The prevalence and prescribing patterns of benzodiazepines and Z-drugs in older nursing home residents in different European countries and Israel: retrospective results from the EU SHELTER study.

BACKGROUND: Benzodiazepines (BZDs) and Z-drugs have high potential for developing frequent adverse drug events in older adults (e.g., psychomotor sedation, drug-related dementia, deliria, drug dependence, etc.). Knowledge of the prevalence and patterns of the use of BZDs/Z-drugs in vulnerable older patients is important in order to prevent and reduce the burden caused by their drug-related complications. Our study focused on international comparisons of the prevalence, country-specific prescribing patterns and risk factors of regular BZD/Z-drug use in nursing home (NH) residents. METHODS: This cross-sectional study retrospectively analysed data of 4156 NH residents, prospectively assessed in the Services and Health in the Elderly in Long TERm care (SHELTER) project conducted from 2009 to 2014. Residents aged 65+ in 57 NHs in 7 European countries and Israel were assessed by the InterRAI Long-Term Care Facilities instrument. Descriptive statistics and multiple logistic regression models were used to describe the country-specific prevalence, patterns and risk factors of BZD/Z-drug use. RESULTS: The mean age of the participants was 83.4 ± 9.4 years, 73% were female and 27.7% used BZDs/Z-drugs. The prevalence of BZD/Z-drug use differed significantly across countries, ranging from 44.1% in Israel to 14.5% in Germany. The most frequently prescribed were zopiclone (17.8%), lorazepam (17.1%) and oxazepam (16.3%). Lorazepam, oxazepam and diazepam were used in most of the countries. Brotizolam, temazepam and zolpidem showed highest prevalence in Israel (99.4% of all regular users of this medication in the sample), the Netherlands (72.6%) and France (50.0%), respectively. Residing in Israel was the most significant factor associated with the use of BZDs/Z-drugs or BZDs only (odds ratio [OR] 6.7; 95% confidence interval [CI] 4.8-9.2 and OR 9.7, 95%CI 6.5-14.5, respectively). The use of Z-drugs only was most significantly associated with residing in France (OR 21.0, 95%CI 9.0-48.9). CONCLUSIONS: Despite global recommendations and warnings, the preference for and extent of use of individual BZDs and Z-drugs in vulnerable NH residents differ significantly across countries. The strong association with country of residence compared to clinical and functional factors denotes that prescribing habits, social, cultural, behavioural, and regulatory factors still play an important role in the current diverse use of these medications.

Validation of a Falls Risk Screening Tool Derived From InterRAI Acute Care Assessment.

OBJECTIVES: This study aimed to develop and validate a falls risk screening tool derived from interRAI Acute Care (AC) Assessment. METHODS: For derivation and validation, two prospective cohorts were recruited from AC hospitals in Australia. The derivation cohort comprised 1418 patients from 11 hospitals. In the validation cohort, 393 patients were recruited from four hospitals. The interRAI AC tool was used to collect comprehensive geriatric assessment data at admission. In-hospital falls were documented from medical records. A falls risk score was calculated using logistic regression. Predictive ability was compared with St. Thomas Risk Assessment Tool In Falling elderlY (STRATIFY), using area under curve (AUC). The validation cohort provided external validity. RESULTS: Complete data in the derivation cohort were available for 1288 patients (91%), with 75 (5.8%) having an in-hospital fall. The derived interRAI AC falls risk score (range = 0-6) had significantly better predictive ability (AUC = 0.70, 95% confidence interval [CI] = 0.63-0.76) compared with St. Thomas Risk Assessment Tool In Falling elderlY (AUC = 0.64, 95% CI = 0.58-0.70) (P = 0.033). At a cut point of three, 54 of 75 falls were correctly predicted by the falls risk score derived from interRAI AC (sensitivity = 0.72 [95% CI = 0.60-0.82] and specificity = 0.60 [95% CI = 0.57-0.62]). The falls risk score performed similarly in the validation cohort. CONCLUSIONS: The falls risk tool developed from interRAI AC is a valid measure to screen for in-hospital falls. Reduction in assessment burden without loss of fidelity can be achieved through integrating the risk screener within the interRAI hospital system, which automatically triggers protocols for falls prevention based on identified risk.

The Association Between Gait Speed and Cognitive Status in Community-Dwelling Older People: A Systematic Review and Meta-analysis.

BACKGROUND: Gait speed and cognitive performance tend to decline with age. A better understanding of the dynamics of the association between gait speed and cognitive status may identify preclinical markers and improve diagnostic assessments. The objective was to quantify the association between gait speed and cognitive status in later life. METHODS: A systematic search was undertaken of relevant databases for original articles published prior to June 2017, measuring the association between gait speed and cognition cross-sectionally or longitudinally among the community-dwelling population. A meta-analysis pooled results of the mean difference between concurrent measures of gait speed in the normal cognition group compared to non-normal cognition groups. RESULTS: Thirty-six studies were selected, providing data from 29,520 participants. The majority of studies reported a significant association between slower gait speed and worse cognitive function in older people. Results of the meta-analysis of 27 studies showed that, compared to normal controls, clinically meaningful reductions in gait speed ranged from 0.11 m/s in those with cognitive impairment, to 0.20 m/s in those with mild dementia, and to 0.41 m/s in those with moderate dementia. CONCLUSION: The strength of evidence for an association between gait speed and cognition was demonstrated by the number and consistency of results, as well as quality of the studies. Identification of diagnostic markers of motor-cognitive risk has led to increasing interest in the effects of interventions for prevention of gait speed loss and cognitive decline in aging.

Validation of the health assets index in the Australian inpatient setting: a multicentre prospective cohort protocol study.

INTRODUCTION: It is well known that frail older adults are at increased risk for mortality and functional decline on admission to hospital. Systematic review demonstrates that health assets are associated with improved outcomes for hospitalised older adults. The health assets index (HAI) has been developed to measure health assets in the hospital setting. A protocol has been developed to determine the predictive validity of the HAI for frail older adults. METHODS AND ANALYSIS: The HAI was developed based on a systematic review and secondary analysis of the interRAI-Acute Care (interRAI-AC) dataset. A pilot study was undertaken to refine the tool.The validation study will be a multicentre prospective cohort. Participants will be adults aged 70 years and older with an unplanned admission to hospital. Frailty, illness severity and demographic data will also be recorded. The primary outcomes are mortality at 28 days postdischarge and functional decline at the time of discharge from hospital. The primary hypothesis is that a higher score on the HAI will mitigate the effects of frailty for hospitalised older adults. The secondary outcomes to be recorded are length of stay, readmission at 28 days and functional status at 28 days postdischarge. The correlation between HAI and frailty will be explored. A multivariate analysis will be undertaken to determine the relationship between the HAI and the outcomes of interest. ETHICS AND DISSEMINATION: Ethical approval has been obtained from Austin Health Human High Risk Ethics Committee. The results will be disseminated in peer-reviewed journals and research conferences. This study will determine whether the HAI has predictive validity for mortality and functional decline for hospitalised, frail older adults.

Health assets in older age: a systematic review.

BACKGROUND: Finding ways to optimise health in older age is key to reducing the impact of population ageing on health and social care systems. A salutogenic approach takes into account an individual's health assets-internal or external strengths or accessible resources which improve and preserve physical, social and mental wellness, independence and quality of life. The aim of this narrative systematic review was to provide a summary and appraisal of the evidence for factors that act as health assets within personal, social, economic and environmental domains. METHODS: Systematic searches of databases were conducted for literature published in peer-reviewed journals between January 2000 and November 2016. Selection criteria included community dwelling populations aged 65 years and over and publications written in English. Data on study population, design, measures of health status, factors within the four previously stated domains and results were extracted. Study quality was independently assessed using an appraisal instrument. RESULTS: Twenty-three publications, including 78 422 participants, from more than 13 different countries were identified for inclusion in this review. There was strong evidence that higher scores of self-rated health, psychological well-being and life satisfaction were associated with better health in older age. Social network and contact with family and friends, and engagement in leisure and social activities were important support mechanisms. Education and financial resources consistently proved to be key economic health assets for older adults. CONCLUSIONS: Implementing an asset-based approach to health promotion uncovers the skills, knowledge, connections and potential of the individual and the community. This approach is an ideal opportunity for government health bodies and their partners to respond to the challenges faced by global ageing.Factors are often interdependent and cumulative, suggesting the potential for an instrument to measure the accumulated effect of health assets on health status in older adults.

Outcomes of cognitively impaired older people in Transition Care.

AIM: The benefits of Transition Care Programs (TCPs) for patients with cognitive impairment are not well established. This study aimed to investigate the impact of TCP on patients according to their cognitive status. METHODS: In this prospective cohort study, 351 patients were comprehensively assessed at TCP admission using the interRAI Home Care instrument and divided into two groups based on scores on the Cognitive Performance Scale. RESULTS: Of 346 patients assessed for cognition, 242 (69.9%) were considered cognitively intact, and 104 (30.1%) were classified as cognitively impaired (Cognitive Performance Scale ≥ 2). There were no significant differences in TCP outcomes between the two groups, including community living at six months (P = 0.1), hospital readmission rates (P = 0.6), or achievement of TCP goals (P = 0.3). CONCLUSIONS: Cognitively intact and cognitively impaired patients have similar outcomes post-TCP. Older patients should not be refused Transition Care based on the presence of cognitive impairment.

Falls prevention interventions for community-dwelling older persons with cognitive impairment: a systematic review.

BACKGROUND: Globally, falls in older people are a leading cause of injury-related mortality and morbidity. Cognitive impairment is a well-known risk factor for falls in this population group. While there is now a large body of evidence to support effective interventions for falls reduction across care settings, very little is known about interventions in the vulnerable, but increasing population of cognitively impaired community-dwelling older people. Therefore, the purpose of this systematic review is to investigate interventions designed to reduce falls in community-dwelling, cognitively impaired older adults. METHODS: A literature search of databases was conducted to identify original research published in English, which met predefined inclusion and exclusion criteria for effective (non-pharmacological) falls prevention interventions in cognitively impaired community-dwelling people over 65 years of age. Data from the selected papers were extracted into data extraction tables and analyzed according to study characteristics, measures, results, and quality. RESULTS: The review identified 11 studies providing data from 1,928 participants. Interventions included exercise, health assessment and management of risk, multi-component and cognitive behavioral programs, and hip protectors as falls risk reduction strategies. Seven of the selected studies showed an intervention effect in decreasing falls risk; however, only two of these showed a significant improvement in physical performance measures specifically in a cognitively impaired group. CONCLUSIONS: The diversity of interventions, study designs, populations, and quality of the studies, which met inclusion criteria, resulted in conflicting evidence and inconclusive results for falls prevention interventions in this highly complex population.

Epidemiology of falls in older age.

Worldwide, falls among older people are a public health concern because of their frequency and adverse consequences in terms of morbidity, mortality, and quality of life, as well as their impact on health system services and costs. This epidemiological review outlines the public health burden of falls and fall-related injuries and the impact of population aging. The magnitude of the problem is described in terms of the classification of falls and measurement of outcomes, including fall incidence rates across settings, sociodemographic determinants, international trends, and costs of falls and fall-related injuries. Finally, public health approaches to minimize falls risk and consequent demand on health care resources are suggested.

Volunteering as a productive ageing activity: the association with fall-related hip fracture in later life.

This paper aims to contribute to the literature on the relationship between productive and healthy ageing as two key theoretical concepts in contemporary ageing. Specifically, volunteering as a productive activity in later life has been associated with social and health benefits for older people. Evidence from the literature has generally focused on global outcomes, such as mortality and self-rated health, or on measures of psychological well-being. This study explored whether volunteering is protective of an important adverse health outcome in later life, that of fall-related hip fracture, utilising data from a case control study of 387 participants. The results showed that volunteer activity in older age remained significantly protective of hip fracture risk [OR: 0.61 (0.38-0.99)], independent of social and physical activity, social support and health status, supporting the hypothesis of a relationship between the concepts of productive and healthy ageing. Whilst further studies are clearly needed to establish causality, these results suggest that health benefits of volunteering in later life might be more extensive than previous studies have shown.

Healthy aging as an intervention to minimize injury from falls among older people.

With global trends toward population aging, many countries are adopting healthy aging policies to minimize disability and increase quality in the extended years of life. Falls in older people are a major contributor to functional decline generally associated with aging. Based on a study quantifying the relationship between healthy aging factors and risk of fall-related hip fracture in community-dwelling older people, this paper discusses evidence for the promotion of healthy aging as a population-based intervention for prevention of injuries from falls. To examine the protective effect of healthy aging on the risk of fall-related hip fractures, a case-control study was conducted with 387 participants. Persons aged 65 and over hospitalized with a fall-related hip fracture were matched with community-based controls recruited via electoral roll sampling. A questionnaire designed to assess lifestyle risk factors, identified as determinants of healthy aging, was administered during face-to-face interviews. After adjustment for health status and demographic factors, a number of lifestyle factors were seen to have a significant independent protective effect on the risk of hip fracture. These included never smoking, moderate alcohol consumption, being active, maintaining normal weight, and being proactive in preventive health care. Psychosocial factors included having supportive environments and personal resources to cope with stress. This study identified a range of modifiable lifestyle factors associated with fall-related hip fracture, suggesting that the "healthy aging" paradigm offers a comprehensive approach to falls injury prevention, and thus supports the adoption of healthy aging policies to extend years of quality life among older persons.

Health-protective behaviours and risk of fall-related hip fractures: a population-based case-control study.

BACKGROUND: Fall-related hip fractures are one of the most common causes of disability and mortality in older age. The study aimed to quantify the relationship between lifestyle behaviours and the risk of fall-related hip fracture in community-dwelling older people. The purpose was to contribute evidence for the promotion of healthy ageing as a population-based intervention for falls injury prevention. METHODS: A case-control study was conducted with 387 participants, with a case-control ratio of 1:2. Incident cases of fall-related hip fracture in people aged 65 and over were recruited from six hospital sites in Brisbane, Australia, in 2003-04. Community-based controls, matched by age, sex and postcode, were recruited via electoral roll sampling. A questionnaire designed to assess lifestyle risk factors, identified as determinants of healthy ageing, was administered at face-to-face interviews. RESULTS: Behavioural factors which had a significant independent protective effect on the risk of hip fracture included never smoking [adjusted odds ratio (AOR): 0.33 (0.12-0.88)], moderate alcohol consumption in mid- and older age [AOR: 0.49 (0.25-0.95)], not losing weight between mid- and older age [AOR: 0.36 (0.20-0.65)], playing sport in older age [AOR: 0.49 (0.29-0.83)] and practising a greater number of preventive medical care [AOR: 0.54 (0.32-0.94)] and self-health behaviours [AOR: 0.56 (0.33-0.94)]. CONCLUSION: With universal exposures, clear associations and modifiable behavioural factors, this study has contributed evidence to reduce the major public health burden of fall-related hip fractures using readily implemented population-based healthy ageing strategies.