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Aims: To measure the prevalence of visual impairment in a large representative sample of people aged 75 years and over participating in the MRC trial of assessment and management of older people in the community.

Methods: 53 practices in the MRC general practice research framework. Data were obtained from 14 600 participants aged 75 years and older. Prevalence of visual impairment overall (binocular visual acuity <6/18) which was categorised separately into low vision (binocular visual acuity <6/18–3/60) or blindness (binocular visual acuity of <3/60). The prevalence of binocular acuity <6/12 was presented for comparison with other studies. Visual acuity was measured using Glasgow acuity charts; glasses, if worn, were not removed.

Results: Visual acuity was available for 14 600 people out of 21 241 invited (69%). Among people with visual acuity data, 12.4% overall (1803) were visually impaired (95% confidence intervals 10.8% to 13.9%); 1501 (10.3%) were categorised as having low vision (8.7% to 11.8%), and 302 (2.1%) were blind (1.8% to 2.4%). At ages 75–79, 6.2% of the cohort were visually impaired (5.1% to 7.3%) with 36.9% at age 90+ (32.5% to 41.3%). At ages 75–79, 0.6% (0.4% to 0.8%) of the study population were blind, with 6.9% (4.8% to 9.0%) at age 90+. In multivariate regression, controlling for age, women had significant excess risk of visual impairment (odds ratio 1.43, 95% confidence interval 1.29 to 1.58). Overall, 19.9% of study participants had a binocular acuity of less than 6/12 (17.8% to 22.0%).

Conclusion: The results from this large study show that visual impairment is common in the older population and that this risk increases rapidly with advancing age, especially for women. A relatively conservative measure of visual impairment was used. If visual impairment had been defined as visual acuity of <6/12 (American definition of visual impairment), the age specific prevalence estimates would have increased by 60%.

Background: Visual impairment and blindness are common in older people in Britain. It is important to know the causes of visual impairment to develop health service and research priorities. The authors aimed to identify the causes of visual impairment in people aged 75 years and older in Britain.

Methods: In the MRC Trial of the Assessment and Management of Older People in the Community, trial nurses tested visual acuity in everyone aged 75 years and older in 53 general practices. For all visually impaired patients in 49 of the 53 medical practices, data regarding the cause of vision loss were extracted from the general practice medical notes. Additional follow up questionnaires were also sent to the hospital ophthalmologist to confirm the cause of vision loss. Visual impairment was defined as a binocular acuity of less than 6/18.

Results: There were 1742 (12.5%) people visually impaired in the 49 participating practices. Of these, 450 (26%) achieved a pinhole visual acuity in either eye of 6/18 or better. In these people, the principal reason for visual loss was considered to be refractive error. The cause of visual loss was available for 976 (76%) of the remaining 1292 visually impaired people identified. The main cause of visual loss was age related macular degeneration (AMD); 52.9% (95% confidence interval 49.2 to 56.5) of people had AMD as a main or contributory cause. This was followed by cataract (35.9%), glaucoma (11.6%), myopic degeneration (4.2%), and diabetic eye disease (3.4%).

Conclusions: A substantial proportion of visual impairment in our sample of older people in Britain can be attributed to remediable causes—refractive error and cataract. There is considerable potential for visual rehabilitation in this age group. For the large proportion with macular degeneration, low vision services will be important.

Objective To examine the determinants of vulnerability to winter mortality in elderly British people.

Design Population based cohort study (119 389 person years of follow up).

Setting 106 general practices from the Medical Research Council trial of assessment and management of older people in Britain.

Participants People aged ≥ 75 years.

Main outcome measures Mortality (10 123 deaths) determined by follow up through the Office for National Statistics.

Results Month to month variation accounted for 17% of annual all cause mortality, but only 7.8% after adjustment for temperature. The overall winter:non-winter rate ratio was 1.31 (95% confidence interval 1.26 to 1.36). There was little evidence that this ratio varied by geographical region, age, or any of the personal, socioeconomic, or clinical factors examined, with two exceptions: after adjustment for all major covariates the winter:non-winter ratio in women compared with men was 1.11 (1.00 to 1.23), and those with a self reported history of respiratory illness had a winter:non-winter ratio of 1.20 (1.08 to 1.34) times that of people without a history of respiratory illness. There was no evidence that socioeconomic deprivation or self reported financial worries were predictive of winter death.

Conclusion Except for female sex and pre-existing respiratory illness, there was little evidence for vulnerability to winter death associated with factors thought to lead to vulnerability. The lack of socioeconomic gradient suggests that policies aimed at relief of fuel poverty may need to be supplemented by additional measures to tackle the burden of excess winter deaths in elderly people.

Objective To determine the effectiveness of screening for visual impairment in people aged 75 or over as part of a multidimensional screening programme.

Design Cluster randomised trial.

Setting General practices in the United Kingdom participating in the MRC trial of assessment and management of older people in the community.

Participants 4340 people aged 75 years or over randomly sampled from 20 general practices, excluding people resident in hospitals or nursing homes.

Intervention Visual acuity testing and referral to eye services for people with visual impairment. Universal screening (assessment and visual acuity testing) was compared with targeted screening, in which only participants with a range of health related problems were offered an assessment that included acuity screening.

Main outcome measures Proportion of people with visual acuity less than 6/18 in either eye; mean composite score of 25 item version of the National Eye Institute visual function questionnaire.

Results Three to five years after screening, the relative risk of having visual acuity < 6/18 in either eye, comparing universal with targeted screening, was 1.07 (95% confidence interval 0.84 to 1.36; P = 0.58). The mean composite score of the visual function questionnaire was 85.6 in the targeted screening group and 86.0 in the universal group (difference 0.4, 95% confidence interval -1.7 to 2.5, P = 0.69).

Conclusions Including a vision screening component by a practice nurse in a pragmatic trial of multidimensional screening for older people did not lead to improved visual outcomes.

Background

We previously have shown that chronic kidney disease (CKD) is associated with cardiovascular and all-cause mortality in community-dwelling people 75 years and older. The present study addresses the hypothesis that CKD is associated with a higher rate of hospital admission at an older age.

Study Design

Cohort study.

Setting & Participants

15,336 participants from 53 UK general practices underwent comprehensive health assessment between 1994 and 1999.

Predictor

Data for estimated glomerular filtration rate (eGFR, derived from creatinine levels using the CKD Epidemiology Collaboration [CKD-EPI] study equation) and dipstick proteinuria were available for 12,371 participants.

Outcomes

Hospital admissions collected from hospital discharge letters for 2 years after assessment.

Measurements

Age, sex, cardiovascular risk factors, possible biochemical and health consequences of kidney disease (hemoglobin, phosphate, and albumin levels; physical and mental health problems).

Results

2,310 (17%) participants had 1 hospital admission, and 981 (7%) had 2 or more. After adjusting for age, sex, and cardiovascular risk factors, HRs were 1.66 (95% CI, 1.21-2.27), 1.17 (95% CI, 0.95-1.43), 1.08 (95% CI, 0.90-1.30), and 1.11 (95% CI, 0.91-1.35) for eGFRs <30, 30-44, 45-59, and ≥75 mL/min/1.73 m2, respectively, compared with eGFRs of 60-74 mL/min/1.73 m2 for hospitalizations during <6 months of follow-up. HRs were weaker for follow-up of 6-18 months. Dipstick-positive proteinuria was associated with an increased HR throughout follow-up (HR, 1.29 [95% CI, 1.11-1.49], adjusting for cardiovascular risk factors). Dipstick-positive proteinuria and eGFR <30 mL/min/1.73 m2 were independently associated with 2 or more hospital admissions during the 2-year follow-up. Adjustment for other health factors and laboratory measurements attenuated the effect of eGFR, but not the effect of proteinuria.

Limitations

Follow-up limited to 2 years, selection bias due to nonparticipation in study, missing data for potential covariates, and single noncalibrated measurements from multiple laboratories.

Conclusions

The study indicates that community-dwelling older people who have dipstick-positive proteinuria and/or eGFR <30 mL/min/1.73 m2 are at increased risk of hospitalization.

Objective To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions.

Design Cost effectiveness analysis within a randomised controlled trial.

Setting Community hospital and district general hospital in Yorkshire, England.

Participants 220 patients needing rehabilitation after an acute illness for which they required admission to hospital.

Interventions Multidisciplinary care in the district general hospital or prompt transfer to the community hospital.

Main outcome measures EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation.

Results The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group £7233 (euros 10 567; $13 341) (£5031), district general hospital group £7351 (£6229), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of £10 000 per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is £30 000 per QALY.

Conclusion Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.

Purpose:

To estimate the burden of blindness and visual impairment due to cataract in Egbedore Local Government Area of Osun State, Nigeria.

Materials and Methods:

Twenty clusters of 60 individuals who were 50 years or older were selected by systematic random sampling from the entire community. A total of 1,183 persons were examined.

Results:

The age- and sex-adjusted prevalence of bilateral cataract-related blindness (visual acuity (VA) < 3/60) in people of 50 years and older was 2.0% (95% confidence interval (CI): 1.6–2.4%). The Cataract Surgical Coverage (CSC) (persons) was 12.1% and Couching Coverage (persons) was 11.8%. The age- and sex-adjusted prevalence of bilateral operable cataract (VA < 6/60) in people of 50 years and older was 2.7% (95% CI: 2.3–3.1%). In this last group, the cataract intervention (surgery + couching) coverage was 22.2%. The proportion of patients who could not attain 6/60 vision after surgery were 12.5, 87.5, and 92.9%, respectively, for patients who underwent intraocular lens (IOL) implantation, cataract surgery without IOL implantation and those who underwent couching. “Lack of awareness” (30.4%), “no need for surgery” (17.6%), cost (14.6%), fear (10.2%), “waiting for cataract to mature” (8.8%), AND “surgical services not available” (5.8%) were reasons why individuals with operable cataract did not undergo cataract surgery.

Conclusions:

Over 600 operable cataracts exist in this region of Nigeria. There is an urgent need for an effective, affordable, and accessible cataract outreach program. Sustained efforts have to be made to increase the number of IOL surgeries, by making IOL surgery available locally at an affordable cost, if not completely free.

Patterns of sexual partnership formation and dissolution are key drivers of sexually transmitted infection transmission. Sexual behavior survey participants may be unable or unwilling to report accurate details about their sexual partners, limiting the potential to capture information on sexual mixing and timing of partnerships. We examined how questions were interpreted, including recall strategies and judgments made in selecting responses, to inform development of a module on recent sexual partnerships in Britain’s third National Survey of Sexual Attitudes and Lifestyles (“Natsal-3”). Face-to-face cognitive interviews were conducted with 14 men and 18 women aged 18–74 years, during development work for Natsal-3. People with multiple recent partners were purposively sampled and questions were presented as a computer-assisted self-interview. Participants were generally agreeable to answering questions about their sexual partners and practices. Interpretation of questions designed to measure concurrent (overlapping) partnerships was broadly consistent with the epidemiological concept of concurrency. Partners’ ages, genders, ethnicity, and participants’ perceptions of whether partner(s) had had concurrent partnerships were reported without offense. Recall problems and lack of knowledge were reported by some participants (of all ages), especially about former, casual, and/or new partnerships, and some reported guessing partners’ ages and dates of sex. Generally, participants were able to answer questions about their sexual partners accurately, even when repeated for multiple partners. Cognitive interviews provided insight into the participants’ understanding of, ability to answer, and willingness to answer questions. This enabled us to improve questions used in previous surveys, refine new questions, and ensure the questionnaire order was logical for participants.

All acute admissions of patients with sickle cell disease who lived in the London borough of Brent and attended this hospital were analysed for a period of one year. Sixty three of the 211 patients who were followed up by the haematology department required 161 acute admissions during the year. Most admissions (126) were for the 42 patients with homozygous sickle cell disease; 147 (91%) were for vaso-occlusive episodes, 142 of which were for painful crises, three for cerebrovascular accidents, and two for renal papillary necrosis. Preschool children with sickle cell disease were admitted predominantly with limb pain, whereas in schoolchildren and adults the incidence of trunk pain was higher. Twenty four of the 93 episodes of trunk pain culminated in an episode of severe visceral sequestration usually affecting the lungs, the liver, or the mesenteric circulation. Two patients died: an 18 month old baby with an acute splenic sequestration crisis and a 19 year old man with a severe girdle syndrome (sickling in the mesenteric circulation, liver, and lungs). Infective episodes were rare (11 episodes) but severe: one haemophilus meningitis, two salmonella infections, and three aplastic crises due to parvovirus infections. The average duration of the hospital stay was 7.4 days per admission. It is concluded that because sickle cell disease causes appreciable morbidity in older children, adolescents, and adults a systematic approach to management is needed to deal with acute episodes such as sequestration syndromes.

STUDY OBJECTIVE—To analyse to what extent differences in income, using two distinct measures—as distribution across quintiles and poverty—explain social inequalities in self rated health, for men and women, in Sweden and Britain.
DESIGN—Series of cross sectional surveys, the Swedish Survey of Living Conditions (ULF) and the British General Household Survey (GHS), during the period 1992-95.
PARTICIPANTS AND SETTING—Swedish and British men and women aged 25—64 years. Approximately 4000 Swedes and 12 500 Britons are interviewed each year in the cross sectional studies used. The sample contains 15 766 people in the Swedish dataset and 49 604 people in the British dataset.
MAIN RESULTS—The magnitude of social inequalities in less than good self rated health was similar in Sweden and in Britain, but adjusting for income differences explained a greater part of these in Britain than in Sweden. In Britain the distribution across income quintiles explained 47% of the social inequalities in self rated health among women and 31% among men, while in Sweden it explained, for women 13% and for men 20%. Poverty explained 22% for British women and 8% for British men of the social inequalities in self rated health, while in Sweden poverty explained much less (men 2.5% and women 0%).
CONCLUSIONS—The magnitude of social inequalities in self rated health was similar in Sweden and in Britain. However, the distribution of income across occupational social classes explains a larger part of these inequalities in Britain than in Sweden. One reason for this may be the differential exposure to low income and poverty in the two countries.


Keywords: health inequality; income; self rated health

OBJECTIVES: To describe the pattern of clinical disease in women with HIV infection and to examine the effect of potential cofactors, including oral contraceptive use, alcohol and smoking, ethnic group, and route of HIV transmission, on progression to AIDS and death. DESIGN: Prospective observational cohort study. SETTING: 15 HIV and genitourinary medicine (GUM) clinics in Britain and Ireland. PARTICIPANTS: 505 women aged over 18 years with a positive HIV antibody test entered the study between June 1992 and August 1995, with outcome data available for 503 women, and 1208 woman years of follow up to April 1996. MAIN OUTCOME MEASURES: AIDS defining conditions, incidence of AIDS, and death. RESULTS: 120 women (24%) had AIDS at entry to the study. There were 99 incident AIDS cases and 132 deaths during 1208 woman years of follow up. Pneumocystis carinii pneumonia (PCP) was the commonest first AIDS defining condition in white women (31% of AIDS cases), followed by oesophageal candidiasis (19%) while tuberculosis was the most common first AIDS defining condition among black African women (24% of AIDS cases), followed by oesophageal candidiasis (19%). In multivariate analyses, rate of progression to AIDS was significantly related to CD4 lymphocyte count at entry and PCP prophylaxis, but not to ethnic group, route of HIV transmission, alcohol, smoking, or oral contraceptive use. Mortality from all causes was not significantly different in women infected through injecting drugs (adjusted ratio 1.1, 95% confidence interval 0.7-1.8) compared with those infected through sexual intercourse, and non-significantly lower in black African women (0.7, 0.3-1.2) compared with white women. Survival was not significantly related to smoking, alcohol, or oral contraceptive use. CONCLUSIONS: In women attending GUM/HIV clinics, the pattern of AIDS defining conditions differs by ethnic group, but progression of HIV disease is not importantly related to smoking, alcohol, oral contraceptive use, route of HIV transmission, or ethnic group. 




Study objective: To identify socioeconomic differentials in quality of life among older people and their explanatory factors.

Design: Baseline data from a cluster randomised controlled trial of the assessment and management of older people in primary care. Outcome measures were being in the worst quintile of scores for, respectively, the Philadelphia geriatric morale scale and four dimensions of functioning from the sickness impact profile (home management, mobility, self care, and social interaction).

Setting: 23 general practices in Britain.

Participants: People aged 75 years and over on GP registers at the time of recruitment, excluding those in nursing homes or terminally ill. Of 9547 people eligible, 90% provided full information on quality of life and 6298 also did a brief assessment.

Results: The excess risk of poor quality of life for independent people renting rather than owning their home ranged from 27% for morale (95% CI 9% to 48%) to 62% for self care (95% CI 35% to 94%). Self reported health problems plus smoking and alcohol consumption accounted for half or more of the excess, depending on the outcome. Having a low socioeconomic position in middle age as well as in old age exacerbated the risks of poor outcomes. Among people living with someone other than spouse the excess risk from renting ranged from 24% (95%CI –10% to 70%) for poor home management to 93% (95%CI 30% to 180%) for poor morale.

Conclusions: Older people retain the legacy of past socioeconomic position and are subject to current socioeconomic influences.

A geriatric assessment unit has been in operation in a Canadian teaching hospital since October 1979. In the first 15 months of operation there were 203 admissions involving 153 persons aged 65 years or older, many of whom were impaired both physically and mentally.In many cases these patients could be discharged back to the community following assessment and rehabilitation. Only a few had to be placed immediately in extended care facilities. The mean stay in the unit was less than 3 weeks. There was a mortality of 3% among patients in the unit. For older persons who present with complex health problems a geriatric assessment unit provides an environment for comprehensive assessment, treatment and rehabilitation. A thorough assessment at, or preferably before, the point at which their health breaks down enables older people to return to and remain in the community and helps to prevent them from being admitted to an institution while they are still able to function with reasonable independence.

Background

Weight loss and under-nutrition are relatively common in older people, and are associated with poor outcomes including increased rates of hospital admissions and death. In a pilot study of 49 undernourished older, community dwelling people we found that daily treatment for one year with a combination of testosterone tablets and a nutritional supplement produced a significant reduction in hospitalizations. We propose a larger, multicentre study to explore and hopefully confirm this exciting, potentially important finding (NHMRC project grant number 627178).

Methods/Design

One year randomized control trial where subjects are allocated to either oral testosterone undecanoate and high calorie oral nutritional supplement or placebo medication and low calorie oral nutritional supplementation. 200 older community-dwelling, undernourished people [Mini Nutritional Assessment score <24 and either: a) low body weight (body mass index, in kg/m2: <22) or b) recent weight loss (>7.5% over 3 months)]. Hospital admissions, quality-adjusted life years, functional status, nutritional health, muscle strength, body composition and other variables will be assessed.

Discussion

The pilot study showed that combined treatment with an oral testosterone and a supplement drink was well tolerated and safe, and reduced the number of people hospitalised and duration of hospital admissions in undernourished, community dwelling older people. This is an exciting finding, as it identifies a treatment which may be of substantial benefit to many older people in our community. We now propose to conduct a multi-centre study to test these findings in a substantially larger subject group, and to determine the cost effectiveness of this treatment.

Trial registration

Australian Clinical Trial Registry: ACTRN 12610000356066

Background

The objective is to estimate the cost-effectiveness of an intervention that reduces hospital re-admission among older people at high risk. A cost-effectiveness model to estimate the costs and health benefits of the intervention was implemented.

Methodology/Principal Findings

The model used data from a randomised controlled trial conducted in an Australian tertiary metropolitan hospital. Participants were acute medical admissions aged >65 years with at least one risk factor for re-admission: multiple comorbidities, impaired functionality, aged >75 years, recent multiple admissions, poor social support, history of depression. The intervention was a comprehensive nursing and physiotherapy assessment and an individually tailored program of exercise strategies and nurse home visits with telephone follow-up; commencing in hospital and continuing following discharge for 24 weeks. The change to cost outcomes, including the costs of implementing the intervention and all subsequent use of health care services, and, the change to health benefits, represented by quality adjusted life years, were estimated for the intervention as compared to existing practice. The mean change to total costs and quality adjusted life years for an average individual over 24 weeks participating in the intervention were: cost savings of $333 (95% Bayesian credible interval $ -1,932∶1,282) and 0.118 extra quality adjusted life years (95% Bayesian credible interval 0.1∶0.136). The mean net-monetary-benefit per individual for the intervention group compared to the usual care condition was $7,907 (95% Bayesian credible interval $5,959∶$9,995) for the 24 week period.

Conclusions/Significance

The estimation model that describes this intervention predicts cost savings and improved health outcomes. A decision to remain with existing practices causes unnecessary costs and reduced health. Decision makers should consider adopting this program for elderly hospitalised patients.

Evidence of continuing hospital admissions of patients with Asian rickets and osteomalacia led to a further attempt to provide more effective preventive measures for the Glasgow Asian community. Dose-response studies showed that the equivalent of 10 microgram of vitamin D daily would provide effective prophylaxis, and a general practice survey showed that self-administered vitamin D supplements would reduce the prevalence and severity of Asian rickets. A multidisciplinary working group devised a preventive campaign based on the free issue of vitamin D supplements on demand to children who required them. Supported by a health education programme for community health personnel and the Asian community, the first 16 months of the campaign produced an eight-fold rise in the issue of supplements to older Asian children and a 33% increase in their issue to infants of all ethnic groups. Because more children are receiving vitamin D supplementation the campaign seems likely to reduce the prevalence of Asian rickets in Glasgow.

Objective: To test the hypothesis that material disadvantage explains the increased risk among children and young people of adverse health, educational, and behavioural problems associated with living in lone parent households in Britain

Study design: Secondary analysis of a cross sectional survey of a representative sample of British households with children and youth

Main outcomes: Parent reported fair/poor health, longstanding illness and disability, statement of special educational needs, suspension and/or expulsion from school, and in trouble with the police.

Participants: Data were available on 15 636 (8049 boys and 7587 girls) aged 0–18 years in 8541 households in the third sweep (2001) of the British government's families and children study

Results: Lone parenthood was associated with increased risk of health and educational problems, and antisocial behaviour among boys and girls in a logistic regression model adjusting for child's age alone. Adding age of main carer, number of dependent children, and child's rank in the household made little difference to the associations. Addition of housing tenure, household hardship index, and an interaction term for lone parenthood and hardship eliminated the relation with lone parenthood for all outcomes except parent reported health among girls. Similar results were obtained for households headed by lone parents for at least a year. An interaction effect of lone parenthood with hardship for parent reported health and statement of special educational needs was noted.

Conclusion: Adverse effects of lone parenthood on health, education, and antisocial behaviour were apparently explained by material disadvantage in this cross sectional sample of British households with children and youth.

Study objective: To estimate the number of accident and emergency (A&E) attendances, admissions to hospital, and the associated costs as a result of unintentional falls in older people.

Design: Analysis of national databases for cost of illness.

Setting: United Kingdom, 1999, cost to the National Health Service (NHS) and Personal Social Services (PSS).

Participants: Four age groups of people 60 years and over (60–64, 65–69, 70–74, and ⩾75) attending an A&E department or admitted to hospital after an unintentional fall. Databases analysed were the Home Accident Surveillance System (HASS) and Leisure Accident Surveillance System (LASS), and Hospital Episode Statistics (HES).

Main results: There were 647 721 A&E attendances and 204 424 admissions to hospital for fall related injuries in people aged 60 years and over. For the four age groups A&E attendance rates per 10 000 population were 273.5, 287.3, 367.9, and 945.3, and hospital admission rates per 10 000 population were 34.5, 52.0, 91.9, and 368.6. The cost per 10 000 population was £300 000 in the 60–64 age group, increasing to £1 500 000 in the ⩾75 age group. These falls cost the UK government £981 million, of which the NHS incurred 59.2%. Most of the costs (66%) were attributable to falls in those aged ⩾75 years. The major cost driver was inpatient admissions, accounting for 49.4% of total cost of falls. Long term care costs were the second highest, accounting for 41%, primarily in those aged ⩾75 years.

Conclusions: Unintentional falls impose a substantial burden on health and social services.

Background

Influenza vaccination policy for elderly people in Britain has changed twice since 1997 to increase protection against influenza but there is no information available on how this has affected vaccine uptake, and socioeconomic variation therein, among people aged over 74 years.

Methods

Vaccination information for 1997–2000 was collected directly from general practices taking part in a MRC-funded Trial of the Assessment and Management of Older People in the Community. This was linked to information collected during assessments carried out as part of the Trial. Regression modelling was used to assess relative probabilities (as relative risks, RR) of having vaccination according to year, gender, age, area and individual socioeconomic characteristics.

Results

Out of 106 potential practices, 73 provided sufficient information to be included in the analysis. Uptake was 48% (95% CI 45%, 55%) in 1997 and did not increase substantially until 2000 when the uptake was a third higher at 63% (50%, 66%). Vaccination uptake was lower among women than men (RR 0.9), people aged 85 or more compared to people aged under 80 (RR 0.9), those in the most deprived areas (RR 0.8) compared to the least deprived, and was relatively high for those in owner-occupied homes with central heating compared to other non-supported housing (RR for remainder = 0.9). This pattern did not change over the years studied.

Conclusions

Increased uptake in 2000 may have resulted from the additional financial resources given to practices; it was not at the expense of more disadvantaged socioeconomic groups but nor did they benefit disproportionately.

Objectives

To characterize the functional trajectories of older persons admitted to a nursing home with disability after an acute hospitalization.

Design, Setting and Participants

Prospective cohort study of 754 community-living residents of greater New Haven, Connecticut, who were 70 years or older and initially nondisabled in four essential activities of daily living. The analytic sample included the 296 participants who were newly admitted to a nursing home with disability after an acute hospitalization.

Measurements

Information on nursing home admissions, hospitalizations, and disability in essential activities of daily living was ascertained during monthly telephone interviews for up to nine years. Disability was defined at the need for personal assistance in bathing, dressing, walking inside one's home, or transferring from a chair.

Results

The median time to the first nursing home admission with disability after an acute hospitalization was 46 (interquartile range, 27.5–75.5) months; and the mean number of disabled activities of daily living upon admission was 3.0 (standard deviation, 1.2). In the month preceding hospitalization, 189 (63.9%) participants had no disability. The most common functional trajectory was discharged home with disability (46.3%), followed by continuous disability in the nursing home (27.4%), discharged home without disability (21.6%), and noncontinuous disability in the nursing home (4.4%). Only 96 (32.4%) participants returned home at their premorbid level of function.

Conclusion

The functional trajectories among older persons admitted to a nursing home with disability following an acute hospitalization are generally poor. Additional research is needed to identify the factors responsible for these poor outcomes.

Background

If brief and easy to use self report screening tools are available to identify frail elderly, this may avoid costs and unnecessary assessment of healthy people. This study investigates the predictive validity of three self-report instruments for identifying community-dwelling frail elderly.

Methods

This is a prospective study with 1-year follow-up among community-dwelling elderly aged 70 or older (n = 430) to test sensitivity, specificity, and positive and negative predicted values of the Groningen Frailty Indicator, Tilburg Frailty Indicator and Sherbrooke Postal Questionnaire on development of disabilities, hospital admission and mortality. Odds ratios were calculated to compare frail versus non-frail groups for their risk for the adverse outcomes.

Results

Adjusted odds ratios show that those identified as frail have more than twice the risk (GFI, 2.62; TFI, 2.00; SPQ, 2,49) for developing disabilities compared to the non-frail group; those identified as frail by the TFI and SPQ have more than twice the risk of being admitted to a hospital. Sensitivity and specificity for development of disabilities are 71% and 63% (GFI), 62% and 71% (TFI) and 83% and 48% (SPQ). Regarding mortality, sensitivity for all tools are about 70% and specificity between 41% and 61%. For hospital admission, SPQ scores the highest for sensitivity (76%).

Conclusion

All three instruments do have potential to identify older persons at risk, but their predictive power is not sufficient yet. Further research on these and other instruments is needed to improve targeting frail elderly.

Objectives

To examine the rates of and risk factors for acute hospitalization in a prospective cohort of older community-dwelling Alzheimer’s disease (AD) patients

Design

Longitudinal patient registry

Setting

AD Research Center

Participants

827 older persons with AD

Measurements

Acute hospitalization after AD research center visit was determined from Medicare database. Risk factor variables included demographics, dementia-related, comorbidity and diagnoses were measured by interviews and Medicare data.

Results

Of 827 patients during 1991–2006 (median follow-up 3.0 years), 542 (66%) were hospitalized at least once, and 389 (47%) were hospitalized ≥ 2 times, with a median of 3 days spent in the hospital per person-year. Leading reasons for admission included syncope or falls (26%), ischemic heart disease (17%), gastrointestinal disease (9%), pneumonia (6%), and delirium (5%). Five significant independent risk factors for hospitalization included higher comorbidity (hazard ratio (HR), 1.87; 95% confidence interval (95%CI) 1.57, 2.23), previous acute hospitalization (HR, 1.65; 95%CI 1.37, 1.99), older age (HR, 1.51; 95%CI 1.26, 1.81), male sex (HR, 1.27; 95%CI 1.04, 1.54) and shorter duration of dementia symptoms (HR, 1.26; 95%CI 1.02, 1.56). Cumulative risk of hospitalization increases with the number of risk factors present at baseline: 38% with 0 factors; 57% with 1 factor; 70% with 2–3 factors; and 85% with 4–5 factors (Ptrend<0.001).

Conclusion

In community-dwelling population with generally mild AD, hospitalization is frequent, occurring in two-thirds of participants over a median follow-up time of 3 years. With these results, clinicians may be able to identify dementia patients at high risk for hospitalization.

Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.

Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008.

Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.

Participants Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.

Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94).

Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.

Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P<0.001 for difference).

Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.

Trial registration Clinicaltrials.gov NCT00704886.

Background:

Studies that have investigated the relation between depression and the type, nature, extent and outcome of general hospital admissions have been limited by their retrospective designs and focus on specific clinical populations. We explored this relation prospectively in a large, community-based sample of older men.

Methods:

A cohort of 5411 men aged 69 years and older enrolled in the Health in Men Study was assessed at baseline for depressive symptoms, defined as a score of 7 or higher on the 15-item Geriatric Depression Scale. Participants were followed for 2 years for occurrence and number of hospital admissions, type of hospital admission, length of hospital stay and inpatient death as recorded in the Western Australian Data Linkage System.

Results:

Of 339 men with depressive symptoms, 152 (44.8%) had at least 1 emergency hospital admission, compared with 1164 of 5072 (22.9%) nondepressed men (p < 0.001). In multivariate analyses, the presence of depressive symptoms was a significant independent predictor of hospital admission (hazard ratio 1.67, 95% confidence interval [CI] 1.38–2.01), number of hospital admissions (incidence rate ratio [IRR] 1.22, 95% CI 1.07–1.39) and total length of hospital stay (IRR 1.65, 95% CI 1.36–2.01).

Interpretation:

Participants with depressive symptoms were at higher risk of hospital admission for nonpsychiatric conditions and were more likely to have longer hospital stays and worse hospital outcomes, compared with nondepressed participants. These results highlight the potential to target this high-risk group to reduce the burden of health care costs in an aging population.

Background

Falls are very common among the older people. Nearly one-third older people living in a community fall each year. However, few studies have examined factors associated with falls in a community-dwelling population of older Taiwanese adults.

Objectives

To identify the associated factors for falls during the previous 12 months among the community-dwelling Taiwanese older people receiving annual geriatric health examinations.

Participants

People aged sixty-five years or older, living in the community, assessed by annual geriatric health examinations

Methods

1377 community-dwellers aged ≥65 years who received annual geriatric health examinations at one hospital in northern Taiwan between March and November of 2008. They were asked about their history of falls during the year prior to their most recent health examination.

Results

The average age of the 1377 participants was 74.9±6.8 years, 48.9% of which were women. Three-hundred and thirteen of the participants (22.7%) had at least one fall during the previous year. Multivariate analysis showed that odds ratio for the risk of falling was 1.94 (95% CI 1.36-2.76) when the female gender group is compared with the male gender group. The adjusted odds ratios of age and waist circumference were 1.03 (95% CI 1.00–1.06) and 1.03 (95% CI 1.01–1.05) respectively. The adjusted odds ratios of visual acuity, Karnofsky scale, and serum albumin level were 0.34 (95% CI 0.15–0.76), 0.94 (95% CI 0.89–0.98), and 0.37 (95% CI 0.18–0.76) respectively. Larger waist circumference, older age, female gender, poorer visual acuity, lower score on the Karnofsky Performance Scale, and lower serum albumin level were the independent associated factors for falls.

Conclusion

In addition to other associated factors, waist circumference should be included as a novel risk factor for falls.