The effect of perindopril on postural instability in older people with a history of falls-a randomised controlled trial.

Design: double-blind, parallel group, placebo-controlled randomised trial. Methods: we recruited people aged >65 years with at least one fall in the previous year. Participants received 4 mg perindopril or placebo daily for 15 weeks. The primary outcome was the between-group difference in force-plate measured anteroposterior (AP) sway at 15 weeks. Secondary outcomes included other measures of postural sway, limits of stability during maximal forward, right and left leaning, blood pressure, muscle strength, 6-min walk distance and falls. The primary outcome was assessed using two-way ANOVA, adjusted for baseline factors. Results: we randomised 80 participants. Mean age was 78.0 (SD 7.4) years; 60 (75%) were female. About 77/80 (96%) completed the trial. At 15 weeks there were no significant between-group differences in AP sway with eyes open (mean difference 0 mm, 95% CI -8 to 7 mm, P = 0.91) or eyes closed (mean difference 2 mm, 95% CI -7 to 12 mm, P = 0.59); no differences in other measures of postural stability, muscle strength or function. About 16/40 (42%) of patients in each group had orthostatic hypotension at follow-up. The median number (IQR) of falls was 1 (0,4) in the perindopril versus 1 (0,2) in the placebo group (P = 0.24). Conclusions: perindopril did not improve postural sway in older people at risk of falls. Clinical Trials Registration: ISRCTN58995463.

Sufficient levels of 25-hydroxyvitamin D and protein intake required to increase muscle mass in sarcopenic older adults - The PROVIDE study.

BACKGROUND: Inadequate nutritional intake and altered response of aging muscles to anabolic stimuli from nutrients contribute to the development of sarcopenia. Nutritional interventions show inconsistent results in sarcopenic older adults, which might be influenced by their basal nutritional status. OBJECTIVE: To test if baseline serum 25-hydroxyvitamin D (25(OH)D) concentrations and dietary protein intake influenced changes in muscle mass and function in older adults who received nutritional intervention. METHODS AND DESIGN: Post-hoc analysis was performed in the PROVIDE study that was a randomized controlled, double blind trial among 380 sarcopenic older adults. This study showed that those who received a vitamin D and leucine-enriched whey protein medical nutrition drink for 13 weeks gained more appendicular muscle mass (aMM), and improved lower-extremity function as assessed by the chair stand test compared with controls. To define low and high groups, a baseline serum concentration of 50 nmol/L 25(OH)D and baseline dietary protein intake of 1.0 g/kg/d were used as cut offs. RESULTS: At baseline, participants with lower 25(OH)D concentrations showed lower muscle mass, strength and function compared with participants with a high 25(OH)D, while the group with lower protein intake (g/kg/day) had more muscle mass at baseline compared with the participants with higher protein intake. Participants with higher baseline 25(OH)D concentrations and dietary protein intake had, independent of other determinants, greater gain in appendicular muscle mass, skeletal muscle index (aMM/h2), and relative appendicular muscle mass (aMM/body weight × 100%) in response to the nutritional intervention. There was no effect modification of baseline 25(OH)D status or protein intake on change in chair-stand test. CONCLUSIONS: Sufficient baseline levels of 25(OH)D and protein intake may be required to increase muscle mass as a result of intervention with a vitamin D and protein supplement in sarcopenic older adults. This suggests that current cut-offs in the recommendations for vitamin D and protein intake could be considered the "minimum" for adults with sarcopenia to respond adequately to nutrition strategies aimed at attenuating muscle loss.

Factors associated with change in objectively measured physical activity in older people - data from the physical activity cohort Scotland study.

BACKGROUND: Cross-sectional relationships between physical activity and health have been explored extensively, but less is known about how physical activity changes with time in older people. The aim of this study was to assess baseline predictors of how objectively measured physical activity changes with time in older people. METHODS: Longitudinal cohort study using data from the Physical Activity Cohort Scotland. A sample of community-dwelling older people aged 65 and over were recruited in 2009-2011, then followed up 2-3 years later. Physical activity was measured using Stayhealthy RT3 accelerometers over 7 days. Other data collected included baseline comorbidity, health-related quality of life (SF-36), extended Theory of Planned Behaviour Questionnaire and Social Capital Module of the General Household Survey. Associations between follow-up accelerometer counts and baseline predictors were analysed using a series of linear regression models, adjusting for baseline activity levels and follow-up time. RESULTS: Follow up data were available for 339 of the original 584 participants. The mean age was 77 years, 185 (55%) were female and mean follow up time was 26 months. Mean activity counts fell by between 2% per year (age < =80, deprivation decile 5-10) and 12% per year (age > 80, deprivation decile 5-10) from baseline values. In univariate analysis age, sex, deprivation decile, most SF-36 domains, most measures of social connectedness, most measures from the extended Theory of Planned Behaviour, hypertension, diabetes mellitus, chronic pain and depression score were significantly associated with adjusted activity counts at follow-up. In multivariate regression age, satisfactory friend network, SF-36 physical function score, and the presence of diabetes mellitus were independent predictors of activity counts at follow up after adjustment for baseline count and duration of follow up. CONCLUSIONS: Health status and social connectedness, but not extended Theory of Planned Behaviour measures, independently predicted changes in physical activity in community dwelling older people.

How active are women who play bingo: a cross-sectional study from the Well!Bingo project.

BACKGROUND: The benefits of physical activity are well established, yet large numbers of people are not sufficiently active to gain health benefits. Certain population groups are less physically active than others, including older women from areas of high economic deprivation. The Well!Bingo project was established with the aim of engaging such women in the development of a health promotion intervention in a bingo club. This paper reports on the assessment of health status, physical activity and sedentary behaviour of women attending a bingo club in central Scotland, UK as part of the Well!Bingo project. METHODS: Women attending the bingo club were invited to provide information on demographic characteristics, and self-reported physical activity and sedentary behaviour via a self-complete questionnaire as part of a cross-sectional study (n = 151). A sub-sample (n = 29) wore an accelerometer for an average of 5.7 ± 1.4 days. Differences between younger (under 60 years) and older adults (60 years and over) were assessed using a chi-square test for categorical data and the independent samples t-test was used to assess continuous data (p < 0.05). RESULTS: The mean age was 56.5 ± 17.7 years, with 57% living in areas of high deprivation (Scottish Index of Multiple Deprivation quintile one and two). Sixty-three percent of women (n = 87) reported they were meeting physical activity guidelines. However, objective accelerometer data showed that, on average, only 18.1 ± 17.3 min a day were spent in moderate to vigorous physical activity. Most accelerometer wear time was spent sedentary (9.6 ± 1.7 h). For both self-report and accelerometer data, older women were significantly less active and more sedentary than younger women. On average, older women spent 1.8 h more than younger women in sedentary activities per day, and took part in 21 min less moderate to vigorous physical activity (9.4 mins per day). CONCLUSION: The findings of this study suggest that bingo clubs are settings that attract women from areas of high deprivation and older women in bingo clubs in particular would benefit from interventions to target their physical activity and sedentary behaviour. Bingo clubs may therefore be potential intervention settings in which to influence these behaviours.

Association between bisphosphonate therapy and outcomes from rehabilitation in older people.

BACKGROUND: Bisphosphonate therapy may have actions beyond bone, including effects on cardiovascular, immune and muscle function. We tested whether bisphosphonate treatment is associated with improved outcomes in older people undergoing inpatient rehabilitation. METHODS: Analysis of prospectively collected, linked routine clinical datasets. Participants were divided into never users of bisphosphonates, use prior to rehabilitation only, use after rehabilitation only, and current users (use before and after rehabilitation). We calculated change in 20-point Barthel scores during rehabilitation, adjusting for comorbid disease and laboratory data using multivariable regression analysis. Cox regression analyses were performed to analyse the association between bisphosphonate use and time to death or hospitalisation. RESULTS: 2797 patients were included in the analysis. Current bisphosphonate users showed greater improvement in Barthel score during rehabilitation than non-users (5.0 points [95%CI 4.3-5.7] vs 3.8 [95%CI 3.6-3.9]), but no difference compared to those receiving bisphosphonates only after discharge (5.1 [95%CI 4.6-5.5]). Previous bisphosphonate use was significantly associated with time to death (adjusted hazard ratio 1.41 [95%CI 1.15-1.73]) but less strongly with time to combined endpoint of hospitalisation or death (adjusted hazard ratio 1.18 [95%CI 0.98-1.48]). Use after discharge from rehabilitation was associated with reduced risk of death (adjusted hazard ratio 0.64 [95%CI 0.55-0.73]; hazard ratio per year of bisphosphonate prescription 0.98 [95%CI 0.97-0.99]). CONCLUSION: Bisphosphonate use is unlikely to be causally associated with improved physical function in older people, but continuing use may be associated with lower risk of death.

Association between GDF-15 levels and changes in vascular and physical function in older patients with hypertension.

BACKGROUND: Growth differentiation factor-15 (GDF-15) may be a biomarker of disease, protective response and/or prognosis, in older people with hypertension. AIMS: To correlate baseline GDF-15 levels with physical and vascular health data in this population. METHODS: Baseline blood samples were analysed using a GDF-15 ELISA assay kit. Correlations with baseline and 12-month outcome data, including measures of physical and vascular function, were performed. RESULTS: A total of 147 individuals, mean age 76.8 ± 4.7 years, were included. 77 (52 %) were male. Baseline log10GDF-15 showed significant correlations with age (r = 0.37, p < 0.001), total cholesterol (r = -0.33, p < 0.001) and 6-min walking distance (r = -0.37, p < 0.001). Age remained significantly associated with log10GDF-15 in multivariable analysis (beta = -0.29, p = 0.001). Baseline log10GDF-15 was significantly associated with decline in 6-min walk distance over 12 months (beta = -0.27, p = 0.01) in multivariable models. No significant correlations were seen with changes in vascular function over 12 months. CONCLUSION: Baseline GDF-15 predicts declining physical, but not vascular, function in our population.

Validation of the AX3 triaxial accelerometer in older functionally impaired people.

BACKGROUND: Studying physical activity (PA) trends in older populations and potential interventions for increasing PA is important, as PA is a factor in many age-related health outcomes such as chronic disease, premature mortality, physical function and injuries from falls. Objective measures of PA provide valuable information regarding the functional impact that ageing and chronic disease states may have on a patient's life. AIMS: The purpose of this study was to test the validity of the AX3 PA monitor in an older population and to investigate whether the AX3 is a valid measure of distinct types or levels of activity in older people with a spectrum of mobility. METHODS: Validity of the AX3 PA monitor was tested using the RT3 as a means of cross-validating the AX3. Study participants wore both the AX3 and the RT3 accelerometers, positioned on their non-dominant side, whilst completing a series of standardised everyday activities. RESULTS: Although overall correlation was high (r > 0.8) between the RT3 and lower-limb-mounted AX3 counts, the correlation between the two devices was much stronger for walking activity than for any of the non-walking activities. DISCUSSION: Activity counts at all lower limb positions for the AX3 and RT3 were highly correlated. Correlation between wrist-mounted AX3 counts and lower limb AX3 counts was only moderate, and worsened when walking aids were in use. CONCLUSIONS: The results of this study indicate that the AX3 monitor is a valid tool, which might be used to objectively measure walking activity in older functionally impaired adults, a welcome finding for this under-researched area.

Slower Decline in C-Reactive Protein after an Inflammatory Insult Is Associated with Longer Survival in Older Hospitalised Patients.

BACKGROUND: Enhancing biological resilience may offer a novel way to prevent and ameliorate disease in older patients. We investigated whether changes in C-reactive protein (CRP), as a dynamic marker of the acute inflammatory response to diverse stressors, may provide a way to operationalize the concept of resilience in older adults. We tested this hypothesis by examining whether such changes could predict prognosis by identifying which individuals are at greater risk of 6-month mortality. METHODS: Analysis of prospective, routinely collected datasets containing data on hospitalization, clinical chemistry and rehabilitation outcomes for rehabilitation inpatients between 1999 and 2011. Maximum CRP response during acute illness and CRP recovery indices (time and slope of CRP decay to half maximum, and to <50mg/L if peak values were greater than 50mg/L) was derived from biochemistry data. 6-month survival plots were conducted on quartiles of CRP recovery indices. Cox proportional hazards models were used to test univariate and multivariate predictors of 6-month mortality. Covariates included age, sex, number of medications, serum calcium, haemoglobin level, renal function, and the presence of previous myocardial infarction, stroke, chronic heart failure, COPD and diabetes. RESULTS: 3723 patients, mean age 84 years, were included. 1535 (41%) were male and 733 (20%) died during six-month follow-up. The lower an individual's peak CRP reading, and the longer the time taken for their CRP to fall, the better their 6-month survival. The time for CRP to reach half of its maximum value was the best dynamic CRP index of survival (HR 0.93 per week, 95% CI 0.89 to 0.98; p = 0.004); this remained significant even after adjustment for maximum CRP level and covariates listed above. CONCLUSION: CRP recovery indices are associated with survival in older people; further work is required to explain differences in physiology between patients with a fast and slow CRP recovery.

Accessing and engaging women from socio-economically disadvantaged areas: a participatory approach to the design of a public health intervention for delivery in a Bingo club.

BACKGROUND: Our aim was to use participatory methods to investigate the feasibility and acceptability of using Bingo clubs for the design and delivery of an evidence-based physical activity and/or healthy eating intervention to socio-economically disadvantaged women. This paper describes the participatory process that has resulted in a physical activity intervention for women aged >55 years, ready for pilot-testing in a Bingo club setting. METHODS: Studies using different quantitative and qualitative approaches were conducted among customers and staff of a Bingo club in a city of 85,000 inhabitants in central Scotland. These were designed to take the views of different stakeholders into account, with a view to enhancing uptake, engagement and effectiveness with any proposed intervention. RESULTS: Sixteen relevant studies were identified in a literature review that generated ideas for intervention components. A questionnaire completed by 151 women in the Bingo club showed that almost half (47 %) aged >55 years were not meeting physical activity guidelines; evidence backed up by accelerometer data from 29 women. Discussions in six focus groups attended by 27 club members revealed different but overlapping motivations for attending the Bingo club (social benefits) and playing Bingo (cognitive benefits). There was some scepticism as to whether the Bingo club was an appropriate setting for an intervention, and a dietary intervention was not favoured. It was clear that any planned intervention needed to utilise the social motivation and habitual nature of attendance at the Bingo club, without taking women away from Bingo games. These results were taken forward to a 5-h long participative workshop with 27 stakeholders (including 19 Bingo players). Intervention design (form and content) was then finalised during two round table research team meetings. CONCLUSIONS: It was possible to access and engage with women living in areas of socio-economic disadvantage through a Bingo club setting. A physical activity intervention for women >55 years is realistic for recruitment, will address the needs of potential recipients in the Bingo club, appears to be feasible and acceptable to club members and staff, and has been designed with their input. A pilot study is underway, investigating recruitment, retention and feasibility of delivery.

Association between allopurinol use and hip fracture in older patients.

BACKGROUND: Allopurinol reduces oxidative stress and interacts with purinergic signalling systems important in bone metabolism and muscle function. We assessed whether allopurinol use was associated with a reduced incidence of hip fracture in older people. METHODS: Analysis of prospective, routinely-collected health and social care data on patients undergoing health and social work assessment in a single geographical area over a 12year period. Exposure to allopurinol was derived from linked community prescribing data, and hospitalisation for hip fracture and comorbid disease was derived from linked hospitalisation data. Fine and Gray modelling was used to model time to hip fracture accounting for the competing risk of death, incorporating previous use of allopurinol, cumulative exposure to allopurinol as a time dependent variable, and covariate adjustments. RESULTS: 17,308 patients were alive at the time of first social work assessment without previous hip fracture; the mean age was 73years. 10,171 (59%) were female, and 1155 (8%) had at least one exposure to allopurinol. 618 (3.6%) sustained a hip fracture, and 4226 (24%) died during a mean follow-up of 7.2years. In fully-adjusted analyses, each year of allopurinol exposure conferred a hazard ratio of 1.01 (95% CI 0.99, 1.02; p=0.37) for hip fracture and 1.00 (0.99, 1.01; p=0.47) for death. Previous use of allopurinol conferred a hazard ratio of 0.76 (0.45, 1.26; p=0.28) for hip fracture and 1.13 (0.99, 1.29; p=0.07) for death. CONCLUSION: Greater cumulative use of allopurinol was not associated with a reduced risk of hip fracture or death in this cohort.

Psychoactive prescribing for older people--what difference does 15 years make?

OBJECTIVE: The objective of the study was to review prescribing of psychoactive medications for older residents of the Tayside region of Scotland. METHODS: The analysis used community prescribing data in 1995 and 2010 for all older residents in Tayside. For each psychoactive drug class, the name of the most recently prescribed drug and the date prescribed were extracted. The relative risk (RR) and 95% confidence intervals (CI) for patients receiving psychoactive medication in 2010 were compared with those for patients in 1995. Psychoactive prescribing was analyzed by year, age, gender, and deprivation classification. The chi-squared test was used to calculate statistical significance. RESULTS: Total psychoactive prescribing in people over the age of 65 years has increased comparing 1995 with 2010. Antidepressant [RR = 2.5 (95% CI 2.41-2.59) p < 0.001] and opioid analgesia [RR = 1.21 (1.19-1.24) p < 0.001] prescriptions increased between 1995 and 2010. Hypnotics/anxiolytic [RR = 0.69 (0.66-0.71) p < 0.001] and antipsychotic [RR = 0.83 (0.77-0.88) p < 0.001] prescriptions decreased between 1995 and 2010. An increase in psychoactive prescribing is particularly marked in lower socioeconomic groups. Patients in the least affluent fifth of the population had RR = 1.25 (1.20-1.29) [p < 0.001] of being prescribed one to two psychoactive medications and RR = 1.81 (1.56-2.10) [p < 0.001] of being prescribed three or more psychoactive medications in 2010 compared with those in 1995. The RRs for the most affluent fifth were RR = 1.14 (1.1-1.19) [p < 0.001] and RR = 1.2 (1.01-1.42) [p < 0.001] for one to two, and three or more medications, respectively. CONCLUSION: Psychoactive medication prescribing has increased comparing 1995 with 2010, with increases disproportionately affecting patients in lower socioeconomic groups. The availability of new psychoactive drugs, safety concerns, and economic factors may explain these increases.

Hospital-acquired pneumonia incidence and diagnosis in older patients.

BACKGROUND: hospital-acquired pneumonia poses a hazard to older people who are hospitalised, yet few data exist on the incidence or risk factors in non-intensive care patients. This study aimed to determine the incidence of hospital-acquired pneumonia (HAP) in a sample of hospitalised older people. METHODS: prospective survey of hospitalised older patients (>65 years) at a single centre over a 12-month period. Casenote and chart data were collected on acute medical, orthopaedic and Medicine for the Elderly wards. HAP was defined in accordance with the European and Scottish National Prevalence Survey 2011 definition. Key analyses were incidence of clinically suspected and case definition clinically confirmed HAP. RESULTS: one thousand three hundred and two patients were included in the analysis. Five hundred and thirty-nine (41%) were male; mean age was 82 years (SD 8). Median length of hospital stay was 14 days (IQR 20). One hundred and fifty-seven episodes of HAP were clinically suspected in 143 patients (10.9% of admissions), but only 83 episodes in 76 patients met the diagnostic criteria (5.8% of admissions). The risk of HAP was 0.3% per day in hospital. Reasons for failure to meet the diagnostic criteria in 75 cases were lack of radiographic evidence in 60/75; lack of evidence of inflammation in 42/75, and lack of respiratory signs or symptoms in 13/75; 35/75 (47%) of cases lacked evidence in two or more domains. CONCLUSION: HAP is common but over-diagnosed in older hospitalised patients.

Spironolactone for People Age 70 Years and Older With Osteoarthritic Knee Pain: A Proof-of-Concept Trial.

OBJECTIVE: To determine whether spironolactone could benefit older people with osteoarthritis (OA), based on a previous study showing that spironolactone improved quality of life. METHODS: This parallel-group, randomized, placebo-controlled, double-blind trial randomized community-dwelling people ages ≥70 years with symptomatic knee OA to 12 weeks of 25 mg daily oral spironolactone or matching placebo. The primary outcome was between-group difference in change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale scores. Secondary outcomes included WOMAC stiffness and physical function subscores, EuroQol 5-domain (EQ-5D) 3L score, and mechanistic markers. Analysis was by intent to treat, using mixed-model regression, adjusting for baseline values of test variables. RESULTS: A total of 421 people had eligibility assessed, and 86 were randomized. Mean ± SD age was 77 ± 5 years and 53 of 86 (62%) were women. Adherence to study medication was 99%, and all participants completed the 12-week assessment. No significant improvement was seen in the WOMAC pain score (adjusted treatment effect 0.5 points [95% confidence interval (95% CI) - 0.3, 1.3]; P = 0.19). No improvement was seen in WOMAC stiffness score (0.2 points [95% CI -0.6, 1.1]; P = 0.58), WOMAC physical function score (0.0 points [95% CI -0.7, 0.8]; P = 0.98), or EQ-5D 3L score (0.04 points [95% CI -0.04, 0.12]; P = 0.34). Cortisol, matrix metalloproteinase 3, and urinary C-telopeptide of type II collagen were not significantly different between groups. More minor adverse events were noted in the spironolactone group (47 versus 32), but no increase in death or hospitalization was evident. CONCLUSION: Spironolactone did not improve symptoms, physical function, or health-related quality of life in older people with knee OA.

Association between retinal vasculature and muscle mass in older people.

UNLABELLED: Sarcopenia in older people is a major health issue and its early detection could help target interventions and improve health. Evidence suggests that poor muscle mass is associated with greater arterial stiffness and cardiovascular risk. Arterial stiffness in turn is associated with smaller retinal artery width. This study examined the association of muscle mass in older people with retinal vascular width, a non-invasive measure of vascular function. METHODS: Participants >65 years were recruited to a cross-sectional study. EXCLUSIONS: Inability to walk independently; diabetes mellitus; stroke (within 6 months), severe macular degeneration, glaucoma, retinal dystrophy; advanced cataract. Digital Retinal images of both eyes were analysed using the VAMPIRE software suite. Central Retinal Artery and Vein Equivalents (CRVE and CRAE) were measured. Body composition was measured using Dual Energy X ray Absorptimetry (DXA). Appendicular Skeletal Muscle Mass/Height(2) was calculated. Physical function was measured: 6-min walk distance, Short Physical performance battery, handgrip strength and quadriceps strength. RESULTS: 79 participants with mean age 72 (SD 6) years were recruited. 44% were female. Digital Retinal images of sufficient quality for measuring CRAE and CRVE were available for 51/75 (68%) of participants. Regression analysis showed significant association between larger ASMM/H(2) and smaller CRAE (ß=-0.20, p=0.001) and CRVE (ß=-0.12, p=0.05). Handgrip strength, body mass index and sex combined with CRAE explained 88% and with CRVE explained 86% of the variance in ASMM/H(2). CONCLUSION: Larger muscle mass was significantly associated with smaller retinal artery size in older people. This unexpected finding needs further investigation.

Does oral sodium bicarbonate therapy improve function and quality of life in older patients with chronic kidney disease and low-grade acidosis (the BiCARB trial)? Study protocol for a randomized controlled trial.

BACKGROUND: Metabolic acidosis is more common with advancing chronic kidney disease, and has been associated with impaired physical function, impaired bone health, accelerated decline in kidney function and increased vascular risk. Although oral sodium bicarbonate is widely used to correct metabolic acidosis, there exist potential risks of therapy including worsening hypertension and fluid overload. Little trial evidence exists to decide whether oral bicarbonate therapy is of net benefit in advanced chronic kidney disease, particularly in older people who are most commonly affected, and in whom physical function, quality of life and vascular health are at least as important outcomes as decline in renal function. METHODS/DESIGN: BiCARB is a multi-centre, double-blind, placebo controlled, randomised trial evaluating the clinical and cost-effectiveness of oral sodium bicarbonate in the management of older people with chronic kidney disease and severely reduced glomerular filtration rate (GFR) who have a mild degree of metabolic acidosis. The trial will recruit 380 patients from renal, Medicine for the Elderly, and primary care services across centres in the United Kingdom. Male and female patients aged 60 years and older with an estimated glomerular filtration rate of <30 mL/min/1.73 m(2), not on dialysis, and with serum bicarbonate concentrations <22 mmol/L will be eligible for participation. The primary clinical outcome for the trial is the between-group difference in the Short Physical Performance Battery score at 12 months. Secondary outcomes include muscle strength, quality of life measured using the EQ-5D score and KDQoL tools, cost effectiveness, renal function, presence of albuminuria and blood pressure. Markers of bone turnover (25-hydroxyvitamin D, 1,25-hydroxyvitamin D, tartrate-resistant acid phosphatase-5b and bone-specific alkaline phosphatase) and vascular health (B-type natriuretic peptide) will be measured. Participants will receive a total of 24 months of either bicarbonate or placebo. The results will provide the first robust test of the overall clinical and cost-effectiveness of this commonly used therapy in older patients with severely reduced kidney function. TRIAL REGISTRATION: www.isrctn.com; ISRCTN09486651, registered 17 February 2012.

Effects of a vitamin D and leucine-enriched whey protein nutritional supplement on measures of sarcopenia in older adults, the PROVIDE study: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Age-related losses of muscle mass, strength, and function (sarcopenia) pose significant threats to physical performance, independence, and quality of life. Nutritional supplementation could positively influence aspects of sarcopenia and thereby prevent mobility disability. OBJECTIVE: To test the hypothesis that a specific oral nutritional supplement can result in improvements in measures of sarcopenia. DESIGN: A multicenter, randomized, controlled, double-blind, 2 parallel-group trial among 380 sarcopenic primarily independent-living older adults with Short Physical Performance Battery (SPPB; 0-12) scores between 4 and 9, and a low skeletal muscle mass index. The active group (n = 184) received a vitamin D and leucine-enriched whey protein nutritional supplement to consume twice daily for 13 weeks. The control group (n = 196) received an iso-caloric control product to consume twice daily for 13 weeks. Primary outcomes of handgrip strength and SPPB score, and secondary outcomes of chair-stand test, gait speed, balance score, and appendicular muscle mass (by DXA) were measured at baseline, week 7, and week 13 of the intervention. RESULTS: Handgrip strength and SPPB improved in both groups without significant between-group differences. The active group improved more in the chair-stand test compared with the control group, between-group effect (95% confidence interval): -1.01 seconds (-1.77 to -0.19), P = .018. The active group gained more appendicular muscle mass than the control group, between-group effect: 0.17 kg (0.004-0.338), P = .045. CONCLUSIONS: This 13-week intervention of a vitamin D and leucine-enriched whey protein oral nutritional supplement resulted in improvements in muscle mass and lower-extremity function among sarcopenic older adults. This study shows proof-of-principle that specific nutritional supplementation alone might benefit geriatric patients, especially relevant for those who are unable to exercise. These results warrant further investigations into the role of a specific nutritional supplement as part of a multimodal approach to prevent adverse outcomes among older adults at risk for disability.

Association between kidney function, rehabilitation outcome, and survival in older patients discharged from inpatient rehabilitation.

BACKGROUND: Chronic kidney disease (CKD) is common in older people, but it is unclear if it affects survival and rehabilitation outcomes independent of comorbid conditions and physical function in this population. STUDY DESIGN: Cohort analysis of prospective, routinely collected, linked clinical data sets. SETTING & PARTICIPANTS: Patients discharged from a single inpatient geriatric rehabilitation center over a 12-year period. PREDICTORS: Admission estimated glomerular filtration rate (eGFR) category as a predictor of improvement in the 20-point Barthel score (activities of daily living measure) during rehabilitation; discharge eGFR category and Barthel score as predictors of survival postdischarge. OUTCOMES: Survival postdischarge was modeled using Cox regression analyses, unadjusted and adjusted for age, sex, morbidities (ischemic heart disease, chronic obstructive pulmonary disease, stroke, diabetes, and heart failure), Barthel score and eGFR category on discharge, and serum calcium, hemoglobin, and albumin levels. The effect of admission eGFR category on change in Barthel score during admission was modeled using analysis of covariance, adjusted for admission, Barthel score, and comorbid conditions. RESULTS: 3,012 patients were included; mean age, 84 years. 2,394 patients died during a mean follow-up of 8.3 years. Compared with patients with eGFR of 60 to 89mL/min/1.73m(2), adjusted HRs for death were 1.26 (95% CI, 1.13-1.40), 1.45 (95% CI, 1.29-1.63), and 1.68 (95% CI, 1.42-1.99) for eGFR categories of 45 to 59, 30 to 44, and <30mL/min/1.73m(2), respectively. The relationship between discharge Barthel score and survival was similar within each discharge eGFR category (HRs of 0.95, 0.93, 0.92, 0.95, and 0.90 per Barthel score point within eGFR categories of ≥90, 60-89, 45-59, 30-44, and <30mL/min/1.73m(2); P for interaction = 0.2). Similar improvements in Barthel score between admission and discharge were seen for each admission eGFR category. LIMITATIONS: Single-center study using routinely collected clinical data. CONCLUSIONS: eGFR category and Barthel score are independent risk markers for survival in older rehabilitation patients, but advanced CKD does not preclude successful rehabilitation.

The role of perceived barriers and objectively measured physical activity in adults aged 65-100.

OBJECTIVE: to test the predictive utility of perceived barriers to objectively measured physical activity levels in a stratified sample of older adults when accounting for social-cognitive determinants proposed by the Theory of Planned Behaviour (TPB), and economic and demographic factors. METHODS: data were analysed from the Physical Activity Cohort Scotland survey, a representative and stratified (65-80 and 80+ years; deprived and affluent) sample of 584 community-dwelling older people, resident in Tayside, Scotland. Physical activity was measured objectively by accelerometry. RESULTS: perceived barriers clustered around the areas of poor health, lack of interest, lack of safety and lack of access. Perceived poor health and lack of interest, but not lack of access or concerns about personal safety, predicted physical activity after controlling for demographic, economic and TPB variables. DISCUSSION: perceived person-related barriers (poor health and lack of interest) seem to be more strongly associated with physical activity levels than perceived environmental barriers (safety and access) in a large sample of older adults. Perceived barriers are modifiable and may be a target for future interventions.

Construction of a linked health and social care database resource--lessons on process, content and culture.

BACKGROUND: Combining routinely collected health and social care data on older people is essential to advance both service delivery and research for this client group. Little data is available on how to combine health and social care data; this article provides an overview of a successful data linkage process and discusses potential barriers to executing such projects. METHODS AND RESULTS: We successfully obtained and linked data on older people within Dundee from three sources: Dundee Social Work Department database (30,000 individuals aged 65 years and over), healthcare data held on NHS Tayside patients by the Health Informatics Centre (400,000 individuals), Dundee, and the Dundee of Medicine for the Elderly rehabilitation database (4300 individuals). Data were linked, anonymized and transferred to a Safe Haven environment to ensuring confidentiality and strict access control. Challenges were faced around workflows, culture and documentation. Exploiting the resultant data set raises further challenges centered on database documentation, understanding the way data were collected, dealing with missing data, data validity and collection at different time periods. CONCLUSION: Routinely collected health and social care data sets can be linked, but significant process barriers must be overcome to allow successful linkage and integration of data and its full exploitation.