Allied health assistant management of people with hip fracture is feasible and may improve patient adherence to hip fracture mobilisation guidelines: a feasibility randomised controlled trial.

OBJECTIVES: Determine the feasibility of allied health assistant (AHA) management of people with hip fracture an acute hospital. DESIGN: Assessor-blind, parallel, feasibility randomised controlled trial with qualitative component. SETTING: Acute orthopaedic ward. PARTICIPANTS: People with surgically-managed hip fracture, who walked independently pre-fracture and had no cognitive impairment. INTERVENTIONS: Rehabilitation from an AHA, under the supervision of a physiotherapist, compared with rehabilitation from a physiotherapist. MAIN OUTCOME MEASURES: Feasibility was evaluated according to focus areas of demand, acceptability, practicality and implementation. Secondary outcomes included estimates of effect of adherence to hip fracture mobilisation guidelines, discharge destination, 30-day readmission, functional activity, and length of stay. RESULTS: Fifty people were allocated to receive rehabilitation from an AHA (n = 25) or physiotherapist (n = 25). AHA rehabilitation had high demand with 60% of eligible participants recruited. Satisfaction with AHA rehabilitation was comparable with physiotherapy rehabilitation (acceptability). The AHA group received an average of 11 min (95% CI 4 to 19) more therapy per day than the physiotherapy group (implementation). The AHA group may have had lower cost of acute care (MD -$3 808 95% CI -7 651 to 35) and adverse events were comparable between groups (practicality). The AHA group may have been 22% (HR 1.22, 95% CI 0.92 to 1.61) more likely to walk on any day and may have had a shorter length of stay (MD -0.8 days, 95% CI -2.3 to 0.7). CONCLUSIONS: AHA management of patients with hip fracture was feasible and may improve adherence to mobilisation guidelines and reduce cost of care and length of stay. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12620000877987. CONTRIBUTION OF THE PAPER.

Consumer perspectives of allied health involvement in a public hospital setting: cross-sectional survey and electronic health record review.

Objective Consumer-centred care is fundamental to high-quality health care, with allied health professionals playing a pivotal role in hospital settings. Allied health typically operates within standard weekday working-hours. Consumer preferences for receiving allied health services are largely unexplored but could inform whether weekend and/or out-of-hours services are required. This study aims to understand consumer preferences for hospital-based inpatient and outpatient allied health services. Methods Using a cross-sectional survey and convenience sampling approach, consumers of a public health service in Melbourne, Australia were surveyed about preferences for allied health service delivery. Electronic health record reviews compared the accuracy of self-reported service delivery times. Descriptive statistics, concordance and predictive values were calculated. Responses to free-text survey items were analysed using content analysis. Results Of 120 participants (79% response rate), most (69%) received allied health services, however, almost half of inpatient responders (44%) were unsure of the specific allied health professional involved. Audit results found moderate-high concordance overall (range, 77-96%) between self-reported and audit-identified allied health services by profession. Most inpatient responders had no strong day of week preference, equally selecting weekdays and weekend days, with most preferring services between 8 am and 4 pm. Outpatient responders (81%) preferred a weekday appointment between 8 am and 12 pm or before 8 am (29%) to complete scheduled activities early in the day. Conclusion While provision of allied health services during standard working-hours was preferred by most consumers, some inpatient and outpatient consumers are receptive to receiving weekend and out-of-hours services, respectively. Decisions about offering these services should consider operational capacity and research evidence.

Healthcare consumer acceptability of routine use of the EQ-5D-5L in clinical care: a cross-sectional survey.

PURPOSE: Patient reported outcome measures, such as the EQ-5D-5L, provide a measure of self-perceived health status or health-related quality of life. Understanding the consumer acceptability of a patient reported outcome measure can help to decide about its implementation across a healthcare organisation and possibly increase the likelihood of its use in clinical care. This study established the acceptability of the EQ-5D-5L from the perspective of clients receiving healthcare, and determined if acceptability varied by client sub-types. METHODS: A cross-sectional survey explored clients' experience of the EQ-5D-5L. Eligible clients were aged ≥ 18 years and completed the EQ-5D-5L on admission and discharge to one of two multi-disciplinary community health services. Likert scale items explored acceptability, and open-ended questions determined if the EQ-5D-5L reflects experience of illness. Associations between acceptability and client characteristics were established using χ2 test. Open-ended questions were analysed using content analysis. RESULTS: Most of the 304 clients (mean age 70 years, SD 16) agreed that the EQ-5D-5L: was easy to use/understand (n = 301, 99%) and useful (n = 289, 95%); improved communication with their therapist (n = 275, 90%); and made them feel more in control of their health (n = 276, 91%). Most clients also agreed that they wished to continue using the EQ-5D-5L (n = 285, 93%). Clients aged ≥ 60 years reported lower acceptability. Clients noted that the EQ-5D-5L did not capture experience of illness related to fatigue, balance/falls, cognition, and sleep. CONCLUSION: The EQ-5D-5L is acceptable for use in care but does not capture all aspects of health relevant to clients, and acceptability varies by subgroup.

The eye of the beholder: how do public health researchers interpret regression coefficients? A qualitative study.

BACKGROUND: Calls for improved statistical literacy and transparency in population health research are widespread, but empirical accounts describing how researchers understand statistical methods are lacking. To address this gap, this study aimed to explore variation in researchers' interpretations and understanding of regression coefficients, and the extent to which these statistics are viewed as straightforward statements about health. METHODS: Thematic analysis of qualitative data from 45 one-to-one interviews with academics from eight countries, representing 12 disciplines. Three concepts from the sociology of scientific knowledge and science studies aided analysis: Duhem's Paradox, the Agonistic Field, and Mechanical Objectivity. RESULTS: Some interviewees viewed regression as a process of discovering 'real' relationships, while others indicated that regression models are not direct representations, and others blended these perspectives. Regression coefficients were generally not viewed as being mechanically objective, instead interpretation was described as iterative, nuanced, and sometimes depending on prior understandings. Researchers reported considering numerous factors when interpreting and evaluating regression results, including: knowledge from outside the model, whether results are expected or unexpected, 'common-sense', technical limitations, study design, the influence of the researcher, the research question, data quality and data availability. Interviewees repeatedly highlighted the role of the analyst, reinforcing that it is researchers who answer questions and assign meaning, not models. CONCLUSIONS: Regression coefficients were generally not viewed as complete or authoritative statements about health. This contrasts with teaching materials wherein statistical results are presented as straightforward representations, subject to rule-based interpretations. In practice, it appears that regression coefficients are not understood as mechanically objective. Attempts to influence conduct and presentation of regression models in the population health sciences should be attuned to the myriad factors which inform their interpretation.

Staying Active with Multimorbidity In Acute hospital settings (StAMInA) trial: protocol for a feasibility randomised controlled trial of allied health assistant mobility rehabilitation for patients with multimorbidity.

INTRODUCTION: Key to improving outcomes for patients with multimorbidity is increasing mobility through prescription of a physical activity programme, but this can be difficult to achieve in acute hospital settings. One approach that would assist physiotherapists to increase levels of physical activity is delegation of rehabilitation to allied health assistants. We aim to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient mobility rehabilitation for patients with multimorbidity. METHODS AND ANALYSIS: Using a parallel group randomised controlled design, participants will be allocated to allied health assistant mobility rehabilitation or physiotherapist mobility rehabilitation. Adult inpatients (n=60) in an acute hospital with a diagnosis of multimorbidity who walked independently preadmission will be included. The experimental group will receive routine mobility rehabilitation, including daily mobilisation, from an allied health assistant under the supervision of a physiotherapist. The comparison group will receive routine rehabilitation from a physiotherapist. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: Acceptability (patient satisfaction); demand (proportion of patients who participate); implementation (time allied health assistant/physiotherapist spends with participant, occasions of service); and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant rehabilitation will be interviewed to explore their perspectives on feasibility. Secondary outcomes include: Physical activity (daily time spent walking); daily mobilisation (Y/N); discharge destination; hospital readmission; falls; functional activity (Modified Iowa Level of Assistance Scale); and length of stay. Descriptive statistics will be used to describe feasibility. Secondary outcomes will be compared between groups using Poisson or negative binomial regression, Cox proportional hazards regression, survival analysis, linear regression or logistic regression. ETHICS AND DISSEMINATION: Ethics approval was obtained from Peninsula Health (HREC/97 431/PH-2023). Findings will be disseminated in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trial Registry ACTRN12623000584639p.

Interactive clinical supervision training added to self-education leads to small improvements in the effectiveness of clinical supervision of physiotherapists: a randomised trial.

QUESTION: Does adding an interactive clinical supervision training program to self-education improve the effectiveness of clinical supervision of physiotherapists, reduce burnout, decrease intention to leave and increase participation in clinical supervision? DESIGN: Randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. PARTICIPANTS: Physiotherapists (n = 58) working at a publicly funded health service. INTERVENTION: Participants in both groups received a self-education clinical supervision training package. In addition, participants in the experimental group received interactive clinical supervision training consisting of three 90-minute workshops. OUTCOME MEASURES: The primary outcome measure was effectiveness of clinical supervision 4 months after training measured using the Manchester Clinical Supervision Scale (MCSS-26). Secondary outcomes were the Maslach Burnout Inventory, the Intention to Leave Scale, and participation in supervision. Focus groups were also used to gauge impressions of the intervention. RESULTS: The addition of interactive clinical supervision training slightly improved effectiveness of clinical supervision, with a between-group mean difference of 6.3 units (95% CI 0.3 to 12.3) on the MCSS-26. The estimate of the effect on the proportion of physiotherapists reporting effective clinical supervision (ie, MSCC-26 score ≥ 73) was unclear (OR 1.97, 95% CI 0.50 to 7.81). Physiotherapists in the experimental group reported slightly lower levels of depersonalisation (MD -3.0 units, 95% CI -4.6 to -1.3). There were negligible or uncertain effects on the other burnout domains, intention to leave and participation in clinical supervision. Qualitatively, participants reported that the workshops made them realise that supervisees could take greater ownership of where supervision focused. CONCLUSION: Adding interactive clinical supervision training to self-education leads to small improvements in the effectiveness of clinical supervision of physiotherapists. REGISTRATION: osf.io/yz3kx.

Accuracy of transcutaneous bilirubinometry in term infants after phototherapy: a prospective observational study.

OBJECTIVE: To test the accuracy of transcutaneous bilirubinometry (TcB) in neonates 12 h after discontinuing phototherapy. STUDY DESIGN: In a prospective study of 91 neonates at ≥35 weeks of gestation, paired measurements of total serum bilirubin (TSB) and TcB were obtained 12 h after discontinuation of phototherapy. TcB measurements were obtained on the uncovered skin of the sternum and the covered skin of the lower abdomen. Bland-Altman plots were used to evaluate agreement between TSB and TcB. RESULTS: TcB was found to systematically underestimate TSB on both covered and uncovered skin. The smallest but statistically significant difference between TSB and TcB was found on the covered lower abdomen (-1.03, p < .0001) compared with the uncovered skin of the sternum (-1.44, p < .0001). The correlation between TSB and TcB was excellent on both covered (r = 0.86, p < .001) and uncovered skin (r = 0.90, p < .001). Bland and Altman plots showed poor agreement between TcB and TSB. CONCLUSIONS: This study demonstrated excellent correlation between TcB and TSB 12 h after phototherapy but poor TcB-TSB agreement. TcB cannot be reliably used in neonates exposed to phototherapy.

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis.

Background: Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke. Methods: We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in 2012. Findings: We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference -0.16%/month (95% CI -0.29, -0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality -0.18%, (95% CI -0.34, -0.02). Interpretation: This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design. Funding: Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults.

BACKGROUND: Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort. METHODS: Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities. RESULTS: At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability. CONCLUSIONS: PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.

Delegation of patient related tasks to allied health assistants: a time motion study.

BACKGROUND: Allied health assistants (AHAs) are support staff who complete patient and non-patient related tasks under the delegation of an allied health professional. Delegating patient related tasks to AHAs can benefit patients and allied health professionals. However, it is unclear whether the AHA workforce is utilised optimally in the provision of patient care. The purpose of this study was to determine the proportion of time AHAs spend on patient related tasks during their working day and any differences across level of AHA experience, clinical setting, and profession delegating the task. METHODS: A time motion study was conducted using a self-report, task predominance work sampling method. AHAs were recruited from four publicly-funded health organisations in Victoria, Australia. AHAs worked with dietitians, occupational therapists, physiotherapists, podiatrists, social workers, speech pathologists, psychologists, and exercise physiologists. The primary outcome was quantity of time spent by AHAs on individual task-categories. Tasks were grouped into two main categories: patient or non-patient related activities. Data were collected from July 2020 to May 2021 using an activity capture proforma specifically designed for this study. Logistic mixed-models were used to investigate the extent to which level of experience, setting, and delegating profession were associated with time spent on patient related tasks. RESULTS: Data from 51 AHAs showed that AHAs spent more time on patient related tasks (293 min/day, 64%) than non-patient related tasks (167 min/day, 36%). Time spent in community settings had lower odds of being delegated to patient related tasks than time in the acute hospital setting (OR 0.44, 95%CI 0.28 to 0.69, P < 0.001). Time delegated by exercise physiologists and dietitians was more likely to involve patient related tasks than time delegated by physiotherapists (exercise physiology: OR 3.77, 95% 1.90 to 7.70, P < 0.001; dietetics: OR 2.60, 95%CI 1.40 to 1.90, P = 0.003). Time delegated by other professions (e.g. podiatry, psychology) had lower odds of involving patient related tasks than physiotherapy (OR 0.37, 95%CI 0.16 to 0.85, P = 0.02). CONCLUSION: AHAs may be underutilised in community settings, and by podiatrists and psychologists. These areas may be targeted to understand appropriateness of task delegation to optimise AHAs' role in providing patient care.

Combination of gait speed and grip strength to predict cognitive decline and dementia.

Introduction: To determine whether slowed gait and weakened grip strength independently, or together, better identify risk of cognitive decline or dementia. Methods: Time to walk 3 meters and grip strength were measured in a randomized placebo-controlled clinical trial involving community-dwelling, initially cognitively healthy older adults (N = 19,114). Results: Over a median 4.7 years follow-up, slow gait and weak grip strength at baseline were independently associated with risk of incident dementia (hazard ratio [HR] = 1.44, 95% confidence interval [CI]: 1.19-1.73; and 1.24, 95% CI: 1.04-1.50, respectively) and cognitive decline (HR = 1.38, 95% CI: 1.26-1.51; and 1.04, 95% CI: 0.95-1.14, respectively) and when combined, were associated with 79% and 43% increase in risk of dementia and cognitive decline, respectively. Annual declines in gait and in grip over time showed similar results. Discussion: Gait speed and grip strength are low-cost markers that may be useful in the clinical setting to help identify and manage individuals at greater risk, or with early signs, of dementia, particularly when measured together. Highlights: Grip strength and gait speed are effective predictors and markers of dementia.Dementia risk is greater than cognitive decline risk with declines in gait or grip.Decline in gait speed, more so than in grip strength, predicts greater dementia risk.Greater risk prediction results from combining grip strength and gait speed.

Associations of Sex, Age, and Cardiometabolic Risk Profiles With Brain Structure and Cognition: A UK Biobank Latent Class Analysis.

BACKGROUND AND OBJECTIVES: It is unknown whether there are sex-related profiles of cardiometabolic health that contribute differently to age-related changes in brain health during midlife. We studied how latent classes of middle-aged individuals clustering by age, sex, menopause, and cardiometabolic health were associated with brain structure and cognitive performance. METHODS: Health, brain, and abdominal MRI data from the UK Biobank cohort (men and women aged >40 years in the United Kingdom) were used. We applied latent class analysis to identify groups of individuals based on age, sex, menopausal status, and cardiometabolic health. We examined associations of class membership with brain volumes (total brain volume [TBV], gray matter volume [GMV], white matter volume [WMV], hippocampal volume, and white matter hyperintensity volume) and cognitive performance. RESULTS: Data were available for 36,420 individuals (mean age 64.9 years, 48.5% women). Eight latent classes differing in age, sex, and cardiometabolic risk were identified. Class 1 (reference class) included individuals with the lowest probability of older age and cardiometabolic risk, and the healthiest levels of brain volumes and cognition. In those aged >60 years, but not in those aged 50-60 years, the negative associations of age with TBV, GMV, and WMV were greater in the class comprising healthier older women than classes comprising older men of varying cardiometabolic and vascular health. There were no age-class interactions for cognitive test performance. DISCUSSION: Latent class analysis detected groups of middle-aged individuals clustering by cardiometabolic health. The relationship of age with brain volumes varies by sex, menopausal status, and cardiometabolic health profile.

Longitudinal associations of childhood fitness and obesity profiles with midlife cognitive function: an Australian cohort study.

OBJECTIVES: Clusters of low fitness and high obesity in childhood are associated with poorer health outcomes in later life, however their relationship with cognition is unknown. Identifying such profiles may inform strategies to reduce risk of cognitive decline. This study examined whether specific profiles of childhood fitness and obesity were associated with midlife cognition. DESIGN: Prospective study. METHODS: In 1985, participants aged 7-15 years from the Australian Childhood Determinants of Adult Health study were assessed for fitness (cardiorespiratory, muscular power, muscular endurance) and anthropometry (waist-to-hip ratio). Participants were followed up between 2017 and 2019 (aged 39-50). Composites of psychomotor speed-attention, learning-working memory and global cognition were assessed using CogState computerised battery. Latent profile analysis was used to derive mutually exclusive profiles based on fitness and anthropometry. Linear regression analyses examined associations between childhood profile membership and midlife cognition adjusting for age, sex and education level. RESULTS: 1244 participants were included [age: 44.4 ±â€¯2.6 (mean ±â€¯SD) years, 53% female]. Compared to those with the highest levels of fitness and lowest waist-to-hip ratio, three different profiles characterised by combinations of poorer cardiorespiratory fitness, muscular endurance and power were associated with lower midlife psychomotor-attention [up to -1.09 (-1.92, -0.26) SD], and lower global cognition [up to -0.71 (-1.41, -0.01) SD]. No associations were detected with learning-working memory. CONCLUSIONS: Strategies that improve low fitness and decrease obesity levels in childhood could contribute to improvements in cognitive performance in midlife.

Association of Dual Decline in Cognition and Gait Speed With Risk of Dementia in Older Adults.

Importance: Dual decline in gait speed and cognition has been found to be associated with increased dementia risk in previous studies. However, it is unclear if risks are conferred by a decline in domain-specific cognition and gait. Objective: To examine associations between dual decline in gait speed and cognition (ie, global, memory, processing speed, and verbal fluency) with risk of dementia. Design, Setting, and Participants: This cohort study used data from older adults in Australia and the US who participated in a randomized clinical trial testing low-dose aspirin between 2010 and 2017. Eligible participants in the original trial were aged 70 years or older, or 65 years or older for US participants identifying as African American or Hispanic. Data analysis was performed between October 2020 and November 2021. Exposures: Gait speed, measured at 0, 2, 4, and 6 years and trial close-out in 2017. Cognitive measures included Modified Mini-Mental State examination (3MS) for global cognition, Hopkins Verbal Learning Test-Revised (HVLT-R) for memory, Symbol Digit Modalities (SDMT) for processing speed, and Controlled Oral Word Association Test (COWAT-F) for verbal fluency, assessed at years 0, 1, 3, 5, and close-out. Participants were classified into 4 groups: dual decline in gait and cognition, gait decline only, cognitive decline only, and nondecliners. Cognitive decline was defined as membership of the lowest tertile of annual change. Gait decline was defined as a decline in gait speed of 0.05 m/s or greater per year across the study. Main Outcomes and Measures: Dementia (using Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] criteria) was adjudicated by an expert panel using cognitive tests, functional status, and clinical records. Cox proportional hazard models were used to estimate risk of dementia adjusting for covariates, with death as competing risk. Results: Of 19 114 randomized participants, 16 855 (88.2%) had longitudinal gait and cognitive data for inclusion in this study (mean [SD] age, 75.0 [4.4] years; 9435 women [56.0%], 7558 participants [44.8%] with 12 or more years of education). Compared with nondecliners, risk of dementia was highest in the gait plus HVLT-R decliners (hazard ratio [HR], 24.7; 95% CI, 16.3-37.3), followed by the gait plus 3MS (HR, 22.2; 95% CI, 15.0-32.9), gait plus COWAT-F (HR, 4.7; 95% CI, 3.5-6.3), and gait plus SDMT (HR, 4.3; 95% CI, 3.2-5.8) groups. Dual decliners had a higher risk of dementia than those with either gait or cognitive decline alone for 3MS and HVLT-R. Conclusions and Relevance: Of domains examined, the combination of decline in gait speed with memory had the strongest association with dementia risk. These findings support the inclusion of gait speed in dementia risk screening assessments.

Frailty Is Associated With Cognitive Decline Independent of Cerebral Small Vessel Disease and Brain Atrophy.

BACKGROUND: To examine the effect of frailty on cognitive decline independent of cerebral small vessel disease (cSVD) and brain atrophy, and whether associations between neuropathology and cognition differed depending on frailty status. METHODS: The Tasmanian Study of Cognition and Gait was a population-based longitudinal cohort study with data collected at 3 phases from 2005 to 2012. Participants aged 60-85 were randomly selected from the electoral roll. Various data were used to operationalize a 36-item frailty index (FI) at baseline. Brain MRI was undertaken to obtain baseline measures of neuropathology. A neuropsychological battery was used to assess cognition at each time point. Generalized linear mixed models were used to examine the effect of frailty and MRI measures on cognition over time. The associations between MRI measures and cognition were explored after stratifying the sample by baseline frailty status. All analyses were adjusted for age, sex, and education. RESULTS: A total of 385 participants were included at baseline. The mean age was 72.5 years (standard deviation [SD] 7.0), 44% were female (n = 171). In fully adjusted linear mixed models, frailty (FI × time ß -0.001, 95% confidence interval [CI] -0.003, -0.001, p = .03) was associated with decline in global cognition, independent of brain atrophy, and cSVD. The association between cSVD and global cognition was significant only in those with low levels of frailty (p = .03). CONCLUSION: These findings suggest that frailty is an important factor in early cognitive dysfunction, and measuring frailty may prove useful to help identify future risk of cognitive decline.

Impact of COVID-19 lockdowns on hospital presentations and admissions in the context of low community transmission: evidence from time series analysis in Melbourne, Australia.

BACKGROUND: Melbourne, Australia, successfully halted exponential transmission of COVID-19 via two strict lockdowns during 2020. The impact of such restrictions on healthcare-seeking behaviour is not comprehensively understood, but is of global importance. We explore the impact of the COVID-19 pandemic on acute, subacute and emergency department (ED) presentations/admissions within a tertiary, metropolitan health service in Melbourne, Australia, over two waves of community transmission (1 March to 20 September 2020). METHODS: We used 4 years of historical data and novel forecasting methods to predict counterfactual hospital activity for 2020, assuming absence of COVID-19. Observed activity was compared with forecasts overall, by age, triage category and for myocardial infarction and stroke. Data were analysed for all patients residing in the health service catchment area presenting between 4 January 2016 and 20 September 2020. RESULTS: ED presentations (n=401 805), acute admissions (n=371 723) and subacute admissions (n=15 676) were analysed. Substantial departures from forecasted presentation levels were observed during both waves in the ED and acute settings, and during the second wave in subacute. Reductions were most marked among those aged >80 and <18 years. Presentations persisted at expected levels for urgent conditions, and ED triage categories 1 and 5, with clear reductions in categories 2-4. CONCLUSIONS: Our analyses suggest citizens were willing and able to present with life-threatening conditions during Melbourne's lockdowns, and that switching to telemedicine did not cause widespread spill-over from primary care into ED. During a pandemic, lockdowns may not inhibit appropriate hospital attendance where rates of infectious disease are low.

Is Blood Pressure Lowering in the Very Elderly With Previous Stroke Associated With a Higher Risk of Adverse Events?

Background We investigated whether blood pressure lowering for secondary prevention is associated with a reduction in recurrent stroke risk and/or a higher risk of adverse events in very elderly compared with younger trial participants. Methods and Results This is a random effects meta-analysis of randomized controlled trials of blood pressure lowering for secondary stroke prevention to evaluate age-stratified (<80, ≥80 years) risk of adverse events. Ovid-MEDLINE was searched for trials between 1970 and 2020. Summary-level data were acquired including outcomes of stroke, cardiovascular events, mortality, and adverse events. Seven trials were included comprising 38 596 participants, of whom 2336 (6.1%) were aged ≥80 years. There was an overall reduction in stroke risk in the intervention group compared with controls (risk ratio [RR], 0.90 [95% CI, 0.80, 0.98], I2=49%), and the magnitude of risk reduction did not differ by age subgroup (<80, ≥80 years). There was no increase in the risk of hypotensive symptoms in the intervention group for patients aged <80 years (RR, 1.19 [95% CI, 0.99], 1.44, I2=0%), but there was an increased risk in those ≥80 years (RR, 2.17 [95% CI, 1.22], 3.86, I2=0%). No increase was observed in the risk of falls, syncope, study withdrawal, or falls in either age subgroup. Conclusions Very elderly people in secondary prevention trials of blood pressure lowering have an increased risk of hypotensive symptoms, but with no statistical increase in the risk of falls, syncope, or mortality. However, evidence is lacking for frail elderly with multiple comorbidities who may be more vulnerable to adverse effects of blood pressure lowering.

Feasibility of allied health assistant management of people with acute hip fracture: protocol for a feasibility randomised controlled trial.

INTRODUCTION: Guidelines for hip fracture care state that patients with hip fracture should be mobilised on the day after surgery and at least once a day thereafter. However, compliance with these guidelines is poor. One approach that would assist physiotherapists to meet mobility guidelines after hip fracture is to delegate the provision of daily mobilisation to allied health assistants under their supervision. Therefore, we plan to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient rehabilitation to patients with hip fracture. METHODS AND ANALYSIS: Using a parallel group randomised controlled design with one-to-one allocation, participants will be randomly allocated to an experimental group (allied health assistant management) or a comparison group (physiotherapist management). Inclusion criteria are: adult with diagnosis of hip fracture; inpatient in acute hospital; walked independently pre-hip fracture and able to communicate in conversational English. The experimental group will receive routine physiotherapy rehabilitation, including daily mobilisation, from an allied health assistant following initial physiotherapist assessment. The comparison group will receive routine rehabilitation from a physiotherapist. The primary outcome will be the feasibility of allied health assistant management of patients with hip fracture. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: acceptability (patient satisfaction), demand (proportion of patients who participate), implementation (time allied health assistant/physiotherapist spends with participant, occasions of service) and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant care will be interviewed to explore their perspectives on feasibility. Secondary outcomes include compliance with daily mobilisation guidelines, discharge destination, hospital readmission, falls, functional activity and length of stay. We aim to recruit 50 participants. Descriptive statistics will be used to describe feasibility and mobilisation rates will be calculated using Cox proportional hazards regression to compare compliance with mobilisation guidelines. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Peninsula Health human research ethics committee (HREC/63 005/PH-2020). The findings will be disseminated in peer-reviewed journals and conference presentations. TRAIL REGISTRATION NUMBER: Australian and New Zealand Clinical Trial Registry; ACTRN12620000877987; Pre-results.

A Cohort Study of Anticholinergic Medication Burden and Incident Dementia and Stroke in Older Adults.

BACKGROUND: Anticholinergic medications may increase risk of dementia and stroke, but prospective studies in healthy older people are lacking. OBJECTIVE: Compare risk of incident dementia and stroke by anticholinergic burden among initially healthy older people. DESIGN: Prospective cohort study. SETTING: Primary care (Australia and USA). PARTICIPANTS: 19,114 community-dwelling participants recruited for the ASPREE trial, aged 70+ years (65+ if US minorities) without major cardiovascular disease, dementia diagnosis, or Modified Mini-Mental State Examination score below 78/100. MEASUREMENTS: Baseline anticholinergic exposure was calculated using the Anticholinergic Cognitive Burden (ACB) score. Dementia was adjudicated using Diagnostic and Statistical Manual of Mental Disorders volume IV criteria, and stroke using the World Health Organization definition. RESULTS: At baseline, 15,000 participants (79%) had an ACB score of zero, 2930 (15%) a score of 1-2, and 1184 (6%) a score of ≥ 3 (indicating higher burden). After a median follow-up of 4.7 years and adjusting for baseline covariates, a baseline ACB score of ≥ 3 was associated with increased risk of ischemic stroke (adjusted HR 1.58, 95% CI 1.06, 2.35), or dementia (adjusted HR 1.36, 95% CI 1.01, 1.82), especially of mixed etiology (adjusted HR 1.53, 95% CI 1.06, 2.21). Results were similar for those exposed to moderate/highly anticholinergic medications. LIMITATIONS: Residual confounding and reverse causality are possible. Assessment of dose or duration was not possible. CONCLUSIONS: High anticholinergic burden in initially healthy older people was associated with increased risk of incident dementia and ischemic stroke. A vascular effect may underlie this association. These findings highlight the importance of minimizing anticholinergic exposure in healthy older people.

Interactions Between Age, Sex, Menopause, and Brain Structure at Midlife: A UK Biobank Study.

OBJECTIVES: Age and female sex are risk factors for dementia, and menopause is associated with cognitive dysfunction. Previous work largely considered the effects of sex and menopause as being independent of age. We studied whether age interacts with sex or menopause in explaining imaging biomarkers of dementia during midlife. METHODS: In this cross-sectional study of UK Biobank participants with brain magnetic resonance imaging (MRI), we explored the interaction of age with sex or menopausal status in explaining total brain volume (TBV), gray matter volume (GMV), white matter volume (WMV), white matter hyperintensity volume (WMHV), regional cortical volume , and subcortical volume. RESULTS: Data were available for 1827 postmenopausal women, 230 pre/perimenopausal women and 2165 men (median age 63.3 years). There was a significant interaction between age and sex (P = .024) for TBV, where the inverse association age with TBV was steeper in women (ß = -5.35 mL/year) than in men (ß = -4.77 mL/year). Similar age-sex interactions were also observed for GMV and WMV. In women, there was a significant interaction between age and menopausal status (P = .007) where the inverse association of age with TBV was steeper in postmenopausal (ß = -5.89 mL/year) than in pre/perimenopausal women (ß = -1.61 mL/year). Similar age-menopause interactions were found in predicting lower GMV and higher WMHV. Differences in the direction of these age-sex and age-menopause interactions were found for regional cortical and subcortical brain volumes. CONCLUSION: Sex and menopause both interact with age during midlife in explaining MRI biomarkers of dementia. Further work is required to understand the mechanisms driving these interactions to develop strategies for delaying dementia.