Sex and gender analysis improves science and engineering.

The goal of sex and gender analysis is to promote rigorous, reproducible and responsible science. Incorporating sex and gender analysis into experimental design has enabled advancements across many disciplines, such as improved treatment of heart disease and insights into the societal impact of algorithmic bias. Here we discuss the potential for sex and gender analysis to foster scientific discovery, improve experimental efficiency and enable social equality. We provide a roadmap for sex and gender analysis across scientific disciplines and call on researchers, funding agencies, peer-reviewed journals and universities to coordinate efforts to implement robust methods of sex and gender analysis.

COVID-19 gender policy changes support female scientists and improve research quality.

With more time being spent on caregiving responsibilities during the COVID-19 pandemic, female scientists' productivity dropped. When female scientists conduct research, identity factors are better incorporated in research content. In order to mitigate damage to the research enterprise, funding agencies can play a role by putting in place gender equity policies that support all applicants and ensure research quality. A national health research funder implemented gender policy changes that included extending deadlines and factoring sex and gender into COVID-19 grant requirements. Following these changes, the funder received more applications from female scientists, awarded a greater proportion of grants to female compared to male scientists, and received and funded more grant applications that considered sex and gender in the content of COVID-19 research. Further work is urgently required to address inequities associated with identity characteristics beyond gender.

Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line.

Background: Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods: Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results: Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion: Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.

Addressing Barriers to Reducing Prescribing and Implementing Deprescribing of Sedative-Hypnotics in Primary Care.

OBJECTIVE: To describe interventions that target patient, provider, and system barriers to sedative-hypnotic (SH) deprescribing in the community and suggest strategies for healthcare teams. DATA SOURCES: Ovid MEDLINE ALL and EMBASE Classic + EMBASE (March 10, 2021). STUDY SELECTION AND DATA EXTRACTION: English-language studies in primary care settings. DATA SYNTHESIS: 20 studies were themed as patient-related and prescriber inertia, physician skills and awareness, and health system constraints. Patient education strategies reduced SH dose for 10% to 62% of participants, leading to discontinuation in 13% to 80% of participants. Policy interventions reduced targeted medication use by 10% to 50%. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Patient engagement and empowerment successfully convince patients to deprescribe chronic SHs. Quality improvement strategies should also consider interventions directed at prescribers, including education and training, drug utilization reviews, or computer alerts indicating a potentially inappropriate prescription by medication, age, dose, or disease. Educational interventions were effective when they facilitated patient engagement and provided information on the harms and limited evidence supporting chronic use as well as the effectiveness of alternatives. Decision support tools were less effective than prescriber education with patient engagement, although they can be readily incorporated in the workflow through prescribing software. CONCLUSIONS: Several strategies with demonstrated efficacy in reducing SH use in community practice were identified. Education regarding SH risks, how to taper, and potential alternatives are essential details to provide to clinicians, patients, and families. The strategies presented can guide community healthcare teams toward reducing the community burden of SH use.

Predicting response to a community-based educational workshop on incontinence among community-dwelling older women: Post hoc analysis of the CACTUS-D trial.

AIMS: Our goal was to identify which women participating in an educational workshop on incontinence were most likely to benefit from it. METHODS: We included women aged 65 or older, living in the community, and not treated for incontinence despite reporting urinary leakage at least twice a week. The workshop's aims were to change beliefs about accepting incontinence as a normal part of ageing, explain that incontinence is not irreversible, and that solutions exist. We performed structured interviews at 6 and 12 months to assess impressions of improvement (PGI-I) and changes in both continence (ICIQ-FLUTS) and quality of life (I-QOL). RESULTS: The analysis included 392 women, 39% aged 80 or older and 57% with daily urinary incontinence. Twelve months after the workshop, 16% of women were "much better" (PGI-I); factors associated with impression of improvement were refusal to believe that incontinence is part of normal ageing at baseline and improvement of urinary symptoms. The median improvement was 4 points on the ICIQ-FLUTS and 8 on the I-QOL. Factors associated with a clinically significant improvement in urinary symptoms were more severe baseline urinary incontinence, obesity, and starting Kegel exercises. Factors associated with a clinically significant improvement in quality of life were a poor urinary quality of life at baseline and an age younger than 81 years. CONCLUSIONS: A short, inexpensive and nonmedical intervention can change the mind-set and behavior of older women with incontinence who are not seeking care. A clinically significant improvement is possible even in women with severe symptoms.

A 10-year longitudinal evaluation of science policy interventions to promote sex and gender in health research.

BACKGROUND: Over the past decade, the Canadian Institutes of Health Research (CIHR) has implemented multicomponent interventions to increase the uptake of sex and gender in grant applications. Interventions included mandatory reporting on applicant forms, development of resources for applicants and evaluators, and grant review requirements. Here, we aim to inform science policy implementation by describing the 10-year outcomes and lessons learned from these interventions. METHODS: This is a prospective longitudinal study. The population is all applicants across 15 investigator-initiated CIHR competitions from 2011 to 2019 and grant evaluators from 2018 to 2019. Quantitative data were derived from applicants' and grant evaluators' mandatory reporting of sex and gender integration in the grants management database. The application was the unit of analysis. Trends in sex and gender uptake in applications were plotted over time, stratified by research area. Univariate logistic regression was used to assess associations between the sex of the applicant and the uptake of sex and gender, and the latter with funding success. Qualitative review of the quality and appropriateness of evaluators' comments informed the development of discipline-specific training to peer review committee members. Feedback was compiled from a subset of evaluators on the perceived usefulness of the educational materials using a brief questionnaire. RESULTS: Since 2011, 39,390 applications were submitted. The proportion that reported integration of sex rose from 22 to 83%, and gender from 12 to 33%. Population health research applications paid the greatest attention to gender (82%). Across every competition, applications with female principal investigators were more likely to integrate sex (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.50-1.63) and gender (OR 2.40, 95% CI 2.29-2.51) than those who identified as male. Since 2018, applications that scored highly for the integration of sex (OR 1.92, 95% CI 1.50-2.50) and gender (OR 2.53, 95% CI 1.83-3.50) were more likely to be funded. Qualitative observations revealed persistent conflation of the terms sex and gender. Eighty-six percent of evaluators appreciated the tailored discipline-specific coaching. CONCLUSIONS: A number of policy interventions improved sex and gender uptake in grant applications, with higher success rates observed over time for applications that integrated sex and gender. Other funders' action plans around sex and gender integration may be informed from our experiences of the timing, type and targets of the different interventions, specifically those directed at evaluators.

Are gender gaps due to evaluations of the applicant or the science? A natural experiment at a national funding agency.

BACKGROUND: Across countries and disciplines, studies show male researchers receive more research funding than their female peers. Because most studies have been observational, it is unclear whether imbalances stem from evaluations of female research investigators or of their proposed research. In 2014, the Canadian Institutes of Health Research created a natural experiment by dividing investigator-initiated funding applications into two new grant programmes: one with and one without an explicit review focus on the calibre of the principal investigator. METHODS: We analysed application success among 23 918 grant applications from 7093 principal investigators in all investigator-initiated Canadian Institutes of Health Research grant programmes between 2011 and 2016. We used generalised estimating equations to account for multiple applications by the same applicant and compared differences in application success between male and female principal investigators under different review criteria. FINDINGS: Overall application success across competitions was 15·8%. After adjusting for age and research domain, the predicted probability of success in traditional programmes was 0·9 percentage points lower for female applicants than male applicants (95% CI 2·0 lower-0·2 higher; odds ratio 0·934, 95% CI 0·854-1·022). In the new programme, in which review focused on the proposed science, the gap remained 0·9 percentage points (3·2 lower-1·4 higher; 0·998, 0·794-1·229). In the new programme with an explicit review focus on the calibre of the principal investigator, the gap was 4·0 percentage points (6·7 lower-1·3 lower; 0·705, 0·519-0·960). INTERPRETATION: Gender gaps in grant funding are attributable to less favourable assessments of women as principal investigators, not of the quality of their proposed research. We discuss reasons less favourable assessments might occur and strategies to foster fair and rigorous peer review. FUNDING: None.

Long-term effect of community-based continence promotion on urinary symptoms, falls and healthy active life expectancy among older women: cluster randomised trial.

BACKGROUND: The long-term effectiveness of group continence promotion delivered via community organisations on female urinary incontinence, falls and healthy life expectancy remains unknown. METHODS: A pragmatic cluster randomised trial was conducted among 909 women aged 65-98 years with urinary incontinence, recruited from 377 community organisations in the UK, Canada and France. A total of 184 organisations were randomised to an in-person 60-min incontinence self-management workshop (461 participants), and 193 to a control healthy ageing workshop (448 participants). The primary outcome was self-reported incontinence improvement at 1-year. Falls and gains in health utility were secondary outcomes. RESULTS: A total 751 women, mean age 78.0, age range 65-98 completed the trial (83%). At 1-year, 15% of the intervention group versus 6.9% of controls reported significant improvements in urinary symptoms, (difference 8.1%, 95% confidence intervals (CI) 4.0-12.1%, intracluster correlation 0.04, number-needed-to-treat 13) and 35% versus 19% reported any improvement (risk difference 16.0%, 95% CI 10.4-21.5, number-needed-to-treat 6). The proportion of fallers decreased from 42% to 36% in the intervention group (-8.0%, 95% CI -14.8 - -1.0) and from 44% to 34% in the control group (-10.3%, 95% CI -17.4 - -3.6), no difference between groups. Both intervention and control groups experienced a gain in health utility (0.022 points (95% CI 0.005-0.04) versus 0.035 (95% CI 0.017-0.052), respectively), with no significant difference between groups. CONCLUSION: Community-based group continence promotion achieves long-term benefits on older women's urinary symptoms, without improvement in falls or healthy life expectancy compared with participation in a healthy ageing workshop.

Is the belief that urinary incontinence is normal for ageing related to older Canadian women's experience of urinary incontinence?

INTRODUCTION AND HYPOTHESIS: Many women consider urinary incontinence (UI) a normal part of ageing. This belief may contribute to delays in treatment seeking. This study examined the relationship among holding that belief, UI type and severity, impact on quality of life, management and healthcare seeking in a sample of older community-dwelling Canadian women. METHODS: This was a secondary analysis of a controlled trial examining the impact of continence promotion workshops on UI self-management. All women who consented and provided baseline data were included in this analysis regardless of eligibility for the main study. RESULTS: The sample included 4446 women (2022 with UI) of mean (SD) age 78.2 (9.0) years and BMI 26.6 (5.6). The belief that UI is normal for ageing was held by 2149 women [48.3% (83.7% of 1798 incontinent women)] and was not associated with age [adjusted odds ratio (OR) (95% CI): 1.00 (0.99, 1.01), p = 0.72] or perception of overall health. Women with this belief had more impaired QoL compared with the women who felt UI was not normal for ageing [mean (SD) 83.9 (19.4) vs. 87.4 (18.6) (p < 0.01)]. This belief remained unaffected by daily UI and pad use up to 2/day. CONCLUSIONS: More than two-thirds of women thought UI normal for ageing. This belief was not associated with age or perception of overall health. More severe incontinence and greater quantities of pad use did not make women less likely to hold this belief.

Performance of a Bayesian Approach for Imputing Missing Data on the SF-12 Health-Related Quality-of-Life Measure.

BACKGROUND: Missing data in health-related quality-of-life outcomes are an ongoing problem. The 12-item short form health survey (SF-12) scores are no exception. Data imputation is complicated, because missingness may be partially predicted by the missing data themselves. OBJECTIVES: To compare the performance of a Bayesian method for imputing SF-12 data with previously described frequentist imputation methods. METHODS: SF-12 data were extracted from a trial assessing continence promotion on health-related quality of life in older women (n = 1052); the data set was split into a model development cohort for creating predictive models and a validation cohort to validate these models. Algorithms were constructed using data from the model development cohort to compute SF-12-related scores (physical health composite scale, the mental health composite scale, and the six-dimensional health state short form utilities). The Bayesian models used missing at random and missing not at random algorithms to impute missing SF-12 answers as categorical data. Comparative models replaced missing data with 0, used the mean weight of the sample, and regressed parameters from sociodemographic predictors. Data randomly deleted from the validation cohort were imputed with each algorithm, and the mean absolute error was used to gauge goodness of fit. RESULTS: Each cohort included 526 persons; mean age was 78.1 ± 7.8 years. In the model development cohort, 15.6% of the participants had missing data. For the physical health composite scale, the mental health composite scale, and the six-dimensional health state short form utilities, the Bayesian model with missing at random data significantly outperformed all five comparison models, including the Bayesian models with missing not at random data. CONCLUSIONS: Bayesian imputation was superior to other previously described methods for computing missing SF-12 data.

Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial.

Importance: High rates of inappropriate prescribing persist among older adults in many outpatient settings, increasing the risk of adverse drug events and drug-related hospitalizations. Objective: To compare the effectiveness of a consumer-targeted, pharmacist-led educational intervention vs usual care on discontinuation of inappropriate medication among community-dwelling older adults. Design, Setting, and Participants: A cluster randomized trial (D-PRESCRIBE [Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly]) that recruited community pharmacies in Quebec, Canada, from February 2014 to September 2017, with follow-up until February 2018, and randomly allocated them to intervention or control groups. Patients included were adults aged 65 years and older who were prescribed 1 of 4 Beers Criteria medications (sedative-hypnotics, first-generation antihistamines, glyburide, or nonsteroidal anti-inflammatory drugs), recruited from 69 community pharmacies. Patients were screened and enrolled before randomization. Interventions: Pharmacists in the intervention group were encouraged to send patients an educational deprescribing brochure in parallel to sending their physicians an evidence-based pharmaceutical opinion to recommend deprescribing. The pharmacists in the control group provided usual care. Randomization occurred at the pharmacy level, with 34 pharmacies randomized to the intervention group (248 patients) and 35 to the control group (241 patients). Patients, physicians, pharmacists, and evaluators were blinded to outcome assessment. Main Outcomes and Measures: Discontinuation of prescriptions for inappropriate medication at 6 months, ascertained by pharmacy medication renewal profiles. Results: Among 489 patients (mean age, 75 years; 66% women), 437 (89%) completed the trial (219 [88%] in the intervention group vs 218 [91%] in the control group). At 6 months, 106 of 248 patients (43%) in the intervention group no longer filled prescriptions for inappropriate medication compared with 29 of 241 (12%) in the control group (risk difference, 31% [95% CI, 23% to 38%]). In the intervention vs control group, discontinuation of inappropriate medication occurred among 63 of 146 sedative-hypnotic drug users (43.2%) vs 14 of 155 (9.0%), respectively (risk difference, 34% [95% CI, 25% to 43%]); 19 of 62 glyburide users (30.6%) vs 8 of 58 (13.8%), respectively (risk difference, 17% [95% CI, 2% to 31%]); and 19 of 33 nonsteroidal anti-inflammatory drug users (57.6%) vs 5 of 23 (21.7%), respectively (risk difference, 35% [95% CI, 10% to 55%]) (P for interaction = .09). Analysis of the antihistamine drug class was not possible because of the small sample size (n = 12). No adverse events requiring hospitalization were reported, although 29 of 77 patients (38%) who attempted to taper sedative-hypnotics reported withdrawal symptoms. Conclusions and Relevance: Among older adults in Quebec, a pharmacist-led educational intervention compared with usual care resulted in greater discontinuation of prescriptions for inappropriate medication after 6 months. The generalizability of these findings to other settings requires further research. Trial Registration: ClinicalTrials.gov Identifier: NCT02053194.

A prototype for evidence-based pharmaceutical opinions to promote physician-pharmacist communication around deprescribing.

CONTEXT: Interprofessional communication is an effective mechanism for reducing inappropriate prescriptions among older adults. Physicians' views about which elements are essential for pharmacists to include in an evidence-based pharmaceutical opinion for deprescribing remain unknown. OBJECTIVE: To develop a prototype for an evidence-based pharmaceutical opinion that promotes physician-pharmacist communication around deprescribing. METHODS: A standardized template for an evidence-based pharmaceutical opinion was developed with input from a convenience sample of 32 primary care physicians and 61 primary care pharmacists, recruited from conferences and community settings in Montreal, Canada. Participants were asked to comment on the need for clarifying treatment goals, including personalized patient data and biomarkers, highlighting evidence about drug harms, listing the credibility and source of the recommendations, providing therapeutic alternatives and formalizing official documentation of decision making. The content and format of the prototype underwent revision by community physicians and pharmacists until consensus was reached on a final recommended template. RESULTS: The majority of physicians (84%-97%) requested that the source of the deprescribing recommendations be cited, that alternative management options be provided and that the information be tailored to the patient. Sixteen percent of physicians expressed concern about the information in the opinions being too dense. Pharmacists also questioned the length of the opinion and asked that additional space be provided for the physician's response. A statement was added making the opinion a valid prescription upon receipt of a signature from physicians. Compared to a nonstandardized opinion, the majority of pharmacists believed the template was easier to use, more evidence based, more time efficient and more likely to lead to deprescribing. CONCLUSION: Physicians and pharmacists endorsed a standardized template that promotes interprofessional communication for deprescribing (available at https://www.deprescribingnetwork.ca/pharmaceutical-opinions). The outcome of the D-Prescribe trial will determine the effectiveness of these evidence-based pharmaceutical opinions on deprescribing processes and outcomes. Can Pharm J (Ott) 2018;151:xx-xx.

Age and sex in drug development and testing for adults.

Individualization of drug therapy requires that the right drug be administered at the correct dose to patients who are likely to achieve the highest benefit and lowest risk. Female sex and age comprise two important risk factors for altered drug exposure and response. This review summarizes the current state of science for considering age and sex-related factors along the drug development pipeline, from cell culture and animal research through all phases of clinical trials in humans. A set of recommendations is provided to improve standards for integrating age and sex into the study design, analysis, and reporting of pre-clinical and clinical assessment of new molecular entities and biologics in adults.

Use of the EMPOWER brochure to deprescribe sedative-hypnotic drugs in older adults with mild cognitive impairment.

BACKGROUND: Evidence-based mailed educational brochures about the harms of sedative-hypnotic use lead to discontinuation of chronic benzodiazepine use in older adults. It remains unknown whether patients with mild cognitive impairment (MCI) are able to understand the information in the EMPOWER brochures, and whether they achieve similar rates of benzodiazepine discontinuation. METHODS: Post-hoc analysis of the EMPOWER randomized, double-blind, wait-list controlled trial that assessed the effect of a direct-to-consumer educational intervention on benzodiazepine discontinuation. 303 community-dwelling chronic users of benzodiazepine medication aged 65-95 years were recruited from general community pharmacies in the original trial, 261 (86%) of which completed the trial extension phase. All participants of the control arm received the EMPOWER brochure during the trial extension. Normal cognition (n = 139) or MCI (n = 122) was determined during baseline cognitive testing using the Montreal Cognitive Assessment questionnaire. Changes in knowledge pre- and post-intervention were assessed with a knowledge questionnaire and changes in beliefs were calculated using the Beliefs about Medicines Questionnaire. Logistic regression was used to compare knowledge gained, change in beliefs and benzodiazepine cessation rates between participants with and without MCI. RESULTS: Complete discontinuation of benzodiazepines was achieved in 39 (32.0% [24.4,40.7]) participants with MCI and in 53 (38.1% [30.5,46.4]) with normal cognition (adjusted OR 0.79, 95% CI [0.45-1.38]). Compared to individuals with normal cognition, MCI had no effect on the acquisition of new knowledge, change in beliefs about benzodiazepines or elicitation of cognitive dissonance. CONCLUSIONS: The EMPOWER brochure is effective for reducing benzodiazepines in community-dwelling older adults with mild cognitive impairment. TRIAL REGISTRATION: Our ClinicalTrials.gov identifier is NCT01148186 , June 21st 2010.

Why sex and gender matter in implementation research.

BACKGROUND: There has been a recent swell in activity by health research funding organizations and science journal editors to increase uptake of sex and gender considerations in study design, conduct and reporting in order to ensure that research results apply to everyone. However, examination of the implementation research literature reveals that attention to sex and gender has not yet infiltrated research methods in this field. DISCUSSION: The rationale for routinely considering sex and gender in implementation research is multifold. Sex and gender are important in decision-making, communication, stakeholder engagement and preferences for the uptake of interventions. Gender roles, gender identity, gender relations, and institutionalized gender influence the way in which an implementation strategy works, for whom, under what circumstances and why. There is emerging evidence that programme theories may operate differently within and across sexes, genders and other intersectional characteristics under various circumstances. Furthermore, without proper study, implementation strategies may inadvertently exploit or ignore, rather than transform thinking about sex and gender-related factors. Techniques are described for measuring and analyzing sex and gender in implementation research using both quantitative and qualitative methods. The present paper describes the application of methods for integrating sex and gender in implementation research. Consistently asking critical questions about sex and gender will likely lead to the discovery of positive outcomes, as well as unintended consequences. The result has potential to strengthen both the practice and science of implementation, improve health outcomes and reduce gender inequities.

Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women: An MRI study.

AIMS: To compare magnetic resonance imaging (MRI) of the pelvic floor musculature (PFM), bladder neck and urethral sphincter morphology under three conditions (rest, PFM maximal voluntary contraction (MVC), and straining) in older women with symptoms of stress (SUI) or mixed urinary incontinence (MUI) or without incontinence. METHODS: This 2008-2012 exploratory observational cohort study was conducted with community-dwelling women aged 60 and over. Sixty six women (22 per group), mean age of 67.7 ± 5.2 years, participated in the study. A 3 T MRI examination was conducted under three conditions: rest, PFM MVC, and straining. ANOVA or Kruskal-Wallis tests (data not normally distributed) were conducted, with Bonferroni correction, to compare anatomical measurements between groups. RESULTS: Women with MUI symptoms had a lower PFM resting position (M-Line P = 0.010 and PC/H-line angle P = 0.026) and lower pelvic organ support (urethrovesical junction height P = 0.013) than both continent and SUI women. Women with SUI symptoms were more likely to exhibit bladder neck funneling and a larger posterior urethrovesical angle at rest than both continent and MUI women (P = 0.026 and P = 0.008, respectively). There were no significant differences between groups on PFM MVC or straining. CONCLUSIONS: Women with SUI and MUI symptoms present different morphological defects at rest. These observations emphasize the need to tailor UI interventions to specific pelvic floor defects and UI type in older women. PATIENT SUMMARY: Older women with UI demonstrate different problems with their pelvic organ support structures depending on the type of UI. These new findings should be taken into consideration for future research into developing new treatment strategies for UI in older women. Neurourol. Urodynam. 35:515-521, 2016. © 2015 Wiley Periodicals, Inc.

Natural history of pessary use in women aged 65 - 74 versus 75 years and older with pelvic organ prolapse: a 12-year study.

INTRODUCTION AND HYPOTHESIS: The feasibility of use and long-term outcomes of vaginal pessaries for the management of pelvic organ prolapse (POP) in older women remains unknown. Our aim was to determine successful fit rates and outcomes among older women seeking care for POP. METHODS: This was a retrospective cohort study of 304 consecutive women aged 65 years and older with symptomatic POP undergoing a pessary trial at the outpatient urogynecology clinic in Québec, Canada. Women successfully fitted with a pessary were followed, and survival curves were used to ascertain the median time to pessary discontinuation for women aged 65 to 74 years in comparison with women aged 75 years and older. Long-term use was defined as longer than 1 year. Predictors of a successful fitting and long-term discontinuation were ascertained using logistic and Cox regression analyses. RESULTS: Half of the women attempting a pessary trial were aged 75 years and older, and 63 % were fitted successfully regardless of age. Women with a history of hysterectomy or reconstructive pelvic surgery, or those with posterior vaginal wall prolapse were more likely to fail initial insertion. For women aged 65 to 74 years and women aged 75 years and older, the cumulative probabilities of continued pessary use were 87.5 % and 80.8 % at 1 year, 80.6 % and 70.9 % at 2 years, and 62.1 % versus 37.8 % at 5 years. Erosions occurred in 19.3 % of long-term users, with women aged 75 years and older more likely to experience vaginal erosions (HR 3.2, 95 % CI 1.6 - 6.3) and discontinue pessary use. CONCLUSION: Pessary use is a feasible and acceptable treatment option for the long-term management of symptomatic prolapse in over 60 % of all women aged 65 years and older.

Small longitudinal study of serum anticholinergic activity and cognitive change in community-dwelling older adults.

OBJECTIVE: The discriminative ability of serum anticholinergic activity (SAA) to differentiate between older individuals with stable versus deteriorating cognition remains undetermined. We examined the relationship between SAA changes, the presence or absence of a mild neurocognitive disorder, age and anticholinergic medication over a one-year time period. METHODS: SAA at baseline and one-year follow-up was measured for 121 older adults without dementia. Participants were classified at both timepoints as being cognitively intact or meeting the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for a mild neurocognitive disorder. Medications were assessed according to the Anticholinergic Cognitive Burden (ACB) scale. RESULTS: SAA changes did not discriminate between individuals whose cognition remained stable versus those with improvement or decline (H[3]=0.725, p=0.867). SAA change did not vary between age groups, and could not reliably differentiate between individuals on ACB medication or not. CONCLUSION: While SAA does not appear to be a valid biomarker for cognitive decline, longitudinal studies with a larger sample size and longer duration are required to confirm this finding.