Age and ageing最新文献

Objective: Patients with chronic limb-threatening ischaemia (CLTI) are often admitted emergently with significant comorbidity and frailty, and little time for pre-optimisation, resulting in longer hospital stays and worse outcomes. Our unit implemented a POPS (Perioperative Medicine for the Older Person undergoing Surgery) service, incorporating the comprehensive geriatric assessment (CGA) to optimise patients. This study assesses its effect on non-elective CLTI inpatients.

Methods: This is a prospective observational cohort study at a single vascular centre, analysing outcomes in non-elective CLTI patients over three different periods: one year prior to POPS ('Pre-POPS'); during the initial delivery when it was nurse-led ('POPS v1'); and after it became physician-led ('POPS v2'). The primary outcome was length of stay (LoS), with 30-day and 12-month secondary outcomes. Cohorts were compared using propensity-score weighted statistical analysis. Economic analysis was undertaken.

Results: Six hundred and two patients were included. LoS reduced sequentially with greater POPS input (17 days vs. 13 days vs. 11 days, P < .001). There was a significant reduction in 30-day acute kidney injury (33% vs. 37% vs. 8%, P < .001), myocardial infarction (15% vs. 2% vs. 2% P < .001) and hospital-acquired pneumonia (17% vs. 10% vs. 9%, P = .048). Cox survival regression found a reduction in 12-month mortality of 37% for the POPS v1 [HR 0.628 (95% CI 0.481-0.891) P = .013] and 40% for the POPS v2 [HR 0.598 (95% CI 0.431-0.913) P = .001] cohorts, respectively. Economic analysis found that handling more medically complex patients with a shorter LoS negated its operational costs.

Conclusion: A Vascular-POPS collaborative service has resulted in major improvements in LoS, adverse events and survival in this most vulnerable of vascular patient cohorts and is a financially sustainable initiative.

Comorbidities are common in older patients with cancer. The Cumulative Illness Rating Scale for Geriatrics (CIRS-G, developed in 1992) provides a comprehensive assessment of comorbidities and is independently associated with the mortality rate, the hospital admission rate and functional limitations. Although the literature data indicate that the CIRS-G's reliability is good to very good, most of the studies were small and did not include cancer patients. Here, we evaluated the CIRS-G's reliability in a large, prospective cohort of cancer patients aged 70 or over. A stratified, random sample of 150 patients was used to assess inter-rater reliability, and a random sample of 30 patients was evaluated by two investigators to assess intra-rater reliability. For inter-rater reliability, the observed intraclass correlation coefficient (ICC) [95% confidence interval] of 0.53 [0.12-0.74] was substantially lower than the literature values. For intra-rater reliability, the ICC was 0.66 [0.40-0.82] for investigator 1 and 0.77 [0.54-0.89) for investigator 2. These findings suggest that applying the CIRS-G consistently across raters and centres may be challenging in real-world oncology settings for older patients with cancer. Revising the scoring guidelines could help improve its reliability.

Objective: To describe the sociodemographic characteristics and comorbidities of people who died from dementia between 2013 and 2023 in England.

Methods: We analysed death certificates reported in England from 2013 to 2023. We report the number, age, sex, country of origin and socioeconomic status of people who died with a dementia diagnosis recorded (as a primary or contributory cause); the dementia subtype diagnoses and recorded comorbidities. We tested the hypothesis that number of comorbid disorders would be higher in more deprived areas.

Results: There were 987 719 certificates in this period that recorded dementia as a cause of death, of which 693 663 (70.2%) recorded dementia as the primary cause of death. In total, 62.2% (n = 614 419) of those who died from dementia were women, 65% (n = 643 026) were aged 85+, and most (846 584, 85.7%) were born in England. Fifteen percent (n = 149 447) of included death certificates recorded dementia as sole cause of death; others included up to 10 other contributory conditions (median = 1; IQR:1-2), of which influenza and pneumonia (183 203; 18.5%), ischaemic heart diseases (114 871; 11.6%), cancers (107 444; 10.8%), hypertensive diseases (99 517; 10%) and diabetes (98 517; 10%) were the most common. After controlling for age and sex, death certificates of people living in areas with higher deprivation included a higher number of comorbidities (β = -0.04, P < .001).

Conclusions: Policies to reduce inequities in dementia care need to account for the more complex health needs of people with dementia living in more deprived areas towards the end of life.

Purpose: Older adults are commonly restricted of oral intake due to concerns of aspiration. Eating and drinking with acknowledged risks (EDAR) is an alternative pathway that facilitates comfort, dignity and autonomy. However, EDAR decision-making is difficult, with guidance only existing in the UK, and support not readily available. This study was the third in a mixed-methods project aiming to understand how to develop EDAR further whilst providing clinicians with optimal support. This study aimed to reveal the factors that shape confidence in healthcare professionals regarding EDAR decision-making.

Methods: We performed a survey regarding the experiences of healthcare professionals in Japan and the UK with EDAR in older adults. We developed the survey based on themes extracted from our previous qualitative study.

Results: There were 1452 responses (1058 Japanese, 394 UK). Confidence towards EDAR was higher in UK-based respondents (β = 2.358, SE = 0.137, P < .001), with greater years of experience (β = 0.028 per year, SE = 0.005, P < .001), higher rate of clinical work related to EDAR (β = 0.341, SE = 0.022, P < .001), a more involved role in the decision-making, and being clinicians who are not doctors. Similar results were observed regarding likeliness to support EDAR, likeliness to acknowledge perceived benefits, and lower levels of difficulty in undertaking EDAR. Framework (such as guidelines/protocols) and education were ranked to be most beneficial in both countries.

Conclusions: Confidence towards EDAR-decision making was shaped through multiple internal and external factors. Acknowledging these allows us to identify areas in need and provide culturally adapted support, leading to improved experiences in patients, families and healthcare professionals.

Background: Identifying strategies to mitigate age-associated cognitive decline is crucial. High-velocity power training enhances physical function in older adults and cognitive training has mixed cognitive benefits, however the combined effects of these interventions remain uncertain.

Objective: This 18-month cluster randomized controlled trial investigated whether dual-task functional power training (DT-FPT) enhances cognition in older adults and assessed if responses differ by apolipoprotein-E and brain-derived neurotrophic factor (BDNF) polymorphisms.

Subjects and methods: Twenty-two independent-living retirement communities (300 residents, ≥65y at increased falls risk) were randomized to 12-months of group-based DT-FPT (6-months supervised +6-months maintenance, 45-60 minutes, 2/week) performed simultaneously with cognitive and/or motor tasks, followed by 6-months follow-up, or usual care control (CON). Cognitive domains were assessed using CogState at baseline, 6, 12 and 18-months. Z-scores were created to form composites for psychomotor-attention, learning-working memory and global cognition. BDNF and APOE polymorphism data were obtained from blood samples.

Results: Overall, 223 (74%) participants completed the 18-month intervention; mean exercise adherence was 50% at 6-months and 40% at 12-months. Net benefits in choice reaction time and attention (0.17 SD, P = 0.016), psychomotor-attention (0.19 SD, P = 0.029), and a composite of psychomotor-attention, learning-working memory (0.11 SD, P = 0.046) were detected in DT-FPT vs CON after the 6-month supervised phase. At 12 and 18 months, benefits from DT-FPT relative to CON were extended to visual learning (0.29 SD, P = 0.013; 0.27 SD, P = 0.008) and learning-working memory (0.13 SD, P = 0.047; 0.18 SD, P = 0.013). CON exhibited a 0.19 SD net benefit for executive function (P = 0.003) after 18 months. BDNF Met carriers at 18 months showed improved working memory (0.35 SD, P = 0.042) and learning-working memory (0.37 SD, P = 0.011) in DT-FPT versus CON.

Conclusions: In older retirement living residents, DT-FPT may improve cognitive domains critical for functional independence, with genotype potentially influencing these outcomes.Australian New Zealand Clinical Trials Registry (ACTRN12613001161718). This project was funded by the National Health and Medical Research Council (NHMRC) (APP1046267).

Atrial fibrillation (AF) is associated with increased risks of stroke, heart failure and mortality. Rate and rhythm control are used to manage symptoms and improve quality of life, and restoration of normal sinus rhythm is also important for many, but not all, patients. AF is more prevalent in older adults, for whom AF management can be compounded by comorbidities and ongoing conditions, frailty, cognitive issues and polypharmacy. The European Society of Cardiology (ESC) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) recently updated recommendations for AF management, which may have implications for older adults in terms of overarching AF management approach, stroke and bleeding risk assessments and anticoagulation considerations. In addition, guideline recommendations and associated levels of evidence have changed for some interventions, such as left atrial appendage closure and AF ablation. In this guideline commentary, key aspects, changes and recommendations in the 2024 ESC guidelines are discussed in the context of older patients, as well as perspectives on specifically addressing the diverse ageing population in future clinical trials and practice guidelines.

Background: Crisis admissions in dementia care are increasing, often leading to negative outcomes for people with dementia, their informal caregivers and healthcare professionals. Crises arise from a complex interplay of health, behavioural, social and environmental factors.

Objective: This systematic review of qualitative studies, using a meta-ethnographic approach, explores the process leading up to and unfolding during crises.

Methods: Five databases were searched for studies published between January 2000 and September 2023. Study selection involved AI-assisted screening (ASReview), followed by manual review and quality appraisal using the Joanna Briggs Institute checklist. Data synthesis was guided by the Strauss and Corbin qualitative framework.

Results: Nineteen studies, mainly reflecting the perspectives of informal caregivers and healthcare professionals, were included in the analysis. The core phenomenon identified is the mechanism in which professionals, persons with dementia and informal caregivers are constantly balancing between safety and autonomy, triggered by disruptions to a previously stable situation. Two contextual factors influence this process: a proactive, collaborative attitude among healthcare professionals, and a healthcare system that often acts as a push system, limiting flexibility and responsiveness.

Conclusions: These findings highlight the need for collaborative care approaches to prevent or manage crises more effectively, offering valuable insights for practice and policy improvements.

Background: Falls are a major health concern for older adults, affecting one-third of those over 65 years annually, with 10%-20% leading to injury or hospitalisation. Whilst falls are often multifactorial, unexplained falls may overlap with syncope. Orthostatic hypotension (OH), characterised by a significant drop in blood pressure (BP) upon standing, is a potent falls risk factor, likely due to cerebral hypoperfusion. While the association between OH and falls is well established, few studies have examined the combined role of OH and real-time cerebral perfusion measures in predicting future unexplained falls.

Methods: Frontal lobe cerebral oxygenation (Tissue Saturation Index, TSI) was measured using near-infrared spectroscopy alongside continuous beat-to-beat BP monitoring (Finometer) during active standing in 2478 participants (≥55 years) from Wave 3 of The Irish Longitudinal Study on Ageing. OH was defined as a sustained SBP drop ≥20 mmHg and/or DBP drop ≥10 mmHg at 30, 60 or 90 seconds post-standing. A TSI drop ≥75th centile at 30 seconds was classified as 'greater TSI drop.' Associations between TSI change and OH were analysed using multilevel mixed-effects regression, and longitudinal relationships with unexplained falls were assessed over four years.

Results: One-fifth of participants had OH, associated with older age and cardiovascular disease. OH was associated with significantly greater TSI change from baseline at 30, 60 and 90 seconds (p < .001) in adjusted models. The combination of OH and greater TSI drops predicted future unexplained falls (OR 2.16, p = .003), whereas OH and lower TSI drops did not (OR 1.25, p = .288).

Conclusion: The risk of falls associated with OH appears to be modified by the extent of cerebral hypoperfusion upon standing. These findings suggest that integrating cerebral perfusion measures with OH assessment may help refine risk stratification in older adults, particularly for unexplained falls.