Research article Quantifying physical resilience after knee or hip surgery in older Australian women based on long term physical functioning trajectories.

INTRODUCTION: To improve outcomes after knee or hip surgery, better insight is needed in long-term recovery patterns in the context of ageing-related decline. We examined long-term trajectories of physical functioning (PF) in older women with and without hip and knee surgery, and described profiles of cases with higher and lower resilience after surgery. METHODS: This observational study used data from 10,434 women (73-79 yrs) who completed survey 2 of the Australian Longitudinal Study on Women's Health. Data were used from surveys 2 (1999) to 6 (2011). Covariable-adjusted linear mixed models were run to examine the surgery-by-time (-12 to +12 yrs) interaction in association with PF (SF-36 subscale). The differences between observed and expected PF were calculated, with positive/negative values reflecting higher/lower resilience, respectively. RESULTS: Women with hip surgery (n=982) had lower PF than those without surgery (n=8117) (p<0.001). Among hip surgery patients, the decline was more rapid pre-surgery than post-surgery (Δslope=-0.7, p<0.001). Women with knee surgery (n=1144) had lower PF than those without surgery (n=7971), but with a slower rate of decline (p=0.01). Among knee surgery patients, the rate of decline was similar pre- and post-surgery (Δslope =-0.3, p=0.25). Both in hip and knee patients, women with higher resilience had fewer comorbidities and symptoms, and were more often physically active and independent in daily activities than those with lower resilience (all p<0.05). CONCLUSION: Compared with women without surgery, PF was lower and declined more rapidly around the time of hip surgery, but not for knee surgery. Women with better long-term recovery after surgery, had fewer health problems and were more independent around the time of surgery.

Preparing for future pandemics: frailty associates with mortality in hospitalised older people during the entire COVID-19 pandemic, a Dutch multicentre cohort study.

PURPOSE: Viral mutations and improved prevention or treatment options may have changed the association of frailty with mortality throughout the COVID-19 pandemic. We investigated how associations of frailty with in-hospital mortality changed throughout the pandemic in older people hospitalised for COVID-19. METHODS: The COVID-OLD study included COVID-19 patients aged ≥ 70 years hospitalised during the first (early 2020), second (late 2020), third (late 2021) or fourth wave (early 2022). Based on the clinical frailty scale, patients were categorised as fit (1-3), pre-frail (4-5) or frail (6-9). Associations of frailty with in-hospital mortality were assessed with pairwise comparisons with fit as reference category and modelled using binary logistic regression adjusted for age and sex. RESULTS: This study included 2362 patients (mean age 79.7 years, 60% men). In the first wave, in-hospital mortality was 46% in patients with frailty and 27% in fit patients. In-hospital mortality decreased in each subsequent wave to 25% in patients with frailty and 11% in fit patients in the fourth wave. After adjustments, an overall higher risk of in-hospital mortality was found in frail (OR 2.26, 95% CI: 1.66-3.07) and pre-frail (OR 1.73, 95% CI: 1.27-2.35) patients compared to fit patients, which did not change over time (p for interaction = 0.74). CONCLUSIONS: Frailty remained associated with a higher risk of in-hospital mortality throughout the entire COVID-19 pandemic, although overall in-hospital mortality rates decreased. Frailty therefore remains a relevant risk factor in all stages of a pandemic and is important to consider in prevention and treatment guidelines for future pandemics.

A Digital Gaming Intervention to Strengthen the Social Networks of Older Dutch Adults: Mixed Methods Process Evaluation of a Digitally Conducted Randomized Controlled Trial.

BACKGROUND: Digital loneliness interventions for older adults are promising, yet conclusive evidence is lacking due to a lack of randomized controlled trials (RCTs) and difficulties with recruitment. Process evaluation of performed RCTs is essential to inform future interventions. Still, it is rarely carried out, resulting in an overly optimistic view of the impact of eHealth interventions on loneliness in older adults and options to conduct such research entirely remotely. OBJECTIVE: We describe a mixed methods process evaluation of a digitally conducted RCT assessing the effectiveness of a mobile social gaming app to facilitate meaningful social interactions in older adults. METHODS: We analyzed the questionnaire and game data of the RCT participants to evaluate recruitment and onboarding, intervention adherence, and intervention acceptability. The RCT participants were allocated either to the main group of older adults (aged 65 years or older) or the side group (aged between 18 and 64 years). The side group used networking to play with the older adults. We also conducted 6 post-RCT evaluation interviews and 1 focus group with a total of 4 RCT participants and 5 welfare organization representatives that aided in RCT recruitment. RESULTS: In total, 371 people aged 18 years or older signed up for the RCT, of which 64% (238/371) were aged 65 years or older. Of the total sample, 20% (76/371) installed the app and signed informed consent, showing a large dropout during onboarding. The high number of questions was a relevant barrier for participants. Both questionnaire and gameplay adherence were low. Participants indicated that the games elicited contact and a feeling of togetherness and proposed challenging and competitive games with increasing difficulty levels. They suggested focusing on enjoying the games rather than administering questionnaires. CONCLUSIONS: Conducting a remote digital trial of a social gaming intervention for older adults is a great challenge. Remote recruitment and informed consent acquisition may often not result in sufficient participation. Personal engagement with fellow participants and researchers might be essential for adherence and enjoyment. Future digital gaming interventions should start with small-scale studies with in-person contact, repeated instructions, and fewer questionnaires.

Understanding multimorbidity requires sign-disease networks and higher-order interactions, a perspective.

Background: Count scores, disease clustering, and pairwise associations between diseases remain ubiquitous in multimorbidity research despite two major shortcomings: they yield no insight into plausible mechanisms underlying multimorbidity, and they ignore higher-order interactions such as effect modification. Objectives: We argue that two components are currently missing but vital to develop novel multimorbidity metrics. Firstly, networks should be constructed which consists simultaneously of signs, symptoms, and diseases, since only then could they yield insight into plausible shared biological mechanisms underlying diseases.Secondly, learning pairwise associations is insufficient to fully characterize the correlations in a system. That is, synergistic (e.g., cooperative or antagonistic) effects are widespread in complex systems, where two or more elements combined give a larger or smaller effect than the sum of their individual effects. It can even occur that pairs of symptoms have no pairwise associations whatsoever, but in combination have a significant association. Therefore, higher-order interactions should be included in networks used to study multimorbidity, resulting in so-called hypergraphs. Methods: We illustrate our argument using a synthetic Bayesian Network model of symptoms, signs and diseases, composed of pairwise and higher-order interactions. We simulate network interventions on both individual and population levels and compare the ground-truth outcomes with the predictions from pairwise associations. Conclusion: We find that, when judged purely from the pairwise associations, interventions can have unexpected 'side-effects' or the most opportune intervention could be missed. The hypergraph uncovers links missed in pairwise networks, giving a more complete overview of sign and disease associations.

Association between Muscle Fatigability, Self-Perceived Fatigue and C-Reactive Protein at Admission in Hospitalized Geriatric Patients.

Background: The capacity to perceived vitality (CPV) ratio is a novel measure for intrinsic capacity or resilience based on grip work and self-perceived fatigue. CPV has been associated with pre-frailty in older adults and post-surgery inflammation in adults. To better understand the utility of this measure in a frail population, we examined the association between CPV and inflammation in geriatric inpatients. Methods: Data were obtained from 104 hospitalized geriatric patients. The average age of participants was 83.3 ± 7.5 years, and 55.8% of participants were women. In the cross-sectional analyses, associations between C-reactive protein (CRP), grip work (GW), self-perceived fatigue (SPF) and the CPV ratio (higher values indicate better capacity) were examined using linear regression adjusted for confounders. Results: The adjusted association between CRP (abnormal vs. normal) and the CPV ratio was not statistically significant (B = -0.33, 95% CI = -4.00 to 3.34). Associations between CRP and GW (B = 25.53, 95% CI = -478.23 to 529.30) and SPF (B = 0.57, 95% CI = -0.64 to 1.77) were also not statistically significant. Similar results were found in unadjusted models and analyses of cases with complete data. Conclusions: In this frail group of geriatric inpatients, inflammation, routinely assessed with CRP, was not associated with CPV or its components, GW and SPF. Further research is needed to explore whether CPV is a useful indicator of frailty or recovery capacity in hospitalized geriatric patients.

Validity and reliability of Eforto®, a system to (self-)monitor grip strength and muscle fatigability in older persons.

INTRODUCTION: We developed Eforto®, an innovative system for (self-)monitoring of grip strength (GS) and muscle fatigability (Fatigue Resistance (FR = time until GS decreased to 50% of maximum during sustained contraction) and grip work (GW = area under the strength-time curve)). The Eforto® system consists of a rubber bulb that is wirelessly connected to a smartphone-based application, and a telemonitoring platform. The aim was to evaluate the validity and reliability of Eforto® to measure muscle fatigability. METHODS: Community-dwelling older persons (n = 61), geriatric inpatients (n = 26) and hip fracture patients (n = 25) were evaluated for GS and muscle fatigability. In community dwellers fatigability was tested twice in the clinic (once with Eforto®, once with Martin Vigorimeter (MV), standard analog handgrip system) and for six consecutive days as a self-assessment at home with Eforto®. In hospitalized participants, fatigability was tested twice using Eforto®, once by a researcher and once by a health professional. RESULTS: Criterion validity was supported by good to excellent correlations between Eforto® and MV for GS (r = 0.95) and muscle fatigability (FR r = 0.81 and GW r = 0.73), and no significant differences in measurements between both systems. Inter-rater and intra-rater reliability for GW were moderate to excellent (intra-class correlation: 0.59-0.94). The standard error of measurement for GW was small for geriatric inpatients and hip fracture patients (224.5 and 386.5 kPa*s) and higher for community-dwellers (661.5 kPa*s). DISCUSSION/CONCLUSION: We established the criterion validity and reliability of Eforto® in older community-dwelling persons and hospitalized patients, supporting the implementation of Eforto® for (self-)monitoring of muscle fatigability.

Supporting Resilience of Older Adults with Cognitive Decline Requires a Multi-Level System Approach.

The concept of resilience, i.e., the capacity of a system to bounce back after a stressor, is gaining interest across many fields of science, policy, and practice. To date, resilience research in people with cognitive decline has predominantly addressed the early stages of decline. We propose that: (1) resilience is a relevant concept in all stages of cognitive decline; and (2) a socio-ecological, multisystem perspective on resilience is required to advance understanding of, and care and support for people with cognitive decline and their support networks. We substantiate our position with literature and examples. Resilience helps understand differences in response to risk factors of (further) cognitive decline and informs personalised prevention. In a curative context, interventions to strengthen resilience aim to boost recovery from cognitive decline. In care for people with dementia, resilience-focused interventions can strengthen coping mechanisms to maintain functioning and well-being of the individual and their support network. A good example of improving resilience in the social and policy context is the introduction of age-friendly cities and dementia-friendly communities. Good care for people with cognitive decline requires a health and social care system that can adapt to changes in demand. Given the interdependency of resilience at micro-, meso- and macro-levels, an integrative socio-ecological perspective is required. Applying the concept of resilience in the field of cognitive decline opens new horizons for research to improve understanding, predicting, intervening on health and social care needs for the increasing population with cognitive decline.

Behaviour Change Techniques in Computerized Cognitive Training for Cognitively Healthy Older Adults: A Systematic Review.

We aimed to describe behaviour change techniques (BCT) used in trials evaluating computerised cognitive training (CCT) in cognitively healthy older adults, and explore whether BCTs are associated with improved adherence and efficacy. The 90 papers included in a recent meta-analysis were reviewed for information about adherence and use of BCTs in accordance with the Behaviour Change Taxonomy. Studies using a specific BCT were compared with studies not using that BCT on efficacy (difference in Hedges' g [Δg]) using three level meta-regression models and on median adherence using the Wilcoxon test. The median number of BCTs per study was 3 (interquartile range [IQR] = 2-5). 'Feedback on behaviour' (if provided by a person; Δg = -0.19, 95% confidence interval [CI] = -0.31;-0.07) and 'non-specific reward' (Δg = -0.19, CI = -0.34;-0.05) were associated with lower efficacy. Certain BCTs that involve personal contact may be beneficial, although none were statistically significantly associated with greater efficacy. The median percentage of adherence was 90% (IQR = 81-95). Adherence was higher in studies using the BCT 'self-monitoring of behaviour' and lower in studies using the BCT 'graded tasks' than studies not using these BCTs (p < 0.001). These findings provide first evidence that BCTs can influence both adherence to and efficacy of CCT programs in cognitively healthy older adults.

One-Legged Balance Performance and Fall Risk in Mid and Later Life: Longitudinal Evidence From a British Birth Cohort.

INTRODUCTION: The one-legged balance test is widely used as a fall risk screening tool in both clinical and research settings. Despite rising fall prevalence in midlife, there is little evidence examining balance and fall risk in those aged <65 years. This study investigated the longitudinal associations between one-legged balance and the number of falls between ages 53 and 68 years. METHODS: The study included 2,046 individuals from the Medical Research Council National Survey of Health & Development, a British birth cohort study. One-legged balance times (eyes open, maximum: 30 seconds) were assessed at ages 53 years (1999) and 60-64 years (2006-2010). Fall history within the last year (none, 1, ≥2) was self-reported at ages 60-64 years and 68 years (2014). Multinomial logistic regressions assessed the associations between balance and change in balance with subsequent falls. Models adjusted for anthropometric, socioeconomic, behavioral, health status, and cognitive indicators. Analysis occurred between 2019 and 2022. RESULTS: Balance performance was not associated with single falls. Better balance performance at age 53 years was associated with decreased risk of recurrent falls at ages 60-64 years and 68 years, with similar associations between balance at age 60-64 years and recurrent falls at age 68 years. Those with consistently lower balance times (<15 seconds) were at greater risk (RRR=3.33, 95% CI=1.91, 5.80) of recurrent falls at age 68 years in adjusted models than those who could balance for 30 seconds at ages 53 years and 60-64 years. CONCLUSIONS: Lower balance and consistently low or declining performance were associated with a greater subsequent risk of recurrent falls. Earlier identification and intervention of those with poor balance ability can help to minimize the risk of recurrent falls in aging adults.

Prevalence of parkinsonism and Parkinson disease in urban and rural populations from Latin America: A community based study.

Background: Age and gender specific prevalence rates for parkinsonism and Parkinson's disease (PD) are important to guide research, clinical practice, and public health planning; however, prevalence estimates in Latin America (LatAm) are limited. We aimed to estimate the prevalence of parkinsonism and PD and examine related risk factors in a cohort of elderly individuals from Latin America (LatAm). Methods: Data from 11,613 adults (65+ years) who participated in a baseline assessment of the 10/66 study and lived in six LatAm countries were analyzed to estimate parkinsonism and PD prevalence. Crude and age-adjusted prevalence were determined by sex and country. Diagnosis of PD was established using the UK Parkinson's Disease Society Brain Bank's clinical criteria. Findings: In this cohort, the prevalence of parkinsonism was 8.0% (95% CI 7.6%-8.5%), and the prevalence of PD was 2.0% (95% CI 1.7%-2.3%). PD prevalence increased with age from 1.0 to 3.5 (65-69vs. 80 years or older, p < 0.001). Age-adjusted prevalence rates were lower for women than for men. No significant differences were found across countries, except for lower prevalence in urban areas of Peru. PD was positively associated with depression (adjusted prevalence ratio [aPR] 2.06, 95% CI 1.40-3.01, I 2 = 56.0%), dementia (aPR 1.57, 95% CI 1.07- 2.32, I 2 = 0.0%) and educational level (aPR 1.14, 95% CI 1.01- 1.29, I 2 = 58.6%). Interpretation: The reported prevalence of PD in LatAm is similar to reports from high-income countries (HIC). A significant proportion of cases with PD did not have a previous diagnosis, nor did they seek any medical or neurological attention. These findings underscore the need to improve public health programs for populations currently undergoing rapid demographic aging and epidemiological transition. Funding: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Associations between depression and cognition, mild cognitive impairment and dementia in persons with diabetes mellitus: A systematic review and meta-analysis.

AIMS: This systematic review aimed to examine whether persons with diabetes and depression had poorer cognition and higher dementia risk than persons with diabetes only. Moreover, the impact of timing, frequency of depressive episodes throughout life, and antidepressant treatment were examined. METHODS: PubMed, Embase and PsycINFO were searched to obtain observational studies between August 2015 and June 2021 that examined the association between depression and cognition, mild cognitive impairment or dementia in people with diabetes. Studies published before August 2015 were retrieved from a previous systematic review. Findings were pooled using meta-analyses. RESULTS: 10 out of 19 included articles were appropriate for the meta-analyses. Persons with diabetes and depression experienced greater declines in executive function (SMD = -0.39 (-0.69, -0.08)), language (SMD = -0.80 (-1.52, -0.09)), memory (SMD = -0.63 (-1.12, -0.14)) and overall cognition (SMD = -0.77 (-1.33, -0.20)), and greater dementia risk (HR = 1.82 (1.79, 1.85)) than persons with diabetes only. No significant differences were observed for complex attention. No studies examined the role of timing and frequency of depressive episodes and antidepressant treatment. CONCLUSION: In persons with diabetes, depression is associated with worse cognition and higher dementia risk. The potential mitigating effect of antidepressant treatment remains unclear.

Prognostic accuracy of the one-legged balance test in predicting falls: 15-years of midlife follow-up in a British birth cohort study.

Introduction: The one-legged balance test is a common screening tool for fall risk. Yet, there is little empirical evidence assessing its prognostic ability. The study aims were to assess the prognostic accuracy of one-legged balance performance in predicting falls and identify optimal cut-points to classify those at greater risk. Methods: Data from up to 2,000 participants from a British birth cohort born in 1,946 were used. The times an individual could stand on one leg with their eyes open and closed were recorded (max: 30 s) at ages 53 and 60-64. Number of falls in the past year was self-reported at ages 53, 60-64 and 68; recurrent falls (0-1 vs. 2+) and any fall (0 vs. 1+) were considered binary outcomes. Four longitudinal associations between balance times and subsequent falls were investigated (age 53 → 60-64; age 53 → 68; age 60-64 → 68; age 53 & 60-64 → 68). For each temporal association, areas under the curve (AUC) were calculated and compared for a base sex-only model, a sex and balance model, a sex and fall history model and a combined model of sex, balance and fall history. The Liu method was used to identify optimal cut-points and sensitivity, specificity, and AUC at corresponding cut-points. Results: Median eyes open balance time was 30 s at ages 53 and 60-64; median eyes closed balance times were 5 s and 3 s, respectively. The predictive ability of balance tests in predicting either fall outcome was poor (AUC range for sex and balance models: 0.577-0.600). Prognostic accuracy consistently improved by adding fall history to the model (range: 0.604-0.634). Optimal cut-points ranged from 27 s to 29 s for eyes open and 3 s to 5 s for eyes closed; AUC consistently indicated that using "optimal" cut-points to dichotomise balance time provided no discriminatory ability (AUC range:0.42-0.47), poor sensitivity (0.38-0.61) and poor specificity (0.23-0.56). Discussion: Despite previous observational evidence showing associations between better one-legged balance performance and reduced fall risk, the one-legged balance test had limited prognostic accuracy in predicting recurrent falls. This contradicts ongoing translation of this test into clinical screening tools for falls and highlights the need to consider new and existing screening tools that can reliably predict fall risk.

Association between clusters of back and joint pain with opioid use in middle-aged community-based women: a prospective cohort study.

BACKGROUND: To determine the relationship between clusters of back pain and joint pain and prescription opioid dispensing. METHODS: Of 11,221 middle-aged participants from the Australian Longitudinal Study of Women's Health, clusters of back pain and joint pain from 2001 to 2013 were identified using group-based trajectory modelling. Prescription opioid dispensing from 2003 to 2015 was identified by linking the cohort to Pharmaceutical Benefit Scheme dispensing data. Multinomial logistic regression was used to examine the association between back pain and joint pain clusters and dispensing of prescription opioids. The proportion of opioids dispensed in the population attributable to back and join pain was calculated. RESULTS: Over 12 years, 68.5 and 72.0% women reported frequent or persistent back pain and joint pain, respectively. There were three clusters ('none or infrequent', 'frequent' and 'persistent') for both back pain and joint pain. Those in the persistent back pain cluster had a 6.33 (95%CI 4.38-9.16) times increased risk of having > 50 opioid prescriptions and those in persistent joint pain cluster had a 6.19 (95%CI 4.18-9.16) times increased risk of having > 50 opioid prescriptions. Frequent and persistent back and joint pain clusters together explained 41.7% (95%CI 34.9-47.8%) of prescription opioid dispensing. Women in the frequent and persistent back pain and joint pain clusters were less educated and reported more depression and physical inactivity. CONCLUSION: Back pain and joint pain are major contributors to opioid prescription dispensing in community-based middle-aged women. Additional approaches to reduce opioid use, targeted at those with frequent and persistent back pain and joint pain, will be important in order to reduce the use of opioids and their consequent harm in this population.

Sex differences in the incidence and prevalence of young-onset Alzheimer's disease: A meta-analysis.

OBJECTIVES: The lifetime incidence of Alzheimer's disease is higher in women than in men, but it remains unclear if similar sex differences exist in young-onset Alzheimer's disease (YOAD). This systematic review test the hypothesis that women have a higher prevalence and incidence of YOAD than men. METHODS: We searched Pubmed and Embase (inception to 11 June 2020) for original publications of population-based observational studies with data on the prevalence and/or incidence of YOAD, defined as a medical diagnosis of Alzheimer's disease before the age of 65 years. Data on cross-sectional and/or prospective numbers, percentages, incidences, and incidence rates (in person-years) were derived from included studies. Quality assessment was done using the Nottingham Ottawa Scale. Meta-analyses were done to test the hypothesis that women have a higher prevalence and incidence of YOAD than men. RESULTS: After screening of 3252 titles, 12 articles were included. The pooled prevalence was 0.4% (confidence interval [CI] = 0.1-2.1) in women and 0.2% (CI = 0-1.2) in men (six studies, relative risk [RR] = 1.54, CI = 0.69-3.44, I2  = 38%). The pooled incidence was 0.02% (CI = 0.01-0.08) in women and 0.01% (CI = 0-0.05) in men (five studies, RR = 1.50, CI = 0.91-2.48, I2  = 0%). The incidence rates per 100,000 person-years ranged from 0 to 132 in women and from 0 to 42 in men. CONCLUSIONS: Given the low prevalence and wide CIs, no firm conclusions can be drawn. Large-scale studies are required to verify that women are more likely than men to develop YOAD.

[Do community-dwelling Dutch older adults receive the care that they need?] / Verschuivingen in formele zorg en mantelzorg voor thuiswonende ouderen in Nederland van 2009 tot 2013.

Background Aged care homes have been substituted by homecare to reduce the increasing Dutch healthcare costs. Ageing in place has led to a growing demand on formal and informal caregivers. The aim of this study was to examine: 1) the trends in formal and informal care, 2) whether care needs of community-living older adults are met, and 3) the association between care needs and quality of life (QoL). Methods Baseline data were used from 'The Older Persons and Informal Caregivers Survey - Minimum DataSet', which combines 54 studies conducted in 2008-2014. 12,735 participants met the inclusion criteria (age ≥65 years, living independently, needing assistance with washing, dressing, medication or household chores). Proportions of participants receiving formal or informal care were reported and associations with QoL were examined using ordinal (self-rated QoL) and linear (EQ-5D) regression. Results Formal care decreased from 75% to 63% and informal care increased from 16% to 28% between 2009 and 2013 (P < .001). Approximately one in four participants received no formal or informal care. Receiving no formal care was associated with a better QoL (self-rated QoL OR=1.39, CI=[1.251-1.544]; EQ-5D regression coefficient=0.038 CI=[0.023-0.053]). Conclusion The shift from formal to informal care together with the unmet care needs of community-living older adults in the Netherlands underlines the need for more support and a higher demand on informal caregivers.

Risk Factors for Incident Dementia Among Older Cubans.

Introduction: Little is known about risk factors of dementia in Latin American countries. We aimed to identify socio-demographic, health and lifestyle risk factors of incident dementia in Cuban older adults. Methods: Data were from 1,846 participants in the Cuban cohort of the 10/66 Dementia Research Group. Participants completed questionnaires, health examinations, and cognitive tests at baseline (2003-2006) and 4.5 years later (2007-2010). Associations between risk factors (baseline) and incident dementia (follow-up) were examined using logistic regression. Results: Just over 9% of participants developed dementia. Overall, older age and low physical activity were associated with incident dementia. In those 65-74 years of age, depression, stroke and low physical activity were associated with incident dementia. In those ≥75 years of age, low physical activity, never eating fish, and smoking were associated with incident dementia. Conclusions: Modifiable lifestyle factors play an important role in developing dementia in Cuban older adults. This knowledge opens up opportunities for preventive strategies.

Clustering of Behavioral Changes and Their Associations With Cognitive Decline in Older Adults.

OBJECTIVES: To examine (1) the clustering of reduced falls-efficacy, social withdrawal, and physical activity withdrawal in Irish adults aged 50 years and older, and (2) the concurrent and prospective associations of these clustered behaviors with cognitive decline. DESIGN: Longitudinal cohort study. SETTING AND PARTICIPANTS: Data were from 4571 participants (mean age 64.5 ± 8.6, 54.9% women) in The Irish Longitudinal Study on Ageing, a population-based study. METHODS: Changes in social and physical activity and falls-efficacy from 2012/2013 to 2014/2015 were used to define the behaviors of social withdrawal, physical activity withdrawal, and reduced falls-efficacy. Patterns of behaviors were associated with concurrent (2012/2013-2014/2015) and prospective (2014/2015-2016/2017) changes in immediate recall, delayed recall, and verbal fluency using random effects mixed models. RESULTS: Eighty-six percent of participants had social withdrawal, physical activity withdrawal, or reduced falls-efficacy, and 15% had all 3 behaviors. Participants with all 3 behaviors showed the greatest declines in immediate recall (concurrent: B = -0.51, confidence interval [CI] = -0.77 to -0.25; prospective: B = -0.51, CI = -0.78 to -0.25), delayed recall (concurrent: B = -0.40, CI = -0.61 to -0.18; prospective: B = -0.47, CI = -0.69 to -0.25) and verbal fluency (concurrent: B = -1.05, CI = -1.58 to -0.52; prospective: B = -1.29, CI = -1.83 to -0.74). CONCLUSIONS AND IMPLICATIONS: The clustering of social withdrawal, physical activity withdrawal, and reduced falls-efficacy is common. Presence of multiple behaviors was associated with greater cognitive declines, suggesting a cumulative association of these behaviors with cognitive decline. These findings guide (1) identification of vulnerable groups, (2) intervention design, and (3) care planning for people presenting with 1 or more of these changes in behavior.

Understanding the aetiology of fear of falling from the perspective of a fear-avoidance model - A narrative review.

Approximately half of older adults experience fear of falling (FoF) but the aetiology is unclear. The aim is to review the literature on physiological, mood and cognitive factors associated with FoF and to interpret these findings in the context of a fear-avoidance model that provides a causal framework for the development of FoF. There is growing evidence that the development of FoF is influenced by balance problems and falls, and emerging evidence for a role for cognitive factors, particularly attention and processing of sensory information. While there may also be a role for mood/temperament in the development of FoF, current evidence is weak. We argue that these factors co-exist and interact, which complicates assessment and design of the most appropriate intervention. The fear avoidance model offers a novel framework for explaining the mechanism of developing FoF and the discrepancy between experienced and perceived fall risk. This model specifically capitalizes on recent insights into fundamental learning mechanisms underlying emotion and fear. The proposed models provide hypotheses for future research and indications for improving efficacy of existing treatment programs.

Late life education and cognitive function in older adults.

OBJECTIVE: The potential role of education attained after the age of 50, for example, vocational training or recreational courses, in cognitive reserve has been unexplored. We examined the cross-sectional and prospective associations between late life education (LLE) and global cognitive function in older adults. METHODS: A total of 5306 participants (50+ years) in The Irish Longitudinal Study of Ageing answered questions about highest level of education completed and LLE (2010). Cognitive function was defined as the number of errors on the Montreal cognitive assessment (MoCA) assessed in 2010 and 2014. The association between LLE and MoCA-errors was examined using Poisson regression stratified by level of education. Sensitivity analyses were done to examine reverse causation and selection bias. RESULTS: In those with primary/no (n = 1312, incidence rate ratio [IRR] = 0.83, 95%CI = 0.70-0.99) and secondary education (n = 2208, IRR = 0.88, 95%CI = 0.80-0.97), but not tertiary education (n = 1786, IRR = 0.93, CI = 0.86-1.00), participating in LLE was associated with lower rate of MoCA errors. The prospective association between LLE and 4-year change in MoCA-errors was (borderline) statistically significant in those with primary/no education only (IRR = 0.86, CI = 0.74-1.00). Sensitivity analyses supported robustness of the findings. CONCLUSIONS: LLE may contribute to cognitive reserve and be a useful intervention to mitigate the increased risk of cognitive decline associated with low levels of education.

Aspirin and fracture risk: a systematic review and exploratory meta-analysis of observational studies.

OBJECTIVES: This review provides insights into the potential for aspirin to preserve bone mineral density (BMD) and reduce fracture risk, building knowledge of the risk-benefit profile of aspirin. METHODS: We conducted a systematic review and exploratory meta-analysis of observational studies. Electronic searches of MEDLINE and Embase, and a manual search of bibliographies was undertaken for studies published to 28 March 2018. Studies were included if: participants were men or women aged ≥18 years; the exposure of interest was aspirin; and relative risks, ORs and 95% CIs for the risk of fracture or difference (percentage or absolute) in BMD (measured by dual energy X-ray absorptiometry) between aspirin users and non-users were presented. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists for observational studies. Pooled ORs for any fracture and standardised mean differences (SMDs) for BMD outcomes were calculated using random-effects models. RESULTS: Twelve studies met the inclusion criteria and were included in the meta-analysis. Aspirin use was associated with a 17% lower odds for any fracture (OR 0.83, 95% CI 0.70 to 0.99; I2=71%; six studies; n=511 390). Aspirin was associated with a higher total hip BMD for women (SMD 0.03, 95% CI -0.02 to 0.07; I2=0%; three studies; n=9686) and men (SMD 0.06, 95% CI -0.02 to 0.13, I2=0%; two studies; n=4137) although these associations were not significant. Similar results were observed for lumbar spine BMD in women (SMD 0.03, 95% CI -0.03 to 0.09; I2=34%; four studies; n=11 330) and men (SMD 0.08; 95% CI -0.01 to 0.18; one study; n=432). CONCLUSIONS: While the benefits of reduced fracture risk and higher BMD from aspirin use may be modest for individuals, if confirmed in prospective controlled trials, they may confer a large population benefit given the common use of aspirin in older people.