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Context: With age, the prevalence of subclinical hypothyroidism rises. However, incidence and determinants of spontaneous normalization remain largely unknown. Objective: To investigate incidence and determinants of spontaneous normalization of TSH levels in older adults with subclinical hypothyroidism. Design: Pooled data were used from the (1) pretrial population and (2) in-trial placebo group from 2 randomized, double-blind, placebo-controlled trials (Thyroid Hormone Replacement for Untreated Older Adults With Subclinical Hypothyroidism Trial and Institute for Evidence-Based Medicine in Old Age thyroid 80-plus thyroid trial). Setting: Community-dwelling 65+ adults with subclinical hypothyroidism from the Netherlands, Switzerland, Ireland, and the United Kingdom. Participants: The pretrial population (N = 2335) consisted of older adults with biochemical subclinical hypothyroidism, defined as ≥1 elevated TSH measurement (≥4.60 mIU/L) and a free T4 within the laboratory-specific reference range. Individuals with persistent subclinical hypothyroidism, defined as ≥2 elevated TSH measurements ≥3 months apart, were randomized to levothyroxine/placebo, of which the intrial placebo group (N = 361) was included. Main Outcome Measures: Incidence of spontaneous normalization of TSH levels and associations between participant characteristics and normalization. Results: In the pretrial phase, TSH levels normalized in 60.8% of participants in a median follow-up of 1 year. In the in-trial phase, levels normalized in 39.9% of participants after 1 year of follow-up. Younger age, female sex, lower initial TSH level, higher initial free T4 level, absence of thyroid peroxidase antibodies, and a follow-up measurement in summer were independent determinants for normalization. Conclusion: Because TSH levels spontaneously normalized in a large proportion of older adults with subclinical hypothyroidism (also after confirmation by repeat measurement), a third measurement may be recommended before considering treatment. [ABSTRACT FROM AUTHOR]

Objective to investigate the association between variability and loss of body weight with subsequent cognitive performance and activities of daily living in older individuals. Design cross-sectional cohort study. Setting PROspective Study of Pravastatin in the Elderly at Risk, multicentre trial with participants from Scotland, Ireland and the Netherlands. Subjects 4,309 participants without severe cognitive dysfunction (mean age 75.1 years, standard deviation (SD) = 3.3), at higher risk for cardiovascular disease (CVD). Methods body weight was measured every 3 months for 2.5 years. Weight loss was defined as an average slope across all weight measurements and as ≥5% decrease in baseline body weight during follow-up. Visit-to-visit variability was defined as the SD of weight measurements (kg) between visits. Four tests of cognitive function were examined: Stroop test, letter-digit coding test (LDCT), immediate and delayed picture-word learning tests. Two measures of daily living activities: Barthel Index (BI) and instrumental activities of daily living (IADL). All tests were examined at month 30. Results both larger body weight variability and loss of ≥5% of baseline weight were independently associated with worse scores on all cognitive tests, but minimally with BI and IADL. Compared with participants with stable weight, participants with significant weight loss performed 5.83 seconds (95% CI 3.74; 7.92) slower on the Stroop test, coded 1.72 digits less (95% CI −2.21; −1.13) on the LDCT and remembered 0.71 pictures less (95% CI -0.93; −0.48) on the delayed picture-word learning test. Conclusion in older people at higher risk for CVD, weight loss and variability are independent risk-factors for worse cognitive function. [ABSTRACT FROM AUTHOR]

Context: Subclinical thyroid dysfunction and anemia are common disorders, and both have increasing prevalence with advancing age. Objective: The aim of this study was to assess whether levothyroxine treatment leads to a rise in hemoglobin levels in older persons with subclinical hypothyroidism. Methods: This preplanned combined analysis of 2 randomized controlled trials included community-dwelling persons aged 65 years and older with subclinical hypothyroidism who were randomly assigned to levothyroxine or placebo treatment. The levothyroxine dose was periodically titrated aiming at thyroid stimulating hormone (TSH) level within the reference range, with mock titrations in the placebo group. The main outcome measure was the change in hemoglobin level after 12 months. Results: Analyses included 669 participants (placebo n = 337, levothyroxine n = 332) with a median age of 75 years (range, 65-97) and mean baseline hemoglobin of 13.8 ± 1.3 g/dL. Although levothyroxine treatment resulted in a reduction in TSH from baseline after 12 months of follow-up compared with placebo, the change in hemoglobin level was not different between the levothyroxine and the placebo groups (-0.03 g/dL [95% CI, -0.16 to 0.11]). Similar results were found in stratified analyses including sex, age, or TSH levels. No difference in change of hemoglobin levels after 12 months was identified in 69 participants with anemia at baseline (-0.33 g/dL [95% CI, -0.87 to 0.21]). Conclusion: In persons aged 65 years and older with subclinical hypothyroidism, treatment with levothyroxine does not lead to a rise in hemoglobin levels, regardless of the presence of anemia. [ABSTRACT FROM AUTHOR]

Background hospital level healthcare in the home guided by comprehensive geriatric assessment (CGA) might provide a less costly alternative to hospitalisation for older people. Objective to determine the cost-effectiveness of CGA admission avoidance hospital at home (HAH) compared with hospital admission. Design/intervention a cost-effectiveness study alongside a randomised trial of CGA in an admission avoidance HAH setting, compared with admission to hospital. Participants/setting older people considered for a hospital admission in nine locations across the UK were randomised using a 2:1 randomisation schedule to admission avoidance HAH with CGA (N  = 700), or admission to hospital with CGA when available (N  = 355). Measurements quality adjusted life years, resource use and costs at baseline and 6 months; incremental cost-effectiveness ratios were calculated. The main analysis used complete cases. Results adjusting for baseline covariates, HAH was less costly than admission to hospital from a health and social care perspective (mean −£2,265, 95% CI: −4,279 to −252), and remained less costly with the addition of informal care costs (mean difference −£2,840, 95% CI: −5,495 to −185). There was no difference in quality adjusted survival. Using multiple imputation for missing data, the mean difference in health and social care costs widened to −£2,458 (95% CI: −4,977 to 61) and societal costs remained significantly lower (−£3,083, 95% CI: −5,880 to −287). There was little change to quality adjusted survival. Conclusions CGA HAH is a cost-effective alternative to admission to hospital for selected older people. [ABSTRACT FROM AUTHOR]

Background: Fatigue often triggers screening for and treatment of subclinical hypothyroidism. However, data on the impact of levothyroxine on fatigue is limited and previous studies might not have captured all aspects of fatigue.Method: This study is nested within the randomized, placebo-controlled, multicenter TRUST trial, including community-dwelling participants aged ≥65 and older, with persistent subclinical hypothyroidism (TSH 4.60-19.99 mIU/L, normal free thyroxine levels) from Switzerland and Ireland. Interventions consisted of daily levothyroxine starting with 50 μg (25 μg if weight <50 kg or known coronary heart diseases) together with dose adjustments to achieve a normal TSH and mock titration in the placebo group. Main outcome was the change in physical and mental fatigability using the Pittsburgh Fatigability Scale over 1 year, assessed through multivariable linear regression with adjustment for country, sex, and levothyroxine starting dose.Results: Among 230 participants, the mean ± standard deviation (SD) TSH was 6.2 ± 1.9 mIU/L at baseline and decreased to 3.1 ± 1.3 with LT4 (n = 119) versus 5.3 ± 2.3 with placebo (n = 111, p < .001) after 1 year. After adjustment we found no between-group difference at 1 year on perceived physical (0.2; 95% CI -1.8 to 2.1; p = .88), or mental fatigability (-1.0; 95% CI -2.8 to 0.8; p = .26). In participants with higher fatigability at baseline (≥15 points for the physical score [n = 88] or ≥13 points for the mental score [n = 41]), the adjusted between-group differences at 1 year were 0.4 (95% CI -3.6 to 2.8, p = .79) and -2.2 (95% CI -8.8 to 4.5, p = .51).Conclusions: Levothyroxine in older adults with mild subclinical hypothyroidism provides no change in physical or mental fatigability. [ABSTRACT FROM AUTHOR]

Iron deficiency anaemia (IDA) is common in older adults and associated with a range of adverse outcomes. Differentiating iron deficiency from other causes of anaemia is important to ensure appropriate investigations and treatment. It is possible to make the diagnosis reliably using simple blood tests. Clinical evaluation and assessment are required to help determine the underlying cause and to initiate appropriate investigations. IDA in men and post-menopausal females is most commonly due to occult gastrointestinal blood loss until proven otherwise, although there is a spectrum of underlying causative pathologies. Investigation decisions should take account of the wishes of the patient and their competing comorbidities, individualising the approach. Management involves supplementation using oral or intravenous (IV) iron then consideration of treatment of the underlying cause of deficiency. Future research areas are outlined including the role of Hepcidin and serum soluble transferrin receptor measurement, quantitative faecal immunochemical testing, alternative dosing regimens and the potential role of IV iron preparations. [ABSTRACT FROM AUTHOR]

Academic geriatric medicine activity lags behind the scale of clinical activity in the specialty. A meeting of UK academic geriatricians was convened in March 2018 to consider causes and solutions to this problem. The meeting highlighted a lack of research-active clinicians, a perception that research is not central to the practice of geriatric medicine and a failure to translate discovery science to clinical studies. Solutions proposed included better support for early-career clinical researchers, schemes to encourage non-University clinicians to be research-active, wider collaboration with organ specialists to broaden the funding envelope, and the need to co-produce research programmes with end-users. Solutions to grow academic geriatric medicine are essential if we are to provide the best care for the growing older population. [ABSTRACT FROM AUTHOR]

Randomised controlled trials provide the most rigorous test of efficacy and effectiveness for interventions used in healthcare. They underpin much of clinical practice, yet older people are often excluded from studies, resulting in uncertainty about risks and benefits of new treatments. Encouraging inclusion of older people in randomised controlled trials and reporting of trial results in a rigorous manner is a key function of clinical geriatrics journals such as Age and Ageing. This article provides practical advice on how to report randomised controlled trials that are targeted at older people. Some of these issues are generic, but there are specific requirements which apply to most studies of older people. Recording and reporting basic characteristics of recruits in terms of physical function, cognition, comorbidity and/or frailty is vital to allow proper interpretation of the external validity of the trial. Adverse effects should include consideration of common geriatric problems including falls. Authors should follow the CONSORT reporting guidelines (CONsolidated Standards Of Reporting Trials) to enhance the transparency and quality of their manuscript. [ABSTRACT FROM AUTHOR]

Introduction: screening all unscheduled older adults for delirium is recommended in national guidelines, but there is no consensus on how to perform initial assessment. Aim: to evaluate the test accuracy of five brief cognitive assessment tools for delirium diagnosis in routine clinical practice. Methods: a consecutive cohort of non-elective, elderly care (older than 65 years) hospital inpatients admitted to a geriatric medical assessment unit of an urban teaching hospital. Reference assessments were clinical diagnosis of delirium performed by elderly care physicians. Routine screening tests were: Abbreviated Mental Test (AMT-10, AMT-4), 4 A's Test (4AT), brief Confusion Assessment Method (bCAM), months of the year backwards (MOTYB) and informant Single Question in Delirium (SQiD). Results: we assessed 500 patients, mean age 83 years (range = 66-101). Clinical diagnoses were: 93 of 500 (18.6%) definite delirium, 104 of 500 (20.8%) possible delirium and 277 of 500 (55.4%) no delirium; 266 of 500 (53.2%) were identified as definite or possible dementia. For diagnosis of definite delirium, AMT-4 (cut-point < 3/4) had a sensitivity of 92.7% (95% confidence interval (CI): 84.8-97.3), with a specificity of 53.7% (95% CI: 48.1-59.2); AMT-10 (<4/10), MOTYB (<4/12) and SQiD showed similar performance. bCAM had a sensitivity of 70.3% (95% CI: 58.5-80.3) with a specificity of 91.4% (95% CI: 87.7-94.3). 4AT (>4/12) had a sensitivity of 86.7% (95% CI: 77.5-93.2) and specificity of 69.5% (95% CI: 64.4-74.3). Conclusions: short screening tools such as AMT-4 or MOTYB have good sensitivity for definite delirium, but poor specificity; these tools may be reasonable as a first stage in assessment for delirium. The 4AT is feasible and appears to perform well with good sensitivity and reasonable specificity. [ABSTRACT FROM AUTHOR]

The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure (BP) and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful. Robust evidence is scant, trials of antihypertensive medications have generally excluded those with dementia. Observational data show changes in risk association over the life course, with high BP being a risk factor for cognitive decline in mid-life, while low BP is predictive in later life. It is therefore possible that excessive BP lowering in older people with dementia might harm cognition. From the existing literature, there is no direct evidence of benefit or harm from treating hypertension in people with dementia. So what practical steps can the clinician take? Assess capacity, establish patient preferences when making treatment decisions, use ambulatory monitoring to thoroughly assess BP, individualise and consider deprescribing where side effects (e.g. hypotension) outweigh the benefits. Future research might include pragmatic randomised trials of targeted deprescribing, which include patient-centred outcome measures to help support decision-making and studies to address mechanistic uncertainties. [ABSTRACT FROM AUTHOR]

The authors discuss articles published within the issue about hypertension treatment in older persons. Topics include benefits of treatment of hypertension in older persons, American College of Cardiology and American Heart Association (ACC/AHA) guidelines for managing high-blood pressure, and recommended blood pressure threshold and treatment goal.

Background: Hypercoagulability may be an important contributor to the pathophysiology of atherosclerosis and atherothrombosis. As thrombin fulfills a central role in coagulation and links to several cellular mechanisms involved in arterial disease, we hypothesized that thrombin generation is associated with cardiovascular events in elderly patients.Methods: We studied the relationship between plasma thrombin generation and incident coronary heart disease (CHD) and stroke in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). From this multicenter prospective cohort, 4,932 samples of subjects (70-82 years) with pre-existing vascular disease or risk factors were available for thrombin generation measurements.Results: Within the 3.2 years of follow-up incident stroke and CHD was observed in 227 and 545 subjects, respectively. Baseline thrombin generation was significantly decreased in subjects with incident stroke compared with subjects without: normalized peak height 71.1±40.8% versus 82.3±44.9%, p = .0002, and normalized endogenous thrombin potential 79.1±23.3% versus 87.0±24.8%, p < .0001 (mean and SDs). Thrombin generation was independently and inversely associated with stroke risk: hazard ratio 0.71 (95%CI: 0.60-0.85), 0.68 (95%CI: 0.58-0.79), for normalized peak height and normalized endogenous thrombin potential, respectively (all p < .001). In subjects with incident CHD, thrombin generation was comparable to subjects without a coronary event. Only an increased normalized peak height was significantly associated with incident CHD (hazard ratio 1.17 [95% CI: 1.06-1.28], p = .002).Conclusions: We demonstrate that a delayed and decreased thrombin generation is a strong and independent predictor for stroke in elderly people at increased risk of vascular disease. However, no convincing consistent association could be demonstrated between thrombin generation and incident CHD. [ABSTRACT FROM AUTHOR]

BACKGROUND Visit-to-visit variability in blood pressure is an independent predictor of cardiovascular disease. This study investigates biological correlates of intra-individual variability in blood pressure in older persons. METHODS Nested observational study within the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) among 3,794 male and female participants (range 70-82 years) with a history of, or risk factors for cardiovascular disease. Individual visit-to-visit variability in systolic and diastolic blood pressure and pulse pressure (expressed as 1 SD in mm Hg) was assessed using nine measurements over 2 years. Correlates of higher visit-to-visit variability were examined at baseline, including markers of inflammation, endothelial function, renal function and glucose homeostasis. RESULTS Over the first 2 years, the mean intra-individual variability (1 SD) was 14.4mm Hg for systolic blood pressure, 7.7mm Hg for diastolic blood pressure, and 12.6 mm Hg for pulse pressure. After multivariate adjustment a higher level of interleukin-6 at baseline was consistently associated with higher intra-individual variability of blood pressure, including systolic, diastolic, and pulse pressure. Markers of endothelial function (Von Willebrand factor, tissue plasminogen activator), renal function (glomerular filtration rate) and glucose homeostasis (blood glucose, homeostatic model assessment index) were not or to a minor extent associated with blood pressure variability. CONCLUSIONS In an elderly population at risk of cardiovascular disease, inflammation (as evidenced by higher levels of interleukin-6) is associated with higher intra-individual variability in systolic, diastolic, and pulse pressure. [ABSTRACT FROM AUTHOR]

Background and objective: single-item screening questions may be a practical first step in screening for cognitive problems in older people. A form of single-item cognitive assessment is proposed in the NHS England and Wales dementia strategy. We aimed to provide a review and synthesis of the evidence regarding the performance of single-item tests for detection of cognitive impairment.Design: this review used Cochrane diagnostic test accuracy procedures. Two independent researchers searched for relevant papers across multiple, cross-disciplinary electronic databases using previously validated search strings. Our index test was any single screening question for cognitive impairment, including factor analysis of multi-item tools. Our reference standards included clinical diagnosis and multi-domain cognitive assessments.Results: from 884 titles, 11 studies were identified as eligible for inclusion. Four studies were graded low risk of bias and recruited a representative patient sample. Five papers described a single screening question for cognitive impairment with each using a different question. Sensitivity ranged from 26 to 96% and specificity from 45 to 100%. Six papers described the component analysis of multiple item tools with broadly worded single questions (‘decline in memory function’, ‘changes in ability to think and reason’ or ‘learning new things’) performing best.Conclusion: informant-based, single-item screening questions show promise for detecting cognitive impairment. However, there was substantial heterogeneity in format and application of single-item screens, and several studies were of poor methodological quality. Currently, there is insufficient evidence to support routine screening using a single-item approach. [ABSTRACT FROM AUTHOR]

The article presents insights on the National Institute for Health and Care Excellence (NICE) guideline "Multi-morbidity: Clinical Assessment and Management." Topics covered include the failure of modern medicine to address the implications of multimorbidity, the recognition of multi-morbidity as an important clinical issue that merits a clinical guideline and the empowerment of patients in clinical decision making.

Background High serum alanine aminotransferase (ALT) levels have been associated with increased risk of diabetes and with increased mortality, but associations of variations of ALT in the normal range with outcomes have been less well studied.Methods We studied the relationship between ALT, mortality and cardiovascular events in the West of Scotland Coronary Prevention Study (WOSCOPS) and the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) trials that explicitly excluded subjects with clinically significant liver damage, plus the Leiden 85-plus, a study of survivors to age 85 years. The associations between ALT and morbidity and mortality outcomes were investigated using Cox proportional hazard models adjusting for a comprehensive panel of cardiovascular risk factors.Results In all three study cohorts, ALT displayed an independent inverse relationship with all-cause mortality so that hazard ratios for fourth versus first quarter of ALT were all below 1.0; HRs 0.64 [95% confidence interval (CI) 0.50–0.81], 0.86 (0.73–1.01), 0.66 (0.50–0.87); WOSCOPS, PROSPER, Leiden 85-plus, respectively. In WOSCOPS and PROSPER, ALT was also inversely associated with risk of fatal plus non-fatal cardiovascular events, including coronary heart disease (CHD) events and stroke.Conclusions In three independent populations, ALT in the normal range displayed an inverse relationship with total mortality, cardiovascular events and non-cardiovascular events in middle-to-older aged subjects without evidence of clinically significant liver damage, independent of traditional cardiovascular and other risk factors. These findings indicate that the relationship between ALT and clinical outcomes is more complex than generally appreciated. [ABSTRACT FROM PUBLISHER]

Aims Atrial fibrillation/flutter (AF) is the most common arrhythmia in older people. It associates with reduced exercise capacity, increased risk of stroke, and mortality. We aimed to determine retrospectively whether pravastatin reduces the incidence of AF and whether any electrocardiographic measures or clinical conditions might be risk factors for its development. Methods and results The PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) was a randomized, double-blind controlled trial that recruited 5804 individuals aged 70–82 years with a history of, or risk factors for, vascular disease. A total of 2891 were allocated to pravastatin and 2913 to placebo; mean follow-up was 3.2 years. Electrocardiograms (ECGs), which were recorded at baseline, annually thereafter, and at run-out, were processed by computer and reviewed manually. In all, 264 of 2912 (9.1%) of the placebo group and 283 of 2888 (9.8%) of the pravastatin-treated group developed AF [hazard ratio 1.08 (0.92,1.28), P= 0.35)]. Multivariate analysis showed that PR and QTc intervals, age, left ventricular hypertrophy, and ST-T abnormalities were related to development of AF after adjustment for many variables including alcohol consumption, which itself was univariately predictive of developing AF. Previous myocardial infarction on the ECG was not a risk factor. A history of vascular disease was strongly linked with developing AF but not diabetes and hypertension. Conclusion Pravastatin does not reduce the incidence of AF in older people at risk of vascular disease, at least in the short–medium term. Risk factors for AF include older age, prolongation of PR or QTc intervals, left ventricular hypertrophy, and ST-T abnormalities on the ECG. [ABSTRACT FROM PUBLISHER]

Background: Inflammation may play an important role in atherothrombosis and in promoting cerebral damage after stroke. We hypothesized that plasma adipocytokine concentrations would be associated with risk of stroke in older people.Methods: Nested case-control study from the Prospective Study of Pravastatin in the Elderly (PROSPER). Subjects were aged 70-82 years and followed up for a mean of 3.2 years: 266 incident stroke cases (179 confirmed as ischaemic) were compared with 532 controls matched for age, gender and treatment allocation (pravastatin or placebo). Adipocytokines [adiponectin, interleukin- (IL-)18 and tumour necrosis factor (TNF)alpha] were measured on stored baseline plasma samples.Results: Elevated plasma adiponectin was associated with lower risk of ischaemic stroke on univariate analysis: odds ratio (OR) 0.78 per 1 SD increase (95% CI 0.62-0.97). There were no associations of IL-18 or TNFalpha with risk for ischaemic or total strokes. In multivariate models the independent predictors of ischaemic stroke were prior cerebrovascular accident (OR 2.68, 95% CI 1.60-4.50), any alcohol use (1.98, 1.33-2.94), triglycerides (1.40, 1.11-1.77), Barthel score (0.75, 0.58-0.96) and known diabetes (1.72, 1.04-2.83); adiponectin, IL-18 and TNFalpha did not contribute. A similar pattern of risk was seen for total stroke.Conclusions: Reduced adiponectin may have a modest role in the aetiology of ischaemic stroke in older people, however IL-18 and TNFalpha are unlikely to play any important part. These adipocytokines do not have clinical predictive utility; history of prior cerebrovascular accident, known diabetes mellitus, prior disability and higher alcohol intake explain much of the stroke risk. [ABSTRACT FROM AUTHOR]

The article discusses the study "Alcohol Consumption in Later Life and Reaching Longevity: The Netherlands Cohort Study" by P. A. van den Brandt, L. Brandts and colleagues, that was published within the issue. Topics discussed include J-shaped association between alcohol intake and mortality, health benefits from low-moderate levels of drinking, and genetic variants associated with lower intake or non-drinking.

Objective: to determine whether a co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduces disability and prevents non-elective hospital readmission in high-risk elderly patients. Design: nested case-control study comparing usual post-discharge care versus usual care plus a comprehensive geriatric assessment and home-based rehabilitation service, comprising nursing, occupational therapy and physiotherapy with geriatric medical review. Patients were ≥65 years with ≥2 non-elective hospital admissions within the previous 12 months. Disability was assessed using the 100-point Barthel index and Nottingham extended activities of daily living (EADL) score. Non-elective hospital admissions were recorded over 1-year follow-up. Results: we studied 84 patients; 56 receiving the new service were matched to 28 controls. Intervention subjects received a median of 19 h [interquartile range (IQR) (7,35)] rehabilitation over 19 [IQR (6,42)] domiciliary visits. At 3 months, there was improvement in median Barthel and Nottingham EADL scores in the intervention group of 3 and 2 points, respectively, compared with reductions in controls of 3 and 6 points (both P<0.001, changes in intervention group versus controls); similar differences persisted in survivors at 12 months. There was a non-significant trend for reduction in the proportion of patients with further non-elective hospital admission in the intervention group (36/56, 64%) compared with controls (21/28, 75%; OR 0.70, 95% CI 0.34, 1.46). Conclusions: a co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduced disability in elderly patients at high risk for non-elective hospital admission. Further research is required to determine whether this approach can reduce the need for hospital admission. [ABSTRACT FROM AUTHOR]

Objective: to determine contributors to decline in functional capacity in elderly patients with known vascular risk factors or disease. Design: secondary analysis of longitudinal data gathered over an average 3.2 years of follow-up. Participants: 5,804 community-dwelling subjects aged 70-82 years with a history of, or risk factors for, ischaemic vascular disease. Measurements: basic activities of daily living were measured serially through the study using the 20-point Barthel index and extended activities using a 14-point Instrumental Activities of Daily Living (IADL). Results: over the period of study 896/5,661 (16%) subjects had deterioration in Barthel (mean reduction 0.35, SD 1.76) and 1,270/5,662 (22%) had a reduction in IADL score (mean 0.63, SD 2.15). Independent risk factors at baseline for a reduction in Barthel and IADL were age, female gender and diabetes mellitus. A history of vascular disease and smoking were also significant predictors of reduction in IADL. The development of a new cerebrovascular event was associated with a greatly increased risk of reduction in the Barthel and IADL score (multivariate OR 3.71 (95% CI 2.94, 4.69) and 3.71 (95% CI 2.96, 4.66), respectively). A similar pattern was seen for non-fatal myocardial infarction. Incident cerebrovascular events and nonfatal myocardial infarction accounted for 31 and 11%, respectively, of the population decline in Barthel, and 24 and 10% of the decline in IADL. Conclusion: incident vascular events were important contributors to functional decline in this population, accounting for almost half of the observed deterioration in basic activities of daily living and approximately one-third of the reduction in IADL. Prevention of ischaemic vascular events over the short to medium term should reduce the burden of disability in high-risk older subjects. [ABSTRACT FROM AUTHOR]

The authors discuss the publication of the updated European Working Group Sarcopenia guidelines that was first issued in 2010 by the journal "Age and Ageing." Resistance training is considered an effective treatment for sarcopenia. There is said to be a stronger focus on muscle strength as the key first determinant of making the diagnosis. There is greater emphasis on the use of dual energy X-ray absorptiometry or bioimpedance to measure muscle mass better.

An introduction to the journal is presented in which the editor discusses the various articles published within the issue on such topics as recurrent urinary tract infection prevention, advance care planning in care homes, and mortality in older diabetics.

The author reflects on the online collection of studies that cover a broad range of research techniques to improve the quality of research for older individuals, including cohort studies, systematic reviews, and qualitative research. Also cited are the importance of conducting high-quality clinical research for older people, as well as the need to describe such major characteristics and markers as cognition, frailty, and multi-morbidity in the studies.

The authors discuss some changes made to the European Working Group Sarcopenia guidelines published by the journal "Age and Ageing" in 2010. The changes should make it easier to do case-finding in an efficient way for research and clinical practice. There is said to be ambiguity as to how muscle mass should be adjusted for body size. It is noted that sarcopenia has the status of a syndrome instead of a precise pathophysiological entity.

Deals with a study which tested the hypothesis that older patients with lower circulating insulin-like growth factor 1 levels would have reduced muscle power and poorer physical performance. Participants and methods; Key determinant of walking speed and stair climbing time; Analysis of the results.

Editorial. Talks about the outbreak of influenza among elderly people in Great Britain. Symptoms of influenza; Prevention of influenza; Treatment options during an influenza outbreak.

An introduction to the journal is presented that focuses on issues related to aging, including proactive integrated care for frail older people, temporal changes in functional impairment in older people, and computerised interventions to improve prescribing in hospital.

The authors reflect on international healthcare charity Cochrane Collaboration, considering its role on geriatric medicine. The authors state that the Cochrane Collaboration, which is celebrating its 20th anniversary in 2013, was inspired by epidemiologist Archie Cochrane from Scotland. They mention that Cochrane provides systematic reviews of evidence on health-care interventions. They add that Cochrane has been helpful in the promotion of older people's evidence-based healthcare.