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STUDY OBJECTIVES: Sleep microarchitecture parameters determined by quantitative power spectral analysis of electroencephalograms have been proposed as potential brain-specific markers of cognitive dysfunction. However, data from community samples remain limited. This study examined cross-sectional associations between sleep microarchitecture and cognitive dysfunction in community-dwelling men. METHODS: Florey Adelaide Male Ageing Study participants (n = 477) underwent home-based polysomnography (2010–2011). All-night electroencephalogram recordings were processed using quantitative power spectral analysis following artifact exclusion. Cognitive testing (2007–2010) included the inspection time task, Trail-Making Tests A and B, and Fuld object memory evaluation. Complete case cognition, polysomnography, and covariate data were available in 366 men. Multivariable linear regression models controlling for demographic, biomedical, and behavioral confounders determined cross-sectional associations between sleep microarchitecture and cognitive dysfunction overall and by age-stratified subgroups. RESULTS: In the overall sample, worse Trail-Making Test A performance was associated with higher rapid eye movement (REM) theta and alpha and non-REM theta but lower delta power (all P

Background: Post-dural puncture headache (PDPH) is an iatrogenic condition following lumbar puncture (LP). Incidence is variable and often associated with young females. Technical features of the procedure (i.e. needle gauge) have been investigated; however there is no investigation on the method of cerebrospinal fluid (CSF) collection. Objective: To investigate whether mild CSF aspiration is associated with increased PDPH in selected patients. Methods: 336 subjects were eligible to the study. Data on 237 patients from a tertiary neurology hospital who underwent diagnostic LP from February 2010 to December 2012 were analysed. Patient demographics, lumbar puncture method, CSF biochemical characteristics, opening pressures, and a follow-up inquire on PDPH occurrence were collected. CSF was collected either by allowing free flow or by mild aspiration. Results: The aspiration arm (n=163) was comprised of 55.8% females with mean age of 52(35‒69) years. Sex distribution was not different between the two arms (p=0.191). A significant larger amount of CSF was obtained in the aspiration arm (p=0.011). The incidence of PDPH in the aspiration arm was 16.5% versus 20.2% in the free flow arm, not statistically significant (p=0.489). No relevant associations emerged from the analyses in the subgroup aged

Objectives To describe the injury profile, hospitalisation rates and health outcomes for older people with cognitive impairment and to determine whether these differ from those with normal cognition. Methods Participants were 867 community-dwelling 70–90 year olds enrolled in the population-based longitudinal Sydney Memory and Ageing Study (MAS). Participant’s cognitive status was classified as normal, mild cognitive impairment (MCI) and dementia at baseline, then 2, 4 and 6 years’ follow-up. MAS records were linked to hospital and death records to identify injury-related hospitalisations for the 2-year period following each assessment. Results There were 335 injury-related hospitalisations for participants; 222 (25.6%) participants had at least one injury-related hospitalisation. The injury-related hospitalisation rate for participants with MCI (63.0 [95%CI 51.6–74.4] per 1000 person-years) was higher than for people with normal cognition (39.3 [95%CI 32.4–46.1] per 1000 person-years) but lower than people with dementia (137.1 [95%CI 87.2–186.9] per 1000 person-years). Upper limb fractures (22.1%) were the most common injuries for participants with normal cognition, and non-fracture head injuries for participants with MCI and dementia (25.9% and 23.3% respectively). Participants with dementia had a higher proportion of hip fractures (20.0%, p = 0.0483) than participants with normal cognition. There was no difference in 30-day mortality between participants with normal cognition, MCI and dementia (3.9%, 1.7%, 3.3% respectively). Conclusion Older people with objectively defined MCI are at higher risk of injury-related hospitalisation than their cognitively intact peers, but lower risk than people with dementia. Falls-risk screening and fall prevention initiatives may be indicated for older people with MCI.

Objective To test whether StandingTall, a home based, e-health balance exercise programme delivered through an app, could provide an effective, self-managed fall prevention programme for community dwelling older people. Design Assessor blinded, randomised controlled trial. Setting Older people living independently in the community in Sydney, Australia. Participants 503 people aged 70 years and older who were independent in activities of daily living, without cognitive impairment, progressive neurological disease, or any other unstable or acute medical condition precluding exercise. Interventions Participants were block randomised to an intervention group (two hours of StandingTall per week and health education; n=254) or a control group (health education; n=249) for two years. Main outcome measures The primary outcomes were the rate of falls (number of falls per person year) and the proportion of people who had a fall over 12 months. Secondary outcomes were the number of people who had a fall and the number of injurious falls (resulting in any injury or requiring medical care), adherence, mood, health related quality of life, and activity levels over 24 months; and balance and mobility outcomes over 12 months. Results The fall rates were not statistically different in the two groups after the first 12 months (0.60 falls per year (standard deviation 1.05) in the intervention group; 0.76 (1.25) in the control group; incidence rate ratio 0.82, 95% confidence interval 0.66 to 1.02, P=0.070). Additionally, the proportion of people who fell was not statistically different at 12 months (34.6% in intervention group, 40.2% in control group; relative risk 0.90, 95% confidence interval 0.72 to 1.12, P=0.348). However, the intervention group had a 16% lower rate of falls over 24 months (incidence rate ratio 0.84, 95% confidence interval 0.72 to 0.98, P=0.027) and a 20% lower rate of injurious falls over 24 months compared with the control group (incidence rate ratio 0.80, 95% confidence interval 0.66 to 0.98, P=0.031). Both groups had a similar proportion of people who fell over 24 months (relative risk 0.87, 95% confidence interval 0.74 to 1.02, P=0.077). In the intervention group, 68.1% and 52.0% of participants exercised for a median of 114.0 min/week (interquartile range 53.5) after 12 months and 120.4 min/week (38.6) after 24 months, respectively. Groups remained similar in mood and activity levels. The intervention group had a 0.03 (95% confidence interval 0.01 to 0.06) improvement on the EQ-5D-5L (EuroQol five dimension five level) utility score at six months, and an improvement in standing balance of 11 s (95% confidence interval 2 to 19 s) at six months and 10 s (1 to 19 s) at 12 months. No serious training related adverse events occurred. Conclusions The StandingTall balance exercise programme did not significantly affect the primary outcomes of this study. However, the programme significantly reduced the rate of falls and injurious falls over two years, with similar but not statistically significant effects at 12 months. E-health exercise programmes could provide promising scalable fall prevention strategies. Trial registration ACTRN12615000138583

Background frailty is a major contributor to poor health outcomes in older people, separate from age, sex and comorbidities. This population-based validation study evaluated the performance of the International Classification of Diseases, 10th revision, coded Hospital Frailty Risk Score (HFRS) in the prediction of adverse outcomes in an older surgical population and compared its performance against the commonly used Charlson Comorbidity Index (CCI). Methods hospitalisation and death data for all individuals aged ≥50 admitted for surgery to New South Wales hospitals (2013–17) were linked. HFRS and CCI scores were calculated using both 2- and 5-year lookback periods. To determine the influence of individual explanatory variables, several logistic regression models were fitted for each outcome of interest (30-day mortality, prolonged length of stay (LOS) and 28-day readmission). Area under the receiving operator curve (AUC) and Akaike information criterion (AIC) were assessed. Results of the 487,197 patients, 6.8% were classified as high HFRS, and 18.3% as high CCI. Although all models performed better than base model (age and sex) for prediction of 30-day mortality, there was little difference between CCI and HFRS in model discrimination (AUC 0.76 versus 0.75), although CCI provided better model fit (AIC 79,020 versus 79,910). All models had poor ability to predict prolonged LOS (AUC range 0.62–0.63) or readmission (AUC range 0.62–0.65). Using a 5-year lookback period did not improve model discrimination over the 2-year period. Conclusions adjusting for HFRS did not improve prediction of 30-mortality over that achieved by the CCI. Neither HFRS nor CCI were useful for predicting prolonged LOS or 28-day unplanned readmission.

BackgroundPhysical and cognitive impairments are important risk factors for falls in older people. However, no studies have been adequately powered to examine whether cognitive or cognitive-motor training can prevent falls in older people. This is despite good evidence of improvements in fall-related cognitive and physical functions following both intervention types. This manuscript describes the study protocol for a three-arm randomised controlled trial to evaluate the effectiveness of home-based cognitive and cognitive-motor training interventions, compared to a minimal-intervention control group, in preventing falls in older people. This trial was prospectively registered with the Australia New Zealand Clinical Trial Registry, number ACTRN12616001325493.Methods and analysisCommunity-dwelling adults aged 65 years and over, residing in Sydney Australia, will be recruited. Participants (n=750) will be randomly allocated to (1) cognitive-only training, (2) cognitive-motor training or (3) control groups. Both training interventions involve the use of thesmart±step home-based computerised game playing system for a recommended 120 min/week for 12 months. Cognitive training group participants will use a desktop electronic touch pad to play games with thesmart±step system while seated and using both hands. The cognitive-motor training group participants will use a wireless electronic floor step mat that requires accurate stepping using both legs for playing the samesmart±stepgames, hence incorporating balance exercises. All groups will receive an education booklet on fall prevention. The primary outcome will be rate of falls, reported by monthly diaries during the 12-month duration of the study and analysis will be by intention-to-treat. Secondary outcomes include the proportion of fallers, physical and cognitive performance in 300 participants, and brain structure and function in 105 participants who will undertake MRI scans at baseline and 6 months. Cost-effectiveness will be determined using intervention and health service costs.Ethics and disseminationEthical approval was obtained from UNSW Ethics Committee in September 2015 (ref number HC15203). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences.Trial registration numberACTRN12616001325493

OBJECTIVE To systematically examine stepping performance as a risk factor for falls. More specifically, we examined (i) if step tests can distinguish fallers from non-fallers and (ii) the type of step test (e.g. volitional vs reactive stepping) that is required to distinguish fallers from non-fallers. DATA SOURCE PubMed, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and reference lists of included articles. STUDY SELECTION Cross-sectional and cohort studies that assessed the association between at least one step test and falls in older people (age ≥ 60 and/or mean age of 65). RESULTS A meta-analysis of 61 studies (n = 9536) showed stepping performance was significantly worse in fallers compared to non-fallers (Cohen'sd 0.56, 95 % CI 0.48 to 0.64, p < 0.001, I2 66 %). This was the case for both volitional and reactive step tests. Twenty-three studies (n = 3615) were included in a diagnostic meta-analysis that showed that step tests have moderate sensitivity (0.70, 95 % CI 0.62 to 0.77), specificity (0.68, 95 % CI 0.58 to 0.77) and area under the receiver operating characteristics curve (AUC) (0.75, 95 % CI 0.59 to 0.86) in discriminating fallers from non-fallers. CONCLUSIONS This large systematic review demonstrated that both volitional and reactive stepping impairments are significant fall risk factors among older adults. Step tests can identify fallers from non-fallers with moderate accuracy.

© 2015 Asian Pacific Society of Respirology. Background and objective The management of chronic refractory breathlessness is one of the indications for regular low-dose (≤30 mg/24 h) oral sustained release morphine. Morphine may disrupt sleep in some conditions and improve sleep quality in others. This study aimed to determine any signal of regular, low-dose morphine on perceived sleep disruption due to breathlessness and perceived sleep quality. Methods This is a secondary analysis of data from 38 participants with refractory breathlessness (30 male; 33 with COPD) aged 76 ± 0.9 years who completed a double-blind, randomized, placebo-controlled, cross-over study in which they received 20 mg oral sustained release morphine daily and placebo for 4 days each. Participant ratings of sleep disruption due to breathlessness and perceived sleep quality were obtained daily throughout the 8-day trial. Results Perceived sleep disruption due to breathlessness over the 4-day period ranged between 13% and 32% of participants for placebo and 13% and 26% for morphine, decreasing by each day of the study during the morphine arm. Most participants reported 'very good' or 'quite good' sleep throughout the trial and were less likely to perceive poor sleep quality during the morphine arm (odds ratio = 0.55, 95% confidence interval: 0.34-0.88, P = 0.01). Participants who reported decreased breathlessness during the 4 days on morphine were also likely to report improved sleep quality with morphine (P = 0.039). Conclusion Four days of low-dose morphine improved perceived sleep quality in elderly participants with refractory breathlessness. Regular low-dose morphine targeted to reduce refractory breathlessness may yield associated benefits by reducing sleep disruption and improving sleep quality.

Study ObjectivesA collapsible or crowded pharyngeal airway is the main cause of obstructive sleep apnea (OSA). However, quantification of airway collapsibility during sleep (Pcrit) is not clinically feasible. The primary aim of this study was to compare upper airway collapsibility using a simple wakefulness test with Pcrit during sleep.MethodsParticipants with OSA were instrumented with a nasal mask, pneumotachograph and two pressure sensors, one at the choanae (PCHO), the other just above the epiglottis (PEPI). Approximately 60 brief (250 ms) pulses of negative airway pressure (~ –12 cmH2O at the mask) were delivered in early inspiration during wakefulness to measure the upper airway collapsibility index (UACI). Transient reductions in the continuous positive airway pressure (CPAP) holding pressure were then performed during sleep to determine Pcrit. In a subset of participants, the optimal number of replicate trials required to calculate the UACI was assessed.ResultsThe UACI (39 ± 24 mean ± SD; range = 0%–87%) and Pcrit (–0.11 ± 2.5; range: –4 to +5 cmH2O) were quantified in 34 middle-aged people (9 female) with varying OSA severity (apnea–hypopnea index range = 5–92 events/h). The UACI at a mask pressure of approximately –12 cmH2O positively correlated with Pcrit (r = 0.8; p < 0.001) and could be quantified reliably with as few as 10 replicate trials. The UACI performed well at discriminating individuals with subatmospheric Pcrit values [receiver operating characteristic curve analysis area under the curve = 0.9 (0.8–1), p < 0.001].ConclusionsThese findings indicate that a simple wakefulness test may be useful to estimate the extent of upper airway anatomical impairment during sleep in people with OSA to direct targeted non-CPAP therapies for OSA.

The aim of this study was to investigate physical decline over 1-year in a cohort of older people across the cognitive spectrum.Physical function was assessed using the Physiological Profile Assessment (PPA) in 593 participants (cognitively normal [CN]: n = 342, mild cognitive impairment [MCI]: n = 77, dementia: n = 174) at baseline and in 490 participants available for reassessment 1-year later. Neuropsychological performance and physical activity (PA) were assessed at baseline.Median baseline PPA scores for CN, MCI and dementia groups were 0.41 (IQR = -0.09-1.02), 0.66 (IQR = -0.06-1.15) and 2.37 (IQR = 0.93-3.78) respectively. All baseline neuropsychological domains and PA were significantly associated with baseline PPA. There were significant interaction terms (Time × Cognitive Group, Global Cognition, Processing Speed, Executive Function and PA) in the models investigating PPA decline. In multivariate analysis the Time × Executive Function and PA interaction terms were significant, indicating that participants with poorer baseline executive function and reduced PA demonstrated greater physical decline when compared to individuals with better executive function and PA respectively.Having MCI or dementia is associated with greater physical decline compared to CN older people. Physical inactivity and executive dysfunction were associated with physical decline in this sample, which included participants with MCI and dementia. Both factors influencing physical decline are potentially amenable to interventions e.g. exercise.

Objectives To evaluate the performance of the Charlson Comorbidity Index (CCI) in the prediction of mortality, 30-day readmission, and length of stay (LOS) in a hip fracture population using algorithms designed for use in International Classification of Diseases, 10th Revision (ICD-10)–coded administrative data sets. Study Design and Setting Hospitalization and death data for 47,698 New South Wales residents aged 65 years and over, admitted for hip fracture, were linked. Comorbidities were ascertained using ICD-10 coding algorithms developed by Sundararajan (2004) and Quan (2005). Regression models were fitted, and area under the receiver operating curve (AUC) and Akaike information criterion were assessed. Results Both algorithms had acceptable discrimination in predicting in-hospital (AUC, 0.72–0.76), 30-day (0.72–0.75), and 1-year mortality (0.69–0.75) but poor ability to predict 30-day readmission (0.54–0.57) or LOS (adjusted R 2 , 0.007–0.045). The Quan algorithm provided better model fit than the Sundararajan algorithm. Models incorporating comorbidities as individual variables performed better than the Charlson weighted or updated Quan weighted score. Including a 1-year lookback period increased predictive ability for 1-year mortality only. Conclusion The CCI is a valid tool for predicting mortality but not resource utilization after hip fracture. We recommend the use of the Quan algorithm rather than Sundararajan algorithm and to model individual conditions rather than categorized weighted scores.

To quantify the incidence and timing of second hip fracture, and to evaluate the relative impact of comorbidities on risk of second hip fracture.Hospitalization records for individuals aged ≥65, admitted to a New South Wales hospital for fall-related hip fracture between 1 January 2005 and 31 December 2009 were linked. Comorbidities were identified from the records using a 1-year look-back period. To calculate second hip fracture rates, individuals were followed until death, fracture or end of study period (31 December 2012). Time-dependent competing-risk hazards regression was used to assess the relative contribution of each comorbidity to fracture risk, adjusting for age and sex.Of the 24 500 individuals who sustained at least one hip fracture, 2.9% experienced a second within a year, 6.1% within 3 years and 9.4% within 8 years. Malnutrition/cachexia (hazard ratio (HR): 2.47; 99.9% confidence interval (CI): 1.87-3.26), dementia (HR: 2.15; 99.9% CI: 1.80-2.57), congestive heart failure (HR: 1.62; 99.9% CI: 1.30-2.04), Parkinson's disease (HR: 1.51; 99.9% CI: 1.08-2.10), cerebrovascular disease (HR: 1.41; 99.9% CI: 1.06-1.89) and osteoporosis (HR: 1.36; 99.9% CI: 1.11-1.67) were associated with increased risk of second hip fracture within 3 years. Mortality was high; with 26% of individuals dying within a year, 44.9% within 3 years and 70.2% within 8 years.One in 11 older individuals with an initial hip fracture sustained a second hip fracture. While the priority is to prevent the first hip fracture, those that have sustained a hip fracture should be seen as a high risk population and be targeted for future falls and fracture prevention strategies.

To identify patient, clinical, and operational factors associated with nontransport of older people who have fallen and received ambulance care; and to develop a nontransport prediction tool that could be utilized during the dispatch process to rationalize allocation of emergency ambulance resources.The study was a planned subanalysis using data collected during a prospective observational cohort study of nonconsecutive emergency responses to older people aged 65 years or more who had fallen between October 1, 2010 and June 30, 2011. The data consisted of routinely collected ambulance dispatch and clinical records, combined with prospectively collected fall-specific information. Missing data were managed using multiple imputation. Multivariate logistic regression modeling was undertaken to identify predictors of nontransport. Results are described for original and imputated data sets, presented as odds ratios (OR) with 95%CI (confidence interval). Receiver operating curve (ROC) statistics were generated, with model discrimination determined by the area under the curve (AUC).There were 1,484 cases eligible for this subanalysis of which 419 (28.2%) were recorded as nontransport. Multivariate regression including dispatch and clinical variables identified a 6-item final model. Younger age group, nonurgent response priority, and presence of a personal alarm were predictors of nontransport, along with clinical variables, including normal vital signs, absence of injury, and unchanged functional status post-fall. The AUC was 0.88 (95% CI 0.86-0.90; p0.0001) (imputed data AUC 0.86 (95% CI 0.84-0.88)). Multivariate modeling of dispatch variables only identified a 3-item final model, which included response nonurgent response priority, younger age, and the presence of a personal alarm. The AUC was 0.68 (95% CI 0.64-0.71; p0.0001) (imputed data AUC 0.69 (95% CI 0.66-0.72)).In this population of confirmed older fallers attended to by paramedics, determination of the prehospital transport outcome is greatly influenced by on-scene findings resulting from paramedic assessment. The presence of new pain, abnormal physiology, and altered function post-fall were strongly associated with increased odds of transport. Conversely the presence of a personal alarm and allocation of a nonurgent dispatch priority increased the odds of nontransport. Accurate discrimination between older fallers who were and were not transported using dispatch data only was not possible.

To conduct a systematic literature review and meta-analysis to evaluate studies that have addressed depressive symptoms as a risk factor for falls in older people.Systematic review with meta-analysis.Community and residential care.Individuals aged 60 and older.Depressive symptoms, incidence of falls.Twenty-five prospective studies with a total of 21,455 participants met inclusion criteria for the systematic review. Twenty studies met criteria for the meta-analyses. Recruitment of participants was conducted randomly or by approaching groups with identified healthcare needs. Eleven measures were used to assess depressive symptoms, and length of follow-up for falls ranged from 90 days to 8 years. Reporting of antidepressant use was variable across studies. The pooled effect of 14 studies reporting odds ratios (ORs) indicated that a higher level of depressive symptoms at baseline resulted in a greater likelihood of falling during follow-up (OR = 1.46, 95% confidence interval (CI) = 1.27-1.67, P.001, I(2) = 77.2%). In six studies reporting relative risks (RRs) or hazard ratios, a higher level of depressive symptoms at baseline resulted in a greater likelihood of falling during follow-up (RR = 1.52, 95% CI = 1.19-1.84, P.001). There was no difference between community samples and those with identified healthcare needs with respect to depressive symptoms being a risk factor for falls.Depressive symptoms were found to be consistently associated with falls in older people, despite the use of different measures of depressive symptoms and falls and varying length of follow-up and statistical methods. Clinicians should consider management of depression when implementing fall prevention initiatives, and further research on factors mediating depressive symptoms and fall risk in older people is needed.

Retrospective chart review. To investigate the extent of renal deterioration in patients with spinal cord injury (SCI) and to identify risk indicators associated with renal deterioration. Clinic for Spinal Cord Injuries, Rigshospitalet, Hornbaek, Denmark. This study included 116 patients admitted to our clinic with a traumatic SCI sustained between 1956 and 1975. Results from renography and 51Cr-EDTA plasma clearance were collected from medical records from time of injury until 2012, and the occurrence of renal deterioration was analysed by cumulative incidence curves. The impact of demographics, neurological level and completeness of SCI, urinary tract stones, dilatation of the upper urinary tract (UUT) and bladder-emptying methods were analysed with Cox proportional hazard ratios. The bladder-emptying methods used for the longest period were reflex triggering (63%), bladder expression (22%), indwelling catheter (5%), normal voiding (4%), ileal conduit (3%) and clean intermittent catheterisation (2%). The cumulative risk of moderate renal deterioration (functional distribution outside 40−60% on renography or relative glomerular filtration rate (GFR) ⩽75% of expected according to age and gender) was 58%. The cumulative risk of severe renal deterioration (functional distribution outside 30−70% on renography or relative GFR⩽51%) was 29% after 45 years postinjury. Only dilatation of UUT and renal/ureter stone requiring removal significantly increased the risk of moderate and severe renal deterioration. Renal deterioration occurs at any time after injury, suggesting that lifelong follow-up examinations of the renal function are important, especially in patients with dilatation of UUT and/or renal/ureter stones.

OBJECTIVE To examine the impact of orthogeriatric services on 30-day mortality and length of stay (LOS) for hip fracture patients undergoing surgery in public hospitals in New South Wales. DESIGN, SETTING AND PATIENTS A retrospective analysis of patients aged 65 years and older who had a fractured hip and received surgical intervention between 1 July 2009 and 30 June 2011 at one of the 37 NSW public hospitals operating on hip fracture patients. MAIN OUTCOME MEASURES 30-day mortality and LOS. RESULTS During the study period, there were 9601 hip fracture cases for which surgery was done. Mean age, sex and comorbidity distribution were similar for hip fracture patients treated in hospitals with an orthogeriatric service compared with those treated in hospitals without an orthogeriatric service. There were 706 deaths within 30 days of hip fracture surgery, and the overall unadjusted 30-day mortality rate was 7.4%. The median adjusted 30-day mortality rate for hospitals with an orthogeriatric service was significantly lower than that for hospitals without an orthogeriatric service (6.2% v 8.4%; P

Objectives To translate, validate, and compare performance of an International Classification of Diseases, 10th revision (ICD-10) version of the Multipurpose Australian Comorbidity Scoring System (MACSS) against commonly used comorbidity measures in the prediction of short- and long-term mortality, 28-day all-cause readmission, and length of stay (LOS). Study Design and Setting Hospitalization and death data were linked for 25,374 New South Wales residents aged 65 years and older, admitted with a hip fracture between 2008 and 2012. Comorbidities were identified according to the MACSS, Charlson, and Elixhauser definitions using ICD-10 coding algorithms. Regression models were fitted and area under the curve (AUC) and Akaike Information Criterion assessed. Results The ICD-10 MACSS had excellent discriminating ability in predicting inhospital mortality (AUC = 0.81) and 30-day mortality (AUC = 0.80), acceptable prediction of 1-year mortality (AUC = 0.76) but poor discrimination for 28-day readmission and LOS. The MACSS algorithm provided better model fit than either Charlson or Elixhauser algorithm for all outcomes. Conclusion This work presents a rigorous translation of the ICD-9 MACSS for use with ICD-10 coded data. The updated ICD-10 MACSS outperformed both Charlson and Elixhauser measures in an older population and is recommended for use with large administrative data sets in predicting mortality outcomes.

Copyright © 2015 Schoene et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Purpose Interactive cognitive-motor training (ICMT) requires individuals to perform both gross motor movements and complex information processing. This study investigated the effectiveness of ICMT on cognitive functions associated with falls in older adults. Methods A single-blinded randomized controlled trial was conducted in community-dwelling older adults (N = 90, mean age 81.5±7) without major cognitive impairment. Participants in the intervention group (IG) played four stepping games that required them to divide attention, inhibit irrelevant stimuli, switch between tasks, rotate objects and make rapid decisions. The recommended minimum dose was three 20-minute sessions per week over a period of 16 weeks unsupervised at home. Participants in the control group (CG) received an evidence- based brochure on fall prevention. Measures of processing speed, attention/executive function (EF), visuo-spatial ability, concerns about falling and depression were assessed before and after the intervention. Results Eighty-one participants (90%) attended re-assessment. There were no improvements with respect to the Stroop Stepping Test (primary outcome) in the intervention group. Compared to the CG, the IG improved significantly in measures of processing speed, visuo-spatial ability and concern about falling. Significant interactions were observed for measures of EF and divided attention, indicating group differences varied for different levels of the covariate with larger improvements in IG participants with poorer baseline performance. The interaction for depression showed no change for the IG but an increase in the CG for those with low depressive symptoms at baseline. Additionally, low and high-adherer groups differed in their baseline performance and responded differently to the intervention. Compared to high adherers, low adherers improved more in processing speed and visual scanning while highadherers improved more in tasks related to EF. Conclusions This study shows that unsupervised stepping ICMT led to improvements in specific cognitive functions associated with falls in older people. Low adherers improved in less complex functions while high-adherers improved in EF. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12613000671763.

Population ageing presents significant challenges for many developed nations. Accurately forecasting the likely future burden of age-related medical conditions, such as hip fracture, is critical. In this study, we present estimates of the current and future burden of hip fracture in NSW, Australia, providing crucial information for future health care planning. The aims of this study were to investigate the burden of hip fracture in Australia’s largest state, New South Wales (NSW), and to build a prediction model to forecast the likely future burden of hip fracture from 2016 to 2036 in persons aged 50 years or more. A retrospective population-based cohort study was conducted using NSW hospitalisation data. Standardised incident hip fracture rates and hip fracture-related acute care length of stay and costs were estimated. Predictive negative binomial regression modelling using age, gender and local health district and year covariates together with projected NSW populations was applied to forecast future hip fractures. Total incident hip fractures increased 8.8 % over a 12-year period from 2000/2001 to 2011/2012 despite declining age-standardised rates. Estimates of acute care length of stay for the treatment of hip fracture ranged from 10 to 15 days and acute care costs ranged between 21 and 29,000 Australian dollars per fracture. By 2036, incident hip fractures are projected to rise by 35.2 %, assuming a continued decline in the rate of hip fracture or by 107.5 % if the current decline in the rate does not continue. Acute care length of stay and costs are each predicted to rise between 37.1 and 110.4 % by 2036. An ageing population and changing demographics will continue to drive the increasing burden of incident hip fractures in NSW and Australia in the foreseeable future. These anticipated changes provide important information for the planning and management of future hip fracture care.

Guidelines for hip fracture care suggest that patients with hip fracture should undergo surgery on the day of or day after admission to hospital. This study examined factors affecting time to surgery for hip fracture extracted from existing administrative datasets in New South Wales (NSW), Australia.A retrospective analysis of patients with hip fracture aged 65 years and over undergoing surgical intervention in NSW public hospitals between 1 July 2000 and 30 June 2011. A multinomial logistic model was used to identify factors impacting on time to surgery from 1 July 2006 to 30 June 2011.A total of 49,317 hip fracture procedures were recorded during 2000-2001 to 2010-2011. Sixty-four per cent of patients received operative treatment on the day of or day after admission. Co-morbidity, type of surgical procedure and day of presentation all impacted significantly on time to surgery. Fourteen per cent required an inter-hospital transfer prior to receiving operative intervention. Transferred patients were 2.6 (95% confidence interval (CI): 2.31-2.85) times more likely to wait 2-4 days and 3.2 times more likely to wait 5 or more days (95% CI: 2.77-3.76) for surgery compared with patients presenting to an operating hospital.Significant variation exists between hospitals in the time to surgery that is not solely explained by measures of case mix or geography. Opportunities exist to consider other factors contributing to this variation and to ensure timely access to surgical intervention in the future.

Introduction Dementia and fall-related hip fractures both contribute significantly to the burden of illness within elderly populations in Australia and elsewhere. The research presented here uses a large probabilistically linked dataset from NSW, Australia to estimate the prevalence of dementia within hip fracture patients and investigate the impact of dementia on hospitalisation length of stay (LOS) and survival. Method The cases considered were NSW residents aged 65 years and above who experienced a fall related hip fracture between 1 July 2000 and 30 June 2009. The prevalence of dementia was calculated for the incident hip fracture using two methods to infer dementia status. Cox proportional hazards regression modelling was used to estimate the relative rate of discharge from a hospitalisation episode, and the relative mortality rate of hip fracture patients suffering dementia versus those who were cognitively intact. Additional covariates used in the models included sex, age group at admission, the Charlson Comorbidity Index and separation mode. Results Of the 44,143 fall-related incident hip fracture cases considered, between 24% (observed diagnosis) to 29% (inferred diagnosis) of these people had dementia. The median LOS for patients with dementia was shorter than those without dementia, but there was a strong interaction with age. The rate of discharge from the fracture-related hospitalisation episode of the cases with dementia was 40% greater (95% CI 1.4–1.5) than the non-demented group. Similarly, the relative mortality rate of those with dementia was greater (2.4, 95% CI 2.3–2.6) than the non-demented group. Both Cox analyses indicated evidence for main effects of age at admission and comorbidity, as well as interaction effects between age group and dementia status. Conclusion The use of linked datasets with tens of thousands of cases enables the calculation of precise estimates of various parameters. People with dementia constitute a significant proportion of the total population of elderly hip fracture patients in hospitals (up to 29%). Their mortality rate is greater than those without a diagnosis of dementia and their hospital length of stay is shorter, particularly if they are discharged to a residential aged care facility.

In this article we report trends in deaths related to drug misuse in England and Wales from 1993 to 2004, looking particularly at the period between 1999 and 2004, for which there was a Government target to reduce these deaths by 20 per cent. Although there was an overall decline in deaths related to drug misuse between 1999 and 2004, the percentage reduction, at 9 per cent, was less than the Government target. There was an increase in deaths between 2003 and 2004, largely accounted for by deaths involving heroin/methadone and morphine. Mortality rates were highest in young adults and an increase in mortality rates within this group appears to have been the driver behind rising mortality trends during the 1990s.