Is polypharmacy associated with difficulty taking medicines in people aged ≥85 living at home? Findings from the Newcastle 85+ Study.

It is unclear whether polypharmacy is associated with difficulty taking medications amongst people aged ≥85 living at home. This is despite the projected decline in availability of family carers, who may support independent living. Using Newcastle 85+ Study data and mixed-effects modelling, we investigated the association between polypharmacy and difficulty taking medications amongst 85-year-olds living at home, over a 10-year time period. Polypharmacy was not associated with difficulty taking medications as either a continuous (OR = 0.99 [0.91-1.08]) or categorical variable (5-9 medications, OR = 0.69 [0.34-1.41]; ≥10 medications, OR = 0.85 [0.34-2.07]). The significant predictors included disability, visual impairment and cognitive impairment. Our results suggest that people aged ≥85 living at home with disability, visual impairment and/or cognitive impairment will have difficulty taking their medications, regardless of how many they are prescribed. Therefore, healthcare professionals should routinely ask about, assess and address problems that these patient groups may have with taking their medicines, independent of the number of drugs taken.

Does polypharmacy shape dependency transitions in the very old? Findings from the Newcastle 85+ Study.

BACKGROUND: helping older people to maintain their independence, and identifying risk factors that compromise this, is of high importance. Polypharmacy is common in the very old (aged ≥ 85) but whether it can shape transitions in dependency in this fastest growing subpopulation is unclear. METHODS: using Newcastle 85+ Study data and multi-state modelling, we investigated the association between each additional medication prescribed and the progression of and recovery from dependency states, over 10 years (age 85-95). Participants were defined as either free from care (independent), requiring care less often than daily (low dependency), or requiring care at regular intervals each day or 24 hourly (medium/high dependency). RESULTS: each additional medication prescribed was associated with a 10% decreased chance of recovery from low dependence to independence (hazard ratio (HR): 0.90, 95% confidence interval (CI): 0.82-0.99). DISCUSSION: when a relatively able person visits the GP or clinical pharmacist, careful consideration should be given to whether the potential benefits from adding a new medication outweigh the risk to reduced recovery of independence.

Is polypharmacy associated with mortality in the very old: Findings from the Newcastle 85+ Study.

Polypharmacy is common in the very old (≥85 years), where little is known about its association with mortality. We aimed to investigate the association between polypharmacy and all-cause mortality in the very old, over an 11-year time period. Data were drawn from the Newcastle 85+ Study (741), a cohort of people who were born in 1921 and turned 85 in 2006. Survival analysis was performed using Cox proportional hazards models with time-varying covariates, wherein polypharmacy was operationalised continuously. Each additional medication prescribed was associated with a 3% increased risk of mortality (hazard ratio: 1.03, 95% confidence interval: 1.00-1.06). Amongst the very old, the risks and benefits of each additional medication prescribed should be carefully considered.

The impact of long-term conditions on disability-free life expectancy: A systematic review.

Although leading causes of death are regularly reported, there is disagreement on which long-term conditions (LTCs) reduce disability-free life expectancy (DFLE) the most. We aimed to estimate increases in DFLE associated with elimination of a range of LTCs. This is a comprehensive systematic review and meta-analysis of studies assessing the effects of LTCs on health expectancy (HE). MEDLINE, Embase, HMIC, Science Citation Index, and Social Science Citation Index were systematically searched for studies published in English from July 2007 to July 2020 with updated searches from inception to April 8, 2021. LTCs considered included: arthritis, diabetes, cardiovascular disease including stroke and peripheral vascular disease, respiratory disease, visual and hearing impairment, dementia, cognitive impairment, depression, cancer, and comorbidity. Studies were included if they estimated HE outcomes (disability-free, active or healthy life expectancy) at age 50 or older for individuals with and without the LTC. Study selection and quality assessment were undertaken by teams of independent reviewers. Meta-analysis was feasible if three or more studies assessed the impact of the same LTC on the same HE at the same age using comparable methods, with narrative syntheses for the remaining studies. Studies reporting Years of Life Lost (YLL), Years of Life with Disability (YLD) and Disability Adjusted Life Years (DALYs = YLL+YLD) were included but reported separately as incomparable with other HE outcomes (PROSPERO registration: CRD42020196049). Searches returned 6072 unique records, yielding 404 eligible for full text retrieval from which 30 DFLE-related and 7 DALY-related were eligible for inclusion. Thirteen studies reported a single condition, and 17 studies reported on more than one condition (two to nine LTCs). Only seven studies examined the impact of comorbidities. Random effects meta-analyses were feasible for a subgroup of studies examining diabetes (four studies) or respiratory diseases (three studies) on DFLE. From pooled results, individuals at age 65 without diabetes gain on average 2.28 years disability-free compared to those with diabetes (95% CI: 0.57-3.99, p<0.01, I2 = 96.7%), whilst individuals without respiratory diseases gain on average 1.47 years compared to those with respiratory diseases (95% CI: 0.77-2.17, p<0.01, I2 = 79.8%). Eliminating diabetes, stroke, hypertension or arthritis would result in compression of disability. Of the seven longitudinal studies assessing the impact of multiple LTCs, three found that stroke had the greatest effect on DFLE for both genders. This study is the first to systematically quantify the impact of LTCs on both HE and LE at a global level, to assess potential compression of disability. Diabetes, stroke, hypertension and arthritis had a greater effect on DFLE than LE and so elimination would result in compression of disability. Guidelines for reporting HE outcomes would assist data synthesis in the future, which would in turn aid public health policy.

Characterising polypharmacy in the very old: Findings from the Newcastle 85+ Study.

BACKGROUND: Polypharmacy is potentially harmful and under-researched amongst the fastest growing subpopulation, the very old (aged ≥85). We aimed to characterise polypharmacy using data from the Newcastle 85+ Study-a prospective cohort of people born in 1921 who turned 85 in 2006 (n = 845). METHODS: The prevalence of polypharmacy at baseline (mean age 85.5) was examined using cut-points of 0, 1, 2-4, 5-9 and ≥10 medicines-so-called 'no polypharmacy', 'monotherapy', 'minor polypharmacy', 'polypharmacy' and 'hyperpolypharmacy.' Cross-tabulations and upset plots identified the most frequently prescribed medicines and medication combinations within these categories. Mixed-effects models assessed whether gender and socioeconomic position were associated with prescribing changes over time (mean age 85.5-90.5). Participant characteristics were examined through descriptive statistics. RESULTS: Complex multimorbidity (44.4%, 344/775) was widespread but hyperpolypharmacy was not (16.0%, 135/845). The median medication count was six (interquartile range 4-8). Preventative medicines were common to all polypharmacy categories, and prescribing regimens were diverse. Nitrates and oral anticoagulants were more frequently prescribed for men, whereas bisphosphonates, non-opioid analgesics and antidepressants were more common in women. Cardiovascular medicines, including loop diuretics, tended to be more frequently prescribed for socioeconomically disadvantaged people (<25th centile Index of Multiple Deprivation (IMD)), despite no difference in the prevalence of cardiovascular disease (p = 0.56) and diabetes (p = 0.92) by IMD. CONCLUSION: Considering their complex medical conditions, prescribing is relatively conservative amongst 85-year-olds living in North East England. Prescribing shows significant gender and selected socioeconomic differences. More support for managing preventative medicines, of uncertain benefit, might be helpful in this population.

The Impact of Smoking and Obesity on Disability-Free Life Expectancy in Older Australians.

BACKGROUND: Smoking and obesity are 2 modifiable risk factors for disability. We examine the impact of smoking and obesity on disability-free life expectancy (DFLE) at older ages, using 2 levels of disability. METHOD: We used the DYNOPTA dataset, derived by harmonizing and pooling risk factors and disability outcomes from 5 Australian longitudinal aging studies. We defined mobility disability as inability to walk 1 km, and more severe (activities of daily living [ADL]) disability by the inability to dress or bathe. Mortality data for the analytic sample (N = 20 401; 81.2% women) were obtained from Government Records via data linkage. We estimated sex-specific total life expectancy, DFLE, and years spent with disability by Interpolated Markov Chain (IMaCh) software for each combination of smoking (never vs ever), obesity (body mass index ≥30 vs 18.5 to <30), and education (left school age 14 or younger vs age 15 or older). RESULTS: Compared to those without either risk factor, high educated nonobese smokers at age 65 lived shorter lives (men and women: 2.5 years) and fewer years free of mobility disability (men: 2.1 years; women: 2.0 years), with similar results for ADL disability. Obesity had the largest effect on mobility disability in women; high educated obese nonsmoking women lived 1.3 years less than nonsmoking, not obese women but had 5.1 years fewer free of mobility disability and 3.2 fewer free of ADL disability. Differences between risk factor groups were similar for the low educated. CONCLUSIONS: Our findings suggest eliminating obesity would lead to an absolute reduction of disability, particularly in women.

Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews.

OBJECTIVE: Polypharmacy is widespread among older people, but the adverse outcomes associated with it are unclear. We aim to synthesize current evidence on the adverse health, social, medicines management, and health care utilization outcomes of polypharmacy in older people. DESIGN: A systematic review, of systematic reviews and meta-analyses of observational studies, was conducted. Eleven bibliographic databases were searched from 1990 to February 2018. Quality was assessed using AMSTAR (A Measurement Tool to Assess Systematic Reviews). SETTING AND PARTICIPANTS: Older people in any health care setting, residential setting, or country. RESULTS: Twenty-six reviews reporting on 230 unique studies were included. Almost all reviews operationalized polypharmacy as medication count, and few examined medication classes or disease states within this. Evidence for an association between polypharmacy and many adverse outcomes, including adverse drug events and disability, was conflicting. The most consistent evidence was found for hospitalization and inappropriate prescribing. No research had explored polypharmacy in the very old (aged ≥85 years), or examined the potential social consequences associated with medication use, such as loneliness and isolation. CONCLUSIONS AND IMPLICATIONS: The literature examining the adverse outcomes of polypharmacy in older people is complex, extensive, and conflicting. Until polypharmacy is operationalized in a more clinically relevant manner, the adverse outcomes associated with it will not be fully understood. Future studies should work toward this approach in the face of rising multimorbidity and population aging.

Contribution of protein intake and its interaction with physical activity to transitions between disability states and to death in very old adults: the Newcastle 85+ Study.

INTRODUCTION: Growth in the number of very old (≥ 85 years) adults will likely lead to increased prevalence of disability. Our aim was to determine the contribution of protein intake, and the interaction between protein intake and physical activity (PA), to the transition between disability states and to death in the very old using the Newcastle 85+ Study. METHODS: The analytic sample comprised of 717 older adults aged 85 years at baseline and living in the community. Protein intake was estimated with 2 × 24-h multiple pass recalls (24 h-MPR) at baseline. Disability was measured as difficulty performing 17 activities of daily living (ADL) at baseline, at 18, 36, and 60 months, and defined as having difficulties in one or more ADL. The contribution of protein intake [g/kg adjusted body weight/day (g/kg aBW/d)] to transition probabilities to and from disability, and to death over 5 years was examined by multi-state models adjusted for key health covariates. RESULTS: Participants were expected to spend 0.8 years (95% CI 0.6-1.0) disability-free and 2.8 years (95% CI 2.6-2.9) with disability between the ages 85 and 90 years. One unit increase in protein intake (g/kg aBW/d) halved the likelihood of incident disability (HR 0.44, 95% CI 0.24-0.83) but not for other transitions. Similar reductions in disability incidence were also found in individuals with protein intake ≥ 0.8 (HR 0.50, 95% CI 0.31-0.80) and ≥ 1 g/kg aBW/d (HR 0.49, 95% CI 0.33-0.73). Participants with high PA and protein intake ≥ 1 g/kg aBW/d were less likely to transition from disability-free to disability than those within the same PA level but with protein intake < 1 g/kg aBW/d (HR 0.45, 95% CI 0.28-0.72). CONCLUSION: Higher protein intake, especially in combination with higher physical activity, may delay the incidence of disability in very old adults.

Serum Thyroid Function, Mortality and Disability in Advanced Old Age: The Newcastle 85+ Study.

CONTEXT: Perturbations in thyroid function are common in older individuals but their significance in the very old is not fully understood. OBJECTIVE: This study sought to determine whether thyroid hormone status and variation of thyroid hormones within the reference range correlated with mortality and disability in a cohort of 85-year-olds. DESIGN: A cohort of 85-year-old individuals were assessed in their own homes (community or institutional care) for health status and thyroid function, and followed for mortality and disability for up to 9 years. SETTING AND PARTICIPANTS: Six hundred and forty-three 85-year-olds registered with participating general practices in Newcastle and North Tyneside, United Kingdom. MAIN OUTCOMES: All-cause mortality, cardiovascular mortality, and disability according to thyroid disease status and baseline thyroid hormone parameters (serum TSH, FT4, FT3, and rT3). Models were adjusted for age, sex, education, body mass index, smoking, and disease count. RESULTS: After adjustment for age and sex, all-cause mortality was associated with baseline serum rT3 and FT3 (both P < .001), but not FT4 or TSH. After additional adjustment for potential confounders, only rT3 remained significantly associated with mortality (P = .001). Baseline serum TSH and rT3 predicted future disability trajectories in men and women, respectively. CONCLUSIONS: Our study is reassuring that individuals age 85 y with both subclinical hypothyroidism and subclinical hyperthyroidism do not have a significantly worse survival over 9 years than their euthyroid peers. However, thyroid function tests did predict disability, with higher serum TSH levels predicting better outcomes. These data strengthen the argument for routine use of age-specific thyroid function reference ranges.

The influence of smoking, sedentary lifestyle and obesity on cognitive impairment-free life expectancy.

BACKGROUND: Smoking, sedentary lifestyle and obesity are risk factors for mortality and dementia. However, their impact on cognitive impairment-free life expectancy (CIFLE)has not previously been estimated. METHODS: Data were drawn from the DYNOPTA dataset which was derived by harmonizing and pooling common measures from five longitudinal ageing studies. Participants for whom the Mini-Mental State Examination was available were included (N»8111,48.6% men). Data on education, sex, body mass index, smoking and sedentary lifestyle were collected and mortality data were obtained from Government Records via data linkage.Total life expectancy (LE), CIFLE and years spent with cognitive impairment (CILE)were estimated for each risk factor and total burden of risk factors. RESULTS: CILE was approximately 2 years for men and 3 years for women, regardless of age. For men and women respectively, reduced LE associated with smoking was 3.82and 5.88 years, associated with obesity was 0.62 and 1.72 years and associated with being sedentary was 2.50 and 2.89 years. Absence of each risk factor was associated with longer LE and CIFLE, but also longer CILE for smoking in women and being sedentary in both sexes. Compared with participants with no risk factors, those with 2þ had shorter CIFLE of up to 3.5 years depending on gender and education level. CONCLUSIONS: Population level reductions in smoking, sedentary lifestyle and obesity increase longevity and number of years lived without cognitive impairment. Years lived with cognitive impairment may also increase.

The association between diagnosed glaucoma and cataract and cognitive performance in very old people: cross-sectional findings from the newcastle 85+ study.

PURPOSE: Common age-related eye diseases including glaucoma, cataract and age-related macular degeneration (AMD) have been proposed to be associated with dementia. Few studies have examined the relationship between cognition and cataract or glaucoma. We explored the association between cognition and cataract and glaucoma diagnoses in community-dwelling 85-year-olds. METHODS: Cross-sectional analysis of data from the Newcastle 85+ Study. Diagnoses of eye disease were extracted from family practice records. Cognitive performance was assessed by the standardized mini-mental state examination (sMMSE) and the sMMSE-blind (MMblind). Relationships between glaucoma diagnosis or cataract diagnosis and lower cognition were examined using ordinal logistic regression. RESULTS: Complete data were available for 839 participants. Of these, 36.0% (302/839) had recorded previous cataract surgery, 11.2% (94/839) untreated cataract and 7.9% (66/839) diagnosed glaucoma. Glaucoma diagnosis was associated with lower sMMSE results (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.05-2.95); but not lower MMblind (OR 1.17, 95% CI 0.65-2.12). When compared to no cataract, cataract diagnosis (treated and untreated combined) was associated with higher sMMSE (OR 0.55, 95% CI 0.38-0.79) and MMblind (OR 0.51, 95% CI 0.34-0.76). Previously treated cataract was associated with higher sMMSE (OR 0.72, 95% CI 0.59-0.88) and MMblind (OR 0.68, 95% CI 0.55-0.85). Untreated cataract was not significantly associated with sMMSE (OR 0.65, 95% CI 0.36-1.19) or MMblind (OR 0.73, 95% CI 0.39-1.36). CONCLUSIONS: This large epidemiological study of 85-year-olds found that lower sMMSE but not MMblind was associated with glaucoma diagnosis, suggesting the association may be driven by poor vision. Cataract diagnosis was associated with higher sMMSE and MMblind. Reasons for this observation are unclear but may relate to enhanced help-seeking behavior in people with diagnosed cataract.

Capability and dependency in the Newcastle 85+ cohort study. Projections of future care needs.

BACKGROUND: Little is known of the capabilities of the oldest old, the fastest growing age group in the population. We aimed to estimate capability and dependency in a cohort of 85 year olds and to project future demand for care. METHODS: Structured interviews at age 85 with 841 people born in 1921 and living in Newcastle and North Tyneside, UK who were permanently registered with participating general practices. Measures of capability included were self-reported activities of daily living (ADL), timed up and go test (TUG), standardised mini-mental state examination (SMMSE), and assessment of urinary continence in order to classify interval-need dependency. To project future demand for care the proportion needing 24-hour care was applied to the 2008 England and Wales population projections of those aged 80 years and over by gender. RESULTS: Of participants, 62% (522/841) were women, 77% (651/841) lived in standard housing, 13% (106/841) in sheltered housing and 10% (84/841) in a care home. Overall, 20% (165/841) reported no difficulty with any of the ADLs. Men were more capable in performing ADLs and more independent than women. TUG validated self-reported ADLs. When classified by 'interval of need' 41% (332/810) were independent, 39% (317/810) required help less often than daily, 12% (94/810) required help at regular times of the day and 8% (67/810) required 24-hour care. Of care-home residents, 94% (77/82) required daily help or 24-hour care. Future need for 24-hour care for people aged 80 years or over in England and Wales is projected to increase by 82% from 2010 to 2030 with a demand for 630,000 care-home places by 2030. CONCLUSIONS: This analysis highlights the diversity of capability and levels of dependency in this cohort. A remarkably high proportion remain independent, particularly men. However a significant proportion of this population require 24-hour care at home or in care homes. Projections for the next 20 years suggest substantial increases in the number requiring 24-hour care due to population ageing and a proportionate increase in demand for care-home places unless innovative health and social care interventions are found.