Changes in the severity and lethality of age-related health deficit accumulation in the USA between 1999 and 2018: a population-based cohort study

BACKGROUND: With an ageing population, the number of people with frailty is increasing. Despite this trend, the extent to which the severity and lethality of frailty have changed over time is not well understood. We aimed to investigate how frailty severity and lethality have changed over an 18-year period in the USA. METHODS: In this population-based observational study, we used data from the National Health and Nutrition Examination Survey (NHANES) to identify community-dwelling individuals (aged ≥20 years) in the USA between 1999 and 2018. We analysed data from a series of ten 2-year, nationally representative, cross-sectional, prospective studies (from 1999–2000 to 2017–18) from the NHANES. Frailty was measured by use of the deficit accumulation approach (ie, a 46-item frailty index). The proportion of individuals categorised as non-frail, or living with very mild frailty, mild frailty, moderate frailty, and severe frailty were compared across cohorts. Random-effects models were used to examine the association between frailty index score and sex, age, and cohort. Mortality status as of Dec 31, 2015, was ascertained by use of National Death Index data, and 5-year mortality was available in the first six cohorts (1999–2010). Cox regression models and Kaplan-Meier curves were used to estimate the association between frailty index scores and mortality. FINDINGS: In total, 49 004 individuals were included in our study. Associations were mainly non-linear (quadratic), with frailty increasing at a faster rate in more recent cohorts. Between 1999 and 2018, the proportion of non-frail individuals decreased by 10·4% (from 2747 [63·8%; 95% CI 61·9–65·6] of 4307 to 2884 [53·4%; 51·3–55·5] of 5399), whereas the proportion of individuals with very mild frailty increased by 2·4% (from 987 [22·9%; 21·3–24·6] to 1365 [25·3%; 23·5–27·2]), by 2·7% (from 370 [8·6%; 7·7–9·6] to 609 [11·3%; 10·1–12·5]) in those with mild frailty, by 3·1% (from 140 [3·3%; 2·7–3·9] to 347 [6·4%; 5·6–7·4]) in those with moderate frailty, and by 2·1% (from 63 [1·5%; 1·1–1·9] to 195 [3·6%; 3·0–4·3]) in those with severe frailty. Being a woman, older, and from a more recent cohort were associated with higher frailty index scores (all p<0·0001). In more recent cohorts, mean frailty index scores increased more quickly with age (p<0·0001), and sex differences in mean frailty index scores decreased (p<0·0001). In men of all ages and in women aged 35 years or older, mean frailty index scores were higher in more recent cohorts, with larger increases in frailty in older age groups. In 28 692 individuals from the first six cohorts (1999–2000 to 2009–10) with linked mortality data, frailty index scores were significantly associated with mortality (hazard ratio 1·053 [95% CI 1·050–1·057] per 0·01 increase in frailty index score). The absence of an interaction between cohort and frailty index score (p=0·58) suggested that the association between frailty and mortality was similar for all cohorts. INTERPRETATION: Increasing frailty levels in more recent cohorts of middle-aged and older adults combined with stable frailty lethality between 1999 and 2018, suggest a challenge to healthy longevity, with the proportion of individuals with a high degree of frailty continuing to increase. FUNDING: Supported in part by the Canadian Institutes of Health Research

Piloting data linkage in a prospective cohort study of a GP referral scheme to avoid unnecessary emergency department conveyance

BACKGROUND: UK Ambulance services are under pressure to safely stream appropriate patients away from the Emergency Department (ED). Even so, there has been little evaluation of patient outcomes. We investigated differences between patients who are conveyed directly to ED after calling 999 and those referred by an ambulance crew to a novel GP referral scheme. METHODS: This was a prospective study comparing patients from two cohorts, one conveyed directly to the ED (n = 4219) and the other referred to a GP by the on-scene paramedic (n = 321). To compare differences in patient outcomes, we include follow-up data of a smaller subset of each cohort (up to n = 150 in each) including hospital admission, history of long-term illness, previous ED attendance, length of stay, hospital investigations, internal transfers, 30-day re-admission and 10-month mortality. RESULTS: Older individuals, females, and those with minor incidents were more likely to be referred to a GP than conveyed directly to ED. Of those patients referred to the GP, only 22.4% presented at ED within 30 days. These patients were more likely to be admitted then than were those initially conveyed directly to ED (59% vs 31%). Those conveyed to ED had a higher risk of death compared to those who were referred to the GP (HR: 2.59; 95% CI 1.14–5.89), however when analyses were restricted to those who presented at ED within 30 days, there was no difference in mortality risk (HR: 1.45; 95% CI 0.58–3.65). CONCLUSIONS: Despite limited data and a small sample size, there were differences between patients conveyed directly to ED and those who were referred into GP care. Initial evidence suggests that referring individuals to a GP may provide an appropriate and safe alternative path of care. This pilot study demonstrated a need for larger scale, methodologically rigorous study to demonstrate the benefits of alternative conveyance schemes and recommend changes to the current system of urgent and emergency care

Associations of word memory, verbal fluency, processing speed and crystallised cognitive ability with one-legged balance performance in mid and later life

BACKGROUND: Cognitive integration of sensory input and motor output plays an important role in balance. Despite this, it is not clear if specific cognitive processes are associated with balance and how these associations change with age. We examined longitudinal associations of word memory, verbal fluency, search speed and reading ability with repeated measures of one-legged balance performance. METHODS: Up to 2934 participants in the MRC National Survey of Health and Development, a British birth cohort study, were included. At age 53, word memory, verbal fluency, search speed and reading ability were assessed. One-legged balance times (eyes closed) were measured at ages 53, 60-64 and 69 years. Associations between each cognitive measure and balance time were assessed using random-effects models. Adjustments were made for sex, death, attrition, height, body mass index, health conditions, health behaviours, education, and occupational class. RESULTS: In sex-adjusted models, one SD higher scores in word memory, search speed and verbal fluency were associated with 14.1% (95%CI: 11.3,16.8), 7.2% (4.4,9.9) and 10.3% (7.5,13.0) better balance times at age 53, respectively. Higher reading scores were associated with better balance, although this association plateaued. Associations were partially attenuated in mutually-adjusted models and effect sizes were smaller at ages 60-64 and 69. In fully-adjusted models, associations were largely explained by education, although remained for word memory and search speed. CONCLUSIONS: Higher cognitive performance across all measures was independently associated with better balance performance in midlife. Identification of individual cognitive mechanisms involved in balance could lead to opportunities for targeted interventions in midlife

Associations between sporting physical activity and cognition in mid and later-life: Evidence from two cohorts

Evidence has linked sporting leisure time physical activity (sporting-LTPA) to healthy cognition throughout adulthood. This may be due to the physiological effects of physical activity (PA), or to other, psychosocial facets of sport. We examined associations between sporting-LTPA and cognition while adjusting for device-measured PA volume devoid of context, both in midlife (N = 4041) participants from the 1970 British Cohort Study and later-life (N = 957) participants from the British Regional Heart Study. Independent of device-measured PA, we identified positive associations between sporting-LTPA and cognition. Sports with team/partner elements were strongly positively associated with cognition, suggesting LTPA context may be critical to this relationship

Associations between a laboratory frailty index and adverse health outcomes across age and sex

Objective: Early frailty may be captured by a frailty index (FI) based entirely on vital signs and laboratory tests. Our aim was to examine associations between a laboratory-based FI (FI-Lab) and adverse health outcomes, and investigate how this changed with age. Methods: Up to 8988 individuals aged 20+ years from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey cohorts were included. Characteristics of the FI-Lab were compared to those of a self-reported clinical FI. Associations between each FI and health care use, self-reported health, and disability were examined in the full sample and across age groups. Results: Laboratory-based FI scores increased with age but did not demonstrate expected sex differences. Women aged 20-39 years had higher FI scores than men; this pattern reversed after age 60 years. FI-Lab scores were associated with poor self-reported health (odds ratio[95% confidence interval]: 1.46[1.39-1.54]), high health care use (1.35[1.29-1.42]), and high disability (1.41[1.32-1.50]), even among those aged 20-39 years. Conclusion: Higher FI-Lab scores were associated with poor health outcomes at all ages. Associations in the youngest group support the notion that deficit accumulation occurs across the lifespan. FI-Lab scores could be utilized as an early screening tool to identify deficit accumulation at the cellular and molecular level before they become clinically visible

Bidirectional associations between word memory and one-legged balance performance in mid and later life

Background: Age-related changes in cognitive and balance capabilities are well-established, as is their correlation with one another. Given limited evidence regarding the directionality of associations, we aimed to explore the direction and potential explanations of associations between word memory and one-legged balance performance in mid-later life. / Methods: A total of 3062 participants in the Medical Research Council National Survey of Health and Development, a British birth cohort study, were included. One-legged balance times (eyes closed) were measured at ages 53, 60–64 and 69 years. Word memory was assessed at ages 43, 53, 60–64 and 69 with three 15-item word-recall trials. Autoregressive cross-lagged and dual change score models assessed bidirectional associations between word memory and balance. Random-effects models quantified the extent to which these associations were explained by adjustment for anthropometric, socioeconomic, behavioural and health status indicators. / Results: Autoregressive cross-lagged and dual change score models suggested a unidirectional association between word memory and subsequent balance performance. In a sex-adjusted random-effects model, 1 standard deviation increase in word memory was associated with 9% (7,12%) higher balance performance at age 53. This association decreased with age (−0.4% /year (−0.6,-0.1%). Education partially attenuated the association, although it remained in the fully-adjusted model (3% (0.1,6%)). / Conclusions: There was consistent evidence that word memory is associated with subsequent balance performance but no evidence of the reverse association. Cognitive processing plays an important role in the balance process, with educational attainment providing some contribution. These findings have important implications for understanding cognitive-motor associations and for interventions aimed at improving cognitive and physical capability in the ageing population

Associations Between Factors Across Life and One-Legged Balance Performance in Mid and Later Life: Evidence From a British Birth Cohort Study

INTRODUCTION: Despite its associations with falls, disability, and mortality, balance is an under-recognized and frequently overlooked aspect of aging. Studies investigating associations between factors across life and balance are limited. Understanding the factors related to balance performance could help identify protective factors and appropriate interventions across the life course. This study aimed to: (i) identify socioeconomic, anthropometric, behavioral, health, and cognitive factors that are associated with one-legged balance performance; and (ii) explore how these associations change with age. METHODS: Data came from 3,111 members of the MRC National Survey of Health and Development, a British birth cohort study. Multilevel models examined how one-legged standing balance times (assessed at ages 53, 60–64, and 69) were associated with 15 factors across life: sex, maternal education (4 years), paternal occupation (4 years), own education (26 years), own occupation (53 years), and contemporaneous measures (53, 60–64, 69 years) of height, BMI, physical activity, smoking, diabetes, respiratory symptoms, cardiovascular events, knee pain, depression and verbal memory. Age and sex interactions with each variable were assessed. RESULTS: Men had 18.8% (95%CI: 13.6, 23.9) longer balance times than women at age 53, although this difference decreased with age (11.8% at age 60–64 and 7.6% at age 69). Disadvantaged socioeconomic position in childhood and adulthood, low educational attainment, less healthy behaviors, poor health status, lower cognition, higher body mass index (BMI), and shorter height were associated with poorer balance at all three ages. For example, at age 53, those from the lowest paternal occupational classes had 29.6% (22.2, 38.8) worse balance than those from the highest classes. Associations of balance with socioeconomic indicators, cognition and physical activity became smaller with age, while associations with knee pain and depression became larger. There were no sex differences in these associations. In a combined model, the majority of factors remained associated with balance. DISCUSSION: This study identified numerous risk factors across life that are associated with one-legged balance performance and highlighted diverse patterns of association with age, suggesting that there are opportunities to intervene in early, mid and later life. A multifactorial approach to intervention, at both societal and individual levels, may have more benefit than focusing on a single risk factor

Obesity in early adulthood and physical functioning in mid-life: Investigating the mediating role of c-reactive protein

INTRODUCTION: Obesity in adulthood is associated with reduced physical functioning (PF) at older ages. However, mechanisms underpinning this association are not well understood. We investigated whether and the extent to which C-reactive protein (CRP) mediates the association between early-adult obesity and mid-life PF. METHODS: We used data from 8495 participants in the 1958 British birth cohort study. Body mass index (BMI), CRP and PF were measured at 33, 45 and 50y, respectively. Poor PF was defined as the lowest (sex-specific) 10% on the Short-form 36 Physical Functioning subscale. We accounted for prospectively measured confounders in early-life (e.g., social class at birth) and in mid-adulthood (e.g., 42y comorbidities). We decomposed the total effect of early-adult obesity on mid-life PF into direct and indirect (via CRP) effects, by employing a mediation analysis based on parametric g-computation. RESULTS: The estimated total effect of obesity at 33y on poor PF at 50y, expressed as an odds ratio (OR), was 2.41 (95% CI: 1.89, 3.08). The direct effect of obesity on poor PF (i.e., not operating via CRP), was 1.97 (95% CI: 1.51, 2.56), with an indirect effect of 1.23 (95% CI: 1.10, 1.37). As such, the proportion of the total effect which was mediated by the effect of obesity on CRP at 45y, was 23.27% (95% CI: 8.64%, 37.90%). CONCLUSION: Obesity in early-adulthood was associated with over twice the odds of poor PF in mid-life, with approximately 23% of the obesity effect operating via a downstream effect on CRP. As current younger generations are likely to spend greater proportions of their life course in older age and with obesity, both of which are associated with poor PF, there is an urgent need to identify mechanisms, and thus potential modifiable intermediaries, linking obesity to poor PF

Discrepancy in clinical outcomes of patients with gunshot wounds in car hijacking: a South African experience

INTRODUCTION: Discrepancy in outcomes between urban and rural trauma patients is well known. We reviewed our institutional experience with the management of gunshot wounds (GSWs) in the specific setting of car hijacking and focused on clinical outcome between rural and urban patients. METHODS: A retrospective review was conducted at a major trauma centre in South Africa over an 8-year period for all patients who presented with any form of GSWs in car hijacking settings. Specific clinical outcomes were compared between rural and urban patients. RESULTS: A total of 101 patients were included (74% male, mean age 34 years). Fifty-five per cent were injured in rural areas and the remaining 45% (45/101) were in the urban district. Mean time from injury to arrival at our trauma centre was 11 hours for rural and 4 hours for urban patients (p < 0.001). Seventy-six per cent (76/101) sustained GSWs to multiple body regions. Sixty-three of the 101 (62%) patients required one or more operative interventions. In individual logistic regressions adjusted for sex and number of regions injured, rural patients were 9 (95% CI: 1.9-44.4) and 7 (95% CI: 2.124.5) times more likely than urban patients to have morbidities or required admissions to intensive care respectively. The risk of death in rural patients was 36 (95% CI: 4.5-284.6) times higher than that of urban patients. CONCLUSIONS: Patients who sustained GSWs in carjacking incidents that occurred in rural areas are associated with significantly greater morbidity and mortality compared with their urban counterparts. Delay to definitive care is likely to be the significant contributory factor, and improvement in prehospital emergency medical service is likely to be beneficial in improving patient outcome

A review of blunt pelvic injuries at a major trauma centre in South Africa.

BACKGROUND: The collective five-year experience with the acute management of pelvic trauma at a busy South African trauma service is reviewed to compare the usefulness and applicability of current grading systems of pelvic trauma and to review the compliance with current guidelines regarding pelvic binder application during the acute phase of resuscitation. METHODS: A retrospective review was conducted over a 5-year period from December 2012 to December 2017 on all polytrauma patients who presented with a pelvic fracture. Mechanism of injury and presenting physiology and clinical course including pelvic binder application were documented. Pelvic fractures were graded according to the Young- Burgess and Tile systems. RESULTS: There was a cohort of 129 patients for analysis. Eighty-one were male and 48 female with a mean age was 33.6 ± 13.1 years. Motor vehicle-related collisions (MVCs) were the main mechanism of injury (50.33%) and pedestrian vehicle collisions (PVCs) were the second most common (37.98%). The most common associated injuries were abdominal injuries (41%), chest injury (37%), femur fractures (21%), tibia fractures (15%) and humerus fracture (14.7%). Thirty patients in this cohort (23%) underwent a laparotomy. They were mainly in the Tile B (70%) and lateral compression (63%) groups. Nine patients underwent pelvic pre-peritoneal packing. Thirty-five (27%) patients were admitted to ICU. Fifteen (12%) patients died. The Young-Burgess classification had a greater accuracy in predicting death than the Tile classification. Forty per cent of deaths occurred in ICU, 33% died secondary to a traumatic brain injury (TBI). Twenty per cent died in casualty and 6.6% in the operating room from ongoing haemorrhage. A pelvic binder was not applied in 66% of patients. In the 34% of patients who had a pelvic binder applied, it was applied post CT scan in 24.8%, in the pre-hospital setting in 7.2%, and on arrival in 2.4% of patients. In 73% of deaths, a binder was not applied, and of those deaths, 54% showed signs of haemodynamic instability. CONCLUSION: It would appear that our application of pelvic binders in patients with acute pelvic trauma is ad hoc. Appropriate selection of patients, who may benefit from a binder and it's timely application, has the potential to improve outcome in these patients