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Introduction During the COVID-19 pandemic, pre-existing dementia was associated with a 3x increase in risk of hospitalisation and (25.6%) of COVID-19 related deaths had dementia. However, it is unclear whether people living with dementia are at higher risk of COVID-19 due to dementia or whether there may be a biologically plausible link between dementia and COVID-19. The ApoE e4 allele is highly associated with dementia. We aimed to test the COVID-19 risk associated with dementia and the association between ApoE e4e4 allele and COVID-19 with the aim of clarifying biological vulnerability. Methods UK Biobank (England) participants baseline (2006 to 2010), plus secondary care data to 2017. Separate analysis tested dementia and ApoE genotype association with COVID-19 status (16th March-31st May 2020) or mortality (to March 31, 2020, plus incomplete deaths from April, 2020) in logistic models, adjusted for demographics and technical covariates. Results In 269,070 participants aged 65+, including 507(0.2%) hospitalized COVID-19 patients, those with pre-existing dementia were at increased risk of being hospitalized for COVID-19 (OR = 3.50 95% CI 1.93 to 6.34) and also for COVID-19 and death (OR = 7.30 95% CI 3.28–16.21). In 375,689 European-ancestry UKB participants, ApoE e4e4 homozygotes were more likely to be COVID-19 test positives (reaching genome-wide significance: OR = 2.24, 95% CI:1.72–2.93, p = 3.24 × 10–9) and of mortality with test-confirmed COVID-19 (OR = 4.29, 95% CI: 2.38–7.72, p = 1.22 × 10–6), compared to e3e3s homozygotes. The associations were little changed in subsets of participants who were free of diseases associated with ApoE e4 and COVID-19 severity. Conclusion Dementia was found to be disproportionally common in older adults who develop severe COVID-19. We have shown a plausible genetic pathway of increased COVID-19 risk with dementia, therefore suggesting that the positive association between dementia and COVID-19 is not just the result of high cases of COVID-19 in care homes.

Background Older adults are at increased risk of COVID-19, resulting in public health shielding measures for all adults over 70 in the UK. Frailty has been proposed for risk stratification in COVID-19 with limited evidence. Cardiovascular risk factors hypertension, diabetes and raised BMI have been associated with increased COVID-19 risk. We sought to test if non-frail older adults with low cardiovascular risk had reduced COVID-19, to inform targeted shielding policies. Methods Fried and Rockwood frailty were ascertained at UK Biobank baseline (2006-2010) and electronic frailty index(eFI) in primary care data to 2017*. A cardiovascular disease risk score(CRS) consisting of smoking status, LDL-cholesterol, blood pressure, BMI, fasting glucose and physical activity was estimated at baseline. Frailty (baseline and eFI; eFI alone) and CRS were tested in logistic models against COVID-19 status and COVID-19 mortality to 14th June 2020 adjusted for demographics and technical covariates. Results N=269,164 UKB participants aged ≥65 at baseline (≥75years in 2020). 13.9% of COVID-19 positive were non-frail with low baseline CRS versus 41.8% frail with moderate/high CRS. Being non-frail and having low CRS were independently associated with reduced COVID-19. The composite of non-frail with low CRS compared to frail with moderate/high CRS had significantly reduced COVID-19 risk (composite non-frail with low CRS HR 0.61; 95% CI 0.45-0.84; p=0.0023; eFI non-frail with low CRS HR 0.16; 95%CI 0.07-0.36; p value=9.9x10-6) and COVID-19 mortality (composite non-frail HR 0.28; 95% CI 0.10-0.82; pvalue=0.02; eFI non-frail 0.07; 95% CI 0.02-0.28; pvalue=0.00014). Conclusion These results show that the COVID-19 risk in non-frail older adults with low cardiovascular risk was up to 84% lower than in those who were frail with cardiovascular risk factors. This could contribute to future work on stratification of shielding risk in older adults in future COVID-19 surges. *Planned data updates prior to the conference should enable updates to 2020.

Importance risk factors for delirium in hospital inpatients are well established, but less is known about whether delirium occurring in the community or during an emergency admission to hospital care might be predicted from routine primary-care records. Objectives identify risk factors in primary-care electronic health records (PC-EHR) predictive of delirium occurring in the community or recorded in the initial episode in emergency hospitalisation. Test predictive performance against the cumulative frailty index. Design Stage 1: case-control; Stages 2 and 3: retrospective cohort. Setting clinical practice research datalink: PC-EHR linked to hospital discharge data from England. Subjects Stage 1: 17,286 patients with delirium aged ≥60 years plus 85,607 controls. Stages 2 and 3: patients ≥ 60 years (n = 429,548 in 2015), split into calibration and validation groups. Methods Stage 1: logistic regression to identify associations of 110 candidate risk measures with delirium. Stage 2: calibrating risk factor weights. Stage 3: validation in independent sample using area under the curve (AUC) receiver operating characteristic. Results fifty-five risk factors were predictive, in domains including: cognitive impairment or mental illness, psychoactive drugs, frailty, infection, hyponatraemia and anticholinergic drugs. The derived model predicted 1-year incident delirium (AUC = 0.867, 0.852:0.881) and mortality (AUC = 0.846, 0.842:0.853), outperforming the frailty index (AUC = 0.761, 0.740:0.782). Individuals with the highest 10% of predicted delirium risk accounted for 55% of incident delirium over 1 year. Conclusions a risk factor model for delirium using data in PC-EHR performed well, identifying individuals at risk of new onsets of delirium. This model has potential for supporting preventive interventions.

Importance treatment of dementia in individuals with comorbidities is complex, leading to potentially inappropriate prescribing (PIP). The impact of PIP in this population is unknown. Objective to estimate the rate of PIP and its effect on adverse health outcomes (AHO). Design retrospective cohort. Setting primary care electronic health records linked to hospital discharge data from England. Subjects 11,175 individuals with dementia aged over 65 years in 2016 and 43,463 age- and sex-matched controls. Methods Screening Tool of Older Persons’ Prescriptions V2 defined PIP. Logistic regression tested associations with comorbidities at baseline, and survival analyses risk of incident AHO, adjusted for age, gender, deprivation and 14 comorbidities. Results the dementia group had increased risk of PIP (73% prevalence; odds ratio [OR]: 1.92; confidence interval [CI]: 83–103%; P Conclusion patients with dementia frequently receive PIPs, and those who do are more likely to experience AHO. These results highlight the need to optimise medication in dementia patients, especially those with comorbidities.

Background Blood pressure (BP) management in frail older people is challenging. An randomised controlled trial of largely non-frail older people found cardiovascular and mortality benefit with systolic (S) BP target Objectives To estimate observational associations between baseline BP and mortality/cardiovascular outcomes in a primary-care population aged above 75, stratified by frailty. Methods Prospective observational analysis using electronic health records (clinical practice research datalink, n = 415,980). We tested BP associations with cardiovascular events and mortality using competing and Cox proportional-hazards models respectively (follow-up ≤10 years), stratified by baseline electronic frailty index (eFI: fit (non-frail), mild, moderate, severe frailty), with sensitivity analyses on co-morbidity, cardiovascular risk and BP trajectory. Results Risks of cardiovascular outcomes increased with SBPs >150 mmHg. Associations with mortality varied between non-frail Conclusions In representative primary-care patients aged ≥75, BP

Background in chronic kidney disease (CKD), hypertension is associated with poor outcomes at ages 60. In the 70 plus group with SBPs 140–169 mmHg, there was no increase in mortality, versus SBP 130–139. Similarly, SBPs 140–169 mmHg were not associated with increased incident heart failure, stroke or myocardial infarctions. SBPs 150 mmHg. Results were little altered after excluding those with declining SBPs during 5 years before baseline, or for longer-term outcomes (5–10 years after baseline). Conclusions in older primary care patients, CKD3 or 4 was the dominant outcome predictor. SBP 140–169 mmHg having little additional predictive value

Background overweight or obesity at ages

Background: the oldest old (85+) pose complex medical challenges. Both underdiagnosis and overdiagnosis are claimed in this group. Objective: to estimate diagnosis, prescribing and hospital admission prevalence from 2003/4 to 2011/12, to monitor trends in medicalisation. Design and setting: observational study of Clinical Practice Research Datalink (CPRD) electronic medical records from general practice populations (eligible; n = 27,109) with oversampling of the oldest old. Methods: we identified 18 common diseases and five geriatric syndromes (dizziness, incontinence, skin ulcers, falls and fractures) from Read codes. We counted medications prescribed ≥1 time in all quarters of studied years. Results: there were major increases in recorded prevalence of most conditions in the 85+ group, especially chronic kidney disease (stages 3–5: prevalence

Background: little is known about changes in the quality of medical care for older adults over time. Objective: to assess changes in technical quality of care over 6 years, and associations with participants' characteristics. Design: a national cohort survey covering RAND Corporation-derived quality indicators (QIs) in face-to-face structured interviews in participants' households. Participants: a total of 5,114 people aged 50 or more in four waves of the English Longitudinal Study of Ageing. Methods: the percentage achievement of 24 QIs in 10 general medical and geriatric clinical conditions was calculated for each time point, and associations with participants' characteristics were estimated using logistic regression. Results: participants were eligible for 21,220 QIs. QI achievement for geriatric conditions (cataract, falls, osteoarthritis and osteoporosis) was 41% [95% confidence interval (CI): 38–44] in 2004–05 and 38% (36–39) in 2010–11. Achievement for general medical conditions (depression, diabetes mellitus, hypertension, ischaemic heart disease, pain and cerebrovascular disease) improved from 75% (73–77) in 2004–05 to 80% (79–82) in 2010–11. Achievement ranged from 89% for cerebrovascular disease to 34% for osteoarthritis. Overall achievement was lower for participants who were men, wealthier, infrequent alcohol drinkers, not obese and living alone. Conclusion: substantial system-level shortfalls in quality of care for geriatric conditions persisted over 6 years, with relatively small and inconsistent variations in quality by participants' characteristics. The relative lack of variation by participants' characteristics suggests that quality improvement interventions may be more effective when directed at healthcare delivery systems rather than individuals.

Background: there is evidence of a U-shaped association between alcohol consumption and physical health outcomes in older people, such that moderate drinking is associated with better outcomes than abstinence or heavy drinking, but whether moderate drinking in older people is associated with better cognition and mental health than non-drinking has not been explored. Objective: to assess the relationship between drinking and cognitive health in middle-aged and older people. Design: prospective observational study. Setting/Participants: six thousand and five individuals aged 50 and over who participated in Wave 1 of the English Longitudinal Study of Ageing (ELSA) and who were not problem drinkers. Exposure and outcome variables: we examined cognitive function, subjective well-being, and depressive symptoms, and compared the risks associated with having never drunk alcohol, having quit drinking, and drinking at 2d rinks per day. Results: for both men and women, better cognition and subjective well-being, and fewer depressive symptoms, were associated with moderate levels of alcohol consumption than with never having drunk any. Conclusions: in middle-aged and older men and women, moderate levels of alcohol consumption are associated with better cognitive health than abstinence.

Background: mobility (locomotor) disability is an early marker of disability progression, health care utilisation and institutionalisation in older people. Whether mobility disability has different causes in the middle-aged has received limited attention. Objectives: to examine associations of mobility disability with sociodemographic, behaviour and disease status and to contrast these with associations in older groups. Design: cross-sectional interview data from the 2002 English Longitudinal Study of Ageing. Mobility status based on reported difficulty walking a quarter of a mile (402 m). Participants: a total of 11,392 community-living respondents aged 50 years and over. Results: in the middle-aged, 8% (95% CI 7–9%) of women and 9% (95% CI 8–11%) of men reported having much difficulty or being unable to walk a quarter of a mile, equating to 787,000 (95% CI 700,000–831,000) people in England. Factors which at least doubled odds of mobility disability in the middle-aged were chronic obstructive lung disease, angina, stroke, recently treated cancer, comorbidity, lower limb and back pain. Factors associated with mobility disability in older groups were similar. Thirty-eight per cent of mobility disability in the middle-aged population was related to high levels of lower limb pain and 15% to high levels of back pain. Conclusions: mobility disability in the middle-aged is relatively common. The associated conditions in the middle-aged are similar to those in older people. Lower limb and back pain make dominant population contributions to mobility disability. Prevention of later disability progression may require more attention being paid to mobility difficulties and its causes in the middle-aged.

Background facing the costs of population ageing, many governments aim to keep older people in employment for longer. Summary health measures predict early retirement, but more specific symptoms and conditions need to be identified to guide efforts to delay retirement. Objective to identify common symptoms and conditions that predict early work exit, at the population level. Design cohort study of community dwelling respondents to the English Longitudinal Study of Ageing. Setting and participants a total of 1,693 workers aged 50 and over at baseline who were younger than the contemporaneous retirement age (60 for women, 65 for men) at 4-year follow-up. Results a total of 308 (18.2%) individuals moved out of employment during the follow-up period. Advancing age, female gender, partner retirement, greater pension wealth, high alcohol consumption and fair or poor self-rated health were all associated with work exit. Accounting for these factors, reported difficulty walking a quarter mile was predictive of early work exit (odds ratio (OR) = 2.23; 95% confidence interval (CI) 1.42-3.52), especially where symptoms included lower limb pain and/or shortness of breath. Symptomatic depression (measured by Centre for Epidemiological Studies Depression scale) was also predictive of early work exit (OR = 1.52, CI 1.07, 2.18). About 50.8% of early retirees reported one or more of these specific health symptoms (depression, general pain, mobility limitations and leg pain when walking). Conclusion older workers who report depressive symptoms or impaired physical mobility, especially with lower limb pain and shortness of breath, are at increased risk of early transition out of work. Health interventions targeting these conditions may enable older workers to remain in the labour force.

OBJECTIVE: to identify socio-economic, behavioural and disease status risks for impaired balance or self-reported dizziness in older people from a large population-based study. METHODS: data were from the English Longitudinal Study of Ageing (ELSA), for 2,925 participants, aged 65+. Multivariate models were used to assess the associations between balance and dizziness and disease status, health behaviours, grip strength and socio-economic markers. RESULTS: there were 21.5% (n = 619) participants with impaired balance and 11.1% (n = 375) reported dizziness. Impaired balance was statistically significantly associated with age, diabetes (OR = 1.53), arthritis (OR = 1.33), eyesight (OR = 1.94) and grip strength. The wealthiest 20% of participants were less likely to have impaired balance than the poorest 20% (OR = 0.46). Dizziness problems were not associated with age, gender or wealth, but were significantly associated with an abnormal heart rhythm (OR = 1.85), hearing (OR = 1.81), eyesight (OR = 1.72) and grip strength. CONCLUSION: the epidemiology of impaired balance differs from that of dizziness, and risk assessment approaches to prevent falls may need to elicit information on different problem-specific factors. Impaired balance test performance in older people may be added to the many outcomes showing strong socio-economic gradients. Language: en

Background Transitions such as retirement may represent points at which changes in health behaviour occur. Objective To assess whether transition into retirement is associated with increased rates of smoking cessation. Design Population-based prospective cohort study in England. Setting and participants One thousand seven hundred and twelve smokers aged 50 years and over, followed up for 5 to 6 years. Measurements Work status (working/retired) and smoking status (non-smoker/smoker) at baseline and follow-up. Results At baseline, 381 (22.2%) of our respondents had retired, 444 (25.9%) were working and remained in work at follow-up, and 167 (9.8%) transitioned from work to retirement. Seven hundred and twenty (42.1%) had some other status (e.g. unpaid work/unemployment). A total of 42.5% (95% CI 34.9-50.1) of those who retired quit smoking; for those remaining in employment this figure was 29.3% (95% CI 25.0-33.6), and for those already retired it was 30.2% (95% CI 25.5-34.9). In adjusted regression analyses, those aged 55-70 who retired were more than twice as likely (fully adjusted odds ratio 2.50 (95% CI 1.35-4.62)) to quit smoking as those who continued to work. Results were robust when those who retired for reasons of ill-health were excluded. Conclusions Our results suggest individuals who undergo the transition into retirement are more likely to quit smoking than those who do not. Interventions should be developed to specifically target those who are retiring, or soon to retire, and those who are due to retire should be helped to incorporate smoking cessation into their retirement planning.

Introduction: socio-economic differences in mobility disability prevalence in old age have been reported from the US and Europe. Brazil is characterised by gross socio-economic inequalities, but there have been no previous national data on disability prevalence. Aim: this study aimed to estimate disability rates and explore associations identifying the most signiWcant socio-economic markers associated with mobility disability prevalence in old age in Brazil. Subjects and methods: a nationally representative sample of 28,943 people aged 60 years or over was interviewed, in the 1998 National Household Survey (PNAD), conducted by the Brazilian Institute of Geography and Statistics. Results: the prevalence rates of markers of mild, moderate and severe disability were higher in women than men, and increased with age. Prevalence rates of difWculty with personal care and medium distance walking were broadly similar to England, but far more Brazilians reported difWculty climbing stairs. In logistic regression analyses, the strongest markers associated with increased mobility disability prevalence were age, gender, lack of education and low income. Rural residence was also associated with reduced prevalence. Limited differences by region were present, and there were mixed effects for self-reported racial group for women. Conclusions: disability in the older population of Brazil shows familiar prevalence patterns by age and gender. Disparity in income and educational attainment in Brazil are the most important markers associated with group differences in mobility disability prevalence in old age.

Background: self-reported disability reXects physical, environmental and attitudinal factors. We have previously reported the empirical identiWcation of three simple tests to provide an index of (ambulatory) mobility-related physiological limitations (MOBLI). Evidence of the MOBLI’s responsiveness over time has been presented. Evidence of the predictive validity of the index is needed. Objective: we aimed to measure the predictive validity for future mortality of the MOBLI and of self-reported mobility disability in a longitudinal cohort study. Methods: data are from the sixth annual interview for two sites in the Established Populations for Epidemiologic Studies of the Elderly study. Included were 3,040 people, with information about self-reported walking difWculties, walking speed, time to complete Wve chair stands and peak expiratory Xow. Age- and sex-adjusted death rates over a 4-year follow-up were computed, and proportional hazards regression models were used in the analysis. Results: the MOBLI score is associated with subsequent mortality over 4 years, with evidence of a ‘dose-response’ relationship. The predictive value for mortality of the MOBLI score is similar to that of self-reported mobility disability in the studied population. Conclusions: the ‘objective’ MOBLI index has predictive validity as a continuous or dichotomised measure of the physiological component of mobility limitation in older populations. Given its empirical basis and face validity, predictive validity and responsiveness to change, MOBLI should be considered for local validation and use in epidemiological comparisons of older populations across countries or over longer periods of time.