Background: advance care planning (ACP) allows a patient to state their preferences for care, so that if in future they cannot make decisions their wishes are known. Our aim was to review systematically the effectiveness of ACP interventions in people with cognitive impairment and dementia.

Methods: systematic searches of key electronic databases, supplemented by hand searches of reference lists and consultation with experts. Two independent reviewers undertook screening, data extraction and quality assessment.

Results: four studies were included; three allocated providers randomly to intervention or control arm. All took place in nursing homes. Three studies reported formal processes of capacity assessment, only up to 36% of participants were judged to have capacity. Three studies reported positive findings in terms of documentation of patient preferences for care. Two studies reported significant reductions in hospitalisation rates; a third found increased use of hospice services in the intervention group. A meta-analysis could not be carried out due to heterogeneity of outcome measures.

Conclusions: there is limited evidence for the effectiveness of ACP in people with cognitive impairment/dementia in terms of ACP documentation and health-care use. In terms of capacity to discuss ACP, nursing home settings may be too late for people with dementia.

Background: the rate of performance decline may influence the risk of disability or death.

Methods: for 4,182 Cardiovascular Health Study participants, we used multinomial Poisson log-linear models to assess the contribution of physical performance in 1998–99, and the rate of performance change between 1992–93 and 1998–99, to the risk of death or disability in 2005–06 in three domains: mobility, upper-extremity function (UEF) and activities of daily living (ADL). We evaluated performance in finger-tapping, grip strength, stride length, gait speed and chair stands separately and together for each outcome, adjusting for age, gender, race and years of disability in that outcome between 1992–93 and 1998–99.

Results: participants’ age averaged 79.4 in 1998–99; 1,901 died over 7 years. Compared with the lowest change quintile in stride length, the highest quintile had a 1.32 relative risk (RR) of ADL disability (95% CI: 1.16 –1.96) and a 1.27 RR of death (95% CI: 1.07 –1.51). The highest change quintile for grip strength increased the risk of ADL disability by 35% (95% CI: 1.13 –1.61) and death by 31% (95% CI: 1.16 –1.49), compared with the lowest quintile. The annual change in stride length and grip strength also predicted disability in mobility and UEF.

Conclusion: performance trajectories independently predict death and disability.

Background: cerebral small vessel disease (SVD) is the most common cause of vascular cognitive impairment (VCI). Despite this, there is a paucity of rapid simple screening tools to identify cognitive impairment in SVD and differentiate it from other common dementia types.

Objective: to validate a new screening test for cognitive impairment in SVD, the Brief Memory and Executive Test (BMET) battery, and examine its ability to detect SVD and differentiate it from Alzheimer's disease (AD).

Subjects: 45 patients with SVD, 27 patients with AD and 80 normal controls.

Methods: the BMET includes brief tests of executive functioning and processing speed, with comparative tests of memory and orientation. Group discrimination was calculated using discriminant function analysis.

Results: the BMET took an average of 10 min to administer. It showed high sensitivity (91%) and specificity (85%) in differentiating SVD patients with cognitive impairment from AD patients. As a comparison the mini-mental state examination had lower sensitivity (63%) and specificity (62%).

Conclusions: the BMET is a simple and quick to administer clinical tool for the detection of VCI in SVD and its differentiation from AD impairment. Further multicentre studies are required to evaluate and compare it with other existing screening tests.

Background

frailty, a multi-dimensional geriatric syndrome, confers a high risk for falls, disability, hospitalisation and mortality. The prevalence and correlates of frailty in the UK are unknown.

Methods

frailty, defined by Fried, was examined among community-dwelling young-old (64-74 years) men (n = 320) and women (n = 318) who participated in the Hertfordshire Cohort Study, UK.

Results

the prevalence of frailty was 8.5% among women and 4.1% among men (P = 0.02). Among men, older age (P = 0.009), younger age of leaving education (P = 0.05), not owning/mortgaging one’s home (odds ratio [OR] for frailty 3.45 [95% confidence interval {CI} 1.01-11.81], P = 0.05, in comparison with owner/mortgage occupiers) and reduced car availability (OR for frailty 3.57 per unit decrease in number of cars available [95% CI 1.32, 10.0], P = 0.01) were associated with increased odds of frailty. Among women, not owning/mortgaging one’s home (P = 0.02) was associated with frailty. With the exception of car availability among men (P = 0.03), all associations were non-significant (P > 0.05) after adjustment for co-morbidity.

Conclusions

frailty is not uncommon even among community-dwelling young-old men and women in the UK. There are social inequalities in frailty which appear to be mediated by co-morbidity.

Background

reduced grip strength is associated with adverse health consequences, and there is interest in identifying modifiable influences. Cardiovascular drugs are commonly used by older people, but their effect on muscle strength is unclear.

Methods

we investigated associations between cardiovascular drug use and grip strength among 1,572 men and 1,415 women, aged 59-73, who participated in the Hertfordshire Cohort Study.

Results

Forty-five percent of participants were taking a cardiovascular drug. Furosemide was associated with average decreases in grip strength of 3.15 kg (95% confidence interval [CI] 0.90, 5.39, P<0.01) among men and 2.35 kg (95% CI 0.93, 3.77, P<0.01) among women after adjustment for age and height. Corresponding differences for nitrates were 1.84 kg (95% CI 0.29, 3.39, P=0.02) among men and 3.66 kg (95% CI 1.99, 5.33, P<0.01) among women. Calcium channel blockers and fibrates were associated with reduced grip among women. Statins were not associated with grip. The associations between grip strength and nitrate use in men and nitrate and fibrate use in women were robust to additional adjustment for comorbidity.

Conclusions

use of some cardiovascular drugs is associated with reduced grip strength in older people. These findings have potential implications for the functional ability of older people treated with these drugs.

Sarcopenia is the age-related loss of skeletal muscle mass and function. It is now recognised as a major clinical problem for older people and research in the area is expanding exponentially. One of the most important recent developments has been convergence in the operational definition of sarcopenia combining measures of muscle mass and strength or physical performance. This has been accompanied by considerable progress in understanding of pathogenesis from animal models of sarcopenia. Well-described risk factors include age, gender and levels of physical activity and this knowledge is now being translated into effective management strategies including resistance exercise with recent interest in the additional role of nutritional intervention. Sarcopenia is currently a major focus for drug discovery and development although there remains debate about the best primary outcome measure for trials, and various promising avenues to date have proved unsatisfactory. The concept of ‘new tricks for old drugs’ is, however, promising, for example, there is some evidence that the angiotensin-converting enzyme inhibitors may improve physical performance. Future directions will include a deeper understanding of the molecular and cellular mechanisms of sarcopenia and the application of a lifecourse approach to understanding aetiology as well as to informing the optimal timing of interventions.

Background: slower gait in older adults is related to smaller volume of the prefrontal area (PFAv). The pathways underlying this association have not yet been explored. Understanding slowing gait could help improve function in older age. We examine whether the association between smaller PFAv and slower gait is explained by lower performance on numerous neuropsychological tests.

Hypothesis: we hypothesise that slower information processing explains this association, while tests of language or memory will not.

Methods: data on brain imaging, neuropsychological tests (information processing speed, visuospatial attention, memory, language, mood) and time to walk 15 feet were obtained in 214 adults (73.3 years, 62% women) free from stroke and dementia. Covariates included central (white matter hyperintensities, vision) and peripheral contributors of gait (vibration sense, muscle strength, arthritis, body mass index), demographics (age, race, gender, education), as well as markers of prevalent vascular diseases (cardiovascular disease, diabetes and ankle arm index).

Results: in linear regression models, smaller PFAv was associated with slower time to walk independent of covariates. This association was no longer significant after adding information processing speed to the model. None of the other neuropsychological tests significantly attenuated this association.

Conclusions: we conclude that smaller PFAv may contribute to slower gait through slower information processing. Future longitudinal studies are warranted to examine the casual relationship between focal brain atrophy with slowing in information processing and gait.

Background: self-rated health (SRH) likely reflects both mental and physical health domains, and is assessed by asking individuals to describe their health status. Poor SRH is associated with disease incidence and subsequent mortality. Changes in SRH across time in persons with different incident diseases are uncharacterised.

Methods: SRH was assessed in the Atherosclerosis Risk in Communities study via annual telephone interviews over a median of 17.6 years. Individual quadratic growth models were used for repeated measures of SRH in persons who remained disease-free during follow-up (n = 11,188), as well as among those who were diagnosed with myocardial infarction (MI; n = 1,071), stroke (n = 809), heart failure (HF; n = 1,592) or lung cancer (n = 433) and those who underwent a cardiac revascularisation procedure (n = 1,340) during follow-up.

Results: among disease-free participants and across time, there was a trend for lowest mean SRH among persons living in low socioeconomic areas and highest mean SRH among persons living in high socioeconomic areas. Factors contributing to the decline in SRH over time included advanced age, lower educational attainment, smoking and obesity.

Conclusion: addressing factors related to poor SRH trajectories among patients pre- and post-incident disease may favourably affect health outcomes among patients regardless of type of disease.

Background: studies of cognitive ageing at the group level suggest that age is associated with cognitive decline; however, there may be individual differences such that not all older adults will experience cognitive decline.

Objective: to evaluate patterns of cognitive decline in a cohort of older adults initially free of dementia.

Design, setting and subjects: elderly Catholic clergy members participating in the Religious Orders Study were followed for up to 15 years. Cognitive performance was assessed annually.

Methods: performance on a composite global measure of cognition was analysed using random effects models for baseline performance and change over time. A profile mixture component was used to identify subgroups with different cognitive trajectories over the study period.

Results: from a sample of 1,049 participants (mean age 75 years), three subgroups were identified based on the distribution of baseline performance and change over time. The majority (65%) of participants belonged to a slow decline class that did not experience substantial cognitive decline over the observation period [−0.04 baseline total sample standard deviation (SD) units/year]. About 27% experienced moderate decline (−0.19 SD/year), and 8% belonged to a class experiencing rapid decline (−0.57 SD/year). A subsample analysis revealed that when substantial cognitive decline does occur, the magnitude and rate of decline is correlated with neuropathological processes.

Conclusions: in this sample, the most common pattern of cognitive decline is extremely slow, perceptible on a time scale measured by decades, not years. While in need of cross validation, these findings suggest that cognitive changes associated with ageing may be minimal and emphasise the importance of understanding the full range of age-related pathologies that may diminish brain function.

Background: telomere length has been used to represent biological ageing and is found to be associated with various physiological, psychological and social factors.

Objective: to explore the effects of income and marriage on leucocyte telomere length in a representative sample of older adults.

Design and subjects: cross-sectional analysis among 298 adults, aged 65–74, randomly selected from the community by census.

Methods: telomere length was measured by quantitative PCR. Participants provided information on sociodemographics, physical illness and completed questionnaires rating mental state and perceived neighbourhood experience.

Results: telomere length was negatively associated with lower income [coefficient −0.141 (95% CI: −0.244 to −0.020), P = 0.021] and positively associated with the marital status [coefficient 0.111 (95% CI: −0.008 to 0.234), P = 0.067] when controlling for gender, age, educational level, physical diseases (including diabetes, hypertension, cardiovascular diseases, cerebrovascular disease and Parkinson's disease), depressive symptoms, minor mental symptoms, cognitive impairment and perceived neighbourhood experience (including social support, perceived security and public facilities).

Conclusions: these results indicate that older adults with higher income or being married have longer telomeres when other sociodemographics, physical diseases, mental status and neighbourhood experience are adjusted.

Objectives: to investigate functional limitations and their association with socioeconomic factors in four Central and Eastern European populations.

Methods: a cross-sectional study of random population samples in Novosibirsk (Russia), Krakow (Poland), Kaunas (Lithuania) and six Czech towns participating in the HAPIEE study. Functional limitations (classified into tertiles of the SF-36 physical functioning subscale), socioeconomic circumstances and health behaviours were available for 34,431 subjects aged 45–69 years.

Results: the proportion of subjects in the worst tertile of the functional limitations score (≤80% of the maximum score) ranged from 21% of the men in Kaunas to 48% in Krakow women. In multivariate ordered logistic regression, functional limitations were strongly inversely associated with education and positively with material deprivation and with being economically inactive. Functional limitations were more common in male smokers and less common in alcohol drinkers. Socioeconomic characteristics explained some of the differences in functional limitations between populations. Health behaviours explained some of the differences between social groups in both genders and between populations in women.

Conclusion: unexpectedly, functional limitations were not most common in the sample from Russia, the country with the highest mortality rates. All socioeconomic measures were strongly associated with functional limitations and made some contribution towards explaining differences in limitations between populations.

Background: poor physical capability is associated with higher subsequent risk of disability and mortality in older people. Energy and macronutrient intakes may play a role in the maintenance of physical capability. This analysis aimed to examine the role of intakes of energy and the macronutrients, protein, carbohydrate and fat in early and mid-adulthood on objective measures of physical capability in later adulthood in the MRC National Survey of Health and Development (1946 British birth cohort).

Methods: adult diet assessed by a 5-day diary at 36 years (1982) and 43 years (1989). Physical capability was assessed at 53 years. Objective measures were height, weight and three measures of physical capability: grip strength, standing balance time and chair rises.

Results: using multiple linear regression analysis, modest positive associations were found between energy intake at 36 and 43 years and grip strength at 53 years. Results for macronutrients were mixed although there was some indication of relationships of protein intake with grip strength and standing balance time.

Conclusions: higher energy intake in midlife may play a role in the prevention of muscle weakness in later life. Higher protein intakes may also be related to physical capability but further research is needed.

Background: reduced telomere length in blood cells has been associated with increased risk of multiple age-related diseases and is widely regarded as a general biomarker of ageing. Therefore, it is important to know both the extent and limitations of this association. We investigated the relation between telomere length and anaemia in two independent cohorts, with the prior expectation of adding anaemia to the list of conditions for which telomere reduction is a risk factor.

Participants and methods: the present study is embedded in the Newcastle 85-plus Study and Leiden 85-plus Study, two population-based studies of inhabitants of Newcastle and North Tyneside, UK (n = 749) and Leiden, the Netherlands (n = 658) aged 85 and over. High-molecular-weight DNA was isolated from full fresh blood (Newcastle) and peripheral blood mononuclear cells samples (Leiden). Telomere length was measured as abundance of telomeric template versus a single gene by quantitative real-time polymerase chain reaction. Anaemia was defined according to World Health Organization criteria.

Results: in both studies, no differences in median telomere length were observed between participants with anaemia and participants without anaemia (Newcastle: 2,846 bp (interquartile range (IQR) 2,433–3,630) versus 2,920 bp (IQR 2,425–3,570), P = 0.63; Leiden: 4,136 bp (IQR 3,879–4,428) versus 4,167 bp (IQR 3,893–4,501), P = 0.41). Telomere length also did not correlate with any other haematological parameter in both men and women.

Conclusions: in contrast to other age-related diseases, telomere length is not associated with anaemia or any other haematological parameter in older individuals in the general population.

Background: physical functioning describes the underlying abilities that make activities necessary for independent living in the community possible.

Objective: to test self-reported and objective measures of physical functioning in predicting subsequent disability in cooking, shopping and housework.

Design: we used data from the first and second waves of the Survey of Health, Ageing and Retirement in Europe. The respondents were asked about physical functioning (climbing, pulling/pushing, stooping/crouching/kneeling, lifting/carrying and reaching/extending were comparable) and they had their grip strength and walking speed measured.

Participants: men and women aged 65 years or over who reported no disability in cooking, shopping and housework at baseline were included in the analysis. There were 6,841 individuals for whom data on disability status at follow-up were available.

Methods: Poisson regression was used to calculate relative risks for the associations between self-reported and objective measures of physical functioning with disability at 2 years, adjusting for age, gender, educational level, cognitive function and chronic conditions.

Results: those with limitations in physical functioning at baseline more frequently reported subsequent disability. Walking ability was most strongly associated with disability; climbing, pulling/pushing, lifting/carrying and reaching/extending were comparable (picking was non-significant). Similar results were obtained with grip strength and walking speed.

Conclusions: both self-reports and objective measures capture information on the functional ability of older people that can be used to predict disability onset. Objective measures offer little to the development of intervention strategies, whereas self-reports provide some insight into the demands of the environment, being more amenable to interventions.

Background: neopterin is a monocyte/macrophage-derived immune activation marker and its levels increase with age. Frailty is an important clinical syndrome of old age. Previous studies have shown significant association between elevated interleukin-6 (IL-6) levels and frailty. The objective of this study was to evaluate IL-6-independent association of serum neopterin levels with prevalent frailty.

Methods: this is a cross-sectional study in community-dwelling older adults recruited from residential and retirement communities in Baltimore, MD, USA. Frailty was determined using validated screening criteria. Serum neopterin and IL-6 levels were measured using standard enzyme-linked immunosorbent assay. Pearson correlation and multivariate linear regression analysis was performed to assess the relationship between log(neopterin) and log(IL-6). Odds ratios (ORs) for frailty were calculated using log(neopterin) and log(IL-6) as continuous measures and across tertiles of neopterin and IL-6 levels, adjusting for age, race, sex, education and body mass index.

Results: one hundred and thirty-three individuals with a mean age of 84 years (range 72–97) completed the study. Neopterin levels were significantly higher in frail older adults than those in non-frail controls [median: 8.94 versus 8.35 nM, respectively, P < 0.001 t-test on log(neopterin)]. Log(neopterin) was significantly associated with prevalent frailty, adjusting for log(IL-6). Participants in the top tertile of neopterin had OR of 3.80 [95% confidence interval (CI) = 1.36–10.6, P < 0.01] for frailty. As expected, participants in the top tertile of IL-6 had OR of 3.29 (95% CI = 1.21–7.86, P < 0.05) for frailty. Log(neopterin) correlated with log(IL-6) (correlation coefficient = 0.19, P < 0.05). Moreover, OR for participants in the top neopterin tertile remained significant after adjusting for IL-6 (OR = 3.97, 95% CI = 1.15–13.72, P < 0.05).

Conclusion: elevated neopterin levels had IL-6-independent association with prevalent frailty, suggesting potential monocyte/macrophage-mediated immune activation in the frail elderly.

Background

modifiable behavioural risk factors including smoking and alcohol consumption are major contributing or actual causes of mortality.

Objective

to examine the effect of alcohol intake on all-cause mortality in older adults.

Design and Setting

prospective population-based cohort study of residents of a California, United States retirement community.

Subjects

8,877 women and 5,101 men (median age, 74 years) who in the early 1980s completed a postal health survey including details on alcohol consumption.

Methods

participants were followed for 23 years (1981–2004) including two follow-up questionnaires (in 1992 and 1998) asking about current alcohol intake. Age-adjusted and multivariate-adjusted risk ratios of death and 95% confidence intervals were calculated separately for men and women, using proportional hazard regression.

Results

of the 8,644 women and 4,980 men with complete information on the variables of interest and potential confounders, 6,930 women and 4,456 men had died (median age, 87 years). Both men and women who drank alcohol had decreased mortality compared with non-drinkers. Those who drank two or more drinks per day had a 15% reduced risk of death. The reduced risk was not limited to one type of alcohol. Stable drinkers (those who reported drinking both at baseline and follow-up) had a significantly decreased risk of death compared with stable non-drinkers. Those who started drinking at follow-up also had a significantly lower risk. Women who quit drinking were at increased risk of death.

Conclusion

in elderly men and women, moderate alcohol intake exhibits a beneficial effect on mortality. Those who quit may do so for health reasons that affect mortality.

Introduction: differentiating mild cognitive impairment (MCI) from normal cognition (NC) is difficult. The AB Cognitive Screen (ABCS) 135, sensitive in differentiating MCI from dementia, was modified to improve sensitivity and specificity, producing the quick mild cognitive impairment (Qmci) screen.

Objective: this study compared the sensitivity and specificity of the Qmci with the Standardised MMSE and ABCS 135, to differentiate NC, MCI and dementia.

Methods: weightings and subtests of the ABCS 135 were changed and a new section ‘logical memory’ added, creating the Qmci. From four memory clinics in Ontario, Canada, 335 subjects (154 with MCI, 181 with dementia) were recruited and underwent comprehensive assessment. Caregivers, attending with the subjects, without cognitive symptoms, were recruited as controls (n = 630).

Results: the Qmci was more sensitive than the SMMSE and ABCS 135, in differentiating MCI from NC, with an area under the curve (AUC) of 0.86 compared with 0.67 and 0.83, respectively, and in differentiating MCI from mild dementia, AUC of 0.92 versus 0.91 and 0.91. The ability of the Qmci to identify MCI was better for those over 75 years.

Conclusion: the Qmci is more sensitive than the SMMSE in differentiating MCI and NC, making it a useful test, for MCI in clinical practice, especially for older adults.

Background

Stroke has been shown to follow a social gradient with incidence rising as socioeconomic status decreases.

Objective

To examine the relationship between socioeconomic status and ischemic stroke risk amongst older people.

Setting

The Cities of Bordeaux, Dijon and Montpellier in France.

Subjects and methods

9294 non institutionalised persons aged 65 years or more followed for 6 years.

Results

The distribution of cardiovascular risks factors was consistent with the classical finding of more favourable risk profiles among the advantaged socioeconomic groups. 136 individuals developed a first ever ischemic stroke (incidence rate: 3.2 per 1000 py, 95% CI 2.7–3.8). The age and sex adjusted incidence of ischemic stroke increased with increasing level of income (from 2.4 to 4.1 per 1000 py, p=0.04). In the multivariable analysis adjusting for cardiovascular risk factors, the higher income group displayed a 80% increased risk of ischemic stroke compared with less wealthy participants (hazards ratio 1.77, 95% CI 1.20–2.61).

Conclusions

In this community-based sample of older individuals, a higher level of household income was associated with a higher risk of ischemic stroke, a reversal of the social gradient usually reported in younger age groups. Selective survival is one of the potential explanations for this unexpected finding.

Background: nearly 61% of older adults do not maintain recommended exercise levels emphasising the need for interventions that promote exercise.

Objectives: to compare self-reported exercise behaviour and functional outcomes over 1 year across three groups of older adults: a cognitive-behavioural therapy group, an attention-control education group and a control group.

Design: randomised intervention.

Setting: community exercise facilities.

Participants: three hundred and thirty-two older adults (mean age = 71.8 ± 5.1 years).

Methods: all three groups received exercise training three times per week for 2 weeks and then one time per week for 8 weeks, during which time the therapy and education groups received their interventions. Blinded data collectors measured follow-up exercise behaviour and functional outcomes at 3-month intervals.

Results: after controlling for previous year exercise behaviour, results showed that relative to the control group, the therapy and education groups increased their strengthening exercises over time (0.05 and 0.06 h/week higher, respectively); only the therapy group's change was significant. Also, relative to the control group, the therapy and education groups significantly reduced their 6-min walking distances over time (−1.6 m, P = 0.030 and −1.5 m, P = 0.026, respectively).

Conclusions: although the therapy group increased their strength training, they reduced their 6-min walking distance.

Objective: to explore the preferences of community-dwelling older persons regarding different programme formats for managing concerns about falls.

Subjects and design: cross-sectional study of 5,755 community-dwelling people aged ≥70 years in the Netherlands.

Methods: a questionnaire assessed people's willingness to participate per programme format (n = 6), i.e. a programme at home, via telephone, via home visits and telephone consultations, via television or via Internet.

Results: of the 2,498 responders, 62.7% indicated no interest in any of the formats. The willingness to participate per programme format varied between 21.5 (at home) and 9.4% (via Internet). Among people interested in at least one of the formats (n = 931), higher levels of fall-related concerns were associated with increased preference for a programme with home visits. Poor perceived health and age ≥80 years were associated with less preference for a group programme. Higher educated people were more in favour of a programme via Internet compared with their lower educated counterparts.

Conclusion: the majority of community-dwelling older people are not likely to participate in any of the six proposed programme formats for managing concerns about falls. However, when diverse formats of effective programmes will be made available, uptake and adherence may be increased since programme preferences are associated to specific population characteristics.