Atypical presentations of COVID-19 in care home residents presenting to secondary care: A UK single centre study

BACKGROUND: Atypical presentations of COVID-19 pose difficulties for early isolation and treatment, particularly in institutional care settings. We aimed to characterize the presenting symptoms and associated mortality of COVID-19 in older adults, focusing on care home residents admitted to secondary care. METHODS: A retrospective cohort study of 134 consecutive inpatients over 80 years old hospitalized with PCR confirmed COVID-19 in the United Kingdom. Symptoms at presentation and frailty were analysed. Differences between community dwelling and care home residents, and associations with mortality, were assessed using between-group comparisons and logistic regression. RESULTS: Care home residents were less likely to experience cough (46.9% vs 72.9%, P = .002) but more likely to present with delirium (51.6% vs 31.4%, P = .018), particularly hypoactive delirium (40.6% vs 24.3%, P = .043). Mortality was more likely with increasing frailty (OR 1.25, 95% CI 1.00, 1.58, P = .049) and those presenting with anorexia (OR 3.20, 95% CI 1.21, 10.09, P = .028). There were no differences in mortality or length of stay based on residential status. CONCLUSION: COVID-19 in older adults often presents with atypical symptoms, particularly in those admitted from institutional care. These individuals have a reduced incidence of cough and increased hypoactive delirium. Individuals presenting atypically, especially with anorexia, have higher mortality

The prevalence and determinants of polypharmacy at age 69: a British birth cohort study

BACKGROUND: To describe the development of polypharmacy and its components in a British birth cohort in its seventh decade and to investigate socioeconomic and gender differences independent of disease burden. METHODS: Data from the MRC National Survey for Health and Development were analysed to determine the prevalence and composition of polypharmacy at age 69 and changes since ages 60 to 64. Multinomial regression was used to test associations between gender, education and occupational social class and total, cardiological and non-cardiological polypharmacy controlling for disease burden. RESULTS: At age 69, 22.8% of individuals were taking more than 5 medications. There was an increase in the use of 5 to 8 medications (+ 2.3%) and over 9 medications (+ 0.8%) between ages 60–64 and 69. The greatest increases were found for cardiovascular (+ 13.4%) and gastrointestinal medications (+ 7.3%). Men experienced greater cardiological polypharmacy, women greater non-cardiological polypharmacy. Higher levels of education were associated with lower polypharmacy independent of disease burden, with strongest effects seen for over five cardiological medications (RRR 0.3, 95% CI 0.2–0.5 p < 0.001 for advanced secondary qualifications compared with no qualification); there was no additional effect of social class. CONCLUSIONS: Polypharmacy increased over the seventh decade. Those with lower levels of education had more polypharmacy (total, cardiological and non-cardiological), even allowing for disease burden. Further analysis of future outcomes resulting from polypharmacy should take into account educational and gender differences, in an effort to identify at-risk populations who could benefit from medication reviews

Beta-Blockers for the Secondary Prevention of Myocardial Infarction in People with Dementia: A Systematic Review

BACKGROUND: Cardiovascular disease remains the most common cause of death in industrialized countries. The use of beta-blockers is well established as a secondary prevention of myocardial infarction. However, little is known about the benefits of beta-blockers for people living with dementia. // OBJECTIVE: To evaluate the use of beta-blockers in people with dementia who have had a myocardial infarction, in order to identify associations between medication use, mortality, re-infarction and functional decline. // METHODS: We searched for all studies (randomized trials, observational cohorts) reporting beta-blocker use in populations with both dementia and previous myocardial infarction. Relevant keywords were used in Medline, Embase, and Web of Science up to October 2018. Titles and abstracts were independently screened by two reviewers. Quality of eligible studies was assessed using the Newcastle-Ottawa Scale. PRISMA recommendations were followed throughout. // RESULTS: Two observational studies were included, representing 10,992 individuals in a community setting and 129,092 individuals from a hospital record-linkage study. One showed use of beta-blockers reduced all-cause mortality (HR 0.74 (95% CI 0.64- 0.86) alongside evidence for an increased rate of functional decline in individuals aged≥65 with moderate to severe cognitive impairment (OR 1.34 (95% CI 1.11- 1.61)). The second study did not find an association between beta-blocker use and mortality in the population living with dementia. // CONCLUSION: There is insufficient evidence to support use of beta-blockers to persons living with dementia. A single study provides limited evidence that beta-blockers improve survival rates but with associated detrimental effects on functional status in nursing home residents with cognitive impairment. Decisions to continue beta-blockers in persons living with dementia should be made on an individual basis

Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study

Background: Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population. Objectives: Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients. Methods: We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality. Results: The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0–9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70–3.01) than in SSD (HR 1.58; 95% CI 1.2–2.09); however, ACB had no impact on this relationship. Conclusions: ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population

Associations Between Polypharmacy and Cognitive and Physical Capability: A British Birth Cohort Study

\ua9 2018 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society. Objectives: To investigate longitudinal associations between polypharmacy and cognitive and physical capability and to determine whether these associations differ with cumulative exposure to polypharmacy. Design: Prospective birth cohort study. Setting: England, Scotland, and Wales. Participants: An eligible sample of men and women from the Medical Research Council National Survey of Health and Development with medication data at age 69 (N=2,122, 79%). Measurements: Cognitive capability was assessed using a word learning test, visual search speed task, and the Addenbrooke\u27s Cognitive Examination, Third Edition (ACE-III). Physical capability was measured using chair rise speed, standing balance time, walking speed, and grip strength. Results: Polypharmacy (5–8 prescribed medications) was present in 18.2% of participants at age 69 and excessive polypharmacy (≥9 prescribed medications) in 4.7%. Both were associated with poorer cognitive and physical capability in models adjusted for sex, education, and disease burden. Stronger associations were found for excessive polypharmacy (e.g., difference in mean ACE-III scores comparing polypharmacy=−2.0, 95% CI=−2.8 to −1.1 and excessive polypharmacy=−2.9, 95% CI=−4.4 to −1.4 with no polypharmacy). Participants with polypharmacy at age 60 to 64 and at age 69 showed stronger Negative associations with cognitive and physical capability were stronger still in participants with polypharmacy at both age 60 to 64 and at age 69 (e.g. difference in mean chair rise speed, comparing polypharmacy with no polypharmacy at both ages=−3.9, 95% CI=−5.2 to −2.6 and at age 60–64 only=−2.5, 95% CI=−4.1 to −0.9). Conclusion: Polypharmacy at age 60 to 64 and age 69 was associated with poorer physical and cognitive capability, even after adjusting for disease burden. Stronger negative associations were seen in participants with longstanding polypharmacy, suggesting a cumulative, dose-dependent relationship (where dose is the number of prescribed medications). Future research aiming to improve cognitive and physical capability should consider interventions to reduce the duration and level of polypharmacy at younger ages, in addition to optimizing disease control with appropriate medications

Identifying the lifetime cognitive and socioeconomic antecedents of cognitive state: seven decades of follow-up in a British birth cohort study

Objectives The life course determinants of midlife and later life cognitive function have been studied using longitudinal population-based cohort data, but far less is known about whether the pattern of these pathways is similar or distinct for clinically-relevant cognitive state. We investigated this for the Addenbrooke’s Cognitive Examination (ACE-III), used in clinical settings to screen for cognitive impairment and dementia. Design Longitudinal birth cohort study. Setting Residential addresses in England, Wales and Scotland. Participants 1762 community-dwelling men and women of European heritage, enrolled since birth in the MRC National Survey of Health and Development (the British 1946 birth cohort). Primary outcome The Addenbrooke’s Cognitive Examination (ACE-III). Results Path modelling estimated direct and indirect associations between APOE status, father’s social class, childhood cognition, education, midlife occupational complexity, midlife verbal ability (National Adult Reading Test; NART), and the total ACE-III score. Controlling for sex, there was a direct negative association between APOE ε4 and the ACE-III score (β=-0.04, [-0.08, -0.002], p=0.04), but not between APOE ε4 and childhood cognition (β=0.03 [-0.006, 0.69, p=0.10] or the NART (β=0.0005 [-0.03, 0.03], p=0.97). The strongest influences on the ACE-III were from childhood cognition (β=0.20 [0.14, 0.26], p<0.001) and the NART (β=0.35 [0.29, 0.41], p<0.001); educational attainment and occupational complexity were modestly and independently associated with the ACE-III (β=0.08 [0.03, 0.14], p=0.002 and β=0.05 [0.01, 0.10], p=0.02, respectively). Conclusions The ACE-III in the general population shows a pattern of life course antecedents that is similar to neuropsychological measures of cognitive function, and may be utilised to represent normal cognitive ageing as well as a screen for cognitive impairment and dementia

LoCuSS: Shedding new light on the massive lensing cluster Abell 1689-the view from Herschel

We present wide-field Herschel/PACS observations of A 1689, a massive galaxy cluster at z = 0.1832, from our open time key programme. We detect 39 spectroscopically confirmed 100 μm-selected cluster members down to 1.5×1010 $L_{\odot}$. These galaxies are forming stars at rates in the range 1–10 $M_{\odot}$/yr, and appear to comprise two distinct populations: two-thirds are unremarkable blue, late-type spirals found throughout the cluster; the remainder are dusty red sequence galaxies whose star formation is heavily obscured with A(Hα)~2 mag and are found only in the cluster outskirts. The specific-SFRs of these dusty red galaxies are lower than the blue late-types, suggesting that the former are in the process of being quenched, perhaps via pre-processing, the unobscured star formation being terminated first. We also detect an excess of 100 μm-selected galaxies extending ~6 Mpc in length along an axis that runs NE-SW through the cluster center at \ga95% confidence. Qualitatively this structure is consistent with previous reports of substructure in X-ray, lensing, and near-infrared maps of this cluster, further supporting the view that this cluster is a dynamically active, merging system

LoCuSS: A Herschel view of obscured star formation in Abell 1835

We present Herschel/PACS, MMT/Hectospec and XMM-Newton observations of Abell 1835, one of the brightest X-ray clusters on the sky, and the host of a strong cool core. Even though Abell 1835 has a prototypically “relaxed” X-ray morphology and no signs of ongoing merger activity in strong- and weak-lensing mass maps, it has a complex velocity distribution, suggesting that it is still accreting significant amounts of mass in the form of smaller satellite systems. Indeed, we find strong dynamical segregation of star-forming dusty galaxies from the optically selected cluster population. Most Herschel sources are found close to the virial radius of the cluster, and almost a third appear to be embedded within a filament feeding the cluster from the SW. We find that the most luminous infrared galaxies are likely involved in galaxy-galaxy interactions that may have triggered the current phase of star formation