He Taonga Te Wareware: Connecting Older Maori Experiences of Wairuatanga with Mate Wareware (Dementia).

Mate wareware (dementia) is a complex disease of the brain that progressively inhibits memory and cognitive ability, affecting many Maori (the Indigenous people of Aotearoa New Zealand) kaumatua (elderly persons) in Aotearoa (New Zealand). Mate wareware care aims to protect and sustain wellbeing, yet Maori perspectives of wellbeing that consider wairuatanga (Maori spirituality) are often neglected within current treatment planning. This study investigates the presence of wairuatanga within kaumatua lives, drawing upon 61 interviews with kaumatua to glean a Maori understanding of mate wareware and to develop a diagnostic screening tool for mate wareware. Recorded responses were thematically analysed using reflexive qualitative analysis, informing four key themes that influence wairuatanga: he hononga tangata (social connection), turangawaewae (places of connection), tuakiritanga (identity) and mahi mauritau (mindful practices). These themes consider the value of creating rich and gratifying lifestyles for kaumatua that cultivate their spiritual wellbeing. This study validates diverse understandings and experiences of wairuatanga as essential to Maori wellbeing, affirming the relevance of wairuatanga to improve outcomes for Maori living with mate wareware.

He Tuhononga Whaiaro: A Kaupapa Maori Approach to Mate Wareware (Dementia) and Cognitive Assessment of Older Maori.

AIM: The aim of this study is to investigate Maori (Indigenous peoples of Aotearoa New Zealand) understandings of dementia (mate wareware) and develop a framework to inform assessment of cognitive impairment. METHOD: Qualitative, kaupapa Maori (Maori approach) research with 241 older Maori (kaumatua) involving 17 focus groups across Aotearoa New Zealand (NZ) and eight families (whanau) from one region. We thematically analyzed transcribed data from audio-recorded interviews. RESULTS: Two overarching themes, namely, connection (Tuhononga) and self (Whaiaro), and eight subthemes in particular mind (hinengaro), spirit (wairua), body (tinana), family (whanau), social connection (whanaungatanga), identity and role (tuakiri), place (wahi), and ancestors (tupuna) emerged. Maori language (Te Reo Maori) was important for cognitive health. CONCLUSION: The findings embedded in cultural values improve understanding of dementia (mate wareware) in Maori. These themes can inform the assessment of older Maori with cognitive impairment. For those without cognitive impairment, the Tuhononga Whaiaro framework suggests factors potentially crucial for healthy aging in Maori.

Predictive factors for entry to long-term residential care in octogenarian Maori and non-Maori in New Zealand, LiLACS NZ cohort.

BACKGROUND: Long-term residential care (LTC) supports the most vulnerable and is increasingly relevant with demographic ageing. This study aims to describe entry to LTC and identify predictive factors for older Maori (indigenous people of New Zealand) and non-Maori. METHODS: LiLACS-NZ cohort project recruited Maori and non-Maori octogenarians resident in a defined geographical area in 2010. This study used multivariable log-binomial regressions to assess factors associated with subsequent entry to LTC including: self-identified ethnicity, demographic characteristics, self-rated health, depressive symptoms and activities of daily living [ADL] as recorded at baseline. LTC entry was identified from: place of residence at LiLACS-NZ interviews, LTC subsidy, needs assessment conducted in LTC, hospital discharge to LTC, and place of death. RESULTS: Of 937 surveyed at baseline (421 Maori, 516 non-Maori), 77 already in LTC were excluded, leaving 860 participants (mean age 82.6 +/- 2.71 years Maori, 84.6 +/- 0.52 years non-Maori). Over a mean follow-up of 4.9 years, 278 (41% of non-Maori, 22% of Maori) entered LTC; of the 582 who did not, 323 (55%) were still living and may yet enter LTC. In a model including both Maori and non-Maori, independent risks factors for LTC entry were: living alone (RR = 1.52, 95%CI:1.15-2.02), self-rated health poor/fair compared to very good/excellent (RR = 1.40, 95%CI:1.12-1.77), depressive symptoms (RR = 1.28, 95%CI:1.05-1.56) and more dependent ADLs (RR = 1.09, 95%CI:1.05-1.13). For non-Maori compared to Maori the RR was 1.77 (95%CI:1.39-2.23). In a Maori-only model, predictive factors were older age and living alone. For non-Maori, factors were dependence in more ADLs and poor/fair self-rated health. CONCLUSIONS: Non-Maori participants (predominantly European) entered LTC at almost twice the rate of Maori. Factors differed between Maori and non-Maori. Potentially, the needs, preferences, expectations and/or values may differ correspondingly. Research with different cultural/ethnic groups is required to determine how these differences should inform service development.

Outcomes of Thyroid Dysfunction in People Aged Eighty Years and Older: An Individual Patient Data Meta-Analysis of Four Prospective Studies (Towards Understanding Longitudinal International Older People Studies Consortium).

Background: Subclinical and overt thyroid dysfunction is easily detectable, often modifiable, and, in younger age groups, has been associated with clinically relevant outcomes. Robust associations in very old persons, however, are currently lacking. This study aimed to investigate the associations between (sub-)clinical thyroid dysfunction and disability in daily living, cognitive function, depressive symptoms, physical function, and mortality in people aged 80 years and older. Methods: Four prospective cohorts participating in the Towards Understanding Longitudinal International older People Studies (TULIPS) consortium were included. We performed a two-step individual participant data meta-analysis on source data from community-dwelling participants aged 80 years and older from the Netherlands, New Zealand, United Kingdom, and Japan. Outcome measures included disability in daily living (disability in activities of daily living [ADL] questionnaires), cognitive function (Mini-Mental State Examination [MMSE]), depressive symptoms (Geriatric Depression Scale [GDS]), physical function (grip strength) at baseline and after 5 years of follow-up, and all-cause five-year mortality. Results: Of the total 2116 participants at baseline (mean age 87 years, range 80-109 years), 105 participants (5.0%) were overtly hypothyroid, 136 (6.4%) subclinically hypothyroid, 1811 (85.6%) euthyroid, 60 (2.8%) subclinically hyperthyroid, and 4 (0.2%) overtly hyperthyroid. Participants with thyroid dysfunction at baseline had nonsignificantly different ADL scores compared with euthyroid participants at baseline and had similar MMSE scores, GDS scores, and grip strength. There was no difference in the change of any of these functional measures in participants with thyroid dysfunction during five years of follow-up. Compared with the euthyroid participants, no 5-year survival differences were identified in participants with overt hypothyroidism (hazard ratio [HR] 1.0, 95% confidence interval [CI 0.6-1.6]), subclinical hypothyroidism (HR 0.9 [CI 0.7-1.2]), subclinical hyperthyroidism (HR 1.1 [CI 0.8-1.7]), and overt hyperthyroidism (HR 1.5 [CI 0.4-5.9]). Results did not differ after excluding participants using thyroid-influencing medication. Conclusions: In community-dwelling people aged 80 years and older, (sub-)clinical thyroid dysfunction was not associated with functional outcomes or mortality and may therefore be of limited clinical significance.

Does potentially inappropriate prescribing predict an increased risk of admission to hospital and mortality? A longitudinal study of the 'oldest old'.

BACKGROUND: Potentially inappropriate prescribing (PIP) is associated with negative health outcomes, including hospitalisation and mortality. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is a longitudinal study of Maori (the indigenous population of New Zealand) and non-Maori octogenarians. Health disparities between indigenous and non-indigenous populations are prevalent internationally and engagement of indigenous populations in health research is necessary to understand and address these disparities. Using LiLACS NZ data, this study reports the association of PIP with hospitalisations and mortality prospectively over 36-months follow-up. METHODS: PIP, from pharmacist applied criteria, was reported as potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs). The association between PIP and hospitalisations (all-cause, cardiovascular disease-specific and ambulatory-sensitive) and mortality was determined throughout a series of 12-month follow-ups using binary logistic (hospitalisations) and Cox (mortality) regression analysis, reported as odds ratios (ORs) and hazard ratios (HRs), respectively, and the corresponding confidence intervals (CIs). RESULTS: Full demographic data were obtained for 267 Maori and 404 non-Maori at baseline, 178 Maori and 332 non-Maori at 12-months, and 122 Maori and 281 non-Maori at 24-months. The prevalence of any PIP (i.e. ≥1 PIM and/or PPO) was 66, 75 and 72% for Maori at baseline, 12-months and 24-months, respectively. In non-Maori, the prevalence of any PIP was 62, 71 and 73% at baseline, 12-months and 24-months, respectively. At each time-point, there were more PPOs than PIMs; at baseline Maori were exposed to a significantly greater proportion of PPOs compared to non-Maori (p = 0.02). In Maori: PPOs were associated with a 1.5-fold increase in hospitalisations and mortality. In non-Maori, PIMs were associated with a double risk of mortality. CONCLUSIONS: PIP was associated with an increased risk of hospitalisation and mortality in this cohort. Omissions appear more important for Maori in predicting hospitalisations, and PIMs were more important in non-Maori in predicting mortality. These results suggest understanding prescribing outcomes across and between population groups is needed and emphasises prescribing quality assessment is useful.

The Association Between Drug Burden Index (DBI) and Health-Related Outcomes: A Longitudinal Study of the 'Oldest Old' (LiLACS NZ).

BACKGROUND: The prescribing of medications with anticholinergic and/or sedative properties is considered potentially inappropriate in older people (due to their side-effect profile), and the Drug Burden Index (DBI) is an evidence-based tool which measures exposure to these medications. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is an ongoing longitudinal study investigating the determinants of healthy ageing. Using data from LiLACS NZ, this study aimed to determine whether a higher DBI was associated with poorer outcomes (hospitalisation, falls, mortality and cognitive function and functional status) over 36 months follow-up. METHODS: LiLACS NZ consists of two cohorts: Maori (the indigenous population of New Zealand) aged ≥ 80 years and non-Maori aged 85 years at the time of enrolment. Data relating to regularly prescribed medications at baseline, 12 months and 24 months were used in this study. Medications with anticholinergic and/or sedative properties (i.e. medications with a DBI > 0) were identified using the Monthly Index of Medical Specialities (MIMS) medication formulary, New Zealand. DBI was calculated for everyone enrolled at each time point. The association between DBI at baseline and outcomes was evaluated throughout a series of 12-month follow-ups using negative binomial (hospitalisations and falls), Cox (mortality) and linear (cognitive function and functional status) regression analyses (significance p < 0.05). Regression models were adjusted for age, gender, general practitioner (GP) visits, socioeconomic deprivation, number of medicines prescribed and one of the following: prior hospitalisation, history of falls, baseline cognitive function [Modified Mini-Mental State Examination (3MS)] or baseline functional status [Nottingham Extended Activities of Daily Living (NEADL)]. RESULTS: Full demographic data were obtained for 671, 510 and 403 individuals at baseline, 12 months and 24 months, respectively. Overall, 31%, 30% and 34% of individuals were prescribed a medication with a DBI > 0 at baseline, 12 months and 24 months, respectively. At baseline and 12 months, non-Maori had a greater mean DBI (0.28 ± 0.5 and 0.27 ± 0.5, respectively) compared to Maori (0.16 ± 0.3 and 0.18 ± 0.5, respectively). At baseline, the most commonly prescribed medicines with a DBI > 0 were zopiclone, doxazosin, amitriptyline and codeine. In Maori, a higher DBI was significantly associated with a greater risk of mortality: at 36 months follow-up, adjusted hazard ratio [95% confidence interval (CI)] 1.89 (1.11-3.20), p = 0.02. In non-Maori, a higher DBI was significantly associated with a greater risk of mortality [at 12 months follow-up, adjusted hazard ratio (95% CIs) 2.26 (1.09-4.70), p = 0.03] and impaired cognitive function [at 24 months follow-up, adjusted mean difference in 3MS score (95% CIs) 0.89 (- 3.89 to - 0.41), p = 0.02). CONCLUSIONS: Using data from LiLACS NZ, a higher DBI was significantly associated with a greater risk of mortality (in Maori and non-Maori) and impaired cognitive function (in non-Maori). This highlights the importance of employing strategies to manage the prescribing of medications with a DBI > 0 in older adults.

Mate wareware: Understanding 'dementia' from a Maori perspective.

AIM: To investigate Maori (Indigenous people of Aotearoa New Zealand) understandings of dementia, its causes, and ways to manage a whanau (extended family) member with dementia. METHOD: We undertook kaupapa Maori research (Maori informed research) with 223 kaumatua (Maori elders) who participated in 17 focus groups across seven study regions throughout Aotearoa New Zealand and eight whanau from the Waikato region. We audio recorded all interviews, transcribed them and then coded and categorised the data into themes. RESULTS: Mate wareware (becoming forgetful and unwell) ('dementia') affects the wairua (spiritual dimension) of Maori. The findings elucidate Maori understandings of the causes of mate wareware, and the role of aroha (love, compassion) and manaakitanga (hospitality, kindness, generosity, support, caring) involved in caregiving for whanau living with mate wareware. Participants perceived cultural activities acted as protective factors that optimised a person's functioning within their whanau and community. CONCLUSION: Whanau are crucial for the care of a kaumatua with mate wareware, along with promoting healthy wairua for all. Whanau urgently need information to assist with their knowledge building and empowerment to meet the needs of a member affected by mate wareware. This requires collaborative healthcare practice and practitioners accessing the necessary matauranga Maori (Maori knowledge) to provide culturally appropriate and comprehensive care for whanau.

Supplementation of Blackcurrant Anthocyanins Increased Cyclic Glycine-Proline in the Cerebrospinal Fluid of Parkinson Patients: Potential Treatment to Improve Insulin-Like Growth Factor-1 Function.

BACKGROUND: Insulin-like growth factor-1 (IGF-1) function is impaired in Parkinson disease. Cyclic glycine-proline (cGP), a metabolite of IGF-1, is neuroprotective through improving IGF-1 function. Parkinson disease patients score lower on Hospital-associated Anxiety and Depression Scale after supplementing blackcurrant anthocyanins (BCA), which may be associated with IGF-1 function. We evaluated the changes of cGP and IGF-1 before and after the supplementation. METHODS: Plasma and cerebrospinal fluid (CSF) were collected from 11 male patients before and after 28 day supplementation of BCA. The concentrations of IGF-1, IGF binding protein (IGFBP)-3, and cGP were measured using ELISA and HPLC-MS assays. The presence of cGP in the BCA was evaluated. RESULTS: cGP presented in the BCA. BCA supplementation increased the concentration of cGP (p < 0.01), but not IGF-1 and IGFBP-3 in the CSF. CSF concentration of cGP was correlated with plasma concentration of cGP (R = 0.68, p = 0.01) and cGP/IGF-1 molar ratio (R = 0.66, p = 0.01). The CSF/plasma ratio was high in cGP and low in IGF-1 and IGFBP-3. CONCLUSION: cGP is a natural nutrient to the BCA. The increased CSF cGP in Parkinson disease patients may result from the central uptake of plasma cGP. Given neurotrophic function, oral availability, and effective central uptake of cGP, the BCA has the potential to be developed to treat neurological conditions with IGF-1 deficiency.

Patterns of multi-morbidity and prediction of hospitalisation and all-cause mortality in advanced age.

Background: multi-morbidity is associated with poor outcomes and increased healthcare utilisation. We aim to identify multi-morbidity patterns and associations with potentially inappropriate prescribing (PIP), subsequent hospitalisation and mortality in octogenarians. Methods: life and Living in Advanced Age; a Cohort Study in New Zealand (LiLACS NZ) examined health outcomes of 421 Maori (indigenous to New Zealand), aged 80-90 and 516 non-Maori, aged 85 years in 2010. Presence of 14 chronic conditions was ascertained from self-report, general practice and hospitalisation records and physical assessments. Agglomerative hierarchical cluster analysis identified clusters of participants with co-existing conditions. Multivariate regression models examined the associations between clusters and PIP, 48-month hospitalisations and mortality. Results: six clusters were identified for Maori and non-Maori, respectively. The associations between clusters and outcomes differed between Maori and non-Maori. In Maori, those in the complex multi-morbidity cluster had the highest prevalence of inappropriately prescribed medications and in cluster 'diabetes' (20% of sample) had higher risk of hospitalisation and mortality at 48-month follow-up. In non-Maori, those in the 'depression-arthritis' (17% of the sample) cluster had both highest prevalence of inappropriate medications and risk of hospitalisation and mortality. Conclusions: in octogenarians, hospitalisation and mortality are better predicted by profiles of clusters of conditions rather than the presence or absence of a specific condition. Further research is required to determine if the cluster approach can be used to target patients to optimise resource allocation and improve outcomes.

Testosterone in advance age: a New Zealand longitudinal cohort study: Life and Living in Advanced Age (Te Puawaitanga o Nga Tapuwae Kia Ora Tonu).

OBJECTIVES: Serum testosterone (T) levels in men decline with age. Low T levels are associated with sarcopenia and frailty in men aged >80 years. T levels have not previously been directly associated with disability in older men. We explored associations between T levels, frailty and disability in a cohort of octogenarian men. SETTING: Data from all men from Life and Living in Advanced Age Cohort Study in New Zealand, a longitudinal cohort study in community-dwelling older adults. PARTICIPANTS: Community-dwelling (>80 years) adult men excluding those receiving T treatment or with prostatic carcinoma. OUTCOMES MEASURES: Associations between baseline total testosterone (TT) and calculated free testosterone (fT), frailty (Fried scale) and disability (Nottingham Extended Activities of Daily Living scale (NEADL)) (baseline and 24 months) were examined using multivariate regression and Wald's χ2 techniques. Subjects with the lowest quartile of baseline TT and fT values were compared with those in the upper three quartiles. RESULTS: Participants: 243 men, mean (SD) age 83.7 (2.0) years. Mean (SD) TT=17.6 (6.8) nmol/L and fT=225.3 (85.4) pmol/L. On multivariate analyses, lower TT levels were associated with frailty: ß=0.41, p=0.017, coefficient of determination (R2)=0.10 and disability (NEADL) (ß=-1.27, p=0.017, R2=0.11), low haemoglobin (ß=-7.38, p=0.0016, R2=0.05), high fasting glucose (ß=0.38, p=0.038, R2=0.04) and high C reactive protein (CRP) (ß=3.57, p=0.01, R2=0.06). Low fT levels were associated with frailty (ß=0.39, p=0.024, R2=0.09) but not baseline NEADL (ß=-1.29, p=0.09, R2=0.09). Low fT was associated with low haemoglobin (ß=-7.83, p=0.0008, R2=0.05) and high CRP (ß=2.86, p=0.04, R2=0.05). Relationships between baseline TT and fT, and 24-month outcomes of disability and frailty were not significant. CONCLUSIONS: In men over 80 years, we confirm an association between T levels and baseline frailty scores. The new finding of association between T levels and disability is potentially relevant to debates on T supplementation in older men, though, as associations were not present at 24 months, further work is needed.

A survey of personal digital assistant use in a sample of New Zealand doctors.

AIM: To gather information about handheld computing hardware and software usage by hospital based doctors in New Zealand (NZ). METHOD: An online tool (SurveyMonkey) was used to conduct the survey from 27 June to 10 September 2010. Distribution of the survey was via an email to all NZ District Health Boards (DHBs). RESULTS: There were 850 responses. About half of respondents (52%) used a personal digital assistant (PDA), 90% using it at least once daily. Usage varied greatly between DHBs (27-100%), perhaps related to institutional support. Among PDA users, the most common applications were the non-clinical; Scheduler (95%), Contacts (97%), and Tasks (83%). Users felt PDAs helped considerably with organisation and time saving. For non-users there were a range of barriers to usage, cost being a large factor. Another major barrier identified by both users and non-users was lack of organisational integration and support. CONCLUSIONS: Half of survey respondents used a PDA. PDA usage of responders from different DHBs varied considerably. Perceived barriers to PDA use included cost and lack of institutional support. A collaborative approach between clinical leadership and Information Technology teams to address barriers may result in increased utility and usage of PDAs in the NZ health system.

Resource usage and outcomes in a facilitated discharge service in Christchurch, New Zealand.

AIM: To describe the type and level of support provided by a facilitated discharge team to frail older patients discharging from a 113-bed elderly rehabilitation hospital and the outcomes achieved. METHOD: Prospective data detailing reasons for referral, services provided and retrospective data on outcomes, were obtained to 90 days post discharge on visits to new patients during 21/2/08 to 15/7/08. RESULTS: Seventy-four patients (mean age 82, 58% female) were included. The mean duration of intervention was 19 days with the most common reasons for referral being poor mobility/falls risk, poor cognition, hygiene concerns. The average number of contacts was 6.5. Patients with the highest number of contacts were those referred with patient anxiety/low confidence (7.4), and family concern (8.4). The most common interventions were family contact and management of carer stress, liaison with medical staff. Unplanned readmission (within 90 days) occurred in 32% whereas 12% and 8% were in residential care or had died respectively. CONCLUSION: Managing the transition from hospital to home for older people requires a large range of interventions, particularly in this highly selected group. Unplanned readmission occurred in a third of this very frail elderly group, yet only 12% needed residential care, suggesting the reasons for readmission could be resolved. Patient or family anxiety resulted in more follow-up visits to patients, and inpatient teams should be mindful of this when planning discharges.