'Atawhai': a primary care provider-led response to family violence in Aotearoa New Zealand.

BACKGROUND: As a key determinant of ill-health, family violence is inadequately responded to within Aotearoa New Zealand health policy and practice. Without adequate system support, health professionals can often be unsure of what to do, or how to help. Developed in response to this system gap, 'Atawhai' aims to make it easier for primary care professionals to respond to family violence. METHODS: Underpinned by indigenous Maori customs, Atawhai combines complexity theory and participatory research methodologies to be responsive to the complexity involved in family violence. We worked with 14 primary care professionals across ten whakawhitiwhiti korero wananga (meetings for deliberate dialogue) to identify and develop primary care system pathways and tools for responding to family violence. This paper focuses on the development of Atawhai through wananga and observation methods. Methods used to capture change will be reported separately. FINDINGS: Atawhai is a relational response to family violence, focused on developing a network of trusted relationships between health and social care professionals to support safe responses to those accessing care. This study identified four key health system pathways to responsiveness and developed associated tools to support health care responsiveness to family violence. We found the quality of relationships, both among professionals and with those accessing care, coupled with critical reflection on the systems and structures that shape policy and practice are essential in generating change within primary care settings. CONCLUSIONS: Atawhai is a unique health care response to family violence evidenced on empirical knowledge of primary care professionals. Our theoretical lens calls attention to parts of the system often obscured by current health care responses to family violence. Atawhai presents an opportunity to develop a grassroots-informed, long-term response to family violence that evolves in response to needs.

He Rourou Whai Painga, an Aotearoa New Zealand dietary pattern for metabolic health and whanau wellbeing: protocol for a randomized controlled trial.

Background: Cardiometabolic diseases are highly prevalent in Aotearoa New Zealand. Dietary intake is a modifiable risk factor for such diseases and certain dietary patterns, specifically the Mediterranean diet (MedDiet), are associated with improved metabolic health. This study aims to test whether an intervention including a Mediterranean dietary pattern incorporating high quality New Zealand foods (NZMedDiet pattern) and behavior change science can improve the metabolic health of participants and their household/whanau. Methods and analysis: This is a multi-center, three-stage trial with two parallel group superiority randomized controlled trials (RCTs), and a longitudinal cohort study embedded within the trial design. The first RCT (RCT 1) is a comparison of the NZMedDiet pattern compared to usual diet for 12 weeks. The Behavior Change Wheel was used to select and implement strategies to support participant adherence to the NZMedDiet, such as web-based nutrition education on healthy shopping and cooking. The second (RCT 2) compares online social support to no online social support for 12 weeks, administered to participants immediately following RCT 1. The third stage is a longitudinal cohort study where all participants are followed from the beginning of their start of the active intervention for 12 months in total. The primary outcome measure for each stage is the metabolic syndrome severity score (MetSSS). The duration of enrolment is 12-15 months. The total recruitment target is 200 index participants and their household/whanau members who participate with them, and the primary analyses will be intention to treat on index participants. Discussion: The trial will test whether the NZMedDiet pattern and behavior change support improves the cardiometabolic health of people in Aotearoa New Zealand. Clinical trial registration: https://www.anzctr.org.au/Default.aspx, identifier ACTRN12622000906752 and https://www.isrctn.com/, identifier ISRCTN89011056 (Spirit 2).

Call to action-the urgent need for a heart health plan in New Zealand.

Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Maori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.

The Role of a Composite Fitness Score in the Association Between Low-Density Cholesterol and All-Cause Mortality in Older Adults: An Individual Patient Data Meta-Analysis.

BACKGROUND: In the general population, an increase in low-density lipoprotein cholesterol (LDL-C) predicts higher cardiovascular disease risk, and lowering LDL-C can prevent cardiovascular disease and reduces mortality risk. Interestingly, in cohort studies that include very old populations, no or inverse associations between LDL-C and mortality have been observed. This study aims to investigate whether the association between LDL-C and mortality in the very old is modified by a composite fitness score. METHODS: A 2-stage meta-analysis of individual participant data from the 5 observational cohort studies. The composite fitness score was operationalized by performance on a combination of 4 markers: functional ability, cognitive function, grip strength, and morbidity. We pooled hazard ratios (HR) from Cox proportional-hazards models for 5-year mortality risk for a 1 mmol/L increase in LDL-C. Models were stratified by high/low composite fitness score. RESULTS: Composite fitness scores were calculated for 2 317 participants (median 85 years, 60% females participants), of which 994 (42.9%) had a high composite fitness score, and 694 (30.0%) had a low-composite fitness score. There was an inverse association between LDL-C and 5-year mortality risk (HR 0.87 [95% CI: 0.80-0.94]; p < .01), most pronounced in participants with a low-composite fitness score (HR 0.85 [95% CI: 0.75-0.96]; p = .01), compared to those with a high composite fitness score (HR = 0.98 [95% CI: 0.83-1.15]; p = .78), the test for subgroups differences was not significant. CONCLUSIONS: In this very old population, there was an inverse association between LDL-C and all-cause mortality, which was most pronounced in participants with a low-composite fitness scores.

Atrial fibrillation incidence and outcomes in two cohorts of octogenarians: LiLACS NZ.

BACKGROUND: Atrial fibrillation (AF), the most common cardiac arrhythmia in the general population, has significant healthcare burden. Little is known about AF in octogenarians. OBJECTIVE: To describe the prevalence and incidence rate of AF in New Zealand (NZ) octogenarians and the risk of stroke and mortality at 5-year follow-up. DESIGN: Longitudinal Cohort Study. SETTING: Bay of Plenty and Lakes health regions of New Zealand. SUBJECTS: Eight-hundred-seventy-seven (379 indigenous Maori, 498 non-Maori) were included in the analysis. METHODS: AF, stroke/TIA events and relevant co-variates were established annually using self-report and hospital records (and ECG for AF). Cox proportional-hazards regression models were used to determine the time dependent AF risk of stroke/TIA. RESULTS: AF was present in 21% at baseline (Maori 26%, non-Maori 18%), the prevalence doubled over 5-years (Maori 50%, non-Maori 33%). 5-year AF incidence was 82.6 /1000-person years and at all times AF incidence for Maori was twice that of non-Maori. Five-year stroke/TIA prevalence was 23% (22% in Maori and 24% non- Maori), higher in those with AF than without. AF was not independently associated with 5-year new stroke/TIA; baseline systolic blood pressure was. Mortality was higher for Maori, men, those with AF and CHF and statin use was protective. In summary, AF is more prevalent in indigenous octogenarians and should have an increased focus in health care management. Further research could examine treatment in more detail to facilitate ethnic specific impact and risks and benefits of treating AF in octogenarians.

Prognostic modelling of clinical outcomes after first-time acute coronary syndrome in New Zealand.

OBJECTIVE: The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported. METHODS: First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity. RESULTS: Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Maori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Maori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log2(NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Maori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084. CONCLUSIONS: In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Maori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score. TRIAL REGISTRATION NUMBER: ACTRN12615000676516.

Navigating the space between co-design and mahitahi: Building bridges between knowledge systems on behalf of communities.

AIMS: To provide knowledge and recommendations for researchers, health professionals and policymakers on navigating between science and matauranga (knowledge) Maori when using co-design methodologies. CONTEXT: It is well known that the health system in Aotearoa/New Zealand does not provide culturally responsive services, programmes or approaches. Indigenous, remote and vulnerable populations that are not well served by medical and scientific models would be better served by the underlying premise of co-design methodology. However, co-design is a Western methodology. Mahitahi is presented here as a culturally responsive method of co-design that builds approaches by utilising the worldview of the people that the health system most needs to have impact upon. Co-design and mahitahi have synergies, and working at the interface between Western and Maori knowledge systems can provide innovative solutions that draw on the strengths of both approaches. APPROACH: Authors will outline the benefit co-design processes have for improving health outcomes for remote and vulnerable populations. Mahitahi will be described and the synergies with co-design emphasised with important distinctions also highlighted. The use of Indigenous knowledge systems, using Maori as the case example, will be outlined. CONCLUSION: Recommendations will be provided to guide researchers, health professionals and policy makers when planning a co-design approach with remote and vulnerable communities.

Cultural context in New Zealand: incorporating kaupapa Maori values in clinical research and practice.

We examined the importance of understanding and incorporating cultural context within Aotearoa/New Zealand when engaging in clinical research and practice. This paper reports on the qualitative findings of a mixed methods study aimed at determining what effect a cardiac risk reduction exercise and lifestyle management programme, embedded within a kaupapa Maori methodological approach, had on Maori participants. This methodology saw participants able to redevelop a western model cardiac risk reduction programme by introducing a Maori worldview. Our study revealed how the kaupapa Maori approach empowered participants to examine and evaluate not only their own health and lifestyle choices, but those of family and the wider community. Combining biomedical and kaupapa Maori components into the programme was found to benefit participants' mental, physical, spiritual and family well-being.

Disentangling the varying associations between systolic blood pressure and health outcomes in the very old: an individual patient data meta-analysis.

OBJECTIVES: While randomized controlled trials have proven the benefits of blood pressure (BP) lowering in participating octogenarians, population-based observational studies suggest an association between low systolic blood pressure (SBP) and faster overall decline. This study investigates the effects of BP-lowering treatment, a history of cardiovascular diseases (CVD), and cognitive and physical fitness on the associations between SBP and health outcomes in the very old. METHODS: Five cohorts from the Towards Understanding Longitudinal International older People Studies (TULIPS) consortium were included in a two-step individual participant data meta-analysis (IPDMA). We pooled hazard ratios (HR) from Cox proportional-hazards models for 5-year mortality and estimates of linear mixed models for change in cognitive and functional decline. Models were stratified by BP-lowering treatment, history of CVD, Mini-Mental State Examination scores, grip strength (GS) and body mass index (BMI). RESULTS: Of all 2480 participants (59.9% females, median 85 years), median baseline SBP was 149 mmHg, 64.3% used BP-lowering drugs and 47.3% had a history of CVD. Overall, higher SBP was associated with lower all-cause mortality (pooled HR 0.91 [95% confidence interval 0.88-0.95] per 10 mmHg). Associations remained irrespective of BP-lowering treatment, history of CVD and BMI, but were absent in octogenarians with above-median MMSE and GS. In pooled cohorts, SBP was not associated with cognitive and functional decline. CONCLUSION: While in the very old with low cognitive or physical fitness a higher SBP was associated with a lower all-cause mortality, this association was not evident in fit octogenarians. SBP was not consistently associated with cognitive and functional decline.

Optimising function and well-being in older adults: protocol for an integrated research programme in Aotearoa/New Zealand.

BACKGROUND: Maintaining independence is of key importance to older people. Ways to enable health strategies, strengthen and support whanau (family) at the community level are needed. The Ageing Well through Eating, Sleeping, Socialising and Mobility (AWESSOM) programme in Aotearoa/New Zealand (NZ) delivers five integrated studies across different ethnicities and ages to optimise well-being and to reverse the trajectory of functional decline and dependence associated with ageing. METHODS: Well-being, independence and the trajectory of dependence are constructs viewed differently according to ethnicity, age, and socio-cultural circumstance. For each AWESSoM study these constructs are defined and guide study development through collaboration with a wide range of stakeholders, and with reference to current evidence. The Compression of Functional Decline model (CFD) underpins aspects of the programme. Interventions vary to optimise engagement and include a co-developed whanau (family) centred initiative (Nga Pou o Rongo), the use of a novel LifeCurve™App to support behavioural change, development of health and social initiatives to support Pacific elders, and the use of a comprehensive oral health and cognitive stimulation programme for cohorts in aged residential care. Running parallel to these interventions is analysis of large data sets from primary care providers and national health databases to understand complex multi-morbidities and identify those at risk of adverse outcomes. Themes or target areas of sleep, physical activity, oral health, and social connectedness complement social capital and community integration in a balanced programme involving older people across the ability spectrum. DISCUSSION: AWESSoM delivers a programme of bespoke yet integrated studies. Outcomes and process analysis from this research will inform about novel approaches to implement relevant, socio-cultural interventions to optimise well-being and health, and to reverse the trajectory of decline experienced with age. TRIAL REGISTRATION: The At-risk cohort study was registered by the Australian New Zealand Clinical Trials registry on 08/12/2021 (Registration number ACTRN 12621001679875 ).

The Diet Quality and Nutrition Inadequacy of Pre-Frail Older Adults in New Zealand.

This study aimed to describe the diet quality of pre-frail community-dwelling older adults to extend the evidence of nutrition in frailty prevention. Pre-frailty, the transition state between a robust state and frailty, was ascertained using the FRAIL scale. Socio-demographic, health status, and 24-h dietary recalls were collected from 465 community-dwelling adults aged 75+ (60 years for Maori and Pacific people) across New Zealand. Diet quality was ascertained with the Diet Quality Index-International (DQI-I). Participants (median (IQR) age 80 (77-84), 59% female) had a moderately healthful diet, DQI-I score: 60.3 (54.0-64.7). Women scored slightly higher than men (p = 0.042). DQI-I components identified better dietary variety in men (p = 0.044), and dietary moderation in women (p = 0.002); both sexes performed equally well in dietary adequacy and poorly in dietary balance scores (73% and 47% of maximum scores, respectively). Low energy 20.3 (15.4-25.3) kcal/kg body weight (BW) and protein intakes 0.8 (0.6-1.0) g/kg BW were coupled with a high prevalence of mineral inadequacies: calcium (86%), magnesium (68%), selenium (79%), and zinc (men 82%). In conclusion, the diet quality of pre-frail older adults was moderately high in variety and adequacy but poor in moderation and balance. Our findings support targeted dietary interventions to ameliorate frailty.

Association of Daily Physical Activity and Sedentary Behaviour with Protein Intake Patterns in Older Adults: A Multi-Study Analysis across Five Countries.

Physical activity and protein intake are associated with ageing-related outcomes, including loss of muscle strength and functional decline, so may contribute to strategies to improve healthy ageing. We investigated the cross-sectional associations between physical activity or sedentary behaviour and protein intake patterns in community-dwelling older adults across five countries. Self-reported physical activity and dietary intake data were obtained from two cohort studies (Newcastle 85+ Study, UK; LiLACS, New Zealand Maori and Non-Maori) and three national food consumption surveys (DNFCS, The Netherlands; FINDIET, Finland; INRAN-SCAI, Italy). Associations between physical activity and total protein intake, number of eating occasions providing protein, number of meals with specified protein thresholds, and protein intake distribution over the day (calculated as a coefficient of variance) were assessed by regression and repeated measures ANOVA models adjusting for covariates. Greater physical activity was associated with higher total protein intake and more eating occasions containing protein, although associations were mostly explained by higher energy intake. Comparable associations were observed for sedentary behaviour in older adults in Italy. Evidence for older people with higher physical activity or less sedentary behaviour achieving more meals with specified protein levels was mixed across the five countries. A skewed protein distribution was observed, with most protein consumed at midday and evening meals without significant differences between physical activity or sedentary behaviour levels. Findings from this multi-study analysis indicate there is little evidence that total protein and protein intake patterns, irrespective of energy intake, differ by physical activity or sedentary behaviour levels in older adults.

An Intervention to Improve Medication Adherence in People With Heart Disease (Text4HeartII): Randomized Controlled Trial.

BACKGROUND: Mobile health technologies have the potential to improve the reach and delivery of interventions for promoting long-term secondary prevention of coronary heart disease. OBJECTIVE: This study aims to determine the effectiveness of an SMS text messaging intervention (Text4HeartII) for improving adherence to medication and lifestyle changes over and above usual care in people with coronary heart disease at 24 and 52 weeks. METHODS: A two-arm, parallel, randomized controlled trial was conducted in New Zealand. Participants with a recent acute coronary syndrome were randomized to receive usual cardiac services alone (control, n=153) or a 24-week SMS text message program for supporting self-management plus usual cardiac services (n=153). The primary outcome was adherence to medication at 24 weeks, defined as a medication possession ratio of 80% or more for aspirin, statin, and antihypertensive therapy. Secondary outcomes included medication possession ratio at 52 weeks, self-reported medication adherence, adherence to healthy lifestyle behaviors, and health-related quality of life at 24 and 52 weeks. RESULTS: Participants were predominantly male (113/306, 80.3%) and European New Zealanders (210/306, 68.6%), with a mean age of 61 years (SD 11 years). Groups were comparable at baseline. National hospitalization and pharmacy dispensing records were available for all participants; 92% (282/306, 92.1%) of participants completed a 24-week questionnaire and 95.1% (291/306) of participants completed a 52-week questionnaire. Adherence with 3 medication classes were lower in the intervention group than in the control group (87/153, 56.8% vs 105/153, 68.6%, odds ratio 0.60, 95% CI 0.38-0.96; P=.03) and 52 weeks (104/153, 67.9% vs 83/153, 54.2%; odds ratio 0.56, 95% CI 0.35-0.89; P=.01). Self-reported medication adherence scores showed the same trend at 52 weeks (mean difference 0.3; 95% CI 0.01-0.59; P=.04). Moreover, self-reported adherence to health-related behaviors was similar between groups. CONCLUSIONS: Text4HeartII did not improve dispensed medication or adherence to a favorable lifestyle over and above usual care. This finding contrasts with previous studies and highlights that the benefits of text interventions may depend on the context in which they are used. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000422426; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370398. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-018-2468-z.

Association between dietary protein intake and change in grip strength over time among adults of advanced age: Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ).

OBJECTIVE: To determine the association between dietary protein intake and change in grip strength (GS) over time among Maori and non-Maori of advanced age. METHODS: Protein intake was estimated from 2×24h multiple pass recall (MPR) in 554 participants, and GS was measured yearly over five years. Anthropometric, physical activity and health data were collected. RESULTS: The median weight-adjusted protein intake was low (for Maori and non-Maori men 1.05 and 0.98g/kg/day; for Maori and non-Maori women 0.87 and 0.91g/kg/day, respectively). There was a general decrease in GS over five years (mean % change of -2.38 ± 15.32 and -4.49 ± 21.92 for Maori and non-Maori women and -5.47 ± 16.09 and -1.81 ± 13.16 for Maori and non-Maori men yearly). Intake of protein was not related to GS at any of the five-year assessment points nor was it related to change over time. CONCLUSION: Protein intake was low in this cohort of octogenarians and was not protective against loss of GS over five years.

Ha Ora: secondary care barriers and enablers to early diagnosis of lung cancer for Maori communities.

BACKGROUND: Lung Cancer is the leading cause of cancer deaths in Aotearoa New Zealand. Maori communities in particular have higher incidence and mortality rates from Lung Cancer. Diagnosis of lung cancer at an early stage can allow for curative treatment. This project aimed to document the barriers to early diagnosis and treatment of lung cancer in secondary care for Maori communities. METHODS: This project used a kaupapa Maori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Community hui included cancer patients, whanau (families), and other community members. Healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed. RESULTS: Barriers and enablers to early diagnosis of lung cancer were categorised into two broad themes: Specialist services and treatment, and whanau journey. The barriers and enablers that participants experienced in specialist services and treatment related to access to care, engagement with specialists, communication with specialist services and cultural values and respect, whereas barriers and enablers relating to the whanau journey focused on agency and the impact on whanau. CONCLUSIONS: The study highlighted the need to improve communication within and across healthcare services, the importance of understanding the cultural needs of patients and whanau and a health system strategy that meets these needs. Findings also demonstrated the resilience of Maori and the active efforts of whanau as carers to foster health literacy in future generations.

Indigenous perspectives on breaking bad news: ethical considerations for healthcare providers.

Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Maori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Maori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairawhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP-patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Maori and Indigenous patients.

Anaemia and physical and mental health in the very old: An individual participant data meta-analysis of four longitudinal studies of ageing.

OBJECTIVE: To determine the physical and mental health of very old people (aged 80+) with anaemia. METHODS: Individual level meta-analysis from five cohorts of octogenarians (n = 2,392): LiLACS NZ Maori, LiLACS NZ non-Maori, Leiden 85-plus Study, Newcastle 85+ Study, and TOOTH. Mixed models of change in functional ability, cognitive function, depressive symptoms, and self-rated health over time were separately fitted for each cohort. We combined individual cohort estimates of differences according to the presence of anaemia at baseline, adjusting for age at entry, sex, and time elapsed. Combined estimates are presented as differences in standard deviation units (i.e. standardised mean differences-SMDs). RESULTS: The combined prevalence of anaemia was 30.2%. Throughout follow-up, participants with anaemia, on average, had: worse functional ability (SMD -0.42 of a standard deviation across cohorts; CI -0.59,-0.25); worse cognitive scores (SMD -0.27; CI -0.39,-0.15); worse depression scores (SMD -0.20; CI -0.31,-0.08); and lower ratings of their own health (SMD -0.36; CI -0.47,-0.25). Differential rates of change observed were: larger declines in functional ability for those with anaemia (SMD -0.12 over five years; CI -0.21,-0.03) and smaller mean difference in depression scores over time between those with and without anaemia (SMD 0.18 over five years; CI 0.05,0.30). CONCLUSION: Anaemia in the very old is a common condition associated with worse functional ability, cognitive function, depressive symptoms, and self-rated health, and a more rapid decline in functional ability over time. The question remains as to whether anaemia itself contributes to worse outcomes or is simply a marker of chronic diseases and nutrient deficiencies.

Outcomes of Thyroid Dysfunction in People Aged Eighty Years and Older: An Individual Patient Data Meta-Analysis of Four Prospective Studies (Towards Understanding Longitudinal International Older People Studies Consortium).

Background: Subclinical and overt thyroid dysfunction is easily detectable, often modifiable, and, in younger age groups, has been associated with clinically relevant outcomes. Robust associations in very old persons, however, are currently lacking. This study aimed to investigate the associations between (sub-)clinical thyroid dysfunction and disability in daily living, cognitive function, depressive symptoms, physical function, and mortality in people aged 80 years and older. Methods: Four prospective cohorts participating in the Towards Understanding Longitudinal International older People Studies (TULIPS) consortium were included. We performed a two-step individual participant data meta-analysis on source data from community-dwelling participants aged 80 years and older from the Netherlands, New Zealand, United Kingdom, and Japan. Outcome measures included disability in daily living (disability in activities of daily living [ADL] questionnaires), cognitive function (Mini-Mental State Examination [MMSE]), depressive symptoms (Geriatric Depression Scale [GDS]), physical function (grip strength) at baseline and after 5 years of follow-up, and all-cause five-year mortality. Results: Of the total 2116 participants at baseline (mean age 87 years, range 80-109 years), 105 participants (5.0%) were overtly hypothyroid, 136 (6.4%) subclinically hypothyroid, 1811 (85.6%) euthyroid, 60 (2.8%) subclinically hyperthyroid, and 4 (0.2%) overtly hyperthyroid. Participants with thyroid dysfunction at baseline had nonsignificantly different ADL scores compared with euthyroid participants at baseline and had similar MMSE scores, GDS scores, and grip strength. There was no difference in the change of any of these functional measures in participants with thyroid dysfunction during five years of follow-up. Compared with the euthyroid participants, no 5-year survival differences were identified in participants with overt hypothyroidism (hazard ratio [HR] 1.0, 95% confidence interval [CI 0.6-1.6]), subclinical hypothyroidism (HR 0.9 [CI 0.7-1.2]), subclinical hyperthyroidism (HR 1.1 [CI 0.8-1.7]), and overt hyperthyroidism (HR 1.5 [CI 0.4-5.9]). Results did not differ after excluding participants using thyroid-influencing medication. Conclusions: In community-dwelling people aged 80 years and older, (sub-)clinical thyroid dysfunction was not associated with functional outcomes or mortality and may therefore be of limited clinical significance.