Interventions to Prevent Hospital Admissions in Long-Term Care Facilities: A Rapid Review of Economic Evidence.

OBJECTIVES: Hospital admissions can be hazardous for older adults, particularly those living in long-term care facilities. Preventing nonessential admissions can be beneficial for this population, as well as reducing demand on health services. This review summarizes the economic evidence surrounding effective interventions to reduce hospital attendances and admissions for people living in long-term care facilities. DESIGN: Rapid review of economic evidence. SETTING AND PARTICIPANTS: People living in long-term facilities. METHODS: We searched MEDLINE, CINAHL, Cochrane CENTRAL, PubMed, and Web of Science on September 20, 2022, and again on January 10, 2023. Full economic evaluations and cost analyses reporting on advanced care planning, goals of care setting, nurse practitioner input, palliative care, influenza vaccinations, and enhancing access to intravenous therapies were eligible. Data were extracted using a prepiloted data extraction form and critically appraised using either the Drummond-Jefferson checklist or an amended NIH Critical Appraisal Tool appended with questions from a critical appraisal checklist for cost analyses. Data were synthesized narratively. RESULTS: We included 7 studies: 3 full economic evaluations and 4 cost analyses. Because of lack of clarity on the underlying study design, we did not include one of the cost analyses in our synthesis. Advanced care planning, a palliative care program, and a high-dose influenza vaccination reported potential cost savings. Economic evidence for a multicomponent intervention and a nurse practitioner model was inconclusive. The overall quality of the evidence varied between studies. CONCLUSIONS AND IMPLICATIONS: A number of potentially cost-effective approaches to reduce demand on hospital services from long-term care facilities were identified. However, further economic evaluations are needed to overcome limitations of the current evidence base and offer more confident conclusions.

Characteristics of older unpaid carers in England: a study of social patterning from the English Longitudinal Study of Ageing.

BACKGROUND: A growing number of older people provide unpaid care, but contemporary research evidence on this group is limited. AIM: This study aims to describe the characteristics of older people who provide unpaid care and how these vary by socioeconomic position. METHODS: Using recent information from the English Longitudinal Study of Ageing (ELSA wave 9, 2019), we analysed cross-sectional data on 1,282 unpaid carers aged ≥50. Data on sociodemographics, health, social wellbeing, care intensity and caregiver-recipient relationships were extracted. Total net non-pension wealth quintiles were used as a relative measure of socioeconomic position. Differences between the poorest and richest wealth quintiles were examined through logistic regression. FINDINGS: Most older carers in ELSA were female and looking after another older person. Poor mental and physical health and social isolation were common, and socially patterned. Compared with carers in the middle wealth group, the poorest group were more likely to be living with the person they cared for (odds ratio (OR) 1.56 [95% confidence interval (CI) 1.03-2.36]) and more likely to experience loneliness (OR 2.29 [95% CI 1.42-3.69]), dependency (i.e. the need for help with activities of daily living) (OR 1.62 [95% CI 1.05-2.51]), chronic pain (OR 1.81 [95% CI 1.23-2.67]), a higher number of diseases (OR 1.75 [95% CI 1.15-2.65]) and fair/poor self-rated health (OR 2.59 [95% CI 1.79-3.76]). The poorest carers were also less likely to have a high quality of life (OR 0.51 [95% CI 0.33-0.80]) or be in work (OR 0.33 [95% CI 0.19-0.59]). CONCLUSION: Our findings suggest that financially disadvantaged unpaid carers (and their households) may have the greatest needs for intervention and support. Focussing resources on this group has potential to address social inequalities.

The impact of digital technology in care homes on unplanned secondary care usage and associated costs.

BACKGROUND: A substantial number of Emergency Department (ED) attendances by care home residents are potentially avoidable. Health Call Digital Care Homes is an app-based technology that aims to streamline residents' care by recording their observations such as vital parameters electronically. Observations are triaged by remote clinical staff. This study assessed the effectiveness of the Health Call technology to reduce unplanned secondary care usage and associated costs. METHODS: A retrospective analysis of health outcomes and economic impact based on an intervention. The study involved 118 care homes across the North East of UK from 2018 to 2021. Routinely collected NHS secondary care data from County Durham and Darlington NHS Foundation Trust was linked with data from the Health Call app. Three outcomes were modelled monthly using Generalised Linear Mixed Models: counts of emergency attendances, emergency admissions and length of stay of emergency admissions. A similar approach was taken for costs. The impact of Health Call was tested on each outcome using the models. FINDINGS: Data from 8,702 residents were used in the analysis. Results show Health Call reduces the number of emergency attendances by 11% [6-15%], emergency admissions by 25% [20-39%] and length of stay by 11% [3-18%] (with an additional month-by-month decrease of 28% [24-34%]). The cost analysis found a cost reduction of £57 per resident in 2018, increasing to £113 in 2021. INTERPRETATION: The introduction of a digital technology, such as Health Call, could significantly reduce contacts with and costs resulting from unplanned secondary care usage by care home residents.

A comparative overview of health and social care policy for older people in England and Scotland, United Kingdom (UK).

BACKGROUND: Responsibility for health and social care was devolved to Scotland in 1999 with evidence of diverging policy and organisation of care compared to England. This paper provides a comparative overview of major health and social care policies in England and Scotland published between 2011 and 2023 relating to the care of older people. METHODS: We searched United Kingdom (UK) and Scotland government websites for macro-level policy documents between 2011 and 2023 relating to the health and social care of older people (aged 65+). Data were extracted and emergent themes were summarised according to Donabedian's structure-process-outcome model. RESULTS: We reviewed 27 policies in England and 28 in Scotland. Four main policy themes emerged that were common to both countries. Two related to the structure of care: integration of care and adult social care reform. Two related to service delivery/processes of care: prevention and supported self-management and improving mental health care. Cross-cutting themes included person-centred care, addressing health inequalities, promoting use of technology, and improving outcomes. CONCLUSION: Despite differences in the structure of care, including more competition, financial incentivization, and consumer-based care in England compared to Scotland, there are similarities in policy vision around delivery/processes of care (e.g. person-centred care) and performance and patient outcomes. Lack of UK-wide health and social care datasets hinders evaluation of policies and comparison of outcomes between both countries.

Are there socioeconomic inequalities in polypharmacy among older people? A systematic review and meta-analysis.

BACKGROUND: Socioeconomic status (SES) may influence prescribing, concordance and adherence to medication regimens. This review set out to investigate the association between polypharmacy and an individual's socioeconomic status. METHODS: A systematic review and meta-analyses of observational studies was conducted across four databases. Older people (≥ 55 years) from any healthcare setting and residing location were included. The search was conducted across four databases: Medline (OVID), Web of Science, Embase (OVID) and CINAHL. Observational studies from 1990 that reported polypharmacy according to SES were included. A random-effects model was undertaken comparing those with polypharmacy (≥ 5 medication usage) with no polypharmacy. Unadjusted odds ratios (ORs), 95% confidence intervals (CIs) and standard errors (SE) were calculated for each study. RESULTS: Fifty-four articles from 13,412 hits screened met the inclusion criteria. The measure of SES used were education (50 studies), income (18 studies), wealth (6 studies), occupation (4 studies), employment (7 studies), social class (5 studies), SES categories (2 studies) and deprivation (1 study). Thirteen studies were excluded from the meta-analysis. Lower SES was associated with higher polypharmacy usage: individuals of lower educational backgrounds displayed 21% higher odds to be in receipt of polypharmacy when compared to those of higher education backgrounds. Similar findings were shown for occupation, income, social class, and socioeconomic categories. CONCLUSIONS: There are socioeconomic inequalities in polypharmacy among older people, with people of lower SES significantly having higher odds of polypharmacy. Future work could examine the reasons for these inequalities and explore the interplay between polypharmacy and multimorbidity.

A systematic review finds a lack of consensus in methodological approaches in health inequality/inequity focused reviews.

OBJECTIVES: To critically review and analyze evidence synthesis articles using health inequality/inequity guidance to support their review. STUDY DESIGN AND SETTING: A comprehensive, systematic search of six social science databases (1990 to May 2022) and grey literature sources was undertaken. A narrative approach to synthesis was adopted, describing and categorizing the characteristics of included articles. A comparison of the existing methodological guides was also conducted, discussing the similarities and differences between them. RESULTS: From 205 identified reviews published between 2008 and 2022, 62 (30%) focusing on health inequality/inequity, met the criteria. The reviews were diverse in terms of methodology, populations, intervention level, and clinical areas. Only 19 (31%) reviews discussed the definition of inequality/inequity. Two methodological guides were identified: (i) the PROGRESS/Plus framework and (ii) the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity checklist. CONCLUSION: A critique on the methodological guides reaffirms a lack of clarity or guidance on how health inequality/inequity should be considered. The PROGRESS/Plus framework narrowly focuses on dimensions of health inequality/inequity but rarely considers the pathways and interactions of these dimensions and their effect on outcomes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity checklist on the other hand provides guidance on report. A conceptual framework is needed to show the pathways and interactions of dimensions of health inequality/inequity.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review.

BACKGROUND: Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients. OBJECTIVE: To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition. DATA SOURCES: MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021. REVIEW METHODS: A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements. RESULTS: Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer. LIMITATIONS: The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered. CONCLUSIONS: Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults. FUTURE WORK: Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness. STUDY REGISTRATION: This study is registered as PROSPERO CRD42020170906. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

WHAT WAS THE QUESTION?: Malnutrition, in the form of undernutrition, is very common in frail older people. Dietary advice is recommended (e.g. adding nutrients to meals) for older adults who are malnourished, while powdered or liquid supplements (oral nutritional supplements) can be prescribed to those who are malnourished or at risk of becoming malnourished. In this study, we reviewed previous studies to see if oral nutritional supplements (as a form of dietary support) work at reducing malnutrition in frail older adults and whether or not they are value for money. WHAT DID WE DO?: We searched for studies up to September 2021 on frail older people who were at risk of malnutrition or were malnourished in care homes, hospitals or the community in any country. We included studies that measured malnutrition and the consequences of malnutrition, quality of life, survival, costs and hospitalisations. We assessed the difference in malnutrition between those receiving oral nutritional supplements and those receiving usual care or other dietary (or nutritional) interventions. We also looked at the value for money of oral nutritional supplements. WHAT DID WE FIND?: We found 12 studies (11 studies looking at whether the supplements worked and one study looking at value for money). Most of which were of low quality, and many were funded by industry. Studies often did not report on longer-term effects, or how older people felt about the supplements. There was no clear or strong evidence that oral nutritional supplements worked or were value for money in reducing malnutrition or its consequences (such as the ability to perform everyday tasks). WHAT DOES THIS MEAN?: There is weak evidence for oral nutritional supplements in frail older adults. Future high-quality studies should be independent, assess longer-term effects, and have better reporting on factors that influence the impacts of oral nutritional supplements.

Factors associated with unmet need for support to maintain independence in later life: a systematic review of quantitative and qualitative evidence.

BACKGROUND: populations are considered to have an 'unmet need' when they could benefit from, but do not get, the necessary support. Policy efforts to achieve equitable access to long-term care require an understanding of patterns of unmet need. A systematic review was conducted to identify factors associated with unmet need for support to maintain independence in later life. METHODS: seven bibliographic databases and four non-bibliographic evidence sources were searched. Quantitative observational studies and qualitative systematic reviews were included if they reported factors associated with unmet need for support to maintain independence in populations aged 50+, in high-income countries. No limits to publication date were imposed. Studies were quality assessed and a narrative synthesis used, supported by forest plots to visualise data. FINDINGS: forty-three quantitative studies and 10 qualitative systematic reviews were included. Evidence across multiple studies suggests that being male, younger age, living alone, having lower levels of income, poor self-rated health, more functional limitations and greater severity of depression were linked to unmet need. Other factors that were reported in single studies were also identified. In the qualitative reviews, care eligibility criteria, the quality, adequacy and absence of care, and cultural and language barriers were implicated in unmet need. CONCLUSIONS: this review identifies which groups of older people may be most at risk of not accessing the support they need to maintain independence. Ongoing monitoring of unmet need is critical to support policy efforts to achieve equal ageing and equitable access to care.

Effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk of malnutrition: a systematic review and meta-analysis.

BACKGROUND: Current management of malnutrition can include prescribed oral nutritional supplements (ONS); however, there is uncertainty whether these supplements are effective in people who are older (≥65 years) and frail. We assessed the effectiveness, cost-effectiveness, and adherence and acceptability of ONS in frail older people who are malnourished or at risk of malnutrition. METHODS: In this systematic review and meta-analysis, five bibliographic databases (MEDLINE, EMBASE, Cochrane Library, Scopus, and CINAHL) and grey literature sources were searched from inception to Sept 13, 2021, to identify studies assessing the effectiveness and cost-effectiveness of ONS (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition. Multiple reviewers independently did study screening, data extraction, and risk of bias assessment. Quality was assessed using version 1.0 of the Cochrane risk of bias tool for randomised controlled trials (RCTs), and the BMJ Drummond checklist was used to assess the quality of the included cost-effectiveness study. A meta-analysis was done for the effectiveness review; for the other reviews, a narrative synthesis approach was used. This systematic review and meta-analysis was registered on PROSPERO, CRD42020170906. FINDINGS: Of 8492 records retrieved and screened, we included 11 RCTs involving 822 participants, six of which were fully or partly funded by industry. For the majority of the outcomes for which meta-analyses were possible (11/12), Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessments suggested that the evidence was of very low certainty. Results suggested that ONS might have a slightly positive effect on energy (kcal) intake (standardised mean difference 1·02 [95% CI 0·15 to 1·88]; I2=87%; four studies), protein intake (standardised mean difference 1·67 [-0·03 to 3·37; I2=97%; four studies), and mobility (mean difference 0·03 [0·02 to 0·04]; I2=0%; four studies), compared with standard care. Narrative syntheses suggested that the effect of ONS on quality of life, compared with standard care, was mixed. In the identified studies, there was very little information related to active components, determinants, or acceptability of interventions. One economic evaluation, done in a care home setting, showed that ONS could be cost-effective. INTERPRETATION: We found little evidence of ONS reducing malnutrition or its associated adverse outcomes in older people who are frail. High-quality, non-industry-funded, adequately powered studies reporting on short-term and long-term health outcomes, determinants, and participant characteristics are needed. FUNDING: UK National Institute of Health and Care Research (NIHR) Health Technology Assessment (NIHR128729).

Measuring older people's socioeconomic position: a scoping review of studies of self-rated health, health service and social care use.

BACKGROUND: The challenges of measuring socioeconomic position in older populations were first set out two decades ago. However, the question of how best to measure older people's socioeconomic position remains pertinent as populations age and health inequalities widen. METHODS: A scoping review aimed to identify and appraise measures of socioeconomic position used in studies of health inequalities in older populations in high-income countries. Medline, Scopus, EMBASE, HMIC and references lists of systematic reviews were searched for observational studies of socioeconomic health inequalities in adults aged 60 years and over, published between 2000 and 2020. A narrative synthesis was conducted. FINDINGS: One-hundred and thirty-eight studies were included; 20 approaches to measuring socioeconomic position were identified. Few studies considered which pathways the chosen measures of socioeconomic position intended to capture. The validity of subjective socioeconomic position measures, and measures that assume shared income and educational capital, should be verified in older populations. Incomplete financial data risk under-representation of some older groups when missing data are socially patterned. Older study samples were largely homogeneous on measures of housing tenure, and to a lesser extent, measures of educational attainment. Measures that use only two response categories risk missing subtle differences in older people's socioeconomic circumstances. CONCLUSION: Poor choice of measures of socioeconomic position risk underestimating the size of health inequalities in older populations. Choice of measures should be shaped by considerations of theory, context and response categories that detect subtle, yet important, inequalities. Further evidence is required to ascertain the validity of some measures identified in this review.

An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England.

BACKGROUND: Government nutritional welfare support from the English 'Healthy Start' scheme is targeted at low-income pregnant women and preschool children, but take-up of its free food vouchers is much better than its free vitamin vouchers. While universal implementation probably requires a more extensive scheme to be cost-effective, the everyday experience of different ways of receiving or facilitating Healthy Start, especially via children's centres, also requires further evidence. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins. METHODS: Informed by quantitative analysis of take-up data, qualitative analysis focused on 42 semi-structured interviews with potentially eligible mothers and healthcare staff (and commissioners), purposively sampled via children's centres in a similarly deprived universal and a targeted implementation-area of North West England. RESULTS: While good food voucher take-up appeared to relate to clear presentation, messaging, practicality, and monetary (albeit low) value, poor vitamin take-up appeared to relate to overcomplicated procedures and overreliance on underfunded centres, organizational goodwill, and families' resilience. CONCLUSION: Higher 'universal' vitamin take-up may well have reflected fewer barriers when it became everyone's business to be vitamin-aware. Substantive Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Our study highlights that 'policy, politics, and problem' should be aligned to reach considerable unmet need.

Community Ageing Research 75+ (CARE75+) REMOTE study: a remote model of recruitment and assessment of the health, well-being and social circumstances of older people.

INTRODUCTION: The Community Ageing Research 75+ (CARE75+) study is a longitudinal cohort study collecting extensive health and social data, with a focus on frailty, independence and quality of life in older age. CARE75+ was the first international experimental frailty research cohort designed using trial within cohorts (TwiCs) methodology, aligning epidemiological research with clinical trial evaluation of interventions to improve the health and well-being of older people. CARE75+ REMOTE is an extension of CARE75+ using a remote model that does not require face-to-face interactions for data collection in the current circumstances of a global pandemic and will provide an efficient, sustainable data collection model. METHODS AND ANALYSIS: Prospective cohort study using TwiCs. One thousand community-dwelling older people (≥75 years) will be recruited from UK general practices by telephone. Exclusions include: nursing home/care home residents; those with an estimated life expectancy of 3 months or less; and people receiving palliative care. DATA COLLECTION: Assessments will be conducted by telephone, web-submission or postal questionnaire: baseline, 6 months, 12 months, 18 months, 24 months, 30 months and 36 months. Measures include activities of daily living, mood, health-related quality of life, comorbidities, medications, frailty, informal care, healthcare and social care service use. Consent will be sought for data linkage and invitations to additional studies (sub-studies). ETHICS AND DISSEMINATION: CARE75+ was approved by the National Research Ethics Service (NRES) Committee Yorkshire and the Humber-Bradford Leeds 10 October 2014 (14/YH/1120). CARE75+ REMOTE (amendment 13) was approved on the 18th November 2020. Consent is sought if an individual is willing to participate and has capacity to provide informed consent. Consultee assent is sought if an individual lacks capacity. Results will be disseminated in peer-reviewed scientific journals and conferences. Results will be summarised and disseminated to study participants via newsletters, local engagement events and on a bespoke website. TRIAL REGISTRATION NUMBER: ISRCTN16588124.

The monetary valuation of informal care to cancer decedents at end-of-life: Evidence from a national census survey.

BACKGROUND: Carers' end-of-life caregiving greatly benefits society but little is known about the monetary value of this care. AIM: Within an end-of-life cancer setting: (1) to assess the feasibility and content validity of a post-bereavement measure of hours of care; and (2) to obtain a monetary value of this informal care and identify variation in this value among sub-groups. DESIGN AND SETTING: A census based cross-sectional survey of all cancer deaths from a 2-week period in England collected detailed data on caregiving activity (10 caregiving tasks and the time spent on each). We descriptively analyse the information carers provided in 'other' tasks to inform content validity. We assigned a monetary value of caregiving via the proxy good method and examined variation in the value via regression analysis. RESULTS: The majority of carers (89.9%) were able to complete the detailed questions about hours and tasks. Only 153 carers reported engaging in 'other' tasks. The monetary value of caregiving at end-of-life was £948.86 per week with social and emotional support and symptom management tasks representing the largest proportion of this monetary valuation. Time of recall did not substantially relate to variation in the monetary value, whereas there was a stronger association for the relationship between the carer and recipient, carer gender and recipient daily living restrictions. CONCLUSION: The monetary valuation we produce for carers' work is substantial, for example the weekly UK Carers' Allowance only amounts to 7% of our estimated value of £948.86 per week. Our research provides further information on subgroup variation, and a valid carer time instrument and method to inform economic evaluation and 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.

SEeking AnsweRs for Care Homes during the COVID-19 pandemic (COVID SEARCH).

The care and support of older people residing in long-term care facilities during the COVID-19 pandemic has created new and unanticipated uncertainties for staff. In this short report, we present our analyses of the uncertainties of care home managers and staff expressed in a self-formed closed WhatsApp™ discussion group during the first stages of the pandemic in the UK. We categorised their wide-ranging questions to understand what information would address these uncertainties and provide support. We have been able to demonstrate that almost one-third of these uncertainties could have been tackled immediately through timely, responsive and unambiguous fact-based guidance. The other uncertainties require appraisal, synthesis and summary of existing evidence, commissioning or provision of a sector- informed research agenda for medium to long term. The questions represent wider internationally relevant care home pandemic-related uncertainties.

Connecting at Local Level: Exploring Opportunities for Future Design of Technology to Support Social Connections in Age-Friendly Communities.

Social connectedness in later life is an important dimension of an age-friendly community, with associated implications for individual health and wellbeing. In contrast with prior efforts focusing on connections at a distance or online communities where the digital technology is the interface, we explore the design opportunities and role of technology for connectedness within a geographically local community context. We present findings from interviews with 22 older adults and a linked ideation workshop. Our analysis identified shared concerns and negative perceptions around local relationships, connections and characteristics of the geographical area. However, local connectedness through technology was largely absent from day-to-day life and even perceived as contributing to disconnection. By uncovering how older adults use and perceive technology in their social lives and combining these findings with their ideas for improving local connections, we highlight the need for thoughtful consideration of the role of technology in optimising social connections within communities. Our research highlights a need for design work to understand the specifics of the local context and reduce emphasis on technology as the interface between people. We introduce an amended definition-'underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical, social and digital environments and its supporting infrastructure'-to conceptualise our approach. We conclude by suggesting areas for future work in developing digitally connected age-friendly communities.

Commentary: COVID in care homes-challenges and dilemmas in healthcare delivery.

The COVID-19 pandemic has disproportionately affected care home residents internationally, with 19-72% of COVID-19 deaths occurring in care homes. COVID-19 presents atypically in care home residents and up to 56% of residents may test positive whilst pre-symptomatic. In this article, we provide a commentary on challenges and dilemmas identified in the response to COVID-19 for care homes and their residents. We highlight the low sensitivity of polymerase chain reaction testing and the difficulties this poses for blanket screening and isolation of residents. We discuss quarantine of residents and the potential harms associated with this. Personal protective equipment supply for care homes during the pandemic has been suboptimal and we suggest that better integration of procurement and supply is required. Advance care planning has been challenged by the pandemic and there is a need to for healthcare staff to provide support to care homes with this. Finally, we discuss measures to implement augmented care in care homes, including treatment with oxygen and subcutaneous fluids, and the frameworks which will be required if these are to be sustainable. All of these challenges must be met by healthcare, social care and government agencies if care home residents and staff are to be physically and psychologically supported during this time of crisis for care homes.

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.

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis.

AIM: To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. DESIGN: Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. SETTING: England. PARTICIPANTS: Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723). MEASUREMENTS: The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption. FINDINGS: There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month. CONCLUSIONS: Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.