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BACKGROUND: Routinely collected health administrative data can be used to estimate the prevalence or incidence of dementia at a population level but can be inaccurate. This study aimed to examine the accuracy of hospital and death data for diagnosing dementia compared with a clinical diagnosis in community dwelling older men in Australia. METHODS: We performed a retrospective analysis of the Concord Health and Ageing in Men Project (CHAMP) in Sydney, Australia. Of the 1705 men aged ≥70 years in the CHAMP study, 1400 had available linked administrative data records from 1 year prior to 1 year post the date of clinical dementia diagnosis. The primary outcome was the accuracy of dementia diagnosis using linked administrative data records compared to clinical dementia diagnosis. The linked data diagnosis was based on hospital and death records for the 1 year pre and post the clinical diagnosis. Clinical dementia diagnosis was a two-stage process with initial screening, followed by clinical assessment for those meeting a validated cut-off. A final clinical diagnosis of dementia based on the Diagnostic and Statistical Manual of Mental Disorders (4th edition) criteria was reached by a consensus panel. RESULTS: Administrative data identified 28 participants as having dementia, compared to 88 identified through clinical assessment. Administrative data had a sensitivity of 20% (95% CI: 13-30%, 18/88), specificity of 99% (95% CI: 99-100%, 1301/1312), positive predictive value (PPV) of 62% (95% CI: 44-77%), negative predictive value of 95% (95% CI: 94-95%), positive likelihood ratio of 24.4 (95% CI: 11.9-50.0) and negative likelihood ratio of 0.80 (0.72-0.89). CONCLUSIONS: Administrative hospital and death data has limited accuracy for dementia diagnosis with poor sensitivity and PPV. The prevalence of dementia is likely underestimated using hospital and deaths data.

Background: To optimise medication use in older people, it is recommended that clinicians evaluate evidence on potential benefits and harms of medicines in light of the patients’ overall health, values and goals. This suggests general practitioners (GPs) should attempt to facilitate patient involvement in decision-making. In practice this is often challenging. In this qualitative study, we explored GPs’ perspectives on the importance of discussing patients’ goals and preferences, and the role patient preferences play in medicines management and prioritisation. Methods: Semi-structured interviews were conducted with GPs from Australia (n = 32). Participants were purposively sampled to recruit GPs with variation in experience level and geographic location. Transcribed audio-recordings of interviews were coded using Framework Analysis. Results: The results showed that most GPs recognised some value in understanding older patients’ goals and preferences regarding their medicines. Most reported some discussions of goals and preferences with patients, but often this was initiated by the patient. Practical barriers were reported such as limited time during busy consultations to discuss issues beyond acute problems. GPs differed on the following main themes: 1) definition and perception of patients’ goals, 2) relationship with the patient, 3) approach to medicines management and prioritisation. We observed that GPs preferred one of three different practice patterns in their approach to patients’ goals in medicines decisions: 1) goals and preferences considered lower priority – ‘Directive’; 2) goals seen as central – ‘Goal-oriented’; 3) goals and preferences considered but not explicitly elicited – ‘Tacit’. Conclusions: This study explores how GPs differ in their approach to eliciting patients’ goals and preferences, and how these differences are operationalised in the context of older adults taking multiple medicines. Although there are challenges in providing care that ali

Background: Perioperative medicine services for older surgical patients are being developed across several countries. This qualitative study aims to explore geriatricians’ perspectives on challenges and opportunities for developing and delivering integrated geriatrics perioperative medicine services. Methods: A qualitative phenomenological semi-structured interview design. All geriatric medicine departments in acute public hospitals across Australia and New Zealand (n = 81) were approached. Interviews were conducted with 38 geriatricians. Data were analysed thematically using a framework approach. Results: Geriatricians identified several system level barriers to developing geriatrics perioperative medicine services. These included lack of funding for staffing, encroaching on existing consultative services, and competing clinical priorities. The key barrier at the healthcare professional level was the current lack of clarity of roles within the perioperative care team. Key facilitators were perceived unmet patient needs, existing support for geriatrician involvement from surgical and anaesthetic colleagues, and the unique skills geriatricians can bring to perioperative care. Despite reporting barriers, geriatricians are contemplating and implementing integrated proactive perioperative medicine services. Geriatricians identified a need to support other specialties gain clinical experience in geriatric medicine and called for pragmatic research to inform service development. Conclusions: Geriatricians perceive several challenges at the system and healthcare professional levels that are impacting current development of geriatrics perioperative medicine services. Yet their strong belief that patient needs can be met with their specialty skills and their high regard for team-based care, has created opportunities to implement innovative multidisciplinary models of care for older surgical patients. The barriers and evidence gaps highlighted in this study may be addressed b

Background: Associations of chronic and intrusive pain with sarcopenia and disability in older men are unclear. Method(s): 1452 community-dwelling men aged >=70 years self-reported chronic pain (pain every day for >=3 months) and intrusive pain (pain interfering with normal activities in the last 4 weeks) at baseline and five years later, and were classified as having no, prevalent (baseline only), incident (follow-up only) or persistent (both baseline and follow-up) pain. Appendicular lean mass (ALM), hand grip strength and gait speed were assessed. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People (EWGSOP2) and Sarcopenia Diagnosis and Outcomes Consortium (SDOC) definitions. Activity of daily living (ADL) and instrumental activity of daily living (IADL) impairment were assessed by questionnaires. Result(s): Approximately 11% of men reported both chronic and intrusive pain. Gait speed, but not ALM or hand grip strength, significantly mediated the relationship of chronic pain and intrusive pain with ADL and IADL disability by 12-57%. Over five years, incident (odds ratio: 1.84; 95% CI: 1.10-3.10) and persistent (3.02; 1.55-5.88) intrusive pain, and persistent chronic pain (2.29; 1.30-4.04), were associated with increased likelihood of incident sarcopenia (SDOC). Incident and persistent intrusive pain were associated with incident ADL (1.91; 1.04-3.52 and 3.78; 1.90-7.51, respectively) and IADL (2.98; 1.81-4.90 and 4.63; 2.22-9.65, respectively) impairment. Conclusion(s): Older men with incident and persistent intrusive pain have increased risk for incident sarcopenia and disability over five years. The association of pain with disability appears to be mediated by gait speed.Copyright © 2021 Elsevier Inc.

Background & aims: Mediterranean dietary patterns may exert favourable effects on various health conditions. This study aimed to determine associations of adherence to Mediterranean diet as well as its components, with circulating cytokine levels, musculoskeletal health and incident falls in community-dwelling older men. Method(s): Seven hundred ninety-four (794) community-dwelling men with mean age 81.1 +/- 4.5 years, who participated in the five-year follow-up of the Concord Health and Ageing in Men Project (CHAMP) were included in the cross-sectional analysis, and 616 attended follow-up three years later. Adherence to Mediterranean diet was assessed using MEDI-LITE (literature-derived Mediterranean diet) score which was obtained using a validated diet history questionnaire. Twenty-four evaluable circulating cytokines were analyzed using Bio-Plex Pro Human Cytokine 27-plex Assay kit. Appendicular lean mass (ALM) and bone mineral density (BMD) were measured using dual-energy x-ray absorptiometry (DXA). Three-year changes in gait speed and hand grip strength were assessed by walking a 6-m course and using a dynamometer respectively and analyzed using linear mixed-effects models. Incident falls over three years were determined through telephone interviews every four months. Multivariable linear regression was utilized to determine the cross-sectional associations between MEDI-LITE scores and circulating cytokines, bone mineral density, ALM, and ALMBMI. Linear mixed-effects models were performed to estimate associations between MEDI-LITE scores and three-year change in hand grip strength and gait speed while negative binomial regression was applied to estimate associations between MEDI-LITE scores and three-year incident falls as well as associations between each MEDI-LITE component and three-year incident falls. Adjustments for multiple comparisons were performed using Benjamini-Hochberg adjustment for multiple testing. Result(s): A higher MEDI-LITE score, indicating

To date, 18 living recommendations for the clinical care of pregnant and postpartum women with COVID-19 have been issued by the National COVID-19 Clinical Evidence Taskforce. This includes recommendations on mode of birth, delayed umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, antenatal corticosteroids, angiotensin-converting enzyme inhibitors, disease-modifying treatments (including dexamethasone, remdesivir and hydroxychloroquine), venous thromboembolism prophylaxis and advanced respiratory support interventions (prone positioning and extracorporeal membrane oxygenation). Through continuous evidence surveillance, these living recommendations are updated in near real-time to ensure clinicians in Australia have reliable, evidence-based guidelines for clinical decision-making. Please visit https://covid19evidence.net.au/ for the latest recommendation updates.Copyright © 2020 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Obstetricians and Gynaecologists

BACKGROUND: Type 2 diabetes mellitus (T2DM) increases falls and fracture risk. Our objective was to compare incidence and risk factors for falls and fractures in community-dwelling older men with and without T2DM. METHOD(S): A total of 1705 men (471 with T2DM; 1234 without T2DM) aged >=70 years were assessed at baseline. Men were contacted every 4 months for 6.0 +/- 2.2 years to ascertain incident falls and fractures, with the latter being confirmed by radiographic reports. Hip fractures were ascertained via data linkage (follow-up: 8.8 +/- 3.6 years). Risk factors for falls and fractures included physical activity and function, body composition, medications, and vision measures. RESULT(S): Men with T2DM had similar fall (incident rate ratio [IRR]: 0.92 [95% confidence interval {CI}: 0.70, 1.12], n = 1246) and fracture rates (hazard ratio [HR]: 0.86 [95% CI: 0.56, 1.32], n = 1326) compared to men without T2DM after adjustment for significant risk factors. In men with T2DM, depression (IRR: 1.87 [95% CI: 1.05, 3.34], n = 333), sulphonylurea usage (IRR: 2.07 [95% CI: 1.30, 3.27]) and a greater number of prescription medications (IRR: 1.13 [95% CI: 1.03, 1.24]) were independently associated with increased fall rates, and higher total hip bone mineral density was independently associated with lower fracture rates (HR: 0.63 [95% CI: 0.47, 0.86], n = 351). Interaction terms demonstrated that better contrast sensitivity was independently associated with lower fracture rates (HR: 0.14 [95% CI: 0.02, 0.87]) in men with T2DM compared to men without T2DM. CONCLUSION(S): Fall and fracture rates were similar in men with and without T2DM after adjusting for significant risk factors. Vision assessments including contrast sensitivity measures may improve fracture prediction in older men with T2DM.Copyright © The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permi

Objective: To investigate associations of sarcopenic obesity with five-year changes in BMD, and six-year incident falls and fractures, among Australian community-dwelling older men. Material(s) and Method(s): 1529 CHAMP participants with complete baseline data for hip, spine and total body DXA (BMD, appendicular lean mass (ALM) and body fat), hand grip strength (HGS) and gait speed were included. 1367 and 958 had DXA at two and five years, respectively. Participants were contacted every 4 months for 6.0+/-2.2 years to ascertain incident falls and fractures (confirmed by radiographic reports). Sarcopenia was defined by European Working Group on Sarcopenia (EWGSOP) and Foundation for the National Institutes of Health (FNIH) algorithms. Obesity was defined as body fat >=30 %. Generalised estimating equations and logistic regression determined associations of sarcopenia and obesity with changes in BMD, falls and fracture adjusting for age, physical activity, smoking, living alone, comorbidity, vitamin D, albumin, haemoglobin, and psychotropic, bisphosphonate and corticosteroid use. Result(s): After multivariate adjustment, ALM was associated with BMD at all sites (beta=0.08; p=0.004). Body fat percentage was associated with hip BMD only (beta=0.01; p<0.001). During follow-up, 51 % of participants reported at least one fall, 26 % had multiple falls, and 10 % had at least one fracture. The likelihood of at least one (beta=-0.87; p=0.004) and multiple (beta=-1.42; p<0.001) falls was reduced with higher gait speed but multiple falls increased with higher body fat percentage (beta=0.03; p=0.03). Higher hip BMD (beta=-4.07; p<0.001), but not body fat or sarcopenia components, was associated with lower likelihood of incident fracture. According to EWGSOP and FNIH definitions, 106 (7 %) and 63 (4 %) participants were sarcopenic obese, respectively. Compared to non-sarcopenic non-obese, EWGSOP-defined sarcopenic obese men had increased likelihood of at least one (odds ratio: 2.0

High-impact physical activities with bone strains of high magnitude and frequency may benefit bone health. This study aimed to investigate the longitudinal associations between changes in loading intensities and application rates, estimated from self-reported physical activity, with bone mineral density (BMD) changes over 5 years and also with incident falls over 2 years and long-term incident fractures in community-dwelling older men. A total of 1599 men (mean age 76.8 +/- 5.4 years) from the Concord Health and Aging in Men Project (CHAMP) were assessed at baseline (2005-2007) and at 2- and 5-year follow-up. At each time point, hip and lumbar spine BMD were measured by dual-energy X-ray absorptiometry, and physical activity energy expenditure over the past week was self-reported via the Physical Activity Scale for the Elderly (PASE) questionnaire. Sum effective load ratings (ELRs) and peak force were estimated from the PASE questionnaire, reflecting the total and highest loading intensity and application rate of physical activities, respectively. Participants were contacted every 4 months over 2 years to self-report falls and over 6.0 +/- 2.2 years for fractures. Hip fractures were ascertained by data linkage for 8.9 +/- 3.6 years. Compared with sum ELR and PASE scores, peak force demonstrated the greatest standardized effect size for BMD maintenance at the spine (beta = 9.77 mg/cm2), total hip (beta = 14.14 mg/cm2), and femoral neck (beta = 13.72 mg/cm2) after adjustment for covariates, including PASE components (all p <.01). Only PASE scores were significantly associated with reduced falls risk (standardized incident rate ratio = 0.90, 95% confidence interval 0.81-1.00, p =.04). All physical activity measures were significantly associated with reduced incident fractures in univariate analyses, but none remained significant after multivariable adjustments. Older men who engaged in physical activity of high and rapid impact maintained higher BMD, while higher energ

BACKGROUND: Type 2 diabetes mellitus (T2DM) increases falls and fracture risk. Our objective was to compare incidence and risk factors for falls and fractures in community-dwelling older men with and without T2DM. METHOD(S): A total of 1,705 men (471 with T2DM; 1234 without T2DM) aged >=70 years were assessed at baseline. Men were contacted every 4 months for 6.0 +/- 2.2 years to ascertain incident falls and fractures, with the latter being confirmed by radiographic reports. Hip fractures were ascertained via data linkage (follow up: 8.8 +/- 3.6 years). Risk factors for falls and fractures included physical activity and function, body composition, medications and vision measures. RESULT(S): Men with T2DM had similar fall (IRR: 0.92 [95%CI: 0.70, 1.12], n=1246) and fracture rates (HR: 0.86 [95%CI: 0.56, 1.32], n=1326) compared to men without T2DM after adjustment for significant risk factors. In men with T2DM, depression (IRR: 1.87 [95%CI: 1.05, 3.34], n=333), sulphonylurea usage (IRR: 2.07 [95%CI: 1.30, 3.27]) and a greater number of prescription medications (IRR: 1.13 [95%CI: 1.03, 1.24]) were independently associated with increased fall rates, and higher total hip BMD was independently associated with lower fracture rates (HR: 0.63 [95%CI: 0.47, 0.86], n=351). Interaction terms demonstrated that better contrast sensitivity was independently associated with lower fracture rates (HR: 0.14 [95%CI: 0.02, 0.87]) in men with T2DM compared to men without T2DM. CONCLUSION(S): Fall and fracture rates were similar in men with and without T2DM after adjusting for significant risk factors. Vision assessments including contrast sensitivity measures may improve fracture prediction in older men with T2DM.Copyright © The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Background: Associations of chronic and intrusive pain with sarcopenia and disability in older men are unclear. Method(s): 1452 community-dwelling men aged >=70 years self-reported chronic pain (pain every day for >=3 months) and intrusive pain (pain interfering with normal activities in the last 4 weeks) at baseline and five years later, and were classified as having no, prevalent (baseline only), incident (follow-up only) or persistent (both baseline and follow-up) pain. Appendicular lean mass (ALM), hand grip strength and gait speed were assessed. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People (EWGSOP2) and Sarcopenia Diagnosis and Outcomes Consortium (SDOC) definitions. Activity of daily living (ADL) and instrumental activity of daily living (IADL) impairment were assessed by questionnaires. Result(s): Approximately 11% of men reported both chronic and intrusive pain. Gait speed, but not ALM or hand grip strength, significantly mediated the relationship of chronic pain and intrusive pain with ADL and IADL disability by 12-57%. Over five years, incident (odds ratio: 1.84; 95% CI: 1.10-3.10) and persistent (3.02; 1.55-5.88) intrusive pain, and persistent chronic pain (2.29; 1.30-4.04), were associated with increased likelihood of incident sarcopenia (SDOC). Incident and persistent intrusive pain were associated with incident ADL (1.91; 1.04-3.52 and 3.78; 1.90-7.51, respectively) and IADL (2.98; 1.81-4.90 and 4.63; 2.22-9.65, respectively) impairment. Conclusion(s): Older men with incident and persistent intrusive pain have increased risk for incident sarcopenia and disability over five years. The association of pain with disability appears to be mediated by gait speed.Copyright © 2021 Elsevier Inc.

Background & aims: Mediterranean dietary patterns may exert favourable effects on various health conditions. This study aimed to determine associations of adherence to Mediterranean diet as well as its components, with circulating cytokine levels, musculoskeletal health and incident falls in community-dwelling older men. Method(s): Seven hundred ninety-four (794) community-dwelling men with mean age 81.1 +/- 4.5 years, who participated in the five-year follow-up of the Concord Health and Ageing in Men Project (CHAMP) were included in the cross-sectional analysis, and 616 attended follow-up three years later. Adherence to Mediterranean diet was assessed using MEDI-LITE (literature-derived Mediterranean diet) score which was obtained using a validated diet history questionnaire. Twenty-four evaluable circulating cytokines were analyzed using Bio-Plex Pro Human Cytokine 27-plex Assay kit. Appendicular lean mass (ALM) and bone mineral density (BMD) were measured using dual-energy x-ray absorptiometry (DXA). Three-year changes in gait speed and hand grip strength were assessed by walking a 6-m course and using a dynamometer respectively and analyzed using linear mixed-effects models. Incident falls over three years were determined through telephone interviews every four months. Multivariable linear regression was utilized to determine the cross-sectional associations between MEDI-LITE scores and circulating cytokines, bone mineral density, ALM, and ALMBMI. Linear mixed-effects models were performed to estimate associations between MEDI-LITE scores and three-year change in hand grip strength and gait speed while negative binomial regression was applied to estimate associations between MEDI-LITE scores and three-year incident falls as well as associations between each MEDI-LITE component and three-year incident falls. Adjustments for multiple comparisons were performed using Benjamini-Hochberg adjustment for multiple testing. Result(s): A higher MEDI-LITE score, indicating

To date, 18 living recommendations for the clinical care of pregnant and postpartum women with COVID-19 have been issued by the National COVID-19 Clinical Evidence Taskforce. This includes recommendations on mode of birth, delayed umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, antenatal corticosteroids, angiotensin-converting enzyme inhibitors, disease-modifying treatments (including dexamethasone, remdesivir and hydroxychloroquine), venous thromboembolism prophylaxis and advanced respiratory support interventions (prone positioning and extracorporeal membrane oxygenation). Through continuous evidence surveillance, these living recommendations are updated in near real-time to ensure clinicians in Australia have reliable, evidence-based guidelines for clinical decision-making. Please visit https://covid19evidence.net.au/ for the latest recommendation updates.Copyright © 2020 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Obstetricians and Gynaecologists

BACKGROUND: Type 2 diabetes mellitus (T2DM) increases falls and fracture risk. Our objective was to compare incidence and risk factors for falls and fractures in community-dwelling older men with and without T2DM. METHOD(S): A total of 1705 men (471 with T2DM; 1234 without T2DM) aged >=70 years were assessed at baseline. Men were contacted every 4 months for 6.0 +/- 2.2 years to ascertain incident falls and fractures, with the latter being confirmed by radiographic reports. Hip fractures were ascertained via data linkage (follow-up: 8.8 +/- 3.6 years). Risk factors for falls and fractures included physical activity and function, body composition, medications, and vision measures. RESULT(S): Men with T2DM had similar fall (incident rate ratio [IRR]: 0.92 [95% confidence interval {CI}: 0.70, 1.12], n = 1246) and fracture rates (hazard ratio [HR]: 0.86 [95% CI: 0.56, 1.32], n = 1326) compared to men without T2DM after adjustment for significant risk factors. In men with T2DM, depression (IRR: 1.87 [95% CI: 1.05, 3.34], n = 333), sulphonylurea usage (IRR: 2.07 [95% CI: 1.30, 3.27]) and a greater number of prescription medications (IRR: 1.13 [95% CI: 1.03, 1.24]) were independently associated with increased fall rates, and higher total hip bone mineral density was independently associated with lower fracture rates (HR: 0.63 [95% CI: 0.47, 0.86], n = 351). Interaction terms demonstrated that better contrast sensitivity was independently associated with lower fracture rates (HR: 0.14 [95% CI: 0.02, 0.87]) in men with T2DM compared to men without T2DM. CONCLUSION(S): Fall and fracture rates were similar in men with and without T2DM after adjusting for significant risk factors. Vision assessments including contrast sensitivity measures may improve fracture prediction in older men with T2DM.Copyright © The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permi

Objective: To investigate associations of sarcopenic obesity with five-year changes in BMD, and six-year incident falls and fractures, among Australian community-dwelling older men. Material(s) and Method(s): 1529 CHAMP participants with complete baseline data for hip, spine and total body DXA (BMD, appendicular lean mass (ALM) and body fat), hand grip strength (HGS) and gait speed were included. 1367 and 958 had DXA at two and five years, respectively. Participants were contacted every 4 months for 6.0+/-2.2 years to ascertain incident falls and fractures (confirmed by radiographic reports). Sarcopenia was defined by European Working Group on Sarcopenia (EWGSOP) and Foundation for the National Institutes of Health (FNIH) algorithms. Obesity was defined as body fat >=30 %. Generalised estimating equations and logistic regression determined associations of sarcopenia and obesity with changes in BMD, falls and fracture adjusting for age, physical activity, smoking, living alone, comorbidity, vitamin D, albumin, haemoglobin, and psychotropic, bisphosphonate and corticosteroid use. Result(s): After multivariate adjustment, ALM was associated with BMD at all sites (beta=0.08; p=0.004). Body fat percentage was associated with hip BMD only (beta=0.01; p<0.001). During follow-up, 51 % of participants reported at least one fall, 26 % had multiple falls, and 10 % had at least one fracture. The likelihood of at least one (beta=-0.87; p=0.004) and multiple (beta=-1.42; p<0.001) falls was reduced with higher gait speed but multiple falls increased with higher body fat percentage (beta=0.03; p=0.03). Higher hip BMD (beta=-4.07; p<0.001), but not body fat or sarcopenia components, was associated with lower likelihood of incident fracture. According to EWGSOP and FNIH definitions, 106 (7 %) and 63 (4 %) participants were sarcopenic obese, respectively. Compared to non-sarcopenic non-obese, EWGSOP-defined sarcopenic obese men had increased likelihood of at least one (odds ratio: 2.0

High-impact physical activities with bone strains of high magnitude and frequency may benefit bone health. This study aimed to investigate the longitudinal associations between changes in loading intensities and application rates, estimated from self-reported physical activity, with bone mineral density (BMD) changes over 5 years and also with incident falls over 2 years and long-term incident fractures in community-dwelling older men. A total of 1599 men (mean age 76.8 +/- 5.4 years) from the Concord Health and Aging in Men Project (CHAMP) were assessed at baseline (2005-2007) and at 2- and 5-year follow-up. At each time point, hip and lumbar spine BMD were measured by dual-energy X-ray absorptiometry, and physical activity energy expenditure over the past week was self-reported via the Physical Activity Scale for the Elderly (PASE) questionnaire. Sum effective load ratings (ELRs) and peak force were estimated from the PASE questionnaire, reflecting the total and highest loading intensity and application rate of physical activities, respectively. Participants were contacted every 4 months over 2 years to self-report falls and over 6.0 +/- 2.2 years for fractures. Hip fractures were ascertained by data linkage for 8.9 +/- 3.6 years. Compared with sum ELR and PASE scores, peak force demonstrated the greatest standardized effect size for BMD maintenance at the spine (beta = 9.77 mg/cm2), total hip (beta = 14.14 mg/cm2), and femoral neck (beta = 13.72 mg/cm2) after adjustment for covariates, including PASE components (all p <.01). Only PASE scores were significantly associated with reduced falls risk (standardized incident rate ratio = 0.90, 95% confidence interval 0.81-1.00, p =.04). All physical activity measures were significantly associated with reduced incident fractures in univariate analyses, but none remained significant after multivariable adjustments. Older men who engaged in physical activity of high and rapid impact maintained higher BMD, while higher energ

BACKGROUND: Type 2 diabetes mellitus (T2DM) increases falls and fracture risk. Our objective was to compare incidence and risk factors for falls and fractures in community-dwelling older men with and without T2DM. METHOD(S): A total of 1,705 men (471 with T2DM; 1234 without T2DM) aged >=70 years were assessed at baseline. Men were contacted every 4 months for 6.0 +/- 2.2 years to ascertain incident falls and fractures, with the latter being confirmed by radiographic reports. Hip fractures were ascertained via data linkage (follow up: 8.8 +/- 3.6 years). Risk factors for falls and fractures included physical activity and function, body composition, medications and vision measures. RESULT(S): Men with T2DM had similar fall (IRR: 0.92 [95%CI: 0.70, 1.12], n=1246) and fracture rates (HR: 0.86 [95%CI: 0.56, 1.32], n=1326) compared to men without T2DM after adjustment for significant risk factors. In men with T2DM, depression (IRR: 1.87 [95%CI: 1.05, 3.34], n=333), sulphonylurea usage (IRR: 2.07 [95%CI: 1.30, 3.27]) and a greater number of prescription medications (IRR: 1.13 [95%CI: 1.03, 1.24]) were independently associated with increased fall rates, and higher total hip BMD was independently associated with lower fracture rates (HR: 0.63 [95%CI: 0.47, 0.86], n=351). Interaction terms demonstrated that better contrast sensitivity was independently associated with lower fracture rates (HR: 0.14 [95%CI: 0.02, 0.87]) in men with T2DM compared to men without T2DM. CONCLUSION(S): Fall and fracture rates were similar in men with and without T2DM after adjusting for significant risk factors. Vision assessments including contrast sensitivity measures may improve fracture prediction in older men with T2DM.Copyright © The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

INTRODUCTION: Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID-19) experience higher rates of critical illness. There are also people who become critically ill with COVID-19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID-19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia. MAIN RECOMMENDATIONS: The panel was tasked with developing two clinical flow charts for the management of people with COVID-19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID-19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease-directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID-19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care. CHANGES IN MANAGEMENT AS RESULT OF THE GUIDELINE: The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID-19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

BACKGROUND: Residential aged care facility (RACF) staff are well placed to identify opportunities for more appropriate prescribing. However, little is known about their views of polypharmacy, deprescribing and specific medications. OBJECTIVE: The objective of this study was to establish the beliefs and attitudes of RACF staff towards polypharmacy and medication use in residents. METHODS: A cross-sectional survey was conducted on RACF staff in metropolitan New South Wales, Australia using a self-administered questionnaire. The questionnaire was drafted based on the available literature and research team expertise and then piloted by a mixed group of 13 RACF staff. The final version of the questionnaire consisted of 28 questions. A total of 38 RACFs were contacted about the study. The questionnaire was distributed to eligible RACF staff between October 2017 and October 2019. The RACF staff were eligible if they provided direct patient care to residents or worked as a facility manager. Participants were excluded if they had insufficient English language skills. The results were presented in two groups, the nursing and care staff, using descriptive statistics. RESULTS: A total of 176 individuals from nine RACFs completed the questionnaire of whom 160 were eligible for study inclusion. Most considered polypharmacy to be five or more different tablets and capsules per day (95% nursing and 82% care staff respectively). A wide range of beliefs about medication use and deprescribing that centred on what constitutes appropriate polypharmacy was identified. Most thought that preventive medications were essential for residents. Most nurses agreed that sleeping tablets and pharmacological management of verbal aggression and wandering behaviours should be used less frequently whilst most care staff agreed that medications should be used more frequently to manage physical aggression. CONCLUSIONS: To successfully and sustainably optimise medication use in RACF residents, it is impo

INTRODUCTION: Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID-19) experience higher rates of critical illness. There are also people who become critically ill with COVID-19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID-19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia. MAIN RECOMMENDATIONS: The panel was tasked with developing two clinical flow charts for the management of people with COVID-19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID-19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease-directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID-19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care. CHANGES IN MANAGEMENT AS RESULT OF THE GUIDELINE: The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID-19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

BACKGROUND: Residential aged care facility (RACF) staff are well placed to identify opportunities for more appropriate prescribing. However, little is known about their views of polypharmacy, deprescribing and specific medications. OBJECTIVE: The objective of this study was to establish the beliefs and attitudes of RACF staff towards polypharmacy and medication use in residents. METHODS: A cross-sectional survey was conducted on RACF staff in metropolitan New South Wales, Australia using a self-administered questionnaire. The questionnaire was drafted based on the available literature and research team expertise and then piloted by a mixed group of 13 RACF staff. The final version of the questionnaire consisted of 28 questions. A total of 38 RACFs were contacted about the study. The questionnaire was distributed to eligible RACF staff between October 2017 and October 2019. The RACF staff were eligible if they provided direct patient care to residents or worked as a facility manager. Participants were excluded if they had insufficient English language skills. The results were presented in two groups, the nursing and care staff, using descriptive statistics. RESULTS: A total of 176 individuals from nine RACFs completed the questionnaire of whom 160 were eligible for study inclusion. Most considered polypharmacy to be five or more different tablets and capsules per day (95% nursing and 82% care staff respectively). A wide range of beliefs about medication use and deprescribing that centred on what constitutes appropriate polypharmacy was identified. Most thought that preventive medications were essential for residents. Most nurses agreed that sleeping tablets and pharmacological management of verbal aggression and wandering behaviours should be used less frequently whilst most care staff agreed that medications should be used more frequently to manage physical aggression. CONCLUSIONS: To successfully and sustainably optimise medication use in RACF residents, it is impo

Background: Obese older adults have higher bone mineral density (BMD), but other characteristics of obesity may predispose these individuals to fracture. We aimed to compare clinical risk factors for incident fracture in obese and non-obese older men. Method(s): Body mass index (BMI) and body fat percentage were assessed at baseline by anthropometry and dual-energy X-ray absorptiometry, respectively, in 1625 community-dwelling men aged >=70 years. Categories for non-obese and obese were <30 kg/m2and >=30 kg/m2 for BMI, and <30% and >=30% for body fat percentage. Sociodemographic, medical, physical function and blood biochemistry parameters were collected at baseline. Self-reported incident fractures of any type and cause (excluding pathological fractures and fractures of hands, fingers, feet, toes and the skull) were confirmed by radiographic reports and recorded up to 9 years. Hip fractures were followed for 14 years using data linkage. Result(s): Prevalence of obesity was 27% according to BMI and 44% according to body fat percentage. There were no differences in incidence of any fracture between non-obese and obese men by BMI (10.7 vs 9.3%, respectively; P > 0.05) or body fat percentage (10.2 vs 10.6%, respectively; P > 0.05). Significant interactions were observed demonstrating that dementia increased hazard for incident any and hip fracture in non-obese men (adjusted hazard ratio 7.08; 95% CI 3.27-15.36 and 8.36; 3.13-22.31, respectively) but not obese men. Past-year falls increased hazard for any fracture in obese men (2.86; 95% CI 1.60-5.10) but not non-obese men while higher luteinizing hormone concentrations reduced hazard for hip fracture in obese men (0.91; 0.85-0.97 per IU/L) but not non-obese men. Conclusion(s): In community-dwelling older men, obesity does not protect against incident fracture. Assessments of falls history and gonadotrophin levels, in addition to established clinical risk factors for fracture, may contribute to improvements in fracture

BACKGROUND: It is unclear whether older men with osteopenia/osteoporosis and sarcopenia (so-called osteosarcopenia) are at greater risk of falls and fractures than those with either condition alone. METHOD(S): One thousand five hundred seventy-five community-dwelling men aged >=70 years had appendicular lean mass, total hip and lumbar spine bone mineral density determined by dual-energy x-ray absorptiometry, and completed hand grip strength and gait speed tests. Osteopenia/osteoporosis was defined as a T-score at any site <=-1.0 SD. Sarcopenia was defined using the European Working Group on Sarcopenia algorithm. Participants were contacted every 4 months for 6 +/- 2 years to ascertain incident fractures (confirmed by radiographic reports) and for 2 years for incident falls. RESULT(S): Prevalence of osteosarcopenia was 8%, while 34% of participants had osteopenia/osteoporosis alone and 7% had sarcopenia alone. Men with osteosarcopenia had significantly increased fall (incidence rate ratio: 1.41; 95% confidence interval [CI]: 1.02 to 1.95) and fracture risk (hazard ratio: 1.87; 95% CI: 1.07 to 3.26) compared with men with neither osteopenia/osteoporosis nor sarcopenia. There was no statistical interaction between osteopenia/osteoporosis and sarcopenia, and falls and fracture risk were not different for osteosarcopenia compared with either condition alone (all p > .05). CONCLUSION(S): Community-dwelling older men with combined osteopenia/osteoporosis and sarcopenia do not have increased falls and fracture risk compared with those with either condition. Further research is required to clarify whether the term "osteosarcopenia" has any meaning above and beyond either term alone and therefore potential clinical utility for falls and fracture prediction.Copyright © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Background: The relations between diet, chronic inflammation, and musculoskeletal health are unclear, especially among older men. Objective(s): This study aimed to determine associations of the Dietary Inflammatory Index (DII) with inflammatory biomarkers, musculoskeletal health, and falls risk in community-dwelling older men. Method(s): The cross-sectional analysis included 794 community-dwelling men, mean age 81.1 +/- 4.5 y, who participated in the 5-y follow-up of the Concord Health and Aging in Men Project. Of these, 616 were seen again 3 y later for the longitudinal analysis. Energy-adjusted DII (E-DII) was calculated from a validated diet history questionnaire. Bone mineral density (BMD) was measured using DXA. Twenty-four inflammatory biomarkers were analyzed. Incident falls over 3 y were determined through telephone interviews every 4 mo. Multiple regression, linear mixed effects models, negative binomial regression, and mediation analysis were utilized in this study. Result(s): A higher E-DII score (indicating a more proinflammatory diet) was associated with higher concentrations of IL-6 (beta: 0.028 pg/mL; 95% CI: 0.003, 0.053), IL-7 (beta: 0.020 pg/mL; 95% CI: 0.002, 0.037), and TNF-alpha (beta: 0.027 pg/mL; 95% CI: 0.003, 0.051). A higher E-DII score was also associated with lower appendicular lean mass adjusted for BMI (ALMBMI) (beta: -0.006 kg/m2; 95% CI: -0.010, -0.001). For every unit increase in E-DII (range: -4.91 to +3.66 units), incident falls rates increased by 13% (incidence rate ratio: 1.13; 95% CI: 1.05, 1.21) over 3 y. Mediation analysis showed that the association between E-DII and 3-y incident falls was influenced by the concentrations of IL-7 by 24%. There was no association between E-DII and BMD. Conclusion(s): Consumption of a proinflammatory diet was associated with increased concentrations of IL-6, IL-7, and TNF-alpha; increased falls risk; and lower ALMBMI in community-dwelling older men. The association between incident falls and E

BACKGROUND: Weight loss increases fracture risk in older adults. We aimed to determine associations of 2-year body composition trajectories with subsequent falls and fractures in older men. METHOD(S): We measured appendicular lean mass (ALM) and total fat mass (FM) by dual-energy X-ray absorptiometry at baseline and Year 2 in 1,326 community-dwelling men aged >=70 and older. Body composition trajectories were determined from residuals of a linear regression of change in ALM on change in FM (higher values indicate maintenance of ALM over FM), and a categorical variable for change in ALM and FM (did not lose [>=-5% change] versus lost [<-5% change]). Bone mineral density (BMD), hand grip strength, and gait speed were assessed at Years 2 and 5. After Year 2, incident fractures (confirmed by radiographical reports) and falls were recorded for 6.8 years. RESULT(S): Compared with men who did not lose ALM or FM, men who did not lose ALM but lost FM, and men who lost both ALM and FM, had reduced falls (-24% and -34%, respectively; both p < .05). Men who lost ALM but did not lose FM had increased falls (incidence rate ratio = 1.73; 95% CI 1.37-2.18). ALM/FM change residuals were associated with improved lumbar spine BMD (B = 0.007; 95% CI 0.002-0.012 g/cm2 per SD increase) and gait speed (0.015; 0.001-0.029 m/s), and reduced hip fractures (hazard ratio = 0.68; 95% CI 0.47-0.99). CONCLUSION(S): Fracture risk may be increased in older men who lose higher ALM relative to FM. Weight loss interventions for obese older men should target maintenance of lean mass.Copyright © The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Background: Obese older adults have higher bone mineral density (BMD), but other characteristics of obesity may predispose these individuals to fracture. We aimed to compare clinical risk factors for incident fracture in obese and non-obese older men. Method(s): Body mass index (BMI) and body fat percentage were assessed at baseline by anthropometry and dual-energy X-ray absorptiometry, respectively, in 1625 community-dwelling men aged >=70 years. Categories for non-obese and obese were <30 kg/m2and >=30 kg/m2 for BMI, and <30% and >=30% for body fat percentage. Sociodemographic, medical, physical function and blood biochemistry parameters were collected at baseline. Self-reported incident fractures of any type and cause (excluding pathological fractures and fractures of hands, fingers, feet, toes and the skull) were confirmed by radiographic reports and recorded up to 9 years. Hip fractures were followed for 14 years using data linkage. Result(s): Prevalence of obesity was 27% according to BMI and 44% according to body fat percentage. There were no differences in incidence of any fracture between non-obese and obese men by BMI (10.7 vs 9.3%, respectively; P > 0.05) or body fat percentage (10.2 vs 10.6%, respectively; P > 0.05). Significant interactions were observed demonstrating that dementia increased hazard for incident any and hip fracture in non-obese men (adjusted hazard ratio 7.08; 95% CI 3.27-15.36 and 8.36; 3.13-22.31, respectively) but not obese men. Past-year falls increased hazard for any fracture in obese men (2.86; 95% CI 1.60-5.10) but not non-obese men while higher luteinizing hormone concentrations reduced hazard for hip fracture in obese men (0.91; 0.85-0.97 per IU/L) but not non-obese men. Conclusion(s): In community-dwelling older men, obesity does not protect against incident fracture. Assessments of falls history and gonadotrophin levels, in addition to established clinical risk factors for fracture, may contribute to improvements in fracture

BACKGROUND: It is unclear whether older men with osteopenia/osteoporosis and sarcopenia (so-called osteosarcopenia) are at greater risk of falls and fractures than those with either condition alone. METHOD(S): One thousand five hundred seventy-five community-dwelling men aged >=70 years had appendicular lean mass, total hip and lumbar spine bone mineral density determined by dual-energy x-ray absorptiometry, and completed hand grip strength and gait speed tests. Osteopenia/osteoporosis was defined as a T-score at any site <=-1.0 SD. Sarcopenia was defined using the European Working Group on Sarcopenia algorithm. Participants were contacted every 4 months for 6 +/- 2 years to ascertain incident fractures (confirmed by radiographic reports) and for 2 years for incident falls. RESULT(S): Prevalence of osteosarcopenia was 8%, while 34% of participants had osteopenia/osteoporosis alone and 7% had sarcopenia alone. Men with osteosarcopenia had significantly increased fall (incidence rate ratio: 1.41; 95% confidence interval [CI]: 1.02 to 1.95) and fracture risk (hazard ratio: 1.87; 95% CI: 1.07 to 3.26) compared with men with neither osteopenia/osteoporosis nor sarcopenia. There was no statistical interaction between osteopenia/osteoporosis and sarcopenia, and falls and fracture risk were not different for osteosarcopenia compared with either condition alone (all p > .05). CONCLUSION(S): Community-dwelling older men with combined osteopenia/osteoporosis and sarcopenia do not have increased falls and fracture risk compared with those with either condition. Further research is required to clarify whether the term "osteosarcopenia" has any meaning above and beyond either term alone and therefore potential clinical utility for falls and fracture prediction.Copyright © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Background: The relations between diet, chronic inflammation, and musculoskeletal health are unclear, especially among older men. Objective(s): This study aimed to determine associations of the Dietary Inflammatory Index (DII) with inflammatory biomarkers, musculoskeletal health, and falls risk in community-dwelling older men. Method(s): The cross-sectional analysis included 794 community-dwelling men, mean age 81.1 +/- 4.5 y, who participated in the 5-y follow-up of the Concord Health and Aging in Men Project. Of these, 616 were seen again 3 y later for the longitudinal analysis. Energy-adjusted DII (E-DII) was calculated from a validated diet history questionnaire. Bone mineral density (BMD) was measured using DXA. Twenty-four inflammatory biomarkers were analyzed. Incident falls over 3 y were determined through telephone interviews every 4 mo. Multiple regression, linear mixed effects models, negative binomial regression, and mediation analysis were utilized in this study. Result(s): A higher E-DII score (indicating a more proinflammatory diet) was associated with higher concentrations of IL-6 (beta: 0.028 pg/mL; 95% CI: 0.003, 0.053), IL-7 (beta: 0.020 pg/mL; 95% CI: 0.002, 0.037), and TNF-alpha (beta: 0.027 pg/mL; 95% CI: 0.003, 0.051). A higher E-DII score was also associated with lower appendicular lean mass adjusted for BMI (ALMBMI) (beta: -0.006 kg/m2; 95% CI: -0.010, -0.001). For every unit increase in E-DII (range: -4.91 to +3.66 units), incident falls rates increased by 13% (incidence rate ratio: 1.13; 95% CI: 1.05, 1.21) over 3 y. Mediation analysis showed that the association between E-DII and 3-y incident falls was influenced by the concentrations of IL-7 by 24%. There was no association between E-DII and BMD. Conclusion(s): Consumption of a proinflammatory diet was associated with increased concentrations of IL-6, IL-7, and TNF-alpha; increased falls risk; and lower ALMBMI in community-dwelling older men. The association between incident falls and E

BACKGROUND: Weight loss increases fracture risk in older adults. We aimed to determine associations of 2-year body composition trajectories with subsequent falls and fractures in older men. METHOD(S): We measured appendicular lean mass (ALM) and total fat mass (FM) by dual-energy X-ray absorptiometry at baseline and Year 2 in 1,326 community-dwelling men aged >=70 and older. Body composition trajectories were determined from residuals of a linear regression of change in ALM on change in FM (higher values indicate maintenance of ALM over FM), and a categorical variable for change in ALM and FM (did not lose [>=-5% change] versus lost [<-5% change]). Bone mineral density (BMD), hand grip strength, and gait speed were assessed at Years 2 and 5. After Year 2, incident fractures (confirmed by radiographical reports) and falls were recorded for 6.8 years. RESULT(S): Compared with men who did not lose ALM or FM, men who did not lose ALM but lost FM, and men who lost both ALM and FM, had reduced falls (-24% and -34%, respectively; both p < .05). Men who lost ALM but did not lose FM had increased falls (incidence rate ratio = 1.73; 95% CI 1.37-2.18). ALM/FM change residuals were associated with improved lumbar spine BMD (B = 0.007; 95% CI 0.002-0.012 g/cm2 per SD increase) and gait speed (0.015; 0.001-0.029 m/s), and reduced hip fractures (hazard ratio = 0.68; 95% CI 0.47-0.99). CONCLUSION(S): Fracture risk may be increased in older men who lose higher ALM relative to FM. Weight loss interventions for obese older men should target maintenance of lean mass.Copyright © The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Introduction It is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a randomised controlled trial (RCT) to examine if ACP undertaken with patients with advanced illnesses attending hospital outpatient clinics can reduce unplanned hospital admissions and improve patient and caregiver well-being.Methods and analysis Pragmatic RCT involving patients from subspecialty outpatient clinics at five clinical sites in Sydney, Australia. Participants will be >=18 years screened as potentially having palliative care needs and at risk of dying in 6–12 months. The patients will be randomised to intervention or control group. Intervention group will undertake ACP discussions facilitated by a trained health professional. The control group will receive written information on ACP, representing the current standard of care. The primary outcome is the number of unplanned hospital admissions at the 6-month follow-up. Secondary outcomes include: (i) patient’s health-related quality-of-life and quality of chronic disease care; (ii) caregiver’s health-related quality-of-life and caregiver burden and (iii) other health outcomes including ambulance usage, emergency department presentations, hospital admissions, resuscitation attempts, intensive care unit admissions, deaths, documentation of patient wishes in patient records and audit of ACP discussions and documents. The staff’s self-reported attitudes and knowledge of ACP will also be measured. The data will be collected using self-report questionnaires, hospital records audit, audit of ACP documentation and data linkage analysis. Semistructured interviews and focus group discussions with patients, caregivers and healthcare professionals will explore the acceptability and feasibility of the intervention.Ethics and dissemination Approved by South-East Sydney Local Health District Human Research Ethic

INTRODUCTION: It is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a randomised controlled trial (RCT) to examine if ACP undertaken with patients with advanced illnesses attending hospital outpatient clinics can reduce unplanned hospital admissions and improve patient and caregiver well-being. METHODS AND ANALYSIS: Pragmatic RCT involving patients from subspecialty outpatient clinics at five clinical sites in Sydney, Australia. Participants will be ≥18 years screened as potentially having palliative care needs and at risk of dying in 6-12 months. The patients will be randomised to intervention or control group. Intervention group will undertake ACP discussions facilitated by a trained health professional. The control group will receive written information on ACP, representing the current standard of care. The primary outcome is the number of unplanned hospital admissions at the 6-month follow-up. Secondary outcomes include: (i) patient's health-related quality-of-life and quality of chronic disease care; (ii) caregiver's health-related quality-of-life and caregiver burden and (iii) other health outcomes including ambulance usage, emergency department presentations, hospital admissions, resuscitation attempts, intensive care unit admissions, deaths, documentation of patient wishes in patient records and audit of ACP discussions and documents. The staff's self-reported attitudes and knowledge of ACP will also be measured. The data will be collected using self-report questionnaires, hospital records audit, audit of ACP documentation and data linkage analysis. Semistructured interviews and focus group discussions with patients, caregivers and healthcare professionals will explore the acceptability and feasibility of the intervention. ETHICS AND DISSEMINATION: Approved by South-East Sydney Local Health District Human Research E

© Author(s) (or their employer(s)) 2019. Introduction It is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a randomised controlled trial (RCT) to examine if ACP undertaken with patients with advanced illnesses attending hospital outpatient clinics can reduce unplanned hospital admissions and improve patient and caregiver well-being. Methods and analysis Pragmatic RCT involving patients from subspecialty outpatient clinics at five clinical sites in Sydney, Australia. Participants will be ≥18 years screened as potentially having palliative care needs and at risk of dying in 6-12 months. The patients will be randomised to intervention or control group. Intervention group will undertake ACP discussions facilitated by a trained health professional. The control group will receive written information on ACP, representing the current standard of care. The primary outcome is the number of unplanned hospital admissions at the 6-month follow-up. Secondary outcomes include: (i) patient's health-related quality-of-life and quality of chronic disease care; (ii) caregiver's health-related quality-of-life and caregiver burden and (iii) other health outcomes including ambulance usage, emergency department presentations, hospital admissions, resuscitation attempts, intensive care unit admissions, deaths, documentation of patient wishes in patient records and audit of ACP discussions and documents. The staff's self-reported attitudes and knowledge of ACP will also be measured. The data will be collected using self-report questionnaires, hospital records audit, audit of ACP documentation and data linkage analysis. Semistructured interviews and focus group discussions with patients, caregivers and healthcare professionals will explore the acceptability and feasibility of the intervention. Ethics and dissemination Approved by South-East Sydney

Purpose: Previous cross-sectional studies investigating associations of sarcopenic obesity with metabolic syndrome (MetS) and insulin resistance have not utilised consensus definitions of sarcopenia. We aimed to determine associations of sarcopenic obesity with MetS and insulin resistance over five years in community-dwelling older men. Method(s): 1231 men aged >=70 years had appendicular lean mass (ALM) and body fat percentage assessed by dual-energy X-ray absorptiometry and hand grip strength and gait speed tests. Sarcopenia was defined as low ALM/height (m2) and low hand grip strength or gait speed (European Working Group definition); obesity was defined as body fat percentage >=30%. MetS was assessed at baseline and 5-years later. Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) was assessed at 5-years only. Result(s): Men with sarcopenic obesity (odds ratio, 95% CI: 2.07, 1.21-3.55) and non-sarcopenic obesity (4.19, 3.16-5.57) had higher MetS likelihood than those with non-sarcopenic non-obesity at baseline. Higher gait speed predicted lower odds for prevalent MetS (0.45, 0.21-0.96 per m/s). Higher body fat predicted increased odds for prevalent and incident MetS (1.14, 1.11-1.17 and 1.11, 1.02-1.20 per kg, respectively) and deleterious 5-year changes in MetS fasting glucose, high-density lipoprotein cholesterol and triglycerides (all P < 0.05). Compared with non-sarcopenic non-obesity, estimated marginal means for HOMA-IR at 5-years were higher in non-sarcopenic obesity only (1.0, 0.8-1.1 vs 1.3, 1.2-1.5; P < 0.001). Similar results were observed when sarcopenic obesity was defined by waist circumference. Conclusion(s): Sarcopenic obesity does not appear to confer greater risk for incident MetS or insulin resistance than obesity alone in community-dwelling older men.Copyright © 2018 Elsevier Inc.

Purpose: Previous cross-sectional studies investigating associations of sarcopenic obesity with metabolic syndrome (MetS) and insulin resistance have not utilised consensus definitions of sarcopenia. We aimed to determine associations of sarcopenic obesity with MetS and insulin resistance over five years in community-dwelling older men. Method(s): 1231 men aged >=70 years had appendicular lean mass (ALM) and body fat percentage assessed by dual-energy X-ray absorptiometry and hand grip strength and gait speed tests. Sarcopenia was defined as low ALM/height (m2) and low hand grip strength or gait speed (European Working Group definition); obesity was defined as body fat percentage >=30%. MetS was assessed at baseline and 5-years later. Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) was assessed at 5-years only. Result(s): Men with sarcopenic obesity (odds ratio, 95% CI: 2.07, 1.21-3.55) and non-sarcopenic obesity (4.19, 3.16-5.57) had higher MetS likelihood than those with non-sarcopenic non-obesity at baseline. Higher gait speed predicted lower odds for prevalent MetS (0.45, 0.21-0.96 per m/s). Higher body fat predicted increased odds for prevalent and incident MetS (1.14, 1.11-1.17 and 1.11, 1.02-1.20 per kg, respectively) and deleterious 5-year changes in MetS fasting glucose, high-density lipoprotein cholesterol and triglycerides (all P < 0.05). Compared with non-sarcopenic non-obesity, estimated marginal means for HOMA-IR at 5-years were higher in non-sarcopenic obesity only (1.0, 0.8-1.1 vs 1.3, 1.2-1.5; P < 0.001). Similar results were observed when sarcopenic obesity was defined by waist circumference. Conclusion(s): Sarcopenic obesity does not appear to confer greater risk for incident MetS or insulin resistance than obesity alone in community-dwelling older men.Copyright © 2018 Elsevier Inc.

© 2018 AJA Inc. Falls in hospital are common and up to 70% result in injury, leading to increased length of stay and accounting for 10% of patient safety-related deaths. Yet, high-quality evidence guiding best practice is lacking. Fall prevention strategies have worked in some trials but not in others. Differences in study setting (acute, subacute, rehabilitation) and sampling of patients (cognitively intact or impaired) may explain the difference in results. This article discusses these important issues and describes the strategies to prevent falls in the acute hospital setting we have studied, which engage the cognitively impaired who are more likely to fall. We have used video clips rather than verbal instruction to educate patients, and are optimistic that this approach may work. We have also explored the option of co-locating high fall risk patients in a close observation room for supervision, with promising results. Further studies, using larger sample sizes are required to confirm our findings.

© 2018 AJA Inc. Falls in hospital are common and up to 70% result in injury, leading to increased length of stay and accounting for 10% of patient safety-related deaths. Yet, high-quality evidence guiding best practice is lacking. Fall prevention strategies have worked in some trials but not in others. Differences in study setting (acute, subacute, rehabilitation) and sampling of patients (cognitively intact or impaired) may explain the difference in results. This article discusses these important issues and describes the strategies to prevent falls in the acute hospital setting we have studied, which engage the cognitively impaired who are more likely to fall. We have used video clips rather than verbal instruction to educate patients, and are optimistic that this approach may work. We have also explored the option of co-locating high fall risk patients in a close observation room for supervision, with promising results. Further studies, using larger sample sizes are required to confirm our findings.

Aims: To investigate associations of sarcopenic obesity with incident falls and fractures among Australian community-dwelling older men. Method(s): 1486 CHAMP participants (mean +/- SD age: 76.6 +/- 5.3 y) with complete baseline data for whole-body DXA (appendicular lean mass [ALM] and body fat percentage), hand grip strength (HGS) and gait speed were included. Participants were contacted every 4 months following baseline for mean 6.1+/-2.1 y to ascertain incident falls and fractures (confirmed by radiographic reports). Sarcopenia was defined by both the European Working Group on Sarcopenia (EWGSOP) and Foundation for the National Institutes of Health (FNIH) algorithms. Obesity was defined as body fat >=30 %. Univariable and multivariable binary logistic regression, negative binomial regression and survival analyses determined associations of sarcopenic obesity with incident falls and fracture adjusting for age, living alone, smoking status, physical activity, psychotropic and corticosteroid use, self-reported chronic pain and health, number of comorbidities, and serum 25OHD, haemoglobin and albumin levels. Result(s): 51 % of men reported at least one fall and 26 % reported multiple falls. Sarcopenic obese men according to the EWGSOP definition had over two-fold higher likelihood of being a faller (odds ratio: 2.05; 95%CI: 1.24, 3.39) or multiple faller (2.46; 1.51, 4.01) compared to non-sarcopenic non-obese, but FNIH-defined sarcopenic obesity was not associated with falls or multiple falls (both P>0.05). Similarly, the highest rates for falls were observed for EWGSOP-defined sarcopenic obese (incidence rate ratio 2.49; 95%CI: 1.89, 3.29 compared to non-sarcopenic non-obese) but, according to the FNIH definition, the highest rate of falls was observed for sarcopenic non-obese men (1.38; 1.08, 1.77). 152 (10 %) participants sustained a fracture during follow-up. There was a shorter time to first fracture for men with EWGSOP-defined sarcopenic obesity (mean: 7.6; 95%

Body composition and muscle function have important implications for falls and fractures in older adults. We aimed to investigate longitudinal associations between sarcopenic obesity and its components with bone mineral density (BMD) and incident falls and fractures in Australian community-dwelling older men. A total of 1486 men aged >=70 years from the Concord Health and Ageing in Men Project (CHAMP) study were assessed at baseline (2005-2007), 2-year follow-up (2007-2009; n = 1238), and 5-year follow-up (2010-2013; n = 861). At all three time points, measurements included appendicular lean mass (ALM), body fat percentage and total hip BMD, hand-grip strength, and gait speed. Participants were contacted every 4 months for 6.1 +/- 2.1 years to ascertain incident falls and fractures, the latter being confirmed by radiographic reports. Sarcopenic obesity was defined using sarcopenia algorithms of the European Working Group on Sarcopenia (EWGSOP) and the Foundation for the National Institutes of Health (FNIH) and total body fat >=30% of total mass. Sarcopenic obese men did not have significantly different total hip BMD over 5 years compared with non-sarcopenic non-obese men (p > 0.05). EWGSOP-defined sarcopenic obesity at baseline was associated with significantly higher 2-year fall rates (incidence rate ratio [IRR] 1.66; 95% confidence interval [CI] 1.16-2.37), as were non-sarcopenic obesity (1.30; 1.04-1.62) and sarcopenic non-obesity (1.58; 1.14-2.17), compared with non-sarcopenic non-obese. No association with falls was found for sarcopenic obesity using the FNIH definition (1.01; 0.63-1.60), but after multivariable adjustment, the FNIH-defined non-sarcopenic obese group had a reduced hazard for any 6-year fracture compared with sarcopenic obese men (hazard ratio 0.44; 95% CI 0.23-0.86). In older men, EWGSOP-defined sarcopenic obesity is associated with increased fall rates over 2 years, and FNIH-defined sarcopenic obese men have increased fracture risk over 6 year

Aims: To investigate associations of sarcopenic obesity with incident falls and fractures among Australian community-dwelling older men. Method(s): 1486 CHAMP participants (mean +/- SD age: 76.6 +/- 5.3 y) with complete baseline data for whole-body DXA (appendicular lean mass [ALM] and body fat percentage), hand grip strength (HGS) and gait speed were included. Participants were contacted every 4 months following baseline for mean 6.1+/-2.1 y to ascertain incident falls and fractures (confirmed by radiographic reports). Sarcopenia was defined by both the European Working Group on Sarcopenia (EWGSOP) and Foundation for the National Institutes of Health (FNIH) algorithms. Obesity was defined as body fat >=30 %. Univariable and multivariable binary logistic regression, negative binomial regression and survival analyses determined associations of sarcopenic obesity with incident falls and fracture adjusting for age, living alone, smoking status, physical activity, psychotropic and corticosteroid use, self-reported chronic pain and health, number of comorbidities, and serum 25OHD, haemoglobin and albumin levels. Result(s): 51 % of men reported at least one fall and 26 % reported multiple falls. Sarcopenic obese men according to the EWGSOP definition had over two-fold higher likelihood of being a faller (odds ratio: 2.05; 95%CI: 1.24, 3.39) or multiple faller (2.46; 1.51, 4.01) compared to non-sarcopenic non-obese, but FNIH-defined sarcopenic obesity was not associated with falls or multiple falls (both P>0.05). Similarly, the highest rates for falls were observed for EWGSOP-defined sarcopenic obese (incidence rate ratio 2.49; 95%CI: 1.89, 3.29 compared to non-sarcopenic non-obese) but, according to the FNIH definition, the highest rate of falls was observed for sarcopenic non-obese men (1.38; 1.08, 1.77). 152 (10 %) participants sustained a fracture during follow-up. There was a shorter time to first fracture for men with EWGSOP-defined sarcopenic obesity (mean: 7.6; 95%

Body composition and muscle function have important implications for falls and fractures in older adults. We aimed to investigate longitudinal associations between sarcopenic obesity and its components with bone mineral density (BMD) and incident falls and fractures in Australian community-dwelling older men. A total of 1486 men aged >=70 years from the Concord Health and Ageing in Men Project (CHAMP) study were assessed at baseline (2005-2007), 2-year follow-up (2007-2009; n = 1238), and 5-year follow-up (2010-2013; n = 861). At all three time points, measurements included appendicular lean mass (ALM), body fat percentage and total hip BMD, hand-grip strength, and gait speed. Participants were contacted every 4 months for 6.1 +/- 2.1 years to ascertain incident falls and fractures, the latter being confirmed by radiographic reports. Sarcopenic obesity was defined using sarcopenia algorithms of the European Working Group on Sarcopenia (EWGSOP) and the Foundation for the National Institutes of Health (FNIH) and total body fat >=30% of total mass. Sarcopenic obese men did not have significantly different total hip BMD over 5 years compared with non-sarcopenic non-obese men (p > 0.05). EWGSOP-defined sarcopenic obesity at baseline was associated with significantly higher 2-year fall rates (incidence rate ratio [IRR] 1.66; 95% confidence interval [CI] 1.16-2.37), as were non-sarcopenic obesity (1.30; 1.04-1.62) and sarcopenic non-obesity (1.58; 1.14-2.17), compared with non-sarcopenic non-obese. No association with falls was found for sarcopenic obesity using the FNIH definition (1.01; 0.63-1.60), but after multivariable adjustment, the FNIH-defined non-sarcopenic obese group had a reduced hazard for any 6-year fracture compared with sarcopenic obese men (hazard ratio 0.44; 95% CI 0.23-0.86). In older men, EWGSOP-defined sarcopenic obesity is associated with increased fall rates over 2 years, and FNIH-defined sarcopenic obese men have increased fracture risk over 6 year

OBJECTIVES: This 10 weeks feasibility study investigated whether residential care nurses with 12 hours advanced oral health training in assessments and saliva testing could formulate, implement and monitor individualised oral care plans of early dementia residents. METHOD: Four trained lead advocate nurses using SXI-D, OHIP14, oral health assessment tool (OHAT) assessments and a modified saliva test formulated nurse scheduled comprehensive oral care plans (NSCOCPs) by selecting and scheduling preventive products and procedures multiple times throughout the day to alkalise the mouth of 8 residents as an adjunct to assisted brushing and high-fluoride toothpaste. RESULTS: Nurse assessments, saliva tests and care plans were validated against oral health therapist (OHT) findings. Care plan agreement between Nurse and OHT intervention selection and scheduling was high (75%-88%). Untrained nurse compliance was very high, 86%-99% for the 4930 scheduled interventions. Untrained nurses delivered multiple scheduled interventions by following NSCOCPs despite initially not understanding the reason for each of 9 interventions categories. NSCOCPs could track and monitor whether a recommended intervention had been completed by general nursing staff over 3 nursing shifts. CONCLUSION: The role of nurses may have to be expanded beyond traditional roles to meet the growth and changes in oral health needs in residential facilities. Intensive training of a few lead advocate nurses to assess risk and formulate individualised NSCOCPs provides a method to transfer knowledge to untrained staff and deliver multicomponent preventive interventions soon after entry into residential care where timely visits by dental professionals to examine residents and prescribe preventive interventions are infrequent or unlikely.

Background: Anticoagulation control is a strong predictor of Iclinical outcomes for patients on warfarin. Aim: To identify instances of excessive anticoagulation in hospitalised patients on warfarin and to determine the causes of international normalised ratios (INRs) of 5 and above and the management strategies used to correct it. Method: An observational descriptive study undertaken at a teaching hospital over a 3-month period. Data were reviewed prospectively and retrospectively to measure the percentage of time patients were maintained within their target INR range while in hospital and to identify cases of excessive anticoagulation. Patients were divided into a control group (INR < 5) and a high INR group (INR ≥ 5). Possible causes of INRs of 5 and above and its management strategies were recorded. Results: Out of a total of 208 patients on warfarin identified in the geriatric, orthopaedic and cardiology wards, 144 patients met the study criteria. The mean percentage of time spent within, above and below the target INR range by the control group was 60%, 0% and 15%, and by the high INR group was 41%, 33% and 16%, respectively. In the high INR group, 26 possible causes of INRs of 5 and above were identified and the co-administration of roxithromycin and warfarin were implicated in 7 cases. Management strategies for INRs of 5 and above were compared between two stratified groups (INR 5-9 and INR ≥ 9). The management strategies adopted included warfarin dose reduction (83%; 86%), temporary withholding of warfarin (100%; 100%), administration of vitamin K (58%; 100%), fresh frozen plasma (13%; 43%) and prothrombin complex concentrate (8%; 29%). The time to return to the upper limit of the target INR range was INR 5-9 (1.6 SD 1.5 days) and INR ≥ 9 (0.5 SD 0.4 days). Conclusion: Anticoagulation control is difficult for hospital patients and drug interactions are an important contributing factor. The management strategies adopted to correct excessive anticoagulation f

Background: Anticoagulation control is a strong predictor of Iclinical outcomes for patients on warfarin. Aim: To identify instances of excessive anticoagulation in hospitalised patients on warfarin and to determine the causes of international normalised ratios (INRs) of 5 and above and the management strategies used to correct it. Method: An observational descriptive study undertaken at a teaching hospital over a 3-month period. Data were reviewed prospectively and retrospectively to measure the percentage of time patients were maintained within their target INR range while in hospital and to identify cases of excessive anticoagulation. Patients were divided into a control group (INR < 5) and a high INR group (INR ≥ 5). Possible causes of INRs of 5 and above and its management strategies were recorded. Results: Out of a total of 208 patients on warfarin identified in the geriatric, orthopaedic and cardiology wards, 144 patients met the study criteria. The mean percentage of time spent within, above and below the target INR range by the control group was 60%, 0% and 15%, and by the high INR group was 41%, 33% and 16%, respectively. In the high INR group, 26 possible causes of INRs of 5 and above were identified and the co-administration of roxithromycin and warfarin were implicated in 7 cases. Management strategies for INRs of 5 and above were compared between two stratified groups (INR 5-9 and INR ≥ 9). The management strategies adopted included warfarin dose reduction (83%; 86%), temporary withholding of warfarin (100%; 100%), administration of vitamin K (58%; 100%), fresh frozen plasma (13%; 43%) and prothrombin complex concentrate (8%; 29%). The time to return to the upper limit of the target INR range was INR 5-9 (1.6 SD 1.5 days) and INR ≥ 9 (0.5 SD 0.4 days). Conclusion: Anticoagulation control is difficult for hospital patients and drug interactions are an important contributing factor. The management strategies adopted to correct excessive anticoagulation f