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Key summary points Aim To investigate how food and dietary intakes, protein daily distribution and source were associated with appendicular lean mass (ALM)/m2 in the oldest-old community-dwelling men. Findings ALM/m2 was associated with total protein intake, source and distribution as well as fruit and vegetable intakes. Message Not only protein intake, but also source and distribution as well as healthy overall diet characterized by abundant amounts of fruits and vegetables were important in maintaining muscle mass in the oldest-old men in our study., Purpose We explored how food and dietary intakes, protein daily distribution and source are associated with appendicular lean mass (ALM)/m2 of the oldest-old community-dwelling men. Methods Cross-sectional analyses of Helsinki Businessmen Study (HBS, mean age 87 years) participants who came to clinic visit in 2017/2018. Nutritional status, physical performance and fasting blood samples were measured. Food and dietary intakes were retrieved from 3-day food diaries. Body composition was measured and appendicular lean mass (ALM) per m2 was dichotomized as ALM/m2

Key summary points Objective Multimorbidity, phenotypic prefrailty and frailty are frequent in ageing populations Findings This long-term follow-up of home-dwelling older men reveals the relationship of phenotypic frailty to long-term prognosis, independently of the presence of significant chronic diseases and disability. Message Assessment of phenotypic frailty and already prefrailty provides extra clinical value for the assessment of prognosis in old age., Purpose Multimorbidity, prefrailty, and frailty are frequent in ageing populations, but their independent relationships to long-term prognosis in home-dwelling older people are not well recognised. Methods In the Helsinki Businessmen Study (HBS) men with high socioeconomic status (born 1919–1934, n = 3490) have been followed-up from midlife. In 2000, multimorbidity (≥ 2 conditions), phenotypic prefrailty and frailty were determined in 1365 home-dwelling men with median age of 73 years). Disability was assessed as a possible confounder. 18-year mortality follow-up was established from registers and Cox regression used for analyses. Results Of the men, 433 (31.7%) were nonfrail and without multimorbidity at baseline (reference group), 500 (36.6%) and 82 (6.0%) men had prefrailty or frailty, respectively, without multimorbidity, 84 (6.2%) men had multimorbidity only, and 201 (14.7%) and 65 (4.8%) men had prefrailty or frailty together with multimorbidity. Only 30 (2.2%) and 86 (6.3%) showed signs of ADL or mobility disability. In the fully adjusted analyses (including ADL disability, mental and cognitive status) of 18-year mortality, frailty without multimorbidity (hazard ratio 1.62, 95% confidence interval 1.13–2.31) was associated with similar mortality risk than multimorbidity without frailty (1.55, 1.17–2.06). The presence of both frailty and multimorbidity indicated a strong mortality risk (2.93, 2.10–4.07). Conclusion Although multimorbidity is generally considered a substantial health problem, our long-term observational study emphasises that phenotypic frailty alone, independently of disability, may be associated with a similar risk, and a combination of multimorbidity and frailty is an especially strong predictor of mortality.

BackgroundPositive emotions and happiness may improve health and prolong life. Diet quality, Mediterranean dietary pattern, fruit and vegetable, chocolate, and fish consumption have been linked to positive affect, improved mood, and reduced risk of depression. We examined the associations between diet, nutrition, and perceived happiness in the oldest-old men.MethodsThe participants in this cross-sectional analysis were the oldest-old, home-dwelling men (n=338, mean age 88years, range 82-97years) from the longitudinal Helsinki Businessmen Study cohort. In 2016, a postal health and nutrition survey was performed. Happiness was evaluated using the Visual Analog Scale of Happiness (0-100mm). The nutrition survey included a 3-day food diary, Mediterranean Diet Adherence score, and Index of Diet Quality designed to measure adherence to Finnish dietary recommendations. The participants were divided into quartiles according to happiness scores, and diet quality scores, food intakes, and other indicators were compared between the happiness quartiles.ResultsHappiness was linearly associated with total fruit and vegetable intakes (p=0.002) and inversely associated with age (p=0.016), blood glucose levels (p=0.049), skipping lunch (p=0.023), reduced food intake (p=0.002), and weight loss (p=0.016).ConclusionsFruit and vegetable intakes indicated happiness in the oldest-old men while reduced food intakes and weight loss were inversely associated with happiness. Maintaining good nutrition and increasing fruit and vegetable consumption may be important for psychological health of older people.

Background Health-related quality of life (HRQoL) is associated with survival in older people with multimorbidities and disabilities. However, older people differ in their characteristics, and less is known about whether HRQoL predicts survival in heterogeneous older population samples differing in their functional, cognitive, psychological or social disabilities. The aim of this study was to explore HRQoL in heterogeneous samples of older men and women, and to explore its prognostic significance for mortality. Methods We analysed combined individual patient data from eight heterogeneous study samples all of which were assessed with the same methods. We used 15D, a generic, comprehensive instrument for measuring HRQoL, which provides a single index in addition to a profile. Two-year mortality was retrieved from central registers. Results Health-related quality of life measurements with 15D were available for 3153 older adults. The mean HRQoL was highest among older businessmen (0.878) and lowest among nursing home residents (0.601). 15D predicted independently and significantly the 2-year survival in the total sample [hazard ratio (HR)/SD 0.44, 95% CI 0.40-0.48)]. However, 15D did not predict mortality in samples of spousal caregivers, lonely older adults and cardiovascular patients. Conclusions 15D captures health and disability factors associated with prognosis whereas in older populations suffering from psychological and social impairments such as caregiver burden or loneliness HRQoL may not reflect their health risks.

Introduction There are few longitudinal studies of relationships between vacation and later health outcomes. We studied these during a 26-year follow-up of the Helsinki Businessmen Study. Methods In 1974, at mean age of 47 years, 2741 members of a cohort of executives and businessmen born 1919–1934 were clinically examined and reported their annual vacation time (dichotomized >21 [n = 2001] vs. ≤21 days [n = 740]), self-rated health (SRH) and perceived physical fitness using a five-step scale. In old age in 2000 (mean age 73 years), the survivors filled in the RAND-36/SF-36 health-related quality of life (HRQoL) questionnaire. Mortality between 1974 and 2000 was retrieved from national registers. Results At baseline, shorter vacation was associated with longer work time, higher BMI, more coffee consumption and worse SRH. During the 26-year follow-up, 778 men out of 2741 (28.4%) had died. Shorter annual vacation was associated with higher mortality with curves starting to diverge after 18 years of follow-up, (fully adjusted hazard ratio 1.29, 95% confidence interval 1.08–1.55, P = 0.005). In old age, shorter vacation in midlife was tentatively associated with worse general health. Conclusions Shorter vacation time in midlife was associated with characteristics related to lifestyle and with worse perceived health status, and predicted mortality up to old age in men.

Background The prevalence and overlap of psychotic symptoms among patients with dementia compared to those with delirium superimposed to dementia have received little attention. The aim of our study was to investigate the overlapping and distinguishing capability of psychotic symptoms among patients with dementia or with delirium superimposed to dementia, and to clarify their prognostic value. Methods We assessed 255 residents with dementia in nursing homes and acute geriatric wards for psychotic symptoms and delirium. The residents were divided into three groups: those with delirium (Group 1; n =66), those with psychotic symptoms without delirium (Group 2; n =74), and without psychotic symptoms or delirium (Group 3; n =115). Results Of the participants, 30.9% suffered from delusions, 22.1% from visual hallucinations and 14.2% from auditory hallucinations. Delusions occurred more often in Group 2 than in Group 1. Of the subjects in Group 3, 6.5% suffered from misidentifications, whereas the respective figures in Groups 1 and 2 were 17.5% and 20.8%, respectively. Of those suffering from psychotic symptoms ( n =109), one in three ( n =35) suffered delirium, and two in three ( n =74), psychotic symptoms without delirium. In the adjusted Cox proportional hazard model with Group 2 as the referent, we found no difference between the groups in mortality rates (Group 1: HR 0.98, 95% CI: 0.64–1.52 and Group 3: HR 1.49, 95% CI: 0.92–2.42). Conclusions Psychotic symptoms cannot be used to distinguish patients with dementia from those with delirium superimposed to dementia.

Purpose Vascular risk factors in midlife may play a role in the development of cognitive decline, dementia and Alzheimer' disease (AD). The role of serum total cholesterol has yielded inconsistent results in diverse cohorts. Objective To analyze the relationship between the midlife cholesterol level and AD in late life in a homogenous cohort of Caucasian men. Methods The Helsinki Businessmen Study is a cohort of male business executives who have been followed-up since 1964. Midlife cholesterol level was available in 3293 men, of whom 205 developed a register-verified AD. Cognitively intact men in 2007 ( n =844) served as controls, and logistic regression adjusted for age and cardiovascular risk factors was used to investigate the association between cholesterol and AD. Results At baseline, the men with subsequent AD diagnosis had 0.4mmol/L higher total cholesterol level than controls (6.7 vs 6.3mmol/L). In adjusted analyses 1mmol/L rise in total cholesterol was associated with a 22% increased risk of AD (odds ratio [OR] 1.22, 95% confidence interval 1.06 to 1.40, P =0.005). Risk of AD (OR with 95% CI) also increased in a stepwise manner from the lowest to highest quartile of midlife cholesterol from 1.0 (referent) to 1.6 (1.01–2.6), 1.9 (1.2–3.0), and 2.0 (1.2–3.3), respectively. Conclusion In this longitudinal study with up to 43 years of follow-up, higher serum total cholesterol in early midlife was clearly associated with a higher risk of AD in late life.

Background In 2001 and 2008, the Finnish Geriatrics Society (SG) performed postal surveys to its members to investigate their work satisfaction, work burden and views on older people's care. This survey was repeated in spring 2013. Methods The questionnaire of earlier surveys was used in order to compare answers. The questionnaire was distributed to members via emails and through the website. Results Altogether 121 doctors (71% women) responded, 119 of them actively working, corresponding to 52% of geriatricians in Finland. Geriatricians are well-trained, half of them also had another specialty, and a third had a PhD degree. One third had a position of physician-in-chief. In 2001 and 2008, 36% and 60%, respectively, felt that the work of a geriatrician is appreciated very well or well, but the proportion had risen to 75% in 2013. Responders experienced the general working atmosphere in older people's care as good, and coping at work was generally good. Instead, geriatricians felt that they cannot satisfactorily influence the geriatric care in their communities, and possibilities for this have weakened during the past 5 years. Lack of timely geriatric rehabilitation and lack of general geriatric knowledge were considered as the biggest problems in geriatric care. Similarly to the year 2008, geriatricians considered geriatric rehabilitation, care of memory patients, and geriatric acute care as core activities in their work. Conclusions Due to their solid training, Finnish geriatricians have a wide perspective on older people's care and this knowledge must be appropriately utilized in communities.

Background No previous studies have investigated the effectiveness and feasibility of self-management groups for people with dementia and their caregivers. Purpose We present the baseline findings of a randomized controlled trial examining the effectiveness of a psychosocial group intervention to enhance self-management skills of persons with dementia and their spouses and have evaluated the feasibility of the intervention. Subjects and methods Altogether 136 individuals with dementia living with their spousal caregivers in the community were recruited from the memory clinics. They were randomized into two arms: group-based self-management intervention (n = 67 couples) and controls (n = 69 couples). The patients and spouses met in separate closed groups once a week for 8 weeks. Intervention sessions were based on discussions, including topics according to participants’ preferences. Their aim was to enhance participants’ self-efficacy, problem-solving skills and peer support. Anonymous feedback from the intervention group was collected at 3 months. Results The mean age of participants with dementia was 76.8 years, 51 (38%) were females, and 98 (72%) were at a mild stage of dementia. Cognitive status was poorer in the intervention group than in controls [MMSE; 19.9 (SD 5.7) vs. 21.7 (SD 3.7), P = 0.04]. The participation rate in-group sessions was high among patients (93%, range 86–98%) and caregivers (93%, range 86–99%). Participants described the group sessions as beneficial and supportive. Conclusion We have successfully randomized 136 dyads in a self-management group rehabilitation trial. The feedback from participants was favourable, and the drop-out rate during the first 3 months was low.

Aim To evaluate the effect of diabetes onset on health-related quality of life (HRQoL) in men. Methods A prospective cohort study with a 34-year follow-up (The Helsinki Businessmen Study, Finland). A socio-economically homogenous group of 1815 men (born 1919–1934), free of diabetes and clinically healthy in 1974, when cardiovascular risk factors were measured and self-related health (SRH) evaluated with a five-step scale. In 2000 and 2007, HRQoL was assessed with a questionnaire, including the RAND-36 (SF-36) instrument. Incidence of diabetes up to 2007 was retrieved using the National Reimbursement Register for diabetes medication, or from questionnaire surveys between 2000 and 2007. Onset of diabetes was divided as follows: 1991 or earlier, 1992–1995, 1996–2000, 2001–2003, 2004–2007. Results Altogether 216 men (11.9%) developed diabetes during the 34-year follow-up, and they had more cardiovascular risk factors at baseline than those without diabetes. According to the evaluation in 2000, and compared to men free of diabetes during follow-up, three RAND-36 scales (physical function, general health, social functioning) were significantly worsened already after 0–4 years from diabetes onset and did not deteriorate thereafter. Instead, HRQoL was not worsened up to 7 years before diabetes onset (between 2000 and 2007). No consistent impact of diabetes was observed on mental health-related scales. Conclusion Diabetes does not affect physical health-related quality of life until after diabetes onset. Lack of an association between the prediabetic state and HRQoL may offer an important window for the prevention and argument for early detection also from the HRQoL viewpoint.

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Background There are scarce studies exploring effectiveness and feasibility of intensive and long-lasting exercise among patients with dementia. Purpose To present baseline findings of a randomized controlled trial exploring effectiveness of intensive physical exercise among home-dwelling patients with Alzheimer disease (AD), and to evaluate feasibility of the intervention by exploring feedback from spousal caregivers. Subjects and methods We used central AD registers in Finland to recruit AD patients ( n =210) living with their spousal caregiver in the community. They were randomized into three arms: 1): tailored home-based exercise twice weekly ( n =70); 2): group-based exercise in rehabilitation centers twice weekly in ( n =70), and; 3): a control group with usual care and information of exercise and nutrition ( n =70). Anonymous feedback from spousal caregivers was collected at 6 months of the intervention. Results The mean age of AD patients was 78.1 years (SD 5.3), 81 (39%) were women, and 104 (50%) were at moderate stage of dementia according to the Clinical Dementia Rating Scale (CDR). Of the caregivers, 94% had made the decision to participate in the trial because of their spouse's need for rehabilitation, and 93% felt that the study nurses' assessments had been beneficial for them. Only 16 participants (8%) had dropped out before the first (3-month) follow-up assessment. Conclusion We have successfully randomized 210 patients with Alzheimer's disease and their spousal caregivers into an intensive exercise rehabilitation trial. The feedback from spousal caregivers was favourable and drop-out rate low at 6 months.

Old age frailty has no consensus definition so far, but it is commonly operationalised as a physical phenotype consisting of weight loss, exhaustion, physical inactivity, slowness and weakness. Phenotypic frailty is characterised by reductions in the reserves of various organ systems and impaired stress tolerance, with increased risk of important endpoints: disability, morbidity and death. The development of sarcopenia is often a conspicuous characteristic, and cognitive decline is a frequent companion; frail individuals may also be obese. According to epidemiological studies, phenotypic frailty can be discerned in 5 to 10% of community-living older individuals, prefrailty even in 20 to 40%. To prevent deterioration and development of disability, prefrail and frail individuals should be recognised in time to target interventions in primary care. There is also an emerging interest in various specialties to recognise frailty to better adjust treatments and prevent complications. Multidomain and multisystem interventions are probably the best options for prevention and treatment, but at the moment best evidence is available from exercise. Various pharmacological treatments are being investigated for frailty components, but trial data are scarce so far. In advanced frailty, treatment is moved to appropriate geriatric palliative care.

Background Although geriatrics is recognised as an effective strategy in the secondary care of older people, adoption of the specialty has been variable in the developed world. Information is needed on factors that affect recruitment and retention of geriatricians. Method Based on postal questionnaire survey undertaken in 2001, a largely identical survey was undertaken among all Finnish geriatricians (167 in active practice in 2008) in 2008. Items included work position, work satisfaction, and general views about delivery of care for older people. Results A total of 112 physicians returned the 2008 questionnaire (60% of active specialists). The varied working profile and views about geriatricians' status were largely similar to those in 2001. Half of all responders were employed by municipalities in primary care, 19% were employed by secondary or tertiary hospitals. The most important clinical settings for geriatricians were considered to be in memory clinics, rehabilitation and acute care. Most geriatricians ( n =84, [75%]) considered either general practitioners (GP), or GPs with specific training in geriatrics to be the best option for the management of common problems of older patients in the community. In general, geriatricians were optimistic about their work and possibilities to influence, even more so than in 2001. The biggest challenge was perceived to increase and distribute geriatric medicine knowledge and skills in health care for older people. Discussion Finnish geriatricians believe that geriatrics is a rewarding speciality. However, the incorporation of the principles and practice of geriatrics across other is viewed as a major challenge.

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Introduction: In Finland (pop 5.6 million), geriatrics is a main specialty with a 5-year training and with increasing popularity among physicians. The Society of Finnish Geriatricians performed in spring 2013 a postal survey to its members, who virtually include all geriatricians in Finland to investigate their work satisfaction, work burden and views on older people’s care. Methods: The questionnaire template of earlier surveys in 2001 and 2008 was used to compare the responses, and it was electronically distributed to members. Results: Altogether 121 doctors (71% women) responded, 119 of them in active work, corresponding to 52% of geriatricians in Finland. The geriatricians were well trained, half of them had another specialty, and a third had a PhD degree. One third hold a position of physician-in-chief. The proportion of responders who felt that the work of geriatricians is appreciated very well or well was 75% (in 2001 and 2008, 36% and 60% respectively). The general atmosphere in older people’s care and personal coping at work was generally good. Lack of timely geriatric rehabilitation and lack of geriatric knowledge were considered as the biggest problems in geriatric care. Geriatric rehabilitation, care of memory patients, and geriatric acute care were considered as core activities of geriatricians’ everyday work. Conclusions: Due to their solid training Finnish geriatricians have a wide perspective on older people’s care and they feel their work appreciated.

Results.– Twenty-seven countries completed the questionnaire. Geriatric Medicine is an independent specialty in 19 countries (70%). In 7, it is accepted as a subspecialty mainly attributed to Internal medicine. In 1, it is not officially approved. Twenty countries (74%) answered in favor of a published common European core curriculum, amongst those, 17 (63%) declared written objectives and goals. Validation of the training is generally provided by the national Ministries of Health. Universities and national geriatric societies usually determine contents and quality. Sixteen out of the 28 European countries (60%) have a final obligatory examination, whose assessment formats and standards differ widely. In 3 countries (11%), periodic recertification is requested. Quality control of training and assessments seem to be heterogeneous. Twenty-one UEMS Geriatric Section delegates (78%) gave positive reflections for a standardized training program and for a postgraduate European exam. Conclusion.– Postgraduate training standards and the establishment of a European postgraduate exam in Geriatric Medicine seem to be welcomed by the majority of UEMS Geriatric Section. Efforts are being made to harmonize postgraduate training in Geriatric within the EU. An educational board was created amongst major European Geriatric Medicine Stakeholders (UEMS/EUGMS/EAMA/IAGG-EU).