Do financial hardships affect health? A study among older adults in Switzerland.

BACKGROUND: A growing number of studies have underlined the relationship between socioeconomic status and health. Following that literature, we explore the causal effect of financial hardships on changes in health at older ages. Rather than traditional measures of socioeconomic variables, we study the role of financial hardships. The declarative measurement of financial hardships is particularly relevant for assessing the impact of short-term financial difficulties on health among older adults. METHODS: In this study, we use data from the Lausanne cohort 65+. Participants are community-dwelling older adults representative of the population aged 65-70 years in 2004 and living in Lausanne (Switzerland) (n = 1352). We use longitudinal annual data with 11 years of follow-up (2006-16) to estimate dynamic panel models on several indicators measuring older adults' health (self-rated health, number of medical conditions, depressive symptoms, difficulties with daily living activities). RESULTS: We find evidence of causal effects of financial hardships on self-rated health (coef. = 0.059, P < 0.10) and on depressive symptoms (coef.=0.060, P < 0.05). On the other hand, we find no evidence of causality running from financial hardships to the number of medical conditions and the difficulties in daily living activities. CONCLUSION: These results make a contribution to the literature where nearly all previous research on associations between financial hardship and health does not establish causal relationships. Our results support the need to integrate health policies that mitigate the potential adverse health effects of financial hardship for older adults.

Executive function and prospective falls: a 6-year longitudinal study in community-dwelling older adults.

BACKGROUND: Older people with impaired executive function (EF) might have an increased fall risk, but prospective studies with prolonged follow-up are scarce. This study aimed to investigate the association between a) EF at baseline; b) 6-year decline in EF performance; and fall status 6 years later. METHODS: Participants were 906 community-dwelling adults aged 65-69 years, enrolled in the Lausanne 65 + cohort. EF was measured at baseline and at 6 years using clock drawing test (CDT), verbal fluency (VF), Trail Making Test (TMT) A and B, and TMT ratio (TMT-B - TMT-A/TMT-A). EF decline was defined as clinically meaningful poorer performance at 6 years. Falls data were collected at 6 years using monthly calendars over 12 months. RESULTS: Over 12-month follow-up, 13.0% of participants reported a single benign fall, and 20.2% serious (i.e., multiple and/or injurious) falls. In multivariable analysis, participants with worse TMT-B performance (adjusted Relative Risk Ratio, adjRRRTMT-B worst quintile = 0.38, 95%CI:0.19-0.75, p = .006) and worse TMT ratio (adjRRRTMT ratio worst quintile = 0.31, 95%CI:0.15-0.64, p = .001) were less likely to report a benign fall, whereas no significant association was observed with serious falls. In a subgroup analysis among fallers, participants with worse TMT-B (OR:1.86, 95%CI = 0.98-3.53, p = .059) and worse TMT ratio (OR:1.84,95%CI = 0.98-3.43,p = .057) tended to have higher odds of serious falls. EF decline was not associated to higher odds of falls. CONCLUSIONS: Participants with worse EF were less likely to report a single benign fall at follow-up, while fallers with worse EF tended to report multiple and/or injurious falls more frequently. Future studies should investigate the role of slight EF impairment in provoking serious falls in active young-old adults.

Fear of falling and all-cause mortality among young-old community-dwelling adults: a 6-year prospective study.

This study investigated whether fear of falling (FOF) measured by two different instruments, the Falls Efficacy Scale-International (FES-I) and the single question on FOF and activity restriction (SQ-FAR), is associated with mortality at 6-year follow-up. Participants (n = 1359, 58.6% women) were community-dwelling persons enrolled in the Lausanne cohort 65 + , aged 66 to 71 years at baseline. Covariables assessed at baseline included demographic, cognitive, affective, functional and health status, while date of death was obtained from the office in charge for population registration. Unadjusted Kaplan Meyer curves were performed to show the survival probability for all-cause mortality according to the degree of FOF reported with FES-I and SQ-FAR, respectively. Bivariable and multivariable Cox regression analyses were performed to assess hazard ratios, using time-in-study as the time scale variable and adjusting for variables significantly associated in bivariable analyses. During the 6-year follow-up, 102 (7.5%) participants died. Reporting the highest level of fear at FES-I (crude HR 3.86, 95% CI 2.37-6.29, P < .001) or "FOF with activity restriction" with SQ-FAR (crude HR 2.42, 95% CI 1.44-4.09, P = .001) were both associated with increased hazard of death but these associations did not remain significant once adjusting for gender, cognitive, affective and functional status. As a conclusion, although high FOF and related activity restriction, assessed with FES-I and SQ-FAR, identifies young-old community-dwelling people at increased risk of 6-year mortality, this association disappears when adjusting for potential confounders. As a marker of negative health outcomes, FOF should be screened for in order to provide personalized care and reduce subsequent risks.

Development and validation of a knowledge-based score to predict Fried's frailty phenotype across multiple settings using one-year hospital discharge data: The electronic frailty score.

Background: Most claims-based frailty instruments have been designed for group stratification of older populations according to the risk of adverse health outcomes and not frailty itself. We aimed to develop and validate a tool based on one-year hospital discharge data for stratification on Fried's frailty phenotype (FP). Methods: We used a three-stage development/validation approach. First, we created a clinical knowledge-driven electronic frailty score (eFS) calculated as the number of deficient organs/systems among 18 critical ones identified from the International Statistical Classification of Diseases and Related Problems, 10th Revision (ICD-10) diagnoses coded in the year before FP assessment. Second, for eFS development and internal validation, we linked individual records from the Lc65+ cohort database to inpatient discharge data from Lausanne University Hospital (CHUV) for the period 2004-2015. The development/internal validation sample included community-dwelling, non-institutionalised residents of Lausanne (Switzerland) recruited in the Lc65+ cohort in three waves (2004, 2009, and 2014), aged 65-70 years at enrolment, and hospitalised at the CHUV at least once in the year preceding the FP assessment. Using this sample, we selected the best performing model for predicting the dichotomised FP, with the eFS or ICD-10-based variables as predictors. Third, we conducted an external validation using 2016 Swiss nationwide hospital discharge data and compared the performance of the eFS model in predicting 13 adverse outcomes to three models relying on well-designed and validated claims-based scores (Claims-based Frailty Index, Hospital Frailty Risk Score, Dr Foster Global Frailty Score). Findings: In the development/internal validation sample (n = 469), 14·3% of participants (n = 67) were frail. Among 34 models tested, the best-subsets logistic regression model with four predictors (age and sex at FP assessment, time since last hospital discharge, eFS) performed best in predicting the dichotomised FP (area under the curve=0·71; F1 score=0·39) and one-year adverse health outcomes. On the external validation sample (n = 54,815; 153 acute care hospitals), the eFS model demonstrated a similar performance to the three other claims-based scoring models. According to the eFS model, the external validation sample showed an estimated prevalence of 56·8% (n = 31,135) of frail older inpatients at admission. Interpretation: The eFS model is an inexpensive, transportable and valid tool allowing reliable group stratification and individual prioritisation for comprehensive frailty assessment and may be applied to both hospitalised and community-dwelling older adults. Funding: The study received no external funding.

Trajectories of phenotypical frailty over a decade in young-old community-dwelling adults: results from the Lc65+ study.

BACKGROUND: Few studies have examined the frailty trajectories of young-old adults using Fried frailty phenotype. Dropouts due to death were rarely taken into account. This longitudinal study aimed to identify trajectories with and without adjustment for non-random attrition and to analyse related factors. METHODS: We used the first two samples of community-dwelling people in the Lausanne cohort 65+. Frailty phenotype was assessed at age 66-71 years and every third year over 10 years. A group-based trajectory modelling-first without and then with adjustment for non-random attrition-identified trajectories among all individuals with at least two observations (n=2286), excluding dropouts for reasons other than death. Multinomial logistic regressions estimated independent effects of participants' baseline characteristics. RESULTS: We identified three frailty trajectories (low, medium and high). Participants in the highest trajectory had a higher mortality over 10 years. (Pre)frailty at baseline was the main factor associated with adverse trajectories. Smoking, obesity, comorbidity and negative self-perceived health were associated with unfavourable trajectories independently of baseline frailty, while social engagement was related to the lowest frailty trajectory. Ignoring transitions to death attenuated the estimated effects of age on trajectories. CONCLUSIONS: Fried frailty phenotype should be assessed in individuals aged late 60s as it is strongly associated with frailty trajectories in the following decade of their life. Lifetime prevention of behavioural risk factors such as smoking and obesity is the strategy most likely to influence the development of frailty in older populations. Furthermore, our results underline social engagement as an important area of interest for future research.

Instrumented 5-Time Sit-To-Stand Test: Parameters Predicting Serious Falls beyond the Duration of the Test.

BACKGROUND: Falls are a major cause of injuries in older adults. To evaluate the risk of falls in older adults, clinical assessments such as the 5-time sit-to-stand (5xSTS) test can be performed. The development of inertial measurement units (IMUs) has provided the possibility of a more in-depth analysis of the movements' biomechanical characteristics during this test. The goal of the present study was to investigate whether an instrumented 5xSTS test provides additional information to predict multiple or serious falls compared to the conventional stopwatch-based method. METHODS: Data from 458 community-dwelling older adults were analyzed. The participants were equipped with an IMU on the trunk to extract temporal, kinematic, kinetic, and smoothness movement parameters in addition to the total duration of the test by the stopwatch. RESULTS: The total duration of the test obtained by the IMU and the stopwatch was in excellent agreement (Pearson's correlation coefficient: 0.99), while the total duration obtained by the IMU was systematically 0.52 s longer than the stopwatch. In multivariable analyses that adjusted for potential confounders, fallers had slower vertical velocity, reduced vertical acceleration, lower vertical power, and lower vertical jerk than nonfallers. In contrast, the total duration of the test measured by either the IMU or the stopwatch did not differ between the 2 groups. CONCLUSIONS: An instrumented 5xSTS test provides additional information that better discriminates among older adults those at risk of multiple or serious falls than the conventional stopwatch-based assessment.

Does the frailty phenotype at the age of 66 to 71 predict death? A 14-year survival analysis of the Lc65+ study.

BACKGROUND: Frailty is a health characteristic resulting from the loss of physiological reserve of multiple organs, leading to exposure to adverse outcomes, and is possibly reversible in its earliest stages. It is identified by a specific phenotype that contributes to the practice of geriatric medicine, where it is considered a potential target for preventive action. This phenotype has recently attracted interest in other medical specialties for risk assessment before stressful interventions in older adults. Whereas frailty is unusual in sexagenarians, pre-frailty is common. This longitudinal study aimed to evaluate the significance of fulfilling at least one criterion of the frailty phenotype in the late sixties as a predictor of short- and long-term mortality in males and females. METHODS: Data came from the first sample of the Lc65+ cohort, representative of the community-dwelling Lausanne population born between 1934 and 1939 (n = 1315). After baseline assessment of the five criteria of Fried's frailty phenotype (shrinking, exhaustion, muscular weakness, motor slowness and low physical activity) in 2005 (age 66-71 years), deaths were recorded over 14 years. We separated individuals into non-frail (fulfilling 0 criterion) and (pre-)frail (1+ criteria). The relationship between the phenotype and mortality was investigated graphically using Kaplan-Meier survival curves and quantified in Cox models. Multivariable analyses incrementally controlled age, socioeconomic and health characteristics. The prediction of fully adjusted models was evaluated using the Harrell's C index. RESULTS: Overall, 401 persons (30.5%) were (pre-)frail at baseline. A quarter of the 1315 participants died over 14 years (n = 336, 25.6%). The mortality rate was significantly higher in males in the (pre-)frail subgroup only. Survival curves showed a significant effect of (pre-)frailty on the risk of dying for both sexes. The effect of (pre-)frailty on mortality was stronger during the first 4 years of the follow-up. In males, it was significant both in short (0-4 years) and longer (>4-14 years) terms. In females, it was significant in the short term only. In all models, the estimated effect was stronger in males. The fully adjusted model was fairly predictive of death in the short term both in males (Harrell's C 0.79) and females (0.75). CONCLUSIONS: The significantly higher mortality of individuals presenting 1+ frailty criteria supports the appropriateness of a systematic assessment of the frailty phenotype at the age of 66-71 years. In both females and males, early identification of pre-frailty has the potential to limit or reverse the development of frailty and extend lifespan through adequate individual management.

Potentially inappropriate prescriptions: Associations with the health insurance contract and the quality of the patient-physician relationship?

CONTEXT: Potentially Inappropriate Prescriptions (PIP) are often used as an indicator of potential drug overuse or misuse to limit adverse drug events in older people. OBJECTIVE: To determine whether PIP exposure differs as a function of the patient's health insurance scheme and the patient-physician relationship. METHODS: Our dataset was collected from two surveys delivered to two cohorts of the Swiss Lc65+ study, together with a stratified random sample of older people in the Swiss canton of Vaud. The study sample consisted of 1,595 people aged 68 years and older living in the community and reporting at least one prescription drug. Logit regression models of PIP risk were run for various categories of variables: health related, socioeconomic, health insurance scheme and patient-physician relationship. RESULTS: 17% of our respondents had at least one PIP. Our results suggested that being enrolled in a health plan with restriction in the patient's choice of providers and having higher deductibles were associated with lower PIP risk. PIP risk did not differ as a function of the quality of the patient-physician relationship. CONCLUSION: Our study helps to raise awareness about the organizational risk factors of PIP and, more specifically, how health insurance contracts could play a role in improving the management of drug consumption among community-dwelling older people.

Slowness Predicts Mortality: A Comparative Analysis of Walking Speed and Moberg Picking-Up Tests.

OBJECTIVES: Slow walking speed (WS) is predictive of mortality but may be difficult to measure, which compromises the assessment of frailty, based on Fried et al's phenotype. The timed Moberg picking-up test (MPUT), developed to evaluate hand's function, was found moderately but significantly correlated with WS. We compared the relationship between slowness, assessed by MPUT and WS tests, and mortality. DESIGN: Observational (prospective cohort study). SETTING AND PARTICIPANTS: 4731 community-dwelling adults included in 2004, 2009, or 2014 in the ongoing Lausanne cohort 65+ (Lc65+) were assessed at the age of 66-71 years. METHOD: Mortality was compared for individuals above and below percentile 80 of MPUT, and respectively WS performance time, according to the Fried criterion. Multivariable analysis using Cox's regression models were adjusted for age, sex, height and grip strength. The predictive capability of MPUT and WS was assessed in adjusted models using Harrell C. RESULTS: Slowness in MPUT and in WS test was associated with mortality at 4, 9, and 14 years (P < .001). Survival curves showed lower survival rates in the highest percentile for both tests (P < .001), regardless of the follow-up period. Cox models indicated a higher risk of death at 4 years [adjusted hazard ratio (95% confidence interval): MPUT, 2.1 (1.5-3.0); WS, 2.2 (1.5-3.1)], 9 years [MPUT 1.7 (1.3-2.3); WS 2.0 (1.5-2.6)] and 14 years [MPUT 1.8 (1.4-2.3); WS 1.8 (1.4-2.4)] for participants above the 80th percentile (all P < .001). The 2 tests had similar predictive capability (Harrell C: MPUT, between 61% and 68%; WS, between 62% and 69%). CONCLUSIONS AND IMPLICATIONS: Poor performance in MPUT is associated with increased mortality at the short and long term among community-dwelling older adults. This alternative to WS in the assessment of slowness has similar predictive capability for mortality and avoids biased estimates because of nonrandom exclusion of individuals unable to complete WS.