Medications and cognitive risk in Aboriginal primary care: a cross-sectional study.

BACKGROUND: Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population. AIM: The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs). METHODS: Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression. RESULTS: The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24-0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62-4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08-16.81), hypertension (OR = 2.14, 95% CI = 1.34-3.44), diabetes (OR = 2.72, 95% CI = 1.69-4.39) or depression (OR = 1.91, 95% CI = 1.19-3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03-3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19-0.85) and remote (OR = 0.58, 95% CI = 0.29-1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37-4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02-8.83), depression (OR = 2.67, 95% CI = 1.50-4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39-5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31-5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03-0.34) and remote (OR = 0.51, 95% CI = 0.25-1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50-6.30) or depression (OR = 3.32, 95% CI = 1.70-6.47). CONCLUSION: Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients.

Potentially modifiable dementia risk factors in all Australians and within population groups: an analysis using cross-sectional survey data.

BACKGROUND: Dementia is the second leading cause of disease burden in Australia. We aimed to calculate the population attributable fractions (PAFs) of dementia attributable to 11 of 12 previously identified potentially modifiable health and social risk factors (less education, hearing loss, hypertension, obesity, smoking, depression, social isolation, physical inactivity, diabetes, alcohol excess, air pollution, and traumatic brain injury), for Australians overall and three population groups (First Nations, and those of European and Asian ancestry). METHODS: We calculated the prevalence of dementia risk factors (excluding traumatic brain injury) and PAFs, adjusted for communality, from the cross-sectional National Aboriginal and Torres Strait Islander Health Survey (2018-19), National Aboriginal and Torres Strait Islander Social Survey (2014-15), National Health Survey (2017-18), and General Social Survey (2014) conducted by the Australian Bureau of Statistics. We conducted sensitivity analyses using proxy estimates for traumatic brain injury (12th known risk factor) for which national data were not available. FINDINGS: A large proportion (38·2%, 95% CI 37·2-39·2) of dementia in Australia was theoretically attributable to the 11 risk factors; 44·9% (43·1-46·7) for First Nations Australians, 36·4% (34·8-38·1) for European ancestry, and 33·6% (30·1-37·2) for Asian ancestry. Including traumatic brain injury increased the PAF to 40·6% (39·6-41·6) for all Australians. Physical inactivity (8·3%, 7·5-9·2), hearing loss (7·0%, 6·4-7·6), and obesity (6·6%, 6·0-7·3) accounted for approximately half of the total PAF estimates across Australia, and for all three population groups. INTERPRETATION: Our PAF estimates indicate a substantial proportion of dementia in Australia is potentially preventable, which is broadly consistent with global trends and results from other countries. The highest potential for dementia prevention was among First Nations Australians, reflecting the enduring effect of upstream social, political, environmental, and economic disadvantage, leading to greater life-course exposure to dementia risk factors. Although there were common dementia risk factors across different population groups, prevention strategies should be informed by community consultation and be culturally and linguistically appropriate. FUNDING: Australian National Health and Medical Research Council and University College London Hospitals' National Institute for Health Research (NIHR) Biomedical Research Centre, and North Thames NIHR Applied Research Collaboration.

Potentially suboptimal prescribing of medicines for older Aboriginal Australians in remote areas.

OBJECTIVES: To investigate the prevalence of polypharmacy, under-prescribing and potentially inappropriate medicine use among Aboriginal Australians living in remote Western Australia. DESIGN: Cross-sectional study. SETTING: Six remote communities and the town of Derby in the Kimberley, Western Australia. PARTICIPANTS: Aboriginal people aged 45 years or more with complete medication histories. MAIN OUTCOME MEASURES: Proportions of patients with medicine histories indicating polypharmacy, potential under-prescribing of indicated medicines, or potentially inappropriate prescribing (including potential prescribing cascades or drug interactions). RESULTS: Complete medicine histories were available for 273 participants. The mean number of prescribed medicines was 5.1 (SD, 3.6). At least one form of suboptimal prescribing was identified for 166 participants (61%), including polypharmacy for 145 (53%), potential under-prescribing of at least one indicated medicine for 33 (12%), and potentially inappropriate prescribing for 54 participants (20%). Potential prescribing cascades or drug interactions were identified for 12 participants (4%). CONCLUSIONS: Potentially suboptimal prescribing affected more than half the participating older Aboriginal Australians from the Kimberley. If generalisable to other remote Indigenous Australians, the prevalence of polypharmacy, potentially inappropriate prescribing, and under-prescribing of indicated medicines is problematic, and suggests that older Indigenous people in remote areas are at risk of medicine-related harm.

Mortality in a cohort of remote-living Aboriginal Australians and associated factors.

OBJECTIVES: We aimed to describe mortality in a cohort of remote-living Aboriginal Australians using electronic record linkage. METHODS: Between 2004 and 2006, 363 Aboriginal people living in remote Western Australia (WA) completed a questionnaire assessing medical history and behavioural risk factors. We obtained mortality records for the cohort from the WA Data Linkage System and compared them to data for the general population. We used Cox proportional hazards regression to identify predictors of mortality over a 9-year follow-up period. RESULTS: The leading causes of mortality were diabetes, renal failure, and ischaemic heart disease. Diabetes and renal failure accounted for 28% of all deaths. This differed from both the Australian population as a whole, and the general Indigenous Australian population. The presence of chronic disease did not predict mortality, nor did behaviours such as smoking. Only age, male sex, poor mobility, and cognitive impairment were risk factors. CONCLUSIONS: To reduce premature mortality, public health practitioners should prioritise the prevention and treatment of diabetes and renal disease in Aboriginal people in remote WA. This will require a sustained and holistic approach.

In older men, lower plasma 25-hydroxyvitamin D is associated with reduced incidence of prostate, but not colorectal or lung cancer.

CONTEXT AND OBJECTIVE: Prostate, colorectal and lung cancers are common in men. In this study, we aimed to determine whether vitamin D status is associated with the incidence of these cancers in older men. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: 4208 older men aged 70-88 years in Perth, Western Australia. MAIN OUTCOME MEASURES: Plasma 25-hydroxyvitamin D [25(OH)D] concentration was measured by immunoassay. New diagnoses of prostate, colorectal and lung cancers were determined via electronic record linkage. RESULTS: During a mean follow-up of 6.7±1.8 years, there were 315, 117 and 101 new diagnoses of prostate, colorectal and lung cancer. In multivariate competing risks proportional hazards models, every 10 nmol/l decrease in 25(OH)D concentration was associated with a 4% reduction in prostate cancer incidence (sub-hazard ratio [SHR] 0.96, 95% confidence interval [CI] 0.92-1.00). Every halving of 25(OH)D concentration was associated with a 21% reduction in incident prostate cancer in multivariate analysis (SHR 0.79, 95% CI 0.63-0.99). Following exclusion of prostate cancer cases diagnosed within 3 years of blood sampling, low 25(OH)D <50 nmol/l was associated with lower incident prostate cancer, and higher 25(OH)D >75 nmol/l was associated with higher incidence, when compared to the reference range 50-75 nmol/l, respectively (p = 0.027). Significant associations were also observed when 25(OH)D was modeled as a quantitative variable. No associations were observed between plasma 25(OH)D concentration with incidence of colorectal or lung cancer. CONCLUSION: Lower levels of vitamin D may reduce prostate cancer risk in older men. By contrast, levels of vitamin D did not predict incidence of colorectal or lung cancers. Further studies are needed to determine whether a causal relationship exists between vitamin D and prostate cancer in ageing men.

Associations between testosterone levels and incident prostate, lung, and colorectal cancer. A population-based study.

BACKGROUND: The relationship between testosterone and cancer is relatively unexplored. We sought to examine whether testosterone and related hormones are associated with incident prostate, lung, and colorectal cancer. METHODS: This was a population-based cohort study. Demographic and clinical predictors of cancer, and testosterone, sex hormone-binding globulin (SHBG), and luteinizing hormone (LH) were measured between 2001 and 2004 in 3,635 community-dwelling men aged 70 to 88 years (mean 77 years). Cancer notifications were obtained via electronic record linkage until December 31, 2010. RESULTS: During a mean follow-up period of 6.7 ± 1.8 years, there were 297, 104, and 82 cases of prostate, colorectal, and lung cancer. In adjusted competing risks proportional hazards models, each one SD increase in free testosterone was associated with a 9% increase in prostate cancer risk (95% confidence interval [CI], 1.00-1.18), but other hormones were not significantly associated. No significant associations were observed between hormonal parameters and colorectal cancer. Higher total testosterone was associated with lung cancer. Compared with the mean of 15 nmol/L, men with levels of 20 nmol/L were 1.38 times more likely to be cases (95% CI, 1.21-1.57), whereas those with levels of 30 nmol/L were 3.62 times more likely to be cases (95% CI, 2.53-5.18). Higher free testosterone was also associated with lung cancer, though SHBG and LH were not. Associations were maintained after exclusion of current smokers. CONCLUSIONS: Higher free testosterone was associated with incident prostate cancer. Higher testosterone levels may also be associated with lung cancer. IMPACT: Further studies should investigate whether these risks apply to men receiving testosterone therapy.

Low free testosterone predicts mortality from cardiovascular disease but not other causes: the Health in Men Study.

CONTEXT: Low testosterone is associated with all-cause mortality, but the relationship with cause-specific mortality is uncertain. OBJECTIVE: Our objective was to explore associations between testosterone and its related hormones and cause-specific mortality. DESIGN: This was a population-based cohort study. SETTING AND PARTICIPANTS: Demographic and clinical predictors of mortality, and testosterone, SHBG, and LH were measured from 2001-2004 in 3637 community-dwelling men aged 70-88 yr (mean, 77 yr). MAIN OUTCOME MEASURE: Cause of death was obtained via electronic record linkage until December 31, 2008. RESULTS: During a mean follow-up period of 5.1 yr, there were 605 deaths. Of these, 207 [34.2%; 95% confidence interval (CI) = 30.4-38.1%] were due to cardiovascular disease (CVD), 231 to cancer (38.2%; 95% CI = 34.3-42.1%), 130 to respiratory diseases (21.5%; 95% CI = 18.2-24.8%), and 76 to other causes (12.6%; 95% CI = 9.9-15.2%). There were 39 deaths attributable to both cancer and respiratory diseases. Lower free testosterone (hazard ratio = 1.62; 95% CI = 1.20-2.19, for 100 vs. 280 pmol/liter), and higher SHBG and LH levels were associated with all-cause mortality. In cause-specific analyses, lower free testosterone (sub-hazard ratio = 1.71; 95% CI = 1.12-2.62, for 100 vs. 280 pmol/liter) and higher LH predicted CVD mortality, while higher SHBG predicted non-CVD mortality. Higher total testosterone and free testosterone levels (sub-hazard ratio = 1.96; 95% CI = 1.14-3.36, for 400 vs. 280 pmol/liter) were associated with mortality from lung cancer. CONCLUSIONS: Low testosterone predicts mortality from CVD but is not associated with death from other causes. Prevention of androgen deficiency might improve cardiovascular outcomes but is unlikely to affect longevity otherwise.

Quality use of medicines and health outcomes among a cohort of community dwelling older men: an observational study.

AIM: To determine the prevalence of potentially suboptimal medication use and association with adverse outcomes. METHODS: A prospective, observational cohort study of 4260 community-dwelling older men from Perth, Western Australia (mean age of 77 ± 3.6 years) was conducted. Follow-up was for 4.5 years (or until death, if sooner). Cox proportional hazard models were used to explore associations between suboptimal medication use and prospective clinical outcomes. Logistic regression analyses were used to explore predictors of a fall in the previous 12 months. RESULTS: Use of potentially inappropriate medicines (48.7%), polypharmacy (≥5 medications, 35.8%) and potential under-utilization (56.7%) were highly prevalent, and overall 82.3% of participants reported some form of potentially suboptimal medication use. A self-reported history of falls in the previous 12 months was independently associated with the number of medicines taken (odds ratio [OR]= 1.06, 95% confidence interval [CI] 1.02, 1.09) and use of one or more potentially inappropriate medicines (OR = 1.23, 95% CI 1.04, 1.45). After adjusting for age, co-morbidity, smoking status, body mass index, hypertension and educational attainment, the number of medicines reported was associated with admission to hospital (hazard ratio [HR]= 1.04, 95% CI 1.03, 1.06), cardiovascular events (HR = 1.09, 95% CI 1.06, 1.12) and all cause mortality (HR = 1.04, 95% CI 1.00, 1.07). Use of one or more potentially inappropriate medicines was associated with admission to hospital (HR = 1.16, 95% CI 1.08, 1.24). Potential under-utilization was associated with cardiovascular events (HR = 1.20, 95% CI 1.03, 1.40). CONCLUSIONS: These data suggest that both medication over-use and under-use occur frequently among older men and may be harmful.

Prevalence of sexual activity and associated factors in men aged 75 to 95 years: a cohort study.

BACKGROUND: Knowledge about sexuality in elderly persons is limited, and normative data are lacking. OBJECTIVE: To determine the proportion of older men who are sexually active and to explore factors predictive of sexual activity. DESIGN: Population-based cohort study. SETTING: Community-dwelling men from Perth, Western Australia, Australia. PARTICIPANTS: 3274 men aged 75 to 95 years. MEASUREMENTS: Questionnaires from 1996 to 1999, 2001 to 2004, and 2008 to 2009 assessed social and medical factors. Sex hormones were measured from 2001 to 2004. Sexual activity was assessed by questionnaire from 2008 to 2009. RESULTS: A total of 2783 men (85.0%) provided data on sexual activity. Sex was considered at least somewhat important by 48.8% (95% CI, 47.0% to 50.6%), and 30.8% (CI, 29.1% to 32.5%) had had at least 1 sexual encounter in the past 12 months. Of the latter, 56.5% were satisfied with the frequency of activity, whereas 43.0% had sex less often than preferred. In cross-sectional analyses, increasing age, partner's lack of interest, partner's physical limitations, osteoporosis, prostate cancer, diabetes, antidepressant use, and ß-blocker use were independently associated with reduced odds of sexual activity. Living with a partner and having a non-English-speaking background were associated with increased odds. In longitudinal analyses, higher testosterone levels were associated with increased odds of being sexually active. Other factors were similar to the cross-sectional model. LIMITATIONS: Response bias may have influenced findings because sexuality can be a sensitive topic. Attrition may have resulted in a healthier-than-average sample of older men. CONCLUSION: One half of elderly men consider sex important, and one third report being sexually active. Men's health problems were associated with lack of sexual activity. Key modifiable risk factors include diabetes, depression, and medication use. Endogenous testosterone levels predict sexual activity, but the role of testosterone therapy remains uncertain. PRIMARY FUNDING SOURCE: National Health and Medical Research Council of Australia.

Population-based observational study of claudication in older men: the Health in Men Study.

OBJECTIVES: To assess the prevalence of and risk factors for claudication and its association with subsequent cardiovascular events. DESIGN, SETTING AND PARTICIPANTS: Observational cohort study of 12 203 Western Australian men aged 65 years and over, recruited from 1996 to 1999, and followed up from 2001 to 2004. MAIN OUTCOME MEASURES: Prevalence of claudication and incidence of peripheral arterial disease (PAD); risk factors for claudication and its association with subsequent cardiovascular events. RESULTS: The prevalence of claudication was 5.3% (638 of 11 970 men). At follow-up, after exclusion of 148 men with claudication at baseline and 76 with missing data at follow-up, the crude average annual incidence of new PAD (claudication or procedure for PAD) was 0.85% (95% CI, 0.72%-0.96%). The risk factors for prevalent claudication and incident PAD were similar, with age, smoking, hypertension, diabetes and history of cardiovascular disease dominating. Of the men with claudication at baseline, nearly half (47.5%; 303 of 638) were not taking aspirin. At follow-up, 42.5% (82 of 193) of the men with incident PAD were not taking aspirin. Claudication at baseline was associated with twice the risk of cardiovascular death (hazard ratio, 2.00; 95% CI, 1.52-2.64). There was a J-shaped relationship between aortic diameter, and both prevalent claudication and subsequent cardiovascular events. CONCLUSIONS: Among older men, claudication is prevalent and is associated with factors that can still be modified in older age, including smoking, exercise and diet. Relatively few men with claudication or at risk of PAD use aspirin. Claudication is a significant predictor of cardiovascular outcome.

Low free testosterone predicts frailty in older men: the health in men study.

CONTEXT: The prevalence of frailty increases, whereas testosterone decreases, as men age. Low testosterone may be a risk factor for development of this syndrome. OBJECTIVE: Our objective was to determine whether testosterone levels are associated with frailty. DESIGN: We conducted a prospective cohort study. SETTING AND PARTICIPANTS: Between 2001 and 2004, frailty was assessed in 3616 community-dwelling men aged 70-88 yr. Frailty was reassessed in 1586 men aged 76-93 yr in 2008-2009. MAIN OUTCOME MEASURES: Frailty was assessed with the FRAIL scale, comprising five domains: fatigue, difficulty climbing a flight of stairs, difficulty walking more than 100 m, more than five illnesses present, or weight loss greater than 5%. Testosterone, SHBG, and LH were assayed at baseline. Free testosterone was calculated using mass action equations. RESULTS: At baseline, 15.2% of men (n = 548) were frail (at least three deficits), increasing to 23.0% (n = 364) at follow-up. At baseline, each 1 sd decrease in total or free testosterone level was associated with increased odds of frailty [odds ratio (OR) = 1.23; 95% confidence interval (CI) = 1.11-1.38, and OR = 1.29; 95% CI = 1.15-1.44 for total and free testosterone, respectively]. Lower LH was associated with reduced odds of frailty (OR = 0.88; 95% CI = 0.81-0.95). Adjustments were made for age, body mass index, smoking, diabetes, social support, and other covariates. At follow-up, only lower free testosterone levels (OR = 1.22; 95% CI = 1.05-1.42) predicted frailty. CONCLUSIONS: Lower free testosterone was independently associated with frailty at baseline and follow-up. Randomized trials should explore whether testosterone therapy can prevent the development of frailty.

Alcohol, tobacco and illicit drug use amongst same-sex attracted women: results from the Western Australian Lesbian and Bisexual Women's Health and Well-Being Survey.

BACKGROUND: The prevalence of alcohol, tobacco and illicit drug use has been reported to be higher amongst lesbian and bisexual women (LBW) than their heterosexual counterparts. However, few studies have been conducted with this population in Australia and rates that have been reported vary considerably. METHODS: A self-completed questionnaire exploring a range of health issues was administered to 917 women aged 15-65 years (median 34 years) living in Western Australia, who identified as lesbian or bisexual, or reported having sex with another woman. Participants were recruited from a range of settings, including Perth Pride Festival events (67.0%, n = 615), online (13.2%, n = 121), at gay bars and nightclubs (12.9%, n = 118), and through community groups (6.9%, n = 63). Results were compared against available state and national surveillance data. RESULTS: LBW reported consuming alcohol more frequently and in greater quantities than women in the general population. A quarter of LBW (25.7%, n = 236) exceeded national alcohol guidelines by consuming more than four standard drinks on a single occasion, once a week or more. However, only 6.8% (n = 62) described themselves as a heavy drinker, suggesting that exceeding national alcohol guidelines may be a normalised behaviour amongst LBW. Of the 876 women who provided data on tobacco use, 28.1% (n = 246) were smokers, nearly double the rate in the female population as a whole. One third of the sample (33.6%, n = 308) reported use of an illicit drug in the previous six months. The illicit drugs most commonly reported were cannabis (26.4%, n = 242), meth/amphetamine (18.6%, n = 171), and ecstasy (17.9%, n = 164). Injecting drug use was reported by 3.5% (n = 32) of participants. CONCLUSION: LBW appear to use alcohol, tobacco and illicit drugs at higher rates than women generally, indicating that mainstream health promotion messages are not reaching this group or are not perceived as relevant. There is an urgent need for public health practitioners working in the area of substance use to recognise that drug consumption and use patterns of LBW are likely to be different to the wider population and that special considerations and strategies are required to address the unique and complex needs of this population.

Lower testosterone levels predict incident stroke and transient ischemic attack in older men.

CONTEXT: Lower circulating testosterone concentrations are associated with metabolic syndrome, type 2 diabetes, carotid intima-media thickness, and aortic and lower limb arterial disease in men. However, it is unclear whether lower testosterone levels predict major cardiovascular events. OBJECTIVE: We examined whether lower serum testosterone was an independently significant risk factor for symptomatic cerebrovascular events in older men. DESIGN: This was a prospective observational study with median follow-up of 3.5 yr. SETTING: Community-dwelling, stroke-free older men were studied. PARTICIPANTS: A total of 3443 men at least 70 yr of age participated in the study. MAIN OUTCOME MEASURES: Baseline serum total testosterone, SHBG, and LH were assayed. Free testosterone was calculated using mass action equations. Incident stroke or transient ischemic attack (TIA) was recorded. RESULTS: A first stroke or TIA occurred in 119 men (3.5%). Total and free testosterone concentrations in the lowest quartiles (<11.7 nmol/liter and <222 pmol/liter) were associated with reduced event-free survival (P = 0.014 and P = 0.01, respectively). After adjustment including age, waist-hip ratio, waist circumference, smoking, hypertension, dyslipidemia, and medical comorbidity, lower total testosterone predicted increased incidence of stroke or TIA (hazard ratio = 1.99; 95% confidence interval, 1.33-2.99). Lower free testosterone was also associated (hazard ratio = 1.69; 95% confidence interval, 1.15-2.48), whereas SHBG and LH were not independently associated with incident stroke or TIA. CONCLUSIONS: In older men, lower total testosterone levels predict increased incidence of stroke or TIA after adjusting for conventional risk factors for cardiovascular disease. Men with low-normal testosterone levels had increased risk. Further studies are warranted to determine whether interventions that raise circulating testosterone levels might prevent cerebrovascular disease in men.