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1.  Association of stressful life events with incident falls and fractures in older men: the Osteoporotic Fractures in Men (MrOS) Study 
Age and Ageing  2014;43(1):103-108.
Background: small, retrospective studies suggest that major life events and/or sudden emotional stress may increase fall and fracture risk. The current study examines these associations prospectively.
Methods: a total of 5,152 men aged ≥65 years in the Osteoporotic Fractures in Men study self-reported data on stressful life events for 1 year prior to study Visit 2. Incident falls and fractures were ascertained for 1 year after Visit 2. Fractures were centrally confirmed.
Results: a total of 2,932 (56.9%) men reported ≥1 type of stressful life event. In men with complete stressful life event, fall and covariate data (n = 3,949), any stressful life event was associated with a 33% increased risk of incident fall [relative risk (RR) 1.33, 95% confidence interval (CI) 1.19–1.49] and 68% increased risk of multiple falls (RR = 1.68, 95% CI = 1.40–2.01) in the year following Visit 2 after adjustment for age, education, Parkinson's disease, diabetes, stroke, instrumental activities of daily living (IADL) impairment, chair stand time, walk speed, multiple past falls, depressive symptoms and antidepressant use. Risk increased with the number of types of stressful life events. Though any stressful life event was associated with a 58% increased age-adjusted risk for incident fracture, this association was attenuated and no longer statistically significant after additional adjustment for total hip bone mineral density, fracture after age 50, Parkinson's disease, stroke and IADL impairment.
Conclusions: in this cohort of older men, stressful life events significantly increased risk of incident falls independent of other explanatory variables, but did not independently increase incident fracture risk.
doi:10.1093/ageing/aft117
PMCID: PMC3861336  PMID: 24002237
accidental falls; fractures; life change events; psychological stress; prospective studies; aged; male; men; older people
2.  Impairments in hearing and vision impact on mortality in older people: the AGES-Reykjavik Study 
Age and Ageing  2014;43(1):69-76.
Objective: to examine the relationships between impairments in hearing and vision and mortality from all-causes and cardiovascular disease (CVD) among older people.
Design: population-based cohort study.
Participants: the study population included 4,926 Icelandic individuals, aged ≥67 years, 43.4% male, who completed vision and hearing examinations between 2002 and 2006 in the Age, Gene/Environment Susceptibility-Reykjavik Study (AGES-RS) and were followed prospectively for mortality through 2009.
Methods: participants were classified as having ‘moderate or greater’ degree of impairment for vision only (VI), hearing only (HI), and both vision and hearing (dual sensory impairment, DSI). Cox proportional hazard regression, with age as the time scale, was used to calculate hazard ratios (HR) associated with impairment and mortality due to all-causes and specifically CVD after a median follow-up of 5.3 years.
Results: the prevalence of HI, VI and DSI were 25.4, 9.2 and 7.0%, respectively. After adjusting for age, significantly (P < 0.01) increased mortality from all causes, and CVD was observed for HI and DSI, especially among men. After further adjustment for established mortality risk factors, people with HI remained at higher risk for CVD mortality [HR: 1.70 (1.27–2.27)], whereas people with DSI remained at higher risk of all-cause mortality [HR: 1.43 (1.11–1.85)] and CVD mortality [HR: 1.78 (1.18–2.69)]. Mortality rates were significantly higher in men with HI and DSI and were elevated, although not significantly, among women with HI.
Conclusions: older men with HI or DSI had a greater risk of dying from any cause and particularly cardiovascular causes within a median 5-year follow-up. Women with hearing impairment had a non-significantly elevated risk. Vision impairment alone was not associated with increased mortality.
doi:10.1093/ageing/aft122
PMCID: PMC3861337  PMID: 23996030
AGES-Reykjavik study; hearing; vision; dual sensory impairment; all-cause mortality; cardiovascular disease mortality; older people
3.  Sensorimotor and psychosocial determinants of 3-year incident mobility disability in middle-aged and older adults 
Age and Ageing  2014;43(1):64-69.
Objective: to identify sensorimotor and psychosocial determinants of 3-year incident mobility disability.
Design: prospective.
Setting: population-based sample of community-dwelling older persons.
Participants: community-living middle-aged and older persons (age: 50–85 years) without baseline mobility disability (n = 622).
Measurements: mobility disability, defined as self-reported inability to walk a quarter mile without resting or inability to walk up a flight of stairs unsupported, was ascertained at baseline and 3-year follow-up. Potential baseline determinant characteristics included demographics, education, social support, financial condition, knee extensor strength, visual contrast sensitivity, cognition, depression, presence of chronic conditions and history of falls.
Results: a total of 13.5% participant reported 3-year incident mobility disability. Age ≥75 years, female sex, knee extensor strength in the lowest quartile, visual contrast sensitivity <1.7 on the Pelli-Robson chart or significant depressive symptoms (CESD score >16) were independent determinants of 3-year incident mobility disability (ORs 1.84–16.51).
Conclusions: low visual contrast sensitivity, poor knee extensor strength and significant depressive symptoms are independent determinants of future onset of mobility disability.
doi:10.1093/ageing/aft135
PMCID: PMC3861339  PMID: 24042004
mobility; disability; depression; vision; muscle strength; older people
4.  Prevalence of chronic illnesses and characteristics of chronically ill informal caregivers of persons with dementia 
Age and Ageing  2014;43(1):137-141.
Objectives: to examine the prevalence of and the link of chronic illnesses (CIs) to informal caregivers of persons with dementia (PWDs), as well as to identify characteristics of caregivers with CIs.
Methods: the sample included 124 caregivers of PWDs from a caregiver programme of research. Sociodemographic information and caregivers CIs were collected by an in-person interview. Descriptive statistics, t-tests, chi-square analysis and binary logistic regressions were performed for data analysis.
Results: approximately 81.5% (n = 101) of caregivers reported having at least one CI, 60.5% (n = 75) reported two or more CIs. Caregivers with CIs were more likely to be older and unemployed; advanced age and female gender were risk factors for CIs. The link of CIs to caregivers was stronger in younger caregivers but weaker in older caregivers when compared with the general population.
Conclusion: targeted interventions based on this study need to be developed to improve the health of caregivers of PWDs.
doi:10.1093/ageing/aft142
PMCID: PMC4047288  PMID: 24072413
informal caregivers; Alzheimer's disease; dementia; chronic illness; community; older people
5.  Economic evaluation of the differential benefits of home visits with telephone calls and telephone calls only in transitional discharge support 
Age and Ageing  2014;44(1):143-147.
Background: home visits and telephone calls are two often used approaches in transitional care, but their differential economic effects are unknown.
Objective: to examine the differential economic benefits of home visits with telephone calls and telephone calls only in transitional discharge support.
Design: cost-effectiveness analysis conducted alongside a randomised controlled trial (RCT).
Participants: patients discharged from medical units randomly assigned to control (control, N = 210), home visits with calls (home, N = 196) and calls only (call, N = 204).
Methods: cost-effectiveness analyses were conducted from the societal perspective comparing monetary benefits and quality-adjusted life years (QALYs) gained.
Results: the home arm was less costly but less effective at 28 days and was dominating (less costly and more effective) at 84 days. The call arm was dominating at both 28 and 84 days. The incremental QALY for the home arm was −0.0002/0.0008 (28/84 days), and the call arm was 0.0022/0.0104 (28/84 days). When the three groups were compared, the call arm had a higher probability being cost-effective at 84 days but not at 28 days (home: 53%, call: 35% (28 days) versus home: 22%, call: 73% (84 days)) measuring against the NICE threshold of £20,000.
Conclusion: the original RCT showed that the bundled intervention involving home visits and calls was more effective than calls only in the reduction of hospital readmissions. This study adds a cost perspective to inform policymakers that both home visits and calls only are cost-effective for transitional care support, but calls only have a higher chance of being cost-effective for a sustained period after intervention.
doi:10.1093/ageing/afu166
PMCID: PMC4255617  PMID: 25355620
transitional discharge support; home visits; telephone calls; hospital readmissions; cost-effectiveness analysis; older people
6.  Prevalence of and interventions for sarcopenia in ageing adults: a systematic review. Report of the International Sarcopenia Initiative (EWGSOP and IWGS) 
Age and Ageing  2014;43(6):748-759.
Objective: to examine the clinical evidence reporting the prevalence of sarcopenia and the effect of nutrition and exercise interventions from studies using the consensus definition of sarcopenia proposed by the European Working Group on Sarcopenia in Older People (EWGSOP).
Methods: PubMed and Dialog databases were searched (January 2000–October 2013) using pre-defined search terms. Prevalence studies and intervention studies investigating muscle mass plus strength or function outcome measures using the EWGSOP definition of sarcopenia, in well-defined populations of adults aged ≥50 years were selected.
Results: prevalence of sarcopenia was, with regional and age-related variations, 1–29% in community-dwelling populations, 14–33% in long-term care populations and 10% in the only acute hospital-care population examined. Moderate quality evidence suggests that exercise interventions improve muscle strength and physical performance. The results of nutrition interventions are equivocal due to the low number of studies and heterogeneous study design. Essential amino acid (EAA) supplements, including ∼2.5 g of leucine, and β-hydroxy β-methylbutyric acid (HMB) supplements, show some effects in improving muscle mass and function parameters. Protein supplements have not shown consistent benefits on muscle mass and function.
Conclusion: prevalence of sarcopenia is substantial in most geriatric settings. Well-designed, standardised studies evaluating exercise or nutrition interventions are needed before treatment guidelines can be developed. Physicians should screen for sarcopenia in both community and geriatric settings, with diagnosis based on muscle mass and function. Supervised resistance exercise is recommended for individuals with sarcopenia. EAA (with leucine) and HMB may improve muscle outcomes.
doi:10.1093/ageing/afu115
PMCID: PMC4204661  PMID: 25241753
exercise intervention; nutrition intervention; prevalence; age-related; sarcopenia; older people
7.  Exploring the relationship between national economic indicators and relative fitness and frailty in middle-aged and older Europeans 
Age and Ageing  2013;42(5):614-619.
Background: on an individual level, lower-income has been associated with disability, morbidity and death. On a population level, the relationship of economic indicators with health is unclear.
Objective: the purpose of this study was to evaluate relative fitness and frailty in relation to national income and healthcare spending, and their relationship with mortality.
Design and setting: secondary analysis of data from the Survey of Health, Ageing and Retirement in Europe (SHARE); a longitudinal population-based survey which began in 2004.
Subjects: a total of 36,306 community-dwelling people aged 50 and older (16,467 men; 19,839 women) from the 15 countries which participated in the SHARE comprised the study sample. A frailty index was constructed as the proportion of deficits present in relation to the 70 deficits available in SHARE. The characteristics of the frailty index examined were mean, prevalence of frailty and proportion of the fittest group.
Results: the mean value of the frailty index was lower in higher-income countries (0.16 ± 0.12) than in lower-income countries (0.20 ± 0.14); the overall mean frailty index was negatively correlated with both gross domestic product (r = −0.79; P < 0.01) and health expenditure (r = −0.63; P < 0.05). Survival in non-frail participants at 24 months was not associated with national income (P = 0.19), whereas survival in frail people was greater in higher-income countries (P < 0.05).
Conclusions: a country's level of frailty and fitness in adults aged 50+ years is strongly correlated with national economic indicators. In higher-income countries, not only is the prevalence of frailty lower, but frail people also live longer.
doi:10.1093/ageing/aft010
PMCID: PMC3745086  PMID: 23443511
ageing; frailty; Europe; SHARE; older people
8.  ‘It could be worse … lot's worse!’ Why health-related quality of life is better in older compared with younger individuals with heart failure 
Age and Ageing  2013;42(5):626-632.
Background: health-related quality of life (HRQOL) is markedly impaired in patients with heart failure (HF). Despite worse prognosis and physical status, older patients have better HRQOL than younger patients.
Objective: to determine reasons for differences in HRQOL in older compared with younger HF patients.
Methods: a mixed methods approach was used. HRQOL was assessed using the Minnesota Living with HF Questionnaire and compared among HF patients (n = 603) in four age groups (≤53, 54–62, 63–70 and ≥71 years). Socio-demographic/clinical and psychological factors related to HRQOL were determined in four groups using multiple regressions. Patients (n = 20) described their views of HRQOL during semi-structured interviews.
Results: HRQOL was worse in the youngest group, and best in the two oldest groups. The youngest group reported higher levels of depression and anxiety than the oldest group. Anxiety, depression and functional capacity predicted HRQOL in all age groups. Qualitatively, patients in all age groups acknowledged the negative impact of HF on HRQOL; nonetheless older patients reported that their HRQOL exceeded their expectations for their age. Younger patients bemoaned the loss of activities and roles, and reported their HRQOL as poor.
Conclusions: better HRQOL among older HF patients is the result, in part, of better psychosocial status. The major factor driving better HRQOL among older patients is a change with advancing age in expectations about what constitutes good HRQOL.
doi:10.1093/ageing/aft078
PMCID: PMC3745088  PMID: 23832262
health-related quality of life; older adults; anxiety; depression; older people
9.  Predicting risk of 2-year incident dementia using the CAMCOG total and subscale scores 
Age and Ageing  2013;42(5):649-653.
Background: being able to identify individuals at high risk of dementia is important for diagnostics and intervention. Currently, there is no standard approach to assessing cognitive function in older aged individuals to best predict incident dementia.
Objective: to identify cognitive changes associated with an increased risk of 2-year incident dementia using the Cambridge Cognitive Examination (CAMCOG).
Design: longitudinal population representative sample aged 65+ years.
Methods: individuals were from the Medical Research Council Cognitive Function and Ageing Study. Classification and Regression Tree analysis was used to detect the optimal cut-off value for the CAMCOG total, subscales and composite memory and non-memory scores, for predicting dementia. Sensitivity and specificity of each cut-off score were assessed.
Results: from the 2,053 individuals without dementia at the first assessment, 137 developed dementia at the 2-year follow-up. The results indicate similar discriminative accuracy for incident dementia based on the CAMCOG total, memory subscale and composite scores. However, sensitivity and specificity of cut-off values were generally moderate. Scores on the non-memory subscales generally had high sensitivity but low specificity. Compared with the CAMCOG total score they had significantly lower discriminative accuracy.
Conclusion: in a population setting, cut-off scores from the CAMCOG memory subscales predicted dementia with reasonable accuracy. Scores on the non-memory scales have lower accuracy and are not recommend for predicting high-risk cases unless all non-memory subdomain scores are combined. The added value of cognition when assessed using the CAMCOG to other risk factors (e.g. health and genetics) should be tested within a risk prediction framework.
doi:10.1093/ageing/aft082
PMCID: PMC3745089  PMID: 23872637
cognition; dementia risk prediction; Cambridge Cognitive Examination (CAMCOG); classification and regression tree (CART) analysis; predictive accuracy; older people
10.  Much more medicine for the oldest old: trends in UK electronic clinical records 
Age and Ageing  2014;44(1):46-53.
Background: the oldest old (85+) pose complex medical challenges. Both underdiagnosis and overdiagnosis are claimed in this group.
Objective: to estimate diagnosis, prescribing and hospital admission prevalence from 2003/4 to 2011/12, to monitor trends in medicalisation.
Design and setting: observational study of Clinical Practice Research Datalink (CPRD) electronic medical records from general practice populations (eligible; n = 27,109) with oversampling of the oldest old.
Methods: we identified 18 common diseases and five geriatric syndromes (dizziness, incontinence, skin ulcers, falls and fractures) from Read codes. We counted medications prescribed ≥1 time in all quarters of studied years.
Results: there were major increases in recorded prevalence of most conditions in the 85+ group, especially chronic kidney disease (stages 3–5: prevalence <1% rising to 36.4%). The proportions of the 85+ group with ≥3 conditions rose from 32.2 to 55.1% (27.1 to 35.1% in the 65–84 year group). Geriatric syndrome trends were less marked. In the 85+ age group the proportion receiving no chronically prescribed medications fell from 29.6 to 13.6%, while the proportion on ≥3 rose from 44.6 to 66.2%. The proportion of 85+ year olds with ≥1 hospital admissions per year rose from 27.6 to 35.4%.
Conclusions: there has been a dramatic increase in the medicalisation of the oldest old, evident in increased diagnosis (likely partly due to better record keeping) but also increased prescribing and hospitalisation. Diagnostic trends especially for chronic kidney disease may raise concerns about overdiagnosis. These findings provide new urgency to questions about the appropriateness of multiple diagnostic labelling.
doi:10.1093/ageing/afu113
PMCID: PMC4255615  PMID: 25103030
oldest; prevalence; admission; prescribing; kidney; older people
11.  Understanding vitamin D deficiency 
Age and Ageing  2014;43(5):589-591.
doi:10.1093/ageing/afu104
PMCID: PMC4143492  PMID: 25074537
vitamin D deficiency; vitamin D receptor; muscle and vitamin D; vitamin D deficiency threshold; vitamin D testing older people
12.  Self-reported quality of care for older adults from 2004 to 2011: a cohort study 
Age and Ageing  2014;43(5):716-720.
Background: little is known about changes in the quality of medical care for older adults over time.
Objective: to assess changes in technical quality of care over 6 years, and associations with participants' characteristics.
Design: a national cohort survey covering RAND Corporation-derived quality indicators (QIs) in face-to-face structured interviews in participants' households.
Participants: a total of 5,114 people aged 50 or more in four waves of the English Longitudinal Study of Ageing.
Methods: the percentage achievement of 24 QIs in 10 general medical and geriatric clinical conditions was calculated for each time point, and associations with participants' characteristics were estimated using logistic regression.
Results: participants were eligible for 21,220 QIs. QI achievement for geriatric conditions (cataract, falls, osteoarthritis and osteoporosis) was 41% [95% confidence interval (CI): 38–44] in 2004–05 and 38% (36–39) in 2010–11. Achievement for general medical conditions (depression, diabetes mellitus, hypertension, ischaemic heart disease, pain and cerebrovascular disease) improved from 75% (73–77) in 2004–05 to 80% (79–82) in 2010–11. Achievement ranged from 89% for cerebrovascular disease to 34% for osteoarthritis. Overall achievement was lower for participants who were men, wealthier, infrequent alcohol drinkers, not obese and living alone.
Conclusion: substantial system-level shortfalls in quality of care for geriatric conditions persisted over 6 years, with relatively small and inconsistent variations in quality by participants' characteristics. The relative lack of variation by participants' characteristics suggests that quality improvement interventions may be more effective when directed at healthcare delivery systems rather than individuals.
doi:10.1093/ageing/afu091
PMCID: PMC4143491  PMID: 25015897
quality of care; geriatrics; epidemiology; older people
13.  Changes in hospitalisation and surgical procedures among the oldest-old: a follow-up study of the entire Danish 1895 and 1905 cohorts from ages 85 to 99 years 
Age and Ageing  2013;42(4):476-481.
Objective: to examine whether the Danish 1905 cohort members had more active hospital treatment than the 1895 cohort members from ages 85 to 99 years and whether it results in higher in-hospital and post-operative mortality.
Methods: in the present register-based follow-up study the complete Danish birth cohorts born in 1895 (n = 12,326) and 1905 (n = 15,477) alive and residing in Denmark at the age of 85 were followed from ages 85 to 99 years with regard to hospitalisations and all-cause and cause-specific surgical procedures, as well as in-hospital and post-operative mortality.
Results: the 1905 cohort members had more frequent hospital admissions and operations, but they had a shorter length of hospital stay than the 1895 cohort at all ages from 85 to 99 years. The increase in primary prosthetic replacements of hip joint was observed even within the 1895 cohort: no patients were operated at ages 85–89 years versus 2.2–3.6% at ages 95–99 years. Despite increased hospitalisation and operation rates, there was no increase in post-operative and in-hospital mortality rates in the 1905 cohort. These patterns were similar among men and women.
Conclusions: the observed patterns are compatible with more active treatment of the recent cohorts of old-aged persons and reduced age inequalities in the Danish healthcare system. No increase in post-operative mortality suggests that the selection of older patients eligible for a surgical treatment is likely to be based on the health status of old-aged persons and the safety of surgical procedures rather than chronological age.
doi:10.1093/ageing/aft031
PMCID: PMC3693434  PMID: 23531440
cohort comparison; hospitalisation; surgical procedure; old age; post-operative mortality; in-hospital mortality; register study; Denmark; older people
14.  Time trends of incidence of age-associated diseases in the US elderly population: medicare-based analysis 
Age and Ageing  2013;42(4):494-500.
Objectives: time trends of age-adjusted incidence rates of 19 ageing-related diseases were evaluated for 1992–2005 period with the National Long Term Care Survey and the Surveillance, Epidemiology and End Results Registry data both linked to Medicare data (NLTCS-Medicare and SEER-Medicare, respectively).
Methods: the rates were calculated using individual medical histories (34,077 individuals from NLTCS-Medicare and 199,418 from SEER-Medicare) reconstructed using information on diagnoses coded in Medicare data, dates of medical services/procedures and Medicare enrolment/disenrolment.
Results: increases of incidence rates were dramatic for renal disease [the average annual percent change (APC) is 8.56%, 95% CI = 7.62, 9.50%], goiter (APC = 6.67%, 95% CI = 5, 90, 7, 44%), melanoma (APC = 6.15%, 95% CI = 4.31, 8.02%) and Alzheimer's disease (APC = 3.96%, 95% CI = 2.67, 5.26%), and less prominent for diabetes and lung cancer. Decreases of incidence rates were remarkable for angina pectoris (APC = −6.17%, 95% CI = −6.96, −5.38%); chronic obstructive pulmonary disease (APC = −5.14%, 95% CI = −6.78,−3.47%), and ulcer (APC = −5.82%, 95% CI = −6.77,−4.86%) and less dramatic for carcinomas of colon and prostate, stroke, hip fracture and asthma. Incidence rates of female breast carcinoma, myocardial infarction, Parkinson's disease and rheumatoid arthritis were almost stable. For most diseases, an excellent agreement was observed for incidence rates between NLTCS-Medicare and SEER-Medicare. A sensitivity analysis proved the stability of the evaluated time trends.
Conclusion: time trends of the incidence of diseases common in the US elderly population were evaluated. The results show dramatic increase in incidence rates of melanoma, goiter, chronic renal and Alzheimer's disease in 1992–2005. Besides specifying widely recognised time trends on age-associated diseases, new information was obtained for trends of asthma, ulcer and goiter among the older adults in the USA.
doi:10.1093/ageing/aft032
PMCID: PMC3684110  PMID: 23482353
Medicare; disease onset; time trends; comorbidity; age-associated disease; older people
15.  Alcohol consumption and physical functioning among middle-aged and older adults in Central and Eastern Europe: Results from the HAPIEE study 
Age and Ageing  2014;44(1):84-89.
Background: light-to-moderate drinking is apparently associated with a decreased risk of physical limitations in middle-aged and older adults.
Objective: to investigate the association between alcohol consumption and physical limitations in Eastern European populations.
Study design: a cross-sectional survey of 28,783 randomly selected residents (45–69 years) in Novosibirsk (Russia), Krakow (Poland) and seven towns of Czech Republic.
Methods: physical limitations were defined as <75% of optimal physical functioning using the Physical Functioning (PF-10) Subscale of the Short-Form-36 questionnaire. Alcohol consumption was assessed by a graduated frequency questionnaire, and problem drinking was defined as ≥2 positive responses on the CAGE questionnaire. In the Russian sample, past drinking was also assessed.
Results: the odds of physical limitations were highest among non-drinkers, decreased with increasing drinking frequency, annual consumption and average drinking quantity and were not associated with problem drinking. The adjusted odds ratio (OR) of physical limitations in non-drinkers versus regular moderate drinkers was 1.61 (95% confidence interval: 1.48–1.75). In the Russian sample with past drinking available, the adjusted OR in those who stopped drinking for health reasons versus continuing drinkers was 3.19 (2.58–3.95); ORs in lifetime abstainers, former drinkers for non-health reasons and reduced drinkers for health reasons were 1.27 (1.02–1.57), 1.48 (1.18–1.85) and 2.40 (2.05–2.81), respectively.
Conclusion: this study found an inverse association between alcohol consumption and physical limitations. The high odds of physical limitations in non-drinkers can be largely explained by poor health of former drinkers. The apparently protective effect of heavier drinking was partly due to less healthy former heavy drinkers who moved to lower drinking categories.
doi:10.1093/ageing/afu083
PMCID: PMC4255613  PMID: 24982097
ageing; alcohol consumption; Central and Eastern Europe; older people; physical functioning
16.  Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial 
Age and Ageing  2014;43(6):794-800.
Purpose of the study: to examine the costs and cost-effectiveness of ‘second-generation’ telecare, in addition to standard support and care that could include ‘first-generation’ forms of telecare, compared with standard support and care that could include ‘first-generation’ forms of telecare.
Design and methods: a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care.
Primary outcome measure: incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective.
Results: cost per additional QALY was £297,000. Cost-effectiveness acceptability curves indicated that the probability of cost-effectiveness at a willingness-to-pay of £30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of £161,000 per QALY.
Implications: while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs.
Trial registration number: ISRCTN 43002091.
doi:10.1093/ageing/afu067
PMCID: PMC4204660  PMID: 24950690
telecare; economic evaluation; social care; older people
17.  Exploring psychosocial pathways between neighbourhood characteristics and stroke in older adults: the cardiovascular health study 
Age and Ageing  2012;42(3):391-397.
Objectives: to investigate whether psychosocial pathways mediate the association between neighbourhood socioeconomic disadvantage and stroke.
Methods: prospective cohort study with a follow-up of 11.5 years.
Setting: the Cardiovascular Health Study, a longitudinal population-based cohort study of older adults ≥65 years.
Measurements: the primary outcome was adjudicated incident ischaemic stroke. Neighbourhood socioeconomic status (NSES) was measured using a composite of six census-tract variables. Psychosocial factors were assessed with standard measures for depression, social support and social networks.
Results: of the 3,834 white participants with no prior stroke, 548 had an incident ischaemic stroke over the 11.5-year follow-up. Among whites, the incident stroke hazard ratio (HR) associated with living in the lowest relative to highest NSES quartile was 1.32 (95% CI = 1.01–1.73), in models adjusted for individual SES. Additional adjustment for psychosocial factors had a minimal effect on hazard of incident stroke (HR = 1.31, CI = 1.00–1.71). Associations between NSES and stroke incidence were not found among African-Americans (n = 785) in either partially or fully adjusted models.
Conclusions: psychosocial factors played a minimal role in mediating the effect of NSES on stroke incidence among white older adults.
doi:10.1093/ageing/afs179
PMCID: PMC3633364  PMID: 23264005
neighbourhood; psychosocial factors; stroke; older adults
18.  Tumour necrosis factor receptor 1 and mortality in a multi-ethnic cohort: the Northern Manhattan Study 
Age and Ageing  2013;42(3):385-390.
Objective: to study the association between soluble tumour necrosis factor receptor 1 (sTNFR1) levels and mortality in the population-based Northern Manhattan Study (NOMAS).
Methods: NOMAS is a multi-ethnic, community-based cohort study with mean 8.4 years of follow-up. sTNFR1 was measured using ELISA. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals (HR, 95% CI) for the association of sTNFR1 with risk of all-cause mortality after adjusting for relevant confounders.
Results: sTNFR1 measurements were available in 1,862 participants (mean age 69.2 ± 10.2 years) with 512 all-cause deaths. Median sTNFR1 was 2.28 ng/ml. Those with sTNFR1 levels in the highest quartile (Q4), compared with those with sTNFR1 in the lowest quartile (Q1), were at an increased risk of all-cause mortality (adjusted HR: 1.8, 95% CI: 1.4–2.4) and non-vascular mortality (adjusted HR: 2.5, 95% CI: 1.5–3.6), but not vascular mortality (adjusted HR: 1.3, 95% CI: 0.9–1.9). There were interactions between sTNFR1 quartiles and medical insurance-status [likelihood ratio test (LRT) with 3 degrees of freedom, Pinteraction = 0.02] and alcohol consumption (LRT with 3 degrees of freedom, Pinteraction < 0.01) for all-cause mortality. In participants with no insurance or Medicaid, those with sTNFR1 in the top quartile had nearly a threefold increased risk of total mortality than the lowest quartile (adjusted HR: 2.9, 95% CI: 1.9–4.4).
Conclusion: in this multi-ethnic cohort, sTNFR1 was associated with all-cause and non-vascular mortality, particularly among those of a lower socioeconomic status.
doi:10.1093/ageing/afs175
PMCID: PMC3693433  PMID: 23321203
inflammation; insurance status; mortality risk; alcohol use; older people
19.  Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis 
Age and Ageing  2014;43(3):326-333.
Background: delirium affects up to 40% of older hospitalised patients, but there has been no systematic review focussing on risk factors for incident delirium in older medical inpatients. We aimed to synthesise data on risk factors for incident delirium and where possible conduct meta-analysis of these.
Methods: PubMed and Web of Science databases were searched (January 1987–August 2013). Studies were quality rated using the Newcastle-Ottawa Scale. We used the Mantel–Haenszel and inverse variance method to estimate the pooled odds ratio (OR) or mean difference for individual risk factors.
Results: eleven articles met inclusion criteria and were included for review. Total study population 2338 (411 patients with delirium/1927 controls). The commonest factors significantly associated with delirium were dementia, older age, co-morbid illness, severity of medical illness, infection, ‘high-risk’ medication use, diminished activities of daily living, immobility, sensory impairment, urinary catheterisation, urea and electrolyte imbalance and malnutrition. In pooled analyses, dementia (OR 6.62; 95% CI (confidence interval) 4.30, 10.19), illness severity (APACHE II) (MD (mean difference) 3.91; 95% CI 2.22, 5.59), visual impairment (OR 1.89; 95% CI 1.03, 3.47), urinary catheterisation (OR 3.16; 95% CI 1.26, 7.92), low albumin level (MD −3.14; 95% CI −5.99, −0.29) and length of hospital stay (OR 4.85; 95% CI 2.20, 7.50) were statistically significantly associated with delirium.
Conclusion: we identified risk factors consistently associated with incident delirium following admission. These factors help to highlight older acute medical inpatients at risk of developing delirium during their hospital stay.
doi:10.1093/ageing/afu022
PMCID: PMC4001175  PMID: 24610863
delirium; risk factors; older people; hospitalised; medical unit
20.  European undergraduate curriculum in geriatric medicine developed using an international modified Delphi technique 
Age and Ageing  2014;43(5):695-702.
Introduction: the rise in the number of older, frail adults necessitates that future doctors are adequately trained in the skills of geriatric medicine. Few countries have dedicated curricula in geriatric medicine at the undergraduate level. The aim of this project was to develop a consensus among geriatricians on a curriculum with the minimal requirements that a medical student should achieve by the end of medical school.
Methods: a modified Delphi process was used. First, educational experts and geriatricians proposed a set of learning objectives based on a literature review. Second, three Delphi rounds involving a panel with 49 experts representing 29 countries affiliated to the European Union of Medical Specialists (UEMS) was used to gain consensus for a final curriculum.
Results: the number of disagreements following Delphi Rounds 1 and 2 were 81 and 53, respectively. Complete agreement was reached following the third round. The final curriculum consisted of detailed objectives grouped under 10 overarching learning outcomes.
Discussion: a consensus on the minimum requirements of geriatric learning objectives for medical students has been agreed by European geriatricians. Major efforts will be needed to implement these requirements, given the large variation in the quality of geriatric teaching in medical schools. This curriculum is a first step to help improve teaching of geriatrics in medical schools, and will also serve as a basis for advancing postgraduate training in geriatrics across Europe.
doi:10.1093/ageing/afu019
PMCID: PMC4143490  PMID: 24603283
European; undergraduate curriculum; geriatric medicine; consensus; Delphi
21.  Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people 
Age and Ageing  2014;43(4):496-502.
Objective: to evaluate the performance of the 4 ‘A’s Test (4AT) in screening for delirium in older patients. The 4AT is a new test for rapid screening of delirium in routine clinical practice.
Design: prospective study of consecutively admitted elderly patients with independent 4AT and reference standard assessments.
Setting: an acute geriatrics ward and a department of rehabilitation.
Participants: two hundred and thirty-six patients (aged ≥70 years) consecutively admitted over a period of 4 months.
Measurements: in each centre, the 4AT was administered by a geriatrician to eligible patients within 24 h of admission. Reference standard delirium diagnosis (DSM-IV-TR criteria) was obtained within 30 min by a different geriatrician who was blind to the 4AT score. The presence of dementia was assessed using the Alzheimer's Questionnaire and the informant section of the Clinical Dementia Rating scale. The main outcome measure was the accuracy of the 4AT in diagnosing delirium.
Results: patients were 83.9 ± 6.1 years old, and the majority were women (64%). Delirium was detected in 12.3% (n = 29), dementia in 31.2% (n = 74) and a combination of both in 7.2% (n = 17). The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in patients without dementia and 0.89 in patients with dementia.
Conclusions: the 4AT is a sensitive and specific method of screening for delirium in hospitalised older people. Its brevity and simplicity support its use in routine clinical practice.
doi:10.1093/ageing/afu021
PMCID: PMC4066613  PMID: 24590568
delirium; cognitive impairment; screening; geriatrics; dementia; older people; validation; delirium detection; diagnostic accuracy
22.  Objective measurements of daily physical activity patterns and sedentary behaviour in older adults: Age, Gene/Environment Susceptibility-Reykjavik Study 
Age and Ageing  2012;42(2):222-229.
Background: objectively measured population physical activity (PA) data from older persons is lacking. The aim of this study was to describe free-living PA patterns and sedentary behaviours in Icelandic older men and women using accelerometer.
Methods: from April 2009 to June 2010, 579 AGESII-study participants aged 73–98 years wore an accelerometer (Actigraph GT3X) at the right hip for one complete week in the free-living settings.
Results: in all subjects, sedentary time was the largest component of the total wear time, 75%, followed by low-light PA, 21%. Moderate-vigorous PA (MVPA) was <1%. Men had slightly higher average total PA (counts × day−1) than women. The women spent more time in low-light PA but less time in sedentary PA and MVPA compared with men (P < 0.001). In persons <75 years of age, 60% of men and 34% of women had at least one bout ≥10 min of MVPA, which decreased with age, with only 25% of men and 9% of women 85 years and older reaching this.
Conclusion: sedentary time is high in this Icelandic cohort, which has high life-expectancy and is living north of 60° northern latitude.
doi:10.1093/ageing/afs160
PMCID: PMC3575120  PMID: 23117467
physical activity; accelerometry; sedentary behaviour; older adults; BMI; AGES-Reykjavik; older people
23.  The association between life course socioeconomic position and life satisfaction in different welfare states: European comparative study of individuals in early old age 
Age and Ageing  2014;43(3):431-436.
Background: whether socioeconomic position over the life course influences the wellbeing of older people similarly in different societies is not known.
Objective: to investigate the magnitude of socioeconomic inequalities in life satisfaction among individuals in early old age and the influence of the welfare state regime on the associations.
Design: comparative study using data from Wave 2 and SHARELIFE, the retrospective Wave of the Survey of Health, Ageing, and Retirement in Europe (SHARE), collected during 2006–07 and 2008–09, respectively.
Setting: thirteen European countries representing four welfare regimes (Southern, Scandinavian, Post-communist and Bismarckian).
Subjects: a total of 17,697 individuals aged 50–75 years.
Methods: slope indices of inequality (SIIs) were calculated for the association between life course socioeconomic position (measured by the number of books in childhood, education level and current wealth) and life satisfaction. Single level linear regression models stratified by welfare regime and multilevel regression models, containing interaction terms between socioeconomic position and welfare regime type, were calculated.
Results: socioeconomic inequalities in life satisfaction were present in all welfare regimes. Educational inequalities in life satisfaction were narrowest in Scandinavian and Bismarckian regimes among both genders. Post-communist and Southern countries experienced both lower life satisfaction and larger socioeconomic inequalities in life satisfaction, using most measures of socioeconomic position. Current wealth was associated with large inequalities in life satisfaction across all regimes.
Conclusions: Scandinavian and Bismarckian countries exhibited narrower socioeconomic inequalities in life satisfaction. This suggests that more generous welfare states help to produce a more equitable distribution of wellbeing among older people.
doi:10.1093/ageing/afu004
PMCID: PMC4001174  PMID: 24476800
socioeconomic factors; welfare; ageing; satisfaction; quality of life; older people
24.  Association of age at diagnosis and Crohn's disease phenotype 
Age and Ageing  2012;42(1):102-106.
Background: fifteen percent of patients with Crohn’s disease (CD) are elderly; they are less likely to have complications and more likely to have colonic disease.
Objective: to compare disease behaviour in patients with CD based on age at diagnosis.
Design: cross-sectional study.
Setting: tertiary referral centre.
Subjects: patients with confirmed CD.
Methods: behaviour was characterised according to the Montreal classification. Patients with either stricturing or penetrating disease were classified as having complicated disease. Age at diagnosis was categorised as <17, 17–40, 41–59 and ≥60 years. Logistic regression analysis was performed to examine the association between advanced age ≥60 and complicated disease.
Results: a total of 467 patients were evaluated between 2004 and 2010. Increasing age of diagnosis was negatively associated with complicated disease and positively associated with colonic disease. As age of diagnosis increased, disease duration (P < 0.001), family history of Inflammatory bowel disease (IBD) (P = 0.015) and perianal disease decreased (P < 0.0015). After adjustment for confounding variables, the association between age at diagnosis and complicated disease was no longer significant (OR: 0.60, 95% CI: 0.21–1.65).
Conclusions: patients diagnosed with CD ≥60 were more likely to have colonic disease and non-complicated disease. However, the association between age at diagnosis and complicated disease did not persist after adjustment for confounding variables.
doi:10.1093/ageing/afs107
PMCID: PMC3518904  PMID: 22918090
Crohn's disease; aged; phenotype; inflammatory bowel disease; older people
25.  Cognitive screening in the acute stroke setting 
Age and Ageing  2012;42(1):113-116.
Background: current literature suggests that two-thirds of patients will have cognitive impairment at 3 months post-stroke. Post-stroke cognitive impairment is associated with impaired function and increased mortality. UK guidelines recommend all patients with stroke have a cognitive assessment within 6 weeks. There is no ‘gold standard’ cognitive screening tool. The Montreal cognitive assessment (MoCA) is more sensitive than the Mini-Mental State Examination (MMSE) in mild cognitive impairment and for cognitive impairment in the non-acute post-stroke setting and in a Chinese-speaking acute stroke setting.
Methods: a convenience sample of 50 patients, admitted with stroke or transient ischaemic attack (TIA), were screened within 14 days, using the MoCA and the MMSE.
Results: the mean MoCA was 21.80 versus a mean MMSE of 26.98; 70% were impaired on the MoCA (cut-off <26) versus 26% on MMSE (cut-off <27). The MoCA could be completed in <10 min in 90% of cases.
Conclusion: the MoCA is easy and quick to use in the acute stroke setting. Further work is required to determine whether a low score on the MoCA in the acute stroke setting will predict the cognitive and functional status and to explore what the best cut-off should be in an acute post-stroke setting.
doi:10.1093/ageing/afs116
PMCID: PMC3518905  PMID: 22923608
stroke; cognitive impairment; post-stroke dementia; older people

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