Costs of inpatient hospitalisations in the last year of life in older New Zealanders: a cohort study.

BACKGROUND: Rapidly ageing populations means that many people now die in advanced age. This paper investigated public hospital and long-term care home costs in the 12 months before death in Maori and non-Maori of advanced age in New Zealand. METHODS: Data from an existing longitudinal study (LiLACS NZ) was used, in which 937 older New Zealanders were enrolled in 2010. At the time of this study, 213 Maori and 241 non-Maori in the cohort had died. National Health Index numbers were linked to the hospitalisation National Minimum Dataset to ascertain public hospitalisation and care home costs in the last year of life. RESULTS: The average total publicly funded hospital and long-term care home costs in the 12 months prior to death were $16,211 and $17,351 for Maori and non-Maori respectively. Non-Maori tended to have long lengths of stay in their last year of life, and non-Maori men had the highest proportion with high costs and long lengths of stay in care homes. Costs in the last year of life were 8.1 times higher in comparison to costs for individuals who did not die in the same time period. CONCLUSION: Despite New Zealand's commitment to providing an equitable level of healthcare, this study illustrated that ethnic and gender disparities are still apparent at the end of life. This raises questions as to whether money at the end of life is being spent appropriately, and how it could potentially be more equitably targeted to meet the diverse needs of older people and their families.

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.

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.

Gait, cognition and falls over 5 years, and motoric cognitive risk in New Zealand octogenarians: Te Puawaitanga o Nga Tapuwae Kia Ora Tonu, LiLACS NZ.

BACKGROUND: Understanding falls risk in advanced age is critical with people over 80 a rapidly growing demographic. Slow gait and cognitive complaint are established risk factors and together comprise the Motoric Cognitive Risk Syndrome (MCR). This study examined trajectories of gait and cognition and their association with falls over 5 years, and documented MCR in Maori and non-Maori of advanced age living in New Zealand. METHOD: Falls frequency was ascertained retrospectively at annual assessments. 3 m gait speed was measured and cognition was assessed using the Modified Mini-Mental Status Examination (3MS). Frequency of MCR was reported. Gait and cognition trajectories were modelled and clusters identified from Latent Class Analysis. Generalised linear models examined association between changes in gait, cognition, MCR and falls. RESULTS: At baseline, 138 of 408 Maori (34%) and 205 of 512 non-Maori (40%) had fallen. Mean (SD) gait speed (m/s) for Maori was 0.66 (0.29) and 0.82 (0.26) for non-Maori. Respective 3MS scores were 86.2 (15.6) and 91.6 (10.4). Ten (4.3%) Maori participants met MCR criteria, compared with 7 (1.9%) non-Maori participants. Maori men were more likely to fall (OR 1.56; 95% CI 1.0-2.43 (P = 0.04) whilst for non-Maori slow gait increased falls risk (OR 0.40; 95% CI 0.24-0.68(P < 0.001). Non-Maori with MCR were more than twice as likely to fall than those without MCR (OR 2.45; 95% CI 1.06-5.68 (P = 0.03). CONCLUSIONS: Maori and non-Maori of advanced age show a mostly stable pattern of gait and cognition over time. Risk factors for falls differ for Maori, and do not include gait and cognition.

Quality of prescribing predicts hospitalisation in octogenarians: life and living in advanced age: a cohort study in New Zealand (LiLACS NZ).

BACKGROUND: Prescribing for older people is complex, and many studies have highlighted that appropriate prescribing in this cohort is not always achieved. However, the long-term effect of inappropriate prescribing on outcomes such as hospitalisation and mortality has not been demonstrated. The aim of this study was to determine the level of potentially inappropriate prescribing (PIP) for participants of the Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) study at baseline and examine the association between PIP and hospitalisation and mortality at 12-months follow-up. METHODS: PIP was determined using STOPP/START. STOPP identified potentially inappropriate medicines (PIMs) prescribed, START identified potential prescribing omissions (PPOs). STOPP/START were applied to all LiLACS NZ study participants, a longitudinal study of ageing, which includes 421 Maori aged 80-90 years and 516 non-Maori aged 85 years. Participants' details (e.g. age, sex, living arrangements, socioeconomic status, physical functioning, medical conditions) were gathered by trained interviewers. Some participants completed a core questionnaire only, which did not include medications details. Medical conditions were established from a combination of self-report, review of hospital discharge and general practitioner records. Binary logistic regression, controlled for multiple potential confounders, was conducted to determine if either PIMs or PPOs were associated with hospital admissions and mortality (p < 0.05 was considered significant). RESULTS: Full data were obtained for 267 Maori and 404 non-Maori. The mean age for Maori was 82.3(±2.6) years, and 84.6(±0.53) years for non-Maori. 247 potentially inappropriate medicines were identified, affecting 24.3% Maori and 28.0% non-Maori. PIMs were not associated with 12-month mortality or hospitalisation for either cohort (p > 0.05; adjusted models). 590 potential prescribing omissions were identified, affecting 58.1% Maori and 49.0% non-Maori. PPOs were associated with hospitalisation (p = 0.001 for Maori), but were not associated with risk of mortality (p > 0.05) for either cohort within the 12-month follow-up (adjusted models). CONCLUSION: PPOs were more common than PIMs and were associated with an increased risk of hospitalisation for Maori. This study highlights the importance of carefully considering all indicated medicines when deciding what to prescribe. Further follow-up is necessary to determine the long-term effects of PIP on mortality and hospitalisation.

Physical Activity, Function, and Mortality in Advanced Age: A Longitudinal Follow-Up (LiLACS NZ).

The relationship between physical activity, function, and mortality is not established in advanced age. Physical activity, function, and mortality were followed in a cohort of Maori and non-Maori adults living in advanced age for a period of 6 years. Generalized linear regression models were used to analyze the association between physical activity and Nottingham Extended Activities of Daily Living scale, whereas Kaplan-Meier survival analysis and Cox proportional hazard models were used to assess the association between the physical activity and mortality. The hazard ratio for mortality for those in the least active physical activity quartile was 4.1 for Maori and 1.8 for non-Maori compared with the most active physical activity quartile. There was an inverse relationship between physical activity and mortality, with lower hazard ratios for mortality at all levels of physical activity. Higher levels of physical activity were associated with lower mortality and higher functional status in advanced-aged adults.

Micronutrient intake in advanced age: Te Puawaitanga o Nga Tapuwae Kia ora Tonu, Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ).

A high prevalence of undernutrition has previously been reported in indigenous Maori (49 %) and non-Maori (38 %) octogenarians and may be associated with risk of micronutrient deficiencies. We examined vitamin and mineral intakes and the contributing food sources among 216 Maori and 362 non-Maori participating in Life and Living to Advanced age a Cohort Study in New Zealand, using a repeat 24-h multiple-pass recall. More than half of the Maori and non-Maori participants had intakes below the estimated average requirement from food alone for Ca, Mg and Se. Vitamin B6 (Maori women only), folate (women only), vitamin E (Maori women; all men) and Zn (men only) were low in these ethnic and sex subgroups. Women had intakes of higher nutrient density in folate, vitamin C, Ca, Mg, K, vitamin A (non-Maori) and ß-carotene (Maori) compared with men (P<0·05). When controlling for age and physical function, ß-carotene, folate, vitamin C, Ca and Mg were no longer significantly different, but vitamins B2, B12, E and D, Fe, Na, Se and Zn became significantly different for Maori between men and women. When controlling for age and physical function, vitamins A and C and Ca were no longer significantly different, but vitamin B2, Fe, Na and Zn became significantly different for non-Maori between men and women. For those who took nutritional supplements, Maori were less likely to be deficient in food alone intake of vitamin A, folate and Mg, whereas non-Maori were less likely to be deficient in intakes of Mg, K and Zn, but more likely to be deficient in vitamin B12 intake. A lack of harmonisation in nutrient recommendations hinders the interpretation of nutrient adequacy; nonetheless, Ca, Mg and Se are key micronutrients of concern. Milk and cheese were important contributions to Ca intake, whereas bread was a key source of Mg and Se. Examination of dietary intake related to biochemical status and health outcomes will establish the utility of these observations.

Macronutrient intake in advanced age: Te Puawaitanga o Nga Tapuwae Kia ora Tonu, Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ).

As part of the 12-month follow-up of the longitudinal cohort study, Life and Living in Advanced Age: A Cohort Study in New Zealand, dietary intake was assessed in 216 Maori and 362 non-Maori octogenarians using repeat 24-h multiple pass recalls. Energy and macronutrient intakes were calculated, and food items reported were allocated to food groups used in the New Zealand Adult Nutrition Survey (NZANS). Intakes were compared with the nutrient reference values (NRV) for Australia and New Zealand. The median BMI was higher for Maori (28·3 kg/m2) than for non-Maori (26·2 kg/m2) P=0·007. For Maori, median energy intake was 7·44 MJ/d for men and 6·06 MJ/d for women with 16·3 % energy derived from protein, 43·3 % from carbohydrate and 38·5 % from fat. Median energy intake was 7·91 and 6·26 MJ/d for non-Maori men and women, respectively, with 15·4 % of energy derived from protein, 45 % from carbohydrate and 36·7 % from fat. For both ethnic groups, bread was the top contributor to energy and carbohydrate intakes. Protein came from beef and veal, fish and seafood, bread, milk and poultry with the order differing by ethnic groups and sex. Fat came mainly from butter and margarine. Energy-adjusted protein was higher for Maori than non-Maori (P=0·049). For both ethnic groups, the median energy levels were similar, percent carbohydrate tended to be lower and percent fat higher compared with adults aged >70 years in NZANS. These unique cross-sectional data address an important gap in our understanding of dietary intake in this growing section of our population and highlight lack of age-appropriate NRV.

A Peer-Support and Mindfulness Program to Improve the Mental Health of Medical Students.

PROBLEM: There is evidence that peer-support programs can improve mental health indices and help-seeking behavior among students in some secondary school and university settings and that mindfulness can improve mental health in medical students. Peer-led programs have not been formally assessed in a medical student population, where psychological issues exist and where it has been shown that students approach peers for help in preference to staff members or professional services. INTERVENTION: Medical students elected peer leaders who underwent training and then provided the intervention. The peer leaders provided support to students in the intervention group, as well as offering teaching in mindfulness meditation. CONTEXT: An exploratory study was conducted with 2nd- and 3rd-year medical students at 1 medical school in New Zealand randomized into 2 groups. In addition to existing mental health resources, intervention participants received a program including peer support and peer-taught mindfulness practice. Study participants not offered the intervention participants could use existing mental health resources. Primary measures included depression (PHQ-9) and anxiety (GAD-7) scores. Secondary measures were quality of life, resilience (15-item resilience scale), academic self-concept, and motivation to learn, assessed at baseline and 6 months. OUTCOME: Of the 402 students eligible, 275 (68%) participated and 232 (58%) completed the study. At baseline, 53% were female and mean age was 21 years (SD = 3)-PHQ-9 score (M = 5.2, SD = 3.7) and GAD-7 score (M = 4.5, SD = 3.4). Twelve peer leaders were elected. There was good participation in the intervention. One fourth of intervention students used the face-to-face peer support and more than 50% attended a peer social event and/or participated in the mindfulness program. Although improvements in mental health were seen in the intervention group, the difference between the intervention and nonintervention groups did not reach statistical significance. LESSONS LEARNED: Although evidence exists for effectiveness of peer support and mindfulness in other contexts, this exploratory study was not able to show a statistically significant effect. Future studies could consider using a longer training period for the peer leaders, as well as targeting the study population to those most likely to benefit such as those with poorer mental health, or using a more intensive intervention or larger sample size. A cluster randomized study design would also reduce the risk of contamination.

The psychopathology of James Bond and its implications for the revision of the DSM-(00)7.

OBJECTIVE: To develop a more concise, user-friendly edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM advisory board is probably already hard at work on the DSM-6, so this study is focused on the DSM-(00)7 edition. DESIGN: We conducted an observational study, using a mixed methods approach to analyse the 50th edition boxset of James Bond experiences. James Bond was selected as a suitably complex subject for the basis of a trial of simplifying the DSM. SETTING: Researchers' televisions and computers from late January to mid-April in Auckland, New Zealand. RESULTS: Following a review of the 23 James Bond video observations, we identified 32 extreme behaviours exhibited by the subject; these could be aggregated into 13 key domains. A Delphi process identified a cluster of eight behaviours that comprise the Bond Adequacy Disorder (BAD). A novel screening scale was then developed, the Bond Additive Descriptors of Anti-Sociality Scale (BADASS), with a binary diagnostic outcome, BAD v Normality Disorder. We propose that these new diagnoses be adopted as the foundation of the DSM-(00)7. CONCLUSIONS: The proposed DSM-(00)7 has benefits for both patients and clinicians. Patients will experience reduced stigma, as most individuals will meet the criteria for Normality Disorder. This parsimonious diagnostic approach will also mean clinicians have more time to focus on patient management.

The cluster-randomized BRIGHT trial: Proactive case finding for community-dwelling older adults.

PURPOSE: People are now living longer, but disability may affect the quality of those additional years of life. We undertook a trial to assess whether case finding reduces disability among older primary care patients. METHODS: We conducted a cluster-randomized trial of the Brief Risk Identification Geriatric Health Tool (BRIGHT) among 60 primary care practices in New Zealand, assigning them to an intervention or control group. Intervention practices sent a BRIGHT screening tool to older adults every birthday; those with a score of 3 or higher were referred to regional geriatric services for assessment and, if needed, service provision. Control practices provided usual care. Main outcomes, assessed in blinded fashion, were residential care placement and hospitalization, and secondary outcomes were disability, assessed with Nottingham Extended Activities of Daily Living Scale (NEADL), and quality of life, assessed with the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF). RESULTS: All 8,308 community-dwelling patients aged 75 years and older were approached; 3,893 (47%) participated, of whom 3,010 (77%) completed the trial. Their mean age was 80.3 (SD 4.5) years, and 55% were women. Overall, 88% of the intervention group returned a BRIGHT tool; 549 patients were referred. After 36 months, patients in the intervention group were more likely than those in the control group to have been placed in residential care: 8.4% vs 6.2% (hazard ratio = 1.32; 95% CI, 1.04-1.68; P = .02). Intervention patients had smaller declines in mean scores for physical health-related quality of life (1.6 vs 2.9 points, P = .007) and psychological health-related quality of life (1.1 vs 2.4 points, P = .005). Hospitalization, disability, and use of services did not differ between groups, however. CONCLUSIONS: Our case-finding strategy was effective in increasing identification of older adults with disability, but there was little evidence of improved outcomes. Further research could trial stronger primary care integration strategies.

Effects of an Exercise Program to Reduce Falls in Older People Living in Long-Term Care: A Randomized Controlled Trial.

OBJECTIVES: To investigate the effect of an exercise program on falls in intermediate and high-level long-term care (LTC) residents and to determine whether adherence, physical capacity, and cognition modified outcomes. DESIGN: Randomized controlled trial. SETTING AND PARTICIPANTS: Residents (n = 520, aged 84 ± 8 years) from 25 LTC facilities in New Zealand. METHODS: Individually randomized to Staying UpRight, a physical therapist-led, balance and strength group exercise program delivered for 1 hour, twice weekly over 12 months. The control arm was dose-matched and used seated activities with no resistance. Falls were collected using routinely collected incident reports. RESULTS: Baseline fall rates were 4.1 and 3.3 falls per person-year (ppy) for intervention and control groups. Fall rates over the trial period were 4.1 and 4.3 falls ppy respectively [P = .89, incidence rate ratio (IRR) 0.98, 95% CI 0.76, 1.27]. Over the 12-month trial period, 74% fell, with 63% of intervention and 61% of the control group falling more than once. Risk of falls (P = .56, hazard ratio 1.08, 95% CI 0.85, 1.36) and repeat falling or fallers sustaining an injury at trial completion were similar between groups. Fall rates per 100 hours walked did not differ between groups (P = .42, IRR 1.15, 95% CI 0.81, 1.63). Program delivery was suspended several times because of COVID-19, reducing average attendance to 26 hours over 12 months. Subgroup analyses of falls outcomes for those with the highest attendance (≥50% of classes), better physical capacity (Short Physical Performance Battery scores ≥8/12), or cognition (Montreal Cognitive Assessment scores ≥ 18/30) showed no significant impact of the program. CONCLUSIONS/IMPLICATIONS: In intermediate and high-level care residents, the Staying UpRight program did not reduce fall rates or risk compared with a control activity, independent of age, sex, or care level. Inadequate exercise dose because of COVID-19-related interruptions to intervention delivery likely contributed to the null result.

Increased prevalence of albuminuria among non-European peoples with type 2 diabetes.

BACKGROUND: A high incidence of albuminuria, varying by ethnicity, has been found in a number of populations worldwide. There have been few opportunities to explore the prevalence of albuminuria as a marker of chronic kidney disease while adjusting for other risk factors in the different ethnic groups in New Zealand. METHODS: We examined the association between albuminuria and ethnicity using cross-sectional data from a large cohort study of type 2 diabetes conducted in New Zealand. RESULTS: The study population was 65 171 adults in primary care with type 2 diabetes, not on renal replacement therapy; median age was 64.7 years, median diabetes duration 5.1 years and 48.5% were non-European. Microalbuminuria or greater was present in 50% of Maori, 49% of Pacific people, 31% of Indo- and East-Asians and 28% of Europeans. Regression analyses were used to examine the association between ethnicity and albuminuria-measured as albumin:creatinine ratio-after controlling for study site and other known risk variables: age, sex, duration of diabetes, smoking status, socioeconomic status, body mass index, systolic and diastolic blood pressure, triglyceride levels, HbA(1C) and being on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker. After controlling for these risk factors and compared with Europeans, odds ratios for 'advanced' albuminuria (≥100 mg/mmol) were 3.9 (95% confidence interval: 3.2-4.6) in Maori, 4.7 (3.6-6.3) in Pacific people, 2.0 (1.5-2.7) in Indo-Asians and 4.1 (3.2-5.1) in East-Asians. CONCLUSION: Non-European ethnicities appear to carry significantly higher risks of albuminuria in type 2 diabetes.

Life and living in advanced age: a cohort study in New Zealand--e Puawaitanga o Nga Tapuwae Kia Ora Tonu, LiLACS NZ: study protocol.

BACKGROUND: The number of people of advanced age (85 years and older) is increasing and health systems may be challenged by increasing health-related needs. Recent overseas evidence suggests relatively high levels of wellbeing in this group, however little is known about people of advanced age, particularly the indigenous Maori, in Aotearoa, New Zealand. This paper outlines the methods of the study Life and Living in Advanced Age: A Cohort Study in New Zealand. The study aimed to establish predictors of successful advanced ageing and understand the relative importance of health, frailty, cultural, social & economic factors to successful ageing for Maori and non-Maori in New Zealand. METHODS/DESIGN: A total population cohort study of those of advanced age. Two cohorts of equal size, Maori aged 80-90 and non-Maori aged 85, oversampling to enable sufficient power, were enrolled. A defined geographic region, living in the Bay of Plenty and Lakes District Health Board areas of New Zealand, defined the sampling frame. Runanga (Maori tribal organisations) and Primary Health Organisations were subcontracted to recruit on behalf of the University. Measures--a comprehensive interview schedule was piloted and administered by a trained interviewer using standardised techniques. Socio-demographic and personal history included tribal affiliation for Maori and participation in cultural practices; physical and psychological health status used standardised validated research tools; health behaviours included smoking, alcohol use and nutrition risk; and environmental data included local amenities, type of housing and neighbourhood. Social network structures and social support exchanges are recorded. Measures of physical function; gait speed, leg strength and balance, were completed. Everyday interests and activities, views on ageing and financial interests complete the interview. A physical assessment by a trained nurse included electrocardiograph, blood pressure, hearing and vision, anthropometric measures, respiratory function testing and blood samples. DISCUSSION: A longitudinal study of people of advanced age is underway in New Zealand. The health status of a population based sample of older people will be established and predictors of successful ageing determined.

Modifiable Risk Factors and Change in Cognition of Maori and Non-Maori in Advanced Age: LiLACS NZ.

OBJECTIVE: This study investigated whether previously identified modifiable risk factors for dementia were associated with cognitive change in Maori (indigenous people of New Zealand) and non-Maori octogenarians of LiLACS NZ (Life and Living in Advanced Age; a Cohort Study in New Zealand), a longitudinal study. METHOD: Multivariable repeated-measure mixed effect regression models were used to assess the association between modifiable risk factors and sociodemographic variables at baseline, and cognitive change over 6 years, with p values of <.05 regarded as statistically significant. RESULTS: Modifiable factors associated with cognitive change differed between ethnic groups. Depression was a negative factor in Maori only, secondary education in non-Maori was protective, and obesity predicted better cognition over time for Maori. Diabetes was associated with decreased cognition for both Maori and non-Maori. CONCLUSION: Our results begin to address gaps in the literature and increase understanding of disparities in dementia risk by ethnicity. These findings have implications for evaluating the type and application of culturally appropriate methods to improve cognition.

Process evaluation of the Safer Prescribing and Care for the Elderly (SPACE) cluster randomised controlled trial in New Zealand general practice.

Introduction The Safer Prescribing and Care for the Elderly (SPACE) cluster randomised controlled trial in 39 general practices found that a search of the practice database to identify and generate for each general practitioner (GP) a list of patients with high-risk prescribing, pharmacist-delivered one-on-one feedback to GPs, and electronic tick-box for GPs to select action for each patient (Patient letter; No letter but possible medication review when patient next in; No action), prompted safer prescribing at 6 months but not at 1 year. Aim This process evaluation explores research participation, intervention uptake and effect on GPs. Methods Mixed methods were used including quantitative data (log of practice recruitment, demographic data, intervention delivery and GP responses including tick-box selections) and qualitative data (trial pharmacist reflective journal). Data were analysed using descriptive statistics and general inductive analysis, respectively. Results Recruitment of general practices was challenging, with only 39% of eligible practices agreeing to participate. Those who declined were often 'too busy'. Engagement was also challenging, especially in larger practices, with the trial pharmacist managing to meet with only 64% of GPs in the intervention group. The GPs who did engage were positive about the intervention, but elected to send letters to only 23% of patients with high-risk prescribing, either because the high-risk prescribing had already stopped, the GP did not agree the prescribing was 'high-risk' or the GP was concerned a letter would upset the patient. Conclusions Effectiveness of the SPACE cluster randomised controlled trial could be improved by changes including ensuring searches are current and relevant, repeating cycles of search and feedback, and integrating pharmacists into general practices.

Safer Prescribing and Care for the Elderly (SPACE): a cluster randomised controlled trial in general practice.

BACKGROUND: Safer prescribing in general practice may help to decrease preventable adverse drug events (ADE) and related hospitalisations. AIM: To test the effect of the Safer Prescribing and Care for the Elderly (SPACE) intervention on high-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet medicines and related hospitalisations. DESIGN & SETTING: A pragmatic cluster randomised controlled trial in general practice. Participants were patients at increased risk of ADEs from NSAIDs and/or antiplatelet medicines at baseline. SPACE comprises automated search to generate for each GP a list of patients with high-risk prescribing; pharmacist outreach to provide education and one-on-one review of list with GP; and automated letter inviting patients to seek medication review with their GP. METHOD: The primary outcome was the difference in high-risk prescribing of NSAIDs and/or antiplatelet medicines at 6 months. Secondary outcomes were high-risk prescribing for gastrointestinal, renal, or cardiac ADEs separately, 12-month outcomes, and related ADE hospitalisations. RESULTS: Thirty-nine practices were recruited with 205 GPs and 191 593 patients, of which 21 877 (11.4%) were participants. Of the participants, 1479 (6.8%) had high-risk prescribing. High-risk prescribing improved in both groups at 6 and 12 months compared with baseline. At 6 months, there was no significant difference between groups (odds ratio [OR] 0.99; 95% confidence intervals [CI] = 0.87 to 1.13) although SPACE improved more for gastrointestinal ADEs (OR 0.81; 95% CI = 0.68 to 0.96). At 12 months, the control group improved more (OR 1.29; 95% CI = 1.11 to 1.49). There was no significant difference for related hospitalisations. CONCLUSION: Further work is needed to identify scalable interventions that support safer prescribing in general practice. The use of automated search and feedback plus letter to patient warrants further exploration.