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Aims: To assess the impact of diabetes and frailty on self-rated health, depressive symptoms and quality of life (QoL). Methods: Data were pooled for participants aged ≥50 years from five waves of the Survey of Health, Ageing and Retirement in Europe. Measures included diabetes (self-reported), physical frailty (≥3/5 criteria), low self-rated health (SRH; “poor” or “fair”), depression (screened using the EURO-D ≥4) and low QoL (CASP-12

Introduction: This study examines the attitudes of Irish consultant physicians towards euthanasia and physician-assisted suicide. Methods: Data were collected between May and October 2016. A questionnaire was distributed to all consultant physicians listed in the Irish Medical Directory under general internal medicine specialties. Demographic details were collected. Likert-type questions assessed attitudes towards euthanasia and physician-assisted suicide. Results: The overall response rate was 28.7% (238/830). The majority, 67.2%, opposed legalising euthanasia, with 14% in favour and 18.8% remaining neutral. A majority, 56.3%, also opposed legalising physician-assisted suicide, while 17% were in favour and 26.7% remained neutral. Over one-third, 37.5%, had received a request from a patient to hasten that patient’s death. Receiving such a request did not significantly influence attitudes towards either euthanasia (p=0.53) or physician-assisted suicide (p=0.48). There was a significant association between self-expressed level of religiosity and opposition to both euthanasia (p

Frailty in middle-aged and older adults is associated with diabetes-related complications. The impact of and interaction between diabetes and frailty on psychosocial wellbeing and mortality in Ireland for adults aged &ge, 50 years were assessed using data from the Survey of Health, Ageing and Retirement in Europe. Measures included diabetes status (self-reported), frailty phenotype (&ge, 3/5 criteria), low self-rated health (&ldquo, fair&rdquo, or &ldquo, poor&rdquo, ), depression screening (EURO-D index score &ge, 4), and low quality of life (QoL) (CASP-12 index score &lt, 35). Among the 970 participants, those with diabetes (n = 87) were more likely to be frail (23% vs. 8%, p &lt, 0.001), have low self-rated health (46% vs. 19%, 0.001), depression (25% vs. 17%, p = 0.070), and low QoL (25% vs. 18%, p = 0.085). Adjusting for diabetes, age and sex, frailty independently predicted low self-rated health (OR: 9.79 (5.85&ndash, 16.36)), depression (9.82 (5.93&ndash, 16.25)), and low QoL (8.52 (5.19&ndash, 13.97)). Adjusting for frailty, age and sex, diabetes independently predicted low self-rated health (2.70 (1.63&ndash, 4.47)). The age-sex adjusted mortality hazard ratio was highest for frailty with diabetes (4.67 (1.08&ndash, 20.15)), followed by frailty without diabetes (2.86 (1.17&ndash, 6.99)) and being non-frail with diabetes (1.76 (0.59&ndash, 5.22)). Frailty independently predicts lower self-reported wellbeing and is associated with reduced survival, underpinning its role as an integral part of holistic diabetes care.

Background: COVID-19 has disproportionately affected older people. Visiting restrictions introduced since the start of the pandemic in residential care facilities (RCFs) may impact negatively on visitors including close family, friends, and guardians. We examined the effects of COVID-19 visiting restrictions on measures of perceived loneliness, well-being, and carer quality of life (QoL) amongst visitors of residents with and without cognitive impairment (CI) in Irish RCFs. Methods: We created a cross-sectional online survey. Loneliness was measured with the UCLA brief loneliness scale, psychological well-being with the WHO-5 Well-being Index and carer QoL with the Adult Carer QoL Questionnaire (support for caring subscale). Satisfaction with care (“increased/same” and “decreased”) was measured. A history of CI was reported by respondents. Sampling was by convenience with the link circulated through university mail lists and targeted social media accounts for 2 weeks in June 2020. Results: In all, 225 responses were included of which 202 noted whether residents had reported CI. Most of the 202 identified themselves as immediate family (91%) and as female (82%). The majority (67%) were aged between 45 and 64 years. Most (80%) reported that their resident had CI. Approximately one-third indicated reduced satisfaction (27%) or that restrictions had impaired communication with nursing home staff (38%). Median loneliness scores were 4/9, well-being scores 60/100 and carer QoL scores 10/15. Visitors of those with CI reported significantly lower well-being (p = 0.006) but no difference in loneliness (p = 0.114) or QoL (p = 0.305). Reported CI (p = 0.04) remained an independent predictors of lower WHO-5 scores, after adjusting for age, sex, RCF location, and dementia stage (advanced), satisfaction with care (reduced), and perception of staff support measured on the Adult Carer QoL Questionnaire. Conclusion: This survey suggests that many RCF visitors experienced low psychosocial and emotional well-being during the COVID-19 lockdown. Visitors of residents with CI report significantly poorer well-being as measured by the WHO-5 than those without. Additional research is required to understand the importance of disrupted caregiving roles resulting from visiting restrictions on well-being, particularly on visitors of residents with CI and how RCFs and their staff can support visitors to mitigate these.

Background Cutoff values of cognitive screen tests vary according to age and educational levels. Objective The objective of this study was to compare the accuracy and determine cutoffs for 3 short cognitive screening instruments: the Mini-Mental State Examination, Montreal Cognitive Assessment (MoCA), and Quick Mild Cognitive Impairment Screen-Turkish version (Qmci-TR), in older adults with low literacy in Turkey. Methods In all 321 patients, 133 with subjective cognitive complaints (SCC), 88 amnestic-type mild cognitive impairment (aMCI), and 100 with probable Alzheimer disease (AD) with a median of 5 years education were included. Education and age-specific cutoffs were determined. Results For the overall population, the Qmci-TR was more accurate than the MoCA in distinguishing between aMCI and AD (area under the curve=0.83 vs. 0.76, P=0.004) and the Qmci-TR and Mini-Mental State Examination were superior to the MoCA in discriminating SCC from aMCI and AD. All instruments had similar accuracy among those with low literacy (primary school and lower educational level or illiterate). Conclusions To distinguish between SCC, aMCI, and AD in a sample of older Turkish adults, the Qmci-TR may be preferable. In very low literacy, the choice of the instrument appears less important.

Frailty is an independent age-associated predictor of morbidity and mortality. Despite this, many countries lack population estimates with large heterogeneity between studies. No population-based standardised metric for frailty is available. We applied the deficit accumulation model of frailty to create a frailty index (FI) using population-level estimates from the Global Burden of Disease (GBD) 2017 study across 195 countries to create a novel GBD frailty index (GBD-FI). Standard FI criteria were applied to all GBD categories to select GBD-FI items. Content validity was assessed by comparing the GBD-FI with a selection of established FIs. Properties including the rate of deficit accumulation with age were examined to assess construct validity. Linear regression models were created to assess if mean GBD-FI scores predicted one-year incident mortality. From all 554 GBD items, 36 were selected for the GBD-FI. Face validity against established FIs was variable. Characteristic properties of a FI&mdash, higher mean score for females and a deficit accumulation rate of approximately 0.03 per year, were observed. GBD-FI items were responsible for 19% of total Disability-Adjusted Life Years for those aged &ge, 70 years in 2017. Country-specific mean GBD-FI scores ranged from 0.14 (China) to 0.19 (Hungary) and were a better predictor of mortality from non-communicable diseases than age, gender, Healthcare Access and Quality Index or Socio-Demographic Index scores. The GBD-FI is a valid measure of frailty at population-level but further external validation is required.

Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is defined, limiting comparability between studies and reducing the ability to scale effective interventions. To identify and define the characteristics of intermediate care models. A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted. Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models. There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination. This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.

Objectives: Brief screening instruments are useful in busy clinical practice to identify those requiring further assessment. This study aims to translate and validate a Portuguese version of the fo...

Introduction The prevalence of frailty at population level is unclear. We examined this in population-based studies, investigating sources of heterogeneity. Methods PubMed, Embase, CINAHL and Cochrane Library databases were searched for observational population-level studies published between 1 January 1998 and 1 April 2020, including individuals aged ≥50 years, identified using any frailty measure. Prevalence estimates were extracted independently, assessed for bias and analysed using a random-effects model. Results In total, 240 studies reporting 265 prevalence proportions from 62 countries and territories, representing 1,755,497 participants, were included. Pooled prevalence in studies using physical frailty measures was 12% (95% CI = 11–13%; n = 178), compared with 24% (95% CI = 22–26%; n = 71) for the deficit accumulation model (those using a frailty index, FI). For pre-frailty, this was 46% (95% CI = 45–48%; n = 147) and 49% (95% CI = 46–52%; n = 29), respectively. For physical frailty, the prevalence was higher among females, 15% (95% CI = 14–17%; n = 142), than males, 11% (95% CI = 10–12%; n = 144). For studies using a FI, the prevalence was also higher in females, 29% (95% CI = 24–35%; n = 34) versus 20% (95% CI = 16–24%; n = 34), for males. These values were similar for pre-frailty. Prevalence increased according to the minimum age at study inclusion. Analysing only data from nationally representative studies gave a frailty prevalence of 7% (95% CI = 5–9%; n = 46) for physical frailty and 24% (95% CI = 22–26%; n = 44) for FIs. Conclusions Population-level frailty prevalence varied by classification and sex. Data were heterogenous and limited, particularly from nationally representative studies making the interpretation of differences by geographic region challenging. Common methodological approaches to gathering data are required to improve the accuracy of population-level prevalence estimates. Protocol registration PROSPERO-CRD42018105431.

PurposeTo identify transitional palliative care (TPC) interventions for older adults with non-malignant chronic diseases and complex conditions.Design/methodology/approachA systematic review of the literature was conducted. CINAHL, Cochrane Library, Embase and Pubmed databases were searched for studies reporting TPC interventions for older adults, published between 2002 and 2019. The Crowe Critical Appraisal Tool was used for quality appraisal.FindingsA total of six studies were included. Outcomes related to TPC interventions were grouped into three categories: healthcare system-related outcomes (rehospitalisation, length of stay [LOS] and emergency department [ED] visits), patient-related outcomes and family/carer important outcomes. Overall, TPC interventions were associated with lower readmission rates and LOS, improved quality of life and better decision-making concerning hospice care among families. Outcomes for ED visits were unclear.Research limitations/implicationsPositive outcomes related to healthcare services (including readmissions and LOS), patients (quality of life) and families (decision-making) were reported. However, the number of studies supporting the evidence were limited.Originality/valueStudies examining the effectiveness of existing care models to support transitions for those in need of palliative care are limited. This systematic literature review identified and appraised interventions aimed at improving transitions to palliative care in older adults with advanced non-malignant diseases or frailty.

Non-communicable chronic diseases (NCCDs) are the main cause of morbidity and mortality globally. Demographic aging has resulted in older populations with more complex healthcare needs. This necessitates a multilevel rethinking of healthcare policies, health education and community support systems with digitalization of technologies playing a central role. The European Innovation Partnership on Active and Healthy Aging (A3) working group focuses on well-being for older adults, with an emphasis on quality of life and healthy aging. A subgroup of A3, including multidisciplinary stakeholders in health care across Europe, focuses on the palliative care (PC) model as a paradigm to be modified to meet the needs of older persons with NCCDs. This development paper delineates the key parameters we identified as critical in creating a public health model of PC directed to the needs of persons with NCCDs. This paradigm shift should affect horizontal components of public health models. Furthermore, our model includes vertical components often neglected, such as nutrition, resilience, well-being and leisure activities. The main enablers identified are information and communication technologies, education and training programs, communities of compassion, twinning activities, promoting research and increasing awareness amongst policymakers. We also identified key ‘bottlenecks’: inequity of access, insufficient research, inadequate development of advance care planning and a lack of co-creation of relevant technologies and shared decision-making. Rethinking PC within a public health context must focus on developing policies, training and technologies to enhance person-centered quality life for those with NCCD, while ensuring that they and those important to them experience death with dignity.

Assessment of cognitive impairment is a common requirement in clinical practice, especially in geriatric medicine. The use of valid, reliable, and brief tests of cognitive function is vital in determining the need for further investigations of symptomatic patients. Such tests are also important in population screening, albeit the benefits of this are yet unproven. A number of brief cognitive screening instruments are used in clinical practice but none meets all the requirements across the spectrum of clinical practice, able to separate subjective deficits from mild cognitive impairment and dementia across all subtypes. The Quick Mild Cognitive Impairment (Qmci) screen has been validated in multiple clinical settings and countries. It has similar accuracy compared with the commonly used Montreal Cognitive Assessment and is more accurate than the Mini-Mental State Examination in differentiating those with normal cognitive function and cognitive impairment. The short time requirement for administering the Qmci screen makes it suitable for doctors in busy clinical practice.

Journal article Aims: As populations age there is an increased demand for nursing home (NH) care and a parallel increase in the prevalence of diabetes. Despite this, there is growing evidence that the management of diabetes in NHs is suboptimal. The reasons for this are complex and poorly understood. This study aimed to identify the current level of diabetes care in NHs using a mixed methods approach. Methods: The nursing managers at all 44 NHs in County Galway in the West of Ireland were invited to participate. A mixed methods approach involved a postal survey, focus group and telephone interviews. Results: The survey response rate was 75% (33/44) and 27% (9/33) of nursing managers participated in the qualitative research. The reported prevalence of diagnosed diabetes was 14% with 80% of NHs treating residents with insulin. Hypoglycaemia was reported as ‘frequent’ in 19% of NHs. A total of 36% of NHs have staff who have received diabetes education or training and 56% have access to diabetes care guidelines. Staff education was the most cited opportunity for improving diabetes care. Focus group and interview findings highlight variations in the level of support provided by GPs and access to dietetic, podiatry and retinal screening services. Conclusions: There is a need for national clinical guidelines and standards of care for diabetes management in nursing homes, improved access to quality diabetes education for NH staff, and greater integration between healthcare services and NHs to ensure equity, continuity and quality in diabetes care delivery. "This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors." peer-reviewed 2018-03-21

Background: Although required to improve the usability of cognitive screening instruments (CSIs), the use of cut-off scores is controversial yet poorly researched. Objective: To explore cut-off scores for two short CSIs: the Standardized Mini-Mental State Examination (SMMSE) and Quick Mild Cognitive Impairment (Qmci) screen, describing adjustments in scores for diagnosis (MCI or dementia), age ( 75 years), and education (= 12 years), comparing two methods: the maximal accuracy approach, derived from receiver operating characteristic curves, and Youden's Index. Methods: Pooled analysis of assessments from patients attending memory clinics in Canada between 1999-2010 : 766 with mild cognitive impairment (MCI) and 1,746 with dementia, and 875 normal controls. Results: The Qmci was more accurate than the SMMSE in differentiating controls from MCI or cognitive impairment (MCI and dementia). Employing the maximal accuracy approach, the optimal SMMSE cut-off for cognitive impairment was < 28/30 (AUC 0.86, sensitivity 74%, specificity 88%) versus < 63/100 for the Qmci (AUC 0.93, sensitivity 85%, specificity 85%). Using Youden's Index, the optimal SMMSE cut-off remained < 28/30 but fell slightly to < 62/100 for the Qmci (sensitivity 83%, specificity 87%). The optimal cut-off for MCI was < 29/30 for the SMMSE and < 67/100 for the Qmci, irrespective of technique. The maximal accuracy approach generally produced higher Qmci cut-offs than Youden's Index, both requiring adjustment for age and education. There were no clinically meaningful differences in SMMSE cut- off scores by age and education or method employed. Conclusion: Caution should be exercised selecting cut-offs as these differ by age, education, and method of derivation, with the extent of adjustment varying between CSIs.

We read with interest the recent editorial examining the relationship between geriatric syndromes and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of Covid-19 (1), particularly the authors recognition of the need to identify frailty among older adults presenting with suspected symptoms and the importance of mobilising a range of healthcare professionals to tackle this disease (1). However, the identification of frailty and the utilisation of screening instruments by those without geriatric training and especially in acute care is challenging. Frailty is a complex condition. While age-associated, it is multi-dimensional and remains difficult to define (2). Although the Covid-19 pandemic has disproportionately affected older adults (1), data are lacking and pathophysiological mechanisms and the impact of differential management strategies on the course of the disease among older adults is uncertain (1). Further, the prevalence of frailty among those diagnosed, admitted or dying is not clearly reported at present. Nevertheless, the rationale for using frailty to identify those at risk and to allocate care has been correctly highlighted (1). We suggest however, that the use of instruments such as the Clinical Frailty Scale (CFS) (3) and particularly by non-specialised staff in this setting warrants more careful examination.

Impaired sleep is common in hospital. Despite this, little is known about sleep disturbance among older adults attending Emergency Departments (ED), particularly overnight-boarders, those admitted but housed overnight while awaiting a bed. Consecutive, medically-stable patients aged &ge, 70, admitted through a university hospital ED were evaluated for overnight sleep quality (Richards Campbell Sleep Questionnaire/RCSQ) and baseline sleep (Pittsburgh Sleep Quality Index/PSQI). Additional variables included frailty, functional and cognitive status, trolley location, time in ED and night-time noise levels. Over four-weeks, 152 patients, mean age 80 (&plusmn, 6.8) years were included, 61% were male. Most (68%) were ED boarders (n = 104) and 43% were frail. The majority (72%) reported impaired sleep quality at baseline (PSQI &ge, 5) and 13% (20/152) had clinical insomnia. The median time spent in ED for boarders was 23 h (Interquartile &plusmn, 13). After adjusting for confounders, median RCSQ scores were significantly poorer for ED boarders compared with non-boarders: 22 (&plusmn, 45) versus 71 (&plusmn, 34), respectively, (p = 0.003). There was no significant difference in one-year mortality (p = 0.08) length of stay (LOS) (p = 0.84), 30-day (p = 0.73) or 90-day (p = 0.64) readmission rates between boarders and non-boarders. Sleep disturbance is highly prevalent among older adults admitted through ED. ED boarders experienced significantly poorer sleep, without this impacting upon mortality, LOS or re-admission rates.

Early identification of frailty through targeted screening can facilitate the delivery of comprehensive geriatric assessment (CGA) and may improve outcomes for older inpatients. As several instruments are available, we aimed to investigate which is the most accurate and reliable in the Emergency Department (ED). We compared the ability of three validated, short, frailty screening instruments to identify frailty in a large University Hospital ED. Consecutive patients aged &ge, 70 attending ED were screened using the Clinical Frailty Scale (CFS), Identification of Seniors at Risk Tool (ISAR), and the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 item questionnaire (PRISMA-7). An independent CGA using a battery of assessments determined each patient&rsquo, s frailty status. Of the 280 patients screened, complete data were available for 265, with a median age of 79 (interquartile &plusmn, 9), 54% were female. The median CFS score was 4/9 (&plusmn, 2), ISAR 3/6 (&plusmn, 2), and PRISMA-7 was 3/7 (&plusmn, 3). Based upon the CGA, 58% were frail and the most accurate instrument for separating frail from non-frail was the PRISMA-7 (AUC 0.88, 95% CI:0.83&ndash, 0.93) followed by the CFS (AUC 0.83, 95% CI:0.77&ndash, 0.88), and the ISAR (AUC 0.78, 95% CI:0.71&ndash, 0.84). The PRISMA-7 was statistically significantly more accurate than the ISAR (p = 0.008) but not the CFS (p = 0.15). Screening for frailty in the ED with a selection of short screening instruments, but particularly the PRISMA-7, is reliable and accurate.

Although there is a high prevalence of delirium and cognitive impairment among hospitalised older adults, short, reliable cognitive measures are rarely used to monitor cognition and potentially alert healthcare professionals to early changes that might signal delirium. We evaluated the reliability, responsiveness, and feasibility of logical memory (LM), immediate verbal recall of a short story, compared to brief tests of attention as a bedside &ldquo, cognitive vital sign&rdquo, (CVS). Trained nursing staff performed twice-daily cognitive assessments on 84 clinically stable inpatients in two geriatric units over 3&ndash, 5 consecutive days using LM and short tests of attention and orientation including months of the year backwards. Scores were compared to those of an expert rater. Inter-rater reliability was excellent with correlation coefficients for LM increasing from r = 0.87 on day 1 to r = 0.97 by day 4 (p &lt, 0.0001). A diurnal fluctuation of two points from a total of 30 was deemed acceptable in clinically stable patients. LM scores were statistically similar (p = 0.98) with repeated testing (suggesting no learning effect). All nurses reported that LM was feasible to score routinely. LM is a reliable measure of cognition showing diurnal variation but minimal learning effects. Further study is required to define the properties of an ideal CVS test, though LM may satisfy these.

Short but accurate cognitive screening instruments are required in busy clinical practice. Although widely-used, the diagnostic accuracy of the standardised Mini-Mental State Examination (SMMSE) in different dementia subtypes remains poorly characterised. We compared the SMMSE to the Quick Mild Cognitive Impairment (Qmci) screen in patients (n = 3020) pooled from three memory clinic databases in Canada including those with mild cognitive impairment (MCI) and Alzheimer&rsquo, s, vascular, mixed, frontotemporal, Lewy Body and Parkinson&rsquo, s dementia, with and without co-morbid depression. Caregivers (n = 875) without cognitive symptoms were included as normal controls. The median age of patients was 77 (Interquartile = &plusmn, 9) years. Both instruments accurately differentiated cognitive impairment (MCI or dementia) from controls. The SMMSE most accurately differentiated Alzheimer&rsquo, s (AUC 0.94) and Lewy Body dementia (AUC 0.94) and least accurately identified MCI (AUC 0.73), vascular (AUC 0.74), and Parkinson&rsquo, s dementia (AUC 0.81). The Qmci had statistically similar or greater accuracy in distinguishing all dementia subtypes but particularly MCI (AUC 0.85). Co-morbid depression affected accuracy in those with MCI. The SMMSE and Qmci have good-excellent accuracy in established dementia. The SMMSE is less suitable in MCI, vascular and Parkinson&rsquo, s dementia, where alternatives including the Qmci screen may be used. The influence of co-morbid depression on scores merits further investigation.

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

Background: Visit-to-visit blood pressure (BP) variability (VVV) is increasingly recognized as a marker of cardiovascular risk. Although implicated in cognitive decline, few studies are currently available assessing its effects on established dementia. Objective: To investigate if VVV is associated with one-year rate of decline in measures of cognition and function in patients with mild to moderate Alzheimer’s disease (AD) in the Doxycycline And Rifampicin for Alzheimer’s Disease study. Methods: Patients were included if ≥3 BP readings were available (n = 392). VVV was defined using different approaches including the coefficient of variation (CV) in BP readings between visits. Outcomes included rates of decline in the Standardized Alzheimer’s Disease Assessment Scale–Cognitive Subscale (SADAS-cog), Standardized MMSE, Clinical Dementia Rating Scale, the Quick Mild Cognitive Impairment screen and the Lawton-Brody activities of daily living (ADL) scale. Results: Half of the patients (196/392) had a ≥4-point decline in the SADAS-cog over one-year. Using this cut-off, there were no statistically significant associations between any measures of VVV, for systolic or diastolic BP, with and without adjustment for potential confounders including treatment allocation, history of hypertension and use of anti-hypertensive and cognitive enhancing medications. Multiple regression models examining the association between systolic BP CV by quartile and decline over one-year likewise showed no clinically significant effects, apart from a U-shaped pattern of ADL decline of borderline clinical significance. Conclusions: This observational study does not support recent research showing that VVV predicts cognitive decline in AD. Further studies are needed to clarify its effects on ADL in AD.

No disease-modifying treatments for dementia are available. Sleep disturbance is strongly associated with cognitive impairment. Non-pharmacological treatments targeting sleep may offer an alternative therapeutic approach. We searched PubMed, CINAHL, EMBASE and the Cochrane library for non-pharmacological treatments for sleep disturbance in mild cognitive impairment (MCI) and dementia, published in English from October 1965 to 2018, including all designs, excluding studies of drug therapies. In all, 53 papers representing 48 studies were included. Participant age ranged from 67.3 to 89.4 years. Most studies (79%) had small samples (50 participants, range 1-173) and were conducted in long-term/residential care (62%). The majority (85%) recruited participants with moderate-severe dementia; mean MMSE scores ranged from 0 to 28.3/30. Four studies examined MCI. Light therapy delivered over 1-10 weeks was the most studied stand-alone intervention (n = 27), and the majority (81.5%) of these studies found improvements on objective or subjective sleep measures, though the evidence was inconclusive with significant clinical and methodological heterogeneity. Seven multi-modal intervention studies were identified, all incorporating light exposure, and six of these reported improved sleep. Other interventions included electrotherapy stimulation (n = 4), physical exercises/activities (n = 4), acupressure/acupuncture (n = 3) and mindfulness/cognitive behavioural therapy (n = 3). Those examining MCI utilised different mono-modal approaches. A meta-analysis of data from randomised controlled trials showed a statistically significant (mean difference = 3.44, 95% CI: 0.89-5.99, I

The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty.

Early detection of dementia provides opportunities for interventions that could delay or prevent its progression. We developed the Japanese version of the Quick Mild Cognitive Impairment (Qmci-J) screen, which is a performance-based, easy-to-use, valid and reliable short cognitive screening instrument, and then we examined its validity. Community-dwelling adults aged 65&ndash, 84 in Niigata prefecture, Japan, were concurrently administered the Qmci-J and the Japanese version of the standardized Mini-Mental State Examination (sMMSE-J). Mild cognitive impairment (MCI) and dementia were categorized using established and age-adjusted sMMSE-J cut-offs. The sample (n = 526) included 52 (9.9%) participants with suspected dementia, 123 (23.4%) with suspected MCI and 351 with likely normal cognition. The Qmci-J showed moderate positive correlation with the sMMSE-J (r = 0.49, p &lt, 0.001) and moderate discrimination for predicting suspected cognitive impairment (MCI/dementia) based on sMMSE-J cut-offs, area under curve: 0.74, (95%CI: 0.70&ndash, 0.79), improving to 0.76 (95%CI: 0.72 to 0.81) after adjusting for age. At a cut-off of 60/61/100, the Qmci-J had a 73% sensitivity, 68% specificity, 53% positive predictive value, and 83% negative predictive value for cognitive impairment. Normative data are presented, excluding those with any sMMSE-J &lt, 27. Though further research is required, the Qmci-J screen may be a useful screening tool to identify older adults at risk of cognitive impairment.

Incontinence is common and associated with adverse outcomes. There are insufficient point prevalence data for incontinence in hospitals. We evaluated the prevalence of urinary (UI) and faecal incontinence (FI) and their predictors among inpatients in an acute university hospital on a single day. Continence status was recorded using the modified Barthel Index (BI). Baseline characteristics, Clinical Frailty Scale (CFS) and ward type were recorded. In all, 435 patients were assessed, median age 72 &plusmn, 23 years and 53% were male. The median CFS score was 5 &plusmn, 3. The point prevalence of UI was 26% versus 11% for FI. While UI and FI increased with age, to 35.2% and 21.1% respectively for those &ge, 85, age was not an independent predictor. Incontinence also increased with frailty, CFS scores were independently associated with both UI (p = 0.006) and FI (p = 0.03), though baseline continence status was the strongest predictor. Patients on orthopaedic wards had the highest prevalence of incontinence. Continence assessments were available for only 11 (2%) patients. UI and FI are common conditions affecting inpatients, point prevalence increases with age and frailty status. Despite this, few patients receive comprehensive continence assessments. More awareness of its high prevalence is required to ensure incontinence is adequately managed in hospitals.

Introduction Vascular cognitive impairment (VCI) is common and important to detect as controlling risk factors, particularly hypertension, may slow onset and progression. There is no consensus as to which cognitive screening instrument (CSI) is most suitable for VCI. We systematically reviewed the psychometric properties of brief CSIs for vascular mild cognitive impairment (VMCI) and vascular dementia (VaD). Methods Literature searches were performed using scholarly databases from inception until 31 May 2018. Studies were eligible if participants were aged 18 or older, interviewed face-to-face, and standard diagnostic criteria for VCI were applied, excluding those specifically identifying post-stroke dementia. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Results Fifteen studies were identified including eight types of CSIs (27 subtests/variants) and 4575 participants (1015 with VCI), mean age range: 51.6 to 75.5 years. Most studies compared more than one instrument. Five papers examined clock-drawing; four, the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE); and three used the Brief Memory and Executive Test (BMET). The MoCA (AUC > 0.90) and MMSE (AUC: 0.86-0.99) had excellent accuracy in differentiating VaD from controls; the MoCA had good internal consistency (Cronbach's α: .83-.88). The MoCA (AUC: 0.87-0.93) and BMET (AUC: 0.94) had the greatest accuracy in separating VMCI from controls. Most studies had low to moderate risk of bias in all domains of the QUIPS. Data were heterogeneous, precluding a meta-analysis. Conclusions Although few studies were available and further research is required, data suggests that the MoCA is accurate and reliable for differentiating VaD and VMCI from controls.

Neurocognitive Disorders (NCD) is an increasingly common condition in the community. The General Practitioner (GP) in Primary Care Services (PCS), have a crucial role in early detection of NCD and is usually the first professional to detect the signs of MCI. The objective of this study was to test the feasibility and utility of the cognitive screening instrument QMCI in Primary Care. A community sample of 436 people 65+ living in the community was randomly selected from a larger group of old people with mental health concerns (N=2734), referred by their GPs. The mean age of the sample was 75.2 years (sd 7.2), with 41.3% men and 58.7% women; 60.4% married followed by 28.7% widows. The education level was low with 21% illiterate and 69,8% people with 4 years education. The QMCI mean was 37.1/100 (sd 16.2). The amount of people screening positive for cognitive impairment QMCI (

Background: A high prevalence of cognitive impairment and frailty complicates the feasibility of advance care planning in the long-term-care population. Research aim: To identify challenges in implementing the ‘Let Me Decide’ advance care planning programme in long-term-care. Research design: This feasibility study had two phases: (1) staff education on advance care planning and (2) structured advance care planning by staff with residents and families. Participants and research context: long-term-care residents in two nursing homes and one community hospital. Ethical considerations: The local research ethics committee granted ethical approval. Findings: Following implementation, over 50% of all residents had completed some form of end-of-life care plan. Of the 70 residents who died in the post-implementation period, 14% had no care plan, 10% (with capacity) completed an advance care directive and lacking such capacity, 76% had an end-of-life care plan completed for them by the medical team, following discussions with the resident (if able) and family. The considerable logistical challenge of releasing staff for training triggered development of an e-learning programme to facilitate training. Discussion: The challenges encountered were largely concerned with preserving resident’s autonomy, avoiding harm and suboptimal or crisis decision-making, and ensuring residents were treated fairly through optimisation of finite resources. Conclusions: Although it may be too late for many long-term-care residents to complete their own advance care directive, the ‘ Let Me Decide’ programme includes a feasible and acceptable option for structured end-of-life care planning for residents with variable capacity to complete an advance care directive, involving discussion with the resident (to the extent they were able) and their family. While end-of-life care planning was time-consuming to deliver, nursing staff were willing to overcome this and take ownership of the programme, once the benefits in improved communication and enhanced peace of mind among all parties involved became apparent in practice.

Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults (>65years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors.

Introduction The Montreal Cognitive Assessment (MoCA) accurately differentiates mild cognitive impairment (MCI) from mild dementia and normal controls (NC). While the MoCA is validated in multiple clinical settings, few studies compare it with similar tests also designed to detect MCI. We sought to investigate how the shorter Quick Mild Cognitive Impairment (Qmci) screen compares with the MoCA. Methods Consecutive referrals presenting with cognitive complaints to a teaching hospital geriatric clinic (Fremantle, Western Australia) underwent a comprehensive assessment and were classified as MCI (n = 72) or dementia (n = 109). NC (n = 41) were a sample of convenience. The Qmci and MoCA were scored by trained geriatricians, in random order, blind to the diagnosis. Results Median Qmci scores for NC, MCI and dementia were 69 (+/−19), 52.5 (+/−12) and 36 (+/−14), respectively, compared with 27 (+/−5), 22 (+/−4) and 15 (+/−7) for the MoCA. The Qmci more accurately identified cognitive impairment (MCI or dementia), area under the curve (AUC) 0.97, than the MoCA (AUC 0.92), p = 0.04. The Qmci was non-significantly more accurate in distinguishing MCI from controls (AUC 0.91 vs 0.84, respectively = 0.16). Both instruments had similar accuracy for differentiating MCI from dementia (AUC of 0.91 vs 0.88, p = 0.35). At the optimal cut-offs, calculated from receiver operating characteristic curves, the Qmci (≤57) had a sensitivity of 91% and specificity of 93% for cognitive impairment, compared with 87% sensitivity and 80% specificity for the MoCA (≤23). Conclusion While both instruments are accurate in detecting MCI, the Qmci is shorter and arguably easier to complete, suggesting that it is a useful instrument in an Australian geriatric outpatient population. Copyright © 2016 John Wiley & Sons, Ltd.

PURPOSE: To evaluate the long-term effectiveness and safety of combined LASIK and small-aperture intracorneal inlay implantation (KAMRA; AcuFocus, Irvine, CA) for the surgical compensation of presbyopia and refractive errors. METHODS: Retrospective chart review of all ametropic, presbyopic patients who underwent combined LASIK and KAMRA inlay implantation at a single clinic. Demographic data and preoperative uncorrected and corrected monocular and binocular near and distance visual acuity (UNVA, UDVA, and CDVA) with manifest refractive spherical equivalent (MRSE) were collected and analyzed. All perioperative adverse events were recorded. RESULTS: In total, 132 patients were available (median age: 56 years; interquartile range (IQR) ± 5; range: 44 to 68 years). Median preoperative MRSE was +1.37± 1.20 diopters (D). The majority (113; 85%) were hypermetropic. Preoperative median UNVA improved from N24 (J13) ±6 to N6 (J5) ±1 by day 1 postoperatively, remaining stable throughout follow-up. At last follow-up, 97% of patients achieved UNVA of N5 (J3) or better. Median UDVA (implanted eye) improved from 20/40 (0.50 ± 0.41 on the decimal chart) preoperatively to 20/25 (0.80 ± 0.13) at month 12. Binocular UDVA was 20/20 in 88%, with CDVA unchanged for 84% at 12 months. No patient lost more than one line of CDVA. MRSE was also stable, albeit +0.25 D off-target refraction (−0.75 D). Two inlays were explanted due to suboptimal adaptation/corneal haze. CONCLUSIONS: The results of this follow-up study show that combined insertion of a small-aperture corneal inlay with LASIK in presbyopic patients improves near vision with a slight compromise in distance vision in the implanted eye. Overall, it appears to be a safe, effective procedure for the treatment of presbyopia. [ J Refract Surg. 2016;32(6):379–384.]

Background: Sensitive and specific instruments are required to screen for cognitive impairment (CI) in busy clinical practice. The Montreal Cognitive Assessment (MoCA) is widely validated but few studies compare it to tests designed specifically to detect mild cognitive impairment (MCI). Objective: Comparison of two "MCI specific" screens: the Quick Mild Cognitive Impairment screen (Qmci) and MoCA. Methods: Patients with subjective memory complaints (SMC; n=73), MCI (n=103), or dementia (n=274), were referred to a university hospital memory clinic and underwent comprehensive assessment. Caregivers, without cognitive symptoms, were recruited as normal controls (n=101). Results: The Qmci was more accurate than the MoCA in differentiating MCI from controls, area under the curve (AUC) of 0.90 versus 0.80, p=0.009. The Qmci had greater (AUC 0.81), albeit non-significant, accuracy than the MoCA (AUC 0.73) in separating MCI from SMC, p=0.09. At its recommended cut-off (

Background: Although caregivers are important in the management of frail, community-dwelling older adults, the influence of different caregiver network types on the risk of adverse healthcare outcomes is unknown. Objective: To examine the association between caregiver type and the caregiver network subtest of The Risk Instrument for Screening in the Community (RISC), a five point Likert scale scored from one (“can manage”) to five (“absent/liability”). To measure the association between caregiver network scores and the one-year incidence of institutionalisation, hospitalisation and death. Design: Observational cohort study. Setting and Participants: Community-dwelling adults, aged >65,attending health centres in Ireland,(n=779). Procedure and Measurements: The caregiver network subtest of the RISC was scored by public health nurses. Caregivers were grouped dichotomously into low-risk (score of one) or high-risk (scores two-five). Results: The majority of patients had a primary caregiver (582/779;75%), most often their child (200/582;34%). Caregiver network scores were highest, indicating greatest risk, when patients had no recognised primary caregiver and lowest when only a spouse or child was available. Despite this, patients with a caregiver were significantly more likely to be institutionalised than those where none was required or identified (11.5% versus 6.5%,p=0.047). The highest one-year incidence of adverse outcomes occurred when state provided care was the sole support; the lowest when private care was the sole support. Significantly more patients whose caregiver networks were scored high-risk required institutionalisation than low-risk networks; this association was strongest for perceived difficulty managing medical domain issues, odds ratio (OR) 3.87:(2.22-6.76). Only perceived difficulty managing ADL was significantly associated with death, OR 1.72:(1.06-2.79). There was no association between caregiver network scores and risk of hospitalisation. Conclusion: This study operationalizes a simple method to evaluate caregiver networks. Networks consisting of close family (spouse/children) and those reflecting greater socioeconomic privilege (private supports) were associated with lower incidence of adverse outcomes. Caregiver network scores better predicted institutionalisation than hospitalisation or death.

Because of the dynamic nature of frailty, prospective epidemiological data are essential to calibrate an adequate public health response.A systematic review of literature on frailty incidence was conducted within the European Joint Action ADVANTAGE.Of the 6 studies included, only 3 were specifically aimed at estimating frailty incidence, and only 2 provided disaggregated results by at least gender. The mean follow-up length (1-22.2 years; median 5.1), sample size (74-6306 individuals), and age of participants (≥ 30-65) varied greatly across studies. The adoption of incidence proportions rather than rates further limited comparability of results. After removing one outlier, incidence ranged from 5% (follow-up 22.2 years; age ≥ 30) to 13% (follow-up 1 year, age ≥ 55).Well-designed prospective studies of frailty are necessary. To facilitate comparison across studies and over time, incidence should be estimated in person-time rate. Analyses of factors associated with the development of frailty are needed to identify high-risk groups.

Little is known about programmes or interventions for the screening, monitoring and surveillance of frailty at population level.Three systematic searches and an opportunistic grey literature review from the countries participating in the ADVANTAGE Joint Action were performed.Three studies reported local interventions to screen for frailty, two of them using a two-step screening and assessment method and one including monitoring activities. Another paper reviewed both providers' and participants' experiences of screening activities. Three on-going European projects and population-screening programmes in primary care await evaluation. An electronic Frailty Index for use with patients' primary care records has been recently validated. No study described systematic processes for the surveillance of frailty.There is insufficient evidence for the effectiveness of population-level screening, monitoring and surveillance of frailty. Development and evaluation of community-based two-step programmes including those that incorporate electronic health records, particularly in primary care, are now needed.