Association between polymorphisms of the VKORC1 and CYP2C9 genes and warfarin maintenance dose in Peruvian patients.

AIMS: The aim of this study was to investigate the association between VKORC1 and CYP2C9 genes polymorphisms and the maintenance dose of warfarin in Peruvian patients. METHODS: An observational study was conducted on outpatients from the Hospital Grau ESSALUD in Lima, Peru. The participants were selected using nonprobabilistic convenience sampling. Inclusion criteria required patients to have been on anticoagulation therapy for >3 months, maintain stable doses of warfarin (consistent dose for at least 3 outpatient visits), and maintain an international normalized ratio within the therapeutic range of 2.5-3.5. DNA samples were obtained from peripheral blood for gene analysis. RESULTS: Seventy patients (mean age of 69.6 ± 13.4 years, 45.7% female) were included in the study. The average weekly warfarin dose was 31.6 ± 15.2 mg. The genotypic frequencies of VKORC1 were as follows: 7.1% (95% confidence interval, 2.4-15.9) for AA; 44.3% (32.4-56.7) for GA; and 48.6% (36.4-60.8) for GG. No deviation from the Hardy-Weinberg equilibrium was observed in the variants studied (P = .56). The mean weekly warfarin doses for AA, GA and GG genotypes were 16.5 ± 2.9, 26.5 ± 9.5 and 37.9 ± 17.1 mg, respectively (P < .001). The genotypic frequencies of CYP2C9 were as follows: 82.8% (72.0-90.8) for CC (*1/*1); 4.3% (1.0-12.0) for CT (*1/*2); and 12.9% (6.1-23.0) for TT (*2/*2). We did not find a significant association between the CYP2C9 gene polymorphism and the dose of warfarin. CONCLUSIONS: The AA genotype of the VKORC1 gene was associated with a lower maintenance dose of warfarin in Peruvian patients.

Core requirements of frailty screening in the emergency department: an international Delphi consensus study.

INTRODUCTION: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. METHODS: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. RESULTS: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. CONCLUSIONS: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Frailty on the island of Ireland: evidence from the NICOLA and TILDA studies.

BACKGROUND: Aimed to compare the prevalence, characteristics, and associated mortality risk of frailty in Northern Ireland (NI) and the Republic of Ireland (ROI). METHODS: Secondary analysis of the first wave of two nationally representative cohorts, the Northern Ireland Cohort for the Longitudinal Study of Ageing or NICOLA study (N = 8504) and the Irish Longitudinal Study on Ageing or TILDA study (N = 8504). Frailty was assessed using a harmonized accumulation deficits frailty index (FI) containing 30 items. FI scores classified individuals as non-frail (<0.10), pre-frail (0.10-0.24) and frail (≥0.25). Linkage to respective administrative data sources provided mortality information with a follow-up time of 8 years. RESULTS: The prevalence of frailty was considerably higher in NI compared with the ROI (29.0% compared with 15.0%), though pre-frailty was slightly lower (35.8% and 37.3%, respectively). Age, female sex, and lower socio-economic status were consistently associated with a higher likelihood of both pre-frailty and frailty. In the pooled analysis, both frailty and pre-frailty were higher in NI (RR = 2.68, 95% CIs 2.45, 2.94 and RR = 1.30, 95% CIs 1.21, 1.40, respectively). Frailty was associated with an increased mortality risk in both cohorts, even after full adjustment for all other characteristics, being marginally higher in TILDA than in NICOLA (HR = 2.43, 95% CIs 2.03, 2.91 vs. HR = 2.31, 95% CIs 1.90, 2.79). CONCLUSIONS: Frailty is a major public health concern for both jurisdictions. Further research and monitoring are required to elucidate why there is a higher prevalence in NI and to identify factors in early life that may be driving these differences.

Were Frailty Identification Criteria Created Equal? A Comparative Case Study on Continuous Non-Invasively Collected Neurocardiovascular Signals during an Active Standing Test in the Irish Longitudinal Study on Ageing (TILDA).

BACKGROUND: In this observational study, we compared continuous physiological signals during an active standing test in adults aged 50 years and over, characterised as frail by three different criteria, using data from The Irish Longitudinal Study on Ageing (TILDA). METHODS: This study utilised data from TILDA, an ongoing landmark prospective cohort study of community-dwelling adults aged 50 years or older in Ireland. The initial sampling strategy in TILDA was based on random geodirectory sampling. Four independent groups were identified: those characterised as frail only by one of the frailty tools used (the physical Frailty Phenotype (FP), the 32-item Frailty Index (FI), or the Clinical Frailty Scale (CFS) classification tree), and a fourth group where participants were not characterised as frail by any of these tools. Continuous non-invasive physiological signals were collected during an active standing test, including systolic (sBP) and diastolic (dBP) blood pressure, as well as heart rate (HR), using digital artery photoplethysmography. Additionally, the frontal lobe cerebral oxygenation (Oxy), deoxygenation (Deoxy), and tissue saturation index (TSI) were also non-invasively measured using near-infrared spectroscopy (NIRS). The signals were visualised across frailty groups and statistically compared using one-dimensional statistical parametric mapping (SPM). RESULTS: A total of 1124 participants (mean age of 63.5 years; 50.2% women) were included: 23 were characterised as frail only by the FP, 97 by the FI, 38 by the CFS, and 966 by none of these criteria. The SPM analyses revealed that only the group characterised as frail by the FI had significantly different signals (p < 0.001) compared to the non-frail group. Specifically, they exhibited an attenuated gain in HR between 10 and 15 s post-stand and larger deficits in sBP and dBP between 15 and 20 s post-stand. CONCLUSIONS: The FI proved to be more adept at capturing distinct physiological responses to standing, likely due to its direct inclusion of cardiovascular morbidities in its definition. Significant differences were observed in the dynamics of cardiovascular signals among the frail populations identified by different frailty criteria, suggesting that caution should be taken when employing frailty identification tools on physiological signals, particularly the neurocardiovascular signals in an active standing test.

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.

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.

The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing.

BACKGROUND: Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up. METHODS: OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures. RESULTS: Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture. DISCUSSION: The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

Building resilience and reversing frailty: a randomised controlled trial of a primary care intervention for older adults.

BACKGROUND: There is a need for effective primary care interventions that help older people combat frailty and build resilience. OBJECTIVE: To study the effectiveness of an optimised exercise and dietary protein intervention. DESIGN: Multicentre, randomised-controlled, parallel-arm trial. SETTING: Six primary care practices, Ireland. METHODS: Six general practitioners enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to May 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment. Intervention comprised a 3-month home-based exercise regime, emphasising strength, and dietary protein guidance (1.2 g/kg/day). Effectiveness was measured by comparing frailty levels, based on the SHARE-Frailty Instrument, on an intention-to-treat basis. Secondary outcomes included bone mass, muscle mass and biological age measured by bioelectrical impedance analysis. Ease of intervention and perceived health benefit were measured on Likert scales. RESULTS: Of the 359 adults screened, 197 were eligible and 168 enrolled; 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, 17.7% of intervention and 16.9% of control participants were frail by SHARE-FI. At follow-up, 6.3 and 18.2% were frail, respectively. The odds ratio of being frail between intervention and control groups post-intervention was 0.23 (95% confidence interval: 0.07-0.72; P = 0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%-22.9%). Number needed to treat was 8.4. Grip strength (P < 0.001) and bone mass (P = 0.040) improved significantly. 66.2% found the intervention easy, 69.0% reported feeling better. CONCLUSION: A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health.

Effect of immunology biomarkers associated with hip fracture and fracture risk in older adults.

Osteoporosis is a skeletal disease that can increase the risk of fractures, leading to adverse health and socioeconomic consequences. However, current clinical methods have limitations in accurately estimating fracture risk, particularly in older adults. Thus, new technologies are necessary to improve the accuracy of fracture risk estimation. In this observational study, we aimed to explore the association between serum cytokines and hip fracture status in older adults, and their associations with fracture risk using the FRAX reference tool. We investigated the use of a proximity extension assay (PEA) with Olink. We compared the characteristics of the population, functional status and detailed body composition (determined using densitometry) between groups. We enrolled 40 participants, including 20 with hip fracture and 20 without fracture, and studied 46 cytokines in their serum. After conducting a score plot and two unpaired t-tests using the Benjamini-Hochberg method, we found that Interleukin 6 (IL-6), Lymphotoxin-alpha (LT-α), Fms-related tyrosine kinase 3 ligand (FLT3LG), Colony stimulating factor 1 (CSF1), and Chemokine (C-C motif) ligand 7 (CCL7) were significantly different between fracture and non-fracture patients (p < 0.05). IL-6 had a moderate correlation with FRAX (R2 = 0.409, p < 0.001), while CSF1 and CCL7 had weak correlations with FRAX. LT-α and FLT3LG exhibited a negative correlation with the risk of fracture. Our results suggest that targeted proteomic tools have the capability to identify differentially regulated proteins and may serve as potential markers for estimating fracture risk. However, longitudinal studies will be necessary to validate these results and determine the temporal patterns of changes in cytokine profiles.

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).

Development of a Frailty Index in the Irish Hip Fracture Database.

INTRODUCTION: In older people, hip fracture can lead to adverse outcomes. Frailty, capturing biological age and vulnerability to stressors, can indicate those at higher risk. We derived a frailty index (FI) in the Irish Hip Fracture Database (IHFD) and explored associations with prolonged length of hospital stay (LOS ≥ 30 days), delirium, inpatient mortality and new nursing home admission. We assessed whether the FI predicted those outcomes independently of age, sex and pre-operative American Society of Anaesthesiology (ASA) score. MATERIALS AND METHODS: A 21-item FI was constructed with 17 dichotomous co-morbidities, three 4-level ordinal pre-morbid functional variables (difficulty with indoor mobility, outdoor mobility, and shopping) and nursing home provenance (yes/no). The FI was computed as the proportion of items present and divided into tertiles (low, medium, high risk). Independent associations between FI and outcomes were explored with logistic regression, from which we extracted adjusted Odds Ratios (aOR) and Areas Under the Curve (AUC). RESULTS: From 2017 to 2020, the IHFD included 14,615 hip fracture admissions, mean (SD) age 80.4 (8.8), 68.9% women. Complete FI data were available for 12,502 (85.5%). By FI tertile (low to high risk), prolonged LOS proportions were 5.9%, 16.1% and 23.1%; delirium 5.5%, 13.5% and 17.6%; inpatient mortality 0.6%, 3.3% and 10.1%; and new nursing home admission 2.2%, 5.9% and 11.3%. All associations were statistically significant (p < 0.001) independently of age and sex. AUC analyses showed that the FI score, added to age, sex, and ASA score, significantly improved the prediction of delirium and new nursing home admission (p < 0.05), and especially prolonged LOS and inpatient mortality (p < 0.001). CONCLUSIONS: A 21-item FI in the IHFD was a significant predictor of outcomes and added value to traditional risk markers. The utility of a routinely derived FI to more effectively direct limited orthogeriatric resources requires prospective investigation.

How can urban environments support dementia risk reduction? A qualitative study.

OBJECTIVE: Interventions to reduce the risk of cognitive decline and dementia largely focus on individual-level strategies. To maximize risk reduction, it is also necessary to consider the environment. With the majority of older people living in cities, we explored how urban environments could support risk reduction. MATERIALS AND METHODS: In our qualitative study, we conducted semi-structured interviews with community members aged ≥65 years and stakeholders, all living in Leipzig, Germany. Interview guides were informed by the framework on modifiable risk factors for dementia of the Lancet Commission on Dementia Prevention, Intervention, and Care. Interviews were audio-recorded, verbatim-transcribed, and thematically analysed. RESULTS: Community members (n = 10) were M = 73.7 (SD = 6.0) years old and 50% were women. Stakeholders (n = 10) were aged 39-72 years, and 70% were women. Stakeholders' fields included architecture, cultural/arts education, environmental sciences, geriatrics, health policy, information and technology, philosophy, psychology, public health, and urban sociology. Across interviews with both older individuals and stakeholders, three main themes were identified: (i) social participation and inclusion (emphasizing social contacts, social housing, intergenerationality, neighbourhood assistance, information and orientation, digital and technological literacy, lifelong learning, co-creation/co-design), (ii) proximity and accessibility (emphasizing proximity and reachability, mobility, affordability, access to health care, access to cultural events, public toilets), (iii) local recreation and wellbeing (emphasizing safety in traffic, security, cleanliness and environmental protection, urban greenery, climate change and heat waves, outdoor physical activity). DISCUSSION: The design of urban environments holds large potential to create favourable conditions for community-dwelling individuals to practice lifestyles that promote brain health. Public policy should involve community members in co-creating such environments.

Hospital-associated deconditioning: Not only physical, but also cognitive.

INTRODUCTION: Hospital-associated deconditioning (HAD) or post-hospital syndrome is well recognized as reduced functional performance after an acute hospitalization. Recommendations for the management of HAD are still lacking, partly due to a poor understanding of the underlying processes. We aimed to review existing data on risk factors, pathophysiology, measurement tools, and potential interventions. MATERIALS AND METHODS: We conducted a systematic review from bibliographical databases in English, Spanish and French with keywords such as 'post-hospitalization syndrome' or 'deconditioning'. We selected studies that included people aged 60 years or older. Three researchers independently selected articles and assessed their quality. RESULTS: From 4421 articles initially retrieved, we included 94 studies. Most were related to risk factors, trajectories and measures, and focused on the physical aspects of deconditioning. Risk factors for HAD included age, nutritional status, mobility, and pre-admission functional status, but also cognitive impairment and depression. Regarding interventions, almost all studies were devoted to physical rehabilitation and environmental modifications. Only one study focused on cognitive stimulation. DISCUSSION: In the last decade, studies on HAD have mostly focused on the physical domain. However, neurological changes may also play a role in the pathophysiology of HAD. Beyond physical interventions, cognitive rehabilitation and neurological interventions should also be evaluated to improve deconditioning prevention and treatment in the hospital setting.

The giants of education in geriatric medicine and gerontology.

In 2014, the European undergraduate curriculum in Geriatric Medicine was published to cover the minimum requirements that a medical student should achieve by the end of medical school. In 2019, the European postgraduate curriculum in Geriatric Medicine outlined the minimum recommended training requirements to become a geriatrician at specialist level in the EU. The postgraduate dimension of Geriatric Medicine education is a highly relevant topic for all, since most physicians-independently of their specialty-are inevitably involved in the care of older patients, but for most physicians, geriatrics is not part of their postgraduate generalist or specialty training. A key area for postgraduate education remains the provision of Geriatric Medicine competencies to all specialties outside geriatrics. There is also need for wider educational initiatives to improve the gerontological education of patients and the public. Bernard Isaacs famously coined the expression 'geriatric giants' or the four clinical I's: Intellectual impairment, Incontinence, Immobility, and Instability. However, non-clinical giants exist. In education, we face challenges of Investment, Inspiration, Integration, and Interprofessionality; and in research, we need to attract Interest and Income, and generate Innovation and Impact. Without strengthening the links between all giants, we will not be able to achieve the ambition of age-attuned societies. A key goal for gerontological education is to enhance everyone's understanding of the wide diversity underlying the 'older people' demographic label, which will ultimately promote services and societies that are more responsive and inclusive to the needs of all older adults, irrespective of their health status.

Atrial fibrillation and acceleration of frailty: findings from the Irish Longitudinal Study on Ageing.

INTRODUCTION: both atrial fibrillation (AF) and frailty are increasingly prevalent with age. Cross-sectional studies have suggested a relationship between AF and frailty, but longitudinal data are lacking. We explored if the presence of AF was associated with accelerated progression of frailty over 8 years in community-dwelling older adults. METHODS: a longitudinal retrospective case-control study was conducted using data from Waves 1 and 5 of the Irish Longitudinal Study on Ageing (TILDA). Participants with electrocardiographically detected AF at Wave 1 were matched to controls without AF (1:2) based on age and gender. Frailty was assessed using both the frailty phenotype (FP) and a 31-item frailty index (FI). Change in cases' and controls' FP and FI scores from Waves 1 to 5 were modelled using repeated measures analysis of variance (RM-ANOVA). RESULTS: one hundred eighteen TILDA participants with AF at Wave 1 were matched to 236 controls. By FP, participants with AF were not significantly more frail than controls at Wave 1 (P = 0.166) but were at Wave 5 (P = 0.011), and RM-ANOVA suggested that frailty progressed more in participants with AF between Waves 1 and 5 compared with controls (P = 0.033). By FI, participants with AF were significantly more frail at Wave 1 (P < 0.001) and 5 (P = 0.010), and RM-ANOVA did not show a difference in frailty progression between groups (P = 0.955). CONCLUSION: AF may drive the development of the FP. The FP is a pre-disability syndrome and hence may be better than the FI as a focus for disability prevention in adults with AF.

Involving older people in co-designing an intervention to reverse frailty and build resilience.

BACKGROUND: An essential consideration in health research is to conduct research with members of the public rather than for them. Public and patient involvement (PPI) of older people in research can improve enrolment, relevance and impact. However, few studies with PPI in frailty research have been identified. PPI has fallen during the Covid-19 pandemic. OBJECTIVE: We aimed to involve older people in co-designing a randomised control trial (RCT) intervention to reverse frailty and build resilience. We also wished to encourage wider use of PPI with older people by outlining our approach. METHODS: Involvement of older people was undertaken in three stages. Eighteen over 65-year-olds helped co-design an exercise intervention in two group discussions using the Socratic education method. Ninety-four contributed intervention feedback in one-on-one telephone interviews over nine months. Ten contributors helped optimise the intervention in three online workshops. Multidisciplinary team input and systematic review supported co-design. RESULTS: Eleven home-based resistance exercises were co-designed by group discussion contributors (mean age 75, 61% female). Frailty intervention format, gender balance and GP follow-up were shaped in telephone interviews (mean age 77, 63% female). Dietary guidance and patient communication were co-designed in workshops (mean age 71, 60% females). Technology proved no barrier to PPI. The co-designed frailty intervention is being evaluated in a definitive RCT. CONCLUSIONS: We enabled meaningful the involvement of 112 older people in the co-design of an intervention to reverse frailty and build resilience in diverse ways. Inclusive involvement can be achieved during a pandemic. Feedback enhanced intervention feasibility for real-world primary-care.

Our research paper describes how we involved 112 older adults in the co-design of an intervention aiming to reverse frailty and build resilience. Involving participants in research can improve its feasibility and impact. However, there have been few studies involving older people in frailty research and involvement has fallen further during the Covid-19 pandemic. Involvement of older people was undertaken in three stages. Eighteen over 65-year-olds helped co-design an exercise intervention in two group discussions. Ninety-four older adults contributed intervention feedback in one-on-one telephone interviews over nine months. Ten contributors helped optimise the intervention in three online workshops. The co-designed intervention involved resistance exercises and dietary guidance and will be tested in a full randomised control trial. We enabled the meaningful involvement of 112 older people in our research in diverse ways. Inclusive involvement can be achieved during a pandemic.

Transitions between degrees of multidimensional frailty among older people admitted to intermediate care: a multicentre prospective study.

BACKGROUND: Frailty is a dynamic condition that is clinically expected to change in older individuals during and around admission to an intermediate care (IC) facility. We aimed to characterize transitions between degrees of frailty before, during, and after admission to IC and assess the impact of these transitions on health outcomes. METHODS: Multicentre observational prospective study in IC facilities in Catalonia (North-east Spain). The analysis included all individuals aged ≥ 75 years (or younger with chronic complex or advanced diseases) admitted to an IC facility. The primary outcome was frailty, measured by the Frail-VIG index and categorized into four degrees: no frailty, and mild, moderate, and advanced frailty. The Frail-VIG index was measured at baseline (i.e., 30 days before IC admission) (Frail-VIG0), on IC admission (Frail-VIG1), at discharge (Frail-VIG2), and 30 days post-discharge (Frail-VIG3). RESULTS: The study included 483 patients with a mean (SD) age of 81.3 (10.2) years. At the time of admission, 27 (5.6%) had no frailty, and 116 (24%), 161 (33.3%), and 179 (37.1%) mild, moderate, and severe frailty, respectively. Most frailty transitions occurred within the 30 days following admission to IC, particularly among patients with moderate frailty on admission. Most patients maintained their frailty status after discharge. Overall, 135 (28%) patients died during IC stay. Frailty, measured either at baseline or admission, was significantly associated with mortality, although it showed a stronger contribution when measured on admission (HR 1.16; 95%CI 1.10-1.22; p < 0.001) compared to baseline (HR 1.10; 1.05-1.15; p < 0.001). When including frailty measurements at the two time points (i.e., baseline and IC admission) in a multivariate model, frailty measured on IC admission but not at baseline significantly contributed to explaining mortality during IC stay. CONCLUSIONS: Frailty status varied before and during admission to IC. Of the serial frailty measures we collected, frailty on IC admission was the strongest predictor of mortality. Results from this observational study suggest that routine frailty measurement on IC admission could aid clinical management decisions.

Investigation of the role of sleep and physical activity for chronic disease prevalence and incidence in older Irish adults.

BACKGROUND: Chronic diseases are the leading cause of death worldwide. Many of these diseases have modifiable risk factors, including physical activity and sleep, and may be preventable. This study investigated independent associations of physical activity and sleep with eight common chronic illnesses. METHODS: Data were from waves 1, 3 and 5 of The Irish Longitudinal Study on Ageing (n = 5,680). Inverse probability weighted general estimating equations were used to examine longitudinal lifetime prevalence and cumulative incidence of self-reported conditions. RESULTS: Sleep problems were significantly associated with increased odds of incident and prevalent arthritis and angina. Additionally sleep problems were associated with higher odds of lifetime prevalence of hypertension and diabetes. Physical activity was negatively associated incident osteoporosis and respiratory diseases and negatively associated with lifetime prevalence of hypertension, high cholesterol and diabetes. CONCLUSIONS: Worse sleep quality and lower physical activity were associated with higher odds of chronic diseases. Interventions to improve sleep and physical activity may improve health outcomes.

A Novel Methodology for the Synchronous Collection and Multimodal Visualization of Continuous Neurocardiovascular and Neuromuscular Physiological Data in Adults with Long COVID.

Background: Reports suggest that adults with post-COVID-19 syndrome or long COVID may be affected by orthostatic intolerance syndromes, with autonomic nervous system dysfunction as a possible causal factor of neurocardiovascular instability (NCVI). Long COVID can also manifest as prolonged fatigue, which may be linked to neuromuscular function impairment (NMFI). The current clinical assessment for NCVI monitors neurocardiovascular performance upon the application of orthostatic stressors such as an active (i.e., self-induced) stand or a passive (tilt table) standing test. Lower limb muscle contractions may be important in orthostatic recovery via the skeletal muscle pump. In this study, adults with long COVID were assessed with a protocol that, in addition to the standard NCVI tests, incorporated simultaneous lower limb muscle monitoring for NMFI assessment. Methods: To conduct such an investigation, a wide range of continuous non-invasive biomedical sensing technologies were employed, including digital artery photoplethysmography for the extraction of cardiovascular signals, near-infrared spectroscopy for the extraction of regional tissue oxygenation in brain and muscle, and electromyography for assessment of timed muscle contractions in the lower limbs. Results: With the proposed methodology described and exemplified in this paper, we were able to collect relevant physiological data for the assessment of neurocardiovascular and neuromuscular functioning. We were also able to integrate signals from a variety of instruments in a synchronized fashion and visualize the interactions between different physiological signals during the combined NCVI/NMFI assessment. Multiple counts of evidence were collected, which can capture the dynamics between skeletal muscle contractions and neurocardiovascular responses. Conclusions: The proposed methodology can offer an overview of the functioning of the neurocardiovascular and neuromuscular systems in a combined NCVI/NMFI setup and is capable of conducting comparative studies with signals from multiple participants at any given time in the assessment. This could help clinicians and researchers generate and test hypotheses based on the multimodal inspection of raw data in long COVID and other cohorts.

Cardiovascular Signal Entropy Predicts All-Cause Mortality: Evidence from The Irish Longitudinal Study on Ageing (TILDA).

In this study, the relationship between cardiovascular signal entropy and the risk of seven-year all-cause mortality was explored in a large sample of community-dwelling older adults from The Irish Longitudinal Study on Ageing (TILDA). The hypothesis under investigation was that physiological dysregulation might be quantifiable by the level of sample entropy (SampEn) in continuously noninvasively measured resting-state systolic (sBP) and diastolic (dBP) blood pressure (BP) data, and that this SampEn measure might be independently predictive of mortality. Participants' date of death up to 2017 was identified from official death registration data and linked to their TILDA baseline survey and health assessment data (2010). BP was continuously monitored during supine rest at baseline, and SampEn values were calculated for one-minute and five-minute sections of this data. In total, 4543 participants were included (mean (SD) age: 61.9 (8.4) years; 54.1% female), of whom 214 died. Cox proportional hazards regression models were used to estimate the hazard ratios (HRs) with 95% confidence intervals (CIs) for the associations between BP SampEn and all-cause mortality. Results revealed that higher SampEn in BP signals was significantly predictive of mortality risk, with an increase of one standard deviation in sBP SampEn and dBP SampEn corresponding to HRs of 1.19 and 1.17, respectively, in models comprehensively controlled for potential confounders. The quantification of SampEn in short length BP signals could provide a novel and clinically useful predictor of mortality risk in older adults.