Exercise and physical activity promotion for people newly diagnosed with Parkinson's disease: a UK survey exploring current practice and the views of healthcare professionals.

OBJECTIVES: Exercise and physical activity (PA) are increasingly recognized as important components in the management of Parkinson's disease (PD). Their promotion at diagnosis is essential for better management of symptoms and overall well-being. Healthcare professionals (HCPs) are pivotal to the promotion of exercise and PA, but there is limited guidance on the content of such interventions. This study describes current practice, and explores views of HCPs around PA and exercise promotion at diagnosis for people with PD (PwP) DESIGN: A cross-sectional study using an anonymous online survey. PARTICIPANTS: HCPs working with PwP in the UK. RESULTS: Twenty-nine doctors, 17 nurses and 106 physiotherapists completed the survey. All nurses, 99% of physiotherapists and 72% of doctors reported that they always promote exercise and PA during clinic appointments. HCPs identified how PA impacts PD symptoms, evidence on the role of exercise, and signposting to support groups as core topics in PA promotion for PwP. However, these topics are mainly addressed during physiotherapy appointments. Referrals to physiotherapy occur most frequently when PwP experience falls or mobility issues, rather than at diagnosis. HCPs (52% doctors and 41% of nurses) identified lack of confidence as a barrier to prescribing exercise to PwP. CONCLUSION: The importance of promoting PA at diagnosis is widely acknowledged by HCPs. There are variations between disciplines in terms of the tools used, and the timing and duration of interventions. Previously identified barriers to exercise promotion were also found in this study, and should be explored further in order to aid the implementation of effective interventions.

Older Hospitalised Patients' Reported Confidence in Managing Discharge Needs: A Retrospective Observational Study.

Objectives: To evaluate the introduction of a patient-reported outcome measure (PROM) of self-confidence in managing discharge needs in an acutely hospitalised older adult population. Methods: A retrospective service evaluation in an English hospital. The PROM measure consisted of a visual analogue scale asking patients to rate their confidence with managing the things that they would need to do at home. This was collected on admission and discharge. Results: Of 923 patients, 461 had both admission and discharge confidence scores. Median confidence was higher at discharge (8.00, IQR: 6.20-9.80) than on admission (7.20, 5.00-9.00) (P<0.001). Predictors of high confidence with managing discharge needs at admission were: being male; having a lower number of morbidities; self-reporting fewer falls over the last year; and a higher level of functional mobility. Low confidence score on admission, being from one's own home, and a higher number of physiotherapy contacts were associated with improvement in PROM scores. Self-confidence in managing discharge needs at discharge was not associated with readmission within 30 days. Conclusions: Measuring patient-reported confidence to manage discharge needs is feasible in an older inpatient population. Confidence improved from admission to discharge, and more frequent physiotherapy input was associated with improved confidence.

Implementing a perioperative care of older people undergoing surgery (POPS) service: findings from a multi-site qualitative implementation study.

BACKGROUND: The Perioperative care for Older People undergoing Surgery (POPS) service model is increasingly being implemented across care providers in the English and Welsh National Health Services. OBJECTIVE: The study aimed to produce evidence regarding clinical leaders' activities to implement POPS across different service contexts and to produce generalisable recommendations for future implementation. METHODS: A qualitative interview study was undertaken across six National Health Services hospitals with established POPS services. Interview participants were recruited on the basis of their direct involvement in the implementation and leadership of the service. Data collection involved semi-structured interviews with 26 people carried out between November 2022 and May 2023. RESULTS: The implementation of POPS is often hampered by a lack of managerial and financial support, and apprehension amongst surgeons and anaesthetist about new ways of working. POPS leaders address these through five interconnected activities, each targeted at a combination of implementation factors. (i) Securing management and financial support. (ii) Professional engagement. (iii) Evidence building as a resource for demonstrating the clinical and operational benefits of POPS. (iv) Communication and engagement activities to promote and legitimise POPS to stakeholder groups. (v) Designated and distributed leadership to promote and coordinate implementation activities and to spread the service to new pathways. CONCLUSIONS: Through a combination of activities POPS can be effectively implemented across different organisational contexts. Some aspects of these activities can be guided by shared resources and learning across sites, but others require adaption to local contextual barriers and drivers.

Interrupting bedtime to reverse frailty levels in acute care: a study protocol for the Breaking Bad Rest randomized controlled trial.

BACKGROUND: Hospitalized older patients spend most of the waking hours in bed, even if they can walk independently. Excessive bedrest contributes to the development of frailty and worse hospital outcomes. We describe the study protocol for the Breaking Bad Rest Study, a randomized clinical trial aimed to promoting more movement in acute care using a novel device-based approach that could mitigate the impact of too much bedrest on frailty. METHODS: Fifty patients in a geriatric unit will be randomized into an intervention or usual care control group. Both groups will be equipped with an activPAL (a measure of posture) and StepWatch (a measure of step counts) to wear throughout their entire hospital stay to capture their physical activity levels and posture. Frailty will be assessed via a multi-item questionnaire assessing health deficits at admission, weekly for the first month, then monthly thereafter, and at 1-month post-discharge. Secondary measures including geriatric assessments, cognitive function, falls, and hospital re-admissions will be assessed. Mixed models for repeated measures will determine whether daily activity differed between groups, changed over the course of their hospital stay, and impacted frailty levels. DISCUSSION: This randomized clinical trial will add to the evidence base on addressing frailty in older adults in acute care settings through a devices-based movement intervention. The findings of this trial may inform guidelines for limiting time spent sedentary or in bed during a patient's stay in geriatric units, with the intention of scaling up this study model to other acute care sites if successful. TRIAL REGISTRATION: The protocol has been registered at clinicaltrials.gov (identifier: NCT03682523).

The use of the World Guidelines for Falls Prevention and Management's risk stratification algorithm in predicting falls in The Irish Longitudinal Study on Ageing (TILDA).

BACKGROUND: the aim of this study was to retrospectively operationalise the World Guidelines for Falls Prevention and Management (WGFPM) falls risk stratification algorithm using data from The Irish Longitudinal Study on Ageing (TILDA). We described how easy the algorithm was to operationalise in TILDA and determined its utility in predicting falls in this population. METHODS: participants aged ≥50 years were stratified as 'low risk', 'intermediate' or 'high risk' as per WGFPM stratification based on their Wave 1 TILDA assessments. Groups were compared for number of falls, number of people who experienced one or more falls and number of people who experienced an injury when falling between Wave 1 and Wave 2 (approximately 2 years). RESULTS: 5,882 participants were included in the study; 4,521, 42 and 1,309 were classified as low, intermediate and high risk, respectively, and 10 participants could not be categorised due to missing data. At Wave 2, 17.4%, 43.8% and 40.5% of low-, intermediate- and high-risk groups reported having fallen, and 7.1%, 18.8% and 18.7%, respectively, reported having sustained an injury from falling. CONCLUSION: the implementation of the WGFPM risk assessment algorithm was feasible in TILDA and successfully differentiated those at greater risk of falling. The high number of participants classified in the low-risk group and lack of differences between the intermediate and high-risk groups may be related to the non-clinical nature of the TILDA sample, and further study in other samples is warranted.

Eight-year longitudinal falls trajectories and associations with modifiable risk factors: evidence from The Irish Longitudinal Study on Ageing (TILDA).

BACKGROUND: The label 'faller' and the associated stigma may reduce healthcare-seeking behaviours. However, falls are not inevitably progressive and many drivers are modifiable. This observational study described the 8-year longitudinal trajectories of self-reported falls in The Irish Longitudinal Study on Ageing (TILDA) and studied associations with factors, including mobility, cognition, orthostatic hypotension (OH), fear of falling (FOF) and use of antihypertensive and antidepressant medications. METHODS: Participants aged ≥50 years at each wave were categorised by whether they averaged ≥2 falls in the previous year (recurrent fallers) or not (≤1 fall). Next-wave transition probabilities were estimated with multi-state models. RESULTS: 8,157 (54.2% female) participants were included, of whom 586 reported ≥2 falls at Wave 1. Those reporting ≥2 falls in the past year had a 63% probability of moving to the more favourable state of ≤1 fall. Those reporting ≤1 fall had a 2% probability of transitioning to ≥2 falls. Besides older age and higher number of chronic conditions, factors that increased the risk of transitioning from ≤1 fall to ≥2 falls were lower Montreal Cognitive Assessment score, FOF and taking antidepressants. Conversely, male sex, higher timed up and go time, the presence of OH and being on antidepressants reduced the probability of improving from ≥2 falls to ≤1 fall. CONCLUSION: The majority of recurrent fallers experienced favourable transitions. Improvements in cognitive and psychological status, psychotropic prescribing, mobility and OH may help improve trajectories. Findings may help combat stigma associated with falling and promote preventative healthcare-seeking behaviours.

What dietary interventions have been tested in heart failure with preserved ejection fraction? A systematic scoping review.

AIMS: To determine what dietary interventions have been tested in heart failure with preserved ejection fraction (HFpEF), the modulation method, and outcomes employed and to summarize any evidence for benefit. METHODS AND RESULTS: We performed key word searches in five bibliographic databases from 2001 to 2021, to identify randomized or experimental dietary interventions tested in HFpEF or mixed heart failure (HF) samples. Study characteristics were summarized according to population, intervention, comparator, outcome categories and intervention complexity was assessed. Twenty-five clinical investigations were retrieved; only 10 (40%) were conducted exclusively in HFpEF; the remainder enrolled mixed HF samples. Most studies employed either highly tailored prescribed diets (n = 12, 48%) or dietary supplementation (n = 10, 40%) modalities. Dietary pattern interventions (n = 3, 12%) are less well represented in the literature. CONCLUSION: Heterogeneity made pooling studies challenging. Better reporting of baseline characteristics and the use of standardized HF lexicon would ensure greater confidence in interpretation of studies involving mixed HF populations. The field would benefit greatly from explicit reporting of the biological mechanism of action (e.g. the causal pathway) that an intervention is designed to modulate so that studies can be synthesized via their underlying mechanism of action by which diet may affect HF. An extension of the current set of core outcomes proposed by the European Society of Cardiology Heart Failure Association would ensure dietary clinical endpoints are more consistently defined and measured. REGISTRATION: PROSPERO: CRD42019145388.

What are the outcomes of dietary interventions in Heart Failure with preserved Ejection Fraction? A systematic review and meta-analysis.

AIMS: To determine the efficacy of dietary interventions in Heart Failure with preserved Ejection Fraction (HFpEF). METHOD AND RESULTS: Keyword searches were performed in five bibliographic databases to identify randomized or controlled studies of dietary interventions conducted in HFpEF or mixed heart failure (HF) samples published in the English language. Studies were appraised for bias and synthesized into seven categories based on the similarity of the intervention or targeted population. The quality of the body of evidence was assessed via the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. Twenty-five unique interventions were identified; 17 were considered for meta-analysis. Most studies were judged to be at high risk of bias. There was moderate-quality evidence that caloric restriction led to clinically meaningful improvements in blood pressure and body weight. There was moderate-quality evidence that carbohydrate restriction resulted in meaningful reductions in blood pressure. There was very low-quality evidence that protein supplementation improved blood pressure and body weight and moderate-quality evidence for clinically meaningful improvements in function. CONCLUSIONS: While some types of dietary interventions appeared to deliver clinically meaningful change in critical outcomes; the study heterogeneity and overall quality of the evidence make it difficult to make firm recommendations. Greater transparency when reporting the nutritional composition of interventions would enhance the ability to pool studies. REGISTRATION: PROSPERO CRD42019145388.

Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma.

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.

Exercise for acutely hospitalised older medical patients.

BACKGROUND: Approximately 30% of hospitalised older adults experience hospital-associated functional decline. Exercise interventions that promote in-hospital activity may prevent deconditioning and thereby maintain physical function during hospitalisation. This is an update of a Cochrane Review first published in 2007. OBJECTIVES: To evaluate the benefits and harms of exercise interventions for acutely hospitalised older medical inpatients on functional ability, quality of life (QoL), participant global assessment of success and adverse events compared to usual care or a sham-control intervention. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was May 2021. SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials evaluating an in-hospital exercise intervention in people aged 65 years or older admitted to hospital with a general medical condition. We excluded people admitted for elective reasons or surgery. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our major outcomes were 1. independence with activities of daily living; 2. functional mobility; 3. new incidence of delirium during hospitalisation; 4. QoL; 5. number of falls during hospitalisation; 6. medical deterioration during hospitalisation and 7. participant global assessment of success. Our minor outcomes were 8. death during hospitalisation; 9. musculoskeletal injuries during hospitalisation; 10. hospital length of stay; 11. new institutionalisation at hospital discharge; 12. hospital readmission and 13. walking performance. We used GRADE to assess certainty of evidence for each major outcome. We categorised exercise interventions as: rehabilitation-related activities (interventions designed to increase physical activity or functional recovery, but did not follow a specified exercise protocol); structured exercise (interventions that included an exercise intervention protocol but did not include progressive resistance training); and progressive resistance exercise (interventions that included an element of progressive resistance training). MAIN RESULTS: We included 24 studies (nine rehabilitation-related activity interventions, six structured exercise interventions and nine progressive resistance exercise interventions) with 7511 participants. All studies compared exercise interventions to usual care; two studies, in addition to usual care, used sham interventions. Mean ages ranged from 73 to 88 years, and 58% of participants were women. Several studies were at high risk of bias. The most common domain assessed at high risk of bias was measurement of the outcome, and five studies (21%) were at high risk of bias arising from the randomisation process. Exercise may have no clinically important effect on independence in activities of daily living at discharge from hospital compared to controls (16 studies, 5174 participants; low-certainty evidence). Five studies used the Barthel Index (scale: 0 to 100, higher scores representing greater independence). Mean scores at discharge in the control groups ranged from 42 to 96 points, and independence in activities of daily living was 1.8 points better (0.43 worse to 4.12 better) with exercise compared to controls. The minimally clinical important difference (MCID) is estimated to be 11 points. We are uncertain regarding the effect of exercise on functional mobility at discharge from the hospital compared to controls (8 studies, 2369 participants; very low-certainty evidence). Three studies used the Short Physical Performance Battery (SPPB) (scale: 0 to 12, higher scores representing better function) to measure functional mobility. Mean scores at discharge in the control groups ranged from 3.7 to 4.9 points on the SPPB, and the estimated effect of the exercise interventions was 0.78 points better (0.02 worse to 1.57 better). A change of 1 point on the SPPB represents an MCID. We are uncertain regarding the effect of exercise on the incidence of delirium during hospitalisation compared to controls (7 trials, 2088 participants; very low-certainty evidence). The incidence of delirium during hospitalisation was 88/1091 (81 per 1000) in the control group compared with 70/997 (73 per 1000; range 47 to 114) in the exercise group (RR 0.90, 95% CI 0.58 to 1.41). Exercise interventions may result in a small clinically unimportant improvement in QoL at discharge from the hospital compared to controls (4 studies, 875 participants; low-certainty evidence). Mean QoL on the EuroQol 5 Dimensions (EQ-5D) visual analogue scale (VAS) (scale: 0 to 100, higher scores representing better QoL) ranged between 48.9 and 64.7 in the control group at discharge from the hospital, and QoL was 6.04 points better (0.9 better to 11.18 better) with exercise. A change of 10 points on the EQ-5D VAS represents an MCID. No studies measured participant global assessment of success. Exercise interventions did not affect the risk of falls during hospitalisation (moderate-certainty evidence). The incidence of falls was 31/899 (34 per 1000) in the control group compared with 31/888 (34 per 1000; range 20 to 57) in the exercise group (RR 0.99, 95% CI 0.59 to 1.65). We are uncertain regarding the effect of exercise on the incidence of medical deterioration during hospitalisation (very low-certainty evidence). The incidence of medical deterioration in the control group was 101/1417 (71 per 1000) compared with 96/1313 (73 per 1000; range 44 to 120) in the exercise group (RR 1.02, 95% CI 0.62 to 1.68). Subgroup analyses by different intervention categories and by the use of a sham intervention were not meaningfully different from the main analyses. AUTHORS' CONCLUSIONS: Exercise may make little difference to independence in activities of daily living or QoL, but probably does not result in more falls in older medical inpatients. We are uncertain about the effect of exercise on functional mobility, incidence of delirium and medical deterioration. Certainty of evidence was limited by risk of bias and inconsistency. Future primary research on the effect of exercise on acute hospitalisation could focus on more consistent and uniform reporting of participant's characteristics including their baseline level of functional ability, as well as exercise dose, intensity and adherence that may provide an insight into the reasons for the observed inconsistencies in findings.

Exploring bi-directional temporal associations between timed-up-and-go and cognitive domains in the Irish longitudinal study on ageing (TILDA).

INTRODUCTION: The bi-directional longitudinal associations between mobility and cognition in older adults are poorly understood. Our objective was to study the temporal associations between timed-up-and-go (TUG) and five cognitive function domains: global cognition, processing speed, verbal fluency, executive function, and sustained attention. METHODS: We designed two longitudinal samples: A (for cognition as predictor of mobility), and B (for mobility as predictor of cognition). To examine the associations between the five cognitive domains at wave 1 and change in TUG times up to wave 5 (eight years), five linear mixed-effect models were fitted. To examine the associations between TUG times at wave 1 and change in the five cognitive domains between waves 1 and 3 (four years), five linear-regression models were fitted. RESULTS: After removing participants with missing data, sample A numbered 4913 participants (mean age 62), and sample B 3675 (mean age 61). Baseline cognitive domains were all significant predictors of future change in TUG times. Baseline TUG time was also a significant predictor of future change in all five cognitive domains. In both cases, poorer performance at baseline predicted greater future loss of function. CONCLUSION: There was evidence of bi-directional temporal relationships between cognition and mobility. In both directions, the effect of the explanatory variable was small, though cognition as predictor of future mobility may have greater clinical relevance than vice versa. Our findings underscore the importance for clinicians of considering the bi-directional associations between cognition and mobility when observing subtle changes in either, especially as impairments emerge.

Clinical and demographic correlates of accelerometer-measured physical activity in participants enrolled in the OPTIMISE HFpEF study.

AIMS: This study aimed to measure physical activity (PA) in participants with suspected heart failure with preserved ejection fraction (HFpEF) and assess associations between PA and participant characteristics. METHODS AND RESULTS: Adults with presumed HFpEF were recruited and received diagnostic evaluation and clinical assessment. Physical activity was objectively measured using accelerometers over 7 days. To examine predictors of PA, a best subset analysis was used, with the optimal model defined as that with the lowest Bayesian information criterion. One hundred and twenty-four participants with presumed HFpEF who had valid accelerometer data were included in this study. Seventy-six were confirmed by a cardiologist as meeting the European Society of Cardiology diagnosis criteria for HFpEF. The median age of all participants was 80.1 years, and 47.4% were female. Patients spent most of each 24-h period at low-intensity PA and few or no durations at high-intensity PA, with lower activity for those with HFpEF. Gait speed was the best univariate correlate of activity levels (adjusted R2 0.29). The optimal model using best subsets regression included six variables and improved adjusted R2 to 0.47. In the model, lower levels of PA were associated with slower gait speed, lower levels of anxiety, higher levels of depression, past smoking history, a confirmed HFpEF diagnosis, and higher body mass index. CONCLUSION: Participants demonstrated very low PA levels. The study has identified important patient characteristics associated with PA, which may help to identify those most in need of interventions. Notably, participants with confirmed HFpEF were more inactive than participants with other heart failure phenotypes.

Frail by different measures: a comparison of 8-year mortality in The Irish Longitudinal Study on Ageing (TILDA).

PURPOSE: We compared the ability of four frailty identification tools (frailty phenotype: FP; FRAIL scale; 32-item Frailty Index: FI; and Clinical Frailty Scale: CFS) to predict 8-year mortality in TILDA. METHODS: We included wave 1 (2010) participants with data for all four tools. Mortality was ascertained at wave 5 (2018). Age, sex and education-adjusted binary logistic regression models were computed. RESULTS: At baseline, there were 5700 participants (mean age 63, range 50-98, 54% women). Frailty prevalences were 2.3% by FRAIL, 3.8% by FP, 10.9% by CFS, and 12.8% by FI. Mortality was 41.2%, 44.9%, 25.3% and 27.0%, respectively. The highest adjusted OR for mortality was for FRAIL (OR 4.48, 95% CI 2.93-6.85, P < 0.001), followed by FP (OR 3.55, 95% CI 2.52-5.00, P < 0.001), FI (OR 2.10, 95% CI 1.68-2.62, P < 0.001), and CFS (OR 1.88, 95% CI 1.48-2.38, P < 0.001). CONCLUSIONS: All tools significantly predicted mortality, but FRAIL and FP seemed more specific.

A mixed-methods feasibility study of a sit-to-stand based exercise programme to maintain knee-extension muscle strength for older patients during hospitalisation.

OBJECTIVES: To determine the acceptability of an exercise programme and to identify barriers and facilitators to compliance with the programme from the participants' perspective. METHODS: Patients aged 75 years or older were recruited within the first 36 hours of hospital admission. Participants were randomised to complete two strengthening-based (intervention arm) or stretching-based (control arm) exercise sessions per-day. At hospital discharge, participants were asked to take part in interviews with a member of the research team exploring the barriers and facilitators to adherence to the intervention. RESULTS: 15 participants (7 intervention arm, 8 control arm) were recruited before the trial was stopped due to COVID-19. Both groups showed reductions in knee-extension strength, and improvements in functional mobility at discharge from hospital. A total of 23/60 intervention sessions were classed as 'complete', 12/60 as partially complete, and 25/60 were missed entirely. Eight participants took part in interviews. Intrinsic factors that impacted participation in the research, related to current health, health beliefs, and experience of multi-morbidity or functional decline. Staff had both a positive and negative effect on participant adherence to the intervention. CONCLUSIONS: The exercise intervention was well received, with most participants describing health benefits, though intervention fidelity was lower than expected.

Frailty index transitions over eight years were frequent in The Irish Longitudinal Study on Ageing.

Background: The frailty index (FI) is based on accumulation of health deficits. FI cut-offs define non-frail, prefrail and frail states. We described transitions of FI states in The Irish Longitudinal Study on Ageing (TILDA). Methods: Participants aged ≥50 years with information for a 31-deficit FI at wave 1 (2010) were followed-up over four waves (2012, 2014, 2016, 2018). Transitions were visualized with alluvial plots and probabilities estimated with multi-state Markov models, investigating the effects of age, sex and education. Results: 8174 wave 1 participants were included (3744 men and 4430 women; mean age 63.8 years). Probabilities from non-frail to prefrail, and non-frail to frail were 18% and 2%, respectively. Prefrail had a 19% probability of reversal to non-frail, and a 15% risk of progression to frail. Frail had a 21% probability of reversal to prefrail and 14% risk of death. Being older and female increased the risk of adverse FI state transitions, but being female reduced the risk of transition from frail to death. Higher level of education was associated with improvement from prefrail to non-frail. Conclusions: FI states are characterized by dynamic longitudinal transitions and frequent improvement. Opportunities exist for reducing the probability of adverse transitions.

Informing patterns of health and social care utilisation in Irish older people according to the Clinical Frailty Scale.

Background: There is increasing policy interest in the consideration of frailty measures (rather than chronological age alone) to inform more equitable allocation of health and social care resources. In this study the Clinical Frailty Scale (CFS) classification tree was applied to data from The Irish Longitudinal Study on Ageing (TILDA) and correlated with health and social care utilisation. CFS transitions over time were also explored. Methods: Applying the CFS classification tree algorithm, secondary analyses of TILDA data were performed to examine distributions of health and social care by CFS categories using descriptive statistics weighted to the population of Ireland aged ≥65 years at Wave 5 (n=3,441; mean age 74.5 (SD ±7.0) years, 54.7% female). CFS transitions over 8 years and (Waves 1-5) were investigated using multi-state Markov models and alluvial charts. Results: The prevalence of CFS categories at Wave 5 were: 6% 'very fit', 36% 'fit', 31% 'managing well', 16% 'vulnerable', 6% 'mildly frail', 4% 'moderately frail' and 1% 'severely frail'. No participants were 'very severely frail' or 'terminally ill'. Increasing CFS categories were associated with increasing hospital and community health services use and increasing hours of formal and informal social care provision. The transitions analyses suggested CFS transitions are dynamic, with 2-year probability of transitioning from 'fit' (CFS1-3) to 'vulnerable' (CFS4), and 'fit' to 'frail' (CFS5+) at 34% and 6%, respectively. 'Vulnerable' and 'frail' had a 22% and 17% probability of reversal to 'fit' and 'vulnerable', respectively. Conclusions: Our results suggest that the CFS classification tree stratified the TILDA population aged ≥65 years into subgroups with increasing health and social care needs. The CFS could be used to aid the allocation of health and social care resources in older people in Ireland. We recommend that CFS status in individuals is reviewed at least every 2 years.

Transitions in frailty phenotype states and components over 8 years: Evidence from The Irish Longitudinal Study on Ageing.

AIM: Fried's frailty phenotype (FP) is defined by exhaustion (EX), unexplained weight loss (WL), weakness (WK), slowness (SL) and low physical activity (LA). Three or more components define the frail state, and one or two the prefrail. We described longitudinal transitions of FP states and components in The Irish Longitudinal Study on Ageing (TILDA). METHODS: We included participants aged ≥50 years with FP information at TILDA wave 1 (2010), who were followed-up over four longitudinal waves (2012, 2014, 2016, 2018). Next-wave transition probabilities were estimated with multi-state Markov models. RESULTS: 5683 wave 1 participants were included (2612 men and 3071 women; mean age 63.1 years). Probabilities from non-frail to prefrail, and non-frail to frail were 27% and 2%, respectively. Prefrail had a 32% probability of reversal to non-frail, and a 10% risk of progression to frail. Frail had an 18% probability of reversal to prefrail and 31% risk of death. Probabilities of transitioning from not having to having a component were: 17% for LA, 11% for SL, 9% for EX, 7% for WL and 6% for WK. Probabilities of having a FP component and dying were: 17% for WL, 15% for WK, 14% for SL, 13% for EX, and 10% for LA. Probabilities of having a component and recovering at the next wave were: 59% for WL, 58% for EX, 40% for WK, 35% for LA and 23% for SL. CONCLUSIONS: FP states and components are characterized by dynamic longitudinal transitions. Opportunities exist for reducing the probability of adverse transitions.

Changes in muscle strength and physical function in older patients during and after hospitalisation: a prospective repeated-measures cohort study.

AIM: to investigate changes in knee-extension strength and physical function in older adults during and after acute hospital admission, and the contributions of illness severity, frailty and sedentary activity to changes in knee-extension strength. METHODS: prospective repeated-measures cohort study on a sample of participants aged ≥75 recruited within 24 hours of acute hospital admission. Knee-extension, grip strength and functional mobility (de Morton Mobility Index, DEMMI) were measured at recruitment, day 7 (or discharge if earlier), and at follow-up 4-6 weeks later. During the first 7 days, continuous measurement of physical activity and daily measurements of muscle strength were taken. Participants recalled the functional ability they had 2-weeks before admission and self-reported it at follow-up (Barthel Index, BI). RESULTS: sixty-five of 70 participants (median age 84 years) had at least one repeated measure of muscle strength in hospital. Knee-extension strength declined during hospitalisation by 11% (P < 0.001), but did not change post-hospitalisation (P = 0.458). Grip strength did not change during hospitalisation (P = 0.665) or from discharge to follow-up (P = 0.508). General functional ability (BI) deteriorated between 2 weeks before admission and follow-up (P < 0.001). Functional mobility (DEMMI) improved during hospitalisation (P < 0.001), but did not change post-hospitalisation (P = 0.508). A repeated-measures mixed model showed that greater loss in knee-extension strength during hospitalisation was associated with increased sedentary time, frailty and baseline strength and lower baseline inflammatory levels. CONCLUSIONS: our observations add to a growing body of evidence on potential risk factors for hospital-associated deconditioning.

Predictors of physical activity in older adults early in an emergency hospital admission: a prospective cohort study.

BACKGROUND: Reduced mobility may be responsible for functional decline and acute sarcopenia in older hospitalised patients. The drivers of reduced in-hospital mobility are poorly understood, especially during the early phase of acute hospitalisation. We investigated predictors of in-hospital activity during a 24-h period in the first 48 h of hospital admission in older adults. METHODS: This was a secondary analysis of a prospective repeated measures cohort study. Participants aged 75 years or older were recruited within the first 24 h of admission. At recruitment, patients underwent a baseline assessment including measurements of pre-morbid functional mobility, cognition, frailty, falls efficacy, co-morbidity, acute illness severity, knee extension strength and grip strength, and consented to wear accelerometers to measure physical activity during the first 7 days (or until discharge if earlier). In-hospital physical activity was defined as the amount of upright time (standing or walking). To examine the predictors of physical activity, we limited the analysis to the first 24 h of recording to maximise the sample size as due to discharge from hospital there was daily attrition. We used a best subset analysis including all baseline measures. The optimal model was defined by having the lowest Bayesian information criterion in the best-subset analyses. The model specified a maximum of 5 covariates and used an exhaustive search. RESULTS: Seventy participants were recruited but eight were excluded from the final analysis due to lack of accelerometer data within the first 24 h after recruitment. Patients spent a median of 0.50 h (IQR: 0.21; 1.43) standing or walking. The optimal model selected the following covariates: functional mobility as measured by the de Morton Mobility Index and two measures of illness severity, the National Early Warning Score, and serum C-reactive protein. CONCLUSIONS: Physical activity, particularly in the acute phase of hospitalisation, is very low in older adults. The association between illness severity and physical activity may be explained by symptoms of acute illness being barriers to activity. Interdisciplinary approaches are required to identify early mobilisation opportunities.