Changes in hospitalisation rates in older people before and after moving to a retirement village.

OBJECTIVES: An increasing proportion of older people live in Retirement Villages ('villages'). This population cites support for health-care issues as one reason for relocation to villages. Here, we examine whether relocation to villages is associated with a decline in hospitalisations. METHODS: Retrospective, before-and-after observational study. SETTING: Retirement villages, Auckland, New Zealand. PARTICIPANTS: 466 cognitively intact village residents (336 [72%] female); mean (SD) age at moving to village was 73.9 (7.7) years. Segmented linear regression analysis of an interrupted time-series design was used. MAIN OUTCOME MEASURES: all hospitalisations for 18 months pre- and postrelocation to village. SECONDARY OUTCOME: acute hospitalisations during the same time periods. RESULTS: The average hospitalisation rate (per 100 person-years) was 44.9 (95% confidence interval [CI] = 36.3-55.6) 18-10 months before village relocation, 58.9 (95% CI = 48.3-72.0) 9-1 months before moving, 47.9 (95% CI = 38.8-59.1) 1-9 months after moving and 62.4 (95% CI = 51.2-76.0) 10-18 months after moving. Monthly average hospitalisation rate (per 100 person-years) increased before relocation to village by an average of 1.2 (95% CI = 0.01-1.57, p = .04) per month from 18 to 1 month before moving, and there was a change in the level of the monthly average hospitalisation rate immediately after relocation (mean difference [MD] = -18.4 per 100 person-years, 95% CI = -32.8 to -4.1, p = .02). The trend change after village relocation did not differ significantly from that before moving. CONCLUSIONS: Although we cannot reliably claim causality, relocation to a retirement village is, for older people, associated with a significant but non-sustained reduction in hospitalisation.

Atrial fibrillation incidence and outcomes in two cohorts of octogenarians: LiLACS NZ.

BACKGROUND: Atrial fibrillation (AF), the most common cardiac arrhythmia in the general population, has significant healthcare burden. Little is known about AF in octogenarians. OBJECTIVE: To describe the prevalence and incidence rate of AF in New Zealand (NZ) octogenarians and the risk of stroke and mortality at 5-year follow-up. DESIGN: Longitudinal Cohort Study. SETTING: Bay of Plenty and Lakes health regions of New Zealand. SUBJECTS: Eight-hundred-seventy-seven (379 indigenous Maori, 498 non-Maori) were included in the analysis. METHODS: AF, stroke/TIA events and relevant co-variates were established annually using self-report and hospital records (and ECG for AF). Cox proportional-hazards regression models were used to determine the time dependent AF risk of stroke/TIA. RESULTS: AF was present in 21% at baseline (Maori 26%, non-Maori 18%), the prevalence doubled over 5-years (Maori 50%, non-Maori 33%). 5-year AF incidence was 82.6 /1000-person years and at all times AF incidence for Maori was twice that of non-Maori. Five-year stroke/TIA prevalence was 23% (22% in Maori and 24% non- Maori), higher in those with AF than without. AF was not independently associated with 5-year new stroke/TIA; baseline systolic blood pressure was. Mortality was higher for Maori, men, those with AF and CHF and statin use was protective. In summary, AF is more prevalent in indigenous octogenarians and should have an increased focus in health care management. Further research could examine treatment in more detail to facilitate ethnic specific impact and risks and benefits of treating AF in octogenarians.

Seasonal variations in acute diverticular disease hospitalisations in New Zealand.

PURPOSE: Seasonal variation of acute diverticular disease is variably reported in observational studies. This study aimed to describe seasonal variation of acute diverticular disease hospital admissions in New Zealand. METHODS: A time series analysis of national diverticular disease hospitalisations from 2000 to 2015 was conducted among adults aged 30 years or over. Monthly counts of acute hospitalisations' primary diagnosis of diverticular disease were decomposed using Census X-11 times series methods. A combined test for the presence of identifiable seasonality was used to determine if overall seasonality was present; thereafter, annual seasonal amplitude was calculated. The mean seasonal amplitude of demographic groups was compared by analysis of variance. RESULTS: Over the 16-year period, 35,582 hospital admissions with acute diverticular disease were included. Seasonality in monthly acute diverticular disease admissions was identified. The mean monthly seasonal component of acute diverticular disease admissions peaked in early-autumn (March) and troughed in early-spring (September). The mean annual seasonal amplitude was 23%, suggesting on average 23% higher acute diverticular disease hospitalisations during early-autumn (March) than in early-spring (September). The results were similar in sensitivity analyses that employed different definitions of diverticular disease. Seasonal variation was less pronounced in patients aged over 80 (p = 0.002). Seasonal variation was significantly greater among Maori than Europeans (p < 0.001) and in more southern regions (p < 0.001). However, seasonal variations were not significantly different by gender. CONCLUSIONS: Acute diverticular disease admissions in New Zealand exhibit seasonal variation with a peak in Autumn (March) and a trough in Spring (September). Significant seasonal variations are associated with ethnicity, age, and region, but not with gender.

Prevalence of Loneliness and Its Association With General and Health-Related Measures of Subjective Well-Being in a Longitudinal Bicultural Cohort of Older Adults in Advanced Age Living in New Zealand: LiLACS NZ.

OBJECTIVES: There is evidence that loneliness is detrimental to the subjective well-being of older adults. However, little is known on this topic for the cohort of those in advanced age (80 years or older), which today is the fastest-growing age group in the New Zealand population. We examined the relationships between loneliness and selected subjective well-being outcomes over 5 years. METHODS: We used a regional, bicultural sample of those in advanced age from 2010 to 2015 (Life and Living in Advanced Age: a Cohort Study in New Zealand). The first wave enrolled 937 people (92% of whom were living in the community): 421 Maori (Indigenous New Zealanders aged 80-90 years) and 516 non-Maori aged 85 years. We applied standard regression techniques to baseline data and mixed-effects models to longitudinal data, while adjusting for sociodemographic factors. RESULTS: For both Maori and non-Maori, strong negative associations between loneliness and subjective well-being were found at baseline. In longitudinal analyses, we found that loneliness was negatively associated with life satisfaction as well as with mental health-related quality of life. DISCUSSION: Our findings of adverse impacts on subjective well-being corroborate other evidence, highlighting loneliness as a prime candidate for intervention-appropriate to cultural context-to improve well-being for adults in advanced age.

The prevalence and intensity of pain in older people living in retirement villages in Auckland, New Zealand.

Chronic pain is common in older people. However, little is known about how pain is experienced in residents of retirement villages ('villages'), and how pain intensity and associations are experienced in relation to characteristics of residents and village living. We thus aimed to examine pain levels, prevalence and associated factors in village residents. The current paper is a cross-sectional analysis of baseline data from the 'Older People in Retirement Villages' study in Auckland, New Zealand. Between July 2016 and August 2018, 578 village residents were interviewed face-to-face by gerontology nurse specialists, using interRAI Community Health Assessment (CHA) and customised survey. We used a validated pain scale and multivariable logistic regression analyses adjusted for pre-specified confounders. Residents' median age was 82 years; 420 (73%) were female; 270 (47%) exhibited/reported daily pain, and in 11% this was severe. After controlling for confounders, daily pain was positively associated with self-reported arthritis (OR = 3.88, 95% CI = 2.57-5.87), poor/fair self-reported health (OR = 3.19, 95% CI = 1.29-7.93), having no health clinic on-site (OR = 1.76, 95% CI = 1.10-2.83), and minimal fatigue (diminished energy but completes normal day-to-day activities) (OR = 1.77, 95% CI = 1.11-2.81). Similar associations were observed for levels of pain. We conclude that levels of pain and prevalence of daily pain are high in village residents. Self-reported arthritis, self-reported poor/fair health, no health clinic on-site and minimal fatigue are all independently associated with a higher risk of daily pain and with levels of pain. This study suggests potential opportunities for villages to better provide on-site support to decrease prevalence and severity of pain for their residents, and thus potentially increase wellbeing and quality-of-life, though as we cannot prove causality, more research is needed.

Learning from a multidisciplinary randomized controlled intervention in retirement village residents.

BACKGROUND: Retirement villages (RVs), also known as continuing care retirement communities, are an increasingly popular housing choice for older adults. The RV population has significant health needs, possibly representing a group with needs in between community-dwelling older adults and those in long-term residential care (LTC). Our previous work shows Gerontology Nurse Specialist (GNS)-facilitated multidisciplinary team (MDT) interventions may reduce hospitalizations from LTC. This study tested whether a similar intervention reduced hospitalizations in RV residents. METHODS: Open-label randomized controlled trial in which 412 older residents of 33 RVs were randomized (1:1) to an MDT intervention or usual care. SETTING: RVs across two District Health Boards in Auckland, New Zealand. Residents were eligible if considered high risk of health/functional decline (triggering ≥3 interRAI Clinical Assessment Protocols or needing special consideration identified by GNS). INTERVENTION: GNS-facilitated MDT intervention, including geriatrician/nurse practitioner and clinical pharmacist, versus usual care. Primary outcome was time from randomization to first acute hospitalization. Secondary outcomes were rate of acute hospitalizations, LTC admission, and mortality. Twelve residents died before randomization; all others (n = 400: MDT intervention = 199; usual care = 201) were included in intention-to-treat analyses. RESULTS: Mean (SD) age was 82.2 (6.9) years, 302 (75.5%) were women, and 378 (94.5%) were European. Over median 1.5 years follow-up, no difference was found in hazard of acute hospitalization between the MDT intervention (51.8%) and usual care (49.3%) groups (Hazard ratio [HR] = 1.01, 95% CI = 0.77-1.34). No difference was found in the incidence rate of acute hospitalizations between the MDT intervention (0.69 per person-year) and usual care (0.86 per person-year) groups (incidence rate ratio = 0.81, 95% CI = 0.59-1.10). Similar results were seen for the proportion of residents with LTC transition (HR = 1.18, 95% CI = 0.65-2.11) and mortality (HR = 0.70, 95% CI = 0.36-1.35). CONCLUSION: Further studies are needed to assess the effects of other patient-centered interventions and outcomes with adequate primary care integration.

Factors associated with healthcare utilization and trajectories in retirement village residents.

BACKGROUND: To study healthcare utilization and trajectories, and associated factors, in older adults in retirement villages (RVs), also known as continuing care retirement communities. METHODS: Prospective cohort study of 578 cognitively intact residents from 34 RVs in Auckland, New Zealand (NZ). MEASUREMENT: InterRAI-Community Health Assessment (includes core items that may trigger functional supplement (FS) completion in those with higher needs, and generates clinical assessment protocols (CAPs) in those with potential unmet needs). OUTCOMES: time to acute hospitalization, long-term care (LTC), and death during average 2.5 years follow-up. RESULTS: Three hundred seven (53%) residents had acute hospitalizations, 65 (11%) moved to LTC, and 51 (9%) died over a mean of 2.5 years. Factors associated with increased risk of acute hospitalization included CAP-falls (high risk) triggered, number of comorbidities, not having left RV in 2 weeks prior, moderate/severe hearing impairment, CAP-cardiorespiratory conditions triggered, acute hospitalization in year prior and age, with significant hazard ratios (HR) ranging between 1.03 and 2.90. Factors associated with reduced risk of hospitalization included other (non-NZ) European ethnicity (HR 0.73, 95% CI 0.55-0.98, p = 0.04), presence of on-site clinic (HR 0.62, 95% CI 0.45-0.85, p = 0.003), no influenza vaccination (HR 0.56, 95% CI 0.38-0.83, p = 0.004). Factors associated with LTC transition included FS triggered (HR 3.84, 95% CI 1.92-7.66, p < 0.001), CAP-instrumental activities of daily living (IADL) (HR 2.62, 95% CI 1.22-5.62, p = 0.01), CAP-social relationship triggered (HR 2.00, 95% CI 1.13-3.55, p = 0.02), and age (HR 1.13, 95% CI 1.07-1.18 p < 0.001). Factors associated with mortality included number of comorbidities (HR 3.75, 95% CI 1.54-9.10, p = 0.004 for 3-5 comorbidities), CAP-IADL triggered (HR 3.05, 95% CI 1.30-7.16, p = 0.01), and age (HR 1.11, 95% CI 1.05-1.18, p < 0.001). CONCLUSION: A large proportion of cognitively intact RV residents are admitted to hospital in mean 2.5 years of follow-up. Multiple factors were associated with acute hospitalization risk. On-site clinics were associated with reduced risk and should be considered in RV development.

Research in the retirement village community-The problems of recruiting a representative cohort of residents in Auckland, New Zealand.

OBJECTIVES: Retirement villages are semi-closed communities, access usually being gained via village managers. This paper explores issues recruiting a representative resident cohort, as background to a study of residents, to acquire sociodemographic, health and disability data and trial an intervention designed to improve outcomes. METHODS: We planned approaching all Auckland/Waitemata District villages and, via managers, contacting residents ('letter-drop'; 'door-knocks'). In 'small' villages (n ≤ 60 units), we planned contacting all residents, randomly selecting in 'larger' villages. We excluded those with doubtful or absent legal capacity. RESULTS: We approached managers of 53 of 65 villages. Thirty-four permitted recruitment. Some prohibited 'letter-drops' and/or 'door-knocks'. Hence, we recruited volunteers (23 villages) via meetings, posters, newsletters and word-of-mouth, that is representative sampling obtained from 11/34 villages. We recruited 578 residents (median age = 82 years; 420 = female; 217:361 sampled:volunteers), finding differences in baseline parameters of sampled vs. volunteers. CONCLUSION: Due to organisational/managers' policy, and national legislation restrictions, our sample does not represent our intended population well. Researchers should investigate alternative data sources, for example electoral rolls and censuses.

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.

Effect of monthly vitamin D on diverticular disease hospitalization: Post-hoc analysis of a randomized controlled trial.

BACKGROUND & AIMS: Some studies have linked low vitamin D status and high risk of diverticular disease, but the causal relationship between vitamin D and diverticular disease remains unclear; clinical trial data are warranted. The objective was to assess the efficacy of vitamin D3 supplementation on diverticular disease hospitalization. METHODS: Post-hoc analysis of a community-based randomized double-blind placebo-controlled trial (RCT) with 5108 participants randomized to receive monthly 100,000 IU vitamin D (n = 2558) or identical placebo (n = 2550). The outcome was time to first diverticular disease hospitalization from randomization to the end of intervention (July 2015), including a prespecified subgroup analysis in participants with baseline deseasonalized 25-hydroxyvitamin D (25(OH)D) levels < 50 nmol/L. RESULTS: Over a median of 3.3 years follow-up, 74 participants had diverticular disease hospitalization. There was no difference in the risk of diverticular disease hospitalization between vitamin D supplementation (35/2558 = 1.4%) and placebo (39/2550 = 1.5%) groups (adjusted hazard ratio (HR) = 0.90; p = 0.65), although in participants with deseasonalized 25(OH)D < 50 nmol/L (n = 1272), the risk was significantly lower in the vitamin D group than placebo (HR = 0.08, p = 0.02). DISCUSSION: Monthly 100,000 IU vitamin D3 does not reduce the risk of diverticular disease hospitalization in the general population. Further RCTs are required to investigate the effect of vitamin D supplementation on the diverticular disease in participants with low 25(OH)D levels.

Lonely in a crowd: loneliness in New Zealand retirement village residents.

OBJECTIVES: The number of older people choosing to relocate to retirement villages (RVs) is increasing rapidly. This choice is often a way to decrease social isolation while still living independently. Loneliness is a significant health issue and contributes to overall frailty, yet RV resident loneliness is poorly understood. Our aim is to describe the prevalence of loneliness and associated factors in a New Zealand RV population. DESIGN: A resident survey was used to collect demographics, social engagement, loneliness, and function, as well as a comprehensive geriatric assessment (international Resident Assessment Instrument [interRAI]) as part of the "Older People in Retirement Villages Study." SETTING: RVs, Auckland, New Zealand. PARTICIPANTS: Participants included RV residents living in 33 RVs (n = 578). MEASUREMENTS: Two types of recruitment: randomly sampled cohort (n = 217) and volunteer sample (n = 361). Independently associated factors for loneliness were determined through multiple logistic regression with odds ratios (ORs). RESULTS: Of the participants, 420 (72.7%) were female, 353 (61.1%) lived alone, with the mean age of 81.3 years. InterRAI assessment loneliness (yes/no question) was 25.8% (n = 149), and the resident survey found that 37.4% (n = 216) feel lonely sometimes/often/always. Factors independently associated with interRAI loneliness included being widowed (adjusted OR 8.27; 95% confidence interval [CI] 4.15-16.48), being divorced/separated/never married (OR 4.76; 95% CI 2.15-10.54), poor/fair quality of life (OR 3.37; 95% CI 1.43-7.94), moving to an RV to gain more social connections (OR 1.55; 95% CI 0.99-2.43), and depression risk (medium risk: OR 2.58, 95% CI 1.53-4.35; high risk: OR 4.20, 95% CI 1.47-11.95). CONCLUSION: A considerable proportion of older people living in RVs reported feelings of loneliness, particularly those who were without partners, at risk of depression and decreased quality of life and those who had moved into RVs to increase social connections. Early identification of factors for loneliness in RV residents could support interventions to improve quality of life and positively impact RV resident health and well-being.

Health profile of residents of retirement villages in Auckland, New Zealand: findings from a cross-sectional survey with health assessment.

OBJECTIVES: Retirement villages (RV) have expanded rapidly, now housing perhaps one in eight people aged 75+ years in New Zealand. Health service initiatives might better support residents and offer cost advantages, but little is known of resident demographics, health status or needs. This study describes village residents-their demographics, socio-behavioural and health status-noting differences between participants who volunteered and those who were sampled. DESIGN: Cross-sectional study of village residents. The cohort formed will also be used for a longitudinal study and a randomised controlled trial. Village managers (sometimes after consulting residents) decided if representative sampling could be undertaken in each village. Where sampling was not approved, volunteers were sought. SETTING: 33 RV were included from a total of 65 villages in Auckland, New Zealand. PARTICIPANTS: Residents (n=578) were recruited either by sampling (n=217) or as volunteers (n=361) during 2016-2018. Each completed a survey and an International Resident Assessment Instrument (interRAI) health needs assessment with a gerontology nurse specialist. RESULTS: Median age of residents was 82 years, 158 (27%) were men; 61% lived alone. Downsizing (77%), less stress (63%) and access to healthcare assistance (61%) were most common reasons for entry. During the 2 weeks prior to survey, 34% received home supports and 10% personal care. Hypertension, heart disease, arthritis and pain were reported by over 40%. Most common unmet needs related to managing cardiorespiratory symptoms (50%) and pain (48%). Volunteers and sampled residents differed significantly, mainly in socio-behavioural respects. CONCLUSIONS: Common conditions including hypertension, arthritis and atrial fibrillation, are recorded in interRAI as text, and thus overlooked in interRAI reports. Levels of unmet need indicate opportunities to improve health services to better manage chronic conditions. Healthcare service providers and village operators could cooperate to design and test service initiatives that better meet residents' needs and offer cost benefits. TRIAL REGISTRATION NUMBER: ACTRN12616000685415.

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.

Association between post-discharge secondary care and risk of repeated hospital presentation, entry into long-term care and mortality in older people after acute hospitalization.

AIM: Hospitalizations are frequent among acutely ill older people, and might be reduced by post-discharge secondary care (PDSC). We aimed to determine the proportion of older patients planned to receive or attending PDSC after acute hospitalization and the association with undesirable outcomes. METHODS: A retrospective observational study was carried out using an electronic health record system in two hospitals in New Zealand. Patients were aged ≥75 years, initially presented at an emergency department (ED) and were discharged from medical, surgical, geriatrics or orthopedics wards in three 2-week periods. Planned PDSC at discharge, attended PDSC, ED presentation, long-term care (LTC) admission and death in 90 days after discharge were obtained through the health record system. Proportional hazards regression assessed the associations of planned or attended PDSC with undesirable outcomes (ED presentation, LTC admission and death) within 90 days of discharge. RESULTS: Clinical records for 1085 patients were extracted, 963 were eligible. Of these, 413 (42.9%) had planned PDSC in discharge summaries, and 573 (59.5%) actually attended in 90 days. Patients planned for PDSC had a similarly adjusted hazard of ED presentation (HR 0.99, P = 0.92), LTC admission (HR 0.73, P = 0.25) and death (HR 0.80, P = 0.34) within 90 days of discharge, compared with those not planned. Similar non-significant associations were observed between attended PDSC and undesirable outcomes. CONCLUSIONS: In patients aged ≥75 years in New Zealand, we did not find "planned PDSC" at discharge or "attended PDSC" after an acute hospitalization to be associated with ED presentation, LTC admission and death within 90 days after discharge. Other potential benefits of planned or attended PDSC require further investigation. Geriatr Gerontol Int 2019; 19: 1048-1053.

Diverticular disease management in primary care: How do estimates from community-dispensed antibiotics inform provision of care?

BACKGROUND: The literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed. AIM: To estimate how often DDI is managed in primary care, using antibiotics dispensing data. DESIGN AND SETTING: Hospitalisation records of New Zealand residents aged 30+ years during 2007-2016 were individually linked to databases of community-dispensed oral antibiotics. METHOD: Patients with an index hospital admission 2007-2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007-2016 for these people with ten individually-matched non-DDI residents, taking the case's index date. Multivariable negative binomial models were used to estimate rates of antibiotic use. RESULTS: From almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation. CONCLUSION: DDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.

Diverticulosis and nine connective tissue disorders: epidemiological support for an association.

Purpose: An underlying connective tissue disorder (CTD) may predispose to formation of intestinal diverticula. We assess the association of diverticulosis with nine selected CTDs, to inform the pathophysiology of diverticula. Methods: A population-based period-prevalence study. Individuals (3.5 million New Zealand residents born 1901-1986) with a health system record 1999-2016 were grouped into those with a hospital diagnosis of diverticulosis or diverticulitis (ICD-10-AM K57), and those without. Also recorded were any hospital diagnoses of nine selected CTDs. The association of exposure to diverticulosis and each CTD was assessed using logistic regressions adjusted for age, gender, ethnicity and region. Results: In all, 85,958 (2.4%) people had a hospital diagnosis of diverticulosis. Hospitalisation with diverticulosis was highly significantly associated with rectal prolapse (adjusted odds ratio [OR] = 3.9), polycystic kidney disease (OR = 3.8), heritable syndromes (Marfan or Ehlers-Danlos) (OR = 2.4), female genital prolapse (OR = 2.3), non-aortic aneurysm (OR = 2.3), aortic aneurysm (OR = 2.2), inguinal hernia (OR = 1.9) and dislocations of shoulder and other joints (OR = 1.7), but not subarachnoid haemorrhage (OR = 1.0). Conclusion: People with diverticulosis are more likely to have colonic extracellular matrix (ECM)/connective tissue alterations in anatomical areas other than the bowel, suggesting linked ECM/connective tissue pathology. Although biases may exist, the results indicate large-scale integrated studies are needed to investigate underlying genetic pathophysiology of colonic diverticula, together with fundamental biological studies to investigate cellular phenotypes and ECM changes.

Feasibility and reliability of clinical coding surveillance for the routine monitoring of adverse drug events in New Zealand hospitals.

AIM: To explore the feasibility and reliability of Clinical Coding Surveillance (CCS) for the routine monitoring of Adverse Drug Events (ADE) and describe the characteristics of harm identified through this approach in a large district health board (DHB). METHOD: All hospital admissions at Waitemata DHB from 2015 to 2016 with an ADE-related ICD10-AM code of Y40-Y59, X40-X49 or T36-T50 were extracted from clinical coded data. The data was analysed using descriptive statistics, statistical process control and Pareto charts. Two clinicians assessed a random sample of 140 ADEs for their accuracy against what was clinically documented in medical records. RESULTS: A total of 11,999 ADEs were identified in 244,992 admissions (4.9 ADEs per 100 admissions). ADEs were more prevalent in older adults and associated with longer average length of stays and medicines such as analgesics, antibiotics, anticoagulants and diuretics. Only 2,164 (18%) of ADEs were classified as originating within hospital. Of ADEs originating outside of the hospital, the main causes were poisoning by psychotropics, anti-epileptics and anti-parkinsonism agents and non-opioid analgesics. Clinicians agreed that 91% of ADE positive admissions were accurately classified as per clinical documentation. CONCLUSION: CCS is a feasible and reliable approach for the routine monitoring of ADEs in hospitals.

Multimorbidity among middle-aged and older persons in urban China: Prevalence, characteristics and health service utilization.

AIM: The knowledge on multimorbidity and its impact on healthcare systems is lacking in low- and middle-income countries. We aimed to estimate the prevalence of multimorbidity, and analyze the health service use of middle-aged and older persons with multimorbidity in urban China. METHODS: Study participants included 3737 urban residents aged ≥45 years from the China Health and Retirement Longitudinal Study 2011. A total of 16 pre-specified self-reported chronic conditions were used to measure multimorbidity, which was defined as having two or more conditions. Logistic regression was used to analyze the characteristics and health service use of persons with multimorbidity. Analyses were weighted to adjust for sampling design and non-response. RESULTS: Of the study population, 51.9% were men and 20.1% were aged >70 years. Hypertension (33.1%) was the most prevalent condition, followed by arthritis (25.4%), digestive disease (18.7%), dyslipidemia (18.3%) and heart disease (17.7%). The prevalence of multimorbidity was 45.5% (95% CI 41.4-49.7%). Multivariate analyses showed that the prevalence of multimorbidity was significantly higher in respondents who are older and socioeconomically disadvantaged than that in their counterparts. Multimorbid patients used 72.7% of outpatient services and 77.3% of inpatient services. After controlling for demographic, socioeconomic, health behavior and health insurance factors, condition counts still had a positive relationship with outpatient or inpatient service use. CONCLUSIONS: The burden of multimorbidity is high among the middle-aged and older urban Chinese population. Management of multimorbidity therefore deserves more attention from health policymakers, providers and educators of health professionals in China and in other low- and middle-income countries. Geriatr Gerontol Int 2018; 18: 1447-1452.

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.