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Purpose Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes.

INTRODUCTION: Meaningful ageing research across the UK is dependent on a network of engaged geriatricians. The research in geriatric specialty training (RGST) survey aimed to establish current research opportunities available to geriatric medicine specialty trainees in the UK. METHODS: The RGST survey was disseminated to UK higher specialist trainees in geriatric medicine in 2019 via the Geriatric Medicine Research Collaborative network. RESULTS: Among the 36.9% (192/521) of respondents, 44% (83/188) reported previous research involvement and 7% (n=8) held a PhD or MD. Of the respondents with no research experience to date, 59.0% (n=49) reported a desire to undertake a period of research. One-third (31%) of geriatric registrars surveyed felt that they had gained sufficient research experience during their training. Perceived encouragement and support to undertake research was low (30.7%). Enablers and barriers to research engagement were identified. CONCLUSION: Research opportunity and engagement in geriatric medicine training is lacking. This could jeopardise the future workforce of research-active geriatricians in the UK and limit patient access to emerging research and innovation. Interventions to promote research engagement among geriatric medicine trainees are needed to facilitate integration of research into routine clinical practice to improve the health and care of older people.

IntroductionDespite the myriad advantages associated with physical activity (PA), older adults are often insufficiently active to maximise health benefits. Understanding factors that influence engagement in PA will support practitioners in providing well-designed interventions for older people. Our aim was to review the qualitative evidence exploring the factors affecting older adult’s engagement in PA. MethodsFour electronic databases were searched: CINAHL, Embase, MEDLINE and PsycINFO. Inclusion criteria were community-dwelling older adults (≥70 years), and studies including qualitative methods. Exclusion criteria were studies examining a single disease group, individuals with cognitive impairment, care home residents, and PA interventions. The Critical Appraisal Skills Programme (CASP) checklist was used to assess methodological rigour. Framework synthesis using the COM-B model was applied to analyse data, and the GRADE-CERQual approach was used to assess confidence in findings. (PROSPERO: CRD42021160503)ResultsTwenty-one studies were included in the review. Participants (N = 3955; mean age 78.9 years) included 64% female and 36% male older adults. Most studies were methodologically rigorous (17/21 scored ≥8 CASP). We identified 32 themes mapped against the COM-B framework (16 high confidence). Older adult’s perceived capability was influenced by their functional capacity, illness symptoms and perceived risk of injury from PA. PA was motivated by identifying as an ‘exerciser’, health gains and positive emotions (e.g., enjoyment), while negative sensations reduced motivation (e.g., pain). Opportunity was impacted by the weather, the environment ‘fit’, and the availability of social interaction during PA. Moreover, social opportunity was impacted by socio-cultural ageing stereotypes and discourses, influencing older adults’ PA through media outlets, social norms, and self-stigma. ConclusionsThe review found a complex web of interacting factors that influenced older people’s PA between the sub-domains of capability, motivation, and opportunity. Future initiatives to increase PA in older adults should focus on social influences, environmental barriers, and physical limitations.

The use of technology by firms is changing the way insurance and lending markets function. I study the financial technology, or "fin-tech'', industry, which is characterized by a growing number of online lenders who use data on educational, employment, and financial outcomes to quickly assess the risk of prospective borrowers and offer individualized loan terms. In many ways, their financial "innovations'' can be thought of as movements towards more personalized products: interest rates that better reflect individuals' risk, payment plans that are tailored to individuals' monthly income and expenditures, and user-friendly interfaces that make financial decisions more intuitive and uncomplicated. On an individual level, as firms expand and customize product offerings, there is the potential for large efficiency gains. These innovations could also have wider implications for market structure; for example, if more accurate risk-based pricing creates clear winners and losers, it will change the distribution of consumer surplus.Advances in data-driven underwriting have both efficiency and equity implications for consumer lending markets where private and public credit options coexist. In the $1 trillion student loan market, private lenders now offer a growing distribution of risk-based interest rates, while the federally-run loan program sets a break-even, uniform interest rate. In my first chapter, I measure the overall gains in consumer surplus from such risk-based pricing and quantify the redistributional consequences of low-risk types refinancing out of the government pool into the private market. The empirical analysis is based on a unique applicant-level dataset from an online refinancing firm that contains information on loan terms, household balance sheets, and risk-based interest rates. I first leverage a series of firm-conducted interest rate experiments to estimate the sensitivity of borrowers' maturity and refinancing choices to interest rates. Using the maturity response, I then estimate a structural model of borrowers' repayment preferences. Using the estimated model, I show that comprehensive risk-based pricing generates large absolute gains in welfare of $480 per borrower relative to a break-even uniform price, and $400 relative to a coarser method of FICO-based pricing. If the federal pool conducts breakeven pricing, these efficiency gains come at a direct equity cost -- low risk surplus will increase on average by $2,300, while high risk surplus will fall by $2,100. In order to maintain access to the current uniform rate, the government would have to transition from break-even pricing to an average net subsidy of $2,080 per borrower.In the second chapter, I empirically analyze the fixed and variable rate decisions of borrowers who are financing large personal loans, and are given the option to switch rate types at any point. Many online lending firms now offer financial products that are more flexible and personalized than traditional loans; however, little is known about how consumers will interact with these more complete, but also more complex, contracts. Over my sample time period, the market index interest rate for the fixed and variable rate loans changed considerably. I first present reduced form evidence on the determinants of borrowers' initial rate decisions and the presence of switching costs, and then estimate a structural model that maps these findings to the coefficient of absolute risk aversion and a switching cost parameter. I compare the active and inactive rate choices of borrowers in different interest rate environments to separately identify switching costs from risk preferences.I show that while initial rate choices are very responsive to the prevailing interest rate environment, very few borrowers ever take advantage of the option to switch rate types even when interest rates increase. Specifically, I estimate a risk aversion parameter of .0564, which implies that borrowers are very risk averse, and lower and upper bounds on switching costs from $166 to $1,185. I also show that both the initial probability of choosing a variable rate loan and the probability of never switching are positively correlated with borrower liquidity constraints, which suggests that these borrowers are more focused on current monthly payments than future interest rate risk.

Funding Information: Acknowledgments: M.N.L. is supported by an NIHR Doctoral Fellowship (grant code NIHR300159). D.W. is supported by a NIHR Clinical Lectureship. A.A.S., A.G., C.H., P.H., S.R. and M.D.W. acknowledge support from the NIHR Newcastle Biomedical Research Centre. C.J.S. receives funds from the M.R.C., Wellcome Trust, Chronic Disease Research Foundation. E.R.T. is supported by the Medical Research Council (MRC) and Versus Arthritis as part of the Medical Research Council Versus Arthritis Centre for Integrated Research into Musculoskeletal Ageing (CIMA) [MR/R502182/1]. Funding Information: Importantly, nutrition represents a modifiable risk factor for frailty, and as such, is a target for both prevention and treatment of this debilitating syndrome. However, to design effective dietary interventions, a clearer understanding of the key dietary components and underlying mechanisms of action are needed. Progress in understanding the role and importance of nutrition and to address how diet can be used for the prevention and treatment of frailty, requires a multi-disciplinary approach. This review evolved from a workshop held on 6 November 2020, which was attended by all authors. The workshop was one of a series funded by the Medical Research Council under the UK Nutrition Research Partnership (UK NRP) Call for Nutrition Hot Topic Workshops. It brought together a new group of experts from the fields of nutrition and frailty, from a variety of backgrounds, in order to promote dialogue to address the potential of diet within strategies to prevent and treat frailty. The workshop had two aims: firstly, to review the evidence and current understanding of the links between nutrition and frailty, and secondly, to consider the gaps in the evidence and identify unanswered questions. Funding Information: We would like to acknowledge the Medical Research Council for their support in funding the workshop which led to the production of this paper, as part of the UK Nutrition Research Part-nership (UK NRP) Call for Nutrition Hot Topic Workshops.Acknowledgments: M.N.L. is supported by an NIHR Doctoral Fellowship (grant code NIHR300159). D.W. is supported by a NIHR Clinical Lectureship. A.A.S., A.G., C.H., P.H., S.R. and M.D.W. acknowledge support from the NIHR Newcastle Biomedical Research Centre. C.J.S. re-ceives funds from the M.R.C., Wellcome Trust, Chronic Disease Research Foundation. E.R.T. is supported by the Medical Research Council (MRC) and Versus Arthritis as part of the Medical Research Council Versus Arthritis Centre for Integrated Research into Musculoskeletal Ageing (CIMA) [MR/R502182/1]. Publisher Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. Copyright: Copyright 2021 Elsevier B.V., All rights reserved. Frailty is a syndrome of growing importance given the global ageing population. While frailty is a multifactorial process, poor nutritional status is considered a key contributor to its path-ophysiology. As nutrition is a modifiable risk factor for frailty, strategies to prevent and treat frailty should consider dietary change. Observational evidence linking nutrition with frailty appears most robust for dietary quality: for example, dietary patterns such as the Mediterranean diet appear to be protective. In addition, research on specific foods, such as a higher consumption of fruit and vegetables and lower consumption of ultra-processed foods are consistent, with healthier profiles linked to lower frailty risk. Few dietary intervention studies have been conducted to date, although a growing number of trials that combine supplementation with exercise training suggest a multi-domain approach may be more effective. This review is based on an interdisciplinary workshop, held in November 2020, and synthesises current understanding of dietary influences on frailty, focusing on opportunities for prevention and treatment. Longer term prospective studies and well-designed trials are needed to determine the causal effects of nutrition on frailty risk and progression and how dietary change can be used to prevent and/or treat frailty in the future. publishersversion published

Introduction Increased mortality has been demonstrated in older adults with coronavirus disease 2019 (COVID-19), but the effect of frailty has been unclear. Methods This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS) and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results Data from 5,711 patients from 55 hospitals in 12 countries were included (median age 74, interquartile range [IQR] 54–83; 55.2% male). The risk of death increased independently with increasing age (>80 versus 18–49: hazard ratio [HR] 3.57, confidence interval [CI] 2.54–5.02), frailty (CFS 8 versus 1–3: HR 3.03, CI 2.29–4.00) inflammation, renal disease, cardiovascular disease and cancer, but not delirium. Age, frailty (CFS 7 versus 1–3: odds ratio 7.00, CI 5.27–9.32), delirium, dementia and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusion Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.

Background: Physical activity (PA) is important for older people to maintain functional independence and healthy ageing. There is strong evidence to support the benefits of physical activity interventions on the health outcomes of older adults. Nonetheless, innovative approaches are needed to ensure that these interventions are practical and sustainable. Aim: This systematic review explores the effectiveness of volunteer-led PA interventions in improving health outcomes for community-dwelling older people. Methods: Five databases (MEDLINE, Embase, CINAHL, PEDro, Cochrane library) were systematically searched for studies using trained volunteers to deliver PA interventions for community-dwelling older people aged ≥ 65 years. Meta-analysis was not conducted due to included study heterogeneity. Results: Twelve papers describing eight studies (five papers reported different outcomes from the same study) were included in the review. All eight studies included strength and balance exercises and frequency of PA ranged from weekly to three times a week. Volunteer-led exercises led to improvements in functional status measured using the short physical performance battery, timed up and go test, Barthel Index, single leg stand, step touch test, chair stand test, and functional reach. Frailty status identified by grip strength measurement or the use of long-term care insurance improved with volunteer-led exercises. Interventions led to improvement in fear of falls and maintained or improved the quality of life. The impact on PA levels were mixed. Conclusion: Limited evidence suggests that volunteer-led PA interventions that include resistance exercise training, can improve outcomes of community-dwelling older adults including functional status, frailty status, and reduction in fear of falls. More high-quality RCTs are needed to investigate the effects of volunteer-led PA interventions among older people.

Appetite drives essential oral nutritional intake. Its regulation is complex, influenced by physiology, hedonism (the reward of eating) and learning from external cues within a person’s society and culture.Appetite loss is common in the older population and not always attributable to medical conditions or treatment. Although the physiological basis of the anorexia of ageing (loss of appetite due to the ageing process) has been established, the effect of ageing on hedonism and external cues, which may be equally important, is less well understood. The anorexia of ageing is associated with reductions in dietary diversity and oral intake, and increased risk of malnutrition, sarcopenia and frailty. Early identification of poor appetite could allow timely intervention before weight loss occurs. There is no standardised tool for assessing appetite in clinical settings at present but the 4-item Simplified Nutritional Appetite Questionnaire (SNAQ) has the potential to be used in this way. This review, designed for clinicians, will discuss the regulation of appetite and the pathogenesis of the anorexia of ageing. It will describe the current evidence for interventions to manage the anorexia of ageing, which is limited, with little benefit reported from individual studies of education, physical activity and medication. There is some positive evidence for flavour enhancement, fortified food and oral nutritional supplements but mainly within single studies. Looking ahead, the aim is to develop multicomponent approaches to the treatment of the anorexia of ageing, based on growing understanding of the role of physiological signalling, hedonism and external cues.

© 2019 The Author(s). Academic geriatric medicine activity lags behind the scale of clinical activity in the specialty. A meeting of UK academic geriatricians was convened in March 2018 to consider causes and solutions to this problem. The meeting highlighted a lack of research-Active clinicians, a perception that research is not central to the practice of geriatric medicine and a failure to translate discovery science to clinical studies. Solutions proposed included better support for early-career clinical researchers, schemes to encourage non-University clinicians to be research-Active, wider collaboration with organ specialists to broaden the funding envelope, and the need to co-produce research programmes with end-users. Solutions to grow academic geriatric medicine are essential if we are to provide the best care for the growing older population.

Introduction:Appetite loss in older people, often termed u2018Anorexia of Ageingu2019 (AA), is common. Recognised consequences include undernutrition, sarcopenia, frailty, and in-hospital increased length of stay, morbidity and mortality. There is currently no guidance for the identification and management of AA in clinical practice.This systematic review aimed to identify interventions for AA with reported effects on appetite.Methods:The review followed PRISMA recommendations. Study inclusion criteria were participants aged 65, appetite measurement and an intervention for AA or undernutrition (terms were often used interchangeably). Studies on specific health cohorts e.g. cancer were excluded.Searches were performed in MEDLINE, EMBASE, and CINAHL databases with hand searching of reference lists and citing works. Two researchers independently screened for eligibility and assessed study quality.Results:Authors screened 8729 titles, 402 abstracts and 42 full texts. 16 studies were included. The quality of included studies was largely good with one study rated poor. Settings included own home (n=7), care home (n=5), rehabilitation (n=2) and acute hospital (n=5). Three studies had combinations of settings.The were nine intervention types including education (n = 1), exercise (n = 1), flavour enhancement (n = 1), increased meal variety (n = 1), mealtime assistance (n = 1), fortified food (n = 1), oral nutritional supplement (ONS) (n = 7), amino acids (n = 1), and medication (n = 2). Three studies evaluated combinations: education + exercise, ONS + exercise, and ONS + medication.Five intervention types exhibited favourable effects on appetite (flavour enhancement, fortified food, amino acids, ONS, medication) but in single datasets only.Appetite was measured by multiple different methods, predominantly utilising Likert scales (n= 8), or visual analogue scales (n=5).Heterogeneity of methodologies and interventions made pooling of results for statistical analysis unachievable.Discussion:Few studies have measured appetite with an intervention for AA or undernutrition. There was no standardised method of appetite assessment when determining efficacy of interventions for appetite loss in older people.Single studies suggest potential intervention candidates for AA. However these need further exploration, with standardised assessment. This may provide an avenue to treating undernutrition, with its importance in the trajectory to sarcopenia, frailty and ultimately poor outcomes.Conflict of interest:There is no conflict of interest.