential to be used in this way. This review, designed for clinicians, will discuss the regulation of appetite and the pathogenesis of the anorexia of ageing. It will describe the current evidence for interventions to manage the anorexia of ageing, which is limited, with little benefit reported from individual studies of education, physical activity and medication. There is some positive evidence for flavour enhancement, fortified food and oral nutritional supplements but mainly within single studies. Looking ahead, the aim is to develop multicomponent approaches to the treatment of the anorexia of ageing based on growing understanding of the role of physiological signalling, hedonism and external cues.

Anticholinergic drugs and incident dementia, mild cognitive impairment and cognitive decline: a meta-analysis.

Abstract: Background the long-term effect of the use of drugs with anticholinergic activity on cognitive function remains unclear. Methods we conducted a systematic review and meta-analysis of the relationship between anticholinergic drugs and risk of dementia, mild cognitive impairment (MCI) and cognitive decline in the older population. We identified studies published between January 2002 and April 2018 with ≥12 weeks follow-up between strongly anticholinergic drug exposure and the study outcome measurement. We pooled adjusted odds ratios (OR) for studies reporting any, and at least short-term (90+ days) or long-term (365+ days) anticholinergic use for dementia and MCI outcomes, and standardised mean differences (SMD) in global cognition test scores for cognitive decline outcomes. Statistical heterogeneity was measured using the I2 statistic and risk of bias using ROBINS-I. Results twenty-six studies (including 621,548 participants) met our inclusion criteria. 'Any' anticholinergic use was associated with incident dementia (OR 1.20, 95% confidence interval [CI] 1.09-1.32, I2 = 86%). Short-term and long-term use were also associated with incident dementia (OR 1.23, 95% CI 1.17-1.29, I2 = 2%; and OR 1.50, 95% CI 1.22-1.85, I2 = 90%). 'Any' anticholinergic use was associated with cognitive decline (SMD 0.15; 95% CI 0.09-0.21, I2 = 3%) but showed no statistically significant difference for MCI (OR 1.24, 95% CI 0.97-1.59, I2 = 0%). Conclusions anticholinergic drug use is associated with increased dementia incidence and cognitive decline in observational studies. However, a causal link cannot yet be inferred, as studies were observational with considerable risk of bias. Stronger evidence from high-quality studies is needed to guide the management of long-term use.

Projections of care for older people with dementia in England: 2015 to 2040

Abstract: BACKGROUND: The number of older people with dementia and the cost of caring for them, already substantial, are expected to rise due to population ageing. OBJECTIVE: This study makes projections of the number of older people with dementia receiving unpaid care or using care services and associated costs in England. METHODS: The study drew on up-to-date information for England from multiple sources including data from the CFASII study, output from the PACSim dynamic microsimulation model, Office for National Statistics population projections and data from the MODEM cohort study. A simulation model was built to make the projections. RESULTS: We project that the number of older people with dementia will more than double in the next 25 years. The number receiving unpaid or formal care is projected to rise by 124%, from 530,000 in 2015 to 1,183,000 in 2040. Total cost of dementia is projected to increase from £23.0 billion in 2015 to £80.1 billion in 2040, and average cost is projected to increase from £35,100 per person per year in 2015 to £58,900 per person per year in 2040. Total and average costs of social care are projected to increase much faster than those of healthcare and unpaid care. CONCLUSION: The numbers of people with dementia and associated costs of care will rise substantially in the coming decades, unless new treatments enable the progression of the condition to be prevented or slowed. Care and support for people with dementia and their family carers will need to be increased.

Clinical frailty independently predicts early mortality after ischaemic stroke

Abstract: BACKGROUND Clinical frailty is an important syndrome for clinical care and research, independently predicting mortality and rates of institutionalisation in a range of medical conditions. However, there has been little research into the role of frailty in stroke. OBJECTIVE This study investigates the effect of frailty on 28-day mortality following ischaemic stroke and outcomes following stroke thrombolysis. METHODS Frailty was measured using the Clinical Frailty Scale (CFS) for all ischaemic stroke admissions aged ≥75 years. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). 28-day mortality and clinical outcomes were collected retrospectively. Analysis included both dichotomised measures of frailty (non-frail: CFS 1-4, frail: 5-8) and CFS as a continuous ordinal scale. RESULTS In 433 individuals with ischaemic stroke, 28-day mortality was higher in frail versus non-frail individuals (39 (16.7%) versus 10 (5%), P < 0.01). On multivariable analysis, a one-point increase in CFS was independently associated with 28-day mortality (OR 1.03 (1.01-1.05)). In 63 thrombolysed individuals, median NIHSS reduced significantly in non-frail individuals (12.5 (interquartile range (IQR) 9.25) to 5 (IQR 10.5), P < 0.01) but not in frail individuals (15 (IQR 11.5) to 16 (IQR 16.5), P = 0.23). On multivariable analysis, a one-point increase in CFS was independently associated with a one-point reduction in post-thrombolysis NIHSS improvement (coefficient 1.07, P = 0.03). CONCLUSION Clinical frailty is independently associated with 28-day mortality after ischaemic stroke and appears independently associated with attenuated improvement in NIHSS following stroke thrombolysis. Further research is needed to elucidate the underlying mechanisms and how frailty may be utilised in clinical decision-making.

What is important to people with dementia living at home? A set of core outcome items for use in the evaluation of non-pharmacological community-based health and social care interventions

Abstract: Objectives Inconsistency in outcome measurement in dementia care trials impedes comparisons of effectiveness between trials. The key aim of this study is to establish an agreed standardised core outcome set (COS) for use when evaluating non-pharmacological health and social care interventions for people with dementia living at home. Method We used a mixed-methods research design, including substantive qualitative research with five key stakeholders groups. We consulted with people living with dementia for many aspects of this research. We applied a modified two-round 54 item Delphi approach to attain consensus on core outcomes. The COS was finalised in a face-to-face consensus meeting in 2018. Results Of the 288 who completed round 1 (21 people living with dementia, 58 care partners, 137 relevant health and social care professionals, 60 researchers, 12 policy makers) 246 completed round 2 (85% response rate). Twenty participants attended the consensus meeting. We reached consensus for the inclusion of 13 outcome items. Conclusion We identified 13 outcome items which are considered core; many relate to social health. Providing there are adequate measures, measuring these core outcome items will enhance comparisons for effectiveness making trial evidence more useful. The items will provide commissioners and service planners with information on what types of interventions that are most likely to be valued highly by people living with dementia.

Frailty, a multisystem ageing syndrome.

Abstract: The management of frail older people is a key component of aged care. There has been a plethora of tools developed for the diagnosis and screening of frailty. Some of these tools are entering routine clinical practice at a time when the higher healthcare costs involved in caring for older people who are frail have become a potential target for cost-cutting. Yet there is still only limited evidence to support the widespread adoption of frailty tools, and foundational factors impact on their accuracy and validity. Despite the acceptance of frailty as a valid term in research and clinical practice, older people believe the term carries stigma. Such issues indicate that there may be a need to reconsider current approaches to frailty. Recent advances in the science of ageing biology can provide a new framework for reconfiguring how we screen, diagnose, treat and prevent frailty. Frailty can be considered to be a multisystem ageing syndrome of decreased physiological and functional reserve, where the biological changes of ageing are seen in most tissues and organs and are the pathogenic mechanism for frailty. Likewise age-related chronic disease and multimorbidity are syndromes where ageing changes occur in one or multiple systems, respectively. This model focusses diagnostic criteria for frailty onto the biomarkers of ageing and generates new targets for the prevention and treatment of frailty based on interventions that influence ageing biology.

The future incidence, prevalence and costs of stroke in the UK.

Abstract: BACKGROUND: we project incidence and prevalence of stroke in the UK and associated costs to society to 2035. We include future costs of health care, social care, unpaid care and lost productivity, drawing on recent estimates that there are almost 1 million people living with stroke and the current cost of their care is £26 billion. METHODS: we developed a model to produce projections, building on earlier work to estimate the costs of stroke care by age, gender and other characteristics. Our cell-based simulation model uses the 2014-based Office for National Statistics population projections; future trends in incidence and prevalence rates of stroke derived from an expert consultation exercise; and data from the Office for Budget Responsibility on expected future changes in productivity and average earnings. RESULTS: between 2015 and 2035, the number of strokes in the UK per year is projected to increase by 60% and the number of stroke survivors is projected to more than double. Under current patterns of care, the societal cost is projected to almost treble in constant prices over the period. The greatest increase is projected to be in social care costs-both public and private-which we anticipate will rise by as much as 250% between 2015 and 2035. CONCLUSION: the costs of stroke care in the UK are expected to rise rapidly over the next two decades unless measures to prevent strokes and to reduce the disabling effects of strokes can be successfully developed and implemented.

Blood pressure in frail older adults: associations with cardiovascular outcomes and all-cause mortality.

Abstract: BACKGROUND Blood pressure (BP) management in frail older people is challenging. An randomised controlled trial of largely non-frail older people found cardiovascular and mortality benefit with systolic (S) BP target 150 mmHg. Associations with mortality varied between non-frail <85 and frail 75-84-year-olds and all above 85 years. SBPs above the 130-139-mmHg reference were associated with lower mortality risk, particularly in moderate to severe frailty or above 85 years (e.g. 75-84 years: 150-159 mmHg Hazard Ratio (HR) mortality compared to 130-139: non-frail HR = 0.94, 0.92-0.97; moderate/severe frailty HR = 0.84, 0.77-0.92). SBP <130 mmHg and Diastolic(D)BP <80 mmHg were consistently associated with excess mortality, independent of BP trajectory toward the end of life. CONCLUSIONS In representative primary-care patients aged ≥75, BP <130/80 was associated with excess mortality. Hypertension was not associated with increased mortality at ages above 85 or at ages 75-84 with moderate/severe frailty, perhaps due to complexities of co-existing morbidities. The priority given to aggressive BP reduction in frail older people requires further evaluation.

The prevalence and impact of potentially inappropriate prescribing among older persons in primary care settings: multilevel meta-analysis.

Abstract: Background Potentially inappropriate prescribing (PIP) may not have received as much attention in primary care settings (compared to tertiary hospital and nursing home settings), due to uncertainty about its prevalence in this healthcare setting. We conducted a systematic review with meta-analysis to summarise the prevalence of PIP specific to primary care settings and computed the population attributable risk (PAR) to estimate the impact of PIP in primary care. Method We searched PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO and previous review articles for studies related to 'older persons', 'primary care' and 'inappropriate prescribing'. Two reviewers selected eligible articles, extracted data and evaluated risk of bias. Multilevel meta-analysis was conducted to pool the prevalence estimates across the included studies, while meta-regression was conducted to investigate the sources of heterogeneity. Results Of the 4,259 articles identified, we included 67 articles with 111 prevalence estimates and a total of 5,054,975 participants. Overall, PIP had a pooled prevalence of 33.3% (95% CI 29.7-37.0%). Based on population attributable risks, PIP explained 7.7-17.3% of adverse outcomes related to older persons in primary care. If current PIP prevalence is halved, 37-79 cases of adverse outcomes may potentially be prevented (per 1,000 adverse outcomes). Conclusions The findings demonstrate the relevance and potential impact of PIP specific to primary care settings. Given the increasingly central role that primary care plays in coordinating healthcare, the findings highlight the need to prioritise PIP intervention in primary care as a key strategy to reduce iatrogenic medication-related harm among older persons in current healthcare system.

New horizons in rib fracture management in the older adult.

Abstract: Adults aged ≥60 years now represent the majority of patients presenting with major trauma. Falls are the most common cause of injury, accounting for nearly three-quarters of all traumas in this population. Trauma to the thorax represents the second most common site of injury in this population, and is often associated with other serious injuries. Mortality rates are 2-5 times higher in older adults compared to their younger counterparts, often despite equivalent injury severity scores. Risk scoring systems have been developed to identify rib fracture patients at high risk of deterioration. Overall mortality from rib fractures is high, at approximately 10% for all ages. Mortality and morbidity from rib fractures primarily derive from pain-induced hypoventilation, pneumonia and respiratory failure. The main goal of care is therefore to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications. The provision of analgesia has evolved to incorporate novel regional anaesthesia techniques into conventional multimodal analgesia. Analgesia algorithms may aid early aggressive management and escalation of pain control. The current role for surgical fixation of rib fractures remains unclear for older adults who have been underrepresented in the research literature. Older adults with rib fractures often have multi-morbidity and frailty which complicate their injuries. Trauma services are evolving, and increasingly geriatricians will be embedded into trauma services to deliver comprehensive geriatric assessment. This review aims to provide an evidence-based overview of the management of rib fractures for the physician treating older patients who have sustained trauma.

Morbidity and mortality among older people admitted to nursing home

Abstract: Background the increasing number of multimorbid older people places high demands on future health care systems. To inform the discussion on how to structure future care strategies, we aimed to describe the temporal relationship between admission, and morbidity and mortality in nursing home residents. Methods data on 5,179 older individuals admitted to 94 Danish nursing homes in 12 municipalities during 2015-2017 were linked to the nationwide Danish health registries to retrieve information on the temporal relation between nursing home admission and morbidity and mortality. Results at the time of nursing home admission, the majority were women (63%). Male residents were younger than women (median 82 vs 85 years) and had a higher prevalence of comorbidities (median Charlson score 2 vs 1 among women). The median survival after nursing home admission was 25.8 months, with the 3-year survival being 37%. Three-year survival was lower among men (29 vs 43% among women) and among the oldest residents (23% among those aged ≥90 years vs 64% among individuals ≤65 years). In addition to age and sex, predictors of mortality included hospitalisations prior to nursing home admission and a high burden of comorbidity. The rate of hospitalisations, primarily for reasons related to frailty, increased substantially during the 9 months prior to nursing home admission. Conclusion we provide detailed information on differences in morbidity and mortality across age span and sex at the time of nursing home admission, thereby contributing to the ongoing discussion of how to structure the future health care system.

Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1–4

Abstract: BACKGROUND older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014-2017) since NELA was established. METHODS patient-level data were populated from the NELA data set years 1-4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation. RESULTS in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P < 0.001) and 90-day mortality (20.4 versus 7.2%, P < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P < 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1-4 (8.5 to 16.5%, P < 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35-0.42, P < 0.001; 90-day OR 0.6, CI 0.56-0.65, P < 0.001). CONCLUSIONS older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.