Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90.

OBJECTIVES: To describe the incidence and extent of lying on the floor for a long time after being unable to get up from a fall among people aged over 90; to explore their use of call alarm systems in these circumstances. DESIGN: 1 year follow-up of participants in a prospective cohort study of ageing, using fall calendars, phone calls, and visits. SETTING: Participants' usual place of residence (own homes or care homes), mostly in Cambridge. PARTICIPANTS: 90 women and 20 men aged over 90 (n=110), surviving participants of the Cambridge City over-75s Cohort, a population based sample. MAIN OUTCOME MEASURES: Inability to get up without help, lying on floor for a long time after falling, associated factors; availability and use of call alarm systems; participants' views on using call alarms to summon help if needed after falling. RESULTS: In one year's intensive follow-up, 54% (144/265) of fall reports described the participant as being found on the floor and 82% (217/265) of falls occurred when the person was alone. Of the 60% who fell, 80% (53/66) were unable to get up after at least one fall and 30% (20/66) had lain on the floor for an hour or more. Difficulty in getting up was consistently associated with age, reported mobility, and severe cognitive impairment. Cognition was the only characteristic that predicted lying on the floor for a long time. Lying on the floor for a long time was strongly associated with serious injuries, admission to hospital, and subsequent moves into long term care. Call alarms were widely available but were not used in most cases of falls that led to lying on the floor for a long time. Comments from older people and carers showed the complexity of issues around the use of call alarms, including perceptions of irrelevance, concerns about independence, and practical difficulties. CONCLUSIONS: Lying on the floor for a long time after falling is more common among the "oldest old" than previously thought and is associated with serious consequences. Factors indicating higher risk and comments from participants suggest practical implications. People need training in strategies to get up from the floor. Work is needed on access and activation issues for design of call alarms and information for their effective use. Care providers need better understanding of the perceptions of older people to provide acceptable support services

Falls in advanced old age: recalled falls and prospective follow-up of over-90-year-olds in the Cambridge City over-75s Cohort study.

BACKGROUND: The "oldest old" are now the fastest growing section of most western populations, yet there are scarcely any data concerning even the common problem of falls amongst the very old. Prospective data collection is encouraged as the most reliable method for researching older people's falls, though in clinical practice guidelines advise taking a history of any recalled falls. This study set out to inform service planning by describing the epidemiology of falls in advanced old age using both retrospectively and prospectively collected falls data. DESIGN: Re-survey of over-90-year-olds in a longitudinal cohort study - cross-sectional interview and intensive 12-month follow-up. PARTICIPANTS AND SETTING: 90 women and 20 men participating in a population-based cohort (aged 91-105 years, in care-homes and community-dwelling) recruited from representative general practices in Cambridge, UKMeasurements: Prospective falls data were collected using fall calendars and telephone follow-up for one year after cross-sectional survey including fall history. RESULTS: 58% were reported to have fallen at least once in the previous year and 60% in the 1-year follow-up. The proportion reported to have fallen more than once was lower using retrospective recall of the past year than prospective reports gathered the following year (34% versus 45%), as were fall rates (1.6 and 2.8 falls/person-year respectively). Repeated falls in the past year were more highly predictive of falls during the following year - IRR 4.7, 95% CI 2.6-8.7 - than just one - IRR 3.6, 95% CI 2.0-6.3, using negative binomial regression. Only 1/5 reportedly did not fall during either the year before or after interview. CONCLUSION: Fall rates in this representative sample of over-90-year-olds are even higher than previous reports from octogenarians. Recalled falls last year, particularly repeated falls, strongly predicted falls during follow-up. Similar proportions of people who fell were reported by retrospective and prospective methods covering two consecutive years. Recall methods may underestimate numbers of repeated falls and the extent of recurrent falling. Professionals caring for people of advanced age can easily ask routinely whether someone has fallen at all, or more than once, in the past year to identify those at high risk of subsequent falls

Re-examining tau-immunoreactive pathology in the population: granulovacuolar degeneration and neurofibrillary tangles.

INTRODUCTION: Alzheimer's disease (AD) is associated with neurofibrillary pathology, including neurofibrillary tangles (NFT), neuritic plaques (NP) and neuropil threads containing aggregated microtubule associated protein tau. Aggregated tau is also associated with granulovacuolar degeneration (GVD). The relationships between tau, GVD, NFT and dementia are unclear. METHODS: We assessed hippocampal (CA1) tau-immunoreactive GVD and NFT pathology in brain donations from the population-representative Cambridge City over 75s Cohort (CC75C) using the CERAD protocol and a modified protocol that included a morphological characterisation of tau-immunoreactive deposits within neurons as NFTs or as GVD. Associations between GVD, NFT and dementia were investigated. RESULTS: Hippocampal pyramidal neurons affected with either NFT or GVD are common in the older population. Some tau-immunoreactive deposits resemble ghost GVD neurons. Tau immunoreactivity identified GVD in 95% cases rated as none with haematoxylin and eosin staining. Both severe NFT (odds ratio (OR) 7.33, 95% confidence interval (CI) 2.01; 26.80, p = 0.003) and severe GVD (OR 7.48, 95% (CI) 1.54; 36.24, p = 0.012) were associated with dementia status. Increasing NFT (OR 2.47 95% (CI) 1.45; 4.22, p = 0.001) and GVD (OR 2.12 95% (CI) 1.23; 3.64, p = 0.007) severities are associated with increasing dementia severity. However, when the analyses were controlled for other neuropathologies (NFT, NP, Tar-DNA binding Protein-43 and amyloid deposits), the associations between GVD and dementia lost significance. CONCLUSIONS: Current neuropathological assessments do not adequately evaluate the presence and severity of the GVD pathology and its contribution to dementia remains unclear. We recommend that protocols to assess GVD should be developed for routine use and that tau, in a non-PHF associated conformation, is reliably associated with GVD.CC75C is a member study of the Cambridgeshire and Peterborough Collaboration for Leadership in Applied Health Research and Care (CLAHRC). The Cambridge Brain Bank Laboratory (which processed all CC75C cases) is supported by the National Institute for Health Research, Cambridge BioMedical Research Centre. EM-L is supported by Alzheimer’s Society (London, UK).This is the final version of the article. It first appeared from BioMed Central via http://dx.doi.org/10.1186/s13195-015-0141-

Neuropathological correlates of falling in the CC75C population-based sample of the older old.

BACKGROUND: Previous imaging studies have suggested links between brain pathologies and factors that are associated with falls such as gait, balance and daily function. Possible neuropathological correlates of older people's falls have been suggested based on brain imaging studies, but to date none have been examined in brain tissue. METHODS: Falls data collected from repeated surveys of a population-based cohort of individuals aged at least 75 years old at baseline were related to neuropathological data collected from post-mortem examination of the study's associated brain donor collection (n=212). RESULTS: Amongst people without dementia, most cerebrovascular neuropathological features examined, particularly white matter pallor, microinfarcts and microscopic atherosclerosis, were increasingly common across the subgroups categorised by no reports of falling, only one or at least two reports of falling. The overall burden of pathology was greater in those with dementia, but only microinfarcts showed a similar increase with respect to reported falling status. CONCLUSIONS: Subclinical pathologies sharing a common vascular origin are associated with increased falling amongst people with no dementia, as are microinfarcts in those with dementia. Although further research is needed to address the mechanisms of falls and their neuropathological correlates, the findings from the current study would suggest that if cerebrovascular disease prevention reduces vascular neuropathology changes this may have direct benefits in reducing falls amongst older people with or without dementia

Epidemiology of back pain in older adults: prevalence and risk factors for back pain onset.

OBJECTIVES: To determine the prevalence of disabling and non-disabling back pain across age in older adults, and identify risk factors for back pain onset in this age group. METHODS: Participants aged ≥ 75 years answered interviewer-administered questions on back pain as part of a prospective cohort study [Cambridge City over-75s Cohort Study (CC75C)]. Descriptive analyses of data from two surveys, 1988-89 and 1992-93, estimated prevalence and new onset of back pain. Relative risks (RRs) and 95% CIs were estimated using Poisson regression, adjusted for age and gender. RESULTS: Prevalence of disabling and non-disabling back pain was 6 and 23%, respectively. While prevalence of non-disabling back pain did not vary significantly across age (χ²trend : 0.90; P = 0.34), the prevalence of disabling back pain increased with age (χ²trend : 4.02; P = 0.04). New-onset disabling and non-disabling back pain at follow-up was 15 and 5%, respectively. Risk factors found to predict back pain onset at follow-up were: poor self-rated health (RR 3.8; 95% CI 1.8, 8.0); depressive symptoms (RR 2.2; 95% CI 1.3, 3.7); use of health or social services (RR 1.7; 95% CI 1.1, 2.7); and previous back pain (RR 2.1; 95% CI 1.2-3.5). From these, poor self-rated health, previous back pain and depressive symptoms were found to be independent predictors of pain onset. Markers of social networks were not associated with the reporting of back pain onset. Conclusion. The risk of disabling back pain rises in older age. Older adults with poor self-rated health, depressive symptoms, increased use of health and social services and a previous episode of back pain are at greater risk of reporting future back pain onset

Place of death and end-of-life transitions experienced by very old people with differing cognitive status: retrospective analysis of a prospective population-based cohort aged 85 and over.

BACKGROUND: Despite fast-growing 'older old' populations, 'place of care' trajectories for very old people approaching death with or without dementia are poorly described and understood. AIM: To explore end-of-life transitions of 'older old' people across the cognitive spectrum. DESIGN: Population-based prospective cohort (United Kingdom) followed to death. SETTING/PARTICIPANTS: Mortality records linked to 283 Cambridge City over-75s Cohort participants' cognitive assessments <1 year before dying aged ≥ 85 years. RESULTS: Overall, 69% were community dwelling in the year before death; of those with severe cognitive impairment 39% were community dwelling. Only 6% subsequently changed their usual address. However, for 55% their usual address on death registration was not their place of death. Dying away from the 'usual address' was associated with cognition, overall fewer moving with increasing cognitive impairment - cognition intact 66%, mildly/moderately impaired 55% and severely impaired 42%, trend p = 0.003. This finding reflects transitions being far more common from the community than from institutions: 73% from the community and 28% from institutions did not die where last interviewed (p < 0.001). However, severely cognitively impaired people living in the community were the most likely group of all to move: 80% (68%-93%). Hospitals were the most common place of death except for the most cognitively impaired, who mostly died in care homes. CONCLUSION: Most very old community-dwelling individuals, especially the severely cognitively impaired, died away from home. Findings also suggest that long-term care may play a role in avoidance of end-of-life hospital admissions. These results provide important information for planning end-of-life services for older people across the cognitive spectrum, with implications for policies aimed at supporting home deaths. MESH TERMS: Cognitive impairment, Dementia, Aged, 80 and over, Aged, frail elderly, Patient Transfer, Residential characteristics, Homes for the aged, Nursing Homes, Delivery of Health Care, Terminal care Other key phrases: Older old, Oldest old, Place of death, Place of care, End-of-life care

Neuropathological correlates of dementia in over-80-year-old brain donors from the population-based Cambridge city over-75s cohort (CC75C) study.

Key neuropathological changes associated with late-onset dementia are not fully understood. Population-based longitudinal studies offer an opportunity to step back and examine which pathological indices best link to clinical state. CC75C is a longitudinal study of the population aged 75 and over at baseline in Cambridge, UK. We report on the first 213 participants coming to autopsy with sufficient information for an end of life dementia diagnosis. Clinical diagnosis was ascertained by examining retrospective informant interviews, survey responses, and death certificates according to DSM-IV criteria. The neuropathological protocol was based on the Consortium to Establish a Registry of Alzheimer's Disease (CERAD). Clinical dementia was present in 113 participants (53%): 67% with Alzheimer's disease, 4% vascular dementia, 22% mixed dementia, and 1% dementia with Lewy bodies. As Alzheimer-type pathology was common, the mutually blinded clinical and neuropathological diagnoses were not strongly related. Multivariable analysis identified associations between dementia during life and entorhinal cortex neuritic plaques, hippocampal diffuse plaques, neocortical neurofibrillary tangles, white matter pallor, Lewy bodies, and hippocampal atrophy. These results were consistent in those with clinical Alzheimer's disease. Vascular pathologies, especially microinfarcts, were more common in those with clinical diagnoses including vascular dementia. Alzheimer-type and cerebrovascular pathology are both common in the very old. A greater burden of these pathologies, Lewy bodies, and hippocampal atrophy, are associated with a higher risk of, but do not define, clinical dementia in old age

Falls in advanced old age: recalled falls and prospective follow-up of over-90-year-olds in the Cambridge City over-75s Cohort study.

BACKGROUND: The "oldest old" are now the fastest growing section of most western populations, yet there are scarcely any data concerning even the common problem of falls amongst the very old. Prospective data collection is encouraged as the most reliable method for researching older people's falls, though in clinical practice guidelines advise taking a history of any recalled falls. This study set out to inform service planning by describing the epidemiology of falls in advanced old age using both retrospectively and prospectively collected falls data. METHODS: DESIGN: Re-survey of over-90-year-olds in a longitudinal cohort study - cross-sectional interview and intensive 12-month follow-up. PARTICIPANTS AND SETTING: 90 women and 20 men participating in a population-based cohort (aged 91-105 years, in care-homes and community-dwelling) recruited from representative general practices in Cambridge, UKMeasurements: Prospective falls data were collected using fall calendars and telephone follow-up for one year after cross-sectional survey including fall history. RESULTS: 58% were reported to have fallen at least once in the previous year and 60% in the 1-year follow-up. The proportion reported to have fallen more than once was lower using retrospective recall of the past year than prospective reports gathered the following year (34% versus 45%), as were fall rates (1.6 and 2.8 falls/person-year respectively). Repeated falls in the past year were more highly predictive of falls during the following year - IRR 4.7, 95% CI 2.6-8.7 - than just one - IRR 3.6, 95% CI 2.0-6.3, using negative binomial regression. Only 1/5 reportedly did not fall during either the year before or after interview. CONCLUSION: Fall rates in this representative sample of over-90-year-olds are even higher than previous reports from octogenarians. Recalled falls last year, particularly repeated falls, strongly predicted falls during follow-up. Similar proportions of people who fell were reported by retrospective and prospective methods covering two consecutive years. Recall methods may underestimate numbers of repeated falls and the extent of recurrent falling. Professionals caring for people of advanced age can easily ask routinely whether someone has fallen at all, or more than once, in the past year to identify those at high risk of subsequent falls

The relationship between back pain and mortality in older adults varies with disability and gender: results from the Cambridge City over-75s Cohort (CC75C) study.

BACKGROUND: This study aims to determine whether older adults reporting back pain (BP) are at increased risk of premature mortality, specifically, to examine the association with disabling/non-disabling pain separately. METHODS: Participants aged ≥75 years were recruited to the Cambridge City over-75s Cohort (CC75C) study. Participants answered interviewer-administered questions on BP and were followed up until death. The relationship between BP and mortality was examined using Cox regression, adjusted for potential confounding factors. Separate models were computed for men and women. RESULTS: From 1174 individuals with BP data, the date of death was known for 1158 (99%). A significant association was found between disabling BP and mortality (hazard ratio: 1.4; 95% confidence interval: 1.1-1.8) and this remained, albeit of borderline significance, following adjustment for socio-demographic variables and potential disease markers (1.3; 0.99-1.7). Further, this association was found to vary with sex: women experienced a 40% increase in the risk of mortality associated with disabling BP (1.4; 1.1-1.9), whereas no such increase was observed for men (1.0; 0.5-1.9). Participants with non-disabling BP were not at increased risk of mortality. CONCLUSIONS: This study confirmed previous findings regarding the relationship between pain and excess mortality. Further, we have shown that, among older adults, this association is specific to disabling pain and to women. Clinicians should be aware not only of the short-term implications of disabling BP but also the longer-term effects. Future research should attempt to understand the mechanisms underpinning this relationship to avoid excess mortality and should aim to determine why the relationship differs in men and women