Tess Harris

What factors are associated with physical activity in older people, assessed objectively by accelerometry?

Objectives: To assess physical activity (PA) levels measured objectively using accelerometers in community-dwelling older people and to examine the associations with health, disability, anthropometric measures and psychosocial factors. Design: Cross-sectional survey. Setting: Single general practice (primary care centre), United Kingdom. Participants: Random selection of 560 community-dwelling older people at least 65 years old, registered with the practice. 43% (238/560) participated. Assessment of risk factors: Participants completed a questionnaire assessing health, disability, psychosocial factors and PA levels; underwent anthropometric assessment; and wore an accelerometer (Actigraph) for 7 days. Main outcome measures: Average daily accelerometer step-counts and time spent in different PA levels. Associations between step-counts and other factors were examined using linear regression. Results: Average daily step-count was 6443 (95% CI 6032 to 6853). Men achieved 754 (84 to 1424) more steps daily than women. Step-count declined steadily with age. Independent predictors of average daily step-count were: age; general health; disability; diabetes; body mass index; exercise self-efficacy; and perceived exercise control. Activities associated independently with higher step-counts included number of long walks and dog-walking. Only 2.5% (6/238) of participants achieved the recommended 150 minutes weekly of at least moderate-intensity activity in ⩾10 minute bouts; 62% (147/238) achieved none. Conclusions: This is the first population-based sample of older people with objective PA and anthropometric measures. PA levels in older people are well below recommended levels, emphasising the need to increase PA in this age group, particularly in those who are overweight/obese or have diabetes. The independent effects of exercise self-efficacy and exercise control on PA levels highlight their role as potential mediators for intervention studies.

A Comparison of Questionnaire, Accelerometer, and Pedometer: Measures in Older People

PURPOSE To compare (i) the convergent validity of the self-report Zutphen Physical Activity Questionnaire with the 7-d objective physical activity (PA) measurement by accelerometers and pedometers and (ii) the construct validity of these measures by examining their associations with physical health and psychological and anthropometric variables. METHODS Five hundred and sixty community-dwelling people aged > or =65 yr were invited from a UK primary care practice and 238 (43%) participated (mean age = 74, 53% male). PA was assessed subjectively by the Zutphen questionnaire (modified to include housework questions) and objectively by the 7-d accelerometer monitoring: a random half also had a pedometer. A questionnaire assessed health, disability, and psychological factors, and anthropometric assessment was performed. RESULTS Mean daily PA levels were as follows: Zutphen = 9.1 kcal x kg(-1) x d(-1) (SD = 6.6 kcal x kg(-1) x d(-1)); accelerometer activity count = 226,648 (SD = 121,966); accelerometer step count = 6495 (SD = 3212); and pedometer step count = 6712 (SD = 3526). Zutphen score was moderately correlated with accelerometer activity count (R = 0.34, P < 0.001) and pedometer step count (R = 0.36, P < 0.001). Pedometer step count was highly correlated with accelerometer activity count (R = 0.82, P< 0.001) and accelerometer step count (R = 0.86, P < 0.001). Objective PA measures showed strong associations with health and anthropometric and psychological variables. Zutphen score was not significantly related to most health or anthropometric measures but was associated with psychological variables and provided information about activity type. CONCLUSIONS Convergent validity was strong between accelerometers and pedometers but weaker between these and self-report Zutphen. Pedometers may be preferred to accelerometers for simple studies due to their lower cost. Objective measures had better construct validity, being more strongly associated with established PA determinants, and thus offered better value to researchers than the questionnaire, but the latter provided useful detail on activity type, so a combined approach to PA assessment may be preferable.

Does β‐adrenoceptor blocker therapy improve cancer survival? Findings from a population‐based retrospective cohort study

AIMS To examine the effect of β-adrenoceptor blocker treatment on cancer survival. METHODS In a UK primary care database, we compared patients with a new cancer diagnosis receiving β-adrenoceptor blockers regularly (n= 1406) with patients receiving other antihypertensive medication (n= 2056). RESULTS Compared with cancer patients receiving other antihypertensive medication, patients receiving β-adrenoceptor blocker therapy experienced slightly poorer survival (HR = 1.18, 95% CI 1.04, 1.33 for all β-adrenoceptor blockers; HR = 1.21, 95% CI 0.94, 1.55 for non-selective β-adrenoceptor blockers). This poorer overall survival was explained by patients with pancreatic and prostate cancer with no evidence of an effect on survival for patients with lung, breast or colorectal cancer. Analysis in a cancer-free matched parallel cohort did not suggest selection bias masked a beneficial effect. CONCLUSION Our study does not support the hypothesis that β-adrenoceptor blockers improve survival for common cancers.

A primary care nurse-delivered walking intervention in older adults: PACE (pedometer accelerometer consultation evaluation)-lift cluster randomised controlled trial

Background Brisk walking in older people can increase step-counts and moderate to vigorous intensity physical activity (MVPA) in ≥10-minute bouts, as advised in World Health Organization guidelines. Previous interventions have reported step-count increases, but not change in objectively measured MVPA in older people. We assessed whether a primary care nurse-delivered complex intervention increased objectively measured step-counts and MVPA. Methods and Findings A total of 988 60–75 year olds, able to increase walking and randomly selected from three UK family practices, were invited to participate in a parallel two-arm cluster randomised trial; randomisation was by household. Two-hundred-ninety-eight people from 250 households were randomised between 2011 and 2012; 150 individuals to the intervention group, 148 to the usual care control group. Intervention participants received four primary care nurse physical activity (PA) consultations over 3 months, incorporating behaviour change techniques, pedometer step-count and accelerometer PA intensity feedback, and an individual PA diary and plan. Assessors were not blinded to group status, but statistical analyses were conducted blind. The primary outcome was change in accelerometry assessed average daily step-counts between baseline and 3 months, with change at 12 months a secondary outcome. Other secondary outcomes were change from baseline in time in MVPA weekly in ≥10-minute bouts, accelerometer counts, and counts/minute at 3 months and 12 months. Other outcomes were adverse events, anthropometric measures, mood, and pain. Qualitative evaluations of intervention participants and practice nurses assessed the intervention’s acceptability. At 3 months, eight participants had withdrawn or were lost to follow-up, 280 (94%) individuals provided primary outcome data. At 3 months changes in both average daily step-counts and weekly MVPA in ≥10-minute bouts were significantly higher in the intervention than control group: by 1,037 (95% CI 513–1,560) steps/day and 63 (95% CI 40–87) minutes/week, respectively. At 12 months corresponding differences were 609 (95% CI 104–1,115) steps/day and 40 (95% CI 17–63) minutes/week. Counts and counts/minute showed similar effects to steps and MVPA. Adverse events, anthropometry, mood, and pain were similar in the two groups. Participants and practice nurses found the intervention acceptable and enjoyable. Conclusions The PACE-Lift trial increased both step-counts and objectively measured MVPA in ≥10-minute bouts in 60–75 year olds at 3 and 12 months, with no effect on adverse events. To our knowledge, this is the first trial in this age group to demonstrate objective MVPA increases and highlights the value of individualised support incorporating objective PA assessment in a primary care setting. Trial Registration Controlled-Trials.com ISRCTN42122561

Antipsychotic prescribing to older people living in care homes and the community in England and Wales

Excessive use of antipsychotic medication by older people is an international concern, but there is limited comparative information on their use in different residential settings. This paper describes and compares antipsychotic prescribing to older people in care homes and the community in England and Wales.

Increased risk of acute cardiovascular events after partner bereavement: a matched cohort study.

IMPORTANCE The period immediately after bereavement has been reported as a time of increased risk of cardiovascular events. However, this risk has not been well quantified, and few large population studies have examined partner bereavement. OBJECTIVE To compare the rate of cardiovascular events between older individuals whose partner dies with those of a matched control group of individuals whose partner was still alive on the same day. DESIGN, SETTING, AND PARTICIPANTS Matched cohort study using a UK primary care database containing availale data of 401 general practices from February 2005 through September 2012. In all, 30 447 individuals aged 60 to 89 years at study initiation who experienced partner bereavement during follow-up were matched by age, sex, and general practice with the nonbereaved control group (n = 83 588) at the time of bereavement. EXPOSURES Partner bereavement. MAIN OUTCOMES AND MEASURES The primary outcome was occurrence of a fatal or nonfatal myocardial infarction (MI) or stroke within 30 days of bereavement. Secondary outcomes were non-MI acute coronary syndrome and pulmonary embolism. All outcomes were compared between the groups during prespecified periods after bereavement (30, 90, and 365 days). Incidence rate ratios (IRRs) from a conditional Poisson model were adjusted for age, smoking status, deprivation, and history of cardiovascular disease. RESULTS Within 30 days of their partners death, 50 of the bereaved group (0.16%) experienced an MI or a stroke compared with 67 of the matched nonbereaved controls (0.08%) during the same period (IRR, 2.20 [95% CI, 1.52-3.15]). The increased risk was seen in bereaved men and women and attenuated after 30 days. For individual outcomes, the increased risk was found separately for MI (IRR, 2.14 [95% CI, 1.20-3.81]) and stroke (2.40 [1.22-4.71]). Associations with rarer events were also seen after bereavement, including elevated risk of non-MI acute coronary syndrome (IRR, 2.20 [95% CI, 1.12-4.29]) and pulmonary embolism (2.37 [1.18-4.75]) in the first 90 days. CONCLUSIONS AND RELEVANCE This study provides further evidence that the death of a partner is associated with a range of major cardiovascular events in the immediate weeks and months after bereavement. Understanding psychosocial factors associated with acute cardiovascular events may provide opportunities for prevention and improved clinical care.

Mortality in older care home residents in England and Wales

BACKGROUND mortality in UK care homes is not well described. OBJECTIVE to describe 1-year mortality and predictors in older care home residents compared with community residents. METHOD cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009. RESULTS a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes. CONCLUSIONS older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study

Objective To describe the quality of care for chronic diseases among older people in care homes (nursing and residential) compared with the community in a pay for performance system. Design Retrospective analysis of The Health Improvement Network (THIN), a large primary care database. Setting 326 English and Welsh general practices, 2008-9. Participants 10 387 residents of care homes and 403 259 residents in the community aged 65 to 104 and registered for 90 or more days with their general practitioner. Main outcome measure 16 process quality indicators for chronic disease management appropriate for vulnerable older people for conditions included in the UK Quality and Outcomes Framework. Results After adjustment for age, sex, dementia, and length of registration, attainment of quality indicators was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators. The largest differences were for prescribing in heart disease (β blockers in coronary heart disease, relative risk 0.70, 95% confidence interval 0.65 to 0.75) and monitoring of diabetes (retinal screening, 0.75, 0.71 to 0.80). Monitoring hypothyroidism (0.93, 0.90 to 0.95), blood pressure in people with stroke (0.92, 0.90 to 0.95), and electrolytes for those receiving loop diuretics (0.89, 0.87 to 0.92) showed smaller differences. Attainment was lower in nursing homes than in residential homes. Residents of care homes were more likely to be identified by their doctor as unsuitable or non-consenting for all Quality and Outcomes Framework indicators for a condition allowing their exclusion from targets; 33.7% for stroke and 34.5% for diabetes. Conclusion There is scope for improving the management of chronic diseases in care homes, but high attainment of some indicators shows that pay for performance systems do not invariably disadvantage residents of care homes compared with those living in the community. High use of exception reporting may compromise care for vulnerable patient groups. The Quality and Outcomes Framework, and other pay for performance systems, should monitor attainment and exception reporting in vulnerable populations such as residents of care homes and consider measures that deal with the specific needs of older people.

A new simple primary care morbidity score predicted mortality and better explains between practice variations than the Charlson index

OBJECTIVES Adjustment for morbidity is important to ensure fair comparison of outcomes between patient groups and health care providers. The Quality and Outcomes Framework (QOF) in UK primary care offers potential for developing a standardized morbidity score for low-risk populations. STUDY DESIGN AND SETTING Retrospective cohort study of 653,780 patients aged 60 years or older registered with 375 practices in 2008 in a large primary care database (The Health Improvement Network). Half the practices were randomly selected to derive a morbidity score predicting 1-year mortality; the others assessed predictive performance. RESULTS Nine chronic conditions were robust copredictors (hazard ratio = ≥1.2) of mortality independent of age and sex, producing high predictive discrimination (c-statistic = 0.82). An individuals QOF score explained more between practice variation in mortality than the Charlson index (46% vs. 32%). At practice level, mean QOF score was strongly correlated with practice standardized mortality ratios (r = 0.64), explaining more variation in practice death rates than the Charlson index. CONCLUSION A simple nine-item score derived from routine primary care recording provides a morbidity index highly predictive of mortality and between practice variation in older UK primary care populations. This has utility in research and health care outcome monitoring and can be easily implemented in other primary and ambulatory care settings.

Diabetes and infection: assessing the association with glycaemic control in population-based studies

Diabetes is a leading cause of morbidity and mortality. The global burden of diabetes is rising because of increased obesity and population ageing. Although preventive and treatment measures are well documented for macrovascular and microvascular complications, little such guidance exists for infections in people with diabetes, despite evidence suggesting greater susceptibility to infections, and worse outcomes. In particular, few studies have characterised the relation between glycaemic control and infectious disease, which we discuss in this Review. Some large population-based observational studies have reported strong associations between higher HbA1c and infection risks for both type 1 and type 2 diabetes. However, studies are contradictory, underpowered, or do not control for confounders. Evidence suggests that better glycaemic control might reduce infection risk, but further longitudinal studies with more frequent measures of HbA1c are needed. Older people (aged 70 years or older) with diabetes are at increased risk of complications, including infectious diseases. There is more uncertainty about appropriate glycaemic control targets in this age group, and evidence suggests that glycaemic control is often neglected. Robust evidence from cohorts with sufficient numbers of older people would help to develop clinically relevant guidelines and targets to reduce mortality, morbidity, and antibiotic use, and to improve quality of life.