key: cord-303131-hnfu49x7 authors: shaygan, maryam; bahadori, farzaneh title: considerations for mitigation of the psychological impacts of covid-19 in older adults date: 2020-07-17 journal: int j community based nurs midwifery doi: 10.30476/ijcbnm.2020.86362.1340 sha: doc_id: 303131 cord_uid: hnfu49x7 nan there have been numerous outbreaks of infectious diseases in the world. on january 30, 2020, the world health organization (who) declared the outbreak of novel coronavirus disease (covid-19) a public health emergency. 1 the pandemic has caused not only the risk of death, but also too much psychological pressure on people all over the world. older adults are more susceptible to severe infections, cascade of complications, disability, and death. 2, 3 the elderly might also be more vulnerable to mental health problems because of their higher risk of infection. 4 they may experience adverse feelings such as fear of death because of the potential lethality of the illness. some of them claim that dying from coronavirus is a horrible nuisance for them because none of their family members would be able to attend their funeral. they are also afraid of being hospitalized in medical facilities that lack sufficient equipment. they fear that if they contract the virus, no one will be able to visit or help them. the other fear the elderly experience is the infection of their spouses, children, and siblings. dismal and disappointing news spreading via social media could also increase their fear and anxiety. social distancing; reduced contact with others, especially loved ones; inability to take part in routine day-to-day activities (e.g. shopping for necessities); and cancellation of community events lead to boredom, frustration, and a sense of loneliness and isolation, which is distressing to older adults. this problem is particularly prominent in older adults who have limited access to the internet-based services and smartphones. 5, 6 the statement "coronavirus is mostly deadly to the elderly" increases a sense of fear and worthlessness in them. some older adults have become extremely dependent on their children because they fear in-store shopping of essential items in large supermarkets, while they are not skilled in shopping online; this problem adds to their sense of worthlessness. furthermore, restrictions on public transport and the fear of referring to treatment centers because of the contagion have become major barriers to receiving maintenance treatments for this age-group. limited access to internet-based services and smartphones increases the problems of this age-group. therefore, stakeholders and health policymakers should take measures to prevent the potential mental health problems that might arise in older adults who are quarantined during the covid-19 outbreak. here are some suggestions to help mitigate the consequences of quarantine among shaygan m, bahadori f ijcbnm.sums.ac.ir older adults: -give older adults as much information as possible older adults often have catastrophic appraisals of any physical symptoms they experience, which may further increase feelings of fear and anxiety. this fear might be exacerbated by inadequate information. there is long-standing evidence to suggest that news has a direct impact on mental health. feelings of uncertainty and doubt have long been associated with anxiety. 6 therefore, it is necessary to ensure that older adults shape a good understanding of the disease and the reasons for quarantine. -provide information to older adults mainly via broadcast media fast transmission of covid-19 restricts face-to-face educational interventions. moreover, internet-based services, smartphones, social media (e.g. whatsapp), and electronic books are not widely available to older adults. therefore, governments and community-based health services should provide enough information about the disease via mass media, such as radio and television, which are most accessible to the elderly. -provide community-based health services to address health issues of older adults community-based health services, including primary care, community nursing, and pharmacy services should provide telephone-based consultation services addressing health status, treatment, and medication management. health services must also communicate adequate information to older adults in quarantine about what to do in the case of developing illness symptoms. it would help reassure the elderly that they would be taken care of if they fell ill. -provide mental health services to guide older people on how to manage their negative emotions and feelings of isolation mental health services should consider strategies to guide older people on how to manage stress, anger, and other negative emotions, and how to have effective communication with loved ones who do not live with them, so that the feelings of loneliness, stress, and anger are reduced. such psychoeducational programs should be broadcast on mass media, which are most accessible to the elderly. moreover, the elderly should receive practical advice on the ways which help them to reduce boredom and about the importance of having constant communication with their loved ones to overcome feelings of isolation. -provide adequate supplies public health authorities should provide the older adults with basic supplies, such as food, masks, and disinfectants during quarantine. some studies have shown that insufficient basic supplies during quarantine are associated with the feelings of frustration, anxiety, and anger. 6 considering the conditions in near future and the possibility of lengthy quarantines, respective organizations should practice effective strategies to enhance mental health in the society, especially among older adults. some strategies that stakeholders and health policy-makers should implement to provide effective services to older adults who are quarantined at home during the covid-19 pandemic are suggested in the present article. [cited 24 april 2020]. available from: https://www.who.int/docs/default-source/coronaviruse/ how to mitigate the psychological impacts of covid-19 in older adults risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in wuhan, china novel coronavirus (covid-19) epidemic: what are the risks for older patients? mental health services for older adults in china during the covid-19 outbreak mental health status of people isolated due to middle east respiratory syndrome the psychological impact of quarantine and how to reduce it: rapid review of the evidence key: cord-339292-mhbwjwrg authors: aubertin-leheudre, m.; rolland, y. title: the importance of physical activity to care for frail older adults during the covid-19 pandemic date: 2020-04-30 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.04.022 sha: doc_id: 339292 cord_uid: mhbwjwrg summary covid-19 restrictions could decreased physical and mental health. simple, adapted and specific physical activities should be implemented and considered as the best solution to care for frail elderly during the covid-19 pandemic. health. simple, adapted and specific physical activities should be implemented and 28 considered as the best solution to care for frail elderly during the covid-19 pandemic. coronavirus disease 2019 (covid-19) is currently causing devastating impacts globally. as 36 of march 31 st , 2020, 857,165 covid-19 cases were confirmed around the world, and more 37 than 42,100 people have died. the death rate is estimated at 5%, with older adults making up 38 the vast majority of cases (>80%). not surprisingly, studies show a decline in the number of pedometer steps taken per week by 50 adults due to restrictions put in place to mitigate covid-19. european countries showed the 51 most dramatic decline, ranging from a 7% to 38% reduction in steps between march 15 to 22, 52 2020. 1 hence, it is also important to keep in mind that inactivity is the fourth leading cause of 53 mortality according to the world health organization 2 . 54 55 maintaining functional ability and coping with functional limitations for as long as possible are 56 key healthcare challenges for independent living institutionalized and hospitalized older 57 adults. thus, although covid-19 restrictions aim to protect older adults, such social and 58 physical distancing is also likely to negatively impact the physical and mental health of older 59 furthermore, long-term care residents are characterized by high prevalence of multimorbidity, 61 prescription drug use and dependency in activities of daily living. hospitalization of older 62 adults is also problematic as it leads to functional decline, also known as iatrogenic decline 3 . 63 in a 10-day hospitalization, an older patient typically loses 16% of muscle strength and 6% of risk of falls (34% within three months of discharge) 5;6 and disability (33% will report functional 66 decline one-year after discharge) 7;8 . the vicious circle of frailty is accelerated by physical 67 inactivity and further increases the need for healthcare services. 68 the negative consequences of hospitalization or living in long-term care are largely due to low 69 physical activity. older hospitalized patients are often on confined to bed for 17 hours per day 70 according to who, healthy aging is largely determined by the ability to maintain both mental 85 and physical capacities 13 . no medications currently exist that help maintain physical capacity, 86 nor will any be commercialized in the foreseeable future. however, physical capacity can be 87 maintained through physical stimulus via adapted physical activity. it is well-known that 88 physical activity is key for the health and well-being of people over age 85 14 . 89 90 physical activity has been shown to protect against the incidence of activities of daily living 91 disability, but also disability progression or severity 15 each physical activity color program included 2 specific and adapted exercises (e.g.: seated 156 knee extension; sit to stand; step aside; chair forward bend; bipodal or unipodal static 157 balance; wall squat) and a walking time (figure 1 ). all programs have been created to 158 improve or at least maintain balance, strength but also mobility and cardio-pulmonary function 159 (aerobic capacities). all program are realized unsupervised, without materials (except room 160 equipment: chair or wall) between 2 to 3 times per day, in seated or standing position. adapted physical activity programs without specific materials and using notebook, tv-screen, 164 video or internet live video can be implement to avoid bed rest and immobilization effects 165 during the covid-19 pandemic (e.g: sprint; match vivifrail; laterlifetraining; go4life, 166 move etc.; see table 1 ). in conclusion, to our knowledge, daily simple, adapted and specific physical activities 177 including strength, balance and walk exercises (see figure 1 & 2 or vivifrail©) should be 178 considered as the best solution to care for frail older adults during the covid-19 pandemic. 179 the impact of coronavirus on world health organization. global recommendations on physical activity for change in muscle strength and muscle mass in older 191 hospitalized patients: a systematic review and meta-analysis effect of 10 days of bed rest on skeletal muscle in healthy older 194 adults risk of falls after hospital discharge a simple tool predicted probability of falling after aged care 198 inpatient rehabilitation hospitalization, restricted activity, and the development of disability 200 among older persons geriatric conditions in acutely hospitalized older patients: 202 prevalence and one-year survival and functional decline the underrecognized epidemic of low mobility during hospitalization 205 of older adults twenty-four-hour mobility during acute hospitalization in older 207 medical patients how much exercise are older 209 adults living in long-term cares doing in daily life? a cross-sectional study daytime sleeping, sleep disturbance, and 212 circadian rhythms in the nursing home the world report on ageing and health: a 214 policy framework for healthy ageing exercise in people over 85 : advanced age is no 216 barrier to the benefits of tailored exercise effect of physical interventions on physical performance and 222 physical activity in older patients during hospitalization: a systematic review can exergames contribute to improving 226 walking capacity in older adults? a systematic review and meta-analysis program using gerontechnology in assisted living communities for older adults technology enhance social connectedness among older adults? a feasibility study maintenance 235 access / details information type of resource specific, simple and adapted program for older adults key: cord-265830-6shiocwr authors: frost, rachael; nimmons, danielle; davies, nathan title: using remote interventions in promoting the health of frail older persons following the covid-19 lockdown: challenges and solutions date: 2020-05-25 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.038 sha: doc_id: 265830 cord_uid: 6shiocwr in light of the covid-19 pandemic, many older people across the world are being asked to self-isolate to protect their health. this has led to a rapid reconfiguration of health promotion services, which are diverse in focus, and may include exercise, dietary interventions or psychosocial interventions, towards remote delivery, for example by phone or using computers. whilst currently they are unable to be safely delivered any other way, there are concerns that these remote interventions may replace face-to-face interventions beyond the end of social restrictions. we advocate caution with taking this forward, particularly for frailer older people. 2 in light of the covid-19 pandemic, many older people across the world are being asked to self-isolate 3 to protect their health. this has led to a rapid reconfiguration of health promotion services, which 4 are diverse in focus, and may include exercise, dietary interventions or psychosocial interventions, 5 towards remote delivery, for example by phone or using computers. whilst currently they are 6 unable to be safely delivered any other way, there are concerns that these remote interventions 7 may replace face-to-face interventions beyond the end of social restrictions. we advocate caution 8 with taking this forward, particularly for frailer older people. 9 evidence of effectiveness for remote interventions for frail older people is promising, but very 10 limited at present. small randomised controlled trials have shown positive impacts upon quality of 11 life from video exercises with weekly phone calls, 1 improved mental functioning from computer-12 based home exercises, 2 improved balance from home exercise with phone calls 3 and reduced 13 depression from problem solving therapy delivered by videoconferencing. 4 similarly, for 14 malnourished older people, phone-based nutrition interventions with dieticians improved protein 15 intake and quality of life but not other outcomes in one systematic review of nine studies. 5 however, 16 despite an increase in research on this topic over the last five years, these interventions are rarely 17 compared to face-to-face delivery and small sample sizes often limits the power and generalisability 18 of these studies. most also included a face-to-face session with a healthcare professional to assess 19 and plan treatment beforehand, 1,3,5 an orientation meeting to ensure the technology works 2 or 20 both. 4 21 use of remote interventions therefore needs to facilitate rather than replace contacts with 22 healthcare professionals. phone-based support may be particularly applicable to a population with 23 less internet and computer access, and may improve adherence to independent exercise therapies also showed comparable effects to face-to-face delivery with similar numbers of people 26 completing sessions (49/56 vs 54/63). 4 one systematic review found that mobile health technologies 27 for older people are more acceptable when they facilitate communication with a healthcare provider 28 rather than disrupt it, 7 and a cohort study found that frail older people using teleassistance at home 29 who took up additional specialist telecounselling were almost twice as likely to complete the study 30 after one year (94% vs 44%%). 8 31 there are also known access issues. a recent population-based finnish study suggested that frail 32 older people are less likely than robust older people to have an internet connection (46% vs 79%), to 33 have used the internet in the last 3 months (34% vs 72%) and have used a computer in the last 12 34 months (30% vs 70%). 9 they also found that frail older people are more likely to hold negative 35 opinions about the usefulness and usability of mobile ict. this risks a large proportion of the 36 population being excluded. whilst there is clear evidence of high acceptability scores for remote 37 interventions in those who complete studies, 2,4,6 these can also suffer from high dropout rates, 38 particularly when unsupervised, 3,6 are evaluated mainly for short term interventions and typically 39 lack generalisability to wider populations. 40 services wishing to use remote delivery must therefore ensure the necessary technology is provided 41 to overcome access barriers, and that its use is supported. studies have indicated that it is possible 42 to provide equipment such as tablets, laptops or devices connected to the tv, 4,5,10 however studies 43 also frequently report technical failures even in pilot studies, which can be associated with 44 dropouts. 6 technical support was frequently utilised in feasibility studies, indicating that providing 45 this is an important part of remote intervention delivery. 46 in conclusion, whilst these interventions are potentially effective and received positively by some frail older people, those evaluating or providing services should ensure that digitally underserved 48 older people are not left behind through facilitating contact with healthcare professionals and 49 providing both the technology and technical support needed for interventions to be successful. 50 the authors state that there are no conflicts of interest. 53 home-based video exercise intervention for 56 community-dwelling frail older women: a randomized controlled trial user experience, 59 actual use, and effectiveness of an information communication technology-supported home 60 exercise program for pre-frail older adults telephone calls make a difference in home balance training 62 outcomes: a randomized trial six-month postintervention 64 depression and disability outcomes of in-home telehealth problem-solving therapy for 65 depressed, low-income homebound older adults teleassistance 75 for frail elderly people: a usability and customer satisfaction study information and communication technologies among older people with and without frailty: 79 a population-based survey fit4surgerytv at-home prehabilitation for frail older patients planned for colorectal cancer 82 surgery: a pilot study key: cord-340117-14bmab0n authors: navarrete‐reyes, ana patricia; avila‐funes, josé alberto title: staying in a burning house: perks and perils of a hotline in the times of covid‐19 date: 2020-05-05 journal: j am geriatr soc doi: 10.1111/jgs.16479 sha: doc_id: 340117 cord_uid: 14bmab0n nan to the editor: older people and people with preexisting medical conditions seem to be more vulnerable to becoming severely ill with the coronavirus disease 2019 . since the best way to prevent and slow down transmission is to be well informed about the virus, the disease it causes, and how it spreads, the instituto nacional de ciencias médicas y nutrición salvador zubirán's (incmnsz) geriatric medicine department has made a hotline available to field older adults' inquiries about covid-19 ( figure 1 ). due to the fact that the incmnsz, a public tertiary care center in mexico city, mexico, has recently become a designated care site for covid-19, most outpatient clinics are on hold or working via telephone call or telemedicine, allowing medical staff to answer the hotline queries for now. the hotline is open 7 days a week, from 9 am to 7 pm. i am the attending geriatrician on hotline duty. that is no coincidence: i am self-isolating due to immunosuppressive therapy (apnr). yet, just as ray bradbury's character in fahrenheit 451 stays in her burning house rather than abandon her burning books, i do not stay at home for nothing. 1 although emphasizing the importance of preventive measures, trying to best address concerns, and stopping patients from unnecessarily visiting the emergency room are our main objectives, it is the human experience i would like to write about. in 10 days, i have received 64 calls and text messages about and from older adults. i have classified the addressed issues in the following areas: logistical doubts, preventive measures, patients with respiratory symptoms, and reminders of an unprepared health system. during these few days, i have addressed a myriad of concerns related to covid-19. i have the impression that i have not been speaking with individuals, but with entire families. such interactions, i believe, carry with themselves the possibility of valuable information being disseminated, information much needed to attain the best possible outcome given the particular circumstances of mexico. most logistical doubts have been about canceled outpatient clinic appointments at the incmnsz. a few days ago, a 92-year-old gentleman with long-standing crohn's disease texted the line. he was worried about his canceled clinic appointment since it was meant for treatment adjustment. when the on-call gastroenterology specialists' team was able to program a telephone call consultation for him the next day and his concern was mitigated, he sent me a picture of himself, the message attached read, "so you get to know me." a second group is composed of older adults and their loving family/friends/neighbors wondering what they can do to reduce their risk of infection. this one has been encouraging and heartbreaking at the same time. on the one hand, i have been able to underscore the importance of preventive measures, to solve relatively simple doubts, and to knock down a few myths on the way. on the other, these calls are a frequent reminder of how unfortunate the conflicting messages sent to the population by influential politics and business figures have been. for instance, i received a message from a worried young woman whose 80-year-old grandmother did not want to comply with preventive social distancing. she had seen the head of the mexican government affirm on national television that mexicans could continue hugging and kissing safely in spite of the pandemic. 2 conversations with this group are also an attestation of how conflictive the concepts of preventive social distancing and lockdown are with survival for a great proportion of mexicans who earn their living on a day-to-day basis. 3 interlocutors in the third group are those looking for guidance in the presence of respiratory symptoms. with this group, i have shared information regarding warning signs to go to the emergency room and regarding home care isolation, a sensitive matter when overcrowded households are not unusual 4 assess if the residential setting is suitable for the purpose are nonexistent. in mexico, approximately 26.7% of older adults report overcrowding, 20.7% share their bedroom with 1.5 to 3.9 other persons, and 6% share their bedroom with 4 or more other persons. 5 the last group are those not calling about covid-19. a 60-year-old woman diagnosed with rheumatoid arthritis called the hotline. she was looking to receive financial aid from the government since she did not have any social security benefits and was unable to purchase her medications. this is not an unusual scenario for a physician working in mexico; basic medical expenses are frequently uncovered and advanced medical care scarce or frankly unavailable in some regions, a hint of the lack of readiness of our healthcare system to face emerging contingencies, such as a pandemic. fahrenheit 451 coronavirus en méxico: las críticas a amlo por seguir besando y abrazando a sus seguidores pese a las advertencias sanitarias frente al covid-19 comunicado de prensa número 251/18: en méxico hay 34.1 millones de hogares; 28.5% con jefatura femenina: encuesta nacional de hogares 80% de los mexicanos trabaja sin contrato, sin seguridad social y con bajos salarios comisión económica para américa latina y el caribe the authors would like to thank "salud en corto" (dr jackie lópez) for the graphic design and promotion of our digital image on social media; and dr francisco m. martínez-carrillo and georgina a. tuner, b lit, m psych, for their valuable feedback.financial disclosure: all authors state no financial interest, stock, or derived direct financial benefit.conflict of interest: none. author contributions: dr navarrete-reyes: developed conceptualization and narrative. she wrote the manuscript under the supervision of dr avila-funes. the coauthor certifies that he has participated substantially in the conceptualization and design of this work as well as the writing of the manuscript. they have reviewed the final version of the manuscript and have approved it for publication.sponsor's role: none. key: cord-308677-dr9a3ug0 authors: hall, william j. title: benefits of intensive care unit hospitalization for patients older than 90 years date: 2020-06-27 journal: j am geriatr soc doi: 10.1111/jgs.16626 sha: doc_id: 308677 cord_uid: dr9a3ug0 this editorial comments on the article by haas et al. g eriatricians realize that the decision to admit our oldest patients to an intensive care unit (icu) is never easy. the potential medical benefits are less clear, especially in the case of individuals aged 90 years and older. those potential benefits have to be weighed against well-known downsides, including isolation from family. complications are almost inevitable, including delirium, infection, and adverse reaction to medications. often, these decisions have to be made by surrogates and may infringe on patient autonomy. somewhat surprisingly, there is scant literature regarding the outcomes of icu care for patients older than 90 years in the pre-coronavirus disease 2019 (covid-19) era. recently, during the early days of the covid-19 pandemic, icus were full of patients and in some instances critically short of ventilators. a new ethical debate quickly emerged, namely, how should the oldest patients be regarded when it might become necessary or preferable to develop a triage system to decide which patients receive ventilators? what value set would be most fair and rational? who decides to remove an older patient from a ventilator, so that someone judged to have a better prognosis could benefit? could these decisions be made when even such basic data, such as icu mortality in the pre-covid-19 era, are not readily available? some of these icu admitting recommendations would have had the decision made by third parties, independent of family considerations. 1 fortunately, stocks of ventilators became available and the benefits of ventilator therapy in all cases have become called into question. but the reality is, fundamental data on what benefit icu care might have for older adults were not a paramount decision tool. where are the data in in the pre-covid-19 universe to address even crude end points, such as mortality in the patients older than 90 years? therefore, it is timely that in this current issue of the journal of the american geriatrics society, hass and colleagues report on a large-scale clinical review comparing short-term mortality after icu admission (i.e., icu and hospital mortality) in the population aged 80 to 90 years versus a cohort in the older than 90 years group. 2 the study found that mortality statistics were similar in both cohorts. icu mortality of the patients aged 90 years and older was actually lower (13.8% vs 16.1%; p < .001) and hospital mortality was similar (26.1% vs 25.7%; p < .41) compared with octogenarians. after 3 months, mortality was higher for the patients aged 90 years and older (43.1% vs 33.7%; p < .001), and after 1 year, mortality was 55.0% versus 42.7% (p < .001). thus, long-term mortality was higher in the nonagenarians, yet 75% of nonagenarians were living 1 year following hospital stay. nonagenarians and octogenarians had relatively similar prognoses. this study has several outstanding aspects. first, the investigators were able to identify every icu admission in the netherlands (82 icus) from january 2018 through december 2018. in aggregate, 103,754 patients, including 9,493 nonagenarians, were included. this study may have included the largest cohort of icu patients reported in the medical literature. second, access to advance health care is universally available in the netherlands. the data reported were unlikely to be confounded by access issues due to class differences, such as potential differences in mortality due to socioeconomic variables. third, some attempt was made to factor in key postadmission clinical characteristics of illness severity, such as acute physiologic assessment and chronic health evaluation (apache) scores. there have been previous studies with perhaps lower statistical power that have documented mortality rates among older adults hospitalized in icus similar to those reported here, but hass and colleagues 2 have added a decade of hospital experience for the entire country. hass and colleagues 2 acknowledge they were not able to characterize key differentiating risk factors. chief among these would have been prehospitalization measures of frailty, which at present are recognized as being central predictive factors for morbidity and mortality. 3 apache scores, which the authors factored into their analysis, are recognized as a valuable tool to measure acute illness severity, but do not provide data on prehospitalization functional status. as acknowledged by the authors, the study did not have sufficient granularity to assess how frailty measures might have predictive value in both the 80 and 90 years cohorts. some studies not focused on nonagenarians have reported that the use of relatively simple screening tools, such as the clinical frailty scale, may be highly predictive of the impact of frailty on acute hospital stays and icu mortality. 4 future prospective studies incorporating frailty scores in nonagenarians admitted to the icu will be of great interest, especially when one considers the well-known demographic projections of the oldest populations worldwide. for example, by the year 2050, the u.s. population aged 65 years is projected to be 83.7 million, almost double the estimated 43.1 million in 2012. of these, 3.7 million will be older than 85 years. 5 in addition to the challenge of caring for these oldest, there may be an additional unanticipated change in the physician workforce. in my community, as is true throughout the nation, the bulk of hands-on care for older adults with covid-19 respiratory involvement requiring icu care is being shouldered by selfless young physicians, nurses, and other care providers. they are witnessing the extraordinary respiratory-related mortality in covid-19 patients in this subset of old adults. might these impressionable experiences influence the attitudes of this next generation of caregivers even to the point that it adversely contravenes the somewhat optimistic data presented by hass and colleagues about prognosis of older adults in the icu environment? the evolutionary biologist richard dawkins in his 1976 book, the selfish gene, introduced the concept of a "meme" that he characterized as units of cultural transfer that catch on and pass between people and cultures. 6 his analogy was that a meme was the cultural equivalent of a gene. a wellrecognized example of a medical meme from prior generations might be the description of pneumonia in older adults as "the old man's friend," first attributed to the influential william osler in the first edition of his textbook on medicine. 7,8 "(pneumonia) in the debilitated, in drunkards, and in the aged, the chances are against recovery. so fatal is it in the latter class that it has been termed the natural end of the old man." the meme may have resurfaced in the late 1970s. few physicians trained 30 or 40 years ago will not recognize a variation in the use of the meme, "gomers go to ground" in the book, house of god. 9 fast forwarding to the present time, the meme may reappear when the popular press describes the phenomenon of fatal respiratory complications of covid-19 infection as "only in the elderly." 10 is it possible that the stark experiences of this new generation of frontline healthcare providers will be imbedded with a skewed pessimistic view of the oldest? historically, it has been the responsibility and mission of each successive generation of geriatricians to counter the many memes that still creep into the cultural response of healthcare providers when they encounter older adults. that is perhaps why evidence-based studies, such as that presented by hass and colleagues, 2 are so important to our work. evidence can still trump prejudice. william j. hall, md highland hospital, division of geriatrics, department of internal medicine, university of rochester school of medicine and dentistry, 1000 south avenue, rochester, new york, 14520 fair allocation of scarce medical resources in the time of covid-19 outcomes of intensive care patients over 90 years old, a 11-year national observational study vip1 study group. the impact of frailty on icu and 30-day mortality and the level of care in very elderly patients≥ 80 years clinical frailty scale in acute medicine unit: a simple tool that predicts length of stay an aging nation: the older population in the united states: current population reports the old man's friend. pneumonia the principles and practice of medicine covid-19 kills only old people: only? sponsor's role: there is no sponsor. key: cord-350907-lazslqn0 authors: isik, ahmet turan title: covid-19 infection in older adults: a geriatrician’s perspective date: 2020-07-06 journal: clin interv aging doi: 10.2147/cia.s260972 sha: doc_id: 350907 cord_uid: lazslqn0 the pandemic of the covid-19 virus has become the main issue all over the world. in its current form, the disease is more severe in geriatric cases and individuals with chronic disease, even causing death. in older adults and atypical presentations, testing strategies for covid-19, potential drug interactions of experimental covid-19 therapies, and ageism are important issues in the course of the disease. therefore, health-care professionals should be aware of these, and screening policies for covid-19 should also include atypical presentations with or without classical symptoms of the illness in older adults. furthermore, evaluation of individuals > 65 years of age from a geriatrician’s perspective is very important, because covid-19 is severe and fatal in seniors. the pandemic of the covid-19 virus has become the main issue all over the world. regarding the subject, authorities are making an intense effort to minimize the effects of the pandemic. in its current form, the disease is more severe geriatric cases and individuals with chronic disease, even causing death. 1, 2 regarding the severe course of the disease in the elderly, i would like to draw attention to some issues related to the diagnosis of covid-19 infections in older patients. first, preventive interventions are the most important issue in the fight against the infection. additionally, with covid-19 infection, it should be underlined that the disease is not only fatal in seniors but also that the majority of patients who need intensive care and die are elderly people. typical findings in patients with covid-19 infections, as in other pulmonary infections, are fever, cough, and dyspnea. [1] [2] [3] [4] infectious diseases, more common in older adults, may progress more severely than in young people. such diseases may show atypical presentations in older patients, which should be considered in this regard. 2, 3 older patients, especially frail ones with multiple comorbidities, may not show typical symptoms, such as fever, cough, chest discomfort, or excessive sputum production in pulmonary infections as much as young people do, and thus atypical presentations may be an important issue that causes delayed diagnosis of covid-19 infections. 4 these typical symptoms occur in less than 50% seniors, but they may show such symptoms as confusion or acute mental changes, frequent falls, decreased walking/mobility, unexplained tachycardia or decrease in blood pressure, decreased appetite, difficulty swallowing, and new-onset incontinence. among these, acute mental changes and tachypnea are more common in infectious diseases, such as pulmonary infections, in older people, who cannot produce a fever response as much as young people. 4 the fact that these symptoms can be seen in many diseases other than infectious disease plays an important role in delaying diagnosis in geriatric cases. also, frequent sensory loss, dementia, and polypharmacy in this age-group make it difficult to get an appropriate disease history from older individuals. 4, 5 diagnosis of the infection is easy to achieve with computed tomography, nasopharyngeal swabs, and laboratory tests, but the fact that symptoms of patients are a guide in deciding which patient to test for covid-19 should not be ignored. therefore, it should be kept in mind that older patients with covid-19 show both typical and atypical symptoms. absence of fever may not exclude the infection, 8 as the elderly may not have a fever, which is one of the main symptoms to test for with covid-19. for example, traditionally defined as a body temperature >38°c, fever is absent or blinded in almost a third of older patients with acute infection. 9 diminished thermoregulatory capacity and abnormal production and response to endogenous pyrogens with aging may be partly to blame. in older patients with infections, such as moderate-severe pneumonia, admitted to the clinic, the average temperature in the first 3 days of the disease decreases by 0.15°c every 10 years, 5,10 which is well known as "older is colder". in addition, body temperatures of healthy older people tend to be lower than young people. 5, 6, 10, 11 in evaluation of fever in the elderly, recurrent oral or tympanic body temperature >37.3°c and an increase >1.1°c above basal body temperature would be more realistic. 6, 12 however, hypothermia can be a sign of a serious life-threatening infection. 5, 11 in a study examining the cases in wuhan, china, the origin of the infection, it was reported that the disease progresses more severely and even causes deaths, especially in older patients and individuals with chronic diseases. likewise, in this study, it was noteworthy that fever was detected at similar rates in those were discharged and were died, when fever was defined as > 37.3°c. 3 on the other hand, another study, conducted in china, reported that older individuals with covid-19 did not show the fever response as much as young people, 13 which may be related to definition of the fever. moreover, wang et al found that those who needed intensive care due to the covid-19 were older, and that atypical findings for acute lung infection, such as weakness, dizziness, nausea/vomiting, diarrhea, abdominal pain, and loss of appetite appeared approximately 6.5 days before dyspnea. 14 considering that this period is 2.5 days in covid-19 patients who do not need intensive care and are younger, the fact that dyspnea occurs approximately 6.5 days after the first symptom 14 is also striking in terms of the importance of atypical presentations. therefore, in research it should be kept in mind that atypical presentations of the disease may cause delays in admission or diagnosis of those who required icu care or died. in light of these findings, it can be said that age-related immune-system changes, comorbid conditions, and atypical presentations make it difficult to recognize the early diagnosis of covid-19 infection in geriatric cases, and the disease may cause more severe or even mortality in these cases. furthermore, the fact that testing strategies for covid19 have not included asymptomatic patients or older patients with atypical presentations, which may also have contributed to those results in older adults. 1, 2 additionally, in evaluating these findings, we should not overlook the possibility that a large number of covid-19--infected patients and the limited medical-care capacity available in the world may be causing geriatric cases to be deprived of the necessary medical care, which is called ageism or age discrimination. another important issue to keep in mind in this patient group, who are vulnerable to adverse drug effects, is that experimental covid-19 therapies, especially with main adverse events of chloroquine, such as hypoglycemia, electrolyte imbalance, arrhythmia, neuromuscular pain, irritability, delirium, granulocytopenia, irreversible visual impairment, gastrointestinal symptoms, and potential drugdrug interactions, may have a negative effectson the course of the disease, due to potential drug interactions. 15, 16 finally, atypical presentations, testing strategies for covid-19, potential adverse events of experimental covid-19 therapies, especially in chloroquine, and ageism are important issues in the course of the disease in seniors. therefore, health-care professionals should be aware of these, and screening policies for covid-19 should also include the aforementioned atypical presentations with or without classical symptoms of the illness in older adults. furthermore, while covid-19 is severe and fatal in older adults, evaluation of individuals over 65 years of age with a geriatrician's perspective is very important. there is no funding to report. the author reports no conflicts of interest in this work. case-fatality rate and characteristics of patients dying in relation to covid-19 in italy long-term care facilities and the coronavirus epidemic: practical guidelines for a population at highest risk clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study coronavirus disease 2019 in geriatrics and long-term care: the abcds of covid −19 sepsis and other infectious disease emergencies in the elderly diagnostic accuracy of three different methods of temperature measurement in acutely ill geriatric patients insights into severe sepsis in older patients: from epidemiology to evidence-based management nonspecific symptoms lack diagnostic accuracy for infection in older patients in the emergency department fever in the elderly the relationship between age and fever magnitude is older colder or colder older? the association of age with body temperature in 18,630 individuals clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the infectious diseases society of america clinical feature of covid-19 in elderly patients: a comparison with young and middle-aged patients clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan liverpool: evaluating the drug-drug interaction risk of experimental covid-19 therapies pharmaceutical care of chloroquine phosphate in elderly patients with coronavirus pneumonia medline, cas, scopus and the elsevier bibliographic databases. the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use clinical-interventions-in-aging-journal dovepress isik clinical interventions in aging 2020:15 submit your manuscript | www key: cord-338049-en9ktl4s authors: naarding, p.; oude voshaar, r.c.; marijnissen, r.m. title: covid-19: clinical challenges in dutch geriatric psychiatry date: 2020-05-27 journal: am j geriatr psychiatry doi: 10.1016/j.jagp.2020.05.019 sha: doc_id: 338049 cord_uid: en9ktl4s the covid-19 pandemic has changed everyday life tremendously in a short period of time. after a brief timeline of the dutch situation and our management strategy to adapt geriatric mental health care, we present a case-series to illustrate the specific challenges for geriatric psychiatrists. 1. the knowledge of being vulnerable and the involuntary and inescapable self-isolation are both creating anxiety and maybe other psychiatric signs and symptoms. this will be not only in the known psychiatric patients, but also in the general older population. the covid-19 pandemic has changed everyday life tremendously in a short period of time. the threat of contamination is especially frightening for older persons, as chronological age is a major risk factor for a severe course and mortality [1] . social distancing and self-isolation have been imposed by the authorities to contain or delay the spread of the sars-cov-2 virus (covid-19) and to prevent a shortage of hospital intensive care beds. these measures may have a disproportionately large impact on the older age group since personal assistance on (i)adl has to be minimized and the prohibition of family and other social contacts may worsen feelings of loneliness [2] . this impact on (older) persons, which is already high, may increase even more in the presence of a psychiatric disorder [2] and in the case of lower socio-economic status and smaller social networks [4] . a brief timeline of the dutch situation and our management strategy to adapt geriatric mental health care is presented below, followed by a case-series to illustrate the specific challenges facing geriatric psychiatrists. this case-series included patients treated at ggnet, a large mental health care center covering a population of around 800,000 in the eastern part of the netherlands, and the psychiatry department at university medical center groningen in the northern netherlands. on february 27 th 2020, the first person tested positive for sars-cov-2 in the southern part of the netherlands, followed by the spread of the virus throughout the country. measures were applied in rapid succession, since mental health centers are not prepared for the management of communicable diseases. initially, handshakes were prohibited and social distancing was applied in the conversation room. one week later, only urgent visits were allowed to our outpatient clinics; group sessions were restricted to a maximum of three persons and one week later prohibited entirely. finally, by mid-march, older outpatients were confined to their homes due to the lockdown in the netherlands. many aspects of mental health care facilities make older patients with psychiatric disorders susceptible to the rapid spread of covid-19 [5] . in long-term care facilities and acute inpatient wards, communal meals and different group activities, combined with an inability to follow hygienic and sanitary rules, hinders the prevention of transmission. as a result, older inpatients in acute and long-term care mental health care have been locked-up. beginning on march 20, contact with their closest family members was prohibited. this latter restriction may cause iatrogenic damage, as social isolation of older adults is associated with a higher risk of the onset of chronic diseases such as cardiovascular, autoimmune, neurocognitive, and affective disorders [6] [7] [8] . to comply with national policies on the spread of covid-19 and protect geriatric psychiatric patients, specific covid-19 isolation units with 5-9 beds were set up in most mental health centers. in addition to the fear of infection of our patients, we also in the quarantine ward until they were free of symptoms for 24 hours before isolation was concluded. one patient, suffering from a chronic psychotic disorder, destabilized in isolation and became severely psychotic over the next three days. she refused to cooperate with our program and medication, which resulted in coerced admission and compulsory treatment. members of the clinical staff were allowed to return to work when they were completely free of symptoms for more than 24 hours. case b -in the long-stay ward for older patients, mrs. b, an 83-year old woman, was admitted 7 months ago after the death of her husband. she had a long history of recurrent affective psychosis in the context of a schizo-affective disorder. during the admission, her psychiatric status stabilized and the following month she was transferred to a geronto-psychiatric ward of a nursing home. she complained of pain in her left cheek, which showed some redness and a palpable swelling, suspected to be a local pustule. initially, there were no other symptoms. however, over the following days, she developed a high fever, her entire face became red, and she felt very ill and stayed in bed, which was quite unusual for the patient in question. her oxygen saturation was 91%, low for a patient with no history of copd. she showed no signs of cough or respiratory illness, and her pulse and blood pressure were normal. although a beta-hemolytic group a streptococcus infection (erysipelas) was considered the most likely cause, for which antibiotics were started, we also decided to isolate her in the 'covid' unit. her dosage of clozapine was reduced by half, her leucocyte count was checked, and she was supported with extra oxygen (2l/min). her oxygen saturation improved. the covid-19-test was negative and her blood level of clozapine and leucocyte counts were fine. the isolation was stopped and she recovered. while her condition, especially her anxiety, deteriorated rapidly at home, she gradually improved over the course of the first two weeks of the online group therapy. her husband no longer pressured us to admit her to an inpatient ward and was happy to have her at home isolated from family and friends. the case-vignettes described above illustrate the immediate clinical challenges we faced in our mental health services for older people during the initial weeks of the covid-19 outbreak in the netherlands. 1. the awareness of vulnerability as well as the involuntary and inescapable selfisolation both generate anxiety and possibly other psychiatric signs and symptoms. this will be the case not only in known psychiatric patients, but also in the general older population (see case d). 5. since national policies have restricted outpatient care programs, we rapidly transformed individual and group therapy sessions into e-health programs using telephone or video platforms. for older people, this is not always possible, because they lack the knowledge and experience in the use of these new technologies, and sometimes lack the appropriate resources required for this kind of connection to begin with. it is important to avoid ageism, since most of our patients seem to adapt easily to these opportunities. some patients need additional support to get online, e.g. by setting up online connections with their healthcare providers, and by ensuring that the family will support online access by providing computers or tablets to stay connected. assisting these older people to digitize will also probably lead to easier access to other health care service providers and help them to stay in touch with friends and relatives. a digital day-treatment program can combine these interventions and could be an alternative for the in-person day-treatment (see case e2). nonetheless, some psychiatric conditions may prevent the successful application of online therapy (see case e1). in conclusion, this crisis has had an enormous impact on older persons in our society, and we have to be prepared to face these upcoming challenges and respond to them with sustainable and effective strategies and solutions. our primary concern is our vulnerable older psychiatric group, which is at major risk of contracting covid-19 themselves. isolation and rapid recognition of the infected group is our primary goal. after this, we have to take special care of this group, because they will suffer more from the social isolation and lock-down and are at risk of deterioration from these measures themselves. but this crisis may also offer opportunities. for example, speeding up individual and group e-health therapies and e-health visits is a major task for us now. coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up covid-19 and the consequences of isolating the elderly mental health services for older adults in china during the covid-19 outbreak adressing the covid-19 pandemic in populations with serious mental illness the coronavirus and the risks of the elderly in long term care loneliness as a public health issue: the impact of loneliness on health care utilization among older adults social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older americans (nshap): a longitudinal mediation analysis dealing with sleep problems during home confinement due to the covid-19 outbreak: practical recommendations from a task force of the european cbt-i academy novel coronavirus infection (covid-19) in humans: a scoping review and meta-analysis key: cord-354105-lgkfnmcm authors: office, emma e.; rodenstein, marissa s.; merchant, tazim s.; pendergrast, tricia rae; lindquist, lee a. title: reducing social isolation of seniors during covid-19 through medical student telephone contact date: 2020-06-05 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.003 sha: doc_id: 354105 cord_uid: lgkfnmcm abstract social isolation has been associated with many adverse health outcomes in older adults. we describe a phone call outreach program in which health care professional student volunteers phoned older adults, living in long-term care facilities and the community, at risk of social isolation during the covid-19 pandemic. conversation topics were related to coping, including fears/insecurities, isolation, and sources of support; health; and personal topics such as family and friends, hobbies, and life experiences. student volunteers felt the calls were impactful both for the students and for the seniors, and call recipients expressed appreciation for receiving the calls and for the physicians who referred them for a call. this phone outreach strategy is easily generalizable, and can be adopted by medical schools to leverage students to connect to socially-isolated seniors in numerous settings. social isolation has been associated with many adverse health outcomes in older adults. we 2 describe a phone call outreach program in which health care professional student volunteers 3 phoned older adults, living in long-term care facilities and the community, at risk of social 4 isolation during the covid-19 pandemic. conversation topics were related to coping, including 5 fears/insecurities, isolation, and sources of support; health; and personal topics such as family 6 and friends, hobbies, and life experiences. student volunteers felt the calls were impactful both 7 for the students and for the seniors, and call recipients expressed appreciation for receiving the 8 calls and for the physicians who referred them for a call. this phone outreach strategy is easily 9 generalizable, and can be adopted by medical schools to leverage students to connect to 10 socially-isolated seniors in numerous settings. social isolation, a quantitative loss in a person's social relationships, is common in older adults, 27 with 27% of adults over 60 y/o living alone. 1, 2 during the covid-19 pandemic, social distancing 28 has been an essential public health strategy. 3 while many older adults entered independent 29 living communities for activities and socialization, they have been advised to remain in their own 30 apartments or room. meals are delivered to doors, activities have stopped, exercise rooms 31 closed, and visitors are restricted. these necessary stay-at-home measures unfortunately 32 increase social isolation. 33 social isolation has been associated with adverse health outcomes including increased risk of 34 falls, all-cause mortality, hospitalizations, and cognitive decline, as well as unhealthy behaviors 35 like physical inactivity and poor diet. 4,5 additionally, in the previous sars pandemic, isolating 36 infection control practices were associated with increased depression and traumatic stress 37 response symptoms. 6 social isolation has been associated with less infection resistance, more 38 emergency admissions to hospital, and extended length of stay, factors which may lead to 39 worse outcomes during the covid-19 pandemic. 7-10 40 given the effects on the mental and physical health of the elderly, interventions targeting social 41 isolation are necessary to mitigate risk of increased morbidity and of infection from covid-19. social isolation calls during covid-19 -3 we created a phone call outreach program, seniors overcoming social isolation (sos), in 48 which medical and health professions student volunteers (e.g. md, md/phd, neuroscience, 49 genetic counseling) called older adults, living in long-term-care facilities (ltcf) and the 50 community, at risk of social isolation during covid-19. the sos program entailed providers 51 identifying at-risk older adults and then referring the contact information to coordinators who 52 would then pass the info to student volunteers. student volunteers were provided with an 53 introduction script and a series of conversation starters, general social history questions, and 54 well-being questions (e.g. resource needs, groceries) to ask the older adult. students then 55 phoned the older adults when they had available free time. the goals were (1) to provide 56 companionship and resources for unmet needs of older adults, while (2) fostering health 57 professional students' skills in communicating and understanding the needs of older adults in 58 their community. we propose that social phone calls to older adults may reduce social isolation 59 while providing meaningful engagement with the community and a learning experience for 60 students. perspectives and resolving any identified discrepancies through discussion. in no cases were 80 the coders unable to reach consensus. the coders organized the content into relevant themes. 81 descriptive statistics were used to analyze participant surveys. 82 fourteen volunteers made 25 phone calls, averaging a length of 8.3 min (sd 4.0). nearly all 85 volunteers (85.7%) were in medical school (md or md/phd program), and most of those 86 students were in their first year of medical school (75%). there was 2 graduate health program 87 students (e.g. medical geneticist and neuroscientist programs) who heard about program 88 through word-of-mouth. volunteers were predominantly female (92.9%), and identified as asian 89 or white (50% and 43%, respectively). 90 both conversational and covid-19-related themes were discussed during calls (table 1) . 91 topics related to covid-19 included health, fears, isolation, coping, and sources of support, 92 while other prominent topics ranged from family and friends, to hobbies, to the older adult's past. in addition to providing social connection, several students assisted in addressing unmet 94 needs by referring the older adults to sources of support. 95 most students felt that the calls were well-received; recipients expressed appreciation both for 97 the calls/callers and for those who referred them. (table 2 ) some students felt that the call was 98 less impactful, while one felt that they had disrupted the older adult by calling. student 99 volunteers indicated they had plans to contact a little over a third of older adults (36%) again. 100 we do not have data about follow-up phone-calls. 101 after the telephone contact, many students felt positive and empowered; one described feeling 103 inspired by the older adult's story, and several reflected on the senior's appreciation. other 104 students acknowledged challenges, such as needing patience and talking about different topics 105 than normally discussed with younger adults (table 3) . 106 107 during the covid-19 pandemic, requisite social isolation is a critical problem among older 109 adults living in assisted and independent living communities. there is ample evidence that this 110 is an important problem desperately needing intervention. 111 to reduce social isolation, we present a practical intervention leveraging health professions 112 graduate students contacting older adults and residents of independent and assisted living by 113 phone. our results show that it is feasible and has bi-directional benefit to both student callers 114 and older adult residents. students felt empowered and that they were able to make a difference in the lives of socially isolated seniors. results also showed that they were learning 116 how to be patient and slowdown in conversations with hearing-impaired seniors, specifically 117 learning important tenets of geriatrics in the process. older adults appreciated and enjoyed 118 receiving calls, likely as they were interrupting their social isolation. 119 limitations of this study include the small sample size, single location, and referral of older 120 adults by a provider. while conducted in a single location (chicago), covid-19 was widespread 121 and existed in most of the area's long-term-care communities necessitating isolation. several 122 students struggled to contact their assigned older adults, potentially due to illness or 123 hospitalizations. this intervention depends on student volunteerism; as classes resume, fewer 124 students may have time to participate. moreover, this requires coordination of providers in 125 identifying appropriate older adults, student volunteering, and a coordinator assigning seniors to 126 call. while online sign-ups limit some of the workload, a dedicated volunteer student coordinator 127 is necessary. 128 seniors overcoming social isolation calls are easily generalizable and can be adopted by most 129 medical schools to connect students to socially isolated seniors in multiple settings. for further 130 generalization, student volunteer groups do not need to be in the same area as those being 131 contacted. medical schools can partner with rural communities or low income areas who do not 132 have direct academic partnerships to reduce isolation in hard-to-reach areas. during covid-19 133 pandemic, this simple innovation has been shown to be a feasible route of improving the lives of 134 both older adults and students. 135 national academies of sciences, e. and medicine, social isolation and 139 loneliness in older adults: opportunities for the health care system social distancing, quarantine, and isolation a review of social isolation: an important but underassessed 145 condition in older adults. the journal of primary prevention health risks associated with social isolation in general and in young, 147 middle and old age sars control and psychological effects of quarantine social ties and susceptibility to the common cold social disconnectedness, perceived isolation, and 154 health among older adults does lack of social support lead to more ed visits for older 157 adults? reducing social isolation and loneliness in older people: a 159 systematic review protocol covid-19 and the consequences of isolating the 161 elderly. the lancet public health social distancing in covid-19: what are the 163 mental health implications? the effect of information communication 165 technology interventions on reducing social isolation in the elderly: a systematic 166 review the use of telephone befriending in low 168 level support for socially isolated older people -an evaluation. health & social care in 169 the community the authors wish to thank their families and loved ones for support while in medical school and the health care profession. the authors also wish to thank the volunteers who assisted with the telephone contact of the older adults. key: cord-010965-5jkau3jb authors: berg-weger, m.; morley, john e. title: loneliness in old age: an unaddressed health problem date: 2020-01-16 journal: j nutr health aging doi: 10.1007/s12603-020-1323-6 sha: doc_id: 10965 cord_uid: 5jkau3jb nan older persons are more likely to live alone and tend to be less socially engaged. there has also been a decline in religious involvement. this has been perceived to result in a "loneliness epidemic." declared as a global epidemic by former u.s. surgeon general vivek murthy (1), loneliness and social isolation are reported to occur in approximately onethird or more of older adults with 5% of those often or always feeling lonely (2, 3) . recent u.s.-based research suggests the range is 17% -57% of persons experience loneliness, a figure that increases for those who have mental and physical health concerns, particularly those with heart disease, depression, anxiety, and dementia (4) . loneliness and social isolation have been shown to significantly impact older adults, both physically and emotionally. areas of the older adult's life that can be negatively affected when the individual is experiencing loneliness and/or social isolation are listed in table 1 . the longterm (greater than four years) effects of loneliness and social isolation can be even more devastating, including; increased blood pressure, depression, weight gain, smoking alcohol/ drug use, and alone time (5) and decreased physical activity, cognition, heart health, and sleep, stroke and coronary heart disease, in particular (6). • quality-of-life (7) • cognition (28, 29) • subjective health (30) • stress and depression (31) • decreased quality of sleep (32) • disability (33, 34) • cardiovascular disease (6) • increased use of health care services (29, (35) (36) (37) • increased mortality (29, 38, 39) • institutionalization (29) predictors and risk factors of loneliness and social isolation are numerous, but some may be modifiable. these factors are listed in table 2 (7-13). management of loneliness requires both medical and social interventions. persons with decreased hearing including those who hear poorly in noisy groups need to be evaluated for hearing amplifiers or hearing aids. persons with visual disturbances need to be provided with appropriate vision aids. persons with dual sensory impairment are at particular risk for loneliness (14) . depression can play a major role in loneliness and needs to be treated either with group behavioral therapy especially when minor depression (dysphoria) and medications or electroconvulsive therapy when major depression (15) . cognitive impairment needs to be assessed and where possible reversible causes need to be treated (16) . persons with moderate dementia should be offered cognitive stimulation therapy (17, 18) , an evidence-based, non-pharmacologic individual or group intervention. developing compassionate social communities are a key approach to dealing with loneliness. persons who are isolated need to be recognized and attempts made to provide them with social interaction. in this case, transportation represents a major component as well as mobilizing youth and other community volunteers to become friendly visitors (via phone or in-person visits). a variety of group therapies such as laughter therapy, reminiscence therapy, horticulture therapy, exercise and dancing can all reduction loneliness (19) . emotional loneliness requires a different approach. emotional loneliness is typified by albert einstein, who said, "it is strange to be known so universally and yet to be so lonely." it is clear that for a number of reasons, there are persons in the community who have difficulty making friends. they need coaching in behaviors that will help them make friends and to alter their expectations of friends. these people can suffer loneliness in the presence of multiple social contacts (20) . it is important to recognize the role of maladaptive social cognition in loneliness as it needs a different therapeutic approach. developed by scholars and practitioners at the central union for the welfare of the aged at helsinki university in the early 2000s, circle of friends© is built on a model of group rehabilitation with the aim being alleviation and prevention of loneliness in older adults (21) . the group of approximately eight older adults who have self-identified as being lonely or socially isolated meet 12 times over three months with a facilitator for the purpose of making new friends, feeling less lonely, sharing feelings of loneliness with others: experiencing meaningful things together; and transitioning into a selfsupportive group who continues to meet after the initial three months (22) . each session includes three components: 1) art and inspiring activities with discussion; 2) group exercise and health-themed discussion; and 3) therapeutic writing with sharing and reflecting on issues related to loneliness (23) . evidence for the effectiveness of circle of friends© has been reported by the founders of the intervention to suggest that the intervention is well suited for delivery with older adult populations living in the community, adult day centers, and residential facilities. outcomes for participants encompass physical and emotional health and health care utilization. specifically, in a two-year post-intervention study, 97% of participants were still living, reported improved subjective health with decreased health care costs and hospitalizations, only 2.5% had dropped out, and 6 of 15 groups were still meeting (24) . similarly, a later study reports 95% of participants no longer feel lonely, 45-85% made new friends, 40% of the groups continued meetings, and feeling of being needed and psychological well-being improved (25, 26) . through the geriatric workforce enhancement program (gwep), circle of friends© is being introduced in the st. louis, missouri area. as the first circle of friends© groups to launch outside of finland, two organizations have integrated the intervention into programming for older adults. both funded through the st. louis senior fund, circle of friends© is being offered at the association for aging and developmental disabilities and through a collaborative partnership between chips (community health in partnership) and the st. louis public housing authority. both groups received training during summer 2019 and launched multiple groups in the fall at locations in senior centers and housing complexes. groups continue to meet at both agencies with plans to continue this successful intervention to bring older adults together to build new relationships. in addition, a rural hospital in perry county and the family practice program at saint louis university are both providing circle of friends groups. our preliminary observations have suggested that the circle of friends is an excellent approach to reduce loneliness. physicians and other health and social service providers tend to be poorly trained and equipped to deal with loneliness (27) . patients are seldom asked about loneliness and providers do not have an approach to treating the "problem." there is a need to train medical students and residents and other professionals in recognizing loneliness, e.g., alone screen (table 3) and to manage the problem working together with social workers and the community as so aptly stated by mother theresa, "loneliness and the feeling of being unwanted is the most terrible poverty." health professionals need to become more aware of the importance of loneliness in older persons. disclosures: the authors declare there are no conflicts . work and the loneliness epidemic training professionals to implement a group model for alleviating loneliness among older people-10-year follow-up study predictors and subjective causes of loneliness in an aged population the impact of loneliness on quality of life and patient satisfaction among older, sicker adults loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies loneliness, fear, and quality of life among elderly in sweden: a gender perspective a national survey of adults 45 and older. loneliness and social connections interventions for alleviating loneliness among older persons: a critical review high prevalence and adverse health effects of loneliness in community-dwelling adults across the lifespan: role of wisdom as a protective factor social contacts and their relationship to loneliness among aged people-a population-based study predictors and subjective causes of loneliness in an aged population incontinence and loneliness among chinese older adults with multimorbidity in primary care: a cross-sectional study the impact of sensory impairment on cognitive performance, quality of life, depression, and loneliness among older adults the effectiveness and harms of antidepressants cognitive deficit reversal as shown by changes in the veterans affairs saint louis university mental status (slums) examination scores 7.5 years later cognitive stimulation therapy editorial: nonpharmacological treatment of cognitive impairment social contacts and their relationship to loneliness among aged people -a population-based study a systematic review of interventions for loneliness among older adults living in long-term care facilities geriatric rehabilitation nursing: developing a model circle of friends. group model alleviating loneliness leading groups of older people: a description and evaluation of the education of professionals effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomized, controlled trial effects of psychosocial group rehabilitation on social functioning, loneliness and well-being of lonely, older people: randomized controlled trial psychosocial group rehabilitation for lonely older people: a description of intervention and participants' feedback to support and not to cure: general practitioner management of loneliness an active and socially integrated lifestyle in late life might protect against dementia social networks and dementia changes in and factors related to loneliness in older men. the zutphen elderly study social isolation, loneliness, and health in old age: a scoping review loneliness and sleep in older adults the influence of differing social ties on decline in physical functioning among older people with and without chronic diseases: the longitudinal aging study amsterdam loneliness as a predictor of quality of life among older caregivers someone to talk to? the role of loneliness as a factor in the frequency of gp consultations loneliness as a predictor of hospital emergency department use loneliness and nursing home admission among rural older adults the feeling of loneliness prior to coronary artery bypass grafting might be a predictor of short-and long-term postoperative mortality effects of social and personal resources on mortality in old age: the longitudinal ageing study amsterdam key: cord-311757-qbk4aapf authors: dawes, piers; siette, joyce; earl, joanne; johnco, carly; wuthrich, viviana title: challenges of the covid‐19 pandemic for social gerontology in australia date: 2020-09-23 journal: australas j ageing doi: 10.1111/ajag.12845 sha: doc_id: 311757 cord_uid: qbk4aapf nan older people, particularly those with pre-existing health conditions, are more susceptible to the sars-cov-2 virus that causes covid-19. 1 those who recover may face additional long-term impacts on health 2 that make older people more likely to need additional support and affect future quality of life. public health measures to suppress the virus-social distancing, restrictions on public transport, closure of shops, clinics, public facilities and community, sporting and interest groups-increase anxiety, depression and loneliness in older people. 3 older people may also be impacted as both providers and recipients of volunteer services, as many volunteers are older adults who have had to withdraw their services. 4 older people tend to work in occupations with high infection risk (e.g. health and caring professions). 5 these occupations are also low wage and/or casual, and so, people may be unable or unwilling to take time off while infected. although older people are at lower risk of job loss than the young, they are more likely to remain unemployed after losing their job. 5 losses in financial markets have reduced the value of superannuation funds, affecting pensions for retired people. 6 engagement with family and friends has been limited. internet-based communication and online delivery of mental health interventions offer the potential to redress social and mental well-being impacts, 7 but difficulties with access and computer literacy may exacerbate inequalities in social participation and mental well-being for older people. 8 grandparents have had to withdraw childminding support for families, or risk exposure to the virus. the impacts of social distancing on family dynamics are unknown, although there are positive reports of community and family initiatives to address the social impacts of the virus. 9 closure of clinics, swimming pools and gyms may adversely impact levels of physical activity and management of long-term health conditions. health-care services have cancelled elective surgery and non-urgent clinical care, increasing risk of worsening health in older people. health services have changed practice to support older people with tele-services, though the effectiveness and uptake of these modes of delivery are not known at the population level. the pandemic may exacerbate ageism. 10 in some countries, there was debate about whether politicians should do anything to protect people at most risk, or whether older people should be sacrificed for the sake of the economy; 11 older people are more vulnerable to the virus and less economically productive. some people may blame older adults for the economic and social impacts of the measures taken to suppress covid-19. 10 the pandemic disproportionately impacts those from ethnic minority and low socio-economic backgrounds. 12 indigenous australians are particular risk, with indigenous households more likely to be intergenerational as well as living in overcrowded and inadequate housing, increasing risk of virus transmission. 13 lack of culturally appropriate information and under-engagement with mainstream health services exacerbates risk for indigenous people. 13 dawes et al. residents and staff of aged care facilities are vulnerable to the virus due to the age and long-term health conditions of residents and communal living arrangements. 14 family and friends and allied health services being unable to visit people living in aged care facilities may result in increased social isolation, vulnerability to abuse and neglect, and poorer health outcomes. 14 research with aged care populations is substantially curtailed as facilities are closed to visitors. the royal commission into aged care quality and safety identified several areas of need including focusing on caring relationships, including the voices of residents and family, providing clear information to make informed choices about care, improving regulatory arrangements and supporting the aged care workforce. 15 addressing these needs may also increase resilience to pandemics, although at least in the short term, these questions may be displaced in preference to addressing infection control and the direct impacts of the virus. there is an expectation that transmission of the virus can be suppressed until an effective vaccine is found. however, it is unclear whether an effective vaccine will ever be found. 16 further, likelihood of future global pandemics is high. there is therefore an urgent need to develop and test solutions to facilitate health care and social participation of older adults that minimise the risk of transmitted disease in the long term. australian researchers face numerous short-and long-term challenges in addressing these urgent needs. schools and universities around the world have been closed during the pandemic. 17 an academy of science report on the impact of the pandemic on australian universities identified dramatic reductions in international student fees and research funding. 18 the report projected losses of up to 21,000 fulltime positions including 7,000 research-related academic staff. the federal government excluded universities from a national employment subsidy program to offset the impact of the pandemic. 19 women and early-career researchers may be especially adversely affected. 18 up to 9,000 international research students will not resume their research in 2020 due to research interruptions and travel restrictions. universities are dealing with financial constraints by decreasing the numbers of casual teaching staff and increasing teaching loads of permanent staff, reducing research capacity. 18 in the short term, australian universities have suspended face-to-face testing of research participants. some universities are beginning a phased return to seeing participants, although those from particularly vulnerable populations (including older people, people with long-term health conditions and people living in aged care facilities) are set to be the last groups where data collection will restart. time-dependent studies are most affected, particularly those including longitudinal data collection and intervention studies where outcomes must be assessed at particular time points. disruption to data collection has critical impacts on postgraduate student projects where time for data collection is limited. those on short-term research contracts are disproportionately affected as the projects that they were employed to work on have had to be suspended. many research staff have found their productivity impacted by having to work from home and provide homeschooling to their children. researchers and organisation have attempted to mitigate the impact of the pandemic on research. mitigations included modifying study protocols to rely on online data collection or postal surveys. the main limitations of these approaches are the impossibility of completing certain physical testing remotely, lack of equivalence of online versions of assessments and potential bias if there are systematic differences in access and ability to use computers that are related to the outcomes of interest. institutional ethics committees have fast-tracked ethical approvals for protocol modifications. researchers have switched focus to alternative methodologies that are not reliant on collection of face-to-face data, including analysis of existing data sets, systematic reviews, surveys and internet-based interviews. journals have fast-tracked publication of research papers dealing with the impact of covid-19, which are then published open access. some editors have made allowance for longer revision times and taken a pragmatic approach to shortcomings in research due to the impacts of the pandemic. funders have allowed flexibility in revising the protocols and study timelines for funded projects. the australian research council attempted to mitigate the impact of the pandemic by extending closing dates for applications to some schemes, allowing late submission of applications and extensions or changes of scope for existing projects. 20 funding support for universities is critical to address loss of revenue. some state governments announced measures to mitigate the impact of reduced international student enrolments and supporting universities with research partnerships. the federal government should consider support for universities to carry out the research that addresses the needs of older australians. the effects of the pandemic are greatest for older people and the most vulnerable in society. given altered research priorities following the pandemic, social gerontologists must lobby for support. the current focus is justifiably on the epidemiology and the clinical impacts of the virus. in the longer term, issues of mental health for older people, prevention, and | 3 resilience of health care and social support for older adults will grow in importance. researchers must actively engage with these questions at the earliest opportunity. to ensure that research is of greatest utility, older people should play a central role in identifying research needs and priorities, as well as in the design, implementation and dissemination of research. strategies that do not rely on faceto-face meetings are required to ensure that the voices of older people are heard by researchers and policymakers in the co-design of future solutions. the covid-19 pandemic exposed inequalities and vulnerabilities for older australians, particularly those with long-term conditions, people from minority communities, indigenous backgrounds and residents of aged care facilities. the pandemic also directly impacted social gerontologists. we must grapple with these challenges and take the opportunity to address these inequalities and vulnerabilities and improve health, well-being and quality of life for older australians. estimating the infection and case fatality ratio for coronavirus disease (covid-19) using age-adjusted data from the outbreak on the diamond princess cruise ship association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan covid-19 and the consequences of isolating the elderly volunteering and covid-19 arc centre of excellence in population ageing research, covid-19 and the demographic distribution of health and economic risks australian taxation office. covid-19 (novel coronavirus) -temporarily reducing superannuation minimum payment amounts internet-based cognitive behavior therapy for loneliness: a pilot randomized controlled trial good intentions are not enough: how informatics interventions can worsen inequality eight acts of goodness amid the covid-19 outbreak. greter good magazine at uc berkeley australian human rights commission texas' lieutenant governor suggests grandparents are willing to die for us economy covid-19: an urgent public health research priority urban aboriginal people face unique challenges in the fight against coronavirus the coronavirus and the risks to the elderly in long-term care why we might not get a coronavirus vaccine. the guardian covid-19 educational disruption and response australian academy of science. impact of the pandemic on australia's research workforce australian government moves again to exclude universities from bailout, in times higher education how research funders are tackling coronavirus disruption the authors are supported by the centre for ageing, cognition and wellbeing, macquarie university. no conflicts of interest declared. key: cord-344818-ms2edk3w authors: chu, charlene h.; donato‐woodger, simon; dainton, christopher j. title: competing crises: covid‐19 countermeasures and social isolation among older adults in long term care date: 2020-07-09 journal: j adv nurs doi: 10.1111/jan.14467 sha: doc_id: 344818 cord_uid: ms2edk3w while debate over the appropriate scope and goals of covid‐19 lockdowns has raged, all public health agencies have been clear on one matter: older adults have the highest rates of mortality (comas‐herrera et al., 2020) and should be isolated (public health agency of canada, 2020). older adults and individuals with complex health conditions are most vulnerable to the virus. yet, social isolation contributes to the onset and intensifies depression, feelings of despair and, in older adults with dementia, further cognitive decline. while debate over the appropriate scope and goals of covid-19 lockdowns has raged, all public health agencies have been clear on one matter: older adults have the highest rates of mortality (comas-herrera et al., 2020) and should be isolated (public health agency of canada, 2020). older adults and individuals with complex health conditions are most vulnerable to the virus. yet, social isolation contributes to the onset and intensifies depression, feelings of despair and, in older adults with dementia, further cognitive decline. older adults living in long-term care (ltc) facilities comprise 79% of the covid-19 death toll in canada (rothan & byrareddy, 2020; walsh & semeniuk, 2020) . while our failure to protect long-term care (ltc) facilities has been made apparent both by this high mortality and a shocking recent canadian armed forces report (mialkowski, 2020) , the singular focus on mortality has overshadowed any attention to morbidityparticularly the effects of physical distancing on health, quality of life and autonomy. annual mortality in ltc facilities exceeds 25%, approaching 50% in some jurisdictions (tanuseputro et al., 2015) . this suggests that if physical distancing measures are extended for months or years until either herd immunity or a vaccination, a shocking proportion of ltc residents are likely to die under a "new normal" of isolation that few would choose. many in canada were deeply troubled by the recent news of family members being turned away from the windows of ontario ltc facilities as they attempted to visit loved ones while respecting physical distancing recommendations (pringle, 2020). equally troubling stories have emerged detailing the challenges that ltc residents have faced including restrictions on visitors and volunteers, elimination of the interactions residents enjoyed with their families (armitage & nellums, 2020; gardner, states, & bagley, 2020) and limitations on physical and social activities (bains, 2020; flint, bingham, & iaboni, 2020; harden, 2020; kingdon, 2020; liebermen, 2020; steinman, perry, & perissinotto, 2020; united nations, 2020) . recent changes to ltc visitation policies allow loved ones to visit in-person but continue to be overly restrictive: visits could only be 30-minutes long, outdoors, physically distanced while wearing personal protective equipment (ppe) and the visitor needed to present a covid-19 negative test (ontario ministry of long-term care, 2020). the impracticalities of such visits are obvious: spouses of residents are often older adults themselves and face mobility challenges getting tested, residents have hearing and vision loss making communicating during a physically distanced visit outdoors challenging and covering visitor faces with masks is not helpful or comforting for this article is protected by copyright. all rights reserved residents with memory loss. some residents have been socially isolated for over 3-months due to covid-19 outbreaks, spending all day and every meal trapped alone in their rooms; held hostage by ill conceived policies (bercovici, 2020) . such policies are out of touch with the needs of residents and are causing emotional distress. given the world health organization's holistic definition of health (who, 2020) and the impact of social isolation on the psychosocial wellbeing of older adults, any public health response is morally obligated to mitigate the impact of isolation as a policy consequence. social isolation is defined as an objective lack of a social network, relates to loneliness (the subjective, negative experience that results from social isolation) and a lack of meaningful, supportive relationships with family and friends (hernández-ascanio et al., 2020). more older adults living alone as the population ages (national seniors council, 2017), contributing to a social isolation epidemic among older adults long before physical distancing became a key policy priority. before the covid-19 pandemic, approximately 50% of canadians over the age of 80 reported feelings of loneliness, particularly those with physical or mental illness, cognitive deficits, members of marginalized groups and those experiencing life transitions such as loss of employment, a spouse, or access to a vehicle. those most at risk for social isolation face the greatest number of barriers to support (national seniors council, 2013 , 2017 . this article is protected by copyright. all rights reserved the toll and trauma that covid-19 countermeasures have taken on older adults residing in ltc facilities and their families. the public has generated several solutions to increase the quality of life for older adults during the pandemic. these include the use of mobile devices to engage remotely with older adults. teleconferencing applications such as skype, facetime, or zoom (canadian frailty network, 2020a; klein, 2020; lorinc, 2020), allowing users to interact virtually. conventional telephone calls and written letters provide a familiar form of communication (holtby, 2020 ) that can remind older adults of their support network (canadian frailty network, 2020b; ireland, 2020). written letter campaigns have emerged to combat the isolation experienced by many older adults during the crisis (field, 2020) and before it (harris, 2020) . in these campaigns, strangers write letters to ltc residents, including photographs, poetry and uplifting messages, to remind them that they are valued. while such solutions are helpful, many older adults either lack the access to remote communication; most ltc facilities have a limited number of ipads to share between residents, constraining their access to their loved ones. another problem is that many ltc residents lack the dexterity to hold a tablet steady. family members end up looking at the ceiling, instead of the face of their loved one (cbc news, 2020) . many older adults also lack the technical proficiency to use such devices (klein, 2020), particularly those with limited cognition (bains, 2020). some homes have hired more staff solely to help residents make video calls rather than purchasing tablets for every residenthighlighting a patchwork solution to the real problem of technology that is not well-designed for older adult users. there is room for innovation and improvement. in particular, making technology easier to use and understand for older adults. user-centered design approaches would besuitable to generate technology focused on the needs of older adults and healthcare providers in ltc. the need for innovative collaboration between researchers, developers, older adults and their family members has never been made more clear than during this pandemic. this article is protected by copyright. all rights reserved our current broad strokes approach assumes the priorities of older adults to be largely homogenous and views ltc residents as passive recipients of care, without any particular desires or preferences. that view is paternalistic and antithetical to a person-centred approach that is so central to nursing. implicit to this discussion is the recognition that older adults are valued by their loved ones and community. we must not value incautiously quantity of life over quality of life. little attention has been paid to autonomy and individual acceptance of risk. any pandemic response must balance these risks and recognize that morbidity may be as important as mortality. in this case, it means calculating if and when patients and their families should have the latitude to make autonomous decisions concerning their well-being. in absence of allowing residents the dignity of choice, there are widespread reports of increased suicide rates and of residents preferring death over isolation in their rooms, referring to their treatment as being "held like a prisoner" (aronson, 2020). ltc facilities must collaborate with residents and families to ideate creative solutions and help them understand the risks associated, to establish a care plan that is centered on the physical and psychosocial wellbeing of the resident. additionally, it is a clinical reality that residents will likely experience the end of life in long-term care. thus, the questions surrounding quality and manner of death are intensely important ones. dignity should be paramount when older adults must experience the end of their lives in hospitals and care facilities alone, barred from visits. the unknown duration of isolation means that over one-third of ltc residents could die without seeing their loved ones for months or even years (jayaraman and joseph 2013). this deeply disturbing scenario is a concept which should deeply trouble most of us and is not what residents, families, or staff want. nurses are the primary clinicians responsible for leading and coordinating care in ltc facilities referred to as "ground zero" of covid-19 (barnett & grabowski, 2020) . from a policy perspective, nurses are advocating for more staffing and appropriate resources to be diverted into ltc (registered nurses' association of ontario, 2020). this advocacy should come as no surprise as nurses have been always been revolutionaries during times of infectious diseases for which there were no effective medical interventions. nurses can prepare for future outbreaks by organizing and advocating for reform and investment into ltc, ensuring homes can effectively respond to outbreaks while meeting the physical and psychosocial needs of residents. further, this pandemic is an opportunity for ltc nurses to refocus care on the resident and reintroduce this article is protected by copyright. all rights reserved person-centered care into countermeasures. this means welcoming innovation, user-friendly digital technologies that promote connections to loved ones and leveraging their close relationships with residents to advocate for more person-centered policies. policy makers and nurse leaders need to enable nurses to work to the top of their scope of practice in ltc and provide the resources to support nurses working in their full capacity. covid-19 countermeasures like physical distancing involves a balance of risks for older adults living in ltc facillities. the covid-19 epidemic has upended many assumptions about the safety, health and well-being of older adults and revealed numerous areas for collaboration, innovation and improvement. within this crisis lies an opportunity for nurses to start a deeper conversation about autonomy and values and how to restore person-centered care in ltc facilities. halifax group starts letter-writing initiative for seniors facing loneliness amid covid-19 pandemic -halifax | globalnews.ca effect of covid-19 on the mental health care of older people in canada the coronavirus and the risks to the elderly in long-term care harden: covid-19 -ask seniors to stay home help for canadian seniors' loneliness comes via ontario university students | huffpost canada effectiveness of a multicomponent intervention to reduce social isolation and loneliness in communitydwelling elders: a randomized clinical trial. study protocol how to help seniors feel less isolated | new trail how to help seniors get through the covid-19 pandemic | cbc radio physical distancing: how to slow the spread of covid-19 -canada rnao calls for immediate action in response to the canadian armed forces' ltc report with minister fullerton's the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak meeting the care needs of older adults isolated at home during the covid-19 pandemic development of a community's self-efficacy scale for preventing social isolation among community-dwelling older people (mimamori scale) hospitalization and mortality rates in long-term care facilities: does for-profit status matter? loneliness and social support: differential predictive power on depression and satisfaction in senior citizens accepted article this article is protected by copyright. all rights reserved united nations long-term care connected to 79 per cent of covid-19 deaths in canada -the globe and mail. the globe and mail world health organization: basic documents forty-ninth edition illuminating the psychological experience of elderly loneliness from a societal perspective: a qualitative study of alienation between older people and society the authors have no conflicts of interests to declare. this article is protected by copyright. all rights reserved editorial note: editorials are opinion pieces. this piece has not been subject to peer review and the opinions expressed are those of the authors. key: cord-332918-6kmbaswt authors: dwolatzky, tzvi title: if not now, when? the role of geriatric leadership as covid-19 brings the world to its knees date: 2020-05-15 journal: front med (lausanne) doi: 10.3389/fmed.2020.00232 sha: doc_id: 332918 cord_uid: 6kmbaswt nan the covid-19 virus is a ruthless enemy that knows no borders. the measures that governments have been forced to take are devastating economic life and exposing major inadequacies in health care systems. while the global village dissipates with the halting of international travel, people are facing lockdown in their homes in a desperate effort to curtail the spread of this virulent virus. not surprisingly, those who are older, sicker, frail, and socially isolated, are bearing the brunt of this attack. the respiratory sequelae of covid-19 in the older population are severe, and many require mechanical ventilatory support in intensive care units. mortality is high, and for those who survive recovery is slow. the need to treat a vast number of patients is overwhelming, resources are scarce, and difficult ethical decisions have to be made. triage criteria are being developed and are generally designed out of urgent necessity rather than being based on clear evidence-based scientific criteria (1) . as the world struggles to cope with the worst viral pandemic of the last century, a recent report from spain shocked the reader with a new reality. elderly people have been found dead and abandoned in nursing homes in spain, the country's defence minister has said. margarita robles, speaking in a television interview, said the army had made the discoveries while disinfecting old people's homes. the military had found "the elderly absolutely abandoned, if not dead in their beds", said robles (2). what went wrong? how did a tragedy like this happen in a country that was rated by bloomberg as the world's healthiest nation in 2019? (3) . we certainly are not here to judge, and this specific incident is under investigation by the authorities. however, one may postulate regarding the reasons for such a tragic situation. one must remember that this event occurred in a very unusual situation, where the rapid spread of disease has ruthlessly destroyed infrastructure as health care needs outstrip resources. one may try to understand the personal perspective of health care workers pushed to their physical and mental limits in providing care to old and frail people at a time of crisis, while harboring their own concerns and fears. indeed, providing care for patients in an environment where the rapid spread of a highly infectious disease certainly places the health care worker at significant personal risk. moreover, in an atmosphere where the treatment of older functionally or cognitively impaired older people is considered to be futile, the door to abandonment is wide open. however, this event must serve as a wake-up call for us all-individuals, families, health care workers, policy makers, governments. as i was taught as a resident undergoing a compulsory advanced cardiac life support course, the first thing that one should do when faced with a resuscitation is to "take your own pulse." as health care workers, our first responsibility is to ensure that we are personally prepared both physically and mentally to go out to war against a deadly virus. on answering the call to go out to battle, our role is to save lives where possible, yet always to maintain human dignity and respect and alleviate suffering. this call lies at the very heart of geriatric medicine. in the mid-twentieth century, marjory warren, who is regarded as the pioneer of geriatric medicine, and was co-founder of the medical society for the care of the elderly (later becoming the british geriatrics society), fought for the medical recognition of the neglected older population. she recognized that older people had different needs, and emphasized a multidisciplinary comprehensive rehabilitative approach that forms the basis of the profession today (4). clearly, warren was a visionary, a pioneer and a leader. generations of prominent geriatricians have followed, and geriatric medicine is a recognized medical specialty in most countries. and now, with a viral pandemic sweeping across the globe, geriatricians are actively involved in the clinical care of vast numbers of older people in the community and in hospital settings. yet, geriatricians must take on another role in the fight against coronavirus, a role of leadership. for if you remain silent at this time, relief and deliverance . . . .. will arise from another place, but you and your father's family will perish. and who knows but that you have come to your royal position for such a time as this?" (5). it is at a time like this that geriatricians must step in to take the lead. it is imperative that we identify issues affecting the health and well-being of older people, actively promote awareness, and work to influence policy at both local and national levels. i will relate to some of the central issues that should be addressed. at the time of writing, a third of the global population is on coronavirus lockdown (6) . social distancing and the restriction of movement, with a clear call to stay at home and thus prevent exposure to other people who may be a source of coronavirus infection, is in accordance with the world health organization's efforts to limit the spread of the virus. however, lockdown has major repercussions on the lives of older people. for older people who frequently suffer from a number of chronic conditions, health maintenance is essential. adequate control of factors such as blood glucose, blood pressure, cardiac failure, mobility in parkinson's disease, chronic pain, and many others, is essential in promoting well-being and preventing complications. with the initiation of lockdown, older people are unable to visit their family physician for checkups or to receive prescriptions, and they have limited ability to get to the pharmacy or access other medical services such as physical therapy. as the time spent in lockdown progresses, the likelihood is that many older people will develop unnecessary complications due to poor control of chronic illnesses. to prevent this a "reach-out" policy should be developed, based on the traditional and effective standardized multidimensional comprehensive geriatric assessment. such an approach will help to minimize the development of harmful geriatric syndromes, such as falls, frailty and polypharmacy. community clinics should contact older patients regularly to enquire about health status, and should obtain information regarding measurable physical signs, adequate supplies of medications, and other health needs. technology can play an important role in health monitoring by the use of smart phone applications, telemedicine, and other modalities. in addition, older people who are living alone should be encouraged to install fall detection devices, and to use wearable "call for help" pendants or wristwatches. the obvious result of lockdown is psychosocial isolation. most younger people or those with families manage to adapt to the stresses of social isolation. but for older people who are often alone and functionally limited, the lack of social contact can be devastating. contact with family members and friends is discouraged as part of the call for social distancing. the effect of loneliness on one's mental state at an older age has been clearly determined. the path to depression, anxiety and cognitive decline is often inevitable. a lack of appetite, limited food supplies, and reduced motivation to prepare adequate meals, will likely result in a deterioration of the older person's nutritional status. in an effort to alleviate these untoward results, local agencies in cooperation with volunteer organizations should identify older people who are alone at home. these people must be contacted regularly to "touch base" regarding their needs and to help them replenish dwindling supplies. they should be offered "meals on wheels" and home delivery of provisions. regular telephone contact, discussions with neighbors at a distance "over the balcony rails, " and videoconferencing with family and friends is encouraged. it is essential to maintain mental function by reading, solving crossword puzzles or sudoku, and engaging in other cognitively stimulating activities such as scrabble, chess or bridge, especially by partnering with other people on-line. older people should be encouraged to adopt a daily exercise schedule to include personal preferred forms of activity, such as stretching and isometric exercises, and walks around the house a number of times during the course of the day. current experience with the covid-19 outbreak clearly indicates that older people are at a markedly increased risk for complications and mortality. it has been shown that mortality begins to increase from the age of 60 years, rapidly rising to 21.9% in confirmed cases above the age of 80 (7) . the respiratory manifestations of this disease are severe and frequently require mechanical ventilation in high care and intensive care units. as such, every measure that will decrease the exposure of older people to coronavirus should be adopted, and an approach of early detection and treatment should be adopted. older people who are cognitively and/or functionally impaired and are living at home are usually cared for by nursing assistants. the continuing employment of health workers is essential at the time of crisis. in italy, healthcare workers constitute 9% of covid-19 patients. thus, protecting these workers must be a main priority. as such all health workers should be given appropriate training and protective equipment to prevent infection. in addition, this sector must be given priority for covid-19 testing. not only will this ensure the rights and personal safety of the workers, but it will limit the exposure of the older population to the virus. as the covid-19 pandemic unfolds, the tragedy of a rapid spread of the virus among frail and vulnerable older residents of nursing homes has resulted in catastrophic consequences. the centers for disease control and prevention (cdc) has issued clear guidelines for protecting residents, families and staff of long-term facilities from serious illness, complications, and death (8) . the strategies include closing off the facility by restricting visitors, the use of personal protective equipment, the active screening of residents and staff, the implementation of social distancing and isolation of suspected cases, and the early identification, and treatment of severe illness. geriatricians and gerontologists should spearhead the implementation of these key strategies in nursing homes. as yet there is no proven vaccine or therapeutic agent for covid-19. however, a number of agents are being used empirically based on clinical experience, albeit with limited supportive evidence. these include hydroxychloroquine sulfate and zinc. there is also some interest in using the interleukin-6 inhibitor tocilizumab, which has recently been approved by the us food and drug administration (fda) in a phase 3 trial for severely ill covid-19 patients hospitalized with pneumonia (9) . based on the knowledge that the older population is at the greatest risk, priority should be given for providing therapeutic agents particularly to older people with coronavirus infection, as much as this is possible considering local policy and availability. the unfolding coronavirus pandemic has pushed health systems way beyond their limits. demand has rapidly surpassed supplies in many countries. this has resulted in a chaotic situation where difficult decisions have to be made. probably the most painful of these decisions is who should be entitled to the use of mechanical ventilators. policy makers have rapidly designed triage systems in order to provide scarce lifesaving equipment to those most likely to benefit. considering that the prevalence of major complications is significantly higher in older people in whom the chances of survival are lower, restrictions have been developed based specifically on chronological age. geriatricians should raise their voices in opposition to such a manifestation of ageism. for years chronological age was used as an absolute criterion for withholding critical and lifesaving services from older people. treatment in intensive care units, the provision of hemodialysis, and surgical interventions, as a few examples, were not provided to those over the age of 70 due to limited availability. decades of research, education, and lobbying by geriatricians, have convinced the medical world that one should relate to the physiological and functional state of the older person as a measure of biological age rather than to the absolute criterion of chronological age. when faced with difficult decisions due to a lack of resources we must consider age in the context of comorbidities and function. autonomy is one of the four pillars of bioethics. people have the right to determine their own destiny, and this right must be respected. in the throes of a spreading pandemic, there is a greater likelihood that an older person will have to face difficult decisions regarding life-saving measures. as such geriatricians should encourage patients to express their medical preferences in a living will. as geriatricians we are proud of our role as leaders of the medical teams caring for our older members of society. while countries fight for survival in the battle against coronavirus, we must lead the effort to ensure that older people are not forgotten, that their needs are provided, and that they are treated with the respect that they deserve. and if not now, when? hillel said: . . . if not now, when? (10). td developed the concept of the article and wrote the manuscript. fair allocation of scarce medical resources in the time of covid-19 spanish nursing home world's healthiest nations the relevance of marjory warren's writings today age of coronavirus deaths cdc coronavirus long term care strategies. available online at the author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 dwolatzky. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-011302-pfepyvaw authors: edlmann, ellie; whitfield, peter c. title: the changing face of neurosurgery for the older person date: 2020-04-25 journal: j neurol doi: 10.1007/s00415-020-09854-9 sha: doc_id: 11302 cord_uid: pfepyvaw increased life expectancy and illness prevention and treatment have led to a growing population of older patients. these changes in patient population are apparent in neurosurgery; however, relatively little is reported about specific outcomes and prognostication in this group. this review summarises the challenges and management changes occurring in the treatment of three common neurosurgical pathologies; aneurysmal subarachnoid haemorrhage, head injury, and haemorrhagic stroke. a move towards less invasive neurosurgical techniques has implications on the risk–benefit profile of interventions. this creates the opportunity to intervene in older patients with greater co-morbidity, as long as improved outcomes can be evidenced. a critical part of assessing appropriateness for surgical intervention in older patients may be to change from a mindset of age to one of frailty and growing interest in scales assessing this may aid treatment decisions in the future. increased life expectancy, lower operative morbidities, and enhanced expectations from patients and their families has led to an increasing population of older patients with pathology that may be amenable to neurosurgical treatment. in 2010, chibbaro showed that the proportion of patients aged 70 and over admitted to a parisian neurosurgical unit increased from 11% in 1983 to 25% in 2007 [6] . surgical interventions also increased from 77% to 93% in this group, with a particular rise in brain tumour surgery. such trends are set to continue and a recent report from a uk regional neurosurgical centre showed continued increases in elderly admissions from 2000 to 2013, particularly in emergency conditions such as traumatic head injury and spontaneous subarachnoid haemorrhage [42] . an important driver of increased admissions is the perceived improvement in outcomes in older patients. chibbaro showed a dramatic drop in the immediate mortality rate, from 12 to 0.3% in older patients [6] . shifting treatment algorithms, such as endovascular coiling rather than aneurysm clipping, account, in part, for improved outcomes. however, poor outcomes still prevail in older patients with emergency presentations: whitehouse reported 5-year mortality of around 55% in neurosurgical patients over 65 admitted as an emergency compared with less than 20% in elective patients [42] . mortality is particularly increased within 6 months of neurosurgical treatment and, therefore, surgical approaches and their associated complications need to be carefully considered to improve outcomes. in this review, we consider changes in practice and current treatment outcomes in older patients with aneurysmal subarachnoid haemorrhage, traumatic head injury, and haemorrhagic strokes. we focus on the assessment of frailty in older patients and how this can help to inform future treatment planning. incidental, unruptured cerebral aneurysms pose a risk of rupture over time; factors including size and location influence this risk [43] . it is logical, that as people live longer, there is a greater lifetime risk of incidental aneurysm rupture and presentation with a subarachnoid haemorrhage (sah). conversely, the first detection of an incidental cerebral aneurysm in later life means that there is a reduced effect of any preventative treatment due to the deceased remaining life expectancy in the elderly. in addition, the outcomes, in terms of quality of life and mortality, from treated aneurysmal sah in older patients are variable. as such, it is important that we have robust data on all these aspects, to guide the management of both ruptured and unruptured aneurysms in the older person. in 2006, nieuwkamp et al. reported outcomes in 170 patients aged ≥ 75 years presenting with aneurysmal sah, where only 20% of patients were clipped and 8% coiled [27] . overall, half the patients died and only one in six returned to independent function by discharge. of their 60 patients admitted in a poor condition (those with a glasgow coma score of 12 or less), none were independent at discharge. the strongest predictor of poor outcome in good-grade admissions was re-bleeding. compared to younger sah patients, those aged 75 and over were more likely to be female (perhaps due to greater life expectancy) and suffer with medical complications and hydrocephalus. the authors suggested that the early treatment of patients in a good condition may prevent re-bleeding and thus improve outcomes. in 2013, scholler analysed 265 patients over the age of 60 with aneurysmal sah, with 36% aged between 70 and 79 and only 10% over 80 [33] . challenges identified in this older population included increased co-morbidities (92% had at least one), the use of anti-thrombotic drugs (in 29%) and increased prevalence of hydrocephalus requiring an evd in those aged 70-80 years (77%) compared to 60-70-year-olds (61%). interventional treatment was undertaken in 85% of cases, with clipping in 48% and coiling in 37%, the latter more commonly in those aged over 80. outcome was clearly associated with age; death or poor outcome at discharge occurred in 73% of over 70 years old compared with 51% of 60-70 years old. condition at presentation was also important with no poor grade at presentation patients (wfns 4-5) aged over 80 experiencing a good outcome at discharge. it is important to note that although 70% of conservatively managed patients died, none were due to re-bleed, suggesting that it is the nature of the initial bleed and not any failure to treat, that results in the poor outcome. there has also been a significant shift in practice in the last 15 years towards coiling, rather than clipping since the international subarachnoid aneurysm trial (isat) [25] . subsequent sub-group analysis of patients aged 65 years and over suggested a trend towards better outcomes with endovascular treatment compared to clipping, although this was subject to aneurysm location [30] . lower rates of infectious and pulmonary complications and epilepsy occurred in the endovascular group. this was supported by the barrow ruptured aneurysm trial (brat) which showed significantly poorer outcomes at 1 year in patients over 50 years old treated with clipping [21] . a recent systematic review of endovascular treatment of ruptured aneurysms in patients aged over 65 reported good outcomes in 66%, with a mortality rate of around 26% at 1 year [36] . with an 86% complete or near-complete occlusion rate at long-term follow-up, endovascular treatment is preferred to clipping and probably reduces risks for older patients. koffijberg analysed the cost-effectiveness of treating ruptured aneurysms in patients aged over 70, identifying key parameters including patient age (and thus life expectancy), good or poor clinical condition on presentation, conservative or occlusive treatment (clipping or coiling) and good or poor outcomes [18] . perhaps surprisingly, occlusive treatment of aneurysms translated into a health benefit for all older patients presenting within 4 days of sah, regardless of the good or poor condition at presentation. a later presentation, particularly 10 days or more after sah, was more likely to result in no or minimal treatment benefits. however, occlusive treatment was only found to be cost-effective in women aged 70-79, and men aged 70-74 presenting in a good condition, within 4 days of sah. thus, although potentially offering some clinical benefit, occlusive treatment is clearly more costly than conservative management and may be particularly difficult to justify in those aged 80 years and over presenting in a poor condition. it is, however, also important to highlight that studies assessing interventions such as this will contain inherent selection bias, by virtue of the fact that the patients undergoing intervention differ from those that were not. such results should be treated with caution until clear, prospective, evidence is available. it is apparent that patients presenting in a poor condition and aged over 70 are likely to have a poor outcome, and a conservative approach may be appropriate in these patients. more prospective research is needed to understand the risk-benefit profile of treating well patients, particularly those aged over 80. the current literature supports active intervention for those under 80, with an awareness of the increased risk of complications, but more data are needed specifically in relation to outcomes with endovascular intervention. the vast majority of older patients admitted to a neurosurgical unit with head injury have a subdural haematoma, most commonly chronic subdural haematoma (csdh), followed by mixed and then acute subdural haematoma (asdh) [41] . a csdh is a condition almost exclusively confined to the elderly, with a median age of 77 in the uk [4] . the post-traumatic pathophysiology is complex; it takes weeks to months for the collection of blood and fluid to expand: evidences support the theory that this is, at least in part, due to an escalating inflammatory process [8] . many patients have no recollection of significant trauma and presentation is usually with cognitive impairment, gait disturbance, limb weakness, or headache. the mainstay of treatment has been surgical drainage [4, 31] . however, recent trials have focused on medical treatments, such as steroids, for controlling the inflammatory response in csdh, and, therefore, either reducing csdh recurrence following surgery or even as a first-line treatment [9, 15, 19, 24] . any treatment which reduces csdh recurrence has the potential to reduce mortality, which can be as high as 18% at 6 months [31] . the outcome of these steroid trials is still awaited, but a move to more conservative treatments of csdh could benefit older patients with multiple co-morbidities who are at increased risk from anaesthesia and surgical treatment. asdhs are traditionally considered to occur in higher impact trauma, leading to coma and hence a poorer prognosis, particularly in the elderly. however, due to co-existent cerebral atrophy in older patients, lower energy forces (falls) cause most traumatic brain injuries in this age group, and the onset of neurological deterioration secondary to an asdh may be delayed. this provides an opportunity for definitive management, following an early ct scan, as recommended by nice guidelines [26] . asdh following a minor fall is often exacerbated by the fact that nearly two-third of these patients are on anti-thrombotic medications [20] . the increased use of these medications and an aging population are probably contributing to growing rates of asdh in the elderly. a recent review of 165 asdhs in a german hospital reported 41.2% of them occurring in patients aged 80 or over [44] . importantly, although 90% of the patients aged ≥ 80 years of age underwent surgery, only 24% experienced a favourable outcome at discharge (glasgow outcome scale 4-5), increasing to 36% at 3-months. the mortality rate was high, 48% at 3 months, and predictors of an unfavourable outcome included > 5 co-morbidities, gcs ≤ 8 at admission and 24 hours, re-bleeding, and pneumonia. the use of anti-thrombotic medications at presentation is also clearly a risk factor for poor outcome in all patients [45] . another series reported no survivors in patients with an asdh aged over 90 and only one survivor out of 8 aged over 65 presenting with a gcs of less than 10 [41] . a recent systematic review of asdh in the elderly reported on only seven eligible studies with the mean patient age ranging from 73 to 85 years [10] . outcomes varied with a mortality rate ranging from 27 to 70%, and a good functional outcome in 10-41% but with a presenting gcs ≤ 8 representing a poor prognostic factor. however, overall, the studies were classified as low quality and were particularly lacking in assessments of patient frailty which may aid future research in this field. it is clear that poor neurology from the outset is associated with poor outcome; however, as the incidence of this pathology appears to be increasing in older patients, effective surgical decision-making tools are needed. in patients over 80 years old, with multi-morbidity and poor neurology, caution should be applied; however, it could be advocated that in all other circumstances surgical treatment should at least be considered. attempts have been made at producing scoring systems to aid prognostication in elderly patients with asdh, but more widespread validation of this is required [1] . it is notable that several large-scale studies assessing interventions for severe traumatic brain injury (tbi) in general, including decompressive craniectomy [7, 16] , icp monitoring [5] , and cooling [2] , have either excluded older patients or had minimal numbers of them. whilst this makes understanding treatment in this age group challenging, it may also just be a reflection of the reality that fewer older patients are considered likely to survive intervention. this is supported by collaborations such as impact (international mission for prognosis and analysis of clinical trials in tbi) and crash (corticosteroid randomisation after significant head injury), who have used available evidence to develop prognostic calculators for tbi, where age is a corestratifying component and significantly increases chances of a poor outcome [17, 38] . overall, it is recognised that a lack of evidence has led to varying practices and understanding about interventions for tbi in older patients, but it is clear that functional and cognitive recovery is significantly worse in this age group [13] . understanding patient baseline function and morbidity is important, but recognising the high chance of a poor outcome in this age group often leads clinicians to follow a conservative route, avoiding neurointensive care. intracranial haemorrhage (ich) in older people is often the result of long-standing underlying pathological vascular disease. a patient, therefore, has the intracranial pressure effects and focal neurological deficits associated with the ich in addition to the systemic co-morbidities of cardiac, peripheral vascular disease, and often anti-thrombotic medication use. furthermore, secondary haemorrhage is always a concern. the stich i and ii trials did not demonstrate any overall benefit from early surgery compared with initial conservative management for supratentorial (including lobar) ich. [22, 23] . the median patient age for stich i was 62 years (iqr 52-70) and 65 years (iqr 55-74) for stich ii. the inference from these studies is that surgeons are already appropriately undertaking selective, targeted surgery to the patients that are most likely to benefit from it. when there is equipoise about whether to operate, these studies suggest that it is reasonable to manage the patient conservatively in the first instance and then re-assess. more recently, there has been a move towards minimallyinvasive surgery (mis) for ich, with the potential benefits of being less traumatic, quicker, and more focused than a craniotomy. however, controversy exists concerning the widespread clinical application of such techniques. a recent meta-analysis (2018) on mis for hypertensive ich (the most common cause of spontaneous ich), reported a positive effect on patient prognosis (using gos) compared to both craniotomy and conservative treatment [37] . mortality rates were lower for mis compared to conservative treatment and post-operative re-bleeding rates were lower for mis compared to craniotomy. as this review only included eight randomised controlled trials and most studies also excluded patients that were > 80 years old, more high-quality studies and in a wider population of older patients are needed before firm conclusions can be drawn. this is particularly important as 29-34% of patients diagnosed with an ich are ≥ 80 years old, and this patient group has significantly higher rates of in-hospital mortality and unfavourable outcome [3, 35] . scaggiante also published a meta-analysis of mis in 2018, assessing 15 rcts that mainly deployed endoscopic and/or stereotactic thrombolytic techniques [32] . this consolidated the finding that mis improved outcome compared to both craniotomy and conservative treatment. different mis techniques (endoscopy and stereotactic thrombolysis) both showed significant improvements, but these techniques have not been compared directly. earlier mis evacuation of an ich appeared to be associated with a better chance of achieving functional independence. conversely, the final results of the mistie 3 (minimially invasive surgery with thrombolysis in ich evacuation) trial showed that aspiration and thrombolytic irrigation of an ich with alteplase via an image directed catheter did not improve functional outcomes compared with standard care for large ichs [14] . a modest survival benefit was identified. this trial only included patients aged 52-71 years old, so caution must be exercised in applying the conclusions to older patients. the comprehensive geriatric assessment (cga) is an established tool used to assess the needs of older people and implement investigations and treatments to improve long-term outcomes. the use of this tool has been shown to improve post-operative outcomes in older patients undergoing elective surgery across specialties [28] . it is, therefore, clear that older people have different needs, which when identified and addressed can improve outcomes. the cga is a robust but cumbersome assessment including 6 different domains (medical, mental health, functional capacity, social circumstances, environment, and risk score). identification of simpler tools, possibly even specific to neurosurgery, are necessary. understanding what is meant by frailty is also important, as, although there is some cross-over with disability and co-morbidity, it actually refers to a physiological state of increased vulnerability to stressors due to decreased physiological reserve [12] . a frailty score based on the assessment of data from 27,098 cranial neurosurgical cases has been reported, where higher scores had good sensitivity and specificity for predicting increased 30-day mortality [39] . the score considered 19 predictors of mortality, with the most significant including ascites, ventilator dependency and renal failure, alongside more common problems such as anti-hypertensive medication use, high white cell count and low body mass index. the disadvantages are that this score still contains a large number of variables and requires prospective evaluation. tools such as the modified frailty index (mfi), that have already been well validated in surgical populations, may be more useful [11, 40] . youngerman reviewed 9149 patients with brain tumours and found increased higher mfi scores were associated with increased mortality, severe neurological complications and prolonged length of stay [46] . combined assessment of mfi, age and asa (american society of anaesthesiologists) classification gave the best predictive ability on overall outcome. a simpler scale, the clinical frailty scale, has also been applied in neurosurgical patients, predicting prognosis in operated csdh [29, 34] . frailty has also been correlated with poor outcome in older patients with aneurysmal sah, however this was a very simplistic assessment of frailty based on haemoglobin, albumin and bmi [47] . standardised assessments of frailty are needed, with validation in large cohorts of neurosurgical patients across a range of pathologies. this may then support the development of prognostication tools and aid clinical decisionmaking and family discussions. at what point we consider a person to be "elderly" is shifting, as patients are fitter and more independent until later in life. there are also neurosurgical advances which may preferentially benefit older patients with multiple co-morbidities such as endovascular coiling and mis surgery for ich. patients aged over 65 years of age certainly do benefit from acute neurosurgical interventions, but there is more uncertainty and risk for those aged over 80. an age cut-off itself may not be helpful, but rather frailty should be considered instead, and we advocate improved reporting of this metric in future trials and studies. most importantly, given the lack of robust evidence, determining patient eligibility for intervention is often left to the treating clinician. whilst it is always possible to intervene, it is not always appropriate and a significantly lower likelihood of maintaining the quality of life in older patients for the conditions discussed must be recognised. on the other hand, a therapeutic nihilism may be deterministic and thwart development of improved clinical practice in this group of patients. conflicts of interest on behalf of all authors, the corresponding author states that there is no conflict of interest. development of the subdural hematoma in the elderly (she) score to predict mortality hypothermia for intracranial hypertension after traumatic brain injury spontaneous intracerebral hemorrhage in the elderly population (s10.006) the management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the united kingdom global neurotrauma research g (2012) a trial of intracranial-pressure monitoring in traumatic brain injury neurosurgery and elderly: analysis through the years decompressive craniectomy in diffuse traumatic brain injury pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy the efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematomathe dresh study: straightforward study protocol for a randomized controlled trial prognosis of acute subdural hematoma in the elderly: a systematic review are the frail destined to fail? frailty index as predictor of surgical morbidity and mortality in the elderly untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, and future directions steroids in chronic subdural hematomas (sucre trial): study protocol for a randomized controlled trial trial of decompressive craniectomy for traumatic intracranial hypertension international mission for prognosis and analysis of clinical trials in tbi (2020) impact prognostic calculator aneurysm occlusion in elderly patients with aneurysmal subarachnoid haemorrhage: a cost-utility analysis dexamethasone for adult patients with a symptomatic chronic subdural haematoma (dex-csdh) trial: study protocol for a randomised controlled trial do age and anticoagulants affect the natural history of acute subdural hematomas? the barrow ruptured aneurysm early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the international surgical trial in intracerebral haemorrhage (stich): a randomised trial early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (stich ii): a randomised trial dexamethasone therapy versus surgery for chronic subdural haematoma (decsa trial): study protocol for a randomised controlled trial international subarachnoid aneurysm trial (isat) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial national institute for health and clinical excellence (nice) (2014) head injury: assessment and early management clinical guidelines [cg176 subarachnoid haemorrhage in patients %3e or = 75 years: clinical course, treatment and outcome the impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review a global clinical measure of fitness and frailty in elderly people international subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial minimally invasive surgery for intracerebral hemorrhage aneurysmal subarachnoid hemorrhage in elderly patients: long-term outcome and prognostic factors in an interdisciplinary treatment approach importance of frailty evaluation in the prediction of the prognosis of patients with chronic subdural hematoma oertel matthias f (2012) intracerebral hemorrhage in the very old endovascular treatment of intracranial aneurysms in elderly patients efficacy and safety of minimal invasive surgery treatment in hypertensive intracerebral hemorrhage: a systematic review and meta-analysis the mrc crash trial collaborators (2020) head injury prognosis, crash preoperative frailty score for 30-day morbidity and mortality after cranial neurosurgery association of the modified frailty index with 30-day surgical readmission head injury in the elderly: what are the outcomes of neurosurgical care? neurosurgical care in the elderly: increasing demands necessitate future healthcare planning unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment significant increase in acute subdural hematoma in octo-and nonagenarians: surgical treatment, functional outcome, and predictors in this patient cohort acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome the modified frailty index and 30-day adverse events in oncologic neurosurgery a prognostic model for early post-treatment outcome of elderly patients with aneurysmal subarachnoid hemorrhage key: cord-281344-iswbgqqe authors: jonker, leonie t.; lahr, maarten m.h.; festen, suzanne; oonk, maaike h.m.; de bock, geertruida h.; van leeuwen, barbara l. title: perioperative telemonitoring of older adults with cancer: can we connect them all? date: 2020-09-04 journal: j geriatr oncol doi: 10.1016/j.jgo.2020.08.008 sha: doc_id: 281344 cord_uid: iswbgqqe objectives: although the increasing cancer incidence in older patients is widely recognised, older patients remain underrepresented in clinical cancer trials and ehealth studies. the aim of this research is to identify technological and patient-related barriers to inclusion of this population in a clinical ehealth study. material and methods: this is a retrospective analysis of a prospective cohort study with older patients (≥ 65 years) undergoing cancer-related surgery, who were identified for a perioperative telemonitoring study. reasons for ineligibility and refusal had been prospectively registered. characteristics and postoperative outcomes were compared between participants and non-participants. results: between may 2018 and march 2020, 151 patients were assessed for eligibility, resulting in 65 participants and 86 non-participants. the main reason for ineligibility was lack of internet access at home (n = 16), while main reasons for refusal were perceived high mental burden (n = 46) and insufficient digital skills (n = 12). compared with participants, non-participants were significantly older (mean age 75 vs. 73, p = 0.01); more often female (64% vs. 35%, p = 0.00), unmarried (42% vs. 8%, p = 0.01) living alone (38% vs. 19%, p = 0.02); had a higher asa classification (43% vs. 19%, p = 0.00); often had polypharmacy (67% vs. 43%, p = 0.00); and were more often discharged to skilled nursing facilities (0% vs. 15%, p = 0.00). conclusion: our results confirm the underrepresentation of older female patients with little support from a partner and higher comorbidity. we should be aware of technological and patient-related barriers to including older adults with cancer, in order to avoid further dividing patients with low and high digital health literacy. older patients (over the age of 65) represent the majority of global cancer cases, with a predicted absolute number of 14 million worldwide by 2035 [1] . surgery is a fundamental part of treatment in more than 80% of cancer cases, as well as for older patients [2] . higher age alone does not necessarily increase the risk of adverse postoperative events, but the prevalence of age-associated comorbidities and frailty (age-related cumulative decline in multiple physiological systems) does increase this risk [3] . frail older patients are three to four times more likely to develop postoperative complications compared with non-frail older patients [4, 5] . moreover, the occurrence of complications has a considerable impact on the quality of life and the survival of older patients [6] . together with the fact that hospital admissions have been shortened due to changes in modern health care [7] , this highlights the necessity of prevention and early detection of postoperative complications in this population. new digital technologies (i.e., ehealth) are emerging rapidly in health care to promote patients' self-management and engagement and improve patient-centred cancer care [8] . the interest in remote care delivery by ehealth has increased even more during the current covid-19 pandemic, as remote consultation decreases the risk of spreading the virus and could decrease the pressure on health care resources [9, 10] . additionally, ehealth is used to remotely monitor patients' postoperative recovery in surgical wards or at home after hospital discharge [11, 12] . this so-called telemonitoring could contribute to timely detection of postoperative complications and therefore potentially decrease the impact of these complications in frail older patients with cancer [13] . although the increasing incidence of cancer in older patients is widely recognised, these patients remain underrepresented in clinical cancer trials [14, 15] . they are excluded from clinical cancer trials because of study restrictions, comorbidity, polypharmacy, or physicians' attitudes [16] . older patients are also underrepresented in most perioperative ehealth intervention studies. this underrepresentation of older, and often frail, patients leads to a bias in research outcomes, non-generalisable results and inequality in healthcare provided [17] . this poses a real risk that ehealth interventions will remain geared towards a younger, more flexible population, and will result in the exclusion of the population likely to show the greatest benefit. also, ehealth literacy is known to be lower among older adults with cancer compared with their younger counterparts [18] . the covid-19 pandemic has further increased the need for new digital solutions in health care and clinical research [9, 10] . it is thus of the utmost importance to identify barriers to participation in clinical ehealth trials among the older population. when these barriers are known, both clinical ehealth trials and ehealth applications may be adjusted so that they may benefit the entire oncological population, including frail older patients. in a prospective cohort study with the aim of assessing feasibility of perioperative telemonitoring of older patients with cancer, we were able to include approximately half of the identified patients. to investigate possible technological and patient-related barriers to participation, we analysed reasons for ineligibility and refusal and differences in characteristics of non-participants and participants. to explore the impact of possible benefits a postoperative telemonitoring intervention could provide for our population, we additionally compared the postoperative outcomes between non-participants and participants. this study is a retrospective analysis of a prospective cohort study with older patients undergoing cancer-related surgery, who were identified for a perioperative telemonitoring study (netherlands trial registration number: nl 8253) [19] . the prospective telemonitoring study was conducted in a tertiary referral hospital in the north of the netherlands and approved by the local medical ethical committee (registration number: 2017/286). in consultation with legal officers at our local medical ethical committee we obtained permission to collect additional routine data on care of all identified patients. the principal reason was to collect reasons why candidates did not participate, to identify potential modifiable factors to improve on this situation for future studies. also, it was evaluated that obtaining additional consent was perceived too burdensome for patients and/or carers. we had identified patients over the age of 65 with an indication for oncological resection of a solid malignant tumour. patients had been approached at the hospital's outpatient clinic or by telephone in the period between may 2018 and march 2020, after they were identified for the study by a surgical nurse or surgeon from the treatment team. patients were eligible if they had internet access at home. exclusion criteria were severe auditory, visual and cognitive impairment that were expected to impair the ability to use digital technologies or hear/understand the explanation by telephone; being wheelchair-or bed-ridden; having contact dermatitis; insufficient understanding of dutch; and emergency surgery. participants had been assessed at three moments in time: before surgery, before hospital discharge and at three months after surgery. participants had used a mobile application connected to various electronic monitoring devices. physical activity had been measured using an accelerometer-based wearable activity monitor (fitbit charge 2, fitbit inc., san francisco, ca, usa) during the entire study period. for two weeks after hospital discharge, postoperative recovery had been monitored using the mobile application and additional devices to measure temperature, blood pressure, heart rate, pain, and the occurrence of other postoperative symptoms. due to the observational character of the study, no intervention followed when a deviation had been detected in monitored data. patients had only been contacted by telephone by the research physician if no data was transferred or if alarming parameters had been observed. following the latter, the treating physician would have been contacted if there was a need for medical consultation. we had implemented several strategies in our study design to minimise refusal, based on solutions presented in previous studies for approaching older patients [20] . first, we recognised the importance of adequate communication, especially with older patients. we preferred face-to-face contact to inform patients, offered clearly written study information and emphasized that the study case manager in charge was easily available by telephone for any questions during the study period. second, we involved patients' family members in the recruitment process, as family members have a major influence on the decision to participate. the study information at the outpatient clinic was preferably provided with a family member present. the supporting role of the family member was emphasized before the start of the study, and if the patient preferred that communication about study participation or technological explanation was given to a family member, this family member was approached by telephone. third, we decided to plan follow-up visits with patients at home or schedule appointments to coincide with planned hospital visits because additional hospital visits discourage patients from participating [20] . these strategies to minimise refusal were also meant to promote study completion. family members were involved in technical actions. technology support was provided by the case manager throughout the whole study period by telephone and if necessary, at home or coinciding with planned hospital visits [19] . reasons for ineligibility and refusal had been prospectively registered in a database by the case manager directly after assessing eligibility or after approaching patients for the prospective telemonitoring study. relevant demographics, preoperative indicators of frailty, surgical data and postoperative complications of participants were prospectively collected in face-to-face assessments and from hospital medical records. routine care data about non-participants was retrospectively collected from hospital medical records to evaluate health outcomes. no additional non-consented patient data was collected outside routine care. collected data on the somatic domain of frailty included preoperative physical status assessed by an anaesthesiologist (american society of anesthesiologists [21] [asa classification]), comorbidity (charlson comorbidity index [22] ) and, polypharmacy (>4 different types of medication [23] ). nutritional status was assessed using body mass index (bmi). marital status and housing data were collected to indicate social status. data on the psychological domain was collected from the routine consultation with a nurse at admission and registered in the medical records; including i) concerns about hospital admission, ii) anxiety that influenced daily life and, iii) the use of any psychiatric medication. functional status had been determined using the reported katz activities of daily living (adl [24] ) score. data on tumour location, recurrence of disease, primary malignancy, neoadjuvant therapy, and anaesthesia time was collected. postoperative outcome measures found in the medical records of the individual treatment centre, were collected from its administration. postoperative outcome measures included postoperative icu (intensive care unit) admission, length of hospital stay, complications related to surgery in-hospital and within 30 days after discharge (clavien-dindo classification ≥2 [25] ), unplanned hospital readmission to the individual treatment centre and outside the treatment centre within 30 days after discharge, referral to a nursing home or skilled nursing facility (snf) post-discharge, and overall survival at three and twelve months. we compared characteristics and outcomes from non-participants and participants using an independent sample t-test for parametric continuous data, mann-whitney u test for non-parametric continuous data, and pearson's chi-squared or fisher's exact test for categorical data. a pvalue <0.05 was considered statistically significant. data on baseline characteristics was only used for analysis if it was available for more than 90% of both groups. we compared postoperative outcomes for all patients and per subgroup, classified by type of primary malignancy (gastro-intestinal, gynaecological, or other oncology). the participants and non-participants who underwent surgery were included in overall survival analyses using the kaplan-meier with log-rank testing. data was analysed with ibm spss statistics version 23 (ibm corporation, armonk, ny). out of 151 patients who were assessed for eligibility, 65 patients consented to participate, and 86 patients did not participate (fig. 1) . of the 86 non-participants, 21 patients were not eligible for participation and 65 patients did not want to participate. technological barriers to participation were lack of internet access at home (n = 16) and the perceived inability to work with electronic devices and mobile applications (digital illiteracy, n = 12). the main patient-related barrier was a perceived high mental burden (n = 46). baseline characteristics of participants and non-participants are presented in table 1 . compared with participants, non-participants were significantly older and more often female (table 1 ). in addition, non-participants had a significantly higher asa classification, more polypharmacy and less social support based on data regarding marital status and housing circumstances. nonparticipants were more often adl-dependent compared with participants, although this difference was not statistically significant. from the 65 patients who consented to participate, seven patients were excluded before surgery and 43 patients completed the study. reasons for study drop-out were cancellation of surgery, logistic issues regarding baseline assessment, or the combination of a high burden of disease and treatment and performing measurements at home. results of our feasibility study demonstrated that the compliance of performing vital sign measurements and completing electronic health questionnaires was lower than synchronising physical activity (fitbit-)data, suggesting that these aspects were challenging for the patients [19] . surgery was cancelled for four participants and six non-participants, resulting in analysis of postoperative outcomes of 61 participants and 80 non-participants ( fig. 1; table 2 ). compared with participants, non-participants had similar complication rates. difference in readmission rates were not statistically significant (23% vs. 15%, p = 0.27). in sub-analysis, these differences in postoperative adverse event rates tended to be larger in the patients who underwent gastro-intestinal oncological surgery, although the difference remained not statistically significant. non-participants were significantly more often discharged to an snf compared with participants. the twelve patients who were discharged to an snf were significantly older (mean age 79.0 versus 73.6 years old [p = 0.01]), had a higher asa classification (asa 3-4 58% versus 29% [p = 0.05]), used more medication (% polypharmacy 92% versus 50% [p = 0.00]) and were more often living alone or in a nursing home before surgery (50% versus 30%, 17% versus 0% [p = 0.00]). the survival analysis in fig. 2 demonstrates no difference in survival between three and twelve months for non-participants compared with participants (p = 0.37). in this prospective cohort study, we investigated technological and patient-related barriers to participation of older patients with cancerrelated surgery in a perioperative telemonitoring study. main inclusion barriers were ineligibility due to lack of internet access at home, refusal due to digital illiteracy (the perceived inability to work with electronic devices and mobile applications), and a perceived high mental burden. non-participants were older, were more often female, had a higher asa classification, used more medication, and were more often living alone compared with participants. about one fifth of participants and non-participants experienced a serious complication after hospital discharge. in addition, we observed significantly more snf referrals for non-participants compared with participants. no statistical differences were observed in other postoperative outcomes between participants and non-participants. in our study, 11% of all patients who were assessed for eligibility could not participate because they had no internet access at home. this corresponds with statistics provided by the dutch central bureau of statistics [26] . although access to the internet in the netherlands has improved considerably in the past decade, in 2019 6% of the dutch population aged 65-75 and 23% of people aged over 75 still had no internet access at home [26] . another 8% of all patients who were assessed for eligibility refused because they thought they possessed insufficient digital skills or felt uncomfortable with acquiring these skills for study purposes. studies have confirmed that the main reason people refuse to learn new technologies is anxiety about using them [27] . in addition, ageing causes a decrease in self-efficacy, memory and speed of learning [27] . however, if the perceived advantages of new digital technologies are large and relevant enough and family or peer support is present, older adults are able to overcome their fears and start learning to use new technology [28, 29] . one of the main reasons for refusal was a perceived high mental burden, which might be related to technological barriers as well. an inclusion rate of 50% (65/130) was achieved through several strategies in our study design such as face-to-face contact, involving family members in the recruitment process and, flexible home study visits [20] . the difference in characteristics of participants and non-participants in our study corresponds with previous studies [15, 17, 18, 30] . previous ehealth studies have also demonstrated that older, unmarried, less educated, and lower-income patients use health applications for self-management less frequently than their younger counterparts [30] . unfortunately, we did not have sufficient data on education level and social-economic status in-hospital complications, a n (%) 19 ( in our population. however, data on social status, housing, and referral to snfs suggests that non-participants had less social support. also, the two patients who were residing in a snf both refused participation. we believe that improving social support would decrease both technological barriers and refusal rates due to a perceived high mental burden. the acceptance and implementation of new digital technologies has been accelerated by the covid-19 pandemic, as remote consultation and monitoring decrease the risk of spreading the virus [9] . these changes will lead to a more prominent and perhaps permanent role for telemedicine in future health care and underline the urgency of improving digital technology skills in specific populations such as older adults [9] . because learning new digital skills takes time and energy [27] , it is best to empower older adults to do so when they are relatively healthy and not when they have just been diagnosed with cancer or scheduled for surgery. furthermore, it is essential that people who have insufficient social support can rely on professional or peer support provided by, for example, older adult advocacy groups or the government [31] . a limitation of this study is that we did not have information on the patients' socio-economic status, educational level, geriatric assessment, or impact of complications on functional recovery and quality of life. this is inherent to the retrospective analysis of a prospective cohort study. approximately one fifth of all patients experienced a serious complication within 30 days after hospital discharge, and hospital readmission rates were 15% for participants and 23% for non-participants. because we retrospectively collected data regarding non-participants from hospital medical records, complications and readmissions outside our hospital might have been missed; on the other hand, for participants, data on complications and readmissions were complemented with self-reported data at three months follow-up. in addition, participation in the telemonitoring study might have led to identification of more complications. nonetheless, these results demonstrate a high incidence of postoperative complications post-discharge for all patients. more referrals to snfs among non-participants also suggest that complications have a larger impact on this group. additional parameters to measure the impact of complications, such as functional recovery, quality of life and long-term survival, are needed in future research. subsequent telemonitoring studies with older adults should consider various logistical problems in usability and acceptability [19] . when considering the technological and mental barriers described in this study, studies could be even more inclusive. for example, wifi hotspots could be provided at home for the patients without internet access at home. a technical 'buddy' could be assigned or technological support materials developed to decrease the fear of new technologies and enrol patients with digital illiteracy. the main barriers to older adults' participation in a perioperative telemonitoring study were lack of internet access at home, digital illiteracy, and a perceived high mental burden. non-participants were older and more often female, had a higher asa classification and more polypharmacy, and more often lived alone without a partner compared with participants. the complication rate was high in both participants and non-participants, with a seemingly greater impact of those complications in non-participants. this demonstrates the need for inclusion of underrepresented patients, who are at a high risk for severe postoperative complications and who experience a large impact of these complications. we should be aware of the barriers to participation of this population in order to avoid further dividing patients with low and high digital health literacy. solutions to improve this situation are needed on a societal level and include improving internet accessibility, teaching digital skills and expanding social support for older people. the prospective telemonitoring study was funded by european union's horizon 2020 research & innovation program (project grant agreement number 689802, connecare). the funding source had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; nor in the decision to submit the paper for publication. ltj: no conflicts of interest to declare; mmh: no conflicts of interest to declare; sf: no conflicts of interest to declare; mhmo: no conflicts of interest to declare; ghdb: no conflicts of interest to declare; blvl: no conflicts of interest to declare. global cancer incidence in older adults, 2012 and 2035: a population-based study global cancer surgery: delivering safe, affordable, and timely cancer surgery frailty and post-operative outcomes in older surgical patients: a systematic review assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study long-term survival in octogenarians after surgical treatment for colorectal cancer: prevention of postoperative complications is key costs and consequences of early hospital discharge after major inpatient surgery in older adults the increasing value of ehealth in the delivery of patient-centred cancer care telemedicine and the covid-19 pandemic, lessons for the future interpreting covid-19 and virtual care trends: cohort study. jmir public health surveill continuous versus intermittent vital signs monitoring using a wearable, wireless patch in patients admitted to surgical wards: pilot cluster randomized controlled trial a mobile app for postoperative wound care after arthroplasty: ease of use and perceived usefulness meta-analysis of clinical trials that evaluate the effectiveness of hospital-initiated postdischarge interventions on hospital readmission underrepresentation of patients 65 years of age or older in cancer-treatment trials barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review never too old? age should not be a barrier to enrollment in cancer clinical trials high hospital research participation and improved colorectal cancer survival outcomes: a population-based study ehealth literacy in older adults with cancer remote home monitoring of older surgical cancer patients: perspective on study implementation and feasibility inclusion of frail elderly patients in clinical trials: solutions to the problems asa physical status classifications: a study of consistency of ratings a new method of classifying prognostic comorbidity in longitudinal studies: development and validation measurement properties of the groningen frailty indicator in home-dwelling and institutionalized elderly people studies of illness in the aged the index of adl: a standardized measure of biological and psychosocial function the clavien-dindo classification of surgical complications: five-year experience internet acces at home in the netherlands technology fear stops older adults from logging on: but scientists are breaking the computer block older adults talk technology: technology usage and attitudes social support and "playing around": an examination of how older adults acquire digital literacy with tablet computers acceptance and use of ehealth/mhealth applications for self-management among cancer survivors attitudes towards and limitations to ict use in assisted and independent living communities: findings from a specially-designed technological intervention we wish to express our gratitude to all colleagues in the connecare consortium for providing input during the development and supporting of the it systems and connected devices used in the prospective telemonitoring study. key: cord-331378-3nqn48z7 authors: wand, anne pamela frances; zhong, bao-liang; chiu, helen fung kum; draper, brian; de leo, diego title: covid-19: the implications for suicide in older adults date: 2020-04-30 journal: international psychogeriatrics doi: 10.1017/s1041610220000770 sha: doc_id: 331378 cord_uid: 3nqn48z7 nan in an effort to reduce rates of infection, governments have adopted various policies such as social distancing, social isolation, and quarantine. older people have been specifically advised to stay home given their vulnerability to covid-19 and to reduce the burden on health services by limiting the spread of the illness. the adverse effects of isolation may be especially felt by older people (armitage and nellums, 2020) and people with preexisting mental illness (druss, 2020) . living alone, loneliness, and social isolation are well-recognised risk factors for suicide in late life (draper, 2014) . before the pandemic, even older adults living in senior housing communities designed to reduce social isolation described moderate levels of loneliness (morlett paredes et al., 2020) , presumably now exacerbated by quarantine and social isolation. according to the interpersonal theory of suicide, suicide may be the result of thwarted belongingness and perceived burdensomeness, combined with an acquired capability for suicide (joiner, 2005; van orden et al., 2010) . in a pandemic environment of social lockdown, older people may be especially vulnerable to suicide through a heightened sense of disconnectedness from society, physical distancing, and loss of usual social opportunities, as well as greater risk of anxiety and depression (santini et al., 2020) . this may be compounded by feeling devalued or burdensome to society with the explicit knowledge that older people may not receive the health care they need due to resource rationing (rosenbaum, 2020) . during the pandemic, these perceptions may be heightened in older adults with depression and/or self-harm, who already feel a burden on society and their families (crocker et al., 2006; wand et al., 2018) , and now hear from the media that they are deemed less worthy of care (schwartz, 2020; wenger and schapiro, 2020) . such portrayals may contribute to suicidal behaviors in older adults by reinforcing negative internalized views on ageing as associated with loss of value and productivity and dependency (crocker et al., 2006; wand et al., 2018) . quarantine itself has been associated with psychological distress, especially when mandated (brooks et al., 2020) . during the severe acute respiratory syndrome (sars) outbreak, suicides were reported following enforced quarantine in a taipei hospital (barbisch et al., 2015) . stressors associated with poor mental health outcomes and quarantine include longer durations of quarantine, frustration and boredom, insufficient information, inadequate supplies, and fear of infection, many of which disproportionally affect older people (brooks et al., 2020) . a key risk factor for suicide in older people is psychiatric illness, especially affective disorders (troya et al., 2019) . the pandemic may result in new cases of affective disorders and create barriers to accessing treatment. during the sars epidemic, high rates of psychological distress were associated with quarantine including symptoms of depression and post-traumatic stress disorder (ptsd), with greater prevalence of ptsd symptoms associated with longer periods of quarantine (hawryluck et al., 2004) . psychiatric disorders, ptsd more so than depression, may also be long-term sequelae of an epidemic (mak et al., 2009) . further, higher rates of probable ptsd and greater intensity of symptoms were found in residents of high sars-prevalent areas compared to low sars-prevalent areas, and in older people (aged 60 + ), even in those not infected (lee et al., 2006) . the covid-19 pandemic compounds this and other preexisting trauma in older adults, further contributing to risk of suicide and mental illness, and in addition to the "parallel epidemic" of anxiety, depression, and fear in the general community (yao et al., 2020) . the pandemic may also reduce access to psychiatric treatment. people with severe mental illness already experience discrimination and stigma, may be more susceptible to covid-19 infection, have greater barriers to receiving timely medical care, and treatment may be less effective (yao et al., 2020) . those residing in nursing homes may be especially at risk of neglect with inadequate resources, overwhelmed staff (thomas, 2020) , and less community service in reach during lockdown. regular appointments for mental health follow-up and prescriptions may be cancelled as determined to be "nonessential" or attendance hampered by disruptions to public transport, advice to stay home, and the media focus on emergency medical care, all undermining efforts to manage psychiatric illness in the community (reger et al., 2020) . people presenting to emergency departments with suicidal behaviors may also be disadvantaged through overcrowding, long wait times (reger et al., 2020) , and the prioritization of suspected covid-19 cases and infection control measures, resulting in suboptimal care and follow-up and potentially influencing suicide rates. finally, it is widely expected that the covid-19 pandemic will result in a global recession (reger et al., 2020) , if not depression. the great recession in europe and north america was estimated to have resulted in an additional 10,000 "economic suicides" between 2008 and 2010 (reeves et al., 2014) , through mechanisms such as loss of employment, indebtedness, and housing insecurity (associated with depression, anxiety, and suicide). financial insecurity for older people may be further exacerbated by the collapse in the stock market and low interest rates worldwide, reducing income from retirement savings (reger et al., 2020) . china's elderly suicide rate is relatively high, particularly for those living in central and rural regions (zhong et al., 2016) . wuhan, the largest city in central china with a population of over 10 million one-fifth of whom are aged 60 + , was seriously hit by the covid-19 pandemic. the lack of preparation for this sudden outbreak and mass quarantine measures adopted in all communities and villages of this city especially affected older adults. initially, there were inadequate social support services for older people living alone. during the peak of the outbreak, some older adults could not receive timely and necessary medical services for their chronic diseases because routine services were cancelled in overwhelmed general hospitals, public transport was suspended, and concerns about acquiring the infection in hospitals. these barriers to treatment would be expected to increase distress and relapse of mental illness in older people (yang et al., 2020) , increasing suicide risk. later, community workers and volunteers were mobilized to provide social support services, groceries, and purchase medication for older residents. due to the high case-fatality rate among infected older patients (novel coronavirus pneumonia emergency response epidemiology, 2020), older adults may have heightened fears of contracting infection and dying. further, most older adults obtain information from television and radio, which relayed limited information about covid-19 prevention and mental health care, resulting in anxiety and misinformation about the pandemic. loneliness increased too, as chinese older adults prefer face-to-face social interactions, interrupted by social distancing requirements. the negative impact of all these factors on chinese older adults may increase suicide risk. an online survey of 227 wuhan-based older adults from 27 january to 2 february 2020 (b-lz, unpublished data) revealed 39.2% had a low mood and 4.4% endorsed suicidal ideation in the last two weeks, clearly indicating need for urgent psychosocial and crisis intervention. although there is no prepandemic comparison data for wuhan, a recent meta-analysis revealed a 12-month prevalence of 9.7% for suicidal ideation in chinese older adults (wang et al., 2020) . the apparent lower prevalence in the wuhan online survey is likely an underestimate given that it only assessed a 2-week period. early on, china launched strategies for preventing and reducing mental health crises, including suicidal behaviors, in the general population . guidelines and public health educational material for health professionals and the general public complemented new online mental health services and the positioning of mental health professionals in isolation hospitals . the covid-19 outbreak occurred at a time when hong kong was already devastated by the social unrest and economic downturn which started in june 2019 and continued until late january 2020, when the epidemic began. people were afraid to go out due to violent protests on the streets. the economy of hong kong had deteriorated sharply and many businesses closed. the prevalence of depression and post-traumatic stress increased substantially during the period of major social unrest in hong kong compared with previously (ni et al., 2020) . many health and community services for older people have been suspended or much scaled down since the start of the covid-19 outbreak including mental health services, day hospitals, and daycare services. core outpatient and inpatient mental health services have been maintained, but some older patients are afraid to attend hospitals for fear of contracting covid-19, contributing to inadequately treated mental illness and associated suicide risk. in general, older people currently have heightened levels of depressed and anxious mood. hong kong has experienced a severe epidemic before having been struck by sars in 2003. in hong kong, sars lasted just over 3 months, affected 1755 patients, caused~300 deaths, and was associated with a sharp upturn in the elder suicide rate for 2003 (chan et al., 2006) . the sars epidemic was associated with increased risk of completed suicide in older women, but not men or the population aged under 65. factors such as breakdown of social networks and limited access to health care may have been contributory. it was postulated that female elders, because of their preexisting ready engagement in social and health services, were more susceptible to the effects of temporary suspension of these services during the sars outbreak (chan et al., 2006) . the hong kong-specific elderly suicide prevention program established in 2002, with efficacy in reducing suicide rates (chan et al., 2011) , has continued throughout the pandemic. the traumatic experience of sars, especially for the elderly, has predisposed to much fear and anxiety in older people in hong kong during the covid-19 outbreak. this has been exacerbated by the lack of community and family support due to social distancing measures and reduced daycare services. the crisis and hardship to hong kong now are much more protracted than the sars outbreak because of the preceding social unrest. while economic hardship and unemployment may predominantly affect younger people, the lack of medical, social, and community support particularly affects older people. it is likely that the suicide rates in both younger and older populations will increase in hong kong in the coming year. in italy, the covid-19 epidemic developed with extreme virulence, disproportionately affecting older adults. according to the istituto superiore di sanità (april 6, verified on a pool of 48,129 cases), the infection rates were 36% in people >70 years, with 83.6% of all deaths derived from this age group. nursing homes paid an especially high price for the lack of protective measures and social distancing. in just 20 days, the nursing homes of bergamo (lombardy) had >600 deaths (trabucchi and de leo, 2020) , a hecatomb. combined, this has resulted in tragic television images of long lines of military trucks carrying coffins to incinerators, often very far from the deceased's place of origin. there has been no way to celebrate funeral rites, nor accommodation in the cemeteries of the place of residence. the inability to accompany relatives in the last moments of life has been especially heartbreaking. the isolation imposed by the infection meant that thousands of people who subsequently died were last seen by family when they were taken to hospital by ambulance. the resulting widespread grief would be expected to increase suicide rates. the pandemic is severely testing the entire italian system, in particular welfare structures and a largely unprepared health service. the serious difficulties assisting the critically ill, combined with the scarcity of places suitable to receive such patients, and the insufficient number of ventilators have given rise to very painful ethical choices for health professionals on whom to provide care (rosenbaum, 2020) . this is widely reported in the media, likely heightening anxiety and distress in older people, who may choose suicide over uncertain health care. during this period, national media (such as corriere della sera and gazzettino) have reported at least five cases of suicide manifestly related to covid-19. there are no reported cases of suicide among older adults, but there is strong concern for their physical and mental health (intolerance of being too long confined at home and often distressed by living with relatives or other virus-positive persons). there have been numerous calls for psychological assistance to helplines recently activated to meet the psychological needs of the people. in australia, the pandemic began not long after a disastrous bushfire season that has already had a huge impact in regional parts of australia with over 3000 homes destroyed and an economic cost of >us $60 billion (read and denniss, 2020; richards et al., 2020) . before the pandemic, australians were being encouraged to travel to tourist areas affected by bushfires in order to help with their recovery. now travel is banned apart from that required for essential needs such as health care, groceries, work, or exercise. people aged over 70 and those with chronic conditions are advised to self-isolate at home. for those older people living at home with the support of home care services, a new online training program is available for carers about infection control along with general advice about how to approach caregiving in the pandemic (department of health, 2020). there is an expectation that as the pandemic worsens that the carers will need to wear personal protective equipment to minimize cross contamination. this may be difficult for some older people to tolerate and could cause misunderstandings and distress particularly in those with cognitive impairment. there are reports that older and disabled people are cancelling home care services to minimize face-to-face contacts out of fear of contracting the virus (uibu, 2020) , with adverse commentary 3 implications for physical health care, another risk factor for suicide (fassberg et al., 2016) . family carers are being advised to minimize face-to-face contact with their older relatives. grandparenting roles have been affected too with restricted contact for those living apart. suicide prevention organizations in australia have recognized the "perfect storm" created by covid-19 and are focusing their efforts. lifeline, a charity which provides crisis support and suicide prevention, is focusing on mental health and wellbeing during covid-19 through telephone lines, text, and webchat. ruok is a non-profit suicide prevention organization which is also promoting connectivity during the pandemic through initiatives such as "connection cards," which can be left on doorsteps with contact details for volunteers willing to listen and talk or provide practical support. population approaches (primary prevention) various organizations have issued advice for coping with anxiety and stress during the covid-19 pandemic, which may reduce suicide risk. the australian psychological society (aps) has issued tips for older adults to stay mentally healthy (australian psychological society psychology and ageing interest group committee, 2020). information is important to mitigate the risk of psychological distress, including providing older people with a clear rationale for why self-isolation is important, general education about the virus to reduce stigmatization, and emphasizing the altruistic decision to stay home (brooks et al., 2020) . conveying such information via television may be an effective approach that reaches many older people. the aps includes seeking information from reliable sources and in moderation, keeping concerns in perspective, and utilizing existing healthy coping skills. there are suggestions for coping with social distancing such as using videoconferencing, text messaging, phone calls, and e-mail with friends and family instead of faceto-face meetings. a sense of belonging, connectedness, and social support can be derived through online technologies (armitage and nellums, 2020) , addressing key suicide risk factors. for some older people, this will involve learning new skills; australians aged 65 + , for example, are the most digitally excluded population group, least able to use digital technology for social connectivity and accessing information and services (thomas et al., 2017) . continuity of access to mental health care (secondary and tertiary prevention) community older persons' mental health services should review their patient lists and screen for (reger et al., 2020) or otherwise identify clients who are especially vulnerable to mental illness and suicide (e.g. those who live alone, were already socially isolated, have chronic medical comorbidities or functional disability, are currently unwell, or who are at risk of relapse) and institute regular welfare checks and enhanced follow-up. patients receiving depot antipsychotics or requiring regular medication monitoring (e.g. blood tests for lithium or clozapine) may need additional support from mental health services to ensure continued access to treatment, especially for those whose general practitioners have reduced hours or closed and no longer provide this care. people who contract covid-19 and have suicide risk factors should be actively followed-up (reger et al., 2020) . telehealth has rapidly come to the fore during the covid-19 pandemic and may improve the access of older people internationally to mental health care now, but also later if embedded in mainstream health care. this involves switching from a hospital and clinic-based model of mental health care to telephone-and internet-based services and increasing public awareness about where and how to access the off-site services. there are online psychotherapy courses available for anxiety and depressive illnesses (see, e.g. https://thiswayup.org.au/) and for loneliness (kall et al., 2020) , although specific telehealth treatments for suicidal ideation are less developed (reger et al., 2020) . grief counseling for those bereaved during the pandemic could also be delivered online. older people may require additional support and education from families, friends, and healthcare professionals to access these services. informal and professional services have a role in reducing social isolationa factor increasing suicide riskin older people during the covid-19 pandemic. grassroots initiatives to reduce loneliness have emerged such as #thekindnesspandemic, developed by celebrate ageing, to promote acts of intergenerational kindness. children can be encouraged to keep contact with their older parents to reduce fear and loneliness. for those without relatives, support services could be provided by community workers. online technologies can also be utilized to promote a sense of belonging and provide social support for older people (newman and zainal, 2020) . formal services, such as tele-help/tele-check in italy, telephone support, and monitoring, have demonstrated benefits in suicide prevention for older people (de leo et al., 2002) . this model of proactive connection of older adults with health services via phone could be used to provide home assistance to older people at risk of suicide through social isolation, and/or psychological or physical illness. variations of this approach could be delivered by family and friends, charities, voluntary organizations, or healthcare professionals (armitage and nellums, 2020) . telephone crisis line services too have played a role in suicide prevention and crisis support in the community providing an inexpensive, convenient and anonymous means of seeking support (krysinska and de leo, 2007) with the potential to reach a large proportion of community-dwelling older people (chan et al., 2018) . although quarantine is necessary to reduce the spread of covid-19, measures can be taken to reduce the factors associated with poor mental health (brooks et al., 2020) . this could include a public health campaign explaining why quarantine is important; minimizing the total duration of the quarantine period; ensuring older people have access to sufficient food, household essentials, and medicine (including through welfare strategies such as those implemented in china); and promoting suggestions for homebased activities to stave off boredom. there may be unintended adverse consequences of policies to prevent contagion for older people. advice regarding exercise and movement outside the home varies between countries and age groups, but social distancing may lead to more physical deconditioning, greater pain, and ultimately greater disability for older people. each of these negative sequelae is also risk factors for suicide in older people (fassberg et al., 2016) . exercise is also an effective treatment for depression (lópez-torres hidalgo et al., 2019) , and if no longer available as a coping strategy for older adults, could potentially increase suicide risk. there are several ways in which the covid-19 pandemic will have an impact on suicide in older adults, including by increasing the prevalence of known risk factors for suicide and infection control measures which increase isolation and vulnerability. countries grapple with the pandemic crisis in the midst of their own challengeseconomic, political, and natural disasters. however, there are common elements to suicide prevention in older adults: accessible dissemination of accurate information, promoting self-help and positive coping, reducing 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[the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) with costs approaching $100 billion, the fires are australia's costliest natural disaster. the conversation economic suicides in the great recession in europe and north america suicide mortality and coronavirus disease 2019 -a perfect storm australian bushfires-frequently asked questions: a quick quide. parliament of australia facing covid-19 in italy -ethics, logistics, and therapeutics on the epidemic's front line social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older americans (nshap): a longitudinal mediation analysis letters to the editor: withholding ventilators from older covid-19 patients harms young people too measuring australia's digital divide: the australian digital inclusion index the impact of covid-19 on people with severe and complex mental health problems. concerted action needed urgently nursing homes or besieged castles: covid-19 in northern italy self-harm in older adults: systematic review carers for family members withdraw from support services to limit contact during coronavirus pandemic the interpersonal theory of suicide understanding self-harm in older people: a systematic review of qualitative studies the prevalence of suicide ideation among the chinese elderly: a meta-analysis op-ed: as hospitals become overwhelmed with coronavirus, how do we decide who gets treatment? mental health services for older adults in china during the covid-19 outbreak patients with mental health disorders in the covid-19 epidemic rates and characteristics of elderly suicide in china key: cord-309267-ihc7h8ik authors: vervaecke, deanna; meisner, brad a title: caremongering and assumptions of need: the spread of compassionate ageism during covid-19 date: 2020-09-12 journal: gerontologist doi: 10.1093/geront/gnaa131 sha: doc_id: 309267 cord_uid: ihc7h8ik the coronavirus disease 2019 (covid-19) pandemic has highlighted the pervasive ageism that exists in our society. although instances of negative or hostile ageism have been identified, critical attention to the nuances of ageism throughout the pandemic, such as the prevalence and implications of positive or compassionate ageism, has lagged in comparison. this commentary uses stereotype content theory to extend the conversation regarding covid-19 and ageism to include compassionate ageism. we offer the ‘caremongering’ movement, a social movement driven by social media to help individuals impacted by covid-19, as a case study example that illustrates how compassionate ageism has manifested during the pandemic. the implications of compassionate ageism that have and continue to occur during the pandemic are discussed using stereotype embodiment theory. future actions that focus on shifting attention from the intent of ageist actions and beliefs to the outcomes for those experiencing them is needed. further, seeking older individuals’ consent when help is offered, recognizing the diversity of aging experiences, and thinking critically about ageism in its multiple and varied forms are all required. we begin by describing stereotype content theory and compassionate ageism and then explore how the oversimplification of covid-19 risks for older adults has contributed to expressions of compassionate ageism. to substantiate our claims, we offer a case study example of the "caremongering" movement to illustrate how compassionate ageism has manifested during the pandemic. some potential implications of caremongering, and compassionate ageism more broadly, are explained using stereotype embodiment theory. finally, we consider how we, as citizens and broader society, can move forward to address ageism in its multiple and varied forms during the covid-19 pandemic and beyond. despite common conceptions of stereotypes as either positive or negative, stereotype content theory recognizes that stereotypes are often a mix of perceptions of an out-group in two dimensions, warmth and competence (fiske, cuddy, glick, & xu, 2002) . in this combination of dimensions, out-groups can be "positively" stereotyped in one dimension and "negatively" stereotyped in the other. when this theory is applied to aging, research demonstrates that older individuals are typically stereotyped as warm or likeable but incompetent or dependent . mixed stereotypes high in perceived warmth and low in perceived competence, a c c e p t e d m a n u s c r i p t as is the case for older adults, often result in paternalism where the assumed power of dominant groups is combined with perspectives and actions of nurturing and protecting those positioned as subordinate . importantly, fiske et al. (2002) note that paternalistic stereotypes can result in "compassion, sympathy, and even tenderness, under the right conditions" (p. 880). the covid-19 pandemic appears to have created "the right conditions" for patronizing sentiments and helping behaviors targeted at older adults. the mixed nature of stereotype content and resultant paternalism described in stereotype content theory aligns closely with definitions of compassionate ageism. binstock (1985) defines ageism as, "the attribution of the same characteristics, status, and deserts to an artificially homogenized group labeled "the aged"" (p. 422). in the case of compassionate ageism (also known as benevolent ageism), so-called positive or warm perceptions of older people are combined with attributes of incompetence, frailty, dependence, passivity, and victimhood (binstock, 1985; cary, chasteen, & remedios, 2017; marier & revelli, 2017) , reflecting the mixed content of age stereotypes. compassionate ageism often results in paternalistic actions that are patronizing to some older individuals, such as helping behaviors (cary et al., 2017) . these behaviors can fall under the dependency-support script described by baltes and wahl (1996) , where often relatively younger people create an overresponsive and overaccommodating environment that assumes older adults are frail or dependent, without attention to their actual competence levels or interest in being helped. these age-biased labels and actions uphold the status of younger groups, and consequently lower the status of older individuals . paternalistic age stereotypes and assumptions of older adults" competence that frame older people as dependent have homogenized older adults, cultivated the conditions of high risk a c c e p t e d m a n u s c r i p t with aging, and demonstrated the intersections between ageism and ableism during the pandemic. covid-19 has been framed as an infectious disease that primarily impacts older adults since its beginnings (ayalon, 2020) . in this messaging, older adults are considered a homogeneous group with an equally high risk of contracting and suffering from covid-19 . this assumed uniformity as a "vulnerable population" has upheld and bolstered age stereotypes of frailty and dependence. the pandemic has also highlighted society"s tendency to conflate chronological age with impairment by assuming that all older adults have health conditions that place them at higher risk of experiencing a severe case of covid-19 (meisner, 2020) . the widespread classification of older adults as "vulnerable" has occurred throughout the pandemic despite consistent findings that age alone is not a reliable measure of the medical outcomes of covid-19 (ehni & wahl, 2020; meisner, 2020; rahman & jahan, 2020) . indeed, the generally unchallenged labeling of older people as "vulnerable" due to presumed health conditions demonstrates the persistent connections of ageism and ableism more broadly (overall, 2006) . the oversimplification of covid-19 risk for older adults as a supposedly uniform frail and dependent population has spread into many governmental directives during the pandemic. numerous examples of ageist language have been identified in the pandemic"s early stages . references to all older adults as equally vulnerable have continued as many governments adopt a phased approach to reopening services, with many restricting community-dwelling older adults" movement in certain phases while most younger and working adults reintegrate. creating such age-based restrictions may have good intentions and a desire to respond to the epidemiological trends of covid-19 cases; however, that does not excuse the use of communication that is paternalizing and homogenizingboth hallmarks of compassionate a c c e p t e d m a n u s c r i p t ageism (fraser et al., 2020) . for example, a news article reporting france"s ambiguous directives regarding the restrictions on older adults states that, "the elderly and vulnerable are allowed out, but must use common sense" (coronavirus, 2020, france section, bullet 4) . this statement groups the "elderly" and "vulnerable" people together and appears to question the competence of the "elderly" to use logic when in a social gathering, now that they are "allowed" out, despite many instances of people of all ages failing to use "common sense" during the pandemic (rasmussen, 2020) . while these examples appear to demonstrate that governments are "looking after their most vulnerable" during the pandemic, some citizens believe these actions are not enough. the lack of government support and action is a commonly cited spark for the recent "caremongering" movement that has emerged because of covid-19 (moscrop, 2020; su, 2020) . started in canada, caremongering is a social movement driven by social media to help individuals impacted by the covid-19 pandemic (gerken, 2020) . positioned as the anti-thesis of covid-19 scaremongering, caremongering groups are designed to help those who are (or are perceived to be) at highest risk of covid-19 infection and/or negative personal or social impacts (estrada, 2020; gerken, 2020) . through social media, typically younger and perhaps more able-bodied individuals have self-organized into many caremongering groups, first across canada and now internationally. on social media platforms, such as facebook, people can post "in search of" help (i.e., caremongerees) or "help offer" services they are willing and able to provide (i.e., caremongerers) (gerken, 2020) . the help requested and received via caremongering groups has included deliveries of groceries, homecooked meals, and prescriptions, as well as calling isolated individuals and creating care packages (small acts of kindness, 2020; venn, 2020) . above all, caremongering is described as a grassroots service provided to "anyone who needs it" a c c e p t e d m a n u s c r i p t (mahomed, 2020, para. 1 ). there are numerous encouraging stories from both caremongerees and caremongerers (gerken, 2020; cohen, 2020) , as well as individuals who simply like to scroll through caremongering groups to read about or see photos and videos of the uplifting actions that have occurred in an otherwise tumultuous time (gerken, 2020) . however, caremongering has also emerged as a unique setting to view how the oversimplification of covid-19 risks to an artificially homogenized older adult group in society has manifested during the pandemic, and how this narrative has been continuously reinforced in media coverage of caremongering. there are several news articles reporting on the caremongering movement that use "doddering but dear" (cuddy & fiske, 2002, p. 4 ) age stereotypes as well as patronizing and homogenizing language to describe the movement. for example, the following quote from a global news article in canada highlights many of the attributions and assumptions resulting from compassionate ageism: one of the most vulnerable communities in this pandemic is our elderly. but it is not just their physical well-being at risk; with strict visitor restrictions at retirement and nursing homes, their mental health has been put in a fragile state. (estrada, 2020, para. 9) this statement reinforces the oversimplified view that older adults are "most vulnerable" for covid-19 infection and other negative impacts, while using language (i.e., "elderly") that is criticized for representing and reinforcing negative age stereotypes (lundebjerg, trucil, hammond, & applegate, 2017) . it then goes further to homogenize all older adults by immediately discussing older individuals who live in retirement and nursing homes, neglecting m a n u s c r i p t to consider that many, in fact most, older adults continue to live in the community (statistics canada, 2017) . it also demonstrates paternalizing language when it refers to older people as "our elderly" (emphasis added). the presumed ownership of the "elderly" stems from compassionate ageism and mixed age stereotypes which position older individuals as worthy of, and dependent upon, the support of younger people. despite caremongering being defined as a service provided to "anyone who needs it" (mahomed, 2020, para . 1) (emphasis added), a dependence-support script is promoted through the media and potentially adopted by those participating in caremongering. the fact that frailty and dependence are not experienced by all older adults was featured on social media in a recent viral tiktok video pertaining to covid-19. the video is of a younger woman recording herself making a sign that read, "hope you"re ok let me know if you need anything" (emphasis in original) (bracewell, 2020a ). the video then shows her posting the sign on the side of her house, facing her neighbor"s house, and recording her neighbor"s reaction. her neighbor, an older woman, responded with a sign of her own that read, "fuck off" (emphasis in original). this video was a satirical commentary on the caremongering movement offered by the social media influencer and comedian and her mother. a second video clarifies that her mother is irritated by the language used in reference to older people in her country (new zealand) during the covid-19 pandemic. as she holds up her "fuck off" sign from the first video, she says, "this is to all the people that call me "elderly"" (bracewell, 2020b, 0:10) . both videos serve as social criticism of the assumptions being made about people characterized as and presumed to be "elderly" by governments and by some individuals in broader society that have resulted in helping behavior that is perhaps unneeded or unwanted. these videos also acknowledge and ridicule the performative aspect of some a c c e p t e d m a n u s c r i p t caremongering. indeed, other social media users are noting this form of ageism and urge others to engage in critical thinking about caremongering efforts. as one twitter user aptly voiced, "please don"t let your local "#caremongering" group become a venue for performative charity and privileged "positivity"" (low, 2020) . this tweet demonstrates that caremongering can uphold recurrent relations of youth-centered power and privilege via advantaged individuals recording and sharing actions towards an often less-privileged stereotyped group. these tiktok videos and tweet highlight how it is imperative to verify need and seek consent before engaging in helping behavior, especially in such a performative manner. if the younger woman"s sign in the tiktok video had continued to be displayed, the neighbor could have been labeled as a frail and dependent older individual by both her geographical community and the larger virtual community watching tiktok. while the tiktok videos and tweet begin to illustrate the potentially hurtful and damaging outcomes of the performative aspects of caremongering, we must consider what the lasting harms could be of compassionate ageism aimed at older individuals who do not need or want help. research documenting the consequences of compassionate ageism predates the covid-19 pandemic. stereotype embodiment theory explains how age stereotypes, such as the warm but incompetent stereotypes of compassionate ageism, influence the health and well-being of older adults (levy, 2009) . specifically, age stereotypes that exist at broader societal levels are learned, even unconsciously manifested, at the individual level across the lifespan (levy, 2009; meisner & levy, 2016) . the manifestation of age stereotypes at the individual level can occur through consistent exposure to compassionate ageism in interpersonal and communication contexts. these relational and social encounters reinforce age stereotypes of warmth and incompetence such that older individuals may consider others" evaluations of their competence a c c e p t e d m a n u s c r i p t as true, even if it is not, and learn to exhibit helpless behavior to meet expectations of them and their age group (chasteen, pichora-fuller, dupuis, smith, & sing, 2015; levy, 2009 ). the results of reinforced and learned compassionate ageism on older individual"s health and well-being are established in research and include decreased self-esteem, empowerment, and motivation as well as declines in physical functioning, cognitive and psychological performance, and social engagement (baltes & wahl, 1996; chasteen & cary, 2015; hehman & bugental, 2015; kemper, othick, warren, gubarchuk, & gehring, 1996; meisner, 2012; meisner & levy, 2016) . for example, hehman and bugental (2015) explored the impact of elderspeak, a form of patronizing communication directed at older people. the authors found that older adults, especially those with pre-existing negative perceptions of aging, experienced deficits on a cognitive task and increased activation of cortisol, a well-known stress hormone, following an experience of elderspeak (hehman & bugental, 2015) . given that many younger individuals often adjust their behavior when interacting with older people according to age stereotypes they hold (o"connor & st. pierre, 2004) , it is likely that those engaging in helping behaviors during the covid-19 pandemic, such as caremongering, are doing so in ways that have long-term implications for older recipients of this help. the impact and prevalence of compassionate ageism will likely continue after the urgency of this pandemic has passed. the literature regarding learned helplessness following compassionate ageism clearly demonstrates the consequences if we do continue. this calls for sustained efforts in resisting this form of ageism. compassionate ageism requires us to think of our actions through the perspectives of older people who experience differential treatment because of their perceived or actual age. younger people often highlight their connections to older adults, such as spending time with grandparents or volunteering in settings that serve older a c c e p t e d m a n u s c r i p t individuals, to falsely demonstrate that their proximity to older adults negates their ageist beliefs or actions. using relationships with older individuals as a token of all older peoples" consent to ageism does not alleviate the impacts of such attitudes and behaviors. there is also a tendency to consider compassionate ageism as incompatible with potential discriminatory outcomes due to the often "good intentions" behind compassionate ageism (johnson, 2020) . dichotomizing behavior as either "discrimination against" or "compassion for" older individuals fails to recognize that actions can in fact be both. we need to interrupt prejudice and discrimination against older adults even if there are good intentions, as the experience and outcomes of this differential treatment, from older persons" perspectives, may not be inherently "good." the examples provided throughout this commentary indicate that paying careful attention to our assumptions about aging and older people, the language we use, and the actions we take is crucial. numerous calls for adjustments to how we think about, refer to, and engage with older people have been published prior to the pandemic (lundebjerg et al., 2017) . notably, critical perspectives regarding the impact of the assumptions that inform compassionate ageism have largely come from the public sphere during the pandemic, such as on tiktok and twitter, as described. in comparison, there are currently very few academic articles that discuss compassionate ageism and covid-19. in the existing published articles, there appears to be a focus on the unintended consequences of, and rationale for, ageist actions during the pandemic. for example, recognizing that strict guidelines directed at older individuals have inadvertently resulted in social isolation and reasoning that the outcomes of protective actions were ultimately good-natured and a demonstration of valuing older people (monahan, macdonald, lytle, apriceno, & levy, 2020; petretto & pili, 2020) . however, this literature does not yet acknowledge the necessity of seeking older peoples" consent, perspectives, and experiences a c c e p t e d m a n u s c r i p t when others decide to provide help or implement public health directives pertaining to covid-19 based on perceived or actual age. focusing on the reasons motivating such actions without considering consent, interest in, or need of receiving help, effectively represents and reinforces paternalism, the homogenization of older people, and subsequent detrimental health outcomesthe very things we are trying to prevent. it is our responsibility to reflect upon and adjust our beliefs, attitudes, communication and actions when needed. likewise, we must hold others accountable and challenge systems (including governments) that use stereotypical terms and ideas that reproduce and enable socially stigmatizing environments. one way to challenge these ingrained narratives is to shift the script when offering help. for example, moving away from a dependency-support script of, "you are an old and frail person. i am here to help you, and i expect you to accept my help and support" (baltes & wahl, 1996, pp. 227-228) toward a script that recognizes older individuals" autonomy and agency, "you are a person. i can be here to offer help if you want it, but i don"t expect you to need or accept help and support." assuming that older adults fit the stereotype of needing or wanting care, and that those who break or reject the dependency-support script are "exceptional" (massie & meisner, 2019, p. 36) , should be replaced by the realization that aging is complex and older adults are diverse. most older people are merely living their ordinary lives when they are thought to reinforce or refute ageist and ableist assumptions that others have been taught to believe about aging and older adults" capabilities (massie & meisner, 2019) . promoting more accurate media messaging that resists oversimplification and recognizes the heterogeneity and multifaceted complexity of aging is another strategy needed to encourage nuanced representations and understandings of aging (binstock, 1985; marier & revelli, 2017) . intergenerational relationship-building opportunities, such as caremongering, could also be a c c e p t e d m a n u s c r i p t reimagined as mutually-beneficial social experiences that focus on the relationships generated, rather than on the benefits to one group. as such, assumptions that help is unidirectionally provided to older adults by relatively younger adults or younger generations must be overcome. we must recognize that older adults in many instances and cultures are net providers (rather than receivers) of help and care through various roles, such as volunteers and unpaid caregivers of peers, spouses, and grandchildren. these roles existed long before the pandemic and have continued during it, despite government directives limiting the mobility and independence of older individuals (macdonell, 2020) . we must also consider how younger people can be disadvantaged by assumptions that they do not need or want help, which could be consensually provided by a person of any age. the covid-19 pandemic intensified experiences and examples of age discrimination and catalyzed discussions motivating us to think more critically about the various forms and subtleties of ageism. in these complex understandings of aging and older adulthood, there is space to understand that some older adults will appreciate the helping behaviors that result from social movements, such as caremongering, while also acknowledging that some older individuals will not need, want, or appreciate this help. we must carefully ensure that, although older adults are sometimes the objects of our concern and targets of our help with good intentions, they must maintain their autonomy and agency as individuals to remain the subjects of their own decisions and lives. therefore, being critical of compassionate ageism does not mean we should not interact with older adults. rather, it encourages us to reflect upon why and how we engage with older adults in the ways we do and how much these actions teach them, others, and ourselves about what it means to be "older." we must consider the extent to which older adults are surrounded by people and social environments that unintentionally encourage them to be and a c c e p t e d m a n u s c r i p t become vulnerable. moving forward, messages and actions should be grounded in the latest evidence, rather than on ageist beliefs and behaviors. this evidence must include first-person accounts of older adults" experiences of various forms and encounters of ageism that often intersect with other systems of oppression . exploring the lived experiences of ageism before, during, and after the pandemic should be done in partnership with a variety of diverse older people, through interdisciplinary collaboration, with the aim to cultivate a more equitable and just aging society. a c c e p t e d m a n u s c r i p t there is nothing new under the sun: ageism and intergenerational tension in the age of the covid-19 outbreak aging in times of the covid-19 pandemic: avoiding ageism and fostering intergenerational solidarity patterns of communication in old age: the dependence-support and independence-ignore script the oldest old: a fresh perspective or compassionate ageism revisited? march 30a). well that didnt go as expected #newzealand #isolation part 2. my mama/neighbour is legendary #yesitwasajoke #obviously #newzealand age stereotypes and age stigma: connections to research on subjective aging do negative views of aging influence memory and auditory performance through self-perceived abilities? how lockdown is being lifted across europe doddering but dear: process, content, and function in stereotyping of older persons a covid-19 side effect: virulent resurgence of ageism six propositions against ageism in the covid-19 pandemic commentary: how coronavirus launched a 'caremongering' movement. global news a model of (often mixed) stereotype content: competence and warmth respectively follow from perceived status and competition ageism and covid-19: what does our society"s response say about us? coronavirus: kind canadians start 'caremongering' trend responses to patronizing communication and factors that attenuate those responses navigating covid-19: compassion or ageism facilitating older adults" performance on a referential communication task through speech accommodations stereotype embodiment: a psychosocial approach to aging please don't let your local '#caremongering' group become a venue for performative charity and privileged 'positivity when it comes to older adults, language matters: journal of the american geriatrics society adopts modified american medical association style 77-year-old sewing hundreds of masks for health care workers at closed alteration shop caremongering" spreads amid covid-19 crisis compassionate canadians and conflictual americans? conservative media perceptions of aging and experiences of ageism as constraining factors of moderate to vigorous leisure-time physical activity in later life a meta-analysis of positive and negative age stereotype priming effects on behavior among older adults are you ok, boomer? intensification of ageism and intergenerational tensions on social media amid covid-19. leisure sciences. advance online publication age stereotypes" influence on health: stereotype embodiment theory interdisciplinary and collaborative approaches needed to determine impact of covid-19 on older adults and aging: cag/acg and cja/rcv joint statement ageism: how positive and negative responses impact older adults and society. american psychologist. advance online publication in canada, an inspiring movement emerges in response to the coronavirus older persons" perceptions of the frequency and meaning of elderspeak from family, friends, and service workers old age and ageism, impairment and ableism: exploring the conceptual and material connections ageism and covid-19 ageing and covid-19: what is the role for elderly people? defining a "risk group" and ageism in the era of covid-19 close contact: spring breakers play tug-of-war amid calls for social distancing small acts of kindness have big impact in the n.w.t. amid pandemic age (20) and sex (3) for the population in occupied dwellings of canada, provinces and territories, census metropolitan areas and census agglomerations caremongering and the risk of "happy-washing" during a pandemic the 'caremongers' getting food and essentials to the country's most vulnerable key: cord-034435-yp0gfl47 authors: medetalibeyoglu, a.; senkal, n.; kose, m.; catma, y.; caparali, e. bilge; erelel, m.; oncul, m. oral; bahat, gulistan; tukek, t. title: older adults hospitalized with covid-19: clinical characteristics and early outcomes from a single center in istanbul, turkey date: 2020-10-08 journal: j nutr health aging doi: 10.1007/s12603-020-1499-9 sha: doc_id: 34435 cord_uid: yp0gfl47 objective: older adults have been continuously reported to be at higher risk for adverse outcomes of covid-19. we aimed to describe clinical characteristics and early outcomes of the older covid-19 patients hospitalized in our center comparatively with the younger patients, and also to analyze the triage factors that were related to the in-hospital mortality of older adults. design: retrospective; observational study. setting: istanbul faculty of medicine hospital, turkey. participants: 362 hospitalized patients with laboratory-confirmed covid-19 from march 11 to may 11, 2020. measurements: the demographic information; associated comorbidities; presenting clinical, laboratory, radiological characteristics on admission and outcomes from the electronic medical records were analyzed comparatively between the younger (<65 years) and older (≥65 years) adults. factors associated with in-hospital mortality of the older adults were analyzed by multivariate regression analyses. results: the median age was 56 years (interquartile range [iqr], 46–67), and 224 (61.9%) were male. there were 104 (28.7%) patients ≥65 years of age. more than half of the patients (58%) had one or more chronic comorbidity. the three most common presenting symptoms in the older patients were fatigue/myalgia (89.4%), dry cough (72.1%), and fever (63.5%). cough and fever were significantly less prevalent in older adults compared to younger patients (p=0.001 and 0.008, respectively). clinically severe pneumonia was present in 31.5% of the study population being more common in older adults (49% vs. 24.4%) (p<0.001). the laboratory parameters that were significantly different between the older and younger adults were as follows: the older patients had significantly higher crp, d-dimer, tnt, pro-bnp, procalcitonin levels, higher prevalence of lymphopenia, neutrophilia, increased creatinine, and lower hemoglobin, alt, albumin level (p<0.05). in the radiological evaluation, more than half of the patients (54.6%) had moderate-severe pneumonia, which was more prevalent in older patients (66% vs. 50%) (p=0.006). the adverse outcomes were significantly more prevalent in older adults compared to the younger patients (icu admission, 28.8% vs. 8.9%; mortality, 23.1% vs. 4.3%, p<0.001). among the triage evaluation parameters, the only factor associated with higher mortality was the presence of clinically severe pneumonia on admission (odds ratio=12.3, 95% confidence interval=2.7–55.5, p=0.001). conclusion: older patients presented with more prevalent chronic comorbidities, less prevalent symptomatology but more severe respiratory signs and laboratory abnormalities than the younger patients. among the triage assessment factors, the clinical evaluation of pulmonary involvement came in front to help clinicians to stratify the patients for mortality risk. it was early december 2019 that atypical cases of pneumonia were described due to a previously unknown pathogen in wuhan city, china (1) . the pathogen was identified as a novel, positive-sense single-stranded, enveloped rna virus that has a close similarity with sars-cov and named sars-cov-2 (2) . the associated disease was then named as coronavirus disease 2019 . it rapidly spread through the world, becoming a pandemic and global health emergency, which affected over 10 million people with a death toll of more than 500 thousand by july 2020 (3) . while the disease has been relatively controlled in some regions, when considered globally, it is still in the acceleration phase (3) . it is a new disease, and our clinical understanding of the disease relies on the studies that report its clinical course and associated factors. the early reports in this regard came from china, where the disease started from and continued with europe and the us in line with its spread pattern. older adults have been continuously reported to be at higher risk for adverse outcomes of covid-19 (4) (5) (6) . however, the specific information about older patients is limited despite their significant involvement with the disease (6) (7) (8) (9) (10) (11) (12) . our hospital is a major teaching hospital. we identified the first covid-19 case in turkey in istanbul city on march 11, 2020 , in the emergency clinic of our university hospital. since then, our center has become a pandemic hospital followed by the many others in turkey. istanbul has been the major center of the pandemic in turkey with the highest number of covid-19 cases from the beginning of the pandemic in the country as it is a crossroad between europe and asia, an international hub. istanbul is also the most crowded city in the country, with a population number of about 15 million, higher than many european countries (13). istanbul has been reported to have more than half (54.8%) of all of the cases in turkey as of june 28, 2020 (14) . there are differences between countries in terms of, e.g. demographics, comorbidities, and also in actions taken during the pandemic. these may reflect as differences in presenting clinical features and outcomes (5) . our center has been one of the most crowded centers in the pandemic era in turkey. in this report, we aimed to describe clinical characteristics and early outcomes of the older covid-19 patients consecutively hospitalized in our center comparatively with the younger patients. a secondary aim was to analyze the triage factors that were related to the in-hospital mortality of older adults. in this retrospective observational study, we included the hospitalized patients aged ≥18 years with confirmed covid-19 from march 11, 2020 to may 11, 2020. all patients were followed until meeting the outcome measure, death, or discharge from the hospital with recovery. we recorded demographic information, associated comorbidities presenting clinical, laboratory, and radiological characteristics on admission from the electronic medical records. in our center, after the world health organization (who)'s declaration of covid-19 as a public emergency with international concern on january 30, 2020, all of the patients with respiratory symptoms and/or fever were directed to the emergency clinic. all patients were first evaluated in the triage room, where they were assessed in a structured manner involving covid-19 directed history taking and measurements of the body temperature, pulse rate, respiration rate, blood pressure, and room air peripheral oxygen saturation (sao2). the history included inquiries on the covid-19 classical symptoms (i.e., fever, cough and dyspnea), myalgia/ fatigue, contact history, and international travel history. after observation and reports that covid-19 patients occasionally complained from diarrhea, nausea/vomiting, loss of smell and taste symptoms, these symptoms were also considered as potential symptoms of the disease and included in the structured history on march 25, 2020. the patients that were identified as suspected covid-19 cases have undergone nasopharyngeal and oropharyngeal swab specimen collection for real-time reverse-transcriptase-polymerase-chain-reaction (rt-pcr) examination, routine laboratory examination, and chest x-ray. laboratory confirmation (rt-pcr examination) of sars-cov-2 was performed at the official public health care laboratory till march 30, 2020, and consequently at our institution certified in this process. rt-pcr assays were carried out in accordance with the protocol defined by the who (15). laboratory examination included complete blood count, blood chemistry (liver and renal function tests, ldh, albumin), crp, ferritin, d-dimer, high sensitive troponin t (tnt), n-terminal pro-brain natriuretic peptide (pro-bnp) and procalcitonin. in all hospitalized patients with confirmed covid-19, low dose pulmonary computerized tomography (ct) was also performed at baseline if there were no contraindication (i.e., pregnancy). pulmonary ct images were evaluated by a structured manner by the attending radiologists that have taken care of the covid-19 pandemic patients. covid-19 related ct findings were classified as mild to moderate or severe, as described elsewhere (16) . additionally, we evaluated the clinical severity of covid-19 pneumonia on admission, considering the respiration rate, peripheral oxygen saturation, and dyspnea identified by the attending physician. the patients that had resting respiration rate ≥30/min or room air peripheral oxygen saturation <90% or dyspnea (identified by the use of accessory respiration muscles at rest) were designated as clinically severe pneumonia according to the diagnostic and treatment guidelines for sars-cov-2 issued by the turkish national scientific committee (17). the need for oxygen support was assessed by the presence of resting oxygen saturation in the room air <93% (17). body temperature was assessed by a noncontact infrared thermometer from the forehand. fever was defined as temperature >38.3°c. the temperatures between 37.8-38.3 °c were defined as subfebrile. the cut-offs of the laboratory parameters were designated by the local laboratory thresholds. hospitalization criteria: hospitalization criteria were defined by the national scientific board covid-19 diagnosis and treatment guideline-directed by the ministry of health (17). accordingly, the patients that had respiration rate ≥30/ min, room air sao2 <90%; moderate or severe pneumonia on pulmonary imaging; and/or laboratory results associated with a worse prognosis on admission (lymphocyte <0.8 x10 9 /l, crp >40 mg/l, ferritin >500 ng/ml or d-dimer >1000 ug/l), and/or the patients that had mild pneumonia but associated chronic comorbidities (e.g. cardiovascular diseases, diabetes mellitus, hypertension, cancer, chronic lung diseases, immunosuppression etc.) and/or older age (≥50 years) have been hospitalized (17). the treatment schedule of the hospitalized patients was decided by a constant team and composed of mainly supportive treatment. the additional treatments included hydroxychloroquine, azithromycin, ± oseltamivir, anticoagulant/antiaggregant treatments, antiviral treatments (lopinavir/ritonavir, favipiravir), anti-inflammatory treatments (steroid, tocilizumab, anakinra), antibiotics largely in concordance with the recommended treatment schedule of the national scientific board. admission to the intensive care unit (icu) and the outcome measure: discharge from hospital or death were recorded from the electronic medical records. we recorded the times between the potential earliest date of symptom onset to hospitalization, hospitalization to icu admission, length of icu stay, and length of hospital stay, as applicable. the study was approved by the institutional review board (number: 2020/747). the data were collected for routine clinical practice and handled anonymously. we expressed continuous variables as medians and interquartile ranges. categorical variables were given as counts and percentages. two groups were compared with mann whitney u test when necessary. chi-square test with yates correction and fisher's exact test was used for 2x2 contingency tables when appropriate for non-numerical data. correlations between numerical parameters were analyzed with spearman's rho correlation test. we made univariate and multivariate regression analyses (cox survival and logistic regression, backward lr method) to analyze factors associated with mortality in older adults. in the regression analyses, we included the variables that were significantly associated with mortality in the univariate analyses and were clinically significant. the multicollinearity among the possible regression analyses independent variables were checked with spearman or kendall's tau-b correlation analyses. the variables that were detected having multicollinearity in between were not analyzed in the same regression models. in the regression analyses, as there were a high number of variables associated with mortality in the univariate analyses, two events per predictor variable were used in regression analyses (18) . p values less than 0.05 were accepted as significant. the significance of the regression analyses was checked, and the significance of the logistic regression was further evaluated by hosmer and lemeshow test. we used spss (statistical package for social sciences) for windows 15.0 program for data analyses. we outlined the baseline demographic and clinical characteristics of the patients stratified by age in table 1 . there were 362 patients with laboratory-confirmed covid-19 hospitalized in the study period. the date at which the outcome measure (death or discharge from hospital) was completed was june 02, 2020. the median age was 56 years (interquartile range [iqr], 46-67; range, 21-90), and 224 (61.9%) were male. there were 104 (28.7%) patients ≥65 years of age. the data are given as median (interquartile range) for the continuous variables and as counts (%) for the categorical variables; the cut-offs of the laboratory parameters were designated by † the local laboratory thresholds and ‡ the suggestion of diagnostic and treatment guidelines for sars-cov-2 issued by the turkish national scientific committee directed by the turkish ministry of health (17); admission laboratory studies were selected to be included here based on their relevance to the characterization of covid-19 patients (5); ct: computerized tomography, probnp: n-terminal pro-brain natriuretic peptide, tnt: high sensitive troponin t; *statistically significant median age for older adults (≥65 years) was 73 years (iqr, 68-81 range, 65-90). more than half of the patients (58%) had chronic comorbidity. the older patients had significantly more prevalent hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, malignancy, a higher number of accompanying comorbidities and less prevalent smoking history (p<0.01 for all). contact history was present in 37% of the population, older adults reporting significantly less contact history than the younger adults (28.8% vs 40.3%, p=0.04). fatigue/myalgia (90.6%), dry cough (81.2%), and fever (73.2%) were the three most common presenting symptoms in the study population with the prevalence in the older patients as 89.4%, 72.1%, and 63.5%, respectively. cough and fever were significantly less prevalent in older adults compared to younger patients (p=0.001 and 0.008, respectively). a higher percentage of the older adults complained of dyspnea at presentation, but the prevalence was not statistically different across the age groups (50% vs. 41.1%, p=0.12). median time from first symptom to hospitalization was 5 days (iqr, 3-7 days), and this was constant across the age groups. in the triage assessment, clinically severe pneumonia was present in 31.5% of the study population, and it was more common in older adults (49% vs. 24.4%) (p<0.001). in line with this finding, respiration rate per minute was higher, room air sao2% was lower in the older adults with significantly higher rates of patients having respiration rate ≥30/min, sao2 <90% and requiring the use of accessory respiratory muscles among older adults (p<0.001 for all). while triage body temperature and fever prevalence were not different across the older and younger patients, the prevalence of subfebrile temperature was also higher in the older adults (20.2% vs. 10.9%, p=0.002). table 2 shows the laboratory and radiological findings at hospital admission stratified by age. in the overall study population, lymphopenia was a prominent feature of the infection, 40.1% had lymphocyte <1x10 9 /l, neutrophilia was present in 28.7%, leukopenia and leukocytosis were each present in 10-15%, and platelet <100x10 9 in only 3.6%. crp was >40 mg/l in more than half of the patients (56.9%), d-dimer was higher than 1000 ug/l and ferritin was higher than 500 ng/ml in about 1/3 patients (34.5% and 34.4%, respectively ), pro-bnp was elevated in 40.3%, tnt was elevated in about 1/5 patients (22.4%), and procalcitonin was elevated in 7.5%. ldh was increased in half of the patients (53.9%), creatinine was increased in 27.6%, alt and ast was increased in 16.6% and 25.1%. the laboratory parameters that were significantly different between the older and younger adults were as follows: the older patients had significantly higher crp, d-dimer, tnt, pro-bnp, procalcitonin levels, higher prevalence of lymphopenia, neutrophilia, increased creatinine, and lower hemoglobin, alt, albumin levels ( table 2) . chest ct was performed in almost all patients [358 (98.9%) patients] except for four patients who were pregnant. 355 (99.2%) patients had pneumonic infiltration. in more than half of the patients (54.6%), there was moderate-severe pneumonia. moderate-severe pneumonia was more prevalent among older patients (66% vs 50%) (p=0.006). outcome and follow-up characteristics are outlined in table 3 . icu admission and death occurred in 14.6% (n=53) and 9.7% (n=35) of the patients, respectively. the adverse outcomes were significantly more prevalent in older adults compared to the younger patients (icu admission, 28.8% vs. 8.9%; mortality, 23.1% vs. 4.3%, p<0.001 for all). time from hospitalization to icu was similar in older and younger patients (median, 2 days), but the length of hospital stay was significantly longer in the older adults (median 10 vs. 8 days, p=0.01). in the patients that admitted to icu, length of icu stay was also higher in the older adults (36.5 days vs. 15 days). this difference was not statistically different, probably due to the lower number of patients admitted to icu, but close to the significance level (p=0.06). among 104 hospitalized older adults, 24 (23.1%) died in the hospital follow-up. in the univariate analyses of the factors on admission, the factors associated with mortality were the absence of cough and presence of dyspnea by history; the presence of clinically severe pneumonia and its components (dyspnea, higher respiration rate, lower room air peripheral sao2, higher pulse rate) on physical examination, and by laboratory examination; the presence of crp >40 mg/l, higher d-dimer, tnt, pro-bnp, ldh, alt, and lower albumin levels according to the laboratory thresholds, serum creatinine level and presence of moderate-severe pneumonia in ct (p<0.05 for all). none of the comorbidities was specifically associated with mortality nor the number of comorbidities. after checking for multicollinearity, the presence of dyspnea and components/ indicators of the clinically severe pneumonia was not included in the regression. the covariates that were included in regression analyses were the presence of cough, clinically severe pneumonia on admission, presence of crp >40 mg/l, higher d-dimer, tnt, pro-bnp, ldh, alt, and lower albumin levels, serum creatinine and presence of moderate-severe pneumonia on ct. we ran cox-regression analyses at first, but the model was not significant (p=0.08). therefore, we performed a logistic regression analysis. the significance of the logistic regression was acceptable (r2= 0.961 (hosmer and lemeshow test), model x2 (8)=2.5; p<0.001). among the triage evaluation parameters, the only factor associated with higher mortality was the presence of clinically severe pneumonia on admission (odds ratio=12.3, 95% confidence interval=2.7-55.5, p=0.001). from the beginning of the pandemic, older adults have been more seriously affected by the outcomes of covid-19. as an example, death over 60 years old accounted for 81% of the total deaths in china (6) . in turkey, cases ≥65 years constituted 11% of the confirmed infections. the overall death rate was 2.6%, but 70% of the overall deaths were in people aged 65 years or older (14). despite the vulnerability of the older population, specific information about the clinical characteristics of the disease in older adults is limited in the literature (6) (7) (8) (9) (10) (11) (12) . to our knowledge, only seven studies were focusing on older adults, all reported from china. the older patient numbers ranged between 18 and 60 in three studies (10) (11) (12) , 105-136 in two of them (8, 9) , and 204-339 patients in the two more comprehensive studies (6, 7) . all the studies that included >100 older adults set the cut-off for older adults as 60 years. in this study, we included 104 older patients ≥65 years, which accounted for 28.7% of hospitalized patients in the study period. therefore, this study aimed to be one of the studies, including a high number of older adults among studies focusing on older adults and thereby add data to increase our knowledge on clinical characteristics of covid-19 in this group. as reported in the other studies, the older adults had more prevalent associated comorbidities compared to the younger patients, hypertension (62.5%), diabetes mellitus (32.7%), coronary heart disease (25%) being the top three comorbidities. of note, hypertension and diabetes were more common in this study than in all of the chinese studies of older adults with covid-19 which were between 27.8%-48.4% and 7.9-25.7%, respectively, this may be due to ethnical differences in the prevalences of these chronic diseases probably reflecting the lower prevalence of hypertension and diabetes among chinese people compared to the nonhispanic whites (19, 20) . older adults had less prevalent contact history, and this is probably due to the early isolation of older adults starting from the beginning of the pandemic. this reflects that older adults are more prone to develop the infection with lower microorganism load, probably indicating that asymptomatic infectious patients were an important source of covid-19 infection in older adults. the most common presenting symptoms were similar across the age groups as fatigue/myalgia, dry cough, and fever being 89.4%, 72.1%, and 63.5% in the older adults. dyspnea was also very prevalent, affecting half of the older adults. dry cough and fever are, in general, the two most common symptoms of covid-19 in older adults, reported between 33.3-69.1% and 40.4-94.5% in the reports in china. in our structured history, we asked for fatigue and/or myalgia together, and this symptom was the most common presenting symptom differing from the other reports. cough and fever were less prevalent, and subfebrile fever at the triage was more prevalent in older adults, probably reflecting the decreased host response-ability in the elderly. however, in a study including 136 older adults ≥60 years of age, fever was more prevalent among older adults (8) . thus, this is not a consistent finding and needs to be addressed in future studies. importantly, clinically severe pneumonia which was identified by the presence of triage respiration rate ≥30/min or resting room air peripheral oxygen saturation <90% or dyspnea (detected by use of accessory respiration muscles at rest) was present in about half of the older adults (49%). it was significantly more prevalent than in the younger patients (24.4%), while the time from the first symptom to hospitalization was not different. admission of older adults with severe clinical disease compared to younger adults is also a constant finding across the studies (8, (10) (11) (12) . as the time from the first symptom to hospitalization was not different between the older and younger adults, these results indicate that the infection probably displays a more rapid course in older adults. another factor may be, as we found less common fever and cough among older adults, the older adults might have had progression of the disease before being symptomatic classically. the common laboratory findings of the hospitalized covid-19 patients at the triage were significantly elevated crp (>40 mg/l), high pro-bnp and ldh, lymphopenia, high ferritin and d-dimer levels, neutrophilia, high creatinine, ast, tnt levels and presence of moderate-severe pneumonic infiltration in descending order ( table 2 ). the significantly different laboratory findings between the older and younger patients were also indicators of more severe involvement with more prevalent abnormalities in the laboratory evaluation i.e. crp, d-dimer, tnt, pro-bnp, procalcitonin, lymphopenia, neutrophilia, creatinine, hemoglobin, alt, albumin and more prevalent moderate-severe pneumonia (66% vs. 50%) on ct. our findings are in accordance with the other studies (8, 11, 12) the mortality rate was 9.7% in the total study population, which has a median age of 56 years. the mortality rate was much higher in older patients compared with the younger counterparts (23.1% vs. 4.3%, p<0.001). the icu admission, as an indicator of severe disease, was 14.6% in the general study population, and this was also much more prevalent in the older adults (28.8% vs. 8.9%, p<0.001) occurring at a median of 2 days after hospitalization. these figures also reflect the rapid course and more prevalent adverse outcomes of the covid-19 in older adults, which is in line with the previous recent studies (8, 12) . the fatality rate among older adults has been reported higher as 37.3% in which the authors noted that most of the patients had to be isolated at home without medical support due to lack of in-patient hospital beds (7). this point is, therefore, important suggesting that again, earlier supportive measures may improve prognosis in older adults. in this study, we analyzed the triage factors that were related to the in-hospital mortality of older adults. the older adults that died had many significant abnormal laboratory findings reflecting more extensive involvement of the disease and associated with poor prognosis suggested in the published covid-19 literature (e.g., higher inflammatory markers, a variety of biochemical abnormalities, and presence of moderate-severe pneumonia in ct). this data can help physicians in stratifying patients with higher and lower risk according to the triage assessment. of note, in the multivariate analysis, the only factor at triage assessment related to mortality was the presence of clinically severe pneumonia on admission. this is valuable as it supports the general medical principle that the clinical evaluation of the patient is more important than the laboratory examinations in medical assessment. this result has also been reported indirectly, as the presence of dyspnea was an independent correlate of mortality in the studies that could have performed multivariate analysis for correlates of mortality in the older adults (6, 7, 12) . it seems that the more extensive pulmonary involvement on presentation reflected by the presence of dyspnea, tachypnea, and low oxygen saturation, is probably the main driver of the fatality in the course of this disease. our findings, together with the others, support the suggestion that older adults should be evaluated carefully for early diagnosis of the disease, which may hopefully reduce mortality rates by the introduction of supportive respiratory measures earlier (7, 12) . on the other hand, other studies noted some additional factors, with some differences between each other associated with higher mortality, e.g., older age, male gender, neutrophilia, lymphopenia, elevated troponin or d-dimer levels, underlying chronic diseases, cardiovascular diseases, chronic obstructive pulmonary disease, elevated creatinine and procalcitonin levels (6, 7, 12) . this study has several limitations. it is a single-center retrospective study with a limited patient number, and we considered only the triage factors but not included the progress data and treatment modalities. however, it was the aim of this study to describe the presenting clinical characteristics of covid-19 on admission and among them to identify the factors associated with higher mortality among older adults. follow-up data that could enable clinicians to stratify patients as having lower or higher risk likely present, but this was beyond the scope of this study. while we did not include treatment details, as the treatments were managed by a constant team, a significant difference between the management of the patients was unlikely but could not be eliminated by the study design. an important strength of the study is, we introduced a structured approach to the triage patients, and therefore, there is no missing data except for the data on less frequent potential presenting symptoms of the infection (loss of smell/ taste and gastrointestinal symptoms). also, in this study, we had complete data for the in-hospital outcome for all patients. in conclusion, this study shows that older covid-19 patients that were hospitalized presented with more prevalent chronic comorbidities, less prevalent symptomatology (i.e., cough and fever) but more severe respiratory signs and laboratory abnormalities than the younger patients. among the triage assessment factors, while there were several laboratory indicators related to mortality of the older adults, the clinical evaluation of pulmonary involvement came front to help clinicians to stratify the patients for mortality risk. ethical approval: the study was approved by the institutional review board (number: 2020/747). clinical features of patients infected with 2019 novel coronavirus in wuhan cov-2: an emerging coronavirus that causes a global threat who coronavirus disease (covid-19) dashboard characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up clinical features and short-term outcomes of elderly patients with covid-19 analysis of epidemiological and clinical features in older patients with corona virus disease 2019 (covid-19) out of wuhan clin infect dis clinical characteristics of elderly patients with covid-19 in hunan province, china: a multicenter, retrospective study clinical characteristics of older patients infected with covid-19: a descriptive study clinical features of covid-19 in elderly patients: a comparison with young and middle-aged patients clinical characteristics and outcomes of older patients with coronavirus disease 2019 (covid-19) in wuhan, china (2019): a single-centered, retrospective study eklenti/37743,covid-19-situation-report-v4pdf.pdf?0 accessed on world health organization. laboratory testing for 2019 novel coronavirus (2019-ncov) in suspected human cases severe acute respiratory syndrome: temporal lung changes at thin-section ct in 30 patients relaxing the rule of ten events per variable in logistic and cox regression racial/ethnic differences in hypertension prevalence, treatment, and control for outpatients in northern california 2010-2012 race/ethnic difference in diabetes and diabetic complications the authors would like to thank dr. merve meryem ören for her contributions to statistical analysis. key: cord-332652-wm9krxve authors: koslik, hayley j.; joshua, jisha; cuevas-mota, jazmine; goba, daniel; oren, eyal; alcaraz, john e.; garfein, richard s. title: prevalence and correlates of obstructive lung disease among people who inject drugs, san diego, california date: 2020-07-02 journal: drug alcohol depend doi: 10.1016/j.drugalcdep.2020.108158 sha: doc_id: 332652 cord_uid: wm9krxve background: pulmonary tissue damage leading to obstructive lung disease (old) could result from intravenous administration of insoluble particles found in illicit drugs. this study described the prevalence and identified correlates of old among people who inject drugs (pwid). methods: in 2012-2016, a community-based cohort of pwid who had injected within the past month were enrolled in a study to assess hiv, hepatitis c virus (hcv) andmycobacterium tuberculosis (mtb) infections and their related risk factors. data were obtained through face-to-face interviews, serological testing and spirometry. baseline data were used for a cross-sectional analysis of the prevalence and correlates of old, defined as fev1/fvc < 0.7. univariate and multivariable logistic regression were used to identify factors associated with old. results: among 516 participants who had complete spirometry and interview results, the mean age was 43.3 years, 73.6% were male, 9.5% were black, 91.1% smoked cigarettes and 18.2% had old. few (9.6%) pwid with old reported a previous diagnosis of copd although many (44.7%) reported related symptoms. black race (aor = 2.66, 95%ci: 1.37, 5.17), pack-years smoked (aor = 1.06/5 years, 95%ci: 1.01, 1.12), and duration of injection drug use (aor = 1.13, 95%ci: 1.01, 1.27) were independently associated with old after controlling for age. conclusions: the prevalence of old was high in this cohort and associated with black race and cigarette smoking—known risk factors. in addition, old prevalence increased with greater duration of injection drug use, suggesting a link between cumulative exposure to injected insoluble particles and old. further examination of these adulterants and lung pathology are needed. obstructive lung disease (old) is a group of conditions characterized by episodic or persistent airflow limitation that makes breathing difficult, which may be partially irreversible (global initiative for chronic obstructive lung disease, 2018). these conditions include chronic obstructive pulmonary disease (copd) and asthma, and are characterized by symptoms of shortness of breath, chest tightness, wheezing, cough, and mucus production. among united states (u.s.) adults, the number of physician-diagnosed copd and asthma cases annually is a staggering 14.8 and 25 million, respectively (office of disease prevention and health promotion, 2019), and globally the number has reached 251 and 235 million cases, respectively (world health organization (who), 2017, 2019). copd is the fourth leading cause of death in the u.s. (heron, 2018) and remains the third leading cause of death worldwide (world health organization (who), 2018). mortality outcomes for individuals with copd vary by patient phenotype (whether there is overlap with asthma, moderate/severe exacerbations with chronic bronchitis or j o u r n a l p r e -p r o o f emphysema, etc.), but is predominantly due to disease progression (golpe et al., 2018) . old costs the u.s. healthcare system an estimated $50 billion annually in copd-related expenditures -$30 billion going to direct healthcare costs, and the rest to indirect costs, such as patients' inability to work or time taken off from work (guarascio et al., 2013) -and $20.7 billion per year in asthmarelated expenditures (office of disease prevention and health promotion, 2019). the leading risk factor for copd is cigarette smoking (bhatt et al., 2018) , but studies have also reported associations with older age (de marco et al., 2011) , low socioeconomic status (wheaton et al., 2015) , human immunodeficiency virus (hiv) infection (drummond et al., 2012) and history of pulmonary tuberculosis (byrne et al., 2015) . copd has been found to be associated with injection drug use (crothers et al., 2006) , although this could be confounded by the very high prevalence of smoking among people who inject drugs (pwid) (clarke et al., 2001) . to date, only one study has assessed old specifically among pwid (horyniak et al., 2017) . in addition to factors such as age, gender, lower education and history of childhood respiratory illness being associated with copd among non-smokers (lamprecht et al., 2011) , there is evidence to suggest that the risk of old among pwid might not be entirely attributable to smoking (ward et al., 2000) . one hypothesis is that non-soluble contaminants added to illicit drugs by dealers to increase their volume, or excipients added to oral prescription medications as binders or to help them dissolve faster, may become lodged in the alveoli when they are injected intravenously, causing lung pathology (gotway et al., 2002) . for example, pulmonary fibrosis and granulomas, in addition to emphysema and pulmonary hypertension, have been reported with injection of talc-containing j o u r n a l p r e -p r o o f drugs (griffith et al., 2012; paré et al., 1989) . other drug excipients like microcrystalline cellulose, crospovidone (an insoluble, hygroscopic powder contained in pills to help them dissolve), and starch have also been reported to lead to pulmonary complications when injected (fields et al., 2005; ganesan et al., 2003; lamb and roberts, 1972; nguyen et al., 2014) ; however, these may be less likely than talc to enter the lungs as they tend to be larger in size (kringsholm and christoffersen, 1987) . considering these mechanisms, certain injection drug-related factors (e.g., type of drugs injected, frequency and duration of injection drug use) may increase exposure to adulterants, thereby contributing to the increased risk of old among pwid. the primary objectives of this study were to measure the prevalence of old among pwid in san diego, ca, and to identify pwid-specific correlates of old in this population after controlling for known risk factors. it was hypothesized that old would be independently associated with factors related to injection drug use. due to the reported lack of access to healthcare (chitwood et al., 1999) and/or the over-utilization of emergency department care in this population (kerr et al., 2004) , a secondary analysis evaluated whether there was an association between utilization of healthcare in pwid and old. the present study used baseline data from the study of tuberculosis, aids, and hepatitis c risk (stahr ii) cohort for a cross-sectional analysis of the prevalence and correlates of old among pwid. stahr ii was a prospective cohort study in which community-recruited pwid who had injected at least once in the prior month (actively injecting) were enrolled in 2012-2014, and j o u r n a l p r e -p r o o f followed for two years through semi-annual follow-up visits to determine the prevalence, incidence, and risk factors for mycobacterium tuberculosis (mtb), hiv, and hepatitis c virus (hcv) infections among pwid in san diego, ca. stahr ii methods were published in detail elsewhere (robertson et al., 2014) . the stahr ii study protocol was approved by an institutional review board at the university of california san diego, and all participants provided written informed consent. the current analysis also received a non-human subjects research determination from san diego state university's human research protections program. study participants were recruited through targeted sampling, which consisted of street outreach and posting flyers in areas where pwid generally gather (e.g., syringe exchange program sites), print and online advertising (e.g., local newspaper, craigslist), as well as through participant referrals (robertson et al., 2014) . eligible participants were at least 18 years old, spoke english or spanish, had illicitly injected drugs in the past 30 days, were non-institutionalized (i.e., hospitalized, incarcerated or in-patient substance use treatment), and resided in san diego county without plans to move away in the next 24 months. old status (yes/no) was determined at baseline by spirometry using a forced expiratory volume per second/forced vital capacity (fev1/fvc) ratio without the use of bronchodilators. spirometry j o u r n a l p r e -p r o o f was repeated three times in the same visit and then averaged according to 1994 american thoracic society recommendations (1995) . old was defined as a fixed ratio fev1/fvc value <0.70 based on global initiative for chronic obstructive lung disease (gold) cut-offs (güder et al., 2012) . computer-assisted personal interviews were conducted at baseline by trained interviewers in a private setting and lasted an average of 60-90 minutes. interviews collected information about potential correlates and known risk factors for old including socio-demographics (i.e., age, gender, race/ethnicity, homelessness), smoking status, lifetime and recent drug use and injection behaviors, symptoms and previous diagnosis of respiratory illness, and healthcare utilization. due to the non-linear relationship between age and risk of old, age (collected in years) was categorized for this analysis as a binary variable (<40 years and 40 years) for consistency with other studies as this is the age that copd symptoms typically begin (national heart lung and blood institute) and copd prevalence increases (ntritsos et al., 2018) . eight individuals reported being transsexual/transgender and were grouped by their preferred binary gender (male/female). since prior studies found only black race to be associated with old compared to other races (chatila et al., 2006; drummond et al., 2012) , race was dichotomized for this analysis (black/non-black). for descriptive purposes, a non-binary race variable (asian, black, hispanic, other, white) was reported. self-perceived homelessness was queried, "in the past 6 months, have you ever thought of yourself as homeless?" (yes or no). to obtain cigarette smoking status, participants were asked about lifetime history of smoking ("have you ever smoked at least 100 cigarettes in your entire life?" [yes/no]), and current smoking status ("do you smoke cigarettes now?" [yes/no]). responses to these questions were used to create a "cigarette smoking status" variable (never smoker, former smoker, current smoker). packyears of smoking among former and current smokers was calculated as the number of cigarettes smoked per day times the number of years smoked divided by 20. participants were also asked if they had ever used marijuana or hash (yes/no). to examine injection drug use practices, participants were asked to specify the number of years they had been injecting drugs (continuous) and the specific types of drugs (e.g., heroin, cocaine, methamphetamine) they had injected, smoked, or inhaled in their lifetime (yes/no). types of heroin injected (black tar, white powder, brown powder, other) were assessed among those who reported injecting heroin in the past 6 months. the main reasons for not seeking medical care in the past 6 months, if applicable, were grouped into 6 categories due to small sample sizes (visit not expected to be helpful, avoidance of bad news; fear of hostility, disrespect, or arrest; too embarrassed, ashamed, tired, sleepy, lazy, depressed, ill, weak, sick, or busy to go; transportation issues; no insurance, too expensive; or other). questions also queried whether participants had received professional help for drug or alcohol use in their lifetime (yes/no), and if yes, the type of professional help received (drugs only, alcohol only, both), and the number of times help was received (continuous). respiratory-related symptoms and previous diagnoses were also assessed. j o u r n a l p r e -p r o o f following the interview, participants received pre-test counselling and serologic testing for hiv (uni-gold recombigen, trinity biotech plc, bray, ireland), hcv (oraquick®, orasure technologies, bethlehem, usa) and mtb (quantiferon-tb gold in-tube, qiagen, hilden, germany) infection using commercially-available assays (described elsewhere) (horyniak et al., 2017) . post-test counselling and referrals for care were also provided depending on test results. descriptive statistics were calculated for all variables. for skewed data we report medians and interquartile ranges (iqrs) instead of means. bivariate associations were assessed between old and other covariates using chi-square tests for categorical variables and t-tests or wilcoxon rank sum tests for continuous variables, and simple logistic regression. covariates with a p-value<0.10 in bivariate analysis or supported by the literature as potential risk factors for old were included in multivariable analyses. collinearity was assessed using tolerance (<0.1) and variance inflation (>10) statistics. a backwards stepwise regression procedure was used to determine factors independently associated with old. pack-years smoked, age, and race were kept in models examining correlates of old to control for known risk factors (chatila et al., 2006 of the 573 stahr ii participants, 516 (90.5%) had complete baseline spirometry and interview data for this analysis. fifty-five participants had missing spirometry results because of either recent surgery or participant refusal precluded measurement. most participants were 40 years of age or older (63.6%), male (73.6%), and non-black (90.5%). overall, the mean number of years injecting drugs was 20.7 (standard deviation [sd] 13.3) and the median number of times injected in the past six months was 200 (iqr 78-420). the most common drugs ever injected were heroin (85.6%), methamphetamine (81.4%), and cocaine (64.7%) (lesser used drugs not shown and are available from the authors). the overall prevalence of old was 18.2% (n=94). on bivariate analysis (table 1) , we found that having old was associated with age greater than 40 (p=0.030), black race (p=0.002), higher smoking intensity (median pack-years: 19.5 vs 12.5, p=0.002), and longer duration of injection drug use (mean years: 24.9 vs 19.8, p<0.001). we did not observe statistically significant associations between old and other socio-demographics, type of drug injected, frequency of injecting in the past 6 months, behavioral factors and hiv, hcv or mtb infection. compared to pwid without old (table 2) , a greater proportion of pwid with old reported shortness of breath (p=0.003) or a physician diagnosis of emphysema (p<0.001) or other lung diseases (p=0.036). although 44.7% of pwid with old reported respiratory symptoms, only 10.6% reported physician-diagnosed emphysema. pwid with old were more likely to see a doctor or healthcare provider (p=0.030) and marginally more likely to report healthcare utilization in the past 6 months in terms of emergency department visits (p=0.082) and having healthcare j o u r n a l p r e -p r o o f coverage/insurance (p=0.068). the main reason for not seeking medical care when needed differed between groups, with pwid with old more often reporting that the "visit [was] not expected to be helpful, avoidance of bad news" (p=0.021) and "fear of hostility, disrespect or arrest" (p=0.065). no other respiratory symptoms or illnesses or healthcare utilization variables were associated with old. in multivariable logistic regression analysis adjusting for age, pack years smoked, and black race ( smoking history, with a 6% increase in the odds of old for every 5 pack-years smoked (aor=1.06, 95% ci:1.01, 1.12). this study found the prevalence of old to be 18.2% among pwid in san diego, ca. black race, pack-years smoked, and duration of injection drug use were independently associated with old after adjusting for age. although pwid with old have increased need for healthcare, access to and utilization of health services were not associated with old in this study. the observed prevalence of old in this study is similar to that found among current and former pwid in baltimore, md (16.3%) (drummond et al., 2011) . the prevalence among pwid is much higher than the general population where the prevalence of copd is approximately 3.4% (world health organization (who), 2017). this finding highlights the disparity faced by pwid potentially due to behavioral, economic, and environmental factors. factors that might account for this disparity include a high prevalence of current smokers (clarke et al., 2001) , high rates of hiv (alcabes and friedland, 1995; morris et al., 2011) and mtb infection byrne et al., 2015) , socioeconomic disadvantage (wheaton et al., 2015) , and delayed detection and/or treatment of old due to healthcare stigma or limited access (drummond et al., 2011; neale et al., 2008) . our findings provide further evidence that old disproportionately affects pwid, and a multilevel approach is needed to address the disparity. our findings provide novel information about old among pwid. nearly the entire cohort smoked cigarettes, and consistent with the evidence in a smoking population (jaen diaz et al., 2003) , packyears smoking was independently associated with old status. the fact that smoking was nearly ubiquitous in this cohort was a relative strength of the study in that it allowed for assessment of other correlates of old. black race was found to be independently associated with old. black race has been previously identified as a risk factor for early-onset copd, defined as age <55 years (foreman et al., 2011) . the older age category in this study included those considered for earlyonset copd in the prior study, which may explain the high prevalence of old among blacks in this cohort. higher prevalence of old among blacks may occur because of greater vulnerability to the effects of tobacco smoking (dransfield et al., 2006) . despite smoking fewer cigarettes per day, blacks with emphysema showed similar lung impairment to their white counterparts in the national emphysema treatment trial (chatila et al., 2006) . duration of injection drug use was also independently associated with old status. this comports with the hypothesis that exposure to non-soluble particles in illicit drugs or medications meant for oral use might increase the risk for old, because injection duration is a proxy for cumulative exposure to excipients. the specific drug type or administration route (injected, smoked, or inhaled) was not associated with old. without knowing the type or quantity of contaminants and lifetime frequency of exposure, it is difficult to assess whether specific drugs increase the risk of old. assuming all drugs contain some contaminants, it is also the case that lack of specificity between drugs may mask any association. this hypothesis merits further investigation in a larger sample that more precisely measures the quantities and types of contaminates injected over time. old is often not recognized among pwid in healthcare settings (drummond et al., 2011) , despite our finding no association between old and healthcare variables in this study. less than half of this cohort (45.2%) reported receiving healthcare in the past 6 months and a similar proportion (40.7%) reported not going to see a doctor or healthcare provider even if they perceived the need to go. while 50% of pwid in baltimore had a diagnosis of old or emphysema from a physician (drummond et al., 2011), only 9.6% and 10.6%, respectively, had these diagnoses among those with old in our cohort; however, 44.7% reported shortness of breath (dyspnea) suggesting that old is underdiagnosed among pwid in san diego, ca. dyspnea is one of the most commonly reported symptoms of copd and is part of its pathophysiology (anzueto and miravitlles, 2017) . despite experiencing symptoms indicative of old (i.e. dyspnea), few in this cohort sought primary care. pwid with old were less likely to seek care because they expected their visit to be unhelpful, they would receive bad news, or they would be mistreated. prior studies report less access to healthcare among pwid compared to the general population (chitwood et al., 1999) , which could result in underutilization of primary healthcare services. aside from the obstacles j o u r n a l p r e -p r o o f perceived by pwid, healthcare providers also cite that insufficient education on the "unique and demanding nature of pwids" (lang et al., 2013) as an additional obstacle to care. in addition, pwid may over-utilize emergency department care for injection-related complications (kerr et al., 2004; raven et al., 2009) . a slight trend of over-utilization was seen in those with old; participants only reported on emergency department visits in the past 6 months, which might have attenuated this finding. specialized treatment programs however were heavily utilized with nearly 80% having received substance use treatment in their lifetime. screening for old remains important in this underserved population, and better access to healthcare is crucial. the sars-cov-2 virus responsible for a pandemic of novel coronavirus disease (covid-19) that began in 2019 disproportionately affects older individuals, particularly those with underlying immunosuppressive conditions and lung disease such as copd (chinese center for disease control and prevention, 2020). mortality rates for covid-19 are reportedly higher for those with chronic respiratory diseases (6.3% vs 2.3% overall) (chinese center for disease control and prevention, 2020). our findings suggest that pwid should be considered an additional high-risk group for developing complications from covid-19 due to the high prevalence and underdiagnoses of old. pwid are also thought to be at higher risk of infection, transmission, and complications from the virus due to the high prevalence of homelessness and incarceration, which make it difficult to maintain social distancing and adequate hygiene precautions. more research is needed to understand the associations between covid-19 case outcomes and a history of substance abuse as well as the impact caused by the global pandemic (national institute on drug j o u r n a l p r e -p r o o f abuse (nida), 2020). clinicians need to be aware of the special challenges in caring for pwid and not postpone rehabilitation efforts (ornell et al., 2020) . this study had limitations that should be taken into consideration when interpreting the findings. it did not measure the types and quantities of potential contaminants found in the drugs injected by participants. therefore, duration of injection drug use and frequency of injection in the last 6 months were used as proxies for cumulative exposure to these contaminants. further research is needed to verify whether injecting contaminants caused old. factors such as second-hand smoke, air pollution, occupational dust or fumes, and other lung irritants were not measured, and might contribute to the overall burden of old in this population. as this study was cross-sectional, we cannot infer temporality of the associations. lastly, this study relied on self-report of drug use and healthcare-related factors, potentially leading to misclassification due to recall problems. however, we have no reason to expect that misclassification differed by old status; therefore, misclassification would tend to bias our results toward null findings. old prevalence was high in this cohort of pwid and consistent with findings from pwid elsewhere (drummond et al., 2011) . we also found a high prevalence of previously undiagnosed and untreated old in symptomatic pwid. while prior research found a relationship between injection drug use and old, this study was the first to address whether injection-related factors were associated with old in a cohort made up entirely of pwid. this study is also the first to identify an association between duration of injection drug use and old, although the mechanisms for this association need further exploration. it is unclear whether an accumulation of exposure to excipients in the drugs or another factor contributed to this relationship. future research is needed that more precisely measures exposure to injected particles. smoking also continues to be an important contributor to old in pwid. thus, smoking cessation programs in this population remain extremely pertinent. the study of tuberculosis, aids and hepatitis c risk (stahr ii) was funded by the national institutes of drug abuse (nida) grant #r01 da031074 (pi: richard s. garfein). the study of tuberculosis, aids and hepatitis c risk (stahr ii) was funded by the national institutes of drug abuse (nida) grant #r01 da031074 (pi: richard s. garfein). the funding source had no involvement in the study design, the collection, analysis and interpretation of data or in the writing of the report and in the decision to submit the article for publication. dr. garfein received a grant from the national institutes of health to conduct this study. chitwood, d.d., mcbride, d.c., french, m.t., comerford, m., 1999 injection drug use and human immunodeficiency virus infection pathophysiology of dyspnea in copd mycobacterium tuberculosis infection among persons who inject drugs in smoking duration alone provides stronger risk estimates of chronic obstructive pulmonary disease than pack-years tuberculosis and chronic respiratory disease: a systematic review advanced emphysema in african-american and white patients: do differences exist? pulmonary embolization of microcrystalline cellulose in a lung transplant recipient early-onset chronic obstructive pulmonary disease is associated with female sex, maternal factors, and african american race in the copdgene study embolized crospovidone (poly[n-vinyl-2-pyrrolidone]) in the lungs of intravenous drug users global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease mortality in copd patients according to clinical phenotypes thoracic complications of illicit drug use: an organ system approach intravascular talcosis due to intravenous drug use is an underrecognized cause of pulmonary hypertension the clinical and economic burden of chronic obstructive pulmonary disease in the usa gold or lower limit of normal definition? a comparison with expert-based diagnosis of chronic obstructive pulmonary disease in a prospective cohort-study deaths: leading causes for cross-border injection drug use and hiv and hepatitis c virus seropositivity among people who inject drugs in prevalence of chronic obstructive pulmonary disease and risk factors in smokers and exsmokers high rates of primary care and emergency department use among injection drug users in vancouver the nature and the occurrence of birefringent material in different organs in fatal drug addiction starch and talc emboli in drug addicts' lungs copd in never smokers: results from the population-based burden of obstructive lung disease study qualitative investigation of barriers to accessing care by people who inject drugs in saskatoon, canada: perspectives of service providers hiv and chronic obstructive pulmonary disease: is it worse and why? national heart lung and blood institute covid-19: potential implications for individuals with substance use disorders barriers to accessing generic health and social care services: a qualitative study of injecting drug users pulmonary effects of iv injection of crushed oral tablets: "excipient lung disease gender-specific estimates of copd prevalence: a systematic review and meta-analysis office of disease prevention and health promotion the covid-19 pandemic and its impact on substance use: implications for prevention and treatment long-term follow-up of drug abusers with intravenous talcosis medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks evaluating the impact of mexico's drug policy reforms on people united states: a binational mixed methods research agenda talcosis associated with iv abuse of oral medications: ct findings employment and activity limitations among adults with chronic obstructive pulmonary disease -united states chronic obstructive pulmonary disease (copd) the top 10 causes of death abbreviations: iqr: interquartile range. sd: standard deviation. hcv: hepatitis c virus. hiv: human immunodeficiency virus. mtb: mycobacterium tuberculosis *p-values were based on chi-square test, t-test, or simple logistic regression. a : ≥25% of cell sizes <5 **participants that are "missing" or "n/a" were excluded from the analysis. values are shown for reporting purposes *p-values were based on chi-square test don't know" or "refuse to answer" were excluded from the analysis. values are shown for reporting purposes. a variables are descriptive only and were not considered for multivariable analysis. b treatment includes rehabilitation center the authors are grateful to the study participants for sharing their stories and making this research possible. j o u r n a l p r e -p r o o f key: cord-332579-7950xjmv authors: aravena, j. m.; aceituno, c.; nyhan, k.; shi, k.; vermund, s.; levy, b. r. title: 'drawing on wisdom to cope with adversity:' a systematic review protocol of older adults' mental and psychosocial health during acute respiratory disease propagated-type epidemics and pandemics (covid-19, sars-cov, mers, and influenza). date: 2020-06-07 journal: nan doi: 10.1101/2020.06.04.20122812 sha: doc_id: 332579 cord_uid: 7950xjmv background: mental health has become one of the fundamental priorities during the covid-19 pandemic. situations like physical distancing as well as being constantly tagged as the most vulnerable group could expose older adults to mental and psychosocial burdens. nonetheless, there is little clarity about the impact of the covid-19 pandemic or similar pandemics in the past on the mental illness, wellbeing, and psychosocial health of the older population compared to other age groups. objectives: to describe the patterns of older adults' mental and psychosocial health related to acute respiratory disease propagated-type epidemics and pandemics and to evaluate the differences with how other age groups respond. eligibility criteria: quantitative and qualitative studies evaluating mental illness, wellbeing, or psychosocial health outcomes associated with respiratory propagated epidemics and pandemics exposure or periods (covid-19, sars-cov, mers, and influenza) in people 65 years or older. data source: original articles published until june 1st, 2020, in any language searched in the electronic healthcare and social sciences database: medline, embase, cinahl, psycinfo, scopus, who global literature on coronavirus disease database, china national knowledge infrastructure ( cnki). furthermore, eppi centre's covid-19 living systematic map and the publicly available publication list of the covid-19 living systematic review will be incorporated for preprints and recent covid-19 publications. data extraction: two independent reviewers will extract predefined parameters. the risk of bias will be assessed. data synthesis: data synthesis will be performed according to study type and design, type of epidemic and pandemic, types of outcomes (mental health and psychosocial outcomes), and participant characteristics (e.g., sex, race, age, socioeconomic status, food security, presence of dependency in daily life activities independent/dependent older adults). comparison between sex, race, and other age groups will be performed qualitatively, and quantitatively if enough data is available. the risk of bias and study heterogeneity will be reported for quantitative studies. conclusion: this study will provide information to take actions to address potential mental health difficulties during the covid-19 pandemic in older adults and to understand responses on this age group. furthermore, it will be useful to identify potential groups that are more vulnerable or resilient to the mental-health challenges of the current worldwide pandemic. according to the world health organization (who), mental health is defined as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community". 1 this definition considers several aspects of wellbeing and psychosocial health that are fundamental to maintain an optimal state of health. on the other hand, a relevant part of mental health acknowledges the influence of mental illness in the life of people. mental illness is described by the american psychiatric association (apa) as "health conditions involving changes in emotion, thinking or behavior (or a combination of these). mental illnesses are associated with distress and/or problems functioning in social, work, or family activities." 2 under both definitions, mental health will be influenced by psychosocial situations as well as mental illness. the presence of harmful psychosocial exposures (e.g., loneliness, stigma, social isolation) and an increase in mental illness can be triggered by exposure to natural disasters that affect populational health such as epidemics and pandemics. the recent sars-cov-2 virus (covid-19) outbreak has meant a major threat to the worldwide population in several aspects of health, including mental health and psychosocial health, being an emerging significant challenge and research priority for the global population. 3 a good point of comparison to understand covid-19 present and future mental-health consequences are the past and present experiences observed during epidemics and pandemics outbreaks of similar characteristics. experiences observed in other acute respiratory infections-propagated epidemics and pandemics like sars-cov, mers, and influenza, 4 have left us a precedent of information regarding its substantial impact on people's mental health. situations such as physical distance as one of the most critical measures, uncontrolled exposure to media news about the virus, spread biased or false information, quarantine, isolation, economic hardships, loss of love ones, health consequences, burden, stigma, fear, and anxiety; consequences that have been observed in the present and passed epidemic and pandemic scenarios. 5-8 therefore, these experiences must be carefully considered to generate an early response at an individual and populational level, and to anticipate prospective mental health scenarios. in that regard, recently rogers and cols have observed through a systematic review and meta-analysis of psychiatric and neuropsychiatric consequences associated with coronaviruses infections 9 that among patients with severe sars or mers coronavirus infections, delirium, post-traumatic stress disorder, depression, anxiety, and fatigue are common. moreover, in some preliminary data, covid-19 would present delirium as well as confusion, agitation, depressive symptoms, anxiety, and insomnia. this study set an important precedent about how impactful the coronavirus infection in mental health could be. although, the study did not include the contextual impact of epidemic and pandemics, the full range of psychosocial and wellbeing aspects, and did not compare the mental health among different ages. areas that must be analyzed to understand the full range of influences in mental health and experiences across age groups. a group that could be highly affected are those who have been categorized as high-risk to present severe symptoms or mortality related to the virus such as people with chronic diseases and groups of older adults. covid-19 pandemic has demonstrated to be a critical challenge for older people's physical health. people 65 years or older are the population with the highest risk of mortality associated with covid-19 worldwide. 10 patients with multimorbidity and cardiovascular risk, which increase exponentially after 65 years old, are particularly prone to manifest severe symptoms. [11] [12] [13] thus, many communities have suggested or enforced particularly strict prevention measures for older persons with these characteristics. mental health burden could be an associated consequence of being the population at the highest risk and the exposure to strict social isolation in a pandemic. covid-19 virus and its preventive methods imply important mental health challenges for older people and caregiver's health that must be addressed on time. the classification of "population of high-risk" or in need of shielding could be a source of stress and stigma for older adults, incrementing its social isolation and mental illness symptoms such as anxiety or depression. 14, 15 mental health burden is particularly harmful to older adults with some degree of dependence in daily life activities or multimorbidity because they manifest a higher risk to experience increased physical frailty and worsening of other diseases. [16] [17] [18] [19] [20] if mental illness symptoms and psychosocial difficulties increase in the frail and geriatric older adult' populations during a pandemic period, the rise of dependency, chronic diseases, and emergency visits for causes other than covid-19 would be an enormous collateral impact of the current worldwide pandemic. diverse and often underlooked realities of aging constitute older adulthood, from independent older adults who have not stopped their work activity, caregivers of family members (e.g., other older adults, grandchildren), older people living on their own, or heads of household, to older persons who require the support of a third person, or others who live in long-term care institutions. in this context, older adults' mental health during natural disasters is controversial. some studies about resilience in other contexts have shown that older adults tend to report a higher resilience and more positive outcome than other age groups, 21, 22 and others have estimated that older adults are 2.11 and 1.73 more likely to experience ptsd and adjustment disorder symptoms after natural disasters compared to younger adults, respectively. 23 nevertheless, under normal circumstances, the evidence has shown that older people then to manifest greater levels of wellbeing, lower levels of negative affects, and less distress during their social interactions than other age groups. 24 furthermore, studies have evidenced that older adults are more prone to put attention to positive stimulus than negative ones compared to younger people that present opposite patterns, putting more focus on negative situations. 25, 26 this talks about certain ability to allocate emotional resources that could be fundamental to cope in a more positive manner with unpredictable or emotionally demanding events. 27 despite all of these, there has not yet been a systematic evaluation to understand these patterns in the context of epidemics or pandemics. therefore, although older adults have been constantly classified as a vulnerable population for covid-19, there exists uncertainty about how older adults, compared to other age groups, could respond to a situation that requires an important mental endurance like an epidemic or pandemic. published and ongoing studies, such as roger et al, 9 who have characterized the mental illness and neuropsychiatric consequences associated to coronavirus infections in the general population, and qin and cols who have registered a protocol for a meta-analysis of the impact of covid-19 on the mental wellbeing of elderly population, 28 have focused their reviews just on clinical outcomes related to mental health. in this context, and considering the increasing number of covid-19 related articles, a systematic review targeted to older people mental health considering a full-range of neuropsychiatric, psychiatric, psychosocial, and wellbeing parameters associated with the infection or the contextual impacts related to acute respiratory disease propagated-type epidemics and pandemics, contrasting the results among groups seems pertinent and necessary to fully understand the response and experiences of older adults and other age groups in the context of pandemics. . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 7, 2020. . to comprehend what could be the potential mental health impact associated with respiratory propagated epidemics and pandemics in older adults, and to evaluate the contrast among different age groups it is critical information for the development and planning of policies and programs to address these consequences early and to understand intergenerational differences and similarities in the mental health response to epidemic and pandemics. at the same time, it is fundamental information for the development of interventions and the implementation of policies targeted to change or promote behaviors related to compliance of nonpharmacological measures to prevent the spread of acute respiratory diseases during the context of epidemics and pandemics. considering this background, the main goal of this review is to describe the patterns of older adults' mental health related to acute respiratory disease propagated-type epidemics and pandemics. specifically, this systematic review aims 1) to describe the associations between respiratory propagated epidemic and pandemics and older adult's mental health, 2) to describe the differences between older adults and other age groups in the effects of mental health factors related to acute respiratory disease propagated-type epidemics and pandemics periods in the mental health, 3) to assess the effect of interventions in the older adult's mental health associated to respiratory propagated epidemic and pandemics, and 4) to consider moderators of the impact of pandemics on older adults' mental health. the report of the study will follow the prisma statement for reporting systematic reviews and metaanalyses guidelines. 29 we will select studies that: 1) describe the effects of acute respiratory disease propagated-type epidemics or pandemics on mental health or psychosocial parameters, and 2) include older adults in the sample. quantitative, qualitative, and mixed-method studies will be included in order to consider different aspects of mental health and psychosocial impact. any study evaluating people 60 years or older residing in any setting. research involving people from other age groups (e.g. children, adolescents, adults) additionally to people 60 years or older will be included for analysis. for this review, studies conducted evaluating the impact on mental health during defined acute respiratory disease propagated-type epidemic or pandemic according to the infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care: who guidelines. 2014: 4 sars coronavirus (sars-cov), middle east respiratory syndrome (mers), and influenza/flu (h1n1, h5n1). sars coronavirus 19 (sars-cov-2 or covid-19) will be also included. these viruses are selected because they share similar epidemiological characteristics, where its pathogens can cause large scale outbreaks with high morbidity and mortality. 4 . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 7, 2020. . https://doi.org/10.1101/2020.06.04.20122812 doi: medrxiv preprint for the purpose of this review, any study describing outcomes associated with mental health parameters in older adults will be included. mental health will be understood under the who definition: "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community." 1 for practical operationalization, it will be divided into two main components: mental illness and psychosocial health/wellbeing. examples of mental illness parameters are depression, anxiety, and mood disorders, including intervention studies. studies analyzing parameters such as cognition, dementia, and delirium would be incorporated under the umbrella of mental illness aspects because people with these diagnoses frequently manifest neuropsychiatric symptoms. examples of psychosocial health/wellbeing factors are quality of life, stigma, isolation, and loneliness. studies evaluating the mental illness and psychosocial health/wellbeing parameters of caregivers of older adults will be incorporated. original articles published until june 1st, 2020, in any language searched in the electronic healthcare and social sciences databases: medline (ovid), embase (ovid), cinahl (ebsco), psycinfo (ovid), scopus, who global literature on coronavirus disease database, china national knowledge infrastructure (中国知网 -cnki). because of limitations in database coverage and indexing speed, covid-19 related articles will be identified in two other ways. first, studies in the eppi centre covid-19 living systematic map of the evidence screening review 30 which are tagged with "health impacts," "social/economic impact," or "mental health impacts" will be added to the screening workflow. the eppi centre covid-19 map consists of studies on covid-19, identified in medline and embase, and published in 2019 or later. second, for better coverage of preprints, we will use the publicly available publication list of the covid-19 living systematic review 31 , which retrieves articles from the preprints databases biorxiv and medrxiv and it is continuously updated. because more covid-19 related articles are published week by week, after the title-abstract screening is completed, another search exclusively for covid-19 related-articles will be performed in order to include manuscripts that potentially were published or indexed after the date of the first round of database searches. articles included from this second covid-19 related-articles extraction will be screened in the same fashion as the other studies. an example of the medline search strategy and a search source scheme are described in the supplement section. the search will be adjusted for appropriate controlled vocabulary and syntax in each database. in each database, the search has three elements: queries for the exposure of interest (covid-19 or other respiratory-propagated pandemics), the outcomes of interest (mental health), and the population of interest (older adults). controlled vocabulary and indexing status will be used, where possible, to maximize the retrieval of papers dealing with the older adult population and to minimize the burden of screening papers about other age groups. no specifications about the type of study are included in the search strategy to reduce the risk of missing studies. mental illness terms were included following the dsm-v and the cochrane common mental disorders group search strategies (https://cmd.cochrane.org/). some psychosocial health/wellbeing terms . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 7, 2020. . https://doi.org/10.1101/2020.06.04.20122812 doi: medrxiv preprint were incorporated from other systematic reviews about psychosocial health and wellbeing and based on expert opinion. 32, 33 because an important part of the epidemics and pandemics of these viruses has been experienced in the chinese population, culturally sensible terms to describe mental illness ('impulsive personality disorder,' 'qigong-induced disorders,' 'traveling psychosis,' 'shenjing shuairuo,' and 'neurasthenia') and psychosocial health/wellbeing conditions ('shame,' 'humiliation,' 'low spirits,' 'witchcraft,' 'curses,' 'zou huo ru mo -走火入魔-or qigong deviation -氣功偏差-') were included. 34, 35 studies will be divided into two main categories for its analysis: 1) studies describing the direct effect of virus infection on mental health outcomes, and 2) studies illustrating mental health impact associated with the contextual situation of the epidemic or pandemic (e.g. quarantines, social distancing, isolation). the results from all the database searches will be collated in endnote and deduplicated by the cushing/whitney medical library cross-departmental team. the deduplicated results will be uploaded to covidence, an online platform for evidence synthesis. reviewers (ja and ca) will screen articles at the title abstract level, discarding only those articles which are evidently off-target. the full-text screening will also take place in covidence. two independent screeners will vote on each article; disagreements will be solved by consensus or third-party adjudication (bl). articles in english and spanish language will be manipulated by two reviewers (ja and ca). articles in other languages will be handled by two research members (ks and sv). two independent reviewers will perform data extraction using a prespecified data abstraction form designed for this study. the data abstraction form will be pilot-tested on five randomly-selected studies and refined accordingly. data extraction will include characteristics of the study (e.g. country, data source, data collection date, year), methods (e.g. study design, sample characteristics, outcome measurement), and results. extracted studies will be tagged according to the type of outcome they are describing: a) virus infection mental health-related outcomes, b) epidemic or pandemic context mental health-related outcomes, or c) both types of outcomes. data will be entered in a duplicated google questionnaire specifically designed for the study. every researcher will enter the data on independent questionnaires. qualitative and mixed-method studies will be described. quantitative studies will be included for assessment of the risk of bias. two reviewers will independently assess the internal validity of each included quantitative study. study risk of bias will be categorized as low risk of bias, some concerns of bias, and high risk of bias. in the case of observational studies, bias will be evaluated following the next standards: 1) ttype of study design, 2) temporality of the evaluation of the exposure: concordance in the evaluation timing of the impact of the epidemic/pandemic episode with the study goals, 3) outcome evaluation: evaluation of the outcome with standardized and defined measurement instrument or methods, 4) adjusted analysis: the . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 7, 2020. . inclusion of an adjusted analysis of the main outcome considering relevant variables. for this review, analyses adjusting for age, sex, and pre-existing medical conditions or functional performance will be considered acceptable. 5) attrition bias: for cohort studies, 30% of loss of follow-up will be considered as acceptable. for intervention studies evaluating efficacy or effectiveness in one or more mental health and psychosocial health as a primary outcome, the criteria to evaluate the risk of bias will be: 1) type of study design, 2) bias arising from the randomization process, 3) bias due to deviations from intended interventions, 4) bias due to missing outcome data, 5) bias in measurement of the outcome, and 6) bias in selection of the reported result. studies incorporating mental health parameters as secondary outcomes will be included for description yet will be considered at a high risk of bias. observational study's risk of bias was designed considering strobe and the ahrq methods guidelines. 36, 37 intervention study risk of bias follows the cochrane handbook for systematic reviews. 38 in the case of quantitative studies, for the continuous variables related to mental health, because of the variety of scores and outcomes produced by the diverse measurement scales, measures such as frequency and prevalence of symptoms and diagnosis (%) or adjusted prevalence, mean and standard deviation (sd) of total scores will be used. in comparison studies, mean differences (md), proportions (%), standardized mean differences (smd), b coefficient, and standardized error, with 95% confidence intervals (ci) for continuous outcomes will be included. dichotomous outcomes such as adjusted risk ratios (rr), odds ratio (or), and hazard ratio (hr) with 95% cis will be considered. unadjusted and adjusted results will be extracted. these measures will be extracted for people 65 years older, other age groups described in every article, sex, and race if it is included. for treatment, in the case of cluster randomized trials or interventions delivered in groups, the unit of analysis will be the cluster. for interventions including individuals, the unit of analysis will be the subjects. in the case of rcts, we will seek data irrespective of compliance, in order to allow the intention to treat analysis. for cohort studies, we will make a qualitative evaluation of every study to identify if the missed data lead to a bias in the result. we will judge heterogeneity among studies (the type of study design, inclusion criteria, type of exposure/intervention, outcome measurement) during the qualitative synthesis of the data. additionally, statistical heterogeneity was evaluated using the i2 statistics, classifying no heterogeneity (<25%), low (25-49%), moderate (50-74%), and high heterogeneity (equal or >75%). we will decide on the appropriateness of conducting a meta-analysis based on qualitative and quantitative information. . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 7, 2020. . to avoid publication bias, we will search for published studies in multiple databases which include published journal articles and preprints. every study will be evaluated and discussed considering its bias and strengths for inclusion in the review. we will report the number of articles that do not fulfill requirements. for studies with two documents (preprint and journal publication), the official publication will be considered. in the studies with more than one analysis, the most tailored to our study aim publication will be considered. funnel plots will be performed for publication bias if we have enough data. a descriptive analysis of the included studies will be conducted through a flow diagram describing the number of included and excluded studies, exclusion reasons (e.g. older population not included, different epidemic/pandemic exposure, non-mental health outcomes), and the final number of selected studies. the results will be synthesized in tables and figures which may include the following. table 1 will display study characteristics (country, data source, data collection dates, year, type of study/study design, total sample by group, follow-up, participants basic characteristics, exposed epidemic/pandemic), table 2 outcome measurement (name of the outcomes, type of outcome -mental health/psychosocial-, outcome measurement, and results). a third table will describe intervention studies and its results (country, data collection and intervention delivery dates, year, type of research design, inclusion/exclusion criteria, description of the intervention, exposed epidemic/pandemic, sample by group, intervention/control characteristics, outcome measurement, results). data synthesis will be performed according to study type and design, type of epidemic and pandemic, types of outcomes (mental health and psychosocial outcomes), and participant characteristics (sex, race, comparison to other age groups, independent/dependent older adults). comparison between sex, race, and other age groups will be performed qualitatively, and quantitatively if the data available is enough. the risk of bias and heterogeneity will be reported for quantitative studies published in journal articles or preprints. if the available data is enough, we plan to conduct a subgroup analysis considering the following categories: type of study design, type of outcome measured, type of epidemic, or pandemic. if the data available is enough quantitative comparison of age groups will be conducted. we will perform a sensitivity analysis based on studies with a low risk of bias. mental health understood as a state of wellbeing has been a topic of special discussion and concern in the health and medical sciences because of its impact on the people's lives and the high burden for societies. in the context of large-scale natural disasters such as epidemics and pandemics, mental health would be highly determined by the manifestation of mental illnesses, neuropsychiatric conditions, and psychosocial aspects that will influence people's health and their capacity to cope with a mentally demanding . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june 7, 2020. . situation. 3 this topic takes major relevance in the current scenario triggered by the covid-19 worldwide pandemic, where there exist and evident relevance of understanding the patterns of mental coping and adaptation of the global population. in our actual society, people 65 years or older have been increasingly exposed to situations that are a threat to their mental health such as isolation and loneliness. 39 at the same time, the constant exposure to 'ageism' or negative stereotypes associated with the aging as well as classifications of 'population of highrisk' or in need of shielding could be an important source of stress, fear, and segregation. nevertheless, even in the presence of these negative ideas about older people, the evidence has been uncertain about older adult's mental resilience and adaptation compared to other age groups in front of natural disasters. under normal situations, older adults have shown that they report higher general wellbeing and satisfaction with social connection than the younger groups. 24 to our knowledge, this is the first systematic review evaluating the older adult's mental and psychosocial health compared to other age groups in the context of acute respiratory disease epidemics and pandemics. therefore, to understand how mental and psychosocial health could change during epidemics and pandemics of similar characteristics than covid-19 in older adults in contrast to other ages will be critical to elucidate the natural emergence of mental and behavioral coping mechanisms across life-stages, and to comprehend the major necessities referred by these groups. this information will be critical for the design of interventions and policies oriented to increment positive behavioral changes across age population groups and to promote the adherence to nonpharmacological preventive measures during epidemics and pandemics. promoting mental health: concepts, emerging evidence, practice (summary report). geneva: world health organization what is mental illness? washington: american psychiatric association multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care: who guidelines. geneva: world health organization, 2014. 5.-shimizu k. 2019-ncov, fake news, and racism mental health status of people isolated due to middle east respiratory syndrome stress and psychological distress among sars survivors 1 year after the outbreak long-term psychiatric morbidities among sars survivors psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid-19 pandemic older adults presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region out-of-hospital cardiac arrest during the covid-19 outbreak in italy active coping shields against negative aging self-stereotypes contributing to psychiatric conditions experiences of ageism and the mental health of older adults moderate to severe depressive symptoms and rehabilitation outcome in older adults with hip fracture factors mediating the effects of a depression intervention on functional disability in older african americans psychosocial and socioeconomic determinants of cardiovascular mortality in eastern europe: a multicentre prospective cohort study the relationship of psychosocial factors to total mortality among older japanese-american men: the honolulu heart program are older people more vulnerable to long-term impacts of disasters? individual, community, and national resiliencies and age: are older people less resilient than younger individuals? mental health implications for older adults after natural disasters--a systematic review and meta-analysis social and emotional aging aging and attentional biases for emotional faces unpleasant situations elicit different emotional responses in younger and older adults selective optimization with compensation a meta-analysis of the impact of covid-19 on the mental wellbeing of elderly population the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration systematic screening and assessment of psychosocial well-being and care needs of people with cancer. cochrane database syst rev eppi centre covid-19: a living systematic map of the evidence screening review what is the impact on health and wellbeing of interventions that foster respect and social inclusion in community-residing older adults? a systematic review of quantitative and qualitative studies challenging mental health related stigma in china: systematic review and meta-analysis. i. interventions among the general public chinese classification of mental disorders (ccmd-3): towards integration in international classification the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies cochrane handbook for systematic reviews of interventions version 6 available from www.training.cochrane.org/handbook social isolation and loneliness in older adults-a mental health/public health challenge key: cord-333959-8ermzrmr authors: gao, zan; lee, jung eun; mcdonough, daniel j.; albers, callie title: virtual reality exercise as a coping strategy for health and wellness promotion in older adults during the covid-19 pandemic date: 2020-06-25 journal: j clin med doi: 10.3390/jcm9061986 sha: doc_id: 333959 cord_uid: 8ermzrmr the december 2019 covid-19 outbreak in china has led to worldwide quarantine, as recommended by local governments and the world health organization. particularly affected are older adults (i.e., those aged ≥ 65 years) who are at elevated risk for various adverse health outcomes, including declines in motor ability and physical activity (pa) participation, increased obesity, impaired cognition, and various psychological disorders. thus, given the secular increases in the older adult population, novel and effective intervention strategies are necessary to improve physical activity behaviors and health in this population. virtual reality (vr)-integrated exercise is a promising intervention strategy, which has been utilized in healthcare fields like stroke rehabilitation and psychotherapy. therefore, the purpose of this editorial is to synthesize recent research examining the efficacy and effectiveness of vr exercise in the promotion of favorable health outcomes among the older adults. results indicate the application of vr exercise to facilitate improved physical outcomes (e.g., enhanced motor ability, reduced obesity), cognition and psychological outcomes. vr exercise has also been observed to be an effective intervention strategy for fall prevention in this population. future research should employ more rigorous research designs to allow for a more robust quantitative synthesis of the effect of vr exercise on the preceding outcomes to elucidate which type(s) of vr-based pa interventions are most effective in promoting improved health outcomes among older adults. findings from this study will better inform the development of technology-savvy pa programs for wellness promotion in older adults who practice social distancing and exercise from home under the unprecedented global health crisis. the december 2019 novel coronavirus outbreak in china has infected more than 9.97 million people and resulted in over 480,000 deaths worldwide [1] , which has led to global quarantine as recommended by local governments and the world health organization. indeed, quarantine can help mitigate individuals' exposure to covid-19 and, therefore, minimize the risk of contracting the virus. however, the quarantine orders have created many national challenges that have had profound impacts on financial, physical, psychological, and emotional health among people of all ages [2, 3] . particularly affected are older adults (i.e., those 65 years and older) who are more likely to suffer from serious covid-19 illness. in fact, 8 out of 10 deaths reported in the u.s. have been in older adults [4] . this may be partially attributed to compromised immune systems with age, making it harder to fight off coronavirus diseases and infection. in the past 30 years, researchers have found regular physical activity (pa) participation to have beneficial effects on older adults' health and wellbeing [5, 6] . from 2020 to 2030, the number of older adults in the u.s. is expected to increase from 56 million to 74 million, which amounts to one in five americans [7] . this generation has higher rates of chronic disease and disability compared to any other generation [8] , and studies have shown that the four most common poor health conditions seen in older adults are decreased motor ability, increased obesity, impaired cognition, and psychological disorders, which lead to a lower quality of life [9, 10] . for example, an inactive lifestyle, along with a natural decline in physiological markers with age, contributes to a loss in muscle strength and balance [9] , and, through deterioration of motor abilities, older adults' risk for falls and fractures increases [8] . furthermore, the prevalence of obesity in older adults puts them not only at higher risk for developing cardiovascular diseases but also acquiring a disability and remaining physically impaired [10] . cognitive impairment is a health concern that makes it difficult for older adults to live independently and also places them at a higher risk for falls [9] . for instance, it has been shown that older adults with cognitive impairment are twice as likely to have a fall compared to older adults without impaired cognition [9] . lastly, depression, anxiety disorder, and dementia are the most prevalent psychological problems in older adults [10] . it is dismaying that 21% of older adults report experiencing symptoms of anxiety that contribute to significant distress, lower quality of life, and a higher chance of having depression [11] . thus, it is important to develop and implement effective intervention strategies that can prevent or reverse these adverse health outcomes in order to improve older adults' quality of life. given that many are experiencing stressful life challenges under the covid-19 pandemic crisis, it is imperative to develop innovative and effective pa intervention programs that reduce stress and promote health and wellbeing in older adults [12, 13] . one innovative intervention strategy that has shown promise in the healthcare field is virtual reality (vr)-based pa interventions [14] . however, reviews investigating the effectiveness of vr in the promotion of better health outcomes in older adults are scarce [15] . therefore, the purpose of this editorial was to determine the efficacy and effectiveness of vr exercise in aiding healthy older adults to have increased motor ability, reduced obesity, improved cognition, and better psychological outcomes. as known, vr is a new and engaging technology that has received limited research with regards to health promotion in older adults. the findings of this paper may provide healthcare practitioners and researchers with valuable information on the utility of vr that they could apply in community and home settings under challenging circumstances. one intervention strategy which has shown promise for promoting healthy aging among older adults is vr-integrated exercise [16, 17] . vr exercise is a novel and innovative technology, which immerses individuals in a computer-generated, multi-sensory, three-dimensional world wherein they interact with the virtual environment using either a headset and/or exercise equipment [18] [19] [20] . vr technology can be dichotomized by immersion (i.e., immersive and non-immersive). immersive vr typically requires the use of a head-mounted display (e.g., oculus rift, menlo park, ca, usa) or an entire room display which encloses the user (e.g., cave automatic virtual environment (cave)) [21] . non-immersive vr, on the other hand, offers users a computer-generated world which typically uses a desktop or projector [18] . examples of non-immersive vr include the nintendo wii switch and the xbox 360 kinect, which are often more cost-effective and better for use in the home setting compared to immersive vr equipment [22] [23] [24] [25] [26] [27] [28] . vr technology is currently used in a variety of health field areas, such as psychotherapy and stroke rehabilitation [14] , and has been shown to be effective in improving balance and overall health and promoting weight loss in older adults [9, 14, 16, 29] . for instance, vr has been implemented within therapeutic programs for phobias related to height and public speaking, in which patients were immersed into an environment where they progressively worked on their fears [30, 31] . furthermore, vr exercise has been successfully used within rehabilitation settings for motor learning following a stroke, which led to patients' increased brain plasticity [17, 32] . vr has also been shown to be effective in exercise promotion, which led to multiple health benefits, including reduced obesity and anxiety, as well as improved cognition [9, 16, 29] . additionally, studies have suggested that vr consisting of cognitive behavioral treatment could aid in weight loss and alleviation of psychological disorders [11, 33] . along with all these health benefits, vr also presents itself as a potential candidate for promoting leisure activity. participants who were immersed into nature via vr while using a traditional exercise bike reported that it was much more enjoyable than traditional exercise biking alone [34] . the application of vr has been shown to have positive benefits on older adults' physical and mental health; however, these findings are still limited. therefore, more innovative and technology-savvy interventions need to be employed to help control obesity rates and poor health concerns in this population. due to aging, older adults naturally exhibit decreased motor ability, including compromised coordination, balance, muscular strength, and speed [22] . in general, vr exercise has demonstrated positive effects on the preceding components of older adults' motor ability by engaging older adults' motor skills and promoting sensorimotor learning and cortical plasticity to improve their motor ability. for example, a home-based vr intervention, which used an xbox 360 gaming console and your shape fitness evolved software and consisted of tai chi and yoga exercise programs, indicated positive effects of vr exercise on older adults' motor ability outcomes, such as hip muscle strength and balance control [22] . furthermore, significantly improved muscle strength as assessed by hand grip dynamometry and an arm curl test and improved balance measured by a postural sway test were evident in another study that implemented a three-dimensional vr kayak program [9] . while these two studies had muscular strength as an outcome measure which significantly improved, one looked at hip strength and the other used grip strength. due to this difference, the effect of vr on targeted muscle strength is inconclusive, and more research is needed in the future. rehabilitation methods (e.g., therapeutic exercise) have been employed extensively with the aim of improving older adults' motor ability. however, current rehabilitation methods with this aim often fail to account for the characteristics and needs of patients and, consequently, the patients often do not see rehabilitative success in the real world [35] . findings suggest that the learning of new skills and activation of brain plasticity are enriched when a patient is placed in an appropriate environment that resembles real life [35] . for example, in a recent study that employed an immersive vr intervention (the cave), the scenario placed participants in an apple orchard, where they had to reach out as quickly as possible to grab the virtual apple then place it in the basket to score points [35] . the results demonstrated a gradual increase in scores and improved postural stability, which is an important component of motor ability. overall, existing vr exercise programs were all shown to significantly improve older adults' motor ability through increased balance. with improved balance control, older adults can achieve better health outcomes, such as reduced falls. however, research examining the effect of vr exercise on strengthening the larger musculature (e.g., hips, arms) is needed to determine if it is an effective intervention strategy for improving motor ability in older adults. studies show that over one third of older adults are obese, and the prevalence is steadily increasing [36] . this calls for effective and innovative intervention strategies to manage and prevent obesity in older adults. while vr exercise's utility for weight loss and control is relatively new, it is well established that technology-based interventions targeting weight loss are scalable and cost-effective [37] . for example, manzoni and colleagues [33] and thomas and bond [37] examined the efficacy of vr-integrated cognitive-behavioral treatment (cbt) for reducing obesity among older adults. cbt is a type of psychotherapy commonly used to help treat eating disorders, which aims to change individuals' thinking patterns using a goal-oriented approach [37] , whereas vr-integrated cbt aims to teach problem-solving techniques and reduce body weight and problematic eating. manzoni and colleagues [33] utilized the neurovr open space software to station participants in real-world environments where they had to handle situations of daily living, such as working out at a gym, shopping at the grocery store, or dining at a restaurant. the researchers observed at one-year follow up that the vr group displayed consistent weight loss maintenance, whereas the control group gained back most of their lost weight. additionally, thomas and bond [25] conducted research using a vr-based behavioral weight loss program (second life virtual world), in which participants learned to navigate difficult situations. although the sample size in this study was small, the results suggest that vr may be more beneficial for long-term weight loss compared to traditional, face-to-face treatments. beyond vr-integrated cbt's implications for weight loss, vr may also encourage weight loss indirectly through the promotion of pa. wii fit, for example, is readily accessible, affordable, and motivating for older adults and has shown promise for promoting pa and weight loss in this population. for example, one study observed wii fit sports to increase daily energy expenditure and time spent in moderate to vigorous pa in older adults at risk for obesity [38] . although no significant correlations could be made due to the small sample size, the findings showed modest weight loss and enjoyment among participants while they engaged in the exercise, which may be promising for long-term adherence [38] . while vr-integrated cbt studies [33, 37] have reported chronic effects on weight loss as compared to controls, the preceding wii fit study [38] primarily targeted participants' attitudes toward pa, which indicated vr exercise to be more a more engaging form of exercise compared to traditional exercise. overall, findings suggest vr-integrated cbt is effective for assisting older adults in weight loss maintenance for months after the cessation of the intervention programs [33, 37] . further, wii fit sports games increased participants' pa levels and pa-related enjoyment following an 8-week program. notably, however, given the small sample size and short intervention length, these findings warrant further empirical support [38] . vr-based exercise interventions like cbt and wii fit exercise programs are highly accessible, cost-effective, and motivating strategies, which show promise for obesity reduction in older adults. however, further research addressing the preceding research gaps are needed. declines in cognitive ability is a part of normal aging and may eventually develop into cognitive disorders [11] . vr has shown promise for improving cognitive functions, such as executive function, visuospatial processing, and memory [9] . specifically, vr interventions like immersive memory training and a three-dimensional kayaking exercise program significantly improved older adults' shortand long-term memory [9, 39] . further, another study observed a 6-week vr kayaking program to significantly improve cognitive older adults' cognitive functioning, including executive functions, conceptual thinking, concentration, attention, visuoconstructive skills, working memory, mathematical calculations, language, and orientation [9] . results indicated these cognitive domains to significantly improve from pre-to post-intervention only in the vr experimental group. another study indicated that vr exercise may also be a promising tool for improving cognitive functioning using vr memory training [39] . in this study, participants in the vr group used a head-mounted display and a joystick to maneuver along city paths within the immersive vr environment and were then asked to memorize and recall those paths. findings from the neuropsychological tests showed significant improvements in overall cognitive functioning and verbal memory. notably, only small, non-significant improvements in executive functioning and visuospatial processing were observed. this may be attributable to some of the tests requiring drawing pictures, and not all participants may have had the natural drawing abilities needed to adequately perform on these tests. although these two studies [9, 39] targeted similar cognitive domains, such as executive function, memory, and visuoconstruction/visuospatial skills, as health outcomes, the two differed in terms of the level of improvement in such outcomes. possible explanations for these differences include different samples and intervention components and inconsistency in the employed cognitive domain tests. therefore, more research with consistent intervention components and testing is warranted to determine if vr exercise truly facilitates significant improvements in these cognitive functions. however, memory was observed to significantly improve in both studies. in sum, vr exercise shows promise for improving cognitive functioning and memory in older adults as well as other cognitive outcomes, but further research is warranted to confirm this. with an increase in cognitive function and ability, older adults will experience improved mental health outcomes and exhibit a lower risk for falls. findings indicate that over 21% of older adults experience anxiety symptoms [11] . the use of vr exercise has shown promise for decreasing anxiety and depression in older adults, which may translate to improved overall mental health outcomes in this population [29] . this preliminary review identifies and examines five eligible studies, which reported that vr exercise programs can relieve feelings of anxiety and depression and increase enjoyment and daily energy levels [29] . for example, one study had 54 older female participants undergo either a group-based exercise program or a vr-based tai chi exercise program. the investigators observed the vr exercise group to report significantly greater decreases in anxiety and depression compared to the traditional exercise program. on the other hand, one study not included in the review utilized the geriatric depression scale and observed no significant differences in these outcomes following a vr-based, wii fit balance intervention [40] . there is also the possibility of using vr with cbt to decrease anxiety in older adults. in another preliminary review, which examined three meta-analyses to determine the potential of vr-enhanced cbt in treating anxiety disorders in older adults [11] , the authors revealed that the number of cbt randomized controlled trials in older adults was half that of studies on younger adults and none have been designed to explore vr-enhanced cbt for adults 65 and older. since vr-enhanced cbt has been successful in treating anxiety disorders in younger adults, grenier et al. [11] proposed a pilot study that investigates the efficacy of an 8-week cbt program which integrates vr. the treatment will teach participants how to cope with the triggers and episodes of anxiety. in sum, vr has been purported as a promising tool for facilitating better mental health outcomes in older adults when combined with cbt and for its ability to relieve feelings of anxiety and depression. however, more supporting empirical evidence is needed in this field of inquiry, considering that only one empirical study and two preliminary reviews were identified. both the wii fit and vr-based tai chi studies used anxiety and depression as the mental health outcomes. however, compared to controls, only the vr-based tai chi pa program prompted significant improvements in feelings of anxiety and depression. conversely, the wii fit program, compared to the control group, observed some improvement in feelings of anxiety and depression, though statistical significance was not reached for either outcome. differences in outcomes between studies may be explained by differences in modality, duration, intensity, and/or frequency of the exercise programs. thus, more research is needed to discern the effectiveness of vr exercise in the promotion of improved psychological outcomes in older adults, such as depression and anxiety. approximately 30% of older adults experience at least one fall each year, and those that have a fallen are at increased risk of falling again [41] . older adults who have a history of falls tend to have significantly lower muscle strength in their hip musculature [22] . pa has been shown to improve muscular strength and balance, and, therefore, reduce the risk of falls among the elderly [42] . research has identified two main types of vr-based exercises that are related to older adults' reduced fall rates: vr-based treadmill exercises and wii fit exercises. to date, two studies have examined the effects of vr-based treadmill exercise, both of which found significant decreases in the incidence of falls in the vr training group compared with a traditional treadmill exercise group [43, 44] . with regard to wii fit exercise, studies suggested that both immersive and non-immersive wii fit exercise can decrease older adults' risk for falls by improving their motor functioning, such as by improving their center of balance [14, 45] . chiarovano et al. [45] used immersive vr (oculus rift dk2 vr headset) in conjunction with the wii fit balance board and the balancerite application, while other researchers [14] used a non-immersive nintendo wii fit exercise wherein participants played ski slalom, table tile , and balance bubble. findings suggested that, through having older adults perform the dual task of working on postural stability as well as respond to powerful visual stimuli, older adults increased their capacity for attention demands and decreased their risk of falls. these findings support the effectiveness of vr exercise interventions in reducing fall rates and improving balance in older adults. thus, the use of vr exercise training can be a more effective fall prevention tool compared to treadmill exercise training alone through increased balance and speed and the teaching of reactive strategies. it has been reported that age-related cognitive declines increase older adults' risk for falls, which are a major contributor to morbidity and mortality rates in this population [43] . for instance, 60-80% of older adults who have cognitive impairments report at least one a year. these falls often occur due to compromised executive functioning and, therefore, navigation, causing them to trip over obstacles and basic objects [43] . therefore, improving cognition is of paramount importance for reducing the risk of falls and improving quality of life in older adults. one study [43] that examined the use of vr treadmill exercise as an intervention strategy to reduce falls also targeted cognitive functioning. in detail, the vr simulation was composed of real-life situations and challenges, such as obstacles and distractions, in order to enhance older adults' cognitive functioning (i.e., executive function and attention) while walking. executive functioning and attention play a major role in obstacle clearance and are, therefore, essential in the prevention of falls. the findings from this study indicate that treadmill training concurrent with vr exercise is more effective than treadmill exercise alone for improving cognitive functioning and, therefore, reducing falls among older adults. in addition, findings from two other studies [22, 45] showed that both immersive and non-immersive vr treadmill exercise and the wii balance board were effective for reducing rates of falls in older adults by lessening the severity of falls and teaching more effective fall prevention strategies. fear of falling in older adults entails an intense fear of standing or walking. the prevalence of this phenomenon is 24-55% in older adults and up to 92% in older adults who have experienced at least one fall [46] . serious consequences come with fear of falling, including decreased social interactions, physical injury, reduced quality of life, and accidental death, which further supports the need for effective exercise-based therapeutic interventions. current available treatments include traditional exercise interventions and protectors worn at the hip. however, these methods have only shown minimal effects and do not consider the psychological aspect of the fear of falling [46] . that said, vr exercise has shown promise for addressing the fear of falling in older adults. for instance, levy and colleagues [46] examined the effect of immersive vr games in participants who reported having a fear of falling, such as fighting off enemies by moving their hands and washing a window with foam. a questionnaire regarding the activities of daily life (e.g., getting out of bed, putting on clothes) demonstrated significant improvements in older adults' fear of falling after the vr exercise intervention compared to a control group. these findings showed promise for the utility of vr-based exercise interventions for successfully reducing older adults' fear of falling and, thus, improving their motor ability and overall quality of life. noteworthy is the fact that this study had a small sample size and, therefore, more research is needed to further support these findings. vr is a promising tool for effective treatment in the rehabilitation setting. by implementing non-immersive vr on the treadmill or immersing a patient into a realistic environment, such as a city or park setting with a head-mounted display or within the cave, physical and occupational therapy sessions can be enhanced, subsequently increasing the chance of successful adaptation to the real world [35] . participants also found that exercising on a stationary bike with vr that immersed them into nature was significantly more enjoyable than traditional biking without vr [34, 47] . since vr was found to be an engaging activity for older adults, this could lead to better adherence to a rehabilitation program, which in turn may lead to better health outcomes in patients. vr exercise interventions also include home-based interventions, such as vr-based tai chi and yoga programs [22] . the use of at-home rehabilitation techniques would lead to more effective rehabilitation, as older adults can receive real-time feedback from home by using vr during times in which they are not at the clinic. this may be especially important during the covid-19 pandemic, as older adults may wish to remain quarantined in their homes given their increased risk of contracting the virus. home-based vr exercise interventions can also help relieve stress from healthcare services with the surge of baby boomers reaching older age. this reduction in overscheduling for physical and occupational therapists may allow them to provide better care during their sessions. further, during in-person appointments, vr exercise can be supplemented to increase patients' exercise motivation and enjoyment. though some studies support vr exercise's effectiveness in promoting better health outcomes among older adults, they are not without limitations. for example, older adults' success in using vr-integrated exercise may be limited by perceptual, mental, and physical declines that naturally come with age [10] . thus, these individuals may be discouraged from participating in vr exercise interventions and may negatively impact retention rates in such studies. second, many of the included studies had small sample sizes (≤30 participants), which may have affected the external validity of the findings. additionally, the implemented vr exercise interventions varied greatly, in that immersive and non-immersive vr-integrated exercise equipment and vr-enhanced cbt, among other intervention strategies, were used across studies. this renders it difficult to confidently conclude that all vr exercise modalities and programs can facilitate better health outcomes in older adults. as such, we recommend more research be conducted in this area of inquiry to better discern which vr interventions are the most effective among older adults. future studies should address the research design issue observed in most studies by increasing sample sizes [48] . more research focusing on the mental health problems seen in older adults is also needed. in addition, there is a need for more research investigating the effectiveness of vr exercise programs on older adults' weight loss, as vr exercise has only recently been applied as a means for weight control. in addition, examining the motivation to maintain or increase pa participation [49] during leisure time among older adults using vr at homes or community centers is warranted. finally, as stated above, health professionals need to determine which specific types of vr are most effective for improving health outcomes in healthy older adults. this may include determining factors, such as modality, intensity, duration, and frequency, as well as vr exercise setting(s) most suitable for older adults. the purpose of this paper was to explore the potential of using vr exercise as a coping strategy for health and wellness promotion in older adults during the covid-19 pandemic. vr is an emerging technology that is a valuable tool for healthy aging in older adults. empirical studies support that vr leads to improvements, although not always significant, in the four most common health concerns seen in older adults: decreased motor ability, increased obesity, impaired cognition, and various psychological disorders. across studies, findings demonstrate that vr exercise interventions lead to significant improvements in older adults' balance and memory, which contribute to a lower risk for falls. given the secular increases in the older adult population, healthcare services must be equipped to meet their specific health needs. indeed, chronic disease and disability prevalence in this generation of older adults can be compared to any other generation and vr is purported to be a valuable intervention tool and strategy in rehabilitation and/or home settings in this population. integrating vr into physical and occupational therapy may serve to minimize stress in clinicians and patients by allowing patients to engage in vr-based rehabilitation from home. further, compared to traditional exercise intervention strategies, vr exercise has been shown to be more effective in leading to more significant and faster recoveries. this may be partially attributed to vr's engaging nature, making it well tolerated by older adults. additionally, vr exercise interventions may have multiple health benefits pertaining to older adults' motor ability, obesity status, cognition, and psychological outcomes. however, much more research is needed to investigate this novel treatment strategy among older adults. it is especially imperative for health professionals to deliver exercise programs remotely due to social distancing under covid-19 and for possible future pandemic crises. author contributions: z.g. conceived the study and drafted the manuscript; j.e.l., d.j.m. and c.a. helped draft the manuscript. all authors agree with the order of presentation of the 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three-dimensional display of a field of moving dots or at a virtual reality scene fear of falling: efficacy of virtual reality associated with serious games in elderly people comparison of college students' blood pressure, perceived exertion, and psychosocial outcomes during virtual reality, exergaming, and traditional exercise: an exploratory study. games for health the effect of gamification through a virtual reality on preoperative anxiety in pediatric patients undergoing general anesthesia: a prospective, randomized, and controlled trial group dynamics motivation to increase exercise intensity with a virtual partner key: cord-034443-rptylxmw authors: morley, john e. title: covid-19 — the long road to recovery date: 2020-10-05 journal: j nutr health aging doi: 10.1007/s12603-020-1497-y sha: doc_id: 34443 cord_uid: rptylxmw nan the long term effects of covid-19 older persons who underwent lockdown with the covid-19 pandemic are likely to have decreased their exercise and developed sarcopenia. during this period health professionals and public health professionals failed to increase public awareness to reduce the development of sarcopenia and frailty (11) (12) (13) . the marked increase in inflammatory cytokines in covid-19 leads to an acceleration of muscle destruction and cachexia (14) . the loss of muscle can be further aggravated by immobilization during hospitalization, which is even greater if the persons received artificial ventilation. all persons with covid-19 should have bioavailable 25(oh) vitamin d measured (15) as during lockdown lack of sunlight can markedly reduce vitamin d in covid-19 patients (16) . in addition to the muscle loss in "long covid", the extended time at bedrest can lead to postural hypotension (17) . also, vasculitis during covid-19 can lead to baroceptor damage editorial covid-19 -the long road to recovery resulting in autonomic dysregulation (18) . further, the increase in cytokines can damage the autonomic nervous system (19) . postural orthostatic tachycardia has also been observed in "long covid." these factors can lead to an increase in falls, possibly associated with syncope. persons who fall frequently or who are unsteady are likely to develop "fear of falling" (20) . because of the increase in coagulopathy, persons with covid-19 are at risk for having a stroke. these patients require neurorehabilitation to a similar degree of other persons with a cerebral vascular accident (21) . delirium is not uncommon in acute covid-19. any precipitating causes should be avoided. persons with delirium should not be physically restrained nor receive antipsychotics nor long acting benzodiazepines (22, 23) . delirium is associated with an increased mortality rate over the year following hospital admission (24) . persons with delirium show frontal hypometabolism and cerebellar hypermetabolism (25) . delirium should be screened for daily using either the confusion assessment method (cam) or the 4-at rapid clinical test for delirium (26) (27) (28) (29) . cognitive impairment is not unusual following covid-19. besides the possibility of increased microthrombi in the brain, cerebral micro-structural changes have been identified in the hippocampus and multiple other brain areas (30) . these changes were correlated with deterioration in cognition. persons with cognitive impairment tend to describe a "brain fog" associated with fluctuations in behavior (31) . fatigue, while common, tends to fluctuate. acute covid-19 is associated with renal tubular injury and focal sequential glomerulonephritis (32, 33) . kidney function needs to be carefully followed in persons who have had covid-19 and care needs to be taken not to prescribe potentially nephrotoxic drugs. in view of the multiple complications associated with "long covid" it is essential that during recovery older persons are carefully followed by physicians and other health professionals. it is important to recognize that symptoms fluctuate and may go away for a few days and then return. there is a need for an integrated interprofessional care model to obtain the optimum recovery after covid-19 (34) . the key to a good recovery is an exercise program adjusted to the ability of the patient to perform it. as has been shown by izquierdo and his colleagues, these programs should be started in hospital and continued following hospital (35) (36) (37) . the vivifrail exercise program is ideally adapted to doing this. also, it is essential that while in the intensive care unit, patients receive as much exercise as possible (38) . these include respiratory exercises, passive joint motion, stretching, electrical stimulation of muscles, standing at bedside and walking where possible (39) . on discharge the exercise program should include respiratory, resistance, aerobic and balance exercises as well as a focus on making sure the activities of daily living can be adequately carried out. in view of the fatigue, exercises may need to be spread out during the day. speech therapy may need to help persons who have been ventilated to regain adequate speech patterns. in addition, they can work with occupational therapy to provide a variety of forms of cognitive stimulation therapy in those who have had a decline in their cognition (40, 41) . dietetics needs to work on creating taste enhancement of food in those who have lost their sense of taste and smell. persons with sarcopenia or cachexia need supplementation with 10-15g/kg/day of leucine enriched essential amino acids (42, 43) . in view of the social isolation that occurs during the covid epidemic it is important that programs are developed to provide socialization (44, 45) . this can include telehealth programs such as the "circle of friends" as enhanced use of social media (46) . care should be taken to screen for dysphoria/depression and provide psychological therapy when it occurs (47) . it is suggested that at discharge from hospital and at 3 months discharge from hospital all covid-19 patients are screened for frailty with the frail test (48) (49) (50) (51) , sarcopenia with the sarc-f (52-55), anorexia with the snaq (56, 57) and cognitive failure with the rapid cognitive screen (rcs) (58) . these tests are simply combined into the rapid geriatric assessment (59, 60) and are available in an app form (61) . persons who screen positive and need to receive appropriate therapy which needs to be provided free to the individual. "long covid" is an important condition which can respond to an interprofessional team approach. its fluctuations can be frustrating both for the patient and the health care provider. an additional factor that needs to be taken into account is whether, in the long term, chronic subclinical chronic inflammation may lead to accelerated aging both in the periphery and as a neurodegenerative process (62, 63) ? disclosures: the author declares there are no conflicts. editorial: covid-19 and older adults editorial: covid-19 spiraling of frailty in older italian patients covid-19 and the renin angiotensin system: implications for the older adults management of post-acute covid-19 in primary care post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study myalgic encephalomyelitis (me) or what? an operational definition unexpected features of cardiac pathology in covid-19 infection palliative care for people with covid-19-related symptoms 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prevalence of geriatric syndromes and review of its feasibility a public health perspective of aging: do hyper-inflammatory syndromes such as covid-19, sars, ards, cytokine storm syndrome, and post-icu syndrome accelerate short-and long-term inflammaging? implication of aging related chronic neuroinflammation on covid-19 pandemic key: cord-313413-qx6fo1x2 authors: cipriano, catia; giacconi, robertina; muzzioli, mario; gasparini, nazzarena; orlando, fiorenza; corradi, attilio; cabassi, enrico; mocchegiani, eugenio title: metallothionein (i+ii) confers, via c-myc, immune plasticity in oldest mice: model of partial hepatectomy/liver regeneration date: 2003-06-19 journal: mech ageing dev doi: 10.1016/s0047-6374(03)00146-5 sha: doc_id: 313413 cord_uid: qx6fo1x2 because of its similarity to ageing in impaired immune efficiency 48 h after surgical procedures on young partially hepatectomised mice, partial hepatectomy/liver regeneration (phx) provides a good model for the study of inflammation in ageing. in old age, high metallothionein (i+ii) (mt) sequesters a substantial number of intracellular zinc ions consequently leading to low zinc ion bioavailability for an adequate immune response. corticosterone and il-6 affect mtmrna induction in inflammation and after phx against oxidative damage. the aim of this study was to investigate the role played by mt in conferring immune plasticity in ageing and in very old age using the phx model. 48 h after their partial hepatectomy, the crude zinc balance was negative in young, old and very old mice coupled with increased mt, corticosterone, sil-6r and il-6. concomitantly, natural killer (nk) cell activity and il-2 production decreased. complete restoration of the nutritional–endocrine–immune parameters occurred 15 days from the surgical procedures in young and very old mice, but not in old or transgenic mice overexpressing mt. a significant positive or inverse correlation among nutritional–endocrine–immune parameters exists in young and very old mice, but not in old mice during liver regeneration. since mt also affects c-myc, the gene expression of c-myc declines from 48 h to days 7 and 15 after phx in young and very old mice, but remains constantly high in old phx mice for the same days. this circumstance leads to the appearance of tumours in the long run in old phx mice and survival times that are shorter than old sham controls. because complete remodelling also occurs in il-6 and in sil-6r in very old mice during liver regeneration, the pre-existing inflammation is not detrimental in very old age. as such, very old mice are still responsive to large inflammation, such as phx, thanks to correct mt homeostasis. correct mt homeostasis, via c-myc, is therefore pivotal in both suitable liver regeneration and in conferring immune plasticity with subsequent successful ageing. high mt plays an extremely harmful role in ageing: on one hand it lowers zinc ion bioavailability levels required for immune efficiency and on the other hand it increases c-myc expression. the combination of immune depression and enhanced c-myc, via high mt, may trigger the appearance of age-related degenerative diseases. healthy centenarians differ from ''normal'' aged individuals because of their optimal metabolic compensation and immune response as well as their ability to efficiently counter the alteration of the oxidative status typical of ageing (franceschi et al., 1995) . though the molecular basis underpinning this exception has yet to be fully elucidated. a special asset of zinc-bound metallothionein (zná/mt) (i'/ii) is known to play a central role both in zinc-related cell homeostasis during oxidative stress, inflammation and in immune response (mocchegiani et al., 2000) . partial hepatectomy/liver regeneration (phx) is a good model for the study of acute and constant inflammation in ageing because of its similarity to ageing and inflammation in impaired thymic endocrine activity and peripheral immune efficiency [natural killer (nk) cell activity and il-2 production] (mocchegiani et al., 1997) as well as in enhanced corticosterone (shimada et al., 1996) and proinflammatory cytokines (il-6 and tnf-alpha) (kelley-loughnane et al., 2002) in young phx mice 48 h after partial hepatectomy. these altered immune and hormonal parameters are also a characteristic of inflammation and ageing (mocchegiani et al., 2000) . therefore, the model of partial hepatectomy is useful for the study of inflammation in ageing, other than liver regeneration. many growth factors are involved in liver regeneration after phx. il-6 and corticosterone are co-mitogens during liver regeneration for hepatocytes crossing from the g0 to the g1 phase (hoffman et al., 1994; michalopoulos and defrances, 1997) . however, without the presence of soluble il-6 receptor (sil-6r), il-6 alone cannot provide the degree of stimulus necessary to promote hepatocyte proliferation (maione et al., 1998) . moreover, il-6 increases during inflammation for a prompt immune response (buunsgaard et al., 2001) , and some proto-oncogenes, such as c-myc, are involved from the first early phases in liver regeneration after phx (moser et al., 2001) . in this context, zn á/mt plays a key role for four reasons: first, the mt gene expression is induced by corticosterone and il-6 in inflammation (andrews, 2000) and during liver regeneration (tohyama et al., 1993) against oxidative damage; second mt affects the c-myc gene expression (tohyama et al., 1993) ; third, in order to accomplish these tasks, mt sequesters intracellular zinc ions (kagi and shaffer, 1988) , which are pivotal for immune efficiency including nk cell activity and il-2 production (mocchegiani et al., 1998) ; fourth, zn á/mt does not release zinc under constant stress, such as in ageing (mocchegiani et al., 2002a) , causing low free zinc ion bioavailability which immune efficiency and antioxidant activity depend on (mocchegiani et al., 2000) . thus, the continuous sequestering of intracellular zinc by mt under conditions of constant stress may be harmful and offset the beneficial effects arising from transient stress, as can occur in young-adult mice (kelly et al., 1996) . zn á/mt, zinc ion bioavailability and immune performances undergo remodelling during liver regeneration in young but not in old phx mice, suggesting that zn á/mt may be involved in affecting immune plasticity during inflammation (mocchegiani et al., 1998) . such a remodelling is also due to a correct liver regeneration, via c-myc (hoffman et al., 1994) . no c-myc data exist in old phx mice. the aim of this study was to investigate, through the phx model, the role played by zn á/mt (i'/ii) in liver regeneration and in conferring immune plasticity, which is indispensable to successful ageing (mocchegiani et al., 2002b) . young, old, very old and transgenic mice overexpressing mt (mt-i*) were used. we included the latter group of mice as their zinc ion bioavailability and immune response, both under normal conditions and the constant stress of being deprived of light for 10 days, are similar to that of old mice (mocchegiani et al., 2002a) . we used ten 2 á/3-month-old (young age) balb/c inbred male mice, ten 20-month-old mice (old age) and ten 28á/30-month-old (very old age) mice. the mice were housed in non-galvanised plastic cages (five to six mice per cage) and fed with standard pellet food (nossan, italy) and tap water ad libitum. under our housing conditions, the life-span was of 30 months (mocchegiani et al., 1998) . since there was an approximate 50% survival rate of 20 months, mice of this age were considered ''old'' (mocchegiani et al., 1998) . ten young transgenic male mice over-expressing mt (mt-i*) (jackson lab., bar harbor, me, usa) were also used. c57bl/6j mice were used as controls of mt-i* mice. the animals were maintained on a 12-h light:12-h dark cycle from 07:00 to 19:00 h at a constant temperature (209/1 8c) and a constant level of humidity (509/5%). even though intrinsic genetic variability is almost absent in inbred balb/c mice, environmental factors, such as stress, caused by conventional in-house breeding condition nevertheless produced genetic variability (wesselkamper et al., 2000) . indeed because environmental factor-induced variability is also fundamental in man (houlston and tomlinson, 1998) , the data yielded by our very old inbred mice may be comparable and reflect successful ageing in human. young, old and very old balb/c mice were partially hepatectomised (phx) under ether anaesthesia by aseptic extirpation of the median lobe. to avoid diurnal variability, all operations were performed between 08:00 and 09:00 h (mocchegiani et al., 1997) . the animals were killed at 48 h and on day 15 following their hepatectomy using ether (ten young, ten old and ten very old animals for each time interval considered). ten young sham, ten old sham, and ten very old sham mice were used as controls at time 0. heparinised blood samples were collected by cardiac puncture for cytokines and corticosterone determinations in the plasma. the spleen was removed and teased for testing nk cell cytotoxicity. the liver was removed and frozen in liquid nitrogen for mtmrna determination. since no differences were found between sham-operated and control mice (mocchegiani et al., 1997) , sham-control mice (as time 0) were herein used. moreover, no differences existed between inbreed balb/c and c57bl/6j mice in nutritional á/immune á/endocrine response (mocchegiani et al., 2002a) . for survival analysis (kaplaná/meier), 30 mice (20 months old) were partially hepatecomised. 30 old sham mice of the same age were used as controls. the mice were censored every 3 days. because the maximum life span of mice in our breeding conditions is of 30 months, 20 months are considered as ''old age'' and 30 mice are sufficient for survival analysis from this age (mocchegiani et al., 1998) . another two groups of 20 old phx and 20 old sham mice were used for histological analysis in order to determine physio/pathological conditions which are in turn necessary to reflect survival analysis and causes of death. for this purpose, all the mice belonging to the latter two groups were killed 1 month after their partial hepatectomy (i.e. at 21 months of age) as this is a sufficient time in which to show definitive hepatocytes differentiation and regeneration after a partial hepatectomy (gordon et al., 2000) . immediately after euthanasia necropsies were performed and tissue specimens, from organs of the splanchnic cavities (thorax, abdomen), were collected and fixed in a phosphate formalin buffer ph 7.4. tissues were paraffin wax embedded (56 á/58 8c) and microtome sections 5 mm thick were cut for routine histological staining. before surgical procedures, the health status of the mice was monitored with bacteriological analysis at bronchoalveolar and gastrointestinal levels using standard laboratory methods. serological analysis (sendai virus, mouse hepatitis virus, mycoplasma pulmonis and corona virus) (elisa kits) following felasa guidelines (felasa, 1994) , was carried out (inrca veterinary service). for acclimatisation purposes, the animals were housed in non-galvanised metabolic cages (techniplast, italy) for a period of 7 days prior to their partial hepatectomy. the crude zinc balance was performed in ten operated mice (young, old and very old) for each of the time interval considered (48 h and 15 days) from surgical procedures. faecal weight was determined in humid faeces. zinc present in food, water, urine and faeces was measured for each animal every day. crude zinc balance is the difference between zinc uptake and zinc loss and indirectly represents the amount of zinc in the body (turnlund et al., 1986) . zinc determination in urine was performed in aas on 24 h urine collected in non-galvanised metabolic cages and zinc content in faeces, food and water was carried out by aas using methods extensively described elsewhere (mocchegiani et al., 1997) . nk splenocytes activity, as described elsewhere (mocchegiani et al., 1997) , was measured using yac-1 lymphoma cell line as a target. 1 )/10 5 ml (1 target cells and 2 )/10 6 ml (1 liver effector lymphocytes were used. 100 mci of 51 cr was used as a marker for nk lysis. the data were expressed in lytic unit 20/10 7 cells. plasma interleukin il-2 and il-6 levels were measured using elisa kits (endogen, usa). the data were expressed in pg ml (1 . the sensitivity of the kit was 5/7 pg ml (1 for il-6 and 5/3 pg ml (1 for il-2. plasma (diluted 1:40) sil-6r was tested using sil-6r quantikine elisa kit (r&d systems, minneapolis, usa). the data were expressed in ng ml (1 . the sensitivity of the kit was 5/140 pg ml (1 . plasma corticosterone levels were determined by ria rat-corticosterone-3 h kit (icn, usa). the data were expressed in ng ml (1 . the percentage of cross-reaction with other steroids was b/ 0.01. the sensitivity of the kit was of 0.05 ng ml (1 . total rna was extracted from frozen liver using tri-reagent according to the manufacture's instructions (sigma, usa). 3 mg of total rna was reverse transcribed using a reaction mixture containing 50 mm tris á/hcl pcr reactions were size-fractionated by 2% agars gel electrophoresis and visualised by staining with ethidium bromide. the data are also expressed as a relative unit determined by normalisation of the density of mt-1 or c-myc band to that of b-actin band, as suggested by okuda et al. (1995) . the differences between means were assessed using paired student's t-test and one-way anova test. x 2test was used in tables 2 and 3 . for survival analysis, the kaplan á/meir test was used and the significance was log-rank tested. correlations were determined by linear regression analysis using the least square method. the differences between various regression lines were evaluated by analysis of covariance. differences were considered to be significant when p b/0.05. 3.1. crude zinc balance, nk cell activity, il-2, il-6, sil-6r and corticosterone plasma levels during liver regeneration in young, old and very old mice table 1 shows that the crude zinc balance was positive in sham young and sham very old mice, while it was negative in sham old mice. at 48 h after their partial hepatectomy, the crude zinc balance was negative in young, old and very old phx mice with a more significant negativity in old phx mice than in young and very old phx mice (p b/0.05). positive values were newly observed at on day 15 following a partial hepatectomy in young and very old phx mice but not in old phx mice (table 1) . young and very old phx mice display significant reductions in nk cell activity and il-2 production at 48 h after their partial hepatectomy as compared with respective sham controls (time 0) (p b/0.01). restoration occurred in the late period of compensatory liver growth (day 15) in young and very old phx mice, but not in old phx mice with no modifications as compared with respective controls (table 1) . il-6, sil-6r and corticosterone plasma levels increased in young and very old phx mice at 48 h from partial hepatectomy as compared with respective sham controls (p b/0.01), with restoration on day 15 of compensatory liver growth (table 1) . no significant modifications in il-6, sil-6r and corticosterone were observed in old phx mice during liver regeneration (table 1 ). it is noteworthy that il-6 and sil-6r are high in very old sham mice in comparison with young sham mice (p b/0.01), but less high in comparison with old sham mice (table 1) . however, very old mice displayed the same trend in il-6, sil-6r and corticosterone of young mice during liver regeneration. moreover, a small number (n 0/3) of old mice display il-6 near to 16 pg ml (1 : values similar to higher ones observed in very old mice (15.8 pg ml (1 ) at time 0. therefore, relatively low levels of il-6 may be considered a marker to reach successful ageing, as previously reported in very old humans (bonafe et al., 2001) . table 1 crude zinc balance and endocrine á/immune parameters studied in young, old and very old mice in each time interval considered during compensatory liver growth from phx mtmrna increases in old sham mice in comparison with young sham and very old sham mice (p b/0.001) (fig. 1) . at 48 h from partial hepatectomy, mtmrna increases in young and very old phx mice in comparison with respective sham controls (p b/0.001). no substantial variations occurs in old phx mice at 48 h in comparison with respective controls (p /0.05) (fig. 1) . complete mtmrna downregulation is observed in young and very old mice in the late period of compensatory liver growth (day 15), but not in old mice (fig. 1) . no modifications in the pattern of mtmrna are observed either during liver regeneration in transgenic mt-i* mice (fig. 2) showing a close likeness to old phx mice (fig. 1) . it is noteworthy that the differences in mt data among young, old and very old mice at time 0 obtained using rt-pcr reflect the values of liver mt protein using ag'/ saturation method (mocchegiani et al., 2002b) . at time 0, the c-myc gene expression is already high in old sham controls in comparison with young and very old mice (p b/0.01). it increases in all mice at 1 h after partial hepatectomy with progressive decrements at 24 and 48 h from surgical procedures and is significantly lacking on days 7 and 15 of liver regeneration exclusively in young and very old mice as compared with old mice (p b/0.01) (fig. 3) . indeed, c-myc is constantly high from 24 h to day 15 in old phx mice with similar values of old sham controls (time 0) (fig. 3) . mt-i* mice display the same pattern of old mice in all time intervals considered after partial hepatectomy reinforcing the notion that mt over-expression is deleterious in constant inflammation with a likeness of mt-i* and old mice (mocchegiani et al., 2002a) . it is noteworthy that the differences in c-myc data among young, old and very old mice at time 0 obtained using rt-pcr reflect the values of c-myc quantification using immunocytochem significant inverse correlation exists in young and very old phx mice, but not in old phx mice, for the whole period of liver regeneration between mt and nk cell activity (r0/(/0.85, p b/0.01; r 0/(/0.68, p b/0.05, respectively) and between mt and il-2 (r0/(/0.78, p b/ 0.01; r0/(/0.65, p b/0.05, respectively). significant positive correlation exists in young and very old phx mice, but not in old phx mice, for the whole period of liver regeneration between: mt and il-6 or sil-6r (r0/ 0.76, p b/0.01; r0/0.61, p b/0.05, respectively); mt and corticosterone (r0/0.75, p b/0.01, r 0/0.62, p b/0.05, respectively); crude zinc balance and nk cell activity (r0/0.75, p b/0.01; r 0/0.67, p b/0.05, respectively); crude zinc balance and il-2 (r 0/0.73, p b/0.01; r0/ 0.60, p b/0.05, respectively); c-myc and mt (r 0/0.85, p b/0.01); c-myc and nk cell activity (r0/0.77, p b/ 0.01); c-myc and il-2 (r0/0.81, p b/0.01). before survival and physio/pathological analysis, the health status of the chosen old mice was within the felasa ''conventional housing'' normal rage (inrca veterinary service). old mice with no evident pathologies but underweight (5/20 g) were also discarded because of the presence of malnutrition (mocchegiani et al., 1998) and the subsequent risk of cancer (temple, 2002) . fig. 4 shows that the survival rate in old phx mice is shorter (24 months) than in old sham controls (30 months) (p b/0.01). the majority of deaths occurs at 21 months of age (i.e. after 1 month after partial hepatectomy). the cause of death is primarily due to cancer (hepatoma and lung metastasis) alone or associated with hyperplasia of bronchus associated lymafter mrna isolation and cdna synthesis, the amount of mrna for mt-i was determined by semi-quantitative pcr. the densitometry analysis was also performed using gel-doc instrument (bio-rad). the results are shown in the histograms and are expressed as mt-i/b-actin ratio. no differences exist in immune parameters between balb/c and c5bl/6j mice used as controls of mt-i* mice (mocchegiani et al., 2002a) . phoid tissue (balt) (90%) whereas the other 10% died for chronic glomerulonephritis. the histological analysis performed other groups of old phx and sham old mice at 1 month from partial hepatectomy shows the presence of carcinoma alone or associated with hyperplasia of balt complex (60%) in old phx mice with respect to 30% in old sham controls ( table 2) . hyperplasia of balt complex, on the whole, does not seem to constitute a factor in causing death (75% in both groups) ( table 2) . therefore, the differences in survival are due to cancer. also, chronic glomerulonephritis does not seem to affect survival (5% in both groups) ( table 2 ). it is worthy to note that old sham mice (20%) show good health, which is not present in old phx mice (0%), thus explaining the shorter survival time in old phx mice with respect to old sham controls as well as the maximum life span of 30 months (fig. 4) . in view of this, the 20% of old sham mice showing good health could represent possible candidates for successful ageing, as has been reported for old humans (15 á/18%) (octo study) (wikby et al., 1998) . indeed, as reported in table 3 , very old sham mice and very old phx mice display no appearance of carcinoma both at time 0 and fig. 3 . liver c-myc mrna (rt-pcr) concentrations in young, old, very old and mt-i* mice after partial hepatectomy/liver regeneration. rt-pcr analysis was performed using specific primers for mouse cmyc and b-actin under conditions described in section 2. after mrna isolation and cdna synthesis, the amount of mrna for c-myc was determined by semi-quantitative pcr. the densitometry analysis was also performed using gel-doc instrument (bio-rad). the results are expressed as c-myc /b-actin ratio. *p b/0.01 as compared with young sham (time 0) and to young phx mice (15th day), respectively. fig. 4 . percent of survival (kaplan á/meier) in old phx mice (direct line) and in old sham controls (hatched line) from the age of 20 months. the survival is reduced in old phx mice in comparison with old sham controls (p b/0.01, log-rank test). high percent of death (90%) occurs at 21 months of age in old phx mice due specially to the appearance of carcinoma (see table 2 ). carcinoma is referred to hepatoma'/lung metastasis in old phx mice. in old sham mice, hepatoma is not present, but exclusively lung carcinoma. *p b/0.01 and **p b/0.05 as compared with health status in old phx mice and to the same pathology in old sham mice. '/p b/ 0.01 and '/'/p b/0.05 as compared with health status in old sham mice. 8p b/0.05 as compared with old phx mice. glomerulonephritis is not significant when compared with health status in both groups of mice. after 1 month from partial hepatectomy, respectively. therefore, the absence of carcinoma is one of the requisites to reach successful ageing. moreover, the health status is more present in very old sham mice (50%) than old sham mice (20%) (p b/0.01). this means that a reduced inflammation in very old age (relatively low il-6 at time 0, as shown in table 1 ) is also one of the requisites for a good health status. compared with their respective sham controls, a negative crude zinc balance, reduced nk cell activity and decreased il-2 production coupled with increased il-6, sil-6r and corticosterone and enhanced mtmrna were recorded in young, old and very old mice 48 h after their partial hepatectomy. restoration occurred at days 7 and 15 after the partial hepatectomy in young and very old mice, but not old mice. these findings, yielded by the partial hepatectomy/ liver regeneration (phx) model, suggest that zinc-bound mt homeostasis is pivotal in conferring immune plasticity, which is indispensable to successful ageing (mocchegiani et al., 2002b) . the presence of a significant inverse or positive correlation between mtmrna and nutritional or endocrine or immune parameters exclusively in young and very old phx mice is consistent with this assumption. there is absolutely no doubt that mt increases after a partial hepatectomy (tohyama et al., 1993) because mt induction is related to inflammation, which is a common event after partial hepatectomy (fausto, 2000) . the problem, however, is that enhanced mt sequesters many of the intracellular zinc ions with no subsequent zinc release during constant inflammation, including ageing (mocchegiani et al., 2002a) . high zinc-bound mt (zn á/mt) was always associated with a negative crude zinc balance in old mice at all the time intervals considered during liver regeneration whereas it is present in young and very old mice exclusively 48 h after their partial hepatectomy. inflammation by high il-6 provokes consistent zinc loss (wapnir, 2000) , but, at the same time, il-6 affects mtmrna induction (andrews, 2000) . thus, the inflammation, on one hand, induces zinc loss from urine and faeces; while on the other hand, it induces mtmrna induction. as a result, the crude zinc balance is negative, the zinc ion bioavailability is low and mt increases sequestering the remaining zinc ions, as reported in young mice during transient inflammation (mocchegiani et al., 2002a) . this phenomenon is marked in constant inflammation, such as in ageing. indeed, the crude zinc balance is more negative (48 h) in old phx mice than in others and strictly related to deeper inflammation (high constant il-6, table 1 ). therefore, increments of zn á/mt and negative crude zinc balance are synergistic in ageing thus making the role of zn á/mt detrimental to immunity. the presence of thymic and immune dysfunctions in mt-i* mice (mocchegiani et al., 2002a) with no changes in mtmrna during liver regeneration (fig. 2) suggest a similarity between mt-i* and old mice lending further support to the notion that mt overexpression is harmful for immune efficiency. conversely, when mtmrna is low (at days 7 and 15 of liver regeneration in young and very old mice), the inflammation decreases (low il-6, sil-6r and corticosterone), the crude zinc balance regains positive values and the immune response is restored. therefore, correct zn-mt homeostasis is crucial in inducing good zinc ion bioavailability for immune efficiency and plasticity, which leads to successful ageing. indeed, very old mice display the same remodelling as young mice in the nutritional á/endocrine á/immune response during liver regeneration. an intriguing point is related to the remodelling of sil-6r as well during liver regeneration in young and very old mice, but not in old mice. it has been reported that the il-6/sil-6r complex is a primary stimulus to hepatocytes proliferation after phx (maione et al., 1998) . but, at the same time, the constant high **p b/0.05 as compared with health status in very old phx mice and to the same pathology in very old sham mice. glomerulonephritis is present in similar percent in old sham and very old sham mice, whereas carcinoma is absent in very old sham mice and very old phx mice in comparison with old sham mice and old phx mice in table 2 (p b/ 0.001). hyperplasia of balt does not seem relevant between old sham mice and very old sham mice before and after 1 month from partial hepatectomy. presence of this complex causes hepatocellular transformation with the appearance of liver tumours (maione et al., 1998) . therefore, on the whole, such remodelling also correctly affects hepatocytes regeneration in young and very old mice. by contrast, carcinoma appears in old phx mice in the long run coupled with shorter survival compared with that of the old sham controls (fig. 4) . carcinogenesis may occur due to the high constant expression of c-myc proto-oncogene, which changes from being beneficial for liver regeneration during the first hours following the partial hepatectomy (hoffman et al., 1994) to dangerous in the long run because of the possible abnormal proliferation of damaged liver cells as well. indeed, the gene expression of c-myc is constantly high in old phx, as well as in mt-i* mice, at days 7 and 15 following their partial hepatectomy in contrast to that of young and very old mice. taking into account that mt induces c-myc gene expression (tohyama et al., 1993) , which in turn provokes proliferation in the presence of growth factors and apoptosis when such factors declines (harrington et al., 1994) , it is evident that liver regeneration (from 48 h to day 7) is correct in young and very old mice due to apoptosis indispensable in eliminating damaged liver cells and in blocking the compensatory liver growth, as normally occurs in young phx rats (de miglio et al., 1999; moser et al., 2001) . by contrast, the constant presence of growth factors (mt, il-6/sil-6r complex) in old and mt-i* phx mice (from 48 h to days 7 and 15) may provoke continuos proliferation, via c-myc, of damaged liver cells too with the appearance of cancer in the long run, as is also shown by no health status in old phx mice after 1 month following their partial hepatectomy in contrast to the old sham controls ( table 2 ). the presence of abnormal liver proliferation and tumours in il-6/sil-6r complex transgenic mice after a partial hepatectomy (maione et al., 1998) , the short survival of il-6/sil-6r complex transgenic mice (maione et al., 1998) , the short survival and the peripheral organs dysfuction in mt-transgenic mice (quaife et al., 1999) , which are also more susceptible to the lethal effect of cancer-provoking tnf injections (waelput et al., 2001) and, finally, the correlation between high c-myc and depressed immune performances in old phx mice (present study) and in phx mt-i* mice (at 1 month after their partial hepatectomy) (e. mocchegiani, unpublished results) , are consistent with this interpretation. on the other hand, c-myc overexpression (kawate et al., 1999) , high mt (ebadi and swanson, 1988) , persistent inflammation (high il-6 and tnf-a) (sharma and anker, 2002) , low zinc ion bioavailability and depressed immune functions (mocchegiani et al., 1998) are common events in cancer. therefore, a correct zn á/mt homeostasis is crucial in conferring both suitable liver regeneration and immune plasticity not only after partial hepatectomy, but also in obtaining healthy longevity. the correct zn á/mt homeostasis in lymphocytes taken from centenarians (mocchegiani et al., 2002b) coupled with good immune performances (franceschi et al., 1995) and (as indirect evidence) the presence of c-myc polymorphism in elderly cancer patients (shih et al., 2002) , support this assumption. in this context, the low gp130 and the reduced sil-6r in centenarians despite of high il-6 (giuliani et al., 2001) is intriguing. low gp130 also occurs in very old mice (mocchegiani et al., 2002b) . consequently, inflammation is less detrimental in very old age as there is a loss of the target (i.e. gp130) of il-6 or il-6/sil-6r complex, thereby explaining the similar patterns of nutritional á/endocrine á/immune parameters that are found in young and very old mice during liver regeneration. this means that very old mice are still responsive to severe inflammation, like phx, just as young mice are, reflecting the major responsiveness to oxidative stress in human centenarians (mecocci et al., 2000) . in conclusion, phx is a good model as it reveals the presence of a lesser degree of inflammation in very old age. this fact is due to a correct mt homeostasis, which in turn leads to suitable liver regeneration via c-myc conferring also immune plasticity even in very old age with subsequent successful ageing. hence, in ageing high mt plays an extremely harmful role: on one hand it lowers zinc ion bioavailability levels required for immune efficiency; on the other hand increases c-myc expression. the combination of immune depression and enhanced c-myc, via high mt, may thus allow the appearance of age-related degenerative diseases. in order to further confirm this assumption, our lab is presently performing studies in mt-i* and mt null mice as well as in elderly infected and cancer patients. regulation of metallothionein gene expression by oxidative stress and metal ions a gender-dependent genetic predisposition to produce high levels of il-6 is detrimental for longevity aging and proinflammmatory cytokines correlation of c-myc overexpression and amplification with progression of preneoplastic liver lesions to malignancy in the poorly susceptible wistar rat strain zinc and metallothioneins in cancer 19 á/31. felasa (working group on animal health), 1994. recommendations for the health monitoring of mouse, rat, hamster, guinea pigs and rabbit breeding colonies the immunology of exceptional individuals: the lesson of centenarians serum interleukin-6, soluble interleukin-6 receptor and soluble gp130 exhibit different patterns of age-and menopause-related changes temporal analysis of hepatocyte differentiation by small hepatocyte-like progenitor cells during liver regeneration in retrorsine-exposed rats c-mycinduced apoptosis in fibroblasts is inhibited by specific cytokines hepatic regeneration: current concepts and clinical implications modifier genes in humans: strategies for identification biochemistry of metallothionein amplification of c-myc in hepatocellular carcinoma: correlation with clinic pathologic features, proliferative activity and p53 overexpression independent and overlapping transcriptional activation during liver development and regeneration in mice metallothionein i and ii against zinc deficiency and zinc toxicity coexpression of il-6 and soluble il-6r causes nodular regenerative hyperplasia and adenomas of the liver plasma antioxidants and longevity: a study on healthy centenarians. free radic liver regeneration zinc and metallothioneins on cellular immune effectiveness during liver regeneration in young and old mice zinc, t-cell pathways, ageing: role of metallothioneins zinc and immunoresistance to infections in ageing: new biological tools metallothionein (i'/ii) and thyroid-thymus axis efficiency in old mice: role of corticosterone and zinc supply mtmrna gene expression, via il-6 and glucocorticoids, as potential genetic marker of immunosenescence: lessons from very old mice and humans immediate-early protooncogene expression and liver function following various extents of partial hepatectomy in the rat expression of the inducible isoform of nitric oxide synthase in the central nervous system of mice correlates with the severity of actively induced experimental allergic encephalomyelitis ectopic expression of metallothionein-iii causes pancreatic acinar cell necrosis in transgenic mice cytokines, apoptosis and cachexia: the potential for tnf antagonism association of l-myc polymorphism with lung cancer susceptibility and prognosis in relation to ageselected controls and stratified cases the effect of a perioperative steroid pulse on surgical stress in hepatic resection nutrition and diseases: challenges of research design induction of metallothionein and its localization in the nucleus of rat hepatocytes after partial hepatectomy stable isotope studies of zinc absorption and retention in young and elderly men mediator role for metallothionein in tumor necrosis factor-induced lethal shock zinc deficiency, malnutrition and the gastrointestinal tract genetic susceptibility to irritant-induced acute lung injury in mice changes in cd8 and cd4 lymphocyte subsets, t cell proliferation responses and non-survival in the very old: the swedish longitudinal octo-immune study supported by inrca, italian health ministry (r.f.no. 99/107 to e.m.) and cee (imagine no. qlk6-ct-1999-02031). we thank professor paul bowerbank for revising the manuscript. key: cord-318977-4ng6gxpv authors: zittoun, tania; baucal, aleksandar title: the relevance of a sociocultural perspective for understanding learning and development in older age date: 2020-09-26 journal: learn cult soc interact doi: 10.1016/j.lcsi.2020.100453 sha: doc_id: 318977 cord_uid: 4ng6gxpv this paper proposes a sociocultural psychology approach to ageing in the lifecourse. it proposes to consider sociogenetic, microgenetic and ontogenetic transformations when studying older age. on this basis, it considers that older people's lives have two specificities: a longer life experience, and a unique view of historical transformation. the paper calls for a closer understanding of the specific and evolving conditions of ageing, and for more inclusion of older citizens in public debate and policy making. finally, while this paper was being reviewed, the covid-19 hit the world, with important consequences for the life of older persons; we conclude the paper with a short reflexion on the implications of our proposal. we aim at defining an approach to development in older age which is grounded on four assumptions. first, we examine the developing person all life-long, and not development as an outcome; development is thus understood in an open-systemic and relational way. second, and in order to do so, life-long developing persons need to be understood in their sociocultural environments, these also being in transformation. third, the approach needs to adequately account for the specificities of developing as an older person -older than others. finally, we thus attempt to show how people can develop and maintain meaningful engagements in society (elder & giele, 2009; hviid & villadsen, 2015; teo, 2015; valsiner, 2008; valsiner et al., 2009; zittoun et al., 2013) . on this basis, we will deliberately turn our back on individualistic approaches focused on the ageing person in isolation, as well as on approaches focused on the evolution, or rather decline, of specific functions (such as cognition or memory), or on studies that consider older age independently of the life-long of the person, or even, that start with normative assumptions about what may be a successful or positive ageing, − approaches which develop widely since the mid-1950's and are still exponentially growing (for recent synthesis, see anderson & craik, 2017; biggs, 2005; li, 2015; park & festini, 2017; tournier, this issue) . to develop such a theoretical frame, we draw on a sociocultural psychology of learning and development, which so far has been mainly focused on children, young adults and adults, as well as on the growing field of anthropological (droz-mendelzweig, 2013; lieblich, 2014; sarason, 2011) , critical gerontology, sociological and narrative approaches (freeman, 2011; gubrium, 1995 gubrium, , 2011 , and clinical studies of the lives of older people (aumont & coconnier, 2016; bergeret-amselek, 2016; gutton, 2016; quinodoz, 2008; villa, 2010) . sociocultural psychology is a theoretical approach to human experience and development that considers the mutual constitution of the person and their social and cultural world, as these dynamics are located in time and space; it also gives a central role to human experience and sense-making (cole, 1996; rosa & valsiner, 2018; valsiner, 2012; wertsch, 1998) . inspired by american pragmatism (dewey, 1938; james, 2007; peirce, 1974) and russian psychology (vygotsky, 1986 (vygotsky, , 1997 , it is now a flourishing field. some of its current sub-orientations such as narrative cultural psychology (bruner, 2003; daiute, 2014) , historico-cultural psychology (hedegaard et al., 2008) , and semiotic cultural psychology (valsiner, 2014; wagoner et al., 2014) meet in their dialogical epistemologies, and their interest for formal and informal learning as well as for human development (césar & kumpulainen, 2009; mäkitalo et al., 2017; zittoun et al., 2013) . in these conditions, it is surprising that sociocultural psychology has very little addressed psychology of ageing -it is hardly surprising for vygotsky, one of the main inspirations in the field who died aged 34 (zavershneva & van der veer, 2018) , but more so for more recent studies. indeed, such silence reproduces a tendency visible in mainstream psychology, that is, a strong divide between psychology of the life-course-ending somewhere in mid-adulthood-and gerontology, considering older age mainly as it is accompanied by illnesses and other ailments (jeppson grassman & whitaker, 2013) . there are however a couple of recent sociocultural studies of the older person, such as that of manuti et al. (2016) , who propose a dialogical perspective that "implies the acknowledgement of elderly subjectivity inside social discourses and, as a consequence, the need for catching what they can say" (manuti et al., 2016, p. 4) , of authors focusing on the materiality of people's lives and can therefore adopt a mediated activity approach (e.g., engeström & sannino, 2016; woll & bratteteig, 2018) which examines care (boll et al., 2018) . why has sociocultural psychology not studied ageing more? it may be that it has been privileging an analysis of the cultural conditions of growth which appeared more clearly in childhood; or perhaps it is due to the fact that, as a discipline, it has to be accountable for its existence, and thus studying learning and work in youth and adults can have more direct implications for practice. more generally, sociocultural psychology may also simply reflect a global tendency, both sociocultural and theoretical-an avoidance of thinking ageing and death: beyond a classic interest for ageing in ancient greece, modern psychology has long avoided the topic. indeed, the preoccupation of the "fathers of psychology", such as piaget or watson, did not find ageing relevant for their enquiry (birren & schroots, 2001) ; in addition, studying ageing raises specific methodological challenges (säljö, this issue). here we aim at developing a more systematic and thorough definition of a sociocultural perspective on age. for this, we propose to approach developing ageing persons through an understanding of sociogenetic, microgenetic, and ontogenetic dynamics (duveen, 2013; gillespie & cornish, 2010; zittoun, 2016) . ageing cannot be approached today without an understanding of societies and their historical changes-beyond the obvious fact that older people have a very different status in communities where age is associated with wisdom than in industrialized societies. this includes three aspects that have been documented in ageing studies and critical gerontology, and that are linked to practices of social inclusion and boundary work, practical arrangements and affordances, and social representations. first, one has to examine how various groups (nation states, region, and communities), as social collectives, explicitly or implicitly include, marginalize, or exclude their oldest members (de beauvoir, 1970) . such dynamics of exclusion for instance take place when older people are ignored in public debates about the role of older citizens or the future of society, or by a subtle logic of suspicion (e.g., in many countries people after a certain age have to test their driving capacities every year, independently of their actual state of health). moreover, "age" as social category has to be understood in articulation with other categories: ageing poor or rich, ageing migrant, or ageing hetero-or homosexual might create specific dynamics of social inclusion and exclusion, recently addressed in terms of cross-sectionality (machat-from, 2017; rosenberg et al., 2018) . second, societies and their historical transformations have to be understood in terms of their institutions, and in industrialized societies, the policies that create the financial, symbolic and material conditions of living of the older citizens, and their related various affordances. institutions define who is "retired" and when, what guarantees and rights people have after they have finished a working life (or, for non-working people, when they reach the same age). it is thus important to note that the consensus considering the "third age" starting at around 65 is aligned on the age of the pension (stuart-hamilton, 2011). institutions also define modes of housing for older citizens, urban arrangements and transports, allocations for home care, cultural offers such as universities of third age, or cheaper museum entrance, etc. developing as older person is thus radically different if one has a pension that covers 70% of the person's former salary and enables them to maintain their lifestyle, or if the pension falls beyond the 50% and demands the person to radically limit their expenses; if one lives in a town with low-buses or with no public transports, etc. (abramson, 2015; aneshensel et al., 2016; bengston, 2016; quesnel-vallée et al., 2016) . however, it is important to note that older people still may define their lives, and create margins of freedom beyond the local institutional possibilities and constraints, as we will see. third, societies produce and are shaped by social representations and discourses on ageing and what "older people" are, and what they are expected to do or not to do. important attention has been paid to "ageism" as the negative social representation of older age in societies that privilege youth and its appearance in terms of beauty, strength and performances (angus & reeve, 2006; casas, 2014; nelson, 2005) . in turn, older people have been said to develop resistance to their "mask of age" and become alienated (humberstone & cutler-riddick, 2015) . also, the emphasis on "successful", "active" or "positive" ageing, both in psychology (since the 1960s) and in institutional and public discourses (balard, 2015; havighurst, 1961; rowe & cosco, 2016 ), mostly individualizing "success" and ignoring sociocultural and economic conditions facilitating or impeding such modes of lives (bülow & söderqvist, 2014) , has brought some people to experience their own less-active older age as failure, even though it may be meaningful to them (stenner et al., 2011) . however, with the development of critical perspectives on these categories, and also probably with the growing population of older active people, there is currently an increasing transformation of social representations of becoming older. this change can for instance be observed in a growing number of films depicting the realities of living with age (haneke, 2012; sorrentino, 2015) , an increased market of products targeting ageing persons (whether cosmetics, insurance, travel packages, clothing, etc.) or with fashion movement valorising the beauties of older people (campone, 2018) . hence, at a sociogenetic level, we call for a careful analysis of the historical evolution and local specificities of the dominant discourses on ageing persons, the institutional arrangements setting conditions for older people's lives, and the differentiated dynamics of social inclusion and exclusion of elderly persons. research needs to examine how older people meet these discourses, arrangements and dynamics in their everyday lives, and how they can negotiate, resist or accept them, for instance as empowering and supportive social scaffoldings for pursuing meaningful ageing. in this rapidly changing field, older people play an active role themselves, for instance through specific forms of political involvement (recently, the swiss "grand-parents for the climate", 1 or the danish "grand-parents for asylum" [hviid, 2020] ). a sociocultural psychological perspective also demands an understanding of the person in her context and along her life-course. in other words, it requires understanding the person in time, in a dynamic moment of their life: how the present is related to the past and how it is oriented toward the future. to move out of a negative representation of ageing as decline, a first step would be to abandon classic models of development that consider the lifecourse as a staircase or as a curve where ageing is designated by a declining slope (e.g., sato et al., 2007; sato et al., 2013; zittoun et al., 2013) . drawing on recent theorisation, we propose to consider the course of life as constantly changing, and to conceptualize it as dynamic assemblage of spheres of experience (zittoun & gillespie, 2015) . drawing on phenomenology on the one hand, and on more psychosocial descriptions of the frames of living on the other, the notion of "sphere of experience" describes an experiential unit that a person can recognize as "the same" over time, place, and relationships, and usually includes specific activities, modes of relating to others, range of feelings, aspects of one's identity or positioning, and certain specific knowledge or know-how. spheres of experience can, for instance, include eating-with-good-friends, or gardening, or remembering one's childhood, or participate in a scientific inquiry as citizen scientist. each occurrence of "eating-with-good-friends" may be located in different places and include different foods and conversations; yet it may be the overall "same" range of experience. these spheres may be "proximal" (they take in the here-and-now of specific material and social affordances) or "distal", when they are achieved through a loop of imagining, such as "remembering one's childhood". over the day, people pass from one sphere to another through a "mild shock" (schuetz, 1944) . however, new experiences may demand a radical reconfiguration of some spheres of experiences (such as an illness that prevents some type of food) or their destruction, as when a good friend dies and all the possibilities of joined experience disappear. new spheres of experience can also be created, such as when one moves to a new place-liminal experiences that we have coined as transitions (zittoun & gillespie, 2015; zittoun et al., this issue) . in line with the main assumptions of lifecourse research, we assume of course the historical and social embeddedness of peoples' course of life, the fact that people's lives are interrelated, and that the results and timing of past event may constitute, enable or constrain current and future developments (elder, 1994; janet zollinger giele & elder, 1998) . however, we are also very sensitive to people's capacities to "rewrite" their course of life, to find or create alternative developmental trajectories, and to live not only from what has been actually achieved or failed, but also, from what has been dreamed or anticipated, or from what has not come to be actualized but is still relevant (zittoun & gillespie, 2016; zittoun & valsiner, 2016) . it is also worth noticing that we conceptualize the persons' capacities not only as individual characteristics, but as capacities emerging from the relationship between individual capacities and sociocultural conditions, policies, institutions, discourses, and tools that enhance or limit, empower or disempower, support or prevent personal navigation and capacities during a lifecourse. altogether, the approach we propose brings us to highlight the fact that development occurs if, and only if, people can maintain a sense of continuity and integrity across their spheres of experience (erikson, 1959) , and confer meaningfulness to their lives and future perspectives. the idea of meaningfulness may be described in several ways, but here we put emphasis on two main components. on the one hand, it implies "sense-making" of one's experience (bruner, 2003; freeman, 2011) , or "engagement" in significant activities (hviid, 2020; hviid & villadsen, 2015; lido et al., 2016) . it also entails a minimal orientation to the future, that has been called "creativity" of living (gutton, 2016; winnicott, 2001; zittoun & de saint-laurent, 2015) , or "desire for life" (quinodoz, 2008; villa, 2010) , or "imagination" as way to go beyond the here-and-now and as existential tension to what has-to-come or could possibly occur (zittoun & gillespie, 2016) . on the other hand, meaningfulness can be related to meaningful interpersonal relationships, social recognition, and more generally, social inclusion (sarason, 2011b) . in this sense, meaningfulness or orientation to the future engage one's fundamental dialogicality (marková, 2016) with self and society, past and future, real and imaginary others, that is, an intention of living. a sociocultural psychology perspective on ageing proposes to explore the making of the person and the social as a meeting between sociogenetic and ontogenetic dynamics precisely in specific activities and interactions, that is, at the level of microgenesis. it thus proposes to identify and examine socially situated experiences and practices in the making, in all kind of real and imaginary situations that constitute everyday life. microgenetic dynamics take place in a wide range of situations and relationships, and have been studied with various focuses: in older people's daily interactions with neighbours, family members, or objects, or with objects mediating interpersonal interactions (aarsand, 2007; iannaccone, 2015) ; as part of promenades in the urban, countryside, or institutional environment (badey-rodriguez, 2003; guglielmetti, 2015; mallon, 2005; meijering & lager, 2014) ; as activities of learning, working, gardening, exercising (humberstone & cutler-riddick, 2015; stenner et al., 2012) ; or as encounters with representatives of institutions, such as doctors or care practitioners (meijering & lager, 2014; mortenson et al., 2016; sarason, 2011; wapner et al., 1990) . hence, most aspects of daily life, from walking on the beach to remembering one's childhood, have been approached microgenetically (butler, 1963; gubrium & holstein, 1999; lieblich, 2014) . studies have recently proposed to consider these socio-material environments as part of the conditions or the arrangements enabling life, such as for instance in studies on the "landscape of care" (milligan & wiles, 2010) . more generally, the invitation is to pay a close attention to the actual social, material, technical, spatial environments or "ecologies" of older people's lives, and to study the dynamic of their mutual co-constitution (säljö, this issue) . from the perspective proposed here, the socio-materiel environments are thus the settings in which people may support, or develop their spheres of experiences. these microgenetic dynamics are, we believe, key-elements to document and understand the experience of becoming and being older; but we also claim that a sociocultural psychology of growing older can only be achieved by combining these dynamics with an understanding of the sociogenetic movement involved, and by preserving the unique perspective and experience of the person unfolding in time through ontogenesis. considering ageing as part of people's lifecourses from a triple socio-, onto-and microgenetic perspectives has the advantage of being integrative, but is not specific to older people's life. our main theoretical innovation lies in the identification of the specificities of development in the life of older people, first in a rapidly changing environment, and second, as a result of life experiencing. the evolutions noted above create new life conditions for older people; as the generation of baby-boomers becomes older, we observe the making of new societal configurations. on the one hand, the societal and institutional conditions of living when growing older may differ across places. life settings may radically vary, depending on local socioeconomic living conditions (abramson, 2015) , or at the scale of nation-states. a recent international comparison thus shows that location (i.e., specific region/state) is the best explanation for variations in factual conditions of living and in the self-evaluated quality of life in older people, all others variables being controlled (stewart et al., 2018) . some national retirement systems make life difficult; others systems, which may appear better, have however for long privileged sending older people to retirement homes located at the periphery of cities or in the countryside, de facto marginalizing and excluding older citizens from the social arena. on the other hand, however, these social and geographical inequalities are themselves in transformation. institutional movements start to develop measures to fight against this tendency, for instance by rearrangements of the urban space to facilitate the mobility of frailer people, by developing intergenerational housing options (for instance in many swiss cities) or by creating new city spaces to support meaningful engagement of older citizens (e.g., "the old people's playground project" in london [perry & blason, 2016] ). as these conditions are rapidly growing, we have to keep a special attention on these: first, the existing or newly designed conditions may not correspond to what people getting older use to expect for their older age when they were younger. for instance, in many eastern european countries, people grew up in three-generation houses with a grand-parent, and may have expected the same for themselves when they would reach the same age. however, with the rapid urbanization and professional mobility, this expectation is often not met, adding thus to the solitude of older people the disappointment of betrayed expectations. in contrast, in urban centres, people who may have feared growing old alone may now find new shared housing for older citizens, beneficiating from new and unexpected options. second, the social categories of "older people" are also rapidly diversifying, some of them being the object of public discourses: there is currently a heightened sensitivity to gender inequalities, due to fact that former baby-boomers who may have had unconventional lifestyles now access older age; there is also an increased presence of an ageing migrant population. these "new olds", unequally social and geographically located, encounter national and institutional evolutions that were frequently designed without their active participation and that are currently evolving. not only does society try to render meaningful the increase of older citizens, but older people have also a need to make sense of becoming older in this rapidly changing society, and to take part in reshaping it, with or without the younger generation. as the younger generations shape their own present and future living conditions, society would have everything to gain if they could do so in an inclusive, participative and dialogical way. older people have the specificities of having a longer life experience and often of being released from engaging daily activities. this has some implications. first, having lived longer lives, older people are more likely to have lived through more spheres of experiences, and more reconfiguration of spheres of experiences than younger people: many family or friend-related experiences, numerous professional situations, situations related to social life, events related to leisure activities, diverse cultural events. they may have witnessed the slow transformation of some of their spheres of experience and their relatedness with social changes, for instance through technological, economic, political, and cultural changes; they may have lived many ruptures, as some spheres disappeared, and others appeared. going through these many experiences and changes, people may have learned from experience something valuable not only for them as individual persons, but for other related persons, and for the society in which they are engaged. for example, they may have developed more nuanced ways to address loss and newness, to handle the daily life and exceptional events, to deal with emotions and make sense of it. this may be called "learning from experience" (bion, 1989) , or also, the development of personal life philosophies (valsiner, 2007; van der veer & valsiner, 1993, p. 16; zittoun et al., 2013 ) (comparable intuitions have been addressed by the notion of "wisdom" in psychology [baltes, 2004; baltes & kunzmann, 2004] ). this may thus become people's life motives (thomae, 1968) , "practical wisdom" and engagements (hviid, 2020) , or "melodies of living" (zittoun et al., 2013) . second, as people lived their lives, they may precisely have had the opportunity to experience many and diverse social changes and transformations as well: they lived through wars, economic crises, massive population movements, radical innovations, or political transformations. experiencing first-hand sociogenetic dynamics as they were themselves developing may have brought them to identify historical or societal patterns of change, evolutions, or on the contrary, to radically change their views on the world. they may thus have developed "personal world philosophies" colouring their interpretation of social histories as well as their understanding and participation in social life (de saint-laurent, 2017) . depending on these two aspects (the development of personal life, and world philosophies) people becoming older may diversely engage in, or maintain activities that are meaningful to them and society. if we try to develop more general understandings of ageing, we thus need to consider the tensions between the developing persons and their evolving environment (and not only the person's functions or psyche), and to account for the diversity of dynamics taking place. at one extreme, we may hypothesize that some older people have strong engagements within their spheres of experiences, to which they confer sense, and a clear orientation to the future; they also may have learned to read patterns in the social world. as a result, they may actively engage in, and create activities in which they find sense, inclusion and purpose, and feel that they can participate to societal changes. this is for instance the case of older people engaging in political action (caissie, 2011) , as also exemplified in the case-study reported by pernille hviid (2020) . at another extreme, older people may have developed negative representations of institutions and the social world, which, they feel, have closed down their opportunities to participate; excluded from social life, with spheres of experience that may be less satisfying, the may have very little occasions to produce meaningful activities and therefore to develop imaginations of their future. this is for instance the case of retiree in serbia for which socioeconomic conditions are de facto marginalizing. finally, somewhere in between, people may be more or less satisfied with their social world, while having a set of good-enough engagements; thus, they may maintain a sense of orientation toward the future and create new sphere of experience even in relatively constraining situations. such position is exemplified by the cases of people living in the retirement home who may find spaces of imagining and creating in the relatively limited zone of free movement left to them (zittoun et al., this issue) . identifying how older people's development emerges out of specific sociocultural environment may thus invite us to reflect on the condition that may facilitate life engagements and meaningfulness. our societies are largely changing in terms of structure of the population and economical balances, at a period where ecological and political challenges are everyday more present. the reality of the ageing of the population is undeniable, and societies expect a rapid increase of the proportion of older people in good health, ready to engage in meaningful living, even though they are excluded (or liberated) from active professional life. older age thus constitutes the future of most of us. it is therefore not only a theoretical imperative, but an ethical one as well, to include older persons in our society. we need to empower them and secure their involvement and voice in (re)shaping institutions and policies that have significant implications for their quality of life, as well as for the future courses of lives of others. this imperative is based on two key arguments. on the one hand, older people have the right to keep developing and live meaningful lives. on the other hand, and more specifically, they are also de facto the ones with the longest life experience, and are likely to remember the past, to have learned from the changing world, and from their own course of life. they may have much to contribute to our current and future situations, and it may be essential for our societies to rely on their experiences and philosophies as well. as a consequence, as social scientists and educational researchers, as well as citizens, it is necessary to create conditions of participation, in which people can pursue meaningful lives, manifest, use and share their life experience, and become producers of the institutional conditions of their living. while we have been finalizing this paper, the covid-19 pandemic has transformed the everyday life of almost all people in the world, both in terms of their activities and their social relationships. it is especially true for the persons of older age since they have been recognized as sensitive group of citizens in many countries. consequently, they have been the object of various sets of policies and practices related to the covid-19 pandemic. in order to protect them, sanitary measures have resulted in social isolation, and interdiction to engage in the daily activities and social relationships through which their main engagements take place. most older people had to question their projects and modes of lives; 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(1) this dramatic and exponential increase in the prevalence and deaths related to covid-19 is spreading rapidly through europe, as it is now reporting more cases and deaths than the rest of the world combined. specifically, the numbers in italy have climbed, with over 80,000 cases and 8,000 deaths as of march 26th, 2020, placing italy now as the country with the highest mortality rate (1) importantly, older adults are particularly vulnerable to get severe illness and complications from this disease, and they also have a higher mortality rate than any other age group. the case fatality rate in italy jumped from the 0.8% in those 50 to 59 years of age, to 2.7% in those 60 to 69 years of age, and to 21.1% in those 90 years and older (table 1) . dr matteo cesari, professor and chair of geriatric medicine of the university of milan, replied to our questions on march 26th, 2020, which are transcribed below. mmo: thank you, matteo, for making this time for our questions. we know you are under extreme pressure and busy with unprecedented clinical demands, therefore we appreciate you providing us with direct information. how is the situation in lombardy and, specifically, milan, now (march 25, 2020)? the situation in milan is still very complicated. we have not yet reached the peak of the number of new covid cases, which is expected to arrive in the very next few days. figure 1 shows the distribution of cases among italian regions, and it can be seen how the north of italy took the first hit. the hospitals have been struggling since the beginning of the crisis because they needed to substantially redraw their matteo cesari, md, phd 1,2 and manuel montero-odasso, md, phd, agsf, fgsa, frcpc 3,4,5 figure 1. number of covid-19 cases regionally in italy pathways in an attempt to isolate covid-positive patients from the others. at the same time, the system was not ready to sustain the massive number of patients with respiratory symptoms arriving all together at the emergency departments. as we can see in figure 2 , 25% of our patients presented with severe disease and 5% are critical, all of them require hospitalization. this, combined with the shortage of icu beds and the gradual decrease in health-care professionals that were falling sick, has made things extremely difficult. how is the clinical presentation of the symptomatic disease in older adults? have you found any differences when compared with younger adults? do older patients with severe covid-19 illness present with severe dyspnea and hypoxemia, as do the younger adults? or do older patients present with geriatric syndromes, such as delirium? the clinical manifestation is usually characterized by fever and cough. it might appear as a normal pneumonia. in fact, very frequently, the covid-19 case manifests itself as a pneumonia resistant to antibiotics and standard care. the worsening of respiratory symptoms is today considered a clear sign suggestive of covid infection. since the very beginning, we have tried as much as possible to isolate patients with respiratory symptoms or flu-like manifestations from the others, given the high contagiousness of the coronavirus. this was also to allow the time to test for the possible sars-cov-2 infection. in this context, however, things are made difficult by the relatively high number of false-negative cases found from the nasopharyngeal swab. for this reason, people tend to be kept isolated even when tested negative, if the clinical suspicion remains high. overall, the istituto superiore di sanitá (iss) from italy reports that the most common complications are the following: acute respiratory distress syndrome (97.5% of cases), acute renal failure (28.9%), acute cardiac injury (11.2%), and superinfection (10.2%). nevertheless, the clinical manifestation of the covid in older persons can be associated with delirium. the main difference is the unexpectedly rapid course of the disease. many patients convert in 20-30 min from relatively stable conditions into severe respiratory distress. in other words, preliminary signs can be there, but their identification and management is often impossible given the quick evolution of the case. it is also noteworthy that hospitals have relatively few geriatricians, and they had to reorganize their workforces creating mixed teams. this was needed to face the shortage of personnel. i have to say that, in this emergency situation, it is very difficult for non-specialized clinicians to pay attention and detect geriatric syndromes that are largely overlooked and underestimated even in normal times. mmo: how are access to emergency room (er) care, inpatient beds, and critical care beds being managed? there have been reports in the media that older citizens should get a lower priority for access to medical services that are now limited, such as intensive care facilities and ventilation. this begs the question of whether this practice should go unchallenged as a form of "pragmatism", or whether we should think through how to engage with this in order to at least reduce the risk of the most egregious forms of discrimination. ers have been exponentially overwhelmed over the past weeks. the shortage of beds, especially in icus, has sometimes led to very difficult decisions. the relatively few number of ventilators, in fact, has generated discussions about the ethics of procedures applied to certain patients. the italian society of analgesia, anaesthesia, resuscitation, and intensive care (siaarti) released a document recommending a triage in a low-resource scenario based on age, comorbidities, and functional status. (2) unfortunately, the ageistic approach diffused in our society and in traditional medicine, as well as the poor knowledge about how to operationally apply these recommendations, makes critical decisions still (too largely) governed by the age criterion. i do not/cannot justify these decisions, but we also need to consider that the rapid course of the disease leads to taking quite rapid decisions. related to the previous question, in the stratification or triage of sick patients to maximize health resources, do you use a functional scale, or frailty status scale, or dementia severity scale for clinical decisions? age of the patient itself has been the easiest parameter to obtain in an emergency to decide on allocation of care. it is wrong and we know it. unfortunately, our system does not yet consider more robust and reliable alternatives for measuring the resilience of the person. perhaps, we should have thought about nesting more geriatric principles (i.e., meaning of the disease construct at old age, importance of functions) in other specialties. the simple adoption of the clinical frailty scale measuring the pre-illness status of the patient might have already represented an important parameter in order to take better decisions. (3) (4) (5) mmo: how does a covid unit look like in italy for geriatricians? a covid unit is very far from our usual geriatric world. the communication between health-care professionals and patients is extremely limited by the personal protective equipment (ppe), as well as by the patient's clinical conditions and respiratory devices. the unit environment is not age-friendly; its design is not oriented to individuals with sensory deficits or cognitive and/or mobility impairment. these units are busy, noisy, and only distinguish the "dirty" areas from the "clean" ones. family members are not allowed to enter the unit. therefore, patients have no contact with them, and family members are usually not receiving news of their relatives. for this reason, we have volunteers who are regularly keeping families updated about the status of the patients over the phone. we try to maintain such contacts, knowing that the worst thing happening with covid is the isolation of the person. mmo: how is the situation in long-term care facilities? do you have any recommendations to provide-particularly in this setting? figure 2. percentage of clinical presentation of patients who tested covid-19-positive mc: long term facilities have initially tried to contain the diffusion of the virus within their facilities by reducing/ closing admissions from the hospitals. suspected cases have been isolated and/or sent to the emergency units in order to guarantee the safety of the rest of the residents. the work in long-term care is not easy these days, also because resources to test patients (and personnel) remain limited. there have also been limitations in some cases of protected personal equipment's (ppes). just in these last few days, the who has released recommendations for the management of covid in long term care. (https://apps.who.int/iris/bitstream/handle/ 10665/331508/who-2019-ncov-ipc_long_term_care-2020.1-eng.pdf) (6) medication access for older adults mmo: as many older adults suffer from chronic conditions requiring medication, the question of how medication access is being managed is of paramount importance. how are you managing medication access to older patients with chronic conditions? mc: outpatient clinics were closed at the very beginning of the coronavirus outbreak. only visits that could not be postponed or that met urgency criteria were maintained. a lot of older persons have found themselves completely isolated from medications, but also from the simple access to groceries. in this scenario, consider that general practitioners have found themselves in huge difficulties (shortage of ppes, a lot of cases of covid, some even died). the consequent shortage of primary care physicians has further complicated things. frail older persons with chronic diseases will likely pay a huge toll for this coronavirus pandemic, even if not directly infected by it. this emergency situation has destroyed our already weak integration of care services, critical for the health of frail individuals. mmo: an additional fact is that the case mortality rate is higher in older adults, but particularly in those with cardiovascular disease, hypertension, and diabetes or having more than three comorbidities ( table 2 ). it has been suggested that angiotensin-converting enzyme 2 (ace-2) inhibitors may explain the higher risk and severity of the disease in older adults (7) because they increase the up-regulation of ace-2 receptor expression-the receptor that the sars cov-2 virus uses to enter the human cells. (7) are clinicians changing the ace-2 inhibitor medication in their patients for another medication such as calcium channel blockers? mc: there have been many news items around about the positive or negative effects of certain medications in face of the covid. to my knowledge, most of the clinicians have not changed the prescriptions of cardiovascular drugs of their patients, also given the recommendations from the american heart association, the heart failure society of america, and the american college of cardiology. another news item was related to a possible association of ibuprofen to negative outcomes in covid cases. this led to the suggestion of using paracetamol over ibuprofen. in this other case, the who explained that the news was not supported by evidence and discouraged the non-utilization of ibuprofen. is there something else that you want to add? mc: thank you, manuel, for reaching out and i hope our experience will help canadian geriatricians and health-care workers dealing with older adults during this overwhelming pandemic. we are in uncharted territory. 1. older adults present the highest mortality rate in this pandemic, in the italian epicenter and worldwide. 2. clinical presentation in older adults with severe illness is quite sudden; patients can develop severe hypoxemia and need ventilation support in very few hours. 3. geriatric syndromes are overlooked as a form of presentation of covid-19 severe illness, being this dominated by severe respiratory symptoms. 4 . stratification by frailty level may help to early detect the most vulnerable. 5. decision concerning health-care utilization resources should not be taken based only on age itself or isolated diagnoses, such as the presence of dementia; rather, advanced directives or functional/frailty stratification may be considered. md: bloomberg school of public health clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances a global clinical measure of fitness and frailty in elderly people the frailty phenotype and the frailty index: different instruments for different purposes clinical frailty scale in an acute medicine unit: a simple tool that predicts length of stay infection prevention and control guidance for long-term care facilities in the context of covid-19: interim guidance are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? the authors declare that no conflicts of interest exist. key: cord-329344-06uk5sjp authors: neumann-podczaska, agnieszka; al-saad, salwan r; karbowski, lukasz m; chojnicki, michal; tobis, slawomir; wieczorowska-tobis, katarzyna title: covid 19 clinical picture in the elderly population: a qualitative systematic review date: 2020-07-23 journal: aging dis doi: 10.14336/ad.2020.0620 sha: doc_id: 329344 cord_uid: 06uk5sjp the sars-cov-2 tendency to affect the older individuals more severely, raises the need for a concise summary isolating this age population. analysis of clinical features in light of most recently published data allows for improved understanding, and better clinical judgement. a thorough search was performed to collect all articles published from 1st of january to 1st of june 2020, using the keywords covid-19 and sars-cov-2 followed by the generic terms elderly, older adults or older individuals. the quality assessment of studies and findings was performed by an adaptation of the strobe statement and cerqual approach. excluding duplicates, a total of 1598 articles were screened, of which 20 studies were included in the final analysis, pertaining to 4965 older covid-19 patients (≥60 years old). variety in symptoms was observed, with fever, cough, dyspnea, fatigue, or sputum production being the most common. prominent changes in laboratory findings consistently indicated lymphopenia and inflammation and in some cases organ damage. radiological examination reveals ground glass opacities with occasional consolidations, bilaterally, with a possible peripheral tendency. an evident fraction of the elderly population (25.7%) developed renal injury or impairment as a complication. roughly 71.4% of the older adults require supplementary oxygen, while invasive mechanical ventilation was required in almost a third of the reported hospitalized older individuals. in this review, death occurred in 20.0% of total patients with a recorded outcome (907/4531). variability in confidence of findings is documented. variety in symptom presentation is to be expected, and abnormalities in laboratory findings are present. risk for mortality is evident, and attention to the need for supplementary oxygen and possible mechanical ventilation is advised. further data is required isolating this age population. presented literature may allow for the construction of better predictive models of covid-19 in older populations. aging and disease • volume 11, number 4, august 2020 989 the elderly and geriatric population are amongst the highest risk patients for severe complications as a result of covid-19 [1, 2, 3, 4, 5] . early data has shown that individuals > 59 years of age are estimated to be 5 times more likely to die following the onset of covid-19 symptoms as compared to those between the ages of 30-59 [6] . early recognition of at-risk older patients and awareness of potential atypical clinical presentation in the older population becomes vital to circumvent lethal complications. to date, the collection of clinical parameters and comprehension of the covid-19 infection and how it may present in older individuals is limited. such understanding becomes key in guiding clinical judgement and may allow for better preparation of health care professionals yet to face the disease. in the following study, we constructed a systematic review to concisely summarize the clinical features, comorbidities, radiological/laboratory findings, and outcomes in the older adults. data for the current therapeutic approaches currently being used was also collected. systematic search was performed for articles published between january 1, 2020, and june 1, 2020, using the primary databases pubmed and sciencedirect. to ensure greater coverage of literature, complementary databases such as wiley online library and google scholar were also used, with no restriction to language. the keywords covid-19 or sars cov 2 were followed by each of elderly or older adults or older individuals independently during the search of literature. studies were also collected from brief screening of reference lists of high relevance articles. due to large search results and overlap of studies, the complementary databases were screened with more strict search settings (such as the necessity of "covid 19" or "sars cov 2" presence in the title and presence of at least one of "elderly" "older adult" "older individuals" in the article text or abstract). such limits were not implemented in the search of primary databases (pubmed and sciencedirect). following removal of duplicates and to ensure quality of standard selection, the two researchers who completed the literature search performed an initial screening of the collected articles independently [7] . papers such as guidelines, public health advice, psychological studies, surveys, genetic and viral studies (oriented to pathogenesis and mechanisms or other serotypes) were all excluded based on brief view of the paper, abstract, and title. once relevant articles were isolated, the two reviewers further independently assessed full text eligibility based on few major, yet strict, criteria. only older individuals (≥60 years old) with confirmed sars-cov-2 infection were of interest in this review, hence any study that did not clearly separate the data according to this age bracket was excluded. calculations were made to ensure that the interquartile range (iqr), standard deviations (sd), and ranges mentioned in any study indeed fit the age criteria. study populations with iqr, sd, or min/max range that include patients of <60 years of age were excluded, unless the paper explicitly stated that the participants were ≥60 years old. retrospective studies (descriptive, case reports, case series, case-control, cross sectional studies) and cohort studies were included, except in cases where unique conditions were considered to possibly influence the disease presentation and data. this includes patients with extremely unique underlying diseases, following extensive medical treatment for certain comorbidities, or clinical trials of drugs. any studies with only few reported data were considered on an individual basis and excluded or included accordingly. considering the descriptive nature of this review, studies with larger sample sizes were deemed more valuable, therefore studies with only ≤ 2 older patients were excluded. review articles and other systematic reviews were assessed for reference list relevance, however the review articles themselves were excluded. results that may disproportionately sway the incidence rates due to sums of patients irreflective of the general population were also isolated. any disparities concerning the studies were settled by means of discussion and eventual consensus between all the reviewers. initial search of databases revolved around identifying and isolating the number of search findings, followed by the exclusion of duplicates. once this was established, two independent reviewers screened the studies for general relevance to the review topic. studies with unrelated subject matter or studies with indirect relevance (incorrect study population) were then excluded. next, the remaining studies were assessed more thoroughly for eligibility. at this stage, closer assessment for inclusion/exclusion criteria was performed (criteria mentioned in "selection and eligibility"). discussion and eventual consensus were reached between reviewers regarding the final included studies. once the relevant studies were isolated, the two reviewers extracted the data independently into a standardized form with the following subheadings: paper aging and disease • volume 11, number 4, august 2020 990 information (such as publication date, number of patients, country, and gender), symptoms, comorbidities, laboratory findings, radiographic findings, complications, treatment, and outcome. to better reflect current literature, all the data and all the variables accessible from the studies concerning covid-19 patients ≥60 years old was extracted into the forms. if a study had relevant data merged with age groups <60 years old, that data was not included. cross checking and discussion was then performed concerning the 2 forms, with 3rd reviewer involvement in occasional differences. consensus was reached regarding variables to include within subheadings. all the data is relative to date of publication, no follow up on cases was performed. concerning data synthesis in tables, all the subheadings, besides laboratory findings, included incidence data in the form of a percentage (%), with or without the number of patients. the use of incidence percentage to describe the data facilitated easier visualization of patterns within subheadings. percentage of involved patients was calculated based on total patients ≥60 in the respective study. when finding a combined percentage for multiple studies, incidence was added and divided by the total study populations (≥60 years old) included. as for case series, where results of patients were presented individually, median and interquartile range (iqr) was calculated for the pertinent subpopulation. the quality assessment of the individual studies was performed using an adaptation of the strobe (strengthening the reporting of observational studies in epidemiology) statement [8] . the elements scrutinized the most included study population demographic and characteristics, eligibility, methodology and methods of attaining data, duration of follow up, possible source of bias (particularly selection bias), and incomplete or missing data. implementing the cerqual approach [9] , the review findings were then given a transparent confidence score based on combined qualitative assessment of contributing studies, taking into consideration any relevant limitations. this allows for better judgement of findings based on allocated confidence. components analyzed include methodological limitations, coherence of results, adequacy and sufficiency of data, as well as aligned relevance to review topic. four levels of confidence in findings were utilized: high (highly likely that review findings is a reasonable representation of phenomena), moderate (likely that review findings is a reasonable representation of phenomena), low (it is possible that review findings is a reasonable representation of phenomena), and very low (it is not clear whether the review finding is a reasonable representation of phenomena). initial search of databases showed 4262 findings, which yielded 1598 articles when excluding the duplicates. of those articles, 222 were considered relevant based on screening of title, abstract and brief view of content. 1376 studies were excluded due to unrelated subject matter (psychological studies, surveys, virological/gene-related studies, mechanisms and pathogenesis), study type (guidelines, reviews), or incorrect study population (children, adolescence, adults <60 years old). following individual assessment of the 222 studies, twenty met the inclusion criteria, in which 2 were retrieved from screening of reference lists. all relevant studies were retrospective in nature. most studies were excluded due to improper separation of covid-19 patients ≥60 years old or insufficient data presentation (fig. 1 ). aging and disease • volume 11, number 4, august 2020 991 hdc [18] . few other comorbidities with less than 5% incidence were also reported ( table 1, table 4 ). out of the 20 articles, only 9 reported radiological findings for the older individuals [12, 14, 15, 18, 20, [22] [23] [24] 26] . the nine studies totalled 402 patients. the most common description reported was ground glass opacities (ggo) ( table 4 ). studies comparing data from solely dead vs discharged patients, were excluded from review estimation of mortality rate due to unclear total hospitalized elderly covid-19 population [13, 25] . limited studies reported hospital stay duration [10, 14, 24, 26, 27, 29] . the shortest median hospital stay duration was 4.5 days with the longest being 28 days [10, 29] . despite difficulty in assessing coherence due to limited data, the majority of studies reported a median hospital stay duration between 10 to 23 days [14, 24, 26, 27] . the laboratory findings of 1194 patients were reported [10] [11] [12] [13] [14] [15] [16] [17] [18] 24, [26] [27] [28] . the majority of the results were presented as median (iqr), except for cheng b et al. as mean and sd [13] . lymphopenia (<1.1 x 10 9 /l) was observed in a considerable amount of the studies, as was occasional thrombocytopenia (<150 x 10 9 /l). moreover, the median/mean c-reactive protein and esr were evidently elevated in the patients, with majority reporting levels >10 mg/l and >35 mm/h respectively. only 3 studies reported il-6 levels [10, 14, 25] . sun h and colleagues found elevated il-6 levels (median of 75.5 with an iqr of 35.2-162.2) in the deceased elderly patients [25] . few studies also reported higher levels of ldh (>300 u/l) and d-dimers (>1.0 mg/l). hepatic and cardiac markers (alt/ast and cardiac troponin) were mainly within normal range, while some studies showed slightly abnormal renal markers (creatinine and bun). additional laboratory findings may be found in table 2 . aging and disease • volume 11, number 4, august 2020 999 despite only 9 studies reporting complications, the results pertained to 3241 patients [10, 12, [15] [16] [17] [18] 24, 26, 29] . renal impairment/injury was the most prominent complication with an incidence rate of 25.7%. the second and third most commonly reported complications were co-infection (4.9%) and hepatic impairment/injury (4.5%). moreover, roughly 126 patients (3.9%) developed ards according to the data. cardiovascular related complications, such as acute heart injury (2.4%), cardiac insufficiency (1.8%), and arrhythmia (1.1%) were also reported ( table 3, table 4 ). in order to better reflect the current use of therapeutic approaches, in the summary table (table 4 ) treatment was separated into studies which documented relevant drugs used (9 studies -476 patients) [11, 12, 14, 15, 17, 18, 24, 26, 28] , studies with mention to supplementary oxygen use (9 studies -1424 patients) [11,14-16, 18,21,24,26,27] , and studies with announced information concerning mechanical ventilation (10 studies -4018 patients) [12, 14, 15, 17, 18, 21, 24, 26, 27, 29] . treatment approaches implemented in less than 5% of patients can be observed in table 3 . unspecified antiviral use was the most commonly reported therapeutic approach (330/476-69.3%). lopinavir/ritonavir was the most common type of antivirals used (12.8%), followed by umifenovir (10.3%), and some cases documented the use of oseltamivir (1.1%) and ribavirin (0.8%). unspecified antibiotics were also amongst the most common treatments administered (41.8%). almost twenty to thirty percent of patients additionally received interferon therapy (20.6%), glucocorticoids (22.5%), and supplementary immuneglobulins (28.2%). all, except 1 study, reporting drug treatment originated in china. from 9 studies that recorded the use of supplementary oxygen, 1020 older patients out of 1424 (71.6%) required the administration of inhalant oxygen [11, [14] [15] [16] 18, 21, 24, 26, 27] . 7 out of the 9 studies recorded the need for supplementary oxygen in >80% of their elderly covid-19 population [11, 14, 15, 18, 24, 26, 27] . a concise breakdown per study can be observed in table 3 . mechanical ventilation data was additionally extracted into table 3 and summarized in table 4 . roughly one in three (33.5%) older patients with reported respiratory status (10 studies -4018 patients) required invasive mechanical ventilation (mv) [12, 14, 15, 17, 18, 21, 24, 26, 27, 29] . non-invasive mv was recorded to a lesser extent in 2.4% of the patients. other notable treatments, including renal replacement therapy (rrt) and traditional chinese medicine, was implemented by <5% of patients and can be referenced in table 3 . the summarized review findings and their qualitative confidence levels, presented as per cerqual approach, can be found in table 5 . the studies were mainly observational and descriptive in nature. methodological limitations were noted to varying extents, amongst which selection bias was the most prominent due to 8 studies admitting mainly serious cases, including 1 study that solely revolved around icu patients [10, 11, 14, 15, 21, [25] [26] [27] . the data was the thinnest in relation to radiological findings and current use of treatment. due to urgency of the current situation, the majority of studies reported a short follow up duration of <1 month. as such, an estimated 50.5% of the patients were still hospitalized as of date of publication. such limitations may hinder the accuracy of outcome data (mortality rate) and complications. the highest coherence in results was found in symptoms and comorbidities, followed by laboratory findings. with 14/20 studies originating from 1 geographic region (china), there are concerns for lack of international representation of data, especially pertaining to current use of treatments. the combination of short duration of studies, novelty of subject, large hospitalized population, and studies being largely from homogenic regions, no high confidence was allocated. aging and disease • volume 11, number 4, august 2020 1002 less common: minority of studies reported patients with chronic renal, hepatic, cerebrovascular disease or malignancy. elderly covid-19 patients with a variety of other immune, endocrine, nutritional, and neurological comorbidities were also occasionally reported. description: ground glass opacities (ggo) was the most commonly reported observation in radiological imaging of older covid-19 patients. also, isolated consolidations or in combination with ggo were, to a lesser extent, documented with occasional cases of pleural effusion. few patients demonstrate normal imaging findings. low 4 studies with minor to moderate methodological limitations. gaps and inconsistency in reporting of radiological findings was observed. inadequate data, pertaining to only 402 elderly covid-19 patients. moreover, only 2 studies originating from regions other than china (israel and italy), which raises concern for lack of geographic diversity. insufficient reported radiological findings clouds coherency judgement, however reasonable coherence can be seen from preliminary data. 12, 14, 15, 18, 20, [22] [23] [24] 26 distribution: adults ≥60 years old experience multiple lobe involvement in a bilateral distribution mainly. with primary data showing peripheral tendency of covid-19. almost half of total patients were still hospitalized as of date of individual study publication. however, hospitalized elderly covid-19 patients with clear outcome show an evident risk for mortality. majority of studies show an estimated mortality rate of >15%, with the total combined mortality rate being close to 20%. hospital stay duration ranges from a few low 14 studies with minor to significant methodological limitations. possible selection bias due to hospital admission of mainly serious cases was noted in 7 studies, and in 1 study involvement of strictly icu patients was observed. the dynamic nature of the situation led to short follow up time 10-12,14,15, 18 -21, 24, 26-29 aging and disease • volume 11, number 4, august 2020 1003 days to few weeks, with a common median of hospitalization being >10 days. by majority of studies, which raises concerns for inadequacy of data. reasonable coherence. lymphopenia (<1.1 x 10 9 /l) and elevated inflammatory markers, crp (>10 mg/l) and esr (>35 mm/h), are commonly observed in the elderly covid-19 patients. occasionally, thrombocytopenia (<150x10 9 /l), higher levels of ldh (>300 u/l), d-dimers (>1.0 mg/l), and renal markers (creatinine & bun) can be seen. other markers indicating organ damage, such as hepatic or cardiac, are mainly within normal range. il-6 was an underreported biochemical variable. moderate 6 studies with minor to moderate methodological limitations. minor concern for underlying comorbidities, baseline health, and associated medication use influence on results in 3 studies. relatively adequate data pertaining to 1194 elderly covid-19 patients. overwhelming majority of data stemming from one geographic region (china), raises concern for lack of diversity. moderate to high coherence. 10-18, 24-26, 28 besides a risk for secondary infection or ards, older covid-19 patients are prone to renal injury over the course of the disease. hepatic injury and cardiovascular related complications (including cardiac insufficiency or arrhythmia) can be observed to a lesser extent. low 7 studies with minor to significant methodological limitations. 3 studies admitted mainly severe cases of covid-19, raising concern for potential selection bias. 6 as of date of publication, more than 7 million people have been infected by sars-cov-2 worldwide. the virus continues to spread, and it has become crucial for health professionals to familiarize themselves with disease presentation in different age populations, amongst which the older individuals are at high risk. to our knowledge, this is the first systematic review to focus strictly on covid-19 patients ≥60 years old, in an attempt to comprehensively and concisely describe the clinical picture in this age group. due to the novelty of sars-cov-2 pandemic, the majority of studies, post selection criteria, mainly predominated patients from china. studies from the usa, israel, italy, and france were also selected. 2 studies provided information on a more age homogenous group of patients (70 years in age and greater) [11, 18] with the remaining 18 studies having a greater age distribution (60 years and greater) of elderly patients. out of 20 studies, 18 specified the gender of the patients of which a clear majority was male (1442 male vs 804 female). this coincides with other reported studies, where a pattern of males being more prone to covid-19 infections is observed [30] . according to our systematic review of literature, the older adult population experience a spectrum of disease presentation. a high coherence was observed between studies in terms of reported symptoms and their incidence. while a majority of older individuals presented with common symptoms such as fever and cough, approximately 15% to 25% of older individuals also present with concurrent respiratory related symptoms such as dyspnea, sputum production, or chest tightness. various reports have compared these concurrent symptoms between older and younger populations, and some significant differences have been observed [12, 14, 15, 19, 22] . older adults also presented a large variety of symptoms including fatigue, with or without myalgia, gastrointestinal symptoms (diarrhea, nausea/vomiting, abdominal pain), anorexia, headache, dizziness, and others. wang l et al. found that presence of dyspnea, low lymphocyte count, or cardiovascular and lung comorbidities in the elderly population were all factors predictive of worse disease progression [10] . however, further research is required to analyze the association of such symptoms to outcome. in general, the laboratory findings in the covid-19 elderly population revealed lymphopenia, elevated inflammatory markers (crp and esr), as well as elevated ldh and d-dimers. few studies also showed thrombocytopenia in the patients [14, 16, 17] . when compared to younger populations, liu k and colleagues demonstrated that older covid-19 patients (≥60 years old) had significantly lower lymphocyte proportion as well as significantly higher crp levels [15] . chen t et al. further demonstrated this difference by comparing 148 younger covid-19 patients (<65 years old) to 55 elderly covid-19 patients (≥65 years old) [14] . in their study, findings of lymphopenia and higher levels of crp were present in older individuals, as well as significantly larger proportion of the elderly population experiencing elevated hepatic injury markers (alt/ast), renal injury marker (creatinine), inflammatory markers (il-6, procalcitonin, and esr), ldh, and d-dimers. such differences in biochemical markers in older adults, as compared to the young populations, illustrate the potential for more grievous organ damage caused by the sars-cov-2 infection. in a retrospective analysis of almost 120 older patients (≥60 years old), cheng b et al. showed that monitoring levels of d-dimers, ldh, albumin, urea nitrogen, and nlr can be used to early recognize severe cases of older covid-19 patients [13] . hospital stay duration, explicitly for the older covid-19 population, was reported by 5 out of 20 studies reviewed [10, 14, 24, 26, 27] . the shortest time for hospital stay was recorded at 4.5 days (2.7-7.2) with the longest stay duration of 28 days (15-28) before discharge. an important notion to consider is the origin of patients and their health status when admitted into the hospital. patient symptoms ranged from mild to severe with certain studies focusing mainly on severe patients. as a result, collected hospital stay duration data may not reflect the true nature of covid-19 infection and patient treatment aging and disease • volume 11, number 4, august 2020 1005 response. additionally, only 1 study provided information with respect to the duration from onset of symptoms to the negative test confirmation of rt-pcr, for confirmatory clearance of the covid-19 infection [14] . guo t and colleagues revealed a median of 18 days (14-25) from symptom presentation to a measure of negative presence of the viral infection, providing evidence for ethical discharge [24] . even due to the low volume of studies providing rt-pcr covid-19 detection and hospital stay duration information, preliminary case study reports do reflect a similar time period of disease onset and progression [31] . furthermore, yuan y et al. described 4 dynamic cases of recovered elderly covid-19 patients (tested negative on rt-pcr), who eventually shifted and tested positive for virus rna again [28] . such phenomena indicate the need for further research analyzing the possible propensity of certain older adults to experience remission, and its significance on prognosis. studies isolating the older populations can help illuminate the progression of covid-19 and its estimated timeline in the elderly population. radiological findings were under-reported in our included studies, raising concerns for inadequacy of data for conclusive findings. however, the primary data showed reasonable coherence, documenting mainly ground glass opacities (ggo), in some cases with consolidations, affecting multiple lobes in a bilateral distribution. tendency for peripheral distribution and involvement of middle and lower lung was also described [20, 22, 23] . studies by liu k et al. and chen z et al. revealed that the older population, when compared to younger populations, demonstrate more prominent radiological changes [15, 23] . it is unclear whether such differences can be attributed to the overall immunological fragility of the aged adults or perhaps be linked to use of certain concurrent medications. the most common comorbidities amongst the elderly covid-19 population were hypertension, cardiovascular disease, diabetes, chronic lung disease (such as copd) and hypercholesterolemia. a high coherence was observed between studies, with data pertaining to over 2000 patients in total. despite being the most commonly observed comorbidity, schiffrin el et al. explained that hypertension, and its associated therapeutic drugs (ace inhibitors/arbs), are yet to show an association with the sars-cov-2 infection [32] . moreover, in a recent study by mehra mr et al., it was shown that underlying cardiovascular disease, copd, and current smoking were all associated with a higher mortality rate amongst hospitalized covid-19 patients [33] . their findings also concluded that hypertension, hyperlipidemia, and diabetes were not factors independently predictive of death in this disease. additionally, lippi g. and henry bm estimated that patients with copd were about five and a half times more likely to develop severe infection due to sars-cov-2 [34] . given that comorbidities in older individuals act as detrimental prognostic factors, careful attention to underlying disorders and their association with sars-cov-2 infection, through up-todate scientific literature, is necessary to avoid worse prognosis [35] . due to novelty of the subject, combined with short follow up time, a significant proportion of the older covid-19 patients were still hospitalized as of day of publication of studies. such limitations lead to a restricted assessment of the full extent of complication development in the elderly population. from 9 included studies, [10, 12, [15] [16] [17] [18] 24, 26, 29] the distribution of complications revealed renal impairment/injury to be of highest prevalence, developing in almost 25% of older individuals with the sars-cov-2 infection. subsequent complications included secondary infections, hepatic impairment/injury, ards, and cardiovascular related complications (acute heart injury, cardiac insufficiency, arrhythmia). a considerable variability amongst studies was noted, raising concerns for coherence and validity of findings. currently, to the authors' knowledge there is no supporting literature, with respect to covid-19 mechanisms of injury on kidney or hepatic systems. however, some suggested mechanisms include the virus causing direct cellular damage, or perhaps injury due to a triggered cytokine storm [36] . renal and hepatic complications can further exacerbate the clinical prognosis, leading to more complicated treatment plans, longer hospital stays, and higher chances for mortality [37] [38] [39] . such detrimental consequences raise the need for further research on the association between the renal and hepatic systems with the sars-cov-2. further understanding can allow for more effective preventative measures, and also provide a different perspective on covid-19 multi-organ effect and its process in this age group. besides the inadequacy of data, eight out of the nine studies with reported treatment originated from 1 geographic region (china), resulting in extremely limited international representation data. nonetheless, a large proportion of observed patients received antiviral therapy, of which umifenovir and lopinavir/ritonavir were most commonly specified. interferon, immunoglobulins, antibiotics, and glucocorticoids were also therapies being applied, usually in different combinations. only one study reported the use of chloroquine [28] . keeping in mind the incidence of renal complications, a proportion of the elderly covid-19 patients also received renal replacement therapy (rrt). it was reported by graselli et al. that 73.7% (709/961 patients) of older covid-19 patients (≥61 years old) admitted to the icu required mechanical ventilation [21] . on the other hand, when aging and disease • volume 11, number 4, august 2020 1006 describing 5700 patients in new york city (of which 2582 were ≥65 years old), richardson s. and colleagues had an estimated 21.6% (558/2582) of older individuals requiring invasive mv. the total proportion of the elderly population in our review that required invasive mv was 33.4% (1344/4018), however this includes icu patients, and as such the numbers can be partially overestimating the general incidence [21] . the epidemiological history and mode of infection of the elderly patients may carry important clues to patterns of disease presentation and spread. seven studies within this review included patients from the wuhan province, china, however only 1 described the mode of virus contraction [18] . additionally, six other studies characterized the epidemiological history of the older covid-19 population, all within the region of china [12, 17, 19, 23, 28, 24] . direct or indirect contact with infected individuals from wuhan, usually via family clusters, was the main mode of transfer in included patients. mi b et al. described covid-19 nosocomial infection of some older patients hospitalized for fracture [18] . preliminary data from the united states has shown the vulnerability of old age/nursing homes as potential vectors for rapid covid-19 infection and spread [40] . the person-to-person contact within the nursing home environment seems to provide ideal conditions for older adult's infection. implementation of protective measures, especially within the elderly population, may prove extremely beneficial in mitigating the severe progression of covid-19 in the most vulnerable. more data is required from various geographic regions to further assess any association between mode of infection and covid-19 development in the older population. with the uninterrupted spread of the coronavirus, and many patients continuing to be hospitalized and battling the disease, collecting and accurately summarizing the outcomes in the elderly population becomes challenging. however, the preliminary numbers collected in this review, pertaining to 4531 patients, suggest that approximately one-in-five cases of covid-19 in older individuals will lead to death. similarly, few studies with considerable population sizes have also reported the range of mortality rate in the elderly population to be between 16% to 24% [10, 11, 29] . this is the most severe in any age group [14, 15, 21, 29] . several limitations were experienced throughout the construction of this systematic review. due to the novelty of the subject matter, sampling of data was limited to a relatively short time frame (1 st january to 1 st june 2020) and mostly included data originating from homogenous populations in articles stemming from regions of china. concerns of a possible bias may exist within data, reflecting certain demographic populations more than others. language barrier and limited search tools can lead to the possibility of undetected studies and missing reports within our search criteria. limited samples from other populations/country regions were found as of the date of conducting this review. furthermore, the selected studies were observational (retrospective) in nature. only hospitalized or older individuals with a definite outcome were analyzed in this review, this may lead to full clinical spectrum not being adequately represented. moreover, reviewed studies may have given priority to reporting of more severe cases in the attempt to provide a clearer picture of the infection. medical standards and economic conditions vary from region to region, this may further influence patient care and community outcomes. finally, the vetting process required the removal of samples that had results merged with other age populations (individuals <60 years of age), resulting in the exclusion of a significant proportion of available data. the purpose of this systematic review was to summarize the general clinical picture of sars-cov-2 infection in the elderly population. a large variety of symptom presentations can be observed, including respiratory, gastrointestinal, cardiovascular and neurological manifestations. abnormalities in inflammation related laboratory measures are also evident, and in some cases indicative of multi-organ involvement. development of renal complications and to a lesser extent hepatic and cardiac complications should also be monitored. further research is required to analyze possible patterns of disease presentation and effective treatment plans in older populations. presented literature can assist in the construction of better predictive models of covid-19 in older adults. covid-19 in elderly covid-19 infection in the elderly in french-speaking switzerland: an inventory of beliefs, convictions and certainties lower mortality of covid-19 by early recognition and intervention: experience from jiangsu province clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china clinical features of patients infected with 2019 novel coronavirus in wuhan severe outcomes among patients with coronavirus disease 2019 (covid-19) -united states estimating clinical severity of covid-19 from the transmission dynamics in wuhan, china meta-analysis of observational studies in epidemiology a proposal for reporting the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (grade-cerqual) coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up clinical features and short-term outcomes of 114 elderly patients with covid-19 in wuhan, china: a singlecenter, retrospective, observational study analysis of epidemiological and clinical features in older patients with corona virus disease 2019 (covid-19) out of wuhan clinical features predicting mortality risk in older patients with covid-19 clinical characteristics and outcomes of older patients with coronavirus disease 2019 (covid-19) in wuhan, china (2019): a single-centered, retrospective study clinical features of covid-19 in elderly patients: a comparison with young and middle-aged patients clinical characteristics of older patients: the experience of a geriatric short-stay unit dedicated to patients with covid-19 in france clinical and biochemical indexes from 2019-ncov infected patients linked to viral loads and lung injury characteristics and early prognosis of covid-19 infection in fracture patients clinical characteristics of older patients infected with covid-19: a descriptive study imaging findings in four covid-19 patients baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region, italy a comparative study of chest computed tomography features in young and older adults with corona virus disease high-resolution computed tomography manifestations of covid-19 infections in patients of different ages clinical characteristics of elderly patients with covid-19 in hunan province, china: a multicenter, retrospective study risk factors for mortality in 244 older adults with covid-19 in wuhan, china: a retrospective study short-term outcomes in individuals aged 75 or older with severe coronavirus disease (covid-19): first observations from an infectious disease unit in southern italy characteristics and clinical outcomes of adult patients hospitalized with covid-19 -georgia caution should be exercised for the detection of sars-cov-2, especially in the elderly presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area sex-and gender-specific observations and implications for covid-19 therapeutic potential of ciclesonide inahalation for covid-19 pneumonia: report of three cases hypertension and covid-19 cardiovascular disease, drug therapy, and mortality in covid-19 chronic obstructive pulmonary disease is associated with severe coronavirus disease 2019 (covid-19) comorbidity of five chronic health conditions in elderly community residents: determinants and impact on mortality the novel coronavirus 2019 epidemic and kidneys management of patients at risk of acute kidney injury evolving epidemiology and transmission dynamics of coronavirus disease 2019 outside hubei province, china: a descriptive and modelling study ace2 expression in kidney and testis may cause kidney and testis damage after 2019-ncov infection. medrxiv covid-19 in long-term care facilities: an upcoming threat that cannot be ignored this study received no funding or grant from any agency in the commercial, public, or not-for-profit organizations authors declare no conflict of interest. key: cord-259618-kl0aq0ut authors: de leo, diego; trabucchi, marco title: the fight against covid-19: a report from the italian trenches date: 2020-04-20 journal: international psychogeriatrics doi: 10.1017/s1041610220000630 sha: doc_id: 259618 cord_uid: kl0aq0ut nan our senior citizens are the most exposed to the consequences of the covid-19. frailty caused by comorbidities makes the advanced age of many people particularly vulnerable to the infection of this new coronavirus, the characteristics of which are still largely unknown to fellow scholars. what is clear is that older adults die more frequently than younger age groups, everywhere in the world. in the veneto region, 36.3% of individuals who died were 85 + years old, with the mean age of those who lost their lives to coronavirus being 81 years (regione del veneto, 2020). in the last days, italian citizens were hugely impressed by watching on television a long series of military trucks transporting the coffins of dead people away from their home places because there is no more room in the close cemeteries or opportunities for cremation. the mental health of our seniors is particularly challenged: they feel scared by the news and aware that, if infected, they would not receive the same attention (e.g. intubation, a bed in resuscitation unit, etc.) of younger individuals. older adults with mental health conditions feel more frail and vulnerable than before: contacts with carers are now reduced to the minimum, with loneliness and abandonment becoming an excruciating reality. checking on regular assumption of drug therapies may become problematic; eating properly and keeping with personal hygiene at a sufficient level can also be quite difficult. this may increase the sense of demoralization and despair in people. a few cases of suicide have been signaled by media (gazzettino, 2020) , but in the present chaotic situation, it would not be surprising if similar fatalities would remain mostly undetected. demented people are particularly exposed to the impact of covid-19; there are anecdotal reports from domiciliary care nurses and staff in nursing homes that cases of delirium are on sharp increase. this could be justified by the positioning of the virus in the central nervous system (li et al., 2020) . on the other hand, in the present situation, caregivers of people with dementia are also exposed to extra stress: limited opportunities to offer the usual level of care; food and cleaning management more problematic; worries and concerns for the possibility of contaminating an older adult that would not survive the disease; and, in a situation like the italian one, the many "badanti" (carers from eastern europe) without a regular contract (rugolotto et al., 2017) , now impeded to reach the home of the older adults they take care of because they are intercepted by the police at check points. while we are writing this commentary from italy (april 10th), it appears that the number of people tested positive to the virus in the united states has almost quadrupled the number of people found positive in our country; however, italy counts a disproportionately high number of deaths. chinathe country where everything reportedly originatedhas now smaller figures than those of the us, italy, spain, and germany. these countries, together, make more than one million people detected as infected (worldometers, 2020) . not much can be said about the reliability of these figures or their comparability. it is good to say that the numbers are based on subjects who tested positive to the swab. unfortunately, italy has lost the opportunity to keep reliable records of those subjects. so, it is not known what is the percentage of those who repeated the test several times but are represented as different individuals; equally unknown, because not standardized, are the criteria for which the tests were performed, if to patients with initial symptoms (fever? fever and coughing? fever, coughing, and dyspnea? what?); with "full-blown" clinical syndromes (severe symptomatology); to individuals potentially exposed by contiguity or direct contact (living in the same environment does not necessarily imply proximity or contact), etc. in essence, it is not known in which of these situations the swabs have been made. in this waywe believea big opportunity to study contagion modalities has been lost. each region of italy has run autonomous strategies to protect its citizens and counteract the disease. this has applied also to testrelated policies. thus, aggregating data from regions looks like a problematic, though unreliable, process. we were expecting tests to be performed to all health personnel of common health settings: from general medicine surgeries to protected residences (including those for older adults), to emergency departments, and to general hospitals. unfortunately, this elementary strategy to guarantee that health professionals were sufficiently protected toward the virus was not applied with due care, and up to date the number of doctors who died from the infection during their professional activity is unbearable (109 victims, at the time of writing). the number of other health workers who have lost their life is also tragically unbearable: 28. it has been reported that the costs involved in performing the tests in appropriate numbers (at least to all health professionals and people presenting with light symptoms) are too heavy, and the availability of skilled technicians and reagents for carrying out the tests is scarce. in italy, and probably elsewhere, nothing is and will be like before the pandemic. for the moment, we must overcome the crisis, but there could be a lot to say, on a clinical level, on that of the organization of services, and on how to protect the life of our older adults. the latter have been too affected by imprudent and superficial colleagues to feel accepted by the community again; in a few days, in deciding if the death was "by coronavirus" or "with coronavirus," we have undone decades of geriatric education, but above all, we have destroyed a fundamental relationship of trust. how will we approach patients if they are now convinced that today we ask for their age to make critical decisions (intubation) and maybe tomorrow the administration of expensive drugs? a discrepancy between the gift of a long life and public acceptance of older adults is increasingly noticeable and clearly expressed by the deprecated document on "damages caused by longevity," which christine lagarde (now the president of the european central bank) spoke about a few years ago (2012): "old people live too long and this is a risk for the global economy. we must do something, urgently." the scenario we are witnessing today is characterized by different situations in which people affected by covid-19 are forced to live. the main ones are schematically summarized below, even if there are significant differences, related to the different organization of services in the regions: a. older adults who remain at home even when the first symptoms appear are entrusted in most cases to themselves and to the care of their loved ones. family doctors are afraid; they tend to block visits, and families do not call emergency services because they fear seeing the family member get on the ambulance and not being able to greet him/her before they die. so they keep the sickespecially if a seniorin their homes, assist them with fear and affection until the negative or positive resolution of the clinical picture. there is no mention of swabs or blood chemistry analyses, let alone ct or other scans. our fellow citizens risk ending their lives without even being told what is happening to them. many seniors live alone; many have limited or no familiarity with the internet and are poorly connected with other family or community members (newman and zainal, 2020) . some die in complete isolation and their corpses are discovered many days after death (gazzettino, 2020) . b. in the last couple of months, the people who live in nursing homes have been completely forgotten by administrative powers. frail older adults are certainly the subjects who have suffered the most from the difficulties of the italian health system. in cities of lombardy such as bergamo and brescia, the deaths have followed at an impressive rate giving rise to sad images in the televisions of the italians of long lines of military trucks carrying coffins to incinerators, often very far from the place of origin of the deceased. as reported elsewhere (trabucchi and de leo, in press) , in just 20 days, in the nursing homes of the province of bergamo (lombardy), which have a total accommodation capacity of 6,400 beds, there were more than 600 deaths, which is a hecatomb. the real dimensions of the phenomenon will only be known after some time; it is probable that the number of infected people is far greater than that officially reported. it is also likely that the number of deaths is far greater than that officially attributed to covid-19. no attention was paid to those who manage the residences, no support in terms of means of protection, the possibility of making swabs, or even economic support in the face of damage caused by the release of beds caused by the death of guests. the access of new guests has been blocked, but the residences are increasingly pressed to admit elderly people discharged from hospitals. the staff is exhausted, as a consequence of heroic commitment. in small communities, the warmth that stirs around the residences compensates for the solitude of guests and operators, but this is not the case in large centers, where the bigger turnover of personnel makes the atmosphere more impersonal. in any case, since doctors and other operators get sick in rapid progressionand despite the extreme commitment of those on dutyguests feel progressively more fearful and abandoned. c. in italy, hospitals are at the center of the covid-19 cyclone: the attention of the media and the whole nation is focused on them. schematically, the hospital system moves according to this model: (a) the emergency department, where patients arrive after days spent at home, sometimes already exhausted by the disease. it is rarely possible to send them back home: in most cases, they are kept under observation, waiting for a bed; (b) resuscitation units, where patients are intubated and followed mainly by doctors specialized in anesthesia and resuscitation; and (c) departments where patients are treated with oxygen therapy (with different levels of intensity) and checked for overall health conditions, including psychological problems. at this point in time, all remaining wards for the management of the diseases that "normally" refer to hospitals are in progressive reduction. to cope with the emergency, resuscitation units were built in record time, and entire hospitals were reconverted into the care of covid-19. unfortunately, the pandemic has found the country largely unprepared and unable to provide the necessary protection in time even to its health workers, resulting in serious shortcomings regarding the supply of eyeglasses, masks, gloves, and gowns. as said, this has resulted in the loss of far too many health professionals' lives. the very serious difficulties in assisting critical situations, combined with the scarcity of places suitable for the reception of patients in severe conditions and the lack of a sufficient number of ventilators, have given rise to very painful ethical choices for health professionals on whom to privilege in the care with available equipment (rosenbaum, 2020) . d. from hospitals, patients are discharged when they achieve clinical recovery; they can return home, or to low-intensity "hotels," where they can manage themselves in isolation. the problem of older adults remains unsolved; often, after reaching clinical recovery, they show such a degree of disability that returning home is not possible, and it is difficult to resort to rehabilitation or long-term care facilities. the described picture seems to apply to many northern territories of italy. any criticism must be postponed; however, we seriously doubt that transferring people discharged from hospitals to rest homes may represent an appropriate choice. and certainly we should find a way to respond to those families that cannot accompany their loved ones to intensive care units and are left without any information and prognostic indication. this often means that the patients were kept too long at home, without effective tools to catch the signs of aggravation in time, which is frequently sudden and characterized by the discrepancy between symptoms and objectivity (e.g. oxygen saturation or temperature). the south of italy is generally less equipped than the north of the country, and grave concerns rest on a possible dramatic evolution of the next few days over there. social distancing and isolation remain at the moment the only strategies available to citizens. however, the latter need to feel supported by governments; mental health should soon regain a very high status on the agenda of all nations, especially if confinement at home expects to be very long, and financial, family, and relationship problems risk to aggravate a future now seen with serious concerns and deep anxieties. there are too many unanswered questions regarding the disease, and even the duration and quality of immunity post-infection remain a big question mark. while waiting for a vaccine to be ready, several protocols and drugs are being proposed by clinicians. noneat the momentappears as particularly promising. however, we remain confident that a serious and open collaboration among researchers, institutions, and countries across the globe will offer concrete hope for our future. for the time being, the mental health of people needs to be supported in any possible way. social distancing, loneliness, forced isolation, and fear of contracting the illness are all big challenges for the general population facing the expansion of the epidemic, but the risk of psychological consequences can be greater for the frail senior (armitage and nellums, 2020) . we need to activate all possible opportunities to offer help, at least in the form of tele-assistance, to our patients (krysinska and de leo, 2007) . psychological support should be made available to all via ngos and public services, with contact with psychiatrists and other physicians actively established. as much as possible, health professionals should contact their patients and make the continuity of care a reality as soon as possible. active outreach seems to be imperative, especially for older adults (de leo et al., 2002) , in order to counteract feelings of abandonment and disempowerment that covid-19 is imposing on all community members, especially to the most fragile ones. covid-19 and the consequences of isolating the elderly suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern italy e' contaminato" [coronavirus positive: 54-year-old businessman kills himself in the house. those tickets in front of the house telecommunication and suicide prevention: hopes and challenges for the new century presentation of the global financial stability report the neuroinvasive potential of sars-cov2 may play a role in the respiratory failure of covid-19 patients the value of maintaining social connections for mental health in older people daily reports on covid-19 facing covid-19 in italy -ethics, logistics, and therapeutics on the epidemic's front line how migrants keep italian families: badanti and the private care of older people nursing homes or besieged castles: covid-19 in northern italy coronavirus update live key: cord-253735-0wi67tuw authors: niu, shengmei; tian, sijia; lou, jing; kang, xuqin; zhang, luxi; lian, huixin; zhang, jinjun title: clinical characteristics of older patients infected with covid-19: a descriptive study date: 2020-04-10 journal: arch gerontol geriatr doi: 10.1016/j.archger.2020.104058 sha: doc_id: 253735 cord_uid: 0wi67tuw objectives: since the outbreak of 2019 novel coronavirus (covid-19), which has spread in the world rapidly. population have a susceptibility to covid-19, older people were more susceptible to have a variety diseases than younger, including covid-19 infection with no doubt. this study focused on older patients with covid-19 infection and analyzed the epidemiological and clinical characteristics of them. methods: we collected information on confirmed older patient transferred by beijing emergency medical service (ems) to the designated hospitals from jan 20 to feb 29, 2020. the information including demographic, epidemiological, clinical, classification of severity and outcomes. all cases were categorized into three groups and compared the difference between aged 50–64 years, 65–79 years and older than 80 years. results: 56.7 % of elderly confirmed patients were male, fever (78.3 %), cough (56.7 %), dyspnea (30.0 %), and fatigue (23.3 %) were common symptoms of covid-19 infection. classification of severity has statistically significant differences between the three groups, compared with middle-aged patients and aged 65–79 years group, older than 80 years group had significant statistical differences in contacted to symptomatic case in 14 days. as of feb 29, 38.3 % patients had discharged and 53.3 % patients remained in hospital in our study, the fatality of covid-19 infection in elderly was 8.3 %. conclusions: the covid-19 infection is generally susceptible with a relatively high fatality rate in older patients, we should pay more attention to the elderly patients with covid-19 infection. along with the outbreak of the epidemic of 2019 novel coronavirus , the number of older patients infected with covid-19 was increasing in the world and it brought a serious threat to life and health. a study in the new english journal of medicine (nejm) by guan reported the clinical characteristics of coronavirus diseases 2019 in china that the rate of older patients older than 65 years with covid-19 infection was 15.1 % (guan et al., 2020) , while the proportion of older than 80 years was 3 % reported in the jama by wu and mcgoogan (wu & mcgoogan, 2020) . it was proved that population including old people was generally susceptible, and the older patients with high infection rate and fatality (yang, yu et al., 2020) . unfortunately, the clinical characteristics of covid-19 infection in older patients is unknown. according to the world health organization (who) report, as of march 3, 2020, a total of 90,870 cases with laboratory-confirmed with covid-19 infection have been detected in the world (who, 2020). as a new disease and a new global health issue, covid-19 infection is understandable that its emergence and spread cause anxiety and fear among the older population. in addition, aging population has been one of the largest problems in many countries, and there were a higher prevalence of multimorbidity and lower resistance in older patients (feng, liu, guan, & mor, 2012; low et al., 2019) , no doubt, there are many old people who will face the risk of infected with covid-19 with the globalization and aging population, which imposing a heavy burden on the public and health care systems in the world. furthermore, the clinical clues that an infection might be present in an older person include fever and some obvious clinical signs, such as fever, cough, and rales, the elder patients may have typical or atypical presentations of infection as that described by the infectious diseases society of america (idsa) (high et al., 2009) , how about the covid-19 infection? given that, we collected the data on the 60 older patients infected with laboratoryconfirmed covid-19, described and analyzed the epidemiological and clinical characteristics of the older patients with covid-19 infection. we did a retrospective review of medical records from 60 older patients with covid-19 infection who was transferred from the general hospitals to the designated hospitals for special treatment infectious diseases by beijing emergency medical service (ems) from jan 20 to feb 29, 2020. a confirmed case was defined as a suspected cases with the laboratory test for the 2019-ncov virus from the respiratory specimens show positive result by means of real-time reverse-transcriptionpolymerase-chain-reaction (rt-pcr) assay, while a suspected case was defined as a case that fulfilled both the following criteria: clinical have fever, radiographic evidence of pneumonia, low or normal white-cell count or low lymphocyte count; and the epidemic history have a travel to wuhan or direct contact with patients from wuhan who have fever or respiratory symptoms within 14 days before illness according to the new coronavirus pneumonial diagnosis and treatment program (3id ed.) which were published by the national health commission of china. a mild case was defined as a confirmed case with fever, respiratory symptoms and radiographic evidence of pneumonia. while a severe case was defined as a mild cases with dyspnea or respiratory failure. only laboratory-confirmed covid-19 infection was enrolled in this study, laboratory confirmation of covid-19 was detected in the first admission hospital and verified by the local center for disease control and prevention (cdc). we collected the data on the demographic, epidemiological, clinical, laboratory tests, diagnosis types, cluster cases and outcomes of covid-19 infection in elderly patients, and categorized into three groups and compared the difference between middle aged 50-64years, aged 65-79 years and older than 80 years. if the data we need was missing, we directly communicated with ems providers. the study was approved by ethics committee of beijing emergency medical center (no.2020-01) and the written informed consent was waived. all statistical analyses were conducted using the spss software version 21.0. the continuous variables were expressed as mean ± sd and were compared with mann-whitney u test between two groups. percentages for categorical variables were analyzed using the wilcoxon test, although fisher's exact test was used with limited data. p < 0.05 was the threshold for statistical significance. there were 60 older patients and 81 middle aged patients identified as confirmed covid-19 infection in this study by feb 29, 2020. of them, 44 patients were categorized into aged 65-79 years group, 16 patients were categorized into older than 80 years group. 34 (56.7 %) patients were male, there were no significant differences between male and female in three groups (χ2 = 2.060, p = 0.151). 31 patients had medical history record information, including hypertension (15, 48.4 %), chronic obstructive pulmonary disease (copd) (9, 29.0 %), coronary heart disease (5, 16.1 %), diabetes (3, 9.7 %), cerebrovascular disease (2, 6.5 %) and other diseases (8, 25.8 %), there were significant differences between in three groups (χ2 = 8.164, p = 0.004) in medical history, especially copd in older than 80 years group were significantly higher than those in other two groups (χ2 = 12.024, p < 0.001). in this study, the most common symptom of diagnosed confirmed covid-19 infection in older patients were fever (47, 75 %) and other common symptoms were cough (34, 56.7 %), dyspnea (18, 30.0 %) and fatigue (14, 23.3 %) respectively. the body temperature of 13 (21.7 %) patients were less than 37.3 ℃, while 24 (40.0 %) were between 37 ℃ to 38 ℃, and 23 (38.3 %) were over 38 ℃ (table1). there were no significant differences in fever and highest temperature between the older patients and middle aged groups (χ2 = 0.006, p = 0.937), but there were significant differences in dyspnea and respiratory rate between two groups (χ2 = 14.597, p < 0.001).the difference in classification of severity between the two groups was statistically significant (χ2 = 17.31, p < 0.001), 32 (53.3 %) patients were classified as severe cases, including 13 patients older than 80 years, accounted for 81.3% in this group. both the number of patients with underlying diseases and the severe patients were increased as aging (fig. 2) . nearly half of the all cases contacted to symptomatic case in 14 days, and older than 80 years group had a higher proportion compared with aged 65-79 years and 50-64 years group (χ2 = 4.804, 0.028). the mean time from contact symptomatic case to illness onset was 7.4 days, from illness onset to visit hospital was 3.6 days, from visit hospital to defined confirmed case was 2.6 days. 36 (60.0 %) and 41 (68.3 %) patients were indigenous cases and clustering cases respectively. by the end of feb 29, 2020, 32 (53.3 %) older patients are still hospitalized, 23 (38.3 %) were discharged. 5 (8.3 %) patients died. however, the fatality in the aged older than 80 years group was 18.8 %, significantly higher than those in other two groups (χ2 = 7.413, p = 0.025) (fig. 1) . the covid-19 strokes and as emergencies continued to developing, the who declares global emergency on jan 31, 2020 (sohrabi et al., 2020) . older people are more susceptible to a variety of diseases than younger, of course, including covid-19 infection, which could dramatically increased the healthcare burden under the background of an aging society (kingston, robinson, booth, knapp, & jagger, 2018; rasmussen et al., 2017) . the entire population is susceptible to the covid-19, and the confirmed patients, asymptomatic carrier and people in the incubation period are contagious, it is difficult to control source of infection (yang & duan, 2020) , and most of the adult patients were old people, who had higher morbidity and case-fatality rate (sun, lu, xu, sun, & pan, 2020) . however, the clinical characteristics of covid-19 infection in older patients were not reported currently. in this study, to our knowledge, we firstly described and analyzed the epidemiological and clinical characteristics of the older patients with covid-19 infection and compared the difference between aged 50-64 years, aged 65-79 years and older than 80 years groups in beijing. in our study, the most common symptom were fever (78.3 %) and cough (56.7 %) in the older patients, which was same as the results of many studies (deng & peng, 2020; guan et al., 2020; wu, liu et al., 2020; yang, cao et al., 2020) . usually, the infected older patients initially have fever, fatigue, dry cough, and gradually appear dyspnea, some patients may develop acute respiratory distress syndrome (ards) and septic shock, even die (chen et al., 2020) . 40 % older patients have a fever, the body temperatures were between 37.3-38.0 ℃, and the body temperature of 38.3 % patients were higher than 38.0 ℃, only two patients were over 39 ℃, while not all old patients had fever, 21.7 % old patients were afebrile in our study, which may be caused by old populations with low immune function. the afebrile and low-grade fever, especially older patients, may increase the difficulty to identify and diagnosis covid-19 in clinical practice if too much attention was given to fever detection, the results same as that described by idsa. a research reported that the first death of covid-19 infection mostly occurred in old people, and developed quickly (wang, tang, & wei, 2020) . existing research found that the overall fatality rate of infected covid-19 was estimated 2 %-5 % (elisabeth, 2020; ji, ma, maikel, & pan, 2020; sun, qie et al., 2020; wu, chen, & chan, 2020; wu & mcgoogan, 2020; ) , however, the case-fatality rate were 8.0 % and 14.8 % in aged 70-79 years and older than 80 years patients respectively (wu & mcgoogan, 2020) . the case-fatality rate was 18.8 % of older than 80 years patients in our study, and higher than it mentioned in previous study, which was mainly for the older patients got the more underlying diseases as a result of the weaker immune functions. when old populations were infected with covid-19, prompting administration of antibiotics to prevent infection and strengthening of immune support treatment might reduce the case-fatality rate (chen et al., 2020) . our study found that number of older patients with underlying diseases were relatively susceptible to covid-19 and indicated that the infected covid-19 elderly with relatively high proportion of comorbidities, and the most common comorbidities were hypertension (48.8 %), coronary heart disease (16.1 %), copd (29.0 %), diabetes (9.7 %) and cerebrovascular disease (6.5 %) respectively, which was in accordance with previous studies (chen et al., 2020; yang, cao et al., 2020) . latest research stated that the older patients and among those with coexisting conditions had a higher morbidity and case-fatality rate (fauci, lane, & redfield, 2020; peng et al., 2020) . covid-19 confirmed older patients who were older than 65 years with comorbidities were at increased risk of death (yang, yu et al., 2020) in our study, severe patients were significantly more than mild patients in older patients, which was similar with recent study that patients have more severe symptom in elderly population (chan et al., 2020) . multiple factors lead to a higher proportion of elderly patients fig. 1 . distribution of outcomes of covid-19 infections by age. s. niu, et al. archives of gerontology and geriatrics 89 (2020) 104058 with severe situation, such as senior, comorbidities, low immune functions and so on. there is no doubt that old severe patients are more likely to die, therefore, the clinical treatment capacity need to improve to decrease the case-fatality rate of severe patients with covid-19 infection, and the elderly should be pay special attention. there was a 65year-old man who was afebrile and well, and noteworthy, he was an asymptomatic case, which is one of the particular features of our study. the proportion of contacted to symptomatic case in 14 days was significantly higher in aged older than 80 years group compared with the aged 65-79 years group in our study, which owing to the aged older than 80 years elderly were mostly accompanied by their families. familial cluster of infected with covid-19 have been reported in homes, especially without obvious symptoms. if the asymptomatic and mild cases cannot be found or ignored, they will spread the virus to others quickly. therefore, to identify and control the infected cases, as well as early quarantine for their close contacts, especially in families are important measures to prevent transmission of the covid-19 infection in older population. this study has some limitations. first, only the covid-19 confirmed older cases transferred by ems in beijing were included, the first admission to the designated hospitals cases were not enrolled, nor other provinces or cities which dominated by imported. it would be better to cover as wide population as possible to get more accurate results. second, the observation time of this study is 39 days, which is still short, many patients need time to further observed. however, this study represents characteristics of early stage of covid-19 confirmed elderly in beijing, which has practical significance for the control and research of the older patients. the older confirmed patients with covid-19 infection has a high proportion of severe cases, and the covid-19 infection is generally susceptible with a relatively high fatality rate in older population. we should pay more attention to the older patients. this study was supported by funding from beijing municipal science and technology project (z191100004419003). all authors declare to have no conflict of interest. fig. 2 . the distribution of mild, severe and medical history after covid-19 infection by age. s. niu, et al. archives of gerontology and geriatrics 89 (2020) a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study characteristics of and public health responses to the coronavirus disease 2019 outbreak in china covid-19 -navigating the uncharted china's rapidly aging population creates policy challenges in shaping a viable long-term care system clinical characteristics of coronavirus disease 2019 in china clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities 2008 update by the infectious diseases society of america potential association between covid-19 mortality and health-care resource availability. the lancet global health projections of multi-morbidity in the older population in england to 2035: estimates from the population ageing and care simulation (pacsim) model epidemiologic characteristics of multimorbidity and sociodemographic factors associated with multimorbidity in a rapidly aging asian country coronavirus covid-19 has killed more people than sars and mers combined, despite lower case fatality rate new coronavirus pneumonial diagnosis and treatment program clinical characteristics and outcomes of 112 cardiovascular disease patients infected by 2019-ncov cohort profile: the 1895, 1905, 1910 and 1915 danish birth cohort studies -secular trends in the health and functioning of the very old world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) clinical characteristics of 50466 hospitalized patients with 2019-ncov infection understanding of covid-19 based on current evidence updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan world experts and funders set priorities for covid-19 research the outbreak of covid-19: an overview clinical characteristics of imported cases of covid-19 in jiangsu province: a multicenter descriptive study characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention imaging and clinical features of patients with 2019 novel coronavirus sars-cov-2 analysis on the epidemic factors for the corona virus disease clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (covid-19):a multi-center study in wenzhou city clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study. the lancet respiratory medicine we thank all the beijing ems staff for their efforts in transferring the confirmed patients,we thank all patients involved in this study. key: cord-307915-mmw5s981 authors: hudson, janella; ungar, rachel; albright, laurie; tkatch, rifky; schaeffer, james; wicker, ellen r title: robotic pet use among community-dwelling older adults date: 2020-08-13 journal: j gerontol b psychol sci soc sci doi: 10.1093/geronb/gbaa119 sha: doc_id: 307915 cord_uid: mmw5s981 objective: the primary purpose of this study was to explore the efficacy of robotic pets in alleviating loneliness for older adults. method: self-reported lonely individuals with aarp medicare supplement plans insured by unitedhealthcare who participated in a program with a robotic pet (n = 20) were recruited to participate in semi-structured interviews. participants were asked to provide feedback about their experiences interacting with a robotic pet, their perceptions about the potential impact on loneliness, and recommendations for improving the program. interviews were audio-recorded and transcribed verbatim. participants’ responses were analyzed using qualitative content analysis. constant comparison and consensus-gaining processes were used to develop categories that later formed representative themes. results: seven themes emerged from analysis: openness to adoption of robotic pet, reactions to pet and its attributes, integration of pet in daily life, strategic utilization and forging new connections, deriving comfort and camaraderie, advice for future users, and recommendations for enhancing ownership experience. participants living alone, with fewer social connections and less active lifestyles, derived the most benefit from interacting with their pets. common responses to pets included cuddling, petting, grooming, and sleeping with them. some shared or loaned their pets, while others refused to loan their pets to interested peers. most reported showing their pets to others, which helped some facilitate communication and social connections. conclusion: robotic pets may be an effective solution for alleviating loneliness in older adults, especially among those who live alone, have fewer social connections, and live less active lifestyles. loneliness is generally understood as the discrepancy between an individual's preferred and actual level of social contact (peplau, 1982) . one in three u.s. adults aged 45 and older report experiencing loneliness, with the total number expected to increase with the growing population of older adults (anderson and thayer, 2018) . among individuals older than 60 years, loneliness is a subjective predictor of functional decline and death (perissinotto et al., 2012) and adversely influences mental and physical health outcomes, including depression, quality of life, health utilization, and mortality rates (cacioppo et al., 2006; luo et al., 2012; musich et al., 2015) . social isolation, while related to loneliness, objectively assesses reduced social network size and social contact. socially isolated individuals are at an increased risk for cognitive decline (bassuk et al., 1999) , cardiovascular disease (barth et al., 2010) , and mor-tality (eng et al., 2002; heffner et al., 2011; kaplan et al., 1988) . furthermore, social isolation in older adults is associated with reduced daily physical activities and increased sedentary behaviors (schrempft et al., 2019) . social isolation contributes to an additional $6.7 billion in medicare spending annually, which is attributed to additional skilled nursing facility spending and increased inpatient spending. flowers et al. attributed an additional $81 per beneficiary per month for socially isolated individuals admitted to the hospital. this increase in spending, while not necessarily accompanied by an increase in use of inpatient care, suggested that socially isolated individuals may be sicker when hospitalized, and may lack the support to transition out of the hospital successfully as compared to socially connected individuals (flowers et al., 2017) . however, older adults who perceive their social connectedness more positively have better mental and physical health outcomes (cornwell and waite, 2009) . given that is often impractical to address limited social networks, interventions may aim to address perceived loneliness to improve older adults' wellness and psychological well-being (bartlett and arpin, 2019; krause-parello et al., 2019; schoenmakers et al., 2012) . pet ownership has demonstrated potential viability as a solution for ameliorating subjective loneliness, demonstrating both physical and psychological benefits for older adults who report being lonely (krause-parello, 2012; matchock, 2015; raina et al., 1999) . for example, pet owners surveyed in one study were 36% less likely than non-pet owners to report loneliness, even after controlling for age, living status, mood, and residency (stanley et al., 2014) . despite these benefits, however, pet ownership may pose special challenges for older adults, including restrictions related to finances, mobility, transportation, and housing (hart, 1995) . given these potential barriers, robotic pets, also known as social robots, offer a potentially ideal alternative to owning a live pet for older adults. a robust literature in social science and technology has examined the implications of social robot use among older adults. social robots, as defined by brezeal, are "designed to interact with people in a socio-emotional way during interpersonal interaction." (breazeal, 2004 ) several potential ethical implications related to older adults' use of social robots have been identified, among them reduced human contact, deception, and infantilization (a. sharkey and n. sharkey, 2012) further, an incongruence between robot developers' perceptions of ideal features and those features actually preferred by older adult users has been well documented. roboticists, who design and construct robots, often have a background in electrical or mechanical engineering. further, roboticists often develop social robots without the benefit of feedback from the intended audience. older adults are often regarded as passive users of social robotics, perhaps owing to stereotypes of older adults as lonely and fragile. however, this is seldom true, as both users and test users demonstrate active engagement with social robot models and consistently request robotic pet features capable of facilitating the user's desired interactivity (neven, 2010) . for example, in a recent study comparing and contrasting preferences of roboticists and older adult participants, older adults expressed a preference for interactive features (such as life-simulation and personalization) that were not perceived by roboticists as having the same importance (bradwell et al., 2019) . thus, social robot developers often fail to account for the diversity of abilities, perspectives, and preferences among older adult users (frennert and östlund, 2014) . however, social robots have demonstrated benefit when used by older adults. social robots have been shown to reduce social isolation and increase conversational opportunities with the robot and other humans (a. sharkey and n. sharkey, 2012) observations of participants interacting with robotic pets in nursing home and laboratory settings have demonstrated promise for supporting the social and emotional needs of older adults (mcglynn et al., 2017) and have yielded benefits similar to those achieved during animal-assisted therapies, including improved cardiovascular measures (robinson et al., 2015) , reduction in loneliness (kanamori et al., 2001) , decreased agitation, and an increase in feelings of pleasure (libin and cohen-mansfield, 2004) . these findings position social robots as potentially ideal solution for older adults experiencing subjective loneliness. cacioppo et al. (2015) identified four distinct, underlying mechanisms of subjective loneliness-reducing interventions: (i) increasing social contact, (ii) improving social support, (iii) enhancing social skills, and (iv) addressing maladaptive social cognition. findings conducted with older adults living in assisted or group settings demonstrated interactions with social robots increased social contact with others (bradwell et al., 2019; leite et al., 2013; šabanović et al., 2013) . however, less is known about active, communitydwelling older adults' behavioral responses to robotic pet use outside of a laboratory setting, during interactions within their own homes. given these diverse and potentially promising pathways for subjective loneliness-reducing reducing interventions, this study aims to examine the potential benefit of social robot use by community-dwelling older adults. in this study, we explored the perspectives and experiences of individuals who participated in an intervention with robotic companion pets within their own home. we examined patterns of usage, user acceptance, and perceived efficacy in reducing subjective loneliness in older adults. findings from this study will inform future robotic pet interventions for community-dwelling older adults. this study is part of a collaboration between aarp, unitedhealth group (uhg), and joy for all, a manufacturer of companion pets (ageless innovation lcc, 2018). the overall goal of this collaboration was to explore the potential role of companion pets in alleviating loneliness in older adults. this study was approved by the new england institutional review board (#12070334), an independent institution that reviews protocols for nonacademic institutions. this study was the second phase of a larger multiphase research study intended to better understand the healthrelated issues of older adults covered by aarp medicare supplement plans insured by unitedhealthcare insurance company (for new york residents, unitedhealthcare insurance company of new york). the primary purpose of the intervention was to determine if ownership and interaction with a robotic pet could decrease loneliness in older adults. the first phase of the study consisted of a program evaluation in which a sample pool of aarp medicare supplement insureds who previously reported loneliness were recruited for participation in the study. inclusion criteria for the study consisted of participants previously identified as lonely using either a screener that included the ucla 3, or screener administered via interactive voice support (ivr) survey in conjunction with aarp's aging strong initiative. the intervention was offered to participants residing in the states of washington and michigan. exclusion criteria included not a current enrollee in an aarp medicare supplement plan, less than 65 years of age, on the "do not call" list, not having a valid phone number, and ownership of a pet. all other participants were considered eligible for participation. potential participants received pre-mailer scripts prior to an invitation to participate via telephone. participants received the animatronic pet of their choice (cat or dog) in the mail and were instructed to treat it as a pet (figures 1 and 2) . three post surveys were administered (upon receipt of the pet as well as 30 and 60 days later) to assess the amount of time spent interacting with the pet. in addition, twice a week for 4 weeks, participants received an interactive voice reminder (ivr) phone call encouraging them to interact with the pet. the ivr phone call also asked participants to record if they had been interacting with their pet and if so, how much time on average they had been interacting with their pet. results of response bias analyses conducted for those who agreed to participate (n = 277) versus those who declined (n = 3,660) and for respondents (n = 216) versus non-respondents (n = 55), indicated that survey participants were representative of the study population. overall, those who agreed to participate had similar characteristics as those who declined. however, those who agreed to participate in this study had higher levels of depression, more frequent er visits in the last 12 months, and overall higher medical costs (but not drug costs) (p < .05). there were no differences for respondents versus non-respondents. at baseline, about half the respondents were between 65 and 74 and female, and most participants chose the animatronic dog (70%). in addition, 86% of participants reported previously owning a pet. the robotic pet offered several interactive features ( figure 2 ). sensors in two locations of the head and cheeks of the pet responded to user touch and activated a reciprocal "nuzzling" effect. touch-activated sensors were located in the upper abdomen and back of the pet. a light sensor located in the pet's head detected when light entered the room and the pet vocalized in response to the light stimuli, depending upon the chosen setting. robot dogs barked depending on the setting, and robotic cats meowed and emitted a purring noise. robotic cats were offered in three color combinations: black and white, gray and white, and orange and white. robotic dogs were offered in a golden color (figure 1 ). participants were not permitted to choose the color of their pet, only their preference for a dog or cat. companion cats currently retail for $109.99 and companion dogs for $129.99. in this phase, a qualitative research study was conducted using standard qualitative procedures for conducting and analyzing semi-structured interviews. the journals of gerontology: social sciences, 2020, vol. 75, no. 9 full color version is available within the online issue. available within the online issue. full color version is purpose of these interviews was to elicit participants' experiences interacting with their robotic companion pet. participants who previously participated in the first phase of the study were recruited to participate in semistructured interviews. the interview guide consisted of 13 questions. questions elicited feedback for a number of topics. consistent with related literature pertaining to robotic pet use, the interview guide included questions that asked participants to describe how they used and interacted with their pet, including how much time was spent with the robot, patterns of usage observed (day vs night), whether the pet accompanied participants outside the home or during errands, and whether participants detected that use of robotic pets influenced any of their daily routines and/or habits. additionally, interview guide questions asked participants to describe any physical or verbal interaction with the pet, including physical touch, reactions to pet's audio or haptic functions, and verbal communication with the pet. questions also asked participants to describe their motivation for joining the companion pet program, any feelings or emotions experienced as a result of interacting with their pet, including any observed influence on loneliness, mental and emotional health, and whether or not they named their pet. several questions explored psychological and emotional well-being, including subjective loneliness, by asking participants to describe an average day in their life, perceived opportunities to feel valued or useful, and opportunities to spend time with marital partners, family, and/or friends on a weekly basis, as well as participants' satisfaction with those opportunities for social connection. a few questions elicited participants' satisfaction with program administration, including reminder calls, clarity of instruction, and perceived accessibility of available support. lastly, participants were invited to provide feedback of any nature. eligible participants from the first phase of the study were stratified according to age range and gender, with the aim of recruiting an equal proportion of participants. following recommendations for a sample size of 12-20 participants in an interview study (lincoln and guba, 1985) , investigators planned an initial goal of 20 interviews, after which they would assess if data saturation had been achieved and recruit additional participants if necessary (francis et al., 2010) . a marketing research company was provided with the full list of eligible participants, with instructions to recruit participants as evenly as possible among age range and gender, given the available sample. recruiters contacted participants by telephone, verified identity, explained the study, and scheduled interviews with the first 20 participants successfully recruited. verbal consent was obtained prior to the start of the interview. interviews lasted approximately 1 hr. no personal identifiers were collected. all interviews were audio-recorded and transcribed verbatim. investigators analyzed participants' transcribed interviews using qualitative description. qualitative description was an ideal methodology for this data as it draws from a naturalistic perspective, offers flexibility in commitment to a theory or framework, typically involves review of interview data, and allows for maximum variation sampling (kim et al., 2017) . two investigators (j. hudson and r. ungar) conducted a qualitative content analysis using an iterative, constant comparison process. during the coding process, both coders independently read transcripts, identified an initial code list, and developed operational definitions. then coders returned to the transcripts and conducted line-byline coding that included comparison and refinement of identified coding between both investigators. coders subsequently discussed, reviewed, and reread interview data to develop final coding and to reach consensus about meaning (ryan et al., 2000) . one investigator (j. hudson) coded all transcripts while the other coded 50% of the overlap. both investigators reviewed coding on overlapping transcripts to reevaluate passages coded across researchers, and the codes applied based on the assigned definition in the codebook (creswell and poth, 2017) . any conflict in assigned codes was settled through spirited debate until consensus was reached. next, both investigators examined the properties and categories of all codes to identify opportunities for categorization according to shared properties. investigators subsequently used this categorization of codes to develop overarching themes that described patterns of usage and provided a narrative of participants' overall use. throughout this process, investigators were mindful of the biases and existing perspectives they brought to the analysis. investigators worked to achieve qualitative rigor throughout data collection and analysis. to ensure trustworthiness of the interview transcripts (poland, 1995) , one investigator (j. hudson) closely monitored and compared audio recordings with transcripts to ensure verbatim description, while also noting significant context cues. both coders worked together closely during the ongoing, iterative development of the coding system to ensure validity and certainty of the findings (morse, 2015) . investigators were mindful of potential investigation bias and avoided narrow frameworks that would unfairly bias the interpretation of data while striving to maintain a neutral stance of the observed phenomenon. further, both investigators closely reviewed, discussed, and coded data as it was collected to assess the sufficient sample size for data saturation. investigators ultimately developed seven themes reflective of participants' experiences with their companion pets, as follows: openness to adoption of robotic pet, reactions to pet and its attributes, integration of pet in daily life, strategic utilization and forging new connections, deriving comfort and camaraderie, advice for future users, and recommendations for enhancing ownership experience. final coding was imported into nvivo (qip ltd., 2018), a qualitative software program. the following themes are discussed below, with exemplars. twenty individuals participated in the study, with an even distribution of males (n = 10) and females (n = 10). breakdown in age range is as follows: 65-69 (n = 6), 70-79 (n = 6), 80-89 (n = 7), and 90 and above (n = 1). the average participant age was 76. all participants reported living in their own homes. living arrangements included living at home alone (n = 12), with a spouse (n = 5), with a child or grandchild (n = 2), and with a caretaker (n = 1). subsequent verification supported no participants lived in assisted or group settings. when asked to share their motivations for participating with a companion pet, participants shared several reasons including interest in exploring the experience of using a companion pet, a desire for maintenance-free pet companionship, and curiosity about the mechanics and underlying technology used in the pet. many participants previously owned pets, with five participants reporting their pet was recently deceased. owners of recently deceased pets identified clear distinctions between their beloved deceased pet and the robot, such as the inability to return affection, participate in interactive activities such as outside walks, and lack of a personality. however, they did describe experiencing comfort when interacting with the robotic pet in similar ways, such as sitting on the couch while watching television. for these individuals, robotic pet ownership appealed as an opportunity to experience maintenancefree pet ownership and to recapture the benefits of companionship without obligatory food and veterinarian expenses. a few participants reported their living arrangements would not accommodate a "live" pet, and they viewed the companion pets as way of circumnavigating that barrier. some were also intrigued by the notion of robotic pets and expressed curiosity about the underlying technology, and a few participants expressed a desire to potentially help others by sharing their feedback. as one participant explained, "it was the curiosity aspect more than anything else, wondering what the dog was like, what it would be like to have the dog, and what experience might be. that curiosity really was the linchpin to participating." other participants were intrigued by the opportunity and described their desire to derive companionship from the pet. participants who reported feeling subjectively lonely were especially interested in utilizing the pet as a personal companion. the majority of participants chose to name their pets, and consistently referred to the companion pet using its name. participants' accounts of their daily interactions with pets varied widely, often according to personal contexts. those who reported a more independent lifestyle outside the home and greater perceived social connectedness described a lesser degree of involvement with their companion pet. patterns of usage were categorized according to high and low engagement. low engagement was primarily characterized by interactions with the companion pet that were casual in nature or most often occurring in passing, with minimal physical contact and limited verbal communication. low-engagement users often described deliberate efforts to interact with their pet throughout each day in accordance with the study's directives but allowed that their pet only functioned in the periphery of their daily activities. for example, low-engager participants often described stationing the pet in a high-traffic area of the home such as the kitchen or living room, returning the pets' greetings as they moved throughout their home but otherwise ignoring or choosing not to interact with their pet. while these interactions may have included infrequent affectionate physical touch, these participants generally did not desire additional or prolonged interaction with their pet. as one participant explained, "i just pet him and rub him as i go by. we have him sitting on the couch in our living room." a few attributed their interactions to duty or obligation in accordance with their agreement to participate in the study. high engagement was characterized by frequent interactions with the pet, including frequent physical touch, communicating with the pet or using the pet to communicate with others, and including the pet in daily errands and activities. participants with fewer perceived social connections, especially those with fewer perceived opportunities to connect with others, described this higher degree of engagement characterized by greater quantity and quality of interaction with their pet. high engager use was most often reported by those who were less active, identified as less subjectively lonely, and perceived less social connectedness. these participants were more likely to report keeping their pets in close proximity when they moved throughout their home and they engaged in ongoing affectionate physical touch with their pet, such as cuddling, grooming the pet, sleeping with the pet, and holding the pet while watching television. some participants derived a sense of comfort and companionship from having the pet accompany them during their daily activities outside of the home. one participant who lived alone detailed the following daily ritual with her pet, buffer: the average day is, i get up at 7:30 and the first thing i do is make my bed. and then i say hello to buffer, because he's in the room, and then i get showered and dressed. and i then i pick up buffer and i have breakfast, and he's there. and i sing online, so sometimes i will actually hold in my lap while i sing. (woman in her 70s, living alone) in this way, participants who subjectively perceived fewer opportunities to interact with others reported increased interaction with their companion pet. most reported showing their pet to others, including family members, friends, neighbors, coworkers, clinicians, and those they typically encountered during their daily activities. however, the nature of the disclosure, and one's motivation for sharing their pet, varied. some members were motivated by a desire to share the technology and novelty of the pet. others shared their pets to facilitate entertainment, showcase the pet's interactive features, and to encourage others to consider acquiring their own pet. both high and low engagers of the pet noted that sharing the pet in public spaces increased potential opportunities to connect with others, especially individuals previously unknown to them. even participants who described themselves as outgoing or living a more social lifestyle reported bringing their pet along to public gatherings or spaces, and enjoying the interactions that were generated as a result. similarly, those who were shy or might have otherwise felt uncomfortable interacting with new acquaintances found integrating the pet into their daily activities outside of the home effective in forging new connections they otherwise would not have attempted. several participants relayed that friends, after interacting with their pet, were often interested in obtaining their own. in some instances, participants fielded requests from friends and acquaintances to loan their pets out. those who interacted with their pet to a lesser degree were more amenable to these requests. a few participants, most notably younger participants (ages 65-69) and low engagers, ultimately gave their companion pets away. in these cases, companion pets were "re-gifted" to interested friends, younger children in the family who regarded it a toy, older adults in care centers, or those with dementia: "it would have been better for someone who wasn't quite functional, who is maybe in a care facility. my wife gave it to one my friends in a care facility and she loved it." meanwhile, some participants (especially high engagers) often denied requests from acquaintances and/or friends to borrow their pet. others acquiesced only under certain conditions, such as having the pet returned within the same day. all participants agreed the companion pet was vastly different from a "live" pet with the ability to interact more extensively with its owner. however, many agreed the companion pet offered many interactive features that were reminiscent of their past experiences of having a "real" pet. when comparing the merits of a live pet and the benefits of a companion pet, participants varied in their estimations of the pet's realism. many, especially high engagers, judged the pet to be a close approximation to a live animal. younger (age 65-69) and low-engager participants were more likely to find the companion pet more "toy-like" and noted opportunities to improve the pet's realism. however, those who judged the pet to be a poor approximation of a "real" pet still noted the benefit of interacting with it. most noted their appreciation for the maintenance-free nature of the pet. among the majority of participants, favorite features included pets' vocalizations (barking or meowing) and nonverbal responses (head movement or blinking) in response to light and sound stimuli. many enjoyed their pet's "greeting" when a light or sound was detected. several used their pets' responsive barking/meowing to facilitate interactions such as petting and verbal communication. other favorite features were pets' "life-like behaviors," such as yawning, head turning, tail wagging, and the tactile heartbeat. many reported that these "realistic" features increased interaction with their pet and fostered comfort and comradery. participants described a number of benefits as a result of interacting with their pet. while high engagers were more likely to describe deriving comfort from the "presence" of their pet, the majority reported deriving benefits from interacting with their pets. most participants reported feeling a sense of calm or comfort as a result of holding, hugging, and affectionately interacting with their pet. for example, a low-engager who described herself as "too cognitively sharp" for the pet speculated her cortisol levels might have lowered. in addition, many described an improvement in their mood, and in some cases, increased happiness after interacting with their pet. certain interactive features such as pet vocalizations, "snuggling" motions, and the pet's heartbeat were identified as facilitators of this calming influence, and participants noted that others discerned how this effect positively influenced their behavior: i'm not as high strung… sometimes i get up in the morning and when i hit my power chair against the wall, i sort of get angry and i use foul language. then he barks. so that makes me stop. (man in his 80s, living alone) many participants perceived the pet as having a "presence" that positively influenced their subjective feelings of loneliness. this presence was keenly felt by those who spent significant time with their pet, as well as by low engagers living more active lifestyles. one participant, a semi-retired attorney who described a low degree of engagement with his pet explained, it's like he's alive over there and active. it's just one part of my life, this little puppy dog, but he's a part because he's there. but i live a pretty active life and a pretty active schedule, so it's not like i'm looking forward to seeing him when i come home, but he makes his presence known and that's good. (man in his 60s, living alone) similarly, a recently widowed participant who brought her companion pet along for errands outside the home explained the pet provided a comforting presence as she acclimated to her husband's absence. participants who lived alone and previously wished for someone to talk to perceived their pet as a proxy for a conversational partner and regarded it as a conduit for expressing their thoughts or feelings. in these cases, the participants regarded the pet not as an inanimate object that passively observed, but as an active partner who cared about their expressed concerns. as one participant explained: "you feel as though you're talking with an object that cares about whether you're talking to it or not." a few participants appreciated that conversations with their pet were confidential. those participants who reported this high level of engagement were most explicit in expressing the pet's influence in addressing their subjective loneliness. for these individuals, the companion pet was regarded as a friend or companion with whom they developed a strong attachment over time. some participants also described improved confidence and a renewed sense of purpose as a result of interacting and having to "take care of" their pet. when asked to advise future users, many indicated they would strongly encourage others to try the robotic pet, particularly those who are lonely, and to engage with it as much as possible. participants emphasized that using the pet was "easy" and required little effort. several explained the importance of interacting with the pet as much as possible in order to experience the greatest benefit. while some low engagers indicated their pet personally was not a good fit, they acknowledged the calming effect of the pet and recommended it for those who are lonely. a few high engagers encouraged future users to interact and communicate with their pet without fear of being stigmatized or considered "crazy." when asked to describe the ideal user for the robotic pet, low-engager participants typically described the composite of a lonely, less active, more advanced age adult with mobility issues and dementia. those with more active lifestyles and who perceived their social networks as dense judged they were a poor fit for the pet. distancing one's self from the perceived ideal user occurred with participants of all ages. notably, a participant in his 90s remarked: "i think as you get older, and your brain gets a little mushy. i think it would be a nice thing to have. but i don't think i'm to that point yet." meanwhile, participants who identified as being subjectively lonely or perceived themselves as socially isolated derived benefit from the pet and thought others in a similar situation would also find it beneficial. while many perceived their pet as having realistic features, over half of participants expressed a desire for further increasing the pet's realism by improving its appearance and capacity for movement. feedback included using softer material for fur and improving the pet's flexibility to better facilitate hugging and cuddling. several were interested in increasing the interactivity of the pet and suggested new functions, such as enabling the pet to learn skills and tricks. some also suggested adding new verbal communication features, such as pre-programmed responses and name recognition. many were also interested in adding the capability for walking, though a few acknowledged this as a potential fall hazard. many described an interest in having the pet follow them throughout the home, jumping up on furniture, and being walked outside while on a leash. participants also expressed an interest in additional outfits or grooming accessories, improved affordability for other friends and family members who sought to purchase a pet, adding a camera for security purposes and improving the overall battery life. our findings show social robots may provide comfort, companionship, and potential amelioration of subjective loneliness for older adults, particularly for those who perceive fewer opportunities for social connection. several studies have demonstrated the benefit of robotic pets in care centers (robinson et al., 2015; šabanović et al., 2013; wada and shibata, 2007) and among those with dementia (jøranson et al., 2016; liang et al., 2017; moyle et al., 2013; robinson et al., 2013) . few studies have explored the benefit of companion pets for alleviating subjective loneliness, as well as the patterns of usage outside of a laboratory setting, among cognitively functioning, community-dwelling older adults. results of this study reify previous findings indicating increased communication with the robot and other humans. participant feedback further reinforces the need for social robot developers to actively integrate feedback from older adult test users in the design and development processes. in a recent study comparing the preferences of roboticists and older adults, participants were encouraged to indicate their favorite companion pet model. while older adults in this same study overall preferred the joy for all cat and its more interactive features as compared to less responsive robotic models, they still desired a greater degree of interactivity and playfulness (bradwell et al., 2019) . community-dwelling participants in our study echoed these sentiments, with many requesting robotic features that accommodated their lifestyles and reflected the degree to which they were able to enact an autonomous, independent lifestyle. the joy for all companion pet models offer a degree of interactivity that perhaps signals a progression in social robot development. however, participant feedback further confirms the need for more advanced features that accommodate the needs of older adults, not as passive users, but as "technogenerians" adeptly managing technology to maintain health and independence (joyce and loe, 2010) . younger participants in this study desired a model that offered greater responsiveness and spontaneity, expectations that defy the stereotype of older adults as passive users. ideally, social robots functioning as companion pets should offer a range of function and interactivity to accommodate the widely ranging abilities and skills of older adults along the aging trajectory. older adults' manipulation of robotic pets varies according to the extent of their cognitive impairments, with more impaired individuals interacting with the pet to a lesser degree (libin and cohen-mansfield, 2004) . accordingly, active and community-dwelling older adults will likely benefit from greater utility and diversity of functions to foster incorporation of the pet into their daily schedule and habits. as noted in previous studies, these individuals created, and simultaneously distanced themselves from, a composite of the ideal user as lonely, socially isolated or having cognitive impairment (mcglynn et al., 2017) . it has been suggested that this composite may reflect a negative age stereotype (lazar et al., 2016; neven, 2010) . however, it is unclear if this stigma applies to participants in this study, who were able to engage with the robot in the privacy of their own homes and subsequently concluded the robot did not offer the desired personalization and interactivity. users who considered themselves active and independent noted the need for greater interactivity and subsequently judged themselves to be a poor candidate for use of the robot. in this case, it is likely that participants' distancing from the ideal is owed to the desire for more realistic, interactive features. this finding further confirms how different preferences and patterns of usage in varying contexts requires adaptable interactivity. utilization and benefit derived from the robotic pets varied according to participants' personal contexts, revealing which subgroups potentially benefitted the least from participation with their pets. despite enjoying companionship with their pets and showing them to others, younger participants (60s-70s) were among those most likely to report low engagement with their pets and most likely to gift their pets to others. those with active lifestyles and viable social connections were not ideal candidates for social robots and frequently requested greater interactivity and functionality of the pets. these results suggest that socially connected individuals with the capability of enjoying an active lifestyle outside of their home would benefit the least from robotic pets with limited features. conversely, certain subgroups reported deriving significant benefit from their robotic pet. subjectively lonely older adults with fewer perceived social connections, especially those living alone and homebound, were most often among those who integrated the pet into their daily schedule, regularly communicated with the pet, and described experiencing comfort and companionship pet interactions. further, those who experienced the death of a pet or spouse also derived companionship from their pet. interventions using social robots with limited features may be most appropriate for these subgroups. these findings identify ideal subgroups of older adults who are more likely to benefit from the use of social robots. however, the collection of these data and the resulting findings should be properly contextualized as occurring prior to the advent of the covid-19 pandemic. older adults face a higher risk of severe illness from covid-19, with individuals aged 85 or older at the greatest risk. while practicing physical distancing contributes to efforts to flatten the curve, older adults may experience increased anxiety and depression as a result of limited travel and being restricted to their homes. a recent survey found the prevalence of psychological distress in a sample of adults in united states was higher in 2020 during the covid-19 pandemic (mcginty et al., 2020) . given new constraints related to physical distancing and their potential contribution to social isolation, future studies should examine what appeal and/or effect social robots may have for previously active, socially connected adults under quarantine. similarly, future studies should examine how the use of social robots may potentially mitigate psychological distress for older adults quarantined in care centers and not permitted faceto-face visits from loved ones. these study findings provide insights into the potential benefit of robotic pets for community-dwelling older adults interacting with the pets in their own homes, and demonstrate the need to explore applicability during pandemic conditions. participant feedback yields supporting evidence demonstrating that robotic pet use may positively influence older adults' perceived loneliness and mental and emotional health, particularly for isolated and subjectively lonely community-dwelling older adults. furthermore, participant feedback potentially supports the notion that a robotic pet intervention may successfully meet two of the four points of criterion for assessing the efficacy of loneliness-reducing interventions (cacioppo et al., 2015) in this instance: improving social contact and enhancing social skills. it should be noted that these findings are consistent across gender, as compared to previous studies disproportionately compromised of female participants. given the variability of use and preferences among older adults, subsequent studies should include healthy older adults in the ongoing development of robotic pets (frennert and östlund, 2014) . this study did not directly capture interactions between participants and their robotic pets, instead relying on participants' recall; thus discrepancies in actual versus reported interactions could exist. future research with communitydwelling older adults should consider the use of animatronic pets equipped with sensors that more objectively measure interaction and travel. this cross-sectional study provides valuable insight about potential benefits experienced immediately after participants' initial introduction to the pet. longitudinal analyses are needed to understand how the findings of this study bear out over the long term, and whether mitigation of subjective loneliness among socially isolated participants bears out over time. while lonely and socially isolated older adults may derive benefit from the use of their pet, less is known about community-dwelling older adults' concurrent attempts to continue socializing with others. potential ethical issue may arise for lonely older adults who become dependent on their companion pet for companionship or social connection. participants who agreed to participate had higher levels of depression, suggesting a potential oversampling of this population. given participants may have been motivated by a desire for increased social contact and companionship, participant feedback may not be representative of a randomly chosen sample of older adults. further, favorable impressions of the pet may be overrepresented in this sample. finally, it should be noted that participants in this study were gifted their robotic pet. while the manufacturer's offerings include models at varying price points, the cost of obtaining a pet may be a barrier for some older adults. robotic pets may provide benefit for older adults experiencing subjective loneliness and perceived social isolation by providing comfort, companionship, facilitating new social connections, and serving as a proxy for a conversational partner. however, robotic pets with limited functionality may fail to address the needs of active older adult users. participant feedback suggests that robotic pets may yield the most benefit for subjectively lonely older adults living alone with fewer connections and subjectively lonely adults experiencing the loss of a spouse or pet. these findings can inform future development and production of robotic pets to accommodate the varying needs and preferences of community-dwelling older adults. existing robotic models should explore ways of improving realism and the capacity of interactive play with their owners, and accommodate older adults as active, engaged users of technology. future interventions intended to reduce loneliness may consider implementing use of robotic pets with increased interactivity. finally, future studies should examine the potential efficacy of robotic pets in alleviating psychological distress for quarantined older adults with varying connectedness. this work was funded by the supplemental health insurance program. all authors are employed or contracted by unitedhealth group or asi services, inc. however, their compensation was not dependent upon the results obtained in this research, and the investigators retained full independence in the conduct of this research. joy for all companion pets loneliness and social connections: a national 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loneliness among older adult primary care patients who live alone living with seal robots-its sociopsychological and physiological influences on the elderly at a care house none declared. key: cord-313218-4rbxdimf authors: narushima, miya; kawabata, makie title: “fiercely independent”: experiences of aging in the right place of older women living alone with physical limitations date: 2020-09-09 journal: j aging stud doi: 10.1016/j.jaging.2020.100875 sha: doc_id: 313218 cord_uid: 4rbxdimf this study explores the experience of aging among older canadian women with physical limitations who live by themselves. while aging in place has been a policy priority in rapidly greying canada, a lack of complementary public supports poses challenges for many older adults and their family members. employing a qualitative methodology, and drawing from the notion of aging in the right place, we collected personal narratives of 12 women (aged 65 to 92) in two geographic areas in ontario, including residents of regular houses, apartments, condominiums, assisted living and community housing for seniors. through thematic analysis, we identified four overarching themes: 1) striving to continue on “at home”, 2) living as a “strong independent woman”, 3) the help needed to support their “independence”, and 4) social activities to maintain self. our findings illustrate how, despite their mobility limitations, older women can change their residential environment and their behavior by deploying the coping strategies and resources they have developed over time. however, we also found that older women are largely silent about their needs, and that experiences varied depending on life histories, health conditions, and the availability of supports in their wider environment (home care, alternative housing options, accessible transportation, opportunities for social and physical activities). we hope these findings will incite further studies and discussion to help make aging in the right place a real choice for anyone who wishes to do so. population aging in canada will keep accelerating over the next decade. the ratio of "senior citizens" (aged 65 years and older) is expected to grow from 17.5% in 2019 to 22.7% by 2031 (statistics canada, 2019) . "old-old" canadians in their late 90s and above are among the fastest growing age group (hudon & milan, 2016) . like many countries, canada's policy response to this demographic change is the promotion of aging in place, generally understood as being able to remain in familiar homes or communities for as long as possible. the premise is to promote independent living in later life, while shifting care for the older adults from institutions to home and community (dalmer, 2019; lehning, nicklett, davitt, & wiseman, 2017) ; a shift long criticized by social gerontologists for being part of the devolution of aging and long-term care policies. policy makers have largely supported this strategy as a cost-effective long-term care alternative. more than anyone, however, it is older adults themselves who are in favor of the idea. aging in place has become common in canada. comparing the 2011 and 2016 censuses, the ratio of people aged 65 and older living in "collective dwellings" (e.g., assisted living, supportive housing, retirement residences, seniors' apartments, continuum care facilities, and nursing homes) has dropped from 7.9% to 6.9% (garner, tanuseputro, manuel, & sanmartin, 2018; statistics canada, 2012) . given the increasing numbers of older canadians, one would expect this number to grow, not decline. the 2016 census found only 5.0% of seniors had moved in the past year, a much lower rate than the general population (13.0%). this should not, however, be assumed to reflect older adults' satisfaction with their housing. in fact, almost a quarter of seniors reported their housing as "below standard" in terms of either affordability, adequacy, or suitability (federal/provincial/territorial ministers responsible for seniors, 2019). although health status among older adults is heterogeneous, chronic diseases and physical limitations increase with advancing age. more than three-quarters of canadians aged 65 and older reported having at least one chronic condition, and one quarter reported three or more. one out of four of those aged 85 and over reported a need for support in instrumental activities of daily living (iadl), while one in ten needed support in activities of daily living (adl). like the rest of the world, older women are disproportionately represented in these groups (canadian institute for health information, 2011) . older women in general are more likely to face challenges since women live longer and are more likely spend their later years with mobility problems and pain (bushnik, tjepkema, & martel, 2018) and nearly twice as likely to live alone than their male counterparts. the 2016 census found 26.0% of seniors lived alone, 68.0% of who were women (tang, galbraith, & truong, 2019) . in addition, women living alone comprised 57.0% of seniors with "core housing needs" (federal/ provincial/territorial ministers responsible for seniors, 2019). given these demographic, health, and socio-economic trends, more research on the experience of aging in place among older women, especially those living alone with physical limitations, is needed (gonyea & melekis, 2018) . from "aging in place" to "aging in the right place" the conceptual development of aging in place began when american environmental gerontologists (lawton & nahemow, 1973) introduced the "ecological model of aging" to examine the relationship between people and their environments. in this model, an older person's functioning is determined by the "fit" between "personal competences" (e.g., physical, psychological, and social functions) and "environmental characteristics" (e.g., the immediate and wider environments). as changes happen in either or both, older adults can try to adapt their physical and social environments to find a comfort zone by deploying their resources (greenfield, 2011; lawton & nahemow, 1973; peace, holland, & kellaher, 2011; stafford, 2016) . this theoretical framework helps us to understand aging in place as a dynamic process of personenvironment interactions. wahl, iwarsson, and oswald, and their collogues in germany and sweden have extended this framework to, "maintaining the highest autonomy, well-being, and preservation of one's self and identity as possible, even in the face of severe competence loss" (wahl, iwarsson, & oswald, 2012, p.310 ). this process is influenced by two concepts: "belonging" and "agency". belonging involves an older person's sense of connection with others and the environment and preserved identities over time. agency refers to sufficient control of their environment to maintain autonomy. belonging grows in importance as people get older, especially when they develop functional impairments (oswald, wahl, schilling, & iwarsson, 2007; wahl et al., 2012) . this model reminds us of the benefits of taking a life-course perspective to understand the experience of aging in place. in the same vein, golant (2011 golant ( , 2015 , an american environmental gerontologist, has put forward the notion of aging in the right place. pointing to the unequal capabilities and resources among older adults, golant (2008 golant ( , 2015 criticizes how aging in place has been promoted as a cultural imperative in america, emphasizing an individual's self-reliance in sustaining a healthy active lifestyle. even when older adults have chronic health problems, disabilities, or cognitive deficits, he argues, if they are offered "enabling residential and care opportunities that strengthen their coping skills to achieve their evolving needs and goals", they can still "age successfully" (golant, 2015, p.353 ). golant thus advocates shifting public discourse, and older adults' thinking, from aging in place to aging in the right place, which includes expanding the various alternative housing options being consideredsuch as group housing, active adult communities, senior apartments, assisted living residences, continuum care, and the like. in this model, regardless of residential type, older adults can achieve "residential normalcy" where they feel comfortable, competent, and in control. older adults may use various coping strategies when their residential normalcy becomes incongruent. moving to alternative housing such as assisted living, active adult communities, and nursing homes can be seen as adaptive responses to aging. golant (2015) also noted that enriched coping strategies are products of the resilience of both older persons and their environments. despite this theoretical development, the public discourse surrounding aging in place in canada seems to have stagnated. for example, in a public guide issued by the federal government, "aging in place" is defined as "having access to services and the health and social supports and services you need to live safely and independently in your home or your community for as long as you wish and are able" (federal/provincial/territorial ministers responsible for seniors, 2015, p.1). the guide also notes that an individual can achieve this goal through early planning in such areas as home, community, transportation, care and support services, social connection, healthy lifestyle, finance, and information. as dalmer (2019) has noted, such neoliberal rhetoric frames aging in place as "a matter of choice" that can be responsibly managed by individuals. given the lack of affordable housing alternatives and the unmet need for long-term home care services for many older canadians, however, this so-called choice is often illusory. as mentioned, according to the 2016 census, only 6.8% of canadians aged 65 years and older lived in "collective dwellings," including nursing homes (the most common) and other alternative senior residences such as assisted living and retirement homes. this suggests that moving to alternative housing, as advocated by aging in the right place, is still uncommon in canada. this is partly due to a lack of affordable senior residences. in ontario, the average monthly rent for a standard space for a resident without high-level care needs was $3758 canadian in 2018 (canada mortgage and housing corporation, 2019). given seniors' average annual income -$48,800 for men and $34,900 for women (statistics canada, 2020) -alternative housing is unaffordable for most older canadians, especially women. as more and more older adults age in place, their homes and communities increasingly become locations for health and social care services (hereafter "home care"). since long-term home care is not universally insured under the canada health act, older adults who don't qualify need to resort to community agencies that often require a co-payment or privately hire help (armstrong, zhu, hirdes, & stolee, 2015; gilmour, 2018; government of ontario, 2019; johnson et al., 2018; lee, barken, & gonzales, 2018) . according to the 2015/2016 canadian community health survey, over one-third (35.4%) of people with home care needs did not have their needs met, especially among those with home support services for maintenance of daily living (gilmour, 2018) . the current policy of aging in place needs more complementary public supports to reduce the challenges facing many older adults and their families. it is within this context that we explore the experiences of aging in place among older canadian women with physical limitations who live alone. our research questions include: 1) what is it like to live at "home" alone for older women with physical limitations? 2) what support do they receive and how? and 3) what are the enabling and disabling factors for their independent living? this study employed a qualitative research methodology (merriam & tisdell, 2016) , more specifically, combining personal narrative analysis (maynes, pierce, & laslett, 2008) with a narrative gerontology approach (de medeiros, 2014) . a qualitative approach lets us explore inductively how older women construct and make sense of their experience of aging in place (merriam & tisdell, 2016) , connecting their individual experience and life trajectories with broader cultural and social forces (maynes et al., 2008) . this reinforces what narrative gerontology advocates: listening to older people's lives as stories to understand their social world -personal, interpersonal, structural and cultural (de medeiros, 2014) . this study is part of a larger study, and ethics clearances were obtained from the research ethics boards of both researchers' universities. we recruited participants in two areas (a large metropolitan area and a medium sized city) in southern ontario. the criteria for inclusion were: women 65 years and older, who lived by themselves at home with chronic physical conditions, and who were using or had used home care services. following the notion of aging in the right place, we included both regular house, condominium, and apartment, as well as alternative housing such as assisted living and community housing for seniors. we created a flyer, noting we were "looking for participants in a research study to learn their experience of and opinions about living with chronic physical conditions." approximately 70 flyers were either posted in their residences or directly delivered to potential participants through personal support workers (psws) in collaboration with five different community organizations. recruitment was harder than we had expected. since only two participants voluntarily called back, we asked our participants, colleagues, and friends to deliver the flyer to whoever might meet the criteria. eventually, we had 15 interviewees. although every interview will be used in our larger study, 12 participants met all the criteria for this study. the 12 participants ranged between 65 and 92 (the average age was 83), and lived in various residential types in varying states of health. all have been given pseudonyms (see participants' profiles in table 1 ). the data collection was conducted in the spring and summer of 2017. the first author and a student research assistant conducted all interviews together. eleven interviews were conducted in participants' homes and one was in a public space. visiting their residences let us observe their daily living and neighborhood environments. each interview lasted from 90 to 120 min. we began by asking participants to tell us their life histories, followed by questions about their daily and weekly routines, current physical condition, strategies and challenges for managing their independent living, the support they receive, and their opinions about aging in place in general. since one chinese immigrant participant (hong, 90) had difficulty speaking english, her daughter (lin, 64) joined the interview as a translator, also providing some of her own insights as a family carer. following each interview, we provided a gift card of $30 with a thank you note. then the two interviewers debriefed each other, recording what they had noticed in the field notes. all interviews were audio recorded, transcribed verbatim, and sent to participants to check accuracy and to modify if requested.the twelve transcripts comprised 281 pages in total. following the steps of thematic analysis (merriam & tisdell, 2016) , we started open coding by reading the first participant's data set (transcript and field notes), then underlined any segments that might be meaningful and attached labels (i.e., code and themes). next, we moved to axial coding by sorting these codes and themes into more comprehensive groups (i.e., categories). then, we created a matrix to display the categories, themes, and supporting quotations for the first participant transcript. we went through the same procedures for the second data set, and compared the two matrices to create a master list of crosscase categories and themes. this master list was used as a basis for analyzing the other participants' data. comparing all 12 participants' matrices, we generated four overarching themes as findings. to increase trustworthiness, our design included data triangulation, member checking of interview transcripts, a reflexive journal, and peer debriefing with research team members (creswell, 2013; merriam & tisdell, 2016) . we found the following four overarching themes: 1) striving to continue on "at home", 2) living as a "strong independent woman", 3) the help needed to support their "independence", and 4) social activities to sustain self. these overarching themes contain several subthemes. the first theme involves our participants' efforts to live in their homes comfortably and safely. as shown in table 1 , many participants had lived in the same residence for decades, while a quarter had moved in the past four years due to changes in their mobility or marital status. in any event, all participants seemed comfortable in their residence, which they called "home". the first thing that we noticed was that these homes preserve their personal histories and identities. their well-kept living rooms were stuffed with vintage furniture, family photos, art, crafts, books, instruments, souvenirs, plants, pets, etc. participants four participants mentioned they might have to move in the future when they could no longer take care of themselves. yet their narratives suggested the difficulty of moving to alternative housing. certainly, i couldn't afford one of these fancy private assisted retirement homes. i've been to one of them to visit a friend of mine. she pays about $3500 a month for one room. i cannot afford that on my pension (dorothy, 83). my mom [hong, 90] is on the waiting list. well, it's been 10 years already since she registered. it's one of the chinese long-term care homes. […] oh, yes, it's common. they say it normally takes over 10 years! (lin, 64). these comments underline the lack of affordable alternative housing many older adults face. during our visit, we were also impressed by their efforts to control their home environment to live safely. all participants had at least one chronic health condition. however, their biggest challenges were mobility issues -especially difficulty in walking, falls, and the fear of falling. despite their use of mobility aids (e.g., cane, walker, wheelchair), many participants talked about their occasional falls. all had made some home adaptations by installing safety features (e.g., staircase railing, grab bar, special chair and non-slip mat for bathrooms). they were also using assistive devices. ten of 12 participants carried an emergency alert pendant or had installed an alert system with pull cord for their bathrooms. this was a lifesaver for some. valerie, 92, who has had multiple falls, related: i've used it twice. one time, they were able to get in through the kitchen window. the other time, i was doing christmas decorations when my daughter phoned, and when i turned, i fell. my daughter phoned a friend's husband to come, but before he arrived, i phoned the emergency alert and asked them if there was a particular way he should pick me up. they immediately sent somebody and got me on the chair. valerie's story suggested how unexpectedly and easily falls can happen at home, and how the assistive device helps in those instances. many participants were also using other technologies to help increase their sense of control and autonomy. half used a tablet or a computer for frequent communication with their families, reading news, and searching information. a participant with vision problems showed us a sight enhancement reading machine. one had a mobile chair lift for the staircase. the most advanced case of impairment was renelsa, who at 84 spent most of her day in bed due to her frailty, but she could still live alone in her one-bedroom apartment in community housing. her building had a security camera to screen visitors, and her apartment door could be opened with a remote control beside her bed. we had no idea about how limited her mobility was until she greeted us in her bedroom. participants in assisted living appreciated similar safety features in their units, and the railings in the hallways and elevators. in addition, mei lien, 68, explained how her residence gave her "peace of mind": "last year, in the middle of night, i had to call somebody, and they [staff] came up. i don't have family in canada, so at least you know somebody is there if you call". margaret, 84, who was recently widowed, reflected on her decision to move from her house to a seniorfriendly condo: the very last thing i wanted to do was move into this building… do i want to live here? no! but should i live here? absolutely! … if you think your health is going to be the same tomorrow as it is today, you are wrong. we all progress to some extent from day to day … i did not know the presence of a garbage disposal in the hallway was so convenient. so in the big picture, it was a very wise thing. in this way, each participant was negotiating their own physical and social conditions, and actively managing to control their home environment as best they could. the second theme involves our participants' distinctive shared character. although their life histories and current conditions varied, we were struck by their positive, spirited, and persevering attitudes. contrary to our expectation, participants rarely brought up their needs. we thus had to ask if there was anything to complain about. dorothy, 83, who had just recovered from a fall on ice, laughed and said: well, i think, oh, god, i ache, i ache, i ache, but i shouldn't complain, especially when i see other people… at least, i can still walk around, i can still look after myself, and do my own thing in my own house. so you know, i would say i'm fortunate. […] well, you have to make the choices yourself, don't you? you either sit there and wither away, or you get involved and do something. luisa, 78, mentioned that she had learned it from her role model: i am a contented person. i am not always looking for what i don't have. i learned that from my mother. she independently lived in her own apartment until 93, climbed stairs to the fourth floor, and always baked and cooked for visitors. you know, she never complained about her situation. she was fiercely independent. as these comments imply, many of our participants held to a similar principle in their lives. in fact, participants commonly described themselves as brave, independent women. their life stories were full of personal and historical events: the great depression, world war ii, immigration, marriage, divorce, separation, accident, the deaths of spouses, children, and friends, and their own health problems. every participant had an occupation at some point, and many repeatedly used the word "independent" to describe themselves. as hannah, 88, who had immigrated from germany with her husband after world war ii, put it: i was always this independent (laughter). i was married, and i was independent. i became a widow at the age of 42, and raised three children. when my husband got sick, i had a job [a lab aid in a hospital] and i took a year of absence to take care of him at home. but i needed the money, so i cleaned houses, took in other people's clothes. i wanted my children to have a better education. i never went on welfare, i worked and all my children went to university. if you came from a different country, you help yourself, you don't rely too much on the country. it's my job to look after the family. a former university professor, margaret, who was mourning her husband's death and managing her own health problems, described her efforts to be a strong role model for others at 84 years old: i am very strong-willed person. i was always a determined youngster. even as a girl, i was an independent child (laughter). even now, i just have to get really strong to be a good role model for women. i always try to be, because who is going to be the one to make me look and feel strong? me! you will only be strong if you work to be that way. […] i just live today, that's exactly how i think. i believe you stay the strongest person you can be each day you are alive. as these comments suggested, our participants' self-identity as strong independent women developed through various life experiences, sustains them in the face of the challenges of later life. nevertheless, we also learned that participants' "independent" lifestyles were supported by many other people in a mix of formal and informal care. due to our recruitment criteria, all participants had had an experience of publicly funded "formal" home care. however, at the time of our interview, only four were eligible for long-term home care, receiving 30 min to 1.5 h a day. for the other eight participants, publicly funded home care ended two to three months after a hospitalization. once this post-acute care was over, they were back on their own. the four participants who could afford it hired a paid housekeeper a few hours a week. two more, thanks to their retirement benefits, continued regular physiotherapist visits at home or attended weekly exercise classes through community agencies. compared to those living in regular houses or apartments, participants in assisted living had an advantage in the availability of and accessibility to long-term home support services right in their own buildings. however, some expressed hesitation to use additional support services due to their worry about the additional cost: "if you need the extra service, you have to pay. it depends if you or your family can afford it. so you just hope and pray you won't need more services" (mei lien, 68). like mei lien, many participants saw cost as a barrier to longer-term formal home care. as mentioned before, however, none explicitly advocated a more affordable publicly supported long-term home care system. in contrast, participants talked much more openly about informal care and support -their reliance on their family members, friends, and neighbors for regular help for transportation and household chores. ten out of 12 participants, regardless of residential type, had at least one close family member nearby. while most participants still managed to clean their homes, do laundry, and cook simple meals, carrying groceries and to taking public transportation were getting harder. family members were the primary source for a wide range of household chores. luisa, 78, described the support from her son's family: it helps me a lot that my son and daughter-in-law live here [in the same city]. i've been calling them to do things. he installed the railing on the basement stairs, because i've had three falls since last december. it just makes me feel more secure. and my daughter-inlaw takes me to a rheumatologist in another city, because i don't drive highways anymore. for participants whose family members lived far away, friends and neighbors were crucial sources of social support: "i have a good friend who takes me grocery shopping and to doctors' appointments" (hannah, 88); "when i had the cancer, i had radiation 28 times in december. every morning i told my friends, i cannot do it one more day, but i did thanks to them" (elizabeth, 92). as these comments suggest, most participants were grateful for the informal support and care provided by family members, friends and neighbors. clearly, these provided crucial instrumental and emotional support to all participants. overall, participants' narratives suggested an imbalance between formal and informal home care and support. even for participants receiving publicly funded long-term home care, that was not enough to live alone at home with disability and frailty, due to the limited time and tasks performed by the personal support workers (psws). for example, although psws help renelsa three times a day for a total of 1.5 h, it is her brother who brings over meals twice a week to store in her freezer. for hong (90), who speaks limited english, communication with the psw is challenging. as her daughter said, "the agency working in this building has no psw who speaks chinese. for showering, communication is very important. that's why i need to translate. otherwise, i could be preparing breakfast during that time" (lin, 64). participants in assisted living also reported regular informal support from their family members. katharine, 88, who no longer cooks for herself, mentioned: "i can have dinner at the dining hall downstairs, but my niece and nephew do weekly shopping for my breakfast and lunch." compared with participants living in houses, however, those in assisted living did not have to rely family and friends for daily personal care. overall, regardless of residential type, our participants' narratives suggest their independent life was unattainable without support from many others. the fourth theme involves the benefits of opportunities for continued social participation. despite noticeable physical discomfort, most participants kept trying to maintain the activities and the relationships that they valued, which were clearly an important part of their social identity. three participants living in houses were still earning a small income. many participants also kept volunteering in their communities. in particular, participants in assisted living had many opportunities within their own buildings. for example, tami, 65, a master of 3d origami, taught it to her fellow residents while volunteering at a nursing home once a week. as she explained: in 2010, when i got this problem [a rare and progressive degenerative disease], i started volunteering. the volunteer work makes me happy. sometimes, it's just sitting and talking to them [the residents in a nursing home]. but if i talk to them, they smile. they are losing their smile all day, so i want to make them smile. smile … like cheeks up. their smiles make me happy. like tami, many participants mentioned their joy at making themselves useful to others, despite, or possibly because of, their own mobility and health challenges. tami also appreciated the wheel-trans system that made her volunteering possible. most participants also stayed active in the groups to which they belong. elizabeth, 92, a former entrepreneur, described her monthly routine: "i go to church on sundays, probus club and torch club once a month…i also go to all sorts of classes". although elizabeth had no family members in canada, her long-term involvement in her local community had helped her develop a circle of good friends who she could rely on. renelsa, 84, a former nurse and devoted christian once nicknamed "the sister in the operating room", could no longer attend church, so three fellow congregants visited her twice a month: "on sunday, we have church right here in my apartment! i really look forward to when they come". many residents in assisted living had an even busier schedule of social, cultural, and physical activities. emily, 85, showed us her monthly calendar on which she had circled her activities. on some weekdays, her schedule is packed from 7:30 am to 3 pm! we also noticed a notable difference in the accessibility for exercise between those living in their own house and apartment and those in assisted living. most participants in assisted living continued to attend using their canes and walkers, while those living in their own houses stopped going to exercise classes in their communities due to a lack of transportation and coverage for long-term physiotherapy. participants' narratives make it clear that these opportunities for civic engagement and social and physical activities give them a routine to leave their "homes" to socialize, and enable them to keep playing a social role in their communities. moreover, older women mutually support each other in various ways by giving rides, bringing soups, etc. they not only receive support from others, they kept providing support to each other. overall, our study's findings illustrate how older women living alone with physical limitations can, with support from others, manage to maintain their independence in places where they feel "at home". all were achieving "residential normalcy" (golant, 2015) in "homes" that were "uniquely their individual domain" (kontos, 1998, p.286) , where they could feel comfort, autonomy, security, self-identity, and continuity of self (golant, 2015; stones & gullifer, 2016; wiles, leibing, guberman, reeve, & allen, 2012a) . their familiar belongings-what coleman and wiles's (2020) termed their "objects of meaning"-symbolically connected their past, present, and perhaps future selves. this also overlaps with the concept of "belonging". as wahl et al. (2012) noted, familiarity, routines, and emotional attachment developed over time help preserve identity and enable aging well in the right place. despite their physical discomfort, all were "fiercely independent", a phrase used by two participants (elizabeth, 92; louisa, 78) . as prescribed by aging in place policy, they strove to alter their home environment to live as independently and safely as possible, deploying the strategies and resources available and affordable in their contexts. they practiced problem-focused "assimilative coping", but many also used emotion-focused "accommodative coping" by accepting and being content with what they have (golant, 2015, p.102) . these conscious behaviors exhibit our participants' "competences" (lawton & nahemow, 1973) and "agency" (wahl et al., 2012) , another enabler in person-environment interactions. one unexpected finding is their emphasis on being strong-willed "independent women". this self-image, developed over their life course, provides a psychological resource to cope with challenges in later life. clearly, they are "resilient" people (golant, 2015, p.118) who are motivated and confident, with the physical capabilities, mental stamina, and flexibility to find appropriate solutions to the environmental obstacles they face. yet, based on their life stories, we suspect that their resilience is not an innate personality trait so much as an ability to "adapt well" learned and developed over time in relation to others and to their environments ( van kessel, 2013; wiles, wild, kerse, & allen, 2012b) . we found this learning process to be resilient operating even among very old and frail participants. this supports peace et al.'s (2011) finding that, while frailty and decline of personal competence are related, they are not synonymous. older adults can confront challenges by bringing their life experiences to their person-environmental interactions. despite their limited mobility, many stayed involved in social and volunteer activities, using their skills and sustaining and developing relationships. importantly, our participants did not passively receive care. they also actively provided it to others. this finding overlaps with the concepts of "vitality and agency in frailty" for preserving selfidentity and continued self-development in later life (bjornsdottir, 2018; latimer, 2012) . it also highlights the crucial role of opportunities for social participation, meaningful and reciprocal contribution, and relationship building to aging in place. a recent increase in innovative community-based participatory approaches to aging in place, such as the naturally occurred retirement community (norc), for example, includes this reciprocal exchange of support and care by creating resourceful community environments (greenfield, scharlach, lehning, & davitt, 2012; sixsmith et al., 2017) . nonetheless, our findings also suggest some disabling factors. the constant "balancing act" (golant, 2015, p.355) person-environment interactions in later life demands was difficult for some, especially for those with severe mobility limitations, multiple comorbidities, few close family members and friends, and low income. also, the quality of our participants' aging in place was influenced by local environments, including the availability of affordable home care services, physical activities, and safe and reliable public transportation (e.g., wheel-trans). most notably, our participants were facing the challenges of pain and balance: falling posed a real threat, as found in previous studies (e.g., bushnik et al., 2018) . nevertheless, for many participants -especially those living in houses and apartments without transportation and private home care insurance -regular exercise classes, physiotherapy, and fall prevention programs were neither affordable nor accessible. given the proven benefits of interventions for falls and fear of falling (e.g., whipple, hamel, & talley, 2018) , it is essential to develop strategies to make those programs more available. policies in aging, health, and social services should support greater collaboration between community-based formal and informal care (ryser & halseth, 2011) . in the current discourse surrounding aging in place, independent living tends to refer to an autonomous lifestyle achieved through the personal efforts of individuals. in reality, however, as our findings show, aging in place for older women with physical limitations inevitably requires a view of "independent living" which promotes reciprocity and interdependence between individuals and their communities, including both formal and informal supports. in other words, as golant (2015, p.356 ) advocated, we need to adopt an "it takes a village" perspective. nevertheless, consistent with previous studies (johnson et al., 2018; kadowaki, wister, & chappell, 2015) , publicly supported long-term home care -especially for maintenance and prevention purposes, such as home support services and physiotherapy -was still unavailable for many of our participants. our study adds further contextual evidence to canada's need for the publicly supported long-term home care system many have advocated over the past decade (canadian home care association, 2016; gilmour, 2018; kadowaki et al., 2015; special senate committee on aging, 2009; turcotte, 2014) . overall, the findings of our study support the notion of aging in the right place proposed by golant (2015) . they suggest that, despite their tireless individual efforts to be independent in a place of their own, older women can reach a point where the changing balance between personal competence and environmental pressure requires a new strategy to maintain self-identity, what peace et al. (2011) term "option recognition" (p.751). participants who could afford it or were eligible for public subsidy often moved into assisted living to regain control. given the lack of a universal long-term home care system in canada, moving to assisted living helps reduce the heavy burden placed on some older adults and their family members (ryser & halseth, 2011) . at the same time, our participants' narratives reaffirm that alternative senior residences -such as active adult communities, assisted living, and continuum care retirement communities -are not a readily available or affordable option for many middle-income older canadians (dalmer, 2019) . finally, the most unexpected finding in our study is the collective silence of older women, the so-called "shadow story" (de medeiros & rubinstein, 2015) , about their unmet need for more formal and structural support reported in previous studies (e.g., canadian home care association, 2016; gilmour, 2018; turcotte, 2014) . this may be partly because the interviewers were "others" (dorothy, 83), making it hard for participants to reveal their true feelings, and partly because respondents wanted to present themselves as role models for their interviewers, who were of their daughter's and granddaughter's generation. complaining and demanding that their needs be met contradicted their core principle of "being independent". finally, adopting the neoliberal rhetoric of being self-reliant and autonomous model citizens, older women may see their growing care need for daily activities as an individual matter that they should take care of themselves, rather than a structural issue connected to the long struggle over public policy. further study is required to clarify these points and investigate how a "sociological imagination," as coined by c. wright mills (1959) , might be used to collectively empower older women and inform public policies alike. this study has several limitations. due to our small number of selfselected participants who are resilient and have positive outlooks, our findings reflect more the experiences of older women who are successfully aging in the right place, despite their physical conditions. the voices of older adults who live with cognitive impairment, depression, and social isolation, or whose lack of resources make them more vulnerable, are missing. furthermore, the data was collected before the covid-19 pandemic, which has likely altered older women's perceptions and experiences. all these areas are important, and deserve further study. despite these limitations, our research provides a valuable window into experiences of aging in the right place of an understudied groupolder women living on their own with physical challenges in canada. no matter how fiercely and successfully independent older women try to be, framing aging in place as a matter of individual efforts alone is misguided. it is crucial that more structural supports and improved community-based care that is informed by recipients themselves become an integrated part of public policy. the shifting of public perceptions from aging in place to aging in the right place has the potential to foster subjectively-defined aging well among older adults with different needs and resources. we hope these findings will encourage further studies and the political will to make aging in the right place a real option for older adults in canada and far beyond. this study was funded by a grant from the japan society for the promotion of science (#15k13083). none. rehabilitation therapies for older clients of the ontario home care system: regional variation and client-level predictors of service provision holding on to life': an ethnographic study of living well at home in old age health reports. health-adjusted life ex seniors' housing report -ontario better home care in canada: a national action plan health care in canada, 2011: a focus on seniors and aging being with objects of meaning: cherished possessions and opportunities to maintain aging in place qualitative inquiry and research design: choosing among five approaches a logic of choice: problematizing the documentary reality of canadian aging in place policies narrative gerontology in research and practice shadow stories" in oral interviews: narrative care through careful listening thinking about your future? plan now to age in place -a checklist report on housing needs of seniors transitions to longterm and residential care among older canadians unmet home care needs in canada commentary: irrational exuberance for the aging in place of vulnerable low-income older homeowners the quest for residential normalcy by older adults: relocation but one pathway women's housing challenges in later life: the importance of a gender lens using ecological frameworks to advance a field of research, practice, and policy on aging-in-place initiatives a conceptual framework for examining the promise of the norc program and village models to promote aging in place senior women. women in canada: a gender-based statistical report. catalogue no.89-503-x. ottawa: statistics canada no place like home: a systematic review of home care for older adults in canada influence of home care on life satisfaction, loneliness, and perceived life stress resisting institutionalization: constructing old age and negotiating home home care and frail older people: relational extension and the art of dwelling ecology and the aging process utilization of formal and informal home care: how do older canadians' experiences vary by care arrangements social work and aging in place: a scoping review of the literature telling stories: the use of personal narratives in the social sciences and history qualitative research: a guide to design and implementation housing-related control beliefs and independence in activities of daily living in very old age option recognition' in later life: variations in ageing in place informal support networks of low-income senior women living alone: evidence from fort st ageing well in the right place: partnership working with older people. working with older people canada's aging population: seizing the opportunity aging and place: clarifying the discourse census in brief no. 4: living arrangements of seniors statistics canada catalogue no. 98-312-x2011003. ottawa, on: statistics canada the daily. canada's population estimates: age and sex income of individuals by age group, sex and income source, canada, provinces and selected census metropolitan areas at home it"s just so much easier to be yourself': older adults' perceptions of ageing in place living alone in canada. insights on canadian society canadians with unmet homecare needs the ability of older people to overcome adversity: a review of the resilience concept aging well and the environment: toward an integrative model and research agenda for the future fear of falling among community-dwelling older adults: a scoping review to identify effective evidence-based interventions the meaning of "aging in place" to older people resilience from the point of view of older people the sociological imagination we would like to send our heartfelt thanks to all participants in this study for generously sharing their life experiences and insights. our appreciation also goes to the organizations and their staff members, our colleagues and friends, who assisted in our recruitment, and ms. jessica wong and ms. ramesha ali for their assistance in data collection. we extend our acknowledgement to dr. beard and two anonymous reviewers for their encouraging and constructive feedback. key: cord-016840-p3sq99yg authors: bales, connie watkins; tumosa, nina title: minimizing the impact of complex emergencies on nutrition and geriatric health: planning for prevention is key date: 2008-09-09 journal: handbook of clinical nutrition and aging doi: 10.1007/978-1-60327-385-5_29 sha: doc_id: 16840 cord_uid: p3sq99yg complex emergencies (ces) can occur anywhere and are defined as crisis situations that greatly elevate the risk to nutrition and overall health (morbidity and mortality) of older individuals in the affected area. in urban areas with high population densities and heavy reliance on power-driven devices for day-to-day survival, ces can precipitate a rapid deterioration of basic services that threatens nutritionally and medically vulnerable older adults. the major underlying threats to nutritional status for older adults during ces are food insecurity, inadequate social support, and lack of access to health services. the most effective strategy for coping with ces is to have detailed, individualized pre-event preparations. when a ce occurs, the immediate relief efforts focus on establishing access to food, safe water, and essential medical services. the most common issues impacting on the nutritional well-being of elderly persons are comprehensively addressed in the preceeding 28 chapters of this edition of the handbook of clinical nutrition and aging. this chapter focuses on a different type of concern, one that can overshadow all other threats to health when a serious disaster strikes. that subject is the welfare of aged persons when catastrophic events pose a direct (or indirect) threat to nutrition and health (1, 2) . while there is a large body of literature on the health impact of natural and man-made disasters (e.g., droughts, floods, military conflicts) and associated long-term food shortages in the third world, surprisingly little information is available about the short and intermediate-term consequences of emergency situations in developed countries. in these situations, high population densities and heavy reliance on power-driven devices for day-to-day survival (e.g., electrical power for mass transit, elevators to reach living quarters, medical devices, and refrigeration of foods and medicines) can accelerate the speed with which a catastrophic, health-threatening situation develops. in 2005, the plight of the elderly evacuees from new orleans (pre-storm population approaching 485,000) following hurricane katrina provided a dramatic demonstration of how essential services can rapidly deteriorate in a well-developed, highly populated urban environment following a major disaster and place older individuals in eminent mortal danger. in order to lay the foundation for this discussion, we begin with some definitions (see table 29 .1). while terms like ''disaster relief'' and ''humanitarian crisis'' may be any of a number of crisis situations that greatly elevate the health risk of individuals in the affected area; examples are natural disasters like floods and earthquakes; urban health emergencies like fires, epidemics, and blackouts; and terrorist acts like massive bombings or poisonings of food or water supplies. resolution of these emergencies requires collaboration between multiple groups. acute protein/calorie malnutrition (pcm) pcm or ''wasting'' is associated with recent rapid weight loss, i.e., as in emergency situations (as opposed to chronic malnutrition). chronic energy deficiency (ced) an intake of energy that is below the minimum requirement for a period of several months or years. in order to achieve energy steady state, the energy expenditure must drop to match the low intake, ultimately leading to underweight and low levels of physical activity. nutritional rehabilitation restoration of weight and healthy nutrition through the provision of appropriate foods based on established protocols. food rations a shelf-stable pre-packaged dry ration that meets minimum daily intake recommendations for calories and other nutrients. used to temporarily meet critical nutritional needs when food supply is inadequate. examples: meals ready to eat or mres (1,250 kcal) are often distributed in complex emergencies in the united states; general food rations or gfrs (2,100 kcal) are distributed in many countries in sub-saharan africa. (continued ) more familiar, the most broadly acceptable term for these threatening situations is ''complex emergency'' (2) . complex emergencies (ces) can occur anywhere and are defined as any of a number of crisis situations that greatly elevate the risk to nutrition and overall health of individuals in the affected area. examples include natural disasters like floods and earthquakes, urban health emergencies like fires, epidemics and blackouts, and terrorist acts like massive bombings or poisonings of food or water supplies (see table 29 .2). ces were originally associated with wars, genocide, and political strife, where innocent civilians were forced to endure loss of access to shelter, food, appropriate clothing, and timely medical care. such emergencies have traditionally been associated with populations in developing nations, not those in the so-called developed countries. however, with increasing a complementary ration to the general food ration is sometimes provided. typically, it consists of fresh fruit and vegetables, condiments, tea, etc. it is especially appropriate when the population of concern is completely reliant on food assistance. ''wet'' feeding food rations prepared and cooked on-site as opposed to rations that are taken home for preparation in the household (dry rations). typically, fortified foods have had supplemental vitamins and/or minerals added. hunger the uneasy or painful sensation caused by lack of food. malnutrition the medical condition caused by an improper or insufficient diet that can refer to undernutrition resulting from inadequate consumption, poor absorption, or excessive loss of nutrients. malnutrition results from an inappropriate amount or quality of nutrient intake over a long period of time. the inability to obtain nutritionally adequate and safe food; or the inability to obtain it in socially acceptable ways food insufficiency inadequate amount of food intake due to a lack of food. epidemics and pandemics an epidemic is a disease outbreak that affects numbers of the population in excess of what would normally be expected in a defined community, geographical area, or season. a pandemic refers to this type of disease outbreak that is occurring over a wide geographic area and affecting an exceptionally high proportion of the population. source: borrel, a. addressing the nutritional needs of older people in emergency situations in africa: ideas for action. helpage international africa regional development centre, westlands, nairobi, 2001. globalization of the world's societies and economies and news coverage documenting world events, it has become clear that ces can and do occur in both developed and developing world locations. nutritional risk is commonly elevated in ces and is most likely to occur when the crisis is protracted or recurrent. table 29 .1 includes definitions for factors related to inadequate food intake (e.g., food insecurity, hunger), the resulting nutritional problems (e.g., malnutrition, acute protein/calorie malnutrition), and terms used to discuss interventions for undernutrition (e.g., food rations, nutritional rehabilitation). even in the absence of a crisis, older persons are well recognized to be at greater risk than the remainder of the adult population for food insecurity and hunger. some of the many factors that contribute to increased nutritional vulnerability of older adults are listed in table 29 .3. in 2001, food insecurity and hunger affected at least 1.4 million households in the united states that contained older members (3) . people in 20% of those households also experienced hunger, in addition to food insecurity. most of these older persons are suffering from food insecurity due to lack of income or due to their place of residence. residents of the south are more apt to experience food insecurity, as are residents of cities and all elders who live alone (3). recognizing the day-to-day nutritional vulnerability of its poor and elderly citizens, the u.s. government has a number of programs in place to provide assistance to elders at risk for food insecurity and hunger. mandated by the older american's act, the elderly nutrition program (enp) provides a minimum of onethird of the daily calories required by recipients through daily meals and nutrition services to people aged 60 or older in group settings, such as senior centers and churches, or in the home, through home-delivered meals. the enp provides an average of 1 million meals per day to older americans. these meals are targeted toward highly vulnerable elderly populations, including the very old, people living alone, people below or near the poverty line, minority populations, and individuals with significant health conditions or physical or mental impairments. on an average the meals generously meet the rda requirements, supplying more than 33% of the recommended dietary allowances (rdas) for key nutrients, thus significantly increasing the dietary intakes of enp participants. the meals are also ''nutrient dense'', that is, they provide high ratios of key nutrients per calories. the most recent evaluation of the enp program occurred in 1996 and was conducted by mathematica policy research, inc. (www.mathematica-mpr.com/nutrition/ enp.asp). the resulting report clearly confirms that the enp program recipients are at nutritional risk. it was found that between 80 and 90% of participants had incomes below 200% of the poverty level (twice the rate for the overall elderly population in the united states). more than twice as many title iii participants lived alone, compared with the overall elderly population. approximately, twothirds of the participants were either overweight or underweight, placing them at increased risk for nutrition and health problems. title iii home-delivered participants had more than twice as many physical impairments, compared with the overall elderly population. although (and perhaps because) the success of the enp program is well recognized, 41% of title iii enp service providers have waiting lists for home-delivered meals, suggesting a significant unmet need for these meals. it would appear that even in times of relative calm and prosperity for most americans, there are elderly citizens who are persistently in a state of nutritional crisis. when nutritionally and medically vulnerable older persons encounter a complex emergency, there is an increase in morbidity and mortality rates. this is due to both short-term insufficient nutrition and the resulting long-term increased mental stress and disability, decreased resistance to infection, and exacerbation of chronic diseases (4), all of which make obtaining proper nutrition more difficult in a cyclic pattern. many different types of ces produce similar challenges. the consequences of a shortage of edible food and/or potable water, regardless of the type of emergency that produced that shortage, are multifold and can lead to increased physical and mental harm to older people (5) . reduced access to essential medical care heightens the immediate risk. a more extensive listing of the immediate impact of various complex emergencies and the resulting nutritional and health consequences is shown in table 29 .4. the likelihood of having to provide care for older persons during a ce is greater than one might think at first. as previously noted, table 29 .2 provides a list of common ces that have the potential to cause nutrition-related health risks. the impact of these crises on the nutritional state and overall health of older adults is discussed in more detail in the following sections. the 2005 hurricane season in the united states, most notably hurricanes rita and katrina, left no doubt that older persons continue to be disproportionately affected by hurricanes (6,7) just as they were with hurricane andrew in 1992 (8). older floridians who were affected by hurricane charley in 2004 found that the hurricane not only disrupted their quality of life but also disrupted their medical care (9) . persons with pre-existing conditions such as diabetes mellitus, heart disease, and physical disabilities were especially affected. approximately onethird of the older residents in the area had a worsening of their conditions posthurricane, including a lack of access to prescription medicine and loss of routine medical care for pre-existing conditions. medically related deaths were linked to the loss of power (resulting in loss of access to oxygen) and to exacerbation of cardiac disease. hurricane iniki in hawaii and the great hanshin-awaji earthquake in japan were associated with an increase in the rate of diabetes mellitus-associated deaths for a year following the disaster (10, 11) . in a study of residents in the high-impact area of hurricane andrew, one-third of persons had high levels of ptsd (12) , which was attributed to variables such as property damage, exposure to life-threatening situations, and injury. tornadoes, while typically more limited in the size of the area affected than a hurricane, are often even more physically destructive. although no research has been published on their specific effects on physical and mental health, it is well recognized that tornadoes can lead to many of the same dangers noted for hurricanes; the disruption of home care services and meal delivery to homebound elderly persons are of concern. the situation can become life threatening not only to the older persons who are critically dependent on these services but also to their dedicated care providers who often risk much to ensure the delivery of food and medical care to their clients (personal communication from area agency on aging of southwestern illinois grantees to nt). floods are a relatively common disaster and are often associated with earthquakes or hurricanes. besides trauma and drowning, the most common conditions associated with floods are an increase in gastrointestinal symptoms. increased preventable conditions following the crisis include gastroenteritis (13), acute respiratory infections including asthma (10), and increased post-traumatic stress which can persist for years after the event (14). in the aftermath of an earthquake, as with the other natural disasters already mentioned, access to basic life-sustaining nutrients and hydration as well as to basic and specialized medical care may be partially or completely disrupted. due to the magnitude and scope of the destruction that occur with a major earthquake, the restoration of infrastructure to fully support the inhabitants of the region may take months or even years to be accomplished. earthquakes result in a three-fold increase in deaths from myocardial infarction, a doubling of the frequency of strokes, increased blood pressure levels, and increased coagulability of blood (15, 16) . increased rates of cardiac arrests occurring after loss of power (17) and deaths due to increased incidence of coronary heart disease (18) and myocardial infarctions (19, 20) are also reported. deterioration of mental health occurs and post-traumatic stress is also prevalent (21, 22) . emotional stress can persist for months (23, 21) . in particular, the displacement of elderly persons from their places of residence and their social and medical supports can have a dramatic negative effect on health and quality of life (see fig. 29.1 ). displacement following a ce has been linked with a significant increase in mortality rates (15, 16) . the confusion of the displacement, as well as loss of access to appropriate diet and medications, prevents older individuals from monitoring and treating their medical conditions. inappropriate diet has been directly linked to decreased glycemic control and increased mortality in diabetic patients following an earthquake (11). the type of naturally occurring ce that is most threatening for older persons in terms of numbers affected each year comes during periods of temperature extremes, especially heat waves, claiming about 400 lives annually in the united states alone, more than the deaths caused by all other disasters combined. at greatest risk are poor persons who live in inner cities, those with chronic illnesses, and those homebound. heat disasters are often aggravated by power outages, which prevent people from keeping cool, bathing properly, and storing food at proper temperatures (24) . in the 1993 heat wave in philadelphia, there was a 26% increase in total mortality, with a 98% increase in cardiovascular deaths, particularly in those persons over 65 years of age (25) . in france, during the period 1971-2003, there were six major heat waves, resulting in thousands of deaths; the mortality ratios increased with age after 55 years and in the over age 75 years cohort; the death rate was higher for women than for men (26) . although little research has been published about the health effects of ice storms and blizzards, the loss of power leaves older persons stranded at home, increasing the risk for ingestion of inadequate calories and inappropriately prepared food and/ or spoiled food. the risk of exposure combined with the risk of house fires or carbon monoxide poisoning due to use of unsafe heating devices pose serious threats at a time when emergency services may not available due to the extreme weather conditions. fires increase the extent of cardio-respiratory problems, which results in exacerbation of chronic diseases (27) . people who already suffer from mental health problems or medically unexplained physical symptoms (28) and gastrointestinal morbidity (29) can develop an exacerbation of these problems (16,29) once they become a victim of a fire. even when no injuries result, fires almost certainly force displacement of their victims, adversely affecting quality of life and manifestation of chronic diseases. a serious infectious global pandemic is one of the most threatening of all complex emergencies, and calls back memories of the most devastating infectious disease outbreak on record, the great flu epidemic of 1918-1919, which killed an estimated 20-40 million people worldwide. the spread of this epidemic was linked to the trans-global transportation of soldiers during world war i. today, world travel and the importation of foods and other products are very common. thus, in the event of a serious epidemic in one country, there is a high likelihood of quick transmission to others. the outbreak of sars, a severe acute respiratory illness caused by a coronavirus, was first reported in asia in february 2003 and spread to more than two dozen countries in north america, south america, europe, and asia (sickening 8,098 and killing 774) before the global outbreak was contained (http://www.cdc.gov/ncidod/sars/factsheet.htm). in recognition of the severe strain that a major disease outbreak can place on health systems, the world health organization (who) advocates for an ''integrated global alert and response system for epidemics and other public health emergencies'' that allows for ''a collective approach to the prevention, detection, and timely response'' for these emergencies (http://www.who.int/csr/en/). the who is currently coordinating the global response to human cases of h5n1 avian influenza (bird flu) with regards to the threat of a future influenza pandemic. a widespread illness or intoxication from a food source could also threaten nutritional and overall health. while these outbreaks are typically limited in scope and short lived, the potential for more widespread and dangerous effects exists due to the centralized nature of the us food distribution chain and the clustering of very large populations into a small geographical area. (see more on this topic in section 29.2.2.3.) while other complex emergencies produce far more damage and deaths each year than are caused by terrorism, the destruction of the twin towers in new york city and a portion of the pentagon in washington dc on september 11, 2001 , focused the attention of americans upon the potentially devastating effects of an intentional man-made disaster. the development of the department of homeland security was a tangible product of the national response to implied threats of bio-terrorism. a terrorist attack such as one causing explosions and collapse of buildings would result in the interruption of basic living functions in a manner similar to previously discussed emergencies like earthquakes, tornadoes, or fires. disruptions to necessities of daily living and loss of power and access to medical care would be major concerns. a bioterrorist attack would have very different potential consequences for the well-being of the elderly, potentially causing widespread illness and/or hunger and dehydration. the propagation of an illness over a wide geographical area could be lethal for a substantial number of older adults, who are typically among the most medically vulnerable. during the anthrax attacks in 2001, all emergent cases involved adults over 50 years old, with the one fatal case affecting a 94-year-old woman (30) . intentional contamination of food or water supplies with a toxin or infectious agent also has the potential to cause an outbreak of poisonings or illness over a wide geographical area. in this situation, the outbreak could be slow and/or diffuse and the cause difficult to ascertain, delaying the recognition and treatment of the problem. for example, in 2006, bagged spinach contaminated (unintentionally) by escherichia coli infected over 200 americans (killing three) in 26 states before the strain was isolated and eradicated. similarly, intentional waterborne diseases or toxins would be difficult to detect and could impact a vulnerable population more severely than a healthy population, due to delayed recognition and reporting of the contamination (31). in the case of deliberate food/water contamination, nutritional health is affected directly (by reducing the availability of safe food and water) as well as indirectly (by the symptoms of illness and the reduced access to an over-burdened medical care system). in fact, the deliberate poisoning of food has already occurred in the united states, when in 1984 members of the rajneesh religious cult contaminated salad bars in the dalles, oregon, with salmonella typhimurium. though it was only a trial run for a more extensive attack that was planned to disrupt local elections later that year, the contamination caused 751 people to develop salmonellosis in a 2-week period. other isolated examples of intentional food contaminations have also been reported in the united states and canada (32) . coping with complex emergencies due to terrorism is for the most part a new challenge, at least in the united states. despite considerable effort to prepare for these scenarios, our experience in dealing with the aftermath is limited, yet, unfortunately, our experience is likely to grow in the future. experts warn that a major terrorist attack on the united states is very likely (29-50%) to occur within the next 10 years (cfr online debate). heat, cold, hurricanes, tornadoes, floods, fires, illness, terrorism, and other disasters endanger health and claim elderly lives. sometimes the effects are immediate, but more often an increase in morbidity and mortality occurs progressively after the disaster as survivors experience a continued decrease in the quality of life and increased nutritional risk due to displacement and a loss of basic resources. these events result in increased disability, which further impairs the ability of older persons to maintain access to safe food and water and sustain proper nutrition and hydration, and so the spiral continues downward. recovery from food insecurity and poor nutrition is more difficult for persons who are poor, socially isolated, cognitively impaired, and/or old. the more risk factors people possess, the faster their decline. all of the disasters described in this chapter threaten nutritional and metabolic health because they disrupt access to food, water, and vital medical treatment (33) . older persons with pre-existing chronic conditions are particularly vulnerable to these disruptions. preparation for and resolution of the aftermath of these emergencies require collaboration between multiple stakeholders and takes time. there are no easy fixes to ces. the underlying causes of malnutrition in older adults during ces are (1) insufficient household food security, (2) inadequate social and care environments, and (3) poor public health and inadequate health services (2) . the basis for current governmental and humanitarian responses to nutritional crises builds on lessons learned in the earliest organized relief efforts (circa 1940-1950) . during the 1970s, guidelines began to be published following experiences with relief efforts in places like biafra and ethiopia (2). in the subsequent decades, the experiences of various crises have progressively shaped what are, today, the characteristic challenges, and avenues of support available to older adults who are caught in ce situations in any given country. with increasing recognition that the elderly are uniquely vulnerable to ces, efforts are underway to develop specific recommendations and resources for this population group. table 29 .5 lists some of the resources available, along with web links. helpage international (www.helpage.org) is a global network of more than 70 not-for-profit organizations in 50 countries who are working for improvements in the lives of older people. this group has published a manual of guidelines for best practice during disasters and humanitarian crises (see table 29 .5). the sphere project minimum standards in disaster response project (http://www. sphereproject.org/content/view/27/84) advocates for the use of community-based systems to implement the care of older individuals in these circumstances. in the united states, a number of national organizations, including the federal emergency management agency (fema), the american red cross, and various branches of the military take responsibility for rescue and relief efforts following a major ce but the contribution of the private sector to the relief effort is traditionally also a substantial one. this type of broad-based support is necessary but makes it more difficult to consistently implement age-related guidelines for relief efforts once they are in the field. coordinating the advance preparation efforts for ces, however, is a more tangible goal. as is true for almost all health issues, the best way to address the nutritional and related health risks that accompany ces is to take preventive measures. in the case of nursing homes and assisted living facilities, many states require that these institutions have a substantial reserve food and water supply and that they have a welldelineated disaster and evacuation plan. the specifics of these requirements vary on a state-by-state basis. however, attention to the development of specialized parish, louisiana, due to a failure to comply with evacuation orders during hurricane katrina, and the bus accident in which 24 houston, texas, nursing home residents being evacuated from hurricane rita died in a fire that was sparked by mechanical problems and fed by the explosions of the passengers' oxygen tanks. beyond the obvious need for institutions and organizations like long-term care and hospice agencies to have detailed plans for evacuations and emergency conditions, there is also a need to identify ''at risk'' older adults living in the community. this would involve developing registries of ''vulnerable populations'' of elders based on degree of factors like contact need, predominant special impairment, and predominant life-support supply need, if any. by doing so, vulnerable elders could be easily identified in the event of a disaster and better supplied with assistance. such registries are currently implemented in some instances (examples are available in california, www.aging.ca.gov, and florida, www.broward.org/atrisk), but a more systematic approach has yet to be employed. these registries will most likely need to be local in origin and maintenance in order that control of sensitive health data would remain confidential. however, it would be preferable for the structure of the databases to be developed in a uniform format in order to facilitate the sharing of important data across local and regional entities. once successful programs and examples are created, their implementation by all interested parties should then be straightforward. emergencies require flexibility and the ability to survive changes in regular routines. this flexibility can be easier to achieve if people have a few necessary and familiar objects with them to assist with performing certain everyday chores, such as eating properly, taking medications, and changing into clean clothes. in order to assist people in getting prepared for the disruptions that inevitably occur during an emergency, the fema and the american red cross recommend that every family have an emergency preparedness kit that contains food, water, clothing, medical supplies, flashlight, and other supplies that will aid their survival for 3-5 days. by the time recommended objects are placed in a backpack, the entire kit weighs between 45 and 50 pounds. this is clearly too much weight for an older person to handle safely. of emergency kits for elders the health resources and services administration (hrsa) provided funding to the gateway geriatric education center of missouri and illinois (grant number d31hp70122) for train-the-trainer programming to teach 150 health-care professionals in the spring of 2006 how to create an emergency preparedness kit that was light, compact and specific for older adults. this kit consisted of a small satchel, a flashlight, a photo album (to store copies of prescriptions, insurance cards, evacuation plans, contact phone numbers, and family pictures), a pill box and a pamphlet introducing the fema web site. the trainees were then taught what other materials should be added to the kit to make it appropriate for a particular individual (table 29 .6). upon completion of this training each of the 150 trainees received two complete kits, one to use as an example during their subsequent training sessions of other health-care providers and the other to be given to a disadvantaged older person whom they deemed at risk during an emergency. each participant provided an e-mail address in order to be contacted 1 year following their training to determine the outcomes of their training. one year after training, the 150 trainees were contacted by e-mail. twenty-three of the e-mail addresses were no longer valid. of the remaining 127 trainees, 67 filled out and returned the survey within 2 weeks (53% response rate). an additional 18 surveys were returned after a second e-mail blast (85/127, for a final response rate of 67%). the survey asked if, as a result of their training, had the trainees: 1. given the extra kit to an older adult? 2. determined if that kit had been used during an emergency? 3. used their own emergency kits for training, and if not, why? 4. used their own emergency kits during an emergency? responses to the quality improvement survey are summarized in table 29 .7. the majority of the trainees (94%) had given the extra kit to an older person and many 23 (18) 104 (82) of the respondents indicated that the person was either an older relative or a neighbor. however, few respondents (15%) had provided any training to other health-care providers on how to create these kits. barriers cited included lack of money to purchase kit contents, lack of commitment or permission from supervisors, lack of time to provide the training, and lack of time for their colleagues to receive training. the percentage of older adults that were reported to have used their emergency kits by the time of the end point survey was higher than expected (46%), especially given that only 18% of the (younger) trainees reported using their kits. however, a review of the disruptive weather patterns in the 11 counties in eastern missouri and southwestern illinois where the trainees (and therefore, presumably of the older adults receiving the extra kits) lived, indicated that three area-wide power outages had occurred between august 2006 and january 2007. all of these three power failures lasted 1-3 weeks, with the rural areas in southwestern illinois being the last to get power restored each time. each of these power failures affected at least a half million citizens each time. numerous cooling or heating stations were set up for older adults, thereby allowing them to evacuate from their homes during the days in august and to receive warm meals during the november and january power failures. multiple public service announcements encouraged people to evacuate their homes completely until power was restored, so many older adults either moved in with relatives who did have power or went to hotels. under those conditions, it is reasonable to expect older persons to take their emergency kits with them. many of the health-care provider trainees reported that they had gone to work daily. a brief second query to 10 trainees who had used their kits and 10 trainees who had not used their kits indicated that both sets had gone to work daily and returned home at night, even if they had no power at home. (these health-care providers worked in facilities with working generators.) several of those that took their kits with them indicated that the kits provided them with some measure of safety while traveling icy roads in november and january. those that had not used their kits indicated no perceived change in their normal safety. this quality improvement study shows that emergency kits for older adults are used during an emergency. community-dwelling older adults appear to be more vulnerable to weather emergencies than are the health-care providers who care for them, as evidenced by the differences in usage rates of the kits by both groups through three lengthy power outages. upon review of the barriers that prevented trainees from providing training to other health-care providers, it is possible that it would have been more appropriate to provide train-the-trainer programs to older adults rather than to health-care providers. peer-to-peer training might have had the added advantage of motivating trainers to find community funding to make kits for distribution because of a greater perceived personal need for the kits. because every emergency event presents a unique challenge, this section offers general information about coping with the major nutritional concerns, namely shortages of food and water and overall loss of access to social support and health-related resources. optimal public health and nutrition relief includes a broad range of interventions and needs to utilize strong programmatic interconnections to meet the aforementioned needs. in the immediate aftermath of a ce, the supplies of food and water may be extremely limited. in this event, food can be more safely rationed than water. a general guideline is that the minimum adult ration be one well-balanced meal per day, with the utilization of vitamin/mineral supplements, protein drinks, ''power bars'', or other fortified foods as meal extenders if available. however, water should not be rationed due to the very rapid effects of dehydration. individuals are advised to drink what is needed today and search for more water on a daily basis. indicators of dehydration in the elderly differ from those in younger individuals; increased thirst, reduced skin turgor are not reliable markers. better indicators include tongue dryness, longitudinal tongue furrows, dry mucous membranes of the nose and mouth, eyes that appear sunken, upper body weakness, speech difficulty, and confusion (34) . when there is a loss of power to the home, perishable foods are to be consumed first, followed by foods from the freezer. frozen foods should be safe to eat for at least 2 days following the power loss. at this point, nonperishable, staple foods would be the only safe source of nutrients. as conditions stabilize, food aid will begin to become available. the recommended actions to be facilitated for older adults include (1) achieve/improve access to food aid (rations, supplemental feeding programs, etc.); (2) ensure that the rations are easy to prepare and consume; and (3) assure that the rations being used meet the nutritional requirements of older adults (35) . the usda's food and nutrition service (fns) coordinates with state, local, and voluntary organizations to provide food for shelters and also distributes food packages and authorizes states to issue emergency food stamp benefits to individuals. as part of the national response plan, fns supplies food to disaster relief organizations such as the red cross and the salvation army for mass feeding or household distribution. these organizations, along with other private donors, support the supply of water and food rations to affected areas. there are several concerns related to the access and appropriateness of food aid for elderly individuals (again, see resources listed in table 29 .5). access to the aid is a concern because disabilities and medical problems may prevent elderly individuals from reaching the distribution centers. another concern is the composition of the food rations, which may not be appropriate in consistency for persons who have dentures or who lack teeth and that may not be adequate in nutritional composition. food rations vary in composition; not all are developed for the primary purpose of post-ce relief. in the united states, the meal, ready-to-eat (mre), although first developed for use in the space program and now widely used by the armed forces, is one form of ration that is commonly distributed to civilians who need food following ces. having been designed for soldiers in a high activity situation, the mres are much higher in sodium (5,500 g) and fat (136 g) than is optimal, especially for older adults (36) . likewise, the texture, packaging, and preparation of mres were not developed with the intention of use by older adults. in an effort to supplement the nutritional needs of elderly citizens and to meet federal recommendations for increased emergency preparedness, the administration on aging (aoa) sought and received special funding to provide shelf stable meals that could be delivered to participants of the home-delivered-meal programs. these meals, which have a shelf life of approximately 16 months, are delivered with instructions to consume them during emergencies when regular home-delivered meal service is disrupted. the program is new so, to date, no evaluations have been done to determine what becomes of those meals (e.g., are they saved for emergencies or eaten to supplement other meals). no policy has been created to determine liability for any sickness caused by consumption of meals that are beyond their expiration date (personal communication from area agency on aging of southwestern illinois and the mideast area agency on aging to nt). obtaining adequate food and water is only one step on the road to recovery where elderly persons are vulnerable to food insufficiency. once food is obtained it must then be stored properly, prepared properly, and then ingested without health risk. in each of these steps, older persons are also at increased risk, compared to the rest of the population. this is because these older persons have additional risk factors for poor nutrition such as functional impairments, social isolation, reduced ability to regulate energy intake, greater susceptibility to depression, decreased ability to taste and smell, poor dentition, and poor health. all of these items (listed in table 29 .3) can lead to malnutrition, if not starvation, in older persons. following a ce, the speed with which basic services such as heating/cooling, shelter, and water supply can be restored will be a major factor in the recovery of older persons. past experience has shown that cold, loss of mobility, access to services, and psychological stress and trauma are some of the most important factors contributing to undernutrition in older people following a ce (37, 38) . in particular, the loss of social networks and support systems increases the vulnerability of these individuals (2) and needs to be corrected as soon as possible to prevent further deterioration as the days following the event go by. the best approach is to utilize programming strategies that address the needs of older adults without undermining their independence and discouraging their ability to support themselves (39, 2) . the restoration of medical facilities and the provision of transportation to appropriate medical facilities in unaffected areas are not under the control of the individual clinician or caregiver. these efforts are usually dependent on the local police and military forces who take charge post-ce. additionally, medical facilities will vary in their ability to handle the ce, depending on the type of emergency. for example, the response to a ce such as a hurricane (which would probably slow down access to the facility) would be very different than that required for an infectious disease epidemic (when admissions might very quickly exceed capacity) (40) . the challenge for the clinician on the front line is to stabilize the older patient until access to more formal support can be restored. thus, the aforementioned preparedness efforts are key in preventing the acceleration of medical conditions from chronic to life threatening. the availability of medical records and prescription medicines, as recommended for the evacuation kits of older adults, can play a critical role in this regard. in summary, the long list of complicated and threatening ces that can affect the nutritional status and overall medical welfare of older adults underscores the fact that all older adults and their care givers, as well as administrators of structured living facilities, should plan for and be physically and psychologically prepared for the event of a serious ce. 1. home-dwelling elders should be prepared for a ce by stocking a 2-week safety supply of food, water, and medications, having a carry-away disaster pack with 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nutritionally vulnerable groups in case of emergencies: experience from the athens 1999 earthquake acknowledgments the authors thank caroline friedman for researching the historic and current events cited here. key: cord-284595-0mlwp05f authors: kirkpatrick, james n.; bernacki, gwen m. title: primary prevention statins in older patients: the good news or the bad news first? date: 2020-07-07 journal: j am coll cardiol doi: 10.1016/j.jacc.2020.05.024 sha: doc_id: 284595 cord_uid: 0mlwp05f [figure: see text] it is also relatively old news that statins reduce adverse cardiovascular outcomes, but it remains unclear whether this reduction applies to older adults. where appropriate. for more information, visit the jacc author instructions page. association of statin use with disability-free survival and cardiovascular disease among healthy older adults effect of aspirin on disability-free survival in the healthy elderly effect of aspirin on cardiovascular events and bleeding in the healthy elderly deprescribing in older adults with cardiovascular disease key: cord-325026-k514rh8g authors: parlapani, eleni; holeva, vasiliki; nikopoulou, vasiliki a.; sereslis, konstantinos; athanasiadou, maria; godosidis, athanasios; stephanou, theano; diakogiannis, ioannis title: intolerance of uncertainty and loneliness in older adults during the covid-19 pandemic date: 2020-08-19 journal: front psychiatry doi: 10.3389/fpsyt.2020.00842 sha: doc_id: 325026 cord_uid: k514rh8g objective: the covid-19 pandemic imposed a psychological burden on people worldwide, including fear and anxiety. older adults are considered more vulnerable during public health emergency crises. therefore, the aim of the present study was to investigate the psychological response of older adults during the acute phase of the pandemic in greece. method: this cross-sectional study was part of a larger three-day online survey. a total of 103 participants over the age of 60 fulfilled inclusion criteria. the survey included sociodemographic questions and six psychometric scales: the fear of covid-19 scale (fcv-19s), the brief patient health questionnaire (phq-9) depression scale, the generalized anxiety disorder scale (gad-7), the athens insomnia scale (ais), the intolerance of uncertainty scale (ius-12), and the de jong gierveld loneliness scale (jgls). results: a significant proportion of the participants reported moderate to severe depressive symptoms (81.6%), moderate to severe anxiety symptoms (84.5%), as well as disrupted sleep (37.9%). women reported significantly higher levels of covid-19–related fear, more severe depressive symptoms and sleep disturbances, as well as higher levels of intolerance of uncertainty. participants living alone showed higher levels of loneliness. intolerance of uncertainty was shown to modulate levels of loneliness. conclusions: during the quarantine, attention was promptly drawn upon the risks related with older people’s loneliness. studies identifying factors that may contribute to loneliness during a public health emergency facilitate the implementation of supportive interventions. preparedness to address and manage older people’s loneliness may limit this deleterious emotional response during the pandemic, as well as at the post-covid-19 phase. the world health organization (who) declared covid-19, the disease associated with the novel "severe acute respiratory syndrome coronavirus 2" sars-cov-2, a "public health emergency of international concern" on january 30 (1) , and a "pandemic" on march 11, 2020 (2) . in greece, the first confirmed covid-19 case was reported on february 26. while the number of covid-19 positive cases was constantly increasing, restriction measures were stepwise introduced. after 695 covid-19 confirmed cases and 17 covid-19-related deaths had been reported, a 6-week national lockdown was imposed on march 23 (3) . the covid-19 pandemic induced worry (4), fear (5), anxiety, and depressive symptoms (6) , as well as insomnia (7) . older adults are considered more vulnerable during public emergency crises (8) . their vulnerability is linked with the agerelated compromised physical state, increased prevalence of chronic health conditions and other disabilities, cognitive abilities' decline, as well as the potential presence of adverse psychosocial conditions (9) . similarly, the covid-19 pandemic affected older people in many different aspects. fear of contracting the virus and fear of death impinged on older people (10), since increased age is a risk factor for severe disease due to compromised immune system function and the higher prevalence of risk conditions for severe covid-19, such as hypertension, diabetes mellitus, cardiovascular, and respiratory diseases (11) ; around 66% of people over the age of 70 were shown to suffer from at least one chronic medical condition (12) . the case fatality ratio was estimated at 1.4% for people under the age of 60, at 4.5% for people over 60, whereas at 13.4 for people over 80 (13) . during the pandemic, around 95% of covid-19-related deaths in europe, 80% of fatal covid-19 cases in the united states, and 80% of fatal cases in china involved patients over the age of 60 to 65 (14) . by june 1, 2020, 76.5% of the 179 covid-19-related deaths in greece involved patients over the age of 65 (15) . despite the emphasis placed by who on the older residents of long-term care facilities (16) , a great number of covid-19-related deaths was reported in care homes in countries severely affected by the pandemic. although official records were not always complete and accurate, available data suggested that between the middle of april and the beginning of may, 67% of total covid-19-related deaths in spain and 37% of total covid-19-related deaths in france involved residents in care homes; death numbers in care homes in the united kingdom were the greatest since 1993 (17) , while roughly one out of five covid-19-related deaths in the united states was recorded in nursing homes (14) . the older high-risk group for severe covid-19 illness was also in danger of having to cope with ageism, a term coined by dr. robert butler to broach the matter of discrimination against older people and the common use of stereotypes (18) , since ageism may involve age discrimination in health care as well (19) . during the pandemic and in face of medical equipment shortage, age was a criterion that may have been applied in ventilator triage policies, in such "if patients have similar expected incremental increases in survival, triage decisions may include consideration of patient age based on the principle that people should have the opportunity to live as much of the normal human life cycle as possible"; "in the event that there are ties in priority scores between patients, life-cycle considerations will be used as a tiebreaker, with priority going to younger patients, who have had less opportunity to live through lifestages" (20) . despite criticism against such policies (21) , healthcare professionals in countries severely affected by the pandemic were forced to prioritize younger over older patients due to the healthcare system's overload with covid-19 patients (22) . furthermore, measures to preserve resources for the management of the pandemic, such as suspension and/or postponement of health services for non-emergent conditions unrelated to covid-19 (23) , posed a risk to older people's physical health (10) , since older adults are more likely to suffer from chronic conditions requiring regular doctor visits and longterm medication (14) . similarly to other countries, the guidelines by the hellenic national public health organization (24) to restrict virus spread in hospitals included canceling all nonemergent outpatients' visits and surgical procedures. in addition, fear of retracting the virus may have been associated with decreased hospital visits and hospitalizations for other conditions. although there have been no official data on hospital visits at the emergency departments for covid-19unrelated reasons, there were anecdotal records of markedly decreased visit numbers in all departments (25) . altogether, older people's chronic health issues were in danger of being lower-prioritized, due to the necessity of placing emphasis on containing the pandemic (26) . a pandemic is a worldwide health emergency crisis associated with fear (27) , an "emotional reflex" related with collective memories of former deadly infectious diseases (28) . fear of the unknown (29) and worry (30) are emotions related to intolerance of uncertainty (iu), a characteristic originally conceptualized as the cognitive, emotional, and behavioral responses to uncertainty in everyday situations (29, 31). throughout the years, researchers provided more definitions, in an effort to describe this concept more accurately (29). individuals with high iu consider the possibility of a negative event as unacceptable and threatening (32) , are prone to worry about unpredictable, future negative events and tend to perceive uncertain and ambiguous situations as threatening (33) . two dimensions were incorporated in the concept of iu, prospective and inhibitory iu (34); prospective iu represents the cognitive dimension, that is, cognitive assessments of threat related with unforeseeable events and desire for foreseeable events; inhibitory iu represents the behavioral dimension, that is, behavioral inhibition or "paralysis" due to uncertainty (35) . lately, iu has been conceptualized as an individual feature, a trait, reflecting negative beliefs about uncertainty and, according to carleton (36) , the incapacity to bear the response "triggered by the perceived absence of salient, key, or sufficient information". this tendency toward negative perceptions and responses to uncertain circumstances was associated with worry (37) and anxiety-related disorders (33) . on the other side, "state" iu may also emerge in response to uncertain stimuli, on the ground of high or normal trait iu, or as part of emotional disorders (33) that may have emerged during the covid-19 pandemic (38) . moreover, iu was found to be a predictor of covid-19-related fear (39) . social-physical distancing and quarantine, the main strategies implemented to prevent the spread of covid-19 (40) , were related with psychological distress, depression, anxiety, insomnia, and social detachment (41) . the latter imposed a great psychological burden particularly on dependent older people living alone and/or receiving home care by family members, friends, caregivers or social services. although prompted by empathy and fear for the high-risk community members' safety (42) , physical distancing was associated with reduced home visits, disruption of regular care provision, and focus on only basic needs. still, the fragile health condition of very old people may be affected by inadequate nutrition, lack of personal and home hygiene, restriction of physical exercise, and irregular supervision of medication intake. moreover, lack of social contacts contributes to cognitive decline, which, in turn, may lead to risky behavioral disturbances (25) . in addition, common socialization channels for older people, such as meeting centers and churches, were locked down. as a result, restriction measures deprived older adults of the opportunity to socialize with their peers, compromising psychological wellbeing by bringing on isolation, a condition posing a great risk for depression, anxiety (43) , as well as loneliness (10) . "loneliness" is a term encompassing a wide range of definitions, among which, "a subjective perception of a negative emotional state related with the divergence between desired and existing relations with others" (44) . according to weiss (45) , loneliness may be emotional or social. emotional loneliness, a subjective experience, is related with the absence of a desirable close and affectionate bonding with a person, absence of someone to turn to. social loneliness, an objective condition, involves lack of contacts, social networks and the sense of belonging to a smaller or wider circle of people. therefore, the term "loneliness" encompasses both qualitative and quantitative aspects of relationships (46, 47) . in older adults, loneliness was related with depression, anxiety, increased risk of further social dysconnectivity (48) , poor global sleep satisfaction (49) , and deterioration of cognitive functions (50) . moreover, it was observed that lonely older adults engage in unhealthy practices, such as smoking, alcohol consumption, and less physical activity, which compromise physical health (44, 51) ; loneliness was associated with increased risk of coronary heart disease and deterioration of cardiovascular diseases (52), a well acknowledged risk factor for severe covid-19 (53) . altogether, loneliness was shown to have an impact on older people's mental health, physical health and overall well-being (44, 51) . therefore, loneliness remains an issue of significant research interest in older adults. in 2018, people over the age of 65 represented one fifth of the european union population, an increase of 2.6% compared with 10 years earlier. greece offered the second highest share of people over 65 years in the total population (21.8%) after italy (22.6%). in 2018, the old-age dependency ratio (oadr; an index used to investigate the level of support offered to older people by the working population, defined as the number of old-age dependents over the age of 65 per 100 persons of working ages 20-64) was estimated at 34.1% in greece, that is, around three working age people for every person aged over 65 (54) ; in 2019, the oadr raised at 37% and is expected to reach a 75% by 2050, placing greece within the 10 countries with the highest oadr worldwide (55). altogether, the population is ageing all over the world, a "longevity revolution". by 2050, one out of six individuals worldwide will exceed the age of 65, compared with 2019 data indicating that 1 out of 11 exceeded the age of 65. people will have a 90% chance of surviving up to the age of 65 in countries with high life expectancy. in most developed countries, the proportion of older adult life will correspond to one quarter of total life time (55). moreover, the chronological age may not always be identical with the biological age (56) . according to the latest eurostat data, women and men at the age of 65 are expected to live an average of 9.5 years in good health. specifically, in greece, both women and men at the age of 65 are expected to live in good health until the age of 72.7 (57) . since health expectancy has been prolonged, older people may remain active and contribute to the family and societal life in multiple manners. during the covid-19 pandemic, retired health professionals were called upon to support the overloaded healthcare system in many countries, including italy (58), spain (59), the united kingdom (60), and the united states (61) . taking into account that older adults comprise a significant proportion of the population, may continue to retain an active role in society (62) , and may be more vulnerable during public health emergencies (9), older adults remain a significant research population. therefore, this study focused on an older greek population during the covid-19 crisis. taking available literature into account, the study aimed to investigate the psychological impact of covid-19, that is, fear, depressive and anxiety symptoms, as well as sleep disturbances, on older individuals. furthermore, the study focused on loneliness during the covid-19 pandemic, and investigated whether fear of covid-19, depressive and anxiety symptoms, insomnia, and iu were potential predictors of loneliness. a non-standard, though widely accepted cutoff threshold to define an older population in developed countries is the age of 60. the definition of "old" is also related with one's employmentretirement status; in the majority of countries the retirement age ranges from 60 to 65 years (63). in greece, three out of four employees retire by the age of 61 (64) . taken together, the present study included older adults over the age of 60. this cross-sectional study was part of a larger online survey (3,029 participants) targeting the greek general population. the survey, created via qualtrics online survey software (65) , was distributed through the social media and was available online for a period of three days, three weeks after a national lockdown had been imposed in greece. information about the study's scope and usefulness was provided in the survey's homepage. before taking the survey, respondents were requested to formally consent to their participation. acceptance to participate was a prerequisite for study inclusion. participation was voluntary and anonymous. initially, 120 consenting participants fulfilling the age criterion completed the survey (3.96% of the original sample). among these, 17 (5 males and 12 females) reported that they suffered from a pre-existing psychiatric disorder during the last 6 months, for which they received psychiatric medication (including antidepressants, antipsychotics, tranquilizers, and hypnotics). these participants were excluded from the analysis. as a result, a total of 103 participants (3.4% of the original sample) entered the study. ethical approval was received from the scientific committee of the general hospital "papageorgiou" review board. at first, the survey included basic sociodemographic questions, including age, gender, residential area, living status, and educational level. consequently, respondents completed the following psychometric scales: 1. the greek version of the fear of covid-19 scale (fcv-19s) (38, 66) . the scale is a reliable and valid unidimensional selfreport tool, recently developed to facilitate research during the covid-19 pandemic. the scale assesses covid-19related fear independent of gender and age. it consists of seven items, e.g., item 1, "i am most afraid of coronavirus-19"; item 4, "i am afraid of losing my life because of coronavirus-19"; item 7, "my heart races or palpitates when i think about getting coronavirus-19". each item is rated on a 5-point likert-type scale as follows: 1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree. the total score ranges between 7 and 35. higher scores reflect greater fear of covid-19. 2. the greek version of the brief patient health questionnaire (phq-9) depression scale (67, 68) . the scale constitutes the 9-item depression module from the complete patient health questionnaire (phq). it is a self-report tool used for the diagnosis of major depression and subthreshold depression in the general population (69), assessing depressive symptoms' severity over the past two weeks. each of the nine items (e.g., item 1, "little interest or pleasure in doing things") is rated on a 4-point severity scale (0 = not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day). the total score ranges between 0 and 27. symptoms' severity is assessed based on the following cutoff scores: 0-4 = minimal or none; 5-9 = mild; 10-14 = moderate; 15-19 = moderately severe; 20-27 = severe (the cutoff point of 10 or greater may indicate a clinically significant condition). the last item of phq-9 exploring suicidal ideation (item 9: over the last two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?) was shown to be a strong predictor of suicide attempts regardless of age (70) , and was therefore separately analyzed (item 9 score > 0) to investigate the prevalence of suicidal ideation in the present sample. 3. the greek version of the generalized anxiety disorder scale (gad-7) (71, 72) . the scale was proven a useful selfadministered tool for the assessment of anxiety symptoms' severity over the past two weeks. each of the seven items (e.g., item 1, "feeling nervous, anxious or on edge") is rated on a 4point severity scale (0 = not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day). the total score ranges between 0 and 21. symptoms' severity is assessed based on the following cutoff scores: 0-5 = mild; 6-10 = moderate; 11-15 = moderately severe; 15-21 = severe (the cutoff point of 10 or greater may indicate a clinically significant condition). 4. the athens insomnia scale (ais) (73) . the scale is an 8-item instrument originally developed in greek to evaluate sleep duration and quality according to the international classification of diseases, 10th revision, criteria. the first five items explore sleep induction, awakenings during the night, final awakening, total sleep duration, and sleep quality, while the last three items explore day-time well-being, physical and mental functioning, as well as sleepiness. each item is rated on a 4-point severity scale ranging from 0 (no considerable sleep disturbances) to 4 (serious/intense sleep disturbances). the total score ranges from 0 to 32; higher scores reflect more severe sleep difficulties. the cutoff score of 10 was proposed for usage in the general population (positive predictive value of about 90%) and was applied in this study to distinguish non-insomniacs from insomniacs (74). 5. the greek version of intolerance of uncertainty scale (ius-12) (35, 75) . the scale is a 12-item instrument, derived from the original 27-item iu questionnaire (31) . it assesses reactions to ambiguous conditions, uncertainty and forthcoming events. the scale displayed strong psychometric properties, was accepted as a transdiagnostic assessment tool for trait iu (76) , and demonstrated a two-factor structure, evaluating prospective iu (7-item subscale; sum of items 1, 2, 4, 5, 8, 9, and 11; e.g., item 1: "unforeseen events upset me greatly"), and inhibitory iu, related with avoidance (5-item subscale; sum of items 3, 6, 7, 10, and 12; e.g., item 3: "uncertainty keeps me from living a full life"). each item is rated on a 5-point likert-type scale ranging from 1 (not at all characteristic of me) to 5 (entirely characteristic of me (46, 77) . this is a 6-item measure, the short version of the original 11-item de jong gierveld loneliness scale (78), consisting of two subscales, a 3-item subscale assessing emotional loneliness (e.g., item 1, "i experience a general sense of emptiness") and a 3-item subscale assessing social loneliness (e.g., item 4, "there are plenty of people i can rely on when i have problems"). each question may be answered with "yes", "more or less" or "no". to rate the items, the "more or less" and "yes" answers are scored with one on the negatively worded questions, that is, items 1, 2, and 3 assessing emotional loneliness. on the contrary, on the positively worded items, that is, items 4, 5, and 6 assessing social loneliness, the "more or less" and "no" answers are scored with one. the total score for both emotional and social loneliness ranges from 0 to 3; the total loneliness score ranges from 0 (least lonely) to 6 (most lonely data and parameter estimates were presented as numbers (n) and percentages (%) or as mean values (m) and standard deviations (sd). independent samples t-tests and one-way analyses of variance (anova), with bonferroni correction were performed to explore participants' differences regarding the main psychometric scales. chi-squared cross-tabulation was used to identify significant differences among the severity categories of fear, anxiety, and depression. linear regression analysis was performed to calculate the associations of loneliness (dependent variable) with iu, depressive and anxiety symptoms (independent variables). statistical analyses were performed by the ibm statistical package for social sciences (spss), version 26.0. the study included 40 male and 63 female participants. the majority of survey respondents were urban residents (80.6%), lived together with their family or a caregiver (78.6%) and had a university degree (45.6%) ( table 1) . females reported significantly higher levels of covid-19related fear (p = .012), more severe depressive symptoms (p = .018) and more severe sleep disturbances (p = .043). females and males did not differ with regard to anxiety symptoms' severity and loneliness ( table 1) . participants living alone showed higher levels of loneliness (p = .004) compared with participants living together with their family or a caregiver. on the contrary, there were no statistically significant differences in the levels of covid-19-related fear, depressive and anxiety symptoms' severity, sleep difficulties, as well as iu between participants living alone and participants living together with their family or a caregiver ( table 2) . a significant proportion of the participants reported moderate to severe depressive symptoms (81.6%), moderate to severe anxiety symptoms (84.5%), as well as disrupted sleep (37.9%) ( table 3) . moreover, a total of 35 participants (33.9%; 12 males and 23 females) reported suicidal ideation based on phq-9 item 9 (score > 0), while 70% of the male and 63.5% of the female participants did not report any suicidal thoughts. linear regression analysis was performed to identify significant predictors of loneliness. ais and fcv-19s did not enter the model as their correlation with jgls was nonsignificant (p >.05). the highest correlation of jgls was with ius-12 (r = .335, p <.01) and the lowest with anxiety (r = .263, p <.05). all needed transformation was completed before the analysis and relevant statistical assumptions were met. the results of the analysis revealed that the linear combination of ius-12, phq-9, and gad-7 accounted for a significant amount of variance of loneliness [r 2 = 0.14, f ( table 4 ). the awareness that increased age is a risk factor for covid-19related mortality, together with the restriction of family and social contacts due to quarantine measures, had a psychological impact on older adults during the pandemic (79) . although a study of a chinese population reported that adults over the age of 60 displayed the highest covid-19 peritraumatic distress index (80) , other studies of different chinese populations showed that the prevalence of posttraumatic stress symptoms (81) and the severity of depressive and anxiety symptoms (6) were not differentiated based on age. moreover, a study of a spanish population observed that adults over the age of 65 reported less severe depressive and anxiety symptoms compared with younger adults under the age of 35 (82) . altogether, further research is required to explore the differences in the psychological impact of covid-19 between younger and older adults. according to previous community-based studies, published between 2005 and 2018, the prevalence of moderate to severe depressive symptoms in greek adults over the age of 60 ranged from 30% to 46% (83) (84) (85) (86) (87) (88) (89) , depending on sample size and differences in study groups and assessment methods. this study showed that roughly 8 out of 10 older adults reported moderate to severe depressive and anxiety symptoms. therefore, current results indicated that during the covid-19 pandemic, the prevalence of depressive/anxiety symptoms may have increased. furthermore, around 3 out of 10 participants reported insomnia. greece continues to belong among the countries with the lowest suicide rates (5 suicide deaths/100,000 population in a year versus an average suicide rate of 11.3 in european union countries in 2014) (90, 91) . it has been suggested that suicide rates may increase during the covid-19 pandemic (92) . older adults, especially the ones suffering from depression, may be more vulnerable to suicide during a health crisis (93) . according to current results, 34% of the participants reported suicidal ideation, based on the last phq-9 item, a finding potentially reflecting the pressure experienced during the imposed lockdown. there was evidence that the psychological impact of covid-19 was greater in women compared with men, that is, women expressed more worry (4) and showed more severe depression, anxiety (6), psychological distress (80) , and insomnia (7) . based on current results, older women showed significantly higher levels of covid-19-related fear, more severe depressive symptoms and greater sleep difficulties compared with older men. on the contrary, severity of anxiety symptoms was not differentiated based on gender. therefore, it may be postulated that although older women were shown to report altogether more worry, as well as more severe depressive and anxiety symptoms compared with older this study also explored iu in older individuals, using a gender invariant scale (95) . according to the results, women showed higher levels of iu compared with men; this difference was particularly significant with regard to prospective iu, reflecting more cognitive assessments of threat regarding unforeseeable events and more desire for predictability (35) , a finding related with the fact that women tend to worry more than men (96) . still, there is only limited information about gender differences in iu, suggesting that although women tend to worry more than men, iu levels are not significantly different based on gender (97) . there is also limited evidence that individuals over the age of 65 show lower levels of iu compared with younger individuals (98) , supporting the theory that ageing may modify personality characteristics (99) . older people's better emotional regulation and maturation through long-term experience with unforeseeable and ambiguous situations may attenuate trait iu, alleviating worry in older ages (98) . still, to the best of our knowledge, gender-related differences in iu in older individuals have not been reported yet. further research of iu in older women and men is warranted, since it was suggested that iu constitutes a transdiagnostic mechanism contributing to a variety of psychological symptoms, with a more pronounced involvement in the manifestation of anxiety and depressive symptoms (100) . moreover, during the covid-19 pandemic, iu was related with higher fear of covid-19 (39) , insomnia (7), and less positivity (101) . anecdotal statements of gradually increasing loneliness in older people over the past decades were not supported by longitudinal studies. becoming older is misguidedly identified as becoming lonelier. loneliness affects younger adults as well. the highest prevalence of loneliness was observed over the age of 80 (47) , while loneliness was shown to increase with age only over the age of 80 (102) . therefore, the relatively low loneliness levels observed in this study may be explained by the sample's lower mean age. moreover, old age alone is not a sufficient condition for the manifestation of loneliness, since there are more contributors to loneliness, such as not living together with a spouse/partner and limited socialization (103) . evidence of gender differences in loneliness is inconclusive. reports of increased loneliness in women compared with men were provided by studies using another tool, the ucla loneliness scale, or one item indicators, and not the dejong-gierveld scale, applied in this study. moreover, gender alone may not be an independent factor predicting loneliness in older individuals (102) (103) (104) . similarly, the current results did not support gender-related differences in loneliness. attention was promptly drawn upon the risks related with older people's social isolation during the quarantine (10) . the magnitude of the pandemic's psychological impact on older adults is related with sociocultural factors mediating older people's family and social connectedness (105, 106) . according to reher's work (2004) , the center and north of europe was characterized by weaker, while the mediterranean by stronger family ties (107) . the grade of familialism was shown to increase from north to south europe; greece was shown to be a country with strong familistic attitudes toward older people compared with other european countries (108) . the living status followed the same "north to south" pattern, that is, the proportion of older people living alone was lower in south europe (109) . according to eurostat, an average of 32.1% of older adults in europe live alone, whereas in greece, only about one out of four older adults lives alone (57) although living alone does not necessarily equate loneliness (110) , it was proven a strong predictor of loneliness (111) . similarly, this study showed that living alone was related with higher levels of loneliness in older adults. furthermore, having children (104), as well as being a member of a joint family were related with less loneliness, since "family" offers older people security, comfort, connectedness, and support. loneliness was not shown to be a major issue for older members of an extended family, being collectively taken care of by other family members (112) . the strong family bonds in greece date back to the "golden age" of pericles (fifth century bc). in ancient greece, "geroboskia" or "gerotrophia", that is, providing care for older people, was a sacred duty performed by family members. moreover, severe penalties were imposed on offspring refusing to provide care for their older parents. as a result, at that time, there were no public facilities for the care of older people (113) . ancient greeks' practices toward older people were a legacy to the next generations. during the following centuries, family members remained the traditional caregivers for older people in greece. moreover, in the beginning of the 20 th century, greek families were organized in an extended form, not only embracing older family members, but also placing them on top of the family hierarchy. patriarchal authority exercised by older males involved decisions on financial matters and the future spouses of children and grandchildren, while matriarchal authority exercised by older women involved organization of housework. lately, the development of nuclear families disempowered older people, weakening their position in society (114) . however, strong bonds between the younger and the older family members are maintained. residential proximity is often pursued between parents and at least one of the adult children. the strong family values render "family" a core component of the greek society. altogether, the greek society is still governed by a moral duty toward its older members. moreover, the article 1485 of the greek civil code imposes a legal duty as well, obligating adult children to take care of their parents (115) . although depression and anxiety were shown to contribute to loneliness (48) , the current results highlighted the modulating effect of iu on severity of loneliness. this study was conducted three weeks after a national lockdown had been imposed in greece. the family network remains a cornerstone in the care and welfare of older adults in greece. uncertainty about the duration of the quarantine and the necessity to maintain physical distancing from family and friends may have intensified loneliness. the fact that the greek sociocultural background nurtures the moral obligation to provide support and emotional care to older people may elevate older greeks' expectations and needs from their family. therefore, loneliness may be easier to experience, when expectations are not fully met (47) . in addition, older adults support their adult children in everyday routine. grandparents in greece take care of their grandchildren to facilitate working mothers (115) . caring for a grandchild was shown to expand older people's social network and to reduce loneliness (116, 117) . restriction measures and isolation deprived older people of the opportunity to contribute to their family and therefore to retain the sense of a significant societal role and connectedness. families kept their older members in safety, away from the virus, and managed alone. this new situation may have raised older people's uncertainty about the importance of their family role and their societal position, contributing to loneliness. lastly, restriction measures compelled older people to become more involved in technology. older people are more reluctant with the internet use. in greece, only about 4% of people within the age range of 65-74 use the internet (118) . the necessity to get acquainted with the internet technology and to develop new skills, for instance use of online bill pay, potentially raised older people's uncertainty. the need to undertake new responsibilities may have led to a sense that instead of being taken care of, older people were left to manage on their own. to the best of our knowledge, up to date there have been no published studies of older adults during the covid-19 crisis in greece. this study investigated the psychological impact of covid-19 on older people during the acute phase of the pandemic. according to the results, the majority of study participants manifested moderate to severe depressive and anxiety symptoms, women carried a heavier psychological burden, and intolerance of uncertainty modulated loneliness severity. studies identifying factors that may have contributed to loneliness during the covid-19 pandemic facilitate the implementation of supportive interventions. older individuals show a preference for goals and environments with minimal negative emotional load, that is, a protective, "stable" surrounding, alleviating uncertainty (119) . restriction measures and disruption of daily routine was a significant source of uncertainty during the covid-19 pandemic. therefore, any form of regular care, such as delivering groceries and medical supplies to older people regardless of their ability to provide for themselves or not, signifies care and ensures brief, but frequent meetings. this approach restores some daily routine, mitigates uncertainty, and may therefore alleviate related feelings of loneliness. limiting exposure to information overload by the media is another remedy to relief uncertainty (10) . introducing older people to online technology enhances social contacts (120), while frequent telephone contacts and involvement of older people in decision-making about family matters nurture a sense of connectedness, which was shown to promote older adults' wellbeing during the previous sars outbreak in 2003 (121) . among a variety of other policies and programs (21) , the initiative taken by the doctors of the world/medecins du monde-greece to support isolated older adults over the age of 60 (122) , as well as various national telephone psychosocial support services aimed to provide assistance and psychological care to older greeks in need during the pandemic. still, the present study had some limitations. the crosssectional design did not allow investigation of causal relationships. results were based on self-report tools, and may therefore suffer from bias. moreover, despite the attempts to focus respondents' attention on the covid-19-related impact (the survey's headline was "the psychological burden related with the covid-19 pandemic crisis"; the survey's homepage included a description of the study's scope), and although participants with pre-existing psychiatric disorders were excluded from the analysis, it cannot be ruled out that study results may have reflected, at least partially, pre-existing psychological symptoms. furthermore, due to the strict restriction measures, the study was conducted through an online survey distributed by the social media, which are used only by 2.3-5.5% of adults over the age of 65 in greece (123) . consequently, the sample was relatively small, while less educated and socially disadvantaged older adults may not have been adequately represented. lastly, online surveys suffer from the so-called "volunteer-effect". therefore, responders' characteristics may differ substantially from non-responders, limiting results' generalizability (124) . conclusively, the covid-19 pandemic crisis unveiled a lack of sufficient data on the older population (14), a significant proportion of the total population in many countries that should not be overlooked. healthy ageing does not solely involve physical health attainment, but also nurture of psychological resources (125) . this crisis may offer the opportunity to address issues related with more efficient care for older adults during public health crises (21) . as a result, awareness and therefore preparedness to assess and address loneliness in older adults may rise during the post-pandemic period, allowing the development of management strategies to eliminate this deleterious emotional response (126) . the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. this study involving human participants was reviewed by the scientific committee of the general hospital "papageorgiou" review board, thessaloniki, greece. ethical approval was received prior to data collection. before entering the onlinesurvey, respondents were requested to indicate their consent. the study was anonymous. ep and vh contributed equally to this study. ep contributed to intellectual input and data interpretation, and wrote the first draft of the manuscript. vh contributed to study's conception and design, as well as to data management interpretation. vn contributed to data management and literature search. ks, ma, ag, and ts contributed to literature search and paper editing. id supervised the study and contributed to the final revision of the manuscript. all authors contributed to the article and approved the submitted version. 2019-ncov outbreak is an emergency of international concern. world health organization who announces covid-19 disease outbreak a pandemic. world health organization current state of covid-19 outbreak in greece and timeline of key containment events. national public health organization covid-19: risk perception and coping strategies functional fear predicts public health compliance in the covid-19 pandemic immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china insomnia during the covid-19 pandemic in a greek population older persons in 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users in greece using the internet for surveys and health research psychological approach to successful ageing predicts future quality of life in older adults loneliness and social isolation in older adults during the covid-19 pandemic: implications for gerontological social work the authors would like to thank the survey respondents. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 parlapani, holeva, nikopoulou, sereslis, athanasiadou, godosidis, stephanou and diakogiannis. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-292878-wbfi0v2x authors: merchant, reshma a.; chen, m. z.; ng, s. e.; sandrasageran, s.; wong, b. l. l. title: the role of a geriatrician has become even more important in an academic institution during covid-19 date: 2020-05-13 journal: j nutr health aging doi: 10.1007/s12603-020-1387-3 sha: doc_id: 292878 cord_uid: wbfi0v2x nan geriatricians worldwide continue to face different challenges including the reduction of the number of specialist geriatric units to augment manpower in managing covid-19 patients (1, 2). in singapore, the number of people screened as covid-19 positive has risen exponentially over the past 2 weeks, largely comprising work permit holders residing in foreign worker dormitories (3) . while a lot of the resources are being channelled to manage the increasing numbers of covid-19 patients, frail older adults with multimorbidity continue to be admitted with very complex needs. the national university hospital (nuh), 1 of 3 hospitals under the national university health system cluster, is a tertiary academic center. geriatricians here are considered as super-specialists (4) with dedicated inpatient beds in addition to the specialised innovative longevity elderly recovery (silver) unit for delirious older patients. patients admitted to nuh are primarily those with fever and / or fulfilling the singapore ministry of health case definition of covid-19 requiring isolation or specialist input, while the rest of the patients are transferred to a nearby hospital which is part of the same cluster. in nuh, they are mostly admitted to the isolation facilities during the first 24 to 48 hours for covid-19 swabs, and de-isolated to the general open wards when results are negative. apart from cardiology and oncology, the doctors covering the isolation beds are from all specialties within medicine. increasingly many older adults are being de-isolated with the 'gm frail elderly' tag which alerts the bed management unit to transfer them to dedicated geriatric inpatient beds. geriatricians also work closely with the emergency department to admit patients who do not require isolation but are agitated or delirious directly to the silver unit. these patients invariably get the best of care from the interdisciplinary team, including respect, dignity, reduction of inappropriate prescribing and proper care transition either to home with home care or to community hospitals. due to circuit breaker restrictions in singapore, we have seen increased caregiver stress for patients with known behavioural and psychological symptoms of dementia (bpsd). many of these patients do not comprehend the importance of social distancing (5) . in addition to the increased demand for inpatient geriatric beds, geriatricians have been working closely with the hospital longstayer committee team and are the main lead in the virtual interdisciplinary ward rounds for long-stayers hospitalwide. geriatric consult services are also high in demand hospital-wide and are made available to older patients in the isolation wards. due to visitor restriction policies within the wards, geriatricians have been working closely with ward nurses to facilitate video calls with family members so that the older patients remain connected with their family which alleviates anxiety. due to team segregation and reduction in outpatient ambulatory visits, we have also started offering virtual consultations for patients and their caregivers. to limit the spread of covid-19, circuit breaker measures have been implemented in singapore from 7th april to 1st june 2020. more than 200 senior care centres and senior activity centres attended by large numbers of older adults are now closed (6) . they had previously visited these centres to socialise, exercise, play bingo and participated in many activities. singapore is filled with high-rise housing with void decks on the ground floor built by the housing development board (hdb), which used to be a meeting place for many older adults before the circuit breaker. older adults will be severely affected by social isolation and a number of measures are in place to prevent functional and cognitive decline. the agency of integrated care (aic) together with many charities are looking out for those at risk of social isolation, and providing them with necessary help and meal deliveries 7 days a week. our role as geriatricians include linking our at-risk older patients discharged from hospital to the relevant agencies. prior to the circuit breaker measures, we had a large group of older adults participating in healthy ageing promotion program for you (happy) dual task exercise in the community. to ensure they remained connected while maintaining social distancing in the community, we conducted a brief survey and almost half of them expressed the willingness to adopt technology in order to continue tele-happy exercises in their own home (figure 1 ). stay-home measures have accelerated technology adoption among older adults, and the ability to connect, see and chat with their peers online have brought great happiness. we have two other ongoing initiatives in the community. firstly we work with the people's association whose mission is to build and to bridge communities in achieving one people, one singapore to create joint exercise video clips for the nation (7) . secondly, we work closely with aic in creating a full length public education television program targeted at older adults locally entitled "learn together with me" (8). lastly, we must not forget the influence of geriatricians as academics on behavior modification and policy changes through research findings. many of our findings, including factors that influence social isolation (9) have been featured in the media to encourage local leaders and older adults themselves to take the necessary actions to delay the onset of dementia and frailty. tele-happy exercise the presence of the geriatrician across settings from acute hospitals to the community is important in ensuring that older adults receive the best care and are not marginalised during the covid-19 wave. technology, web-based e-learning modules and many other initiatives cannot fully replace the role of geriatricians but complement and enhance on-theground execution. as published earlier by stefano volpato et al, geriatric teams, together with the infectious disease specialists and department of medicine as a whole need to be integrated in order to develop tailored management strategies (10) . geriatricians will also have a major role to play in the post-covid-19 pandemic and determine what would be the new normal for older adults. staying true to the calling of geriatric medicine amid the waves of covid-19 geriatric medicine in italy in the time of covid-19 updates on the covid-19 situation in singapore geriatricians: the super specialists anticipating and mitigating the impact of the covid-19 pandemic on alzheimer's disease and related dementias elderly hit hard by social isolation amid circuit breaker measures factors associated with social isolation in community-dwelling older adults: a cross-sectional study a frail health care system for an old population: lesson form the covid-19 outbreak in italy the authors declare that they have no conflicts of interest.ethical standards: this manuscript is original research and has not been published, is not under consideration elsewhere and complies with the ethical standards and current laws. key: cord-279631-1hlrx7o4 authors: huang, yan‐mei; hong, xue‐zhi; shen, jian; huang, yi; zhao, hai‐lu title: china's oldest coronavirus survivors date: 2020-04-08 journal: j am geriatr soc doi: 10.1111/jgs.16462 sha: doc_id: 279631 cord_uid: 1hlrx7o4 nan the outbreak of the novel coronavirus disease 2019 (covid-19) represents a global human pandemic. as of march 16, 2020, 167,515 cases were reported in 151 countries and regions. the death toll worldwide has reached 6,606, far exceeding the fatalities of two other coronavirus diseasessevere acute respiratory syndrome (sars) and middle east respiratory syndrome (mers)-combined. 1 clinical studies consistently show that critical conditions and deaths associated with covid-19 occurred particularly in older adults, especially those with chronic multimorbidity. 2, 3 extraordinarily, five older patients aged 98 years and over were discharged from hospitals, four of whom were in wuhan-the epicenter of the global outbreak. here we present their successful stories to inspire medical staff, patients, and the public. the first case was the oldest so far reported. a 103-year-old woman who had a confirmed positive doi: 10.1111/jgs.16462 nucleic acid test result for covid-19 on march 1 was admitted to the li-yuan hospital, tongji medical college of huazhong university of science and technology. 4 she was bedridden with preexisting alzheimer's disease and other comorbidities. ward physicians and nurses tried hard to communicate with her accurately. computed tomography (ct) imaging proved pleural effusion. her condition was severe at admission yet improved with nurses' care and supportive treatments. she became nucleic acid negative on march 6 and returned home two days later. the second patient was a 98-year-old woman who presented with constant fever (>38.5 c) and fatigue on february 3. 5 she lived with her 79-year-old daughter, and her 49-yearold granddaughter, who lived elsewhere, joined them for the chinese spring festival. the three women showed covid-19 pneumonia as confirmed by ct scan and nucleic acid tests. they were admitted to the wuhan first hospital and shared a ward on february 13. after 10 more days of supportive therapies and individualized nutritional supplementation, the 98-year-old woman, together with her daughter and granddaughter, was confirmed to be covid-19-free and was thus released the same day on march 3. the third case was also a 98-year-old woman who had a high body temperature > 40 c in early february. 5 considering her critically ill condition, she and her 55-year-old daughter, who also had the virus, were transferred to an intensive care unit in a makeshift hospital on the evening of february 13; they were discharged on march 1. the major treatments included anti-infection medication, intensive nursing care, and nutritional supplementation. despite her heart failure, she was joyfully all cleared from the severe lung infection. the fourth case who recovered from the coronavirus infection was a 98-year-old bishop. 6 the pastor was diagnosed with covid-19 pneumonia on february 3 and treated at the central hospital in nanyang, henan province, which shares its border with hubei, the province at the heart of the epidemic. he has tested negative since february 12 and was discharged two days later. in addition to the viral infection, the bishop had comorbidities such as arrhythmia and pleural effusions. he was treated with a thoracic drainage catheter and his recovery was exceptional. the last infected patient was a 101-year-old man who spent a week in the wuhan third hospital. 7 he became unwell in february and was immediately hospitalized after being diagnosed with the viral infection. his doctor claimed that the determined pensioner had concentrated on getting better soon so he could go home and take care of his 92-year-old wife. during hospitalization, the 101-year-old gentleman insisted on taking care of himself and was always the first to get up early for a morning walk. he clearly knew that "it is no bother and i can just do it." thanks to the significant commitment, hard work, and intensive care from the frontline medical staff and the chinese government, these five oldest patients clearly show that age is definitely not a barrier to recovering from the infection. these successful stories are indeed a joy to the world: joy can be "infectious" and "pandemic" too. to the editor: covid-19 is a global pandemic with extensive community spread in many countries. 1 older adults and those with chronic medical comorbidities are seen as particularly vulnerable. 2 the effects when covid-19 reaches nursing homes have been devastating, 3 accounting for a disproportionate number of deaths, particularly in the united states. despite covid-19 reaching our shores nearly 2 months ago, there has not been a single case of transmission in nursing homes in singapore. to date, only one case of possible covid-19 transmission has occurred in an acute hospital in singapore. 4 since covid-19 hit singapore, various measures have been rolled out nationally to mitigate the spread of the highly contagious virus including the restriction of visitors to all healthcare institutions, prescreening of visitors, and reduction in unnecessary transfer of patients. 5 nursing home patients admitted to the hospital have to be managed carefully. they have high rates of pneumonia 6 and it can be difficult to differentiate between aspiration pneumonitis and pneumonia. 7 previously, selected nursing home residents with fever and respiratory symptoms could have a trial of oral antibiotics on site or be treated conservatively if they had an advanced care plan. however, in view of the public health consequences of covid-19, nursing homes now refer all patients with fever and respiratory symptoms to acute hospitals to rule out the virus. all nursing home patients admitted to our institution with acute respiratory infections are isolated in negative pressure rooms and tested once for covid-19 if the clinical suspicion is low. if there is significant concern, some patients may even be subject to a repeat swab before transfer to a general ward. contingency plans have been made to cohort patients with respiratory symptoms and pneumonia in designated wards if cases exceed the capacity of our isolation facilities. at present we have not yet had to resort to this alternative. in addition, on discharge, nursing homes have begun to request letters from hospitals to certify that returning residents do not have covid-19. such heightened vigilance has prevented the spread of a single covid-19 case to nursing homes in singapore. the isolation of nursing home patients has led to some negative consequences. fall rates in isolation facilities are much higher than that in general wards. restraint use has also gone up, whereas our geriatric medicine ward practices a no-restraint policy. nursing home patients in particular have higher rates of dementia, delirium, and behavioral issues 8 that require greater nursing care, which is challenging in isolation facilities, especially in the context of a global pandemic. these are inevitable given that protection of healthcare workers is a priority, and it is difficult for healthcare staff to attend promptly to patients in isolation facilities with behavioral issues and cognitive impairment because they would need to don full personal protective equipment before any patient contact. in addition, we have started to use technology such as the beam robot 9 to minimize patient contact, with plans to roll these out to other institutions. however, the use of technology has limitations, especially when dealing with older patients. preventing the spread of covid-19 to long-term care institutions is a priority, and rigorous heightened measures should be put in place to ensure this. coronavirus disease 2019 (covid-19). situation report-44 middle east respiratory syndrome clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan china coronavirus: what do we know so far? mortality associated with influenza and respiratory syncytial virus in the united states hospital diagnoses, medicare charges, and nursing home admissions in the year when older persons become severely disabled advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019-ncov) outbreak: interim guidance centers for disease control and prevention. 2019-ncov: prevention & treatment. 2020 world health organization clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study clinical characteristics of coronavirus disease 2019 in china the 103-year-old! the oldest covid-19 patient in hubei was discharged from hospital 98-year-old covid-19 patient discharged from hospital world health organization. coronavirus disease (covid-19) situation reports novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china uncounted among coronavirus victims, deaths sweep through italy's nursing homes ministry of health] investigating possibility of covid-19 transmission within sgh outbreak of covid-19-an urgent need for good science to silence our fears? nursing home-acquired pneumonia pneumonia versus aspiration pneumonitis in nursing home residents: diagnosis and management influence of cognitive impairment on fall risk among elderly nursing home residents suitable technologies conflict of interest: the authors have declared no conflicts of interest for this editorial.author contributions: both authors conceptualized the manuscript. li feng tan prepared the main manuscript with input from santhosh seetharaman.sponsor's role: none. key: cord-306210-ny3vvu9h authors: clarfield, a. mark; jotkowitz, alan title: age, ageing, ageism and “age-itation” in the age of covid-19: rights and obligations relating to older persons in israel as observed through the lens of medical ethics date: 2020-11-12 journal: isr j health policy res doi: 10.1186/s13584-020-00416-y sha: doc_id: 306210 cord_uid: ny3vvu9h covid-19, the illness caused by the sars-cov-2 virus, has reached pandemic proportions. although the virus can cause disease in anyone, it is particularly dangerous for those with various “co-morbidities” such as heart disease, hypertension, diabetes, obesity and others. furthermore, advancing age (from about 60 on), even in those older persons without any accompanying illnesses, is a strong and independent risk factor for pneumonia, need for an icu bed and death from the virus. it is therefore essential to find ways to protect all at-risk persons (old or young) from the virus but at the same time not harming, more than absolutely necessary their essential freedoms as well as taking into account their social/psychological needs. compared with other oecd countries, israel’s population is still relatively young, with only 11.5% being over 65+ with a smaller proportion of older persons in long-term institutions than that found in most other comparable jurisdictions. these factors might explain a part of the country’s (so far) relatively low rates of serious disease and mortality compared to those seen in other developed countries. however there are still over a million older citizens at risk and the numbers of infected, hospitalized and seriously ill persons are rising once again. this is no time for complacency. an analysis of the effect of age on the disease as seen through the principles of medical ethics is followed by a proposal as to how best to balance these sometimes conflicting goals. this paper relates mainly to older persons in the community since the ministry of health early on in the pandemic initiated an effective program (magen avot) meant to protect those older persons in long-term care institutions. recommendations include the ministry of health publishing clear guidelines as to risk factors and offering sensible advice on how to practice physical (not “social”) distancing without exacerbating an older person’s sense of social isolation. in order to reduce the incidence of influenza (which can clinically be confused with covid-19) and the potentially disastrous consequences of a “double pandemic” this coming winter, a robust flu vaccination program needs immediate implementation. persons at all ages (but especially those 60+) should be encouraged and assisted to sign advance directives, especially those who do not wish to undergo invasive therapy. an individual older person’s wish to “make way” for younger people should be respected as an expression of his/her autonomy. as we enter the second wave, triage mechanisms and protocols need to be circulated in readiness for and well before a situation in which an acute imbalance develops between the availability for acute resources and the population’s need for them. the ministry of health, in cooperation with other relevant ministries and ngos, should take the lead in developing plans, ensuring that they are carried out in an orderly, timely and transparent manner. the blanket is indeed not large enough but we must place it as judiciously as possible in order as much as possible to protect, cover and keep warm the body politic. supplementary information: supplementary information accompanies this paper at 10.1186/s13584-020-00416-y. the sars-cov-2 virus can effect anyone at any age. as it continues to spread throughout the world it will clearly be with us for the foreseeable future. fortunately, at any age, almost all infected people (even older persons) will overcome this infection without serious sequelae. that being said, the waning immunological vigour of older persons and presence of risk factors ("co-morbidity") often accompanying older age (hypertension, increased bmi, diabetes, chronic lung disease, immunomodulation-immunosuppression, smoking, ischemic heart disease and cerebrovascular disease, etc.) make the disease a much more serious event for many older people. furthermore, it presents special challenges to their doctors and to the health care system (ref [1] ). for those infected, the incidence of severe disease rises inexorably and logarithmically with chronological age (beginning around age 60). comorbidity adds to the risk but does not replace age as an independent factor. some older patients will develop viral pneumonia and a relatively small subgroup will require icu and ventilator support. however, should these numbers grow too quickly, they can easily overwhelm the number of medical staff, hospital beds and ventilators available -a dire situation already observed in several places around the world. many of these acutely ill patients will die and the majority, even if they do survive, remain in the icu for many weeks. in this paper we address the issue of old age and how this particular coronavirus specifically effects older people with israel's experience being the framework for this exploration. in order to do so we first describe the country's demography briefly followed by a few words about formal jewish law (halacha) and its role (or surprising lack thereof) in framing health policy. next, the issue of aging itself is dissected: its role as a risk factor for and the influence of lockdown policies on older persons. as well we define "ageism", explaining the concept's relevance: what it is and what it is not as well as how ageism can adversely affect older persons during this crisis. we then analyze some of the trenchant dilemmas relating to covid-19 through the lens of medical ethics, examining the issues of triage and distributive justice, maximizing non-maleficence and how to ensure that older people's autonomy is facilitated while ensuring that they also remain safe (beneficence). given all of the aforementioned, we offer a specific program for how to move forward and help older persons and the health system to stay afloat as we try to ride the second wave of the pandemic without drowning. compared with most other industrialized countries, israel's population is still relatively young. this demographic pattern effects the expression of the pandemic in the country. see sidebar 1 for details. across the globe the reported case-fatality rate (ratio between confirmed deaths and confirmed cases) for covid-19 is around 2.8% (more than 10 times that for influenza), but this number can vary widely by locationas high as 9.7% (italy) to less than 0.3% (iceland) (https://ourworldindata.org/grapher/coronavirus-cfr; accessed 17 oct., 2020). in israel, at least so far (as of late october, 2020), this rate is still relatively low at 0.7% and despite the very sharp recent rise in confirmed cases it has held reasonably steady over the past few months. examining another ratio (again, as of late october, 2020), 231 per million population have died here compared with 637 in the uk or 672 in the us, although the rate in israel may rise given the recent increase in new cases observed. (see https://www.worldometers.info/coronavirus/ accessed october 17, 2020) . for various reasons, early on, in the spring of 2020, the country coped quite well -with a very low infection rate, few severe cases and a very low death rate. however, coinciding with (or because of) a too rapid release from the lockdown, the figures have deteriorated over the past few months, especially recently (late october). for example, according to the ministry of health's (hebrew language) dashboard (see https://datadashboard.health.gov.il/covid-19/?utm_source=go.gov.il& utm_medium=referral; accessed 17 oct., 2020) the number of new confirmed cases almost doubled in the last week of august 2020 and the number of severe and ventilated cases has gone up by 20% in the last week of august. as of late september the government had reclosed the country more or less hermetically after a failed policy of quarantining "hot" cities or neighbourhoods with particularly high rates of infection -most of these being haredi (ultra-orthodox) or arab municipalities. as such, beginning just before judaism's most holy day of atonement (yom kippur) the country has once again been hermetically closed down for a planned two week (at least) period. this after the failure of localized urban quarantines which failed to dampen the epidemic -most of these being in haredi (ultra-orthodox) or arab municipalities. this picture can hardly be considered successful policy management even if there remains legitimate argument about the variance caused by each of the many steps taken (or not) to date. clearly, these numbers express a moving target and it is not easy nor often possible to tease out the exact cause and effect for rising or falling rates which may be affected by many variables such as change in or extent of testing policy and others. furthermore, improved treatment protocols have brought the pressure for icu/ventilator resources down somewhat. equally important, with respect to a possible exhaustion of the health system through care seeking, the number of hospital beds, trained personnel etc. may be much more important than the number of ventilators. overall, given the larger number of asymptomatic people than those identified as infected, the overall death rate for those actually infected may be even lower than that reported. however, we do not yet know if all those who do survive serious illness will return to their premorbid state of health and function. there is some doubt that this will be the case, with a prediction that a significant minority may suffer serious long-term sequelae subsequently requiring rehabilitation (ref [2] ). in israel, in response to this pandemic, as has been the case in many countries, initially broad and very strict social distancing measures were enacted for the whole population. however, after the number of cases fell precipitously in may these strictures were loosened. unfortunately, despite warnings by relevant professionals, this release was allowed to take place much too quickly and in a rather haphazard manner, with a resultant recrudescence of cases. not surprisingly, many older people found these lockdown steps very difficult to tolerate as a result of being almost totally cut off from family and friends, not to speak of having to look after themselves with minimal help from outside. there is concern that the dangers of social isolation for older people may equal or even outweigh its benefits (ref [3] ). as such, some have called for a useful change in terminology from "social" to "physical" distancing. furthermore, some older people in israel were skeptical of the government's motives and felt that they were being "sacrificed" to keep the medical system functioning in order to favour younger citizens. for their part, many younger people continue to express skepticism relating to the dangers of sars-cov-2 as a result of their low chance of suffering a complication should they become infected and in part because of their understandable lack of faith in the present government and its actions. although we are dealing with a fast and erratically moving target, with the present situation in mind this paper will elucidate relevant issues and offer policy recommendations germane to when and how older persons can minimize risk and at some point in the future return to their pre-covid-19 routine in israel. the general approach taken is that of a "soft utilitarianism" (i.e. what promises the greatest good to the greatest number) while at the same time we make every effort to minimize damage to individual human rights and to ensure that the scourge of ageism does not manifest itself. against the odds, if the epidemic once again quickly subsides, the issues addressed herein will be much less relevant. however, this paper is meant to deal with the much more probable scenario in which sars-cov-2 will be with us for months, perhaps years to come, and especially as we now suffer a second wave more severe than the first. and as was the case in the 1919/20 influenza epidemic, we may even have to endure a third wave. around the world, as a first and necessary step, blanket physical distancing has proven itself, as it did in previous influenza pandemics (both 1918 and 2009). along with heightened personal hygiene, hand washing, and especially the use of face masks, this blunt instrument had until very recently (mid-june) largely reduced and delayed peak attack rates in many countries as well as reducing mortality and the number of very sick persons requiring hospital care (ref [4] ). in israel and elsewhere, but unfortunately not everywhere (see northern italy ref [5] and spain), this tool helped save many lives as well as reducing pressure on acute and icu hospital beds, of which israel is lacking. as well, this step has helped at least so far to preserve precious icu/ventilator beds for the use of young and old alike. along with the whole population so far, at least physically, older persons have benefitted from these drastic measures, although the national economy is taking a severe blow adding not surprisingly to social and political instability. as the country locks down again, the question arises once more as to what approach should be taken. an excellent overview of how to manage such a challenge can be found in tomas pueyo's much cited article "the hammer and the dance" in which the "hammer" refers to the lockdown resulting in abrupt social distancing meant to flatten the curve and the "dance" to how we can get out of lockdown with the least possible loss of life whilst making every effort to maintain the economy (https://medium. com/@tomaspueyo/coronavirus-the-hammer-and-thedance-be9337092b56). explaining the hammer in an interview pueyo stated, "i wanted to create a very strong metaphor ….that could represent the idea of something aggressive early on and then something less aggressive afterwards." he termed the next phase a dance …because it is a much more fluid phase. you need to know the steps of the dance and really apply them as if it were choreography. (see: https://abc7news.com/society/viral-hammer-and-thedance-influences-reopening-amid-pandemic/6199923/ accessed 3 sept., 2020). with respect to older persons, however much it reduces risk, there is justifiable concern over the real health costs involved in physical distancing by keeping older persons confined too strictly and for too long to their homes. these include ill effects, both medical and psychological, especially on those of low socio-economic status (https://www.nytimes. com/2020/06/08/opinion/coronavirus-elderly-suicide.html). furthermore, there is some early anecdotal evidence from both here and abroad that many people have delayed clinic or er visits for non-coronavirus conditions, putting their overall health at risk. it is also not clear under lockdown how many isolated older persons have been able to manage their day to day affairsgroceries, medications, household cleaning and repairs. all this is especially problematic when these people cannot avail themselves of the help of their children and/or neighbours. without this aid it is difficult for such older persons to cope with social isolation and resulting loneliness. in order to analyze this complex issue, whilst taking a morally defensible ethical stance, the approach herein attempts to balance the sometimes conflicting principles of medical ethics, namely: autonomy, beneficence (doing good), non -maleficence (not doing evil) and distributive justice. with 80% of its population being jewish and given the country's unique history, it will come as no surprise that jewish law and traditions will sometimes influence both israel's norms and laws. (see sidebar 2.) biological ageing: what is it? the phenomenon of ageing does not necessarily lead to disease but it does gradually reduce the human organism's ability to withstand stress and is thus relevant to considerations re the effects of the sars-cov-2 virus on older persons. (see sidebar 3). just as for many other diseases, there are "risk factors" for developing covid-19, this term refers not to the disease per se but as something that increases a person's chances of developing one. for example, cigarette smoking is a risk factor for lung cancer, as is the metabolic syndrome for heart disease. however, having a risk factor does not guarantee that one will inevitably develop the illness in question. it just makes the disease more likely. for its part, chronological age (even when controlling for other characteristics) is clearly one of the most significant risk factors for covid-19 pneumonia, the need for ventilator support and above all for death (ref [6] ). why this is and what implications this fact might have for relevant policies will now be addressed. fortunately, for reasons not yet clear, young people (especially children 1-9 years old) seem hardly to be affected by this coronavirus. although they are indeed very efficient spreaders to adults for influenza, it appears that with the coronavirus this may fortunately not be the case. furthermore, although further work needs to be done to reach a firm conclusion, it is possible that young children may actually not constitute a significant danger to their teachers, parents or grandparents. however, at the other end of the spectrum, as alluded to above, increasing age is most definitely an independent risk factor for complications and death once a person is infected (ref [6] ). for example, an intensive care audit from the uk showed a very poor covid-19 pneumonia icu survival rate for those over 70 of less than a quarter (only 24.3%) versus more than three quarters survival (75.7%) for those 16-49 years of age (ref [7] ). a more recent study from northern italy indicated an equally dire prognosis for older men admitted to icu with a death rate of 40% for those 71-80 years old and 52% for those 80-90 (ref [8] ). the numbers were even higher if the patient had hypertension. there are similar figures from israeli icus and elsewhere across the world. tragically, although treatment protocols have indeed increased the chance of survival at all ages, the bottom line is that older persons who become ill enough to require ventilator support are very unlikely to survive. an understandable point has been made that not all older persons are the same. for example, it has been argued that one can find an 85 year old who by a combination of good fortune, favourable genetics and careful lifestyle choices, is in better health than an individual 75 year old with none of these three characteristics. in other words, the "biological" age of a particular 85 year old may well be less than the chronological age of an individual younger by a decade or even two. while this may occasionally be the case, it would be very difficult to assess this phenomenon in any accurate or scientific way within an age cohort (e.g. 65-80 or 80+). and unfortunately, despite the wishful thinking of many older persons and some mistaken authorities, the facts show that the older one is, the higher the risk even when controlling for various relevant co-morbidities. one study indicated that an 80 + year old with no known diseases still has fewer years left to live than does an 60-69 year old with 5 (!) co-morbidities (ref [9] ). sadly, these facts put to rest the attractive myth that a heathy older person can be at lower risk from covid-19 than younger people with co-morbidities. to this end, the renowned american centers for disease control (cdc) provide a simple guidance, listing two rubrics for risk: 1) older adults -even without comorbidity and 2) those with underlying conditions -at any age. (see: https://www.cdc.gov/coronavirus/2019ncov/need-extra-precautions/people-at-increased-risk. html; accessed 25 sept., 2020). so too did the canadian geriatrics society make similar recommendations using age 60 + (unrelated to the presence or absence of risk factors) as the number at which risk begins to rise (see: https://cgjonline.ca/index.php/cgj/article/view/443/507; accessed 25 sept., 2020). patients in nursing homes have been and likely will continue to be a particularly hard hit group, as has been observed in europe (https://www.theguardian.com/world/2 020/apr/13/half-of-coronavirus-deaths-happen-in-carehomes-data-from-eu-suggests), canada and in the us (https://www.nytimes.com/2020/04/17/us/coronavirusnursing-homes.html). in israel, although the absolute numbers remain low relative to many other countries, institutionalized residents still make up about one-third of the covid-19 victims. this is of course bad news but fortunately we have not witnessed the terrible scenes of neglect observed abroad. fortunately, early on in the pandemic, the moh published and at least partially enforced comprehensive guidelines as to how to deal with this sector (https://govextra.gov.il/media/16435/elderlycare-covid19.pdf; accessed 25 sept., 2020) with a special team dedicated to dealing with this situation. "lockdown" policies: ageism or age-protective? in israel, despite some protest, chronological age has been considered as one of the first criteria for social isolation or "stay at home directives", and ultimately considered the last to be released from lockdown. there are several reasons to support such a consideration as well as counter arguments. these are addressed now, followed by a possible solution which attempts to balance the main conflicting considerations. such guidelines need to be scientifically valid, transparent, workable, and insofar as possible, fair so that most in society will be able and agree to buy into it. however before moving on, one must address the complex issue of "ageism". it was the late, great gerontologist dr. robert butler who first defined the term, which according to the who constitutes " … the stereotyping, prejudice, and discrimination against people on the basis of their age [alone]. ageism is widespread and an insidious practice which has harmful effects on the health of older adults. for older people, ageism is an everyday challenge. overlooked for employment, restricted from social services and stereotyped in the media, ageism marginalizes and excludes older people in their communities." (see: https://www.who.int/ageing/ageism/en/ accessed 25 sept., 2020). clearly, the use of someone's chronological age to stereotype and discriminate (in the social sense of the word) is completely unacceptable. for example, age cannot be a criterion for a job for which it is not relevant (e.g. accounting, childcare or academic promotions, etc.). but some well-accepted regulations do use chronological (not even "biological") age as an inclusion and exclusion criterion for certain types of work. common sense is called upon here. for example, it is unlikely that most passengers, even the most gerontophilic, would feel completely comfortable watching two otherwise healthy 90 year old pilots enter the cockpit to preside over a 12 h trans-atlantic flight. in recognition of this logic, even though one could claim it is an expression of ageism, most authorities restrict commercial airline pilots' license to those younger than 65. even then they must also prove that they are healthy (https://www.easa.europa.eu/sites/default/files/ dfu/easa_rep_resea_2017_1.pdf). in contrast, a situation in israel where sadly ageism is still definitely at work can be found in the agemandatory retirement laws governing academia and the civil service. in our view these policies are wrongheaded but this issue is beyond the purview of this paper. on a more positive note, chronological age is used to entitle a universal pension or rights for certain services (e.g. in israel, homemaker hours according the nursing care act, etc.). age also confers discounts on public transport to wealthy older persons rather than poorer younger onesa case of "reverse ageism?" more trivial perhaps, but still relevant to this discussion, there seems to be no serious societal objection to older person receiving discounts to films, concerts and even municipal taxes, simply on the basis of age alone. one could even argue that we use age to discriminate to a significant degree against younger people, e.g. forcing (almost) all israeli youth to register for the military draft at age 17 and obligating most of them to serve their country and possibly endangering themselves to protect their elders for at least 2-3 and sometimes many more years during their own early and formative years, returning to serve in the reserves for many subsequent years. might this not be considered another example of "reverse ageism"? writing recently in the bmj, one british authority pointed to a disturbing phenomenon. "what is undoubtedly ageist is a collective fear of ageing and death in our societal and media values, meaning that appearing old is seen as being diminished, invisible, and unvalued by society. this in turn leads to older people themselves 'othering' any older people they see as being vulnerable, different from their more youthful and active selves. this can lead to 'grey on grey' ageism." (ref [10] ). true, but even worse in our view has been society's lack of preparedness for how this virus could affect older persons that constitutes the true expression of discrimination against older personsboth in israel and abroad. for those older persons who, despite knowing the facts, might chose to take risks and expose themselves to this virus, some will argue against an ageist "paternalism" that would prevent them from exercising their human rights. this means that a person at risk at any age must be free to make an individual decision as to whether he/ she is willing to go back out into society, take the risk of falling ill with covid-19 and accept the consequences, however dire they may be. this claim, in contrast to the one re the older airplane pilot falling ill and endangering all passengers, assumes that older persons are only endangering themselves were they end up needing hospitalization or an icu bed. indeed, should this second wave respond to steps being taken and wane quickly and israel be assured that we have enough icu beds to manage any surge, this claim will be valid and the older person or anyone with other risk factors must be free to take their chances. however, as we are now riding a second wave, this argument (supporting autonomy) seems much less valid in that it will be also be crucial to protect the stock of hospital and icu beds so that they would be available for as many as possibleyoung and old. in such a case it may well become necessary to be stricter in regulations taking distributive justice into account by enforcing isolation of all high risk groups, older persons among them. for its part, the israel gerontology association (long the lead in many important age advocacy initiatives) joining a coalition with four other organizations, have mobilized in the direction of protecting the autonomy of older persons against what they view as an ageist paternalism. they argue that using chronological age as a sole criterion discriminates against some older healthy persons who they claim may even be at less risk than younger sicker people. recently this coalition responded to the joint questionnaire of special procedures mandate of older persons sent out by the un (see: https://www. ohchr.org/en/hrbodies/sp/pages/joint-questionnaire-covid-19.aspx; accessed 25 sept., 2020). the coalition did make some important points, warning for example of the dangers posed by ageism to israel's older population brought on by the covid-19 crisis (personal communication prof yitzhak brick). unfortunately, the coalition members also made the incorrect claim that chronological age is not an independent risk factor for covid-19 complications, despite the clear evidence that it is. for example, in error they offer that, "[f] irst, it was clear that there is no difference between old and young people with regard to infection. secondly, most of the older persons who died from the disease suffered from co-morbidities and severe health risk factors. 40% of the people who died from the covid-19, came from long term facilities." their statement goes on, claiming, " … .that the chronological age cannot be the sole criterion [as to who needs to stay at home], as some people at high age are fit and healthy and others who are younger can be sick and frail, old persons are not all the same. policy makers should not depend on the chronological age when they decide about who has the right to go out of his home or not, and the decision should be made by the person himself [italics ours]." this error of fact, the claim that chronological age is not an independent risk factor, does no service to the elderly and will in fact mislead those who need to make difficult decisions in the weeks and months ahead. others, such as the british society of gerontology have made similar claims (ref [11] ). there is also a growing protest movement among some older people in israel (ref [12, 13] ) as well as in europe (https://www.wsj.com/ articles/older-europeans-reject-calls-to-remain-in-isolation-as-lockdowns-ease-11589112002; accessed 25 sept., 2020) arguing against the justification of such strictures. beyond the issue of ageism, this argument rejects any offer of beneficence, adducing autonomy as the highest ethical value. however, most liberal democracies do put a limit on such considerations in other relevant domains and most citizens will accept these restrictions as reasonable. for example, at any age, one must wear a seat belt when driving. societies demand such steps not only to protect the individual and his/her family (principle of beneficence, aka "paternalism") but also in order to preserve the commons (principle of distributive justice). in the absence of such strictures, society would be more likely to lose the productive years left to an individual who is killed or badly injured in a car accident. in the spirit of both beneficence and distributive justice, lowering the costs to society of premature death or the subsequent rehabilitation of those who survive a car accident seems a reasonable consideration which justifies the (partial) curtailment of a citizen's autonomy. closer to the elder pilot argument is the dire effect that too many people (at any age) simultaneously falling ill with covid-19 would have on hospital servicesparticularly but not exclusively icu/ventilator beds (principle of distributive justice). although we are still not (yet) in that dire situation in israel, this is not just a theoretical argument as we have seen examples from around the developed world of health services becoming overwhelmed or coming very close to doing so as a result of too sudden and heavy a surge on bed and personnel availability (ref [5, 14] ). according to this argument, it is not only in the personal interest of high risk people (older persons as well as younger people with co-morbidity) to make every effort to avoid infection. as well, the argument goes, they should do so in order to help maintain the viability of a health system given that this organization needs to be capable of looking after them should they (or their children or other younger persons) fall ill. of interest is the sense that despite the recent relaxation of formal strictures, preliminary data from israel's largest health fund (clalit) suggest that older persons seem to be voting with their feet to protect themselves. they seem to be voluntarily observing stricter behaviours than those demanded by the israeli government. as pointed out in the times of israel on 12 july, 2020, though israel's infection rate has soared to some 1200-1400 new cases a day in recent days, the percentage of serious cases has been far lower. for example, at the height of the first wave in mid-april, some 180 of a total 9800 active cases were considered serious, or about 1.8%. on saturday [11 july, 2020], 134 of 18,296 cases were considered serious, or about 0.7%. (see: https:// www.timesofisrael.com/at-risk-groups-less-hard-hit-in-2 nd-wave-causing-fewer-serious-cases-analysis/; accessed 25 sept., 2020). against the claim of "ageism" and in the spirit of supporting both "distributive justice" and intergenerational solidarity, others feel that especially in a situation of a critical imbalance between demand and icu resources, it is indeed justified to use chronological age as a criterion (among others of course) for the allocation of scarce resources. for example, a noted american medical ethicist franklin miller (himself 71 years old) offered, "if demand for ventilators keeps growing and further outstrips supply, i believe it could be justifiable as a matter of policy to forgo mechanical ventilation for all patients 70 years of age and older who have a medical condition that puts them at elevated risk of death, such as chronic renal disease, cardiovascular disease, diabetes, and chronic lung disease" (ref [15] ). another authority, larry churchill went even further offering ("as i approach my 75 year") his own personal ethical approach which would give priority to a younger person (ref [16] ). closer to home, a.b. yehoshua one of israel's foremost writers and thinkers, expressed himself in a similar vein (ref [17] ). not all will accept nor support this stance but it does seem to be a position taken by at least some older persons. of interest, colleagues from the field of social gerontology have objected that even such self-sacrifice is in their view still ageist. obviously, none of the three abovementioned distinguished older persons would agree. undoubtedly they would hold that not allowing one to take this approach constitutes an unjustified attack on their autonomy. should the present second wave tower high enough to threaten to overwhelm israel's limited supply of icu and ventilator stock (as was observed in italy, spain and ny state several months ago), the need for difficult choices will inevitably arise. much has been written about the vexed subject of ventilator triage (ref [18] [19] [20] ). relevant statements have also been published by the israel geriatrics society in hebrew on the website of the israel medical association (ref [21] ) and in a modified english version in a geriatrics journal (ref [22] ) as well as by a public commission set up by the moh (ref [23] ). should they wish, and we believe many might elect to do so, a significant number of older persons could voluntarily avoid ending up a triage case or at least ensure clarity relating to their wishes should they reach such a fork in the road. in a thoughtful piece in the nejm, aronson recently offered, "i know many happy engaged elders in their 70s, 80s, 90s, and 100s … who would not want to be put on a respirator … patients and [the us] health care system would be better served if all adults and elders use some of the spare time created by our new, home-confined lives to discuss and document their care preferences, whether the goal is aggressive, supportive or palliative care." (ref [24] ). unfortunately, israel is still quite far behind other industrialized countries in this domain, only recently beginning any discussions on the possibility of "a good death" (ref [25] ). even worse, it is still very difficult and expensive to legally appoint someone an enduring power of attorney which is another way to reduce conflict and misunderstandings over this fraught issue. furthermore, problems of cognitive decline, impaired vision and hearing, not to speak of linguistic mismatch between health care personnel and their older patients (not uncommon in israel), could interfere with an older persons' understanding their situation and expressing their relevant wishes. aronson bemoans the dire effects of the absence of such planning (for any reason) which " … increases the suffering at the end of life …" with the presence of such documents helping " … people with serious or lifelimiting illness to live and die according to their personal preferences" (ref [24] ). relevant efforts must swiftly be made to avoid the maleficence that might follow from ignoring this urgent need. for various reasons related to history and culture, israeli elders, even those with a very short life span (including people with advanced cancer or severe dementia) are often subjected to far more aggressive treatment than would be the case in other western countries. sadly, this phenomenon is observed even when such interventions are clearly futile and painful (ref [26, 27] ). as such, in many cases, when an older person falls acutely ill in israel, he/she may be subjected to invasive procedures and an admission to icu etc. this despite the fact that had the older person really understood what was actually involved, they may well not have agreed to such an intervention. it is thus society's solemn duty to ensure that older persons clearly understand what the automatic fallback options are should they not have made their prior wishes known. furthermore, as addressed above, it is essential that older persons understand the fact that age is an independent risk factor for covid-19 complications and death. suggesting otherwise, despite the clear evidence that it is, does them a terrible disservice in that they may act to endanger themselves by thinking that as a "healthy" older person they are at lower risk than they actually are. how to manage this second wave? as israel enters its second lock-down (in late september coinciding with the day of atonement [yom kippur]) it is worth studying the approach by pueyo alluded to above (ref https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56). but the truth is that at this stage, no-one has yet choreographed either a perfect "hammer" or "dance". all agree that it is economically and socially unsustainable to keep most of the population locked down and laid off indefinitely, even at the cost of more covid-19 deaths. without health, there is no wealth; but the opposite is also true. as such we must open up our societies as quickly but as we safely can. all of the suggestions offered below, in order to be humane (encouraging beneficence and maximizing nonmaleficence) and fair (distributive justice) and in part to compensate older citizens for having to wait until the younger ones are first "released", will require that society take some important steps in parallel. these would include ensuring that during the hammer and even for some time afterwards, older housebound persons would have their daily needs metmaterial, medical and psychological. space does not allow us to go into detail but an example would be special "older hours" for food stores, facilitated home delivery, availability of handymen, plumbers and electricians who would be on call via a central number, etc. and other relevant supports. all of these suggestions require that the moh, along with other relevant government agencies, keeps its finger on the pulse of the epidemicopening the faucet, testing and opening or closing it further depending on the results of extensive and focused testing. a step-by-step proposal 1) with respect to the at-risk populations (those with relevant medical illnesses and older age), so far, even though the number of infected person is rising once again, at the date of writing (late october, 2020) the program recommended herein is still voluntary. this however could change should the situation worsen significantly. one hopes that relevant professional organizations (such as the ministry of health and the israel geriatrics society) ngos such as joint-eshel and lay bodies will use their influence to convince older people and others at high risk to voluntarily follow these guidelines, as they are both in their own individual interest and that of society'swith or in the absence of a lockdown. many of these steps have been taken previously but we are aiming at a rapidly moving target. however, should we reach a catastrophic situation of overwhelmed emergency rooms, insufficient ventilators (and/or the team members needed to manage them), mandatory lockdown of all high risk persons of any age might be required. 2) save lives and protect the system (in that order). although it should be obvious by now, the three essential steps are physical distancing, wearing a face mask and frequent hand washing. and it is indeed distressing to observe how few young people in israel (and others around the world) seem to have internalized the need for such simple but efficacious behaviours. there are even a few world leaders who demonstrably refuse to cover their offending upper airways although fortunately this is largely not the case in israel. to this end, the state needs to more aggressively ensure the promulgation, explication and enforcement of relevant regulations and the supply of appropriate kit in public spaces. here we would expect the moh to lead the way with public health announcements supported by the media, neither of which have as yet excelled in this domain. 3) it is critically important that public personalities, cultural figures, athletes and above all politicians follow and are seen to follow the rules. it is particularly difficult to ask the populace to act in a compliant manner especially when at least three of israel's leaders (all over age 70), prime minister benjamin netanyahu, president ruby rivlin, and most egregious of all, the then minister of health (!) rabbi yacov litzman all shamelessly broke the moh rules over the recent passover holiday. and in early july the newly appointed minister of health yuli edelstein also flouted his own ministry's regulations. we are not alone, as many leaders from around the world have acted in a similar irresponsible way, but in this domain all politics are local. of interest is the welcome public apology recently offered by pres rivlin for his un-leader-like behaviour during the last major jewish/national holiday of passover (see: https://www.timesofisrael. com/as-lockdown-set-to-begin-rivlin-apologizes-forleaders-virus-failures/#gs.gk20fz accessed 19 sept,2020). however, to the best of our knowledge, he is the only miscreant who has offered any such contrition. 4) all of the steps outlined herein are mutually supportive. sensible physical distancing must be explained and defined so that older persons aren't unnecessary "imprisoned" in their apartmentsin other words, needlessly distanced socially. for example there is very little risk involved in meeting children and grandchildren outside in a park or garden strictly separated by 2 m and wearing masks, etc. overly stringent, contradictory and irrational guidelines offered by the moh characterized the first wave and caused significant and entirely unnecessary suffering among older persons, especially but not only in sheltered housing (diur mugan). 5) in the fall and early winter it will also be especially important to ensure a robust influenza vaccination program with wide availability of anti-flu medications (e.g. oseltamivir [tamiflu] ) given that the rise in flu cases which usually begins in november will be superimposed on the ongoing covid-19 pandemic. in this vein health personnel must be encouraged and perhaps even legislated to take a mandatory flu vaccine, given the disappointingly low rates of uptake by this crucial sector in israel in past years. further clinical guidance must be offered to older persons and physicians in the field as to how to handle a patient presenting with nonspecific "flu-like" symptoms from nov-marchswabbing, an algorithmic strategy if positive or negative for flu or sars-cov-2, etc. 6) all persons over age 60, even without co-morbidity, must clearly understand that they are at increased risk for complications and death should they become infected; the older, the greater the danger. this is the case even for an otherwise robust older person. comorbidity adds risk to chronological age; patients and their doctors must understand this clearly. despite pushback by some ill-informed pollyanna's, this message must be forceful and clear. here ngos such as the israel association of gerontology and joint-eshel could help spread the evidence-based word. 7) many who fall seriously ill may elect to be hospitalized and if necessary ventilated (see above). however, there will be those who do not wish to undergo this procedure, instead opting for a more palliative approach. in order to exercise their autonomy, all adult citizens (especially those with any relevant co-morbidity and all those > 60 years) should sign an advance directive. these are available on line from the moh (see https://www.health. gov.il/services/citizen_services/dyingpatientlaw/ pages/dyingpatientrequest.aspx). as well, it is advisable to prepare an enduring power of attorney ( ‫י‬ ‫י‬ ‫פ‬ ‫ו‬ ‫י‬ ‫כ‬ ‫ו‬ ‫ח‬ ). it is most unfortunate that in israel this process is so complex and expensive and the ministry of law shares responsibility for this dire situation. hopefully in the near future, it will be simplified and further encouraged. in the true interest of their older clients, relevant groups such as the israel association of gerontology, joint-eshel and other members of the abovementioned "coalition" should lobby to simplify these procedures and to convince more citizens to take this essential step in order to protect the exercise of their autonomy. in the absence of such guidelines, faced with a patient ill with covid-19, clinicians will find it difficult to know what the individual patients' wishes are re ventilation. from the legal point of view in israel, family members have no formal say in such decisions unless they are the legal guardian ( ‫א‬ ‫פ‬ ‫ו‬ ‫ט‬ ‫ר‬ ‫ו‬ ‫פ‬ ‫ו‬ ‫ס‬ ) of an older person or have the enduring power of attorney mentioned above. strain, israel's hospitals are still just able to cope with the influx of covid-19 patients. however, this balance could change rapidly and should a severe mismatch between needs and resources develop, one would seriously have to consider the need for triage (see above). in this domain much has been written about chronological age alone not being a relevant consideration but most understand that this factor cannot be ignored. furthermore, adding a moral twist to the debate, doing so may be considered by some as practicing ageism. however, in our view, while age alone should not be used as a factor in triage decision making, common sense and the fact that mortality goes up logarithmically with age as well as the chance of coming off a ventilator becomes vanishingly small, it cannot be ignored. the moh would do well to introduce these guidelines into the legal regulations where relevant. 9) those persons with significant comorbidity (at any age) are considered as belonging to the older person (60+) category. under present conditions they should be advised, insofar as is possible, to stay "shielded". however, using similar logic to that pertaining to ventilator triage, should the situation worsen significantly, in the spirit of maximizing distributive justice, consideration would be given to enforcing such behaviour. 10) returning to all older persons (60+), depending on the results of the steps described above, if the situation once again allows, they should be encouraged to return to normal function -but only gradually and carefully. this would pertain to all "vulnerable" persons at any age with serious underlying health conditions (as previously outlined) and those whose immune system is compromised such as by chemotherapy for cancer and other conditions requiring such therapy. 11) unfortunately much poor (and confusing) advice was disseminated to older persons during the initial lockdown with the moh failing to provide timely and accurate advice re prevention and health promotion. as we have now entered a new lockdown, the following recommendations would pertain. even now these guidelines are relevant to all older persons and any younger people at high risk. i. although not always easy to do so accurately, each person can try to determine his/her own risk from the coronavirus and make decisions accordingly. the moh should help by providing simple evidence-based guidance to people, taking into account one's risk profile, medical history and, if necessary, consultation with the individual's family doctor. the moh has published a schema on their website, but it is difficult to find, confusing and not known to most older persons. ii. even in the event of a strict "lockdown", persons of any age should still get out of their apartment and enjoy as much physical exercise as possible. there is no good medical rationale to prevent people at any risk not to walk, jog, outdoor yoga /tai chi, etc. -as long as masking and physical distancing are maintained. iii. re essentials (health, shopping, essential services), people at risk should get as much help as possible from delivery services, friends, family and the local authorities in order to minimize going out for these needs. some people will need assistance from the state/municipality to manage. examples of sensible social engineering taken in other countries include having supermarkets maintain certain hours for high risk persons and directing shoppers through aisles in a "one way" direction while also enforcing the two meter rule. to the best of our knowledge, none of this exists today the health funds (kupot haholim) will need to be ready to provide adequate medical services at home and/or at specially configured clinics at specific hours in the day. iv. all persons at risk need to maintain strict physical (not social) distancing including from family members (especially those aged 10+). with any outside contact, masks must be worn by all and no physical contact is allowed, including for example, passing plates of food back and forth. family visits outside in a private garden or public park should be allowed as long as everyone stays more than 2 m apart. v. some older people may choose, in the spirit of maximalising distributive justice and out of a sense social solidarity towards the younger generation (as for example expressed by a. b yehoshua among others alluded to above ref [15] [16] [17] ) and out of concern regarding their individual risk, to maintain even stricter social isolation as well as to give priority to younger persons. this decision should be neither minimized nor mocked. whatever one's thoughts about ageism, this choice is to be honoured and respected as a legitimate expression of the at-risk person's autonomy. we live in a society where certain younger age and occupational groups sacrifice for the health, safety and security of those older than them and this must be a bidirectional phenomenonespecially between consenting adults. vi. as addressed above, all older persons should be encouraged and if necessary helped to make and document decisions about advanced directives so that their wishes can be respected should their health suddenly deteriorate. this expression of autonomy is of paramount importance, especially in times of crisis and uncertainty and given the default option of aggressive icu and ventilation measures too often taken in this country. should a triage situation develop,clarification of this domain will also help reduce family uncertainty as well as decreasing unnecessary pressures on the health care system. 12) as alluded to in sidebar 1, israel enjoys a population of approximately 1.1 million citizens over 65 years, 97.6% of whom live in the community. all of these recommendations refer primarily to older persons dwelling in the community however, they would not be as applicable to the 22% of older persons receiving homemaker care according to the nursing law ( ‫ח‬ ‫ו‬ ‫ק‬ ‫ס‬ ‫י‬ ‫ע‬ ‫ו‬ ‫ד‬ ) or who had an authorization for a personal attendant (usually a foreign worker). such people will be much frailer than the usual older person, exhibiting even a higher prevalence of co-morbidity and cognitive decline. another vulnerable sector would also not be included in this schema, that is persons in institutions for older persons (approximately 23,600, that is 2.6% of the elderly) with the possible exception of those more independent elders living in sheltered housing ( ‫ד‬ ‫י‬ ‫ו‬ ‫ר‬ ‫מ‬ ‫ו‬ ‫ג‬ ‫ן‬ ). as mentioned above, the moh has designed an ongoing mechanism (magen avot) meant to protect this extremely vulnerable population. among other things, this program ensures an adequate supply of ppe as well frequent as pcr testing of both residents and staff. after a rocky start this program now seems to be working quite well and offers area example of what israel got right during the pandemic (ref [28] ). 13) planning needs to consider a sensible exit strategy from the ongoing second wave. these recommendations should be instituted gradually: releasing first those 60-69 years old; then 70-84 and finally all 85+. although such age categories are admittedly arbitrary, they clearly represent the increasing risk of the average person in each group from covid-19 (less clinical reserve, higher likelihood of co-morbidity and shorter life expectancy, etc.) as one climbs the age scale. 14) outreach is needed to populations which traditionally have less access and/or trust in the healthcare system such as citizens from arab and ultra-orthodox communities where infection rates are increasing more than in the general population. this can be done by having citizens from those communities actively involved in the decision making process and encouraging local leadership to take an active role in disease prevention and management. in this paper we have tried to address the vexed issue of age; how a society such as israel's should make every attempt to meet the needs of older persons during the pandemic while taking into account those of the wider society as well as the sometimes conflicting principles of medical ethics. space does not allow us to deal with all relevant issues and for some we can only outline the topic. please see sidebar 4. a final (personal) word from the older author (amc) even today and especially as we ride and try to balance on the second wave without plunging into the roiling seas, this proposal puts much onus on israel's senior citizens, many of whom have not had an easy life. this will be the case whether or not these guidelines are statutory or voluntary. just as they may have begun to enjoy retirement, hobbies, their grandchildren etc., older persons are once again to be restricted (at least partially) by this terrible pandemic. it must however be kept in mind that it is the virus, not society which is responsible. this proposal asks a heavy price of older persons, i.e. to wait inside and struggle relatively alone for longer than younger people. but it is logical and meets the criterion of soft utilitarianism alluded to above (the greatest good to the greatest number.) i am almost 71 and, according to this proposal, will have to wait my turn until i am allowed and/or allow myself more freedom -perhaps for quite a while. as are the two older medical ethicists and a.b. yehoshua quoted above (ref [15] [16] [17] ), i am willing to do so because i believe in the science, logic and moral approach of this "dance". in addition, in social solidarity with younger people, i am willing to take these steps for the sake of my children and their generation which is the one which will drive the economic, defense and social engines of our society out of this crisis. and in the end, as an older israeli, i (and i know of others) am willing to do this for the sake of our society. while many infected persons are asymptomatic and most survive the sars-cov-2 virus, covid-19 can be a serious disease, especially for those with co-morbidity and for many older persons, even without. the sars-cov-2 virus has caused illness and death and wrought severe socio-economic disruption for people at all ages across the globe (see https://www.economist.com/international/2020/09/26/the-pandemic-is-plunging-millionsback-into-extreme-poverty). given the iron laws of biology, on average healthy older persons are at higher risk than younger, even unhealthy people. as such, society pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (covid-19): a review the stanford hall consensus statement for post-covid-19 rehabilitation the silent danger of social distancing from mitigation to containment of the covid-19 pandemic; putting the sars-cov-2 genie back in the bottle facing covid-19 in italy -ethics, logistics and therapeutics on the epidemic's front line estimating excess 1-year mortality associated with the covid-19 pandemic according to underlying conditions and age baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region covid-19 -exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study what the pandemic measures reveal about ageism the price of continued isolation for older persons -a social disaster. maariv (online-hebrew) sheltered housing in the days of corona -worse than a prison why i support age-related rationing of ventilators for covid-19 patients. the hastings center on being an elder in a pandemic ready to die if that will be instead of a younger person ventilator triage policies during the covid-19 pandemic at u.s. hospitals associated with members of the association of bioethics program directors the toughest triage -allocating ventilators in a pandemic fair allocation of scarce medical resources in the time of covid-19 israel ad hoc covid-19 committee: guidelines for care of older persons during a pandemic joint commission of the israel national bioethics council, the ethics bureau of the israel medical association and representatives from the ministry of health age, complexity, and crisis -a prescription for progress in pandemic death is inevitable -a bad death is not; report from an international workshop ethical issues in end-of-life geriatric care. the approach of three monotheistic religions: judaism, catholicism and islam enteral feeding in end-stage dementia: a comparison of religious, ethnic and national differences in canada and israel publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements none. received: 2 july 2020 accepted: 14 october 2020 needs to protect all of those particularly susceptible to this virusboth from the disease as well as from the ill effects of the necessary constraints on their freedoms necessitated by this worldwide emergency. but equally important, governments must act transparently and solely in the interests of citizens. finally, they need to ensure a fair distribution of resources -especially if society is faced with an acute shortage. the trick will be in getting the balance right. supplementary information accompanies this paper at https://doi.org/10. 1186/s13584-020-00416-y. we alone are responsible for the whole text. the authors read and approved the final manuscript.funding none.availability of data and materials not relevant.ethics approval and consent to participate not applicable.consent for publication not relevant. author details key: cord-034438-9kdmljoq authors: sepúlveda-loyola, w.; rodríguez-sánchez, i.; pérez-rodríguez, p.; ganz, f.; torralba, r.; oliveira, d. v.; rodríguez-mañas, leocadio title: impact of social isolation due to covid-19 on health in older people: mental and physical effects and recommendations date: 2020-09-25 journal: j nutr health aging doi: 10.1007/s12603-020-1500-7 sha: doc_id: 34438 cord_uid: 9kdmljoq objectives: to review the impact of social isolation during covid-19 pandemic on mental and physical health of older people and the recommendations for patients, caregivers and health professionals. design: narrative review. setting: non-institutionalized community-living people. participants: 20.069 individuals from ten descriptive cross-sectional papers. measurements: articles since 2019 to 2020 published on pubmed, scielo and google scholar databases with the following mesh terms (‘covid-19’, ‘coronavirus’, ‘aging’, ‘older people’, ‘elderly’, ‘social isolation’ and ‘quarantine’) in english, spanish or portuguese were included. the studies not including people over 60 were excluded. guidelines, recommendations, and update documents from different international organizations related to mental and physical activity were also analysed. results: 41 documents have been included in this narrative review, involving a total of 20.069 individuals (58% women), from asia, europe and america. 31 articles included recommendations and 10 addressed the impact of social distancing on mental or physical health. the main outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. cognitive strategies and increasing physical activity levels using apps, online videos, telehealth, are the main international recommendations. conclusion: mental and physical health in older people are negatively affected during the social distancing for covid-19. therefore, a multicomponent program with exercise and psychological strategies are highly recommended for this population during the confinement. future investigations are necessary in this field. the covid-19 pandemic due to sars-cov-2 has rapidly spread all over the world since last december. although its prevalence in the community is uncertain due to the asymptomatic cases, all age groups seems to be similarly affected (1) . however, older people are at higher risk of suffering negative outcomes, which can lead to an elevated rate of mortality, being five times higher than the global average for those older than 80 years old (2) . over 95% of fatalities due to covid-19 in europe and around 80% in china have included people older than 60 years-old (3, 4) . in the us, 80% of deaths were among adults 65 and over (5) . hence, health strategies to avoid spread of coronavirus (such as quarantine and social distancing) are important (6, 7) . the world health organization (who) describes a close relationship between physical and mental functions with the level of self-governance and social participation in the community [8] . social participation has been defined as active participation in a religious, sports, cultural, recreational, political, and volunteer community organizations (9) (10) (11) (12) . various studies have reported protective effects of social participation for the health of the elderly, being considered as a stimulus to increase the level of physical activity and cognitive functions (9, 13, 14) . the social participation has been associated with a better quality of life, more muscle mass, balance, cognition and lower comorbidities and disability in older people (9, 13, (15) (16) (17) (18) (19) (20) . participating in social meetings and activities are stimuli that increase the level of physical activity as well as the interaction with other older adults stimulating sensory systems, self-esteem, affectivity, emotional and psychological support (9, 13, 21) . as a preventive measure during the covid-19 pandemic, community organizations have closed. old people are constrained from visits with family members, therefore the social participation have been restricted (7) . thus, the decreasing of social interaction produced by social distancing could have a negative impact on mental and physical health in older people (22) (23) (24) , since it has limited the social participation in community organizations and in family activities (23, 25) . who defines the 'intrinsic capacity' as the 'composite of all the physical, functional, and mental capacities of an individual' (26) (27) (28) , changing the focus from a negative aging (disability) towards a positive one (optimal aging), being related to the onset of autonomy decline, falls and death (27) . physical activity has a positive impact on the health and quality of life, reducing the risk of functional and cognitive impairment, falls and risk of fractures, depression, disability, risk of geriatrics syndromes, hospitalization rates and, consecutively, mortality in older people (29) . not only the physical activity is affected during quarantine, but also mental health. several studies have described mental health consequences in previous quarantines, such as higher risk of depression (30) , emotional disturbance (31) , stress (32), low mood (33), irritability (33) , or insomnia (33) , being also associated with higher rates of suicide in elderly population (34) . however, the effects of covid-19 quarantine on the health of older adults have not yet been broadly studied. hence, the aim of this review is to analyse the potential effects of social isolation caused by covid-19 pandemic on mental and physical health in older adults. additionally, we have analysed the recommendations and proposed activities to avoid mental and functional decline to carry out at home. in this narrative review, the literature search was performed by three authors (wsl, irs and rt). pubmed, scielo and google scholar databases were consulted using the following terms ('covid-19', 'coronavirus', 'aging', 'older people', 'elderly', 'social isolation' and 'quarantine'). articles of any type of methodological design published from 2019 to 2020 (may 20th), in english, spanish or portuguese were included. articles that did not include subjects >60 years old were excluded. additionally, we have searched papers, guidelines, recommendations and update documents from different international organizations related to mental and physical activity. the lists of articles in the databases were downloaded in "bib format" and stored in mendeley for analysis of duplicate articles, title, and abstract reading. the content of the review was divided into two main areas: 1) effect of the reduction of social participation produced by quarantine for covid-19 on mental and physical health in elderly people, and 2) recommendations for mental and physical health of older people during the covid-19 quarantine. a detailed summary of the literature search is provided in figure 1 . six hundred and ninety unique records were identified through database and handsearching, resulting in ten articles involving 20.069 participants included in the final review (women 58%) from asia, europe, and america. of these, 9 adopted a cross-sectional design, and 1 was a qualitative design. all of them are descriptive studies. additionally, 31 articles from experts and authors about recommendations were considered in the full-text review. a summary of the characteristics of the included studies is presented in table 1. selection process of studies our results are based on summary data from eight crosssectional studies (35) (36) (37) (38) (39) (40) (41) (42) . the prevalence of anxiety ranged from 8.3%, 18.7% and 35.1% to 49.7% (36, 38) ; corresponding values from depression were 14.6%, 20.1%, 32.8%, 37.8% and 47.2% (36) (37) (38) . finally, sleep disturbances were observed in 18.2% (38) and 36.4% (37) among the participants. six of them (36, (38) (39) (40) (41) (42) pointed out an increased level of psychological stress defined as higher anxiety (36, (38) (39) (40) (41) , depression (36, (38) (39) (40) (41) and loneliness (42) levels and poorer sleep quality (38) during the lock-down by coronavirus. nevertheless, in one study (35) isolation period by covid-19 turned out in a mild stressful impact. additionally, only one study (37) showed that people during quarantine had lower anxiety levels, but more sleep disturbances. risk factors associated to these results varied across the studies. being female (36, 39, 42) , having a negative selfperception of aging (42) , healthcare workers (38) , family and personal resources (42) , time devoted to covid-19 information (42), having an acquaintance or a family member infected with covid-19 or a previous history of medical problems (39) seem to act as potential risk factors. the impact on physical health of the social distancing was studied for two authors (43, 44) (table 1 ). goethals et al (43) reported that covid-19 pandemic has affected the number of seniors attending group physical activity programs. additionally, castañeda-babarro et al (44) observed that the physical activity was highly decreased during confinement in all population, especially the vigorous activities and walking time. there are several recommendations related to the patient to deal with this social isolation (table 2a) such as strengthen social connections (43, 45-48) (using internet apps, video chat (45, 47) ), telephone support lines or support groups (23, 35, 49) , changes on lifestyle (regular sleep-wake up circle (50), physical activity and nutrition habits (37, 51) ) and cognitive stimulation (using apps or stimulating mental exercises, especially in those people with previous cognitive impairment (50) (51) (52) ). caregivers have an important and crucial role guaranteeing the physical and mental well-being. to reduce anxiety and feeling of usefulness, letting the person participate in adapted daily activities depending on the cognitive status is recommended (51) . the exposure to media must be regulated (53) , avoiding doing it in excess and only from official sources (51, 54) , managing to control the effect of news with traumatic content (51) . explaining clearly (55) or accompanying information with illustrations (53) may help, especially in people with cognitive impairment. to improve older people resilience, a combination of health education and psychological counselling could be useful. reinforcing that being quarantined is helping to keep others safe (23, 35, 46, 49) , adopting inclusive language when talking about the elderly, valuing older people's contributions and avoiding negative emphasis on risk (46) could increase also elderly's resilience. during this covid-19 crisis, healthcare system have had to change completely implementing virtual consultations and telemedicine (video-tools, telephone hotlines or online consultations (49) , guaranteeing rapid access to health care (52, 56) . additionally, the scorare ga, an assessment tool, has been proposed for doing a telematic geriatric assessment (52) . in order to minimize isolation related stress, quarantine should be as short as possible. giving good quality information, using channels that older people use like traditional media is also important for reducing stress (23) . the social distancing has reduced the levels of physical activity, which could have a negative impact on physical health (43, 44) . in this review, we include recommendations about increasing physical activity levels from the following eight global organizations: american college of sports medicine (acsm) (57), american heart association (aha) (58) , american physical therapy association (apta) (59) , international association of physical therapists working with older people (iptop) (60), world health organization (who) (61), world confederation for physical therapy (wcpt) and international network of physiotherapy regulatory authorities (inptra) (62) . they recommended 150-300 minutes per week of moderate-intensity aerobic physical activity and two sessions per week of muscle strength training (57, 61) . additionally, exercise circuit at home with cardio and strength exercises in short bursts of 30 seconds for up to three minutes. finally, coordination, mobility and cognitive exercises are also necessary (63) ( table 2b ). the role of caregivers during the quarantine is to supervise the exercise in those patients with unstable chronic diseases (64) . for health professionals, the principal elements to consider when designing an exercise program for older people confined at home are exercise modality, frequency, volume, and intensity (63) . it is recommended the telehealth using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) . iptop has recommended a list of apps[60] such as "otago exercise programme", "clock yourself" and "iprescribe exercise". apta, acsm and aha recommended different online videos and websites (58, 65, 66) (table 2b ). this review suggests a general negative effect on mental health in general population during social isolation for covid-19. this implies higher levels of anxiety and depression as well as poorer sleep quality. the prevalence of anxiety and depression during covid-19 outbreak, varies across the studies, having a wide range from 8.3% (36) to 49.7% (42) for anxiety or 14.6% (36) to 47.2% (42) for depression, in consonance with previous studies of other epidemics. for instance, 39% of prevalence of anxiety was observed in france due to avian influenza (67); 48% of the general population in sierra leone experimented symptoms of anxiety or depression 1 year after ebola outbreak (68); in hong kong due to the sars epidemic, 73% and 57% of individuals presented low mood and irritability (respectively) (33) , as well as depression in 31.2% of 129 quarantined persons for sars epidemic in 2003 (69) . the lower rates of anxiety and depression observed in some studies of our review during activities to improve the mental and physical health at home coronavirus pandemic could be explained for several reasons. the first one is that, based on previous epidemics, strong and quickly measures to keep mental health could have been taken by the governments, avoiding a bigger psychological impact. as time goes by, there was more information about sars-cov-2, which could also lead to a better management of the situation. however, data were collected in a very earlier stage of the pandemic, hence, these results should be taken with caution. some of the risk factors associated to a higher risk of psychological distress have been also described in previous literature. after ebola outbreak, people who knew someone quarantined due to ebola or with any ebola experience were at higher risk of anxiety, depression and post-traumatic stress disorder (68) . additionally, being older than 60 or worried about the recurrence of sars have been also found as risk factors in previous studies (70) . however, we cannot conclude the same in this review, where a more intense effect on older people has not been reported. another parameter that should be taken into account is the duration of isolation, since it is related to the severity of psychological symptoms. a non-significant impact on patients' well-being has been demonstrated during short-term isolation (71) . health providers need to be aware that older adults are at higher risk of having mental health concerns during isolation, and they may have less resources to mitigate them. they should encourage old adults and their families to contact each other daily, as much as they can, to reduce isolation in this population. additionally, maintaining a positive life-style behavior such as regular sleep and meal times, keep a healthy diet, cognitive stimulation and perform physical activity need to be recommended. also, relaxation techniques which may include diaphragmatic respirations or muscular relaxation, practicing a regular routine, alternating with different activities during the day could be useful. it is important for people to be informed by reliable sources and spending a limited time for searching information, maximum once or twice per day. information given to the elderly should be simple, frequent, and displayed in appropriate media. this review has reported that social distancing because of the covid-19 pandemic could lead to negative consequences for the physical health of older adults. this is caused by the decrease of physical activity levels due to the total or partial restriction of social participation in community groups and family activities during the pandemic (42, 43, 44) . social participation has several positive effects on physical health in elderly people (72) . studies have reported that older adults who were enrolled into social activities presented better dynamic balance and muscle strength, healthy lung function and lower disabilities and chronic inflammation compared to those without social participation (14, 72) . for this reason, attending social activities is an important component for successful aging (14, 72) . the relationship between social interaction and physical health may operate through different pathways (14, 72) . a possible explanation for these findings is that participating in meetings or social activities stimulates the musculoskeletal, cardiovascular, respiratory and nervous systems through physical activity and social interaction (73) . physical activity generates benefits for the physical health of older adults, stimulating muscle contraction, energy expenditure, decreasing systemic inflammation and oxidative stress, reducing prevalence of chronic diseases, and geriatric syndromes such as sarcopenia, osteosarcopenia and frailty (74) . as expected decreasing or total restriction of social interaction could generate negative consequences for the health of elderly people, especially in those with chronic diseases, disabilities and geriatric syndromes (14, 63) . evidence has demonstrated a relationship between social isolation and loneliness with disability, chronic diseases, risk of mortality and physical inactivity in elderly population (9, 19, (75) (76) (77) (78) (79) . however, the effect of increased sedentary behavior and decreased physical activity on elderly people during the covid-19 pandemic is unclear. isolated older people have less physical activity and more sedentary behavior than those non-isolated [80] . physical activity is described as any body movement using skeletal muscle that results in energy expenditure > 1.5 metabolic equivalent of task (met), while sedentary behavior is defined as any waking behavior characterized by an energy expenditure 1.5 or less met while in a sitting, reclining or lying posture (81, 82) . increased sedentary behavior has been associated with the prevalence of different comorbidities in elderly people (83) . since a direct association has been reported between sedentary time and time spent at home in elderly people (84) , recommendations have to be made to prevent health consequences in people with social isolation associated to the pandemic covid-19. the global expert organizations included in this review have highlighted the importance of increasing or maintaining the physical activity levels during the pandemic (57-62). although those organization recommended different types of activities or exercises, they are in agreement of using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65). acsm and who recommended 150-300 minutes per week of aerobic physical activity and 2 sessions per week of muscle strength training (57, 61) . however, recommendations for people with social isolation could consider studies that have reported benefits of replacing sedentary time with physical activity. for example, replacing sedentary behavior with 30 minutes of light physical activity and 20 minutes of moderate to vigorous physical activity could have beneficial effects on all cause mortality (85) . in addition, replacing 30 minutes per day of sedentary time with moderate to vigorous physical activity has been associated with a decreased frailty in older people (86) . this information could be used to recommend physical activity as appealing and feasible (87) . additionally, balance, coordination, mobility and cognitive exercises to stimulate neurological system are recommended for older people to reduce the risk of falls and cognitive declining (63) . in those older adults with geriatrics syndromes or unstable chronic diseases, it is recommended the supervision of caregivers to avoid falls, exacerbations and injuries during the exercise (64) . in addition, the health professionals should design the exercise program for older people confined at home with a specific exercise modality, frequency, volume, and intensity (63), using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) . finally, the quarantine implied a radical change in the lifestyle of elderly people, reducing the social interaction, participation in exercise group, religious or spiritual group which have negatively affected the mental and physical health in this population (88) . therefore, to maintain an active lifestyle at home is important for the health of older adults, especially those with chronic diseases and geriatrics syndromes. to summarize all the recommendations and articles included in this review, we have proposed different activities to improve the mental and physical health at home in figure 2 . to the best of our knowledge, this is the first review that includes assessing the physical and mental effects of social isolation by covid-19 among older people. however, this study has some limitations, which deserve to be mentioned. studies included in this review were cross-sectional design and not specific in elderly population. as all of them are descriptive studies, no control group was used. additionally, there is also a lack of evidence regarding the most appropriate psychological and physical recommendations and most of the interventions suggested are based on expert opinions and not on high evidence studies. future investigations should consider a longitudinal or cross-sectional design in older individuals, with larger sample size and different outcomes related to mental and physical health. in conclusion, our study suggests that the mental and physical health in older people are negatively affected during the social distancing for covid-19. the main mental and physical outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. experts organizations and who have given different recommendations to keep older people mentally and physically healthy. therefore, an integrated and multidisciplinary assessment between geriatricians, psychiatrists and physiotherapists could be needed. history in a crisis -lessons for covid-19 world health organization. covid-19 strategy up date who. statements, press and ministerial briefings. 2020 the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china. epidemiol work gr ncip epidemic response, chinese cent dis control prev severe outcomes among patients with coronavirus disease 2019 (covid-19) -united states the covid-19 generation": a cautionary note social distancing" amidst a crisis in social isolation and loneliness the international classification of functioning, disability and health effects of an exercise model based on functional circuits in an older population with different levels of social participation social participation and healthy ageing: an international comparison using share data social capital and health among the aged: comparisons between the united states and germany association between social participation and hypertension among older people in japan: the jages study social participation as an indicator of successful aging: an overview of concepts and their associations with health social participation is associated with better functionality, health status and educational level in elderly women the association between social support and physical activity in older adults : a systematic review association between social participation and hypertension among older people in japan: the jages study social participation reduces depressive symptoms among older adults: an 18-year longitudinal analysis in taiwan social vulnerability as a predictor of mortality and disability: cross-country differences in the survey of health, aging, and retirement in europe (share) social relationships and mortality risk: a metaanalytic review social participation and self-rated health among older male veterans and non-veterans social participation and the prevention of decline in effectance among community-dwelling elderly: a population-based cohort study social participation and depression in old age : a fixed-effects analysis in 10 european countries the psychological impact of quarantine and how to reduce it: rapid review of the evidence covid-19 and older adults covid-19 and the consequences of isolating the elderly the world report on ageing and health: a policy framework for healthy ageing prediction of adverse outcomes in nursing home residents according to intrinsic capacity proposed by the world health organization redesigning care for older people 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during the covid-19 epidemic in southwestern china comparison of the indicators of psychological stress in the population of hubei province and non-endemic provinces in china during two weeks during the coronavirus disease 2019 (covid-19) outbreak in generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey a nationwide survey of psychological distress among italian people during the covid-19 pandemic: immediate psychological responses and associated factors stress , anxiety , and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain symptoms of anxiety and depression during the outbreak of covid-19 in paraguay. symptoms anxiety depress dur outbreak covid-19 paraguay we're staying at home". association of selfperceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of covid-19 impact of home quarantine on physical activity among older adults living at home during the covid-19 pandemic: qualitative interview study impact of covid-19 confinement on the time and intensity of physical activity in the spanish population 15 smartphone apps for older adults to use while in isolation during the covid-19 pandemic covid-19 lockdown: a perfect storm for older people's mental health. j psychiatr ment health nurs multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. the lancet psychiatry policy brief : the impact of covid-19 on older persons mental health interventions during the covid-19 pandemic a conceptual framework by early career psychiatrists alzheimer's disease chinese, psychogeriatric interest group of chinese society of psychiatry et al. expert recommendations on mental health and psychosocial support for persons with cognitive disorders and their caregivers during the covid-19 outbreak development of a telehealth geriatric assessment model in response to the covid-19 pandemic older people and epidemics: a call for empathy multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. the lancet psychiatry potential lethal outbreak of coronavirus disease (covid-19) among the elderly in retirement homes and long-term facilities role of telehealth in outbreaks -where the classic healthcare systems fail active during the coronavirus pandemic create a circuit home workout infographic apta stay physically active during self-quarantine physical exercise as therapy to fight against the mental and physical consequences of covid-19 quarantine: special focus in older people combating physical inactivity during the covid-19 pandemic home exercises from a physical therapist perception of epidemic's related anxiety in the general french population: a cross-sectional study in the rhne-alpes region impact of ebola experiences and risk perceptions on mental health in sierra leone sars control and psychological effects of quarantine population-based post-crisis psychological distress: an example from the sars outbreak in taiwan depression, anxiety, and moods of hospitalized patients under contact precautions association between social participation and 3-year change in instrumental activities of daily living in community-dwelling elderly adults the level of physical activity affects the health of older adults despite being active criteria for social isolation based on associations with health indicators among older people. a 10-year follow-up of the aichi gerontological evaluation study associations between social isolation, loneliness, and objective physical activity in older men and women social isolation, c-reactive protein, and coronary heart disease mortality among community-dwelling adults loneliness and risk of mortality: a longitudinal investigation in alameda county loneliness and social isolation as risk factors for coronary heart 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health and aging: a need for new knowledge to bridge science and service declaration of conflict of interest: none.declaration of sources of funding: co-financed by the european regional development funds (rd120001/0043) and the centro de investigación biomédica en red en fragilidad y envejecimiento saludable-ciberfes (cb16/10/00464).author's contribution: study concept and design: all authors. data collection: wsl, irs, rt. draft of the manuscript: wsl, irs, ppr, fg, rt. full access to all of the data in the study and responsibility for the integrity of the data: wsl, irs. study supervision: lrm. all authors reviewed the manuscript for important intellectual content and approved the final version. key: cord-017461-xw02c7u5 authors: kauffman, carol a. title: fungal infections date: 2009-02-02 journal: infectious disease in the aging doi: 10.1007/978-1-60327-534-7_22 sha: doc_id: 17461 cord_uid: xw02c7u5 older adults are at increased risk of developing opportunistic fungal infections because organ transplantation, intensive cancer chemotherapy regimens, and anti-tumor necrosis factor agents are now used more commonly, and because admission to an intensive care unit, which carries many risk factors for fungal infection, has become commonplace in this group. candida species are the most common cause of opportunistic fungal infections, and bloodstream infections are usually treated with fluconazole or an echinocandin antifungal agent. invasive mold infections are mostly caused by aspergillus species; in older adults, they cause primarily pulmonary and sinus infections, and they are associated with a high mortality rate. the endemic fungi, histoplasma capsulatum, coccidioides species, and blastomyces dermatitidis, cause infection when the mold form is dispersed and inhaled from the environment in those specific areas of the country in which these organisms flourish. amphotericin b is used for initial treatment of severe histoplasmosis, coccidioi­domycosis, and blastomycosis; itraconazole is the therapy of choice for most mild to moderate infections due to these endemic mycoses. serious fungal infections can be separated into two major categories: the opportunistic mycoses that include candidiasis, cryptococcosis, and invasive mold infections such as aspergillosis and zygomycosis, and the endemic mycoses, which in the united states, includes histoplasmosis, blastomycosis, and coccidioidomycosis. the fungal infections represented in these broad categories differ with respect to the characteristics of the organisms causing infection, their epidemiology, the clinical manifestations, the approach to diagnosis, and the principles guiding therapy. in response to these different groups of fungi, host defense mechanisms also differ. except in immunocompromised hosts, serious infection with the opportunistic mycoses is rare. in contrast, the endemic mycoses are true pathogens that cause disease in both healthy and compromised hosts. however, the severity of infection with the endemic mycoses is determined in part by the host's response. as the number of immunocompromised patients has risen, opportunistic fungal infections have increased dramatically in recent years. in the last decade, the elderly appear to be at increasing risk for infections with the opportunistic fungi. there are several reasons for this enhanced risk. first, with increasing realization that older adults with cancer should not be excluded because of age from intensive chemotherapeutic treatment regimens, there are more immunosuppressed older cancer patients. second, as evidence for the efficacy and safety of transplantation in this population has accrued, solid organ transplantation is now more common in patients over the age of 60. third, immunosuppressive regimens, including the use of anti-tumor necrosis factor agents, are now routine in the management of rheumatologic and dermatologic conditions often found in older adults. fourth, and possibly the most important risk factor for older adults, is the increasing role of treatment in intensive care units with the use of life-support systems, catheters, and broad-spectrum antibiotics. the increase in opportunistic infections in elderly patients is primarily due to an increase in infections with candida species. the spectrum of disease varies from localized infections such as oropharyngeal candidiasis to candidemia and disseminated candidiasis. factors that predispose older patients to the development of oropharyngeal candidiasis include xerostomia, broad-spectrum antibiotics, inhaled corticosteroids, and dentures (1) . age alone does not appear to be an independent risk factor for the development of oropharyngeal candidiasis. in older adults, the presence of systemic diseases and a multiplicity of medications frequently lead to xerostomia, which then enhances candida colonization of the mucosa. denture stomatitis due to candida species is very common (see also chapter "orofacial and odontogenic infections in the elderly"). patients who do not remove their dentures at night, and those who have poor oral hygiene, are more likely to have this manifestation of candidiasis. in contrast to other candida infections, candida vulvovaginitis is unusual in older women (2) . without estrogen stimulation, the vaginal epithelium becomes thin and atrophic, glycogen production decreases, vaginal ph rises, and colonization by candida decreases. candiduria is seen more often in older adults than in younger persons (3) . the risk factors for candiduria include diabetes mellitus, obstructive uropathy, neurogenic bladder, indwelling urinary catheters, prior surgical procedures, intensive care stay, and antibiotic therapy (3) . in older adults, many of these factors occur with increasing frequency. candida species are the fourth most common cause of nosocomial bloodstream infections. several studies have found that those over 60 constitute the majority of patients with candidemia and also have the highest mortality rates (4) . elderly patients at the highest risk are those in an intensive care unit who are on broad-spectrum antibiotics, have an indwelling central venous catheter in place, are receiving parental nutrition, require renal replacement therapy, and have had a surgical procedure. c. albicans is the species most commonly found to cause candidemia, but other species, especially c. glabrata , are an increasing problem. several studies have found that c. glabrata occurs disproportionately in older adults (5, 6) but the reasons for this have not been elucidated. in older persons, cryptococcosis is increased modestly. approximately 25% of cases of cryptococcal meningitis not associated with human immunodeficiency virus (hiv) infection are in persons over age 60. the underlying conditions most often noted are hematologic malignancy, organ transplantation, corticosteroids, and cirrhosis. however, 25-30% of patients have no overt underlying immunosuppressive condition, and many of these patients are older adults. in older patients who have cryptococcal meningitis, mortality appears to be increased (7) . although many different types of molds have been described as occasional pathogens in immnuosuppressed patients, only aspergillosis and zygomycosis will be discussed. there are hundreds of aspergillus species that are ubiquitous in the environment, but very few cause infection in humans. the most common pathogenic species are a. fumigatus and a. flavus. infection ensues when conidia (spores) are inhaled into the respiratory tract of a susceptible host. nosocomial aspergillus infections are often traced to hospital construction. depending almost entirely on the immune response of the host, a wide spectrum of infections can occur. although less common than candidiasis, aspergillus infections are life threatening in immunosuppressed patients. several forms of aspergillosis, specifically chronic necrotizing pulmonary aspergillosis and sino-orbital aspergillosis, appear to occur more often in older adults (8, 9) . zygomycosis, also known as mucormycosis, is an uncommon, but often, lethal infection; there is no age predilection. the major genera identified are rhizopus and mucor . the risk factors for zygomycosis include diabetes, hematologic malignancies with neutropenia, organ transplantation, and deferoxamine chelation therapy for iron overload (10) . because of the increased risk of myelodysplastic syndrome and subsequent need for repeated transfusions with increasing age, the latter circumstance is likely the only one in which older adults may be over-represented. white plaques on the buccal, palatal, or oropharyngeal mucosa that can easily be removed are typical of oropharyngeal candidiasis. angular cheilitis and diffuse erythema, which is often present beneath upper dentures, are also manifestations of oropharyngeal candidiasis. because typical plaques are absent, the diagnosis may be overlooked (1) . candida vaginitis usually presents with pruritus and vaginal discharge that may range from "cottage cheese-like" to thin and watery (2) . when cheesy material is absent, candida vulvovaginitis must be differentiated from atrophic vaginitis. most patients with candiduria are asymptomatic and are merely colonized (3) . fewer than 5% of patients have dysuria and frequency, and even fewer have symptoms of upper tract infection. rarely, obstructive symptoms and renal failure have been noted secondary to fungus balls composed of masses of fungi. the manifestations of systemic infection with candida species are quite varied (see table 1 ). after entering the bloodstream, either from an intravenous catheter or the gastrointestinal (gi tract), the organism disseminates widely, causing microabscesses in many organs, including eye, kidney, liver, spleen, myocardium, and brain. patients with candidemia have symptoms that are indistinguishable from those associated with bacteremia (6, 11) . some are quite ill with a sepsis picture, but others may have only unexplained fever. skin lesions occurring during the course of candidemia appear as tiny pustular lesions on an erythematous base and provide a clue to the presence of candidemia (see fig. 1 ). although the major manifestation of infection with c. neoformans is meningitis, the pathogenesis of infection begins with inhalation of the organism from the environment and subsequent pulmonary infection. the chest radiograph may show nodular infiltrates, a pleural-based mass, cavitary lesions, or diffuse infiltrates (12) (see fig. 2 ). however, most often, the pulmonary infection is asymptomatic, and clinical manifestations of cryptococcosis occur only after the organism has spread to the central nervous system. elderly patients may not have the usual symptoms of fever, headache, and cranial nerve palsies but instead can present solely with confusion without fever, nuchal rigidity, or focal neurologic findings (see table 1 ). aspergillus invasion of the upper respiratory tract leads to sinusitis and may proceed to invasion of the orbit. in patients with neutropenia, the acute onset of pain, erythema, fever, serosanguinous drainage, and proptosis is seen. in older patients who are not immunosuppressed, but who may have been on corticosteroids or are diabetic, aspergillus causes a subacute sino-orbital infection with pain, proptosis, ophthalmoplegia, and loss of vision due to invasion of the apex of the orbit (8) . most patients are thought to have a retro-orbital tumor until biopsy reveals hyphae and inflammatory debris. acute pulmonary aspergillosis in immunosuppressed patients presents with fever, pleuritic chest pain, and dyspnea and has a rapidly progressive downhill course if not treated promptly (see table 1 ). chronic necrotizing pulmonary aspergillosis, occurring mostly in middle-aged to elderly men with chronic obstructive pulmonary disease, is a subacute illness. low-dose corticosteroids and broad-spectrum antibiotics are predisposing factors for this form of aspergillosis. patients have fever, cough, purulent sputum, weight loss, and pleuritic chest pain. multilobar involvement is common, cavity formation is the rule, and extension to the pleura is frequent (see fig. 3 ). progressive pneumonia is the rule unless the diagnosis is made and appropriate therapy given. patients with zygomycosis are usually quite ill. diabetics most often have the rhinocerebral form (10) (see also chapter "infections in diabetics"). a black eschar can be seen on the palate or around the orbit, and serosanguinous material is found on endoscopic examination of the sinuses (see table 1 ). orbital invasion progresses rapidly to cavernous sinus thrombosis and can culminate with cerebral infarction. in patients with pulmonary zygomycosis, the chest radiograph shows wedge-shaped chronic necrotizing pulmonary aspergillosis in a middle-aged man with no known risk factors other than chronic obstructive pulmonary disease or nodular infiltrates, which cavitate as necrosis progresses (see fig. 4 ). localized cutaneous forms occur and generally carry a better prognosis than rhinocerebral or pulmonary zygomycosis. because of the life-threatening nature of these infections, the diagnosis of a systemic opportunistic fungal infection must be made promptly. growth in culture of opportunistic fungi is rarely difficult; cultures are usually positive within a few days. the major complicating issue is that organisms as ubiquitous in the environment as aspergillus or rhizopus can easily contaminate specimens. therefore, growth in culture must be carefully assessed as to whether it truly reflects infection (13) . confounding the diagnosis of candidiasis is the fact that candida are normal flora in the gi and genitourinary (gu) tracts and on skin, and thus, growth from samples taken from non-sterile body sites often means only colonization. however, growth of candida from blood or normally sterile body fluids is obviously significant. in contrast to the other opportunists, c. neoformans is neither common in the environment nor part of the normal flora, and thus growth of this organism in culture always reflects infection. especially in immunocompromised patients who are acutely ill, histopathologic demonstration of fungi in tissues is a very important diagnostic tool. unfortunately, fig. 4 right upper lobe zygomycosis in an elderly man who had myelodysplasia leading to dependence on transfusions and treatment with deferoxamine chelation the invasive procedures necessary to obtain lung or other tissue are often precluded in extremely ill immunosuppressed patients. for cryptococcosis, examination of cerebrospinal fluid (csf) with an india ink preparation that highlights the large capsule of c. neoformans is a quick and reliable test. antibody tests have not proved to be useful for the diagnosis of opportunistic fungal infections. detection of fungal cell wall antigens is preferred. the latex agglutination test for cryptococcal polysaccharide antigen has excellent sensitivity and specificity and is routinely performed in both serum and csf (14) . the galactomannan enzyme immunoassay detects an aspergillus -specific cell wall antigen and has proven most useful in the highest risk patients, such as stem cell transplant recipients (15) . the galactomannan assay has not been studied in patients with chronic necrotizing pulmonary aspergillosis, and it is likely that it will not be useful for sino-orbital aspergillosis. other non-culture-based systems for invasive mold infections have not proved useful thus far. treatment of oropharyngeal candidiasis with a topical agent, such as clotrimazole troches, is appropriate first-line therapy. fluconazole, 100 mg daily, should be reserved for patients with severe disease or denture stomatitis that is often difficult to treat (1) . vaginal candidiasis is easily treated with topical antifungal agents such as miconazole or clotrimazole creams. however, fluconazole, 150 mg orally as a single dose, is an attractive alternative, especially for those patients who have underlying illnesses that make topical therapy difficult to use (2, 16) . candiduria often disappears with removal of the predisposing factors, especially indwelling urethral catheters and antimicrobial agents (3) . when candiduria is persistent and shown to be causing symptoms, the most appropriate treatment is fluconazole, 200 mg daily for 14 days (16, 17) . the use of amphotericin b bladder irrigation is discouraged. amphotericin b, previously the mainstay of treatment for serious candida infections, is now rarely used this indication. currently, candidemia is treated most often with fluconazole, 400 mg/day after an initial 800 mg loading dose, or with an echinocandin (16) . three echinocandin agents are available, caspofungin, micafungin, and anidulafungin, and all three appear to have equivalent efficacy for candidemia (16) . the echinocandins are extremely safe, and they have activity against those species of candida , especially c. glabrata , that are often resistant to fluconazole (18) . all intravascular lines should be removed or replaced, and treatment should be continued for 2 weeks beyond the time that blood cultures no longer yield candida unless a focal infection is discovered that will require longer therapy. the most appropriate therapy for cryptococcal meningitis in older adults has not been specifically studied, but trials in acquired immunodeficiency syndrome (aids) patients with cryptococcal meningitis have shown that the best results are obtained when induction therapy is carried out with the combination of amphotericin b (0.7 mg/kg/day) and flucytosine (100 mg/kg/day) for at least 2 weeks, followed by consolidation therapy with fluconazole, 400 mg/day for a minimum of 10 weeks (19) . initial therapy with fluconazole alone is not adequate for patients with meningitis but has been effective for patients with isolated pulmonary cryptococcal infection (20) . in spite of appropriate therapy for meningitis, symptoms of dementia may not improve in older patients. the antifungal agent of choice for treating all forms of aspergillosis is voriconazole, an extended-spectrum azole that has been shown to be superior to amphotericin b for invasive aspergillosis (21) . this agent, which can be given either intravenously or orally, has many drug-drug interactions and is best given with the help of a clinical pharmacist or infectious diseases consultant. the echinocandins also have activity against aspergillus species, but are considered second-line therapy, available if the patient cannot tolerate voriconazole (18) . finally, amphotericin b, previously the agent of choice, can also be used for invasive aspergillosis, but toxicity is much greater than that of the azoles or the echinocandins, and it cannot be recommended for older adults. the treatment of zygomycosis involves correction of the underlying immune defect, aggressive debridement of all necrotic tissue, and antifungal treatment with a lipid formulation of amphotericin b, 5-10 mg/kg daily (22) . a new azole agent, posaconazole, has been used as salvage therapy in patients who initially had been treated with amphotericin b and offers a new option for step-down oral therapy for this devastating infection (23) . as the population of the united states ages, and as older adults remain in better health for a longer period of time, they travel more extensively, visit more exotic places, and experience different outdoor activities such as those arranged on eco-tours that increase their exposure to endemic mycoses. these fungi are found in soil or vegetation; each has its own ecological niche from which it is aerosolized and subsequently inhaled (see table 2 ). older persons may become infected while traveling in an area endemic for a certain fungus, but symptoms often appear only after they return home. older adults who spend the winter months in the desert southwest may develop symptoms of coccidioidomycosis only after returning home. a patient who consults a physician in minnesota with symptoms related to coccidioidomycosis that was acquired in southern california may be the first patient with this infection ever seen by the minnesota physician, and the correct diagnosis may not be made. several endemic mycoses have the propensity to reactivate as immunity wanes with increasing age or because of immunosuppressive medications or diseases. this reactivation event might occur in a person who retired to an area of the country outside of the endemic area for a particular fungal infection. thus, although physicians in the southwestern united states are very familiar with coccidioidomycosis, histoplasmosis or blastomycosis might be overlooked in a patient from kentucky who has retired to arizona and only then develops signs of an endemic mycosis acquired years before in kentucky. the increasing use of the anti-tumor necrosis factor agents, etanercept (enbrel), infliximab (remicade), and adalimumab (humira), for rheumatoid arthritis, inflammatory bowel disease, and several dermatological conditions in older adults has increased the risk for development of histoplasmosis and coccidioidomycosis (24, 25) . these mycoses require cell-mediated immunity to eradicate the organism, and severe disseminated infections have occurred in patients who have either become newly infected or have experienced reactivation of a prior focus of infection. hiv infection is an increasingly reported problem in the older population and constitutes another risk factor for development of either newly acquired or reactivation infection with h. capsulatum or coccidioides species (see also chapter "human immunodeficiency virus/acquired immunodeficiency syndrome"). not only is the risk higher for development of these infections, but the severity of the infection is also increased. h. capsulatum is endemic in the mississippi and ohio river valleys and throughout much of central america. it is estimated that hundreds of thousands of people are infected each year, but usually the illness is self-limited with minimal flu-like symptoms. however, severe life-threatening pneumonia and disseminated infection also occur. histoplasmosis is the only endemic mycosis in which certain manifestations are age-specific; chronic cavitary pulmonary infection and chronic progressive disseminated histoplasmosis occur predominantly in older individuals (26) . b. dermatitidis , the causative agent of blastomycosis, is found most frequently in the southeastern, south central, north central united states, and the canadian provinces of ontario and manitoba. outbreaks have occurred in groups involved in outdoor activities, but most cases are sporadic and a specific point source of infection cannot be found. for blastomycosis, there is no evidence that older individuals are at more risk for developing infection than younger persons, but the mortality does appear to be greater in those age 65 years and older (27) . as the exodus of retirees to the southwestern united states continues, first-time exposure to coccidioides species has increased in older adults. this organism proliferates in the deserts of arizona and california that are typified by flora such as the saguaro cactus. there are now known to be two species of coccidioides , c. immitis in southern california, and c. posadasii in the other areas of the southwestern united states, central america, and south america. the conidia are widely dispersed during windstorms and are highly contagious. several recent epidemics of coccidioidomycosis have occurred in arizona and southern california, and thousands more individuals have been infected (28) . two important trends have been noted recently. there has been a shift in the age of patients with symptomatic coccidioidomycosis so that the annual incidence rate for coccidioidomycosis is now highest in those age 65 years and older (29) . also, older individuals and those with diabetes are more likely to develop severe pulmonary coccidioidomycosis (30) . for reasons that have never been clarified, dark-skinned races, especially african american and filipino, are more likely to experience disseminated infection than white-skinned races. the pathogenesis of the endemic mycoses is similar in that infection starts almost always with inhalation of conidia from the mold phase of the organism in the environment. thus, pulmonary manifestations are prominent in many patients. these fungi have the propensity to silently disseminate through the bloodstream to many different organs and then cause a variety of different manifestations either at the time of the initial infection or months to years later. two forms of histoplasmosis are seen most often in older adults (see table 2 ). chronic cavitary pulmonary histoplasmosis affects mostly middle-aged and elderly men who have emphysema (31) . patients with this form of histoplasmosis have constitutional symptoms of fatigue, weakness, fever, night sweats, and weight loss. pulmonary symptoms include dyspnea, cough, sputum production, and hemoptysis. the disease is subacute to chronic in its course. upper lobe cavitary disease with extensive lower lobe fibrosis is the usual chest radiographic finding (see fig. 5 ). progressive pulmonary insufficiency and death occur unless treatment is given. another form of histoplasmosis that occurs mostly in middle-aged to elderly men is progressive disseminated disease (31) . in this form of histoplasmosis, the host is unable to eradicate the organism from parasitized macrophages, and the disease is fatal if untreated. the clinical manifestations of progressive disseminated histoplasmosis include fever, fatigue, anorexia, and weight loss. dyspnea and cough are often present, lesions on the buccal mucosa, tongue, palate, or oropharynx are common, and hepatosplenomegaly is usual. because of adrenal infiltration and destruction, the patient may also present with symptoms of addison's disease. pancytopenia and increased alkaline phosphatase are frequent, and diffuse pulmonary infiltrates are often present on chest radiograph. in older patients, pulmonary blastomycosis can mimic tuberculosis with dyspnea, cough, sputum production, fever, weight loss, and fatigue (see table 2 ). the pulmonary lesions can be mass-like and mistaken for lung cancer, cavitary, or nodular in fig. 6 ). rarely, patients develop acute overwhelming pneumonia and acute respiratory distress syndrome (ards) (33) . although blastomycosis begins in the lungs, subsequent dissemination to other organs is common. frequently, the only clinical symptom is the development of one or multiple skin lesions that are usually slowly enlarging, verrucous, and have discrete punctate areas of purulence (see fig. 7 ). osteoarticular structures are frequently involved, as is the gu tract, in which the most frequently targeted organ is the prostate. coccidioidomycosis presents in many different ways (see table 2 ). patients experiencing primary disease usually have a self-limited flu-like illness consisting of fever, cough, headache, and fatigue. patchy pneumonitis is seen on chest radiograph fig. 6 pulmonary blastomycosis initially thought to be lung cancer. bronchoscopy with biopsy showed granulomas and thick-walled budding yeasts typical of b. dermatitidis (see fig. 8 ). complications include the development of persistent thin-walled cavities and less commonly, chronic pulmonary disease (34) . the latter occurs predominantly in patients with underlying emphysema and/or diabetes mellitus (30) . diffuse pulmonary infiltrates have been noted primarily in patients who have disseminated infection and are more common in those who are immunsuppressed (35) . the organs most frequently involved with disseminated coccidioidomycosis are skin, bone, and meninges. meningitis, the most feared complication, presents with chronic headache months after the initial infection and can be especially difficult to diagnose in an elderly patient returning from the southwest to other areas of the country. the course of coccidioidal meningitis is protracted, and a successful outcome is not assured, especially in older adults. the approach to diagnosis is similar for all of the endemic mycoses. cultures obtained from the infected tissue; histopathologic or cytologic examination of tissue, body fluids, or purulent material; antibody tests; and antigen detection are variably useful for each infection. the most definitive method of diagnosis is growth of the organism, but for histoplasmosis and blastomycosis growth may take 4-6 weeks. coccidioides species usually grow on fungal or regular media within several days. coccidioides is highly contagious and is classified as a bioterrorism agent. in the laboratory setting, it must be handled under a hood using biosafety level 3 precautions. clinicians must inform the laboratory that coccidioidomycosis is a possibility to avoid transmission to technicians. histopathologic or cytologic demonstration of the organism in tissues or body fluids is extremely helpful for diagnosis, especially for those patients who are acutely ill. the typical thick-walled yeasts of b. dermatitidis , showing single broad-based buds are readily identified in cytological or calcofluor white preparations of sputum and tissue biopsies. the tiny intracellular yeast forms of h. capsulatum are best visualized in tissues using methenamine silver stains. coccidioides species are quite distinctive in tissues; the large spherules (80-100 m m) are readily identified in tissue and also in purulent drainage. serology plays an important role in the diagnosis of histoplasmosis and coccidioidomycosis (31, 36) . a positive test prompts the clinician to consider more invasive procedures such as bronchoscopy, bone marrow aspiration, or liver biopsy in order to establish a diagnosis. there are occasions when the only evidence for infection is the presence of antibodies; this is especially true of meningitis, in which both fungi are exceedingly difficult to grow but csf serology is positive. for blastomycosis, specific and sensitive antibody assays are not available. an enzyme immunoassay that detects a cell wall antigen of h. capsulatum has proved to be extremely useful for the diagnosis of disseminated histoplasmosis (37) . the sensitivity is approximately 90% in patients who have a large burden of organisms; this includes patients who have aids and those who are immunosuppressed. it is not specific, however, showing cross-reactivity with blastomycosis and coccidioidomycosis. a similar assay has been developed for b. dermatitidis . it is too early to know how useful this development will be, but it is known that false positives occur in patients with histoplasmosis (38) . treatment of the endemic mycoses is similar in regard to the antifungal agents that are used. for severe infections with any of the endemic mycoses and for those who have central nervous system involvement, amphotericin b is the agent of choice. increasingly lipid formulations of amphotericin b are used, especially in older adults who often have reduced renal function. the lipid formulations are less toxic than standard amphotericin b, but are not free of toxicity, usually require hospitalization to administer, and can be associated with severe infusion reactions. most patients will require amphotericin b therapy until they have shown clinical improvement and then step-down therapy to an azole is recommended (39, 40) . the azole antifungal agents have revolutionized the treatment of the endemic mycoses; they are much less toxic than amphotericin b, and oral administration is a benefit when treating chronic infections. ketoconazole was the first oral azole agent, but because of its toxicity and lesser efficacy, it has been supplanted by itraconazole. itraconazole is the drug of choice for histoplasmosis and blastomycosis of mild to moderate severity and for step-down therapy following amphotericin b. for coccidioidomycosis, either fluconazole or itraconazole appear to be equally efficacious (41) . the usual dosage of itraconazole is 200 mg twice daily (after a loading dose of 200 mg 3 times daily for 3 days), and the dosage for fluconazole is 400 mg daily (after a single loading dose of 800 mg). therapy generally is given for 6-12 months and sometimes longer. for those patients who have coccidioidal meningitis, fluconazole is the preferred agent because of its superior csf penetration. the dosage is 800 mg daily, and therapy must be given for life as the organism is rarely eradicated from the central nervous system (34) . absorption of itraconazole capsules is dependent on gastric acidity and the presence of food in the stomach. because older adults are more likely to be achlorhydric, absorption may be decreased. histamine (h2) receptor antagonists, proton pump inhibitors, and antacids should not be used when itraconazole capsules are prescribed. however, itraconazole oral suspension does not require food or acid for absorption and is preferred for this reason. fluconazole requires neither gastric acidity nor food for absorption. drug interactions, many of which have serious implications for older adults, are frequently encountered with the azole antifungal drugs (42) . interactions with warfarin, phenytoin, and carbamazepine occur in varying degrees with all of the azole drugs in current use. itraconazole can increase serum digoxin levels with subsequent toxicity, and fluconazole can increase the effect of oral hypoglycemics. if possible, the azoles should be avoided in patients with qt prolongation on electrocardiogram and those on other medications that prolong the qt interval. in a small percentage of mostly elderly patients, itraconazole has caused the triad of edema, hypokalemia, and hypertension. all of the azole agents have been noted to cause hepatitis, and liver enzymes tests should be followed in patients taking azole agents. in spite of these issues, the azoles are exceedingly useful in older adults with endemic mycoses. most therapy is now given in the outpatient setting, and results for most patients with infection with an endemic mycosis are excellent. oropharyngeal candidosis in the older patient treatment of vaginal candida infections a prospective multicenter surveillance study of funguria in hospitalized patients nosocomial bloodstream infections in us hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study epidemiology of candidemia: 3-year results from the emerging infections and the epidemiology of iowa organisms study candida glabrata fungemia: experience in a tertiary care center cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy invasive and allergic fungal sinusitis chronic cavitary and fibrosing pulmonary and pleural 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blastomycosis: findings on chest radiographs in 63 patients acute respiratory distress syndrome and blastomycosis: presentation of nine cases and review of the literature coccidioidomycosis . clinical infectious diseases coccidioidomycosis in persons infected with hiv type 1 current status of serologic studies in coccidioidomycosis improvements in diagnosis of histoplasmosis antigen assay with the potential to aid in diagnosis of blastomycosis clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the infectious diseases society of america clinical practice guidelines for the management of blastomycosis: 2007 update by the infectious diseases society of america comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis -a randomized, double-blind trial antibiotic therapy for geriatric patients suggested reading clinical practice guidelines for the management of blastomycosis: 2007 update by the infectious diseases society of america coccidioidomycosis . clinical infectious diseases histoplasmosis: a clinical and laboratory update zygomycosis: an emerging fungal pathogen with new options for management clinical practice guidelines for the management of candidiasis: 2009 update by the infectious diseases society of america key: cord-025246-zah72cd6 authors: lai, daniel w. l.; ruan, yongxin title: revisiting social work with older people in chinese contexts from a community development lens: when east meets west date: 2020-03-13 journal: community practice and social development in social work doi: 10.1007/978-981-13-6969-8_13 sha: doc_id: 25246 cord_uid: zah72cd6 community development is an empowering and comprehensive method for social workers to address individual and societal challenges facing chinese older people. this chapter explores the different meanings of community development in chinese contexts, including communities in mainland china and chinese immigrant communities. when actualizing community development, social workers require theories to guide their actions, and this chapter proposes three interrelated theoretical bases: ecological system theory, empowerment theory, and anti-oppressive theory. based on these theoretical bases, three practice directions are suggested to guide community development at different levels: “aging in place,” “age-friendly community,” and “gray power.” in particular, social workers need to adapt community development approaches to chinese cultural contexts. case examples are discussed to illustrate how to implement community development projects with older people in chinese contexts and the roles of social workers in such projects. improvements in healthcare and standards of living have resulted in an increase in longevity and in the size of the aging population. with at least one or two decades of life span after official retirement age, many older people are faced with more choices and opportunities to further enhance their own aspirations and enrich their purpose in life. thus, working with older people should not only focus on remedial interventions that deal with problems and challenges but also on supporting these new aspirations and opportunities. social work with older people involves different approaches within different sociocultural contexts. from a community development perspective, social work with older adults can take many forms. while some may address problems such as health concerns or social inequity issues, others have focused on empowerment and addressing personal development among aging populations. this chapter will discuss the conceptual bases of community development approaches that are used for working with older people in the community. focusing on the experience of older people in different chinese contexts, including chinese older adults in chinese societies and older chinese migrants residing in non-chinese societies, this chapter will discuss the alignment of community development and its application in social work practice with older people, with attention to the influence of sociocultural context. as they age, people experience various challenges, on both individual and societal levels. while chinese older adults in chinese societies and older chinese migrants residing in non-chinese societies face particular challenges associated with their different contexts, they also face some similar challenges. at the individual level, older people, including chinese older people, face physical, social, and psychological challenges associated with increased age. they may experience declining cognition and mobility along with increased likelihood of illness and disabilities (coyle and dugan 2012; lai et al. 2016) . their social network may decrease due to the loss of spouses and friends (coyle and dugan 2012) , and they may be more likely to experience negative emotions, anxiety, and depression due to physical decline, life transitions, and a decrease in social networks (parker 2013) . additionally, when older people reflect on their life, they may experience a sense of despair associated with perceived failures and regrets (parker 2013) . at the societal level, challenges facing older people, including chinese older people, may be associated with environment, infrastructure, and wider social network dynamics. community-dwelling older people may rely heavily on facilities provided by housing estates (chan et al. 2016) , and social environments that are not sufficiently age-friendly can hinder social interaction . for example, limited access to transportation can decrease participation in social activities among older people . additionally, older people may experience ageism, which refers to stereotypes and discriminations against older people (harris et al. 2018) . societies convey ageism in various ways, such as media representations of older people as expensive burdens or as vulnerable (hastings and rogowski 2014) . for example, in mainland china, though the chinese tradition emphasizes respect for older people and attaches importance to their contributions, this value is changing (bai et al. 2016) . there is an increasing emphasis on productivity (bai et al. 2016) , which means that the social status of older people is decreasing as they are no longer "productive" after retirement. additionally, in the context of mainland china, as a result of the "one-child" policy, the younger generation faces difficulty in providing sufficient filial support for older people, as expected in chinese tradition. hence, older people may be viewed as a burden for the family, and when older people internalize this view of being a burden to society and family, they experience a greater risk of depression (bai et al. 2016) . some older people experience greater challenges and vulnerability associated with aspects of status, such as being an ethnic minority. this experience, known as "multiple jeopardy," also affects groups of older chinese adults who are immigrants in societies where chinese are the ethno-cultural minority population (chow 2010) . older chinese immigrants not only face challenges common to older people in general but also experience particular physical, psychological, and social challenges associated with their status as ethnic minorities and immigrants in their new communities. owing to language differences, cultural conflicts, and racial or ethnic discrimination, older chinese immigrants may be at greater risk of physical illness (chow 2010) and feelings of marginalization and other psychological distress, such as depression (chow 2010; park 2016) . moreover, worries about being accepted by the majority society can reduce involvement in social life (park 2016) . healthcare and social services may not be user-friendly, due to a lack of culturally sensitive providers as well as language barriers in organizations (chow 2010) , meaning that older chinese immigrants may be prevented from using needed services. the challenges facing older chinese adults, both for those in china and for immigrants, at both individual and societal levels illustrate the need for interventions and supports that address the broader systems and structures that cause these issues. community development, focusing on empowerment and addressing personal development among aging populations, can be effective in addressing physical, psychological, and social challenges. to understand the meaning of community development, it is first important to examine the meaning of "community," given that different definitions of "community" lead to different interpretations of community development. two main definitions can be identified. the first is a "place-based" perspective, which views "community" as a geographic place with physical boundaries, comprised of residents, resources on which residents subsist, and processes through which residents distribute and exchange those resources to address their needs (matarrita-cascante and brennan 2012). the second is a "non-place-based" perspective, which focuses on the connections that people share, such as using the same language or having other shared interests (human resource development canada [hrdc] 1999; twelvetrees 2017) , shaped by boundaries of moral proximity (green 2016) . people may experience both place-based and non-place-based forms of community. for example, older people may be connected with both peers and other age groups within the same neighborhood, as a result of sharing a particular place, while also being connected to other older people in other geographical locations due to commonalities such as challenges, characteristics (including cultural background or migration status), or interests. these two perspectives inform different conceptualizations of community development. scholars adopting a place-based perspective focus on the management of resources in that geographic community (green 2016) , as communities need to rely on resources to subsist and progress (matarrita-cascante and brennan 2012). for example, matarrita-cascante and brennan (2012, p. 297) define community development as a process that "provides vision, planning, direction, and coordinated action towards desired goals associated with the promotion of efforts aimed at improving the conditions in which local resources operate," involving efforts to "harness local economic, human and physical resources to secure daily requirement and respond to changing needs and conditions." scholars following a non-placebased perspective focus on joint efforts by community members to improve their life circumstance. for example, meade et al. (2016) define community development as a process through which "ordinary people" make an impact on their living conditions through collective action, while human resource development canada (1999) interprets community development as a process through which community members take action and propose solutions together to address common challenges. regardless of the perspective adopted, different community development actors will use different approaches, which can be broadly synthesized into three forms of community development (matarrita-cascante and brennan 2012). the first is an "imposed" form of community development, which involves the improvement of community through physical and economic development and is usually promoted by private industry and government actors. the second is a "directed" form of community development, which refers to structural improvement to a community promoted by nongovernmental organizations (ngos) or government, in which community members are invited to participate. the third is a "self-help" form of community development, which implies community members' own efforts to carry out programs or activities (matarrita-cascante and brennan 2012). community development is an important component of social work practice. community development in social work concentrates on empowering various sections of society, such as creating employment opportunity and promoting gender equality (dhavaleshwar 2016) . scholars have discussed different roles for social workers in community development, focusing on advocacy and empowerment. for example, das et al. (2018, p. 389) suggest that social work "has the potential to be mutually supportive to address gaps, design interventions and lobby more influentially for the use of empowering community-based approaches." similarly, gilbert (2014) suggests that through community development, social workers can promote problem-solving in human relationships as well as social change, empowerment, and liberation in order to enhance well-being. effective community development has been described as having the following characteristics: (1) it is long-term, (2) it is well-planned, (3) it is inclusive and equitable, (4) it is holistic and integrated into the bigger picture, and (5) it is initiated and supported by community members (hrdc 1999) . therefore, social workers should pay attention to these characteristics when planning and promoting community development. yet, while the conceptualization of community development is mostly situated in "western" cultural contexts, it is also important to address how community development could be realized as part of social work practice in chinese contexts, which represent the range of different sociocultural and political values emerging among chinese people residing in different juridical contexts. in the context of this chapter, this includes both chinese older adults in chinese societies and older chinese migrants residing in non-chinese societies. given that social, cultural, and other dynamics in chinese community contexts are different from those in "western" countries, community development will involve different approaches and focuses in chinese contexts. even within chinese contexts, community development may be understood differently when working with chinese older adults residing in a chinese jurisdiction such as mainland china as compared to chinese immigrants in other countries such as canada. even within these groups, identities, challenges, and experiences may differ widely. for example, social, political, and economic contexts affecting aging differ across chinese jurisdictions, such as in the cases hong kong and mainland china. similarly, the experiences of older adults in chinese immigrant communities are shaped by factors such as region, community, and language of origin; social, political, and economic contexts in countries and communities of residence; immigration and settlement policies; ethno-cultural community presence; and so on. the following paragraphs further explore meanings of community development among these diverse groups. when working with chinese immigrants, practitioners may adopt a non-place-based perspective on community, focusing on immigrants with chinese nationalities (yeung and ng 2011; yuen 2013) , who may live in different geographic locations. practitioners may have to adapt community development strategies to chinese cultures, which value social harmony, social relationship, and collective good (yeung and ng 2011; yuen 2013) . yeung and ng (2011) suggest that concepts such as empowerment, social change, and equality, which are often identified as elements of community development, may not be easily be adopted by chinese immigrant communities, who may not have been frequently exposed to these western values. although it has been argued that actions focusing on collective good and collective responsibility may be more acceptable (yeung and ng 2011) , social workers can play important roles in facilitating mobilization and socialization with immigrants from chinese cultural contexts, in order to achieve the desire for change as well as processes of individual as well as collective empowerment. for example, yuen (2013) describes a community development project in canada in which chinese immigrants volunteer in building a low-income senior and new immigrant residence and community center. participants enjoyed the socialization aspects of this project, which strengthened their social relationships and contributed to solidarity within the community. family-like connections among chinese immigrations in turn provided sources of support that serve to strengthen social relationships (yuen 2013) . therefore, it is believed that empowerment and equity could also be achieved via focusing on collective efforts and collective goods, reflecting a broader conception of "empowerment" (beyond only individual dimensions). when working with chinese residents in china, the contemporary political situation and structures means that "community" is generally interpreted as a geographic place administrated by a residents' committee and street office (bray 2006) . there are three characteristics of this understanding of community: (1) each community has a territorial space, (2) the nature and functions of the community are determined by the government, and (3) the community performs administrative roles (bray 2006) . this specific definition of "community" means that community development has its own meanings in china, shaped by political, economic, and historical dynamics. since the breakdown of the work unit system (a system intended to facilitate social regulation and provide social welfare in the early developmental stage of modern china (he and lv 2007) ), the community has had to take on functions that were originally performed by the work unit system (li 2013) . additionally, with the increasing number of rural migrant workers in urban centers (bray 2006) , a process of "community building" has been proposed, adapted from the concept of community development (li 2013) . therefore, community development in china often refers to community building, in which the community takes care of various issues (e.g., welfare services, environment, education, grassroots democracy) in order to "promote social development, raise living standards, expand grassroots democracy and maintain urban stability" (see bray 2006, p. 536) . in this sense, community building is, in a way, an imposed form of community development because it is the administrative offices that take on responsibilities to improve the environment in communities, focusing not only on the physical and economic environment but also welfare service provision and cultivation of grassroots organizations in community building. some grassroots organizations have also been initiated and governed by community members in china. for example, the owners' committee was set up by residents, through which they deal mainly with issues in their living areas with their own efforts (li 2013) , reflecting to some extent a "self-help" approach to community development. however, the owners' committee is supervised by the residents' committee (state council of the people's republic of china 2016). therefore, community development in china is mainly promoted by administrative offices in each community, focusing on physical and social environment improvement. when approaching community development work with older people, theories provide the frameworks to enable practitioners to understand events and generate strategies for practice (phillips and pittman 2014). the following sections examine three main frameworks that inform understandings of and approaches to community development with older people as part of social work practice: ecological system theory, empowerment theory, and anti-oppressive practice. ecological system theory provides a framework for understanding the interaction between different levels of systems that comprise both the environment and people (menec et al. 2011 ). the first level is the microsystem, which refers to a person's immediate surroundings, such as family. the next is the mesosystem, which involves the connections between two or more microsystems, such as the interaction between peers and family. this is followed by the exosystem, referring to the social settings that have indirect effects on individuals, such as workplaces, and then by the macrosystem, which consists of larger contexts such as social values and cultural beliefs. the broadest level is the chronosystem, which refers to a person's life transitions or historical events in society. systems in all levels interact with each other (paat 2013) . as community development deals with aspects of the environment, ecological system theory provides a way to comprehensively examine the influence of environments (at different scales) on older people and serves as a guideline to improve these environments. for example, ecological system theory has been used to understand how environmental factors influence the participation of older people in community activities (greenfield and mauldin 2017) . empowerment refers to a process of "letting client, group or community have as much control as possible over the change processes they are involved in" (see vongchavalitkul 2015, p. 14) . empowerment theory emphasizes the participation of community members in the change process, to ensure that they have the power to control this process. as a result of structural challenges, older people, especially those experiencing "multiple jeopardy," may be marginalized from gaining resources and opportunities, which can lead to a sense of powerlessness. therefore, empowerment theory can provide a framework for social workers to facilitate the involvement of older people in community change projects, through which these older people can enhance their resources and address their own needs (irving 2015) . anti-oppressive practice is an approach to work with people who are oppressed by structural inequalities such as poverty and racism, and creating changes to correct the oppressive status is important (dominelli 1998) . this is closely related to empowerment theory, as both pay attention to addressing inequalities resulting from power differences in relationships. therefore, anti-oppressive practice is often used alongside empowerment-focused approaches. societal stereotypes regarding older people mean that they often face oppression. for example, people with dementia might be deprived the right to make their own decisions by carers because they are viewed as people with poor cognitive functions (martin and younger 2000) . therefore, it is important for practitioners to support the establishment of anti-oppressive environments for older people. these three interrelated theories highlight principles of community development such as empowerment, social justice, participation, and so on. together, they can serve to guide the design and operation of community development projects for older people. for example, ecological system theory could be used to raise awareness among older people to examine the influences of their environments (e.g., barriers that lead to inequality, comprising a key element of anti-oppressive practice) or used as a guideline to improve aspects of these environments. as part of community development processes, empowerment can serve as a framework to facilitate the participation of older people and enhance their abilities to cope with and address community issues. it should be noted that when applying these three theories, the different meanings of community development in chinese contexts should be considered, based on the specific experiences and challenges of older adults in chinese jurisdictions as well as older chinese immigrants in other places. for example, the concept of empowerment and anti-oppression could be adapted to emphasize the principle of collective good in community development with chinese older people. in these ways, social workers can "normalize" community issues and raise awareness among older people about how they, as a group, are disadvantaged by the environments in which they live and potential strategies for change. the following paragraphs introduce three broad practice directions for operationalizing community development in working with older peopleaging in place, age-friendly communities, and "gray power"with a focus on their implementation within the general chinese cultural context. aging in place (aip) refers to "the ability of older adults to live in their homes or communities as long as possible" (see lehning et al. 2017, p. 235) . aip aims to enable older people to maintain their social relationships and daily lifestyle in an environment with which they are familiar, which also facilitates independence and a sense of control over their lives (iecovich 2014) . several theories support the concept of aip and guide its operationalization. the "theory of insideness" focuses on people's attachment to place along three dimensions: physical (sense of environmental control), social (social relationships), and autobiographical (attachment to place, developed from memories that shape self-identity) (iecovich 2014) . older people develop strong ties to a place along these three dimensions (iecovich 2014) and have a high willingness to age in their communities. empowerment theory focuses on helping older people age in place by promoting participation and autonomy (mcdonough and davitt 2011) . person-in-environment theory supports the realization of aip by focusing on mutual interactions between individual and environment: individuals are influenced by their environment but can influence the environment at the same time (weiss-gal 2008) . practitioners can assist older people to adapt to their environment (aging in place) by realizing their potentials and mobilizing the community to support adaptation. scholars have described a "village" model to realize the concept of aip, referring to grassroots organizations that are formed, governed, and served by residents in the community (such as community-dwelling older people) (mcdonough and davitt 2011; scharlach et al. 2012) . those nonprofit organizations provide services for older people in the community through volunteers, generally focused on nonprofessional services such as housekeeping, transportation, etc. (mcdonough and davitt 2011) . social workers can play several roles in promoting aip (scharlach et al. 2012) . as community organizers, social workers can help to foster a sense of commitment to the community and mobilize and support residents to provide assistance for older people in the community. as assessors, social workers not only help community members to understand their challenges and make plans but also help them to evaluate the strengths and resources they have and to use their abilities to support older people. as brokers, social workers connect community members with resources to assist them (scharlach et al. 2012 ). the village model reveals a key concept of aip: mobilizing community members to help community-dwelling older people adapting to place. the process of building, mobilizing, and utilizing capacity of community members to assist older people in the community aligns with chinese cultural and political situations, illustrating its applicability in chinese contexts. first, it reflects an emphasis on the collective good. second, as the community shoulders the responsibility for development, this requires joint efforts from residents (yan 2011) . in china, for example, administrative offices encourage self-help from residents to reduce the burden of solving problems in communities, including by cultivating grassroots organizations, which relies on mobilizing, building, and utilizing the capacity of community members. one way to do this is by promoting volunteering, as volunteers acquire knowledge and skills as well as utilizing their abilities in this process (akingbola et al. 2013) . social workers can improve the commitment of community members to be volunteers, by mobilizing them, assessing their existing strengths, and enriching their knowledge and skills through training (guo 2018) . scholars and practitioners in china have emphasized the importance of recruiting volunteers to assist communitydwelling older people, such as a project in which the "young-old" assist the "old-old," which involves cultivating "young-old" volunteer teams who are trained to apply their knowledge and skills to assist "old-old" people with daily living (e.g., meal delivery) and mental health (e.g., reducing loneliness through home visits) (hong 2012 ). age-friendly communities (afcs) focus more on the influence of the environment, referring to "policies, services, settings and structures support and enable people to age actively" (world health organization [who] 2007) . this involves a focus on both the physical and social environment in the community (including issues such as safety, accessibility, and stereotypes) across eight interacting domains: transportation, housing, outdoor spaces and buildings, social participation and interactions, respect and social inclusion, civic participation and employment, communication and information, and community support and health services (who 2007) . two theories can be used to interpret and support afc. first, the personenvironment fit perspective assumes that people are likely to be maladapted if there is a low level of fit between their needs and environment (park et al. 2017) , indicating that environment plays a crucial role in individual's adaptation. therefore, "even those who have limited resources and capability can age optimally if environmental characteristics support them in a way that compensates for their limitations or lack of resources" (see park et al. 2017 park et al. , p. 1328 . in this sense, an age-friendly environment is helpful for vulnerable older people to age well because, for example, it compensates for personal limitations such as disability by building lifts to increase mobility. second, ecological system theory reveals interactions between people and various systems in the environment (menec et al. 2011) , which is highlighted in afc efforts. for example, social participation influences social inclusion, but social participation depends on the accessibility of outdoor spaces (who 2007) . the achievement of afcs relies on addressing issues such as commitment, capacity, collaboration, and consumer involvement (scharlach and lehning 2016) , in which social workers can play a role. first, it is important to improve commitment of relevant stakeholders to facilitate change in a community, and social workers can help to reduce ageism and enhance awareness of the importance of building afcs. second, social workers can serve as educators to enhance community capacity for developing and implementing afc change processes. third, since change processes require joint efforts from various stakeholders, social workers can be mediators to facilitate stakeholder collaboration. creating afcs relies on interdisciplinary collaboration between various stakeholders. however, this is not easy to create and sustain, and social workers require skills and knowledge (and thus training) to lead collaboration (garcia et al. 2010) . finally, social workers can facilitate the involvement of older people in developing afcs, which is important because it can support greater responsiveness to community needs, capacity building, and empowerment, as well as enhanced use of existing and new programs and services (scharlach and lehning 2016) . as rémillard-boilard et al. (2017) note, the inclusion and participation of older people in developing an age-friendly community is important to achieve age-friendliness. for example, in an age-friendly project in guangzhou, china (lai et al. 2017) , older people in different communities were invited to take part in sharing views and generating ideas about how to make their community more age-friendly. however, chinese older people may have different perspectives on community participation. for example, older people in china do not have strong sense of citizenship and may have limited understanding of the importance of community participation and thus may have low willingness to participate in community initiatives (zhao and huo 2018) . older chinese immigrants, who value social relationships where trust is developed, may not be willing to participate in activities that do not include people they trust (yeung and ng 2011) . therefore, social workers should explore and address potential barriers to the participation of chinese older people as part of afc initiatives. "gray power" "gray power" (gp) is a term mentioned frequently in policy and refers to the political power that older people have (davidson 2012) . as the number of older people is increasing and the new generation of older people has higher awareness of improving public services through political actions, their influence on policy is increasing (davidson 2012) . in response to structural barriers such as ageism, older people can use their "gray power" to improve their community and society. two theories support the idea of gp and provide insights into its operationalization. anti-oppressive practice considers how people are deprived of power due to structural inequalities (dominelli 1998) , and this perspective can assist older people to aware of the oppressions they are facing and understand how their powers are restricted. empowerment theory includes three levels, micro, mezzo, and macro, and macro-level empowerment focuses on influencing resource distribution through collective action (kruger 2000) , revealing a process through which older people can use their power to fight for more resources. social workers can play important roles in assisting older people to exert their power. first, social workers can be educators to raise awareness of how structure barriers lead to particular challenges and problems (mchugh 2012) and can support and strengthen older people's abilities to access information and take action (inaba 2016) . second, social workers can serve as facilitators to bring older people together and support them to generate solutions and seek policy changes (inaba 2016) . for some older chinese adults in mainland china, some moderate strategies to address community issues may be preferred, due to their sociocultural and political upbringing. for instance, one approach used by community workers and researchers is photovoice and may be considered. this is a qualitative research method that enables people to record (through photographs) and reflect on strengths and concerns in their communities, promotes critical thinking about the influence of environment on individuals through discussion of photographs, and reaches who can make changes such as policy makers through the exhibition of photographs (sitter 2017) . when discussing their photographs, participants reflect on how they relate to their lives; the reasons for which a problem, concern, or strength exists; and what can be done about it (sitter 2017) . individuals are empowered by voicing their concerns and raising awareness of concerns in the community and among policy makers (sitter 2017) , which can lead to policy changes. chui et al. (2019) describe a photovoice project to raise civic awareness among older people in hong kong. older people received training on skills such as theme identification and presentation, and a public photo exhibition was launched to raise public awareness. this enhanced participants' ability and willingness to participate in community and civic affairs. in this way, social workers can support and facilitate the empowerment of older people and maintain an equal position with participants throughout the process (sitter 2017) . these three practice directions are interrelated and show a progressive relationship. aip focuses more on individuals' adaptation to the environment, at the micro level, while afc emphasizes improving physical and social environment in the community for older people, at the mezzo level. lastly, gp focuses on policy and political changes, at the macro level. through engagement with these three practice directions, social workers can support community development processes with older people in a comprehensive way. chinese older people encounter various challenges, from individual to societal levels, illustrating the need for comprehensive responses beyond the individual level. social workers can apply the practice of community development in working with chinese older people, representing an approach to intervention and support that addresses broader systems and structures and focus on empowerment and personal development among aging populations. this chapter has explored definitions of community development and its meanings, with a focus on diverse chinese contexts, including those of chinese older adults in mainland china and chinese immigrants in non-chinese societies. three interrelated practice directions, including aging in place, age-friendly communities, and "gray power," provide insight into how social workers can engage in community development processes with older people, including in chinese contexts. the following describes two cases of community development projects with older chinese immigrants, which integrate the concepts of empowerment theory and antioppressive practice. the two cases reveal how social workers can apply these two concepts in community development with chinese older people and the roles they can take on in such projects. one particular challenge that older chinese immigrants may experience concerns elder abuse when living with adult children and their families. they may tend to hide abuse due to a fear that their children would desert them and the cultural belief of not disclosing family matters to outsiders. as a result, there may be little awareness of this issue among community members. in a community development project in canada (lai and luk 2012) , raising awareness of elder abuse among chinese older people and their children was the goal. some chinese older people were invited to talk about incidences of elder abuse and then were involved in group discussions to generate solutions for educating community members about this issue. they decided to design a comic book to present the problem of elder abuse, as they thought that pictures would be easier to comprehend than words and would be readable for older people with low literacy capacities. social workers invited some experts to design the comic book with the older participants, and the comic books were distributed to various elderly centers. this case integrates the concept of empowerment. social workers empowered chinese older people by raising their awareness of an important community issue and supporting those older people to take action to tackle this issue. throughout the project, chinese older people were responsible for discussing the issue, generating solutions, and implementing those solutions. social workers acted as facilitators and brokers (linking participants to resources). the most challenging part was raising awareness of elder abuse among older chinese immigrantsan important step in the empowerment processbecause it contrasted with chinese cultural concerns. therefore, social workers needed to normalize the issue and ensure that chinese older people were aware that this issue influenced their wellbeing. the second case involves a project to involve chinese older people in calgary, canada, into combatting discrimination. in 2003, there was a sars (severe acute respiratory syndrome) outbreak in calgary, and some members of the public thought that chinese people had brought the virus to their city. older chinese immigrants not only experienced public discrimination, but also worried about their vulnerability to sars. in this case, workers at a chinese senior center brought the chinese older people together to discuss the issue and later launched a public meeting with representatives of government health officials and local politicians to discuss how to reduce public stereotypes toward sars and the chinese community. in this case, social workers applied the concept of empowerment and antioppressive practice. chinese older people were supported to take collective action and expressed their perspectives in order to reduce public stereotypes. through this process, their capacity to express and present opinions and discussion skills were improved, and their social networks were strengthened or extended. social workers serve as mediators in discussions between chinese older people, health authority officers, and legislative counselors. social workers also took on roles as facilitators and brokers to support chinese older people to take collective action and provide necessary resources. these two cases illustrate that when social workers carry out community development projects with chinese older people, they can serve as facilitators to raise awareness of community issues and as brokers to link older people with resources such as networks with other professionals, in order to support chinese older people to deliver collective action. however, given the increasing educational level of chinese older people, their awareness of their rights and possibilities to mobilize through community development may be stronger, and social workers may work less in the facilitator role and more as brokers to support those older people to improve their well-being through their own collective action. learning and knowledge transfer in volunteering: exploring the experience of red cross volunteers ageism and depression: perceptions of older people as a burden in china building 'community': new strategies of governance in urban china an age-friendly living environment as seen by chinese older adults: a "photovoice" study growing old in canada: physical and psychological well-being among elderly chinese immigrants fostering civic awareness and participation among older adults in hong kong: an empowerment-based participatory photo-voice training model social isolation, loneliness and health among older adults re-engaging with community work as a method of 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participatory action research method the state council of the people's republic of china (2016) the regulation of property in the people's republic of china community development, social action and social planning using empowerment theory in health promotion guided development the home for the elderly in nakhon ratchasima, thailand the person-in-environment approach: professional ideology and practice of social workers in israel global age-friendly cities: a guide how to take part in community management in beijing engaging service users and carers in health and social care education: challenges and opportunities in the chinese community building juniper: chinese canadian motivations for volunteering and experiences of community development the situation and improvement of the community participation of the elderly in the middle and small cities key: cord-281877-r1y1hz4q authors: lavretsky, helen title: scientific autobiography of a spiritual seeker in the year of hindsight's 20/20.: “was i deceived, or did a sable cloud turn forth her silver lining on the night?” john milton “comus” (1634) date: 2020-08-11 journal: am j geriatr psychiatry doi: 10.1016/j.jagp.2020.08.002 sha: doc_id: 281877 cord_uid: r1y1hz4q nan activities are suspended indefinitely, and i have plenty of time to reflect upon the meaning of life. we are living during unprecedented and difficult times when the entire world is asked to find its spiritual center and resilience in order to find collective solutions to its many problems. the surreal nature of the covid-19 pandemic and the global lockdown makes each of us look back and ask "how did i get here?" followed by "and how do i move forward?" reflections upon our life choices that resulted in the situation at hand can be very revealing and can help define our next chapter. perhaps, we have been caught in the pre-programmed game of rules and expectation, and we can use this imposed pause to create a new game with the new rules. for the first time we are asked to consciously consider our choices that define our daily lives and determine our survival that is a truly global existential crisis. the covid-19 pandemic pushed us to "go within" and to take personal responsibility for our existence. however, unfolding events have made us also more hopeful in our ability to create the new order that will support our lives in a new way. we are already witnessing high-paced scientific and technological innovation (1) that will require united trans-disciplinary efforts to meet the demands of the world"s mental health post-covid-19 that are described in our upcoming book co-edited with harris eyre, michael berk and charles reynolds "convergence entrepreneurship" that will be published later this year (2) . my "scientific activities" have been a big part of my spiritual journey focused on seeking to understand the true nature of human mental and emotional suffering and resilience, where all life events are assumed to provide valuable lessons and "silver linings" that ensure individual and collective evolution of consciousness. i look forward to this unprecedented opportunity for reinvention of ourselves, our world, our science, and the global evolution of consciousness as a result of our collective search for peace and alleviation of suffering. i grew up in moscow, russia. i often say that i was born to become a psychiatrist, in part, because, my mother was (and still is) a psychiatrist and my father was a neurologist and i had an easy access to the large library that introduced me to the workings of the mind and brain. before i turned 10, i read books about cerebral palsy and down syndrome and was strangely attracted to the pictures of young children who were clearly suffering. a natural empath, i wanted to help the suffering. my first "patient" was my little friend, a three year old boy who was completely mute. i was able to understand his wishes intuitively and translated them to the adults. although later, i went through decades of medical and psychiatric training, the essence of what i do for patients is not different: empathically understanding their suffering, translating it to the world, and helping in alleviating suffering by empowering them to change their lives. during high school, i developed an interest in psychiatric research, and my first summer job was in a psychiatric hospital" pharmacy. i watched patients who wandered in the beautiful gardens of the psychiatric hospital where they worked in the green houses as a part of their vocational rehabilitation program (the main staple of psychiatry in russia) and tried to imagine what was going on in their minds. for high school science projects, i chose to perform hypnosis on my classmates, as was described in the book on hypnosis, using a pendulum, and described and classified their responses. the following year, after reading an old french phrenology book, i examined their skulls and made phrenological descriptions of their personality based on the skull topography, which gained me some popularity among my schoolmates and was a precursor of my current interest in mindbody interventions and brain biomarkers. psyciatry. at that time, he suggested that i write a paper on the russian concept of schizophrenia because nothing was known about it in the us (3). this paper was published in the schizophrenia bulletin, and also served as a cathartic nine-month-long journey that helped release all of the "soviet" experiences. in the process of working on it, i discovered my passion for academic writing. this was the only paper of to-date that received a single line review "a magnificent contribution". this was more of a "passion project" that one of my supervisors called "avocational," but i highly recommend this type of experience to learn about moving beyond your comfort zone and pushing your own limits. later, i also learned that merging personal interests (e.g., in yoga) with professional activities can eradicated burnout and lead to the ultimate job satisfaction. all you always wanted to know about "academic ladder," but were afraid to ask despite a relatively "smooth sailing" through the academic system, the intricate details and secrets of academic success were still elusive, and the road was rather "bumpy". i attended workshops put together by the american psychiatric association (apa) appropriately entitled "swimming with sharks" explaining unwritten and untold "rules of engagement" and the relational hierarchy that seemed intentionally complex and biased. in the 1990s, there were very few women mentors and role models to share their wisdom and the "operating manual." i used to say that i was well prepared to be "a woman in academia" because i had been "a jew in russia," and after i had read that women in academia had 0.75 children, i felt that i was a close match with my 1.0 son. many academic institutions and scientific societies have recently recognized that the implicit biases that we all harbor can be barriers to fairness and progress and have since provided greater resources and training. also, the landscape of academic medicine and psychiatry has been rapidly changing and becoming more diverse, with over 50% of the psychiatry residents being women and minorities and 30% foreign medical graduates. these difficult experiences at the early stages of my professional journey have made me more sensitive to the implicit and explicit biases within academic medicine, and i now use the knowledge and skills i gained in mentoring others. the main source of professional support, collaborators, mentors and mentees, and simply, in the single year of 2020. i called that the trifecta of 2020, the year of cancelled meetings, which took place in the virtual sur-reality of the covid-19 pandemic. i am certainly hoping that many more will be able to achieve these honors in years to come. i am forever indebted to the numerous mentors i met through these programs who became my colleagues and friends, and later, close collaborators. many former scholars like myself went on to become the sri/cima/ari mentors that also cemented crossgenerational lines of the organizational wisdom transmission. this was also a good way to learn the "do"s and don"ts" of mentoring that helped in shaping up my own mentoring identity. today, i learn as much from my mentees as they learn from me as a result of this training. the big discovery early in my career was the need to participate in the competitive peer modern research is highly complex and requires collaborative work to develop novel ideas and utilize individual talents and the cutting edge technologies in order to advance the field. research community forms a "group-consciousness" that defines the direction of the field"s development and benefits from the advanced "laboratory" that is a research depression that was recently challenged by the covid-19 pandemic. we have proceeded with collaborative problem-solving, learned from each other, and supported each other, making the challenges much easier to cope with. "a greater truth" about that nature of late life mood and cognitive disorders will emerge from this collaboration and will be the source for new research ideas for years to come. another bit of advice regarding developing research ideas and securing funding that i received was to have an idea that is novel "enough" but not too far "ahead of the curve" in order to be accepted as a "fundable idea." the original impetus of studying brainin the later years, new research questions originated from my clinical experience. i wanted to answer clinically relevant questions on the behalf of the entire field. for example, the decades-old question of whether depression and cognition improve with the addition of methylphenidate has been of interest to many psychiatrists and primary care physicians. with the help of the r-01 grant funding, i conducted a study on methylphenidate augmentation of citalopram and the findings of this study put "a nail in the coffin of the decades-old question" proving that the addition of methylphenidate could accelerate and improve treatment response in older adults. because of its high clinical relevance, this paper was named among the top ten articles in psychiatry by the new england journal of medicine in 2015 (8) . i also learned to use the intervention studies to understand brain mechanisms of treatment response, while developing novel pharmacological and behavioral interventions and mastering advanced research tools like neuroimaging, genetics, inflammatory markers (9) (10) (11) (12) . in the early stages of careerdevelopment, my traditional and "expected" neurobiological direction in academic psychiatry was easy to adopt and keep "ahead of the curve" to identify the next important question to answer. at the stage of mid-to-senior career development, one is encouraged to take risks in order to move forward and retain a sense of purpose. it is important to re-invent oneself periodically to avoid repetition. my "dizzying" turn-around shift occurred when i encountered a kundalini yoga practice that captured my imagination by its observed health benefits. it occurred during a very stressful time in my life, and i was looking for tools for stress reduction. everything about this yoga practice seemed amazing: learning about mind-body connections via yogic body postures, breathing, chanting, community, gathering, and vegetarian food. i pursued yoga teacher training and certification followed by years of rigorous practice resulting in the complete makeover of my body, mind, immune system, and discovery of my own spirituality. my colleagues were amused by the transformation of my reductionistic "neurobiological self" into my newly discovered "spiritual self" that emerged, along with my desire to study the brain, health, and consciousness effects of mind-body practices. i turned my attention to developing studies of yoga, tai chi and meditation in older adults and stressed dementia caregivers. the initial studies preceded "the curve" by 10-15 years and were some of the earliest studies of mood and brain effects accompanied by profound epigenetic changes, anti-inflammatory effects, and most importantly, direct neuroplastic effects and cognitive improvement (13) (14) (15) (16) (17) (18) . the findings were novel and well-received by the medical and research communities, and especially, by the yoga communities around the world. this was also an opportunity to turn a passion project into a professional, evidence-based one. a number of new collaborations outside of the comfort zone and the field now include mouse biologists, stress biologists, respiratory physiologists, anthropologsits, and neuroscientists. our goal is to develop a translational center dedicated to the study of mechanisms of breathing control of emotion regulation in the mouse and human models of anxiety and panic. our hope is that this work will take the field of mind-body medicine even further in promoting understanding of how our breath can help regulate our emotions during stress or panic. this has become particularly relevant given the recent global distress emphasizing the importance of promoting personal wellbeing using ancient breath practices as the simplest and all-encompassing solution. in addition, after thirteen years of conducting mind-body research, we have started an integrative psychiatry clinic that uses mind-body, lifestyle, and spirituality-based approaches to help patients with neuropsychiatric symptoms. we hope to empower our patients to take control of their own health and learn resilience-building tools to allow for self-regulation during these difficult times and for stress-related psychiatric disorders. now, more than ever before, the healthcare system is ready to endorse integrative medicine that has accumulated evidence of its low-cost effective therapies for stress-related disorders. experimenting with mind-body research and with my own yoga immersion led me to shift from the medical disease models to the health-promotion and wellbeing models, with resilience being a mechanism of maintaining wellbeing (19) . antidepressants and psychotherapy can improve resilience and prevent depression recurrence. however, providing patients with the ability to learn about their own strengths and utilize their lifestyle choices and spirituality to improve treatment outcomes is another powerful therapeutic and preventive approach to neuropsychiatric diseases of late life, such as depression, caregiver stress and dementia. during this pandemic, the entire world population can benefit from this knowledge and skills of stress reduction that may continue to be beneficial post-pandemic as well. as a clinician and a researcher, it is much more gratifying to understand patients from the point of their own strengths and to empower them to take charge of their health by learning and using the tools of selfregulation of their choice. these resilience-boosting techniques can be powerful additions to the traditional psychiatric practices. the best way to master the subject is to write a book. most of these ideas are expressed in laird, adrienne grzenda, and beatrix krause-sorio, who shared my scientific passions and co-authored many published papers that made writing them so much more fun. all successes and challenges proved to be useful lessons, silver linings and blessings indisguise that led to a greater wisdom and growth. i am certainly looking forward to the new adventures and progress in next 25 years. author contribution: helen lavretsky was the sole contributor to this manuscript. there are no conflicts. rebooting geriatric mental health innovation and entrepreneurship with convergence science convergence mental health: a roadmap towards transdisciplinary innovation and entrepreneurship the russian concept of schizophrenia: a review of the literature programs for developing the pipeline of early-career geriatric mental health researchers: outcomes and implications for other 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binding predicts change in executive function in a pilot clinical trial of geriatric depression changes in neural connectivity and memory following a yoga intervention for older adults: a pilot study a randomized controlled trial of kundalini yoga in mild cognitive impairment a pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity yogic meditation reverses nf-κb and irfrelated transcriptome dynamics in leukocytes of family dementia caregivers in a randomized controlled trial neurochemical and neuroanatomical plasticity following memory training and yoga interventions in older adults with mild cognitive impairment complementary use of tai chi chih augments escitalopram treatment of geriatric depression: a randomized controlled trial psychobiological factors of resilience and depression in late life resilience and aging: research and practice 21. complementary and integrative therapies for mental health and aging key: cord-285521-lvzdmtun authors: olagundoye, olawunmi; enema, oluwayemisi; adebowale, adunola title: recommendations for a national coronavirus disease 2019 response guideline for the care of older persons in nigeria during and post-pandemic: a family physician’s perspective date: 2020-08-11 journal: afr j prim health care fam med doi: 10.4102/phcfm.v12i1.2512 sha: doc_id: 285521 cord_uid: lvzdmtun the older persons in our society are a special group of people in need of additional measures of care and protection. they have medical, financial, emotional and social needs. the novel coronavirus disease 2019 (covid-19) only exacerbates those needs. covid-19 is a new disease, and there is limited information regarding the disease. based on currently available information, older persons and people of any age who have serious underlying medical conditions may be at higher risk of severe illness from covid-19. family physicians provide care for individuals across their lifespan. because geriatricians are internists or family physicians with post-residency training in geriatric medicine, they are major stakeholders in geriatric care. the authors are concerned about the absence of a covid-19 response guideline/special advisory targeting the vulnerable population of older adults. the management and response to covid-19 will be implemented in part based on the local context of available resources. nigeria has been described as a resource-constrained nation. infection prevention in older persons in nigeria will far outweigh the possibilities of treatment given limited resources. the aim was to recommend actionable strategies to prevent covid-19-related morbidity or mortality among older persons in nigeria and to promote their overall well-being during and after the pandemic. these recommendations cut across the geriatric medicine domains of physical health, mental health, functioning ability and socio-environmental situation. the older persons have been defined by the united nations as those who are 60 years and older. 1 in a developing country like nigeria, the same definition applies. 2, 3 the population of older persons in nigeria is reported to be increasing rapidly. 4 their health profile is characterised by decreased immunity, multimorbidity, chronic illnesses, declining physical functions and impaired socialisation necessitating increased demand on healthcare services. 2, 4 unfortunately, a serious combination of the risk factors that have been identified to portend a worse prognosis or manifestations of severe forms of the coronavirus disease 2019 (covid-19) infection is found in older persons. these factors include older age; underlying health problems, often as multimorbidities; and decreased immune status. 5, 6 cumulative data from the nigeria centre for disease control (ncdc) on covid-19 report the highest burden of disease in the age groups spanning 31-60 years. however, the burden of deaths because of covid-19 is highest amongst elderly persons (60 years and above). 7 this confirms their vulnerability. whilst fever and respiratory symptoms have been widely recognised as key symptoms associated with covid-19, these symptoms often present differently in older adults. for instance, fever may the older persons in our society are a special group of people in need of additional measures of care and protection. they have medical, financial, emotional and social needs. the novel coronavirus disease 2019 (covid-19) only exacerbates those needs. covid-19 is a new disease, and there is limited information regarding the disease. based on currently available information, older persons and people of any age who have serious underlying medical conditions may be at higher risk of severe illness from covid-19. family physicians provide care for individuals across their lifespan. because geriatricians are internists or family physicians with post-residency training in geriatric medicine, they are major stakeholders in geriatric care. the authors are concerned about the absence of a covid-19 response guideline/special advisory targeting the vulnerable population of older adults. the management and response to covid-19 will be implemented in part based on the local context of available resources. nigeria has been described as a resource-constrained nation. infection prevention in older persons in nigeria will far outweigh the possibilities of treatment given limited resources. the aim was to recommend actionable strategies to prevent covid-19-related morbidity or mortality among older persons in nigeria and to promote their overall well-being during and after the pandemic. these recommendations cut across the geriatric medicine domains of physical health, mental health, functioning ability and socio-environmental situation. keywords: covid-19; the elderly; prevention; national health policy; older persons. be blunted or absent in infected older persons. respiratory symptoms may either be masked or exacerbated by cooccurring diseases, such as chronic obstructive pulmonary disease or congestive cardiac failure, which can further worsen outcomes. 8 additional consideration of the peculiarities of the older persons during the covid-19 pandemic will be useful for healthcare workers in the management of this age group. the covid-19 pandemic requires measures such as physical distancing, avoidance of social and religious gatherings and self-isolation if indicated. these measures may adversely impact the emotional, social and financial support of older persons. these negative consequences should be factored in to achieve adequate care of older persons during and after the pandemic. given their high risk for the severe manifestation of the disease and a higher rate of mortality, a special advisory/ guideline dedicated to this population group during covid-19 should be made available on the ncdc website similar to the ones that already exist, such as advisory for pregnant women, guidelines for children and nursing mothers, advisory for ramadan and guidelines for isolation. 1. keeping older persons who require ongoing chronic care for chronic illnesses away from health facilities as much as possible. this may be achieved in part through the deployment of telemedicine or phone-a-doctor on dedicated toll-free phone lines by establishing remote access to healthcare for non-emergency cases. in this circumstance, care is coordinated as the doctor regulates the physical contact of the elderly with the health facility based on sound clinical judgement. in settings where telemedicine may not be feasible, adults' clinics can operate a triage system that prioritises older persons for prompt consultation on arrival to reduce their waiting time at healthcare facilities. 2. adoption of a testing policy that prioritises the screening of persons above 60 years for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) because of the possibility of atypical presentations that are not accounted for in the current definition of suspected cases. this requires a heightened index of suspicion and prompt testing of older persons requiring hospital admissions for other morbidities that may mask the presence of the novel coronavirus infection or be worsened by co-morbid covid-19. in essence, older persons requiring hospital admission for other ailments should be tested for covid-19 and their samples should be prioritised to ensure the shortest turnaround time between sample collection and results. 3. prioritising the elderly in the distribution of welfare packages/palliatives. government's social intervention programmes such as the distribution of ₦20 000 ($51.55) to the poorest of the poor based on pensioners data and food items distribution on the streets may leave some older persons disadvantaged. pensioners' associations may be involved in ensuring that the packages get to their members. additionally, non-governmental organisations should channel a portion of their relief packages directly to senior citizens in various communities by engaging with the community and religious leaders. 4. taking cognisance of those problems that older persons are predisposed to (dependence, isolation, and depression) and how some of the current covid-19related safety precautions (physical distancing and selfisolation of exposed persons) may adversely accentuate these problems. this should be matched with the provision of professional psychological support through appropriate means in the light of the covid-19 pandemic. and their grandchildren, this should be preceded by the proper education of both older children and older persons, and physical distancing may also preclude visits between older persons and their grandchildren; (6) addressing the subject of surrogate decision-making or right of attorney in the event of unforeseen circumstances amongst other things. 6. inclusion of the older persons/senior citizens amongst the selected population groups that deserve specific guidelines on the ncdc website addressing their peculiar needs during the covid-19 pandemic. 7. post covid-19 pandemic attention should be given to broadening the scope of health insurance with the inclusion of home-based care in the health insurance schemes at the national and state levels. this will be an improvement on the current status of the national health insurance scheme that emphasises health facility care as the present policy is silent about home-based care. 9 we must revise our practices around the care of older persons during this pandemic, both clinically and socially, to ensure that our most vulnerable populations are protected. 8 ageing, older persons, and the 2030 agenda for sustainable development profile and correlates of functional status in elderly patients presenting at a primary care clinic in nigeria care of the elderly in nigeria: implications for policy clinical characteristics of 113 deceased patients with coronavirus disease 2019: a retrospective study epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study covid-19 situation report covid-19 in older adults: key points for emergency department providers nigeria's national health act, national health insurance scheme act and national health policy: a recipe for universal health coverage or what? we deeply acknowledge engr. olugbenga olatunde olabenjo and all our older persons who inspire us to do more. the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. the authors have declared that no competing interests exist. all authors contributed equally to this work. this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. this article followed all ethical standards for a research without direct contact with human or animal subjects. data sharing is not applicable to this article as no new data were created or analysed in this study. key: cord-308271-zzepl3on authors: calderón-larrañaga, amaia; dekhtyar, serhiy; vetrano, davide l.; bellander, tom; fratiglioni, laura title: covid-19: risk accumulation among biologically and socially vulnerable older populations date: 2020-08-17 journal: ageing res rev doi: 10.1016/j.arr.2020.101149 sha: doc_id: 308271 cord_uid: zzepl3on emerging data show that the health and economic impacts of covid-19 are being disproportionately borne by individuals who are not only biologically, but also socially vulnerable. based on preliminary data from sweden and other reports, in this paper we propose a conceptual framework whereby different factors related to biological and social vulnerability may explain the specific covid-19 burden among older people. there is already some evidence showing large social disparities in the prevention, treatment, prognosis and/or long-term consequences of covid-19. the remaining question is to what extent these affect older adults specifically. we provide the rationale to address this question with scientific methods and proper study designs, where the interplay between individuals’ biomedical status and their social environment is the focus. only through interdisciplinary research integrating biological, clinical and social data will we be able to provide new insights into the sars-cov-2 pandemic and inform actions aimed at reducing older adults’ vulnerability to covid-19 or other similar pandemics in the future. covid-19 has a clear predilection for aged people. up to one quarter of the deaths due covid-19 have been in older people aged 70-79 years and up to two thirds in those over 80 years, regardless of the incidence of the disease or the completeness in the ascertainment of deaths across countries ( table 1) . however, we know that "age" is a summary measure of life-long biological, physiological and functional changes partly determined by and in strong interplay with external social, physical, cultural and economic forces. in fact, emerging data show that the health and economic impacts of the virus are being disproportionately borne by people with a poor socioeconomic background. insert table 1 here j o u r n a l p r e -p r o o f recent statistics from health authorities in e.g. new york 1 , barcelona 2 and even stockholm 3 reveal how the coronavirus outbreak appears to affect immigrant communities and lower-income neighbourhoods the hardest. death records currently show that african americans account for more than half of those who have died from the novel coronavirus in cities like philadelphia or chicago, far in excess of their representation in the general population. in the uk, early research has shown that the proportion of nonwhite patients in intensive care units was 2.3 times greater than their share in the general population 4 , and that people living in more deprived areas have experienced covid-19 mortality rates more than double those in less deprived areas 5 . most of the information on social differences in covid-19 pandemic comes from media reports based on anecdotal or other ad hoc data ( table 2) . moreover, the real magnitude of the inequalities is likely to be underestimated due to the inexistence of accurate socioeconomic and ethnicity data across many local authorities and care services 6 . fortunately, scientific inquiries into these questions have already begun. for instance, a range of social indicators such as population density, ethnic makeup diversity, urban/rural setting, level of education, lifestyle and living conditions that can be inferred from people's area of residence are now starting to be linked to different health and well-being outcomes. early findings from geographic modelling performed in the us indicate that income inequality was an influential factor in explaining covid-19 incidence rates across counties 7 . insert table 2 here similarly, preliminary analyses based on publicly available data from stockholm region (sweden) show differences in excess mortality for covid-19 across community measures of country of birth, median income and education one month after the outbreak (figure 1 ). j o u r n a l p r e -p r o o f some preliminary data show that social disparities related to covid-19 take place at different time windows of the disease process. social differences have been reported in the prevention of the contagion, in the care of the disease and related comorbidities, and in the prognosis and long-term consequences of the infection ( table 3 ). this could be especially relevant for those individuals who experience both a social and biological vulnerability as the older adults. disparities in the prevention of contagion. social disparities in awareness of the risks and in adoption of preventive measures, such as hand hygiene and physical distancing, can be attributed to the shortage of information adapted for minority languages and the unequal access to internet. these barriers are exacerbated in the communities of older adults, frequently characterized by lower health-and technological literacy. in a survey of more than 600 socio-demographically diverse adults living in chicago, those who were black, were living below the poverty level, or had low health literacy were less likely to believe that they might become infected; black respondents also felt less prepared for an outbreak than white adults 8 . people in worse socioeconomic circumstances are more likely to experience overcrowding in the household, and it is also more common that different generations cohabit together. the type of jobs that lower-income people tend to have (e.g. care services, transportation, food and restaurant businesses) also put them, and their often cohabiting parents, at an increased risk of contagion, since they are difficult to perform from home and often require proximity with the client. following quarantine orders could be particularly challenging for those living in smaller, shared, or cramped accommodations. in certain cultures, socially isolating older family members may be viewed as abandonment and will therefore be difficult to adhere to. coronavirus testing seems to be socially patterned, too. for example, in philadelphia (us), individuals living in higher-income communities are reported to have been tested for covid-19 six times more often than those in lower-income neighbourhoods 9 . this is mainly because, for most testing sites, testing is performed from a car and with a referral from the primary care physician to get tested. many in philadelphia's lower-income black neighbourhoods do not have primary care physicians, let alone a car. care disparities for covid-19 and comorbidities. general access to healthcare has been shown to vary widely across socioeconomic groups. this will be especially relevant in countries without universal health care systems and where large numbers of under-or uninsured people are concentrated in certain areas. in the us, many uninsured patients have been faced with substantial medical billings 10 or even denied healthcare 11 for covid-19 treatment. besides the ease of access to health services, care outcomes may have been influenced by different healthcare systems models, and their level of development of primary care, public health, and community medicine, all of which closely interact with individual biological and social factors. in the context of a shortage of hospital beds, intensive care unit beds, and ventilators, implicit involuntary bias on the part of the healthcare system as well as individual providers, could affect the care people receive. much criticism has been voiced against the formulation and implementation of "ageist" policy, whereby resources are prioritized based exclusively on patients' chronological age 12 . older people from minority or disadvantaged groups may thus face double discrimination, placing them in an extremely vulnerable situation. the lack of community capacity and mobilization in deprived areas may be a key bottleneck to providing timely assistance to older patients and their affected families 13 . moreover, the use of telemedicine for in-person clinical evaluation poses special challenges for older adults, particularly those with sensory or cognitive impairments or who are unfamiliar with new technologies. despite being the unique form of connection with healthcare services for some, these technology platforms lack rigorous assessment in older adults 14 . disparities in prognosis and long-term consequences. because older people from lower-income backgrounds are more likely to suffer from chronic conditions (e.g. obesity, diabetes mellitus, chronic lung disease, and cardiovascular disease) 15 , multimorbidity 16 or even frailty 17 , they are also at a higher risk of covid-19-associated complications and mortality 18, 19 . moreover, older and socially vulnerable persons affected by covid-19 could be less likely to be recruited for respiratory rehabilitation and monitoring 20 , especially in those countries with no universal health coverage. indeed, the pulmonary function tests used to follow-up and stratify these patients (e.g. lung plethysmography, carbon monoxide diffusing capacity) are expensive and/or not easily available through telemedicine. those with lower household incomes have been shown to experience significantly greater mental strain as a result of prolonged quarantine, most likely due to over-crowded accommodation as well as to increased risk of losing income 21 . self-isolated older adults are more likely to experience loneliness, poor food availability and unbalanced diet, lack of exercise, and lower cognitive stimulation, which will considerably decrease their levels of resilience, leading to a cascade of physical and mental health problems. such risk will be exacerbated among poor older people, who rely most on social care and community support. in addition, people's ability to maintain remote contact with family and friends, which seems essential for long-term mental health, also depends on their access to smart phones, computers and internet, and above all, their internet literacy, which is especially low among the oldest old. the pandemic's toll will reach dramatic levels in those contexts where all above-mentioned vulnerability factors cluster together, as is the case of conflict zones, prisons, and refugee camps. not to speak about those places where people lack the very access to clean water with which to wash their hands to prevent infections, an intolerable reality for more than 840 million people around the world. the care home sector is another example where several of these factors cluster together, which has led to the highest death rates worldwide 22 . aspects related to their congregate nature, the populations served (i.e. older adults with high burden of morbidity and cognitive and functional impairment), the dominance of private for-profit providers, decreasing quality standards in terms of health promotion and prevention, the often precarious working conditions of the staff, and residents' limited networks of psychosocial support, have placed nursing homes in the eye of the storm. the covid-19 pandemic is far from being the "great equalizer" that affects all social groups alike, as it has been portrayed. it expresses a disproportionate preference for individuals who are not only biologically, but also socially vulnerable. in fact, it is further amplifying the large social inequalities already existing in the older populations. yet, this is nothing new. the 1918 flu pandemic also showed j o u r n a l p r e -p r o o f a significant geographic variation in mortality driven by socioeconomic factors 23 . similarly, during the 2009 h1n1 influenza pandemic, the death rate was found to be three times higher in the poorest compared to the wealthiest quintile of the british population 24 . while the european commission has earmarked €140 million to support research on the diagnoses, treatment, and vaccine development, and another €87 million to produce medical devices and help overburdened healthcare systems and businesses 25 , no funds seem to be specifically allocated to carry out the "social autopsy" of the covid-19 outbreak. there is an urgent need to address these questions with scientific methods and proper study designs, where the interplay between individuals' biomedical status and their social environment is the focus. we propose a conceptual framework addressing biological and social differences in covid-19 burden developed specifically for older people, considering potential disparities in its prevention, treatment, prognosis and/or long-term consequences (figure 2 ). what is currently missing is research focusing on the interplay between the biological and social backgrounds, which is relevant for all, but especially for older adults' health, when challenged by an acute severe disease as covid-19. thus, integrated biological, clinical and social data are urgently needed worldwide to guide actions aimed at reducing older adults' vulnerability to covid-19. in the long run, it is societies' deep-rooted structural inequities as well as the disciplinary fragmentation of research fieldsthat now seem to have intensified due to this new diseasethat we will need to address. combating this and future pandemics will inevitably mean combating outdated research practices and assuring efficient and egalitarian public healthcare systems within each country and worldwide. this research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors. note: excess mortality calculated comparing the mortality rate between 1-10 april 2020 with the average mortality rate recorded for the corresponding 10-day period during the two previous years. income refers to employment (acquisition) income. source: own elaboration based on publicly available data from statistics sweden (https://www.scb.se/). the new york times. a month of coronavirus in new york city: see the hardest-hit areas desigualtats socials i covid-19 a barcelona how are sweden's foreign residents reacting to the country's coronavirus approach? uk government urged to investigate coronavirus deaths of bame doctors covid-19: deprived areas have the highest death rates in england and wales black doctors blast "woefully anemic" data on minority coronavirus cases gis-based spatial modeling of covid-19 incidence rate in the continental united states attitudes, and actions related among adults with chronic conditions at the onset of the u.s. outbreak high-income philadelphians getting tested for coronavirus at far higher rates than low-income residents the commonwealth fund. update on federal surprise billing legislation: new bills contain key differences teenage boy whose death was linked to covid-19 "turned away from urgent care for not having insurance aging in times of the covid-19 pandemic: avoiding ageism and fostering intergenerational solidarity the social determinants of health and pandemic h1n1 2009 influenza severity telemedicine and telecare for older patients--a systematic review preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019 -united states epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. supplementary appendix sociodemographic determinants of worsening in frailty among community-dwelling older people in 11 european countries case-fatality rate and characteristics of patients dying in relation to covid-19 in italy the effect of frailty on survival in patients with covid-19 (cope): a multicentre, european, observational cohort study. lancet public heal respiratory rehabilitation in elderly patients with covid-19: a randomized controlled study the psychological impact of quarantine and how to reduce it: rapid review of the evidence european centre for disease prevention and control. surveillance of covid-19 in long-term care facilities in the eu/eea a socially neutral disease? individual social class, household wealth and mortality from spanish influenza in two socially contrasting parishes in kristiania 1918-19 socio-economic disparities in mortality due to pandemic influenza in england the color of coronavirus: covid-19 deaths by race and ethnicity in the u covid-19: data deaths involving covid-19 by local area and socioeconomic deprivation: deaths occurring between 1 coronavirus (covid-19) related deaths by occupation, england and wales: deaths registered up to and including conclusiones de la territorialización de la pandemia de covid-19 en el área metropolitana de madrid source: own elaboration based on publicly available data from the french institute for demographic studies key: cord-265655-s5c7r6ix authors: krendl, anne c; perry, brea l title: the impact of sheltering in place during the covid-19 pandemic on older adults’ social and mental well-being date: 2020-08-11 journal: j gerontol b psychol sci soc sci doi: 10.1093/geronb/gbaa110 sha: doc_id: 265655 cord_uid: s5c7r6ix objectives: we examined whether social isolation due to the covid-19 shelter-in-place orders was associated with greater loneliness and depression for older adults, and, if so, whether declines in social engagement or relationship strength moderated that relationship. methods: between april 21 and may 21, 2020, 93 older adults in the united states who had completed measures characterizing their personal social networks, subjective loneliness, and depression 6–9 months prior to the pandemic completed the same measures via phone interview, as well as questions about the impact of the pandemic on their social relationships. results: older adults reported higher depression and greater loneliness following the onset of the pandemic. loneliness positively predicted depression. perceived relationship strength, but not social engagement, moderated this relationship such that loneliness only predicted depression for individuals who became closer to their networks during the pandemic. for those who felt less close, depression was higher irrespective of loneliness. discussion: the covid-19 pandemic negatively affected older adults’ mental health and social well-being in the short term. potential long-term impacts are considered. in response to the covid-19 pandemic, more than 90% of u.s. residents were under shelter-in-place orders during april 2020 (mervosh et al., 2020) . one consequence of these orders was increased subjective isolation, generally referred to as loneliness (killgore et al., 2020) . because loneliness negatively affects older adults' mental and physical health luo et al., 2012) , the current study examined whether subjective isolation (loneliness) increased under the shelter-in-place orders and, if so, whether this predicted increased depression. we also explored the social network factors that might moderate this predicted relationship. loneliness is associated with myriad negative outcomes for older adults, including higher rates of depression and higher mortality (luo et al., 2012) . longitudinal research suggests that loneliness predicts increased depression, but not the reverse ; for review, see . the relationship between loneliness and depression is moderated by a variety of social and lifestyle factors segel-karpas et al., 2018) . specifically, prior work suggests that greater social engagement (e.g., seeking social support) attenuates the relationship between depression and loneliness (raut et al., 2014) . however, another potential social factor that might moderate the association between loneliness and depression is relationship strength within individuals' personal social networks (i.e., the group of family members and friends in which individuals are socially embedded). indeed, closeness to the individuals in their network increases and predicts greater emotional well-being for older adults (english & carstensen, 2014) . thus, greater closeness within an individual's personal social network might attenuate the relationship between loneliness and depression. in the current investigation, we examine both social engagement and relationship strength as potential moderators between loneliness and depression. an important theoretical limitation of extant research on loneliness for older adults is that it has typically focused on loneliness over a prolonged timeframe (e.g., over several years; . it thus remains unknown whether relatively brief periods of loneliness negatively affect older adults' health. social isolation imposed by shelter-in-place orders during the covid-19 pandemic provided a natural experiment for examining the short-term effects of temporary social disruptions on older adults' depression. in the present study, we first assessed whether the shelterin-place orders exacerbated loneliness for older adults, and, if so, whether that predicted increases in depression (hypothesis 1). subsequently, we explored social factors (social engagement and relationship strength) that might have moderated this predicted relationship. one possibility is that social engagement, notably spending less time with their personal social networks during the shelter-in-place orders, would exacerbate the relationship between loneliness and depression among older adults (hypothesis 2a). conversely, remaining virtually connected with their network members could attenuate that relationship (hypothesis 2b). indeed, social media use has been implicated in offsetting loneliness for some during the covid-19 pandemic (for further discussion, see galea et al., 2020) . alternatively, relationship strength might moderate the relationship between loneliness and depression such that older adults who felt less close to their network members during the shelter-in-place orders experienced an exacerbated relationship between loneliness and depression (hypothesis 3). to account for potential individual differences in depression, we examined a population of older adults who had completed measures of their personal social networks, mental health, and loneliness 6-9 months prior to the covid-19 pandemic and again during the pandemic. participants from june to october 2019, 120 older adults (m age = 74.68 years, sd = 7.13; 64 female) from the bloomington, indiana community participated in a laboratory study on the impact of their social relationships on their overall well-being. older adults were primarily white (96.7%) and well-educated (86.7% had a college degree or higher). none were cognitively impaired (as indicated by scoring >26 on the mini-mental state examination; folstein et al., 1975) . starting in mid-april 2020, all 120 older adults were re-contacted and invited to participate in a phone interview related to the covid-19 pandemic. a priori power analyses conducted in g*power (faul et al., 2007 ) using a small effect size (f 2 = 0.15), α = 0.05, and power = 0.80, with three predictors indicated 77 participants would be sufficient to detect effects. the interviewers contacted and conducted interviews with 94 of the original participants (m age = 75.20 years, sd = 6.86; 52 female). of these, one female withdrew during the social network interview, and social network data from two others (1 male and 1 female) was lost due to experimenter error. interviews took place between april 21 to may 21, 2020. the shelter-in-place order in bloomington, indiana was issued on march 24 and expired on may 16. in time 1 (summer/fall 2019) and time 2 (april/may 2020), older adults completed an expanded structured network interview adapted from the phenx toolkit social networks battery (hamilton et al., 2011; perry & pescosolido, 2010) . the interview was the same in both waves. at time 1 and time 2, the interview elicited names of individuals in a respondent's social network that were activated for discussions about "important matters," as well as supportive ties, significant family members, neighbors, etc. (perry et al., 2018) . after the full list of names was elicited, respondents provided information about each person in the network, including tie strength (closeness between the respondent and each individual in the network). social network data were then computed in stata 16 using aggregation methods to generate average closeness in the network (tie strength) in the overall networks. an important benefit to using the social network interview instead of proxy questions (e.g., "how many good friends do you have?") is that the latter may produce biased personal social network measures because such questions are cognitively demanding (burt, 1987) . the social network interview was always completed first, but the order of the remaining measures was randomized across participants at time 1 and time 2. directly relevant to the current study, these measures included the eight-item patient health questionnaire (phq), a widely used measure of depression (kroenke et al., 2009) , and the three-item ucla loneliness scale (russell, 1996) . we also collected measures related to anxiety and stress (see supplementary materials). reliability on the phq was acceptable (α time 1 = 0.75, α time 2 = 0.67), and reliability on the loneliness measure was good at time 1 and time 2 (αs = 0.86 and 0.81, respectively). test-retest reliability was high for all measures (rs > 0.60, ps < .001). at time 2 only, older adults also responded to questions about their covid-related behaviors, including whether or not they were currently sheltering in place and, if so, how long they had been doing so (table 1; supplementary table 1 ). older adults also indicated whether their "social life has decreased/been negatively affected by covid-19" (yes or no). social engagement by asking whether they spent much more, somewhat more, just as much, somewhat less, or much less time during the pandemic reconnecting with others, spending time with others, and using social media to keep in touch. respondents also provided an approximate amount of time (in minutes) that they spent "socializing virtually or over the phone each day," and the number of times they had virtually contacted others in the past 2 weeks. see supplementary table 2 for correlations between measures. of the 93 individuals surveyed, 93.5% (n = 87) were still sheltering in place at the time of the interview. of those, 56% (n = 52) had begun sheltering in place before it was state-ordered (table 1) . analyses are reported only for the 87 older adults who were still sheltering in place at the time of the interview, but significant results remain as such for the full sample. the majority of older adults (79.3%; n = 69) said their social life had decreased/been negatively affected by covid-19, and more than two thirds (69.0%; n = 60) reported spending somewhat or much less time with people they cared about. however, 60.9% (n = 53) reported spending somewhat or much more time reconnecting or catching up with people they cared about, and 78.2% (n = 68) were using some form of internet technology to keep in touch during the pandemic. older adults reported spending an average of 78.79 min (sd = 81.20) socializing virtually or over the phone daily. older adults also reported that they had virtually contacted others over the past 2 weeks an average of 42.61 (sd = 47.86) times. no gender effects emerged regarding depression or loneliness, so findings are reported across gender. overall, older adults experienced more depression in time 2 (m phq = 3.24, sd = 3.24) than time 1 (m phq = 2.40, sd = 2.71), t(84) = 3.07, p = .003, 95% confidence interval [ci] 0.29-1.38 and greater loneliness in time 2 (m loneliness = 6.05, sd = 2.83) than time 1 (m loneliness = 5.14, sd = 2.49), t(83) = 3.48, p = .001, 95% ci 0.39-1.42. even though, on average, depression and loneliness increased, this pattern was not present for all older adults. hypothesis 1 predicted that increased loneliness during the shelter-in-place orders would positively relate to increased depression. to test this, we created difference scores (time 2 -time 1) for each variable. consistent with hypothesis 1, greater loneliness between time 2 and time 1 (m ∆loneliness = 0.77, sd = 2.37) predicted greater increases in depression from time 1 to time 2 (m ∆phq = 0.89, sd = 2.52), r(86) = 0.22, p = .045. hypothesis 2a examined whether a reduction in social engagement (e.g., spending less time with others) moderated the relationship between changes in loneliness and depression. to examine this possibility, we conducted two regressions with changes in loneliness, the social engagement measure, and the interaction between the two as predictors. the first model tested spending time with people they cared about (more, less, the same) as a potential moderator, whereas the second model tested spending time reconnecting with others (more, less, the same) as a potential moderator. neither model was significant, both fs < 2.13, ps > .10. we next examined whether virtually connecting with others moderated the relationship between loneliness and depression (hypothesis 2b). we again tested two different moderators here: (a) time spent virtually connecting with people they care about (more, less, the same) and (b) the number of minutes per day they spent socializing virtually or over the phone. again, neither model was significant, both fs < 1.93, ps > .13. finally, we examined whether changes in network closeness (tie strength) moderated the relationship between loneliness and depression for older adults (hypothesis 3). tie strength was an average based on how close the respondent was to each individual in his or her network (1 = not at all, 3 = very much). we created difference scores for tie strength (time 2 -time 1) to measure changes in network closeness during the pandemic (m ∆tie strength = 0.04, sd = 19) and entered these into the regression. the overall model was significant, f(3,83) = 3.97, p = .011, and accounted for 13% of the variance in depression (see table 2 for regression statistics). results revealed that older adults who felt less close to their social network during the pandemic (vs. prior to it) experienced increased depression irrespective of their loneliness. however, for older adults who felt closer to their social networks during the pandemic (vs. prior to it), depression only increased markedly for those who experienced a large increase in loneliness. notably, depression scores were reduced slightly during the pandemic for older adults whose network ties became stronger and who experienced decreases in loneliness during the pandemic (figure 1; supplementary table 3 ). several important findings emerged from this study. first, older adults' mental health was negatively affected by the covid-19 pandemic. they experienced greater depression and loneliness than they had prior to the pandemic. second, relationship strength (perceived closeness to network members), but not social engagement, moderated the relationship between loneliness and depression. specifically, loneliness was associated with higher levels of depression for older adults who felt closer to their social networks during the pandemic. conversely, older adults who felt less close to their social networks experienced more depression, irrespective of their loneliness. finally, older adults' were relatively adaptable in staying connected during the pandemic. specifically, although it did not offset their loneliness (for similar findings, see aarts et al., 2015; bell et al., 2013) , older adults reported spending much more time using social media to reconnect with people they cared about. our finding that older adults experienced increased depression during the covid-19 pandemic is consistent with emerging work with young and middle-aged adults during the pandemic (killgore et al., 2020; wang et al., 2020) . because we were able to compare changes in mental health over time, we were uniquely positioned to capture an important shift in older adults' mental health that might have otherwise gone unnoticed. an important caveat to our finding, however, is that although phq scores increased during the pandemic, the mean score at time 2 was still relatively low (m = 3.24), which is below the cutoff for a clinical diagnosis of mild symptoms (dhingra et al., 2011) . future research should monitor whether these symptoms continue to increase. although we did not find gender differences in the current study (barber & kim, 2020) , this could be because we measured increases in depression over time within our older adult sample. however, it is important to note that recent work found gender differences specific to covid-related worries (barber & kim, 2020) . our results also suggest that perceived closeness to social network ties during the pandemic exacerbated the relationship between loneliness and depression, but only for older adults who felt closer to their networks during the pandemic. put another way, among older adults who became closer to their networks during the pandemic, those experiencing decreased loneliness were slightly less depressed during the pandemic than before it, while those with large increases in loneliness experienced significant increases in depression. although older adults who felt less close to their networks during the pandemic showed the greatest increases in depression, this occurred irrespective of their loneliness. together, these findings suggest that perceived relationship strength might have served a protective function for older adults in combination with low loneliness during the pandemic. however, for those who felt increasingly lonely, even stronger network ties did not attenuate effects on depression. albeit speculative, one possibility as to why some older adults felt lonelier during the pandemic while also feeling closer to their networks could pertain to their perceived value to the network. specifically, older adults who felt less important to their networks during the pandemic (e.g., because they could not provide as much support to others as they had previously) might have felt lonelier, in spite of feeling closer to their network. indeed, providing support to one's network is even more beneficial to older adults' mental well-being than receiving it (thomas, 2010) . moreover, our data showed that loneliness was associated with lower perceived support-giving within the network (supplementary table 2 ). future research should examine this relationship further. there are several limitations to the current study. first, because there is not a young adult comparison, we cannot identify the extent to which these results are unique to older adults. however, because loneliness is two to three times more prevalent among older than young adults , our results are particularly relevant to older adults. moreover, because older adults had the highest fatality rate from covid-19 (wu & mcgoogan, 2020) , shelter-in-place orders in most states were longer and more critical for this population and may have thus been perceived as particularly isolating. second, respondents in this sample were homogeneous (e.g., white and well educated), which limits the overall generalizability of these results. relatedly, potential racial differences in older adults' mental health outcomes also cannot be assessed. this is an important additional avenue for future research because covid-19 disproportionately affects non-white populations (centers for diseases control and prevention, 2020). third, because we did not collect data on household composition, we cannot determine whether sheltering in place had the most deleterious mental health outcomes for individuals living alone. finally, we cannot rule out the possibility that self-reported time in isolation (as reported in table 1 ) was inflated by memory errors because we did not collect data relevant to this point (e.g., confidence ratings). together, our findings suggest that the pandemic had immediate negative impacts on older adults' mental health and social well-being. at the same time, they reinforce the adaptability of this population in maintaining their social relationships and the importance of perceived loneliness and social integration. nevertheless, an important avenue of future research will be to evaluate how these negative impacts and adaptability unfold over time. supplementary data are available at the journals of gerontology, series b: psychological sciences and social sciences online. this publication [or project] was supported by a project development team within the indiana center for translational science institute nih/ncrr grant number ul1tr001108. the relation between social network site usage and loneliness and mental health in community-dwelling older adults covid-19 worries and behavior changes in older and younger men and women examining social media use among older adults social contagion and innovation: cohesion versus structural equivalence perceived social isolation makes me sad: 5-year cross-lagged analyses of loneliness and depressive symptomatology in the chicago health, aging, and social relations study covid-19 in racial and ethnic minority groups phq-8 days: a measurement option for dsm-5 major depressive disorder (mdd) severity selective narrowing of social networks across adulthood is associated with improved emotional experience in daily life g*power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences minimental state". a practical method for grading the cognitive state of patients for the clinician the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention the phenx toolkit: get the most from your measures loneliness matters: a theoretical and empirical review of consequences and mechanisms loneliness: a signature mental health concern in the era of covid-19 the phq-8 as a measure of current depression in the general population loneliness, health, and mortality in old age: a national longitudinal study see which states and cities have told residents to stay at home functional specificity in discussion networks: the influence of general and problemspecific networks on health outcomes egocentric network analysis: foundations, methods, and models study of loneliness, depression and coping mechanisms in elderly ucla loneliness scale (version 3): reliability, validity, and factor structure loneliness and depressive symptoms: the moderating role of the transition into retirement is it better to give or to receive? social support and the well-being of older adults immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention the authors thank jenny zhao, anthony morales, and andrew stewart for assistance with data collection. this study was not preregistered, but data, analytic methods, and study materials will be made available to other researchers upon request. none declared. key: cord-260046-lli6mt29 authors: garnier‐crussard, antoine; forestier, emmanuel; gilbert, thomas; krolak‐salmon, pierre title: novel coronavirus (covid‐19) epidemic: what are the risks for older patients? date: 2020-03-12 journal: j am geriatr soc doi: 10.1111/jgs.16407 sha: doc_id: 260046 cord_uid: lli6mt29 nan the world health organization confirmed 93,090 cases of novel coronavirus sars-cov-2 infections (covid-19) worldwide on march 04, 2020. 3,198 deaths were declared (3%). in the united states, 108 cases were confirmed. 1 coronavirus family members are known to be responsible for severe acute respiratory syndrome (sars-cov) and middle east respiratory syndrome (mers-cov), associated with severe complications, such as acute respiratory distress syndrome, multiorgan failure, and death, especially in individuals with underlying comorbidities and old age. 2, 3 in a recently published large case series of 138 hospitalized patients with covid-19 infected pneumonia, the 36 patients (26.1%) transferred to an intensive care unit were older and had more comorbidities (median age = 66 years; comorbidities in 72.2% of cases) than patients who did not receive intensive care unit care (median age = 51 years; comorbidities in 37.3% of cases). 4 comorbidities associated with severe clinical features were hypertension, diabetes, cardiovascular disease, and cerebrovascular disease, which we know are highly prevalent in older adults. previously, the china national health commission reported that death mainly affects older adults, since the median age of the first 17 deaths up to january 22, 2020, was 75 years (range = 48-89 years). 5 moreover, people aged 70 years or older had shorter median days (11.5 days) from the first symptom to death than younger adults (20 days), suggesting a faster disease progression in older adults. 5 since covid-19 seems to have a similar pathogenic potential as sars-cov and mers-cov, 6 older adults are likely to be at increased risk of severe infections, cascade of complications, disability, and death, as observed with influenza and respiratory syncytial virus infections. 7, 8 the consequences of possible epidemics in long-term care facilities could be severe on a population of older adults who are by definition frail and immunologically naïve towards this virus, even if the risk is of course for the moment mainly theoretical. therefore, it seems essential to limit the risk of spreading the virus in facilities caring for older patients at all costs. this could mean drastic quarantine measures for staff members who have stayed in highrisk areas or have been in close contact with possible cases. if any suspected case of covid-19 infection occurs, transfer to a specialized facility as soon as possible is crucial since long-term care facilities are not adequately equipped to effectively manage case containment. while waiting for the transfer, placing the patient in a single room, wearing a mask (n95 or ffp2 respirators for healthcare practitioners), and careful hand hygiene using alcohol-based hand rub (or soap and water when hands are visibly soiled) are the key prevention measures to limit spread of covid-19. they must also be combined with eye protection and systematic use of disposable blouses and gloves to provide the optimal level of protection. clinical management of covid-19 should be guided by the world health organization and the centers for disease control and prevention. 9, 10 there is no specific recommendation for older adults. the centers for disease control and prevention state that there is no specific antiviral treatment recommended, and patients should receive supportive care to help relieve symptoms. for severe cases, treatment should include care to support vital organ functions. 10 secondary prevention and care of general complications could also be a major issue in older patients. indeed, in seasonal influenza, for example, a large proportion of deaths are related to decompensation of comorbidities and complications occurring after the infection. 7 particularly, reducing incidence of venous thromboembolism, catheterrelated bloodstream infection, pressure ulcers, falls, and delirium is recommended. these measures should be adapted to comorbidities, polypharmacy, and frailty of older patients. 9, 10 we assume that they could also be crucial in case of covid-19 in older adults. coronavirus disease 2019 (covid-19). situation report-44 middle east respiratory syndrome clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan china coronavirus: what do we know so far? mortality associated with influenza and respiratory syncytial virus in the united states hospital diagnoses, medicare charges, and nursing home admissions in the year when older persons become severely disabled advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019-ncov) outbreak: interim guidance centers for disease control and prevention. 2019-ncov: prevention & treatment. 2020 key: cord-258915-lgee3ers authors: liddle, jennifer; pitcher, nicole; montague, kyle; hanratty, barbara; standing, holly; scharf, thomas title: connecting at local level: exploring opportunities for future design of technology to support social connections in age-friendly communities date: 2020-07-31 journal: int j environ res public health doi: 10.3390/ijerph17155544 sha: doc_id: 258915 cord_uid: lgee3ers social connectedness in later life is an important dimension of an age-friendly community, with associated implications for individual health and wellbeing. in contrast with prior efforts focusing on connections at a distance or online communities where the digital technology is the interface, we explore the design opportunities and role of technology for connectedness within a geographically local community context. we present findings from interviews with 22 older adults and a linked ideation workshop. our analysis identified shared concerns and negative perceptions around local relationships, connections and characteristics of the geographical area. however, local connectedness through technology was largely absent from day-to-day life and even perceived as contributing to disconnection. by uncovering how older adults use and perceive technology in their social lives and combining these findings with their ideas for improving local connections, we highlight the need for thoughtful consideration of the role of technology in optimising social connections within communities. our research highlights a need for design work to understand the specifics of the local context and reduce emphasis on technology as the interface between people. we introduce an amended definition—‘underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community’s physical, social and digital environments and its supporting infrastructure’—to conceptualise our approach. we conclude by suggesting areas for future work in developing digitally connected age-friendly communities. social connectedness in later life is important for health and wellbeing. consequently, making it easy for people to develop and maintain social relationships is a fundamental ambition of 'age-friendly' communities. this local, place-based, policy approach recognises that physical and social environments are key determinants of whether people remain independent, autonomous and healthy in later life. human-computer interaction (hci) researchers are directing increasing attention towards the role of technology in shaping and supporting social relationships in later life. much of this work focuses on online communities or connecting across geographical or generational distances, where digital technology is the interface or infrastructure for connection. in addition, approaches commonly place emphasis on addressing technological inexperience, or on physical or cognitive impairment and decline. in this paper, we are interested in considering technology and connectedness in later life within a specific local context, and exploring how innovation in social connection can be age-friendly and embedded within such physical community settings. we consider older adults as a heterogeneous group, rather than a group marked by singular identities of health, cognitive status, or technological proficiency. nevertheless, our place-based approach aims to identify common values and experiences shared by people living in the same geographical area. life events such as retirement, along with experiences of building and maintaining social connections over the life course, will also have implications for how and why older adults wish to develop and sustain proximate relationships in particular ways. we suggest that considering these topics enables a deeper understanding of how to design for a digitally connected age-friendly neighbourhood, where both the design process and its outputs are age-friendly. our paper presents findings from a study comprising two phases: qualitative interviews with 22 older adults; and a linked workshop ideation process to engage interviewees in beginning to consider how connections within their local area might be enhanced over time. the contributions of our paper centre around a context-specific and bottom-up approach to designing for increased local connectedness in later life. the importance of this topic has since been emphasised by the covid-19 pandemic, heightening awareness of the need to consider ways to maintain and create social connectedness, particularly at a local level. our aim is not to design a technological output. instead, we see our approach as prioritising a crucial, and often neglected, stage in technology design, which provides important insights that would be required for any future stage of a design process that aimed to design or create an actual technology. themes that emerged from our interviews suggest that participants viewed technology as acceptable when it filled a 'gap' and did not have too many negative impacts on everyday life. our starting point for the linked workshop was to consider some of these 'gaps' in local connectedness that interview participants had described. the workshop activities were used to facilitate participants in thinking creatively about addressing specific local challenges, or 'gaps' in connectedness. in drawing together participants' ideas about spaces, processes and mechanisms that might address these local challenges, we conclude the paper with implications that offer scope for further exploration and consideration in terms of how technology might support the operationalisation of local people's ideas for improving face-to-face connections in age-friendly community settings. growing interest in what makes places 'good' to grow old in has led to an increasing focus on the 'age-friendliness' of different types of environments [1] . despite variation in emphasis between models of age-friendly environments, most approaches promote consideration of how policies, services and structures can integrate physical and social environments, supporting social engagement and connection [2] . our work adopts the following conceptual definition, with its emphasis on age-friendliness as commitment to a process rather than a standard to be reached: 'underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical and social environments and its supporting infrastructure' [3] . the adopted definition of age-friendliness shapes our research design and methods, with its emphasis on community engagement and the participation of older people in processes to optimise the environment to support social connections. we also draw on concepts from environmental gerontology, such as 'ageing in place' to understand the importance of the local area in older people's lives. an overarching premise of an age-friendly community is that it is 'friendly for all ages and not just "elder-friendly"' [1] . even so, the argument that older people are 'able to remain more independent by, and benefit from, ageing in environments to which they are accustomed' [4] makes it all the more important to consider how environments can support people 'ageing in place' to optimise their social connectedness within their local area. this has become even more apparent during the 2020 covid-19 pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, even with people in proximate locations, has become a greater priority. there has also been a strong emphasis on tackling the counterparts of social connectednessloneliness and isolation. warnings of the 'loneliness epidemic' and its associated public health implications are prevalent in media discourse [5] [6] [7] , and the uk government appointed the world's first minister for loneliness in 2018 [8] . accordingly, responses to the drive for increased social connection have often focused on mitigating unpleasant experiences, risks and deficits at an individual level [9] . efforts along these lines reflect and uphold persistent ageist stereotypes that fail to acknowledge the roles that older people (can) play in communities, or their potential to contribute innovative ideas or create a voice for themselves [10] [11] [12] . indeed, technology is often presented as the ideal way of solving these 'problems' faced by older adults [13] . ten bruggencate et al. draw our attention to the predominant focus on loneliness and/or isolation in studies about social technology, ageing and relationships [14] . in contrast, a growing body of work on social connectedness in later life challenges the image of older people as lonely and isolated. population ageing is leading to increasing numbers of older people, thereby increasing the number of older people in society who experience loneliness. however, loneliness affects only the minority of older people, including the oldest old [15] [16] [17] . the likelihood of reporting feeling lonely decreases with age, with younger adults (16-24 years) reporting loneliness more often than those in older age groups [18] . while older adults may have smaller social networks, they are often more involved in the community than younger adults-socialising with neighbours, participating in religious organisations and volunteering [19] . however, even if social reciprocity and meaningful interactions are desired and enacted by older people, infrastructural barriers can, and do, impede the quantity and quality of such connectedness [20] . technology offers the potential for scalable and cost-effective interventions to address barriers to connectedness. the design, or adoption, of digital technology to support social relationships in later life often results in technology being the core interface for connection between people, rather than a route to facilitating face-to-face connections by overcoming barriers. for example, online communities are promoted as presenting opportunities for older people to meet and interact with peers [21] [22] [23] [24] . in this interfacing role, technology is a bridge across distances. lindley et al. comment that much hci research related to relationships focuses on ways to maintain feelings of connectedness or express intimacy at a distance [25] . distances being bridged may be geographical, for individuals living in remote areas or wanting to connect with people with whom they share interests, friendship or familial bonds. distances may also be generational, where, despite intentions to the contrary, technology replicates asymmetrical family interactions [23, 26, 27] . growing proportions of older people are now using digital technologies. in the uk, 83% of adults aged 65-74, and 47% of adults aged 75 and over use the internet [28] . thus, the majority rather than a minority of older people are technologically connected, suggesting a need to understand more about how this diverse population uses, and feels about, technology for connecting with others. the few studies that have explored older people's attitudes towards, and perceptions about, communication and connection suggest that rich interactions are valued above lightweight connections offered by newer technologies [14, 25, 29] . again, this work primarily considers the capacity of digital technology to bridge geographical or generational distances, where more traditional technologies such as telephone and email are often preferred. thoughtful and meaningful interactions are the goal, and technology provides the interface. research methods centre around questions about how older adults use, or would choose to use, technology in their social relationships. for instance, sayago et al. report on research with 700 older people (across six studies) that examined situated technology use and the reasons why participants did, or did not, incorporate particular forms into their everyday lives [23] . in this way, technological interfaces are often in-built as fundamental foundations for designing for connection, diminishing considerations of technology in non-interfacing roles. research that has explored ways to improve geographically proximate connections has also tended to concentrate on a prominent role for technology, often studying online community networks. these include bespoke online communities for older adults, or those formed on more widely used social networking platforms. righi et al. focussed on how older people's use of social networking sites could be used to promote their involvement in both online and offline local communities [30] . while participants used, for example, facebook to find out information about the local area, most did not post or share information or send messages to others. instead, these interactions took the form of face-to-face conversations. on this basis, the authors conclude that proximity and face-to-face contacts should be kept in mind when designing online community networks. we would extend this argument further, to suggest reversing the design process. such a process would design for proximity and face-to-face contact in offline communities, with technology kept in mind in a background, less visible, role. the research described above concentrates on technology as the interface for connection between people. while the potential of technology to foster involvement in local communities has been explored, less attention has been paid to understanding and drawing on context-specific factors to develop approaches to promote connection in local areas with, rather than for, older people. this would be a fundamental approach for any community engaged in the ongoing process becoming (more) age-friendly. an effective strategy in one community will not necessarily translate to a community with different geographical, social or structural features. likewise, the attitudes of older people towards technology will vary individually and across communities and countries. in their 'manifesto for change' in age-friendly cities and communities, buffel et al. emphasise the necessity of ensuring the empowerment and recognition of older residents in order to achieve age-friendliness [31] . for these reasons, we adopted a bottom-up, place-based approach that can be responsive to local needs, preferences and resources. we recognise community as an inclusive concept, with the participation and empowerment of members (particularly older people) being fundamental to its creation and functioning [3, 32, 33] . the following sections present the methods and findings of our study. our research design (in-depth interviews followed by an ideation workshop) draws on key concepts, theories, gaps and definitions in the literature outlined above. it is a bottom-up place-based approach that focuses on local needs, preferences and resources. it prioritises the participation of older people in exploring context-specific routes to local connection that present opportunities for future design of technology. we see our participants as crucial to developing ideas to increase or improve connection. as residents within the local area, they have a wealth of knowledge and experience and are best placed to identify resources, ideas and options that can lead to context-specific routes to connection. our overall aim within this study is to begin exploring context-specific routes to local connection that do not start the design process with attempts to design technological interfaces. discovering issues or opportunities for increased connection at a community level is the first step in this process. these opportunities and 'gaps' also need to be considered alongside insights into the current practices and perceptions of older people regarding technology in their social lives. once opportunities for increasing connection have been identified, ways to address these can then be explored by older people with local expertise and knowledge. therefore, in practice, the workshop methods were designed after analysis of our interview data so that we could draw on the interview findings as the starting point for workshop activities and discussions. however, for structural clarity, the methods for both the interviews and workshop are presented first in this paper, followed by the findings from our analyses. the first phase of our study aimed to explore opportunities for designing to improve proximate social connections for older people living within a geographically identified 'community'. we also wanted to know more about how and why research participants were using technology, or not, in their social lives. qualitative interviews were an appropriate method for exploring these two topics, with their potential to elicit personal accounts that help people to 'make explicit things that have hitherto been implicit-to articulate their tacit perceptions, feelings and understandings' about their social lives and technology [34] . the study setting was an electoral ward (district) within a city in the north of england, uk, chosen for its proximity to the research team's institutional location. just over 10% of the around 13,600 people living in this geographical area are aged 60 or over (compared to 23% overall in england and wales). it is also one of the most ethnically diverse and socially deprived wards in the region [35] . following institutional ethical approval (ref. 13284), we recruited 22 older adults (15 women, 7 men) to take part in audio-recorded interviews. sixteen interviews were with individual participants and three interviews were with couples living in the same household who chose to be interviewed together. our only inclusion criterion was that participants were aged 60 or over. however, we also sought to achieve a diverse sample in terms of age, gender, ethnicity, social connectedness and living arrangements. table 1 summarises participant characteristics. participants were aged between 60 and 84 and had been living in the area for between seven months and 84 years. one participant was asian and the remaining 21 participants were white. eight participants were living alone, and the others lived with at least one other person (a spouse/partner ± extended family). with the exception of one participant who was working part-time, all participants were retired. recruitment was via face-to-face conversations at community events and locations (such as a weekly café held in a local church) and contact details shared by community groups and organisations based in the area. we made substantial efforts to achieve a sample with greater ethnic diversity, including seeking assistance from individuals running local organisations and groups for people from non-white backgrounds, and posters in local culturally diverse food and clothing shops. we also made provisions for language translation in interviews. however, in the time available, we were unable to identify additional people from different ethnic groups who were willing to take part in an interview. longer-term development of relationships within the community would likely be needed to increase interest and trust, which was not possible in a study of this scale. all potential participants were given an information sheet about the study and a copy of the consent form to read. interviews were arranged at times to suit participants, and they were offered a choice of location. one participant chose to meet for their interview in a community building and all other interviews were conducted in people's own homes. after completing the consent form and giving an opportunity for the interviewee to ask any questions, we audio-recorded the interview with the participant's agreement. interviews were conducted by jl, hs or np. we initiated the interviews with a narrative approach, asking individuals to tell the story of their social lives since they had been living in the area. this facilitated the exploration of each individual's own concerns, meanings and priorities related to their social lives, rather than these being imposed by predetermined questions [36] . the same question was asked at the beginning of each interview: 'can you please tell me the story of your social life while you've been living in [this area]; your relationships with family, friends, neighbours and other people?'. participants were asked to talk about any events and experiences that were important for them, and invited to take as long as long as they needed to tell their story. this narrative section of the interview was followed by supplementary probing questions to explore areas of particular interest, including the role of technology in their social lives. these questions were not pre-defined in order that interviewers were free to explore anything that they felt was of interest and relevant to the overall aims of the study, maintaining a natural and spontaneous flow within the interview. brief reflective field notes were made by interviewers after each interview. electronic data files were stored in password-protected folders in the university filestore. interview recordings were transcribed and names were anonymised. we then completed initial inductive coding [37] of the data to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. codes were organised under themes, following the process outlined by braun and clarke [37] . for example, codes such as 'places people used to socialise no longer exist', 'many buildings are not accessible', and 'there are few facilities' were grouped together under the theme 'few local places to socialise'. coding and theme development were completed independently by two researchers (j.l., n.p.) and then discussed and refined with all members of the research team. while all names used in this paper are pseudonyms, participants in photographs gave consent for their images to be included in research outputs. the second phase of the study comprised an ideation workshop. we drew on the following conclusions from our interview analysis when designing the workshop: • there were concerns and perceptions about local community connections and characteristics that offered opportunities for design; • our participants predominantly used technology to connect with family, or friends at a distance; existing local technological connections in their social lives were less obvious; • many participants were actively using a variety of technologies, but their willingness to do so depended on perceptions of unmet needs and balancing the negative aspects (additional work, potential contribution to face-to-face disconnection) in their everyday lives. we designed the workshop to explore and generate ideas to improve and optimise social connections in the local area, focusing on four of the opportunities we identified in our interview analysis. based on the in-depth understanding about participants' use and perceptions of technology that we gained from the interviews, we designed 'playful' workshop activities that deliberately did not ask participants explicitly to consider how technology could address issues in local social connections. instead, we wanted to begin by eliciting participants' thoughts about the best ways to tackle these issues before considering any technological needs that arose from these suggestions. this approach avoids the tendency of previous research to foreground technology at the start of the design process. by deliberately not seeking to design a technology or technological interface in this study, we could instead reflect on the potential needs or roles for technology once we knew what type of interventions our participants had suggested. our approach also fitted well with our desire to draw on participants' knowledge, experience and capacity for creative thinking, and was in keeping with our aim of developing approaches to promote connection with, not for, older people, prioritising their participation in a bottom-up design process. all interview participants were sent a postal invitation to the workshop. eleven individuals initially confirmed their availability and nine attended on the day (6 women, 3 men). these individuals were aged between 68 and 84 and had been living in the area for between 30 and 69 years. the workshop was held in a church hall in the local area and refreshments were provided. participants were asked to read and complete the consent form on arrival. consent to being photographed was optional. the workshop was structured around four opportunities to improve local social connections that we identified as themes through our interview analysis. each theme represented shared concerns and negative perceptions about local relationships, connections and characteristics of the area that participants had talked about. the four themes were 'few local places to socialise', 'not knowing neighbours well', 'absence of a shared community feeling', and 'activities on offer not always conducive to socialising or making new friends'. these themes were chosen to take forward in the workshop based on their content being both appealing and generic enough for all participants to engage with, regardless of their individual circumstances and experiences. in line with age-friendly models, our aim was for a bottom-up approach in which workshop attendees' participation and contributions were fundamental to the resulting design ideas [38] . confronting ageist stereotypes, we also wanted to capitalise on participants' creative abilities and ingenuity along with their knowledge and experience as residents within the local area. in line with these priorities and our aim to explore participants' thoughts about how to improve connections at a local level without a specific focus on technology, we designed a range of playful ideation (idea-generating) activities to scaffold workshop discussions. choosing activities to maintain a 'playful mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [39] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure 1 ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [39] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure 1 ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure 2 ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure 2 ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. data collection in the workshop comprised ideas written by participants on the templates provided (see figure 1 for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and 12 sub-themes that captured the overall range, content and types of ideas [37] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table 2 outlines the four themes, along with linked examples from the interview data. data collection in the workshop comprised ideas written by participants on the templates provided (see figure 1 for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and 12 sub-themes that captured the overall range, content and types of ideas [37] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table 2 outlines the four themes, along with linked examples from the interview data. beginning with the first of the four themes, most participants reported that there were few places in the immediate local area that they could use for socialising beyond their own homes. they described how there was no central community centre in the area, and no clearly distinguishable main high street. perceptions about the lack of local options contrasted with participants' opinions about the venues, centres and cafés available in other areas where they felt that community spaces and cafés were prominent and actively used and adopted by people living there. some participants were happy to socialise at home, but others saw this as too much of a burden or did not feel comfortable inviting people into their home. a noteworthy and unique characteristic of the local area highlighted by participants was the historic covenant on the land in the vicinity, preventing any licensed premises or pubs from operating. in the face of limited options in terms of usable spaces, local churches often hosted (or were booked to host) activities and events. however, this itself was a deterrent to some participants who felt uncomfortable attending events that had a religious connection-even if religion was not intended to be part of the event, such as a community café. overall, the perspective was that the community's physical features and built environment did not facilitate face-to-face social activities and interactions. the second theme (not knowing neighbours well) did not apply to all interview participants. in fact, some participants described their neighbours as good friends. these interviewees lived in quieter, more spacious streets, accommodating larger houses with gardens. other interview participants felt very disconnected from their neighbours. those living in particularly 'neighbourly' streets were aware that their situations were unusual in the wider local area where different road and housing types and tenures were more dominant, and fewer longstanding residents were living alongside the same neighbours for extended time periods. population churn, the movement of people in and out of streets, was perceived as a factor influencing the extent to which participants knew their neighbours. growing families and the number of properties available to rent in the area were cited as reasons behind this movement. streets were often busy with traffic-a factor that participants identified as not being conducive to unplanned meetings or chats with neighbours. while the physical proximity of neighbours potentially offered the most geographically close opportunities for social interaction, this had not translated into actual interactions for many participants. in particular, participants indicated that local issues of population mobility and transport routes contributed to the under-development of these relationships. the essence of the third theme (a lack of shared community feeling) was expressed by many participants. some attributed the absence of community to the area's geographical characteristics and location within the wider city, including the proximity of a motorway and the absence of a central focal point, or main high street, in the area. interview participants also commented on the lack of interaction between people of different ethnic and cultural backgrounds, despite the fact that the area was home to a diverse population. some talked about how this had been a longstanding issue, first noticed when their children were at school. together, both the physical environment and the population makeup of the area appeared to contribute to participants feeling that there were physical and cultural divisions within the geographical community. the fourth theme illustrates the complexity of developing new connections and relationships that extend beyond acquaintanceship: activities on offer are not always conducive to socialising or making new friends. even when participants were meeting people and seeking new friendships, these interactions did not often translate into deeper relationships. some participants described attending regular or one-off activities where they felt that the type and format of sessions were not helpful for getting to know people. for example, the focus was on a particular activity so chatting was only possible during brief time periods while setting up or packing away. another barrier was that some participants were more passive than others, and did not initiate conversations or connections themselves. in addition, participants mentioned that the same volunteers or people were often involved in several different groups and activities, resulting in a smaller pool of people to form friendships with. in other instances, it was simply that occasional casual conversations participants had with others did not result in deeper friendships or relationships that were sustained or developed beyond interactions at the events themselves, and individuals, therefore, remained acquaintances. taken together, these themes demonstrate clear barriers in, and characteristics of, local community connections. the themes capture issues that were impacting on the quality and quantity of participants' relationships in the local area, offering opportunities for participatory design processes to address these. alongside identifying opportunities to improve connections at a local level, the other focus of our analysis of the interview data was on understanding more about participants' existing engagements with technology in relation to their social lives. this engagement ranged from minimal (i.e., landline telephone only) to extensive (including social media, real-time audio/video interactions and applications). we use eight central themes to capture participants' accounts of the existing roles that technology played, or did not, play in their social lives. these themes, and examples of the data that support them, are outlined in table 3 . capturing and sharing images marie: "it's got an excellent camera. i use it as a camera because i'm useless at taking photographs otherwise." simon: "see, if marie uses a camera to take somebody's photograph, and eventually either cuts them in half or chops their head off, you know, which is-but, with this phone, it's absolutely brilliant." marie: "yes, yes." simon: "the pictures that she's taken when she's been on holiday and things, absolutely superb." "i get loads of photographs of the children when they're opening birthday presents. their mother takes a photograph and sends it with a comment on what they said when they were trying on things." (lynne) the first theme about the role of technology in interviewees' social lives focuses on its use to connect participants with people in geographically distant locations. in fact, many of the digitally mediated interactions described by participants bridged geographical distances. applications and platforms such as facetime, facebook and whatsapp (along with traditional landline phone calls) were commonly used to keep in touch with friends and family located in geographically separate locations. grandchildren were frequently mentioned as being a priority in seeking to connect face-to-face at a distance. while the financial savings of free long-distance technological connection were noted and appreciated by some, interviewees also reflected on the emotional value of being able to stay visually connected with loved ones. for claire, this connection even changed her perception of the duration of time passing between in-person interactions, making it feel like she had seen her son in person more recently than was the case in reality. in contrast to those using technology to bridge distances in order to maintain existing relationships, deborah was unusual among interviewees in that she had formed long-lasting friendships with people she met initially through the use of an online marketplace. as someone living alone in later life, she was using technology designed for one purpose (financial/accommodation transactions) to initiate and facilitate face-to-face interactions with strangers from geographically distant locations, offering the potential for developing new social relationships. our next theme encapsulates the role of technology in connecting family members and groups. family relationships were frequently discussed as examples of connections that were supported by technology, through informal chatting, sharing photographs or stories and news about day-to-day life events. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. whatsapp was often highlighted in this context, particularly for its usefulness in communicating with a group, and across generations. examples included whatsapp groups with interviewees, their children and partners, and grandchildren. these were sometimes longstanding groups for general communication, but at other times were set-up for a specific purpose, such as organising a birthday party. cross-generational interactions were also perceived as improving the connectedness of family members who had previously felt 'left out' of family communications. john described the example of his sister, who was previously less connected with other members of the family but could now see photographs and hear about what other members of the family were doing, without them needing to make a special effort to include her. technology was seen, in cases like this, as a solution to the barriers to instantaneous communication with family members with diverse and busy lives and routines. however, telephone calls were also important to participants as a way of keeping in touch, particularly with others who were nearer in age such as siblings or friends. in addition, paul expressed his unease at the invasive nature of commonly used apps and platforms which, for example, access lists of contacts from the device they are using or collect data to support targeted advertising. his use of whatsapp was 'reluctant' on this basis, but he acknowledged its usefulness in keeping in touch when his son was abroad, highlighting the trade-off he had to negotiate between privacy and connection. we did not ask participants explicitly about the ways in which they chose to record social interactions or events, but the use of in-built cameras in mobile phones featured in participants' accounts of the role of technology in their social lives. we have described this theme as 'capturing and sharing images'. the ease of taking photographs with a smartphone in comparison to using a camera was noted by some participants, facilitating them in documenting social occasions. moreover, despite his privacy concerns about the invasiveness of technology more generally, paul valued the fact that he was able to recover digital images from an automatic cloud backup after he accidentally deleted photos (documenting an international trip) from his mobile phone. photographs as mementos of experiences in participants' social lives, like paul's trip, were treasured. additionally, the act of sharing and receiving images was a central feature of participants' digital interactions, connecting participants with events and experiences when they were not physically present. after initially dismissing much technology (apart from facetime) as insignificant in her social life, claire later reflected that it did play a large role in how she organised and arranged social events and interactions. the theme of 'sharing information and making arrangements' draws on these organisational uses of technology described by interviewees. information was generally not necessarily shared on social networking sites or more visible platforms, but interactions commonly took place through instant messaging and other technological channels rather than solely in person. in fact, for marie, there were additional benefits to using technology as a tool for organising or making arrangements with people. she preferred the control that it gave her in contrast with the unpredictability and social awkwardness she experienced when talking on the phone. technology was mainly described by interviewees in terms of its role as a tool for connecting, or supporting connections between, people. conversely, several participants noted the ways in which technology itself was a dimension of their social life, offering an alternative to interactions with people. perhaps because of its dominant focus on portraying human lives and activities, jane felt that television was a more 'personal' type of technology. patricia and brenda watched television at times when other company or interaction was inaccessible. for patricia, this was at 'silly hours' of the day or night, whereas brenda described how she might watch television, dvds or listen to cds when she found herself alone or 'down'. there were particular times when others living in her housing development were more likely to be spending time with family, such as weekends, where she used music or television as a strategy to deal with loneliness. at the other end of the spectrum, simon tended to avoid face-to-face social activities and events with other people, preferring to spend time playing games or reading on his computer. there were two main ways that participants described technology as contributing to disconnection in terms of social interactions and events: its prevalence as a platform for information about events; and its disruptive potential during face-to-face interactions. sally used the internet but chose not to engage with social media for privacy and security reasons, but felt that this was increasingly disadvantaging her when it came to finding out about local events. she reflected on her reliance on other people to keep her informed, and the difficulties of being separate from the dominant route of information sharing via social media. for sally, information sharing was happening in a way that excluded her, meaning that she missed out on attending social activities and events that she would have chosen to go to otherwise. in contrast, liz highlighted the capacity of technology to disrupt social interactions themselves. she described both a friend's extensive use of a smartphone, and purely the presence of a phone (in use or not), as disrupting face-to-face interactions and impacting on their quality. sally's and liz's accounts indicated a reluctance to allow technology to become pervasive in everyday life, balanced against a recognition that there were places and circumstances where it could be beneficial. along with concerns about the potential for technology to disrupt relationships, the positive impacts of technology in participants' social lives were also, in some cases, accompanied by additional unwanted work. our penultimate theme, therefore, centres around experiences of technological interaction as an additional 'chore'. sally described being 'bombarded' by messages, and she and others found their perceived continual need to respond and interact electronically to be a burden. the perpetual nature of communicating using interactive technologies such as email, texts and instant messages was also unpopular with some interviewees because of the amount of time it consumed. responding was not perceived as an optional activity. even if emails contained welcome content, the task of checking, opening and reading them was viewed as a compulsory individual task and responsibility. catherine likened this to the responsibility to open letters that came through the post, rather than a choice or pleasurable activity. our final theme sums up participants' thoughts about not needing digital technologies. more traditional technologies such as the telephone or television were commonly accepted as integral to daily life. in fact, their deep-seated role in participants' social lives meant that they were often no longer considered or mentioned (by participants) when talking about technology. instead, participants tended to focus on newer digital technologies such as social media, applications and email. regarding these more modern technologies, there was a sense for some participants that they were unnecessary. for example, when talking about social media, liz explained that she did not 'think there's a gap that i need them.' christopher used the internet and email but did not consider it necessary to go online to find out about local social events as he was exposed to paper-based publicity, such as posters and flyers, as well as information via word-of-mouth. for judith, the whole idea of using a computer or the internet was superfluous when she could instead rely on her family for support, asking them for anything she needed. overall, technological connections were predominantly bridging distances, with existing local technological connections less obvious. technology was mainly seen as a tool to be used to make connecting easier where there were needs, barriers or 'gaps' (geographical or generational distances, difficulties sharing information, capturing images, avoiding uncomfortable face-to-face interactions), but not at the expense of disrupting desired face-to-face interactions or in situations where technology was seen as unnecessary (other strategies would suffice). in addition, the additional work required to use technology as an aid to connection was an unwanted consequence. willingness to use technology depended on balancing the positive and negative aspects. as described earlier, the workshop was designed to build on the findings from our interviews. an extensive list of ideas was generated through our ideation activities, which we combined and organised under themes and sub-themes. table 4 summarises the themes and sub-themes identified in our analysis of the written workshop data. participants commented that the workshop had been enjoyable and thought-provoking-an outcome that supports us in challenging ageist stereotypes of older people as unable or unwilling to engage in creative, disruptive or wild thinking. the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up the three main themes we use to understand the workshop data are: social spaces and places; processes to promote social interactions; mechanisms to drive change. these themes capture different dimensions of participants' ideas for facilitating social interactions in the local area. ideas varied in both scale and scope (see table 4 for examples). the first theme describes ideas that related to the physical environment and developing spaces and places to promote interactions. the proposed changes were either to directly provide locations for organised or informal activities to take place, or to change environmental factors to increase the likelihood of people meeting and connecting in their everyday lives. ideas for developing locations for activities included making better use of existing spaces as well as creating new spaces or places. residents suggested taking advantage of the large areas of green space that were nearby and using them in new ways. they also thought that new community premises, such as a community centre, would be helpful. ideas to change other environmental factors included improving the environment for pedestrians and improving security of tenure to increase the length of time that people are resident in the same location before moving home. while some ideas residents suggested were more generic, others were particularly context-specific. participants drew on their local knowledge to consider what resources in the local area could be used, and identified other resources that were lacking. table 4 . themes from workshop data analysis. making better use of existing geographical features and spaces for social purposes, such as large areas of green space (e.g., figure 3 ) longer opening hours e.g., library marquees/undercover spaces in parks etc., for rainy days make better use of open/green spaces for community activities e.g., exercise equipment, open a beach, more benches, ice cream vans to encourage use of parks new transport options to support travel in the immediate local area and into the city centre frequent, small scale local transport e.g., minibus every 10 min extend the metro into the area to improve access to city focusing on proximate relationships i.e., at a street level or between those volunteering at the same events, as well as at the community level encourage greater walking in area e.g., parents taking children to school encourage volunteers to build friendships/relationships outside volunteering activities/context street level interventions e.g., street meetings/cups of tea, annual events community-driven/commissioned or cooperative initiatives around social spaces, information provision, transport and learning/training community/cooperative/volunteer-run hospitality venues buy a property on a co-operative basis and use as community resource/café/party venue community uber-style, tandems/sidecars or other forms of 'fun' transport, bike sharing, motorcycle lessons-teaching/learning/using transport cafes that also operate as training kitchen for cooking healthily, training in basic work skills by involvement in running community hub incentives to: sustain and attract small catering and hospitality businesses to the local area; encourage local people to participate in social activities increase incentives for small catering/hospitality businesses e.g., no rates/taxes for first years after opening happy hours in cafes etc., with free tea/coffee/cake, sponsored by local businesses credits for free attendance at social activities for residents e.g., swimming pool on particular days/times/a month, extra credits could be earned through volunteering dedicated time slots for social and/or physical activity/exercise time finding ways of improving the commitment and contributions of individuals to the local area to create and sustain a sense of community commitment of individuals to community e.g., minimum number of community work hours/community service and strategy to deal with those who do not contribute, volunteers to supervise weekend sporting activities for children, create sense of community between residents/students the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up component that precedes design of technological outputs. we begin our discussion of the findings from this study by considering the interview data, and their position in relation to wider debates and literature around technology and social interaction in later life. we then move on to discuss what the ideas generated by workshop participants offer in terms of implications, scope and challenges for future technology design around social connectedness, particularly when considered in the context of the interview findings. we use three sub-themes from the workshop (making better use of existing geographical places and spaces; focusing on proximate relationships; community driven/commissioned or cooperative initiatives) as examples to avoid our discussion of implications and challenges for future technology design being too generic, and to ensure that our focus remains on designing in the particular context of our research community and participants. within an age-friendly context, our analysis of interview data identifies a number of opportunities to design for increased social connectedness within local communities. participants felt that: there were few local places to socialise; they often did not know their neighbours well; there was an absence of shared community feeling; social activities on offer did not always lead to socialising or making new friends. in a policy and practice environment where technology-based initiatives are increasingly perceived as offering huge potential, our findings highlight the importance of age-friendly approaches that are grounded in the local context [1, 2] . this has become even more apparent during the covid-19 pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, including with people in proximate locations, has become even more important in ways we did not anticipate when conducting this study. every community is unique, so designing to optimise social connectedness at a local level requires understanding and recognition of context-specific characteristics. in addition, taking account of the social and structural particularities of places gives insight into meanings and functions that are the result of cumulative experiences over time [40] . in our study, the geographical layout of the community, restrictions on licensed premises and population churn were all factors that participants highlighted as playing a role in disconnection. however, these issues can also be seen as 'leverage points' where interventions could afford the greatest benefits within a specific local context [40] . our interview data also contribute to understanding more about how older people use and perceive technology in their social lives. unlike dickinson and hill's findings in 2009 that older people did not engage with instant messaging or other forms of computer technology aside from email [29] , participants connected using a range of methods and formations of communication. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. participants were not necessarily using social networking sites to share information, as righi et al. [30] also found, but in our study these information-sharing interactions were commonly taking place through instant messaging and other technological channels rather than solely in person. these findings reflect changing levels of digital connection for older people in the uk [28] and emphasise the need for hci to reconsider longstanding stereotypes of older people as digitally inexperienced or uninterested [13] . the covid-19 pandemic has provided further evidence to counter these outdated stereotypes, with many older people embracing technology to facilitate connections with friends and family at a time when face-to-face meetings have been restricted. yet, while participants in our study made regular use of technology to support their connections with others, this use was carefully considered. technology was not, in itself, an attractive prospect unless it was perceived to fill a 'gap' and the 'chore' of using it did not overly impact on everyday life. similarly, lindley et al. reported that older people were cautious of the time commitments required to use technologies, although they also used technology as a way to manage levels of contact and control their own availability to other people [25] . in addition, participants in our study were aware of the potential for technology to contribute to disconnection. waycott et al. [41] reflect that the mismatching of values and assumptions guiding a technology-based social intervention with those of the older adults participating in the evaluation, noticeably contributed to individual decisions not to participate. in an increasingly digital society, our findings again indicate the importance of design processes that are in tune with the perceptions and values of older adults. marston and van hoof draw our attention to the fact that the world health organization's age-friendly cities model does not explicitly consider the role of technology [1, 42] . by adopting a lens of age-friendliness, studies like ours can ensure that methods and processes are rooted in opportunities, concerns and 'gaps' that are relevant and engaging to participants. consequently, we put forward an amended definition that highlights the need for explicit and thoughtful consideration of the role of technology in an age-friendly setting: underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical, social and digital environments and its supporting infrastructure. another contribution of our work comes from its findings about the potential for technology to contribute to building and strengthening connections in geographically-bounded communities. the combination of shared local concerns and opportunities for improving connections, combined with the knowledge that technology was infrequently used to sustain or support local connections, suggests this is a design space worth exploring. participants in this study were comfortable using digital technology to stay in touch with friends and family in geographically distant locations, particularly to maintain close family connections. kharicha et al. also found that engagement with the outside world by landline telephones and computers was an important strategy adopted by older people experiencing loneliness [43] . for this reason, it would seem plausible that technology to facilitate local, proximate, connections and social lives would also be acceptable, should it fill perceived gaps and not lead to unacceptable levels of additional effort. the methods we used in the workshop were intended to encourage 'playful' creativity, and they were successful in their purpose of generating a wide range of ideas as well as being acceptable and enjoyable for participants. in future, we would consider adapting these methods to reduce their paper-based nature, further enhancing their potential for prompting creative thinking by participants. exploring options beyond face-to-face participation may also be important in the context of covid-19 and its aftermath. drawing the interview findings together with one sub-theme from each of the themes we used to organise the ideas generated by workshop participants, we suggest a number of ways in which technology might support greater face-to-face connection in local community contexts and operationalise local people's ideas. by deliberately not placing technology in the foreground in the workshop, we contend that participants' ideas (technological or otherwise) about how to tackle local issues are more likely to align with their own values and perceptions, meaning that any technological needs that arise from these suggestions will be filling 'gaps' rather than technology being introduced as the automatic interface in connection. we maintain that design processes and spaces should be context-specific and bottom-up, but summarise general implications that offer scope for further exploration and consideration in community settings. workshop participants expressed interest in re-purposing spaces in the local area that they felt were underused, or offered potential as social spaces. this ranged from using existing green spaces or buildings on a permanent or temporary basis, to creating new spaces and places for social activities and events. a real-life example of creative use of space by older people that challenges expectations and norms was the transformation (for one night only) of a nightclub in manchester, uk, into a night-time venue reserved for older people [44] . in our study, there were suggestions that spaces could be acquired or managed by groups of local residents as cooperative initiatives. such work is ongoing in virtual spaces by older people in the uk creating a radio network [45] . other adaptations to the built environment were also suggested by participants to improve suitability for pedestrians. however, operationalising these ideas and coordinating the input of the local community presents challenges at many levels. while online platforms to facilitate community commissioning of digital services exist [46] , it is not immediately clear that these tools and processes would translate to local community commissioning of resources and events. moreover, it is unrealistic to expect the required intense interaction with such digital platforms, leading to the need for alternative situated means of participating and engaging in the processes. given the interest by study participants in leveraging local infrastructures and spaces, it is plausible to consider situated artefacts that would mediate between local, physical, and online engagements. for example, postervote is an innovative electronic polling system aiming to provide easy electronic voting for communities [47] . a traditional poster is augmented with buttons that can be pressed by community members to register digital responses to questions on the poster. providing infrastructure for residents to have greater input and control over the provision of their immediate local environments would facilitate their participation in the process of age-friendliness at a community level. while our workshop focussed on connections at a local i.e., electoral ward level, some discussions were about connecting with people who were located very close nearby or even physically 'connected' by living on the same street. in fact, two participants expressed surprise on discovering that they had both been living in the area for many years a few houses apart on adjacent streets, yet they had never interacted before. concerns about safety, privacy and possible lack of interest by others were mentioned as barriers to interventions at a street level. in recent years, we have witnessed a surge in location-based and serendipitous dating/meet-up services and networks (i.e., tinder [48] ). the core functionalities of these technologies are the abilities to discover similar individuals in your local area; privately extend an invitation to initiate a conversation; whilst maintaining a degree of privacy and safety through the network's services (not revealing personal details such as address or phone number). such solutions would have scope to support the hyper-local match-making of friendships within communities. however, our research showed that participants were not using existing online services designed to develop new relationships, indicating that these did not appeal. this is echoed by findings that older people who were lonely did not report using the internet to cultivate new friendships, despite using telephones and computers to engage with the outside world [43] . in fact, one participant, deborah, had instead capitalised on the ability of an accommodation matching platform to facilitate face-to-face interactions in her home with strangers, who then had the potential to become friends. the opportunity for such encounters (through mutually beneficial financial, or other resource, transactions) to result in long-lasting friendships is an area for further exploration. in particular, it would be interesting to consider how these types of interaction could be translated into a purely local context, given that deborah's formation of new friendships contrasts with experiences of those in our study who attended regular local activities but did not find them conducive to making friends. the findings from our study indicate an opportunity for design around community or cooperative ways of addressing local transport gaps. a number of ideas generated by workshop participants related to improving transport in the immediate local area in order to facilitate connection to physical spaces and locations to meet other people. community or cooperative initiatives were suggested as one option, or mechanism, for driving new models of transport in the area. volunteer-run minibus and car transport did exist in the local area, but these prioritised 'essential' travel such as hospital appointments and did not have the flexibility that participants thought important. while existing schemes (e.g., streetbank [49] -a website that facilitates possession sharing and borrowing between neighbours) have been successful in meeting other needs at a very local level, hyper-local journeys in suburban communities outside busy city centres are unlikely to offer sufficient cost/profit ratios to be attractive to existing sharing economy or peer-to-peer services such as uber. a small number of demand responsive transport (drt) schemes are running in the uk, and in theory sound promising. however, it is notable that a drt service actually operated in our study area in the past, but closed in 2011 [50, 51] . similarly, existing bicycle sharing schemes rely on scale of use within large communities or cities to remain profitable, but in contrast, restricted access to a smaller population might reduce the risk of damage and loss experienced by larger scale operations. consideration of what a hyper-local transport system might look like would include questions about who might provide and use the service, and what their incentives would be. participants in this study also suggested teaching, learning and training opportunities as potentially playing a role. this is another avenue for exploration in future technology design which could serve the dual purposes of creating new connections between those learning and teaching, as well as the transport itself facilitating connections between people living in the area. our study adopted an age-friendly, bottom-up approach to explore opportunities for facilitating social connectedness for older adults in a local community context. we focused on specific community issues that could be addressed and considered the physical, social and structural mechanisms (potentially mediated or supported by technology) that might offer routes to tackling these. by understanding more about our participants' current use and perspectives on the role of technology in their social lives, we highlight a need for design work to reduce emphasis on technology as the interface between people. in contrast to previous work, we focus on connection between people in geographically close locations. we also demonstrate the importance of understanding the specific local context within which any technological interventions will take place. our findings reflect changing patterns of technology use among older adults in the uk, suggesting that adoption of new technology is acceptable when it fills gaps and does not create intrusive levels of additional work or contribute to disconnection. our modified definition of age-friendliness highlights a need for the explicit and thoughtful consideration of the role of technology. we identify topics for consideration by those seeking to design with local communities, and make the case for an age-friendly approach to designing (digital) interventions to address social connectedness in later life. world health organization. global age-friendly cities: a guide; world health organization what makes a community age-friendly: a review of international literature exploring the age-friendliness of purpose-built retirement communities: evidence from england evolving images of place in aging and 'aging-in-place how should we tackle the loneliness epidemic is loneliness a health epidemic lonely older people as a problem in society-construction in finnish media prime minister's office; office for civil society; the rt hon theresa may mp. pm commits to government-wide drive to tackle loneliness the firekeepers: aging considered as a resource never too old older voices: supporting community radio production for civic participation in later life researching age-friendly communities: stories from older people as co-investigators an age-old problem: examining the discourses of ageing in hci and strategies for future research friends or frenemies? the role of social technology in the lives of older people an investigation into the patterns of loneliness and loss in the oldest old-newcastle 85+ study being alone in later life: loneliness, social isolation and living alone the high cost of isolation the social connectedness of older adults: a national profile the importance of social connectedness in building age-friendly communities assistive technology, computers and internet may decrease sense of isolation for homebound elderly and disabled persons ethnographic research on the experience of japanese elderly people online tales of the map of my mobile life: intergenerational computer-mediated communication between older people and fieldworkers in their early adulthood multimodal computer-mediated communication and social support among older chinese internet users desiring to be in touch in a changing communications landscape tsunagari-kan" communication: design of a new telecommunication environment and a field test with family members living apart keeping in touch: talking to older people about computers and communication older people's use of social network sites while participating in local online communities from an ethnographical perspective age-friendly cities and communities: a manifesto for change ageing in urban environments: developing 'age-friendly' cities the who global network of age-friendly cities and communities: origins, developments and challenges. in age-friendly cities and communities in international comparison interviewing for social scientists office for national statistics research interviewing: context and narrative using thematic analysis in psychology les villes amies des aînés au québec: un mouvement de changement à large échelle en faveur des aînés experiences of place and neighbourhood in later life: developing age-friendly communities not for me: older adults choosing not to participate in a social isolation intervention who doesn't think about technology when designing urban environments for older people? managing loneliness: a qualitative study of older people's views an alternative age-friendly handbook later life audio and radio network proceedings of the 2016 chi conference on human factors in computing systems good practice guide: transport and social inclusion we thank all participants who took part in this research. our appreciation also goes to cathrine degnen for her involvement in the design, planning and acquisition of funding for the study, and to drake long, meena nanduri and marlo owczarzak for their support in facilitating the workshop. the authors declare no conflict of interest. key: cord-278423-tluo3ztc authors: strozza, cosmo; pasqualetti, patrizio; egidi, viviana; loreti, claudia; vannetti, federica; macchi, claudio; padua, luca title: health profiles and socioeconomic characteristics of nonagenarians residing in mugello, a rural area in tuscany (italy) date: 2020-08-15 journal: bmc geriatr doi: 10.1186/s12877-020-01689-3 sha: doc_id: 278423 cord_uid: tluo3ztc background: health, as defined by the who, is a multidimensional concept that includes different aspects. interest in the health conditions of the oldest-old has increased as a consequence of the phenomenon of population aging. this study investigates whether (1) it is possible to identify health profiles among the oldest-old, taking into account physical, emotional and psychological information about health, and (2) there are demographic and socioeconomic differences among the health profiles. methods: latent class analysis with covariates was applied to the mugello study data to identify health profiles among the 504 nonagenarians residing in the mugello district (tuscany, italy) and to evaluate the association between socioeconomic characteristics and the health profiles resulting from the analysis. results: this study highlights four groups labeled according to the posterior probability of determining a certain health characteristic: “healthy”, “physically healthy with cognitive impairment”, “unhealthy”, and “severely unhealthy”. some demographic and socioeconomic characteristics were found to be associated with the final groups: older nonagenarians are more likely to be in worse health conditions; men are in general healthier than women; more educated individuals are less likely to be in extremely poor health conditions, while the lowest-educated are more likely to be cognitively impaired; and office or intellectual workers are less likely to be in poor health conditions than are farmers. conclusions: considering multiple dimensions of health to determine health profiles among the oldest-old could help to better evaluate their care needs according to their health status. aging". this has been performed extensively among less older people in recent decades. however, as a consequence of the increasing number of oldest-old people in western societies and their health characteristics and needs, it is only in recent years that studies focusing on the oldest-old have been conducted, aiming to understand the potential drivers of good health conditions at extremely old ages [6] [7] [8] [9] [10] . these studies have always focused on a specific dimension of health, such as cognition, physical and functional status or morbidities. however, health care needs are the result of a complex system of diseases, syndromes or health characteristics that cannot be described by a single dimension of health [11] [12] [13] [14] . to consider the multidimensionality of individual health status, it is necessary to exploit a personcentered approach that is based not on the relationships among variables but rather on the characteristics of the individuals. this approach allows people to be distinguished into groups by taking only their individual characteristics into account [11, 13] . to capture the heterogeneity of health status and evaluate the social disparities among individuals, researchers suggest the use of latent class analysis (lca) as a person-centered approach [11] [12] [13] . lca is a subset of structural equation modeling suitable for addressing multidimensional concepts, as in the case of health, to find groups of cases with similar characteristics in multivariate categorical data. the use of lca in population health studies is extensive, with applications that vary from younger [15] to older individuals and elderly people [12] [13] [14] [16] [17] [18] [19] [20] [21] [22] [23] [24] . some scholars used this approach to identify profiles of health by considering functional, cognitive and psychological indicators [12-14, 16, 17, 22] , with some evaluating socioeconomic differences among the health profiles [12, 13, 17, 22] and others predicting the health care expenditures of people belonging to different groups [14, 16] . other researchers have applied a personcentered approach to identify profiles within a single aspect of health, such as morbidities [15, 19, 25] , physical status [21] , and depression [20] , by considering several outcomes of the same health dimension. according to the existing literature, lca could be used to identify groups of individuals requiring specific forms of health care and to predict their health care needs and expenditures. this approach could also help policymakers understand which groups of people to target with their interventions. the recent covid-19 pandemic has again highlighted, especially in italy, how vulnerable people are, such as the oldest-old and multichronic patients, which are groups that merit greater health policy focus [26] . it is also well documented that among elderly adults, demographic and socioeconomic characteristics influence health status and, consequently, health care needs and utilization [13, 27, 28] . fewer researchers have evaluated this relationship among extremely old people, suggesting the persistence of social disparities in health, even in the last stages of life [29] . gender, education and income were found to be associated with different health outcomes among the oldest-old individuals, prompting further investigation in this direction [6, [29] [30] [31] [32] . evaluating the existence of a demographic and socioeconomic gradient in health among the oldest-old population could drive the attention of policymakers toward people who need interventions. despite the recognized advantage of using a personcentered approach for capturing the heterogeneity of health among elderly people, there is still not much evidence relating to health profiles among the oldest-old and the extremely-old populations [33] . to fill this gap in the literature, we analyzed data from the mugello study [34] , which included 504 nonagenarians from a rural area in tuscany (italy) called mugello. our aim is to determine whether it is possible to classify oldest-old people according to their multidimensional health status, defined by physical, cognitive and psychological health, to help in choosing the best care needed by this growing segment of the population. furthermore, we investigate whether there are demographic and socioeconomic differences among their health profiles, fueling the debate on social disparities in health in the last stages of life. the study population comes from the mugello study [10] , which aimed to evaluate the aging process, focusing on different health aspects among nonagenarians living in 9 of the 11 municipalities of the mugello area in tuscany (italy). it comprised 504 individuals representing approximately 65% of all nonagenarians living in that geographical territory in 2012. the participation rate was 69% after the exclusion of potential participants who died before being interviewed or who were not found. more information about the study design and survey methods is available in molino-lova et al. [10] . much information about the individual health conditions of nonagenarians has been collected. for some of the health tests, it was not possible to assess the health status of several patients. individuals who were not tested due to their (very) poor health conditions were categorized as nontestable. being nontestable is considered the worst health condition for each of the variables, including this category. variables have been categorized according to the existing literature. cognitive function was measured according to the mini-mental state examination (mmse): the higher the score (0-30), the better the cognitive status is [35] . mmse scores were divided into three categories to distinguish people with severe (0-17), mild (18) (19) (20) (21) (22) (23) , and no cognitive impairment (24) (25) (26) (27) (28) (29) (30) [36] . functional status was assessed according to the ability to perform five of the activities of daily living (adls) (eating, dressing, bathing, toileting, transferring) [37] . the number of adls that people could manage independently was used to distinguish between the non-(0), semi-(1-4), and fully-autonomous (5) oldest-old individuals [38] . mugello's nonagenarians were classified as disease-free (0), single-disease (1), and comorbid (2+) according to the number of chronic diseases (cardiovascular, neurological, pulmonary, connective tissue, gastroenterological, endocrine, renal, oncological, immunodeficiency syndrome) reported. the geriatric depression scale (gds) was used to evaluate depression status: the higher the score (0-15), the higher the level of depression is [39] . gds scores were divided into three categories to distinguish nondepressed (0-4), depressed (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) , and nontestable individuals [40] . self-rated health status was assessed using the italian version of the short form-12 questionnaire (sf-12) from which it was possible to obtain the two synthetic indicators combining the 12 items together: the physical and mental component summaries (pcs and mcs) [41] . the pcs and mcs were divided into three categories: those who scored higher (or equal) than the average were considered to be in good health, those who scored lower than the average were considered to be in poor health, and nontestable individuals were considered to be in the worst health. it was also possible to obtain the global self-rated health (srh) of the individual from the sf-12, according to the first item of the questionnaire (in general, you would describe your health status as…). it was divided into three categories to distinguish among nonagenarians declaring excellent/very good/good health, declaring acceptable/poor health and being nontestable. the results are controlled for age (90-91, 92-94, 95+), gender, education (0-2, 3, 4-5, 6+ years of education), and main occupation during the working lifespan defined according to the italian national institute of statistics (istat) classification of jobs [42] : farmer; housewife; and low-skilled (laborer or unskilled worker) or mediumskilled (office, industry or intellectual worker) work. health is a complex state involving different aspects or dimensions. to capture the heterogeneity of the health status among the oldest-old individuals, we supposed that mugello's nonagenarians could belong to unobserved or latent classes according to their health characteristics. for this purpose, we chose lca, which aims to group individuals into classes according to their indicator patterns. each class includes individuals with similar characteristics that nonetheless differ from the characteristics of those in other classes. lca was used to identify different health profiles according to the health condition through the variables described in the previous paragraph, controlling for demographic and socioeconomic characteristics. lca with covariates is an extension of the basic lca, permitting the inclusion of covariates to predict an individual's latent class membership [43, 44] . we performed the lca twice, including the same variables: once on the whole study population and once on the subsample of testable individuals. since we expected to obtain in the first analysis a group populated by only nontestable individuals, we excluded those people in the second analysis to capture more heterogeneity in health status for the remaining oldest-old individuals. the effect of the covariates has been estimated with the "onestep" technique to obtain less biased coefficients: they are estimated simultaneously as part of the latent class model [45, 46] . suppose a latent class model with c classes is to be estimated according to m categorical variables and a covariate x. let y i = (y i1 , …, y im ) be the vector of an individual's response to the m variables, where y im = 1, 2, …, r m . let c i = 1, 2, …, c is the latent class membership of the individual to the class; let i(y = k) be the indicator function that is 1 if y is equal to k and 0 otherwise; and let λ be the probability of membership in each latent class. then, the latent class model can be expressed as follows: is a standard baseline category for the multinomial logistic model. in the case of one covariate, λ can be expressed as the following: where c is the reference class in the logistic regression. as a result, the log-odds of an individual falling into latent class c relative to the reference class c, giving x i as the value for the covariate, is the following: multiple imputation was necessary to address missing values (missing at random (mar)) to avoid a loss of precision in the analysis. the k-nearest neighbor imputation method has been used for its high performance with survey data [47] . to obtain unbiased results, neighbors are found considering all the variables available in the dataset except those that are included in the models. five neighbors were considered to calculate the aggregated values to impute. education, main occupation during the working lifespan, mmse score, adls performed, number of chronic diseases, pcs and mcs were imputed. none had more than 7% missing values. more information about data imputation is included in table s1 in additional file 1. statistical analysis was performed using r version 3.5.0 [48] , vim [49] , and the polca package [46] . the 504 participants included a high number of women (369); the female/male sex ratio of 2.73 confirms the higher longevity of women. the mean age ± standard deviation was 93.1 ± 3.3 in the whole study population: the men's mean age (92.5) was lower than the women's mean age (93.3; t-test p = 0.01). men were more educated (64.5% of males vs 46.1% of females completed more than 3 years of school) but performed more physical jobs: 80% of males vs 52.6% of females were farmers or low-skilled workers. overall, men had better scores on all the health measures considered in the analysis. this result is partially explained by the sex-specific age structure of the study population. large gender differences were found in cognitive and functional status (60.7% of males vs 37.1% of females were not cognitively impaired; 61.5% of males vs 43.6% of females were autonomous). the gap in the remaining health measures is mainly due to the larger number of nontestable women (table 1) . three latent classes were found when both the whole study population and the subsample of testable individuals were considered. this number was chosen according to the "meaning" of the classes, together with the akaike information criterion (aic) and the bayesian information criterion (bic), whose values are shown in table 2 . every latent class has been labeled according to the posterior probabilities (λ) of finding a certain characteristic in the class, as shown in table 3 . lca performed on the whole study population resulted in three health profiles. the first class is characterized by a high probability of being autonomous (λ = 0.89), not depressed (λ = 0.81), not cognitively impaired (λ = 0.78), perceiving good srh (λ = 0.92), and having values of pcs and mcs higher than or equal to the average (respectively, λ = 0.73 and 0.65). this class, labeled the "healthy group", includes 215 individuals (42.9% of the whole study population). the second class is characterized by a high probability of being semi−/not autonomous (respectively, λ = 0.47 and 0.44), cognitively impaired (λ = 0.97), and not testable for depression (λ = 0.97) and srh (λ = 1); consequently, pcs and mcs were not testable (λ = 1 for both indicators). this class has been labeled the "severely unhealthy group". it includes 110 individuals (21.8% of the whole study population), which encompassed almost all nontestable nonagenarians according to the scales in analysis that included this category (srh, depression, pcs and mcs). the third class includes nonagenarians with a high probability of being semiautonomous (λ = 0.72), mild/severely cognitively impaired (respectively, λ = 0.32 and 0.40), depressed (λ = 0.74), and having pcs and mcs scores lower than the average (respectively, λ = 0.74 and 0.66). despite how they performed in the objective health measures, they frequently declare a better health status: λ = 0.43 for declaring good srh conditions is relatively high (poor srh: λ = 0.57). for this reason, the last class, composed of 179 (35.3%) individuals, has been labeled the "partially satisfied unhealthy group". lca performed on the subsample of testable individuals also resulted in three health profiles. the first class is characterized by a high probability of being autonomous (λ = 0.88), not depressed (λ = 0.82), not cognitively impaired (λ = 0.83), reporting good srh (λ = 0.91), with pcs and mcs scores higher than or equal to the average (respectively λ = 0.71 and 0.67). this class has been labeled the "healthy group". it includes 202 individuals (53% of the testable subsample) who were almost the same individuals populating the "healthy group" resulting from the first analysis. the second class is characterized by a high probability of being semiautonomous (λ = 0.7), depressed (λ = 0.81), and reporting poor srh (λ = 0.74), with pcs and mcs scores lower than the average (respectively λ = 0.91 and 0.65). this group of 128 individuals (33.3% of the testable subsample) has been labeled the "unhealthy group". the third group is characterized by a high probability of reporting good srh (λ = 1) and being semiautonomous (λ = 0.60), mild/severe cognitive impairment (respectively λ = 0.43 and 0.48), with mcs scores lower (λ = 0.74) but pcs scores higher than or equal to the average (λ = 0.88). posterior probabilities for depression are similar: λ = 0.43 not-depressed vs λ = 0.57 depressed. this group was labeled "physically healthy with cognitive impairment". it included 55 nonagenarians (13.7% of the testable subsample). all the posterior probabilities are reported in table 3 . the first class has been labeled the "healthy group" in both analyses: posterior probabilities followed a similar pattern, especially in terms of (good) health status items, as shown by the black and white circles in fig. 1 . the second class of the analysis on the whole study population was named the "severely unhealthy group" (see black squares in fig. 1) . it was composed of almost all the nontestable nonagenarians: individuals in the worst health conditions. excluding the nontestables for the second analysis, many individuals populating the third class moved to the second, resulting in an "unhealthy group" with less extreme health characteristics. the consequence of this exclusion was more evident for the last (third) class obtained in both analyses. when considering all nonagenarians, we obtained the "partially satisfied unhealthy group", i.e., people mainly in poor health conditions but not always declaring poor srh. when excluding the nontestable nonagenarians, some of the individuals populating the third group obtained in the previous analysis moved to the second group in the second analysis. as shown in fig. 1 , the "partially satisfied unhealthy group" (first analysis) and the "unhealthy group" (second analysis) had similar posterior probabilities for the (good) health status indicators, especially in terms of functional and cognitive status. within the second analysis, 55 out of the 385 nonagenarians composing the "physically healthy with cognitive impairment group" had a higher probability of declaring good srh and obtaining a high pcs score than the "healthy group", but they had poor cognitive health, sometimes had depression and were mainly semiautonomous nonagenarians. the results are controlled for age, gender, education, and main occupation during the working lifespan (table 4 ). in the analysis on the whole of mugello's nonagenarians, older individuals and housewives are more likely to be part of the "severely unhealthy group" instead of the "healthy group" (92-94 vs 90-91: odds ratio (or) = 2.69; 95+ vs 90-91: or = 7.25; housewives vs farmers: or = 2.19), while being more educated reduces these odds (4-5 vs 3 years of education: or = 0.49; 5+ vs 3: or = 0.08). being older also increases the odds of empty items are due to the subsampling: not testable individuals are not included in the second analysis for both analysis 1: "healthy group"; respectively 2: "severely unhealthy group" and "unhealthy group"; and respectively 3: "partially satisfied unhealthy group" and "physically healthy with cognitive impairment group" to identify health profiles among nonagenarians from mugello (tuscany -italy), lca was performed twice: first on the whole study population and then on the subsample of testable individuals, with nonagenarians in the "extreme" (worst) conditions having been excluded from the analysis. removing these individuals from the analysis allowed us to capture more heterogeneity of health among the remaining oldest-old, especially among those with poor health that were hidden by the nontestable individuals. in both analyses, three classes were identified, resulting in a total of four different health profiles within the two lcas performed, each labeled according to the posterior probabilities of finding certain health characteristics in them. other researchers who looked at health profiles among elderly people by considering their physical, cognitive and psychological status found two to six classes [11-13, 17, 22] . in particular, other researchers could distinguish between a larger number of classes (four to six) [11, 13, 17, 22] , except for ng et al. (2014) , who identified only two profiles [12] . the fact that we found four health profiles within the two analyses means that, even at extremely old ages, there is still heterogeneity in the health conditions of the individuals. lca allowed us to take into account the multidimensionality of health by including several health measures in the analysis. having a larger study population could have helped to find the four profiles within a single lca. the "healthy group" (a), identified in both analyses and composed of almost the same individuals, and the "unhealthy group" (c), resulting from the second analysis, are consistent with other scholars' findings among younger adults, including information on sensory health and specific chronic diseases [11, 16] or quality of life and wellbeing [17] . additionally, among nonagenarians, it was possible to find the two extreme groups of people in overall good and poor health. the "severely unhealthy group" (b), resulting from the first analysis, confirms that nontestable individuals are a stand-alone group of fig. 1 (good) health status item probabilities (λ) per health status resulting from the two latent class analyses (lcas). note 1: class 1: "healthy group", for both first (a) and second (b) lcas; class 2 for lca-a: "severely unhealthy group", for lca-b: "unhealthy group"; class 3 for lca-a: "partially satisfied unhealthy group", for lca-b: "physically healthy with cognitive impairment group". note 2: adls: activities of daily living; mcs: mental component summary; pcs: physical component summary; positive self-rated health: excellent/very good/good self-rated health people who, because of their extremely bad health conditions, cannot be tested on their health status. the "physically healthy with cognitive impairment group" (d), i.e., individuals with good self-rated health and physical condition but bad cognitive status, is similar to what lafortune et al. (2009) called the "cognitively impaired group" in their paper on the canadian elderly, where the authors did not include information on the perception of health [11] . however, this result is at odds with what zammith and colleagues found in 2012, in terms of selfperceived health, among the lothian birth cohort 1936 "good fitness/low spirit group" [11, 17] . it is known that one of the factors influencing the assessment of health among italian elderly people is their physical status [50] . it is possible that, even at extremely old ages, physical health plays an important role in the self-assessment of health status. however, this could also be the result of the poor cognitive status of individuals populating the "physically healthy with cognitive impairment group". certain demographic and socioeconomic characteristics were found to be associated with being part of some of the latent classes found. in this study, it is not possible to evaluate the health deterioration itself, but even at extremely old ages, being older results in having a higher probability of being in worse health. this suggests the need for further investigation on the health deterioration process among the oldest-old as it is commonly performed on the younger-old [51] [52] [53] . males have a lower probability of being in worse general health conditions, confirming the so-called "gender paradox" also exists among the oldest-old: men are healthier than women at older ages [6, 29, 31, 54] . the level of education is known to be associated with cognitive health in later life. researchers analyzing english and finnish nonagenarians show how this relationship still persists at extremely old ages [29, 32, 55] . in the present study, more educated nonagenarians are less likely to belong to an "unhealthy group", while being less educated increases the probability of being among the cognitively impaired. these results are similar to those found in younger-elderly profiles [12, 13] . working experience is also associated with health conditions, showing different results. in line with the existing literature, a person who was a nonmanual (office) worker had a lower probability for both analysis 1: "healthy group"; 2; respectively 2: "severely unhealthy group" and "unhealthy group"; and respectively 3: "partially satisfied unhealthy group" and "physically healthy with cognitive impairment group" of being in bad health condition at older ages compared to someone who worked as a farmer [56, 57] . housewives were more likely to be in the worst health conditions, similar to study findings among finnish nonagenarians [29] . this study has public policy implications that need to be noted. even among nonagenarians, individuals are heterogeneous in terms of health. to capture this heterogeneity by taking into account several dimensions of health, it is necessary to apply a suitable methodology. lca has been widely used for this purpose, and policy makers should take advantage of it to identify heterogeneous groups of individuals to target with their interventions [11] [12] [13] [14] . analyzing different health dimensions at the same time allowed us to distinguish between the most vulnerable individuals with several health problems and those individuals with dimension-specific health deficits. according to our results, it is likely that people with poor physical health also have cognitive impairment, resulting in complex care needs. however, cognitively deteriorated individuals may be in good physical and functional status, requiring a different (specific) type of health assistance. furthermore, health profiles were associated with socioeconomic status, showing that even among the oldest-old, the well-known socioeconomic gradient of health persists. as pointed out by ng et al. (2014) , this should suggest policy makers drive their interventions to the less advantaged groups of the population [12] . other researchers evaluated the health care needs and expenditures among taiwanese elderly people [14, 16] , showing how they differ among the health profiles that they identified. being able to distinguish between groups of people with different health care needs is extremely important for reducing the excess of health expenditure that may result from not considering it holistically [11] . this study has limitations that need to be noted. it is based on a cross-sectional dataset: health characteristics have been collected only once. for this reason, we were not allowed to study the causal relationship between sociodemographic characteristics and health status and profiles. furthermore, much of the information about health status is self-reported, and cutoff points -chosen according to the existing literature -did not equate to a clinical diagnosis. thus, it would be useful to verify their veracity with objective measures. finally, it is important to remark that mugello's nonagenarians are a selected group of individuals in terms of health and mortality. living in a rural area and following a mediterranean diet is, for instance, something that affects this selection. large samples of nonagenarians, for which much information has been collected about their health status, are still rare to find. considering health as a multidimensional concept by identifying health profiles could help to better evaluate the care needs according to the different health profiles of each person, even among extremely old individuals [16, 58] . the demographic and socioeconomic gradient of health resulting from the analysis suggests that policy makers focus their interventions on specific groups of individuals at younger ages to prevent an excess of health care expenditure later on. supplementary information accompanies this paper at https://doi.org/10. 1186/s12877-020-01689-3. additional file 1: table s1 . marginal distribution pre-and post-missing values imputation of characteristics of the study population. absolute values, percentages and differences. srh: self-rated health; who: world health organization cs, pp contributed equally to the conception of the study. cl, fv, cm, lp contributed to data acquisition. cs, pp, ve contributed to the data analysis and the interpretation of the results. all authors contributed to the drafting of the study. all authors read and approved the final manuscript. all authors agreed on both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. the mugello study was partially supported by the italian ministry of health within the current research program performed at national research institutes (irccs). the authors received no financial support for the research, authorship, and/or publication of this article. the data that support the findings of this study are available from mugello study but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. data are however available from the authors upon reasonable request and with permission of mugello study. ethics approval and consent to participate the mugello study was conducted according to the helsinki declaration on clinical research involving human subjects and was approved by the don carlo gnocchi foundation ethics committee. informed written consent was obtained from all the participants, or their proxies, before their inclusion in the study. further details on the survey, including information on the territory and inhabitants, are available on the web (www.mugellostudy.com). not applicable. world 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questionario sullo stato di salute sf-12. versione italiana. milano ist ric farmacol mario negri concomitant-variable latent-class models applied latent class analysis estimating latent structure models with categorical variables: one-step versus three-step estimators polca: an r package for polytomous variable latent class analysis nearest neighbor imputation for survey data r: the r project for statistical computing imputation with the r package vim the latent dimensions of poor self-rated health: how chronic diseases, functional and emotional dimensions interact influencing self-rated health in italian elderly transitions between states of disability and independence among older persons multi-state analysis of cognitive ability data: a piecewise-constant model and a weibull model understanding health deterioration and the dynamic relationship between physical ability and cognition among a cohort of danish nonagenarians the contribution of diseases to the male-female disability-survival paradox in the very old: results from the newcastle 85+ study predicting risk of cognitive decline in very old adults using three models: the framingham stroke risk profile; the cardiovascular risk factors, aging, and dementia model; and oxi-inflammatory biomarkers heterogeneity in multidimensional health trajectories of late old years and socioeconomic stratification: a latent trajectory class analysis socio-economic position and subjective health and well-being among older people in europe: a systematic narrative review ageing and health springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the mugello study working group also includes: guglielmo bonaccorsi, roberta boni, chiara castagnoli, francesca cecchi, francesca cesari, francesco epifani, roberta frandi, betti giusti, maria luisa eliana luisi, rossella marcucci, raffaello molino-lova, anita paperini, lorenzo razzolini, francesco sofi, nona turcan, debora valecchi. the authors declare that they have no competing interests.author details 1 interdisciplinary centre on population dynamics, university of southern denmark, j.b. winsløws vej 9b, 2nd floor, 5000 odense c, denmark. key: cord-317519-yhzv2yjs authors: barzilai, nir; appleby, james c; austad, steven n; cuervo, ana maria; kaeberlein, matt; gonzalez-billault, christian; lederman, stephanie; stambler, ilia; sierra, felipe title: geroscience in the age of covid-19 date: 2020-07-23 journal: aging dis doi: 10.14336/ad.2020.0629 sha: doc_id: 317519 cord_uid: yhzv2yjs the data on covid-19 is clear on at least one point: older adults are most vulnerable to hospitalization, disability and death following infection with the novel coronavirus. therefore, therapeutically addressing degenerative aging processes as the main risk factors appears promising for tackling the present crisis and is expected to be relevant when tackling future infections, epidemics and pandemics. therefore, utilizing a geroscience approach, targeting aging processes to prevent multimorbidity, via initiating broad clinical trials of potential geroprotective therapies, is recommended. multiple age-related chronic diseases at the same time. geroscientists have long hypothesized that by targeting the biology of aging, all diseases of aging can be delayed [3] . hallmarks of aging have been established and shown that they are all interconnected, thus targeting any single hallmark results in improvements in others [4, 5] . in animal preclinical studies, health span and life span have been dramatically increased by targeting those hallmarks, using genetic tools and drugs, demonstrating that aging is a modifiable condition [6, 7] . of particular importance are the hallmarks of immune dysfunction underlying the vulnerability of older adults to infections and the inflammation which accounts for the response to those infections [8] . but beyond improving immunity and inflammation to younger levels, such approaches also increase individuals' resiliency to withstand the sickness itself, as the whole body needs to respond to this major stressor. older people are at such risk in part because the vigor of our immune response flags as we age. in addition to age, many of us are also weakened by coexisting age-related conditions that diminish our resilience further. so, until a vaccine or treatment becomes available, how do we defend ourselves from infection beyond physical distancing and careful hand washing? we can focus on eating well, exercising as regularly as possible (at home and even in increasingly confined long-term care facilities), managing our stress, and getting enough sleep behaviors we know help improve our immune responses at any age. public health interventions that ensure access to healthy foods and safe environments are also critical. in addition to this healthy lifestyle, interventions with existing drugs with established safety profiles that target the biology of aging, immune mechanisms and resiliency (i.e. "geroprotectors" or "gerotherapeutics"), should be explored. while many geroprotectors have been successfully tested in pre-clinical settings, to date none of them has been approved as geroprotectors for use in humans. consequently, self-medication with any of these compounds is highly discouraged. one such drug is metformin which has been shown to target multiple hallmarks of aging [9] and increase health span and life span in animals. in addition, both clinical and observational trials in humans show that the use of this drug is associated with less type 2 diabetes mellitus (t2dm), cardiovascular diseases, cancer, cognitive decline and overall mortality [10] . previous research from as far back as the 1940s, however, has pointed to metformin and metformin-like biguanide drugs as preventing influenza [11] and increasing in vivo and in vitro immune response in humans [12] . it is the first line of treatment for t2dm with 60 years of experience, exceptional safety record and is both generic and cheap. metformin has already indicated protective capacity against covid-19. thus, in a retrospective analysis of 283 t2dm patients from wuhan, china, with confirmed covid-19, investigators found no difference in the length of stay in hospital, but persons taking metformin had significantly lower in-hospital mortality (3 of 104, 2.9%) than those not taking metformin (22 of 179, 12.3%) [13] . moreover, it was reported that diabetic women on metformin had ~20% decrease in mortality and ~80% decrease in the inflammatory marker tnfα [14] . a second line of drugs are mtor inhibitors, which have been shown to increase healthspan and lifespan in almost all animals tested, from yeast to rodents. the mtor inhibitor rapamycin reverses age-related declines in influenza vaccine response in mice [15] and two phase 2 clinical trials completed by restorbio inc. showed that the rapamycin derivative everolimus could enhance influenza vaccine response in healthy elderly people [16, 17] . the second phase 2 trial also reported that those treated with mtor inhibitors for 6 weeks had significantly fewer respiratory tract infections over the next year compared to those that received the placebo [17] . thus, it appears that short-term inhibition of mtor may confer protection not only against the flu, but also other common viruses including other coronaviruses. given the current public health crisis that is disproportionately affecting our aging population, it is imperative that we start discussing pragmatic approaches to rapidly implement the testing of such drugs in the face of the covid-19 pandemic and an aging global population. at this stage, broad clinical trials of potential geroprotective therapies are needed, to enable extensive data collection and analysis of their potential benefits and indications. development and use of drugs like rapamycin and metformin by the at-risk population, notably older adults, may confer broad health benefits by targeting multiple aspects of biological aging and in this way raise the chances that these people can ward off the worst effects of covid-19. metformin for example is already used chronically by more than 100 million people around the world today. metformin is broadly available and low-cost (just a little more than $.10/day). it should be tested rapidly to allow even a small percentage of older people to avoid hospitalization and death from covid-19. the absolute benefits will be substantial. rapamycin has also been used clinically for many years with a wellestablished dosing and safety profile. while significant side effects are associated with high-doses in patients undergoing daily rapamycin treatment, there is accumulating evidence that lower-dose treatment with rapamycin or its derivatives has minimal side-effects in healthy individuals [18, 19] and may confer substantial improvements in immune function [16, 17] . randomized, controlled clinical trials to assess the ability of rapamycin, metformin and other potential geroprotective drugs [20] , to boost response to an eventual covid-19 vaccine in the elderly, as well as protect against covid-19 infection altogether, could have a substantial impact on survival in vulnerable populations and should be pursued. ongoing basic research on geroscience will produce a 'pipeline' into a whole raft of novel compounds that are being developed by biotech around the world. this may provide new insights into how we can modify the aging process and boost our immune response, perhaps even improving the performance of a vaccine for covid-19 whenever it becomes available. epidemiological data indicates that covid-19 is particularly aggressive among older adults. however, even within that group there is a large heterogeneity of response, with some individuals suffering severe effects and/or death, while others recover with little more side effects than those observed in younger cohorts. in fact, heterogeneity of response is a major characteristic of older populations [21] , which is why there is a need to identify those individuals, within an age cohort, that are physiologically younger or older than their chronological age. so, while a percentage of older adults are more robust than expected, so a fraction is more fragile. while no clear data exists yet in humans, those more fragile (i.e., physiologically older) are likely to be the ones who would most benefit from geroscience-based approaches to improve their health. just like there is heterogeneity among older adults, significant heterogeneity has been identified even among younger individuals [21] . it is likely that individuals who are chronologically young, but who display an advanced physiological age will also benefit from a geroscience approach. those include, among others, high-risk individuals such as those with additional multimorbidity in addition to sars-cov-2 infection, as well as those with previous events that leave sequalae, such as controlled-hiv infection, previous chemotherapy or radiation, the disabled, obese and even poor people who cannot modify their interactions with the environment. multimorbidities in general and old-age multimorbidities in particular have proven to be the main risk factors for bad outcomes in covd-19 patients [22, 23] . often, in older patients, multiple aging-related diseases are affected by multiple risk factors, further increasing the disability and mortality. therefore, there is an urgent need to develop and implement analytical methodologies that would allow a diagnostic evaluation of the contribution of several co-existing diseases to covid-19 outcomes. there is a need to identify either unique or combinatorial parameters to identify appropriate biomarkers, or risk factors for severity of disease in covid-19 patients. the ability to weigh risks from multiple diseases and their combinations may also have critical implications for healthcare and social policy, both during the current crisis and in planning for future emergencies. particular contributing factors that may be crucial for outcomes in elderly subjects, for better or worse, may include their drug medications, e.g. ace inhibitors [24] , vaccinations, vitamins and other supplements, and other interventions more prevalent in and differentially affecting the older persons. the effectiveness of specific therapeutic regimens and protocols (such as different modes of oxygen delivery and resuscitation, drugs, vaccines and adjuvants) need to be evaluated and adjusted specifically for older patients whose management may dramatically differ from younger subjects with critical implications for outcomes. the role of multimorbidities and interactions across diseases as synergistically affecting the outcomes should be addressed not only in retrospective analysis, but also when designing new experimental studies. this multimorbidity evaluation should be combined with a systematic assessment of the aging and frailty status, using standardized methods and measures. such standard methods and measures are needed to start creating prospective information on the differential vulnerability of older persons. strategies must be developed for periodic frailty assessment with continuous longitudinal follow-up of older persons which may reveal not only global determinants that are conserved, but also local singularities involved in differential aging health around the world. standard evaluation of biological and physiological age, with appropriate biomarkers, should be developed, both to assess and predict risks of agingrelated ill health and to evaluate the effectiveness of potential geroscience therapies [25] [26] [27] . wide public should be actively involved in such evaluation studies, not just as test subjects, but as active and empowered "citizen-scientists". there is a need to increase public science education in the field of geroscience to inform the public and enhance their ability to evaluate evidence. for the development and advantageous utilization of such evaluation methodologies, it is essential to improve access, openness, sharing and interoperability of clinical data on large cohorts of subjects, preferentially longitudinal data, including their clinical conditions and diseases (with or without covid-19), demographic characteristics, and a wide set of evaluation parameters, including biochemical, metabolic, immunological, physiological, functional and other parameters, most of which are routinely available both in clinical practice and experimental settings. the development and utilization of such methods, on large clinical datasets, will help establish the most significant risk factors and their combinations, for multiple age-related diseases, and their joint contribution to covid-19 outcomes, and facilitate recommendations for the effective combined therapy to mitigate covid-19 and its risk factors. the covid-19 global emergency has emphasized to vast masses of people the vital need to prevent old-age multimorbidity, protect the elderly and improve their health span. proponents of geroscience have argued for the importance of such preventive measures for many years. now we see in front of our own eyes the disastrous consequences of the deficit in such preventive measures, and the portent this gap in our approach represents for the future. we are witnessing how this new infectious disease is wreaking havoc among individuals, the healthcare system and the entire social fabric around the world, while the rapid aging of the population represents the main risk factor and aggravating condition. therefore, arguably, one of the most important lessons to be learned from this pandemic, is the need to therapeutically address degenerative aging processes to prevent aging-related ill health as a whole. this understanding should translate to public health and research policies supportive of geroscience research, development and clinical application [5, 28, 29] , improving the funding, incentives, education and institutional support for the field. with sufficient support and deployment, the preventive geroscience approach may help avoid or mitigate the effects of this and current devastating pandemics of aging-related ill health, presently and for the future. conquering the current pandemic will require a multipronged approach, including primarily an 'offensive' approach represented by the development of vaccines and treatments, as well as a 'defensive' approach focused on strengthening the resilience of affected individuals. importantly, the offensive part of our arsenal requires the urgent development of a new vaccine, curative and palliative treatments for each successive pandemic and epidemic confronting the world. this aspect of our approach is unfortunately both slow and specific to the currently relevant virus or pathogen. in contrast, the defensive arm proposed here is pathogenblind insofar as the interventions are pathogen independent. therefore, a geroscience-focused response to the covid-19 pandemic can be deployed not only against the current emergency, but the same approach will certainly be relevant to future infections, be them pandemic, epidemic, endemic, or even those affecting any one individual. characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention extending life: scientific prospects and political obstacles geroscience and the trans-nih geroscience interest group the hallmarks of aging geroscience: linking aging to chronic disease interventions to slow aging in humans: are we ready? healthy aging: the ultimate preventative medicine immunosenescence: emerging challenges for an ageing population benefits of metformin in attenuating the hallmarks of aging metformin as a tool to target aging metformin: historical overview metformin improves in vivo and in vitro b cell function in individuals with obesity and type-2 diabetes metformin treatment was associated with decreased mortality in covid-19 patients with diabetes in a retrospective analysis observational study of metformin and risk of mortality in patients hospitalized with covid-19 mtor regulation and therapeutic rejuvenation of aging hematopoietic stem cells mtor inhibition improves immune function in the elderly torc1 inhibition enhances immune function and reduces infections in the elderly a randomized control trial to establish the feasibility and safety of rapamycin treatment in an older human cohort: immunological, physical performance, and cognitive effects rapamycin for longevity: opinion article innate and adaptive immunity in aging and longevity: the foundation of resilience quantification of biological aging in young adults prevalence of comorbidities and its effects in patients infected with sars-cov-2: a systematic review and meta-analysis presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area renin-angiotensin-aldosterone system inhibitors in patients with covid-19 strategies and challenges in clinical trials targeting human aging recognizing degenerative aging as a treatable medical condition: methodology and policy measuring biological aging in humans: a quest the critical need to promote research of aging and aging-related diseases to improve health and longevity of the elderly population aging health and r&d for healthy longevity must be included into the who work program the scientific director of the american federation for aging research (nb), the nathan shock center of excellence for the biology of aging p30ag038072 (nb), american federation for aging research (sm), and glenn center for the biology of human aging paul glenn foundation grant (nb). key: cord-269716-x3b0qphd authors: hopper, lydia m.; jacobson, sarah l.; howard, lauren h. title: problem solving flexibility across early development date: 2020-08-26 journal: j exp child psychol doi: 10.1016/j.jecp.2020.104966 sha: doc_id: 269716 cord_uid: x3b0qphd cognitive flexibility allows individuals to adapt to novel situations. however, this ability appears to develop slowly over the first few years of life, mediated by task complexity and opacity. we used a physically simple novel task, previously tested with nonhuman primates, to explore the development of flexible problem solving in 2-, 3-, and 4-year-old children from a developmental and comparative perspective. the task goal was to remove barriers (straws) from a clear tube to release a ball. the location of the ball, and therefore the number of straws necessary to retrieve it, varied across two test phases (four of five straws and two of five straws, respectively). in test phase 1, all children retrieved the ball in trial 1 and 83.61% used the most efficient method (removing only straws below the ball). across phase 1 trials, 4-year-olds were significantly more efficient than 2-year-olds, and solve latency decreased for all age groups. test phase 2 altered the location of the ball, allowing us to explore whether children could flexibly adopt a more efficient solution when their original (now inefficient) solution remained available. in phase 2, significantly more 4-year-olds than 2-year-olds were efficient; the older children showed greater competency with the task and were more flexible to changing task demands than the younger children. interestingly, no age group was as flexible in phase 2 as previously tested nonhuman primates, potentially related to their relatively reduced task exploration in phase 1. therefore, this causally clear task revealed changes in cognitive flexibility across both early childhood and species. flexibility allows individuals to nimbly react to novel situations, playing an important role in adaptive responses to environmental changes and finding optimum solutions to problems. humans are particularly adept at flexible thinking, potentially due to complexity in their environment and social relationship structure (gökçen, petrides, hudry, frederickson, & smillie, 2014) . such flexibility is important because it is linked to our innovative ability and tool use (keen, 2011; neldner, mushin, & nielsen, 2017) . previous research has shown that, as compared with younger children, older children can more flexibly react to environmental or task changes (but see gopnik et al., 2017) . for example, children over 4 years of age can quickly alter sorting techniques on the same objects when given different verbal cues (e.g., ''find the ones that look like a ____" vs. ''find the one that is the same kind as ____"; deák & bauer, 1995) or game rules (e.g., ''sort the red ones" vs. ''sort the small ones"; frye, zelazo, & palfai, 1995; zelazo, frye, & rapus, 1996) , whereas children under age 4 often perseverate on the first cue or rule with which they are provided, making switch errors on 50-100% of trials . indeed, children's flexibility appears to develop slowly over the first few years of life and may be mediated by a child's understanding of the task (karmiloffsmith, 1990; spensley & taylor, 1999) . these findings, and others, suggest that cognitive flexibility might be linked to children's biological age (zelazo, muller, frye, & marcovitch, 2003) , although some evidence finds that children as a whole may also be more flexible than adults in certain situations (lucas, bridgers, griffiths, & gopnik, 2014) . in addition to biological maturation across one's lifespan, we can explore cognitive flexibility from a comparative perspective, for example, by studying nonhuman primates (sneve et al., 2018) . although there appears to be much variability across and within primate species with regard to their flexible or conservative responses to novel tasks (reviewed in brosnan & hopper, 2014) , nonhuman primates do exhibit cognitive flexibility in relation to both physical and social understanding (e.g., amici, call, watzek, brosnan, & aureli, 2018; pope et al., 2020) . in certain cases, and as compared with adult humans, nonhuman primates (e.g., macaques, capuchin monkeys) have been found to be significantly better at quickly and flexibly altering their behavior in response to changing task demands (e.g., avdagic, jensen, altschul, & terrace, 2014; stoet & snyder, 2007; watzek, pope, & brosnan, 2019) . thus, an exploration both across human development and across species might prove to be particularly insightful for understanding the ontogeny and evolutionary development of cognitive flexibility. research with humans and nonhuman primates has revealed that other important factors, including task complexity, opacity, and cognitive demands, influence cognitive flexibility. zelazo, carter, reznick, and frye (1997) proposed that individuals' ability to evaluate their own success in a task (i.e., error detection and correction) is a key component of problem solving as related to executive function. as such, tasks that make error detection easier are more likely to elicit adequate task switching from children. for example, when 3-year-olds are asked to repeat game rules before task switching, they are much more likely to succeed than when they are asked to simply complete the task without this verbal reminder (kirkham, cruess, & diamond, 2003) . whereas understanding the rules of a task can enhance children's success, causally clear tasks are also more efficiently solved by children and nonhuman primates (jacobson & hopper, 2019) . for example, 2-year-olds are more successful at an inhibition task if the actions required of them are obviously causal (e.g., pull a lever to get an object) as opposed to unclear or arbitrary (e.g., answer a phone to get an object) (mcguigan & núñez, 2006) . in this way, causal understanding may allow for solutions to be found and errors to be identified as well as flexibility in response to changes in task demands (hopper, kurtycz, ross, & bonnie, 2015; jacobson & hopper, 2019) . research has suggested that differences in response flexibility also likely depend on the cognitive demands inherent in the task. for example, less demanding lookingtime paradigms often show much earlier evidence for cognitive flexibility than tasks that require children to act on objects (e.g., smith, thelen, titzer, & mclin, 1999) . given this, (davis, schapiro, lambeth, wood, & whiten, 2019) proposed that perseveration is likely mediated by response prepotency (how familiar an action is) and working memory load (how demanding the task is). here, we sought to explore how children's cognitive flexibility (i.e., set shifting; ionescu, 2012) changes across early development and how their strategies compare with those of nonhuman primates (chimpanzees and gorillas tested previously using a comparable task and testing protocol). specifically, research with nonhuman primates has shown that they are less likely to adopt a novel solution after learning one successful one (hrubesch, preuschoft, & van schaik, 2009) but that this is mediated by task transparency, such that individuals tested with a causally clear task appear to be more flexible (jacobson & hopper, 2019) . therefore, unlike many previous studies on early cognitive flexibility, we used a paradigm that was both physically and causally clear and asked children to switch strategies without a large memory demand (e.g., remembering an abstract rule; zelazo et al., 1996) . specifically, we used a novel puzzle that was a clear vertical tube with five paper straws threaded through it at equal intervals. a small ball was placed in the tube such that it rested on a straw, and to retrieve the ball children needed to pull out all the straws below the ball so that it could fall down the tube and out the bottom. each time children retrieved the ball, they could exchange it with the researcher for a sticker. thus, this clear task relied on participants' basic understanding of gravity and support, did not necessitate the use of arbitrary actions, and did not require participants to retain information across trials. in the first configuration of the task, four straws were below the ball and one was above it. this was to test children's spontaneous understanding of the causal mechanics of the task and to verify that it was causally clear to children. research shows that even infants appear to have a basic understanding of gravity (baillargeon & hanko-summers, 1990; needham & baillargeon, 1993) , looking longer at and interacting more with objects if they appear to magically float in space when their support is removed (e.g., stahl & feigenson, 2015) . infants also appear to understand that a solid barrier will stop an object from falling or rolling in a downward trajectory even when that object is behind an opaque occluder (spelke, breinlinger, macomber, & jacobson, 1992) . although 2-year-olds struggle with more cognitively demanding physical adaptation of these looking-time studies, by 3 years of age children are able to track a falling object behind an occluder, correctly select a door to open, and reach for the fallen object (berthier, deblois, poirier, novak, & clifton, 2000) . thus, with this first configuration of our task, we could test whether children would remove only straws below the ball and ignore the straw above it or whether they would ''blindly" pull out all straws, in turn revealing whether they understood the task rules (without explanation or guidance). furthermore, by testing 2-, 3-, and 4-year-olds, we could observe whether their understanding and success differed by age. to examine whether the children could adopt a new solution strategy after repeated experience with the task in the first configuration, we subsequently presented a new configuration where only two straws were below the ball and three straws were above it. in this new configuration, the most efficient solution was to remove two straws instead of four, although the previously efficient strategy remained viable (albeit a less efficient solution). in this way, our paradigm allowed us to test individuals' flexibility in the face of possible conservatism and the interplay between causal understanding and cognitive flexibility across children of different ages and across (primate) species. our previous research with nonhuman primates using the same task revealed that chimpanzees and gorillas showed flexible problem solving when task demands changed, likely due to the apes' causal understanding of the task (jacobson & hopper, 2019) . therefore, we predicted that if children understood the task mechanics, they would respond flexibly when task demands changed. specifically, we predicted that if children solved the task using the most efficient strategy in the first task configuration, they would also be able to adopt a new efficient strategy when the configuration was changed. however, we also predicted that the younger children may be less likely to master the task (i.e., understand the solution and so be less likely to use efficient responses) and, accordingly, may be less flexible than the older children (if task understanding relates to flexibility in response patterns). thus, with our study, we wanted to see how young children responded to changing task demands, how their efficiency and flexibility differed with age, and how their responses compared with those of nonhuman primates. we tested 61 children representing three age groups: 20 2-year-olds (m = 30.0 months, range = 24.0-34.7; 10 girls), 22 3-year-olds (m = 40.6 months, range = 36.0-47.8; 12 girls), and 19 4-yearolds (m = 53.4 months, range = 49.0-59.6; 6 girls). from parental reporting, we determined that 81% of participants were caucasian, 5% were african american, 2% were hispanic, 2% were asian american, and 10% were multiracial (2% of parents opted out of answering questions concerning their child's race/ethnicity). in addition to the 61 children described above, we tested 9 children who were not included in the final sample due to refusing to participate in the given tasks (n = 7), failure to obtain video-recording consent (n = 1), or experimenter error (n = 1). this study received approval from the franklin & marshall institutional review board. after entering the testing room, children sat in a chair placed directly in front of experimenter 1 and the testing apparatus. the apparatus (modeled from the design previously used to test problem solving flexibility in apes; jacobson & hopper, 2019) was a clear pvc tube (approximately 2.5 cm in diameter and 63.5 cm long) affixed to a stand with equally spaced holes for up to five straws to be slotted through the tube (fig. 1 ). experimenter 2 sat on a small chair perpendicular to children. parents sat in a chair opposite from the apparatus, facing children and the experimenters, and were asked to remain quiet and to not intervene in the task or guide children's responses. sessions were videorecorded for later coding, with the camera located diagonal to the testing area (focused on experimenter 1, the testing apparatus, and children's hands. testing comprised a familiarization phase followed by two experimental phases. in the familiarization phase, experimenter 1 introduced children to the test apparatus, saying, ''this is my toy. look what this toy can do. when i put a ball in, it comes out the end." the experimenter then proceeded through 3 familiarization trials to acquaint children with the general mechanics of the tube. during these trials, the experimenter dropped a ball into the tube to show how a ball could fall down the apparatus when no obstructions (straws) were present. with each trial, experimenter 1 verbally prompted children to retrieve the ball that came out of the tube (''can you get the ball?") and told children that they would be rewarded with a sticker by experimenter 2 when they obtained the ball (''every time you give the ball to our friend [experimenter 2], you get a sticker!"). the sticker provided an incentive for children to quickly retrieve the ball by removing the straw obstructions (in the previous study with chimpanzees and gorillas using this task, a food reward was used in place of the ball here, which was inherently rewarding; see jacobson & hopper, 2019) . in test phase 1, participants completed 10 trials whereby they were asked to retrieve the ball from the test apparatus. for each trial, experimenter 1 baited the test apparatus out of view of children (behind a 122 by 91-cm tri-fold display board). experimenter 1 inserted a straw through each of the five holes in the shaft of the tube, with the ball placed into the apparatus such that there were four straws below the ball and one straw above it (configuration 1 in fig. 1 ). in this configuration, children needed to remove the four straws below the ball to obtain it; the fifth straw could also be removed, but doing so was causally irrelevant to obtaining the ball. the experimenter ensured that the straws were aligned equally to avoid any visual cuing that might encourage participants to select specific straws (e.g., one straw sticking out from the apparatus farther than another straw). then, the experimenter removed the tri-fold board so that children could view the tube. a test trial began as soon as the experimenter verbally prompted children to interact with the apparatus (''can you get the ball?"). participants were then given a chance to remove any of the straws (below or above the ball) in whatever manner they wished. if children were hesitant to initiate an interaction with the straws or the apparatus, the experimenter further prompted them with encouraging but noninformative cues (e.g., ''it's okay, you can come up and touch it"; ''the ball is stuck. how do you think you could get it out?"; ''if you get the ball, you'll get a sticker!"). throughout the trial, the experimenter retained a neutral facial expression and a neutral tone of voice to prevent children from receiving any external cues that would interfere with their interaction with the apparatus. similar to the familiarization trials, participants received a sticker whenever they acquired the ball and handed it to experimenter 2. after completing 10 trials with the apparatus in configuration 1, phase 2 commenced. in test phase 2, participants completed test trials with the new task configuration. these trials were run as in phase 1, changing only the apparatus configuration; in phase 2, the experimenter baited the apparatus such that there were only two straws below the ball and three straws above it (configuration 2 in fig. 1) . thus, the total number of straws that could be removed (five) was the same across test phases, but the number of straws that needed to be removed to obtain the ball differed (four in phase 1 and two in phase 2). importantly, the experimenter never highlighted the change in task configuration, or the new location of the ball at the start of the trial, either verbally or via pointing. as with phase 1, the experimenter made statements only to encourage children's engagement (e.g., ''can you get the ball?"). in phase 2, children completed 4 trials. there were two reasons why we ran fewer trials in this second phase. first, our primary interest was assessing children's ability to switch response strategies when the task configuration changed. for this, we were predominantly interested in assessing their the configuration both in phase 1 (four straws below the ball and one straw above it) and in phase 2 (two straws below the ball and three straws above it) and a photograph of one participant completing a trial in phase 1. in either task configuration, participants were free to pull out as many straws us they chose and in any order. thus, although the most efficient strategy would be to only remove straws below the ball, in either configuration children could also adopt inefficient strategies and remove straws both above and below the ball. importantly, the efficient solution for phase 1 (removing straws 1-4) remained viable in phase 2, although a different solution was the most efficient one (removing straws 1 and 2). responses in the first trial post-configuration change (i.e., to see whether they adopted a new solution and whether they adopted the most efficient solution possible with their first response in phase 2). second, although we also wanted to evaluate children's repeated responses in phase 2 with multiple trials (to see whether their responses increased in efficiency over time if they did not make a strategy switch with their first trial of phase 2), we did not want to give children too many opportunities to interact with the task because we wanted to test their spontaneous responses. this is in contrast to phase 1, where we wanted to assess their spontaneous understanding of the task (trial 1) and also wanted to give them repeated experience with the task across multiple trials both to assess their exploration of the task and to generate a modal response (''remove four straws") that would be more likely to be conserved and potentially harder to deviate from in phase 2 (in the sense of jacobson & hopper, 2019) . a trained researcher coded all the test trials from video. a second independent research assistant coded 25% of participants' trials, with the two coders agreeing on approximately 99.9% of total behavioral scores. when there was a coding disagreement, we used the primary coder's scoring for a given trial. for each trial, the coder recorded four elements and associated information: the total number of straws participants removed, the order in which participants removed the straws, the length of each trial (i.e., latency to remove straws), and any comments participants made during the first trial of test phase 2 when they were presented with a new configuration of the task (i.e., the ''switch trial"). for each trial, we coded for the total number of straws removed by children (out of a possible five for each trial) and the order in which children removed each straw. if participants retrieved the reward by pulling only the straws below the ball (four straws for test phase 1 or two straws for test phase 2), we coded the trial as ''efficient," but if participants pulled one or more straws above the ball (thereby pulling straws that were not causally necessary to receive the reward), we coded the trial was as ''inefficient" (as per jacobson & hopper, 2019) . we coded the time at which participants removed each straw within a given trial. thus, we could calculate the latency for participants to complete each of their trials. the start time for each trial began as soon as the experimenter uttered the introductory prompt (''can you get the ball?") and ended once children indicated they were done removing straws by explicitly stating such or moving to experimenter 2 to retrieve a sticker for ball retrieval (typically as soon as the ball fell from the tube). during the first trial of phase 2 (the ''switch trial" when the configuration of the apparatus was altered), we transcribed any verbal comments participants made that might indicate that they noticed a change and/or were seeking information related to the change (i.e., ''why" questions; legare, sobel, & callanan, 2017) . for instance, some participants would recognize the change of the tube arrangement and say, ''why is the ball all the way down there?" or ''how did you do that?" we provide a descriptive summary of these in the results section. to explore participants' spontaneous understanding of the task and their flexibility in response to changing task demands, we analyzed four key aspects of the coded data using r version 3.5.2 (core, 2018): (a) participants' spontaneous understanding of the task, (b) any apparent learning across trials, (c) participants' flexibility and efficiency across and within phases, and (d) the verbal responses participants made, if any. for clarity, the specific analytical approaches that we used for each analysis are reported within that section of the results. for all pairwise comparisons, a bonferroni correction was applied (i.e., a .017). with a .017 and an effect size of .80, our power analysis revealed a value of .63. (to achieve a power value of .80, we would need to have included 29 children per condition, but with the current covid-19 pandemic, additional testing was not feasible.) we plotted all data using the ggplot2 package (wickham, 2016) and beeswarm package (eklund, 2016 ; see also wilkinson, 1999) in r version 3.5.2 (core, 2018). all 61 children tested were able to retrieve the ball from the apparatus in their first trial of phase 1. furthermore, 15 of the 20 2-year-olds (75.00%), 18 of the 22 3-year-olds (81.82%), and 18 of the 19 4year-olds (94.74%) used the most efficient method to do so in trial 1 of phase 1 (i.e., they removed only the lower four of the five straws from the tube) (fig. 1) . we compared children's spontaneous ability to solve the task across the three age groups. to do so, we used first trial efficiency (efficient or inefficient) as our outcome variable and participant id as a random factor. given the binary response variable, we analyzed our data using a binomial generalized linear mixed model (glmm) in r version 3.5.2 (core, 2018). we fit this model using the laplace approximation method via the ''glmer" function in the lme4 package (bates, maechler, & bolker, 2012) to test the relative effect of our predictor variable age group (family = ''binomial"). this revealed that there was no significant difference across the three age groups of children in their likelihood to use the most efficient method in their first trial of phase 1 {z = 0.34, p = .733, 95% confidence interval (ci) [à3.80, 5.41]}. not only were the three age groups equally likely to use an efficient response with their first trial, but of those children who responded efficiently in the first trial of phase 1, there was strong consistency in the action sequence (i.e., straw removal order) that they used: 93.33% of the 2-year-olds who responded efficiently used the 4,3,2,1 action sequence, as did 100.00% of the 3-year-olds and 94.44% of the 4-year-olds who responded efficiently (i.e., they sequentially removed the straw directly below the ball) (fig. 1 ). on average across all their trials in phase 1, 2-year-olds used an efficient action sequence in 60.56% (sd = 27.75) of trials, whereas 3-year-olds were efficient in 71.90% (sd = 32.19) of trials and 4-yearolds were efficient in 86.32% (sd = 24.99) of trials (fig. 2) . using a glmm, we explored the proportion of all the participants' trials in phase 1 that were efficient (family = ''poisson") and used independent t tests, using the ''t.test" function to compare children's efficiency across age groups. this revealed that there was a significant effect of age on the percentage of trials in which children made efficient responses in phase 1 (z = 2.80, p = .005, 95% ci [0.53, 0.30]). specifically, 4-year-olds made significantly more efficient responses than 2-year-olds, t(34.13) = à2.96, p = .006, 95% ci [à4.34, à0.81], but there was no significant difference in the percentages of trials in which 2-and 3-year-olds made efficient responses, t(36.99) = à1.18, p = .245, 95% ci [à3.08, 0.81] or in the percentages of trials in which 3and 4-year-olds made efficient responses, t(37.19) = à1.59, p = .120, 95% ci [à3. 28, 8.63] . when first presented with the task in phase 1, the average latency for 4-year-olds to complete their first trial was 23.05 s (sd = 10.43). the 4-year-olds were significantly quicker to complete their first trial than the 2-year-olds (average latency = 80.35 s, sd = 71.98), t(19.84) = 3.52, p = .002, 95% ci [23.34, 91.26] and the 3-year-olds (average latency = 61.95 s, sd = 70.03), t(22.08) = 2.57, p = .017, 95% ci [7.55, 91.26 ]. there was no significant difference, however, between the 2-and 3-year-olds in the time it took them to complete their first trial, t(39.38) = 0.84, p = .407, 95% ci [à26.00, 62.79]. to test whether children's trial completion times became quicker across trials, as a proxy for learning, we correlated participants' trial latency with trial number using the ''rmcorr" function (bakdash & marusich, 2017) . this takes into account repeated samples from participants to determine whether their trial latency decreased over time. this revealed that there was a significant negative correlation between the trial completion latency and trial number for all three age groups, such that children became quicker to complete trials across the 10 trials in phase 1: 2-year-olds (r = à.385, p < .001), 3-year-olds (r = à.297, p < .001), and 4-year-olds (r = à.232, p = .002). the weaker negative relationship between trial number and latency for 4-year-olds is likely because they completed their first trial faster than the younger children and there is likely a limit to how quickly any children can complete a trial, creating a floor effect. indeed, 4-year-olds' average trial completion latency delta from trial 1 to trial 10 was only 14.89 s (average trial 10 latency = 8.16 s, sd = 23.05), whereas the delta for 3-year-olds was 47.90 s (average trial 10 latency = 14.05 s, sd = 15.51) and for 2-yearolds was 64.35 s (average trial 10 latency = 16.00 s, sd = 10.83). to evaluate children's cognitive flexibility, we assessed their efficiency in the first trial of phase 2 when they were presented with the new task configuration (fig. 1 ). only 7 (11.48%) of the children used the same action sequence (straw removal order) in the first trial of phase 2 as they had used in their last trial of phase 1. specifically, 4 2-year-olds and 2 3-year-olds used the 5,4,3,2,1 action sequence in both trials, whereas 1 4-year-old used the 4,3,2,1 action sequence in the last trial of phase 1 and the first trial of phase 2. thus, the majority of children (88.52%) used a different action sequence across these trials. for all children and action sequences used, in the first trial of phase 2, 7 of the 20 2year-olds (35.00%), 14 of the 22 3-year-olds (63.64%), and 13 of the 19 4-year-olds (68.42%) used the (newly available) most efficient method (i.e., they removed only the lower two of five straws from the tube), highlighting their recognition of the changed task demands. as with test phase 1, we used the ''glmer" function in the lme4 package (family = ''binomial") to compare the numbers of children across the three age groups whose first trial in phase 2 was efficient, and we used independent t tests using the ''t.test" function for post hoc pairwise comparisons across age groups. our analyses revealed that there was a significant effect of age on children's efficiency in the first trial of phase 2 (z = 2.74, p = .023, 95% ci [0.11, 1.51]). in spite of this, after correcting for multiple comparisons, post hoc pairwise comparisons revealed no significant difference across age groups when comparing the numbers of children whose responses in the first trial of phase 2 responses were efficient: 4-year-olds versus 2year-olds, t(35.92) = à2.41, p = .021, 95% ci [à0.68, à0.06]; 4-year-olds versus 3-year-olds, considering all 4 trials that children completed in phase 2, on average children removed significantly fewer straws per trial in phase 2 than they did in phase 1, highlighting their understanding of the changed task demands. this was true for all three age groups of children tested: 2-year-olds, t(21.45) = 3.81, p = .001, 95% ci [0.49, 1.68]; 3-year-olds, t(25.10) = 6.20, p < .001, 95% ci [1.04, 2.08]; 4-year-olds, t(20.65) = 7.55, p < .001, 95% ci [1.21, 2.13]. although children removed fewer straws in phase 2 as compared with phase 1, did they consistently remove the fewest possible number (i.e., two straws)? on average across all trials in phase 2, 2-year-olds used an efficient action sequence in 42.50% (sd = 39.82) of their trials, whereas 3-year-olds used an efficient solution in 68.18% (sd = 41.68) of trials and 4-year-olds were efficient in 81.58% (sd = 32.10) of trials. using a glmm (family = ''poisson"), we found that there was a significant effect of age on the proportion of phase 2 trials in which children made efficient responses (z = 3.04, p = .002, 95% ci [0.11, 0.51]). specifically, 4-year-olds made significantly more efficient responses than 2-year-olds, t(36.07) = à3.38, p = .002, 95% ci [à2.50, à0.63], but there was no significant difference in the proportions of trials in which 3-and 4-year-olds made efficient responses, t(38.54) = à1.16, p = .253, 95% ci [à1.47, 0.40], or in the proportions of trials in which 3-and 2-year-olds made efficient responses, t(39.89) = à2.04, p = .048, 95% ci [à2.04, à0.01]. to further explore children's causal understanding of the task and their ability to flexibly shift strategies across the phases in response to the change in task configuration, we compared children's latency to complete trials across the two phases as a proxy for flexibility (i.e., removing two straws should take less time than removing four straws). across all children tested, they were significantly faster to complete trials in phase 2 (average trial completion latency = 12.03 s, sd = 13.36) compared with phase 1 (average trial completion latency = 17.44 s, sd = 11.45), r(60) = à.426, p < .001. there was also a significant effect of age on children's latency to complete a trial. within phase 2, the average latency for 2-year-olds to complete a trial was 17.40 s (sd = 16.70), whereas the average trial completion latencies for 3-and 4-year-olds were 11.82 s (sd = 13.63) and 6.63 s (sd = 4.61), respectively. the 4-year-olds completed trials significantly faster than both the 2-year-olds, t(49.82) = 4.74, p < .001, 95% ci [7.10, 17.57] and 3-year-olds, t(63.56) = 3.31, p = .002, 95% ci [2.65, 10.68]. in contrast, there was no significant difference between the 2-year-olds' and 3-year-olds' trial completion latency, t(73.10) = 1.88, p = .056, 95% ci [à0. 35, 11.69 ]. in addition to comparing children's understanding of the task and flexibility across ages, we were also interested in how consistently proficient each child was. to examine this, we compared children's efficiency in phase 1 with their efficiency in phase 2. we found that, for all three age groups, children showed intra-individual consistency in their efficiency across phases; that is, the proportion of trials that children solved efficiently in phase 1 was significantly correlated with the proportion of trials that children solved efficiently in phase 2: pearson's product-moment correlation, 2-year-olds, t(18) = 5.066, p < .001, 95% ci [.49, .90]; 3-year-olds, t(20) = 3.635, p = .002, 95% ci [.28, .83]; 4-year-olds, t(17) = 6.093, p < .001, 95% ci [.60, .93]. as reflected by children's responses in the first trial of phase 1, the action sequence most commonly used by children across all trials in phase 1 was repeatedly removing the straw directly below the reward (i.e., 4,3,2,1) ( figs. 1 and 3) . this action sequence represented 53.78% of 2-year-olds' trials, 64.84% of 3-year-olds' trials, and 73.82% of 4-year-olds' trials in phase 1. in addition, and as can be seen in fig. 3 , the modal inefficient action sequence for all three age groups in phase 1 was 5,4,3,2,1 (i.e., pulling out all the straws from top to bottom). not only was there consistency across children in their modal action sequence (4,3,2,1) in phase 1, there was also intra-individual consistency such that some children perseverated in their response phenotype and used an action sequence in multiple successive trials. indeed, 14 children (1 2-yearold, 5 3-year-olds, and 8 4-year-olds) used the same efficient action sequence for every response they made in phase 1, and 2 2-year-olds used the same inefficient sequence in each of their 10 trials. therefore, we explored children's conservatism in this regard. for each child, we calculated the longest run of consecutive trials in which the child used the same action sequence in phase 1, where 2 consecutive trials was the shortest possible run length and 10 consecutive trials was the longest possible run length. in addition, we coded whether each run was efficient or inefficient, and we calculated each child's average efficient run length as a proportion of total possible responses. from this, we found that 4-year-olds made significantly longer efficient runs (average proportion of trials = .63, sd = .41) than 2-year-olds (average = .30, sd = .27), t(25.32) = à2.752, p = .011, 95% ci [à.57, à.08] (fig. 4) . however, there was no significant difference in the average efficient run length made by 4and 3-year-olds (average = .53, sd = .36), t(30.03) = à 0.778, p = .443, 95% ci [à.36, .16] or in the average efficient run length made by 2-and 3-year-olds, t(38.31) = à2.315, p = .026, 95% ci [à.43, à.03]. in spite of the aforementioned conservatism shown by some children to perseverate on an action sequence across multiple trials, there was variation in the action sequences used by the children across trials. thus, even after discovering the 4,3,2,1 solution, children sampled other action sequences. collectively, children used 27 different action sequences in phase 1 (120 were possible) (fig. 3) . they used 12 (50.00%) of the 24 possible action sequences that were efficient, removing straws 1, 2, 3, and 4 first (e.g., 1,3,2,4 and 4,3,2,1), but used only 15 (15.63%) of the 96 possible action sequences that were inefficient in which they pulled out the irrelevant straw before releasing the reward (e.g., 5,4,3,2,1 and 3,5,4,2,1). in addition, 2 (33.33%) of the 6 different action sequences that 2-year-olds used were efficient ones, whereas 6 (50.00%) of the 12 action sequences used by 3year-olds and 10 (45.45%) of the 22 action sequences used by 4-year-olds were efficient. to determine the diversity of action sequences children used, we calculated the diversity index of their responses (shannon & weaver, 1949) . if participants repeatedly used the same action sequence (i.e., developed a habit), their diversity index would be lower than those who did not. we used wilcoxon tests (''wilcox.test") to compare participants' ''h-index" diversity index across age groups and across test phases. children's individual h-index scores in phase 1 ranged from 0.00 to 2.03, where an index score of 0 means that only one action sequence was used and an index score of 2.30 would mean that a different action sequence was used for each of the 10 trials, although this never occurred, as indicated by children's maximum score of 2.03. in phase 1, there was no significant difference in children's h-index scores across the three age groups: 2-year-olds versus 3-year-olds, t(39.12) = 0.443, p = .661, 95% ci [à.22, .34]; 3-year-olds versus 4-year-olds, t(27.40) = à 0.258, p = .799, 95% ci [à.46, .36]; 2-year-olds versus 4-year-olds, t(28.93) = 0.047, p = .963, 95% ci [à.41, .43 ]. in spite of this, we found differences across the three age groups in the relationship between their phase 1h-index score and the proportion of trials in which they used an efficient action sequence. specifically, for 4-year-olds, there was a significant negative correlation between their h-index score and their proportion of trials that were efficient {pearson's product-moment correlation: t(17) = à6.469, p < .001, 95% ci [à.94, à.63]}, and this was also the case for 3-year-olds, t(20) = à3.373, p = .003, 95% ci [à.82, à.24], but not 2-year-olds, t(18) = à1.137, p = .271, 95% ci [à.63, .21] . in contrast to phase 1, children needed to complete only 4 trials in phase 2, so there was a higher probability that they would use the same response in all trials. indeed, whereas only 16 children (26.23%) used the same response across all trials in phase 1 (described above), 29 children (47.54%) used the same response across all trials in phase 2, and 24 of these children used an efficient response for every trial (no 4-year-olds used the same inefficient action sequence repeatedly across trials). reflecting this intra-individual consistency, there was also inter-individual consistency in the specific action sequence that children used in phase 2. as in phase 1, the action sequence most commonly used by children in phase 2 was repeatedly removing the straw directly below the reward (i.e., 2,1) (fig. 5) . this action sequence represented 41.25% of 2-year-olds' trials, 62.50% of 3-year-olds' trials, and 75.00% of 4-year-olds' trials, and as in phase 1 the modal inefficient response for 2-and 3-year-olds was to remove all the straws from top to bottom (i.e., 5,4,3,2,1) (fig. 5) . in spite of children's preference for the 2,1 action sequence in phase 2, they still explored other solution phenotypes, including the alternative efficient action sequence (1,2) and an additional 25 different inefficient action sequences (fig. 5) . in addition to the 2 efficient strategies, 2-year-olds used 17 inefficient action sequences (22.22% of their action sequences were efficient), whereas 3-year-olds used 11 inefficient sequences and 4-year-olds used 10, meaning that 15.38% and 16.67% of the action sequences they used were efficient, respectively. children's individual h-index scores in phase 2 ranged from 0.00 to 1.39, where an index score of 0 means that only 1 action sequence was used and an index score of 1.39 would mean that a different action sequence was used for each of the 4 trials. as in phase 1, in phase 2 there was no significant difference in children's h-index scores across the three age groups: 2-year-olds versus 3-year-olds, t(37.42) = 1.768, p = .085, 95% ci [à.04, .60]; 3-year-olds versus 4-year-olds, t(39.00) = 0.089, p = .930, 95% ci [à.26, .29]; 2-year-olds versus 4-year-olds, t (34.79) = 1.894, p = .067, 95% ci [à.02, .61]. however, as with their responses in phase 1, we found that the older children's diversity of responses (h-index score) was negatively correlated with efficiency. specifically, for 4-and 3-year-olds, there was a significant negative correlation between their hindex score and their proportion of trials in phase 2 that were efficient {4-year-olds: t(17) = à3.101, p = .006, 95% ci [à.83, à.20]; 3-year-olds: t(20) = à2.623, p = .016, 95% ci [à.76, à.11]}, but this was not the case for 2-year-olds, t(18) = à1.776, p = .093, 95% ci [à.71, .07]. during the first trial of phase 2, when children were first presented with the novel configuration of the task (i.e., the ''switch trial"), none of the 2-year-olds made any verbal comment in relation to the task. however, 36.36% of the 3-year-olds did, as did 47.37% of the 4-year-olds. most 3-year-olds' comments reflected the change in task configuration (e.g., ''why did it go down to this one?"; ''it's not up there anymore"), whereas other comments highlighted the configuration change but also flagged the experimenter's agency in causing that change (e.g., ''why did you put two?"; ''how did you do that?"). like 3-year-olds, 4-year-olds' comments referred to the change of task configuration (e.g., ''there's only two straws"; ''hey, it's now down there") and the experimenter's causation of the change (e.g., ''how did you do that?"), but 4-year-olds also commented on how this change affected their own behavior and success (e.g., ''i only had to get two"; ''that was super fast-that's because there were only two straws"). both 3-and 4-year-olds commented on the configuration change in 46.67% of their first trials in phase 2 in which they made an efficient response (i.e., removing only the bottom two straws). in the trials in which children made an inefficient response (i.e., removing three or more straws), 14.29% of 3-year-olds commented on the change, whereas a quarter (25.00%) of 4-yearolds commented on the change. for both age groups, there was no significant difference in the numbers of efficient first trial responses in which children made a comment on the task configuration (fisher's exact test: 3-year-olds, p = .193; 4-year-olds, p = .399). in our study, we explored 2-, 3-, and 4-year-old children's ability to flexibly switch between response patterns as task demands changed. as jacobson and hopper (2019) found previously for nonhuman primates, all the children easily mastered the task and retrieved the ball from the tube. however, 4-year-olds were consistently more efficient than the younger children in terms of both the time it took them to complete trials and the number of straws they removed. this developmental trajectory in children's responses reflects previous research showing that children's problem solving and tool making skills increase with age (gönül, takmaz, hohenberger, & corballis, 2018) . indeed, the cognitive complexity and control theory proposes that ''executive function can be understood in terms of agerelated increases in the maximum complexity of the rules children can formulate and use when solving problems" (zelazo et al., 2003, p. 274) . in spite of this, there was no significant difference across the three age groups of children in their likelihood of using the newly available efficient solution when it was presented in the first trial of phase 2. we also identified intra-individual consistency in children's success such that their efficiency in phase 1 correlated with their efficiency in phase 2. given the general success of children in all age groups, it is likely that this causally clear task facilitated children's success and flexibility (in the sense of davis et al., 2019) , as has been found in chimpanzees and gorillas tested using the same task (jacobson & hopper, 2019) . our aim was to provide a task that was accessible for children in all three age groups to allow us to make meaningful across-age comparisons (as well as comparisons with nonhuman primates' responses). supporting our goal, all children spontaneously solved the task and there was no difference across the three age groups in their initial understanding of the task, as evidenced by their comparable likelihoods to use the most efficient method in their first trial of phase 1 (83.61% of children used an efficient solution in the first trial of phase 1). however, 4-year-olds showed sustained efficiency across trials in phase 1; significantly more of their trials were solved via the efficient method than those of 2-year-olds. although the 4-year-olds were not more likely to spontaneously use the most efficient solution in their first trial of phase 1 than the younger children, they were more likely to stick with it and were significantly quicker to complete their first trial, suggesting enhanced physical dexterity, potentially in combination with a better understanding of the task demands. however, and in spite of 4-year-olds' greater use of efficient solutions, within phase 1 all three age groups showed an improvement in task proficiency over time, as demonstrated by the negative correlation between trial latency and trial number. although the vast majority of children spontaneously used an efficient solution when first presented with the task, when we changed the task demands and introduced the possibility of a new efficient solution in phase 2, only 57.73% of children spontaneously used the most efficient solution with their first attempt (removing only two straws). as with the first trial of phase 1, however, there was no effect of age on children's likelihood to use an efficient solution for the first trial of phase 2. thus, nearly half of the children, irrespective of age, did not switch strategies in the first trial of phase 2. in certain situations, humans react in remarkably fixed ways even when their environment does not necessitate such rigidity (bilalić , mcleod, & gobet, 2008; gopnik, griffiths, & lucas, 2015) . for example, adults often sit in the same seat during classes or meetings even without seat assignment and when there are no repercussions for moving (costa, 2012) . the limited flexibility we observed cannot be explained by pure conservatism (in the sense of hrubesch et al., 2009) ; of the 26 children who used an inefficient solution for the first trial of phase 2, only 7 (26.92%) were inefficient because they used the exact same action sequence as they had used in the previous trial (i.e., the final trial of phase 1). we also note that a large subset of 3-and 4-year-olds remarked on the change in task configuration. although children often verbally seek out information to understand causal elements of their environment (legare et al., 2017) , our experimenters were instructed not to answer children's questions and were not useful as informants (and, anecdotally, children almost never explicitly asked for help). therefore, it is possible that children were describing the changes they observed to help themselves make sense of the changes and respond to the new task demands (winsler, fernyhough, & montero, 2009) . we had predicted that greater exploration of the task (i.e., using a range of action sequences) would protect children against conservatism and allow them to more flexibly respond when task demands changed. paradoxically, although 4-year-olds were the most efficient in their responses, they were also the most conservative; fully 73.82% of their trials in phase 1 were solved using the same action sequence (4,3,2,1), and we saw similar patterns in their responses in phase 2 (when they preferentially used the 2,1 action sequence). indeed, the older children's preferred responses (whether efficient or inefficient) were to remove straws sequentially rather than in a random pattern (although they did this on occasion). reflecting this, of the 14 children who used the same action sequence for every trial in phase 1, 8 were 4-year-olds (only 1 2-year-old used the same action sequence in every trial in phase 1). indeed, for 3-and 4-year-olds, but not 2-year-olds, there was a significant negative correlation between their h-index score and proportion of trials that were efficient. thus, for the older children, decreased diversity was associated with increased efficiency, reflecting the results of their likelihood to display longer runs of efficient action sequences (this was also seen in their phase 2 responses). in this way, the younger children's greater exploration did not benefit them either within phases or in their flexibility across phases. although conservatism is often seen as a sign of reduced cognitive flexibility, because the older children struck on and then stuck with an efficient solution from the start, they were able to sustain their efficiency (i.e., ''if it ain't broke, don't fix it"). furthermore, the older children's apparent flexibility in switching strategies from phase 1 to phase 2 might not reflect a switch but rather a continuation of the same strategy (''pull the straw below the ball"). without further controls, it is difficult to discern whether this is an insightful solution or a rigid response-sticking with the first reinforced pattern used-but we would argue the former given that the younger children also used this solution early on but did not stick with it. the increased exploration in the younger children aligns with some of the ideas outlined in the overlapping waves theory, which states that children do not simply progress from ignorance to full comprehension across development but rather proceed through cognitive waves involving data collection, mapping, strengthening, and refinement when attempting to effectively solve problems (e.g., chen, siegler, & daehler, 2000) . however, although this exploration might be viewed favorably with respect to cognitive flexibility, it is actually counter to maximizing efficiency. in phase 2, there were fewer possible action sequences that were efficient as compared with phase 1, and so we might expect that children with a strong causal understanding of the task, and a desire to be efficient, would use fewer different action sequences in phase 2 than in phase 1. indeed, this is what we saw with 4year-olds. the 4-year-olds used fewer action sequences in phase 2 (12) than in phase 1 (22), whereas the 3-year-olds used a comparable number of action sequences in both phases (12 vs. 13). although our a priori goal for this task was to remove the ball by removing as few straws as possible, we never explicitly shared this goal with the children. therefore, for the younger children, rather than maximizing efficiency, play and exploration might have been stronger drives, which can be advantageous (greve & thomsen, 2016) . a drive to play might explain why the younger children used more action sequences in phase 2, although this could also be explained by a reduced understanding of the task mechanics or could be related to young children's tendencies to be more exploratory when events are surprising (stahl & feigenson, 2017) . in addition to exploring ontogenetic changes in children's cognitive flexibility, we were also interested in comparing children's behavior in this task with that of chimpanzees and gorillas tested previously with the same task under comparable protocols. when first presented with the task, all children spontaneously retrieved the ball and 83.61% used the most efficient method with their first attempt. as noted above, the apes we tested previously were equally successful, with 84.62% of them using the most efficient method when first presented with the same task (jacobson & hopper, 2019) . however, in spite of the seeming similarities across species, there were differences in the way in which the children and apes solved the task. for example, whereas the children used 12 different efficient action sequences collectively in phase 1, the apes deployed 21. furthermore, the children used fewer action sequences on average across the first 10 trials of phase 1 as compared with the apes (see fig. s1 in the online supplementary material). the increased exploration by the apes may be due to differences in experimental protocol (children completed all 10 trials within a single session, whereas apes completed trials over one or more sessions; see jacobson & hopper, 2019, for details) . however, it is notable that whereas the 2-and 3-year-old children never used more than 4 different action sequences each, the 4-year-old children used up to seven and eight different sequences each, revealing exploration rates more similar to that of the apes. a greater percentage of the apes were flexible in adopting a more efficient response in the first trial of phase 2 as compared with the children even when comparing apes with the oldest child age group. as discussed, within phase 1 and across all three age groups, the children predominantly solved the task by repeatedly removing the straw directly below the ball (i.e., 4,3,2,1). this was also the predominant strategy used by the chimpanzees tested previously, but not by the gorillas, whose preferred strategy was to remove straws sequentially from the bottom up (i.e., 1,2,3,4) (cf. fig. 3 here with fig. 2 in jacobson & hopper, 2019) . the strategy of consistently moving the straw that the ball rests on could potentially represent a simple association that was learned by the children rather than a holistic understanding of the task mechanism, but what explains these apparent species differences is not clear at this time. the observed species differences may be a result of methodological elements between this study and that of jacobson and hopper (2019) . namely, we gave the children 10 trials in phase 1 before changing the task configuration, whereas the apes received more than 20 trials spread over multiple sessions before the task was changed. the apes' increased experience with the task may have afforded them greater experience with the task, which may have allowed them to be more flexible or simply gave them more opportunities to explore alternative action sequences. indeed, this might be why the apes' average run length was shorter than that of the children (average proportion of apes' first 10 trials that were runs = .21, sd = .13; cf. with fig. 4 here) ; however, unlike the children, the apes never performed a run of inefficient action sequences in their first 10 trials of phase 1 (see table 2 in jacobson & hopper, 2019) . future work is needed to tease apart the influences of experience, causal understanding, and conservatism on the apparent species differences we identified. from our results, we propose that causal understanding of a task not only promotes problem solving but also reduces the likelihood of conservative perseveration (see also jacobson & hopper, 2019) . however, humans are inherently social, and although we may sometimes solve problems by ourselves, we also often seek out information from others. in a landmark study, bonawitz et al. (2011) found that children were much less flexible when they were directly trained on how to use a certain object. termed the ''double-edged sword of pedagogy," children who observed someone interacting with the object were more likely to explore and learn its multiple functions, whereas those who were directly given instructions did not stray from the singular function they were taught. this effect has now been seen in a number of other contexts, such as children learning to flexibly solve new math problems (loehr, fyfe, & rittle-johnson, 2014) , and may explain children's proclivity for overimitation (lyons, young, & keil, 2007; over & carpenter, 2013; whiten, mcguigan, marshall-pescini, & hopper, 2009 ). thus, although direct social instruction can help children to quickly learn how to complete a task, it might also unnecessarily cause behavioral perseveration. conversely, nonhuman primates appear to be less influenced by social norms as compared with children (e.g., haun, rekers, & tomasello, 2014; horner & whiten, 2005 ; but see hopper, schapiro, lambeth, & brosnan, 2011) . future research could explore the role of individuals' causal understanding and their reliance on social information on cognitive flexibility (e.g., burdett, mcguigan, harrison, & whiten, 2018) from both a comparative perspective and an ontogenetic perspective (e.g., horner & whiten, 2005; pope, fagot, meguerditchian, washburn, & hopkins, 2019; stengelin, hepach, & haun, 2020; wood, kendal, & flynn, 2013) . here, we found that although all three age groups of children were successful in solving the task, 4year-olds were more efficient and more flexible in their approach to solving the task and responding to changing task demands than 2-year-olds. we previously tested apes on the same task and concluded that their ability to alter the solution strategy they used when we changed the task configuration was likely linked to their causal understanding of the task (jacobson & hopper, 2019) . unfortunately, procedural differences in testing protocols across species prevents us from making too many inferences about the apparent species differences we observed or what might drive these differences. however, we note that research using different tests of cognitive flexibility has also identified differences across human and nonhuman primates' responses to matched tasks (e.g., avdagic et al., 2014; pope et al., 2020; watzek et al., 2019) , although typically such research has tested adult humans, not young children as we did. future work exploring the interplay among social information, causal understanding, and cognitive flexibility is needed. social inhibition and behavioural flexibility when the context changes: a comparison across six primate species rapid cognitive flexibility of rhesus macaques performing psychophysical task-switching is the top object adequately supported by the bottom object? young infants' understanding of support relations repeated measures 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rhesus monkeys but not humans show cognitive flexibility in an optional-switch task emulation, imitation, over-imitation and the scope of culture for child and chimpanzee ggplot2: elegant graphics for data analysis dot plots. the american statistician private speech, executive functioning, and the development of verbal selfregulation copy me or copy you? the effect of prior experience on social learning early development of executive function: a problem-solving framework an age-related dissociation between knowing rules and using them the development of executive function in early childhood. monographs of the society for research in child development a portion of this study was funded by the franklin & marshall college hackman scholars program award to lhh, and lmh received support from the lincoln park zoo's women's board. in addition, we thank the following individuals for their assistance with data collection, coding, and methods preparation: lauren hein, natalie hutchins, enya meade, you jin park, ayla saferstein, tian tian, ellen verry, fiona waters, and peiru yu. supplementary data to this article can be found online at https://doi.org/10.1016/j.jecp.2020. 104966. key: cord-253900-ftwuybud authors: mulas, ilaria; putzu, valeria; asoni, gesuina; viale, daniela; mameli, irene; pau, massimiliano title: clinical assessment of gait and functional mobility in italian healthy and cognitively impaired older persons using wearable inertial sensors date: 2020-09-25 journal: aging clin exp res doi: 10.1007/s40520-020-01715-9 sha: doc_id: 253900 cord_uid: ftwuybud aim: the main purpose of the present study was to verify the feasibility of wearable inertial sensors (imus) in a clinical setting to screen gait and functional mobility in italian older persons. in particular, we intended to verify the capability of imus to discriminate individuals with and without cognitive impairments and assess the existence of significant correlations between mobility parameters extracted by processing trunk accelerations and cognitive status. methods: this is a cross-sectional study performed on 213 adults aged over 65 years (mean age 77.0 ± 5.4; 62% female) who underwent cognitive assessment (through addenbrooke’s cognitive examination revised, ace-r) instrumental gait analysis and the timed up and go (tug) test carried out using a wearable imu located in the lower back. results: individuals with cognitive impairments exhibit a peculiar gait pattern, characterized by significant reduction of speed (− 34% vs. healthy individuals), stride length (− 28%), cadence (− 9%), and increase in double support duration (+ 11%). slight, but significant changes in stance and swing phase duration were also detected. poorer performances in presence of cognitive impairment were observed in terms of functional mobility as overall and sub-phase tug times resulted significantly higher with respect to healthy individuals (overall time, + 38%, sub-phases times ranging from + 22 to + 34%), although with some difference associated with age. the severity of mobility alterations was found moderately to strongly correlated with the ace-r score (spearman’s rho = 0.58 vs. gait speed, 0.54 vs. stride length, 0.66 vs. overall tug time). conclusion: the findings obtained in the present study suggest that wearable imus appear to be an effective solution for the clinical assessment of mobility parameters of older persons screened for cognitive impairments within a clinical setting. they may represent a useful tool for the clinician in verifying the effectiveness of interventions to alleviate the impact of mobility limitations on daily life in cognitively impaired individuals. the progressive loss of ambulation and functional mobility performance of humans is a physiologic consequence of aging mainly due to reductions in muscle strength and deterioration of sensory, vestibular and proprioceptive inputs [1] [2] [3] . in presence of specific conditions such as obesity, musculoskeletal and neurologic disorders, depression, etc., reduction in mobility may result exacerbated. similarly, cognitive disorders, whatever their nature, are known to impact gait, balance and mobility. in all these cases, the performance of even simple activities of daily living (adl) is restricted [4] , social participation reduced [5] and, in general, the overall quality of life is significantly compromised [6] . in the last decade, there has been a rising interest in investigating the role played by cognition on mobility, particularly as regards the relationship between cognitive functions and basic motor tasks such as gait and balance. for instance, it is now quite clear that although walking is mostly an automatic task, cognitive performances are strongly implicated in balance/postural control through management of axial musculature and integration of visual, vestibular, proprioceptive and sensory feedback. moreover, this interplay is age-dependent, as different neural substrates are engaged in the execution of cognitive tasks in the young and the older adults [7] . when external conditions tend to reduce the automaticity of the task (i.e., uneven terrain, concurrent motor/cognitive tasks, existence of neurologic disorders), additional cognitive resources are needed, thus compromising gait performance and increasing instability [8] . gait alterations in older persons, common even in absence of specific pathologies, are usually quantified in terms of changes occurring in variables associated with the gait cycle. for instance, modification of spatio-temporal parameters such as speed, stride length and cadence (which all tend to decrease with aging) have been often reported [9] . even other aspects of walking performance such as symmetry, regularity, coordination, dynamic balance and foot movements, may provide information on specific (and sometimes subtle) gait dysfunctions [10, 11] . recent studies suggest that gait parameters can be effectively employed as early clinical marker of cognitive decline and dementia, given that gait abnormalities may precede them by several years. in this regard, it has been observed that even in apparently healthy older persons, early disturbances in cognitive processes such as attention, executive functions and working memory often coexist with slower gait speed and greater instability [12, 13] . verghese et al. [14] observed that in non-demented individuals, the simultaneous presence of subjective cognitive complaints and slow gait depict a predementia syndrome which they defined as motoric cognitive risk (mcr) syndrome. several subsequent studies have pointed out that older persons with mcr are at high-risk of dementia, exhibit more chronic illnesses and are subject to a range of adverse outcomes including disability and falls. poor cognitive performances influence not only gait, but also other motor tasks essential for the independence of the older person, such as rising from and sitting down in a chair, turning, etc. these can be even more demanding than gait in terms of cognitive resources required for planning, orientation in space and organization purposes [15] . the ability to perform such activities, which are commonly classified under the umbrella of "functional mobility", can be easily assessed using a wide range of tools [16] . among them, the timed-up-and-go test (tug, [17] ) is one of the most common, owing to its clinical utility in diagnosing risk of falls [18, 19] in community-dwelling and frail older adults. however, tug has been demonstrated also reliable in detecting functional mobility limitations among individuals with cognitive impairments and dementia at different stages [20] . in particular, it has been observed that older adults with cognitive impairments show a higher tug time with respect to unaffected individuals [21, 22] . they also exhibit moderate to large correlations between cognitive performance (assessed using either addenbrooke's cognitive examination revised ace-r, [23, 24] or the montreal cognitive assessment, moca, [25] ) and overall tug time or tug sub-phase speed (in particular intermediate and final 180° turning time [23] ). the results of a recent meta-analysis [20] suggest that tug time might be effectively employed as a marker to support the diagnosis and identification of dementia stages, including the prodromal phase. it is to be noted that the quantitative assessment of gait and functional mobility parameters in older persons with or without cognitive impairment are usually performed with a variety of methods ranging from the use of a simple stopwatch (suitable for calculating gait speed and recording tug time) to more sophisticated equipment such as optical motion capture systems and electronic walkways that provide data on several spatio-temporal and kinematic parameters [26] [27] [28] . nevertheless, while in principle a large set of quantitative, robust, and reliable data is desirable to accurately investigate mobility, it should also be considered that besides the cost and complexity of such systems, they often require dedicated space and specialized personnel. as a result, they are unsuitable for home-community-and ambulatory-based care [29] . in recent years, inertial measurement units (imus are devices composed of a tri-axial accelerometer, gyroscope and magnetometer) have become widespread in human movement analysis owing to their reliability, reduced cost and ease of use [25, 30] . miniaturized wearable imus allow execution of a variety of tests on balance, gait and functional mobility under ecological conditions, and have already been employed to test older adults with and without cognitive impairments [31] [32] [33] [34] [35] [36] . a simple setup consisting of a single unit placed on the lower back (widely used to test individuals with neurologic disorders, [37] ) appears feasible for use in home and clinical settings since it requires a relatively short time to prepare the subject and perform the analysis. this approach also allows performance of a sort of instrumented version of clinical tests such as the 6-or 2-min walking test and tug, while providing a larger amount of relevant information. for instance, an instrumented tug provides data not only on the overall time required to perform it, but also time, speed and accelerations associated with each tug sub-phase, namely sit-to-stand, intermediate and final 180° turns and stand-to-sit [34, [38] [39] [40] . similarly, it is possible to extract several spatio-temporal parameters such as speed, cadence, step/stride length and duration of stance, swing and double support phases from a gait analysis assisted by imus. moreover, further refined processing of trunk accelerations allows performance of more sophisticated analyses (i.e., those aimed at investigating stride-to-stride symmetry or "smoothness" of gait) [41] [42] [43] , which may reveal slight changes in gait that occur even before they become detectable with conventional spatio-temporal parameters. based on the aforementioned considerations, the main purpose of the present study was to verify the feasibility of using imus in a clinical setting to screen gait and functional mobility in a cohort of community-dwelling older adults in a geriatric outpatient center specialized in diagnosis and treatment of cognitive disorders and dementia. in particular, we intended to verify the capability of imu to discriminate, through the results of the instrumented gait and tug test, individuals with or without cognitive impairments and assess the existence of significant correlations between cognitive status and mobility parameters. if confirmed, such findings would strengthen the idea of systematically employing quantitative analyses of mobility assisted by imu in a clinical setting. since imu-based tests are relatively easy to perform, they might effectively integrate the conventional geriatric assessment and facilitate the early detection of signs of cognitive decline based on changes in gait and functional mobility. in the period november 2019-february 2020, 213 adults aged over 65, consecutively examined at the center for cognitive disorders and dementia (in collaboration with the geriatric unit of "ss. trinità" general hospital, cagliari, italy) were enrolled in the study. exclusion criteria were the presence of neurologic disorders able to interfere in mobility (e.g., parkinson's disease, multiple sclerosis and stroke), severe symptomatic orthopedic conditions and, in general, inability to walk independently. individuals who needed aids to ambulate (i.e., canes, walking frames, crutches, etc.), were also excluded owing to the reduced reliability of instrumental measures of mobility for the specific setup employed herein [44] . purposes and methodology of the study were carefully explained to all participants (or to their family members/ caregivers when necessary) and they signed an informed consent form. they then underwent a detailed geriatric and psychological assessment during which their cognitive status was evaluated using the italian version [45] of addenbrooke's cognitive examination revised (ace-r, [46] ). ace-r is articulated across five cognitive domains, namely attention and orientation, memory, verbal fluency (related to cognitive abilities of the executive function), visuospatial function, and language. the overall ace-r score ranges from 0 to 100, with lower scores indicating superior cognitive impairment. the italian version of ace-r has been found reliable in discriminating individuals with or without mild dementia according to specific cut-offs calculated for young-old (< 75 years) and old-old (> 75 years) older persons [45] . these cut-offs were also employed in the present study to stratify participants into four groups as follows: • healthy controls young-old (age ≤ 75, hc-yo): ace-r score ≥ 79 (n = 64) • healthy controls old-old (age > 75, hc-oo): ace-r score ≥ 60 (n = 78) • cognitively impaired young-old (age ≤ 75, ci-yo): ace-r score < 79 (n = 28) • cognitively impaired old-old (age > 75, ci-oo): ace-r score < 60 (n = 43) their anthropometric and clinical features are reported in table 1 . the study was conducted in accordance with the ethical standards of the institutional research committee and the 1964 helsinki declaration and its later amendments. both gait and tug tests were performed using a miniaturized wearable inertial sensor (g-sensor ® , bts bioengineering s.p.a., italy) previously employed for similar investigations in older adults [40, [47] [48] [49] , as well as in individuals with neurologic disorders [50, 51] . the sensor was attached to the individual's trunk using a semi-elastic belt at two different positions which approximately corresponded to s1 vertebrae (for gait analysis) and l1 vertebrae (for tug test) locations. previous studies reported an overall good-toexcellent test-retest reliability for most parameters considered in the present study. this was true both for gait analysis [52, 53] and tug [54, 55] performed with the same kind of setup, although some specific variables (in particular gait cycle phase duration and sit-to-stand time of tug) should be interpreted with caution. participants were requested to walk along a 30-m hallway, following a straight trajectory at a self-selected speed and in the most natural manner. during the trial, the inertial sensor recorded accelerations along three orthogonal axes: antero-posterior (ap corresponding to the walking direction), medio-lateral (ml), and supero-inferior (v) at a frequency of 100 hz. data were transmitted in real-time via bluetooth to a notebook, where they were later processed using a custom matlab ® routine to calculate the following spatio-temporal parameters of gait: speed, stride length, cadence and duration of stance, swing and double support phase (expressed as a percentage of the gait cycle). in addition, the relationship between step length and cadence (i.e., walk ratio, [56, 57] ) was calculated. it has been reported that the walk ratio is indicative of cautious gait, poor balance and impaired central control of gait and has also been associated with falls and cognitive performance in older persons [57, 58] . the gait parameters known to be influenced by an individual's anthropometry (i.e., gait speed, stride length and cadence) were normalized by dividing them by each participant's height [59] [60] [61] . similarly, walk ratios were adjusted according to participant's height following the approach proposed by sekiya et al. [56] . such procedures also allow removal of the effects of anthropometry on gait variables possibly associated with different m:f ratios of the four groups. in all acquisitions, the first and last two strides were excluded from the analysis to process data associated only with steady state conditions and thus remove the effects of acceleration and deceleration transients. for the instrumented tug (itug) tests, participants were requested to sit, with arms crossed at the wrists and held against the chest, on a standard office chair without armrests (seat height and width 48 cm, seat depth 40 cm) equipped with a back support 34 cm high. at the "start" signal, they stood up, walked for 3 m at a comfortable and safe speed [17] , performed a 180° turn around a cone, walked back to the chair and performed a second 180° turn to sit down and end the test. in this case, two trials were performed: the first was to familiarize with the task and only the second was considered for the subsequent analysis. since tug is characterized by high test-retest reproducibility in older persons [62] , a single trial can be considered sufficient to provide reliable data. even in this case, accelerations were acquired at 100 hz frequency and transmitted via bluetooth to a notebook, where dedicated software (bts g-studio, bts bioengineering s.p.a., italy) calculated the overall itug time and times associated with each sub-phase, namely: • sit-to stand: the transition from sitting to standing position • intermediate 180° turn: performed around the cone to invert the walking direction • final 180° turn: carried out to prepare the body to assume the sitting position at the end of the tug • stand-to-sit: transition from sitting to standing position differences in gait and itug parameters related to the cognitive status of participants were explored using oneway multivariate analysis of variance (manova), where the independent variable was the group and the dependent variables the 7 gait parameters or the 5 itug parameters previously listed. in both cases, the level of significance was set at p = 0.05 and the effect size was assessed using the eta-squared (η 2 ) coefficient. univariate anovas were carried out as a post hoc test by reducing the level of significance to p = 0.007 (0.05/7) for the gait analysis and to p = 0.01 (0.05/5) for the itug test after a bonferroni correction for multiple comparisons. where necessary, post hoc holm-sidak tests were performed to assess pairwise intraand inter-group differences. the relationship between gait/itug parameters and cognitive status (as indicated by the ace-r score), was explored using spearman's rank correlation coefficient rho by setting the level of significance at p < 0.05. rho values of 0.1, 0.3, and 0.5 were assumed to be representative of small, moderate, and large correlations respectively, according to cohen's guidelines [63] . all analyses were performed using the ibm spss statistics v.20 software (ibm, armonk, ny, usa). the results of the experimental test for gait and the itug analysis are summarized in tables 2 and 3 . table 4 reports the results of the correlation analysis between mobility features and ace-r scores. table 2 (and graphically shown in fig. 1) , all parameters exhibit a monotonic decrease on passing from the group of youngest individuals cognitively intact to the oldest participants cognitively impaired. in particular, the post hoc analysis revealed that the ci-oo group exhibited gait speed values significantly lower than any other group (p = 0.003 vs. ci-yo, p < 0.001 vs. hc-oo and hc-yo) while stride length and cadence were reduced with respect to the hc-oo and ci-yo groups (p < 0.001). similarly, stance and double support phases had increased in ci-oo with respect to hc-oo and hc-yo (p = 0.005 and p < 0.001 respectively) and, correspondingly, swing phase was reduced. the ci-yo group was characterized by reduced gait speed and stride length with respect to hc-yo (p < 0.001) and healthy individuals of different age ranges differed only as regards gait speed (p < 0.001). walk ratio values of ci-oo were found significantly reduced with respect to hc-oo (p < 0.001) and hc-yo (p < 0.001), even for functional mobility (see data in table 3 ), the statistical analysis detected a significant main effect of group on itug parameters [f(15, 566.32) = 12.93, p < 0.001, wilks λ = 0.44, η 2 = 0.24]. as shown in the diagrams in fig. 2 , a clear increasing trend, passing from the young-old healthy participants to the old-old cognitively impaired, is visible as regards overall itug time and 180° turns, while in the cases of sit-to-stand and stand-to-sit, differences are much less marked. in both healthy and cognitively impaired groups, the time necessary to stand and sit was very similar across the age groups, even though cognitively impaired people are generally slower in performing both tasks. the post hoc analysis showed that cognitively impaired old-old participants exhibited poorer itug duration and final 180° turning times with respect to all other groups (p < 0.001 in all cases). in particular, the overall itug duration in the ci-oo group was almost double with respect to their cognitively intact age-matched peers (21.7 s vs. 12.3, p < 0.001). ci-oos exhibited significantly higher sit-tostand, intermediate 180° turning and stand-to-sit times with respect to hc-oos and ci-yos (p < 0.001). cognitively impaired young-old participants exhibited significantly higher sit-to-stand and stand-to-sit times with respect to both groups of healthy controls and overall itug duration was higher than for hc-oos. in conclusion, no differences were found in any parameter among healthy controls regardless of their age range. generally speaking, all mobility measures we investigated were found significantly correlated with cognitive status as expressed by the ace-r score, although with some differences in magnitude. in particular, large positive correlations were observed between ace-r and gait speed (rho = 0.580, p < 0.001) and stride length (rho = 0.536, p < 0.001), while a large negative correlation was observed with overall itug duration (rho = − 0.662, p < 0.001). duration of gait cycle phases were found moderately correlated with ace-r (rho values were slightly below 0.3, negative for stance and double support phase and positive for swing phase duration) fig. 2 trend of itug parameters across the groups tested. error bars indicate standard deviation while in the case of cadence and walk ratio, rho was 0.436 and 0.407, respectively (p < 0.001 in both cases). as regards itug, all parameters associated with the sub-phases were found negatively correlated with cognitive status, with rho values ranging from − 0. imus represent an interesting solution in assessing mobility in older persons with and without cognitive impairment in a clinical setting for several reasons. first of all, differently from what occurs with laboratory-based motion capture systems, dedicated space/personnel are not required, the preparation of individuals is simple (i.e., no undressing or marker positioning phases) and thus they can perform the test immediately. moreover, the positioning of the sensor is simple and fast, as the wireless connection with a notebook. the only critical point is represented by the autocalibration of the device, which is performed before the start of the trial: it lasts 4-5 s and requires participants to stay as still as possible. however, in our experience, the whole testing process (from device placement to data download and verification), including a brief familiarization phase, requires no more than 15-20 min for both gait and tug tests. data processing is immediate in the case of tug, while 5 more minutes are necessary to export imu data into a text file and then process it with the matlab routine. however, it must be recalled that the validity and reliability of imu-based gait data may be affected by several factors, including random inclination changes of the sensor during walking, which may influence the results if not properly corrected [64] . similarly, segmentation of the tug phases may represent a critical issue, particularly as regards the definition of onset and offset of turns [38] . finally, reliability of results can be greatly reduced when people who use walking aids are tested [44] and this would exclude from assessment a not-negligible part of the population. the aim of this study was to assess the feasibility of using wearable imus in a "real-world" clinical setting to assess gait and functional mobility in older adults who underwent a geriatric screening for cognitive disorders. another aim was to explore the relationship between mobility parameters instrumentally determined and cognitive status as expressed by the ace-r score. overall, our data suggest that imus can effectively describe changes in mobility associated with the presence of cognitive impairments. the results of the gait analysis appear to reveal a clear pattern of ambulation for individuals with cognitive deficits, regardless of age, which is characterized by reduced speed, stride length and cadence. such findings are in agreement with previous studies that demonstrated the existence of a specific motor signature associated with the presence of cognitive impairments [65] , which has been hypothesized as attributable to a shared pathogenesis in executive functions, memory and gait decline. in older participants, we also observed additional alterations involving the subdivision of gait cycle phases, namely reduced swing phase and increased stance and double support phase duration, as well as significantly reduced walk ratio. reduction in gait speed represents the most distinctive feature associated with cognitive decline. for this reason, but also because it is easy to measure, speed is analyzed in most studies on gait of older persons at risk of mild cognitive impairment (mci) and dementia [8, 66, 67] . in this context, our data are fully consistent with existing literature, which almost unanimously indicates a strong relationship between gait speed and cognitive status (see the recent review and meta-analysis by peel et al. for details [68] ). moreover, the average speed reduction observed herein (0.31 m/s for young-old and 0.35 m/s for old-old participants) can be considered clinically meaningful [68] . however, it must be recalled that aging itself, besides the presence of a coexisting cognitive disorder, causes speed reduction and thus the two effects are probably in some way superposed. in our sample, the influence of aging on speed was estimated at a 16% reduction for healthy participants, a value consistent with previous studies, which reported a speed decline in the range of 7-18% for the same age group [69] [70] [71] . this figure rose to 30% in our participants with cognitive impairment, thus indicating that, on average, approximately one half of the speed change could be attributed to cognitive deficit. it is also to be noted that the observed changes in gait speed due to the presence of cognitive deficits are age-dependent, as old-old individuals experience a more severe reduction with respect to youngold ones (− 58 vs. − 39%). the presence of significant alterations in other spatio-temporal parameters such as stride length (reduced in people with cognitive impairment) and duration of stance/double support phase, also suggest that individuals attempt to adapt their gait pattern to alterations in sensory or motor systems to achieve more stable locomotion and reduce the risk of falls [72] . similarly, the walk ratio values calculated for both young and old cognitively impaired (significantly lower than their unaffected peers) are in agreement, even from a quantitative point of view, with those previously reported for individuals with mild to moderate dementia [73] . in such a context, low walk ratios are indicative of a strategy to compensate for the loss of gait stability [57] . the results of the itug test show that cognitive impairment is associated with higher overall tug time, sit-to-stand and stand-to-sit times, regardless of the individual's age, while only in older participants did we observe increased turning times. these findings suggest that coordination abilities, which are essential to performing optimal turns, are not greatly influenced by the presence of cognitive impairments when the individual is relatively young, while they always significantly affect tug phases, which rely more on postural control and lower limb strength. this is likely due to a reduction in muscle strength (which was previously observed in individuals with mci of similar age [74, 75] ), and is also probably influenced by a limited amount of physical activity [76] and poor balance abilities [77] . it was also observed that old-old participants with cognitive impairments required longer times to perform 180° turns, as they probably adopted a cautious strategy to avoid loss of balance and falls. such findings, observed in previous studies, are the consequence of a deficit in lower limb coordination [78] and poor performance in visual-spatial function and memory [79] . the results of the correlation analysis suggest that the level of cognitive impairment, as assessed by the ace-r score, plays a relevant role in mobility performance, consistent with what is reported in literature. for instance, the review and meta-analysis by demnitz et al. [80] , which summarizes the results of 26 studies involving 26,000 participants, pointed out that speed (for gait) and tug time (for functional mobility) are the variables more strongly associated with cognition measures such as the mini mental state examination (mmse), the trail making test (tmt) stroop, and the verbal fluency and digit span. the strong correlations found between ace-r score and gait speed (0.580) and overall itug time (− 0.662) are partly consistent with previous studies [17, 18] which reported coefficient values in the range 0.36-0.60 for speed (depending on the degree of cognitive impairment of the tested subjects) and − 0.21 to − 0.68 for tug time. unfortunately, no correlation data are available for the remaining gait and itug parameters with ace-r, but it is noteworthy that the recent study by choi et al. [33] detected significant correlations between cadence, double support phase duration and stride length with cognitive status (assessed using moca), which is similar to our findings. moreover, a recent study by lee et al. [58] reported the existence of a significant moderate correlation between walk ratio and mmse score in individuals with dementia. such findings are in agreement with those presented here, which indicate a similar trend for correlation between walk ratio and ace-r score. some limitations of the study are to be acknowledged. firstly, we did not consider the effect of overweight/obesity (which were present in 42 and 11% of participants respectively), although such conditions are known to have a certain impact on mobility [81, 82] . secondly, we had no information about other variables known to influence motor control in gait and functional mobility, such as actual levels of physical activity, fall-related psychological concerns or number of falls that occurred prior to the tests. finally, in the analysis we did not include factors such as education, occupational status and type, wealth, etc., which might, to some extent, affect several aspects of mobility, especially in individuals younger than 70 [70, 83, 84] and thus the generalization of our results to different socio-economic contexts should be performed cautiously. based on the findings of the present study, wearable imus appear to be a very effective solution for the assessment of mobility parameters of older persons screened for cognitive impairments within a clinical setting. as detailed information on a large set of gait and tug parameters is available, it is possible to accurately define which aspects of mobility are more impaired in presence of a cognitive deficit. data provided by such devices are useful not only to integrate the geriatric and neuropsychological assessment (and thus have a broader and more detailed view of the status of the older person) but can also help clinicians to plan specific psychoeducational interventions for caregivers and families and define tailored rehabilitation programs. moreover, imu-based data may support a better evaluation of the effectiveness of interventions aimed to alleviate the impact on daily life of mobility limitations in cognitively impaired individuals. the results obtained in the present study indicate a well-defined framework of mobility alterations in cognitively impaired individuals, especially in the old-old group, expressed in the form of peculiar gait patterns characterized by reduced speed, stride length, cadence and swing phase duration, increased stance and double support duration, and altered coordination. the latter has a strong impact on simple motor tasks such as sitting/standing transition and turns. some of these signs were also observed in young-old participants, even though the whole mobility pattern appeared slightly less compromised. the severity of mobility alterations was found moderately to strongly correlated with the extent of the cognitive impairment, especially for gait speed, stride length and tug duration, which were previously recognized as those mostly co-existing with mild cognitive impairments and 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standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. key: cord-294115-7t7kubf6 authors: miralles, oriol; sanchez-rodriguez, dolores; marco, esther; annweiler, cédric; baztan, ainhoa; betancor, évora; cambra, alicia; cesari, matteo; fontecha, benito j.; gąsowski, jerzy; gillain, sophie; hope, suzy; phillips, katie; piotrowicz, karolina; piro, niccolò; sacco, guillaume; saporiti, edoardo; surquin, murielle; vall-llosera, estel title: unmet needs, health policies, and actions during the covid-19 pandemic: a report from six european countries date: 2020-10-15 journal: eur geriatr med doi: 10.1007/s41999-020-00415-x sha: doc_id: 294115 cord_uid: 7t7kubf6 purpose: the united nations (un) has published a policy brief on the impact of the coronavirus disease 2019 (covid-19) that identifies policies and responses to protect older adults. our objective was to summarize actions, health policies and clinical guidelines adopted by six european countries (belgium, france, italy, poland, spain and united kingdom) during the pandemic, and to assess the impact of national policies on reducing adverse effects of the covid-19 pandemic in older populations. methods: reports by geriatricians on the measures and actions undertaken by governmental institutions in each country between march and july 2020, as well as the role of primary care during the pandemic, covered three areas: (a) general health strategies related to the pandemic; (b) impact of covid-19 on health inequity; and (c) initiatives and challenges for the covid-19 pandemic and beyond. results: in the six countries, covid-19 mortality in nursing homes ranged from 26 to 66%. although all countries endorsed the world health organization general recommendations, the reports identified the lack of harmonized european guidelines and policies for nursing homes, with competencies transferred to national (or regional) governments. all countries restricted visits in nursing homes, but no specific action plans were provided. the role of primary care was limited by the centralization of the crisis in hospital settings. conclusions: the older population has been greatly affected by covid-19 and by the policies initiated to control its spread. the right to health and dignity are transgenerational; chronological age should not be the sole criterion in policy decisions. public health measures recommended by the world health organization (who), such as contact tracing, social distancing and mass testing, there had been 10,357,662 confirmed cases with a total of 508,055 as of 1st july 2020. over two million of these cases and nearly 200,000 of the deaths were in europe [1] . european countries have the largest percentage of the older population in the world. increased age has been associated with worse outcomes in covid-19: older adults are more susceptible to the infection and have a significantly higher risk of severe disease and serious complications. moreover, 95% of deaths from covid-19 have occurred in those older than 60, and 50% in people aged 80 or older [2] . the main reasons suggested for the more severe effects of covid-19 on the older population include the physiological changes associated with ageing, decreased age-related immune function and the presence of frailty (covid-19 frailty spiraling syndrome) [3] . other geriatric syndromes such as cognitive decline or a reduced performance in activities of daily life play an important role in older patients' ability to cope with severe stressors such as critical illness, and might have influenced the higher rates of clinical adverse outcomes during the covid-19 crisis. the characteristics of the healthcare systems and the sociodemographic needs of the different european countries vary widely, and the measures recommended by the who (summarized in fig. 1 ) have been applied differently across different countries and regions. aware of the risks and potential inequalities in access to healthcare, the united nations (un) launched the un policy brief: 'the impact of covid-19 in older persons', a report about health policies to ensure meeting the needs of older populations, especially the most vulnerable [4] . the european union geriatric medicine society (eugms) joined the un effort and gathered the covid-19 task force, which promotes collaborative initiatives from the geriatrics and the national societies across europe [5] . our working group has followed this call to action to ponder the failures and successes of our responses to covid-19 pandemic. our initiative seeks to identify points for further improvement to ensure the highest quality of care for older adults across european countries with the perspective of a second wave or in case covid-19 is here for the long haul [6] . our objective in the present analysis was to compile a brief summary of the actions, health policies and clinical guidelines adopted by six european countries (belgium, france, italy, poland, spain and united kingdom) between march and july 2020. secondly, we discussed their impact on the older population following the four key priorities outlined in the un policy brief: 1. right to health and participation in the decision-making process. 2. social inclusion and solidarity under conditions of physical distancing. 3. necessity to provide adequate and correctly funded care and support services for older adults. 4. expand participation by older adults, share good practice and harness knowledge and data. this is a narrative review and authors' opinion on the impact of the covid-19 pandemic on the older population in belgium, france, italy, poland, spain and united kingdom between march and july 2020. a research group from barcelona formulated the aim of developing a european working group representative of specialists in geriatric medicine. these specialists were asked to provide a report on the covid-19 crisis in their respective countries, to include three areas: (1) response and difficulties related to the pandemic; (2) health inequity and the impact of covid-19; and (3) initiatives and challenges for the covid-19 pandemic and beyond. the information collected from the six national reports was pulled together and discussed following the key priorities for action outlined in the un policy brief: (1) right to health and the participation in the decision-making process; (2) social inclusion and solidarity under conditions of physical distancing; (3) necessity of adequate, correctly funded care and support services for older adults; and (4) need to expand participation by older adults, share good practice and harness knowledge and data [4] . the literature search was conducted in medline (pub-med) and the webpages of government health departments, international health organizations, consensus reports and general position statements from scientific societies. between march and july 2020, high numbers of deaths from covid-19 were recorded in four of the six participant countries (no data available for italy and poland), as shown in fig. 2 . reports from geriatricians detailed responses and difficulties related to the pandemic and the impact of the disease on health inequity in older adults in their respective countries. initiatives and challenges to consider in preparation for a potential second wave of covid-19 are discussed below. the measures implemented against covid-19 in each country are summarized in fig. 3 , which offers a concise comparison of the actions taken. belgium general health strategies related to the pandemic: the first cases in belgium were detected on 2nd march [7] , ten days before the who declared a pandemic on 12th march 2020. the website dedicated to covid-19 launched by the national institute of epidemiology and infectious diseases (sciensano) in the first week of march became an efficient communication tool during the crisis. on 17th march, belgium endorsed the general who recommendations [1] . the strategy of the belgian healthcare authorities was focused to prevent overload of hospital capacity, particularly in intensive care and emergency departments. in the frenchspeaking region, the "plan d'urgence hospitalier" was launched on 14th march and focused on ensuring distribution of hospital equipment, including personal protective equipment (ppe), and human resources (e.g., by reduction/ impact of covid-19 on health inequity: on 25th may, belgium had reported 5734 people with confirmed sars-cov-2 infection in long-term care facilities (ltcf). from a total of 9052 covid-19 related deaths, 4616 (51%) were in ltcf, as shown in fig. 2 [8] . the nursing homes population was the most severely affected, probably due to the baseline health status of residents (higher comorbidity and frailty) and scarcity of resources. general governmental recommendations for the control of sars-cov-2 spread in nursing homes had been given, but not all of them could be implemented. the response of individual nursing homes depended on the local resources in terms of protection, isolation and medical care, which were shown to be insufficient when the demands exploded exponentially. new supplies perhaps became available too late: ppe distribution started on 26th march and systematic reverse transcription polymerase chain reaction (rt-pcr) testing for residents and workers on 10th april. the nursing homes registered each new case of covid-19 as "suspected", "confirmed after rt-pcr test" or "deceased" during part of the crisis. this registration procedure made it difficult to accurately quantify and differentiate the number of covid-19 related deaths from deaths related to worsening of previous chronic conditions or other acute processes, contributing to a general underestimation of the disease burden and mortality. decision-making regarding whether to transfer patients from the community or nursing home setting to a hospital was not based on age, but on functional capacity, health status and previous wishes expressed by the patients or their representatives. guidance to general practitioners regarding levels of therapeutic intensity and transfer decision-making came from scientific societies (e.g. the belgian society of geriatrics and gerontology [bsgg] and the société scientifique de médecine générale [ssmg]). the ssmg developed an algorithm based on rockwood's clinical frailty scale and semiology ("atypical" presentation of illness) of covid-19. general health strategies related to the pandemic: the first three official covid-19 cases in france were listed on 24th january 2020 [7] . the organization of the response of the health system in exceptional health situations (organisation de la réponse du système de santé en situations sanitaires exceptionnelles) launched a plan for epidemic and biologic risks (risques épidémiques et biologiques) [9] . stage one of this plan, called orsan-reb, was launched on 23rd february to limit the introduction of the sars-cov-2 into france. six days later, stage two was started to contain the epidemic by screening suspect cases and treating possible and confirmed cases in "covid-19-ready" hospitals (individual focus). stage three, also known as the epidemic stage, was launched on 14th march [7] and the french population was finally confined two days later [7] , after 6663 cases and 148 deaths. at this stage, given the active circulation of sars-cov-2, the strategy shifted to a collective approach based on three main axes: (1) to protect vulnerable populations, (2) to treat mild patients in ambulatory care [10] , and (3) to treat serious cases in hospital [9] . nevertheless, the protection of vulnerable populations had begun in stage two and all visits to nursing home residents were prohibited from 11th march. during this period and the following three weeks, even if the mortality rate increased in nursing homes, the first deaths in nursing homes were not communicated until 1st april. on 29th may, france had reported 74,402 people with confirmed sars-cov-2 infection in ltcf. of the 45,130 total covid-19 related deaths, 13,539 (30%) were in ltcf [7] (fig. 2) . impact of covid-19 on health inequity: at the beginning of the epidemic stage, the anticipation of a persistent lack of beds in intensive care units (icus) led to a reflection on the prioritization of care according to age. thus, on 19th march the ile-de france regional health agency relayed recommendations about the decision to admit to icu published by the french society of anesthesiology and resuscitation, in which age was clearly a criterion of decision (although without a specified cut-off age) [11] . fortunately, these considerations were reported in mainstream media, which led to strong reactions from the population and to one of the first statements of the french national academy of medicine against ageism [12] . with the intervention of the president of the french society of geriatrics and gerontology, hammering on the importance of self-determination in older adults, this criterion was finally abandoned on 23rd april. general health strategies related to the pandemic: the first confirmed case of sars-cov-2 infection in italy was identified on 18th february 2020 in the town of codogno (lombardy region) [13] . this case was soon found not to be isolated, and the diffusion of the sars-cov-2 in the area was more rapid than expected. in the following days, social distancing measures were applied, culminating in a regional, and subsequent national, lockdown [14] . the magnitude of events together with a general unpreparedness of the healthcare system made the covid-19 pandemic particularly burdensome in italy. in particular, several geriatric settings (e.g., nursing homes) found themselves completely abandoned, with major difficulties in managing their frail older patients [15] . at the same time, hospitals (especially the emergency departments) were overwhelmed by patients with respiratory conditions, requiring clinicians to take tough decisions in an emergency characterized by lack of resources (e.g., ventilators) [16] . impact of covid-19 on health inequity: in this scenario, many critical decisions were taken without supporting evidence (given the novelty of this coronavirus), support from ad hoc specialists, or adequate time to formulate a sufficiently informed plan. in other words, many of the choices made at the time might be at risk of being considered unethical [16] . for example, the italian society of anesthesia, analgesia, and intensive care (siaarti) published the "clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances", in which there is explicit mention about the role of age in the decision-making process: "an age limit for admission to the icu may ultimately need to be set. the underlying principle would be to save limited resources which may become extremely scarce for those who have a much greater probability of survival and life expectancy, in order to maximize the benefits for the largest number of people"; and "together with age, the comorbidities and functional status of any critically ill patient presenting in these exceptional circumstances should carefully be evaluated. a longer and, hence, more 'resource-consuming' clinical course may be anticipated in frail older patients with severe comorbidities, as compared to a relatively shorter and potentially more benign course in healthy young subjects" [17] . although this document suggests consideration of comorbidities and functional status of the patients when taking decisions about covid-19 management, age is the first criterion mentioned, the easiest/quickest factor to be obtained in an emergency situation, and the logical parameter for resource allocation in an ageistic society such as the one we live in. the adoption of age as a cornerstone criterion for clinical decisions during the pandemic is also implicitly present in those directives that tried to limit access to hospital care for nursing home residents. moreover, the discharge of hospital patients-possibly with covid-19to nursing homes (where the frailest and most vulnerable individuals live) was maintained, justified by the need for decompression of emergency departments. again, the traditional stigma affecting nursing homes determined the way in which the system reacted to the pandemic [18] . general health strategies related to the pandemic: in poland, the sars-cov-2 outbreak started on 4th march 2020 with the so-called "patient zero", a 66-year-old man who travelled by bus from germany to poland. as of 17th june, there were 30,701 confirmed cases of covid-19 in poland. unfortunately, as of june 2020, poland lacks regularly updated, publicly available information on the age structure of diagnosed, recovered and deceased persons with covid-19, including separate reports for those aged 65 and older. with regard to national guidelines, "call to action" documents for healthcare workers, patients and their families were launched by the college of family physicians in poland together with the polish college of geriatricians (24th march) [19] and the polish society of gerontology (25th march) [20] . on 9th april, the polish psychiatric association published a comprehensive set of recommendations for patients, caregivers and physicians concerning the appropriate approaches in patients with dementia during the covid-19 epidemic [21] . in mid-march 2020, the national health care system adapted to the changing requirements to sustain medical care. as a result, at the beginning, 19 single-purpose infectious disease hospitals were established across the country for covid-19 patients, supplemented by 70 infectious disease wards. none of these has been dedicated to the care of older patients exclusively. impact of covid-19 on health inequity: as of june 2020, chronic comorbidities and patients' treatments are managed by way of tele-counselling whenever possible; no additional support or modality to facilitate healthcare services contact has been offered for older patients. no specific model of care has been proposed for the most vulnerable older adults (e.g., patients with dementia, frail or disabled). however, a telephone help-line for older persons has been established, dedicated to tackling the anticipated problems of depression and other mood disorders. national and local-level health care authorities have been using television and radio broadcast networks, social media and press for information campaigns covering sars-cov-2 prevention and risks. the first educational campaign concerning sars-cov-2 in poland had been introduced before the first case was confirmed, and was followed by more detailed and specific advice. no specific recommendations to older persons in general, beyond the who recommendations, were issued ( fig. 1) . apart from this advisory position, no particular senior-targeted action was taken at the community level (including social support, meals-on-wheels, extra financial support for those affected by sars-cov-2, etc.). day-to-day support is often provided by formal or informal volunteers, mobilized and coordinated by means of social networking. general health strategies related to the pandemic: spain is third in europe for the number of covid-19 cases, as of 8th june 2020. despite the news coming from italy, no prevention policies were implemented in spain until 15th march. the impact of the covid-19 pandemic was greater than in neighboring countries such as portugal, which closed public facilities at the same time, but with the substantial difference that portugal had recorded 245 cases of and no deaths at the date of closure of international borders (16th march), while spain had already recorded 9191 cases and 309 deaths [7] . although the outbreak began in early march, the first cases of covid-19 were confirmed in the canary and balearic islands in mid-february and mainly involved tourists from germany and italy [22] . the spread of the virus and the impact in number of cases was uneven throughout spain, with madrid and barcelona being the most affected areas [22] , where health resources soon collapsed. redistribution of hospital resources and relocation of health professionals was needed. the capacity of the icus could not keep up with the increasing demand, and they were expanded to double or triple capacity. the number of icu beds for 100,000 habitants in spain was 9.7 before covid-19, in contrast to germany's 33.9 icu beds per 100,000 population [7] . in the city of madrid, the pavilions of the city fair were converted into a field hospital to accommodate 5000 patients. other infrastructures, such as hotels and municipal gyms, were converted into hospitals for the control of post-acute covid-19 patients [23] . impact of covid-19 on health inequity: as scientific societies and ethics committees developed recommendations to optimize the available resources, age was used as the primary variable in decision making in many of these recommendations, such as the protocols from the spanish society of intensive care medicine [24] . the spanish ministry of health published action protocols for hospitals without specifically addressing the management of the older population. one of the most notable emergencies during the covid-19 pandemic was that of nursing homes [25] . the large number of people living together and sharing common areas facilitated the spread of sars-cov-2; the patient profile, with high comorbidity, dependence and care needs, made them more vulnerable to the virus. finally, the lack of resources in nursing homes, such as lack of access to intravenous treatment, oxygen therapy, nurses or doctors, or facilities to treat acute patients, made the situation unsustainable [25] . on 25th may, no exact numbers were available for cases of sars-cov-2 infection in ltcf in spain; nevertheless, of the 26,860 total deaths related to covid-19, 17,730 were in ltcf, which represent 66% of the covid-19 related deaths in the country (fig. 2) [8] . in this context, the spanish ministry of health published hygiene recommendations and isolation measures for nursing homes. however, these did not specify clinical management or referral criteria [25] . in catalonia, the department of health developed an action protocol in nursing homes stating: "it is not necessary to refer probable or confirmed cases to the hospital in a situation of advanced chronic disease, as a limitation of the therapeutic effort has been decided" [26] . nonetheless, no ppe or medical supplies for the management of new covid-19 cases were provided to nursing home facilities, most of which are private and understaffed [27] . it is true that referrals should be reduced as much as possible, but an advanced chronic disease cannot be a criterion for exclusion without previous assessment of functional status and life prognosis. as the health crisis progressed, primary care was instructed to coordinate with nursing homes, but given the results this approach was insufficient [25] . general health strategies related to the pandemic: at the national level, all those deemed "clinically extremely vulnerable" were sent a letter explaining the need to "shield" for 12 weeks [28] [29] [30] . otherwise, social distancing was advised, with people at "moderate risk" or "clinically vulnerable" to take particular precautions, which included all people older than 70 years, or with diabetes, asthma and other chronic conditions. confusion between clinically "vulnerable" and "extremely vulnerable" was perpetuated in public statements, leading to accusations at the government of being ageist [30] . the british geriatrics society (bgs) has curated a helpful "coronavirus and older people" webpage with the most pertinent of many new and updated clinical guidelines [31] . this includes some of the national institute for health and care excellence (nice) rapid covid-19 guidelines [32] , as well as several specific good practice guides and fact sheets written by the bgs, such as "managing the covid-19 pandemic in care homes". in line with the uk's general approach, age has not been a specific point in covid-19 guidelines. the clinical frailty scale was introduced in "covid-19 rapid guideline: critical care in adults" (ng159) as a decision aid regarding whether patients would benefit from intensive care treatment. one of its stated purposes was to "enable services to make the best use of national health system (nhs) resources", albeit caveated with the need to exercise judgement and a reminder that compliance was not mandatory. there may be some positive legacies from new guidelines, such as improved appreciation of the frailty concept amongst non-geriatricians, and community palliative care provision. at the point of writing, 8th june 2020, the uk has had 287,399 confirmed cases of covid-19, and 40,597 covid-19 "associated" deaths [7] . the total excess mortality, however, is currently estimated at 59,500 people, 65% over usual rates for this time of year and one of the world's highest [7] . between may 15-17, scotland reported 5,652 people with confirmed sars-cov-2 infection in ltcf (no data available for england and wales). in scotland, of the total 3,213 deaths related to sars-cov-2, 1,438 (44%) were in ltcf (fig. 2) . in england and wales, of the total 34,978 deaths related to covid-19, 7401 (21%) were in ltcf (fig. 2) [8] . impact of covid-19 on health inequity: primary care was "reminded" to proactively have discussions with patients regarding their treatment escalation wishes. robust responses from the care quality commission, charity sector, and necessary clarifications and retractions followed. in april, nhs england recommended that primary care can "move immediately to total digital triage followed by remote management wherever possible and appropriate…" [33] . non-digital users were able to access telephone support, but the push to online services has created a perceived barrier for some older people. arguably the most widespread implication for this population, however, was the early political emphasis on prioritizing hospitals, without sufficient safeguards for those residing/working in care home and social care sectors. the decision in march to empty nhs hospitals was alongside department of health and social care guidelines stating: "negative tests are not required prior to transfers/admissions into the care home" [34] , despite unreliable ppe deliveries to care homes even by early may. discharging people from hospitals to care homes without sars-cov-2 testing had a devastating impact. by 10th may, 36% of care homes in england and 59% in scotland had a suspected/confirmed outbreak of covid-19 [34] . figures for those receiving domiciliary care are more difficult to get, but in england between 10th april and 8th may, there were 3161 deaths, 1990 more than the 3-year average for the same time period [35] . hospitals and care homes followed national guidance to restrict visiting, and, therefore, many died alone or with only staff members present, and social distancing has also had an impact on the bereavement process. support from institutions and health care providers should aim to address the specific needs of older patients. social adjustments have been made. in the uk, for example, early headlines highlighted difficulties with older adults getting food items, resulting in some supermarkets introducing special shopping hours only for them, and those with "shielding" letters could get priority online food deliveries. a need for digital connectivity and bank cards, or family/social support, was often needed to help access resources online. in many countries, the improved social and digital connectivity has been a positive outcome for some. otherwise mental health, and physical, cognitive and social deconditioning are major concerns, as well as delays to elective surgery and resultant deterioration in health. another shared concern was the lack of attention to providing adequate materials, medications and human resources to nursing homes. right to health is universal; this right cannot be subject to age. a related issue was the lack of guidelines for the management and hospital transfer of older patients with covid-19, along with the subsequent isolation, infection control for residents, staff and visitors, and institutional and individual hygiene measures, as well as consistent reporting protocols. only reports from poland and uk mentioned the development of policies, national guidelines and protocols. development and systematic updating of harmonized european guidelines would provide a shared baseline of good practice, a benefit for all european countries that could save lives, time and confusion. media attention during the covid-19 pandemic has been mainly focused on the hospital centers. however, primary care and community pharmacy have played crucial, less publicized roles. the who recommendations on the role of primary care during the covid-19 pandemic (fig. 1) highlight the importance of rapid diagnosis (given the risk of sars-cov-2 transmission between contacts), health education for the population to prevent infection, and the maintenance of essential health services in the general population [1] . however, in many countries, especially those hardest hit by the pandemic, primary care has played more of a "buffer" role to desaturate hospital emergency departments, address collective anxiety and avoid if possible the admission of patients with chronic decompensated diseases [36] . relocation of health professionals from primary care to hospitals limited the power of action against sars-cov-2 by primary care centers and overlooks the importance of primary care in guaranteeing continuity of care. new models have been developed to cope with the absence of physical consultations. web-based telemedicine (e.g., webpages, apps, etc.) and telephone calls have been given priority, whilst home medical visits have been reserved when physical examinations are required [37] . these strategies have served to follow sars-cov-2-positive patients in self-isolation but failed to fulfill one of the main objectives of primary care, e.g. to look after older people with chronic pathologies. some older people may thus have suffered from a reduction in control of chronic diseases, as well as struggling with fear and anxiety during the pandemic. chronic disease management has also moved almost entirely to remote consultations. on the other hand, several interesting initiatives have been taken across europe because of the covid-19 pandemic, such as an increased move to digital triage and liberalization of home oxygen therapy prescriptions (allowing earlier hospital discharges, or in some cases avoidance of hospital admission). attention has been focused on tasks that add value to clinical practice by filtering the medical consults, distinguishing those that can be solved online from those needing face-to-face attention [38] . there has also been improved collaboration with community healthcarespecific groups and services and third-sector agencies such as independent charities. the role of primary care across europe during the covid-19 pandemic has frequently been limited by the centralization of the crisis in hospital settings, and by the lack of facilities and resources to combat sars-cov-2. in a context of economic recession following the shutdown of the european economy, primary care should be strengthened with sufficient resources to cope with the follow-up and detection of new cases of covid-19, and also to meet the ongoing needs of comorbid patients. the six countries that participated in this project implemented the general who recommendations in the first or second week of march 2020 (fig. 1) [1] . a lack of government planning, the collapse of national health systems, and a scarcity of material and human resources occurred in most of these countries, particularly during march and april 2020. older adults were the most severely affected population in belgium, france, italy, spain, and the uk [39] , particularly those living in nursing homes (no data available for poland). all authors pointed out the scarcity of material and human resources (fig. 3) . in 2011, the international association of gerontology and geriatrics launched the 'global agenda for clinical research and quality of care in nursing homes', which highlighted the general lack of specific medical education in long-term care in most of the european countries and the urgent need to harmonize guidelines across europe [40] . the special interest group (sig) in long term care of the eugms states that shortcomings reflected in the 2011 report have still to be resolved and highlights their negative impact on the management of nursing homes during the covid-19 pandemic [41] . unified and targeted actions are required. it would be crucial to provide common guidelines about the protective measures to prevent sars-cov-2 infections in nursing homes, the priorities (material and human resources) in dealing with outbreaks, the measures for testing and monitoring both older residents and workers, and measures to control infection once it has entered a facility (e.g. isolation protocols) and ensure tailored acute and/or palliative measures for residents with covid-19 [42] . belgium, spain and the uk increased their efforts to implement a treatment escalation plans, which included preventive decisions regarding theappropriateness of transfer from nursing homes to hospitals in case of clinical worsening (fig. 3) . these decisions were not based on age, but rather on functional status, comorbidities, life expectancy and therapeutic options. in belgium, the assessment of baseline frailty was included in the criteria to transfer patients to hospitals. in the uk, the bgs published a position statement to emphasize the need for using standardized meaningful measures and outcomes such as frailty and function rather than age. older people are a heterogeneous population and need multidimensional policies based on equality, high quality of care and intergenerational exchange to ensure high ethical standards and preservation of personal dignity. it is necessary to involve patients, caregivers, nursing home directors and stakeholders in the decisions that directly affect them, developing patient-and care-centered policies [43] [44] [45] . health care is a basic human right, and access to adequate health resources must be guaranteed for all, regardless of functional state, comorbidities and frailty [16, 44] . age discrimination can be seen in this pandemic both in the poor opportunities for participation by older people in the decision-making that affects them and in the inequities in their access to healthcare, where decisions often have been based solely on age [46, 47] . the sars-cov-2 health crisis highlights the need for health decision-making protocols suitable to be applied in clinical practice and based on scientific evidence [48] . specifying steps to support the transition of the social and health model from disease-focused medicine to person-focused medicine might help to address the unmet needs of older people [14, 46] . age has often been identified as the strongest risk factor for negative outcomes in medicine, independent of the context and disease of interest. nevertheless, chronological age is a construct that does not necessarily mirror biology, a concept increasingly recognized but not yet incorporated sufficiently into widespread medical practice. focusing on what really is a result of the aging process (e.g., clinical conditions, physical and mental function) may better estimate the individual's reserves and promote a person-tailored plan of the intervention [18] . the social distancing measures implemented by the majority of countries to stop the spread of sars-cov-2 have inevitably had an impact on the older population. both loneliness (17% in women, 9% in men over 60 living alone) and poor social support have been problems in older populations before, during and after covid-19 pandemic [49, 50] . in an attempt to reduce risks to older people, many hospitals and nursing homes restricted visits, which may also have had an adverse effect on the psycho-cognitive and physical state of older people [49] . in the community, formal arrangements for social support measures were not always instigated alongside distancing guidance, such as ensuring that home care services and food purchases were not interrupted. however, on a positive note, many communities have come together, charities such as age uk have been invaluable, and some older people are benefiting from an increase in confidence with online and social networking. some of these benefits may be longlasting (fig. 3) . the covid-19 crisis has revealed discriminatory attitudes towards older people due to chronological age [50] . despite the high pressure on the healthcare system and the availability of resources, decision-making and treatment options should be based on objective ethical clinical guidelines and parameters, and not solely on age. therefore, early identification of older individuals at higher risk by tailored, comprehensive geriatric assessment, along with the overall goal of providing the highest quality of care, should be prioritized over chronological age in clinical decision-making and the development of health policies [16] . geriatricians need to work together with other medical specialist societies, where some of the ageism is perpetuated, along with older people themselves and society at large, to change these attitudes. our initiative is aligned with the efforts of the un, who and eugms, among others, to share good practice and gather knowledge and data. several predictive models to anticipate the behavior of the disease and counteract this new threat are in progress [6] . moreover, new methodological approaches, such as the integrated approaches to testing and assessment (iata), which bring together current knowledge in different disciplines might be helpful to gather data and develop safe, efficient therapeutic strategies to combat this disease. the strengths of this work include the interdisciplinary nature of the relatively large number of specialists in geriatrics and primary care physicians from different european groups who reported on their countries' experience, offering a broad point of view of the european healthcare situation during the pandemic from the healthcare professionals' point of view. the authors acknowledge that the reporting is anecdotal, not systematic, may have some biases, and inevitably can only reflect partial observations and reflections of the authors on the needs, actions and policies described. furthermore, the opinion of each medical setting might differ compared to those in another center or region of the country, as many countries have decentralized health systems. • guarantee institutional support for long-term care facilities and develop specific, harmonized european guidelines for the management and hospital referral of older patients with covid-19, as well as protocols for action within centers registering positive cases for sars-cov-2 (e.g., case isolation, staff infection control, visitor restriction policies and hygiene measures). in addition, the supply of ppe, medication stocks and other equipment needed to maintain proper clinical management at these centers should be ensured; if needed, medical support units should be made available both in situ as well as by telematic channels. • ensure access to health resources and avoid diagnostic and therapeutic decisions based solely on age. the involvement of the patient in clinical decision-making should be enforced whenever possible, taking their values, preferences and care goals as the cornerstone (empowerment). in case intensive care hospitalization or mechanical ventilation is needed, decision-making should be individualized and take into consideration aspects such as functional status prior to the onset of acute illness, frailty, life expectancy and co-morbidity. specific guidelines for the management and hospital treatment of older covid-19 patients should also be considered. • guarantee support for those providing home care services, with similar protection in terms of ppe provision and sick pay [5] . address the disparities in pay and job security between health care and social care workers. safeguard social support services in an older population, with home assistance or meals and cleaning services, which are often what determine their ability to live alone at their homes. offer systems to avoid social isolation, such as telephone support or apps for social interaction, thus favoring mental resilience and avoiding as far as possible a negative psychological impact of quarantine and social distancing [7] . promote initiatives for psychological, medical or social support for people with dementia and their caregivers in case the day centers and third sector activities are closed. • support primary care to be the gateway to the health system for new cases of covid-19, providing it with diagnostic tools such as rt-pcr and serology for fast diagnosis and contact tracing. the availability of health professionals for the follow-up of chronic diseases should be guaranteed. although we have learned some lessons, there is room to improve with the perspective of a possible second wave of covid-19. some of the lessons learned are that the covid-19 pandemic has hit across our society; however, it has not hit all groups with the same intensity. older people have been the most affected by the virus. this sad reality shows that many of the public policies adopted by different administrations against the covid-19 pandemic did not adjust to the needs of older adults, a population requiring both inclusive and targeted measures. after the pandemic, key questions will remain as to how prevention or provision of ppe failed, questions which society must answer. points to improve have been identified. one hopes that this pandemic will enable some positive changes in future, both in terms of the value society places on care workers and how we as a society support and treat our older generation. however, much of the narrative around covid-19, including the classification of older people as "vulnerable" or recommendations "based on chronological age", may challenge this hope. our goal is to educate healthcare professionals on the scientific evidence behind comprehensive geriatric assessment and biological age in decision-making, and to address widespread perceptions of the predominant importance of chronological age. world health organization (2020) coronavirus disease 2019 (covid-19) situation report-101. world health organization estimates of the severity of coronavirus disease 2019: a model-based analysis editorial: covid-19 spiraling of frailty in older italian patients polic y-brief -the-impac t-of-covid -19-on-older -perso ns eugms executive board on the covid-19 epidemic -eugms how the pandemic might play out in 2021 and beyond an agency of the european union. covid-19 situation update for the eu/eea and the uk, as of 24 surveillance of covid-19 at long-term care facilities in the eu/eea guide méthodologique implementation of the integrated care of older people (icope) app in primary care: new technologies in geriatric care during quarantine of covid-19 and beyond décision d'admission des patients en unités de réanimation et unités de soins critiques dans un contexte d'épidémie à covid-19. societé française d'anesthésie réanimation académie nationale de médecine | une institution dans son temps covid-19 in italy: impact of containment measures and prevalence estimates of infection in the general population epidemiological characteristics of covid-19 cases in italy and estimates of the reproductive numbers one month into the epidemic nursing homes or besieged castles: covid-19 in northern italy covid-19 in italy: ageism and decision making in a pandemic clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the italian perspective during the covid-19 epidemic prognostic indices for older adults: a systematic review medycyna praktyczna (2020) geriatria. list otwarty zarządu głównego polskiego towarzystwa gerontologicznego warszawa: kolegium lekarzy rodzinnych w polsce rekomendacje ptp: epidemia sars-cov-2 a populacja osób z otępieniem polskie towarzystwo psychiatryczne informe situación covid-19 en españa a 11 de febrero plan de contingencia frente a la pandemia covid-19 recomendaciones éticas para la toma de decisiones en la situación excepcional de crisis por pandemia covid-19 en las unidades de cuidados intensivos-cuidados críticos. recomendaciones sobre limitación. www.semic yuc.org covid-19 and nursing homes ' crisis in spain : ageism and scarcity of resources . el covid-19 y la crisis de las residencias de mayores en españa guia d'actuació enfront de casos d'infecció pel nou coronavirus sars-cov-2 a les residències covid-19, adulto mayor y edadismo: errores que nunca han de volver a ocurrir who's at higher risk from coronavirus (covid-19)-nhs information for gps advising both shielding and non-shielding patients on support available during the covid-19 pandemic what is 'shielding' and who needs to do it? -full fact coronavirus: advice to older people about coronavirus (covid-19 advice on how to establish a remote 'total triage' model in general practice using online consultations government rejected radical lockdown of england's care homes | world news | the guardian sharing insight, asking questions, encouraging collaboration: cqc publishes first insight document on covid-19 pressures | care quality commission medication management and adherence during the covid-19 pandemic: perspectives and experiences from low-and middle-income countries telehealth home support during covid-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study fase de transición de la pandemia por sars-cov-2 en atención primaria -semfyc clinical and ct features of the covid-19 infection: comparison among four different age groups international association of gerontology and geriatrics: a global agenda for clinical research and quality of care in nursing homes covid-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in europe could we have done better with covid-19 in nursing homes? aging in times of the covid-19 pandemic: avoiding ageism and fostering intergenerational solidarity age alone is not adequate to determine health-care resource allocation during the covid-19 pandemic covid -19 and older people in asia: asian working group for sarcopenia calls to actions older people and covid-19: isolation, risk and ageism the 'action-research' philosophy: from bedside to bench, to bedside again issue brief on older persons and covid-19: a defining moment for informed, inclusive and targeted responseunited nations for ageing | united nations for ageing is it wrong to prioritise younger patients with covid-19? not only virus spread: the diffusion of ageism during the outbreak of covid-19 publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors gratefully acknowledge elaine lilly phd, for language revisions and unfailing support. oriol miralles 1 · dolores sanchez-rodriguez 2,3,4 · esther marco 5 · cédric annweiler 6,7,8 · ainhoa baztan 9 · évora betancor 1 · alicia cambra 1 · matteo cesari 10,11 · benito j. fontecha 1 · jerzy gąsowski 12 · sophie gillain 13 · suzy hope 14,15 · katie phillips 16 · karolina piotrowicz 12 · niccolò piro 10 · guillaume sacco 6,7 · edoardo saporiti 10 · murielle surquin 16,17 · estel vall-llosera 1 key: cord-306504-0wq7rc6s authors: barakovic husic, jasmina; melero, francisco josé; barakovic, sabina; lameski, petre; zdravevski, eftim; maresova, petra; krejcar, ondrej; chorbev, ivan; garcia, nuno m.; trajkovik, vladimir title: aging at work: a review of recent trends and future directions date: 2020-10-20 journal: int j environ res public health doi: 10.3390/ijerph17207659 sha: doc_id: 306504 cord_uid: 0wq7rc6s demographic data suggest a rapid aging trend in the active workforce. the concept of aging at work comes from the urgent requirement to help the aging workforce of the contemporary industries to maintain productivity while achieving a work and private life balance. while there is plenty of research focusing on the aging population, current research activities on policies covering the concept of aging at work are limited and conceptually different. this paper aims to review publications on aging at work, which could lead to the creation of a framework that targets governmental decision-makers, the non-governmental sector, the private sector, and all of those who are responsible for the formulation of policies on aging at work. in august 2019 we searched for peer-reviewed articles in english that were indexed in pubmed, ieee xplore, and springer and published between 2008 and 2019. the keywords included the following phrases: “successful aging at work”, “active aging at work”, “healthy aging at work”, “productive aging at work”, and “older adults at work”. a total of 47,330 publications were found through database searching, and 25,187 publications were screened. afterwards, 7756 screened publications were excluded from the further analysis, and a total of 17,431 article abstracts were evaluated for inclusion. finally, further qualitative analysis included 1375 articles, of which about 24 are discussed in this article. the most prominent works suggest policies that encourage life-long learning, and a workforce that comprises both younger and older workers, as well as gradual retirement. the older population is growing rapidly. in 2019, approximately 700 million people were aged 65 years or more in the world population. it is anticipated that this number will be doubled to 1.5 billion in order to answer the research questions, we examined studies on the aging labour force that were published between january 2008 and august 2019, to recognize the trends in the literature written in english with respect to motivation issues and potential solutions. we focused on the trends starting from the recession in 2008, when, although the economic growth slowed, the employment rate of older people remained strong, thus basically changing the position of older workers [24] . an additional motivation for focusing on this time period was because in the last decade, many assistive technologies have emerged that can aid older adults in different environments. at the same time, many jobs are transforming and can be successfully performed from home, which has recently become evident with the covid-19 pandemic. considering these two observations, the goal of this research is to investigate whether there is an underlying trend that reveals opportunities for aging at work. we adopted the preferred reporting items for systematic review and meta-analysis (prisma) methodology [25] to review the literature on aging at work policies. the prisma flow distinguishes separate stages of systematic reviews. these stages are the collection of papers, scanning of papers' text, evaluation of eligibility of papers, and meta-analysis. the collected papers on aging at work policies exceeded the capacity that would allow articles to be searched manually. thus, we used natural language processing (nlp) algorithms to perform an efficient search of the identified literature. the nlp toolkit [26] was designed to automate the literature search by using different search phrases, scanning, and evaluating eligibility within the prisma framework while generating visualizations of aggregate results. the nlp toolkit provides increased efficiency of the review process by screening the title and abstract while using the predetermined properties and their synonyms to determine the literature search phrases. it should be noted that the nlp toolkit does not understand the context and, therefore, categorizes more articles as relevant than a human reader would. however, it is a valuable resource that increases the efficiency of the review process, as demonstrated in a scoping review [27] that focused on wearable technology for connected health. the adopted prisma information flow is shown in figure 1 . since the nlp toolkit automates the review process of publications that are indexed in only three digital libraries and because we have not taken into account the nonindexed publishers, some relevant publications (e.g., reference [28] ) have been omitted from the analysis. this one and a few other papers were manually identified, and those publications originated from different digital libraries. they were used to confirm the findings of this review. however, we did not use these papers from other digital libraries to identify trends because the size of the searched digital libraries is sufficient for the purpose of the analysis. the nlp search strategy was applied in order to automatically screen irrelevant articles that have a low correlation with the topics of interest in the study. additionally, it helped in consolidating the collected articles by automatically merging results from multiple digital libraries as well as removing duplicate entries. moreover, it allowed us to iteratively fine-tune and modify the search phrases in the hope of identifying more relevant articles. finally, the nlp toolkit automatically generated charts (such as that highlight the trends of publications for certain topics. for more details about the inner workings of the nlp-based toolkit, we refer interested readers to [26] , and also to [27] , which applied it to review wearable technology for connected health. by using yearly graphs, we were able to analyze and report the potential trends in data by investigating articles in each property group (i.e., theme) separately. the nlp toolkit input parameters are a collection of phrases. keywords, together with their synonyms, are applied as search terms for the digital libraries used in the literature search. the input can be further expanded by nlp toolkit properties. properties are phrases that are being searched within the title, abstract, or keywords section of the articles identified from the previous keywords search. property groups are sets of properties that can be used for a more comprehensive presentation of search results. the input parameters used in this study are shown in table 1 . these keywords, property groups and properties are the final versions after an iterative process in which all authors participated and considered different alternatives of keywords and properties, and analyzed the preliminary results. in the process of selecting articles to be included in the quantitative synthesis, four authors participated, of which at least two had to be in agreement. table 1 . the nlp toolkit input parameters: keywords, property groups and properties. "active aging at work", "older adults at work", "successful aging at work", "healthy aging at work", "productive aging at work" motivations "deficit", "discrimination", "growth" solutions "eu policy", "assistance schemes", "eligibility criteria", "legislation", "national policy" active aging at work healthy aging at work older adults at work productive aging at work successful aging at work . solutions-related properties: "eu policy", "assistance schemes", "eligibility criteria", "legislation", and "national policy". the trends apply to the period from 2008 to 2019. the titles and abstracts retrieved by the nlp-based search strategy were evaluated by two independent researchers. they compared their opinions in order to select articles that satisfied the inclusion and exclusion criteria. the inclusion criteria were as follows: 1. articles that consider the concept of aging at work, i.e., the aging labour force. (a) articles that discuss any of three motivation factors, i.e., discrimination, growth, and deficit; articles that support any of three solution pillars, i.e., assistance, policies, and legislation. 2. articles that use research methodology with any results. the exclusion criteria were as follows: 1. articles that are about aging and older people in general that do not consider the concept of aging at work; 2. articles that cover any of three motivation factors, i.e., discrimination, growth, and deficit, in a context other than the aging labour force; 3. articles that cover any of three solution pillars, i.e., assistance, policies, and legislation, in the context other than the aging labour force; 4. articles that do not provide sufficient information for classification. when researchers differed in their opinions about an article's suitability, the article was selected for further consideration. this resulted in an initial selection of 70 articles. furthermore, the full texts of the chosen articles were reviewed in order to determine their suitability for further discussion. after the data abstraction of the final selected articles, two additional researchers separately reviewed 20% of randomly chosen articles. in the case of any disagreement on the suitability of articles, a third researcher was consulted for recommendation and assessment of the given article. this researcher was a specialist who drew a final conclusion regarding the article selection process. for the selection of the final 24 articles, two of three authors needed to be in agreement, considering the completeness of the methods, relevance to the study goal, details about the population, and impact of the study. we used the inductive approach for the article review and analysis. the selected articles were systematically organized into two groups: 1. articles that focused on motivation factors (i.e., discrimination, growth, and deficit); 2. articles that focused on solution pillars (i.e., assistance, policies, and legislation). we generated a detailed summary of each article and extracted the following items: objective, methods, main findings, limitations, and keywords. the extracted items provided the input data for discussion and conclusions. after searching pubmed, ieee xplore, and springer, we identified 47,330 potentially articles. after performing the prisma steps shown in figure 1 , the number of articles was reduced. specifically, the removal of duplicates reduced the number to 25,187 studies. the first screening process eliminated an additional 7756 studies with an out-of-scope publication year, or other parsing issues (no title, abstract, etc.). then, 17,431 papers were subject to the eligibility estimate using the automated nlp toolkit, which removed articles without any of the required properties. eventually, 1375 papers remained as potentially relevant and eligible for further manual inspection. a total of 70 articles were initially selected to analyze the trends on the aging labour force, while 24 articles were used to explore the motivation issues and solutions in the given context. the selected keywords aimed to show different aspects on the literature corpus on aging at work. figure 2 presents the number of potentially relevant papers that contained the defined keywords and that were additionally filtered manually based on their relevance to the defined properties per year. a relatively similar number of identified articles can be observed in the evaluated time period. "active aging at work" is the keyword with the smallest number of occurrences. the most frequent keyword phrase in the identified publications is "older adults at work". the number of research articles did not grow in the period of interest, but articles that address the associated keywords seem to be distributed more evenly over time. findings related to property groups show that the number of papers related to "motivation" of the adult workforce is relatively constant, with a small decline in the last two years, while the papers focused on the "solutions" property group seems to be slightly more predominant in the last few years ( figure 3) . a more granular analysis was carried out on the property groups data at the properties level, and the chart reveals that "growth" is the primary topic within the motivation group of papers, followed by "discrimination". the papers related to the topic of "deficit" appeared only in recent years ( figure 4 ). the focus of papers within the "solutions" property group ( figure 5 ) seems to move from "national policy" based to "legislation", while "assistant schemes" and "eu policies" seem to be of smaller interest for the scientific community. there was only one paper that addressed "eligibility criteria", which makes this topic interesting for further research. a total of 12 articles out of 24 were selected for the further analysis of motivations that drive the research on the aging labour force. the selected articles were organized into three focus groups according to the considered terms related to motivation, i.e., "discrimination", "growth", and "deficit". a more detailed analysis of these articles is presented in table 2 . the remaining 12 articles out of 24 were used for a more detailed analysis of solutions for the aging labour force. the selected articles were organized into three focus groups according to the considered solutions, i.e., assistance, policy, and legislation. table 3 shows results of the analysis. the ageing labour force could represent a risk both for society and economy unless it is well managed. therefore, the attention that researchers, governments and other stakeholders have devoted to this issue has grown over the time. according to analysis of motivations ( table 2 ) and solutions ( table 3 ) for ageing at work, possible policy implications have been identified and split into five parts: extend the length of work ability. different organizations implement changes by creating common policies and strategies, but they are not oriented toward the older workforce. intentionally interrupting the existing age-graded logic and its replacement with age-neutral logic are proposed in [16] . the authors in [29] found that the expected decline in employment could be partially offset by public policies that encourage the employment of older people. this causes problems for public finances due to expenditures on health, long-term care, pensions, etc. [3] . in order to encourage policies to maintain work ability at an old age, it is necessary to invest in decreasing of both work stress and social inequalities in health care [30] . however, extending the length of work ability does not just pose issues, but provides social and economic opportunities. avoid the age-based discrimination. the labour market will have to adapt working positions and eliminate the attitude of age-based discrimination, since it will have to fight for a working force older than 65 because it is lacking. when facing age-based discrimination at work, the organizational help and friends and family support were found to be significant in achieving better health and adaptability [31] . on the other hand, older workers with high job satisfaction without age-based discrimination remained longer in the labour market [32] . finally, the authors in [10] found that experiences of discrimination were rare and reduced with age among men, whereas almost no age differences were noticed among women. this indicates that age-based discrimination is possibly overstated, and age-related obstacles could have been miscomprehended. therefore, the flexibility of older workers can be seen as an opportunity for the active global aging trend [33] . older workers with high job satisfaction, development possibilities, affirmative relations to management, and no age discrimination stayed longer in the work market. positive relations with colleagues did not affect older workers decisions on early pension. the measures were self-evaluated. the psychosocial factors were measured at single time point. successive changes in the psychosocial work conditions could cause early pension that would be missed by the study. early pension, work conditions, management quality, job satisfaction [31] to examine the relation between successful aging and stress sources at work among older workers in china questionnaire study. study sample-242 workers aged >40 years. method variance. harman's one-factor test. factor analysis. perception of institutional support and social help from family and friends significantly corresponds to efficient aging at work. participants were surveyed at a single time point. the study relied on participants self-reports. successful aging, work stressor, social help, institutional support [10] to improve comprehension of the discrimination at work, with a focus on age and gender challenges. survey study. study sample-3203 workers with mean age 43 years. computer-aided telephone interview. binary logistic regression. daily discrimination was unusual. it appears with age among men, and not among women. the nature of work market age obstacles is not understood correctly, and the degree of aging discrimination is overstated. there was a small number of workers who faced daily discrimination. the degree of daily discrimination has to be further investigated. ageism, employment discrimination, gender, work [33] to investigate the age-related connection between job stress, extreme tiredness, prosperity, and associated personal, institutional, and community factors. survey study. study sample-1298 participants aged 18 years or older. descriptive statistics. linear regression. one-way analysis of variance. job stress was associated with several types of extreme tiredness and prosperity. personal work style, institutional and community factors were associated with prosperity. old age was connected to a poor perception of health. the study did not compare work differences. the data were cross-sectional and the causal relation of the work conditions and style with job stress, extreme tiredness, and prosperity could not be confirmed. age difference, exhaustion, prosperity, work stress, work condition growth [30] to investigate the connection of social, demographic, economic and job related factors with disability. a decrease in job stress and sociable disproportion in healthcare is appropriate for the development of policies that support aging at work. the disability indices were not formulated based on functional testing. the evaluation of stressful work was performed by abbreviated scales. position, aging workforce, work stress, work ability, social disproportion [16] to examine organizational work disrupting age-graded policies. interview study. study sample-23 organizations with employees aged 50-69 years. qualitative content analysis. organizations implement changes by creating common policies and strategies, but not those oriented toward an aging workforce. they propose to intentionally interrupt the existing age-graded logic and replace it with age-neutral logic. creative, high-tech, or communications organizations were not studied. sample size was small, so broader claims about minnesota or u.s. workers cannot be made. organizational logic, older workers, pension, flexibility [29] to examine the influence of demographic trends on the economic growth and employment level that japan is expected to face in the next 20 years the expected decline in employment could be partially offset by public policies that encourage the employment of older people. not reported. low fertility, population decline, population aging [3] to provide a literature review on the need for the senior workforce and recognize main directions for research on this topic. there is a negative association between salary and employment outcomes for the senior workforce. the connection between efficiency and salary is defined by governmental conditions and motivation to take early pension. the variations in micro-, macro-, and meso-level factors were not captured, simultaneously. there is a need for improvements in the analysis of the impact of age-based discrimination on the employing of older workers. work market, employment protection, regulation, legislation deficit [17] to examine the influence of organizational factors on work ability. cross-sectional study (online survey). study sample-306 employees. path analysis modeling. maximum likelihood estimation. organizational culture and professional effort indirectly enabled the prediction of work ability, with job satisfaction mediating these relations. the sample included mostly younger and female workers. the cross-sectional design of the study did not provide the possibility to understand causes and effects related to work ability. work ability, organizational culture [34] to recognize professions prevailed by an older workforce and evaluate their vulnerability to hazards in these professions. survey study (interviews). study sample-6502 workers aged 55 or more. chi-squared test. work-related hazards should be decreased to inhibit professional disturbance in professions prevailed by an older workforce. self-informed data were included in the study. health issues, hazards, profession, musculoskeletal disorders [35] to investigate job discrimination related to age and disability. integrated mission system data from 1993 to 2007. descriptive statistics. job discrimination of aged or disabled workers is focused on challenges involving seating, revenge, and cancellation. data do not contain supplemental information regarding a secondary cause for each filed allegation. job/age/disability discrimination [36] to investigate the relation between psychosocial factors and pension intention of older employees, while considering healthiness and work ability. survey study. study sample-3122 workers aged 50 years or older. pearson correlation. ordinal logistic regression. ageism and the absence of acknowledgement and growth opportunities are connected to older male workers' pension intention. work ability is strongly related to the pension intention of both genders. the pension age could depend on unfamiliar alternations in the worker's environment or health status. psychosocial factors, pension intention, healthiness, work ability table 3 . detailed analysis of articles that focus on solutions. assistance [37] to critically review the literature on older farmers in canada and the usa and describe how musculoskeletal disorders influence their ability to work. literature review. twelve articles analyzed in detail. musculoskeletal disturbance can lead to trauma or loss of ability to farm. it is necessary to develop safer work practices and encourage healthiness, efficiency, and professional longevity. some related articles may have been excluded from the study due to the specificity of the search strings. older farmers, work-related musculoskeletal disorders, pension age [8] to investigate the action plans that workers use to acquire skills in software and complete assignments exploratory study (interviews, surveys). study sample-10 administrative assistants. grounded theory. non-parametric statistics. administrative assistants are regularly communicating and sharing knowledge. exclusion of workers from different organizations, lack of extensive investigation on behavior at work, and creation of software tool design instructions. workplace, generations, collaboration [38] to collect information to direct the preparation of programs for returning older adults to work survey study (questionnaires). study sample-37 jobless participants aged 51-76 years. anova. chi-square test. participants who felt discriminated indicated the preference to acquire technological skills and get classroom-based education. work obstacles could not be generalized. older workers, absence of technological skills, work conditions, work experiences policy [39] to investigate factors related to perceived work ability in a sample of brazilians sample aged 50 years and more longitudinal study (surveys). study sample-8903 workers aged 50 years and over. multivariate analysis. poisson regression. work ability in old age depends on the life course, i.e., academic level, health conditions in younger and older age, minimum working age, etc. policies aiming to extend longevity in the work market must consider these factors. the collection of self-reported data associated with past experiences might have been affected by the preference to demonstrate an acceptable image, causing information bias. establishment of temporal relations for the variable related to current conditions is limited. work ability, health, socioeconomic factors [40] to review the documentation about the influence of psychological health on staying at work after pension and discuss consequences of public health policies. systematic literature review. ten articles analyzed in detail. staying at work after pension can be positive for psychological health. pension action plans are required to provide national policies that will increase the pension age and not exacerbate any disproportion in the older population. only cross-sectional and longitudinal studies investigating the impact of unexpected variables on psychological health were involved in the review. pension, job status, psychological health, social policy [7] to analyze the literature on workplace health promotion (whp) aimed at older workers systematic literature review. eighteen articles analyzed in detail. existing documentation does not demonstrate that whp enhance work ability, retention, efficiency, lifestyle, health, or prosperity of the senior workforce. the heterogeneity and low quality of the studies makes it difficult to synthesize the literature and draw the conclusions. workplace health promotion, senior workforce, health, lifestyle [41] to investigate the results of unfulfilled expectations of staying at work after age 62 on life satisfaction. longitudinal survey. study sample-1684 workers aged 51 and over. growth mixture modeling. descriptive statistics. linear regression. multi-nominal logistic regression. majority of men and almost no women expected to stay at work after age 62. the subjective prosperity of older adults is affected by unmet expectations of staying longer at work . the significance of different job options before full pension was not assessed. work expectations, pension, life satisfaction, subjective prosperity [42] to find out whether the workers' ages determine the evaluation of their work-life balance. survey study. study sample-500 workers aged from 21 to 70 years. kruskal-wallis test. spearman's r correlation analysis. the maintenance of work-life balance will be indicated by older workers. all employees do not have the same possibilities to take advantage of solutions that provide the support of work-life balance. the diversity of the answers given by the participants according to the type and state of particpants affiliation was not analyzed. work-life balance, workers'assessment, aging workforce legislation [13] to estimate the impact on the efficiency of the reduction of assortment mechanisms among senior employees. italian national institute of statistics data from 2009 to 2013. descriptive statistics. multivariate regression analysis. the growth of pension age, as well as limitations on early pension intention, kept older workers at the work without a positive influence on efficiency. more efficient older employees are mroe likely to stay at work in comparison with those who are not as efficient. the number of employees kept at the work was underestimated. the reform's influence on the employees' structure is an additional issue. aging workforce, pension reforms, labor productivity [43] to investigate the workforce participation and absence among older adults in sweden. data from the swedish population register. study sample-workers aged 55-64 years. descriptive statistics. the alternation in regulations affected the share of workers associated with illness and disability pension programs. simultaneously, the share of workers going to early pension has grown. this study noticed no alternation related to the difference in working-life exit patterns associated with hierarchical and academic positions in the organization. workforce participation, older worker, pension, illness benefits [20] to review the expert way of thinking in relation to policies influencing the employment of older adults. survey study. study sample-89 participants aged 50 years or older. descriptive statistics. a broad range of policies recommend possibilities for innovation. there is a sampling bias related to the language and review method. there were no participants from south america, while a few participants from africa demonstrated about limited internet access. aging workforce, older workers, employment policy, mandatory pension, government answers [44] to investigate whether age and mental capabilities mitigate the connection between job stress and negative affect survey study. study sample-139 workers aged 25-69 years. descriptive statistics. correlation and regression analysis. johnson-neyman technique. cognition mitigated the connection between job stress and negative affect. crystallized cognition had a large influence on the connection between job stress and negative affect for senior workers. the mitigating influence of fluid cognition was unchanging. the study did not permit a setup of directionality among variables. better evaluation of professional features and job requirements is needed. job stress, negative affect, older workers improve the well-being of older workers. difficulties that older people experience at work indicates a need for healthcare strategies to adjust the work conditions so that they are suitable for older workforce with decreased physical ability. the authors in [34] identified professions that are dominated by older workers and suggested that work-related hazards (e.g., noise, vibrations, etc.) should be reduced to prevent health problems. older workers and workers with disabilities can be used as the sources of required skills. such unutilized workers need to be recruited and well-managed to ensure that their skills are retained [35] . in order to improve the well-being of older workers, the authors in [17] considered the influence of organizational factors, whereas those in [36] examined psychosocial factors at workplace. unfulfilled prospects for work in old age influenced the prosperity of older workers [41] . therefore, it is necessary to perform workplace health promotion activities [7] . promote the lifelong learning. the growth of the aging labour force and emerging technologies change the work environment, generating a need to train older workers to improve their skills. older workers gain benefits when well-designed training approaches are used. therefore, the authors in [38] studied the training requirements and work experience, as well as the perception of ideal job features. to encourage technology adoption in the work environment, there is a need to understand how workers study software tools and complete assignments [8] . therefore, further research should concentrate on developing safer work practices and supporting worker's productivity and professional longevity [37] . encourage the late retirement. in order to achieve more successful inclusion of older people into labour market, there is a need for more comprehensive policies and harmonized all-age legislation. this is indicated by the fact that the overall decrease in the share of individuals in pension and disability programs is caused by changes in regulations [43] . in this regard, the authors in [20] studied the factors that affect the aging labour force and the range of current policies that suggest the possible opportunities for innovation. the implications for older workers are related to lifespan earnings, job retention, retirement savings, the possibility of changing jobs, or employment assurance [13, 44] . increasing the pension age should not exacerbate social and health disproportion in the older workers [40] . this is important since many older workers report unequal options to take advantage of solutions for supporting the balance between work and private life [42] . the abovementioned policy implications may be useful from policy making perspective. they could lead to the creation of framework that targets government, the non-governmental sector, private sectors and other stakeholders. however, the creation of such policy framework should take into account many other contributing factors [28] that can be the subject for future research activities. furthermore, a future research agenda should consider the concept of ageing at work at national level and intensify collaboration at international level. nevertheless, the following recommendations for governments and other stakeholders can be drawn from this research study: 1. encourage incentives to extend the working ability in old age; 2. eliminate age-based discrimination at work along with promotion of gender equality; 3. invest in education, lifelong learning, health and well-being while increasing the productivity; 4. improve the working conditions to increase the safety at work and health of workers; 5. support late retirement along with the increase of life expectancy; 6. reduce the use of early retirement if workers' health and work ability are satisfactory. this study provides a systematic review of articles related to the aging labour force in terms of recent trends and future directions. additionally, it identifies and evaluates the motivations that drive research on the aging labour force and potential solutions that address the issues related to the aging at work. sustainable growth and age-based discrimination are recognized as the main motivations to perform the research activities in the given context. on the other hand, policies that stimulate life-long learning are identified as a potential solution for the aging labour force. the additional value of this study lies in its identification of policy implications and recommendations for governments and other stakeholders. furthermore, along with this paper, we also provide a supplementary materials of all identified relevant articles that can be filtered in terms of different fields to recognize articles for further analysis in a particular subfield. this initial search for a systematic review design may provide useful results on the relevance, practicability, and time needed to carry out a systematic review. despite the valuable insights in this study, it suffers from several limitations as well. first, this study took into consideration only three digital libraries, so some relevant articles could be unintentionally omitted from the study because of the specificity of the search strings and the fact that we have not taken into account the non-indexed publishers. however, the size of the searched digital libraries is sufficient, so the obtained results are suitable for the purpose of the study. additionally, the articles obtained for this study are the results of a search query sent to different search engines with different retrieving and formatting rules from those that are used in the considered libraries. however, we are convinced that the specificities of the publishers' search engines had no influence on the findings of this study, taking into the account the number of analyzed articles. finally, the articles are categorized to provide the quantitative results that show the recent trends and future directions of aging at work, whereas the qualitative results are manually covered to a limited extent to describe the motivation issues and solutions for the aging labour force. the aging of the population raises many issues and provides many opportunities. it intensifies the requirement for long-term care, healthcare, and a better-skilled workforce, and increases the demand for age-friendly environments. on the other hand, it enables the contributions of older people to their family, local community, or broader society. in order to review articles related to the ageing at work in terms of recent trends and future directions, we performed a scoping literature review using an nlp-based framework to automate some of the steps in the prisma methodology and quickly identify potentially relevant articles. as a result, starting from over 70 thousand potentially relevant articles, we analyzed in detail about 70 of the most relevant approaches and discussed 24 of them. we identified that the most prominent works suggest policies and practices that support life-long learning, a workforce that comprises both younger and older workers, and gradual retirement. approaches like these could be the best response to the globalization issues, reduction of workforce, maintenance of financial independence of the aging workforce, and other social benefits. future work could be focused on standardizing approaches to this problem across different countries, supported by different policymakers. the goal should not be to end up with the same approaches in different environments, as this would hardly encompass all cultural, sociological, and economic factors. instead, we believe that systematically documented and well-thought-out approaches will facilitate the measurement of the results and analysis of causality when investigating benefits and drawbacks. funding: v.t., e.z., i.c. and p.l. acknowledge the support of faculty of computer science and engineering, ss. cyril and methodius university in skopje, north macedonia. in addition, this manuscript is funded by fct/mec through portuguese national funds and when applicable co-funded by feder-pt2020 partnership agreement under the project uidb/eea/50008/2020 (este trabalho é financiado pela fct/mec através de fundos nacionais e quando aplicável cofinanciado pelo feder, no âmbito do acordo de parceria pt2020 no âmbito do projeto uidb/eea/50008/2020). this manuscript is based upon work from cost action ic1303-aapele-architectures, algorithms, and protocols for enhanced living environments and cost action ca16226-sheld-on-indoor living space improvement: smart habitat for the elderly, supported by cost (european cooperation in science and technology). cost is a funding agency for research and innovation networks. our actions help connect research initiatives across europe and enable scientists to grow their ideas by sharing them with their peers. this boosts their research, career and innovation. more information in www.cost.eu. based on ca16226 project, ltc18035 inter cost was proposed for national funding support of cost action framework by meys, czech republic. this work was also supported in part by the project (2020/2206), grant agency of excellence, university of hradec kralove, faculty of informatics and management, czech republic. the demand for older workers. in ageing, health and pensions in europe: an economic and social policy perspective healthy ageing and well-being at work ageing europe: looking at the lives of older people in the eu quality of life framework for personalised ageing: a systematic review of ict solutions workplace health promotion for older workers: a systematic literature review generations in the workplace: an exploratory study with administrative assistants joint report on towards age-friendly work in europe: a life-course perspective on work and ageing from eu agencies; publications office of the european union everyday discrimination in the australian workplace: assessing its prevalence and age and gender differences older women's responses and decisions after a fall: the work of getting "back to normal". health care women int transition from the labor market: older workers and retirement ageing workforce and productivity: the unintended effects of retirement regulation in italy understanding the psychology of diversity organizational change around an older workforce primary-and secondary-level organizational predictors of work ability population aging: opportunity for business expansion, an invitational paper presented at the asia-pacific economic cooperation (apec) international workshop on adaptation sustaining work participation across the life course supporting the labor force participation of older adults: an international survey of policy options accessibility and new technology mooc-disability and active aging: technological support one size does not fit all: uncovering older entrepreneur diversity through motivations, emotions and mentoring needs aging and work: an overview employers' use of older workers in the recession preferred reporting items for systematic reviews and meta-analyses: the prisma statement automation in systematic, scoping and rapid reviews by an nlp toolkit: a case study in enhanced living environments literature on wearable technology for connected health: scoping review of research trends, advances, and barriers the sage handbook of aging, work and society population decline, labor force stability, and the future of the japanese economy socioeconomic position, psychosocial work environment and disability in an ageing workforce: a longitudinal analysis of share data from 11 european countries an investigation of predictors of successful aging in the workplace among hong kong chinese older workers psychosocial work environment and retirement age: a prospective study of 1876 senior employees age differences in work stress, exhaustion, well-being, and related factors from an ecological perspective hazards and health problems in occupations dominated by aged workers in south korea age and disability employment discrimination: occupational rehabilitation implications the association between psychosocial work environment, attitudes towards older workers (ageism) and planned retirement work-related musculoskeletal disorders in senior farmers: safety and health considerations. workplace health saf training older workers for technology-based employment life course and work ability among older adults: elsi-brazil the impact of working beyond traditional retirement ages on mental health: implications for public health and welfare policy unexpected retirement from full time work after age 62: consequences for life satisfaction in older americans work-life balance: does age matter? work has the participation of older employees in the workforce increased? study of the total swedish population regarding exit from working life the moderating effects of aging and cognitive abilities on the association between work stress and negative affect this article is an open access article distributed under the terms and conditions of the creative commons attribution the authors declare no conflict of interest. the founders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. key: cord-016301-vqmqnipq authors: winnick, aaron m.; karabicak, ilhan; distant, dale a. title: elderly transplant recipients date: 2011-01-25 journal: principles and practice of geriatric surgery doi: 10.1007/978-1-4419-6999-6_98 sha: doc_id: 16301 cord_uid: vqmqnipq while the total number of organs transplanted in this country has increased over the years, there is still an ever-widening gap between the need for organs and our capacity to meet that need as the overall waiting list continues to grow. this is due in part to significant advances in transplant techniques and outcomes such that americans with organ failure now seek transplants in greater numbers. additionally, life-expectancy gains in the united states are creating an aging population who are more likely to suffer organ failure than younger americans. the national transplant waiting list has continued to shift toward older candidates. the scientific registry of transplant recipients (srtr) reported that at the end of 2007, 59.7% of all 97,248 candidates on the waiting list for all organs were 50 years old or older, and 14.9% were 65 years or older. these percentages are substantially higher than they were in 1998 (41.5 and 8.1%, respectively) [1]. sn is an 84-year-old african-american male who developed renal failure after undergoing a triple-vessel coronary artery bypass graft (cabg) following a myocardial infarction in 2004. he has a history of hypertension and has been stable on hemodialysis via an av fistula. he has excellent exercise tolerance, a normal ejection fraction on cardiac catheterization, and was asymptomatic with regard to his coronary artery disease. he is fully functional and living independently since he retired from his job as a bus operator. he was placed on the waiting list for renal transplant in 2007. he received a zero mismatch offer from a 75-year-old deceased donor in august 2008. the donor was a 125 lb woman with no significant medical history who died from a cerebrovascular attack (cva). her serum creatinine was 0.7 mg/dl and postprocurement biopsy revealed minimal glomerulosclerosis. both kidneys were pumped and then implanted ipsilaterally in a 4½-h operation. he exhibited good immediate function and mild troponin elevation, but no other complications. he received induction therapy with three doses of thymoglobulin (1.5 mg/kg/dose), prograf, and steroids. he was discharged to home 5 days later with a creatinine of 2.0 mg/dl. no hospital readmissions occurred, and 1 year following transplantation, his creatinine level was 1.2 mg/dl. he is currently being maintained on prograf 2 mg twice daily and prednisone 5 mg daily. he remains quite active working as a producer for a local radio station, and he travels extensively visiting family. loss and death, and the degree and type of immunosuppressive therapy. this discussion focuses primarily on deceaseddonor organ transplants into the elderly, since fewer live-donor transplants are performed in the aged (670 transplants in 2008) . the kidney being the most frequently transplanted solid organ offers the most data in older patients and is therefore a primary focus of this chapter. no consensus exists as to what age defines "elderly" or "geriatric" within the transplant literature, and therefore, no attempt is made to offer such a definition; rather, the studies and data are examined with regard to the issues to be examined and the principles to be applied to older transplant candidates. older americans are an increasingly important consumer of end stage renal disease services in the united states. the u.s. renal data system (usrds) collects and provides national demographic information about patients with kidney disease treated with either dialysis or transplantation. the average age of the dialysis patient continues to increase each year, with nearly half of patients undergoing regular dialysis now over 65 years of age, and the mean age of those beginning treatment is now greater than 60 years [2]. there are currently 48,773 patients on the waiting list for a kidney, with 7,800 (16%) over the age of 65. in 2007, nearly 17,000 kidney transplants were performed in the united states, with 2,377 (14%) going to patients over the age of 65 [1] . kidney transplantation has been shown to improve quality of life and length of life compared with those remaining on dialysis [3] . in one longitudinal study of mortality, investigators evaluated data collected over 6 years on 228,552 patients who were receiving dialysis as treatment for their end-stage renal disease. of these, 46,164 were deemed healthy enough to be placed on the waiting list for transplantation, and 23,275 received a first deceased-donor kidney transplant. the mortality ratio for the patients on dialysis who were awaiting transplantation was 38-58% lower than that for all patients on dialysis (annual death rates of 6.3 and 16.1 per 100 patient-years, respectively). the long-term mortality rate was 48-82% lower among transplant recipients than patients on the waiting list (annual death rate 3.8 per 100 patient-years). recipients over the age of 60 demonstrated significant benefit in mortality after transplantation, with annual death rates per 100 patient-years at risk for all patients on dialysis, patients on the waiting list, and transplant recipients being 23.2, 10, and 7.4, respectively. it is estimated that, among those over the age of 60, projected remaining years of life are approximately 6 and 10 years for those who remain on a waiting list or undergo renal transplant, respectively [4] . multiple studies over the past 10 years have confirmed that patients older than 60 years of age have longer life expectancy with deceased-donor kidney transplantation when compared to patients of the same age group on the waiting list. post-kidney transplant recipients report a better quality of life, from mental well-being to physical functionality and social functioning. in addition, after adjusting for comorbidities, there is no significant difference in graft failure compared to younger patients [5] [6] [7] [8] . as with all organ transplants, the risks and benefits must be carefully weighed, especially in the elderly. will this organ improve the patients' overall survival and quality of life? will an older patient be able to survive the operation, manage the medications, endure the potential side effects of immunosuppression, and have the social and financial support necessary to recover and maintain rigorous doctor appointments? current success in transplanting kidneys into older recipients has quieted misconceptions within medical communities and the general public, among them the erroneous belief that advanced age alone prevents a successful surgical outcome, that the elderly patient with esrd has a very limited life expectancy, and thus cannot receive a transplant, and that older recipients have poor results based upon outdated information from the previous era of transplantation and immunosuppression. older recipients, however, do have a higher risk of cardiovascular events, infection, and malignancy after kidney transplantation compared to younger patients [9] . also, they are more prone to drug side effects and toxicity [10] . the absolute gain in survival provided by a donor kidney varies considerably depending on recipient factors, such as age and comorbid illnesses. although overall graft failure rates are not higher for elderly recipients, death with a functioning graft does occur more often which shortens the lifespan of the donated kidney (especially from a young donor) [10] . clearly, a younger recipient would more likely experience more years of allograft function with the same kidney. with ever-increasing organ shortages, the ethical dilemma of including age as a potential allocation factor has been raised. the argument pits the increased survival and quality of life for the older transplant recipient against the population gain in allograft survival by transplanting kidneys preferentially into younger recipients. what is the best way to deal with these competing allocation philosophies, namely, giving everyone an equal chance to receive an organ vs. getting the maximum benefit from each organ transplanted? in the u.s., the united network for organ sharing (unos) provides regulatory oversight and balances these ethical principles in an effort to achieve socially acceptable allocation policy. an alternate strategy to maximize the benefit of donor organs matches kidneys with lower expected graft survival time (principally older donors) to patients with lower expected longevity (principally older recipients). the current allocation of expanded criteria donor (ecd) kidneys attempts to do this. these kidneys are procured from donors older than 60 years of age or donors aged 50-59 years with at least two of the following conditions: cerebrovascular accident as cause of death, a history of hypertension, or a serum creatinine > 1.5 mg/dl [11] . while ecd kidneys carry a relative risk of graft failure greater than 1.7 compared to a reference group of donors aged 10-39 years without any of the above three conditions, elderly recipients of ecd kidneys were found to have a survival benefit compared with waiting-list candidates (rr = 0.75; 95% ci 0.65-0.86; p < 0.0001) [8] . the benefits (shortening of waiting time) and risk (impaired long-term graft function) associated with the use of ecd kidneys should be addressed on an individual basis. as with all recipients, elderly patients do best with an ideal donor kidney; however, the ecd policy achieves a compromise that enhances the donor pool and provides good alternative to dialysis. another option for increasing the number of organs and decreasing the waiting period for renal transplantation is to perform a dual kidney transplant. both kidneys from an older donor, which individually would be considered marginal or inadequate for transplantation, are transplanted into a single recipient. this expands the use of kidneys that otherwise would not be used. there is a misconception that dual kidney transplantation involves the transferring of an inferior organ; on the contrary, it is just a different type of organ transplant. for all kidneys being evaluated for donation, the creatinine clearance is calculated. if it is greater than 65 ml/min, each individual kidney may be transplanted into two different recipients. if it is below 40 ml/min both kidneys are usually deemed unsuitable for transplant. the area in between, 40 and 65 ml/min, constitutes the range to use two kidneys together to give recipients the function of one kidney. this allows for the transplantation of as much kidney function as, if not more than, a standard single transplant from a nonexpanded criteria donor. with careful selection, the amount of kidney function that is being transplanted with dual kidney is comparable to a single kidney transplant [12] . prior to transplantation of any organs, the prospective recipient has to be carefully evaluated to detect and treat any coexisting illnesses that may affect patient and graft survival after transplantation. in the elderly, this is imperative for two reasons: graft loss in the elderly is related primarily to patient death, and the main causes of morbidity and mortality following transplantation are infection and cardiovascular disease [13, 14] . regardless of the age of the recipient, a thorough medical, surgical, and psychosocial history needs to be obtained, along with a detailed physical examination. careful examination of the abdomen for previous operations is important, as is the presence or absence of peripheral arterial pulses. initial laboratory testing includes blood type, hla typing and a panel reactive antibody assay to detect for previous sensitization, complete blood count (cbc), blood urea nitrogen, creatinine, electrolytes, calcium, phosphorous, albumin, liver function tests, prothrombin time, and partial thromboplastin time. serologic studies for cytomegalovirus (cmv), hepatitis b and c viruses (hbv, hcv), human t cell leukemia virus (htlv-1), and human immunodeficiency virus (hiv) are routine. one element of the evaluation process includes baseline age-appropriate screening tests. it is also important and appropriate to maintain a higher index of suspicion for malignancy in patients of this age group. in women, this consists of gynecologic examination and papanicolaou smear, breast examination, and in those over the age of 40 without a family history of breast cancer in the premenopausal years, mammography. in men, testicular examination, prostate examination, and for those over age 50, prostate-specific antigen (psa) assay should be performed. all patients over the age of 50 should undergo screening colonoscopy. a screening purified protein derivative (ppd) test may be used depending on the patient population and patient history. radiologic studies include chest x-ray and electrocardiogram as routine and can include ultrasound or computed tomography (ct) scan of the abdomen to evaluate anatomy if indicated. estimation of urine output preoperatively is important because it determines the significance of postoperative urine output and helps determine the need for any urologic evaluation. a history of claudication warrants a workup for peripheral vascular disease and may also point towards a higher chance of ischemic heart disease. the presence of strong femoral and peripheral pulses indicates that the pelvic vessels will likely be adequate for the transplant vascular anastomosis. assessment of cardiac risk is critical in the evaluation process of elderly patients. cardiovascular disorders, such as hypertension, coronary artery disease, congestive heart failure, and arrhythmias are common in elderly transplant recipients and account for most of the deaths in this population. blood pressure, blood glucose, and cholesterol control is of particular concern because this patient population frequently have or develop these complications. the prevalence of ischemic heart disease is very high in patients with end-stage renal disease, and almost half of the deaths that occur during the first 30 days posttransplant are due to ischemic heart disease [15] . the current guidelines from the american society of transplantation recommend assessing ischemic heart disease risk factors in any patient with a prior history, men over the age of 45 or women over the age of 55 years, cardiac disease in a first-degree relative, current cigarette smoking, diabetes, hypertension, fasting total cholesterol > 200 mg/dl, highdensity lipoprotein cholesterol < 35 mg/dl, and left ventricular hypertrophy. any patient at high risk, including those with renal disease from diabetes, prior history of ischemic heart disease, or more than two of the above risk factors, should undergo an echocardiogram and cardiac stress test. angiography with possible revascularization, if indicated, should be performed prior to any transplantation. asymptomatic patients can also undergo noninvasive tests first that may help determine the risk for posttransplant complications, in the form of chemical stress echocardiography or scintography [15] . based on an initial evaluation, the 2005 canadian society for transplantation guidelines suggested that the following patients with coronary heart disease may be eligible for kidney transplantation: asymptomatic low-risk patients; asymptomatic patients in whom noninvasive testing is negative; patients on appropriate medical therapy with angiographic results showing noncritical disease; and those patients in whom successful interventions have been performed [16] . currently, there is no strong evidence to suggest a benefit to the routine screening of asymptomatic renal transplant candidates for cerebrovascular disease. risk factors for posttransplant cerebrovascular disease include a history of prior disease, age, smoking, diabetes, hypertension, and hyperlipidemia [15] . patients who have already suffered from a cerebrovascular event and have significant deficits may be poor operative candidates due to their poor operative risk and rehabilitative potential. patients with recent transient ischemic attacks need to be adequately evaluated by a neurologist. pulmonary risks associated with surgery for transplantation include infection, fluid overload, and ventilator dependency. pretransplant evaluation of elderly patients with respiratory disease should be consistent with that for the general population who undergo a preoperative pulmonary assessment [17] . the 2005 canadian transplant guidelines suggest that patients should not be considered candidates for kidney transplantation if they require home oxygen therapy, have uncontrolled asthma, severe cor pulmonale, or severe copd, pulmonary fibrosis, or restrictive disease. the latter is defined by fev1 < 25% predictive value, room air po 2 < 60 mmhg with exercise desaturation sao 2 < 90%, or more than four lower respiratory tract infections in the last 12 months [16] . the transplant candidate must be free of all active infections before transplantation could be considered. whenever possible, all treatable infections should be dealt with appropriately. chronic infection precludes transplantation and the subsequent use of immunosuppressive therapy. infectious complications occur frequently in the transplanted patient, with pneumonia being one of the most common infections seen in elderly hospitalized patients. as such, elderly patients must be immunized against influenza and pneumococcus. not too long ago, most centers considered patients who tested positive for hiv inappropriate for transplantation secondary to immunosuppressant-induced opportunistic infection and the suspected short life span. with the advancement in antiretroviral therapy, more centers now are willing to transplant patients who are hiv positive, but the general recommendation is to evaluate on a case-by-case basis. patients with a malignancy prior to receiving an organ may still be a suitable candidate for transplantation depending on the tumor type, stage, and response to therapy. the concern is that malignancies are common after transplantation, possibly due to immunosuppression favoring the growth of malignant cells and/or viral infection. this part is addressed in a later section on postoperative issues. while it has been reported that patients with esrd on dialysis have a higher rate of cancer compared to the general population, this relative risk has been shown to be higher in younger patients [18] . most patients previously treated for cancer benefit from a waiting period prior to renal transplantation to decrease the risk of recurrence. depending on tumor characteristics, recommendations range from no wait time to 5 years. no waiting time is required for basal cell carcinoma of the skin, in situ cancer of the bladder or cervix. a 2-year waiting time is proposed for lymphoma, leukemia, cancers of the prostate, lung, breast (early stage), testicle, thyroid, uterine body, bladder, wilm's tumor, renal cell carcinoma (<5 cm), or kaposi's or other sarcoma. patients with localized, successfully treated carcinoma of the uterine cervix may benefit from waiting 2 years, and in some cases 5 years, prior to transplantation. a 5-year waiting time is recommended for colorectal, invasive breast, and renal cell carcinoma (>5 cm), and malignant melanoma [15, 16, 19] . while some contraindications to kidney transplantation are absolute, many are relative and determined by individual centers. absolute contraindications to receiving a renal transplant include: recent or metastatic malignancy; active substance abuse; severe extrarenal disease with life expectancy of less than 1 year; untreated current infection; psychiatric or other illness impairing adherence to regimen. relative contraindications include: morbid obesity; active heavy tobacco use; acute coronary or cerebrovascular event; hiv infection if untreated or poorly monitored [13, 15] . the actual surgery for transplanting a kidney is the same for the elderly patients as for any adult, with the caveat that careful attention must be paid to fluid maintenance and monitoring in the elderly, depending on the cardiac and pulmonary history. the standard incision for adult kidney transplantation is an oblique incision from the symphysis in the midline, curving in a lateral and superior direction to the iliac crest. the donor renal artery and vein are anastomosed to the recipient external iliac artery and vein, respectively, and the donor ureter anastomosed to the recipient bladder. the kidney is placed in the iliac fossa where it is easily accessible if an ultrasound, biopsy, or other intervention is required. while the benefit of renal transplantation in the elderly has already been established, there is a paucity of data evaluating the safety and efficacy of immunosuppression regimens. most centers use traditional principles and their transplant protocols with modifications when considering the factors unique to the elderly. analysis of registry data suggests that while the risk of acute rejection decreases with age, the impact of rejection on long-term graft function in this elderly population is greater when compared to younger groups. it is of no surprise that posttransplant mortality is greater in the elderly; however, censoring graft survival data for patient death demonstrates no significant difference between outcome in older and younger patients [5, 6, 20, 21] . the goal of an immunosuppression protocol should be to maintain a level necessary for a reduced risk of infection without increasing the risk for rejection. the elderly have less immunocompetence, and the therapy has to be adjusted in the elderly transplant recipient. this may result in a decreased likelihood of immunologic rejection but increased risk of infection. immunosuppressive therapy also has to be adjusted to account for the different pharmacokinetics and altered effects of drugs in the elderly. the aging process results in physiological changes that affect drug absorption, distribution, and metabolism. in addition, due to the many comorbid conditions in the elderly, they often take many medications which may have drug-drug interactions with immunosuppressive medications [22] . there are currently no prospective multicenter trials that specifically evaluate immunosuppressive medication protocols in the elderly in a randomized fashion. most of the time, the elderly are excluded from trials. as such, most of the data is from single-center, observational studies or retrospective database analyses [23] . any approach should be based on the risks of acute rejection, infections, malignancy, and comorbid conditions. there is no set immunosuppression protocol that has been universally accepted in the elderly or any patient population. although acute rejection decreases with recipient age, chronic allograft nephropathy seems to increase with age, and this phenomenon is further confounded by increased death from infectious disease and drug-related causes. this has led to some protocols that support less-intensive immunosuppressive drug therapy in elderly recipients [24] . current treatments consist of triple therapy with corticosteroids, a calcineurin inhibitor (cyclosporine or tacrolimus), and an antimetabolite, but these regimens may be replaced by substitution or addition of newer antiproliferative agents. treatment with mycophenolate mofetil (mmf), which inhibits purine synthesis, has been found to result in a longer time to the first episode of acute rejection but had significantly greater rates of opportunistic infection and graft loss and mortality [25] . one study comparing mmf to azathioprine evaluated over 5,000 patients over the age of 65 and showed improved patient and graft survival with lower rates of late acute rejection with mmf. the most prescribed immunosuppressive protocol is a combination of mmf with calcineurin inhibitor, and there appears to be no contraindication to use this protocol in the elderly [26, 27] . an alternative or supplement to standard triple therapy is the use of augmented immunosuppression with antilymphocyte antibodies, commonly termed "induction immunotherapy." these cytolytic agents have been found to reduce the risk of early rejection but tend to increase the risk of infection. induction therapy in the form of atgam® (equine antithymocyte globulin) or okt3® (muromonab-cd3) was the mainstay but now has been largely replaced by the use of thymoglobulin® (rabbit anti-lymphocyte globulin) or monoclonal antibody therapy directed against the il-2 receptor -zenapax® (daclizumab) or simulect® (basiliximab) [1] . in addition to the immunosuppression and steroids making the elderly more susceptible to infection, fractures, weight gain, and other side effects, they are at a 30% higher risk of developing new-onset diabetes posttransplant per decade of life [28] . this has led to a movement in recent years for the avoidance or early withdrawal of calcineurin inhibitors and/or corticosteroids. multiple studies demonstrated appropriate patient and graft survival, as well as excellent graft function, after using induction agents and minimizing the use of calcineurin inhibitor [29] [30] [31] . considering the elderly's increased risk for adverse affects and infection, and the limited prospective data available, any protocol must consider that decreasing the risk of acute rejection may augment the morbid consequences of rejection. as such, protocols are currently tailored based on donor type and immunologic status of the elderly recipient. the lowrisk recipient of a kidney from a young donor may be a candidate for rapid steroid withdrawal or steroid minimization strategies due to the lower risk of rejection and increased risk of steroid-induced adverse effects. the low-risk recipient of a kidney from an older donor may have an enhanced risk of chronic allograft nephropathy and nephrotoxicity from the calcineurin inhibitors, so it may be appropriate to use a calcineurin inhibitor minimization strategy. as already mentioned, interleukin-2 receptor antibodies or antilymphocyte antibodies may be used as induction agents with a calcineurin inhibitor, with the interleukin-2 receptor antibody showing a superior safety profile. minimizing immunosuppression is not appropriate in an elderly patient with high immunologic risk, so a regimen consisting of antibody induction, corticosteroids, calcineurin inhibitors, and/or mmf is more reasonable [23] . since there is potential for severe consequences with acute graft rejection in the elderly, a biopsy should be performed in all unexplained cases of allograft dysfunction. treatment should be based on histologic findings, whenever possible, with empiric steroid use for treatment of presumed acute rejection used sparingly due to the increased risk of adverse events in the elderly. renal allograft and patient survival in the elderly transplant recipient are currently excellent, when looked at as a group and compared to younger recipients. patient survival at 1, 5, and 10 years ranges from 80 to 90, 70, and 50%, respectively [1, 5, 6, 32] . this is based in part on the type of allograft. based on the 2008 srtr analyzing transplants from 1998 to 2007, 3-month, 1-, and 5-year patient survival rates for those 65 years of age and older receiving a renal transplant are: 98, 96, and 78% for recipients of living-donor kidney transplants, respectively; 96, 92, and 66% for recipients of deceased-donor nonextended criteria donor kidneys, respectively; and 95, 87, and 58% for recipients of deceased-donor extended criteria donor kidneys, respectively [1]. graft survival has increased in parallel, averaging 85% at 1 year and 70% at 5 years [5, 6] . allograft survival at 3 months, 1, and 5 years for those 65 years of age or older are: 97, 94, and 74% for recipients of living-donor kidney transplants, respectively ( fig. 98.1) ; 94, 88, and 59% for recipients of deceased-donor nonextended criteria donor kidneys, respectively; and 90, 81, and 48% for recipients of deceased-donor extended criteria donor kidneys, respectively ( fig. 98.2) [1]. patient death with a functioning graft accounts for the majority of reported "graft loss" in the elderly patients. nearly 50% of graft loss is due to death in the elderly recipient compared to 15% in the younger recipient. acute rejection is reported to occur less often in elderly recipients, but there is an increased risk of chronic allograft nephropathy, especially if the allograft is from the older donor [33] . the predominant causes of death in elderly transplant recipients are cardiovascular disease and infection. most infectious episodes occur in the first 6 months posttransplant, likely due to the degree of immunosuppression. the risks of overimmunosuppression and cardiovascular disease are related to the natural effects of aging and factors having to do with end-stage renal disease. overimmunosuppression will increase infectious complications in all patients, regardless of age. however, the elderly are less immunocompetent, leading them to be more susceptible to infection at lower lev-els of immunosuppressive therapy. most likely to contribute to this are high-dose corticosteroids and antilymphocyte antibodies at induction. other causes of death in the elderly recipient include malignancy and gastrointestinal hemorrhage. death due to malignancy has been reported to increase disproportionately with time after transplantation in the elderly recipient [22] . despite the mortality risks, there is still a better life expectancy and quality of life afforded by kidney transplantation compared to dialysis. with careful selection and responsible follow-up, advanced age alone is not a contraindication to successful transplantation. age should not be the primary determinant of donor allocation; rather, the focus should be on baseline comorbidity or functional status [10] . end-stage liver disease (esld) results from many etiologies and eventually leads to complications including bleeding, ascites, infection, renal failure, fluid and electrolyte disturbances, hepatic encephalopathy, hepatocellular carcinoma, and eventually, liver failure. currently, the only defin the most common diagnoses in elderly patients waiting for liver transplantation are cirrhosis, alcoholic liver disease, hepatitis, primary biliary cirrhosis, and hepatocellular carcinoma. elderly patients should only be considered for transplantation if they are thought to be capable of surviving the perioperative period and complying with the intense chronic medical regimen and follow-up [34] . older patients are frequently seen as higher risk recipients due to their comorbidities and increased mortality to both hepatic and nonhepatic causes [35] . liver transplantation in patients over the age of 55 was discouraged as recently as 20 years ago. however, since that time, there have been many studies demonstrating success in patients over the age of 60, encouraging more centers to list and operate on older patients [36] [37] [38] [39] [40] [41] . more recent data suggest that patients over the age of 70 may successfully undergo liver transplantation; however, it has to be at a less-severe level of disease to have a good outcome [42] . most contraindications for liver transplantation relate to comorbid conditions. relative contraindications include alcohol or illicit drug use in past 6 months in a patient with a history of abuse, severe extrahepatic disease, adverse psychosocial factors, anatomic difficulties resulting from previous abdominal trauma or surgery, and age. absolute contraindications generally include uncontrolled infection or sepsis, extrahepatic malignancy, advanced hepatic malignancy, and irreversible brain injury [39, 43] . hiv infection had previously been considered to be an absolute contraindication for liver transplantation. however, with the significant improvements with antiretroviral therapy and improved monitoring methods, it is no longer a sufficient reason to refuse surgery. while some centers may still list it as a relative contraindication, many will no longer restrict recipients as long as attention is paid to the comorbid conditions. for more than 30 years, the child-pugh classification system was used to predict morbidity and mortality in patients with liver disease. while useful in stratifying patients for transplantation, it does not provide an adequate method of prioritizing patients on the liver transplant waiting list [44] . as a result, organ allocation in adults is now based on the model for end-stage liver disease (meld), which is a logarithmic transformation of the recipient's bilirubin level, creatinine level, and international normalized ratio (inr) into a mathematical model. it allows for an objective assessment of need for transplantation and short-term prognosis while waiting for a transplant. it does not, however, necessarily correlate with posttransplant survival [45] . preoperative assessment of all liver transplant candidates includes abdominal ultrasound, thoracic and abdominal computed tomography, and upper gastrointestinal endoscopy in addition to routine blood studies. patients older than 50 years must undergo screening colonoscopy, and in male patients older than 55 years, the serum prostate-specific antigen concentration must be studied with digital rectal examination. in female patients, cervical and breast cancer screening must be done as indicated before listing. age-related morbidity is one of the main causes of mortality after liver transplantation. older patients have to be evaluated by specialists in the field of cardiology and pulmonary disease [46] . the cardiovascular workup for patients over the age of 60 years includes a routine history and physical examination, ekg, and twodimensional echocardiography. a history of coronary artery disease (cad) or symptoms of exceptional angina are clear indications for performing cardiac catheterization prior to transplantation. a negative stress test is not sufficient to exclude cardiac disease in patients with clinical history strongly suggestive of cad. in this situation, the clinician may elect to proceed directly to cardiac catheterization [47] . doppler studies of the carotid, vertebral, and peripheral limb arteries are performed on these patients if clinically warranted. revascularization strategy must be performed prior to listing for liver transplantation if there is extensive coronary heart disease [38] . diabetes mellitus may be the most important risk factor for the presence of cad in patients with liver disease and must be assessed and managed appropriately in the perioperative setting [44, 48] . older patients with end-stage liver disease, particularly those with cholestatic liver disease, are also at risk for osteopenia or osteoporosis. postoperative corticosteroid therapy will also contribute to bone loss, increasing the risk of sustaining compression fractures. for all elderly patients, determination of vitamin d serum levels and baseline bone densitometry is encouraged [44] . any patient over the age of 60 with a history of encephalopathy, seizures, or ischemic event should have an mri of the brain prior to being listed. older patients also have to be routinely screened for malignancy. patients waiting for liver transplants need to be evaluated for hepatocellular carcinoma (hcc) in particular, as well as for colon, skin, prostate, and breast neoplasms. for liver transplant recipients, the pretransplant status has been found to be associated with survival, and this is seen more in elderly patients. in a retrospective review of 1,446 liver transplant recipients, of which 241 were over the age of 60, the elderly patients were found to be especially at risk for lower survival if they had a bilirubin level of 10 mg/dl or greater, an albumin level of less than 3 g/dl, a markedly prolonged (>20 s) prothrombin time, or generalized poor nutrition. the authors recommended forgoing transplantation in a patient over the age of 60 who is an inpatient in the hospital or in the intensive care unit with any of the above values [49] . the immunosuppression protocol and dose of immunosuppressive drugs do not drastically differ between older and younger liver transplant patients [43] . immunosuppressive strategies vary from center to center in the selection of specific agents, the number of agents, and the duration of use of each agent. the combinations used have evolved to predominantly tacrolimus, mycophenolate mofetil/mycophenolic acid, and steroids. triple drug therapy remains the predominant drug regimen; however, many centers are attempting to minimize or eliminate long-term steroid use. the key is to tailor the regimen to the patient to best prevent cellular rejection, have no associated morbidity with respect to opportunistic infections, have no nephrotoxicity, and preclude the development of infection, which continues to be a leading cause of death in the year after transplantation. although there are some studies reporting that the long-term survival of patients older than 60 years was lower than younger recipients [50] [51] [52] [53] , most studies report similar [38, 54, 55] or even better [43, 56] survival in recipients older than 60 years old. one study evaluating the survival rates of elderly liver transplant recipients found that the short-term survival of the elderly is comparable to those younger adults, but the longer survival was not encouraging. the long-term survival was significantly lower in elderly recipients, with a 5-year patient survival of 52% in the elderly group and 75% in the younger patients ( p < 0.05). the study period was divided into two eras; 1984-1991 and 1992-1997. in both eras, recipient survival in those older than 60 years was significantly lower than younger recipients, lending support to the idea that older recipients are not good candidates for liver transplantation [50] . a different study showing better survival rates in elderly patients looked at 240 liver transplant recipients, of which 23 were over the age of 60. they reported 87.5 and 83.3% 1-and 3-year patient survival in the elderly, respectively, compared to 77.8 and 73.5% in the younger group. graft survival rates at 1 and 3 years were found to be 79.2 and 75% in the older group and 76.5 and 71% in the younger group, respectively. neither set of data showed any statistical significance [52] . some studies divided older recipients into two groups to show the effect of age more clearly: recipients between 60 and 65 years of age and those older than 65 years. one study reported that the patient survival in the older than 65 years of age group was 99%, 82 and 73% in 3 days, 1, and 5 years, respectively [38] . a different study found a lower survival rate in patients older than 65 years than in patients between 60 and 65 years, although there was no statistical significance. overall, patients older than 60 years had lower survival rates than younger patients, which could possibly be explained since that group had a higher rate of hcc as the reason for transplantation [47] . similar results can be found in smaller studies for recipients over the age of 70. one study found a 58% 3-year survival in 33 patients, while another has 1-and 3-year survival rates of 78.8 and 71.4%, respectively [39, 53] . data is limited in this age group, but transplantation in septuagenarians is definitely feasible if the patient is otherwise healthy. there are few studies looking at the survival in older patients after a living-donor liver transplant (ldlt), and the results have been mixed. some investigators reported that recipient age had an influence on allograft failure [48] , while others found that older recipient age and prolonged cold ischemia time increased the risk of graft failure [49] . one of the larger studies investigated the impact of age in living-donor liver transplantation by following recipients over 60 years of age over a 10-year period. they found the following parameters as risk factors influencing survival rate in patients after ldlt: meld score equal to or greater than 25; child's classification c; preoperative status of the recipient being in an intensive care unit; and blood type incompatibility. recipient age of 60 years of age or older had no influence on the survival. 1-, 3-, and 5-year survival of the recipients older than 60 years were 81.9, 78.7, and 78.7%, respectively. interestingly, their results in older patients were better than in younger patients (1-, 3-, and 5-year survivals in patients younger than 60 years is 75, 70.8, and 69.3%, respectively). a possible explanation for this better survival is that the selection criteria of older recipients were more stringent. the meld score for older group recipients was significantly lower, and high-risk older patients were not considered for ldlt as a treatment option for their advanced liver disease in that study [43] . it is evident that after 5 years, survival of patients aged 65 years and older begins to diminish [38] . the 10-year survival of recipients older than 60 years was found to be 48%, which is significantly lower than the 72% survival rate of recipients younger than 60 [47, 57] . one study evaluated 91 transplant recipients over the age of 60 over a 13-year span and reported a 10-year patient survival of 35% in the elderly group and 60% in the younger patients ( p < 0.05). the most common cause of late mortality in elderly liver recipients was malignancy (35%), whereas most of the young adult deaths were the result of infectious complications (24%) [50] . based on the 2008 srtr analyzing transplants from 1998 to 2007, 3-month, 1-, 5-, and 10-year patient survival rates for those 65 years of age and older receiving a liver transplant are 91, 81, 64, and 42% for recipients of deceaseddonor liver transplants, respectively and 93, 85, 71, and 54% for recipients of living-donor livers, respectively. allograft survival at 3 months, 1-, 5-, and 10-years for those 65 years of age or older are 94, 84, 68, and 53% for recipients of living-donor livers, respectively (fig. 98. 3) and 89, 78, 61, and 40% for recipients of deceased-donor liver transplants, respectively ( fig. 98.4) . the results at all intervals were comparable to those of younger age groups [1]. when evaluating a patient's risk for rejection after liver transplant, younger age has been found to be an independent risk factor [58] . older patients usually have a lower incidence of episodes and severity of graft rejection, possibly a result of immune senescence [46, 51, 59] . one study noted that liver recipients over the age of 65 tended to have lower rates of rejection, although there was no statistical significance [38] . some centers have reported no difference in episodes of acute rejection among older or younger recipients [56, 60] . most studies report no statistical differences in the incidence of complications in terms of hospitalization, infection (surgical or opportunistic), repeat operation, readmission, or repeat transplant between the patients older or younger than 60 years [56] . older patients are more prone to having higher incidence of osteoporosis, nontraumatic bone fractures, coronary artery disease, and malignancy after liver transplantation, with skin cancer being the most common [43, 47] . the most prevalent cause of death in recipients older than 60 years is malignancy (both recurrent and de novo) and sepsis [38, 43, 47] . in one study, investigators reported that seven of ten recipients died secondary to sepsis in the early phase after ldlt within 3 months. in patients younger than 65 years of age, most causes of death are related to cardiovascular (myocardial infarction, congestive heart failure, cerebrovascular accident, intracranial hemorrhage) and sepsis. a possible explanation for not having the cardiac problems as a leading cause of death in older patients may be that the older recipients are more rigorously assessed for comorbidities that could be detrimental to outcome. well-selected patients over the age 60 or 65 have a comparable survival after liver transplantation to younger recipients at 1-, 3-, and 5-years posttransplant. advances in surgical technique, improved intensive care, and standardized immunosuppressive therapy all contribute to the good survival results. unfortunately, long-term results have not been as promising, possibly explained by older patients having fewer years of life remaining. nonetheless, this should not preclude liver transplantation in elderly patients deemed strong and otherwise healthy enough to undergo the procedure [38] . chronic heart failure remains one of the most common diseases affecting the population. with increases in life expectancy and improvements in medical care, more elderly patients are being seen by cardiologists and cardiac surgeons for end-stage heart failure. cardiac transplantation is the treatment of choice for many patients with end-stage heart failure who remain symptomatic despite optimal medical therapy. the 2007 report from the registry of the international society for heart and lung transplantation (ishlt) estimated that slightly more than 5,000 heart transplants are performed annually worldwide [61] . the srtr estimates that anywhere from 2,000 to 2,400 heart transplants were performed in the older patients have been excluded from consideration for heart transplantation in the past, typically due to the supposed adverse effect of increased age on long-term survival and the shortage of donor organs. however, advances in posttransplant care have improved outcomes in older patients, and several centers have demonstrated results comparable to younger patients. the criteria regarding the recipient's older age limit continue to be expanded, and older patients are increasingly being considered as potential heart transplant candidates [62] [63] [64] [65] . over the past decade, there has been a significant decrease in mortality in patients with advanced heart failure treated aggressively with medical and device therapy, leading to a reassessment of the role of cardiac transplantation [66, 67] . the ideal heart transplant candidate is a person with endstage heart disease for whom conventional therapy is not likely to provide acceptable symptomatic benefit or satisfactorily improve life expectancy. the clinical practice committee of the american society of transplantation published recommendations in 2001 for considering heart transplantation in patients with cardiac conditions that have not responded to maximal medical management [13] . although severe heart failure refractory to medical therapy is the most common indication for transplantation, other circumstances warranting transplant include severely limiting ischemia not amenable to interventional or surgical revascularization, recurrent symptomatic ventricular tachyarrhythmia refractory to medical therapy, an implantable cardioverter-defibrillator (icd), or surgery and rarely, for the management of cardiac tumors. nonischemic cardiomyopathy accounts for approximately 45% of cases, and coronary artery disease accounts for about 38% of cases. nonischemic conditions include systolic heart failure, defined by left ventricular ejection fraction < 35% (ischemic and dilated cardiomyopathy, valvular heart disease, and hypertensive heart disease); intractable arrhythmia uncontrolled with implantable cardioverter-defibrillator; and hypertrophic cardiomyopathy with persistent heart failure despite valve replacement, pacemaker, or medical therapy. there are a few absolute contraindications to cardiac transplantation. fixed pulmonary hypertension or any systemic illness that will limit survival despite heart transplant, such as high-grade neoplasm, aids, multisystem or active systemic lupus erythematosus or sarcoid preclude transplantation. hiv infection has been considered to be an absolute contraindication to transplant, primarily due to concerns about the increased frequency of infectious and malignant complications and the previously poor survival of such patients. the prognosis of hiv has changed since the advent of highly active antiretroviral therapy (haart), and guidelines are being amended so that hiv infection itself is not a sufficient reason to refuse heart transplantation [68] . age greater than 70 years was an absolute contraindication in previous guidelines, but the ishlt has recently modified their recommendations in 2006 to state that "carefully selected patients > 70 years of age may be considered for cardiac transplantation. for centers considering these patients, the use of an alternate-type program (i.e., use of older donors) may be pursued." [63] the guidelines regarding neoplasm were also modified, with new consideration being given to tumors with low recurrence rate, response to therapy, and negative metastatic workup. in general, the most objective assessment of functional capacity in patients with heart failure, and what may be the best predictor of when to list a patient for transplantation, is measurement of peak oxygen consumption (vo 2 max). this can be measured using exercise testing with ventilatory gas analysis. several studies have demonstrated that peak vo 2 independently predicted mortality, which is highest for patients with values <10 ml/kg/min, and significantly improved if between 10 and 15 ml/kg/min [69] [70] [71] . although peak vo 2 is an important factor used to guide the selection of heart transplant candidates, it does not provide an optimal risk profile. one model that has been validated prospectively is the heart failure survival score (hfss), derived from a multivariable analysis of 268 patients referred for consideration of cardiac transplantation form 1986-1993 at one institution and validated in 199 similar patients from 1993 to 1995 at another institution. it incorporated noninvasive parameters, including the following seven variables and their pathophysiological constructs: presence or absence of coronary artery disease (myocardial ischemia), resting heart rate (activation of sympathetic nervous system), left ventricular ejection fraction (the degree of systolic dysfunction), mean arterial blood pressure, presence or absence of intraventricular conduction defect on baseline ecg (the extent of myocardial fibrosis), serum sodium (the degree of activation of the renin-angiotensin system), and peak vo 2 [72] . the seattle heart failure model is another model that, in contrast to the hfss, incorporated the impact of newer heart failure therapies on survival, including icds (implantable cardioverter-defibrillators) and crt (cardiac resynchronization therapy) [73] . as with other organs, there is no general consensus regarding a preferred immunosuppressive protocol in this age group. treatment with mycophenolate mofetil/mycophenolic acid, a purine analog, has been shown to reduce the rate of rejection and improve survival, but it did have a higher incidence of nonfatal, opportunistic infections as compared with azathioprine therapy [74] . the two most common regimens in 1997, which was used for 75% of transplant recipients, consisted of cyclosporine with mycophenolate mofetil/mycophenolic acid or another antimetabolite and steroids. over the years, these combinations have evolved to be predominantly tacrolimus, mycophenolate mofetil/mycophenolic acid, and steroids (49% of transplant recipients), and to a lesser extent cyclosporine, mycophenolate mofetil/mycophenolic acid, and steroids (29% of transplant recipients). at 1-year posttransplantation, triple drug therapy remains the predominant drug regimen [1]. the ideal immunosuppressive regimen will prevent cellular rejection, have no associated morbidity with respect to opportunistic infections, have no nephrotoxicity, and preclude the development of coronary allograft vasculopathy, which affects 50% of patients at 5 years. this immunosuppressive therapy used to prevent rejection predisposes patients to infection, which continues to be the leading cause of death in the year after cardiac transplantation [58] . a notable trend over the past 10 years has been the declining number of recipients who needed treatment for rejection episodes in the first year after heart transplantation, decreasing from 36% in 1996 to 25% in 2005. this could reflect the improved efficacy of newer immunosuppression medication and regimens, as well as earlier recognition and prompt treatment [1] . multiple studies have demonstrated comparable survival rates in elderly cardiac transplant recipients compared to younger recipients [59] [60] [61] [62] [75] [76] [77] [78] . included in this is a multi-institutional study of the unos database where it was found that there was a satisfactory but lower 5-year survival between elderly (>60 years) and young (18-59 years) recipients (69% vs. 75%, respectively). the elderly group, however, had more infections, renal failure, and longer postoperative length of stay and were at increased risk of malignancy [62] . one retrospective study showed no statistically significant difference in 1-and 4-year survival (1-year survival: 93.3% vs. 88.3%; 4-year survival: 73.5% vs. 69.1%), length of intensive-care unit stay, incidence of rejection, and incidence of cytomegalovirus infection between patients over the age of 70 and younger patients [59] . a 10-year follow-up of cardiac transplant recipients >65 years of age (n = 66) demonstrated survival rates comparable to those of younger patients (<60 years: n = 679; 60-64 years: n = 137) [60] . the adjusted graft survival for recipients over the age of 65 at 3 months (90%), 1 year (85%), 5 years (66%), and 10 years (44%) were all found to be comparable within a few percentage points to various younger age groups (fig. 98.5) [1]. the increased risk of renal failure has been consistent in various studies over the years and may be attributed to the already known preexisting renal disease in elderly, as suggested by elevated preoperative creatinine. another consideration is the nephrotoxic effects of immunosuppression. tailoring therapy for the elderly may be beneficial, and some data support minimizing the use of calcineurin inhibitors and azathioprine in exchange for using mycophenolate mofetil and mammalian target of rapamycin inhibitors (mtor inhibitors, sirolimus) [79] . transplant patients have been the subject of extensive investigation into the increased risk of malignancy, especially in the elderly. increased age has been independently associated with increased risk of malignancy in nontransplanted controls, and heart transplant recipients have been shown to have a 7.1-fold increase in incidence of malignancy [80] . among all solid-organ transplant recipients, skin cancer is the most common malignancy. heart and/or lung transplant recipients have a 26.2-, 21-, and 9.3-fold increased risk of developing lymphoproliferative disorders, head and neck cancer, and lung cancer, respectively. malignancy does not necessarily shorten survival in older recipients, but one may surmise that it does affect quality of life [75] . the demand for heart transplantations is unlikely to ever be fully met, and more resources are needed to slow down the progression of heart failure and prevent the need for transplant surgery in the first place. as ventricular assist device technology improves, it may be used to complement heart transplantation to avoid immunosuppression and its side effect of malignancy in older patients with advanced heart failure. lung transplantation should be considered for patients with advanced lung disease whose clinical status has progressively worsened despite optimal medical or surgical therapy. one thousand four hundred sixty-five lung transplants from deceased donors were performed in the united states in 2007, increased from 840 in 1998 and 941 in 2000. of these, 223 were for recipients over the age of 65, representing 15% of all lung transplant recipients and dramatically increased from 30 (3.6%) in 1998 and 30 (3.2%) in 2000. the percentage of patients 50-64 years of age receiving lung transplants has not changed substantially over the past few years, with 54% of deceased-donor lungs going to these patients in 2007, up slightly from 48% in 1997. the most recent data list 1,005 active patients on the waiting list, with 91 (9%) being over the age of 65. the median time to transplant in this elderly group is 57 days. donor lung shortage has been the major limiting factor to the number of lung transplants performed. the procurement rate of lung from deceased donors has consistently been lower than those for kidney, liver, and heart. while kidneys and livers are harvested from more than 85% of all cadaveric donors, and hearts from 30% of deceased donors, lungs are harvested from only 15% of all cadaveric donors [1]. this discrepancy may be attributed to the lung's vulnerability to potential complications that arise before and after donor death such as aspiration, pneumonia, ventilator-associated lung injury, and neurogenic pulmonary edema. over the past several years, the number of single lung transplants performed annually in the united states has remained stable, while the number of bilateral transplants has consistently increased and even surpassed the number of single lung procedures [81] . the most common indications for lung transplantation, accounting for 85% of procedures worldwide, are advanced chronic obstructive pulmonary disease (copd), idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and idiopathic pulmonary arterial hypertension. survival benefit has been demonstrated for both single and double lung transplants in patients with cystic fibrosis, pulmonary fibrosis, and primary pulmonary hypertension. there have been less convincing and reproducible results regarding the benefit of transplantation in patients with emphysema or eisenmenger's syndrome [82, 83] . absolute contraindications for lung transplantation include malignancy within the last 2 years (excluding cutaneous squamous and basal cell tumors); significant chest wall deformity; noncurable chronic extrapulmonary infection (active hepatitis b,c, hiv); untreatable advanced dysfunction of another major organ (e.g., heart, liver, kidney); known noncompliance or inability to follow medical regimen, especially if related to an untreatable psychiatric or psychological condition; absence of a consistent or reliable social support system; and substance addiction within the last 6 months [84] . coronary artery disease not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function, is an absolute contraindication to lung transplantation, but heart-lung transplantation could be considered in highly selected cases. relative contraindications to lung transplantation include: age older than 65 years; critical or unstable clinical condition; severely limited functional status with poor rehabilitation potential; colonization with highly resistant or virulent bacteria, fungi, or mycobacteria; severe obesity (body mass index exceeding 30 kg/m 2 ); severe or symptomatic osteoporosis; and poorly controlled or managed medical conditions (diabetes mellitus, systemic hypertension) [81] . as with other organ transplantation, induction therapy has become a major part of the immunosuppression regimen with lung transplantation. induction therapy was used in the first 5-7 days after transplantation for 57% of all lung transplants performed in 2006, up from only 22% of lung transplants in 1997. among the most common were antilymphocyte antibodies (antithymocite globulin or okt3) or monoclonal il-2 receptor antagonists (basiliximab or daclizumab). baseline therapy prior to discharge at most centers included corticosteroids, calcineurin inhibitor (tacrolimus 83%, cyclosporine), and an antimetabolite (azathioprine 39% or mycophenolate mofetil 52%). maintenance immunosuppression administered for the first year following transplantation was essentially the same. steroids are typically tapered to a low dosage or even discontinued in some protocols. acute rejection within the first year was treated most commonly with corticosteroids, used in 95% of acute rejection cases [85, 86] . despite the multitude of medications available, no drug has been found to be consistently superior in delaying rejection or bronchiolitis obliterans or in prolonging long-term survival. protocols vary widely between lung transplant centers the adjusted graft survival for recipients over the age of 65 at 3 months (92%), 1 year (79%), 5 years (42%), and 10 years (13%) are all comparable within a few percentage points to various younger age groups (fig. 98.6) [1]. the average death rate in the first year after transplantation decreased steadily from 290 per 1,000 patient-years at risk in 1997 to 169 deaths per 1,000 patient-years at risk in 2004, a 10-year low. according to the 2007 ishlt registry report, the median survival for all adult recipients is 5 years, but bilateral lung recipients have a better median survival than single lung recipients (5.9 vs. 4.4 years, respectively) [78] . it is not delineated if this survival advantage is related to the underlying patient characteristics or choice of operation. the impact of underlying diagnosis on survival after lung transplantation has often been linked to age, with older recipients having a significantly shorter survival than younger ones. recipients with copd have the best 1-year survival, but a lower 10-year survival when compared to those with cystic fibrosis and alpha-1 antitrypsin deficiency. in contrast, patients with idiopathic pulmonary arterial hypertension have the lowest 1-year survival, but their 10-year survival approaches those with cystic fibrosis and alpha-1 antitrypsin deficiency [87] . this data is significantly different when evaluating patients over the age of 70. an analysis of unos data of lung transplants from 1999 to 2006 showed that patients 70 years and older had substantially increased risks of 30-, 90-day, and 1-year mortality when compared to younger groups. the authors' recommendation was that lung transplantation may be used with caution in older patients over the age of 60, but should not be performed in patients older than age 70 [88] . management strategies have been more effective at reducing early complications than later ones, which may be due to refinements in surgical technique and postoperative care. however, beyond the first year of transplantation, survival is mostly affected by infections and chronic rejection, and the incidence of these complications has not changed substantially since 1988 [84] . the leading cause of death in the first 30 days after lung transplantation is graft failure, a form of acute respiratory distress syndrome (ards), accounting for almost 30% of deaths [78] . the leading cause of mortality after the first year, typically accounting for 40% of deaths, is chronic allograft rejection (e.g., chronic graft dysfunction), which usually manifests as bronchiolitis obliterans syndrome (bos) [89] . survival 3 years after the onset of bos is only 50% and drops to 30-40% at 5 years [90] . infectious complications remain a leading cause of rejection and death at any point after lung transplantation, in any age group. it has been attributable to up to 35% of deaths in the first year and 20% of deaths thereafter. bacterial bronchitis and pneumonia are most common, but cytomegalovirus, mycobacteria, fungi, and community-acquired respiratory viruses all contribute to morbidity and mortality [84, 87] . malignancy accounts for 7-10% of deaths beyond the first year after lung transplantation. nonmelanoma skin cancer is most common overall, but posttransplant lymphoproliferative disease (ptld) is the most common malignancy in the first year after transplant [78] . other malignancies include colon, breast, kaposi's sarcoma, and transitional cell carcinoma of the bladder [91] . often times, there are patients with multiple organ failure that may benefit from dual organ transplantation. examples include kidney-pancreas and heart-lung. while there has been success with these combined organ transplantations over the years, its use has been limited in the elderly population. from 1998 to 2007, there were a total of 14 kidneypancreas transplants in patients over the age of 65, while none were reported for heart-lung for a patient over the age of 65 [1] . as with individual organs, the overall risk-benefit of the surgery needs to be weighed, considering the overall health of the patient and potential survival benefits of transplantation. while age is often considered a significant factor in determining candidacy, it should not be the limiting factor. the elderly population is on the rise in this country, and older patients comprise the fastest growing segment of the population. this trend is mirrored in the transplantation population. the discipline of organ transplantation has grown remarkably over the last half-century and has evolved from infrequent, highly dangerous procedures with very high mortality to complex operations performed regularly across the country and world. data from centers across the country clearly indicate that patients over the age of 65 can undergo kidney, liver, heart, or lung transplantation with excellent results (fig. 98.7) . the limiting factor, however, is the shortage of organs and excess of patients on the waiting list; which raises many ethical and social concerns regarding transplanting healthy organs into older patients who may not have as much of a survival benefit as a younger patient. although the allocation of organs according to age may be a simple approach to satisfying the goal of social justice, the inclusion of patient comorbidity and potential for survival benefit in the elderly must also be considered. kidney and liver transplantation has been successfully performed and results substantiated in patients over the age of 70. the results depend on the selectivity used to identify those elderly candidates on the waiting list for transplant. cardiac and lung transplants have shown some promising results in patients over the age of 65, but not over the age of 70. it is important to note that with cardiac and lung transplantation, there is a slight discrepancy with the proportion of elderly patients on the waiting list and with overall survival rates. this is likely due to patient selection more than the overall results. this patient population is a highly selective group of elderly patients with cardiac and lung disease, who are often not placed on the waiting list until they worsen clinically. all things being equal, discrimination against older candidates for organ transplantation on age-related grounds alone is not warranted. despite potential utilitarian gains to be made limiting transplantation in the elderly recipients, the sense of fairness in the system will be harmed. elderly patients who are healthy will be the ones who suffer. older patients already face huge hurdles to get on the waiting list for transplantation, and they are already such a small number. there already is enough discrimination against the elderly, and we ought not to add to that injustice by further limiting their access. organ procurement and transplantation network and the scientific registry of transplant recipients: transplant data differences in quality of life across renal replacement therapies: a meta-analytic comparison comparison of mortality in all patients on 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mellitus after kidney transplantation a calcineurin antagonist-free induction/maintenance strategy for immunosuppression in elderly recipients of renal allografts from elderly cadaver donors: long-term results from a prospective single centre trial long-term results of calcineurin-free protocols with basiliximab induction in "old-toold" programs preferential allocation of marginal kidney allografts to elderly recipients combined with modified immunosuppression gives good results early mortality rates in older kidney recipients with comorbid risk factors renal transplantation in the elderly: surgical complications and outcome with special emphasis on the eurotransplant senior programme liver transplantation trends for older recipients: regional and ethnic variations chronic liver disease in the extremely elderly of 80 years or more: clinical characteristics, prognosis and patient survival analysis liver transplantation in patients over sixty years of age orthotopic liver transplantation in patients 60 years of age and older orthotopic liver transplantation in patients over 60 years old liver transplantation in patients over 60 years of age liver transplantation in patients over sixty years of age liver transplantation in patients over 60 and 65 years: an evaluation of long-term outcomes and survival liver transplant for the septuagenarians: importance of patient selection minimal criteria for placement of adults on the liver transplant waiting list: a report of a national conference organized by the american society of transplant physicians and the american association for the study of liver diseases meld and peld: application of survival models to liver allocation predicting outcome after liver transplantation: utility of the model for endstage liver disease and a newly derived discrimination function impact of age older than 60 years in living donor liver transplantation older age and liver transplantation: a review the prevalence of coronary artery disease in liver transplant candidates over age 50 the elderly liver transplant recipient: a call for caution liver transplant recipients older than 60 years have lower survival and higher incidence of malignancy allograft survival following adult-to-adult living donor liver transplantation outcomes of 385 adult-to-adult living donor liver transplant recipients: a report from the a2all consortium long-term results of liver transplantation in older patients 60 years of age and older liver transplantation in patients beyond age 60 liver transplantation in recipients over 60 similar outcomes, morbidity, and mortality for orthotopic liver transplantation between the very elderly and the young evolution of liver transplantation in europe: report of the european liver transplant registry prognostic model for early acute rejection after liver transplantation age and liver transplantation: a report of the liver transplantation database transplantation in the elderly patient the registry of the international society for heart and lung transplantation: twentieth official adult heart transplant report -2003 heart transplantation in patients seventy years of age and older: a comparative analysis of outcome long-term survival (>10 years) of patients >60, years with induction therapy after cardiac transplantation long-term results of heart transplantation in patients older than 60 years outcomes in patients older than 60 years of age undergoing orthotopic heart transplantation: an analysis of the unos database listing criteria for heart transplantation: international society for heart and lung transplantation guidelines for the care of cardiac transplant candidates -2006 selection and treatment of candidates for heart transplantation. a statement for health professionals from the committee on heart failure and cardiac transplantation of the council on clinical cardiology solid-organ transplantation in hiv-infected patients correlates and prognostic implication of exercise capacity in chronic congestive heart failure clinical determinants of mortality in chronic congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy ejection fraction, peak exercise oxygen consumption, cardiothoracic ratio, ventricular arrhythmias, and plasma norepinephrine as determinants of prognosis in heart failure. the v-heft va cooperative studies group development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation the seattle heart failure model: prediction of survival in heart failure immunosuppression for cardiac transplantation -the past, present and future should heart transplantation be considered as a treatment option for patients aged 70 years and older? heart transplantation in older candidates a comparative analysis of outcome after heart transplantation in patients aged 60 years and older: the university of alberta experience long-term outcomes of heart transplantation in older recipients poor prognosis of heart transplant patients with end-stage renal failure incidence of malignancies in heart and/or lung transplant recipients: a single-institution experience registry of the international society for heart and lung transplantation: twentyfifth official adult lung and heart/lung transplantation report -2008 assessment of survival benefit after lung transplantation by patient diagnosis listing for lung transplantation: life expectancy and transplant effect, stratified by type of end-stage lung disease, the eurotransplant experience international guidelines for the selection of lung transplant candidates: 2006 update -a consensus report from the pulmonary scientific council of the international society for heart and lung transplantation induction immunosuppression for lung transplantation with okt3 induction therapy in lung transplantation: a prospective, controlled clinical trial comparing okt3, anti-thymocyte globulin, and daclizumab registry of the international society for heart and lung transplantation: twentyfourth official adult lung and heart-lung transplantation report -2007 impact of advanced age in lung transplantation: an analysis of united network for organ sharing data primary graft dysfunction and other selected complications of lung transplantation: a single-center experience of 983 patients post-transplant bronchiolitis obliterans development of malignancy following lung transplantation key: cord-273612-o746vjrn authors: isaacson, michal; barkay, dov title: mobility scooters in urban environments: a research agenda date: 2020-09-30 journal: journal of transport & health doi: 10.1016/j.jth.2020.100917 sha: doc_id: 273612 cord_uid: o746vjrn abstract introduction as our society ages, mobility scooters are a fast-growing mode of transportation. the growing prevalence of mobility scooters as a mode of transportation has the potential to not only affect the lives of older adults who use them but to impact urban environments at large as well as have implications for the safety of pedestrians and of other vehicle users. goal the goal of this paper is to explore the gaps in the existing literature regarding mobility scooters, laying out key areas for future research. results we propose three areas of research that focus on mobility scooter use by older people: (1) research involving users – impacts on older people employing mobility scooters; (2) studying the impact on urban space public spaces and passageways used as travel routes, the barriers impeding travel and lack of appropriate parking solutions in the urban environment; and (3) issues of safety mobility scooter driving and travel regulations and infrastructure design regulations. discussion addressing these gaps in knowledge has the potential to contribute to the social and physical sustainability of future urban environments as well as to the wellbeing of older adults. as population ages, one of the challenges that older people living in urban environments face is remaining mobile. due to physical changes that become more common with age, older adults' mobility may be limited, restricting their autonomy. as a result, restoring older adults' autonomy may require mobility solutions other than driving cars or using public transportation. one possible solution for alternate, more accessible travel could be achieved by using mobility scooters (clarke, 2014; samuelsson,& wressle, 2014) . mobility scooters are simple, electricity-powered vehicles that are suitable for short-distance travel at low speeds. mobility scooters have been in use by older people for several decades. having been used by a small proportion of the population, mobility scooters have mostly been neglected by researchers, planners and policy makers and have not been studied in ways that other vehicles have been. the growth in the number of mobility scooter users and the expected increase in mobility scooter prevalence creates a rising need to address this form of transportation from multiple perspectives. according to the us census bureau (2014), the release report cb14-218 for the years 2008-2012, 40% of people aged 65 and older have to contend with disabilities. two thirds have difficulty walking or climbing. with the population over 65 in the us nearly doubling from 51 million in 2017 to 95 million by 2060 the number of older people that have to contend with mobility disabilities is expected to reach 24 million. this leads to an expected compound annual growth rate in purchase of mobility scooters, worldwide, between 2020 and 2026 is expected to reach 7.3%, not accounting for covid-19. the following research note addresses this need by examining the uniqueness of this transportation mode and by calling attention to possible impacts that the growth in mobility scooter use may have in three domains. these include: the impacts on those who adopt mobility scooters into their lifestyle, potential implications for urban and transportation planning, and impacts on enacting laws and regulations pertaining to the safety of those operating and riding mobility scooters, as well as those surrounding them. following the introduction, this paper consists of two parts. first, mobility scooters will be introduced, describing their uniqueness as a transportation mode. the legal aspects of mobility scooters will be explored, outlining current laws and regulations of relevance to mobility scooter usage from different parts of the world. second, the knowledge gaps that exist in each of the three domains discussed above will be reviewed. these gaps need to be addressed in regard to the growing number of older mobility scooter users. mobility scooters are dedicated assistive vehicles that allow people who have difficulty walking to perform tasks requiring mobility. these include electric-powered wheelchairs and electric-powered mobility scooters (karmarkar et al., 2011; la plante and kate, 2010) . electric-powered wheelchairs have provided a partial solution to mobilizing people with mobility impairment, limited mostly to the confines of their homes and their homes' surroundings. mobility scooters are suitable for farther-reaching travel, and therefore provide a complete solution to mobilizing people by expanding the travel range, allowing users to regain autonomy outside of their homes (su et al., 2010) . mobility scooters have become affordable and reliable vehicles that serve their purpose of mobilizing those in need in an easy to use, efficient, and manageable manner. mobility scooters have a varying seating capacity of one or two passengers. there are two types of mobility scooters (see fig. 1 ). the division is made based on size and motor power: class 2 and class 3, both with three or four-wheeler options (dvla, 2018): 1. class 2 mobility scooters are smaller and lighter-more compact, enabling easy handling and convenient storage. mobility scooters in this class can be folded and stored in the trunk of a car. they are appropriate for indoor use (such as shopping malls and public transportation) as well as outdoor use. their speed is limited to 4 m/h (6.44 km/h). 2. class 3 mobility scooters are larger vehicles that can only be used outdoors. these vehicles include safety features such as lights, reflectors, a horn, and side mirrors. the uk driving and vehicle licensing agency require that the maximum width of class 3 mobility scooters be restricted to 85 cm, and the maximum speed limited to 8 m/h (12.9 km/h). autonomous mobility scooters are currently being developed and at the time of writing, are not available commercially (anderson et al., 2017) . once available commercially, autonomous mobility scooters possess great potential to assist those who need them and may change behavior in significant ways. regulations applied to the use of mobility scooters vary worldwide. in the process of writing this paper, the laws and regulations pertaining use of mobility scooters in north america (usa & canada), western europe (uk, germany), and australia were examined. none of the countries listed above require driving licenses in order to drive mobility scooters. out of the listed countries, only queensland (australia), and the uk require vehicle registration. in these countries, registration is required for larger mobility scooters, class 3 vehicles. regulations regarding use vary as well. the usa, canada, and the uk allow driving on roads sidewalks or pedestrian pathways, while australia, japan, and germany allow driving only on sidewalks and pedestrian pathways. an exception is made when sidewalks are not available. the remainder of this paper lays out a research agenda that is derived from the growth in the use of mobility scooters and covers the ways in which the growing use of mobility scooters may affect those who use them, the urban environments in which they live, and society at large. many people perceive driving not merely as a mode of transportation but as a symbol of independence and wellbeing (cobb and coughlin, 2000; davey, 2007) . driving cessation due to physical or cognitive decline can make day-to-day life difficult as well as undermine people's independence and sense of autonomy. older people are not the only ones affected by their loss of mobility. family members and caregivers who care for older people are burdened by the need to transport those in their care. mobility scooters have the potential to change the lives of those who adopt them when struggling with retaining independent mobility. previous research has found that the average mobility scooter users are between the ages of 75 and 81, with modest walking impairments and who live in their own homes (gitelman et al., 2017; laplante and kaye, 2010) . topics that future research should address include: 1. better understanding of the mobility scooter user profilebroadening the understanding of who uses mobility scooters, defining type of transportation mobility scooters are used for, and outlining who can benefit from their use and in what ways (pettersson et al., 2014; sullivan et al., 2014; mortenson and kim, 2016) . 2. understanding the effect of mobility scooter use on the wellbeing of older adults -understanding the impact that the adoption of mobility scooters has on users. how does using a mobility scooter change older adults' actual mobility? how does mobility scooter use affect the ways in which older adults perceive their mobility? how does adopting the use of mobility scooters affect specific populations differently? specific populations may include divisions on the lines of gender, previous driving experience, education, and life-long disability (thoreau, 2011; löfqvist et al., 2012; lukersmith et al., 2013) . 3. understanding barriers to the adoption of mobility scooters -who are the most successful adopters of mobility scooters? what kind of people try to adopt mobility scooters but are unsuccessful? what are the best practices that can be used to promote mobility scooter adoption among populations that can potentially benefit from their use? what barriers exist to adoption, and how can these barriers be negotiated? 4. issues related to families and caregivers -how are caregivers affected by the adoption of mobility scooters? does the use of mobility scooters relieve or increase caregivers' burden? the growing use of mobility scooters has the potential to impact urban environments in several ways (king et 2014) and needs to be the focus of planners who are required to plan environments that accommodate mobility scooters (king, 2011; korotchenko and clarke, 2014) . mobility scooters provide users with the ability to access a broader range of destinations, possibly affecting the destinations which are frequented by users. making moving about easier may make distance less of a factor when choosing the location in which to carry out day-to-day activities such as grocery shopping and receiving primary medical care (blais et al., 2012; may et al., 2010) . mobility scooters require appropriate parking facilities: once reaching a destination, mobility scooters need dedicated space in which to be parked safely. an important aspect in regard to the urban environment is the availability and accessibility of travel routes. at present, most countries consider mobility scooter riders and drivers as pedestrians and only permit driving mobility scooters on sidewalks and pedestrian paths (not on roads). operating mobility scooters on sidewalks and pedestrian paths raises difficulties of two types. first, pedestrian spaces may have obstacles that are difficult for mobility scooters to navigate. pedestrians are nimble and quick, while mobility scooters are wide and not as flexible. garbage cans, trees, and benches for example can all make moving on sidewalks difficult for mobility scooters (gitelman et al., 2017; thoreau, 2015; may et al., 2010) . su, schmoker & bell (2010) have found that mobility scooter users complain about the need to plan their travel routes before traveling to ensure route accessibility (newton et al., 2010) . next, when operated on sidewalks, mobility scooters compete for space with the most vulnerable users of public space, pedestrians. sidewalks should be a safe refuge for pedestrians, a sanctuary that is threatened when mobility scooters are driven on sidewalks. the prevalence of mobility scooters in pedestrian spaces is creating a conflict among older adults who are both the majority of mobility scooter users as well as some of the most vulnerable pedestrians. injury as a result of a collision between a pedestrian and a mobility scooter can have particularly dire implications when the pedestrian is a (sometimes frail) older adult. another aspect in which the growing prevalence of mobility scooters may influence urban environments is in the need to allocate parking space for mobility scooters. parking spaces need to be located in very close proximity to users' homes as well as in close proximity to the locations to which they travel. optimal parking should protect the vehicles from theft and from sun and rain and should possibly have the infrastructure needed to charge the vehicle's battery. fig. 2 shows a mobility scooter parked on the sidewalk in a dense and crowded urban area. lacking a better solution, the owner of this mobility scooter installed an anchor to which the mobility scooter can be chained, indicating that this is not a casual parking spot but rather the location in which the scooter is frequently parked. with the rise in the number of mobility scooters driven on streets within cities, the transportation infrastructure needs to be modified to accommodate mobility scooters. urban and transportation planners need to address creating accessible passageways and allocating secured parking spaces that do not interfere with pedestrian movement and safety within cities. topics that need to be addressed in a research agenda include: 1. examining the relationship between the built environment and mobility scooter use. this includes understanding how different urban morphology, such as road layout and density, enables ms use or makes it difficult. 2. creating a fuller understanding of the existing situation in cities regarding the use of sidewalks as mutual travel routes for mobility scooters, pedestrians, and other types of vehicles. 3. furthering the understanding of the nature of obstacles to mobility scooter travel incurred by faulty design, construction, or maintenance of public space. 4. development of best practices in planning mobility scooter travel routes in existing urban fabric. this includes developing measurements and indexes that indicate areas and locations that are favorable for mobility scooter use. such indexes may help planners, policy makers as well as older adults make decisions regarding the location of future plans and investments. 5. planning for connectivity with public transit and other existing travel modes needs to be examined. how would one transfer from ms to other transport mode? can one board a train or bus with a ms? what would be the limitations for boarding with a ms? limitations may include size and weight specifications of the ms. unlike other vehicles, most countries do not impose regulatory requirements on mobility scooter use, such as mandatory training, obtaining a driver's license, and registration of the mobility scooter. although mobility scooters are driven at low speeds, collisions, especially those involving pedestrians, can have dire results (murphy et al., 2014; carlsson and lundälv, 2019) . like other vehicles, mobility scooters must be serviced to ensure safe usage. the breaking and steering systems need to be in particularly good working order. the lack of vehicle licensing and routine inspections leaves maintenance at the users' discretion. user safety has become a major controversial issue regarding mobility scooters with a growing number of mobility scooter-related collisions (jancey et al., 2013) . many are self-inflicted crashes due to driving with a lack of proper training and proficiency. some collisions can be accrued to the poor physical capabilities of some older mobility scooter drivers. obstacles on travel paths are another source of frequent collisions that involve mobility scooters (gitelman et al., 2017) . driving mss possess. driver training and licensing remain a topic that needs to be addressed by regulation (nitz, 2008; mortenson et al., 2016) . training those who are transitioning from driving cars to driving mobility scooters as well as instructing first time drivers or those who have not driven for several years to drive a mobility scooter. topics that need to be addressed concerning safety include: 1. developing a better understanding of who can safely drive a mobility scooter. what impairments affect one's capability of being a safe mobility scooter driver? 2. how can training, user licensing, and vehicle inspection and registration be introduced in a way that is sustainable to existing licensing systems? 3. what regulations regarding the use of mobility scooters need to be developed, and who should enforce these regulations? 4. how would regulating mobility scooter endorse its use, receding, or expanding adoption? 5. development of crash testing protocols for mss that take into consideration driver as well as pedestrian safety. how can mss be designed and built to minimize injury and damage in the event to a collision? this paper has presented a research agenda that is warranted by the growth in the number of mobility scooters that are used, and that will be used in urban areas. the research agenda presented in this paper has the potential to benefit the community of mobility scooters users. more importantly, this agenda may have a broader impact by affecting those who do not use mobility scooters. this may be achieved by making urban environments more inclusive of specific populations, by ensuring a safe environment for pedestrians and mobility scooter drivers and by promoting paths clear of obstacles, proper mobility scooter driving training and permitting, and appropriate maintenance of the mobility scooter. stakeholders involved include not only pedestrians and mobility scooter drivers but city administrators and planners who should take charge by providing the proper solutions pursuing appropriate research. at stake are the safety of pedestrians and mobility scooter drivers, aspects of inclusion and sustainability in cities, as well as the wellbeing and independence of older people. michal isaacson: conceptualization, formal analysis, formal analysis. dov barkay: formal analysis. a conflict of interest may exist when an author or the author's institution has a financial or other relationship with other people or organizations that may inappropriately influence the author's work. a conflict can be actual or potential. at the end of the text, under a subheading 'disclosure statement', all authors must disclose any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three (3) years of beginning the work submitted that could inappropriately influence (bias) their work. examples of potential conflicts of interest which should be disclosed include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. mobility scooters for an ageing society acute injuries resulting from accidents involving powered mobility devices (pmds)-development and outcomes of pmd-related accidents in sweden mobility is most common disability among older americans the role of the built environment and assistive devices for outdoor mobility in later life how will we get there from here? placing transportation on the aging policy agenda older people and transport : 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fractures in elderly novice users. clinical cases in mineral and increasing independence for older people through good street design evidence from a cohort of able bodied adults to support the need for driver training for motorized scooters before community participation men's and women's perspectives on using a powered mobility device: benefits and societal challenges powered wheelchairs and scooters for outdoor mobility: a pilot study on costs and benefits mobility scooters on loan -a scheme complementing the existing special transport services in london riding into the future: a snapshot of elderly mobility scooter riders and how they use their scooters personal mobility scooters: health differences between mobility scooter users and the unaided pedestrian the impact of mobility scooters on their users. does their usage help or hinder?: a state of the art review key: cord-033736-bsmqqi6j authors: bajraktari, saranda; sandlund, marlene; zingmark, magnus title: health-promoting and preventive interventions for community-dwelling older people published from inception to 2019: a scoping review to guide decision making in a swedish municipality context date: 2020-10-14 journal: arch public health doi: 10.1186/s13690-020-00480-5 sha: doc_id: 33736 cord_uid: bsmqqi6j background: despite the promising evidence of health-promoting and preventive interventions for maintaining health among older people, not all interventions can be implemented due to limited resources. due to the variation of content in the interventions and the breadth of outcomes used to evaluate effects in such interventions, comparisons are difficult and the choice of which interventions to implement is challenging. therefore, more information, beyond effects, is needed to guide decision-makers. the aim of this review was to investigate, to what degree factors important for decision-making have been reported in the existing health-promoting and preventive interventions literature for community-dwelling older people in the nordic countries. methods: this review was guided by the prisma-scr checklist (preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews), the methodological steps for scoping reviews described in the arksey and o′malley’s framework, and the medical research council’s (mrc) guidance on complex interventions. eligible studies for inclusion were randomised controlled trials (rcts) concerning health promotion or primary prevention for community-dwelling older people implemented in the nordic countries. additionally, all included rcts were searched for related papers that were reporting on additional factors. eligible studies were searched in seven databases: pubmed, scopus, cinahl, academic search elite, psycinfo, socindex, and sportdiscus. results: eighty-two studies met the inclusion criteria (twenty-seven unique studies and fifty-five related studies). twelve studies focused on fall prevention, eleven had a health-promoting approach, and four studies focused on preventing disability. all interventions, besides one, reported positive effects on at least one health outcome. three studies reported data on cost-effectiveness, three on experiences of participants and two conducted feasibility studies. only one intervention, reported information on all seven factors. conclusions: all identified studies on health-promoting and preventive interventions for older people evaluated in the nordic countries report positive effects although the magnitude of effects and number of follow-ups differed substantially. overall, there was a general lack of studies on feasibility, cost-effectiveness, and experiences of participants, thus, limiting the basis for decision making. considering all reported factors, promising candidates to be recommended for implementation in a nordic municipality context are ‘senior meetings’, ‘preventive home visits’ and ‘exercise interventions’ on its own or combined with other components. the population across the world is growing older which calls for effective health-promoting and preventive interventions in order to help older people maintain a good quality of life. in accordance with the world health organisation (who), health promotion is defined as the process of enabling the population/individual to increase control over and improve their health, while disease prevention is defined as measures taken to prevent the occurrence of disease or limit its development [1, 2] . the implementation of health promotion and prevention is imperative given that increased levels of dependency in managing activities of daily living (adls) is related to a reduction in self-rated health [3] as well as higher societal costs [4] . in sweden, municipalities have a responsibility to address health concerns and social care needs among older people ultimately aiming to optimize the person's quality of life by promoting independence and opportunities to participate in society [5] . therefore, municipalities need to consider health promoting and preventive interventions besides, and to complement, the provision of social care. such interventions can promote various aspects of the health and well-being of older people by strengthening the person's opportunities to be active and participate in society [6] . simultaneously, a more health promoting approach to the provision of municipality services for older people could reduce the expected increase in health and social care costs. several studies show that health promotion and prevention in different forms have resulted in a range of positive effects such as maintenance of ability to perform adls [7] , enhanced quality of life [8, 9] , prevention of functional decline [10, 11] , and reduced falls [12] . in addition, some interventions have shown to be cost-effective [13, 14] . in all, examples in the previous literature indicates that positive effects can be achieved from both multi-professional and single-professional interventions [10, 15] , from both short and long-term interventions [16, 17] and both group-based and individual interventions [10, 18] . even though the existing evidence is promising in improving health outcomes among older people, the range of interventions have varied considerably regarding their content, design and outcomes used, making them hard to compare [19] . since resources (e.g. staff) are limited, not all promising health-promoting or preventive interventions can be implemented. thus, more information than mere evidence on effects, based on single trials, is needed to provide sufficient guidance for decision-makers on what type of intervention to implement [20] . the question of which interventions to implement needs to be guided by a systematic decision-making process based on the best available evidence [21] . in this systematic process, a range of factors need to be considered, e.g. intervention design, effects, cost-effectiveness, feasibility of recruitment and intervention procedures as well as an understanding of how participants experience the intervention. the challenge with this task is that many health-promoting interventions often miss to report all such information relevant for decision making [22, 23] . in addition, the issue of context should be considered when assessing how evidence can be transferred from controlled trials to clinical settings [24] . in this study, the context is focused on the nordic countries, because these countries, to a large extent, share similar welfare systems characterized by publicly funded health and social care. a scoping review design has been proposed as an effective tool to disseminate research findings and provide an overview of evidence for decision-makers and policymakers [25] , and is especially appropriate when exploring a heterogeneous or complex body of literature [26] . given the potentially positive effects on older peoplesh ealth and the cost-effective use of societal resources, a comprehensive overview of the existing evidence on health promoting and preventive interventions is needed. therefore, the aim of this review was to investigate to what degree factors important for decision-making have been reported in the existing health-promoting and preventive interventions literature for community-dwelling older people in the nordic countries. this scoping review follows the prisma-scr checklist (preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews) [27] as well as the methodological steps for scoping reviews described in the arksey and o′malley's framework [25] . the arksey and o′malley's framework consists of five stages: 1) identifying the research question; 2) identifying relevant studies; 3) selecting studies; 4) charting the data; 5) collating, summarizing and reporting the results [25] . this scoping review has been conducted following an unpublished work plan. health promotion and prevention often include several interacting components and can, therefore, be considered as complex interventions. the medical research council's (mrc) guidance for the process of developing, evaluating and implementing complex interventions was used to identify the research questions of this scoping review [28] . according to the mrc guidelines, this process includes several phases in which evaluations of feasibility, effectiveness and cost-effectiveness provide essential knowledge. in addition, the pico framework (population, intervention, comparison, outcome) which is recommended to frame the research question but also to guide the whole process in a review, was used as an additional source in guiding the formulation of the research questions regarding the population, intervention/control and effects on possible outcomes [29] . hence, the research questions were: 1. in which contexts have interventions been conducted? 2. for which populations have interventions been conducted? 3. how have the interventions been designed (e.g., which components, duration of interventions and mode of delivery)? 4. which feasibility aspects have been described? 5. how have the participants experienced the interventions? 6. were interventions effective, and on which outcomes? 7. were interventions cost-effective? the eligibility criteria were defined in advance but were modified with increased familiarity with the literature. eligible studies were: 1) interventions categorised as health promotion (hp) or primary prevention (pp) following the who's definition [1, 2] and addressing behavioural risk factors, injury prevention, physical health, social and mental health, 2) including populations of community-living older people 65+ as of it being the lowest retirement age in the nordic countries, hence exclude the risk of missing relevant studies due to the age limitation, 3) implemented in a nordic country (denmark, finland, iceland, norway, sweden and faroe islands), 4) studies applying a randomized controlled trial design (rct) for the evaluation of effects (research question six), 5) studies related to the identified rcts addressing the remaining research question, e.g. experiences of participants, feasibility as well as studies on cost-effectiveness. only studies written in english were included and to decrease the risk of missing relevant articles, no year limit was applied. the exclusion criteria were: secondary prevention programmes related to a specific disease or diagnosis e.g. interventions implemented for participants with a neurological condition such as stroke or alzheimer's disease, tertiary prevention programmes (e.g. rehabilitation, hospital discharge) as well as studies in populations with extensive needs for support in adls. furthermore, interventions focusing on dental health promotion; interventions targeting older people with cognitive malfunction; programmes assessing effects of medication or evaluations of effects only focused on specific body structures [30] , were also excluded. seven online databases were searched: pubmed, sco-pus, cinahl, academic search elite, psycinfo, socindex, and sportdiscus. in designing the most suitable search strategy, a librarian at umeå university was consulted on several occasions. the search strategy was based on a combination of words to capture key terms related to the purpose of this study: "health promotion", "prevention", "old people", "community-dwelling", "nordic countries", "randomised controlled trial" and their synonyms/alternative words. a detailed outline of the search strategy, including the full syntaxes to screen the databases and numbers of search results, is available in additional file 1. the initial search strategy was piloted and refined in the light of early findings. the search for literature was conducted from inception to january 9, 2019 (last date searched). identification of studies, relevant to this review, was done in two stages. at the first stage, we identified rcts in the field of health promoting and preventive interventions for community dwelling older people conducted in the nordic countries. to decrease the risk of missing relevant studies during the first stage of identifying studies, we did not limit our search to only primary prevention programmes. we applied this inclusion criterion when screening titles and abstracts for study selection. in the second stage, reference lists of identified and selected studies from the first stage (the rcts) were examined for the purpose of identifying related studies, i.e. studies evaluating the same intervention but at different follow-ups, looking at different outcomes, or addressing the other research questions. search results were exported in endnote reference manager, which was used to remove duplicates. in the next step, the endnote reference manager was used to ease the process of identifying and excluding irrelevant studies through searching for key exclusion terms (hospital discharge, cognitive malfunction, dementia etc.). titles and abstracts of the remaining studies were organised in an excel document and read independently by all authors. studies that all authors agreed did not meet all of the eligibility criteria were removed. in cases of uncertainty, disagreement was resolved by reading the whole study and discussion among the three authors. after screening titles and abstracts and excluding studies not meeting the inclusion criteria, the remaining studies were read in full text. in line with the process of identifying research questions, the mrc framework and the pico framework were used to guide the process of data extraction. the included studies were distributed between authors sb and mz who independently charted the data for summarizing information related to the research questions, each question targeting one of the seven factors: context, population, intervention content, feasibility, experiences of participants, effects and cost-effectiveness. disagreement was resolved through discussion between all authors. all authors read the extracted data and discussed the results. main results are presented in the text under a specific heading for each of the research questions. results are presented and described by referring to either the original study/ study (at first-hand study protocol, if available. if no study protocol was identified we referred to the first published rct), related studies (other publications related to the original study) or intervention (referring to the specific interventions evaluated in each study). in the section below there is a description of the factors (data items) extracted to address the research questions. to the extent available, data on context, population, intervention content, feasibility, experiences of participants, effects and cost-effectiveness have been extracted from the included studies. the extraction of data regarding intervention context focused on identifying the setting (e.g. primary care, clinical, home, physical activities facilities) in which the specific intervention was evaluated as well as the country, and if available, the municipality in which the study was conducted. data extracted on population concerned how the target population was defined in age, frailty/morbidities, gender, and socio-economic status. the data extracted concerning feasibility was specifically focused on identifying participation rates and retention. if a pilot or feasibility study was published, the aim and main results of the study were also extracted. information on experiences of participants was extracted from related qualitative studies, and main results on experiences of participants were summarised. effects were examined by extracting effects on specific health outcomes at different time-points as reported in each study. in general, the data extracted regarding effects included effect sizes if reported, confidence intervals and p-values for outcomes for which a statistically significant difference was reported. no effect sizes, confidence intervals or p-values were extracted for outcomes upon which no significant difference was reported, they are mentioned in text however. the first step in exploring cost-effectiveness was to identify if such studies had been conducted. the primary objective when looking at identified studies on costeffectiveness was to examine if evaluated interventions were found to be cost-effective and in relation to which outcomes cost-effectiveness was established. furthermore, if available, data concerning methodological aspects of such studies were extracted, e.g. perspective used (health provider/payer or social perspective), outcome-and cost measures and how they were affected by the specific intervention, comparator (e.g. no intervention, alternative intervention) and time horizon (over which time horizon costs and effects were measured) [31] . the search yielded a total of 690 studies. after removing duplicates, 381 titles and abstracts were screened and studies obviously not meeting the inclusion criteria were excluded. all remaining studies were read in full text (n = 35) and studies which did not meet the eligibility criteria were removed (n = 8). all 27 original studies, identified in stage 1, were in stage 2 reference checked resulting in 55 related studies being identified and included. in all, a total of 82 studies were included for analysis, 27 original studies and 55 related studies. the search process is presented in a prisma flowchart in fig. 1 . the total number of participants in the included studies (extracted primarily from the original studies, if available) was 34,238. one municipality-based study included a very large sample (n = 24,365) [40] . considering all studies except the one by poulstrup and jeune [40] , sample sizes varied from 30 participants [16] to 4030 participants [53] . the duration of interventions varied from a one-session discussion group [8] to three weekly group exercise sessions over a period of one year [54] . of the 27 original studies, 12 focused specifically on fall prevention (looking primarily at fall-related parameters and fall risk factors, e.g. falls, fear of falling, balance performance, bone mineral density) [17, 32-35, 37-41, 55] . eight fall prevention interventions were single component and included only exercise [10, 32-36, 38, 39] , while five combined an exercise component with one or more different components, e.g. preventive home visits (phv), discussion groups, nutrition, medication review [17, 37, 40, 41, 55] . eleven studies had a health promoting approach. five of these studies focused on promoting general health (interventions which in addition to focusing on functional status also focused on health-related quality of life and/or social support aspects) [8, 18, 36, 43, 44] , four promoted exercising [48] [49] [50] 56] , and two focused on promoting mental wellbeing [16, 45] . the four remaining studies focused on preventing disability [46, [51] [52] [53] . findings on intervention type, intervention aim, context, and population are presented below in table 1 . these findings are also described in the text, separately for each factor, in the sections below. there were no related studies identified for 12 of the 27 original studies, so all 55 related studies found were linked to only 15 of the 27 original studies. of the 15 original studies: one study reported results in nine related studies [43] , two reported in seven related studies [41, 44] , and one reported in six related studies [18] . the 11 remaining interventions reported results in one to five related studies. for further details, see table 2 below. among the 55 related studies, 38 included evaluations of effects, eight were qualitative studies analysing experiences of participants, four were health economic evaluations, three were study protocols, and two were pilot studies. findings on intervention content, effects and feasibility aspects are also described separately in the sections below, while detailed information on these factors is presented in table 2 . geographically, the studies were conducted in finland (n = 10), sweden (n = 9), denmark (n = 5) and norway (n = 3). no studies were identified from iceland or faroe islands. interventions were implemented either at home (n = 4) or in other settings (n = 11), e.g. gyms and exercise halls [32, 42, 47, 51] , clinics/hospitals [17, 37, 38, 50, 53] or research centres [10, 46] . the remaining interventions were implemented in a combination of settings (n = 12). for further details, see table 1 , "context" column. the population targeted in the included studies varied regarding age and health-related conditions. in six studies, the target population was defined in relation to age and location of residence [16, 33] , four of these studies were municipality-based and targeted a broad population of older people from several municipalities [40, 45, 53, 107] . the remaining studies defined the target population in relation to age and location of residence/municipality in [48] , whereas two applied a narrow age span 77-82 [8] , 75-79 [45] . one study reported only the mean age of the participants [39] . five studies had samples consisting only of female participants [32, table 2 detailed results concerning intervention content, effects on health outcomes, and feasibility aspects of included studies in the field of health-promoting and preventive interventions for community dwelling older people in the nordic countries from inception to 2019 (continued) original study intervention content effects (significant between-group differences) feasibility aspects month after the intervention period. control: 1 counselling session on fall prevention at baseline irr = 0.77*, 95% ci = 0.55-1.06 [68] . no sig. difference in hand grip strength, knee flexion (right/left) [68] , incidence of falls overall [71] or in the incidence of falls requiring medical treatment [69] , depressive symptoms [70] , dynamic balance [65] . 2-year and 3-year: no sig. difference between i vs control in the incidence of falls requiring medical treatment [69] .. walking duration increased* for combined (t and t + n) vs n and c [94] . no sig. differences in balance, mobility, nutritional measures (e.g. body weight, energy intake) [46, 96] , aerobic capacity (maximal work-load or work time) [95] . 9-month: only effects in physical activity level preserved in t vs c and n [94] . no effects were preserved on: rmr, leg press, dips, step test, muscle strength [46] , aerobic capacity (maximal work-load or work time) [95] , adl [94] . 33, 42, 48, 49] . for further details, see table 1 , "population" column. given the broad range of intervention types, interventions varied by content, modes of delivery, duration and professionals involved. in most of the studies, the intervention content included a physical activity component (n = 19). in twelve of these studies, exercise was the only component and included different exercise forms such as resistance/ strength [47] , balance [35] , rocking-chair training [48] , nintendo wii exercise [38] , or a combination of different exercise forms [10, 32-34, 36, 39, 49, 52] . the remaining seven studies included different components, e.g. exercise and multidisciplinary check-ups [51] , exercise and comprehensive information on, e.g. medication, nutrition, removing home hazards [17, 40, 41] , exercise and a social activity programme [45] , exercise and nutrition [46] , and exercise and vitamin d [55] . the eight remaining studies did not include any practical exercise component. these studies included, senior meetings or discussion groups and home visits [37, 43, 44] , a discussion group, activity groups and an individual intervention [8] , case-management [18] , anonymous self-care telephone calls [16] , physical activity counselling [50] , or an education programme for home-visitors [53] . regarding modes of delivery, six studies were individually based [16, 18, 34, 40, 48, 49] , seven were group-based [10, 32, 33, 35, 38, 47, 53] , and 14 studies included group and individual interventions [8, 17, 36, 37, 39, 41, 43-46, 50-52, 55] . studies including only individually based interventions were provided at home and were either self-managed [48] , supervised [18, 34, 40] , telephone-based [16] or digital [49] . studies including only group-based interventions were delivered in the format of exercise groups [10, 32, 33, 35, 38, 56] or an educational group [53] . studies including both group formats and individual interventions included group formats and home visits [8, 17, 37, 41, 43, 44] , group formats and home training [17, 36, 39, 41, 52] group formats and individual counselling on health [8, 45, 46, 50, 51] . the number of sessions included in the interventions varied, as did the duration. for individually-based interventions, the number and duration of sessions ranged from one single home visit [43, 44] or one personal counselling session on nutrition [46] to daily independently performed exercise sessions (5-15 repetitions) over a period of 16 months [52] . group-based components ranged from one single discussion group [8] to three 50 min exercise session a week for over one year [10] , while the education programme for home visitors included regular education over a period of three years [53] . studies combining group and individually-based components ranged from one single home visit and four discussion groups [43, 44] to two weekly exercise sessions over one year in combination with monthly lectures on various themes and psychosocial activities combined with a single individual geriatric assessment and counselling on fall prevention [41] . in 15 studies, the interventions were delivered by a multiprofessional team [16-18, 34, 37, 40, 41, 43-46, 48, 51-53] including, e.g. physiotherapist, occupational therapists, nurses, dietitian, dentist and healthcare students. in twelve studies, the interventions were implemented by one profession, of which seven interventions were delivered by physiotherapists [32, 33, 35, 36, 38, 39, 50] , one by occupational therapists [8] , three by exercise instructors/leaders [10, 42, 49] , and one by unspecified trained personnel [47] . feasibility aspects were reported sporadically across studies. all interventions reported on methodological aspects table 2 detailed results concerning intervention content, effects on health outcomes, and feasibility aspects of included studies in the field of health-promoting and preventive interventions for community dwelling older people in the nordic countries from inception to 2019 (continued) original study intervention content effects (significant between-group differences) duration: regular education (17 municipal meetings) for home visitors during 3 years and one education programme (2 h) for gps in the first year control: no intervention (education program) for home visitors in another 17 control municipalities. increased risk for catastrophic functional decline rr 1.49***, 95% ci 1.27-1.74 [106] . fewer persons (80-year-olds) in the intervention group had moved to a nursing home hr 0.59*, 95% ci 0.37-0.94 [103] . effects on functional ability in women were preserved or 1.22*, 95% ci 1.03-1.44. no sig. difference in functional ability for men [104] . no sig. difference in functional decline or mortality in both man and women [103] . notes: *p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001. a maximum score for fes-1 = 28, higher score implies higher concern for falling, lower score implies lower concern for falling, b maximum score for bbs = 56, higher score implies higher degree of functional balance and vice versa, c maximum score for 13-item of feasibility such as recruitment and retention/dropout numbers. with recruitment numbers, we refer to the total number of eligible participants (meeting inclusion criteria) who agreed to participate in the study. the mean recruitment rate (eligible participating population/total eligible population) in all the studies included in this review was 63%, varying from 9% [49] to 100% [33, 35, 41, 46, 52] . however, there was some inconsistency regarding how the eligible population was defined. for instance, in one study the total eligible population consisted of only those who volunteered [33] , or of the population receiving an invitation [53] or the whole population in a specific community [40] . thus, participation rates are not consistent among included interventions and this inconsistency should be taken into consideration when interpreting the mean recruitment rate. mean retention rate in the total number of original studies included in this literature search was 85%. retention rate varied from 37% [51] to 99% [53] . beside the information related to recruitment and retention rates, only two feasibility/pilot studies were identified [83, 92] . kristensson et al., investigated the feasibility of a case management intervention by specifically assessing sampling and sample characteristics as well as possible effects on perceived health [92] . lood et al., (2016) investigated the feasibility of evaluating senior meetings in the "elderly in the risk zone" intervention [43] among a specific group of older people (foreign-born) by specifically assessing recruitment and retention rates, questionnaire administration, and variability of data [83] . in relation to five of the original studies, eight related studies explored the experiences of participants [75, 76, 82, 85] or both the experiences of participants and professionals delivering the intervention [61, 62, 87, 91] . based on qualitative methods and interviews, participants' experiences were described related to i) a single preventive home visit (phv) [75] , ii) senior meetings [76, 82, 85, 87] , iii) multidisciplinary fall prevention programmes [61, 62] , and iv) case management intervention [91] . findings from interviews on phvs showed that home visits contributed to empowerment and increased selfesteem by making participants feel in control over their health. however, for some, it did not come at the right time, either because they felt too healthy to benefit from it or because they felt too ill to be able to participate [75] . findings on senior meetings revealed that although independent older people may find it difficult to accept or act upon health-promoting information, the discussion groups, provided in a multi-dimensional approach, could motivate acting upon such information, and thus, senior meetings were perceived as a "key to action" [76] . these findings were in line with experiences of foreign-born older people who felt empowered by the opportunities gained, such as the possibility to meet other people, discuss experiences, as well as become acquainted with possibilities to make everyday life better and safer [82] . however, their capabilities to adhere and act upon knowledge in the long-term (six months to one year after their participation in the programme) was dependent on personal and environmental resources [85] . furthermore, professionals delivering the interventions, revealed that for a senior meeting intervention to succeed in reaching out to the target group, it is necessary to recognise the person's resources and empower their capabilities in maintaining health [87] . empowerment and raised awareness were also emphasized in a group-based multidisciplinary fall prevention program delivered through a client-centered approach. the involved professionals observed that building trust and a safe atmosphere within the group increased participants' engagement in discussions which contributed to the success of the intervention. a contributing factor for creating this sort of atmosphere was the role-shifting negotiated by the group leaders from being the expert to being a facilitator of the discussion [61, 62] . however, it was noticed that for a group format to be successful, group composition should be taken into consideration for the participants to feel fellowship [61, 82] . furthermore, in a home-based case-management intervention, participants experienced case managers as a helping hand in navigating within the health system, and thus, contributed to feelings of control and safety [91] . additionally, experiences of participants were explored as secondary outcomes through a survey related to a nintendo wii training fall prevention intervention [38] , or through a single open-ended question related to a telephone-based health-promoting intervention [16] . findings from the survey showed that training with a digital device (wii) was experienced positively and did not lead to any adverse effect [38] . a self-care telephone intervention influenced participant's attitudes positively, e.g. towards self-care [16] . for several interventions, effects were evaluated in relation to a wide range of outcomes, and all, besides one intervention on nutritional counselling [46] , reported a positive effect on at least one health outcome evaluated in comparison to a control group. however, the magnitude of effects and follow-ups at which interventions were evaluated, varied substantially and therefore, should be taken into consideration when evaluating effects. to summarise intervention effects, we classified health outcomes in broader categories (table 3) . for example, balance confidence, balance performance, dynamic balance, impaired balance, postural balance, postural sway, velocity moment in standing balance, are categorised under "balance". details on effects are found in table 2 . four studies presented a health-economic evaluation. three studies adopted a cost-effectiveness analysis method [13, 72, 102] and one a cost-utility analysis method [90] . two studies provided an economic evaluation of single interventions; a case-management intervention [90] and an education programme for home visitors [102] . the other two studies compared different interventions focused on health promotion [13] , and falls prevention [72] . in these four studies, a societal perspective was chosen including cost from different sectors e.g., health care and social care. the time horizon used varied from three months [13] , one year [13, 90] , two years [72] and up to three years [102] . all studies based their estimates of costs on intervention costs, healthcare costs and municipality costs. in addition, the value of informal care was included in one study [90] . costeffectiveness was evaluated in relation to active life-years gained [102] , quality-adjusted life-years (qalys) [13, 90] and number of injurious falls prevented [72] . findings from the economic analysis showed that two interventions were considered cost effective [13, 72] whilst two were not [90, 102] . a one-session discussion group was found to be more cost-effective when compared to an individual intervention or an activity group in an intervention comparing three different occupation-focused healthpromoting interventions to a control group [13] . the discussion group showed significant effects on qalys gained at 3 and 12 month follow up's and lower total costs [13] . furthermore, an exercise intervention showed high probability to be cost-effective in preventing falls in relation to a threshold of 3000 euro per injurious fall prevented when compared to three other fall preventive interventions focusing on exercise and vitamin d supplements [72] . in contrast, no significant difference was observed in total costs or qalys gained when comparing a case management intervention to no intervention in a cost-utility analysis. nevertheless, the case management intervention led to lower levels of informal care and need for help with instrumental adls [90] . neither did a training programme for home visitors result in significant differences in total cost or active life-years gained in comparison with usual practice of performing preventive home visits [102] . this scoping review provides a comprehensive overview of health-promoting and preventive interventions for community-dwelling older people in the nordic countries that to some extent, can guide decision-making in a swedish municipality context. however, while all included studies report some positive effects, not all potentially effective interventions can be implemented since resources are limited. thus, the evidence on effects needs to be critically reflected upon, but several other factors need to be considered as well. our study exposes gaps in knowledge regarding cost-effectiveness, experiences of participants and feasibility of the interventions, knowledge that could broaden the understanding of which interventions seem most promising and feasible to implement from a decision-makers´perspective. while the scope of this review includes interventions with different foci, the summary of findings on the seven evaluated factors, show that some interventions such as senior meetings, preventive home visits (phv) and exercise interventions alone or combined with other components, seem to be strong candidates for implementation, e.g. [10, 43, 50] . in all, the total evidence for these interventions included positive effects on a range of outcomes, in some cases confirmed by evaluations at different follow-ups, with established cost-effectiveness, and supported by qualitative findings based on the experiences of participants. in the section below we provide a deeper discussion about the previously mentioned intervention examples and argument how the findings from this review could guide decision making and how additional knowledge, generally missing across the different interventions, is needed to better guide decisions on which interventions to implement. senior meetings, one type of intervention investigated in four different studies, seems potentially effective in promoting general health and wellbeing among communitydwelling older people [8, 37, 43, 44] . the study which provides the broadest evidence base is the "elderly persons in the risk zone"-study conducted in gothenburg [43] , which evaluated a four-sessions senior meeting intervention combined with a home visit. several related studies support the implementation of senior meetings given the positive results on a range of health outcomes, e.g., physical function [77] and adls [81] , outcomes for which effects were established at different follow-ups (3 months to 2-year follow-ups). qualitative findings on the experiences of participants also provide an understanding of why the intervention was effective by concluding that senior meetings were experienced as a "key to action" in empowering participants to engage in preventive approaches to improve health [76] . the benefits of senior meetings, albeit with other content, were also verified in the studies by zingmark et al., [8] and johansson et al., [37] . in the study by zingmark et al., [8] two group-based formats of interventions (a discussion group and an activity group) were implemented by occupational therapists which both resulted in positive effects. in our results, evidence on costeffectiveness regarding senior meetings was limited to the study by zingmark et al., who found a one-session discussion group to be the most cost-effective intervention format [13] . recently, however, a publication based on data from the "elderly persons in the risk zone" supports the cost-effectiveness of senior meetings as well, even in the long term (over four years) [109] . thus, senior meetings seem to be a strong candidate for implementation in a swedish municipality context. yet, the exact format can be further discussed given the variation in the number of sessions and the specific content, e.g. one session discussion [8] , four sessions combined with a home visit [43] , twelve sessions combined with two home visits [37] . in addition, feasibility aspects related to recruitment during implementation in a municipality context seem to be a critical feature to improve reach in the intended population, thus requiring specific contextual knowledge [110] . our results show that phvs have the potential to improve general health by preventing deterioration in health in community dwelling older people. however, phvs have varied regarding the specific format e.g. from one visit [43] to twelve visits [18] and have shown positive effects on several outcomes e.g. limiting progression in morbidity [78] , reducing the number of emergency department visits [18] , maintaining adl ability [8] reducing lower extremity fractures [40] . positive effects were also reported for an education programme for the home visitors conducting the phvs, in terms of lower admission rates to nursing homes for those receiving two home visits per year [103] . the most promising results on phvs were established in the "elderly persons in the risk zone" study where a single home visit was evaluated and showed positive effects adls [81] , frailty and fear of falling [77] , life satisfaction and morbidity [78] . this study was the only one, among phv interventions, to conduct a 2-year follow up at which some effects persisted and thus validates post-intervention effects [81] . the positive effects of phvs in the "elderly persons in the risk zone" study are partly explained by the experiences of participants, who felt empowered and in control as a result of the information given and having the opportunity to discuss health-related matters with a qualified professional [75] . however, these findings on long-term effects are in contrast to a previous phv trial that indicated that intervention effects remained only for as long as the home visits were ongoing [111] , and thus, highlights the importance of long term follow-ups over. conflicting results regarding specific effects of pvhs and their health-economic effects have been reported also in a recent report from sbu enquiry service (swedish agency for health technology assessment and assessment of social services) about preventive home visits, also referred to from the swedish national board on health and welfare [112] . in some studies, though, phvs have shown to be cost-effective while annual follow-up visits can be potentially even more costeffective. such findings have been established when conducting health economic analysis based on data from the elderly persons in the risk zone [109] as well as in a previous swedish study including twice-annual home visits over a period for two years [111] . despite the conflicting results on some outcome effects of phvs [113] , they still can be considered a good alternative to group-based interventions, e.g. senior meetings, since not all potential participants can or like to engage in a group format. interventions including exercise or combining exercise with other components (e.g. medication review, guidance on nutrition, cessation of alcohol and smoking, home hazard assessment and modifications) showed to be promising for preventing falls. findings on these interventions showed improvements in different factors related to falls risk and physical functioning, e.g. muscle strength, mobility, balance or self-rated health [34, 35, 38, 59] which could indirectly lead to fall reduction [114] . positive effects were observed for both home-based [34] and group-based interventions [39] , regardless of whether they were shorter (3 months) [35] or longer (1 year) in duration [33] . furthermore, interventions including more frequent group sessions reported additional effects, such as improvement in motivation to continue with physical activity [36, 47] , and perhaps consequently a reduction in injurious falls and fractures, as reported in two fall prevention interventions [10, 17] . both interventions included balance exercise in combination with resistance/strength exercise provided over one year or longer, but varied in terms of content, number of sessions, and delivery approaches used e.g. multifactorial [115] and multiple components [17] . in line with evidence from a recent systematic review and metaanalysis, exercise-based interventions, aiming to improve balance and strength, are one of the most feasible and cost-effective approaches to prevent falls among older people living in the community [114] . this approach has also been integrated into some current swedish guidance, on physical training, balance and more, issued from the national board on health and welfare in the form of training for professionals working with older people and fall prevention [116] . however, effectiveness of exercisebased interventions is dependent on the uptake and longterm adherence [117] . groups sessions led by professionals over a longer period (1 year or more) seems to affect this aspect positively but can be costly, foremost in terms of human resources needed if provided to a large population of older people. since group training might not be the solution for all, other effective alternatives such as multifactorial interventions could work in these cases. also, multifactorial interventions have shown positive effects on preventing falls [118] and could be considered an alternative to exercise-based interventions. nonetheless, no health-economic evaluation was identified for these interventions, and thus, still makes them less robust in terms of cost-effectiveness. while our results, indicate that there are several healthpromoting and preventive interventions that could improve health and well-being among community-dwelling older people, implementation needs to be considered, not only in relation to effects but also concerning the resources available, i.e. how limited resources can be used in a way that yields the largest health benefits [20, 21] and other feasibility aspects such as reach in the population; a key factor for successful implemtation of research in practice. health economic evaluations, including evaluation of both costs and effects, can provide such important information. however, in this scoping review, only four health economic evaluations were identified, indicating a general lack of information to guide decision making. however, information regarding intervention content, e.g. duration and intensity of interventions, can at least provide some information about the resources required. regarding individual interventions, the study by dahlin-ivanoff et al. included one single preventive home visit requiring one and a half to two hours of a professional's time [43] in contrast to the study by möller et al. in which a case management intervention, required at least one hour per month during a 12-month intervention of professional's time [18] . similarly, for group-based interventions, the span for the time required was two hours for a one session discussion group [13] , to two and a half hours per week over the course of one year [10] . while these examples all include interventions with some positive effect, the time for which staff need to be allocated differs substantially. even though these examples lack information on other types of costs that can be affected by interventions (e.g. social care consumption), they provide some guidance on which resources are needed and the magnitude of staffing which is a central cost of a healthpromoting or preventive intervention [13] . despite a growing literature of health-promoting and preventive interventions that have shown positive effects in well-controlled trials, the translation of such trials to practice has proven to be challenging [20] . evidence has shown that feasibility or pilot studies are important to ensure effective practical implementation and to decrease threats to validity of health outcomes [119] . however, in our literature search, there was a lack of piloting and feasibility studies. in the absence of feasibility or pilot studies, other reported aspects such as information on study participation rates and adherence could indicate the degree to which an intervention reaches out to the target population, and thus, increase chances of a successful translation of research evidence into clinical practice [119] . reaching older people with health promotion is crucial for achieving a health impact for the whole population, but has also been shown to be challenging [110, 120] . findings from all 27 original studies, in this review, showed that approximately a third of the persons eligible declined to participate due to different reasons, i.e. being too sick or too healthy [75] . qualitative data on experiences of participants could to some extent reveal why an intervention is or is not appealing to larger groups of older people, however, only a few studies on experiences of participants were identified in this review. while this review provides some guidance on which interventions have shown positive health effects in a nordic context, future research is needed on how to translate evidence into practice, e.g. through exploring alternative ways of reaching out to a larger population and incorporating support for behaviour change and adherence in the long-term. some examples of new promising approaches explored in this review were wii training [38] and physical activity counselling [50] . the digital approaches used through video training or self-care telephone calls are potentially feasible to be implemented considering the more limited resources required to implement them, e.g. the smaller number of direct personal contacts needed with providers of health care for older people while still resulting in positive effects. in light of the ongoing coronavirus pandemic and related measures of social distancing, the importance of addressing loneliness and isolation among older people is accentuated. digital approaches to delivering effective interventions could complement the challenge of isolation and the need to reach out to a higher number of older people. for example, using smartphones and tablets may be a potentially cost-effective way to increase reach in the population. at present, there is a big supply of smartphone applications for exercise, however, most lack evidence regarding their scientific and implementation validity in the older population. research in the area is, however, developing and one example is an ongoing large clinical trial on digital fall prevention in sweden [121] . finally, in discussing the results of this study, it is notable that some important aspects of healthy ageing, were less frequently evaluated. only two studies focussed on mental wellbeing and social participation, one showed some effects in reducing loneliness [45] and the other in improving general mental health [16] . this gap in research has also been supported in other reviews, where promoting wellbeing and mental health have shown to be both effective and potentially cost-effective [122, 123] , and should, therefore, be further researched. the scope of this review was broad. it included information on several factors extracted from all identified original and their related studies, and therefore provides an overview of the knowledge base in the field of healthpromoting and preventive interventions in the nordic countries. given the broad scope of this review, we choose to not include some information, e.g. data concerning when studies were performed or adverse events, which could be seen as a limitation of the study. data concerning when studies were performed would enrich information on the context and content of the interventions. however, the description of the study period, e.g. the period for the recruitment of participants, have not been reported consistently among all studies, therefore might not have produced many data. although a wide range of outcome effects was extracted, important information on adverse events was not extracted and beyond the scope of this study, guided primarily by the mrc guidelines. additionally, recent systematic reviews show that adverse events, for example, concerning fall prevention programmes seem to be rather poorly reported hence, would probably not make a significant difference in our conclusions, if included in the analysis [12, 118] . another important factor to consider, which may lead to better developed and evaluated interventions, is if the studies have a theoretical foundation that may explain the causal link between intervention and outcomes [28] . however, considering the already broad focus of this review, we choose to limit the presentation of results and not include data on the theoretical foundations for each intervention. furthermore, the quality of the included studies has not been evaluated the same way it would be assessed in a systematic review, meaning that the quality can differ between the studies. it is, however, in line with prisma guidelines on scoping reviews considering this step optional [27] . yet a quality assessment of the included studies or grading of evidence might have led to stronger conclusions as a result of a reduction in uncertainty related to outcome effects. finally, this review did not include studies from the rest of the world, albeit such studies could have provided relevant information. the choice to do so was due to the importance of contextual factors concerning complex interventions [124] . limiting the inclusion of interventions deriving from countries with similar welfare models and cultural context might increase chances of effective implementations of promising interventions. furthermore, research shows that there is is often a lack of information regarding the influence of the context when conducting and evaluating complex interventions [124] . thus, more research on the influence of contextual factors in the effectiveness of certain interventions would add to the knowledgebase important for decision-makers. this scoping review, following the mrc guidelines, provides an overview of the evidence and evidence gaps of health-promoting and preventive intervention studies for community-dwelling older people in nordic countries hence, of importance for decision-makers, research councils and researchers. all interventions, besides one, showed positive effects on at least one health outcome, although the magnitude of effects and number of follow-ups differed substantially. given that evidence on effects alone are not enough information for decision-makers, information on other factors is needed. overall, there was a general lack of studies related to costeffectiveness, experiences of participants and feasibility. therefore, such studies are strongly warranted. in all, based on the evidence presented, senior meetings, preventive home visits and exercise interventions alone or combined with other components seem to be strong candidates for implementation in a swedish municipality context. supplementary information accompanies this paper at https://doi.org/10. 1186/s13690-020-00480-5. 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fallolyckor preventing falls among older fallers: study protocol for a two-phase pilot study of the multicomponent live life program multifactorial and multiple component interventions for preventing falls in older people living in the community nuts and bolts of conducting feasibility studies evaluating the public health impact of health promotion interventions: the re-aim framework effectiveness of a self-managed digital exercise programme to prevent falls in older community-dwelling adults: study protocol for the safe step randomized controlled trial mental health interventions among older adults: a systematic review mental wellbeing of older people: making an economic case. australian e-journal for the advancement of mental health taking account of context in population health intervention research: guidance for producers, users and funders of research publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations our thanks to umeå university library for assisting with advice in performing the search strategy for the literature. we also thank shion gosrani (public health support officer at north tyneside council) for proofreading the manuscript for english language. authors' contributions sb was involved in designing the search strategy, executing the search strategy, assessing studies for inclusion, extracting, classifying and presenting the data, writing and editing the manuscript. mz was involved in assessing studies for inclusion, extracting, classifying, and presenting the data, writing, revising and commenting the manuscript. ms was involved in assessing studies for inclusion, contributing in presenting the data, revising and commenting the manuscript. sb, mz, ms read and approved the final version of the manuscript. work with this study was included in the ordinary work of the three authors. salary of the doctoral student is partially financed by umeå university's industrial doctoral school for research and innovation (ids). open access funding provided by university of umea. all data analysed during this study are included in this published article and its additional files. the search strategy is available in additional file 1. prisma extensions for scoping reviews-checklist is included in additional file 2.ethics approval and consent to participate not applicable. not applicable. author details 1 key: cord-274858-rx7dlpid authors: payne, brian k. title: criminals work from home during pandemics too: a public health approach to respond to fraud and crimes against those 50 and above date: 2020-06-06 journal: am j crim justice doi: 10.1007/s12103-020-09532-6 sha: doc_id: 274858 cord_uid: rx7dlpid this paper uses the public health framework to address the apparent impact of the coronavirus on the victimization experiences with a specific focus given to those over the age of 50. the bulk of attention is given to fraud victimization, with consideration also given to parent abuse, partner violence, and patient abuse. a review of data from the federal trade commission shows that reports of most types of fraud grew significantly in the first three months of 2020 in comparison to the same time period in 2019. differences between fraud experiences based on age are considered. older persons lost much more to fraud than younger persons, and far more in 2020 than 2019. in addition, they reported being targeted more often for certain types of cybercrime (i.e., tech support scams). while devastating to everyone, it is concluded that the coronavirus will potentially have a more significant impact on the financial health of older persons than younger persons. it is concluded that minimizing the consequences of all forms of crimes targeting older adults will be best achieved by using a public health approach. crime is typically thought of as a young person's game. when considering official statistics, which include crimes such as murder, robbery, rape, assault, and so on, the official data do, in fact, show that criminal victimization is incredibly rare among older persons. those data, however, only tell us about the types of crimes that we tend to identify as worthy of measuring in our official crime data. following these official and scope of criminal victimization in this age group in the covid-19 era. in particular, crimes typically targeting older adults include fraud, elder abuse, and patient abuse. it is common to hear about fraud in the aftermath of hurricanes, tornadoes, and other natural disasters. unscrupulous contractors, fraudulent lenders, and fake charities seem to surface after these events. except for the fact that fraudulent activity surfaced during rather than after the pandemic, parallels between fraud outbreaks after natural disasters and covid-19 exist. as will be shown below, fraudulent acts in covid-19 drew on the vulnerability of at-risk individuals, cost more than comparable fraudulent acts occurring before the pandemic, and varied over the life course. generally speaking, two types of fraud occurred during covid-19: (1) those that traditionally occurred and (2) those that were tailored to fears about the coronavirus. regarding this first group, it is natural to question whether "traditional frauds" changed during the coronavirus. recognizing that only half of those who file complaints to the ftc report their age, a review of complaints made by consumers to the federal trade commission during the first quarter of 2017, 2018, 2019 and 2020 sheds some light on this question (see table 1 ). two patterns, in particular, distinguish fraud in the coronavirus era from prior fraud complaints. first, while the largest number of fraud victims are in their thirties, those in their sixties appear to be overrepresented. specifically, 18% of coronavirus fraud victims were in their sixties, though they make up just 11.5% of the population. it is important to note, though, that this age group, as well as those in their seventies and eighties, reported fewer complaints overall to the ftc in 2020 than in 2019. those between 20 and 60, however, reported more frauds. at the same time, attention should be drawn to the fact that half of all complaints in q1 2020 were filed by those 50 or older. by comparison, this age group makes up just over a third of the entire u.s. population. second, while the sheer number of complaints dropped among older persons, these drops were offset by dramatic increases in the amount lost to the frauds. while losses increased for each age group, the increases were more dramatic for older adults. for those eighty and above, the losses more than doubled from 11 million to 23 million between q1 2019 and q1 2020 (federal trade commission 2020). increases were also high for those in their fifties (~50%), sixties (~50%), and seventies (~43%). it is important to note that fraud losses increased for other age groups. however, proportionally the amount losses are higher for older persons. table 2 shows the ten most common types of fraud experienced across age groups in q1 2019 and 2020. certain types increased by more than 10% across all age categories. these included imposter businesses, fraudulent text messages, online shopping complaints, counterfeit checks, and romance scams. the fact that these offenses have connections to the virtual world (where most activities occurred during the pandemic) is noteworthy. other increases in cyber-type complaints varied across age categories. for instance, increases in tech support scams were found among those in their fifties, seventies, and eighties and internet information services complaints increased among those in their twenties, thirties, sixties, and seventies. finding that older persons fell prey more to tech support scams points to their lack of familiarity with the virtual environment, at least in comparison to younger persons. in addition, the fact that those in their eighties did not report internet services crimes likely reflects routine activities of the age group. some may question drawing conclusions about annual quarters given that covid-19 did not truly surface in the u.s. until early to mid-march. however, evidence suggests that fraudsters, perhaps working internationally where covid-19 surfaced earlier or having foresight about possible new opportunities for victimization, began to exploit the crisis earlier in the year. in late january, right around the same time the world health organization declared the coronavirus "a global emergency," security consultants highlighted one of the first coronavirus phishing scams. the email, supposedly from a virologist, advised potential targets, "go through the attached document on safety measures regarding the spreading of corona virus. this little measure can save you" (newman 2020 ). in addition, in early february, an ftc official warned, "scammers are taking advantage of fears surrounding the coronavirus. they're setting up websites to sell bogus products, and using fake emails, texts, and social media posts as a ruse to take your money and get your personal information" (tressler 2020) . so, comparing the first three months of 2019 and 2020, while including a month where the coronavirus would not have impacted fraud, did include two months (february and march) where some offenders were likely motivated by the pandemic. while it would have been preferable to compare fraud only in those months, the data are not available that way. also, in addition to traditional frauds expanding, a second category of frauds surfaced-covid-19 frauds. at least four of these varieties specifically target older persons: grandparent scams, medical fraud, social security administration frauds, and personal care fraud. table 3 shows how different ftc officials describe these types of fraud. with each type, motivated offenders play on the vulnerabilities of older individuals to carry out the crimes. with grandparent scams, offenders tell older persons that their children or grandchildren are facing a coronavirus emergency and funds are needed to help their offspring. in medical frauds, offenders play on the fact that older persons are at a higher risk of infection and offer fraudulent treatments. in social security administration frauds, offenders target the older person's financial vulnerabilities. finally, with personal care frauds, offenders target the older person's mobility vulnerabilities, fraudulently offering to run errands or go places the older person is unable or unwilling to go. table 4 shows the age patterns with specific coronavirus frauds where victims mentioned the pandemic in filing their report to the federal trade commission through april 23, 2020. while those in their thirties reported the most coronavirus frauds, those over fifties and sixties reported losing more funds overall. in addition, the average losses were higher among those over fifty, with those in their fifties reporting the highest average loss at $3073 per complaint. as of april 24, 2020, the ftc had received 25,406 coronavirus complaints. more than half of those were fraud complaints (n = 13,839) and the rest were identity theft (n = 1966), do not call (n = 1572), and other (n = 8203) complaints. the top fraud varieties included travel/vacation (n = 4049), online shopping (n = 2646), text messages (n = 1252), internet information services (n = 570), and business impostors (n = 540). the travel/vacation complaints included those grandparent scams "in grandparent scams, scammers pose as panicked grandchildren in trouble, calling or sending messages urging you to wire money immediately. they'll say they need cash to help with an emergencylike paying a hospital bill or needing to leave a foreign country. they pull at your heartstrings so they can trick you into sending money before you realize it's a scam. in these days of coronavirus concerns, their lies can be particularly compelling. but we all need to save our money for the real family emergencies" (schifferle 2020a) medical fraud "maybe you've seen the ads. renaissance advertises isoprex primarily through mailings targeting older adults. the ads claim that isoprex provides relief for all types of pain, helps rebuild joints, and reduces inflammation. the ads also promote isoprex as a natural pain reliever that's superior to non-steroid anti-inflammatory drugs like aspirin or ibuprofen. but the ftc's complaint alleges that these claims are false or misleading and that the company can't back them up with clinical proof" (schifferle 2020b). "while some of you are home, practicing social distancing and frequent hand washing to avoid the coronavirus, remember that scammers are still busy trying to take advantage of people. some scammers are pretending to be from the social security administration (ssa) and trying to get your social security number or your money." (kreidler 2020) personal care fraud "older adults may be hard hit by the coronavirusand scammers prey on that. if you or someone you know must stay at home and needs help with errands, you'll want to know about this latest scam. scammers are offering help with errands, and running off with your money. if you're an older adult or a caregiver for one, you may need help picking up groceries, prescriptions, and other necessary supplies. if someone you don't know offers to help, be wary. some scammers offer to buy supplies but never come back with the goods or your money. it's usually safer to find a trusted friend or neighbor or arrange a delivery with a well-known company." (greisman and herndon 2020) when consumers were not reimbursed for cancelled vacations. the top other reports included complaints about credit cards (n = 880), lending/mortgage (n = 803), banks, savings and loans, and credit unions (n = 548), lending/student loans (n = 507), and credit bureaus (n = 489). figure 1 shows the trends in coronavirus complaints over three weeks in april of 2020. what is notable is that the daily increases were relatively stable over the three weeks. just as the pandemic altered fraud trends and dynamics, it also changed the characteristics and consequences of elder abuse. elder abuse has been defined as "(a) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship, or (b) failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm" (national research council 2003) . after interviewing elder advocates and attorneys, one reporter characterized the pandemic as a "breeding ground" for elder abuse (levy 2020) . the risk factors contributing to the breeding ground will be discussed below. for now, attention can be given to three types of elder abuse that potentially increased during the pandemic. first, elder neglect refers to situations when individuals fail to provide the care they have a legal duty to provide to older persons. offenders could be familial caregivers or paid caregivers, and neglect could be active (intentional) or passive (unintentional). given the concerns that individuals have about catching the virus from others, and the general lack of concern some have towards older persons, it is easy to imagine situations where individuals avoid contact with older persons either out of fear or outright disregard for those who might need care. as an example, a reporter quoted a 27-year-old who said, "coronavirus only kills old people, and they are going to die anyway" (neutill 2020) . such an attitude among caregivers would likely foster neglectful behaviors. elder physical abuse refers to situations where individuals physically harm older adults. perpetrators could be spouses, paid caregivers, offspring, or other relatives. advocates have widely talked about the increase in intimate partner violence that has followed the pandemic with some calling it the "silent epidemic" (johnston 2020). when conceptualizing partner violence, individuals usually apply the age/maturation hypothesis and assume that the behavior involves young couples. elder abuse researchers are quick to point out that batterers do not simply stop beating their spouses when they hit a certain birthday (payne 2011) . challenges that older victims face were exacerbated during the pandemic. for example, because they often feel out of place in shelters which house more younger women, some older victims are referred to nursing homes for safety. with the coronavirus outbreaks in nursing homes, this safety outlet was slammed shut. financial exploitation refers to instances when trusted individuals steal money from older persons. the notion of trust distinguishes fraud from exploitation (friedrichs 2009; payne 2011) . with fraud, the offender does not have access to the victim's funds, but gains their trust to steal from them. with exploitation, trust is already present, with the offender having access to their funds, and the offender violates that trust. from this perspective, then, the financial exploitation of older persons would typically be committed by offenders known to the victim while frauds would be committed by strangers. given unemployment increases and the likelihood that financial dependency on older parents will increase among some, the social consequences of coronavirus are a recipe for elder financial exploitation. it is hard to gauge how much these crimes occurred during the pandemic. older victims frequently do not want to report crimes committed by their loved ones to the authorities. patient abuse refers to abusive acts committed in nursing homes or other long-term-care settings. elder abuse in institutions occurs at higher rates than abuse in community settings (yon et al. 2019 ). offenders could be nursing staff or residents. varieties of patient abuse include physical abuse, theft, sexual abuse, and neglect. some have attributed physical abuse to exhaustion and the stressful working environment (dai et al. 2017; payne and cikovic 1996) . with the pandemic creating internal and external stressors for nursing home workers, stress and exhaustion may increase the likelihood of physical abuse. along these lines, reductions in nursing home staffing as a result of the coronavirus are inversely related to the likelihood of neglect. in other words, with fewer nursing home workers able to provide care, some older nursing home residents may not receive the care they are supposed to receive during the pandemic. it is important to note that the vast majority of nursing home professionals are not abusive or neglectful. in fact, resident-to-resident abuse is believed to be more common by some (castle 2013) . when neglect surfaces, the behavior can typically be traced to institutional policies and practices. these institutional practices and policies have implications for covid-19. in fact, a report by the new york post connected the risk of death in nursing homes from covid-19 to past infection-control citations by the state health department (dorn 2020) . in april 2020, california nursing care industries requested legal immunity for decisions made during the coronavirus. elder advocates questioned the need for blanket immunity and suggested that such a decision might be a blank check for abusive and neglectful behaviors (sharma 2020) . scholars have explored risk and protective factors for victimization. interestingly, the risk and protective factors for the victimization of older adults align closely with the direct consequences of covid-19, suggesting that for some types of crimes and age groups, the risk of crime actually increased. traditional risk factors that have been identified in the literature social isolation, dependence, caregiver stress, and mental health problems (payne 2011) , and recent research identified "poor fraud awareness" as a risk factor (shao et al. 2019 ). these factors are discussed below in relation to the coronavirus. social isolation is consistently identified as a risk factor for fraud, elder abuse, and patient abuse. the premise is simple and clearly related to routine activities theory. the more socially isolated individuals are, the more they become a vulnerable target. the connection to the coronavirus is clear: social distancing equals social isolation. given the widespread amount of research that shows how social isolation increases the likelihood of elder abuse (pillemer et al. 2016) , it seems safe to conclude that social distancing in the time of a pandemic increases the risk of victimization for older persons. from a routine activities perspective, this makes older individuals more vulnerable as targets. these risk factors cut across domestic and institutional settings. for institutional settings, the role of social isolation during the pandemic may have escalated. nursing homes are facing staff shortages across the ranksnurses, certified nursing assistants, physicians. reports of staff being infected an unable to work contribute to the shortage. in other cases, fear of being infected may have kept workers at home. social distancing measures also prohibited family members from visiting their loved ones. this, too, increased nursing home residents' isolation. the bottom line is that fewer workers and visits from family members means two things in relation to covid-19: (1) there are fewer capable guardians to protect residents from abuse by other residents or professionals and (2) it's harder for existing staff to meet the needs of residents, so the risk of neglect increases. in fact, nursing homes in new jersey and california evacuated their residents after too many staff no-shows made it impossible for the homes to remain open (brown 2020; zoppo and everett 2020) . in many ways, the no-shows equate to fewer capable guardians to protect the vulnerable adults. dependency is another risk factor for elder financial abuse. typically, those unfamiliar with the elder abuse research believe that the more dependent an older person is on their caregiver, the more likely they are to experience abuse. the relationship, however, is in the opposite direction. the more financially dependent an adult offspring is on their aging parent, the more likely they are to steal from their parents (payne 2011 ). with unemployment rates soaring during the pandemic, more adults will become dependent on their aging parents. these dynamics will create more motivated offenders (the financially dependent offspring) and vulnerable targets (the aging parents). with courts closed and unable to intervene or provide guardianship, the lack of guardianship provides the third element to increase the likelihood of victimization. the connection to routine activities is clear. caregiver stress and mental health problems for offenders and victims have also been identified as risk factors for elder abuse. the caregiver stress explanation fails to explain theft and some have said that the impact of stress is overrated. still, increased stress levels as a result of being quarantined would potentially increase risk for abuse (see agnew 1992) . just as the pandemic has increased stress levels, mental health concerns are also surfacing. the lack of social contact could increase depression and anxiety. with more stress and mental health issues in the pandemic, the risk for elder abuse grows. in this sense, motivated offenders are believed to be driven by the stress and mental health problems. substance abuse by offenders has been identified as a risk factor for elder abuse (pillemer et al. 2016) . a nielsen survey found that alcohol sales went up 55% in the third week of march. describing this increase, one journalist commented, "it has become easier to buy alcohol than toilet paper or eggs" (jernigan 2020) . a direct relationship can be suggestedthe more people abuse alcohol during the coronavirus pandemic, the more at-risk older adults are for abuse. "poor fraud awareness" has been identified as a risk factor for fraud among older persons (shao et al. 2019) . the implication here is that individuals may not be fully aware of the risks they face when engaging in certain transactions. for older persons not accustomed to online transactions, the risk may be exacerbated at a time when all transactions move to the virtual world. the increase in tech support scams among older person highlighted above would be an example of "poor fraud awareness." the poor fraud awareness equates to vulnerability in the routine activities framework. countering these risk factors, protective factors limiting the risks of fraud, elder abuse, and patient abuse include social support, awareness, and increased guardianship. social support protects against multiple forms of elder abuse (hamby et al. 2016 ). in addition, such support helps individuals identify and use services when they need them (burnes et al. 2019) . in many ways, social support provides awareness about crime risks and increased guardianship. from a public health perspective, the task at hand it to use these protective factors to develop programming and initiatives to reduce risk during the pandemic. a wide variety of prevention and intervention strategies have been used to reduce the risk of victimization for older abuse. common strategies include publicity campaigns, home visits, respite care for the caregivers, and nursing home placement for at-risk seniors. note that some of these strategies would be difficult to implement during a quarantine. instead, virtual strategies have been implemented to reduce risk for older adults. for example, some jurisdictions have offered "well calls" as types of home visits where the isolated individual can be called to reduce isolation (hessler 2020) . national organizations have promoted virtual educational offerings to promote public awareness. the national center on elder abuse (ncea), for example, developed virtual resources to arm professionals and advocates with information they could use to help older persons, as well as information older persons themselves could use to guard against victimization. as well, a strategy used by the federal trade commission is blogging about coronavirus to share information about fraud risks for older adults. the covid-19 "fraud blog" entries by ftc staff allow readers to respond to the comments provided by the ftc official. a review of the comments made by readers suggests that the blog entries fill three purposes: comfort, information, and rapport building. regarding comfort, readers writing on the blog made comments suggesting that they were reassured by the content provided by the ftc official. here are three examples of feedback suggesting readers found comfort in the information offered on the blog: & "i purchased this product in desperation and with the hope that it just might work. i was one of the suckers who fell for their hype. i got a rash and no relief whatsoever and have been berating myself ever since for my stupidity. i don't know who i was more upset with -me or them but i've learned my lesson. i'm glad the ftc took action." & "i felt compelled to thank you for your actions to thwart any scam that can have a huge impact on our elder citizens. most of whom are, not only, living on a fixed income, but also experiencing health issues." & "getting older doesn't mean you become more trusting, put the hammer on these scammers, they're nothing more than criminals who want to steal from you." regarding information, some readers made comments suggesting that they valued receiving the information and implied that the information could protect them or other from experiencing similar frauds. consider the following examples: & "it is wonderful that you have sent this out, there are so many things on the internet that we elderly folks need to know what to buy and what not to buy. thank you so much for letting us know about this product. god bless, stay safe." & ""thanks for all you do to inform the public of theses scams be safe" (italics added). & "thank you for your reliable information. our agency does a weekly presentation on elders and scams. your organization is one of the sources i use for my consumers" (italics added). rapport building was evident when readers made comments suggesting appreciation to the ftc official. this appreciation translates to a stronger rapport. the following comments from ftc readers shows how rapport (or at least connections) was developed between the ftc and consumers: & "so glad i signed up for these alerts from ftc. because i'm a senior, it seems like i am on the list of every scam going. your emails have been great reminders of the latest predators' techniques. thank you." & "thank you, all of the people who tirelessly work at the ftc to put out these notifications!! god bless each and every one of you! i have been forewarned on so much! keep up the great work. i appreciate every notification i've received." & "thank you for your determination to protect us all especially the elderly from these scammers. your service is greatly appreciated." rapport building was not just with the ftc. indeed, readers appears to connect with one another as they read each other's comments about fraud on the "ftc fraud blog." the following exchange highlights one such virtual conversation: & brook: that is so true scammers always find a way to act when there is a crisis and people are most vulnerable. & grammy marie: we received this scam a couple of years ago but did not fall for it. we gave all our family a code word that only they would know in case this happens again. & ceaf: i've had two these calls. saying my grandson in jail. i recognize my grandson's voice so i always tell them they can stay in jail. & heather: oh yes the scammers are very hard at work during this outbreak, they know all kinds of tricks just to get into your wallet. there are probably tons of covid-19 scams in the works so please be careful. & cappy: helps to be a miserly old coot with no grandchildren, nieces or nephews. because the ftc, ncea, and local efforts respond to specific risk factors and protective factors, efforts should be underway to promote these responses more widely to lower the risk of fraud, elder abuse, and patient abuse among older adults. the final stage of the public health model is ensuring a widespread approach in responding to the problem identified by using strategies that specifically address the risk factors by expanding protective factors. considering coronavirus crimes targeting those aged 50 and above, including fraud, elder abuse, and patient abuse, five themes can be used to promote a widespread response designed to guard against these crimes. first, it is important that a broad definition of crime is used that includes that behaviors targeting older persons. when narrow definitions of crime are followed, it will appear that crime is decreasing. after all, crimes such as drug crimes, gang-related offenses, and gun violence have dropped during the pandemic. other crimes, however, such as cyber offenses, fraud, patient neglect, and so on have not experienced the same trend. widespread responses, then, must focus on the types of behaviors individuals are experiencing. second, just as public health experts note that disease exists anywhere humans live, criminologists note that crime is committed in all groups. building on this theme, in must also be recognized that crime occurs in all placesincluding in individual's homes. social distancing serves to displace criminal behavior from the streets into the safety of the places we live. recall cohen and felson's important findingthat burglaries increased and new televisions were stolen in the sixties when homes were vacant after an increase in women entering the workforce. five decades later, our homes are filled with residents during the coronavirus. crimes were then committed in our homes through unguarded cyberspace with targets and vulnerabilities varying by age. third, it must be recognized that, in terms of crime, coronavirus does not just have negative consequences for individuals' physical health, it also impacts our financial health. and, older persons are not just more at-risk for the negative physical consequences of the virus, they are also more at risk of experiencing the negative financial consequences of frauds emanating out of the coronavirus. drawing attention to these parallels should also remind us that significant overlap exists between the financial and physical consequences of all types of crimes targeting older persons. fourth, we must not lose sight of both the value and the negative consequences of technology for all age groups during anomic times such as those we are experiencing during the pandemic. on the one hand, technology has made it so we can still work, see our friends and family, and maintain as much normalcy as possible. that same technology, however, has created new opportunities for victimization and these victimization experiences vary by victim age. consider, for example, the finding that older persons reported more technology support scams than younger persons. it is possible these scams targeted younger persons equally. older persons, however, might be more apt to fall for them given their lower level of familiarity with technology. while there are negative consequences, the same technology presents opportunities for offering protective strategies to all individuals. these protections, of course, would vary by age of the individual. finally, in developing fraud, elder abuse, and patient abuse prevention and intervention strategiesand other crime prevention strategies related to the coronavirus for that matterit is recommended that a public health approach be used. clear reasons exist for using a such an approach. first, the public health approach, grounded in science, is effective in identifying risk and protective factors. second, because other professionals use the public health approach, this will make it easier to promote collaborative responses between criminal justice professionals and these other professionals. finally, such an approach recognizes that consequences of all forms of victimization include health consequences as well as financial losses. the conclusions drawn from the ftc data reported in this article should be interpreted with some caution. the data are based on self-reports and the majority of victims may not even consider contacting the ftc, and when they do, only about half report their age. despite these limitations, the ftc data provide a glimpse into the coronavirus victimization experiences. future research should explore how public health and criminal justice officials can work together to address protect older adults from victimization. attention should be given to the way that public awareness campaigns enhance guardianship and whether changes in those campaigns should align with the routine activities of individuals at different stages of the life course. in addition, researchers should more fully evaluate the success of ongoing efforts. all too often, prevention and intervention strategies are implemented but never evaluated. such evaluations can determine what really needs to be done to protect all of us from various forms of victimizationboth during pandemics and after them. foundation for a general strain theory of crime and delinquency nursing home patients moved after over a dozen workers skip shifts amid pandemic utilization of formal support services for elder abuse: do informal supporters make a difference? an examination of resident abuse in assisted living facilities the public health approach to violence prevention social change and crime rate trends: a routine activity approach crime rates across u.s. drop amid the coronavirus pandemic the prevalence of risk factors associated with elder abuse in nursing homes in china nyc nursing homes raved by coronavirus were cited for past hygiene fails data and visualizations trusted criminals: white collar crime in contemporary society avoid scams while finding help during quarantine. federal trade commission poly-victimization and resilience portfolios: trends in violence research that can enhance the understanding and prevention of elder abuse help available for montco seniors isolated during coronavirus pandemic. the mercury america is drinking its way through the coronavirus -that means more health woes ahead. the conversation covid-19 coronavirus: domestic violence is the second, silent epidemic amid lockdown avoiding ssa scams during covid-19. federal trade commission crime rates plummet around the world as the coronavirus keeps people inside pandemic creates breeding ground for elder abuse elder mistreatment: abuse, neglect, and exploitation in an aging america why are so many people ready to let the elderly die? refinery watch out for coronavirus phishing cams an empirical examination of the characteristics, consequences, and causes of elder abuse in nursing homes crime and elder abuse: an integrated perspective elder abuse: global situation, risk factors, and prevention strategies grandparents scams in the age of coronavirus. federal trade commission isoprex misleads seniors. federal trade commission why are older adults victims of fraud? current knowledge and prospects regarding older adults' vulnerability to fraud senior care facilities seek legal immunity during coronavirus pandemic coronavirus: scammers follow the headlines. federal trade commission the prevalence of elder abuse in institutional settings: a systematic review and meta-analysis coronavirus is racing through n.j. nursing homes. a lack of health staff is making the crisis worse publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations payne is vice provost for academic affairs and professor of sociology and criminal justice at old dominion university. he also serves as director of the coastal virginia center for cyber innovation. he is past president of the southern criminal justice association and the academy of criminal justice sciences. he is the author or co-author of eight books including white-collar crime: the essentials key: cord-324635-27q3nxte authors: bouza, emilio; brenes, francisco josé; domingo, javier díez; bouza, josé maría eiros; gonzález, josé; gracia, diego; gonzález, ricardo juárez; muñoz, patricia; torregrossa, roberto petidier; casado, josé manuel ribera; cordero, primitivo ramos; rovira, eduardo rodríguez; torralba, maría eva sáez; rexach, josé antonio serra; garcía, javier tovar; bravo, carlos verdejo; palomo, esteban title: the situation of infection in the elderly in spain: a multidisciplinary opinion document date: 2020-09-08 journal: rev esp quimioter doi: 10.37201/req/057.2020 sha: doc_id: 324635 cord_uid: 27q3nxte infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. it is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. in an attempt to give the widest possible focus to this issue, the health sciences foundation has convened experts from different areas to produce this position paper on infection in the elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. the format is that of discussion of a series of pre-formulated questions that were discussed by all those present. we begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. we also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. in this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed. authors for their corrections and amendments. the final document has been reviewed by all the authors. we will now review the questions posed, the arguments made and the conclusion reached for each one. what do we mean when we talk about the elderly? how many are there in spain? how many will there be in the near future? presentation: the who publishes reports on ageing and health, or old age and its consequences, on a regular basis, at least since the 60's. cited here are a few more. we reproduce a paragraph in full [1, 2] "today, for the first time in history, most people can aspire to live beyond the age of 60. in low and middle-income countries, this is largely due to the significant reduction in mortality in the early stages of life, especially during childbirth and infancy, and in mortality from infectious diseases. in high-income countries, the sustained increase in life expectancy today is mainly due to the decline in mortality among older people". the report focuses on a redefinition of healthy ageing based on the notion of functional capacity: the combination of the individual's intrinsic capacity, relevant environmental characteristics and the interactions between the individual and these characteristics. in spain, according to data from the national institute of statistics [3] , 18 .7% of the population is currently over 65. that's about 8.7 million people. if we focus on those over 85, they currently account for 6% of the total population (about 2.8 million). forecasts for 2031 put the number of people over 65 years old at 12 million (26.2% of the population) and those over 85 at 3.9 million (8.5% of the population). thus, between 1960 and 2031, the number of people over 65 will have increased by a factor of 5 (from 2.5 to 12 million), and the percentage will have increased by a factor of 3 (from 8.2 to 26.2 %), while the number of people over 80 will have increased by a factor of 10 (from 370,000 to 3.9 million) and the percentage will have increased by a factor of 6 (from 1.2 to 8.5 per %). once the figures have been established, it is necessary to clarify that, according to the dictionary of the royal spanish academy of language (drael), "old" is "that person of age, commonly one who has turned 70". however, age is a purely theoretical value to distinguish a person as "old" or "elderly". taking the age of 65 as the threshold for the onset of old age dates back to the late 19th century, when less than 10% of those born reached that age. today, more than 90% of people reach the age of 65, so this age limit is shifting towards older ages. nowadays the concept of "old" is more related to "function" than to age. thus, the drael defines health as "that state in which the organic being normally exercises all its functions". therefore, one of the most relevant aspects in considering a person "old" is that they need help to carry out the activities of daily life (bathing, dressing, feeding, moving, etc.). we can find totally independent people in their 80's and others with a high degree of dependency in their 60's. formato es el de la discusión de una serie de preguntas preformuladas que fueron discutidas entre todos los presentes. empezamos discutiendo el concepto de "anciano", las razones de la predisposición a la infección, las infecciones más frecuentes y sus causas, y la carga laboral y económica que suponen para la sociedad. también preguntamos si teníamos datos para estimar la proporción de estas infecciones que podrían ser reducidas por programas específicos, incluyendo programas de vacunación. en este contexto, se discutió la baja presencia de este problema en los medios de comunicación, la posición de las asociaciones científicas y de pacientes sobre el problema y los aspectos éticos que todo esto plantea. the ageing of the population in more developed societies is an incontrovertible fact. in the face of the indisputable success in achieving a longer life for a large proportion of the population, questions arise as to the viability of social protection systems. by 2030, over 25% of the population will be classed as elderly and their quality of life will depend, to a large extent, on avoiding preventable diseases such as infectious diseases. it is a well-known fact that the elderly constitutes a risk group for distinct types of infectious diseases, whose diagnosis and treatment are hindered by several factors. around this fundamental fact, however, we find a lack of answers to simple questions about the size of the problem, its epidemiology, the capacity of the social response to it and the need to plan useful preventive measures to minimise risk and reduce costs. for this reason, the health sciences foundation, which has prevention as one of its main objectives, has organised a discussion and opinion meeting on the infectious diseases situation in the elderly in spain, aiming to answer a series of questions accepted by all the participants. greater difficulty in eliminating secretions. in the digestive tract it is common to find diverticuli in the mucosa that act as microorganism reservoirs. also, losses in secretory function with a tendency to gastric achlorhydria, but, above all, motor function which at oesophageal level, can favour aspiration phenomena. in the urogenital system there are usually alterations arising from pregnancy, childbirth, previous surgeries and local manipulations that make the free flow of urine difficult. in this vein, it is worth adding the frequency of subjecting the elderly to diagnostic or therapeutic examinations that may favour infections. in addition to the deterioration of mechanical barriers, there are losses in non-specific defence mechanisms. these include limitation to increase blood flow and vascular permeability at the infection entry points. the ability to mobilise polymorphonuclear leukocytes rapidly and the agility of phagocyte function is also impaired. chemotactic capacity decreases from the age of 70, as does the capacity for the intracellular destruction of microorganisms. ageing is associated with a chronic, progressive, nonspecific, low-level pro-inflammatory state, for which the english literature has coined the term "inflammageing", which favours an environment conducive to infection and further limits the possibilities of an effective response to it. the deterioration of adaptive immunity ("immunosenescence") associated with the ageing process has been known for years and affects both innate and acquired immunity [4] [5] [6] . immunosenescence includes qualitative losses in t-lymphocyte subpopulations with decreased activity of cd-4 helpers, cytotoxic cd-8s and a limitation in generating t-cell growth factor. ageing determines a tendency to invert the cd4/cd8 t-cell ratio. the number of dendritic cells decreases with age and the response of nk cells to stimulating cytokines is limited. it also increases the activity of cd-8 suppressors. b-lymphocytes are limited in their ability to produce antibodies and to respond to external antigens. furthermore, there is an increase in the production of autoantibodies and circulating immune complexes. a third group of factors that add to the microorganisms and the individual are environmental and social factors, such as hygiene neglect, poverty, isolation and a sedentary lifestyle. the fact of living in nursing homes and the increase in hospitalisations favours an insufficiently quantified environmental exposure [7] . there are multiple factors that explain the higher incidence of infections in the elderly. the clearest are those that have to do with alterations of the defensive barrier mechanisms. immunosenescence is a complex concept involving various alterations in the immunity of the elderly. what are the main clinical syndromes of infection in the elderly? the frequency and even the aetiology of infections af-therefore, the "elderly" is an enormously heterogeneous group in aspects such as the prevalence of chronic diseases (ischaemic heart disease, hypertension, diabetes, copd, etc), the need for consumption of drugs and the existence or nonexistence of physical, mental (dementia, depression) and social (loneliness, isolation, poverty) problems. conclusion: -the definition of elderly is artificial and refers to any person over a certain age (which can be set at 65, 70 or older) who has serious limitations in the exercise of their physical, mental or social functions. -in our society, currently, almost 20% of the population would meet a definition of elderly based exclusively on the criterion of age, but it is estimated that, with this criterion, the percentage in spain will be greater than 25% by the year 2031. the changes that take place throughout the ageing process favour the existence of infections. the simplest explanation is that with age the numerator of the aggression/defence equation increases (greater arrival of microorganisms that are also more virulent) and the denominator decreases (less defence capacity on the part of the organism). we can therefore divide the causes of the elderly person's predisposition to infection into those that depend on the microorganisms and those that depend on the host's defence mechanisms. there is no evidence that the microbiota of the elderly is quantitatively different from that of younger populations, nor necessarily more aggressive. however, it is an incontestable fact that previous infections, antimicrobial treatments, the greater ease of microorganism acquisition and living in proximity to other elderly people, can predispose the elderly to colonization and subsequent infection by multi-resistant microorganisms, with the presence of "superinfections", with a worse response to antimicrobials and increased resistance to them. in terms of host defence mechanisms, there are many factors that make the elderly more labile. mechanical barriers, for example, are the first element of defence, but they deteriorate progressively throughout the ageing process, facilitating the entry of microorganisms. the skin and mucous membranes experience physiological losses and often also those resulting from local or systemic diseases. the most important changes are: thinning, with loss of epithelial and mucosal cells, worse hydration and vascularization, loss of elasticity, decrease in mucous gland secretions of antimicrobial peptides, worse healing, loss of cellular macrophages in the skin (langerhans cells) and immobility with increased local pressure in certain areas. in the respiratory system, there is a decrease in the number of cilia and a slowing down of their activity, a reduction of alveolar macrophages, a decrease of the cough reflex and pend on their situation. in independent elderly people, the most common infections are respiratory conditions caused by viruses or bacteria prevalent in the community, urinary tract infections and intra-abdominal infections. in contrast, in institutionalised elderly people, bladder catheter-related utis, aspiration pneumonias, skin and soft tissue infections, and infections of the gastrointestinal tract predominate. which microorganisms are most common? how does the problem of multi-resistance impact on the elderly? presentation: it is important to remember that infections in the elderly may be caused by a greater variety of microorganisms than in the younger population, so it is essential to obtain samples for culture before administering empirical antimicrobial treatment [8] . thus, for example, while the vast majority of utis in young patients are caused by e. coli, in the elderly their relative importance is less. in the case of pneumonia, there is a higher incidence of gram-negative bacilli (gnb) and as far as meningitis is concerned, they are rarely of viral aetiology, while we must consider gnb and listeria monocytogenes. in a spanish study, including 333 elderly patients (mean age 81.6 years), with utis, the most frequently isolated microorganisms were e. coli, (67%), enterococcus faecalis (15%), klebsiella pneumoniae (10%) and pseudomonas aeruginosa (9%). in up to 8% of cases, more than one microorganism was isolated in the urine. the frequency of bacteraemia was higher with e. coli and lower with e. faecalis and p. aeruginosa and bacteraemia was not associated with a worse prognosis [22] . the frequency of multi-resistance increases with age and comorbidity. in this spanish study, the proportion of extended-spectrum beta-lactamase (esbl) producing e. coli and k. pneumoniae isolates was 20.1% and 36.3%, respectively. in the previously mentioned study of patients attending the emergency department, the elderly accumulated more risk factors for multi-resistance (p < 0.001) and suffered from septic syndrome more frequently (p < 0.001) [16] . there are few studies that analyse the overall aetiology of respiratory infections in older patients, and most work focuses on describing specific populations or groups of pathogens. the aetiological affiliation rate of respiratory infections in the elderly is very low (<30%), and this is due, among other things, to the difficulty many patients have in producing sputum and to the high frequency of empirical treatment [21] . if we analyse the aetiology of cap, the most frequent pathogen is s. pneumoniae (20-80%), followed by h. influenzae (3-39%), respiratory viruses (3-30%), legionella spp.(1-17%) and gnb (3-14%) . it is also necessary to remember the importance of viral pathogens in this population, since the prescription rate of unnecessary antimicrobials is very high in them (46% of the elderly with viral symptoms) [23] . in a study conducted in china, in 6 sentinel hospitals, it was observed that 31.64% of elderly patients with respiratory infection had a viral aetiology (41.8% among extra-hospital infections and 25.7% among fecting the elderly vary depending on the clinical environment (home, nursing home, hospital) and the functional status of the patient. in older, independent and healthy people, respiratory conditions caused by viruses or bacteria prevalent in the community, urinary tract infections (utis), whether catheter-related or not, and intra-abdominal infections (cholecystitis, diverticulitis) are common. in contrast, in institutionalised elderly people, utis related to the bladder catheter, aspiration pneumonia, skin and soft tissue infections and those of the gastro-intestinal tract (git) predominate. in hospitalised elderly people we have to consider nosocomial pneumonia, intravascular catheter associated infections and c. difficile infections as the most prevalent [8] [9] [10] [11] [12] [13] [14] . there is limited data analysing the comparative overall frequency of the different syndromes. in elderly people living in nursing homes, utis (at least 30-40% of healthcare-associated infections), respiratory infections, skin and soft tissue infections and those of the git predominate [15] . in a recent spanish multicentre descriptive study, conducted in 49 emergency departments, 11,399 patients were included, of whom 4,255 (37.3%) were at least 65 years old. compared to younger adults, older patients (mean 78.8 years) had respiratory, urinary and intra-abdominal infections more often, while there was no difference in the frequency of other syndromes [16] . these data are confirmed in chinese studies that analyse elderly patients attending emergency departments and also show a significantly higher incidence of respiratory and urinary infections [17, 18] . in the case of utis, the relative prevalence is influenced by the gender of the patient. thus, for long-term care facility (ltcf) residents and in hospitalised elderly people, uti is the number one cause of infection and is the second most common in older women living in the community [19] . the incidence in men ranges from 0.05/person year (1/20) in men aged 65-74 and reaches 0.08 (1/12) in men over 85. in women, the incidence of uti increases with menopause (0.07 per person/ year: 1/14), increasing to 0.13 per person-year (1/7.5) after age 85 [20] . in indwelling catheter-wearing patients, the incidence of utis is 3.2 cases per 1,000 catheter days, compared to only 0.57 per 1,000 days for all residents (x18). urinary tract bacteraemia was 3-39 times more common in patients with permanent urinary catheterization [20] and uti is also the most frequent cause of community-acquired bacteraemia in the elderly (40-57%). with respect to respiratory infections, the annual incidence of community acquired pneumonia (cap) ranges from 8-18.2 episodes per 1,000 people over 65 years of age and represents 30-40% of hospitalisations in this age group [21] . in japan, 96% of deaths from pneumonia occur in patients over 65 years of age. the risk of cap is 4 times higher in those over 65 compared to those under 45 and 10.8 times higher in those over 85 compared to adults aged 50-64. viral infections are also common in this age range, as we will see later. the most prevalent infections in the elderly de-is estimated at between 4 and 5 episodes per 1,000 days of stay in the residence [33, 34] . the figures rise to 11 for those with some kind of prosthetic material [35] . we have several european halt studies (healthcare-associated infections and antimicrobial use in long term care facilities), with participation from 24 countries, including spain, with a prevalence of infection of 4.7% and 5% at two different times [36] [37] [38] . a french multi-centre study, conducted in 578 nursing homes with 445,000 beds, shows an infection prevalence of 11.23% [39] . the first data on infection in nursing homes in spain come from the epinger study, conducted in community health centres in catalonia, which reported a prevalence of 6.5%, although it should be pointed out that in catalonia the concept of the community health centre would include medium-long term patients, while in the rest of the spanish autonomous communities this concept would be limited to nursing homes [40] . in another study, conducted by san sebastian's fundación matía, an infection prevalence between 6.44% and 4.80% was reported [41] . data derived from the vincat study in catalonia show a prevalence of healthcare-associated infection in long-term care centres of 10.2%, with a great diversity, depending on the type of care unit (subacute 22.3%, palliative 18.7%, convalescent 11.7%, long stay 8.1%) [42] . home is the most recommendable place for the healthy elderly to live, and even for the elderly patient, with healthcare falling to primary care professionals, although sometimes with the collaboration of some hospital resources. the ministry of health, social services and equality has for the first time published the results of the primary care clinical database (bdcap), a tool that allows for a more precise and systematized knowledge of the main health problems in spain dealt with by the doctors on the healthcare frontline. thanks to this register, a detailed picture of the health problems of the spanish population is available from primary care [43] . in this database, infections appear among those over 64 years old with an elevated frequency of 634.1 cases a year per 1,000 people (569.9‰ men and 682.7‰ women). the most frequent correspond to the respiratory system (317 cases/1000 persons/year), followed by urinary tract infections with (84.4 cases/1000 persons/year) and clear female predominance. finally, nosocomial infections are those that occur in hospitalized patients and are present more than 48 hours after admission. they are acquired by transmission from the environment, from other patients or from healthcare personnel. they are considered to be the most preventable cause of serious adverse events in hospitalised patients [44] . in general, these infections are related to invasive diagnostic or therapeutic procedures (urethral catheterization, surgical procedure, vascular catheter, invasive mechanical ventilation), all of which have in common the disruption of the host's own defences by a device or an incision, allowing the invasion of nosocomial infections) [24] . the most common cause was influenza (14% of all patients studied). rsv is also a significant pathogen in this population [25, 26] . the most important cause of git infection in the elderly is clostridioides difficile. c. difficile (c-diff) infection is currently the most prevalent nosocomial infection, affecting in more than 70% of the episodes patients over 65 years of age [27] . moreover, it is in this population that c-diff causes the highest morbidity and mortality, with an increase in c-diff-related mortality from 5.7 to 23.7 deaths per million population per year from 1999 to 2004 [28] in patients with an average age of 84 years having been described in the usa. it is interesting to note the safety of using the same therapeutic options in elderly patients, including faecal microbiota transplantation [29, 30] . the microorganisms causing infection in the elderly are qualitatively the same as in the population of other age groups, although there are quantitative variations. where do they get these infections? what proportion are acquired in nursing homes? at home? in hospital? in addition to the hospital and home environment, the elderly can acquire infections elsewhere, and in particular in other care units. this is the reason why, almost 20 years ago (2002), the term "health care-associated infection" began to be used, which is not only limited to hospitalized patients, but also extends the concept to patients in contact with the health system (home care of patients with high comorbidity and complexity; day care centres; major outpatient surgery units; outpatient dialysis centres; community health centres for chronic or convalescent patients). to a great extent, it is in nursing homes where patients with more comorbidities, polypharmacy consumption, a high degree of dependency and a high prevalence of invasive devices (bladder catheter, nasogastric tube, percutaneous gastrostomy) will be treated. in addition, the environment can facilitate the transmission of microorganisms between residents and healthcare personnel, as well as between residents. for all these reasons and the excessive or inappropriate use of broad-spectrum antibiotics, either empirically or prophylactically, multi-drug-resistant (mdr) infections can be generated. implementation of effective preventive measures in this population is very difficult to organise. in the united states of america, it is estimated that approximately 1.5 million people live in nursing homes and suffer between 1.6 and 3 million episodes of infection annually [31] . the prevalence of infections in these residences is estimated at 10% of the residents [32] and the incidence of new infections infectious diseases are the second cause of such admissions (16.2%), only surpassed by cardiovascular diseases (28.6%). pneumonia and sepsis are the most common infections causing admission in this population [48] . the elderly population also has longer hospital stays (5.5 days for those over ≥65) than those between 45 and 64 (5.0 days) and those between 15 and 45 (3.7 days) [49] . the elderly are treated by virtually every unit in a hospital but it is worth mentioning that those over 65 years of age represent 40% of those admitted to intensive care units [50] . the other group of interest is that of specialised geriatric units, not available in all hospitals, which have been shown to improve the functional status of patients and reduce the number of discharges to long-term care homes [51] . in a study by saliba et al., conducted in israel [52] , out of a total of 81,077 hospital admissions in the elderly between 2001 and 2010, the proportion of admissions due to infectious diseases rose from 16.9% in 2001 to 19.3% in 2010. globally, the most frequent infections causing admission were: those of the lower respiratory tract (lrt) (41.0%), followed by the utis (21.4%), upper respiratory tract (10.2%) and hepatobiliary (9.8%). in spain we do not have precise answers to the questions asked. the proportion of serious infections in the elderly requiring hospitalisation depends on several factors: type of infection, severity of infection and other factors such as the degree of frailty of the elderly, their place of residence and their ability to receive care at home. the environment and the resources available also influence the hospitalisation decision. however, in our environment, most serious infections in the elderly will require hospitalisation for at least a few hours. in spain, serious infections in the elderly can be treated by different professionals depending on the type and severity of the infection, and the environment in which it occurs. a high percentage are treated by "generalists" hospital specialists, or geriatricians. where infectious disease specialists are available they are of course involved in their management, either in beds in their own departments or as consultants. they can also be treated by specialists of the affected organ such as orthopaedic surgeons in the case of infections of prosthetic material, or vascular surgeons in the case of infections of vascular ulcers. and if, in the end, hospital admission is not decided, the patient is cared for by the primary care team. as an example, we have collated the urinary tract infections treated at the hospital general universitario gregorio marañón between 2015 and 2018. when uti is the main diagnosis that motivates admission (about 700 cases a year) about 90% of cases are cared in the medical departments. when it comes to secondary diagnosis (about 2,000 cases per year), the internal medicine and geriatrics departments take care of about 75% of the cases. preventive programmes, such as flu vaccination programmes, reduce the need for hospitalisation for respiratory infections by nearly 30%, both inside and outside spain [53] [54] [55] . microorganisms that are part of the patient's usual microbiota (endogenous microbiota), or selected by the selective antibiotic pressure (secondary endogenous microbiota), or by one found in the hospital environment (exogenous microbiota). to understand the main epidemiological data on hospital infections, the epine study (estudio de prevalencia de las infecciones nosocomiales en españa (study on the prevalence of nosocomial infections in spain)) was developed. this is a multi-centre system for monitoring nosocomial infections, based on the production of an annual prevalence study, which has been conducted since 1990 in a large group of hospitals in spain and was promoted by the spanish society of preventive medicine, public health and hygiene. its methodology guarantees a homogeneous and systematic collection of information, which allows us to understand the prevalence of healthcare-associated infections (hais) at a national level, by autonomous regions and hospitals. since 2012, every 5 years the epine study has been produced jointly with the european study (in 2012 and 2017) under the coordination of the ecdc [45] . based on the latest data published, in november 2017 (313 hospitals and 61,673 patients), a prevalence of nosocomial infection in patients over 65 years of age of 6.07% (infections acquired during the current admission), 7.45% (infection acquired during the current or previous admission) and 8 .76% (the total, including the centre's own or imported) has been reported. it should also be noted that this register shows that in 22% of patients over 65 years of age admitted for an infection, the infection had been acquired in the community (patient's home). the home, nursing homes and community health centres, healthcare centres other than hospitals and the hospital itself are often the places where the elderly acquire infections. the studies reviewed allow us to estimate a prevalence of infection of between 4 and 10% in nursing homes in spain, depending on their complexity, and between 6 and 9% in hospitalised elderly people. in primary care and in the residential environment, there is no homogeneous epidemiological record of this problem. what proportion of severe infections in the elderly require hospitalisation? by whom are they treated? in the united states of america, patients over 65 years of age account for almost 40% of total adult admissions and the cost of these hospitalisations represents nearly 50% of the total cost for hospitalisation, although those over 65 years of age account for less than 20% of the total adult population [46, 47] . those over 65 years of age are admitted to hospital three times more often than those between 45 and 65 years of age, and those aged 85 or over account for 9.2% of all hospital discharges, although they represent only 1.8% of the population as a whole. moreover, in our opinion, in these departments, emergency assessment should not be focused only on the isolated episode for which the patient consults, but the particulars of the elderly person, their functional, mental and social situation should be taken into account. this is a huge workload for the ed. finally, we should bear in mind that the training of ed physicians on these issues is limited [63] as a direct consequence of the self-training of current professionals, which is not always complete, and the lack of a regulated medical specialty in the ed. in spain, between 15 and 25% of emergency department visits occur in the elderly. elderly people come in 14.5% of the time for infections and one third of the infections seen in the emergency departments occur in the elderly. the population over 65 years of age who attend the emergency department often have multiple pathologies and clinical manifestations of infection that may be atypical. in the spanish national health service, emergency activity accounts for a total of 47.2 million consultations per year, of which 26.5 million are attended to in primary care (pc) (outpatient or home), with an average attendance of 0.6 people/ year [64] one-third of emergency consultations in pc are related to infections [65] . in the older patient, infections are more frequent and serious, associated with greater morbidity and mortality [65] [66] [67] . among the elderly, the rate of infection reaches 634.1 cases per thousand people per year. the most frequent correspond to the respiratory system (317 cases per thousand), particularly those of the upper respiratory tract, followed by acute bronchitis and bronchiolitis and pneumonia [65, [67] [68] [69] . in second place are utis, mainly affecting women (114.8 cases per thousand compared to 44.2 per thousand for men) [67]. these are followed by skin and soft tissue infections [69] . most of these cases are dealt with in primary care and only those more serious situations and of uncertain diagnosis are referred. in 75%-80% of cases, cap is diagnosed in pc [65, 70] and streptococcus pneumoniae is the cause of two-thirds of these cases. invasive forms of pneumococcal disease (ipd) are less common, occur in patients with certain risk factors and have high mortality rates [70] . the vast majority of vaccination programmes in spain are carried out in primary care, but the vaccination schedule for older people is neither complete nor promoted as it should be. what is the workload represented by elderly patients in hospital emergency departments? the number of visits to hospital emergency departments (ed) has been increasing progressively for decades. this increase is greater in the elderly, whose population accounts for 15-25% of all visits to the hospital [56] . the incidence and impact of infection in the ed is estimated quite reliably. in spain it is 14.3%, 21% in the usa and around 30-40% in countries such as nicaragua and mexico [57] . the elderly are characterised by a higher probability of atypical presentation of diseases, of suffering from multiple diseases and of consuming many drugs. with regard to emergency care, this implies a more complex clinical evaluation, which translates into a greater request for additional tests and consultations with other specialists, longer stays in the ed (extended periods under observation and in ssus), as well as a greater probability of admission, discharge with undetected or untreated problems and return visits to the ed [58] . all this entails a high risk of adverse episodes [58] and a significant impact on healthcare pressure, resulting in a negative effect on ed saturation [59, 60] . likewise, the prevalence of the frail elderly in the community varies according to the diagnostic criteria. in a study conducted on elderly people admitted to the observation room of an ed in a spanish tertiary hospital, it was verified that only one of them did not have any fragility criteria and on admission almost half of them suffered significant dependence [61] . the detection of the high-risk or fragile patient is fundamental for these departments, for decision-making and in particular for discharge directly from the emergency department. we could highlight that in the recent work of the in-fur-semes group, in a study conducted in 49 spanish eds, 31.7% of infections occurred in patients over 70 years old. of these, 36% were urinary and 51.2% were lower respiratory. in conclusion, when compared with a similar study, conducted twelve years earlier, an increase in the prevalence of infections is observed, with an older patient profile, comorbidity, risk factors for mdr microorganisms and septic syndrome [62] . the latter almost always presents itself as an acute confusional syndrome, which implies a complex differential diagnosis. to what extent do you think that infection in the elderly is preventable? what proportion could be avoided with proper vaccination? in an article published by umscheid et al. [79] , not specifically addressing to the elderly field, it is estimated that 65%-70% of cases of catheter-related bacteraemia or catheter-associated urinary tract infection and 55% of pneumonias from mechanical ventilation or skin and soft tissue infections could be prevented in the hospital environment using the methodology currently available. an infection control programme for older patients includes methods for surveillance and recording of infections, recording and management of multi-resistant microorganisms, outbreak contingency plans, isolation policy and standard precautions, hand hygiene programmes, ongoing education of employees, resident health plans, audits and plans for reporting incidents to health authorities [80] . this set of resources is not available to most of the world's elderly. a group of experts, gathered in a delphi study on infection prevention measures in patients admitted to institutions for the elderly, agreed on 302 recommendations [81] but unfortunately the level of evidence on the effectiveness of each of them is very limited. data on the reduction of different infections by different measures are extremely scattered and limited. some examples are the reduction by 53% of periprosthetic infections with antibiotic prophylaxis [82] , a 60% reduction in episodes of influenza with the physical separation of the young and the elderly, [83] or a 48% reduction in episodes of pneumococcal pneumonia with the 23-valent vaccine [84] . makris et al. [85] conducted a study to test the effect of an infection control programme in 8 institutions for the elderly in the united states of america. they divided the centres into test centres (4) and control centres (4) and studied the incidence of infections in both groups before and after the programme was introduced. in the year prior to the intervention, test sites experienced 743 infections (incidence density rate, 6.33) and control sites 614 infections (incidence density rate, 3.39). in the intervention year, the test centres reported 621 infections, a decrease of 122 infections (incidence density rate, 4.15), while in the control centres, the number of infections increased slightly to 626 (incidence density rate, 3.15). the greatest reduction in infections at the testing centres was in upper respiratory tract infections (p = 0.06). the intervention programme consisted mainly of implementing environmental cleanliness, hand washing programmes and educational talks. therefore, and speculatively, we dare to estimate that a the infection rate in the elderly exceeds 500 episodes per 1,000 sick people per year. primary care handles the vast majority of these episodes and refers only the most serious cases. primary care is responsible for the vaccination programme for elderly people who attend to request it. the vaccination schedule for older people is neither comprehensive nor proactively promoted. what does infection in the elderly entail in terms of days of hospitalisation, financial expenditure and death? to approximate data/figures for variables such as "days of hospitalisation, economic expenditure and death" in a field as broad as "infection in the elderly" is enormously complicated. it must be taken into account that the infectious pathology is very varied and that it can affect people with different locations (community, community health centre or the hospital itself) and conditions. for example, with reference to nursing homes, lim et al. estimate 4 episodes of infection for every 1,000 cumulative days spent in the home in a small group in australia [71] , while much more extensive north american data report 12% of nursing home residents having an infection at the time of the study [32] . this leads to estimates of between 1.64 and 3.83 million episodes of infection per year [31] with annual costs of no less than us$ 1 billion, prior to 2000. in a study conducted in brazil, the cost of an infection in the elderly requiring admission is estimated at 28,714 brazilian reals (€ 6,305). patients are admitted for a median of 24 days compared to a median of 9 days for elderly people admitted for non-infectious causes [72] . of that cost, only 5% is attributable to the purchase of antibiotics. there is a greater volume of data for community-acquired pneumonia (cap) [73] [74] [75] [76] . the cost of cap varies greatly depending on where the treatment takes place. a spanish study [77] found a cost of only € 196 in the case of an outpatient, compared to €1,153 for pneumonia requiring hospitalisation. the costs were higher for subjects ≥65 years. mortality increases significantly in the older patient (25%) with respect to the general population (10%). it is worth noting a publication in spain with a sample of 2,049 subjects, where mortality due to pneumonia is more clearly related to the age group than to the aetiological agent [78] . we have not found precise data calculating overall clearly no one disputes the usefulness of ongoing education in many aspects of life and particularly in the reduction of nosocomial infections. that said, the literature review on the impact of educational programmes on nosocomial infection is irregular, fragmented and often difficult to assess. published studies generally include education as part of intervention programmes in which other measures are included, making it difficult to assess the role of education in isolation. it is also common to talk about the success or failure of an educational programme without detailing what the programme is, what content it has, how it has been implemented and how many people have accessed it. to complicate matters, in the case of the elderly, we have at least three different areas: home, nursing homes and institutions for the elderly and hospitals. in the first, the educational scope is very general and imprecise and is based on the public health and vaccination campaigns that are usually received not only by the elderly population but by the population in general. in the hospital field, we must assume that the literature produced on the impact of educational measures in the different syndromic entities generally includes the elderly population, but does not specifically differentiate it. most of the limited existing information, which we can consider specific to older people, is that generated in nursing homes and institutions that implement these programmes. a study conducted in the usa on 2,514 randomly selected nursing homes [91] asked the homes for information on 34 points related to infection control programmes. most of those responsible for control programmes, when they responded, claimed to have not only that responsibility but others as well (54%) and also to have no specific training in infection prevention (61%). there was great variability in practices carried out in each residence and 36% acknowledged having received an official citation for deficiencies in such control. those residences cited for deficiencies had a statistically lower proportion of staff trained in infection control. this is therefore an area with clear opportunities for improvement. in a systematic review on non-pharmacological infection prevention in long-term care facilities, only 24 papers were selected, the majority of which were randomised studies (67%) and the most common reason was prevention of pneumonia (66%). 54% showed favourable results for the interventions, but the studies had many potential biases [92] [93] [94] [95] [96] [97] [98] [99] . from these studies the 5 main quality markers in infection control in a nursing home were deduced, namely: percentage of long-term patients with pressure ulcers, urinary tract infection, bladder catheter, and vaccinated against influenza and pneumococcal infection. high quality infection control programme in nursing homes could reduce infection rates by up to 50%. but even if we estimate much lower figures, the impact on morbidity, mortality and the economy of such programmes would be enormous and would certainly outweigh their implementation costs. with reference to the second part of the question, the possibility of reducing the problem with vaccines, the data are again scattered and studied for different vaccines individually. in addition, information on the elderly must often be inferred from data on the general population. we refer readers to a recent review on the subject [86] . below is some data on the impact of vaccines of particular interest to the older population. gross et al. [87] in a meta-analysis of 20 cohort studies estimate the effectiveness of influenza vaccination at 56% in preventing respiratory infections, 53% in preventing pneumonia, 50% in preventing hospitalisations and 68% in preventing deaths. in the case of zoster, the vaccine's efficacy is estimated at more than 90% with minimal adverse effects [88] different pneumococcal vaccines have different impacts on the incidence of invasive pneumococcal disease (ipd) infection. a systematic review shows reductions in ipd incidence ranging from 61% as a combined effect of the use of pcv7, pcv10 and pcv13 in those over 65 in canada [89] to a 21% reduction as an effect of the use of pcv7 and pcv13 in israel [90] . with these data it is possible to imagine the added protection that adequate vaccine coverage would provide. an estimated 50,000 americans die each year from vaccine-preventable diseases, and 99% of those who die are adults [86] . increased provision of medical care in large care homes (e.g. those with more than 200-250 beds) could reduce the referral of many elderly residents to hospital emergency services. this provision of medical care would not necessarily be very complex and would cover both simple diagnostic material and the possibility of establishing and carrying out pharmacological therapeutic courses at the centre itself, the prescription of which in most cases still requires medical staff from outside the centre. it would be a way to reduce costs, lessen the burden on the elderly and reduce the overload on hospital emergency departments. it is impossible to give a precise answer to the questions asked, but it seems reasonable to assume that with appropriate prevention programmes, acquired infections in institutionalised elderly people could be reduced by up to 50%. strict adherence to a vaccination programme for the elderly would have an enormous impact on reducing suffering, death and economic waste. what data exist on the effectiveness of educational measures on the incidence of infection in the elderly? ties specifically dedicated to infection. by way of an example, in spain, this occurs among specialists in microbiology and infectious diseases and intensive care specialists. 9.-specifically promote research aimed at preventing infection in elderly patients. 10 .-introduce much more active involvement of patient associations in their management structures. what we say about societies primarily dedicated to the elderly, can be similarly assumed and applied to societies primarily dedicated to infectious diseases and microbiology. the role of the scientific societies dedicated to geriatrics and infectious diseases is to promote alliances in the common field of infection, in aspects of care, teaching and research. they need to look less to the interests of their members and be more proactive in promoting the interests of the patients they serve and incorporate patient associations more into their structures. capacity, understood as the possibility or potential for influence, is qualified by two variables. firstly, for offering free and truthful scientific information at the service of the community. and secondly, for facilitating the adoption of the best possible political decisions with consistency and realism. the rapprochement between professionals in the scientific and political fields must be adjusted to the interest of citizens, who can act as the third pillar in a transparent relationship model and as guarantor of equity befitting a democratic system of government [110] . while scientific experts advise and inform, it is the responsibility of politicians to make decisions and promote efficient measures to the benefit of the population. a complementary characteristic inherent to the scientific task is to exercise a dissemination action of the activity itself, in understandable terms and through accessible and reliable systems [111] . the configuration of platforms within scientific societies and the growing number of independent agencies advising political power represent a reality that aims to bring the contributions of science closer to the systems of governance [112] . in our country, the main function of the congress of deputies is legislative, which entails the approval of laws. the constitution recognises the legislative initiative of the government, the congress of deputies, the senate, the assemblies of the autonomous communities and the people's legislative initiative on the proposal of no less than 500,000 citizens, subject to the provisions of an organic law. these bills are known in spain as law projects when presented by the government and propositions in other cases. they are always submitted to the congress of deputies, except for the propositions of the senate which have to be considered scientific societies are professional associations that bring together generally specific groups (doctors, nurses, technicians, etc.) that essentially seek to defend the professional interests of their members. until now, it has not been common for groups of patients affected by different diseases under the thematic umbrella of each society to participate in them. in spain their impact and political credit is variable. among the most important objectives of most of these societies are such issues as training programmes for professionals, aspects related to the health education of the population in their particular field of competence, research grants, the preparation -sometimes in collaboration with societies of another related specialty -of specific diagnostic and therapeutic protocols, publications and congresses focussed on these topics, and a wide range of other activities, including health policy recommendations to the corresponding administrations that have a direct bearing on the issues discussed here. membership of societies is also not uniform, and often it is the more "senior" components of the profession that are most highly represented in them. their role, in our opinion, is to continue to improve the teaching, care and research produced in the societies' chosen fields in favour of patients, exercising ever greater mediation between the demands of patients and healthcare administration [100] . all societies must go far beyond issuing guidelines and therapeutic recommendations [81, [101] [102] [103] [104] [105] [106] [107] [108] [109] . in our view, scientific societies dealing with diseases of the elderly should promote, in the field of infectious diseases, among others, the following topics: 1.-encourage a proportionate share of its members to subspecialise in infectious diseases. 2.-coordinate and direct multidisciplinary teams specifically dedicated to the infection in the elderly and its prevention. 3.-participate more actively in specific programmes to reduce infections in the elderly, both at the nursing home level and at home and in hospital. 4.-implement vaccination campaigns in the elderly, taking particular advantage of admission to long-stay centres or hospital as opportunities to vaccinate. 5.-to design and disseminate educational projects on infection prevention practices for the elderly in their different environments. 6.-put pressure on health authorities to carry out a large national programme to reduce infection in older people. 7.-to include in the training programme of residents in geriatrics, a rotation in infectious diseases and microbiology as an essential part of the curriculum. 8.-create scientific and professional alliances with socie-to offer a unique system to access scientific information allowing the recovery of different types of documents such as: journals, books, images, theses, and conference proceedings. revista española de geriatría y gerontología (the spanish journal of geriatrics and gerontology) is the publication channel of the society of the same name, a publication founded in 1966 and the doyenne of the specialty in the spanish language [119] . medes is an initiative of the fundación lilly and its database, open and free, contains bibliographical references published since 2001 in a selection of 98 spanish journals covering 50 subjects in medicine, pharmacy and nursing, published in spanish, with 100,000 articles [120] . finally, pubmed is the widely implemented search engine, with free access to the medline database of citations and abstracts of biomedical research articles, offered by the united states national library of medicine and integrating 5,255 worldwide journals since 1966 [121] . the search was conducted with a double strategy: free text and controlled text using "mesh". in the first strategy, a free text search was conducted in the "science direct" and "clinical key" databases with the term 'infection in geriatrics' resulting in 508 and 1,191 findings respectively. the primo search engine (castilla y león online library) returned a total of 190 results for the same term. secondly, and also in free text, with the term 'infection in the elderly', we proceeded to consult revista española de geriatría (the spanish journal of geriatrics), which generated 195 results and medes (medicine in spanish) with 84 results. the second strategy of controlled text was conducted in the pubmed database, returning the following findings: <infection and geriatrics>: 997 results; <infection and aged> (people from 65 to 79 years old): 122.698 results and <infection and aged or aged, 80 and over>: 122.698 results (identical to the previous one). its development over the last decade has been progressive (from figures close to 4,000 in the 2009-2010 biennium, to over 5,000 from 2014 to 2017), excluding the year 2018 from the assessment. we have adopted their classification into thematic areas [122] and the twelve in which 95% of the results were concentrated are: sepsis and bacteraemia, pneumonia, urinary tract infections, central nervous system infections, endocarditis, prosthetic infections, skin infections, gastrointestinal infection, hiv infection, fever of unknown origin, multi-resistance and vaccinations. the scientific output on infections in the elderly, calculated by different databases, has been increasing in the last decade. how do the problems of the elderly impact on the mainstream media? how should the media contribute to the reduction of infection in the elderly? the impact of the problems of the elderly in the media is in the senate, which will later submit them to congress [113] . non-legislative bills, motions and proposals for resolutions are acts of a similar nature that seek the adoption of a non-legislative resolution by congress, by which congress expresses its position on a given subject or issue, or addresses the government urging it to act in a particular direction. the health and social services commission of the congress in the xii legislature offers access on its website to the 226 initiatives processed since its constitution in september 2016 until its dissolution in march 2019, representing an average of 75 per year [114] . of these, those referring to the field of infectious pathology as a whole do not exceed 3%. of particular relevance in the field of infectious pathology have been those relating to the national plan for the elimination of hepatitis c and antibiotic resistance. governance designates the effectiveness, quality and good orientation of state intervention, which provides the state with a good part of its legitimacy in what is sometimes defined as a "new way of governing". above all, it is used in economic, social and institutional operational terms [115] . an inherent aspect of the exercise of policy is the performance of "authority", which is equally composed of legitimacy (right to exercise), personal prestige (moral strength, leadership, honesty, knowledge, efficiency) and power (ability to administer and lead). it is precisely in the "personal prestige" where their synergy with the scientist (also covered by knowledge, honesty and leadership) should be the lever for the improvement of the society they both serve. initiatives on proposals or projects with reference to infection issues represent less than 3% of the total. of particular relevance in recent years have been those relating to the national plan for the elimination of hepatitis c and antibiotic resistance. in order to respond to the scientific output on infection in geriatrics, we will proceed to describe the data sources, the search methodology and the findings, in a way deliberately guided by the recommendations of professionals in our workplace libraries. sciencedirect [116] is a digital platform that has provided subscription access to a large research database, hosting more than 14 million publications from 3,800 academic journals and 35,000 e-books since 1997. clinical key [117], owned by "elsevier clinical solutions", has an intelligent search system, establishing the connection of medical terms with related content. it accesses a collection of resources of clinical guides, algorithms and patient files from fisterra, the database of monographs of medicines marketed in spain, the treaties of the medical surgical encyclopaedia, and books and journals in spanish from the cited publisher. primo is the discovery/search tool used by the castilla y león healthcare online library [118] as a small demonstration of this paradox -the contrast between the rising presence of the elderly in society and their lukewarm representation in the media-, we offer a chart with a comparison of publications on the websites of three generalist newspapers, "el país", "el mundo" and "abc", between the years 2016-2018, with the search for "elderly" and "infection" as key words. a total of 96 news items are recorded that mention the subject studied ( figure 1 ). this is little news, and in most cases linked to events and to the elderly as a risk group. this sample would require further media analysis to ratify this tendency in the treatment of the problems of the elderly and the infections they suffer, but it serves as the tip of the iceberg of relegation, insensitivity and atrophy in news treatment. since the onset of the economic crisis in 2008, the number of dedicated journalists specialising in social and health issues has been substantially reduced in order to divert manpower and resources mainly to political and economic content. if, in this situation, health, science and social issues have been scaled down and cut back in the operation of the media, the elderly, as journalistic content, have been pushed to the very margins of the newsrooms with complete normality; with no agenda, no specialists, no briefings, no planning, no contextualization; to see themselves as mere circumstantial, inconsequential, occasional content, with a light, sometimes frivolous treatment, lacking depth and sensitivity; building a narrative of topics, irrelevance and disconnection from their value and presence in society. this media portrayal of the elderly is in contrast to the ageing of the population, where reliable and accurate statistics limited, deficient, incomplete, unfocused, out of context, stereotyped and with a not particularly constructive, realistic or objective bias. the elderly are invisible in the media and when they appear, the content relating to them is characterised by simplification, victimhood, dramatization and superficiality. the image that the media convey of old age is linked to inactivity, unproductiveness, seniority, illness, dependence and deterioration. old age and its problems, circumstances, needs and contributions, as a social agent and subject, are not among the priorities and themes of general media planning. other groups, sectors, actors or social issues such as immigration, feminism, equality, children, domestic violence, ngos and their services, new technologies and their advantages, effects and risks, harassment in all its forms, health and sanitation, or scientific advances have much more visibility, relevance, monitoring, currency and presence in the media. the problems related to a stage of life that we can place at around 80 years provoke a disinterest and sidelining in the information and journalism that only is unblocked in the face of news related to events, diseases, negative or sensationalist facts or anecdotes, offering a fixed, unmoving and old-fashioned image of a sector of the population that, nevertheless, is increasing due to the increase in life expectancy. in a world where the 21st century grants youth and technology all the plaudits as to what is interesting and important, whether in the press, television, radio, websites or social networks, ageing and old age, as a concept, social and population sector, and newsworthy subject, are moved to a second or third tier on the podium of current affairs and information. citations regarding "infections" in the "elderly" in 3 major general journals of spain formation on the elderly and very elderly has been strengthened, is to promote health and healthcare information in relation to this sector of the population. in this context, the media would be in a position to treat and report, with much higher presence and representation criteria than at present, on the infections of the elderly within the framework of their health and well-being. it is very difficult to reach this third step without the two previous actions, since the handling of a health problem such as infection in the elderly by the media requires a commitment and responsibility in several phases that is part of a comprehensive strategy to provide a journalistic treatment of their problems on a par with their representation and contribution to society. it is necessary to present older people and the elderly removed from the clichés and stereotypes that link them directly and almost solely to the events, the deterioration of their health, family dependence or the hindrance or burden of their role and function in society. it is necessary to offer complete and balanced information in which tasks such as interest in culture, modernity, the future, technology or travel; their capacity to lea in civil society, family, business or education; their initiative in domestic and community tasks; their political or social contributions; or their skills in the practice of sport are inherent. in short, to show their vitality, enthusiasm, enterprise, activity, determination, solidarity or collaboration, beyond their problems or difficulties, which must also be reflected and analysed. it should not be forgotten that though the generation of elderly people now over 75/80 years old may have a more traditional, reserved and passive profile in certain cases -by no means in all-, the new generation of elderly people forecast for 2050, where their number will rise greatly, will experience a huge change with regard to the distorted image of the elderly today. the information that the general media dedicates to the problems of the elderly is minimal, distorted and biased. it is full of clichés and stereotypes that link them directly and almost exclusively to events, the deterioration of their health, family dependency or the hindrance or burden of their role and function in society. information on infections in this population group is even more scarce. presentation: the answer is yes, without a doubt [95, [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] . the reasons are detailed below: studies conducted following scientific evidence criteria in recent years show that pharmaceutical care and the intervention of the pharmacist improve the overall quality of patient care, while the who itself states that point to a doubling of the number of older people by 2050. the data show that in 1960 in spain, there were 6.7 million children under 10 years and 0.4 million people over 80 years, in 2015 the number of children under 10 had fallen to 4.6 million, and over 80 risen to 2.7 million; by 2050 the trend becomes even more acute, with under 10 years predicted at 3.8 million, and over 80, 6.2 million [123, 124] . globally, in the century from 1950 to 2050, total population will triple; the population over 60 will grow by a factor of 10; and the population over 80 by a factor of 28, this last group going from 14 million in 1950 to 386 million in 2050. if information concerning and affecting the elderly continues to be ignored, marginalised and simplified in the media, they will neglect and fail in their mission of gathering information, analysis, data and opinions from a sector of the population with enormous influence on the life and events of a country. without rigorous, truthful, balanced, comprehensive and complete information on the phenomenon of old age, the view and expression of reality will be distorted, fragmented and fractured. to help reduce infection in the elderly, the media must take several steps beforehand and activate new information strategies and actions [125, 126] . review and reformulation of the contents for current events, relevance and interest agendas. the first step is to place general social and health issues on the same level of importance as national or international political, economic or sports information, with the consequent allocation of space, dedication and resources. enhancement of content for the elderly in social and health information. within the social and health content, the news of the old and elderly must be equated in relevance, dedication, selection, monitoring and treatment to other issues related to this journalistic field, with emphasis on the quantity and quality of the information, from the rigour, planning and contextualization to gather studies and data, human stories, opinions, difficulties and needs, social influence, contributions, and challenges in this sector of the population. the aim is to offer a complete, balanced, objective and true vision of their reality, their contributions, their heterogeneity, their variety, their complexity, their evolution and their demands and needs. the problems arising from the increase in age, health, coexistence and economic situation, as well as cultural, sociological, family and psychological aspects, must be approached with an informational style and treatment where ageing is considered from the standpoint of normality in life, with its ups and downs, and not as a hindrance, obstacle or inappropriate or unsustainable expense. the social and cultural role of the elderly, their knowledge and experience, their skills and abilities, should be valued as useful and enriching elements to society. promotion of health and sanitation information in the elderly. the next step for the media, once the general in-ed following scientific evidence criteria in recent years show that pharmaceutical care and the intervention of the pharmacist improve the overall quality of patient care, while the who itself states that pharmacists "contribute decisively to the rational use of medicines". what is the administration doing and what can it do to reduce these problems? from an educational point of view? from the legislative-regulatory point of view? in order to reduce these problems, the state administration must, among other things, launch: 1. prevention strategies and measures to control the transmission of the infection. 2.-vaccination programmes in the elderly. 3.-training and information programmes for health professionals, particularly in the area of rational use of antimicrobials and promotion of the use of appropriate definitions [140, 141] pharmacists "contribute decisively to the rational use of medicines". the decision on how to treat a given infection correctly with the most appropriate antimicrobial requires detailed knowledge of microbiological, clinical and pharmacological issues, but the causes of an optimal result go beyond this and extend to the so-called non-pharmacological basis, among which the behaviours of doctors, patients and pharmacists, as well as the relationships between them, play a fundamental role. the pharmacist is one of the apices of the so-called "human factor triangle" (made up of doctor-patient-pharmacist), a mirror image of the famous "davis triangle" (antimicrobial-microorganism-host). currently, pharmaceutical care aims to obtain the maximum clinical benefit from medicines and to achieve the lowest possible risk in the use of those medicines, which entails the identification, resolution and prevention of medication-related problems (mrp): adverse drug reactions (adr), drug-drug interactions (ddi), deficiencies in physician prescription, errors in the use of medication by the patient and breaking the vicious circle so frequent in the use of antimicrobials formed by self-medication -noncompliance -storage. pharmaceutical care is a process, which includes different stages: active dispensation (supply, delivery, dispatch >>> assistance, help, care), educational advice (health advice in response to a consultation/problem or instruction on the acquisition of a medicine) and pharmacotherapeutic follow-up (documentation and registration of the activity). as far as the hospital pharmacist is concerned, it must be said that they not only participate actively in the rational use of antimicrobials from their role as an active member of the pharmacy commission and the antimicrobial committee, but also get involved on a daily basis in the prudent and correct application of antimicrobial therapy, in order to obtain the most beneficial result from the clinical point of view and the most efficient from the pharmaco-economic point of view. this implies that: the appropriate antimicrobial has been prescribed in accordance with a correct diagnosis and the special characteristics of the elderly patient, it is dispensed under the proper conditions, administered at the indicated doses, at the intervals and for the period intended, it is used with the lowest possible cost, in such a way as to prevent or minimise the development of bacterial resistance and it achieves the desired therapeutic objective. in short, both the community and the hospital pharmacist as first-level health agents play a central role in the field of therapeutic adherence and rational use of antimicrobials, proposing their use in terms of quality of treatment and considering antimicrobials not only by virtue of the active ingredient contained in the corresponding pharmaceutical specialty, but also in terms of useful information ("software"). furthermore, both must take into account that antibiotics and vaccines are the paradigm of societal treatment and the treatment or non-treatment of an individual can affect the community [139] . conclusion: the answer is yes, without a doubt. studies conduct-another precaution is the sanitation of the space in which the elderly person stays so as to make it a healthy environment, including daily cleaning of surfaces, objects and utensils, ventilation, illumination preferably with natural light, and appropriate environmental temperature and humidity [156] . the tendency to unbalanced diets, malnutrition and low fluid intake increases susceptibility to infection. it is essential to promote healthy lifestyles and to provide structured plans for eating, drinking and exercise adapted to individual needs taking preferences and health problems into account [157] [158] [159] [160] [161] [162] . another strategy is the vaccination of the elderly and carers, adjusted for age, particular situation and the approved schedule in each autonomous community [163] . although infectious diseases in the elderly do not always have obvious signs and symptoms, the caregiver detects changes in their baseline situation that may lead to a suspicion of the presence of an infectious process, so education should be provided on how to proceed in the light of this suspicion and what to do when it is confirmed. finally, it is necessary to emphasise the effective management of treatment (dose, administration and side effects) and periodically monitor therapeutic adherence, avoiding self-medication, in order to achieve the optimal effects of non-pharmacological and pharmacological measures, so as to enable prevention, delay deterioration, recover or maintain health [164] . nurses develop interventions for prevention, monitoring and therapeutic adherence control, participating in the care plan for infection in the elderly. the implementation of many of the health promotion and care plans and regulations is the direct responsibility of the nursing profession. how do senior citizens' associations deal with this problem? the issue of health is a priority for the elderly and infection in particular is one of the most frequent causes of morbidity and mortality in the elderly, as has already been mentioned. elderly associations have traditionally focused on chronic rather than acute diseases and therefore have a huge role to play in this area. it is the mission of the elderly associations to encourage and promote the residence of the elderly in a family and social environment that is agreeable to them. it is well known that an older person who lives comfortably at home with family members has less risk of acquiring infections than one who lives alone. in the case of the elderly institutionalised in residences, the elderly associations have the mission to ensure the quality tions for the prevention and control of healthcare associated infections (hais). some examples of the above are programmes such as: "antibiotics: take them seriously" (2017); the "world antibiotic awareness week" (2018); the "european antibiotic awareness day" (2018). a national plan against antimicrobial resistance (pran) run by the spanish agency of medicines and health products (aemps) is essential [142, [143] [144] [145] [146] [147] . the administration has a constitutional mandate to promote health, which is of particular concern to groups as vulnerable as the elderly. among the measures to be implemented, those of an educational nature are especially necessary, both for patients and for their caregivers and healthcare personnel. from a legislative-regulatory point of view, we cannot forget that spain has one of the best health systems in the world. what is the role of nursing in managing and reducing infection in the elderly? how does the training of the caregiver affect this? nurses develop preventive interventions, participate in the monitoring, control, therapeutic adherence and care plan when the infection is established. these competencies are developed inside and outside of healthcare institutions. in the home setting, the focus is on education and providing support for safe practices [148] [149] [150] [151] . professionals, caregivers and elderly people have to distinguish modes of transmission, identify risk factors and susceptible people who may become reservoirs or constitute a vehicle of contagion and understand basic protective and barrier measures. the simplest, most effective and universal procedure is hand hygiene. the world health organization identifies five key times for washing: before and after contact with the person, before performing a clean/septic task, after the risk of exposure to body fluids, and after contact with the patient's environment [152] [153] [154] . when hygiene guidelines are given, it is worth noting other times: before, during and after handling or preparing food, before eating, before giving medication, before and after treating a wound or handling clinical devices, after using the bathroom and after handling used clothing, whether personal, bath or bedding, diapers or waste. after washing, it is important to dry the hands. personal hygiene and topical hydration are other prevention strategies. the skin constitutes a natural protective barrier and is particularly labile in the elderly. its daily care guarantees its integrity and protects it from external assault. this includes body hygiene and protective measures aimed at moisture control and injury prevention. some studies highlight the importance of oral hygiene in relation to respiratory diseases [155] . the great social esteem that existed in ancient cultures for the elder of the group or tribe is well known. he was not only the oldest person but also the biological father, the political leader and, in many cases, the religious authority. and, as anthropologists have pointed out more than once, the "hard disk" of the community, aware of past events of which the younger generations are not, thereby bringing the social group together and giving it its own identity. hence, the elders were not only respected but highly valued and even revered. it is enough to open the books of the bible, for example, to find testimonies of this. its pages over and over again reverential respect for the elder, applying such venerable terms as "patriarch". the bible attributes an extraordinary longevity to the first patriarchs (gen 5; 11,10-26), and even to the later patriarchs, like abraham (gen 17,1.17; 18,12) and moses (dt 31,1; 34,7), and to the prophets, it is difficult to represent them as young people. respect leads the bible authors to attribute centuries-long lives to them. longevity is a sign of their wisdom. the so-called wisdom literature bears good witness to this veneration for the elderly. in the book of ecclesiasticus we read: in your youth you did not gather. how will you find anything in your old age? how appropriate is sound judgment in the grey-haired, the contrast between the ancient civilization of israel and the archaic greek culture, as presented in the homeric poems, is surprising. it is difficult to imagine ulysses, hector or achilles as elders, even though in those poems there are also venerable subjects such as menelaus, agamemnon and priam. the contrast between agamemnon and achilles is particularly significant, for the poet paints the former as an ambitious and selfish man, with an excessive ego who confronts achilles, his best warrior, again and again. heroes, those beings that the greeks considered perfect and semi-divine, are by necessity young and in the fullness of their life force. in greek statuary of these institutions, that they are equipped with the appropriate medical, nursing and social services and that a systematic accreditation of these services is achieved. ideally, these centres should have very significant prevention measures in place and should work closely, on the one hand, with the primary care physicians responsible for the patients, and on the other hand, with the reference hospitals to which the patients have to be transferred at some point. elderly associations must continue to work to improve the care of the elderly in emergency departments, not only from a technical point of view, but also by ensuring the agility of the assessment and dignified conditions for the elderly in these departments. finally, the elderly who are hospitalised are patients who require very rapid mobilization, avoidance of exposure to multi-resistant microorganisms and the fastest possible transfer back to where they came from. elderly associations promote the provision of geriatric beds and services in all hospitals, where structures and organisations are set up specifically to serve the needs of elderly patients with a comprehensive idea of their care. as we have mentioned, prevention is better than cure, and in that sense, the elderly associations can play an important role in emphasizing to the authorities, to the groups of affected people and to healthcare personnel the importance of promoting vaccination campaigns [86] in short, associations for the elderly, whether they are focused on health or not, can play a very positive role that is often overlooked when it comes to improving health. they could work, if possible, promoting and propagating vaccination campaigns. they could also contribute more than they do to other forms of health education, from those oriented towards nutrition or physical activity, to those focused on fighting toxic habits or reporting abuse. all this is of general interest, as well as directly and indirectly affecting the field of infectious pathology. following the recommendations of the expert consensus on frailty in the elderly, active ageing and drug screening in polymedicated patients are important in preventing infections in these patients. elderly associations must play a major role in demanding quality care policies for elderly patients, both in the fields of prevention and treatment. target areas for intervention are the home environment, the outpatient system, nursing homes, hospital emergency departments and hospital care. patient associations can contribute more than they do to other forms of health education, from those oriented towards nutrition or physical activity, to those focusing on combating toxic habits or reporting abuse. what ethical aspects would you highlight in all these problems? modern systems of work organisation have made "efficiency" a major objective of the culture of the second stage of life. there is no doubt that in spain, for example, efficiency has increased three or fourfold in the last half century. and here is the origin of the problem. what do you do when you are no longer "efficient", at least in the way the economy defines efficiency? efficiency is a value that belongs to the category of socalled "instrumental values", "reference values" or "technical values". they are so called as they have no value in themselves, but only in reference to something else or another value. let's think, for example, of a drug. there is no doubt that it has value, at least financially. its most valuable asset is to relieve a symptom or cure a disease. if it wasn't good enough, we'd say "it's not good enough", and we wouldn't pay for it. this means that the value of the drug is in reference to something other than itself, such as well-being, health, life, etc. this happens to all technical instruments. if we were to find a more effective or less expensive drug, there is no doubt that we would choose it, because this is what efficiency is about: the cost/benefit ratio. efficiency is the unit of measurement for instrumental values. the problem is that not everything is instrumental. if they are always in the service of others, it means that these others must stand on their own, otherwise we fall into an infinite regression. these are called "intrinsic values" or "fundamental values". they are the most important in life. they are essential values, values that have worth in their own right, without reference to others. think, for example, of dignity. or many others, such as health, life, beauty, well-being, justice, solidarity, etc. these are all intrinsic values. without them, life is meaningless [165] . furthermore, they have the characteristic of not being measured in monetary units, nor is efficiency a criterion. "health is priceless" it has always been said; "true love is neither bought nor sold"; "only the foolish confuses value and price" said antonio machado. and the list could go on [166] . we can now understand the importance of promoting a culture of old age. during our working life there is no doubt that the fundamental criterion must be efficiency, and therefore economy. but that is, at the same time, the least human part of life. the day is not far off when that part of our existence can be transferred to the robots. and the problem arises: what will we humans do then? will we have anything to do? older people have a fundamental mission in our society, and that is to take charge of promoting intrinsic values and passing them on to younger generations. it's not all about economics. it's not all about efficiency. there are other values, which moreover are the most important, the most human. conclusion: promoting a new culture of the elderly should lead us to avoid not only the discrimination that has occurred throughout western culture, and particularly in recent centuries, but also to give impetus to the promotion of intrinsic values, the most humane, the most important in the lives of individuals and societies. this is the very im-it is impossible to see the decrepitude of the elderly person represented. the poet menander coined a sentence that soon became famous and that plautus translated into latin: quem di diligunt, adulescens moritur, "those loved by the gods die young" (bacchides, 816-817). perfection is in youth, and old age is almost embarrassing. aristotle says that "disease is an acquired old age, old age a natural disease" (gen. an. 784 b . it was important to remember this about the attitude of our culture, the western one, towards the elderly. they've never been held in high esteem. moreover, we can be seen that this esteem has been decreasing over time. this is demonstrated by the words we use to refer to this age group. "viejo" (old) comes from the latin vetus, the opposite of novus, both of which are terms that were designating things, not people. for people, the correct terms were senex and its opposite iuvenis. from senex comes our word "senescence", only used in a very limited sense today. cicero wrote a dialogue de senectute, using the correct term in his language. though, in the various spanish editions that exist, the translation is invariably sobre la vejez. (on old age). old age is not only an improper term, but also a derogatory one. no one sees it that way anymore, because they don't know about this process. but the transition from one term to another is an evident sign of the devaluation that the figure of the elder has undergone in western culture, even though it was originally already much lower than that of other cultures. if we add to this the spectacular increase in life expectancy at birth in the last century, it turns out that this devalued period, which until the beginning of the 20th century was almost anecdotal in the life of western society (it should be remembered that life expectancy at birth in spain had been stable at 25-30 years from the neolithic revolution to the end of the 19th century), has become a period of no lesser and sometimes greater duration than the active life of a person. so much so that human life today can very well be divided into three 30-year periods, the first of which is devoted to vocational training, the second to production, and the third.. it is not very clear to what, among other things, because the training we were given in the first 30 years was aimed at being productive in the second phase, but we were never educated for the "third age". the third and final phase of life, which today has an average duration of 30 years, is a continuous source of problems. it is, at least, in the economic order, as the present pension system seems difficult to maintain, and will be impossible in the near future. but, as important as this is, that's not the biggest problem. the most serious issue is that we have condemned the elderly to being a "passive class", whom inserso (the institute for the elderly and social services) has to ferry from one place to another in order to at least distract them. there is talk of discrimination and abuse of the elderly. in my opinion, the greatest discrimination is this, the fact that the elderly have been deprived of their own role in society; or, 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hospitalizados. higiene de manos the hygienic efficacy of different hand-drying methods: a review of the evidence the authors declare that they have no conflict of interest. this publication has been funded by glaxosmithkline. key: cord-259560-mmz5vn0q authors: price, sarah; spencer, anne; zhang, xiaohui; ball, susan; lyratzopoulos, georgios; mujica-mota, ruben; stapley, sal; ukoumunne, obioha c; hamilton, willie title: trends in time to cancer diagnosis around the period of changing national guidance on referral of symptomatic patients: a serial cross-sectional study using uk electronic healthcare records from 2006–17 date: 2020-09-09 journal: cancer epidemiol doi: 10.1016/j.canep.2020.101805 sha: doc_id: 259560 cord_uid: mmz5vn0q background: uk primary-care referral guidance describes the signs, symptoms, and test results (“features”) of undiagnosed cancer. guidance revision in 2015 liberalised investigation by introducing more low-risk features. we studied adults with cancer whose features were in the 2005 guidance (“old-nice”) or were introduced in the revision (“new-nice”). we compared time to diagnosis between the groups, and its trend over 2006—2017. methods: clinical practice research datalink records were analysed for adults with incident myeloma, breast, bladder, colorectal, lung, oesophageal, ovarian, pancreatic, prostate, stomach or uterine cancers in 1/1/2006–31/12/2017. cancer-specific features in the year before diagnosis were used to create new-nice and old-nice groups. diagnostic interval was time between the index feature and diagnosis. semiparametric varying-coefficient analyses compared diagnostic intervals between new-nice and old-nice groups over 1/1/2006–31/12/2017. results: over all cancers (n = 83,935), median (interquartile range) old-nice diagnostic interval rose over 2006–2017, from 51 (20–132) to 64 (30–148) days, with increases in breast (15 vs 25 days), lung (103 vs 135 days), ovarian (65·5 vs 100 days), prostate (80 vs 93 days) and stomach (72·5 vs 102 days) cancers. median new-nice values were consistently longer (99, 40–212 in 2006 vs 103, 42–236 days in 2017) than old-nice values over all cancers. after guidance revision, new-nice diagnostic intervals became shorter than old-nice values for colorectal cancer. conclusions: despite improvements for colorectal cancer, scope remains to reduce diagnostic intervals for most cancers. liberalised investigation requires protecting and enhancing cancer-diagnostic services to avoid their becoming a rate-limiting step in the diagnostic pathway. early cancer detection is central to improving outcomes [1] . most early-detection strategies focus on the timely recognition and investigation of people likely to have undiagnosed cancer [2] [3] [4] . as screening detects <6 % of cancer [5] , uk strategies focus on promptly recognising the symptoms, signs or test results associated with undiagnosed cancer ("features of possible cancer", or simply "features") [6] . in 2005, uk suspected-cancer guidance was published, listing features warranting cancer testing or investigation [7] . the guidance was revised in 2011 for ovarian cancer [8] , and in 2015 for remaining cancers [2] . the aim was to expedite cancer diagnosis by lowering the risk of undiagnosed cancer warranting clinical action from ≥5 % to 3 % [2] , which was achieved by introducing more vague features into the guidance [2, 9] . the revised guidance is officially applicable in england, and endorsed in wales and northern ireland [10] . our objective was to explore the timeliness of cancer diagnosis in england, wales and northern ireland in 2006-2017 for 11 common internal cancers. we compared time from first feature to diagnosis between two groups: "old-nice" (with features of possible cancer in the original 2005 guidance) and "new-nice" (only participants with features introduced during guidance revision). we hypothesised that times to diagnosis would be longer for new-nice than for old-nice participants, because diagnosing cancer is more challenging and may take longer when symptoms are vague [9, [11] [12] [13] [14] . we also hypothesised that the difference in time to diagnosis between new-nice and old-nice groups would reduce over time, as evidence on vague cancer features emerged and was translated into practice by guidance revision [2, 15] . this serial, cross-sectional, primary-care study used uk clinical practice research datalink (cprd gold) with linked national cancer registration and analysis service (ncras, set 15) data. cprd gold comprises prospective, coded, and anonymised medical records from >600 uk general practices, with 389 having ncras linkage [16] . the study examined participants in the year before their cancer diagnosis between 2006 and 2017. inclusion criteria: • scotland, where separate guidance applies [17] . • multiple primary cancers. • cancer typical of the opposite sex; e.g. male breast cancer. • screen-detected cancer, identified from ncras or by cprd screening codes in the year before diagnosis. • no primary care attendance or no recorded feature of the participant's cancer in the year before diagnosis. 2.3.1. features of possible cancer cprd codes for features of possible cancer were collated [18] , based on the symptoms, signs or blood test results in the original or revised guidance (table 1) [2, 7, 8] . occurrences of these codes, restricted to the relevant cancer site, identified participants presenting with these features in the year before diagnosis. separate generic "suspected-cancer" codes were identified to explore for changing recording practices. the cancer diagnosis date was the earliest cprd or ncras diagnostic code. the first recorded feature of possible cancer (index feature) was identified, along with the index date. our outcome variable was "diagnostic interval": days from index date to diagnosis [19] . participants were grouped by their index feature(s) (fig. 1 , table 1 ): • old-nice: participants with ≥1 index feature from the 2005 guidance [7] . • new-nice: limited to participants who only had index feature(s) introduced during guidance revision [2, 8] . participants whose only index feature was a generic "suspectedcancer" code were omitted from analyses. age and sex were identified from the cprd year of birth, assigning a birthday of 1st july. simple descriptive statistics summarised age (mean and standard deviation), sex (male, n, %), nice grouping (new-nice group, n, %), and the index feature(s) (n, % of all index features). we summarised diagnostic interval using mean (standard deviation) and the 25th, 50th, 75th, and 90th centiles. diagnostic interval has a skewed distribution and was log-transformed for analyses [13] . semiparametric varying-coefficient methods estimated coefficients representing the percentage difference in mean log-transformed diagnostic interval between new-nice and old-nice groups (see accompanying methodological paper [20] ). a coefficient of 0 represents no difference between the nice groups. positive coefficients indicate that diagnostic intervals are longer for the new-nice than the old-nice group; negative coefficients, that they are shorter. the coefficients are estimated on a daily basis, so cannot be reported using a single summary statistic, and are plotted (with 95 % confidence intervals, using bootstrapping, n = 1000 replications [21] ) to allow visualisation over 2006-17. the models adjusted for age and sex. analyses examined each cancer site separately, sample size permitting (package "np" in r) [22] . numbers of potential inclusions (individual diagnoses), with cancer registry linkage, and exclusions, to give final sample sizes by cancer site. the final sample is described in terms of size (n), age (mean, sd), number (%) who are male, and number (%) with an index cancer feature introduced during guidance revision. for the descriptive statistics, we included all cprd participants meeting our inclusion criteria. semiparametric varying-coefficient analyses were limited to cancer sites with participant numbers providing ≥90 % power at the 5 % level to detect a 14-day difference in diagnostic interval between new-nice and old-nice groups. assuming mean diagnostic intervals of 114 and 100 days, respectively, for the old-nice and new-nice groups, a common standard deviation of 100 days and 10 % of participants classified as new-nice requires 5980 total participants. an effect size of 14 days matches the two-week-wait target for urgent investigation. we assessed uncertainty in the estimates by confidence interval width. to explore for potential bias associated with changing coding practice, we identified, for annual cohorts: (a) the percentages of participants excluded for having no coded features or only suspected-cancer codes; (b) the proportions of old-nice and new-nice participants; (c) demographic characteristics of participants excluded because they lacked coded features. the cprd provided 147,106 participants, of whom 63,171 (42⋅9%) were excluded, leaving 83,935 (57⋅1%) entering the analyses, from 603 practices, of which 384 (63⋅7%) had ncras linkage ( table 2 ). the main reasons for exclusion were lack of recorded features (n = 37,715), scottish residence (n = 17,360) and detection following screening (n = 7757) (fig. 2) . the sex distributions indicate male dominance in bladder (3870/ 5243, 73⋅8 %), oesophageal (2900/4272, 67⋅9%) and stomach (1823/ 2788, 65⋅4 %) cancers ( table 2 ). the overall mean (sd) age at diagnosis (n = 83,935) was 69⋅6 years (12⋅8), ranging from 62⋅9 years (16⋅7) for breast to 73⋅4 years (12⋅2) for stomach (table 2) . the percentage of participants whose index feature was introduced during guidance revision (new-nice group) varied by cancer, ranging from 1529/1534 (99⋅7 %) for myeloma to 858/15,542 (5⋅5%) for breast. more even distributions were observed for colorectal (5017/ 11,842, 42⋅4%), lung (3384/13,107, 25⋅8 %), ovarian (614/2481, 24⋅8%), and uterine (713/2506, 28⋅5%) cancers (table 2 ). (495/2669, 15⋅2%). postmenopausal bleeding accounted for nearly half of all index features of uterine cancer (1305/2619, 49⋅8%), with lower frequencies for high blood glucose (300/2619, 11⋅5%) and low haemoglobin (275/2619, 10⋅5%). overall, the median diagnostic interval was 58 days (interquartile range (iqr) 23-158, n = 83,935). by cancer site, the shortest diagnostic interval was in breast (median, iqr: 20, 10-30 days, n = 15,542) and the longest in lung (median, iqr: 129, 46-263 days, n = 13,107) ( table 4) . median (interquartile range) diagnostic intervals by year and by nice grouping are plotted in fig. 3 fig. 3 ). median diagnostic intervals were longer for new-nice than for old-nice participants for colorectal (70 vs 51 days), oesophageal (77 vs 55 days), and lung (139⋅5 vs 124 days) cancers; however, this difference tended to decrease or disappear over time (fig. 3) . in ovarian cancer, diagnostic intervals were shorter in the new-nice than in the old-nice group overall (56 vs 72 days), notably in 2010-16 (fig. 3) . for bladder, colorectal, oesophageal, pancreatic and uterine cancers, median old-nice diagnostic intervals remained constant over 2006-2017. they were longer in 2017 compared with 2006 for breast (25 vs 16 days), lung (135 vs 103 days), ovarian (100 vs 65⋅5 days), prostate (93 vs 80 days) and stomach (102 vs 72⋅5 days) cancers (fig. 3) . semiparametric varying-coefficient analyses were powered for bladder, breast, colorectal, lung, prostate and uterine cancers. the percentage differences (with 95 % confidence intervals) in mean logtransformed diagnostic interval between new-nice and old-nice groups over time are plotted in fig. 4 . after guidance revision on 23rd june 2015, new-nice diagnostic intervals tended to shorten relative to those of the old-nice group in prostate (fig. 4e) and uterine (fig. 4f) cancers (note the downward trajectory towards the horizontal dashed line). for colorectal cancer, the difference in diagnostic interval between the new-nice and old-nice groups reduced over time. after guidance revision, new-nice diagnostic intervals were shorter than old-nice intervals, as indicated by the trend dropping below the horizontal dashed line (fig. 4c) . for lung cancer, new-nice were longer than old-nice diagnostic intervals in the years 2006-10. in 2010-15, there was no difference between the groups. in 2016 (post guidance revision), new-nice diagnostic intervals shortened relative to old-nice diagnostic intervals, but this was not sustained into 2017-18 (fig. 4d) . the proportions of eligible participants excluded for lack of coded features increased over time for bladder, colorectal, lung, oesophageal, ovarian, pancreatic, stomach, and uterine cancers. this coincided with increased use of suspected-cancer codes (fig. s1) . the demographic details of excluded and included participants were similar (table s1 and table 2 ). the proportions of old-nice and new-nice participants were largely similar across time within cancer sites (fig. s2 ). this study examined diagnostic intervals for 11 cancers in england, table 4 diagnostic interval (25th, 50th, 75th, and 90th centiles, mean and standard deviation) by cancer site. wales and northern ireland over 2006-2017, a period including major revision of national suspected-cancer referral guidance. as hypothesised, times to diagnosis were generally longer for "new-nice" participants (with index feature(s) of cancer introduced during guidance revision) than for "old-nice" participants (with feature(s) in the original guidance). importantly, for colorectal cancer, new-nice diagnostic intervals were shorter than old-nice diagnostic intervals after guidance revision. the gap between new-and old-nice groups decreased for prostate and uterine cancers over time, consistent with decreasing new-nice diagnostic intervals aided by increasing old-nice diagnostic intervals for prostate cancer. the revised national guidance and gp responses to its preceding evidence base may have contributed to these changes, along with other early-diagnosis initiatives. in conclusion, scope remains to reduce time to diagnosis for symptomatic cancers in england, wales and northern ireland. a considerable strength is the study's primary-care setting, where suspected-cancer guidance is implemented. the cprd is the largest primary-care database worldwide and is recognised for its high-quality data [23] . we used established methods for case identification [18] , with validation of cancer diagnosis by ncras where linkage was available. ncras data completeness improved in 2013 [24] . pre-2013 studies report a concordance rate of 83⋅3% between cprd and cancer registry information [25] . the cprd diagnosis date was a median of 11 days (interquartile range -6 to 30 days) later than the registry date pre-2013 for colorectal, lung, gastrointestinal, and urological cancers [26] . thus pre-2013 diagnostic intervals may be overestimated compared with post-2013 values. reassuringly, no step-change in newor old-nice diagnostic intervals were observed around 2013, suggesting that any associated bias is small. we studied diagnostic interval rather than the primary care (time from index date to referral) or secondary care (time from referral to treatment) interval to avoid restricting analyses to participants referred to secondary care [19] . a limitation was the inability to analyse diagnostic intervals separately for participants referred via the two-week-wait pathway [27] because robust data sources for identifying them were unavailable to us. we found conflicting evidence of changes in gp recording practice over time. the proportion excluded for lack of coded features increased over time for some cancers, often coinciding with increased use of "suspected-cancer" codes. the proportions of old-and new-nice groups over time were constant and the similar demographic details for included and excluded participants suggests no marked selection bias. we excluded approximately 26 % of participants for lack of coded features, a proportion consistent with evidence that coded cprd data identifies 80 % of visible haematuria or jaundice events, and 60-70 % of abdominal pain in patients with pancreatic or bladder cancers [28] . of participants without recorded features, some will have presented at emergency departments without prior primary-care consultations [5, 29, 30] , some will had the information recorded in "free text" [28] , and others may have presented with features outside nice guidance. such features were deliberately omitted from our study, as irrelevant to our focus on guidance revision. our analytical method allowed us to explore trends in the difference in diagnostic interval between groups aligned by their index feature(s) to the revised (new-nice) or original (old-nice) guidance [20] . the method was derived to explore the time-varying and gradual impact of emerging clinical evidence that is legitimised into clinical practice by official guidance revision and implementation [20] . our findings build on previous analysis of the original 2005 nice guideline's impact on diagnostic interval [13] . mean diagnostic interval for 15 uk cancers reduced between 2001-2 and 2007-8 by 5⋅4 days (95 % ci: 2⋅4-8⋅5 days) from an initial value of 125⋅8 days. similar to our study, median diagnostic intervals were shortest for cancers commonly presenting with lumps/masses (e.g. 26 days for breast) and longest for cancers often presenting with symptoms shared with other diseases (e.g. 112 days in lung cancer) [13] . our estimates of diagnostic interval for colorectal cancer are similar to those obtained by the international cancer benchmarking partnership using different data sources [31] . our findings are consistent with the taxonomy of cancer symptom "signatures" and diagnostic difficulty [9] . breast cancer had a narrow signature of a single alarm feature (breast lump) highly predictive of undiagnosed cancer plus the shortest diagnostic interval. in contrast, lung cancer had a very broad signature and the longest diagnostic interval. jensen et al. [27] investigated the impact of implementing a standardised cancer patient pathway in denmark in 2007-2009. post-implementation diagnostic intervals were 15 (12) (13) (14) (15) (16) (17) days shorter than peri-implementation values for the 37 % of patients actually referred via a cancer pathway, but were 4 (1-7) days longer for the 63 % of patients diagnosed via other routes. the authors concluded that the cancer pathways expedited diagnosis for a minority of patients. the relationship between diagnostic interval and mortality (and stage) is u-shaped, reflecting confounding by indication [32] [33] [34] . patients with advanced tumours generally receive an expedited diagnosis (possibly as an emergency) and have poor outcomes because of their high inherent mortality: the so-called "sick-quick". conversely, patients presenting with vague symptoms usually have longer diagnostic intervals, and higher mortalitythought to reflect the impact of diagnostic delay, particularly between referral and diagnosis [32] [33] [34] [35] . the revised guidance aimed to benefit patients by legitimising doctors to investigate at a lower risk of undiagnosed cancer. this change can reduce both diagnostic delay and emergency presentation. in this study, for colorectal cancer, new-nice diagnostic intervals reduced relative to old-nice interval after guidance revision. this is consistent with general practitioners acting on the vague ("new-nice") features introduced during guidance revision. indeed, the proportion diagnosed via the urgent cancer referral pathway increased from 30 % (95 %ci 29 %-30 %) in 2013 to 33 % (33 %-34 %) in 2016, spanning the period of guidance revision [36] . our findings of increasing old-nice diagnostic intervals over time may reflect growing strain on nhs diagnostic-endoscopy and imaging services [37], as demand for all indications (not just cancer) rises [38] , particularly if ct-based targeted screening for lung cancer is introduced [39] . in 2018, inadequate diagnostic capacity was considered a rate-limiting step in the diagnostic pathway [40] , and a negative impact of covid-19 on diagnostic services is already becoming apparent [41] . we conclude that scope remains to reduce time to cancer diagnosis. the revised colorectal cancer diagnostic guidance may be exerting a downward pressure on time to diagnosis of this cancer, through impacts on the vague features of cancer introduced during guidance revision. future studies using causal analysis should examine the impact of guidance revision on staging at diagnosis and survival for all cancers, and the possible downstream effects on investigative services. policymakers are urged to enhance cancer diagnostic services so that they do not pose a rate-limiting step in the diagnostic pathway, and to protect them from the pressures of covid-19. this study was funded by cancer research uk [c56843/a21550], who were not involved in any aspect of the conduct of the study, in writing the manuscript or in the decision to submit for publication. this research is also linked to the cantest collaborative, which is funded by cancer research uk [c8640/a23385], of which wh is co-director, gl is associate director, as is senior faculty, and sp is an affiliated research wh was clinical lead of the guideline development group which formulated the revised nice suspected-cancer guidelines (ng12). this paper is written in a personal capacity and is not to be interpreted as representing the views of the group or of nice. the remaining authors report no declarations of interest. achieving world-class cancer outcomes: taking the strategy forward suspected cancer: recognition and referral cancer patient pathways in denmark as a joint effort between bureaucrats, health professionals and politicians-a national danish project the 2015 national cancer program in sweden: introducing standardized care pathways in a decentralized system routes to diagnosis the expanding role of primary care in cancer 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in colorectal cancer: u-shaped association demonstrated for three different datasets variation in 'fast-track' referrals for suspected cancer by patient characteristic and cancer diagnosis: evidence from 670 000 patients with cancers of 35 different sites advanced-stage cancer and time to diagnosis: an international cancer benchmarking partnership (icbp) cross-sectional study national cancer registration and analysis service: routes to diagnosis scoping the future: an evaluation of endoscopy capacity across the nhs in england targeted screening for lung cancer with low radiation dose computed tomography unfinished business: an assessment of the national approach to improving cancer services in england cancer diagnosis and treatment in the covid-19 era supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.canep.2020.101805. key: cord-338332-msjtncek authors: sharifian, neika; sol, ketlyne; zahodne, laura b.; antonucci, toni c. title: social relationships and adaptation in later life date: 2020-09-18 journal: reference module in neuroscience and biobehavioral psychology doi: 10.1016/b978-0-12-818697-8.00016-9 sha: doc_id: 338332 cord_uid: msjtncek social relations encompass a complex and dynamic set of characteristics that have been shown to distinctly affect health and quality of life across the lifespan and especially in older adulthood. in this chapter we begin with a brief review of several prominent theories of social relations. next, we consider how social relations can be understood based on the resource they provide (e.g., contact frequency, social support), the relationship they stem from (e.g., friends, family), the strength of the tie (e.g., strong, weak) as well as the means of communication (e.g., offline, online). we briefly summarize how these characteristics have been shown to uniquely influence health and quality of life in older adulthood. finally, we contemplate potential clinical applications, provide recommendations for the future and offer final concluding comments. social relations have been increasingly recognized as fundamentally important to the health and well-being of individuals in every part of the world and may be especially relevant in later life. older adults may be more susceptible to the risks of social isolation due to age-related changes such as retirement, changes in health, and loss of network members (e.g., widowhood). indeed, survey research conducted in the united states reports that american adults aged 60 years and older report spending over half their waking hours alone (livingston, 2019) . about 28%, estimated to be roughly 13.8 million individuals, of all non-institutionalized american older adults reported living alone in 2017 (administration for community living & administration on aging, 2018). although higher proportions of older adults living alone are seen in north american and nordic countries (reher and requena, 2018) , similar trends are emerging globally. for instance, in singapore, the number of older singaporeans (65 years and older) living alone is estimated to increase by 42% from 2012 (35,000) to 2030 (83,000) (ministry of health, 2016). further, the proportion of older adults world-wide is also increasing (i.e., population aging). as of 2015, an estimated 8.5% of the world's population was aged 65 and older. by 2030, this is projected to increase to 12%, and by 2050, 16.7% of the world's population will be 65 years or older (he et al., 2016) . this increase in the older adult population is paired with the proportion of youth (under 20 years old) remaining flat over the same time period (he et al., 2016) . a rapidly aging population will face several socioeconomic and health-related changes such as increased chronic disease burden, increased healthcare costs, and reduced labor supply (bloom et al., 2015) , this despite the fact that people are remaining healthier longer. as social relations are a modifiable factor that has been linked to a variety of health-related outcomes (cacioppo and cacioppo, 2004; cornwell and waite, 2009; coyle and dugan, 2012; steptoe et al., 2013) , coupled with increases in population aging, the need to understand the implications of social relations or lack thereof (i.e., social isolation) is becoming more relevant and more urgent. in past decades, the field has made great progress in developing increasingly sophisticated evidence to document the who, what, why, and how of social relations. as the field moved forward, social relations was identified as an umbrella term that refers to structural characteristics of the social network (e.g., age, gender, education of network members), social support (e.g., aid, affect or affirmation that is exchanged) and support adequacy or satisfaction (e.g., the evaluation of the support network and social support available to the individual). all of these aspects of social relations, in turn, affect the individual's health and well-being both contemporaneously and longitudinally. while empirical evidence has accumulated in support of positive effects of social relations on health and well-being, there has also been recognition that not all social relations are positive or have a positive effect on people. it is clear that some people are disadvantaged by negative or ambivalent relations which, in turn, have the potential to negatively influence health and well-being. this greater specificity has framed and advanced the scientific study of social relations. in this chapter we begin with a consideration of several prominent theories of social relations, highlighting important characteristics of social relations as well as potential age-related changes in social relations. next, we move to a summary of extant knowledge about how social relations are associated with health and quality of life by examining the hierarchical breakdown of social relations (see fig. 1 ). to exemplify this, we can use contact frequency, one specific dimension of social relations, as an example. contact frequency is one unique social resource stemming from social relations and can be viewed as distinct from other social resources (i.e., social support, social strain, etc.). this resource can further be broken down by examining the source of this social contact. is the individual interacting with friends, family, children, their spouse, a neighbor, etc.? even further, an examination of the strength of that specific relationship tie can also highlight the unique contributions to health. is the individual interacting with a close or more casual friend? or a combination of close family and casual friends? finally, as technology is increasingly facilitating social interactions, we examine how individuals are in contact with their social ties. is the individual interacting with a close friend inperson or simply calling a friend to chat? each of these dimensions may have unique implications for how social relations influence health and quality of life. in this chapter, in line with this breakdown of the complexities of social relations depicted in fig. 1 , we discuss the different dimensions of social relations, including positive and negative aspects of relations. further, we will consider different relationship types from parents and peers in early life to family and friends in later life, noting the critical role of each. we also examine the interesting and evolving research recognizing the strength of weak ties. finally, with recognition of the rapidly changing world and influence of technology, the means of communication are reviewed and discussed. individuals engage in social relationships across the life course and it is important to note that age-related changes in the structure, function and quality of social relations occur in later life. prior theoretical and empirical evidence has documented the structure of older adults' social networks as well as mechanisms that may explain shifts in social relations such as partner selection and how older adults deal with interpersonal conflict. the following section highlights three prominent theories commonly used in the aging literature that focus on social relations: (1) the convoy model of social relations, (2) socioemotional selectivity theory, and (3) the strength and vulnerability integration model. we acknowledge that these are not the only theories regarding aging and social relations. our discussion here is simply meant to be illustrative of prominent theories often cited in prior literature. the convoy model of social relations (antonucci, 2001; kahn and antonucci, 1980) was designed to include the individual as part of a dynamic network across the lifespan and over the life course. this model is less culture laden and allows the individual to project their own convoy as they experience it without being driven by external norms or expectations. under optimal conditions, the convoy surrounds and supports individuals throughout their life-time. personal characteristics, such as age, gender, and personality, as well as situational characteristics, such as role expectations, resources, and demands, shape the individual's current and evolving convoy. ideally, the people who form an individual's convoy provide a reassuring foundation that helps an individual grow, develop and cope with their life experiences. at the same time, situational factors provide the context within which these social relations evolve. context is important because it situates the individual's expectations as well as the demand characteristics of organizations, roles, and/or norms. both are critical in the development of social relations. in 1987, antonucci & akiyama published one of the first empirical examinations of the convoy model using data from a national study of adults 50 years of age and older collected in 1980. they documented the structure and function of respondents' convoys and examined separately the influence of spouse, children, family and friends. in 2019, antonucci, ajrouch and webster replicated that study with data collected in 2005 from a regionally representative sample and showed remarkable similarities in structure. both cohorts had convoys of similar size, gender composition, years known and sources of support, suggesting that these characteristics are fairly consistent over time. network size in both samples included approximately 7 people, included more women than men, and individuals knew their network members, on average, 38 years. there have also been changes in convoys over the 25 years and not always in the direction that might have been predicted. more recent cohorts were older, lived closer to and had more frequent contact with their network members than the earlier 1980 cohort. on the other hand, there was one notable difference in network composition. proportion of family that composed a convoy was significantly smaller in 2005. reports of emotional closeness were largely the same in the two cohorts, assessed as the number of people defined as closest (3-4), closer (2-3) and close (1-2). composition of convoys were also fairly similar. convoys consisted, in both samples, of spouse, children, siblings and other family and friends. only the percentage of family decreased over the two samples. all others were substantially the same. the authors conclude not only that these are critical characteristics of a convoy but also that despite many demographic and social changes, these appear to be basic and critical elements of the convoy. empirical studies of the effect of social relations on health using the convoy model permit a detailed examination of these associations, often resulting in more nuanced findings or greater specificity with respect to long held or traditional findings. we provide three such examples with respect to mortality, socioeconomic status and network member education. a classic and very important finding in the literature indicates that people with more positive social relations live longer. this is a finding we do not mean to contest. however, antonucci and colleagues found that under conditions of serious or life-threatening illness, people with more negative relations live longer. they interpret the finding as indicating that under some situations negative relations may be experienced as negative but prolong life by encouraging life-saving behavior change such as diet, exercise or adherence to a medical regimen. another classic finding is that people of lower socioeconomic status have poorer health than people of higher socioeconomic status. this, too, is generally true. yet, in another study by antonucci and colleagues (antonucci et al., 2003) , middle aged men of lower socioeconomic status with key support from their children were as healthy as men of higher socioeconomic status. and finally, webster and colleagues (webster et al., 2013) found that the education level of network members was significantly associated with an individual's self-rated health, above and beyond their own educational attainment and also controlling for that individual's age, gender, race, and marital status. while it is a long standing finding that higher education is associated with health, this finding indicates the importance of the education level of the people closest to you for your own health. in summary, these findings suggest that careful assessment of personal, situational and social relations characteristics can provide a more nuanced understanding of how social relations influence health and well-being of the individual in later life. socioemotional selectivity theory (sst; carstensen, 1995; carstensen et al., 1999) is based on and derived from baltes' selection, optimization and compensation model (soc: baltes, 1997; baltes et al., 2006) . according to sst, people make active choices about the number and closeness of relationships in which they would like to invest, and older adults become more selective in choosing their social network members due to shifts in motivation (english and carstensen, 2014) . these shifts in social relations are driven, in part, by perceptions of time rather than age per se. sst is fundamentally a lifespan theory which takes into account different life goals at different points in the lifespan (carstensen et al., 1999) . younger people are motivated to reach out and explore the world, in part, due to having more expansive time horizons (i.e., open-ended). thus, younger adults strive for more knowledge-focused goals (i.e., achievement, accumulating information, etc.) to gain more independence from their family of origin and seek new connections as they seek to discover their place in the world. as individuals get older, sst argues people perceive their time left to live as more limited. with age, people become less interested in exploring new relationships but rather focus on relationships they already have that are more emotionally meaningful. with this goal dominating the basis of their social relationships, people begin to reduce the number of relationships in which they are invested in order to devote more of their remaining time to their close relationships, which become increasingly significant to them. in an early empirical examination of sst, three cohorts of nationally representative samples were examined. across all three cohorts, younger people reported wanting to increase the number of social relations (e.g., friends) while older people felt they had enough friends and were quite satisfied with the current size of their social networks (lansford et al., 1998) . experimental data are also supportive. for example, in a cross-sectional study (fredrickson and carstensen, 1990) investigating social partner selection, individuals were asked who they would spend half an hour of free time with: a member of their immediate family (familiar social partner), a recent acquaintance they have a lot in common with (novel social partner) or an author of a book they read (novel social partner). when asked in the unspecified condition, older adults showed greater preference for familiar social partners compared with younger adults. in contrast, in a condition in which participants were told to imagine they were moving across the country by themselves (i.e., a salient ending condition), younger adults showed similar social preferences to older adults (study 2; fredrickson and carstensen, 1990) . in another study, using the same paradigm as the previous study (fredrickson and carstensen, 1990) , researchers examined social partner selection in hong kong before, right after and 4 months after the september 11th terrorist attacks (study 1; fung and carstensen, 2006) . before september 11th, younger people were less likely to select familiar social partners than older people. right after 9/11, however, age differences were no longer present such that both younger and older individuals showed a preference towards familiar social partners. four months after 9/11, age differences reemerged, showing a greater preference of familiar social partners at older ages (study 1; fung and carstensen, 2006) . further, in a longitudinal study, social partner selection was examined in hong kong during the peak of the sars epidemic and right after it subsided. during the sars epidemic, no age differences in social partner selection emerged, however, after the sars epidemic, younger ages were less likely to select familiar social partners compared with older ages (study 2; fung and carstensen, 2006) . overall, sst highlights the role of motivation, life goals, and context (i.e., perceptions of time left and/or the finitude of life) which influence social relationship preferences. that is, older individuals tend to be more likely to prefer familiar social partners, which may reflect a shift from knowledge-focused goals to emotion-focused goals due to changing perceptions of time horizons. prior research has shown that age is a good predictor of time perception such that older adults show more limited future time perspectives than younger adults (lang and carstensen, 2002) . however, life events and experimental manipulations can also reduce time horizons (e.g., fredrickson and carstensen, 1990; fung and carstensen, 2006) and thus, shifts in motivation and social preferences may occur at any life stage. overall, sst argues that close social relationships become more, not less, important as people age, which may be driven by motivational changes in goals. at the same time and perhaps because of this, people become more selective about their relationships. they prefer to invest what they perceive to be their limited remaining time in relationships that are most important to them. the strength and vulnerability integration (savi; charles, 2010) model, building on the tenets of sst (carstensen et al., 1999) , describes age-related gains and losses that influence the process of emotion regulation in older adulthood. in particular, consistent with sst, the savi model addresses the frequent finding that older adults express higher levels of well-being than younger adults. this finding is somewhat counterintuitive in that older adults are known to experience increased susceptibility to the negative consequences of high emotional arousal, such as from conflict and misunderstandings stemming from social relations. to protect themselves from this vulnerability, older adults are theorized to use strategies that allow them to avoid and/or disengage from emotionally laden situations and do so to a much greater extent than younger adults. indeed, prior research has shown that older adults tend to endorse more passive emotion regulation strategies compared with younger adults (blanchard-fields, 2007) which may have more benefits for health and well-being in later life. for example, in a daily diary study of u.s. adults, older age was associated with less affect reactivity to interpersonal stressors when individuals avoided an argument whereas older age was unrelated to affect reactivity when individuals engagement in arguments (charles et al., 2009) . this strategy, of avoiding negative social situations, serves to protect the older individual from their known heightened sensitivity to stress and may explain, at least in part, the observed age-related benefits in well-being achieved by avoiding negative social situations. this interpretation was further supported in a cross-sectional study in which younger and older adults were presented with audiotapes of two actors insulting another person in which they were instructed to imagine that the negative comments were directed at them (charles and carstensen, 2008) . in response to these imagined insults, older adults made fewer cognitive appraisals about the speakers, expressed less negativity and less anger, but equivalent levels of sadness compared with younger adults in response to the overheard insults (charles and carstensen, 2008) . these findings may indicate that older adults protect themselves by shifting attention away from and disengaging from averse social situations, thus dampening negative responses. in another form of self protection from vulnerabilities and consistent with sst, savi theorizes that older adults maintain social relationships with close others while pruning more peripheral social partners (english and carstensen, 2014) . this occurs in order to help maintain important, emotionally meaningful relationships and helps to maximize emotional well-being (see review, rook and charles, 2017) . these changes in social partner selection are another form of self protection, driven not only by perceptions of time left (i.e., sst), but also by accrued knowledge and experience (charles, 2010) . the amount of time lived may be an important indicator of social expertise (luong et al., 2011) such that older adults may have more experience dealing with everyday life which allows them to be selective and increase efficiency at dealing with and avoiding potential stressors (charles, 2010) . savi further expands on sst by highlighting not only age-related gains (i.e., strengths), but also age-related losses (i.e., vulnerabilities). specifically, older adults experience decreases in the body's ability to downregulate strong negative emotional responses that may have consequences for emotional and physical health outcomes (charles, 2010) . increased difficulty at downregulating sustained emotional arousal and reactivity in older adulthood may, in turn, attenuate age-related improvements in emotion regulation when faced with unavoidable stressors (charles, 2010) . while many long-term social ties are positive, some are not. negative close social relations often cannot be avoided and may be a source of strain and ambivalence. thus, when older adults are unable to avoid situations that cause high levels of distress, such as conflicts or misunderstandings in social relationships, they are likely to experience arousal that may challenge their health and quality of life (rook and charles, 2017) . for example, in a classic finding rook (1984) found that negative relations had a more powerful effect on well-being than positive relations. in a related longitudinal study of british adults aged 40 to 77, negative social interactions were more strongly associated with physical health with older age (hakulinen et al., 2016) . overall, the savi model builds on the foundation of sst, further highlighting the age-related gains and losses associated with maintaining emotional well-being. notably, the savi model posits that older adults actively down regulate emotional stress, avoid high arousal circumstances and/or limit their reaction to those circumstances whenever possible. this approach offsets the increased vulnerability of older people to stress and its negative effects on health and well-being. these strengths and vulnerabilities, in turn, may influence the selection of social network members (i.e., social pruning) as well as how individuals choose to interact during social contexts (i.e., avoiding interpersonal stressors/conflicts). each of these theories are lifespan in nature and offer accumulating evidence concerning individual and specific important insights concerning the who, what, why, and how of social relations. the convoy model of social relations offers an overarching, inclusive theory meant to identify specific aspects of social relations (i.e., structure, support and satisfaction) while also detailing what and how personal and situational characteristics influence the individual's needs for specific aspects of social relations. all antecedent elements of the model influence consequences for the individual in terms of health and well-being outcomes. on the other hand, socioemotional selectivity theory focuses on what motivates individuals to seek and invest in relationships, and specifically what influences exactly the types of relationships in which people will invest (e.g., new vs. old, close vs. distant). sst argues that people are motivated by goals which are affected by circumstances (e.g., time, place and context). this, in turn, influences the choices people make about with whom they choose to spend their time. finally, the strength and vulnerability integration model drills down even further the how and why of social relationships. specifically, savi examines the strategies people, especially older adults, use to avoid extremes of emotions and maintain emotional regulation. this is accomplished by maximizing the positive and minimizing the negative in their relationships (i.e., how) thus avoiding emotion regulation problems often caused by and associated with the stress and strain of difficult relationships and/or circumstances (i.e., why). each theory offers guidance about specific aspects of social relations. some theories motivate specific research questions whereas others guide the interpretation of research findings. while the convoy model provides a heuristic framework within which to understand the causes and consequences of social relations over the life course, sst focuses on the individual's time perspective and what motivates social interactions while the savi model specifies a common strategy among older adults used to maintain high levels of well-being through emotion regulation and avoidance of conflict. in the paragraphs below we use these theories to interpret findings that address common dimensions of social relations, relationship types, and means of communication. finally, we end with a consideration of clinical applications and future recommendations. the extent to which people engage with, and receive benefits from, their social relations is influenced by structural, functional, and qualitative aspects of their relationships (holt-lundstad, 2018) . structural aspects refer to the objective components of the network that are directly observable, such as total network size, age of, gender, relationship to and frequency of contact with network members. supportive or functional aspects of social relations refer to the exchange of aid (e.g., tangible goods, instrumental support), affect (e.g., emotional support, affection), and affirmation (e.g., confirmation of values; informational support). on a more evaluative level, qualitative aspects of social relations are those pertaining to one's subjective experiences of interactions with others in their social networks such as satisfaction, enjoyment, strain or conflict with their relationships. one example of the distinction between structural and qualitative aspects of social relations can be found in the growing literature on social isolation versus loneliness (cacioppo and hawkley, 2009) . social isolation refers to the lack of network members and the lack of support exchanges and corresponds to the objective, structural and functional aspects of not receiving support. in contrast, loneliness refers to the distress experienced or the individual's personal assessment that they are not sufficiently supported by others. that evaluation of a lack of support results in low levels of satisfaction which corresponds to a low evaluation of the quality of their relationships. it should be noted that quality of relationship is a subjective evaluation in that two people with the same support exchanges might evaluate those support exchanges differently, which would then have different effects on health outcomes (van tilburg et al., 1998) . greater specificity of structural, functional, and qualitative aspects of social relations has significantly contributed to a better understanding of how social relations influence health in older adulthood. the following sections explicates specific ways in which structural, functional, and qualitative aspects of social relations distinctly contribute to health-related outcomes. in this section, we frequently highlight cognitive health as illustrative both because of its overall importance and link to alzheimer's disease and because significant advances have recently been made demonstrating the association between social relations and cognitive functioning in numerous populations around the world. social network size is a commonly used indicator of network structure which has been shown to be related to physical (i.e., mortality; berkman and syme, 1979; kauppi et al., 2018) and cognitive health (barnes et al., 2004; bennett et al., 2006) outcomes in older adulthood. for instance, in a clinicopathologic study examining social network size, cognitive functioning and brain pathology at autopsy, individuals with a larger social network showed attenuated associations between brain pathology and cognitive functioning. in other words, even when individuals had more severe levels of brain pathology, cognitive function remained high for participants with larger social networks whereas individuals with a smaller social network showed lower cognitive function at higher levels of brain pathology (bennett et al., 2006) . these findings suggest that social network size may be a source of cognitive reserve and may contribute to the maintenance of cognition, in spite of neuropathology. additionally, a cross-sectional investigation of the role of network size on cognition using a cohort of u.s. older adults by katz and colleagues (katz et al., 2020) found that social network size was significantly related to executive functioning but this association varied by race and ethnicity. they reported that the strongest associations existed between executive functioning and quadratic estimates of the number of close children of non-hispanic black participants, and number of close family members for hispanic participants. on the other hand, among black participants, a curvilinear relationship indicated that less than or more than two close children was associated with lower executive functioning. this was not the case for hispanic participants, among whom higher executive functioning was associated with fewer (0-1) and greater (4-5ã¾) numbers of family member contacts. prior research has also shown the potential benefits of contact frequency for health and quality of life. a recent study by grant and colleagues (grant et al., 2009 ) who followed a sample of middle aged adults in britain, showed that people reporting less contact with network members had higher salivary cortisol upon waking and throughout the day, compared with those in more frequent contact with their network members. these findings suggest that less frequent contact with network members, which could be an indication of social isolation, negatively affects the stress response of the body. as is perhaps evident, this has important implications for other health outcomes. indeed, less contact frequency has been associated with higher mortality (berkman and syme, 1979) . as reviewed in more detail later, this biochemical response to social isolation may be one way by which contact frequency contributes to physical health. in a related longitudinal study of american adults by seeman and colleagues, higher frequency of contact was associated with better executive functioning and better memory while decreases in contact frequency over two time points was associated with worse memory (seeman et al., 2011) . this study was unique in that it began to specify exactly what dimensions of cognitive functioning are influenced by contact frequency. similarly, zahodne and colleagues (zahodne et al., 2019a) , using longitudinal data from a u.s. nationally representative sample of older adults, found that more contact was associated with better memory at baseline and slower memory decline over 6 years. on the other hand, social network size was not associated with memory trajectories (zahodne et al., 2019a) . these findings suggest that it is the stimulation of social contact rather than the number of social ties which positively affects cognitive functioning among older people. these authors also examined the reverse, to see whether memory was associated with changes in social contact over the same span of time. it is noteworthy that they report no association between memory and change in contact frequency (zahodne et al., 2019a) , indicating that it is the loss of social relations that is detrimental to cognitive health, rather than declines in cognitive health leading to more isolation. another important structural characteristic of social relations can be measured by the number of social activities in which an individual engages. number of social activities and/or groups represent a form of structural ties. these appear to be beneficial to cognitive health as they help increase the number of weak ties (i.e., peripheral social ties such as neighbors, acquaintances, etc.) in the social network. these activities seem to promote health through the requirement of active contingent interaction and allocation of resources through the exchange of support (i.e., see in-depth discussion regarding the strength of weak ties in the next section). social activities are those that involve actively interacting with others, such as playing cards, going to church, or playing a competitive sport, and these activities may have implications for health in older age. prior research has found that social activity was associated with less disability at baseline and slower decline in function over 9 years (mendes de leon et al., 2003) . similarly, in another study, barnes and colleagues (barnes et al., 2004) reported that more frequent social activity was associated with baseline global cognitive function and slower decline in global cognition over time, independent of network size. furthermore, the number of different types of social groups with which one engages may also be beneficial for health given that number of social groups is associated with increased network size (hawkley et al., 2008) . the above examples and prior research have shown promising links between structural aspects of social relations and health outcomes. it is important to note, however, that these various structural aspects of social relations work in tandem with other aspects of social relations. just as there are structural aspects of social relations, functional support or the exchange of support as well as qualitative aspects of social relations are important components of social relations that merit further discussion. these functional and qualitative aspects of support may also be independently associated with health. functional or social support refers to the actual support that is exchanged and can be subcategorized by whether the support provided included practical aid (e.g., instrumental/tangible support), affect (e.g., emotional/affectional needs) and/or affirmation (e.g., verification of values) (kahn and antonucci, 1980; krause, 1987) . social support has been shown to be associated with a wide variety of physical and mental health outcomes. for example, an irish longitudinal study of older adults found a negative association between social support and depressive symptoms. of note, this pattern of findings varied across men and women, with higher levels of spousal support and less strain from one's spouse as well as better social network integration being protective against depressive symptoms only in men (santini et al., 2016) . further, there were no associations between support and anxiety for either men or women, suggesting that functional aspects are more impactful for mood compared to anxiety (santini et al., 2016) . another longitudinal study similarly found that baseline social support and change in social support over 3 years were both related to depressive symptoms in that more support was related to fewer depressive symptoms, but loss of support was related to more depressive symptoms (oxman et al., 1992) . in regards to cognitive health, in a longitudinal study of american older adults, no associations between baseline social support and change in cognitive function was found; however, the authors did find an association between satisfaction with social support (i.e., quality) and global cognitive function and processing speed/attention at baseline . social support may also facilitate increased physical activity in older adults, which may be another way of promoting health and well-being over time. for instance, in a study of south korean older adults, social support was related to increased physical activity (kang et al., 2018) . this increase may be due to the increased accountability and companionship that comes with joint physical activity, which can help older adults be more motivated to adhere to fitness regimens and other healthy behaviors to promote overall quality of life. examining an outcome such as physical activity engagement may be an area where the type of support given and received can be further disentangled as the reciprocal benefits of support given and support received may have mutually beneficial health outcomes. it is important to note, however, that individuals can both receive and provide social support to network members and these may have distinct effects on health in later life. for example, in a study by thomas (2010) , when simultaneously modeling support received, support given, and other aspects of social relations, the authors found that psychological well-being was positively associated with support given, while support received was not associated with psychological well-being. these findings suggest that when considering indicators of psychological health, it may be more important to consider the effects of support, both given and received, in order to identify more salient effects of social relations on mental health outcomes. to this point, a study by lafleur and salthouse (2017) found that providing both informational and emotional support were beneficial for memory. a similar pattern of findings has also been demonstrated internationally. specifically, in a longitudinal study examining older adults in southwestern france, independent of other indicators of social relations such as network size, receiving more support than giving support was associated with lower odds of dementia incidence (amieva et al., 2010) . of note, another longitudinal study of american older adults found that emotional support received was independently associated with change in overall, better cognitive performance after accounting for other indicators of social relations, including perceptions of support given by the participant (seeman et al., 2001) . in this same study, authors found that the effect of support given as indicated by a measure asking about frequency of instrumental and emotional support given, was not associated with cognition at baseline or change in cognition over two times points. combined, these studies highlight the importance of the type of functional support exchange to improve health, and that the effect of giving support may not be equally associated with positive health outcomes as support received in similar types of support exchanges. the quality of one's social relations may have a unique effect on later life health outcomes. social strain, a distinct negative qualitative aspect of social relations, can be described as the degree of interpersonal conflict and/or obligatory interactions (i.e., family obligations), that results in the person perceiving increased dissatisfaction and distress from these interactions (yang et al., 2014) . prior research has linked social strain in older adulthood to health-related outcomes. for example, in the study mentioned above by antonucci and colleagues investigating the links between social strain and health, under conditions of serious illness, the strength of positive and negative interactions with network members was associated with mortality in a somewhat counterintuitive manner. stronger negative interactions were related to lower mortality as were weaker positive interactions. on the other hand, a study of danish middle aged adults, always or often experiencing social strain had higher risk of mortality compared with those who reported seldom experiencing these strains (lund et al., 2014) . in a longitudinal study, seeman and colleagues (seeman et al., 2011) investigated a cohort of american older adults and found that more social strain was independently associated with worse executive function while accounting for other social relations. of note, these authors did not find measures of quality of social relations to be related to change in cognitive function over time (seeman et al., 2011) . recall that in the longitudinal study of irish older adults mentioned above examining associations of social strain with depressive and anxiety symptoms, a positive association between social strain and depressive symptoms but no association between strain and anxiety was found (santini et al., 2016) . together these studies suggest that while strain may have overtly negative health consequences, there may be aspects of interacting with others that may be protective, indicating that further study into the mechanisms underlying the association between social strain and health is warranted. because of the ways that social strain affects mental health, physical health, and cognitive health, studies have also found that qualitative aspects of social relations are associated with increases in similar biochemical processes in the body. in a study examining social strain and risk of elevated inflammation using a composite of five indicators of inflammation (c-reactive protein, fibrinogen, interleukin-6, e-selectin, intracellular adhesion molecule 1), social strain was independently associated with increased risk for elevated inflammation (yang et al., 2014) . further, the effect of social strain was stronger than the effect of social support, confirming rook's (1984) finding and suggesting that the presence of social strain may be more detrimental to health than the absence of social support (yang et al., 2014) . these findings provide some insight by which social strain can affect physical and mental health outcomes. as the convoy model suggests, both personal and situational characteristics influence the structure, function and quality of life. one manifestation of the situation is culture, which can fundamentally influence expectations and evaluations of social relations. what may be seen as social support in some cultures, may be perceived as social strain or conflict in others. their detrimental effects may then depend on the cultural norms as well as how closely individuals identify with a particular culture and adhere to its norms. as an example, collectivistic cultures may view responsibility of family members, particularly responsibility to older adults, to be important in family relations. a qualitative study by willis (2012) explored this topic in a study on caregiving of older adults in britain around ethnic identity and duty to elders in examining the effects of collectivistic cultures. those who identified with their ethnic group membership, and whose ethnic group valued service and support of elders as one behavioral indicator of collectivistic culture, were more likely to indicate agreement that younger generations should take care of their elders. in this study of largely ethnic minorities, minorities of south asian descent and white irish immigrants endorsed beliefs consistent with collectivistic ideals of taking care of elders, while white british older adults did not endorse these beliefs (willis, 2012 ). an international comparison of perceived filial piety (i.e., responsibility for elders) in five european countries, germany, israel, norway, spain, the united kingdom and the united states similarly found that sense of filial piety depended on the collectivist versus individualist orientation of the european country and, in the case of the united states, the ethnic/racial background of the respondents (jackson et al., 2008) . although perception of obligation regarding elder care may be either individually or culturally based, an elder who perceives a younger person as not adhering to those elder care norms may experience their relationship as strained when these expectations are not met. quality of relationship, as noted above, refers to the individual's evaluation of their social relationships. thus, people with the exact same amount of exchanges (functional support) and number of relationships (structure of social network) can feel differently about the quality of their relationships. one might feel their relationships are perfectly adequate, another might feel dissatisfied with the same relations and, instead of being content with them, feel quite lonely. thus, loneliness is differentiated from structural network characteristics, such as social isolation, and functional characteristics such as support received, in that it is the individual's evaluation of satisfaction with their social relations that affects health and emphasizes the person's negative emotional reaction to their dissatisfaction with the quality of their social relations. loneliness, in particular, may be a salient example of the importance of investigating quality of social relations. increased loneliness in older age has been linked to a number of mental health, physical health, and cognitive outcomes. for example, more loneliness is associated with increased depressive symptoms over time . loneliness has also been associated with poorer physical health, as indicated by increased physical disability (shankar et al., 2017) , hypertension , and increased mortality (patterson and veenstra, 2010) . furthermore, individuals who reported often feeling lonely had a higher risk of mortality due to non-ischemic cardiovascular diseases, compared with those who reported never feeling lonely, when accounting for other aspects of social relations (patterson and veenstra, 2010) . the odds of non-ischemic cardiovascular mortality were higher than all-cause mortality, suggesting that loneliness's impact on cardiovascular health may be a leading cause of death (patterson and veenstra, 2010) . indeed, other studies have examined loneliness and cardiometabolic disease and demonstrated that increased risk of metabolic syndrome (e.g., waist circumference, triglycerides, high density lipoprotein cholesterol, blood pressure, and fasting glucose; whisman, 2010) is associated with higher amounts of loneliness. loneliness may also impact cognitive health in older adulthood. while one cross-sectional study with an american sample of racially and ethnically diverse older adults did not find an association between a comprehensive measure of loneliness and episodic memory when accounting for structural aspects of social relations and other psychosocial factors (sol et al. under revision) , another cross-sectional study with an irish sample did find an independent association between loneliness and global cognition, processing speed, and visual memory when accounting for social network integration (o'luanaigh et al., 2012) . in a recent longitudinal study of social activities among chinese older adults, an independent association emerged between loneliness and global cognitive decline over 9 years, among those engaging in more frequent social activities (zhong et al., 2017) . loneliness has also been associated with increased inflammation, important as inflammation is often associated with all of the aforementioned health outcomes (kiecolt-glaser et al., 2010) , including cognitive function (zahodne et al., 2019b) . increased inflammation is one of the mechanisms proposed by hawkley and capitanio (2015) , as to how loneliness affects health. thus, further study of the biochemical mechanisms between loneliness and various health outcomes may also provide insight into ways to reduce its detrimental effects in older age. additional specification is suggested in a recent study by kang and colleagues (kang et al., 2018) who found that while physical activity did not mediate the relationship between social support and quality of life, the positive relationship between social support and quality of life was mediated through a negative relationship with loneliness. these findings show how other aspects of social relations (i.e., functional exchanges/ support) can affect health outcomes through qualitative factors (i.e., loneliness). furthermore, when modeling both social isolation and loneliness concurrently, their relative impact may depend on the outcome studied, as social isolation may be related to increased likelihood of poorer self reported health, while increased loneliness may be related to increased likelihood of poorer mental health (coyle and dugan, 2012) . taken together, these studies highlight the complexity of various aspects of social relations and loneliness and how they each contribute to overall health. as loneliness may be a potential risk factor for health and quality of life in older adulthood, understanding the antecedents of loneliness may be an important area for future intervention. several factors may contribute to the experience of loneliness. previous experiences of loneliness may be one predictor which leads to a cyclical pattern of behaviors which results in additional feelings of loneliness over time (cacioppo and hawkley, 2009) . personality influences social relationships and these relatively fixed characteristics may contribute to the cycle of loneliness, particularly characteristics indicating neuroticism (buecker et al., 2020) . nonetheless, other research has found that levels of neuroticism decrease over the life course (ormel et al., 2012) , which is promising as older adults who experience elevated levels of neuroticism earlier in the life course may be able to seek and maintain the relationships they desire in order to reduce loneliness. taken together, these concepts and the related studies show the importance of examining not only the structural aspects of social relations but also the exchange of support and the subjective or evaluative aspects of social relations. consistent with the tenets of the social convoy model, this evidence helps identify why structural aspects of social relations are important given its emphasis on the observable aspects of social networks and the ways in which these observable aspects influence health over the life course. in addition, this evidence helps identify why structural characteristics such as network size and frequency of contact contribute to health because the presence of others and contact with them is essential to developing the relationships critical to health. further, an examination of the distinct dimensions of social relations helps identify ways in which the qualitative aspects of relationships helps to motivate reasons for maintaining contact in older age in order to better invest limited time with more meaningful relationships, as proposed by and consistent with socioemotional selectivity theory. similarly, the links between higher quality social relations and health outcomes supports the tenets proposed by the savi model, which suggest that maintaining contact with desired others and pruning unwanted relationships reinforce positive emotional experiences with desired others. these motivations to protect limited time (i.e., sst) and to increase positive emotional experiences (i.e., savi) can be in the form of both support/functional exchanges as well as perceived relationship quality. given that none of these aspects of social relations exists in isolation nor are easily separable, future work can further refine understanding on the ways in which structural, functional, and evaluative aspects of social support may improve overall health. understanding the nuances underlying social relations may also help improve interventions that target improving structural, functional support exchanges, and qualitative aspects of social relations in order to better meet and resolve older adults' specific needs in social relations. further, structural and functional aspects of social relations such as social isolation and support exchanges, as well as qualitative aspects such as loneliness, are specific ways in which social relations affect health. examining these various components of social relations together may help improve future study into ways to increase the beneficial aspects of social relations while reducing those characteristics of social relations that negatively affect health in older adulthood. as we seek to understand the association between social relations and health, it has become clear that specific social relationships may provide unique forms of interaction and support. in the following sections, we highlight the characteristics and importance of several types of social relations and their unique impact on later life health. we highlight (1) the importance of early-life social relationships with parents and peers, (2) the importance and distinctions between friends and family, and (3) the role of weaker social ties such as fellow church members and neighbors in older adulthood. prior research focusing on social relationships in later life as well as a majority of the research covered in this chapter predominantly focus on the associations between current social relationships and health outcomes in older adulthood. it should be acknowledged, however, that social relationships grow and develop across the lifespan. specifically, social relationships in childhood play a critical role in developmental processes that have been shown to have far reaching effects on social, mental, physical and cognitive health in adulthood. as theorized in attachment theory and the social convoy model, social relationships build from previous social experiences (antonucci et al., 2014; bowlby, 1980) . specifically, attachment theory argues that children develop internal working models of attachment (i.e., a representation of one's self and of relationships in general) that will guide expectations and behaviors exhibited in future social relationships (see chapter, siegler et al., 2011) . indeed, prior research examining attachment of white middle-class infants at 12 months old showed that a majority of the infants (72%) received the same secure/insecure attachment classification in early adulthood (waters et al., 2000) . therefore, early life relationships with parents and important others may have far reaching effects on health and quality of life through late life current social relationships. further, prior research also suggests that early life social relationships may influence health more directly through the development of physiological stress response (luecken and lemery, 2004) . that is, children who have poorer quality relationships with parents may be hypervigilant to threat cues in their environments, may exhibit poor self-regulatory responses (i.e., maladaptive coping strategies) and elevated physiological stress responses (see reviews; luecken et al., 2006; luecken and lemery, 2004) . in line with this notion, prior research has linked parental social relationships to a variety of health outcomes later in life. for example, in a cross-sectional study of u.s. adults examining the associations between retrospective childhood social support and allostatic load measured by a sum of risk scores across 7 physiological systems, higher social support in childhood (emotional and instrumental) was associated with less biological dysregulation in midlife (slopen et al., 2016) . consistent with these crosssectional findings, a longitudinal study of harvard undergraduate men found that lower ratings of parental caring in young adulthood was associated with greater risk of illnesses such as coronary artery disease, hypertension, duodenal ulcer, and alcoholism 35 years later (russek and schwartz, 1997 ). an examination of the influence of early parental relationship quality on cognitive health outcomes by sharifian and colleagues revealed that respondents from a nationally representative u.s. sample of older adults who reported higher retrospective maternal relationship quality showed less decline in episodic memory over time through reduced loneliness and depressive symptoms. similarly, in a population-based longitudinal study of non-hispanic african american and white adults, greater retrospective childhood social support was associated with better initial memory through educational attainment and mental (stress) and physical (bmi) health pathways (zahodne et al., 2019c) . these findings highlight the enduring effects of early life social relationships on health-related outcomes directly and indirectly through multiple biopsychosocial pathways. in addition to parental relationships, peer relationships in childhood and adolescence may also have long-term implications for health. peer relationships become especially salient as individuals begin to spend more time with age peers in adolescence and begin to value expectations of peers more highly (see chapter, brown and larson, 2009) . social acceptance by peers has previously been identified as a reliable indicator of socioemotional and behavior adjustment outcomes and are thought to have long-term ramifications for developmental processes over the life course. for example, in a 27-year prospective swedish cohort study, peer problems at age 16, defined by perceived degree of unpopularity and social isolation at school, were linked to greater risk of metabolic syndrome at age 43 (gustafsson et al., 2012) . this finding was robust after accounting for health behaviors, school adjustment and family circumstances in adolescence as well as psychological distress, health behaviors and social circumstances in adulthood (gustafsson et al., 2012) . peer bullying specifically has also been associated with a variety of health-related later outcomes. for example, in a longitudinal study following american children into young adulthood, being a victim of bullying as well as being a bully-victim (i.e., someone who is bullied and is also a bully) was associated with increased risk of poorer health, socioeconomic and social-relationship outcomes in adulthood (wolke et al., 2013) . consistent with the previous study, in a 50-year prospective follow-up of a british birth cohort, bullying victimization in childhood (ages 7 and 11) was associated with worse mental, physical, and cognitive health outcomes in midlife (takizawa et al., 2014) . findings specific to adult social relationships indicate that bullying in childhood was associated with weaker social relationships in adulthood (takizawa et al., 2014) and support the hypothesis that later-life social relationships are based on and develop from earlier relationships such as interactions with adolescent peers. these findings are consistent with the social convoy model and attachment theory, suggesting that parental relationships in childhood and peer relationships in adolescence may act as building blocks for developmental processes in later life. specifically, early life social relationships may influence current and later life health outcomes (i.e., mental, physical, cognitive) through the early development of internal working models of attachment. these early life social relationships may also influence health outcomes through their impact on threat appraisal, self-regulatory and physiological responses to stress (luecken et al., 2006; luecken and lemery, 2004) . additionally, although not discussed in detail in the current chapter, early life social relationships with parents have been linked to self-regulatory behaviors in childhood (eisenberg et al., 1999) and in early adulthood (baker and hoerger, 2012) . thus, children and adolescents who develop appropriate self-regulatory skills in childhood are likely to show better regulation skills later on in life. this may be an important individual difference that influences emotion regulation strategy selection and efficiency in order to avoid age-related vulnerabilities to high arousal situations (i.e., conflicts, misunderstanding) as conceptualized within the savi model. in light of the above summarized findings, we conclude that it is important to consider not only current characteristics of social relations in older adulthood, but also significant social relationships at pivotal developmental periods. an ongoing issue in the field of social relations is the relative importance of family and friends as well as their association with health and well-being, especially in later life. when prior research has compared the distinct effect of friends and family, friendships are often shown to more strongly benefit later life health and quality of life. for example, in a cross-sectional study across 97 countries, valuing both family and friendship relationships was associated with better health and higher happiness, however, valuing friends became a stronger predictor of health and happiness at older ages (study 1, chopik, 2017) . in a longitudinal follow-up study of u.s. older adults, friendship strain was associated with more chronic illness over time. at the same time, support and strain from spouse, children and friends predicted subjective well-being whereas other family relationships (i.e., relatives other than spouse and children) were not associated with health or well-being (study 2, chopik, 2017) . similar patterns were also evidenced in studies examining cognitive health outcomes. for example, in a cross-sectional study of chinese nonagenarians and centenarians, the number of friends and being married, but not the number of children or ties with neighbors, were associated with better cognitive health (wang et al., 2015) . finally, in a recent longitudinal nationally representative study of u.s. older adults, more frequent contact with friends, but not family, was associated with less decline in memory over time (zahodne et al., 2019a) . these converging findings may reflect the distinct features of friendships versus familial ties. friendships can be seen as more voluntary in nature. as individuals actively select their friends, friendships may provide different resources compared with family ties that help to promote health and quality of life. for instance, friendships are often reported as a greater source of companionship in later life, especially in comparison to family ties (crohan and antonucci, 1989; quan-haase et al., 2017) . they may, therefore, influence later life health through shared activities and mutual interests. indeed, prior empirical research has shown activity engagement to mediate the association between friendships and health. for example, in a cross-sectional study of swiss older adults, higher engagement in leisure activities mediated the association between a higher number of close friends and higher cognitive functioning (ihle et al., 2018) . similarly, evidence from a longitudinal study of u.s. adults showed that higher contact frequency with friends, but not family, was associated with higher engagement in cognitive and physical activities, both of which were associated with higher episodic memory and executive functioning . this pattern of findings has also been demonstrated when examining socioemotional outcomes. for example, in a nationally representative longitudinal study of germans, informal social activities with friends were associated with better subjective well-being (i.e., higher positive affect, lower negative affect, and higher life satisfaction) in older adults. in contrast, informal social activities with family were only associated with an increase in positive affect and an increase in negative affect in older adults (huxhold et al., 2014) . using experience sampling, a study of older canadian adults found that when older adults reported being in the company of friends, they also reported more positive subjective well-being compared with when they were with family (larson et al., 1986) . this finding may be partly attributable to the types of activities individuals engage in with friends versus family. specifically, when with family members, older adults reported higher engagement in maintenance activities (i.e., housework) and passive leisure activities (i.e., watching television). in contrast, when with friends, older adults reported higher engagement in more active leisure activities such as hobbies, religious/cultural engagement, and sports (larson et al., 1986) . these findings are also consistent with the notion that friendships bolster activity engagement. family ties, in contrast to friendships, may be viewed as more obligatory in nature. family ties are more permanent relationships with less autonomy at selection (dono et al., 1979) and are sometimes seen as a burden (crohan and antonucci, 1989; quan-haase et al., 2017) . despite friendships often being viewed as a better source of companionship, family ties may be a better source of longterm social support which is critical to maintaining one's quality of life in older adulthood. illustratively, a cross-sectional study of older adults found that family members were identified as greater sources of social support (instrumental and emotional) and social control (i.e., efforts to promote healthy and deter risky health behaviors), whereas friends were identified as greater sources of companionship (rook and ituarte, 1999) . in another cross-sectional study, older adults' expectations for assistance (i.e., services and resources) from family exceed expectations from both close and casual friends. older adults were more likely to endorse expectations that family should help with tasks such as providing shelter, money, unsolicited advice or put themselves at risk for the older adult (mancini and simon, 1984) . of note, reported expectations of family and close friends for intimacy (i.e., feelings and emotions) and social integration (i.e., shared experiences, companionship) were similar (mancini and simon, 1984) . examining a group of older women hospitalized for congestive heart failure in the past year, friedman (1993) found that women who reported emotional support from family and women who reported emotional support from both family and nonfamily (i.e., friends/neighbors) had higher positive affect than those who reported support only from nonfamily (friedman, 1993) . similarly, women who reported tangible support from family and women who reported tangible support from both family and nonfamily had greater life satisfaction than those who reported only tangible support from nonfamily (friedman, 1993) . consistent with cantor's (1979) hierarchy of support, friedman suggested that older women who are ill may feel more satisfied with tangible assistance that comes from family, as it aligns with their expectations and norms (i.e., more appropriate to receive this type of help from family rather than nonfamily). family ties may provide more long-term assistance and support to help older adults that may not be seen as appropriate for non-family ties to provide. antonucci (2001) suggested that people develop a support bank, an informal accounting of what is given and what is received over time from individuals specifically and more generally. it may be that the long-term nature of family relationships means that older people feel that they are more entitled to support from family members as they are more likely to have provided support to these same or related individuals in the past. this is consistent with findings indicating that older adults report that major support services such as caretaking are more commonly expected of family relationships relative to other types of social relationships (quan-haase et al., 2017) , and family members represent more appropriate social ties to help with more long-term issues (cantor, 1979) . in sum, the importance of both family and friends relationships across the lifespan for health and quality of life is clear. less clear, however, is the relative importance of friends versus family (i.e., which is more important?). from a developmental and clinical scientist perspective, it seems most likely that both are important and play different roles, especially in late life. much as motherinfant attachment provides the secure base from which infants discover and explore the world, it appears that close family relations provide a secure base for adults as indicated by the fact that they are known to be a comforting source of instrumental as well as emotional support. with regard to peer relations, it appears that older people are more likely to turn to friends for companionship and leisure activities. both types of relationships contribute in important and significant ways to health and quality of life. with age and a more limited future time perspective, sst would predict that people spend more time with close family and begin to limit interactions with friends. the nature of families and the availability of friendships are idiosyncratic and thus likely to vary depending on specific circumstances. overall, family relationships and friendships occur in very different contexts (i.e., friends outside the home, family within the home, etc.) and situations (i.e., for leisure, during health crises, etc.) and may therefore influence later life health through different pathways. although close social relationships with friends and family are important for successful aging, other more peripheral social ties, such as those with fellow church members, neighbors and acquaintances, may also provide beneficial resources in later life. the strength of weak ties as proposed by granovetter (1973) posits that weak ties may provide unique forms of support in times of need. specifically, weak ties can link individuals to resources to which they might not normally have access and may also provide contrasting views and information not available from strong ties (granovetter, 1983) . weak ties may also provide unique types of support that only geographic proximity and shared communities can, such as a neighbor having a spare set of house keys (dono et al., 1979) . indeed, in a longitudinal study following u.s. adults over a 23-year period, although close and weaker ties were both associated with a reduction in depressed affect, the number of weaker social ties was more strongly associated with maintaining a low level of depressed affect over time than the number of close social ties. weaker ties were also more strongly associated with maintaining positive affect over time compared with close ties (huxhold et al., 2020) . although prior research suggests that older adults reduce the number of peripheral social ties (sst & savi), the convoy model outlines different personal and situational characteristics predicting the types of social ties an individual needs. weak ties are likely useful under those personal and situational circumstances that indicate needs not readily met by stronger social ties. while other forms of weak-ties exist, we specifically highlight two that may be particularly relevant for older adults as illustrative examples: church-related ties and neighbors. religious involvement may be an avenue by which the strength of weak ties has a powerful impact on the individual. prior research has linked religious attendance to physical (ferraro and kim, 2014; krause, 2002) and cognitive health outcomes (hill et al., 2006; kraal et al., 2019) . for example, in a longitudinal study investigating religious involvement and c-reactive protein (a biomarker for cardiovascular disease risk and progression), higher religious attendance was associated with less increase in c-reactive protein in black, but not white, older adults (ferraro and kim, 2014) . similarly, in a cross-sectional study of white and black american older adults, individuals who received more church-based social support also reported better health, and these associations were stronger in black older adult participants (krause, 2002) . an investigation of a third us minority group, mexican american older adults, found that those who attended church monthly, weekly and more than weekly showed slower rates of global cognitive decline (mmse) than those who did not attend church (hill et al., 2006) . similarly, kraal et al. (2019) found in another longitudinal study of american older adults that higher religious attendance and more private prayer were associated with better concurrent memory functioning, even after accounting for nonreligious social participation. further, higher religious attendance and private prayer among black and hispanic older adults partially reduced the magnitude of racial and ethnic inequalities in memory, which suggests that religious involvement may be an important protective resource for racial and ethnic minorities . overall, individuals who are part of a church community may reap health benefits through feelings of belongingness or social support from these community members. further, church members may benefit health outcomes through social control, such that church members encourage healthy behaviors and discourage risky health behaviors. for example, in a cross-sectional study examining older samoan women who attended churches in los angeles county, informal, church-based ties increased the likelihood of utilizing preventive health services, including having a recent mammogram and planning to have a future mammogram (levy-storms and wallace, 2003) . consistently, in a study of malawi congregations, unmarried adolescents who were frequently exposed to messages about hiv/aids prevention within their congregations had higher odds of abstinence (trinitapoli, 2009 ). additionally, married individuals were more likely to be faithful in congregations in which leaders monitored sexual behaviors, and individuals were more likely to use a condom in congregations where leaders privately advised members to do so (trinitapoli, 2009) . in summary, fellow-church members and congregational leaders in one's network may be a distinct source of support and increase feelings of community and may, in turn, influence health-related behaviors that have a beneficial effect on health and quality of life. neighborhoods, specifically social relationships with neighbors, may be especially important in later life as older adults spend more time within their homes and communities (horgas et al., 1998; spalt et al., 2016) due to social role shifts (i.e., retirement) and changes in health and mobility. neighborhood social cohesion is often defined as feelings of mutual trust and solidarity among neighbors and the perception that neighbors are willing to do the right thing. prior research has indeed shown that in a nationally representative sample of american older adults, higher perceived social cohesion was linked to better physical health outcomes (i.e., stroke; kim et al., 2013) , and better cognitive outcomes (i.e., verbal fluency; zaheed et al., 2019) . these findings have been replicated in other populations, including among racial and ethnic minorities. for instance, in a cross-sectional study of south asian (india, pakistan, bangladesh, nepal, sri lanka) adults living in the united states, higher social cohesion was associated with lower prevalence of hypertension in women, but not men (lagisetty et al., 2016) . in another cross-sectional investigation, higher perceived social cohesion was associated with better global cognition, better episodic memory, and better executive functioning in chinese older adults living in the united states (zhang et al., 2019) . neighbors may be a unique source of informal support that helps to facilitate aging in place and the maintenance of life quality due to their close physical proximity. it has been argued that neighbors may help with short-term instrumental tasks particularly in times of emergency or as health and safety monitors (i.e., signs of an intruder or accident; dono et al., 1979) . illustratively, older residents of new york city identified neighbors as potential sources of informal social support when family was not available. a majority of the sample reported knowing one or more neighbors well and that these individuals would help each other out for specific tasks. neighbors tend to help out with short-term and/or emergency related tasks such as assistance with shopping when ill or in inclement weather and are readily available to sit or chat, whereas other more long-term tasks were often left up to family (cantor, 1979) . similarly, in a qualitative study examining older adults living in a naturally-occurring retirement community (norc), neighbors were described as being helpful for particular types of tasks, such as cooking, shopping, or transportation, but were thought of as inappropriate for other tasks like financial or personal issues (greenfield, 2016) . overall, neighbors, although often viewed as weak social ties, provide immediate help and compensate for non-available family members. in addition to providing small, short-term instrumental assistance for older adults they may also provide the opportunity for older adults to reciprocate, thus contributing to a feeling of community belongingness. available evidence indicates that different relationship types offer distinct benefits for health and quality of life and, as shown in fig. 2 , may operate through several distinct pathways. specifically, social relations in general may influence health and quality of life by promoting healthy behaviors (i.e., exercise, going to a doctor, etc.), increasing engagement in stimulating activities (i.e., leisure activities, hobbies, etc.), helping to alleviate stress (i.e., emotional and tangible social support), and providing access to novel information and resources. when examining which pathways each relationship type might operate through, prior research suggests that friends may be a greater source of companionship whereas family may be a greater source of long-term social support and care. further, more peripheral network members also bring about health benefits, for example when neighbors and fellow-church members provide short-term support or access to diverse informational resources. early-life social relationships, such as those with parents and peers, may influence emotional, physical, and cognitive health outcomes through social functioning. that is, consistent with attachment theory and the convoy model, early-life social relationships may be foundational and influence the development of subsequent social relationships in adulthood (i.e., romantic relationships, friendships, etc.) but may also directly impact health and quality of life through the development of physiological stress response patterns. still, despite prior research examining the complexities of social relationships and their implications for health and quality of life, further investigation is necessary to fully disentangle these unique associations of each relationship type. first, future research would benefit from greater attention to life course processes. informed by the convoy model, social relationships occur across the lifespan, and early life relationships may be foundational for the development of future social relationships. although retrospective data regarding early life social relationships have been linked to later life outcomes, scarce prospective research has utilized observed mother-child or peer interactions to alleviate concerns about recall bias. second, future research should focus on the underlying pathways in which social relationships may confer health benefits, specifically with regard to distinctions between friends versus family, in order to clarify intervention targets. finally, given differences found in specific ethnic and racial minority groups, the need for more representative samples is necessary to assess whether the same pattern of findings is consistently found across sociodemographic groups and cultural contexts. the structure of families and the expectations of friends versus family may differ depending on cultural norms. the distinct pathways that explain the link between relationship type and health outcomes may, therefore, not be universal. the role that technology plays in facilitating and shaping social relationships has been steadily increasing. technologies, such as emailing, texting and social media, are being used to a greater extent to connect with others and seem to be fundamentally changing how we interact. consistent with this notion, in a u.s. sample of young adults, 3-in-4 individuals reported that mobile devices were either greatly or moderately altering the way they were conducting interpersonal communication with their friends, and a vast majority of the sample reported almost constantly having their devices with them (pettegrew and day, 2015) . further, some evidence suggests that younger individuals may prefer to use technology-mediated communication over in-person social interactions (chung, 2013; pinchot et al., 2011) . although studies examining shifts in the ways in which individuals prefer to communicate have been conducted in predominantly younger adult populations, evidence suggests that older generations are increasingly engaging with these technologies as well. survey research conducted in the united states has shown that the rates of smartphone, internet and social media adoption steadily increased in older adult populations between 2013 and 2017 (duggan et al., 2015; pew research center, 2017) . the pew research center (2017) reported that around 4-in-10 adults aged 65 and older had a smartphone in 2017, which is more than double that of older adults who reported owning a smartphone in 2013. in a qualitative study of older adults in the toronto (canada) locality of east york, a majority of participants owned a smartphone, and over half reported engaging with digital media to connect with friends and family. further, once older adults began using digital media, it became a part of their routine to promote pre-existing relationships, foster companionship, and receive social support (quan-haase et al., 2017) . overall, technology-mediated communication is not only being used by younger generations, but also being adopted by older generations as well. as the impact of offline social relationships on health-related outcomes in later life may vary depending on multiple factors (i.e., relationships source, type of resource, etc.), it is also essential to understand how these shifts in means of communication may influence health and quality of life as individuals age. research examining social technology in older adult populations is still in its infancy, with scarce research examining its impact on health-related outcomes (antonucci et al., 2017) . further, evidence regarding the effects of social technology use are mixed, with some studies showing health benefits (chopik, 2016; dodge et al., 2015; myhre et al., 2017; quinn, 2018) whereas other studies show costs (frein et al., 2013; meshi et al., 2020; soares and storms, 2018) . as several intervention studies have focused on social technology and cognition, we highlight cognition as our illustrative health example in the subsequent sections to discuss the distinct bodies of research that have found cognitive benefits and cognitive costs of engaging with social technology. offline social relationships and interactions have been consistently linked to better cognitive functioning (e.g., cacioppo and cacioppo, 2004; seeman et al., 2011; , however, less is known regarding whether social resources facilitated through technology confer the same benefits. some evidence suggests that social technologies may provide a unique resource for older adults to connect with others and remain socially active and cognitively stimulated. although research is limited, some intervention research has indicated that engaging with social technology may be associated with improvements in cognitive functioning (dodge et al., 2015; myhre et al., 2017; quinn, 2018) . for example, in a 4-week randomized control trial examining social media use and executive functioning, social media novice older adults received instructional sessions about social media use (i.e., setting up accounts, privacy, etiquette, posting, etc.) and were compared with a wait-list control group (quinn, 2018) . the results revealed that instruction in social media use was associated with improvements in inhibitory control (i.e., ability to ignore irrelevant information) after the 4-week period and 4-months later (quinn, 2018) . in another intervention study examining the cognitive effects of learning how to use facebook, older adults received 1 week of instructional classes on how to use facebook and were instructed to subsequently post/comment daily for 7 weeks (myhre et al., 2017) . results revealed that older adults who learned how to use facebook showed significant improvements in updating, a component of executive functioning, compared with wait-list controls and those who were trained to use a private blog as an online diary (myhre et al., 2017) . finally, in a 6-week randomized controlled trial, older adults received daily 30 min face-to-face online communication, relative to the control group that received a weekly telephone interview. results demonstrated that cognitively-intact older adults who received the intervention showed improvements in semantic fluency immediately after the intervention and improvements in phonemic fluency at an 18-week follow-up assessment, relative to the control group (dodge et al., 2015) . these intervention studies indicate that learning how to use social media or engaging in frequent online communication in later life may help to improve some domains of cognitive functioning, such as executive functioning. that is, it may be that engaging in social media is cognitively stimulating in and of itself. it may also be that social media and online communication bolsters social stimulation, which has been linked to better cognitive outcomes. indeed, prior cross-sectional research in a nationally representative sample of american older adults has shown that the use of social technologies in later life was associated with better psychological and physical health outcomes, and these associations were mediated by lower levels of loneliness (chopik, 2016) . in the same cohort of u.s. older adults, internet use has been linked to lower levels of depressive symptoms in older adults (cotten et al., 2012) . of note, an australian study of older adults' internet use hints at the complicated associations between socioemotional outcomes and technology use. in this study, although time spent on the internet was associated with more social loneliness, using the internet as a communication tool was associated with less social loneliness (sum et al., 2008) . additionally, in the same study, internet use to identify new social ties was associated with higher levels of family loneliness, highlighting the complexities of researching social technology and the implications of how individuals use these tools (sum et al., 2008) . although some intervention research suggests there are cognitive benefits to social technology use in older adulthood, other evidence suggests that there may also be negative consequences for cognitive health. for example, in a cross-sectional study of college-aged adults, individuals who were classified as high facebook users (engaging with facebook more than 1 h per day) scored worse on a memory recall task compared with individuals classified as low facebook users (frein et al., 2013) . in an experimental study, college-aged adults were assigned to either passively view a series of paintings, take photographs of the paintings, or use snapchat (a photo-sharing based social media platform) to document their experience of the paintings. individuals who used snapchat during the experiment had lower recall for the visual details of the paintings than those who simply observed or used a camera to take pictures (experiment 1; soares and storm, 2018) . in another experimental study, college-aged adults were instructed to place their silenced smartphones either in another room, their pocket/bag, or on the desk where subsequent tests of cognitive capacity (working memory, fluid intelligence) were administered. the more salient the individual's smartphone (i.e., the closer it was), the more their cognitive capacity was impaired (ward et al., 2017) . further, in another experiment, these same researchers report that whether the phone was silenced or completely powered down did not alter this effect (ward et al., 2017) . much less observational or experimental research has examined the links between social technology and cognition in older adulthood. however, a daily diary study of u.s. adults aged 25 to 75, found that on days when social media use was high, individuals also reported more memory failures that same day and the subsequent day. these findings were not moderated by age, which suggests that social media use was associated with more memory failures regardless of the age of the user . the negative consequences of engaging with social technologies for cognitive functioning may operate through attentional and/ or cognitive offloading pathways. that is, individuals who are using social technologies may have reduced attentional capacity for other stimuli in their environment (soares and storm, 2018) . individuals may also use these technologies to offload information onto external memory sources (risko and gilbert, 2016) such that individuals are relying more on technology to store information that was once previously remembered (i.e., phone numbers, birthdays, etc.). finally, some evidence also suggests that the use of these tools may alter how we process and store information. for instance, in a series of experiments, individuals who believed they would have access to saved information for a recall task tended to have greater memory for where to find the information needed (i.e., the saved folder names) than for the content of the information itself (sparrow et al., 2011) . overall, some evidence suggests that engaging with social technology, such as social media or smartphones in general, can impair cognitive functioning, at least in younger adulthood. less is known regarding whether these same consequences extend into older adulthood, as prior intervention research has found beneficial effects. an important consideration regarding these mixed findings is how older adults are engaging with social technology in intervention studies. specifically, older adults who are novices (i.e., little to no previous experience) are recruited and subsequently instructed to actively use social media over an extended period of time (myhre et al., 2017; quinn, 2018) . prior research has suggested that more active use of social media (i.e., direct messaging, commenting, etc.) is associated with more beneficial outcomes, whereas passive use (i.e., lurking, mostly browsing, etc.) is associated with more detrimental outcomes, at least in regards to socioemotional health (escobar-viera et al., 2018; thorisdottir et al., 2019) . when measuring the ways in which older adults engage with social technologies such as social media, it is important to note that older adults tend to use these resources more passively in everyday life to keep in touch with family and close friends. for example, older adults tend to engage in more family activities, such as viewing relatives' photos (mcandrew and jeong, 2012) , and view these activities as an effective tool for keeping up with the lives of family and friends (i.e., social surveillance; jung et al., 2017) rather than as a platform to post photos and status updates. in a qualitative study, older adults who used social media tended to report being "lurkers" to keep watch over what their friends and family members posted online (yuan et al., 2016) . older adults report privacy concerns as a major issue when using these technologies (jung et al., 2017; xie et al., 2012) , which may impact how actively they use social media. in addition, the costs and/or benefits of social technology use for cognition may be domain-specific, which could help to explain some contrasting findings. for example, prior intervention research has shown stronger positive associations between social technology and executive functioning (e.g., dodge et al., 2015; myhre et al., 2017; quinn, 2018) , whereas other research has shown costs for memory functioning (e.g., frein et al., 2013; soares and storm, 2018) . in summary, evidence regarding whether the use of social technology affects health outcomes in later life is mixed. further investigation is necessary to understand the potential impact of online social interactions for health and quality of life in older adulthood. in particular, future research should first investigate when, why and how older adults engage with these technologies as their preferred means of communication. in line with the social convoy model, personal and situational characteristics of the individual are likely to influence what means of communication are most likely to be used. additionally, an individual's goals and motivation for contact, such as future time perspective, influence the preferred means of communication as may be predicted by socioemotional selectivity theory while the savi model would argue that the goal of regulating emotions and avoiding conflict might predict one means of contact (e.g., distal versus proximal, virtual versus in-person). future research is necessary to understand not only the implications of social technology on health and quality of life in older adulthood, but also how age-related changes in social relations and socioemotional goals may impact the selection and use of these same technologies. how an individual uses social technology may, in turn, have implications for health and quality of life. in line with this notion, whether an older adult uses technology actively versus passively or to facilitate pre-existing offline relationships versus develop new social connections appears to influence the effects of using social technology. another important consideration is that these technologies have only recently become more prevalent in older adult populations, and therefore, current research can only examine short-term implications of social technology use in later life. it is necessary to recognize and understand the long-term implications of use. for instance, it is important to disentangle the effects of growing up technologically embedded on younger generations' socioemotional and cognitive outcomes over the lifespan as well as long-term use of social technologies in older adults after adoption. further, it is important to understand the historical and contextual contexts that may further influence these associations, such as the greater prevalence of using social technology to interact with friends and family in daily life among younger generations. historical events, such as the experience of a pandemic that encourages physical distancing and self-isolation (e.g., covid-19 pandemic), may shift the relative importance of online social interactions. during such periods, online social interactions may thus have a more prominent role in health and quality of life as they become one of the limited ways in which individuals are allowed to interact and communicate with others. additionally, technology is rapidly changing as researchers try to understand the implications of these tools and therefore, the effects of these technologies for health may also change in tandem. technologies such as virtual and augmented reality technologies are becoming commercially available and these tools may have implications for health as well. for instance, in a recent study in which adults 50 and older played an exergame (i.e., physical activity using video games) in an immersive virtual environment (ive) over the course of 4-weeks, the ive group showed better executive functioning compared with the control group (i.e., non-immersive game) (huang, 2020) . thus, it is essential to continually assess whether changes in these technologies influence their effects on health and quality of life. finally, future research should clarify the potential domain-specific pathways that may explain the mixed findings regarding the costs or benefits of social technology in later life. it may be that gains are seen in one domain (i.e., executive functioning) but costs are seen in another (i.e., memory). the literature reviewed above reveals the powerful influences social relations can have on the physical, mental, and cognitive health of older adults. our increasing understanding of the complexities and nuances of social relations and their health impacts have important implications for multiple aspects of clinical practice. these specific insights may be harnessed to improve the clinical assessment and treatment of older adults. with regard to clinical assessment, the growing literature on social relations highlights the value of considering not only individual factors (e.g., age, educational attainment, comorbid health conditions), but also contextual factors, including characteristics of the social network(s) in which an individual is embedded, when assessing risk of mental and cognitive disorders. collecting more detailed information on the structure, function and the quality of an individual's social network can improve clinicians' understanding of risk and resilience. for example, characterizing objective social isolation without also querying the subjective experience of loneliness could result in an over-or under-identification of risk. similarly, cataloging an individual's social ties without also assessing the frequency and quality of interactions is likely to yield an incomplete picture of social resources that can be considered as promising intervention targets. thus, a comprehensive assessment of contextual factors can improve the development of clinical recommendations and treatment planning. with regard to clinical intervention, a more detailed understanding of links between social relations and health can help to reveal the "active ingredients" of social relations, allowing for more targeted interventions. for example, a recent longitudinal study that considered multiple structural aspects of social relations as predictors of cognitive aging found that contact frequency, but not social network size, was associated with slower declines in episodic memory (zahodne et al., 2019a,b,c) . findings such as these may be used to guide the development of interventions by suggesting that increasing the frequency of interaction with existing social network members may be more effective than introducing new network members, especially if contact with those new network members will be limited. similarly, seminal studies on older adults' physical and mental health (antonucci, 2001 ) and more recent studies on cognitive aging have drawn attention to the unique value of diverse social networks containing not only close family members but also more peripheral family members and friends (see review ; fingerman, 2009; zahodne et al., 2019a,b,c; ying et al., in press) . as another example, a more nuanced understanding of the costs and benefits of social strain within particularly salient relationships (e.g., the spousal relationship; birditt and antonucci, 2008) may help clinicians working with individuals and couples modify behaviors and/or interpretations to optimize the emotional and instrumental support derived from a key relationship. additionally, understanding the unique pathways in which different social relationships benefit health may help to clarify intervention targets. for instance, an understanding that friends may promote health through increased shared activities may inform future interventions to bolster friendships through activity/shared interest groups (i.e., art, bird watching, etc.). in line with a changing technological landscape, rapidly evolving research on the mode(s) by which individuals interact with social network members is also highly relevant to the design and implementation of interventions targeting social relations. the benefits of social interaction may differ when it occurs in-person, over the phone, or online. in particular, the role that newer social technologies (e.g., texting, video chats, social media) can play in shaping health outcomes is an active area of research. for example, research on younger adults suggests that active social media use (e.g., posting, commenting) is associated with better mental health, whereas passive social media use (e.g., scrolling, lurking) is associated with worse mental health (escobar-viera et al., 2018) . if findings such as these are extended to older adults, then interventions involving social media should focus on promoting active use rather than just getting older adults online. importantly, reducing the digital divide is necessary to ensure that efficacious interventions involving social technologies are also effective and that all older adults who would benefit from online social interaction have access. indeed, a recent systematic review concluded that various technologies have the potential to reduce social isolation in older adults, but more systematic trials are needed (khosravi et al., 2016) . in conclusion, the examination of social relations and health has made significant advances from early, small, qualitative studies to large quantitative studies. social relations encompass a complex and dynamic set of characteristics that may have distinct effects on health and quality of life in older adulthood. informed by the social convoy model, identifying the specific aspects of social relations (i.e., structure, function, quality) as well as detailing personal and situational characteristics (i.e., age, race, ethnicity, gender, etc.) may help to clarify how social relations specifically influence the individual. further, taking a life course perspective, it is important to understand the role of age-related gains and losses that may influence changes in social relationships in later life. socioemotional selectivity theory highlights the importance of motivational goals on social partner selection such that perceptions of time left may influence changes in social network size and composition. the strength and vulnerability integration model further exemplifies these points by highlighting that age-related vulnerabilities may impact social partner selection as well as how older adults cope with potential social stressors (i.e., avoidance or disengagement from negative social interactions). an understanding of the who, what, why and how of social relations helps to clarify the potential protective and/or harmful effects of each dimension of social relations on later life outcomes. specific social resources (i.e., social network size vs. loneliness), relationship types (i.e., friends vs. family), and means of communication (i.e., online vs. 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biopsychosocial effects of retrospective childhood social support and later-life cognition neighborhood social cohesion and cognitive function in u.s. chinese older adults: findings from the pine study loneliness and cognitive function in older adults: findings from the chinese longitudinal healthy longevity survey key: cord-283779-mudwcypl authors: lauretani, fulvio; ravazzoni, giulia; roberti, maria federica; longobucco, yari; adorni, elisa; grossi, margherita; de iorio, aurelio; la porta, umberto; fazio, chiara; gallini, elena; federici, raffaele; salvi, marco; ciarrocchi, erika; rossi, francesca; bergamin, marina; bussolati, giacomo; grieco, ilaria; broccoli, federica; zucchini, irene; ielo, giuseppe; morganti, simonetta; artoni, andrea; arisi, arianna; tagliaferri, sara; maggio, marcello title: assessment and treatment of older individuals with covid-19 multi-system disease: clinical and ethical implications date: 2020-05-11 journal: acta biomed doi: 10.23750/abm.v91i2.9629 sha: doc_id: 283779 cord_uid: mudwcypl covid-19 infection is a multisystem disease more frequent in older individuals, especially in those with multiple chronic diseases. this multimorbid and frail population requires attention and a personalized comprehensive assessment in order to avoid the occurrence of adverse outcomes. as other diseases, the covid-19 presentation in older patients is often atypical with less severe and unspecific symptoms. these subjects both at home and during hospitalization suffer isolation and the lack of support of caregivers. the geriatric care in covid-19 wards is often missing. the application of additional instruments would be necessary to facilitate and personalize the clinical approach, not only based on diseases but also on functional status. this narrative review starts from diagnostic evaluation, continues with adapted pharmacologic treatment and ends with the recovery phase targeting the nutrition and physical exercise. we developed a check-list of respiratory, gastro-intestinal and other less-specific symptoms, summarized in a table and easily to be filled-up by patients, nurses and general practitioners. as second step, we reported the clinical phases of this disease. far to be considered just viral infective and respiratory, this disease is also an inflammatory and thrombotic condition with frequent bacterial over-infection. we finally considered timing and selection of treatment, which depend on the disease phase, co-administration of other drugs and require the monitoring of renal, liver and cardiac function. this underlines the role of age not just as a limitation, but also an opportunity to increase the quality and the appropriateness of multidisciplinary and multidimensional intervention in this population. (www.actabiomedica.it) these countries differ in terms of percentages of population over 65, the most afflicted by infection, with italy reaching 23%. italy for instance has higher life expectancy than the majority of countries affected by covid-19 infection (83.4 overall vs 76.7 in china) (2) . these demographic differences could also explain the different outcomes between countries. italy has one of the highest covid-19 mortality (26,644 deaths) and case-fatality rate (7.2%), much higher than china (2.3%). interestingly, the case-fatality rate in italy and china are very similar for age-groups 0 to 69 years, but rates are higher in italy especially among those aged 80 years or older (52% of deaths and 20% of case fatality rate). this difference can be at least partially explained by the higher number of people aged 80 years or older (n=11563), age group having a very high fatality rate (22.7%) and not reported in china (2) . gender issue has been raised by scientists and epidemiologists with men experiencing higher prevalence (64.2 % in the last italian report) and severity (they die more and at earlier age) of covid-19 infection than women. many hypotheses have been formulated to explain this difference between two sexes. cov-id-19 virus can be localized in the testes, which are potential target of sars-cov-2 infection, and one of the reasons for the rapidly spreading disease. moreover, testosterone, the male hormone, has been shown to upregulate the expression of transmembrane protease, serine 2 (tmrpss2) which is an enzyme involved in the penetration of virus in the lung cells. age is accompanied by changes in immune competence and a higher prevalence of inflammation, socalled "inflammaging" (3) . the chronic increase in inflammatory cytokines, augmented by covid-19 infection, may explain the higher tendency for "the cascade leading to pulmonary fibrosis and insufficiency and activation of clotting" and poorer clinical prognosis, especially in multimorbid older persons (4) . multimorbidity defined by the concomitant presence of two or more chronic diseases, is highly prevalent in older persons, affecting more than 60% of people aged 65+ (5) . data collected in 21.551 sars-cov-2 italian patients who died from covid19 show that the mean number of diseases is 3.2 (median sd 3 ±1.9). seventy patients (3.7 % of sample) had no diseases, 273 (14.4%) 1 disease, 400 (21.2%) 2 diseases, and 1147 (68.7%) 3 or more (2) . cardio-renalrespiratory (heart failure, atrial fibrillation, chronic renal failure, copd), metabolic diseases (obesity and type 2 diabetes), active cancer during the last 5 years and dementia seem to be the clusters more associated with adverse clinical outcomes. as a consequence of multimorbidity, polypharmacy defined as the number of drugs reported at hospital admission and the potential drug-drug interactions require a careful evaluation in older covid-19 patients. the combination of antiviral and anti-inflammatory drugs (never tested before in these individuals) and the concomitant treatment for other chronic diseases, especially in subjects with smoking exposition or sarcopenic obesity, increase the risk of adverse drug effects. diarrhea, dehydration, acute kidney insufficiency and liver failure can frequently occur and need to be monitored (6) . diseases, drugs and the primum movens cov-id-19 are also associated with hyperactive delirium, especially in hospitalized patients with preexisting dementia and cognitive impairment (7) . this syndrome requires a multidisciplinary evaluation balancing cost/effectiveness of therapeutic treatment (sedation or precipitation of respiratory and cardiac failure) and opens a large window of ethical issues, especially in older patients (8) . as suggested by nice rapid guideline and the canadian frailty network, the assessment of all adults for frailty, irrespective of age and covid-19 status, is highly recommended especially at hospital admission (6) . as already reported for other diseases, the cov-id-19 clinical presentation in older patients is often atypical with less severe symptoms. these subjects both at home and during hospitalization also suffer the isolation and the lack of fundamental support of formal and informal caregivers required for their safety (9) . despite the peculiar aspects of older patients and the epidemiology of the phenomenon, the geriatric culture and care in covid-19 wards is often missing. their application together with additional instruments would be such necessary to facilitate and personalize the clinical approach, not only based on number of diseases but also on functional status of older patient (10) . this narrative review has the specific aim to address different aspects of covid-19 multi-system disease starting from diagnostic evaluation, continuing with innovative classification of phases and proposing sequential adapted pharmacological treatment. the document wants also focus on the recovery phase and ethical considerations regarding the risk of limited access of care and accelerated exitus in this vulnerable age-category. the most common symptoms of covid-19 disease in the adults are represented in table 1 . this table describes a check-list of more frequent symptoms in adults and would be a guide to orient patients and primary care physicians in assessing older patients with suspected covid-19 infection. the range of symptoms is similar for covid-19 and influenza infection, although the fraction with severe disease is different. for covid-19, actual data suggest that 80% of infections are mild or asymptomatic, 15% are severe infections, requiring oxygen and 5% are critical infections, requiring ventilation. these fractions of severe and critical infection would be higher than influenza infection (11, 12) . symptoms can be traditionally classified into two main groups, including respiratory and gastro-intestinal, and a third group of less organ specific. the quality and severity of symptoms can be different in older persons. the most common symptoms are fever (98%), cough (77%), dyspnea (63.5%) and muscle/joint soreness (13) . the rationale of symptoms distribution across organs is partially explained by the concentration of angiotensin-converting enzyme 2 (ace-2) virus receptors, which is particularly higher in the lung and lower in the gut. this can explain why less common symptoms include abdominal pain, vomiting and diarrhea and virus might be detected in stool samples although gastro-intestinal transmission remains to be demonstrated (14) . it has been also hypothesized that covid-19 virus can also alter central nervous system directly or alternatively disrupt the gut-barrier permeability and induces the gut-brain link via vagus nerve. this justifies the reduced sense of taste and smell, headache, dizziness and vertigo also observed in covid-19 patients (15) . elderly patients, especially with multiple chronic conditions, display less severe and atypical symptoms. the presence of mild symptoms is disproportionate to the severity of their illness (16) . they might be afebrile, without cough or sputum production, and show higher prevalence of muscle-joint pain, tachypnea, altered mental status or delirium, unexplained tachycardia and decrease in blood pressure (17) . atypical presentation may be due to several factors, including physiologic changes with age, comorbidities, and inability to provide an accurate history given the constant lack of caregivers during covid-19 hospitalization (18) . despite the presence of less severe and atypical symptoms, older patients have a significantly higher mortality. as nicely shown in an elegant retrospective study male sex, time from disease onset to hospitalization, abnormal kidney function, and elevated procalcitonin levels were all significant predictors of increased mortality (14) . swab and or lung ct scan. the diagnosis of covid-19 requires the combination of swab and radiologic features. the algorithm initially considers a swab performed with sterile cotton wool suitably rolled around the end of a glass or metal rod, and intended to be swiped on the surface of a natural pharynx and nose cavity. the main nasal swab tests examine the nasopharynx, where the back of the nose meets the top of the throat. this requires a trained hand to perform and some portion of the false negatives arises from improper procedures and poor compliance especially in older adults with acute confusion state (19) . the pharyngeal and nasal swab, once carried out (in some centers not even getting out of the car but with the prior authorization and appointment of the public health office of the local healthcare companies) is sent to an authorized laboratory where the presence of viral rna or genetic material of the virus is appreciated. in case of positivity, there is the certification that the subject has a covid-19 infection. but even if done correctly, the swab may produce a negative result. that is because as the disease progresses, the virus passes from the upper to the lower respiratory system. importantly, the swab test has a sensitivity of 60-70% and strictly depends on the timing of assessment. this means that in 30-40% of cases, even in the case of a negative buffer, the presence of the virus cannot be excluded. in these cases, the patient may be asked to try to cough up sputum -mucus from the lower lungs -or doctors may need to take a sample more invasively when a patient is under sedation. radiological findings are useful complements in the diagnosis covid-19 and in the management of one of its most common complications, pneumonia. the most common computed tomography (ct) findings of the covid-19 pneumonia are ground glass and/or consolidation, and mainly reflect the diffuse and bilateral alveolar damage and/or organizing interstitial pneumonia. it has also been reported a strong correlation between the severity of ct pulmonary findings and patients' outcome. hence, it has been suggested that chest ct could be used as a reliable diagnostic test in the emergency workup of covid-19, complementing pcr. a further confirmation of the covid-19 infection comes from a chest x-ray or even better from a high-resolution chest ct scan (hrct) which highlights the percentage of lungs and the number of lung lobes affected by the virus. the radiologist, using specific software, processes a visual score or score in percentage. the higher the visual score the greater the severity of the lung involvement of virus. visual scores at the time of admission to the hospital of more than 70% are usually associated with a bad prognosis and more than 50% identify a severe disease. another parameter assessed through the ct scan is the number of lung lobes affected by the infection, which can vary from 0/5 to 5/5. also in this case, the greater the number of lung lobes involved, the greater the severity of the ongoing lung involvement of virus. the diagnostic process is the first step of clinical assessment of the patient. interestingly the initial hypothesis that the covid-19 is just an infectious disease has been gradually abandoned. an intriguing recent theory suggests that there are different phases in the same disease ( figure 1 ). the viral disease is limited to phase 1, where an early infection (8 days of duration) predominates and the host fights to solve the infection. however, if the attempt fails, the activation of an exaggerated response is capable to damage different tissues and organs (kidney, liver, myocardium, brain). another interesting theory suggests an early endothelial cell damage induced by covid-19 as common mechanism of vascular impairment across different organs (20) . three other phases (mainly depicting the host response to virus) are even more important for the clinical course and the outcomes of the patients. more effective will be the host response to virus, more chances the individuals have to survive. together with clinical evaluation (for instance peripheral capillary oxygen saturation), the functional assessment should also guide clinicians in the admission to intensive care unit (icu), in selecting therapeutic choices, and in predicting clinical and functional responses. both uk and canadian frameworks suggest the usefulness of easy to use instruments such as the clinical frailty scale to assess frailty (10) . other additional tests include chair stand test (cst) which is one of the best and validated physical performance tests for older people, and it is reported to be associated with muscle strength of the lower leg. the cst is a simple and feasible physical performance test, even for evaluating older people with limited mobility. then, many representative cohort studies have demonstrated that the cst is a predictor of disability and falls in older people (21) . (figure 1 and table 2 ) phase 1. infectious-virological phase or early infection phase 1 (max duration 8 days). the virus is present in the upper airways and digestive tract and usually induces specific symptoms (dry cough, fever, fatigue with normal peripheral oxygen saturation, diarrhea, headache, conjunctivitis) in the adult individuals (13) . the body response produces immune (igm in phase 1, viral response predominates and respiratory and gastrointestinal symptoms can be treated at home with hydroxychloroquine and antivirals. in phase 2: pulmonary, fever and dyspnea worsen and rapid diagnosis by ct and hospitalization is required. in phase 3, pulmonary and hyperinflammatory, clinically represented by ards, corticosteroids and il-6 receptor antagonists should be started in sub-intensive wards. in phase 4, thrombotic, anticoagulant therapy should be introduced and admission to icu indicated. there is a transverse phase: bacterial over infection, typically characterized by high fever, increased white blood cells and procalcitonin, where broad-spectrum antibiotic therapy is the choice treatment. legend of figure . both responses, especially if supported by appropriate pharmacological treatment, translate into an infective resolution in 80% of cases. the different response in older patients and in different categories (fit, frail, disable) is an interesting topic to be investigated (12) . the phase 1 treatment includes drugs with mixed anti-viral and anti-inflammatory activity (hydroxychloroquine) and antibacterial drug with minimal anti-viral action (azithromycin) (14, 17) . these drugs act synergistically on heart rhythm and require, because of the frequent concomitant use and especially in subjects with previous cardiac disease, electrocardiogram (ekg) trace to monitor qtc interval (22) . low molecular weight heparin, in the presence of good renal and liver function, at prophylaxis doses is also suggested (23) . in older patients, these specific aspects require additional and careful evaluation given the inadequate formulas currently used to assess for instance renal function (24) . in about 80% of cases, the disease ends at this stage and can be managed at home. however, the onset and persistence of symptoms within 2-3 days requires an immediate communication to primary care physician (or general practitioner) for a timely diagnosis and therapy. pharmacological treatment must be accompanied by the adoption of home behavioral measures in order to avoid contagion of the other family members. if the fever is persistently higher ≥38°c, especially for more than 3-4 days, or if peripheral oxygen saturation drops below 95% and/or dyspnea increases, we should suspect an exaggerated inflammatory response and the extension to the lung and recommend the hospitalization. the typical serum biomarker picture of this phase could be represented by low wbc, crp and d-dimer mildly increased, normal troponin i hs levels ( table 2) . this phase usually occurs after 10 days on average from the onset of symptoms in which the virus migrates to the lower respiratory tract lung. characterizing symptoms lasting 5 days or longer, range from shortness of breath to severe dyspnea and fatigue. this phase can be characterized by low peripheral oxygen saturation (spo2 <95%). endothelial and initial cardiac damage are also possible (25) . at this stage, hospitalization in semi-intensive wards could be necessary. acute confusional state in older persons is frequently observed and sedative and palliative treatment are important and detrimental confounders. men experience more clinical complications than women. this different exposure can be explained by higher expression pattern of ace2 receptors in adult human testes at the level of single-cell transcriptome suggesting that this organ is a potential target of sars-cov-2 infection, and one of the reasons for the rapidly spreading disease (26) . the typical serum biomarker picture of this phase could be represented by normal wbc, further increase in crp and d-dimer levels, troponin i hs levels that require to be monitored for the potential involvement of myocardium and pericardium ( table 2) . phase 3. pulmonary-hyper-inflammatory phase 3, which is characterized by systemic symptoms with multi-organ involvement (ards sirs/ shock cardiac failure) (27, 28) . individualized treatment in this phase is required, considering for example corticosteroids (methylprednisolone 1 mg/kg/day or dexamethasone at 20 mg/day intravenously), human immunoglobulin, inhibitors of the il-6, il-2, and jak2 receptor. this phase requires hospitalization in icus or respiratory intensive care unit (29) . the typical biomarker picture of this phase could reproduce phase 2 ( table 2) . phase 4. vasculitic-thrombotic phase 4 (coexisting or immediately following the previous phase) consists of endothelial damage, local and diffuse thrombotic phenomena and pulmonary hypertension (30) . there is the rationale, especially in this phase, to support, at high dosages, and based on weight and renal function, the use of enoxaparin, very known also for its antiviral activity (31, 32) . the presence of pulmonary hypertension suggests also the potential usefulness of phosphodiesterase inhibitors releasing nitric oxide such as sildenafil (33) . the typical serum biomarker picture of this phase could be represented by normal wbc, very-high levels of d-dimer and troponin i hs levels that require to be monitored for the potential occurrence of thrombotic events in different organs ( table 2) . the separation of different phases of disease contributes to delineate a specific timing for starting appropriate pharmacological treatment and establishing setting (home and hospital wards) at increased intensity of care. in case of persistent fever, higher than 37.5°c for a time longer than 3 days and peripheral oxygen level lower than 95% after starting therapy, we should consider and proceed to hospitalization especially in multimorbid older patients with cardiac, respiratory diseases and diabetes. the use of antivirals is poorly supported by randomized controlled clinical trials performed only in adult patients (34) and should be limited to the initial phase of the disease. antivirals are poorly indicated during phase 2 (35), and not indicated at all during phases 3 and 4. vice-versa, the anti-inflammatory-immunosuppressive therapy, are contraindicated during phases 1 and 2 in which the organism/host is elaborating or implementing its defensive strategy. corticosteroids and other anti-inflammatory medications should be also carriedout, once having careful evaluated specific contraindications, during phases 3 and 4, where the combination anti-inflammatory/ anticoagulant therapy is suggested in case of significant increase of d-dimer and/or positive pulmonary ct with contrast. late phases are usually characterized by exaggerated phase response of the host which is harmful to the host and needs to be attenuated (28, 36) . this might be particularly detrimental in older patients where a chronic inflammatory status is often present. every single phase of the pathology is also influenced by the undergoing pharmacological treatment and related side effects. drug-drug interaction deserves particular attention especially in older persons with polypharmacy. all these medications may induce gastro-intestinal symptoms (especially diarrhea) and worsen kidney and liver function. the ekg at the basal entry should be carried out on regular basis to monitor the qtc interval and to exclude the potential myocardial and pericardial damage induced by the infectious process. treatment in this phase, usually lasting about 7-8 days, consists of drugs with anti-inflammatory activities. these drugs, such as chloroquine or hydroxychloroquine should be started as soon as possible (37) . however, their utilization is actually based on in vitro data (38, 39) and single open label non-randomized trial conducted in 36 patients with covid-19 (40) . antiviral drugs derive their use from trials verifying their effective treatment of other viruses including sars (severe acute respiratory syndrome-related coronavirus) and mers (middle east respiratory syndrome coronavirus). in particular, preliminary genomic studies on 2019-ncov showed that the sequence has similarities with the corresponding sars and mers enzymes, and this justifies why repurposing exiting sars and mers inhibitors for 2019-ncov (14) . although the use of many anti-viral drugs has been proposed, particular attention received lopinavir/ ritonavir and remdesivir. the first antiviral drug, lopinavir/ritonavir, has specific indication for treat hiv and was also utilized in the 2003 for sars. convincing evidence of its therapeutic effects on covid-19 is lacking. moreover, a recent randomized clinical trial found no different clinical effect compared to standard care on 2019-ncov infection. only in the modified intention-to-treat analysis, which excluded three pa-tients with early death, the between-group difference in the median time to clinical improvement (median, 15 days vs. 16 days) was significant, albeit modest (34) . another virally targeted agent is the remdesivir, a very promising drug, which is a drug currently being investigated as a potential covid-19 treatment through several clinical trials. in details, two phase iii randomized, placebo-controlled double-blind, multicenter trials were initiated in early february to investigate remdesivir in two different dosages 200 mg/day and 100 mg/day for 9 days with estimated complete results at the end of april 2020 (41) . finally, the favipiravir, an antiviral drug manufactured by japanese pharmaceutical company fujifilm toyama chemical, was approved for treatment of novel influenza on february 15, 2020 in china, and clinical trials testing this medication are undergoing. preliminary data from 80 patients indicated that favipiravir had more potent antiviral effect than lopinavir/ ritonavir and even with lower side-effects (42) . however, given that no current definitive specific treatment for covid-19 infection has been proved based on randomized clinical trial, who has now launched the solidarity trial to investigate four potential treatments: remdesivir, chloroquine/hydroxychloroquine; lopinavir and ritonavir; and lopinavir and ritonavir plus interferon-β. 1 the only limitation of this study is that will not be double blind, but it will include thousands of patients from several countries (43) . this phase normally is associated in the adults with the presence of persistent high fever. this symptom often requires admission to emergency department and hospitalization for the execution of pulmonary ct scan. this technique is the gold standard for the diagnosis of typical interstitial pneumonia. the most important observation of this infection phase is the rapid progression into pulmonary impairment with a rapid worsening hypoxia. therefore, patients who failed to standard oxygen therapy required an advanced oxygen/ventilatory. patients may also have increased work of breathing, demanding positive pressure breathing assistance, which could be guaranteed by non-invasive ventila-tion (including continuous positive airway pressure [cpap] or bi-level positive airway pressure [bipap]) in patients with hypoxemic respiratory failure. prone ventilation in patients with persistent severe hypoxic failure should be considered. finally, patients who are acutely deteriorating undergo intubation and mechanical ventilation. two thirds of patients who required critical care in the uk had mechanical ventilation within 24 hours of admission (44) . in this phase, the presence of elevated serum levels of inflammatory cytokines, such as il-6 could induce pulmonary damage or proliferative pulmonary phase. il-6 receptor antagonists (e.g., tocilizumab, sarilumab, siltuximab) can be used. in particular, the tocilizumab which is a monoclonal antibody that blocks the il-6 signalling pathway is currently used to treat rheumatoid arthritis. however, given the limited evidence on the safety or efficacy of the drug in clinical treatment of covid-19, the fda launched through a double blind, a randomised phase iii clinical trial as a treatment for severe covid-19 pneumonia with tocilizumab in combination with standard of care (44) . acute respiratory distress syndrome (ards) is an acute, diffuse, inflammatory form of lung injury related with high mortality. diagnostic criteria (berlin definition 2012) include non-cardiogenic respiratory failure, with respiratory symptoms, bilateral opacities on ct scan and presence of a moderate to severe impairment of oxygenation (45, 46) . the pao2/fio2 defines the severity of the ards (calculated data with a positive end-expiratory pressure (peep) or continuous positive airway pressure (cpap) ≥5 cm h2o) in the absence of cardiac failure or fluid overload. • mild ards -pao2/fio2 is >200 mmhg, but ≤300 mmhg. • moderate ards -pao2/fio2 is >100 mmhg, but ≤200 mmhg. • severe ards -the pao2/fio2 is ≤100 mmhg (47) . excessive inflammatory response is an essential characteristic of ards pathophysiology, with an increase of interleukin-1 beta (il-1β), interleukin-2 (il-2), il-6, interleukin-17 (il-17), interleukin-8 (il-8), tumor necrosis factor-α (tnf-α) and c-c motif chemokine ligand 2 (ccl2) (48) . it is known that in patients with ards, elevated plasma il-6 at baseline predict a poor survival (28) . also in covid-19 patients, higher il-6 levels are associated with an increased risk of hospitalization and other negative outcomes (49) . at this stage of the disease, patients typically show dyspnea, tachypnea, fever and tachycardia. they can also show severe, acute confusion (especially in older persons), respiratory distress and cyanosis. as lung dysfunction progresses, it is necessary to increase oxygen-therapy until non-invasive mechanical ventilation is required (50, 51) . the use of corticosteroids could be beneficial to modulate the excessive immune response, but their use is controversial. a recent study shows that the use of corticosteroids in ards reduced all-cause mortality and duration of mechanical ventilation, and increased ventilator-free days (52) . in this regard, we hypothesized that patients already taking corticosteroids for other diseases, such asthma, pulmonary fibrosis, rheumatologic diseases and without indication for bacterial over-infections, can take advantage from adequate dosages of corticosteroids. however, future clinical trials are required to verify these aspects. in this phase, convalescent plasma from patients who have recovered from viral infections can be used as a treatment. clinical trials to determine the safety and efficacy of convalescent plasma that contains antibodies to sars-cov-2 in patients with covid-19 have started. a small preliminary case-series of five critically ill patients reported clinical improvement after convalescent plasma transfusions (53) . another study of 10 patients with severe illness in china noted symptomatic improvement within 3 days. viral load was undetectable within 7 days in 70% of patients. no serious adverse reaction was noted. covid-19 and ards can evolve into thrombotic phenomena. prolonged inflammation is responsible for a pro-coagulation state, with activation of the endothelial vasoconstrictors and formation of lung micro thrombi, also found during autoptic examination (52, 54, 55) . intriguingly, sars-cov-2 can directly infect engineered human blood vessel organoids in vitro. very recent case-series in patients with cov-id-19 have demonstrated an endothelial cell involvement across vascular beds of different organs especially in those with preexisting thrombotic disease (32, 56) . for all these reasons, a vasculitic/thrombotic phase can be hypothesized during covid ards. clinically, episodes of intense dyspnea and respiratory distress may occur. fever can be resolved. the pro-coagulant state is characterized by an increase in the d-dimer, which must therefore be regularly analyzed (28) . in details, if d-dimer level, normally performed every three days, increase more than 6 times from admission to later check, this parameter represents a good index for identifying high-risk groups of venous thromboembolism and anticoagulant treatment, if not contraindicated, should be prescribed (57) . respiratory distress syndrome (ards) is a common complication of covid-19 infection. ozoline and colleagues demonstrated that in patients with ards higher plasma concentrations of tissue factor and plasminogen activator inhibitor-1 were present at day seven compared to non-ards (58) . the mechanisms contributing to this lung coagulopathy are localized tissue factor-mediated thrombin generation, and depression of bronchoalveolar plasminogen activator-mediated fibrinolysis, mediated by the pai-1 increase (59) . thus, treatment with heparin might be helpful in mitigating this pulmonary coagulopathy. moreover, adjunctive treatment with low-molecular-weight heparin (lmwh) within the initial seven-day onset of ards reduces the risk of 7-day mortality by 48% with a meaningful improvement of the pao2/fio2 ratio (31) . in the same study, the risk of 28-day mortality was reduced by 37% as well. in a report from a wuhan university hospital, heparin use was associated with lower mortality in patients with sepsis-induced-coagulopathy (sic) score ≥4 (40.0% vs 64.2%, p=0.029), but not in those with sic score <4 (29.0% vs 22.6%, p=0.419). in the same report patients with d-dimer > 3.0 ug/ml experienced a 20% mortality reduction after heparin treatment (32.8% vs 52.4%, p=0.017) (57) . another fascinating concept is the antiviral role of heparin which has been studied in experimental models. given its polyanionic nature, heparin can bind to several proteins and thus act as effective inhibitors of viral attachment (60). one example is in herpes simplex virus infections. heparin competes with the virus for host cell surface glycoproteins inhibiting the virus entrance in the cells. also, in zika virus infection, it prevents virus-induced cell death (61) . finally, the use of heparin at a concentration of 100 μg/ml halved the infection in an experimental model of cells injected with sputum from a patient with sars-associated cov pneumonia (62) . however, the clinical benefits in any of these viral infections are yet to be determined. moreover, heparin may also be helpful in microvascular dysfunction and this is of importance given the well-known role of endothelial dysfunction in the cardiac failure, another increasingly recognized complication of covid-19. finally, a recent document of the italian national drugs agency (63) advices to consider the use of lmwh in serious cases of covid-19 (defined by the presence of one of the following conditions: pao2/fio2 < 300, respiratory rate > 30/min and spo2< 93% at rest) when the d-dimer is markedly increased (4-6 fold) and the sic score is > 4 ( table 2 ) and myocardial infarction or other thrombotic events cannot be excluded. however, high rate of high incidence of venous thromboembolic events may occur in severe covid-19 patients, irrespective of anticoagulation (64) . all previous phases of the covid-infection can be complicated by the presence of bacterial over-infection. this condition should be suspected when specific serum biomarkers such as wbc and procalcitonin are pathologically elevated (table 2) (65) . in this case, specific antibiotic therapy should be promptly prescribed, even in accordance with suggested guidelines (66) . polypharmacy is one of the main characteristics in older subjects. there is an increased risk of adverse events in this specific age-group. although there are no food and drug administration (fda)-approved drugs to prevent or treat covid-19, nevertheless pre-liminary clinical research, based on in vitro-data, have suggested the use of pharmacologic agents as chloroquine or hydroxychloroquine, azithromycin, lopinavir/ritonavir and other anti-retrovirals (67) . some of these drugs may increase risk of qt prolongation, ventricular proarrhythmia and sudden cardiac death. some of the current covid-19 repurposed drugs have known risk of us food and drug administration adverse event reporting system (faers), long qt syndrome and torsade de points (tdp) and cardiac arrest for azithromycin, and hydroxychloroquine, and possible risk for lopinavir/ritonavir. in the prevention of qtc-prolongation, special attention should go to high-risk patients. age is one of the main determinants of this risk score which has been derived and validated by tisdale et al. (68) , for prediction of drug-associated qt prolongation among cardiac-care-unit-hospitalized patients. the application of this scale identifies maximum risk score of 21 and three different classes of risk, low (score ≤ 6 points), moderate (7-10 points) and high (≥ 11 points) ( table 3 ) (69) . the goal of qtc screening in this setting is not to identify patients whom are not candidates for therapy, but to identify those who are at increased risk for tdp in order that aggressive countermeasures may be implemented. 1. baseline a. discontinue and avoid all other non-critical qt prolonging agents. b. assess a baseline ecg, renal function, hepatic function, serum potassium and serum magnesium. c. when possible, have an experienced cardiologist/ electrophysiologist measure qtc, and seek pharmacist input in the setting of acute renal or hepatic failure. 2. relative contraindications (subject to modification based on potential benefits of therapy) a. history of long qt syndrome, or b. baseline qtc >500 msec (or >530-550 msec in patients with qrs greater than >120 msec) 3. ongoing monitoring, dose adjustment and drug discontinuation a. place on telemetry prior to start of therapy. b. monitor and optimize serum potassium daily. c. acquire an ecg 2-3 hours after the second dose of hydroxychloroquine, and daily thereafter. d. if qtc increases by >60 msec or absolute qtc >500 msec (or >530-550 msec if qrs >120 msec), discontinue azithromycin (if used) and/ or reduce dose of hydroxychloroquine and repeat ecg daily. e. if qtc remains increased >60 msec and/or absolute qtc >500 msec (or >530-550 msec if qrs >120 msec), reevaluate the risk/benefit of ongoing therapy, consider consultation with an electrophysiologist, and consider discontinuation of hydroxychloroquine (70) . during covid-19 infection adult and older patients may also experience a higher incidence of gastrointestinal symptoms including diarrhea. the ongoing treatment with antivirals and anti-inflammatory could worsen this symptomatology, increasing potassium and magnesium deficiency and amplifying the risk already described of cardiac events and arrhythmia. in older patients it is widely observed the chronic, not always appropriate, use of proton pump inhibitors (ppi). one year ppi treatment has been associated with increased risk of all-cause mortality (71) . authors suggest that magnesium deficiency, clostridium difficile infection and intestinal colonization with multidrug-resistant microorganisms might justify the link between inappropriate use of ppi and mortality (72) (73) (74) . interestingly their chronic use has been associated with malnutrition and functional decline (75, 76) , two main aspects to be assessed and monitored in older patients with covid-19 infection. older age and the presence of multimorbidity are almost invariably associated with impaired nutritional status and sarcopenia (77) . some studies have demonstrated that hospitalization and associated bed rest even for short time-period (20 days) promote detrimental reduction in muscle mass, strength and physical function, with altered aerobic exercise capacity (78, 79) . covid-19 also amplifies these symptoms if we consider that muscle pain and fatigue are frequent symptoms also in older persons. the bed rest and high inflammatory and hypercatabolic status following covid-19 infection can promote a further reduction in walking speed, stair ascent power and chair stand test. these functional parameters, as well as the loss of strength, may compromise the recovery of functional skills in the elderly and induce the loss of autonomy. although albumin and prealbumin circulating levels should not be considered as nutritional markers in patients with acute inflammatory response, studies have shown an association between low prealbumin levels and increased risk of respiratory failure with increased need for mechanical ventilation (80) . all infected patients at hospital admission, especially those at nutritional risk should undergo nutritional assessment and receive nutritional support as early as possible. there is evidence that nutritional derangements should be systematically and urgently managed in patients affected by covid-19, also considering that the immune response is weakened by inadequate nutrition. nutritional intervention should be complementary to pharmacological treatment and the presence of a standardized protocol would be extremely helpful. for example, in italy, a nutritional protocol has been developed and proposed by university of milan and pavia in lumbardy which is one of the main italian regions affected by the italian covid-19 crisis (81) . this is based on systematic supplementation of certain nutrients (e.g. vit. d, whey proteins and omega 3 fatty acids) with anabolic and anti-inflammatory activity, oligo-elements stimulating immune system and particularly indicated in this high systemic inflammaheart failure 3 one qtc-prolonging drug 3 * a cut-off ≥ 7 can be used to assess moderate-severe risk. modified by reference 69. tory and catabolic condition. obesity can be considered a specific type of malnutrition, where the excess of macronutrients intake could also be accompanied by micronutrients deficiency (82) . the centers for disease control and prevention considers those with bmi ≥ 40 kg/m 2 as being at risk for flu complications. during the 2009 h1n1 pandemic, obesity was recognized as an independent risk factor for complications from influenza (80) . it is now well accepted that obesity increases one's risk of being hospitalized with, and dying from, an influenza virus infection, and it can be considered a predictor for poor outcome during covid-19 infections (83) . it has been reported that the presence of obesity in a group of metabolic associated fatty liver disease (mafld) patients was associated with a ~ 6-fold increased risk of severe covid-19 illness (unadjusted-or 5.77, 95% ci 1.19-27.91, p=.029). given the high prevalence of obesity and overweight in european countries (30-70%), the challenge for virus pandemics is therefore to protect these subjects (84) . although the effects of covid-19 on patients with obesity have not yet been well-described, it is well known the impact of h1n1 influenza the care of patients with obesity and with severe obesity, due to its adverse effect on pulmonary function (85) . the increased morbidity associated with obesity in covid-19 infections may be explained by increased inflammatory cytokines, other important determinants of severity infection include basal hormone milieu, defective response of both innate and adaptive immune system and sedentariness. it has been suggested by recent evidences that a large obese population increases the chance of appearance of more virulent viral strain, prolongs the virus shedding throughout the total population and eventually may increase overall mortality rate of an influenza pandemic (86) . finally, some authors outlined a framework whereby adipose tissue may be as a reservoir for more extensive viral spread with increased shedding, immune activation and cytokine amplification (83) . even, there are no specific studies on nutrition management in covid-19 infection, espen promotes considerations based on the best of knowledge and clinical experience. first, patients at risk for poor outcomes and higher mortality following infection with sars-cov-2, namely older adults and multimorbid individuals, should be checked for malnutrition through screening and assessment. criteria can be used are the must criteria or, for hospitalized patients, the nrs-2002 criteria. recently it has been introduced the glim (global leadership initiative on malnutrition) criteria for malnutrition diagnosis. obese individuals should be screened and investigated according to the same criteria, as they are malnourished. in a recent review about potential interventions for novel coronavirus based on the chinese experience authors suggested that the nutritional status of each infected patient should be evaluated before the administration of general treatments (87) . subjects with malnutrition should optimize their nutritional status, ideally by diet counseling from an experienced professional. macronutrients intake proposed by espen are the following. energy needs can be assessed or predicted by equations or weight-based formulae such as: • 27 kcal per kg body weight and day; total energy expenditure for polymorbid patients aged >65 years; • 30 kcal per kg body weight and day; total energy expenditure for severely underweight polymorbid patients*; • 30 kcal per kg body weight and day; guiding value for energy intake in older persons, this value should be individually adjusted with regard to nutritional status, physical activity level, disease status and tolerance. *the target of 30 kcal/kg body weight in severely underweight patients should be cautiously and slowly achieved, as this is a population at high risk of refeeding syndrome. protein needs are usually estimated using formulae such as: • 1 g protein per kg body weight and day in older persons; the amount should be individually adjusted with regard to nutritional status, physical activity level, disease status and tolerance. • ≥ 1 g protein per kg body weight and day in polymorbid medical inpatients in order to prevent body weight loss, reduce the risk of complications and hospital readmission and improve functional outcome. fat and carbohydrate needs are adapted to the energy needs while considering an energy ratio from fat and carbohydrates between 30:70 (subjects with no respiratory deficiency) to 50:50 (ventilated patients) percent. also micronutrients, such as vitamins and minerals, should be ensured to potentially reduce disease negative impact, by supplementation and/or adequate provision. low levels or intakes of micronutrients such as vitamins a, e, b6 and b12, zn and se have been associated with adverse clinical outcomes during viral infections (86) . recently, a chinese review (88) proposed that also vitamin c, omega-3 polyunsaturated fatty acids, as well as selenium, zinc and iron should be considered in the assessment of micronutrients in covid-19 patients. oral nutritional supplements (ons) should be used whenever possible to meet patient's needs, when dietary counseling is not sufficient to reach nutritional goals. individuals infected with sars-cov-2 outside of the icu should therefore be treated to prevent or improve malnutrition. the oral route is always preferred when practicable. nutritional treatment should start early during hospitalization (within 24-48 h) and targets should be met gradually to prevent refeeding syndrome. ons provide energy-dense alternatives to regular meals and may be specifically enriched to meet targets in terms of protein as well as micronutrients (vitamins and trace elements). the daily estimated requirements of these nutrients should be regularly provided. nutritional treatment should continue after hospital discharge with ons and individualized nutritional plans; this is particularly important since preexisting nutritional risk factors continue to apply and acute disease and hospitalization are likely to worsen the risk or condition of malnutrition. according to espen statements, in multimorbid inpatients and in older persons with reasonable prognosis, when nutritional requirements cannot be met by the oral route, enteral nutrition (en) should be preferred to parenteral nutrition (pn), because of a lower risk of complications (related or not related to infectious). pn should not be started until all strategies to maximize en tolerance have been attempted. about the nutritional management of covid-19 patients admitted to intensive care units, espen guidelines on this specific topic are available giving suggestions on different stages of treatment according to patients' condition and respiration. infected patients not intubated who do not reach nutritional requirements by normal diet, first should be supplemented by ons, then en treatment can be considered. when limitations are present to en, pn can be prescribed. in covid-19 intubated and ventilated icu patients, enteral nutrition (en) should be started through a nasogastric tube; post-pyloric feeding should be performed in patients with gastric intolerance after prokinetic treatment or in patients at high-risk for aspiration; the prone position per se does not represent a limitation or contraindication for en. patients' energy expenditure can be derived from ventilator (vo2, oxygen consumption from pulmonary arterial catheter or vco2, carbon dioxide production), and energy is administered according to its value. hypocaloric nutrition (not exceeding 70% of ee) should be administered in the early phase of acute illness with increments up to 80 and 100% after day 3. regarding protein intake, 1.3 g/kg protein equivalents per day can be delivered progressively. in obese subjects, 1.3 g/ kg "adjusted body weight" protein equivalents per day is recommended. adjusted body weight is calculated as ideal body weight + (actual body weight -ideal body weight) * 0.33. after mechanical ventilation, patients may present swallowing difficulties and texture-adapted food can be considered after extubation. if swallowing is proven unsafe, en should be administered. in cases with a very high aspiration risk, post-pyloric en or, if not possible, temporary pn during swallowing training with removed naso-enteral tube can be performed. hydration status of patients should be considered and assessed after the acute and critical phases. high grade of inflammation and infectious status with long lasting fever period may cause dehydration which needs to be treated before discharge. furthermore, some patients with covid-19 show intestinal disease, thus nutritional and gastrointestinal function should be assessed for all patients. some authors suggest that nutritional support and application of prebiotics or probiotics should be suggested to regulate the balance of intestinal microbiota and reduce the risk of secondary infection due to bacterial translocation (89) . almost no information is available on metabolic and nutritional needs of icu survivors, and known nutritional practices reveal a poor nutritional performance during icu stay and after discharge. a few evidences showed that currently poor nutritional practices are adopted for older patients who leave the icu in the ward, and further research are needed to fill the gap. following hospital discharge, especially patients should comply with high-protein targets either by prolonged tube feeding or by enhanced high-protein oral nutrition (supplement) intake. further, nutritional and metabolic therapies such as anabolic/anti-catabolic agents in the recovery need urgent studies (90) . nutritional intervention should be combined (whether possible) with physical exercise in order to optimize its anabolic effect (91) . different phases and week programs could be also followed with the specific aim of recovering physical and motor skills (table 4) . phase 1. recover of orthostatism. once the acute phase has been resolved, the multidomain intervention should include exercise and target the recovery of orthostatic and motor skills. it would be important progressively increase the anti-gravity position starting from the sitting position on the bed with slow exercises and movements to be repeated several times a day, until the complete recovery of the upright position. phase 2. train balance and coordination of movements. following this first phase, static and dynamic balance exercise should be performed for improving balance impairment. holding on the back of a chair, stand on tiptoe and then return to the starting position, or keep the balance in monopodalic support. phase 3. regain muscle strength. low intensity muscle strengthening exercises might be useful for recovering strength and functional autonomy, improving stability, balance and reducing the risk of falls. for example, sitting back on a chair, slowly raise left leg until it is fully extended, pause for a breath, then slowly lower left leg back to the ground. this sequence should be repeated 10 times both sides. phase 4. start endurance training. aerobic exercise, like walking inside the house or stationary bike, can be started after the regaining of motor skills and strength, initially 10 minutes of activity then up to 20 minutes. maintenance: individual multicomponent exercise program. at the end of the total recovery, a multicomponent exercise program can include aerobic, resistance, balance, coordination and mobility training exercises (92) . twenty minutes of aerobic exercise every day and three days a week of resistance exercises at low and medium intensity should be the ideal choice for older people to enhance the protective role of physical activity (93) (94) (95) . the pathophysiology of the covid-19 infection especially in older adults requires a dynamic process with important clinical and ethical implications in the hospital and community care. now it is quite clear that the infection produces a systemic disease with different phases at increasing severity of symptoms. older patients infected by covid-19 often experience atypical and less severe symptoms in older persons, side-effects of the drugs and require specific nutritional and motor treatment for avoiding disability and death. by expanding the proposal of hasan k et al. (96) , we added to the already known infective, pulmonary and inflammatory, a potential iv phase for emphasizing the presence of a vascular-thrombotic process more frequent during the severe pulmonary disease. we also underlined the bacterial over-infection, which can be transversally present in all phases and requires the need of antibiotic treatment. as addressed by italian ethics committee it is ethically unacceptable, each selective care criterium based on «age, gender, condition and social role……and disability». these principles have been often ignored, especially in older covid-19 patients. examples reported from the sociologist giuseppe de rita and coming from uk or holland, describe that patients 70 year or older are invited to sign a declaration where they refuse to be cured if another younger patient requires the same treatment. a statement signed on march 23rd 2020 by the european geriatric medicine society (eugms) (97) suggests that advanced age should not by itself be a criterion for excluding patients from specialized hospital units and care. simplified models of comprehensive geriatric assessment and tailored interventions (including evaluation of frailty, hydration and nutritional with body mass index and cst, social and psychological support, management of polypharmacy) are mandatory to guide appropriate clinical approaches, especially if older subjects are really fit, without any cognitive and motoric dysfunction, and to improve the patient's quality of life (98) . these principles should be applied to every setting of care including community/primary care, hospital and nursing home placement. innovative organizing multidisciplinary models are especially important during the transition care and coronavirus outbreak, because older people might experience an understandable slowing down of physi-cal and mental capacities in the discharge from acute care with prolonged hospital stays and increased risk of iatrogenic consequences. all the necessary 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as therapy to fight against the mental and physical consequences of covid-19 quarantine: special focus in older people a tale of two pandemics: how will covid-19 and global trends in physical inactivity and sedentary behavior affect one another? considerations for obesity, vitamin d, and physical activity amidst the cov-id-19 pandemic physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic covid-19 illness in native and immunosuppressed states: a clinical-therapeutic staging proposal state-ment of the eugms executive board on the covid-19 epidemic prevalence, incidence, and clinical impact of cognitive-motoric risk syndrome in europe, usa, and japan: facts and numbers update 2019 we deeply appreciated our patients and families for their patience and kindness and our nurse coordinator rosetta castellino and her staff for the excellent work and the strong support during covid 19 epidemic. each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article key: cord-305743-rnfn6opa authors: anton, stephen d.; cruz-almeida, yenisel; singh, arashdeep; alpert, jordan; bensadon, benjamin; cabrera, melanie; clark, david j.; ebner, natalie; esser, karyn a.; fillingim, roger b.; goicolea, soamy montesino; han, sung min; kallas, henrique; johnson, alisa; leeuwenburgh, christiaan; liu, andrew c.; manini, todd m.; marsiske, michael; moore, frederick; qiu, peihua; mankowski, robert t.; mardini, mamoun; mclaren, christian; ranka, sanjay; rashidi, parisa; saini, sunil; sibille, kimberly t.; someya, shinichi; wohlgemuth, stephanie; tucker, carolyn; xiao, rui; pahor, marco title: innovations in geroscience to enhance mobility in older adults date: 2020-10-22 journal: exp gerontol doi: 10.1016/j.exger.2020.111123 sha: doc_id: 305743 cord_uid: rnfn6opa aging is the primary risk factor for functional decline; thus, understanding and preventing disability among older adults has emerged as an important public health challenge of the 21st century. the science of gerontology – or geroscience has the practical purpose of “adding life to the years.” the overall goal of geroscience is to increase healthspan, which refers to extending the portion of the lifespan in which the individual experiences enjoyment, satisfaction, and wellness. an important facet of this goal is preserving mobility, defined as the ability to move independently. despite this clear purpose, this has proven to be a challenging endeavor as mobility and function in later life are influenced by a complex interaction of factors across multiple domains. moreover, findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, as well as the environment in which a person lives, can have a dramatic effect on an older person's mobility and function. for these reasons, behavioral interventions that incorporate complex walking tasks and other activities of daily living appear to be especially helpful for improving mobility function. other pharmaceutical interventions, such as oxytocin, and complementary and alternative interventions, such as massage therapy, may enhance physical function both through direct effects on biological mechanisms related to mobility, as well as indirectly through modulation of cognitive and socioemotional processes. thus, the purpose of the present review is to describe evolving interventional approaches to enhance mobility and maintain healthspan in the growing population of older adults in the united states and countries throughout the world. such interventions are likely to be greatly assisted by technological advances and the widespread adoption of virtual communications during and after the covid-19 era. stephen d. anton a (santon@ufl.edu), yenisel cruz-almeida b (cryeni@ufl.edu), arashdeep singh c (a.singh@ufl.edu), jordan alpert d (jordan.alpert@ufl.edu), benjamin bensadon a (bensadon@ufl.edu), melanie cabrera a (melanie.cabrera@ufl.edu), david while prolongation of life remains an important public health goal, of even greater significance is that extended life should involve preservation of the capacity to live independently and to function well [1] . the field of geroscience seeks to understand the genetic, molecular, and cellular mechanisms that make aging a major risk factor and driver of common chronic conditions and diseases of older people. interventions targeting the fundamental biology of human aging have the potential to delay, if not prevent, the onset of aging-associated conditions [2] [3] [4] [5] [6] . the unprecedented growth of the aging population and increasing prevalence of chronic disease have underscored an urgent need for such interventions. if this the current trend in aging continues, the number of older persons (aged >60 years) will nearly triple in size globally, increasing from 673 million in 2005 to almost 2 billion by 2050 [7] . accordingly, the science of gerontologyor geroscience -has the practical purpose of understanding how aging processes enable diseases and to then apply this knowledge to reduce the emergence and progression of age-related diseases and disabilities. the ultimate goal is to develop feasible, practical, and safe interventions to delay the development of chronic diseases and conditions, while also increasing enjoyment, satisfaction, and quality of life, during the latter stages of an individual's lifespan. [8] interventions that can achieve these objectives may also dramatically lower health care costs. as we have previously described, [9, 10] a hallmark of successful aging is mobility, i.e. the ability to move without assistance, which is necessary for the maintenance of basic independent functioning [11, 12] . additionally, mobility performance (i.e., walking speed) has emerged as a surrogate marker of overall health and functional ability among older adults. [13] improvements in usual gait speed predict better survival and quality of life in older adults [14] . in contrast, mobility limitation is associated with more rapid functional decline, reduced quality of life [15] , as well as hospitalization, nursing home placement, and increased mortality [16] [17] [18] [19] [20] (see figure 1 ). for these reasons, understanding and preventing mobility disability among older adults has emerged as one of the most important public health opportunities of the 21 st century. therefore, identification of promising interventions to preserve mobility that can be widely implemented in older adults is a major clinical and public health priority [21] . since our previous review, [9] several advances in the field of geroscience have been achieved and are highlighted in this paper. for example, discoveries made in the past few years have illuminated the complex interactions between the brain and the body in affecting changes in mobility with aging. more specifically, the important role that the central and neuromuscular systems have in affecting mobility has spawned a host of new treatment options, such as use of neuro-modulatory adjuvants (e.g., transcranial direct stimulation) to enhance the beneficial effects of physical activity. in line with this, a growing body of research indicates that interventions designed to improve cognitive/emotional function (e.g., oxytocin) also have benefits effects on mobility and physical function. thus, it appears virtually impossible to influence an individual's cognitive/emotional function without affecting their physical function, and vice-versa. an increased understanding of biopsychosocial factors that may contribute to functional decline can aid in the development of future interventions designed to improve mobility and function in at-risk older adults. aided by technological developments, the range of interventions now available has greatly increased in the past five years. thus, we have expanded our conceptual model to incorporate technology, neural factors, and environmental factors. although there is a strong consensus on this goal, there are challenges to developing such interventions as an older adult's mobility and functional level are affected by factors across j o u r n a l p r e -p r o o f journal pre-proof multiple domains. moreover, the complex interactions between factors within biological, psychological, and social domains may increase the risk for functional decline and other agerelated chronic disease conditions. as such, promising interventions will need to take into account these multifaceted interactions and also recognize that affecting change in one domain can lead to changes in other domains. with this goal in mind, we first review the role of specific biological contributors to functional decline. next, we describe key behavioral and psychosocial factors that can affect physical function and risk for functional decline in older adults. we then discuss promising interventions from clinical trials that can enhance physical function and mobility, as well as the role of smart and connected technologies in the delivery of these interventions (see figure 2 ). in the final sections, we discuss the importance of preclinical models in guiding intervention selections, statistical considerations in aging research, as well as key strategies to effectively disseminate and implement efficacious interventions in clinical and community settings. the rising prevalence of metabolic syndrome in older adults, a condition diagnosed based on the presence of three or more metabolic risk factors, including abdominal obesity, high triglycerides (tg), low hdl-cholesterol (hdl-c), high blood pressure (bp), and impaired glucose tolerance, correlates with sedentary lifestyles, and poor nutrition habits [22] [23] [24] [25] . approximately one-third of older adults in the usa are obese; however, nearly 55% of those aged 60 years or older are estimated to have metabolic syndrome [26] . given the aging us population, the disproportionately high prevalence of the metabolic syndrome in older adults is a significant public health concern, as it substantially increases the risk for cardiovascular disease j o u r n a l p r e -p r o o f journal pre-proof (cvd) [27] [28] [29] [30] and is associated with increased all-cause mortality, disability, cvd mortality, myocardial infarction, and stroke [31] . additionally, the metabolic syndrome is associated with impairments in basic activities of daily living, social activities, and lower extremity mobility [7, 32] . aging typically promotes a loss of fat-free mass which parallels to the reduction in metabolic rate and energy expenditure, particularly after the age of 50 [32] . this age-related muscle loss (i.e., sarcopenia) can diminish both the metabolic and mechanical functions of the skeletal muscle, [33, 34] a point of concern since skeletal muscle has the greatest contribution to an individual's metabolic rate [35] . in addition to the loss of total muscle mass, the muscle quality also declines with age due to increased fat infiltration within the muscle thus resulting in decreased muscle strength [36] and power [37] . after the age of 50, it is noteworthy that adults lose muscle strength (i.e., dynapenia) at a much faster rate, approximately 3-4% year, than they lose muscle mass, approximately 1-2% per year. therefore, while muscle atrophy and weakness are certainly correlated, the former cannot fully explain lost muscle strength in late-life. moreover, muscle weakness is a major independent contributor to maintaining physical independence in later life. [38] [39] [40] [41] [42] [43] it was originally thought that the loss of skeletal muscle mass largely explained the muscle weakness observed in older adults; however, more recent findings suggest that other anatomical and physiological factors also play an important role in muscle weakness. the mechanisms determining loss of muscle strength or power output are related to both neurological and skeletal muscle properties, as it is well known that the output from these sources control j o u r n a l p r e -p r o o f journal pre-proof muscle force and power production. within the neuromuscular system, there are several potential mechanisms that may contribute to reductions in strength during aging, including reduced excitatory drive to the spinal motor neurons, reductions in motor neuron discharge rates, impairments in neuromuscular transmission, muscle cell death, muscle protein imbalance, reduced repair/regeneration of muscle cells and impairments in the excitation-contraction (e-c) coupling processes. aging in humans has been shown to be accompanied by robust reductions in the population of motor neurons and axon density [44] [45] [46] [47] . between the ages of 60 and 70 there is a ~30% reduction in the number of functional motor units (motor units = motoneuron and innervated muscle fibers) [48] [49] [50] [51] and once the loss of motor units reaches a critical threshold, muscle strength begins to decline [52] . the exact underlying mechanisms of exhausted nmj plasticity and motor neuron cell death remain obscure, but many factors such as deregulated inflammation, autophagy, reduced igf-1 signaling, oxidative stress, and mitochondria dysfunction have been suggested to drive accelerated loss of muscle mass and function in late life [53, 54] . many factors contribute to a loss of automaticity of walking in older adults. one likely factor is impairment of the communication between the nervous system and muscle. motor neurons innervate their axon terminals to the skeletal muscle fibers to form a neuromuscular junction (nmj), which allows the presynaptic motor neurons to transmit chemical signals to the post-synaptic muscle fibers, leading to muscle contraction. during most of the adult life, there is considerable plasticity of the nmj, where surviving motor units expand through collateral axonal sprouting to reinnervate any denervated nmjs [54] [55] [56] . exhaustion of this plasticity (persistent denervation and failed reinnervation) accelerates muscle atrophy during aging and is associated with movement impairment and functional decline [44, 57] . accumulating evidence supports that models of cognitive brain aging may help us understand the decline in walking function in older adults [58] [59] [60] . changes in brain structure and function may also contribute directly to loss of automaticity, as well as reduce the capacity for recruiting additional resources to compensate for the loss of automaticity [60, 61] . additional research is needed to better understand the major modifiable neural factors that influence control of walking with older age, so that targeted interventions can be designed [58] . chronic pain conditions represent three of the five leading causes of disability in the us, including low back pain, which is the leading cause of disability both in the us and worldwide [62, 63] . while pain affects individuals throughout the lifespan, older adults are disproportionately impacted [64] . another important contributor to mobility decline among older adults is movement-evoked pain (mep). mep refers to pain that is generated or exacerbated through physical movement or activity, and some evidence suggests that mep may be driven by different mechanisms than pain at rest [65] . recent findings in middle-aged and older adults with knee pain demonstrated a relationship between mep and physical performance, highlighting the need to directly measure mep when assessing functional performance in older adults [66] . thus, one key mechanism through which pain may contribute to functional decline is through activity limitations among older adults [67] [68] [69] [70] [71] [72] [73] . emerging evidence also suggests that pain may affect aging processes. indeed, several recent studies suggest that pain is associated with cellular aging. specifically, a combination of high psychosocial stress and high levels of knee pain were associated with shorter telomeres among j o u r n a l p r e -p r o o f journal pre-proof middle-aged and older adults [74] , and subsequently these authors showed that more severe knee pain was associated with shorter telomeres [75] . more recently, chronic pain in older adults has been associated with brain aging [76] and a validated epigenetic measure of aging [77] . thus, the relationship between pain and aging appears to be bidirectional and complex, impacting multiple body systems. one area that is gaining recognition for the potential to impact aging processes is circadian rhythms, which are endogenously generated 24h cycles that can be observed in behavior, physiology and metabolic processes. driven by the circadian clock, circadian rhythms are found in virtually every cell in the body [78] . over the last ten years, research has uncovered that the circadian clock functions within cells to support daily tissue homeostasis, and disruption of the clocks leads to lowered resilience [79] . studies in animal models support the decline in function of the circadian system with age, and this age-related decline appears to impact virtually all systems in the body including skeletal muscle and areas of the brain important for learning and memory [80] [81] [82] . in humans, studies have shown that circadian output changes with aging of muscle mass and strength [85] [86] [87] [88] [89] . thus, the available evidence to date strongly implicates mitochondria as having a pivotal role in the pathogenesis of age-related functional decline, and it has been suggested that a substantial decrease in mitochondrial oxidative capacity in aging muscle might contribute to reduced exercise capacity in older adults [90] . why there is a decrease in mitochondrial function with aging remains under debate, but emerging science indicates that there is a clear connection between mitochondrial biogenesis and function with fuel metabolism and circadian rhythms [91] . cardiovascular disease (cvd) is a leading cause of death among older adults in the united states and the prevalence increases proportionally with age. in particular, 70% of older adults between 60-79 years old and 85% of older adults 80 years and older suffer from cvd [92] . during aging, endothelial dysfunction induced by oxidative stress, inflammation and decline in bioavailability of nitric oxide (no) leads to arterial stiffness, which overloads the heart leading to ventricular hypertrophy and myocardial fibrosis [93] . endothelial dysfunction and the overloaded heart reduce arterial-ventricular coupling, reflecting impaired global cardiovascular performance [94] . recent evidence has demonstrated that subclinical declines in cardiovascular function contribute to functional decline by impaired peripheral tissue perfusion [95] . although sepsis can affect all ages, it is recognized to be the "quintessential disease of the elderly" [96] . studies have shown that both the incidence of sepsis and hospital mortality increases exponentially beyond the age of 65 years, with more than 1 million us medicare recipients hospitalized each year with sepsis. numerous age-related factors increase the risk for j o u r n a l p r e -p r o o f developing sepsis including comorbidities (e.g., chronic lung disease and renal insufficiency), malnutrition, increased aspiration risk from altered mental status and decreased gag/cough reflex and immobility. the diagnosis of sepsis is commonly delayed in older patients because of a blunted systemic inflammatory response syndrome (sirs) and the presence of comorbidities that can cause confounding symptoms. as a result, older patients present as septic later in the process. they are more likely to progress into septic shock due to limited cardiac reserve and have worsening of existing organ dysfunctions. the principal cause of sepsis is a dysregulated systemic immune response, which is negatively affected by aging. in contrast to younger adults, older patients have difficulty returning to immunity homeostasis, increasing their risk for sepsis recidivism. pre-existing sarcopenia, frailty and cognitive disabilities all adversely affect recovery. additionally, ongoing sirs induces profound catabolism with tremendous loss of vital lean body mass despite early nutritional support intervention. moreover, care for sepsis in the icu often involves bedrest and mechanical ventilation, exacerbating the ongoing loss of muscle mass and function. once sirs has resolved, older sarcopenic sepsis survivors have anabolic resistance that makes them nonresponsive to nutritional and physical therapy interventions. our senses, hearing, vision, touch, smell, and taste play critical roles in survival throughout the course of life. aging can affect all of these sensory systems, but the auditory system is thought to be especially vulnerable to age-related damages. hearing loss is the third most prevalent chronic health condition affecting older adults and age-related hearing loss (ahl) is the most common form of hearing impairment [97] . the world health organization(who) estimates that one-third of persons over 65 years are affected by hearing j o u r n a l p r e -p r o o f loss [98] . worldwide, approximately 466 million people suffer from hearing impairment and this number is expected to rise to 630 million by 2030 and over 900 million by 2050. ahl is characterized by poor speech understanding (especially in noisy situations), central auditory processing deficits, and social isolation [99] . as humans age, both males and females undergo various changes in hormone levels, leading to numerous long term and significant internal changes. although some of these changes may be more detrimental than others, common and problematic alterations include loss of muscle mass [100] , decreased bone mass [101] , and various cognitive impairments [102] , which all increase risk for mobility loss and loss of independence. in men, aging is often associated with decreased testosterone [100] , which has been linked to bone loss [103] and decreased muscle mass [104] . with the loss of muscle and bone comes an increased risk of sarcopenia, oftentimes resulting in frailty, decreased functional mobility, and growing difficulties with independent living. in females, decreased estrogen levels post-menopause are often postulated to increase one's risk of sarcopenia and frailty [100] . loss of estrogen is accompanied by an increase of pro-inflammatory cytokine il-6, which downregulates insulin-like growth factor-1(igf-1) [100] . high il-6/low igf-1 levels have been shown to significantly limit walking and mobility tasks of daily living [105] , increasing the risk for progressive disability in older females. in addition to sex hormones, a decline in growth hormone (gh) has been observed with aging and is often associated with various changes in body composition, as well as physical and psychological functions [101] . as one approaches the fourth decade of life, there is a progressive decrease of gh secretion by ~15% each decade thereafter [101] . age-related increases in body j o u r n a l p r e -p r o o f mass index (bmi) and diminished functional capacity tend to parallel the decline in gh secretion, although many other factors also likely contribute [101] . in many cases, physical disability is directly caused or aggravated by acute events (stroke and hip fracture) and disease states (heart failure, coronary heart disease, diabetes, arthritis and peripheral artery disease) [106, 107] . however, a large and growing number of older adults experience progressive declines in physical function over several years culminating in agerelated physical disability with no clear connection to a single disease [108, 109] . research over the past decade has highlighted the role of multiple body/biological/health systems in contributing to this decline. moreover, many age-related conditions appear to affect other systems and may induce similar adverse changes at the cellular level. among the behavioral factors, low levels of physical activity combined with excessive and unhealthy calorie intake appear to strongly contribute to functional decline among older adults [110] . in line with this, a recent review of trends in us health by the u.s. burden of disease collaborators found that high body mass index (bmi), smoking, and high fasting plasma glucose are the three most important risk factors for disease and disability in the united states [111] . among these, only the prevalence of smoking is decreasing, while bmi and fasting plasma glucose levels are steadily increasing. skeletal muscle loses the ability to switch between metabolizing lipids and carbohydrates. in addition to the role caloric excess can have in promoting metabolic inflexibility, there is also increasing evidence that the "western-type" diet that is high in sugar, fat, and processed foods seems to be associated with less ideal aging phenotypes [112] . high levels of sedentary behavior (sitting) contributes to lipid accumulation [113] [114] [115] , metabolic impairments [116] , and loss of muscle mass during aging [117] , all of which strongly contribute to functional decline [118] [119] [120] [121] . these findings are of concern as the majority of middle-age americans spend over half their waking day (~8-9 hours) engaged in sedentary pursuits [122, 123] , with older adults spending an even greater proportion (75%) of their waking hours engaged in sedentary behavior (~11 hours per day) [124] . moreover, each additional hour of sedentary behavior was associated with increased risk of the metabolic syndrome, whereas every additional hour of light intensity activity was associated with reduced risk. perhaps the most common complaint older adults have is the lack of quality sleep. sleep affects nearly every tissue and system in the body, from the brain, heart and muscle to metabolic, endocrine, cardiovascular and immune functions, as well as numerous cognitive processes such as learning and memory, emotion and motor control [125] . similar to food and water, sleep is a basic human need, and sleep timing, duration, and quality are all essential to health. despite this, sleep deficiency is prevalent in modern society, including an insufficient amount of sleep, low quality sleep, and sleep at the wrong time of day. according to a recent report from the centers for disease control and prevention (cdc), 30% of u.s. adults report some form of sleep deficiency [126, 127] . sleep deficiency is more prevalent in older adults, exhibiting common nighttime sleep abnormalities, such as early bedtime and rise time, sleep fragmentation (i.e. less consolidated sleep with frequent awakenings), short sleep duration, less total sleep, and deep sleep [128] ; which is correlated with more frequent daytime naps. in fact, 1 in 4 older adults report severe daytime sleepiness that affects daytime mental and physical performance [129] . these agerelated sleep deficiencies have significant consequences for brain and body health, increasing the risk of chronic inflammatory and neuropsychiatric diseases, metabolic and cardiovascular disease, as well as mental health problems and even pain. for example, poor sleep quality and chronic pain are both tied to significant reductions in quality of life in aging [130] . emerging evidence from our group suggests that sleep may negatively impact brain structure and function in older individuals, which may lead to worse self-reported pain [131, 132] . an increased understanding of the behavioral factors that contribute to functional decline in otherwise healthy older adults can assist in both identifying at-risk older adults and designing targeted interventions for individuals in the later stages of life that maintain mobility and slow the rate of functional decline. it is recognized that there are many causes of functional decline and ultimately disability. while we believe behavioral factors, including over and undernutrition, physical inactivity, and sleep, have a central role in maintaining mobility in later life, the pathways leading to physical disability in older adults are likely complex and involve consideration of a larger number of etiologic factors. environment and social relationships can serve as either risk or protective factors for aging adults. environmental factors across the lifespan interact with biology and contribute toward health outcomes [133] . research shows that early life stressors can influence biological functioning, priming the stress system toward a level of heightened sensitivity increasing greater risk for later life health conditions and earlier mortality [134] . as individual age, environmental factors, life experiences, and personal and financial resources can buffer or exacerbate healthrelated conditions. social relationships also influence health and well-being. limitations in social relationships can be experienced as social isolation and loneliness [135] . of concern, approximately one fourth of adults, individuals aged 65 years and older meet social isolation criteria and among individuals aged 60 years and older, greater than 40% endorse loneliness [135] . age-related life changes that increase susceptibility to social isolation and loneliness includes changes in health status limiting functioning and mobility; changes in family structure (divorce, childless); death of friends, family members, and spouse; auditory and visual changes reducing the ability to communicate and interact; and resource reductions including healthcare access and quality of care [135] . there is also research evidence that socially isolated older adults are less physically active independent of any mobility limitations [136] . however, whether or not declines in mobility mediate the well-established relationship between social isolation and all-cause mortality [137, 138] remains unclear. minority older adults are at an even greater risk to the health consequences of environmental and social factors. higher frequency of negative environmental exposures, limited j o u r n a l p r e -p r o o f environmental resources, possible language limitations, and experiences of stigma and discrimination might be further contributing to increased risk of morbidity and mortality [133] . despite this increased risk for poor health outcomes, access to medical care is often limited and the extended wait times to receive care may discourage healthcare utilization, particularly preventive health services among minority populations [139] [140] [141] . thus, environmental and social factors represent an area where research and evidence-based strategies can contribute to improved health outcomes [133, 142, 143] . older adults perceive mobility as essential to feeling whole and identify mobility assistance and adaptation as key to managing age-related changes [144] . in fact, older adults who met just one of five established frailty phenotype criteria were more likely to also be depressed, suggesting frailty has both physical and psychological components [145] . also noteworthy, psychological factors such as balance efficacy and falls efficacy have previously been found to be more important than physical factors (e.g., fall history, medical morbidity, and balance tests) in predicting future falls [146] . theoretically, self-efficacy for specific tasks, mood, and behavior have a reciprocal influence on an older person's decision making and performance. for example, lower baseline self-efficacy for functional tasks predicted decreased walking performance and stair ascent among older women with osteoarthritis [147] . falls efficacy, a measure of falls-specific selfefficacy, can be independently predicted by normal walking pace, anxiety, and depression [148] . dizziness, another common mobility-related complaint of older adults, has been associated with lower falls efficacy and slower walking speed [149] . these trends are consistent with other data j o u r n a l p r e -p r o o f showing fall history and female gender independently predict fear of falling [150] and mobility device use [151] . consistent with the data on the importance of psychosocial factors in mobility, a number of mobility-related clinical interventions are integrating falls-specific self-efficacy [152 2017 ], balance-specific [153] and other psychological concepts into trials targeting frailty in older adults [154] . further, these trials are also targeting motivation for physical activity [155] , adherence to exercise programs [156] , fall prevention [157] , and interventions to reduce the fear of falling and improve balance such as yoga [158] . protocols are emphasizing the need to tailor to older adult's preferences, personal choice, and providing social support [159] . these factors should align with older adults' own attitudes and perceived needs [160] , as well as older adults' perceived enablers and barriers to participation in strength and balance activities (barriers = risk of cardiac events, death, and hyper muscularity; enablers = potential improvement in the ability to complete daily activities, prevent deterioration /disability, and decreased risk and fear of falling) [161] . in a 6month integrated care program that included problem-solving psychotherapy reported improvements in frailty were sustained at one year follow up [162] . although these studies suggest promising results, the integrated biopsychosocial approach to mobility is still underutilized. poor nutrition may be a key factor that promotes metabolic syndrome and can exacerbate a decline in physical function and mobility. given the link between metabolic syndrome or obesity with the musculoskeletal decline among the older population, it is no surprise that dietary interventions that reduce bodyweight also improve health outcomes in older adults. dietary j o u r n a l p r e -p r o o f restriction (or caloric restriction), defined as a mild reduction of energy intake without malnutrition, delays aging in nearly all animal species tested so far [163] . in addition to promoting longevity in various model organisms (e.g., yeast, worm, fly, mouse) [163, 164] , dietary restriction had also been shown to be beneficial for enhancing physical function and mobility in older adults [254] [255] [256] [257] . furthermore, in overweight humans, caloric restriction has been shown to reduce several cardiac risk factors [165] [166] [167] , improving insulin-sensitivity [168] , and enhancing mitochondrial function [169] . current challenges: despite health-promoting biological changes, there are two important concerns related to calorie restriction interventions in older adults. first, weight loss could accelerate aging-associated muscle loss and thereby have adverse effects on physical function [170, 171] . second, most individuals have difficulty engaging in caloric restriction over the long-term and frequently regain weight that was lost [172] . for these reasons, alternative innovative dietary approaches for reducing body weight, specifically body fat, in overweight, older adults at risk for the functional decline are currently being explored. innovations from geroscience: one alternative dietary approach that has been suggested to produce similar biological changes as calorie restriction that has received increasing interest from the scientific community is intermittent fasting or time-restricted eating (tre) [173] . in contrast to traditional calorie restriction paradigms, there is typically no restriction to calorie consumption in tre during designated eating periods (typically 8 -12 hours). in a recent review of the effects of intermittent fasting regimens, specifically tre and alternate-day fasting, we found that tre produced significant reductions in body fat without significant loss of lean tissue, suggesting it may be an effective intervention approach for overweight, older adults [173] . another area of increasing scientific interest is understanding the role of dietary composition in impacting human physiology and physical performance. for example, the mediterranean diet, which consists of healthy fats, fiber, fish, and minimally processed, plantbased foods, has been shown to provide health benefits including improving cardiovascular function, glucose control and decreasing body weight among older adults [174] [175] [176] . also, noteworthy, in some preclinical studies conducted in rodent models, the ketogenic diet has been shown to extend longevity and healthspan, [270[177] improve memory and cognition, [177] [178] [179] and improve endurance athletic performance [274, 275] . based on such findings, the lowcarbohydrate, high-fat ketogenic diet has attracted increasing attention as a potential dietary intervention to promote healthy aging. future directions: to date, the impact of diet interventions on physical function and mobility among seniors with aging-associated morbidities is unknown. although some risk may be associated with lifestyle-based weight loss interventions in older adults, obesity, and sedentary lifestyle are known to predict the development of disability in otherwise healthy older adults [119, 180] . however, randomized controlled studies are needed to demonstrate whether the benefits of these interventions outweigh the risks before implementing these interventions on a broad scale. an important primary focus of these interventions should be enhancing and/or maintaining fat-free mass, as high-quality muscle is the primary driver of metabolism and also directly impacts mobility and physical function [14, 181] . notably, as multimorbidity is often a characteristic feature observed in older individuals with impairments in mobility, a geroscience approach will be instrumental in determining the long-term efficacy of nutrition-based interventions and addressing the potential challenges with aging-associated comorbidities. exercise provides benefits to all major body systems, including the nervous system. aerobic exercise, in particular, can enhance brain health by upregulating neurotrophic factors that improve nerve structure and function [182] . to prevent functional decline, the american college of sports medicine (acsm) guidelines for older adults recommend a regular exercise program that includes a combination of endurance and resistance training [183] . in support of these recommendations, low-intensity aerobic activity such as walking 4-7 days per week [184] or going up and down a 10-stair staircase [185] , have been shown to be protective against loss of mobility and functional decline [184] [185] [186] . current challenges: while structured physical activity is a powerful tool to improve overall health in older adults, involvement in structured physical activity may be overwhelming for frail older adults who are home-bound and have poor physical performance. older adults may not be capable of participating in structured, institution-based physical activity programs with multiple visits to research sites due to poor health status and distant living locations. innovations from geroscience. our group has shown that a structured, moderate-intensity physical activity program compared with a health education program reduced the incidence of major mobility disability over 2.6 years among older adults at risk for disability [187] . other studies have found that resistance training can reduce and delay age-related changes in functional mobility [188] , improves leg strength [189] , and prevents falls by improving transfer of weight and swooping motions in the elderly [190] . reduction of sedentary behavior may be an alternative way to deliver a home-based and remotely supervised intervention to improve the functional status in older adults who cannot engage in center-based physical activity programs. for example, an intervention to reduce sedentary time over 12-weeks improved scores on the short physical performance battery (sppb) and self-reported moderate-to-vigorous physical activity (mvpa) levels in older men and women [192] . such it could be a promising intervention to improve physical function in frail older adults in a home-based setting. strong positive associations between breaks in sedentary time with physical function in older adults have also recently been reported [193] . challenges: remotely delivered interventions are more difficult to achieve long-term adherence to the intervention tasks. additionally, considering heterogenous levels of daily activity and sedentary time among individuals, it is challenging to set daily frequency of sedentary time reduction breaks and design the methods for prompting these breaks as well as an amount of steps to be reached daily. [194] innovations from geroscience: thanks to new developments of well-accepted wearable technology in older adults [195] , such as the fitbit alta device, activity and sedentary-behavior levels can be monitored and registered remotely, and importantly, users can be reminded automatically to transition from sitting to standing position and perform brief light-intensity activity such as leisurely walking [196] . for example, participants using wearable technology aimed to achieve a minimum goal of 25% increase in daily posture breaks, and an additional 1,000 steps a day to baseline, which is considered clinically meaningful in a geriatric rehabilitation population [197] . this novel and practical approach, is less physically strenuous, j o u r n a l p r e -p r o o f does not require frequent visits to research sites, and can be operated and monitored remotely by a research team. future directions: future randomized clinical trials are needed to test wearable technologies in a population of frail older adults with poor physical function, multi-morbidities, and live a far distance from research facilities. given the importance of physical activity and exercise for healthy aging, it is important to consider how these can be optimized to promote neural control of walking. the mode of activity/exercise may be important, and there may be adjuvant interventions that promote neural plasticity. innovations from geroscience. task-specific aerobic exercise that incorporates complex walking tasks and other activities of daily living may be especially helpful for mobility function [198] . an example of these interventions is the use of non-invasive neuromodulation such as transcranial direct current stimulation (tdcs), a mild form of electrical stimulation that is safely delivered via electrode sponges placed on the scalp. tdcs does not directly activate brain neurons, but rather alters the neuronal membrane potential, which is believed to alter the likelihood of eliciting neuron activity (either increased or decreased likelihood, depending on the stimulation parameters) [199] . when paired with task practice, excitatory tdcs might reinforce task-specific neural circuits, enhance learning, retention of new skills, and has been shown to benefit walking tasks in preliminary studies [200] [201] [202] [203] . cognitive interventions refer to a broad set of methods designed to improve or maintain cognitive functioning [204] . because many forms of cognition (e.g., memory, reasoning, speed, executive functioning, attention, working memory) are change with age, and are associated with functional losses in later adulthood [204] [205] [206] , the field of cognitive intervention research has been rather broad. methods of intervention have varied from cognitive training (e.g., providing elders with strategic instruction and practice/feedback in age-vulnerable cognitive domains i ), engagement [207] (having elders engage in complex real-world or leisure activities, including video games) [208] , quilting and digital photography [209] , performing arts [210, 211] interacting with technology [211, 212] , to a wide variety of physical and nutritional strategies (e.g., cardiovascular and strength training, anti-inflammatory diets [213] ). most of this research has sought to investigate whether interventions can improve cognition and/or cognitively demanding activities of daily living. innovations from geroscience. useful field of view training progressively and adaptively trains older individuals to improve the speed with which they make accurate perceptual judgments about targets presented in the center of the field of view, while also correctly noting the location of peripheral objects presented on a display [214] . restrictions in useful field of view have been associated with problems of mobility [215] , balance [216] and increased risk of falling [217] , although direct training benefits have not yet been widely reported. of relevance to the mobility domain, older drivers who received useful field of view training showed a roughly 50% reduction in five-year motor vehicle crash rates [218] , presumably because of the improved ability to rapidly monitor a broad visual display and to divide attention between central and j o u r n a l p r e -p r o o f peripheral targets. the unifying feature of each of these domains of successful cognitive training is the focus on divided attention. in all cases, training included the feature of exposing elders to two tasks at once with one task usually representing a balance/gait or visual-perceptual challenge. generalization of training to mobility tasks seems to be associated with the improved ability to attend to multiple tasks at once, or perhaps to be resistant to distracting tasks by having greater control over attentional prioritization (i.e., reducing the effects of distraction, or improving the ability to exert controlled attentional processing over mobility-relevant tasks). the question of whether cognitive interventions might also improve mobility and physical functioning has received less attention, but a few areas of inquiry have yielded supportive findings. first, dual-task training has been shown to improve standing balance, gait, and to reduce fall risk [213, [219] [220] [221] . the rationale for such studies is that balance and gait are thought to be under central (executive) control, and improving attentional capacity to concurrently conduct cognitive and motor challenges will improve the ability to maintain adequate mobility under distracting conditions, as distractions are thought to put elders at a high risk for falls. there are a number of hormonal interventions that have the potential to impact mobility and improve physical function. we focus on one promising compound, the neuropeptide oxytocin, which serves various adaptive and interrelated physiological, behavioral, and cognitive functions [222] . as a hormone, oxytocin is released into the peripheral circulation and acts directly on multiple organ systems. for example, in humans, low plasma oxytocin levels were associated with increased prevalence of chronic pain, and acute (i.e., one-time) intranasal oxytocin administration decreased experimental pain sensitivity, increased pain inhibition, and j o u r n a l p r e -p r o o f journal pre-proof improved mood and positive affect. in addition, there is increasing evidence of improved wound healing and anti-inflammatory effects associated with oxytocin [223] , promoting physical health. innovations from geroscience: the ability to administer oxytocin centrally via nasal spray [224, 225] , with minimal and inconsistent side effects [226] , has spurred research to explore the neuropeptide's therapeutic potential across functional domains, including physical health and in aging [227] [228] [229] [230] . going beyond its classic role in labor and lactation [231] , oxytocin has been demonstrated to modulate higher-order cognitive processing [232] , improve vasculature in the cardiovascular system, benefits weight control, and insulin sensitivity [222, 233] . oxytocin has also been shown to play a crucial role in endogenous analgesia and has recently been discussed as a promising treatment for pain in older individuals [234] . these analgesic mechanisms may be explained by oxytocin's role as both a neurotransmitter and a paracrine hormone and may be associated with brain-morphological processes. as a neurotransmitter, oxytocin may provide analgesia via widespread effects on the brain and spinal cord. in humans, emerging evidence supports an association between plasma oxytocin levels and brain volumes [235, 236] . preliminary data from a 4-week intranasal oxytocin intervention in older men found increased regional gray matter volume following oxytocin but not placebo treatment, with this oxytocin-induced enlargement in brain volume was associated with improved processing speed [237] . furthermore, animal models that administer repeated oxytocin treatment have documented brain changes driven by cell proliferation, differentiation, and dendritic complexity of new-born neurons in the hippocampus [238] . findings in both models offer promise for future investigations into the potential of intranasal delivery of oxytocin to counteract cognitive decline and positively affect physical health in aging. additionally, data j o u r n a l p r e -p r o o f from an animal model that systematically administered oxytocin found that the administration enhanced muscle regeneration after injury through activation of stem cells and mapk/erk signaling [239] . future directions: only one study to date has specifically examined the effects of intranasal oxytocin administration on physical health among older adults and found that 10-days of oxytocin spray was associated with less self-reported physical decline and reduced selfreported fatigue [240] . the promising findings from these diverse emerging fields call for more systematic research on both acute and chronic oxytocin intervention towards physical function among older adults. examination of exogenous oxytocin's direct and mediated effects, and interaction with the endogenous oxytocin system (e.g., naturally circulating neuropeptide levels, oxytocin receptor gene polymorphisms and methylation levels [228, 241] ), forms an interesting angle for future research on interventions promoting physical function and mobility in aging. in addition, there is growing support in the literature of sex dimorphism in the oxytocin system [226] , including in aging [241] , and evidence of sex-dimorphic effects of intranasally administered oxytocin on both brain [222, 228] and behavior [50, 222, 228] , including among older adults. in an age-heterogenous sample of generally healthy women and men, plasma oxytocin levels were higher in women than men, with young women showing the numerically highest levels and older men showing the numerically lowest plasma oxytocin levels [241] . based on this emerging evidence, future research on the application of oxytocin's effects across different functional domains during aging will benefit from consideratin of sex-by-age variations. pharmacological interventions targeted at underlying mechanisms of mobility decline may also lead to improvements in mobility and physical function in older adults. for example, cell senescence characterized by a loss of cell proliferative capacity, increased metabolic activity, and resistance to apoptosis is a major contributing factor to the development of various agerelated conditions. thus, targeting the removal of senescent cells or suppressing the senescenceassociated secretory phenotype may be helpful in improving physical function [242] . specifically, inhibition of cytoplasmic hsp90 (a chaperone protein needed for proper protein folding) induced by hsp90 inhibitors causes senescent cells to be more susceptible to apoptosis. other pharmacological agents aimed to help proper protein folding or remove misfolded protein aggregates may also delay the onset of age-related diseases and subsequently prevent or ameliorate physical functional decline from these sources. the idea that aging itself may be modified through a pharmaceutical intervention will be tested in the targeting aging with metformin (tame) proposal, the first clinical trial to examine an intervention to slow aging rather than to treat a specific age-related chronic disease in humans pharmacologically [243] . the impetus for this trial is that metformin has been demonstrated to have protective effects against several agerelated diseases in humans. however, there does not appear to be a single biological mechanism targeted. rather metformin appears to have broad systemic effects, which can enhance insulin sensitivity and upregulate stress responses at the cellular level. further, targeting cognition pharmacologically to improve mobility or prevent further decline may be possible, given the brain's neurotransmitter systems shared between cognitive function and the circuits controlling gait. specifically, drugs targeting the cholinergic, j o u r n a l p r e -p r o o f dopaminergic and glutamatergic systems have been reported with various degrees of success in individuals with alzheimer's and parkinson's disease [244] , but may be an additional option to explore in cognitively intact older adults with poor mobility. future directions: to date, there is very limited research focused on pharmacologically targeting aging for improving physical function. given the mosaic of aging processes and potential multi-factorial underlying mechanisms, a geroscience approach will be needed to test interventions with multi-functional properties that target the biopsychosocial contributors to aging processes. natural compounds may also represent an important source of potential new interventions for older individuals. similar to pharmaceutical agents, these compounds would likely be most effectively used as an adjunct treatment with lifestyle interventions, behavioral self-management programs, physical exercise, or cognitive interventions. current challenges: for the vast majority of these compounds, the findings have primarily been shown in preclinical models and have not yet been translated to humans, and/or few clinical trials have shown positive effects on mobility in older adults when biologically based approaches are used alone and not in combination with a behavioral intervention [245] . innovations from geroscience: studies to date suggest some natural compounds may be effective adjuvants to lifestyle interventions. in this section, we will focus on one promising nutraceutical compound, nicotinamide riboside (nr), a form of vitamin b3 that stabilizes the nad metabolome (nad+, nadh, nadp+ and nadph), which in a homeostatic state, mediates transformations from food into energy and repair processes [246, 247] . given the nad metabolome destabilizes with age [248] , supplementation with nr has been shown to stabilize j o u r n a l p r e -p r o o f the nad metabolome in a variety of tissues [249] . clinical studies have demonstrated excellent tolerabilty and safety of nr supplementation in middle-aged and older adults, and improved vascular function [250] and reduced fat tissue [251] following 6 weeks of supplementation. future directions: the effects of nr supplementation alone on physical performance in older humans are unclear, and therefore future studies warrant investigations of longer-duration nr supplementation on physical performance, weight loss and cardiovascular function in humans [252, 253] . much will be learned about the promise of preclinical findings to translate to humans, as well as their compatibility with other interventions, in the coming years. there are many promising complementary and alternative treatment modalities, including biofeedback, hypnosis, meditation, mindful exercise, massage and other types of body-work, acupuncture, and music therapy, that have the potential to improve mobility and physical function in older adults. here we will focus on the potential role of massage therapy (mt), which is a mind-body intervention that has been shown to improve muscle function and quality, preserve of neuromuscular function, improve sleep quality and psychological functioning [229, [254] [255] [256] [257] [258] ; [259] ; [260] . additionally, a growing body of literature supports the use of mt to treat chronic musculoskeletal pain associated with aging [261] [262] [263] [264] . current challenges: while mt shows significant promise for improving factors associated with physical function and quality of life, there are important considerations for older adults, including access, attitudes, and approach. attitudes towards complementary health approaches, specifically mt, are often biased towards a luxury service instead of an actual medical intervention. also declines in mobility and independence may inhibit treatment seeking. innovations from geroscience: specific to biological processes in aging, mt has been shown to modify gene expression, protein synthesis, and inflammatory responses [254] [255] [256] [257] , as well as improve peak isometric torque recovery following intense exercise [265] , and protect against loss of strength and fibrotic nerve and connective tissue changes associated with repetitive motion injuries [266] . massage therapy has also been demonstrated to modulate inflammatory processes that may be protective in aging [267, 268] . of particular relevance, recent preclinical studies using rodent models, demonstrated mt induced immunomodulatory changes (e.g., increased satellite cell number) comparable to those seen in younger animals without damaging muscle tissues. [269] the beneficial effects of massage therapy appear to take place quickly, as a single 10-minute massage therapy session following exercise-induced muscle damage was found to be beneficial for reducing inflammation and promoting mitochondrial biogenesis [270] . additionally, massage therapy is capable of altering proprioceptive feedback to the central nervous system [271, 272] , a critical component for maintaining mobility in aging. adults have yet to be fully elucidated, it is likely that massage therapy can serve a vital role in helping older adults maintain mobility by reducing pain, improving muscle functioning, maintaining proprioceptive abilities, and altering negative inflammatory processes, while improving psychological functioning [259, 260, [273] [274] [275] . although mt may need to be modified to accommodate older adults' needs, it appears to be a safe and effective intervention. given that mt acts upon multiple important pathways for mobility and independence, applying an integrated geroscience approach will improve our understanding of mt in addressing agerelated mobility and functional declines. there is now evidence to support a wide variety of intervention approaches to improve mobility and attenuate functional decline in older adults. both behavioral and biological interventions hold great promise for improving function and mobility and thereby extending healthspan and promoting wellness in functionally limited but healthy older adults. as noted previously, such interventions may enhance physical function directly, as well as indirectly through modulation of cognitive and socioemotional processes. these processes include depression, social stress, and anxiety, which all have high relevance in aging and may contribute to social isolation and reduced well-being among older adults. the utility of such interventions to produce desired outcomes is directly impacted by participant adherence to prescribed treatments, and even the most efficacious intervention can be ineffective if the patient fails to follow treatment recommendations. thus, it is very important to carefully evaluate the sustainability of such interventions, especially in light of research demonstrating that individuals who are not fully adherent to health interventions experience significantly fewer health benefits [276] . a variety of factors can affect long-term adherence to health promotion behaviors, including the complexity of the required changes, the number of decision points needed to carry out such changes on a daily basis, and a number of environmental, socio-cultural, and psychological influences [276] . this suggests the need for two approaches to enhance the effectiveness of behavioral and biologically-based interventions: 1) continued refinement of strategies that can enhance the delivery of and adherence to such interventions, and 2) development of novel intervention approaches (e.g., intermittent fasting and intermittent activity bouts) that have the potential to produce similar health benefits as traditional lifestyle approaches and also may be easier to sustain over the long-term. the role that technological advances may have in increasing the effectiveness of both traditional interventions, as well as more novel intervention approaches, is a topic of great interest. in the section below, we describe some of the key considerations in delivering digital and mobile health (mhealth) based interventions in older adults. personally-held devices, such as smartphones, smartwatches and fitness trackers, provide a ubiquitous infrastructure for researchers and clinicians to passively collect a moment-bymoment quantification of individuals' behavior in their own environment, or recently referred to as digital phenotyping. smartphones are considered the most common electronically held devices. pew research center (prc) conducted a survey about the ownership of smartphones in 2019 showing that 81% of americans and 53% of older adults own smartphones, usage doubling among americans and nearly quadrupling among older adults since 2010 [277, 278] . smartwatches are also growing rapidly. the international data corporation (idc) worldwide quarterly wearable device tracker published that smartwatches accounted for 44.2% of the wearable market in 2018 and is expected to rise to 47.1% by 2023 [279] . prc has published recently a survey showing that onein-five americans (21%) wear a smartwatch or a fitness tracker [280] . a recent study by manini and colleagues [281] about the perception of older adults (65+ years) towards the use of smartwatch technology for assessing pain showed an overall positive view. data collected using smart devices fall under two main categories: active and passive data. the essential difference between these two types is the involvement of participants in reporting data. the active data is described as questions or surveys that a participant has to self-j o u r n a l p r e -p r o o f report at specific times. this data is commonly used for ecological momentary assessment (e.g., pain, mood, or fatigue). in contrast, passive data collection does not require participants to report any data. participants are only required to carry the smart device to be able to continuously collect data through built-in sensors. the type of passively collected data and the quality depend on the availability and modalities of sensors. the most common sensors available are: 1) global positioning sensor (gps) that could be used to measure life-space mobility; which is a measure of the spatial size and frequency of interaction with the surrounding environment; 2) accelerometer that could be used to track physical activity pattern and energy expenditure; 3) microphone that could be used to collect voice samples to be used to extract vocal markers that can serve as a prognostic value for neurological disorders; and 4) call and text logs that can convey information about the size and reciprocity of a person's social network and can also serve as a prognostic value for neurological and psychological disorders. the huge amount of data collected from personally held devices contain hidden, but useful knowledge about the behavior of an individual. fortunately, the advancement of machine learning techniques allowed us to tap into this data and extract patterns. in recent years, sensors embedded into wearable and personal devices such as smartphones have made it possible to develop many mhealth apps, e.g. for tracking physical activity, monitoring blood pressure and heart rate, medication reminders, and many more [282, 283] . some mhealth apps additionally provide just in time (jit) interventions (figure 4) , such as prompting physical activity based on inferred levels of activity or daily steps. a number of recent studies have utilized such mhealth tools in controlled trials to examine mhealth interventions, especially for chronic disease management [284] . several studies have used mhealth intervention tools in cardiovascular and diabetes patients, including the pilot mobile atrial fibrillation (maf) [285] trial (n = 113, cluster randomized design pilot study). as the first mhealth trial of atrial fibrillation patients, maf showed improved drug adherence and anticoagulant satisfaction versus the usual care. in a larger study, the heart failure ii (tim-hf2) trial [286] (n = 1571, randomized parallel-groups), utilized remote monitoring and demonstrated that it could reduce the percentage of days lost due to unplanned cardiovascular hospital admissions and all-cause mortality. in a remote monitoring study, giacomelli et al. [287] showed that remote monitoring after hospitalization for heart failure in older adults had no impact on the primary end-point but it significantly improved patients' quality of life. physical activity promotion also has been examined in several mhealth trials, including the mactive [288] trial which showed that tracking and texting intervention increased physical activity. amorim and colleagues [289] carried out a randomized controlled trial by integrating mhealth, health coaching, and physical activity for patients sufferings from chronic low back pain, demonstrating feasibility and acceptance and a reduction in care-seeking after treatment discharge. other studies have examined mhealth interventions for promoting mental health in clinical trials, including using smartphone cognitive behavioral therapy for refractory depression [290] and smartphone-delivered intervention in patients with a serious and persistent mental health condition, with the improvement shown among patients from racial minority groups [291] . these recent intervention studies and especially controlled trials show promise for the potential scalability and acceptance of mhealth tools. an important but sometimes overlooked j o u r n a l p r e -p r o o f aspect of developing mhealth intervention tools is conducting formative usability evaluation research, besides evaluating efficacy in formal trials. tools must be designed to effectively communicate the proper information by being interactive, interoperable, engaging, and accessible for diverse audiences [292, 293] . therefore, the following attributes should be considered during the development, adoption, and implementation of mhealth tools: 1) ease of use; 2) how the tool fits within the policies, practices, and technical infrastructure of existing health and social systems; and 3) whether intended users can understand and apply the health information provided. performing needs analysis and audience analysis can help guide the design to achieve such objectives [293] . in summary, while mhealth tools may enhance the delivery of some interventions, especially in chronic disease management, evidence regarding their effectiveness for geriatric conditions is still mixed [284, 294] . additionally, most controlled trials have been carried out in high-income countries, and evidence on the effectiveness of such tools in lower-income countries is missing [284] . finally, there is a lack of end-to-end systems for sharing jit intervention results with providers through existing electronic health record (ehr) systems. both humans and animals exhibit an age-dependent progressive decline in mobility [295] [296] [297] [298] . thus, mechanistic studies of age-related mobility impairment in pre-clinical models could advance our understanding of the fundamental mechanisms underlying disability. for example, there is much that can be learned from the study of the simple organism c. elegans. despite its simple anatomy, c. elegans is capable of multifaceted behaviors in response to diverse environmental and intrinsic cues, and exhibits an age-associated decline in locomotion [296, 299] . the multitude of genetic tools available also makes c. elegans an invaluable model system for the study of cellular and molecular mechanisms underlying aging-related locomotor and j o u r n a l p r e -p r o o f movement decline [300] . in c. elegans, the progressive deterioration of muscle occurs with age, which resembles human sarcopenia [301] . importantly, the functional decline of motor neurons at the neural muscular junctions precedes the deterioration of muscle tissues during c. elegans aging [302] , indicating an important role of motor neurons in the age-related mobility impairment. findings from pre-clinical models have led to the identification of important biological mechanisms related to the aging process including mitochondrial function and dynamics [303, 304] , autophagy [305, 306] , oxidative stress [307] , chronic inflammation [308] , muscle composition [309] , hormonal factors [310] , and neurodegeneration [311] . moreover, preclinical studies have led to the transformative discovery that interventions targeting the fundamental biology of human aging have the potential to delay, if not prevent, the onset of aging-associated conditions [2] [3] [4] [5] [6] . ultimately a strong translational geroscience approach is needed to understand the disease-mediated pathways associated with functional decline and identify promising interventions to maintain mobility and physical function (see figure 4 ). as aging research becomes more information-based, statistics plays a critical role in almost all research topics discussed in the previous sections. for any given aging research project, statistical support is needed at almost all stages starting with the formulation of a scientific hypothesis, study design, data collection, data management and analysis, and conclusion making and ending with manuscript writing. often, the earlier a statistician is involved in an aging research project, the more productive the project will become. let us use a specific example to demonstrate how statistics can significantly help aging research. assume that a research project aims to investigate whether an intervention (e.g., a j o u r n a l p r e -p r o o f nutritional supplement) can improve older adults' mobility. to make the hypothesis more specific, we first need to determine major mobility measurements. according to webber [312] , mobility can be measured in five dimensions (i.e., cognitive, psychosocial, physical, environmental, and financial), and there are many different ways to measure mobility in each dimension. if we are interested in all five dimensions and would like to develop a single mobility index or choose some important ones from all possible mobility measures, then some preliminary studies to collect data on these measures are needed. the data from these preliminary studies can be analyzed by statistical modeling and variable selection approaches, allowing us to come up with either a single mobility index or a relatively small number of mobility measures. these variables can then be used as the response variables of the original study. second, the sample size for the study needs to be properly calculated. to do this, researchers need to specify the smallest meaningful difference between the intervention and control groups for each response variable. the next step is to check whether all model assumptions of the related sample size formula are valid. if not, then a new formula needs to be derived, which could be challenging. for data collection, statisticians are vital in determining which study design is best, such as deciding between a double-blinded randomized study or other types of studies. these steps of study design are extremely important to make the collected data useful in testing the major scientific hypothesis. after data collection, much statistical expertise is required to analyze the data and make solid conclusions. during data analysis, proper statistical methods that clearly describe the observed data need to be chosen, all model assumptions should be verified, and develop new statistical methods when necessary. primary care physicians and geriatricians play an instrumental role in the identification of older adults who have or are at risk for impaired mobility. unfortunately, healthcare providers encounter several barriers to the proper evaluation and treatment of mobility issues in older adults. some of these barriers include insufficient knowledge in latest research findings in the field of geroscience, time constraints in busy clinics, lack of needed resources for treatment interventions, weak patient support systems, and even language barriers in some minority communities. despite these barriers, most patients can be quickly and efficiently screened for cognitive concerns and/or mobility issues with validated assessments, such as the "get up and go" test. when appropriate, providers should deliver succinct but impactful counseling on the importance of adopting a healthy diet, practicing regular physical exercises, and obtaining adequate sleep. the use of educational hand-outs can be very helpful for some patients. clinicians should also use available resources for the enhancement of mobility, such as referrals to physical /occupational therapy, ophthalmology, audiology, and massage therapy. there is a need for more educational programs for healthcare providers covering the latest research findings in the treatment of geriatric conditions including impaired mobility. optimal communication between clinical researchers and clinicians might facilitate the prompt implementation of efficacious new treatments. collaboration among academic investigators and community partners also has the potential to increase the relevance of the research and its potential for addressing public problems such as general health disparities [313] and health problems more specific to seniors, such as limited mobility. such collaborations require (a) culturally sensitive, multidisciplinary academic research teams, (b) empowerment of community members through training them to assume leadership in implementing and disseminating research center-tested j o u r n a l p r e -p r o o f interventions and assisting in getting the institutional review board credentials for being equal research partners, (c) paying trained community member researchers as research professionals, (d) mobilizing community resources and partners (e.g., businesses and local officials) to make policy changes to reduce the social determinants of health (e.g., no/limited public transportation in target low-income black communities) that impede implementation and dissemination efforts. interventions shown to be efficacious in research centers are typically implemented and tested under controlled conditions with non-representative samples of motivated participants [314] . there is a need to implement and disseminate efficacious interventions in communities where uncontrollable social determinants of health (e.g., poverty, race and racism) and associated health disparities negatively influence the length and quality of community members' lives. these communities are where seniors, racial/ethnic minorities, the poor, and/or the medically underserved (i.e., health disparity groups) often live. because of this, ideal implementation and dissemination sites in such communities are churches [315, 316] and primary care centers [317] . it is these sites that commonly serve the aforementioned groups, are stable community structures with physical resources (e.g., meeting spaces), and have human resources (e.g., pastors and physicians) who can influence members of health disparity groups to participate in efforts to implement and disseminate health promotion interventions. the empirically supported community-based participatory research (cbpr) approach [318] is useful in implementing and disseminating efficacious interventions in communities in general and in racial/ethnic minority, poor, and/or medically underserved communities in particular. cbpr creates a paradigm shift from traditional research practices that have characterized academics as experts towards a collaborative research process in which academics are also learners [319] . accordingly, the cbpr approach requires that community members be j o u r n a l p r e -p r o o f actively involved in all aspects of the research process, including the selection of the research topic and methodology, participant recruitment, research implementation, data collection, interpretation of study results, and dissemination of research findings [319, 320] . the patient-centered culturally sensitive healthcare (pc-cshc) model [317] , explains the linkages between provider cultural sensitivity and patients' health outcomes and is useful in guiding implementation and dissemination in community-based healthcare settings. notably, cultural sensitivity extends beyond cultural competence and enables patients to feel comfortable with, trusting of, and respected by providers and researchers, and involves recognizing and overcoming biases and stereotypes that these groups have towards to each other [317] . the provider being culturally sensitive is one key aspect of the pc-cshc model and is a major factor in health promotion. further, patients must be allowed to determine what behaviors, methodologies, etc. enable them to feel comfort, trust and respect. the other key aspect of this model is patient and community empowerment. in accordance with the pc-cshc model, implementation and dissemination of research centertested interventions in community primary care sites that serve health disparity groups requiring that patients and community health workers are active partners with academic researchers. for example, patients should ideally be involved in focus groups and/or interviews to identify culturally sensitive strategies for making these efforts successful. community health workers, physicians, and other providers can then (a) implement these strategies and disseminate the target interventions, and (b) participate with researchers in town hall meetings to disseminate information to the community about the impact of these interventions. culturally diverse, multidisciplinary academic research teams can provide the training needed for physicians/providers and patients to be empowered, equitable partners in implementing and j o u r n a l p r e -p r o o f disseminating target interventions. such empowerment by academic researchers is particularly important for patients such as minority, senior, poor, and medically underserved patients with limited actual and/or perceived power to take charge of their health. patient empowerment is the appropriate response to the increasing national calls for social, health, and healthcare justice. can we really slow the decline in mobility that occurs during aging? and can function improve as we age? the good news is that the answer to both questions appears to be an emphatic yes. effective future interventions, however, will need to take into consideration factors across multiple domains, as well as the complex interaction among these factors. findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, can have a dramatic effect on an older person's mobility and function. additionally, several biological and behavioral factors have been identified as directly related to functional capacity. these are exciting times within the field of gerontology with novel discoveries happening across different fields of study that have direct implications for function and/or functional capacity. for example, the discoveries made within the biology of the aging realm have informed of the types of intervention targets that could truly make a difference in an older adult's functional capacity. furthermore, covid-19 has highlighted the importance of self-care and preventative medicine to promoting wellness and extend healthspan. covid-19 has also highlighted the clear need to protect our older population, particularly minority older adults, as there are clear biological and metabolic factors that increase older adults' susceptibility to this condition. additionally, covid-19 has greatly increased the adoption of virtual communication; j o u r n a l p r e -p r o o f thus, the acceptability of technologically based future interventions is likely to be much greater than prior to covid-19. before translating interventions on a broad scale, however, their suitability and effectiveness across a number of domains are needed to help inform decision making. clearly, there is an important need to evaluate safety outcomes, first and foremost, with the next benchmark related to whether such interventions 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physical health outcomes. sage journals community-based participatory research conceptual model: community partner consultation and face validity the three r's: how community based participatory research strengthens the rigor community-based participatory research from the margin to the mainstream: are researchers prepared? circulation key: cord-266239-l0ulr2ep authors: freeman, shannon; marston, hannah r.; olynick, janna; musselwhite, charles; kulczycki, cory; genoe, rebecca; xiong, beibei title: intergenerational effects on the impacts of technology use in later life: insights from an international, multi-site study date: 2020-08-07 journal: int j environ res public health doi: 10.3390/ijerph17165711 sha: doc_id: 266239 cord_uid: l0ulr2ep as the use of technology becomes further integrated into the daily lives of all persons, including older adults, it is important to investigate how the perceptions and use of technology intersect with intergenerational relationships. based on the international multi-centered study technology in later life (till), this paper emphasizes the perceptions of older adults and the interconnection between technology and intergenerational relationships are integral to social connectedness with others. participants from rural and urban sites in canada and the uk (n = 37) completed an online survey and attended a focus group. descriptive and thematic analyses suggest that older adults are not technologically adverse and leverage intergenerational relationships with family and friends to adjust to new technologies and to remain connected to adult children and grandchildren, especially when there is high geographic separation between them. participants referenced younger family members as having introduced them to, and having taught them how to use, technologies such as digital devices, computers, and social networking sites. the intergenerational support in the adoption of new technologies has important implications for helping older persons to remain independent and to age in place, in both age-friendly cities and in rural communities. the findings contribute to the growing literature in the fields of gerontology and gerontechnology on intergenerational influences and the impacts of technology use in later life and suggest the flexibility and willingness of older persons to adopt to new technologies as well as the value of intergenerational relationships for overcoming barriers to technology adoption. from monitoring personal health and wearable devices to playing online games and using social media to connect with friends and family, technology has become a valued component of daily life for many individuals. interest in technology has steadily increased over the past decade, associated with unprecedented growth and innovation in information and communication technologies (icts) [1, 2] . there has been an increase in the proportion of older adults (persons aged over 65 years) in countries across the world utilizing technology [3] . as the use of technology and associated icts increases, there is a greater need to expand the understanding of the intersection of technology, ageing, and intergenerational relationships. a particular gap in knowledge exists regarding the role of intergenerational elements in motivating older adults to learn how to use technology and associated icts. across the globe, societies are aging rapidly due to increased life expectancy as a result of better health and social care, and lower birth rates [4] . recent united kingdom (uk) population estimations suggest the proportion of those aged 65+ years in rural and urban environments will increase by 50% between 2016 and 2039, whilst those aged <65 years are projected to increase by eight percent in urban areas and to stagnate in rural locations [5] . in 2014, 15.6% of the canadian population, equating to over 6 million persons, were aged 65, and it is predicted that by 2030, older adults will exceed 9.5 million persons, accounting for 23% of the canadian population [6] . in canada, the majority of older adults (56.4%) lived with a spouse or a common-law partner in 2011 while about one-quarter (24.6%) lived alone [6, 7] . the increase in the migration of younger cohorts from rural to urban areas and of older adults from urban to rural areas leaves an increased proportion of older adults in rural areas who prefer to "age in place" [8, 9] . research focused on aging in urban areas has emphasized the challenges older adults face in accessibility, especially in access to public transportation, shopping, and green space [10] . as geographic separation between family members increases, the role of icts in helping to strengthen and maintain family bonds becomes more important [11] . however, the extent to which older adults use technologies for this purpose remains unclear. although, in the future, aged cohorts may be more "tech savvy" [12] , having used technologies regularly across their life course, new technologies may still arrive that could be disproportionately challenging for older people to adopt. technology (e.g., digital devices, the internet, digital gaming, and mobile apps) use in later life is a growing field of research, with much new exploration and study [13] [14] [15] [16] . technology and associated icts are often aimed towards improving the health, wellbeing and quality of life of older adults, whether through applications for home healthcare and connected health services [17] , medication reminders [18, 19] , mirrors that display health data [20] , or wearable technology [21] . technology use to enhance communication is routine practice for many older adults, with home computers being used to create a common interest among older and younger family members and improve family ties [22] . technology use among older adults is growing [3] . for example, in canada, between 2007 and 2016, internet use increased from 32% to 68% among those aged 65 and older [23] . in 2016, 85% of people aged 65-69 used the internet compared to 62% of those aged 70-79 and 40% of those aged 80 years and older [23] . challenges with technology have been linked to age, evidenced by differences in use [24, 25] and variation in the learning of technology (computers and internet) between older and younger adults [12, [26] [27] [28] [29] [30] [31] . older adults in canada were less likely than younger adults to perceive technology as useful for communicating with others, making informed decisions, and saving time [23] . several studies reported that internet use is lower among older-aged cohorts than younger cohorts [32] [33] [34] ; however, there is evidence of a cohort effect as there has been an increase in technology use within older-aged cohorts over time [2] . older adults who do use the internet report lower confidence in their ability to do so than younger adults [35] , which may be tied to challenges older adults experience with technology use (e.g., visual difficulties and cognitive declines) [36, 37] . older adults are likely to make more errors and require assistance when learning computer systems and software [36, 37] . previous research suggests that older adults may be "technophobic" [38, 39] and struggle to use technology [2] , as they embrace technology differently and at a slower pace than younger adults [2] , [32, 40] . as the canadian and uk populations age, differences in technology adoption and use across age cohorts may increase, amplifying the "generational gap" [41] . while learning to use technology serves as a rite of passage for today's youth, playing an important role in the self-definition of young adults [42] , this may not be the case for older generations. individuals not born into the current rapidly evolving digital age, sometimes referred to as "digital immigrants", must find ways to adapt to a changing society [43] . rama noted that each "technology generation" may have been affected by common experiences during their formative years that influence behaviours towards and the use of technology [44] . however, these notions are challenged by bennett and maton, who note the diverse range of experience and engagement with technology among youth, as well as by loos, who describes technology use as a spectrum affected not only by life stage but also by socialization and degree of age-related functionality [16, 45] . technology use is complex and can no longer simply be split into user vs. non-user groups. instead, the heterogeneity in the use of technology includes not only use of the technology for an intended purpose but also the meaning and value that the use of technologies has in mediating social relationships and connection to the external world [46] . existing research highlights differences in technology use between the generations; however, research on the connection between intergenerational factors, social variables, and technology use among older adults is less prevalent, with notable exceptions including [26] [27] [28] . however, other research suggests that age is not a consistent driving factor associated with aversion to technology such as computer anxiety [24] . as such, it remains less clear how factors such as intergenerational intelligence, solidarity, and adaptiveness apply to the learning and use of technology, especially by older adults [47] [48] [49] [50] [51] . younger generations are the dominant early users and adopters of social networking sites [12, 52] , with few older adults (between 10% and 27%) using this form of technology [2, 3] . social networking and other technologies present opportunities for older generations to connect with younger generations and individuals in diverse geographic locations [22, [53] [54] [55] . technology has been shown to enhance an older adult's quality of aging [56] , independence [57] , social status [56] , interpersonal relationships, control, self-esteem, and integration into society [57, 58] . to understand how to meet the needs of an aging population in a technology-suffused society, it is useful to understand why older adults choose (or not) to use technology and whether (or not) they perceive the reasons driving their choice as constraints requiring negotiation or benefits to everyday life. the challenges to acquiring new technology skills and strategies for connecting with younger generations to overcome them suggest the importance of intergenerational influences on older adults' understanding and use of technology, which must be further explored. the above findings are concerning in light of research reports that older adults are more likely to experience loneliness and isolation [34] . there is, to date, a growing body of scholarly work exploring the relationships between intergenerational relationships and technology [27, 28] , offering insight into how technology and associated icts lay within and across intergenerational networks. taipale and colleagues [27] discuss ict use through various lenses including both older and younger adults-a generational perspective, the family, and the home. to further extend research in this area, we describe further the relationship between technology use and interpersonal relationships-more specifically, the how older adults' understanding and use of technology is affected by their intergenerational relationships. the technology in later life (till) study examined the experiences of older adults aged 70+ years with technology, exploring how they adopted, accepted, and used various types of technology. subsequently, the team sought to identify the implications of using icts for current and future aging populations in rural and urban locations. the technology in later life (till) study was an exploratory study conducted in canada and the uk across four study sites. canada and the uk were selected for this study as they both have aging populations and exposure to technology and contain different rural and urban populations. in each country, two sites were selected: one rural and one urban. the rural site in canada was the town of mcbride (bc), and the urban site selected was the city of regina (sk). the rural sites in the uk included the village of cwmtwrch and the village of ystalyfera in wales, and the urban site was the town of milton keynes (buckinghamshire) in england. participants were recruited through the use of posters and mailing list scripts tailored to each site distributed to local organizations including the older people's forum, seniors' centers, public libraries, seniors' community newsletters, and local public radio. participants were also recruited through word of mouth in the community. participants each voluntarily contacted the lead investigator for the research site closest to them to request to participate in the study. upon contact, the participants were sent an email containing a link to the online survey, information on the study and a request for written consent to participate, and an invitation to set a date to join a focus group interview. all participants completed the online survey prior to participation in a focus group. the survey was an iteration of an earlier survey [14, 59] , which covered eight domains: (1) technology use, (2) internet ownership and use, (3) social networking, (4) digital device ownership, (5) purchasing patterns, (6) quantified self-and life-logging, (7) information sharing and privacy issues, and (8) demographics. bivariate analyses of the survey data were conducted using spss version 24. an inductive approach was taken to generate new knowledge from the qualitative data. a descriptive approach is beneficial for an initial study, as such an approach allows the researchers to richly describe the phenomenon being studied. focus group discussions, led by the lead researcher from each site, lasting between 40 and 60 minutes, were digitally audio-recorded and then transcribed verbatim in microsoft word by a uk-based transcription company. all the lead researchers were experienced in conducting qualitative research analyses and in leading focus groups. a semi-structured interview guide containing questions and probes was used to facilitate discussion (supplementary materials). the questions examined several areas including the ownership of technology, the purpose for using technology, internet social media use, life-logging, privacy issues and the sharing of information (e.g., what type of information and rationale for sharing), and willingness to embrace new technology (supplementary materials). content and inductive analyses [60] were conducted across all the transcripts. given the exploratory nature of this analysis, the transcriptions were read closely for familiarization with the data, coded, and analyzed thematically. the data were classified into categories as a way of describing key themes [61] . in addition, areas of concordance and discordance were examined through the analysis. specifically, open coding, with the creation of categories and abstraction, was undertaken. coding was first conducted independently by a research assistant, trained in qualitative research methodologies and experienced in conducting analysis, and by a co-investigator, both of whom then came together to come to a consensus on the coding. discrepancies were addressed by recoding areas of discordance, and then, the transcripts were reanalyzed by the research assistant and reviewed by a co-investigator of the study to promote accuracy and trustworthiness [62] . ethics approval was granted by all four institutions. thirty-seven participants both completed an online questionnaire and attended a focus group discussion. this included 20 rural participants (mcbride, canada, n = 10, cwmtwrch and ystalyfera, uk, n = 10) and 17 urban participants (regina, canada, n = 6 and milton keynes, uk, n = 11) from 2015 to 2016. most participants were female (67.6%), retired/not employed (86.5%), and in their late 70s (mean age, 77.4 years). five themes were identified relating to intergenerational relationships. three themes focused on the benefits of intergenerational relationships to support use of technology including 1) motivation for older adults to use technology, 2) use of technology as a facilitator of intergenerational connection and 3) technology use for safety reasons. additionally, two themes focused on the impediments of intergenerational relationships to use of technology including 1) using technology to appease younger family members; and 2) learning how to use technology in later life. all participants used technology, the majority of whom did so on a regular basis (table 1) . nearly all participants used a computer (97.3%) and owned a computer (89.2%). most participants had used a computer for at least 10 years (75.7%) and used a computer more than once per day (62.2%). all participants used a digital device, typically a mobile/cell phone (70.3%), and to share information (82.7%). nearly all participants identified having internet at home (94.3%) and most had used the internet for more than 10 years (75.8%). participants used technology for a variety of tasks including e-mail, word processing, playing games, making telephone calls, online shopping, online banking, sharing information, social networking, searching/checking information, instant messaging, reading, uploading content, and lifelogging. over half reported using social media (54.1%, n = 20) with more canadian participants' self-reporting use of social media when compared to participants from the uk (62.5% vs. 47.6%) ( table 2 ). a primary motivation for participants to use technology was as a "digital gathering place" to communicate with family, especially adult children and grandchildren, and friends. participants communicated through technology in a variety of ways including skype, facetime, e-mail, social networking sites (e.g., facebook), and texting through cellular networks or whatsapp. interestingly, it was common that participants who used technology were taught how to do so by younger family members. the value of digital communication was enhanced when participants' children and/or grandchildren lived far away. "skype is brilliant. i've got a daughter in spain, i've got a granddaughter in spain, i've got a son in the west indies and a daughter in london, and skype is one of the most brilliant things that's happened because you can see, you can talk." [mk6, male]. "i've used skype because my daughter lives in south africa, but it's an atrocious service because south african broadband is atrocious. we now use apple facetime and that is far superior." . it is also useful to note that participants adjusted the platforms they used not only due to personal preferences but also in response to the variance in the infrastructure and broadband support across the locations. older adults reported using technology to connect with friends and family members, and to share information, also likely with family members. participants often used computers for email (85.3%) and social networking (38.2%), most often in their own home (97.1%) and occasionally at an adult child's home (17.1%). social networking sites were used to stay connected with children and/or grandchildren and friends, to share photos and information with friends and/or family, and to keep up to date with news. the internet was used for sending/receiving e-mails, social media, making phone calls through skype/viber, and instant messaging. older adults both created and sent content (e.g., photos and emails), as well as receiving content. it was both older adults and their family members/friends who took turns initiating contact. most participants identified that they used technology to write or speak with other family members; there were a few instances where participants reported using technology to partake in and share the hobbies of younger family members. older adults were keen to try new things with their grandchildren such as interactive videogames and immersed themselves in the flow of the games. one participant noted, "[ . . . ] jumping up and down to the things that they've got on the screen when you play tennis or jump up and down and dance, or whatever you're chasing, something. yes. video games, i suppose. childish ones." [mcb2, female]. another participant used her daughter and granddaughter's ipad to take pictures of the community garden. participants suggested that technology is not only used to connect and communicate with younger family members but also to learn about and actively participate in activities with younger generations. of the participants using technology to stay in contact with family, some also acknowledged having started using a digital device for safety reasons at the suggestion of another family member, commonly an adult child. most participants reported owning a mobile device or cell phone, many of whom owned these devices for "safety" [regina2, female] and "emergencies only" [mk5, female]. one participant living in rural british columbia described how they started using a digital device specifically for driving purposes as well as feeling the need to maintain a sense of peace with their adult children. "i got the cell phone because my kids kept thinking something was going to happen to me. i said, "well you know if i have a breakdown on the highway, we managed for 70 years for god's sake by just stopping someone and they'd help you. but now, "oh my god they could murder you." so, this was supposed to be a safety element to keep peace in the family." [mcb1, female]. this participant further described displeasure with the cell phone because it cost them money each month and they never used the device. several participants identified that they got digital devices at the suggestion of an adult child after having suffered a health scare. for example, when asked why they got a cell phone, one participant replied, "oh, well it was the bright idea of my son. i had a mini stroke . . . ever since, but they're [kids] always frightened . . . of a recurrence. so, my son gave me a cell phone, his old one, which i used right away, or more or less. i think, they decided that i should have one, because i did get a few dizzy spells. so, now i just use it" [mcb2, female]. even though it was often a younger family member, such as an adult child, who suggested the participant carry a digital device for safety-related reasons, most participants had positive perceptions of using technology for such reasons. for example, one participant spoke positively of how they wore a certain piece of technology that they can press in an emergency situation to notify a family member or emergency service that help is needed. while it seems that most participants use technology to keep in touch with younger family members, the reasons for this contact vary, from safety and emergency situations to routine check-ins with children and grandchildren. in some instances, participants seemed to use technology to make a younger relative happy even if they did not seem to need the technology. for example, "i don't even have an iphone or ipad so i'm really out of date . . . i will get more modernized so that my children will be happy" [regina2, female]. another participant stated, "i've got a tablet that i was to take away with me because my grandchildren said it would be useful to have and i wouldn't be using theirs whenever i'm away on holiday with them. i don't get on terribly well with a tablet . . . " [mk2, female]. common responses for why participants owned technology included similar motivations, stemming from the children: " . . . the kids decided we should have one [computer]" [mcb4, male] and that their grandchildren were putting pressure on them to keep up with the latest technology. furthermore, one participant explained that they were learning technology because the " . . . grandchildren push me and they go, 'oh nana, you're so far behind, you should be up to date and you should be doing this and doing that.' so, they want me to be up to date with all the latest technology and i'm not." [regina3, female]. in certain cases, younger family members purchased technology for older family members as gifts. one participant reflected on a life logging device they owned, explaining, "my daughter bought it for my birthday . . . " [wales1, female] after her husband began experiencing a health decline. these examples illustrate, across the different study sites, how the respective participants felt about technology and how digital devices had been implemented into their lives without consideration of their respective feelings, needs, and choice. many participants used computers as integral components of their jobs decades ago and were among the early adopters of computing technologies. one participant who was familiar with computers explained that they used to do it at milton keynes college. similarly, a participant from mcbride learned the fundamentals of using a computer for their accounting position, explaining that they learned about spreadsheets. however, with the rapid pace of technology development, the technological skills participants had employed prior to retirement became quickly outdated. participants described that the challenges in keeping up with the rapid pace of changes in the technology itself were compounded by their frustrations in keeping up to date on the expanded language used to describe the technologies. participants described the complexity in language and terminology used in technology tutorial classes and instruction manuals as too complicated and inhibiting their ability to adopt new technologies. one participant identified that instructors at computer classes "go way too fast for me. i can't keep up; there is too much new information . . . the language like computer and technological language is totally different from what we were raised with" [mcb2, male]. another participant identified similar grievances about learning to use technology, such as the fact that they "can't understand technology words" [mcb1, female] in instruction manuals and that when speaking with information technology (it) specialists, the it specialist would explain too quickly. although participants noted how they were confused about how to use technology, they still managed to do so, most commonly with assistance from younger family members. participants were frequently introduced to digital devices and to social networking sites by a relative or adult child. participants alluded to younger family members playing a key role in the learning process, saying things such as "my son set it [skype] up . . . " [mk2, female] and "oh, my daughter is the one that does all the computerizing. she helps . . . " [mcb2, female]. they emphasized that they were not technophobic or averse to use of the technology itself but felt outpaced by the speed of change of technology. for many, they were unable to overcome the language barriers created to adapt and adjust to changes in technology on their own or with those of a similar age. instead, they would connect with younger generations for help. where confusion over technology existed, younger family members took on a teaching role, especially for newer technologies such as digital devices and social networking programs. "i ask my grandchildren. 'okay, how do i do this?' they say, 'don't you know?' but they will help me eventually" [regina3, female]. younger generations were able to bridge the technology gap and communicate complex language in lay language that was non-threatening. "anything i want to know, i have to phone up my sons or my grandchildren because they're a lot more knowledgeable than i am . . . " [mk1, female]. even after being introduced to technology and learning how to use it, participants continued to contact their adult children and other relatives for assistance when faced with difficulties. for instance, one participant stated that "my son is an it expert. if i have any problems, 'can i speak to the it man please.' he knows it's me. he sorts my problems" [mk3, female]. some participants seemed to solely rely on younger family members for information when necessary. for instance, one participant concluded, "if i need to know something, i will get my daughter to look it up on her, whatever thing she packs in her pocket" [mcb4, male]. for many older adults, intergenerational relationships are leveraged to support the understanding and use of technology. the challenges in the adoption of and adaptation to the rapid developments in digital technologies facilitate opportunities and meaningful purposes for participants to connect and communicate with younger generations. the leveraging of technologies, including social media and virtual communication platforms, supported older adults in maintaining and enhancing social connections, especially with adult children and grandchildren who lived in different cities and countries. these findings support the idea that the use of digital technologies can enhance social connectedness across generations; as taipale noted, "[ . . . ] distributed families can today nevertheless remain connected and feel a sense of togetherness, even when their members are not physically close to one another" [28] . the benefits of intergenerational relationships for technology, including motivation for older adults' use of technology and the use of technology as a facilitator of intergenerational connections, underlie each domain of the who checklist of essential features of age-friendly cities [63] . furthermore, this reinforces the need for a revised smart age-friendly ecosystem framework as coined and posited by marston et al. [10] , who proposed an extension, noting that these features also apply to the rural, and non-urban, context. the desire to mitigate the digital divide fuels older adults' motivation to invest time in building and fostering intergenerational digital connections. previous research similarly suggests that computers are commonly used by older adults as a method of communication with younger generations, serving as a gateway to the world of younger family members and a means to strengthen relationships [64] . studies show that individuals will often play games, not because of enjoyment of the game itself, but because of the social interaction with others with whom they are playing [65] . therefore, when creating an age-friendly environment or helping older persons to age in place, it is worthwhile to challenge those designing built environments to consciously address how they may seize opportunities to effectively and efficiently leverage icts to facilitate intergenerational engagement. older adults leveraged technology to connect, communicate, and actively participate in the interests and hobbies of their adult children and grandchildren in online formats, including digital gaming and photography. participants encouraged and enjoyed interacting with younger family members to learn about different technologies (e.g., digital games) as a way of immersing themselves in the culture of younger generations. as previous research illustrates, participants in this study were using digital games as a "computational meeting place" that supported meaningful social interactions and shared motivation for group gaming [66] . further evidence shows that gaming technologies foster intergenerational group interactions of up to four generations, including adult children and extended families [67] . our study revealed findings similar to those noted above but for multiple digital technologies, which suggests a more universal and generalizable use of technologies among older adults to increase intergenerational family social interactions as a "digital gathering place". health limitations, the costs of transportation, and social isolation can create barriers for travel, all of which might explain why communication technologies such as skype were often used to connect with family members. these technologies can come close to replicating the face-to-face experience of conversing with another person and are an effective communication method to use when travel is not an option. the extended value of the support of intergenerational connection may be further amplified given the context of covid-19 and in the post-covid-19 context. language and terminology often impede the ability of older adults to learn how to use technology. this disconnect and incomplete understanding of technological language could explain why few respondents identified using social media/networking sites but went on to further indicate they do in fact use this form of technology. this discrepancy in responses may stem from a lack of clarity in the question about what social networking entails for the respective participants, or this may reflect a lack of recognition by older adults that they did in fact use social media/networking platforms. despite these complications, participants were able to use technology and associated icts by learning to do so with their adult children and grandchildren, who were able to translate the jargon and technical terms used in information technology courses into a language that older adults could understand within the context of intergenerational relations. this is consistent with the findings from previous studies showing that adult children often initiate the technology use process for older adults and that extended family members (such as grandchildren) are important educators for older adults as they learn to use technology [64] [65] [66] [67] [68] [69] . intergenerational informal education between those with existing relationships may be more effective for knowledge/information exchange. when considering why adult children and grandchildren were common educators, there are a few ways to explain this finding. first, older adults might feel more comfortable learning from family members due to feelings of trust. second, as it was often adult children and other relatives who introduced participants to technology, it makes sense that they would be the ones providing the lessons and education. third, participants may have been learning from younger generations because they may have a greater knowledge of technology, having grown up in the information age. fourth, older adults might choose to learn from younger family members as they use less confusing terminology (compared to user manuals or classes) and they are comfortable enough to ask questions. many older adults in the present study used technology comfortably and were among the early adopters of computers and technology. the role younger generations play in guiding and motivating older adults to use technology may contribute to family cohesion and strengthen relationships. this supports the notion of the "change in family roles" put forward by taipale [28] , who highlighted the variance of perception between italian and slovenian contexts. nearly all participants reported using a computer at their own home, but other locations such as an adult child's home were also identified. studies have shown that, among older adults who use computers, a majority do so in the comfort of their own home, although computers are also used in public locations such as at work, in a library, or at a friend's/family member's home [14, 37, 53, 70] . computers might be used at an adult child's home because this is where the learning and introduction to technology take place. however, this pattern of usage could also be indicative of locational convenience, access to computers, privacy issues, what the computer is being used for, or another combination of variables. these preliminary findings point to the importance of investigating further how these intergenerational factors influence the location of technology use. even though participants highlighted the many benefits and uses of technology, some participants remarked on the drawbacks and risks of living in the digital age. the finding that older adults often chose to use computers for leisure to share information and communicate, whereas cell phones were often used to appease worried children, suggests both positive and negative associations of technology. for instance, surveillance and privacy issues, along with digital crime, are risks of using certain technologies [71] . despite the existence of privacy legislation, there exist privacy threats with the use of technology, such as the tracking of personal information, profiling, and privacy-violating interactions [72] . despite voiced concern over privacy issues, participants continued to use technologies because of the benefits, such as bridging geographical distances to communicate with younger family members. as such, it seems the rewards outweigh the risk for older adults to use technology. nonetheless, the acknowledgment of such risks by participants draws attention to the importance of providing clear education communicated in lay language on how to safely use technology. this research specifically addressed intergenerational elements of technology use among individuals in both rural and urban areas in two countries. research often overlooks social elements of technology use, viewing technology engagement as a solo activity. a strength of this study is the combination of an in-depth online survey and focus groups, which allowed for a deeper understanding of the topics being studied. upon further validation, the survey could be used in future studies as a standard measure of technology use, social media habits and behaviour, information sharing, and privacy issues. given the exploratory nature of the study, a small sample was acceptable as the aim was for each site to recruit 10 participants. although our sample sizes enabled us to reach saturation of information, a larger sample is needed to confirm our findings. differences in the recruitment methods across sites may have contributed to the difficulties of achieving the targeted number of participants. future studies should recruit participants who use and who do not use technology to compare and contrast their behaviours and identify further barriers to and enablers of technology use in later life. further investigations may extend this work to examine the intersection of technology and intergenerational relationships among older adults who are aging without family to expand the understanding of the roles that peers, friends, or even siblings play in comparison to that of adult children [73, 74] . at a time when technology development and population aging research are prevalent, it is vital to capitalize on opportunities to learn about how technology can be used and deployed to increase social connectedness, improve the quality of life of older adults, and support aging in place. with rapid technological developments occurring, there are great opportunities to expand the understanding of gerontechnology and human-computer interaction from a multi-disciplinary standpoint. technology has the potential to play an integral role in ensuring all attributes complement each other and keep knowledge up to date. many participants used technology to maintain social connectedness with younger family members who were geographically dispersed. the findings from this study provide insight into the strengths and opportunities that technologies provide to older adults. understanding how intergenerational relationships impact technology use in later life can inform further research and technological and social practices. tech adoption climbs among older adults. pew research center media use in the european union older adults and technology use world 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processes of learning to use computers internet use among midlife and older adults: an aarp bulletin poll digital crime and digital terrorism privacy in the internet of things: threats and challenges the lived experience of older involuntary childless men ageing without children, gender and social justice we would like to thank all participants who agreed to take part in this study across the different study sites. the authors declare no conflict of interest. key: cord-288479-ti9x8p6m authors: cobo, antonio; villalba-mora, elena; pérez-rodríguez, rodrigo; ferre, xavier; escalante, walter; moral, cristian; rodriguez-mañas, leocadio title: automatic and real-time computation of the 30-seconds chair-stand test without professional supervision for community-dwelling older adults date: 2020-10-14 journal: sensors (basel) doi: 10.3390/s20205813 sha: doc_id: 288479 cord_uid: ti9x8p6m the present paper describes a system for older people to self-administer the 30-s chair stand test (cst) at home without supervision. the system comprises a low-cost sensor to count sit-to-stand (sist) transitions, and an android application to guide older people through the procedure. two observational studies were conducted to test (i) the sensor in a supervised environment (n = 7; m = 83.29 years old, sd = 4.19; 5 female), and (ii) the complete system in an unsupervised one (n = 7; age 64–74 years old; 3 female). the participants in the supervised test were asked to perform a 30-s cst with the sensor, while a member of the research team manually counted valid transitions. automatic and manual counts were perfectly correlated (pearson’s r = 1, p = 0.00). even though the sample was small, none of the signals around the critical score were affected by harmful noise; p (harmless noise) = 1, 95% ci = (0.98, 1). the participants in the unsupervised test used the system in their homes for a month. none of them dropped out, and they reported it to be easy to use, comfortable, and easy to understand. thus, the system is suitable to be used by older adults in their homes without professional supervision. the present paper describes a system for older people to self-administer the 30-s chair stand test (cst) at home without supervision. the system comprises a low-cost sensor that automatically detects and counts sit-to-stand (sist) transitions in real-time, and a home care application that guides older people through the whole procedure. since using novel technologies is not a trivial issue for older adults, we studied whether such a system would be able to match older people's abilities and expectations, so they can use it without supervision. the 30-s cst is a medical exam used to assess older adults' lower-limb strength [1] . it requires a subject to spend thirty seconds repeatedly standing up from, and sitting down on, a chair, with his arms folded on his chest, as fast as possible [1] . the number of times the said subject reached an upright position is then taken as a proxy to lower-limb strength [1] . it is used in combination with other medical exams to assess the functional status of older people. depending on the results of such a functional assessment, older people may be diagnosed as robust, pre-frail, or frail [2] . frailty is a state of increased vulnerability to low power stressors, leading to difficulties in maintaining homeostasis that increases the risk of disability and other adverse outcomes, such as falls, hospitalization, permanent institutionalization, and death [3] [4] [5] [6] . in fact, frailty is a major predictor of disability, with frail elders showing twice the risk of disability than non-frail older adults [7] . disability is one of the major challenges for elderly care, because improvements in life expectancy are not coming together with similar improvements in impairment-free life expectancy (ifle); on the contrary, a decline in the latter has even been observed in some countries [8] . disability imposes a heavy psychological and economic burden on older people and their relatives over a long time; fortunately, frailty, which may precede the development of disability by several years [2] , can be reversed [9] [10] [11] . hence the paramount role of frailty detection in the prevention of disability. several models have been proposed to explain frailty, with two of them prevailing as major approaches, namely, rockwood's deficit accumulation model [12] [13] [14] and fried's phenotypic model [2] . the latter is the most widespread, and identifies the following markers of frailty: (i) weight loss, (ii) exhaustion, (iii) weakness, (iv) slowness, and (v) low physical activity [2] . an older adult is classified as pre-frail if he tests positive to one or two of the frailty components in the phenotypic model, and as frail if he tests positive to three or more of them; otherwise he is classified as robust [2] (see table 1 ). table 1 . the phenotypic model for frailty involves the assessment of five different components (weight loss, exhaustion, weakness, slowness, and low physical activity); and then diagnosing the subject as robust, pre-frail, or frail, according to the number of components that resulted positive in the tests: robust (green rows) for zero components, pre-frail (yellow rows) for 1 or 2 components, or frail (red rows) for 3, 4, or 5 components. he is diagnosed as: 0 components robust. 1 component 2 components pre-frail. frail. frail older adults can reduce their levels of frailty, and even be restored back to robustness, with exercise-based interventions, especially if combined with early diagnosis and continuity of care [9, 11, 15] . many different instruments are currently involved in the diagnosis and assessment of frailty. for instance, hand grip strength is used to assess weakness, in fact, the data in the original study of fried et al. came from hand grip strength measurements [2] , but it has also been explored as a measurement of overall frailty on its own; just as the stand up and go (tug) test, which is a standard test for gait speed [6] . on the other hand, other sources of weakness measurements, such as those based on lower-limb strength, have been observed to be associated with either hand grip strength, gait speed, and even overall frailty [16] . in fact, instruments to assess lower-limb strength, such as the 30-s cst [1] , and the sts5 (measuring how long it takes for an older person to repeatedly stand up from a chair five times) [17] , are usually included as part of a comprehensive geriatric assessment (cga). both early diagnosis and continuity of care require frailty to be frequently assessed in search of early signs of functional decline. for instance, if two consecutive measurements of lower-limb strength taken two weeks apart with the 30-s cst show a decrease bigger that a given threshold, an alarm should be raised. however, it is not feasible to assess every older adult at risk of developing frailty every two weeks with the currently available means to conduct the functional assessment exams. most of them require the involvement of a specifically trained professional in a geriatrics department to supervise their execution, and compute their corresponding scores. obviously, a geriatrics department in specialized care cannot afford to undertake such a screening task. in fact, they should be focusing on taking care of the most severe cases. as a result, older people do not have their functional capacity assessed for early signs of frailty very often. automatic sensors that do not require the involvement of any specifically trained personnel could help to alleviate this problem. on the one hand, a single staff member in a geriatrics department could supervise several tests on multiple patients simultaneously. on the other hand, and probably involving a bigger potential impact, general practitioners or nurses in primary care could add functional assessment to routine follow-ups of their older adult patients. the potential benefits of such automatic sensors become even more remarkable within the current context of the covid-19 pandemic. olde people are at greater risk of developing severe complications and dying from covid-19 [18] . therefore, they have been advised to carefully comply with distancing measures to lower the risk of transmission. however, distancing measures favor social isolation and sedentary behaviors. such sedentary behaviors increase the risk of developing frailty [19] , and have been hypothesized to persist and become habits, based on observations from previous natural disasters, in particular, from the three years following the 2011 earthquake and tsunami in east japan [20] . in such a scenario (i.e., fewer visits to the doctor and increased risk of frailty due to sedentary behavior) older adults would benefit from having automatic sensors to conduct functional assessment exams at home, on their own or helped by their care givers. in the particular case of the 30-s cst, the setup is rather simple; it just requires a regular rigid chair to repeatedly stand-up and sit-down, and a timer to control the duration of the test [1] . nevertheless, a trained professional is required to judge which sist transitions are valid and must be added to the final score. valid sist transitions occur when the subject reaches an upright position [1] . however, some older adults suffer from mobility constraints, and upright positions might differ from one subject to another. a 30-s cst is not a transparent procedure embedded into people's daily lives. it requires older adults to interrupt their daily activities and go through a specific sequence of actions. our approach involves a system that comprises an automatic sensor and a home care application to guide older adults through the procedure. one of the determinant factors of such a system is the specifics of the sensing device. according to millor et al., the study of sist and stand-to-sit (stsi) transitions with inertial sensors can be traced back to the mid-1990s [21] ; in particular to kerr et al., in 1994 [22] . over half of the works that millor et al. reviewed were based on the assessment of daily life activities [21] . only a few of them involved the assessment of repeated sist/stsi cycles in traditional tests for frailty assessment [21] . while some works relied on the use of multiple devices on different parts of the body, a low number of devices is recommendable to simplify the setup, lower the cost, and eventually improve acceptance and adoption. a very popular approach is to place a single inertial measurement unit (imu) on the subject's lower back (l3-l5 region), close to the body center of mass, and take advantage of the quasi-periodic nature of the body movement [23, 24] . this approach is exemplified in the works of van lummel et al. (where the authors apply it to the sts5) [23] and millor et al. ( where the authors apply it to the 30-s cst) [24] . in particular, van lummel et al. developed a fully automated method of processing repeated sit-to-stand-to-sit (sts) cycles [23] . they used triaxial acceleration and triaxial angular velocity signals from a single imu device (dynaport) on the lower back to compute trunk pitch-angle and vertical velocity signals. they used the morphological properties of the trunk pitch-angle signal to identify and delimit the sub-phases and transitions in repeated sts cycles. they used the vertical velocity signal to spot and discard failed attempts. however, they do not explain which features of the vertical velocity and which criteria were used to classify an attempt as a failure. on the other hand, millor et al. developed a fully automated method to process repeated sts cycles in a 30-s cst [24] . they computed vertical velocity and vertical position from the vertical acceleration signal, from a single imu device (mtx orientation tracker-xsens technologies b.v. enschede, netherlands) on the lower back. they applied double integration, combined with fourth-level polynomial curve adjustment and cubic splines interpolation. they used the morphological properties of the vertical position signal to identify and delimit complete sts cycles. a complete sts cycle can be found between two minima in the vertical position signal. they also used the mtx's onboard kalman filter estimation for the x-orientation, and combined it with the vertical acceleration, the vertical velocity, and the vertical position signals to identify the sub-phases (i.e., impulse, stand up, and sit down) within each sts cycle. in a subsequent paper millor, lecumberri, gómez, martínez-ramírez, and izquierdo argued that they automatically detected failed attempts "... based on a threshold applied to both the time elapsed between a maximum and a minimum of the z-position and to their difference." [25] , (p. 4). however, they did not clarify what the values for these thresholds were nor how they were computed. in both cases, the authors complemented their studies by computing multiple kinematic parameters, such as transition duration (td), maximum and minimum values of the vertical acceleration (max., min., v-acc.), area under the curve (auc) of v-acc., and roll range, and processed them to obtain additional information beyond the test score [25] . van lummel et al. were able to identify seat-off and seat-on instants [26] , establish a relationship between the subjects' stand up strategies and their overall muscle strength [27] , and compare the sensitivity of stair ascending (sa) and leg-extension power (lep) to detect age-related changes [28] . when they analyzed the associations between clinical outcomes (both health and functional outcomes) and the functional tests results, they observed stronger associations for their instrumented sts5 test than for manual records [29] . on the other hand, millor et al. were able to detect differences in frailty status (robust, pre-frail, frail) across different subjects directly from their kinematic parameters [25] . they even identified the set of most informative parameters (i.e., anterior-posterior (ap) orientation range during the imp phase, maximum vertical acceleration and vertical power peaks during sist phase, and total impulse during the stsi phase) [30] . in fact, they claimed that these parameters outperformed the number of completed cycles in the 30-s cst, as a criterion for frailty classification [30] . other locations for the sensing devices, such as the chest, have also been explored [31] . recently, in that line, jovanov, wrigth, and ganegoda presented some preliminary results from their automated 30-s cst [32] . instead of attaching a sensor directly to the subject's chest, they took advantage of the fact that the 30-s cst requires the subject to fold his arms over his chest, and used the inertial sensors onboard a smartwatch. they used 3d acceleration signals from two different models (fossil gen 4 and polar m600). they obtained excellent reliability between automated and manual counts, with little processing load. however, their experimental subjects were not older adults (12 subjects, mean age: 39.1 y.o.). they did not provide any explanation of the sts cycle identification and delimitation criteria and algorithms, and they did not mention any mechanism to spot and dismiss failed attempts. lately, we have explored a different approach ourselves by using an ambient sensor instead of a body-worn sensor [33] . in our study we explored " . . . the feasibility of using the quasi-periodic nature of the distance between a subject's back and the chair backrest during a 30-s cst to carry out unsupervised measurements based on readings from a low-cost ultrasound sensor" [33] , (p. 3). our sensor comprised an ultrasound sensing module, an arduino controller board, and a wireless communications module. all three of them were integrated into our own design for a portable device that the end-users could attach to the backrest of any regular rigid chair. we observed older people to generate very noisy signals. we applied a moving minimum filter to cancel the effects of said noise and an adaptable threshold to tell the difference between sitting and standing regions in the signal. even though intra-class correlation coefficients showed good levels of reliability between the sensor outcomes and the trained professional's manual counts, the differences between these outcomes resulted in the performance of some subjects not being correctly classified as average, better than average, or worse than average. in the present paper we come back to the body-worn sensor approach. we propose to measure the thigh angle with respect to a horizontal plane perpendicular to the direction of gravity (i.e., tilt) with a single device on the subject's thigh itself, and to use the variation of the angle as the subject stands up and down over time to identify sist and stsi transitions. measurements of the thigh angle from a single device have already been used in previous literature to study sist and stsi transitions, mostly to identify different postures and activities (sitting, standing, walking, ramp or stair ascending, etc.) while performing activities of daily living (either in controlled lab settings or in free-living conditions) [34] [35] [36] [37] . however, we have not found any descriptions of an instrumented version of the 30-s cst based on this approach. the accurate estimation of tilt based on imu readings relies on the fusion of accelerometer and gyroscope data [38] . smartphones come equipped with imus and relatively high computing power. however, smartphone adoption among the geriatric population (i.e., people over 70 years old) is low, especially among low-income and low-education elders, because they use much simpler and cheaper mobile phones. smartphones would be too expensive, and oversize, for the single purpose of being used as a sensor; since a home kit for frailty monitoring usually comprises multiple sensors, devices of a much lower cost are required. kalman and complementary filters are the most widespread data fusion methods for imu-based applications [38] . kalman filters are computationally expensive and, as stated by abhayasinghe, murray, and sharif bidabadi, 32-bit microcontrollers with a digital signal processor (dsp) are necessary to run them in real time [39] . conversely, the algorithm for the complementary filter is much simpler and, even though it involves the computation of an arc tangent, can be run on much cheaper 8-bit microcontrollers in real time [39] . according to tognetti et al., making use of a simple accelerometer instead of a complete imu may contribute to further decreasing the complexity and cost of the sensing device [40] ; however, the complementary filter still relies on fusing accelerometer and gyroscope data. fortunately, tilt can be estimated solely from accelerometry if the main contributor to the accelerometer readings is gravity. during a 30-s cst, however, an accelerometer will be exposed to sudden acceleration and deceleration forces when reaching the upright and sitting positions. thus, the question remains whether the resulting noise will harm the correct identification of valid transitions. on the other hand, using novel technologies is not a trivial issue for older adults. moreover, the sensors described above have been tested in controlled settings, under the supervision of their corresponding research teams. we have found no works reporting older adult's performance when using this kind of automatic sensors on their own. our approach involves a system that comprises an automatic sensor and a home care application to guide older adults through the procedure. thus, the question remains whether such a system will match older people's abilities and expectations so they can use it without supervision. we implemented our own design for a low-cost sensor for counting sist transitions, which estimates the thigh angle solely form the readings of a single accelerometer. in addition, we implemented a home care app for android that guides the older adults throughout the whole procedure. we first tested the sensor in a supervised environment, and then we tested the complete system in an unsupervised one. to test the sensor, we studied the impact of noise by analyzing the statistical significance of the estimated probability of finding harmless noise in a valid sist transition. we observed the noise in all the valid transitions in the critical scenario (i.e., test scores around the value used to spot patients not fit enough to remain independent) to be harmless. we then delivered the complete system to seven older adults' homes for a month, and conducted an acceptability study. the participants reported finding it easy to use, feeling comfortable using it, understanding the features and functionalities of the app, and feeling able to use it on their own. the sensor was tested in an observational study, described in section 2.1, where the participants used it while taking a 30-s cst, under the supervision of a trained member of the research team. the home care system was tested in another observational study, described in section 2.2, where the participants used it to take several 30-s csts over the course of a month, at their own homes and without any kind of supervision. seven older subjects (age: m = 83.29 years old, sd = 4.19; gender: 5 female and 2 male) were recruited from a pool of participants that expressed a general interest in participating in research studies from the university hospital of getafe. all subjects gave their informed consent for inclusion before they participated in the study. the study was conducted in accordance with the declaration of helsinki, and the protocol was approved by the ethics committee of the universidad politécnica de madrid on 9 may 2019 (positive: maintaining and improving the intrinsic capacity involving primary care and caregivers). the following inclusion and exclusion criteria were applied: • a subject could enter the study if all the following inclusion criteria applied: • the subject is willing and able to give written informed consent for participation in the study. the subject is 70 years old or older. the subject is able to perform the 30-s cst in a safe way. the subject has not been diagnosed with cognitive impairment. • a subject could not enter the study if any of the following exclusion criteria applied: • subjects suffering from any major disability. • subjects suffering from cognitive impairment. the overall setup is depicted in figure 1 , and consisted of a regular rigid chair with a backrest, an instance of the wearable device under study, and a tablet device. the chair played the same role as usual in any regular 30-s cst. the subjects wore the sensing device on one of their thighs. the sensor is longitudinally aligned with the subject's femur and tightly attached to her thigh with a velcro strap as shown in figure 2 . since the sensor is sensitive to orientation, a green sticker was attached to one of its ends to signal which one has to remain closer to the knee. however, it is not visible in figure 2 , because once the sensor is put in place and secured, the velcro strap covers it. the tablet hosts an app to control the sensor, and it is paired to the latter via bluetooth. a member of the research team used the app to switch the sensor into either calibration or measurement mode, and to visualize the sensor automatic count at the end of each 30-s cst. in calibration mode, the readings from the accelerometer in the device are used to compute the thigh angle in both a sitting and an upright static posture, as a measurement of the subject's mobility constraints; then, the parameters in the automatic count algorithm are set accordingly to a personalized value. in measurement mode, the subject takes the 30-s cst itself, and the accelerometer readings are processed by the automatic count algorithm (aka sts analysis algorithm). finally, the sensor sends the automatic count to the tablet via bluetooth once the test is over. further details about the sensor hardware, the automatic count algorithm, and the tablet app can be found in sections 2.1.2.1 to 2.1.2.3, respectively. the wearable sensor is placed on the subject's thigh longitudinally aligned with her femur. the sensor is tightly attached to the subject's thigh with a velcro strap to prevent it from sliding. the led in the sensor is turned off when the subject is sitting; (b) and it is turned on every time a valid sist transition is detected. the device consists of three main building blocks, as shown in scheme 1. these blocks are, from left to right: scheme 1. schematic block diagram of the interconnection between the device components. the arduino nano board (center) acts as the control and processing unit, collecting readings from the accelerometer (sparkfun block on the left), computing the estimations of the thigh angle over time, and analyzing the resulting signal. the arduino nano board also makes use of the bluetooth module (hc-06 block on the right) to exchange messages with the external mobile device over a wireless communication channel. the whole device was powered by a 9v 6lp3146 battery. while the arduino nano board was directly powered by the battery, the accelerometer and the bluetooth boards were indirectly powered by connecting them to the arduino's 5v and 3.3v dc outputs, respectively. the battery was omitted in this scheme for the sake of clarity. an accelerometer (a sparkfun 9dof sensor stick board with an lsm9ds1 imu chip). this sparkfun board comes with a nine degrees of freedom imu (i.e., it comprises a triaxial accelerometer, a triaxial gyroscope, and a triaxial magnetometer). however, we did not use the gyroscope and the magnetometer because, as explained in section 2.1.2.2, acceleration readings are enough to compute an estimation of the thigh angle. • a control and processing unit (an arduino nano board with an atmega328p microcontroller). the arduino board acts as the processing unit in the device thanks to its onboard micro-controller. our processing algorithm runs on board the arduino, and is responsible for collecting the accelerometer readings, computing the estimations of the thigh angle over time, and analyzing the resulting signal to automatically detect and count sist and stsi transitions in real time, without storing or transmitting the individual samples. • a communications unit: (hc-06 bluetooth 2.0 + edr module). end users (in this case, the researcher conducting the experiment) control the behavior of the sensing device by interacting with a mobile app in an external tablet device. this communication unit enables wireless communication between the two devices via bluetooth. the researcher can issue calibration and measurements commands to the sensing device, and the latter automatically sends the results to the tablet once a 30s-cst is over. the device is powered by a 9 v battery (6lp3146). however, only the arduino nano board was directly powered by this battery. the accelerometer board was powered by connecting it to the arduino's 5 v dc output, and the bluetooth board was indirectly powered via the arduino as well, by connecting the bluetooth board to the arduino's 3.3v dc output. the device also has an on/off switch, a led, and a vibrator. the color of the led helps to tell the difference between calibration mode and measurement mode. once the device enters into measurement mode, the vibrator tells the subject when to start and stop the test. all these additional elements (the battery and its corresponding case, the on/off switch, the led, and the vibrator) were omitted in scheme 1 for the sake of clarity. the sts analysis algorithm itself involves two steps. first, the thigh angle is estimated in real-time as the acceleration samples arrive. the thigh angle in the 30-s cst was defined as the angle between the subject's thigh and a horizontal plane perpendicular to gravity (e.g., the seat of the chair), as shown in figure 3b . during a 30-s cst, this angle is expected to vary over time between 0 • in the sitting position ( figure 3a ) and 90 • in the upright position (figure 3c) . the thigh angle can then be computed from the gravity readings of the accelerometer on the subject's thigh, as demonstrated in figure 4 . the thigh angle (red angle, dubbed as alfa) is equal to the angle between gravity itself and the z-gravity component of the accelerometer readings (green angle, dubbed as beta) because the gravity is always perpendicular to the horizontal plane (the seat of the chair), and the z-gravity component is always perpendicular to the thigh. . computation of the thigh angle from the decomposition of gravity into orthogonal components along the axis of the reference system (blue lines) of an accelerometer on the subject's thigh. according to the convention applied in the preceding figure the thigh angle is represented by the red angle (alfa). gravity and its components are depicted in green. the green angle (beta) between gravity itself and its z-component is equal to the thigh angle (alfa), because gravity is always perpendicular to the horizontal plane, and the z-gravity component is always perpendicular to the thigh. thus, if the y-axis of the accelerometer is aligned with the thigh itself, as it is in the case of our experimental setting, the angle value at any given moment can be computed from the accelerometer z-gravity and y-gravity readings according to the following expression: obtaining the gravity components from the accelerometer readings would require filtering the raw acceleration signals. however, in order to lower the computational complexity of our algorithm we estimated the thigh angle directly from raw acceleration samples as: where a y (i.e., the y-acceleration component) and a z (i.e., the z-acceleration component) include the contribution of both gravity and the forces exerted by the subject to execute the sist and stsi transitions. the outcome of the expression above is limited by the fact that the tangent function is a periodic function, and the arc tangent function only returns values for the first period of the angle values, i.e., values between −p/2 and p/2. theoretically, this should not be a problem because, as stated before, the value of the thigh angle is expected to oscillate within that range (between 0 and p/2 radians, i.e., between 0 • and 90 • ). however, when the subject is close to the upright position, there are some non-ideal behaviors that should result in an angle estimation bigger than 90 • , but will not if we applied equation (2) . for instance, the value of the z-acceleration component is expected to always have a negative sign, except at the upright position where it is expected to be zero. nevertheless, nearby the upright position, the noise from the acceleration and deceleration forces exerted by the older adult could alter the z-acceleration sign, and turn it into a positive value. in that case, equation (2) does not return a value bigger than p/2 but a negative value between −p/2 and zero. in order to make a correct estimation of the angle, the sign of the accelerometer readings must be taken into account according to the following expression:α please note that the sign of the y-acceleration component cannot be negative while the sign of the z-acceleration component is positive, unless the device is upside down, because gravity always points downwards. while the variation of the actual thigh angle over time, and even an estimation based on gravity components, are smooth quasi-periodic signals like the blue line in figure 5 , the values of the thigh angle estimated from raw acceleration readings, and their variation over time, result in a noisy signal like the green line in figure 5 . the said noise is particularly strong close to the maxima and minima of the actual angle, due to the abrupt deceleration forces applied to the sensor upon reaching the upright and sitting positions. consequently, while the blue signal shows smoothly and clearly defined maxima that can be used to identify the end of a sist transition into the upright position, the local maxima and minima in the noisy green signal do not serve that purpose anymore. which brings us to the second step in the sts analysis algorithm. in the second step, hysteresis thresholding was applied to the signal to remove the effect of the noise in the green signal. the output of such a filter was a binary signal (standing vs. sitting) like the red line in figure 5 . the threshold values and the computational algorithm described below were defined to filter the signal and spot valid sist transitions in real time. the output of the hysteresis thresholding algorithm switches between two different states (i.e., sitting and standing) as follows: the estimated value of the thigh angle is compared to two values configured in a previous stage (see the next paragraph). these two values are known as the sitting-threshold and the standing-threshold. if the previous sample was in a standing state and the current estimated thigh angle reaches a value greater than 0 • , and lower than the sitting-threshold, the subject is considered to have completed a stsi transition, the state changes to sitting, and the subsequent sist transition is an eligible candidate to count as a valid attempt; otherwise the subsequent sist transition will not count as a valid attempt no matter what. on the other hand, if the previous sample was in a sitting state and the extension angle reaches a value greater than the standing-threshold, and lower than 90 • during an eligible sist transition, the state changes to standing, and the transition counts as a valid attempt; otherwise it is dismissed as a failure. the rationale behind using the sitting-threshold and the standing-threshold comes from the fact that even though the expected angle values theoretically range from 0 • (sitting) to 90 • (standing), there are two sources of non-ideal behavior that require the definition of more flexible threshold values. first, mobility constraints may narrow this range for some older subjects. a subject's readings whose default standing position does not exceed 80 • , will never reach the theoretical 90 • standing-angle. thus, valid standing attempts would be dismissed and the automatic count of valid sist transitions would result in a wrong score. analogously, a subject's readings whose default sitting position does not fall down below 10 • , will never reach the theoretical 0 • sitting-angle. thus, subsequent valid standing attempts would be dismissed and the automatic count of valid sist transitions would result in a wrong score as well. the other source of non-ideal behavior is the non-ideal nature of the sensor readings themselves. even if a subject reaches his default standing position, the sensor might provide a reading slightly lower than the subject's default standing angle. in such a case a valid attempt would be dismissed as a failure, and the automatic count of sist transitions would result in a wrong score. the analogous situation applies to the sitting position and the subject's default sitting angle. to avoid the negative impact of these situations on the sensor performance, the sensor is calibrated before initiating a 30-s cst. the subject's thigh angle in a static sitting position is measured and recorded. in particular, the sitting angle is computed as the mean value of the angle readings collected while the subject is sitting in a static position for four seconds. then, a correction is applied to allow for some error tolerance. the sitting-threshold is set to its final value by adding 10º to the subject's default sitting angle. analogously, the subject's thigh angle in a static upright position is measured and recorded, and then the standing-threshold is set to its final value by subtracting 10º from the subject's default standing angle. the application was developed in java for android. the tablet device was a huawei m2-a01l with android 5.1.1. the application is used to configure the personalized parameters in the sensor algorithm (i.e., the sitting-threshold and the standing-threshold), to issue a command to the sensor for it to begin the measurement process, and to visualize the test results after completion. the application home screen shows a list of all the sensor devices paired with the tablet so the end-user gets to pick which one to configure. in the case of the data collection stage in the present study, only one device was paired with the tablet. the application has two operation modes, namely, calibration mode and measurement mode. in calibration mode, the values for the sitting-threshold and the standing-threshold are computed and set according to the following process: 1. the researcher puts the sensor into calibration mode by issuing the corresponding command with the app. the researcher asks the sensor to compute sitting angle readings for four seconds and send them back to the app by issuing the corresponding command with the app. the app computes the mean value of these sitting-angle readings and stores them as the subject's default sitting-angle. the researcher asks the sensor to compute standing-angle readings for four seconds and send them back to the app by issuing the corresponding command with the app. 5. the app computes the mean value of these standing-angle readings and stores them as the subject's default standing-angle. 6. the researcher enters an error tolerance value for each default angle. 7. the researcher asks the sensor to set the value of the sitting-threshold and the standing-threshold by issuing the corresponding command with the app. the sitting-threshold is computed as the sum of the subject's default sitting-angle and the error tolerance value for the sitting position. on the other hand, the standing-threshold is computed as the subtraction of the error tolerance value for the standing position from the subject's default standing-angle. in measurement mode the application waits for the sensor to send the results of the 30-s cst according to the following process: 1. the researcher puts the sensor into measurement mode by issuing the corresponding command with the app. the researcher asks the sensor to start the 30-s cst measurement sequence by issuing the corresponding command with the app. the application waits idle for the results of the 30-s cst. the application shows the results of the 30-s cst on screen. seven older subjects were administered a 30-s cst each, in accordance with the following procedure. a member of the research team gave instructions to the subjects to guide them through the process. first, a member of the research team paired the wearable sensor with the tablet device via bluetooth, and asked the subject to put on the wearable device. the subject was then asked to sit down on the chair to calibrate the sensor sitting-threshold. next, the subject was asked to stand up to calibrate the sensor standing-threshold. after the calibration stage, the subject was asked to repeatedly stand up from, and sit down on, the chair as fast as possible for 30 s. the subject was asked to do so with his arms folded over his chest, and starting from a sitting position. the sensor emitted a short vibration to indicate to the subject when to start. a trained member of the research team manually counted sist transitions. once the 30 s were over, the sensor emitted another short vibration to signal the subject to stop. then, the sensor sent the outcomes of the automatic count algorithm to the mobile app, which showed them on screen. a member of the research team took note of the values for the manual and automatic counts. the correlation between the manual and the automatic counts were studied. these two variables are of the interval type, therefore we decided to compute their correlation with pearson's moment-product correlation coefficient. before applying pearson's r to the data, the normality of the two data sets (manual vs. automatic counts) was tested. due to the size of the sample, normality was studied with a shapiro-wilk test that resulted not statistically significant in both cases. therefore, both data sets could be considered to be normally distributed, and we proceeded with pearson's r. the shapiro-wilk test was calculated using the shapiro.test function, and pearson's r was calculated using the cor.test function; in both cases r statistical software, version 3.6.3, was used. the 95% ci for the pearson's r estimate was computed by applying fisher's transformation. to further characterize the impact of noise on the sensor performance we studied the statistical significance of our estimation for the probability of finding harmless noise levels in a valid sist transition. this situation was modeled as a binomial experiment, where each sist transition in the data set corresponds to a binomial event, a correct sist identification means harmless noise and, therefore, success, and an incorrect sist identification means harmful noise and, therefore, failure. the probability of harmless noise was estimated as the number of correct identifications in the data set divided by the total number of sist transitions in the data set. the 95% ci for the probability of success was calculated by applying a binomial test with the binom.test function in the r statistical software, version 3.6.3. seven older subjects (3 female and 4 male), between 64 and 74 years old, participated in the unsupervised validation of the home care system. all subjects gave their informed consent for inclusion before they participated in the study. the study was conducted in accordance with the declaration of helsinki, and the protocol was approved by the ethics committee of the universidad politécnica de madrid on 9 may 2019 (positive: maintaining and improving the intrinsic capacity involving primary care and caregivers). the following inclusion and exclusion criteria were applied: • a subject could enter the study if all the following inclusion criteria applied: • the subject is willing and able to give written informed consent for participation in the study. the subject is 64 years old or older. the subject is able to perform the 30-s cst in a safe way. • the subject has not been diagnosed with cognitive impairment. • a subject could not enter the study if any of the following exclusion criteria applied: • subjects suffering from any major disability. • subjects suffering from cognitive impairment. the sensor hardware was ported to a more ergonomic case which included a sticker with clear instructions about the proper orientation of the ends of the device, with the help of two tags, namely, "rodilla", which is the spanish word for knee, and "cabeza", which is the spanish word for head (see figure 6 ). figure 6 . second version of the sensor casing. the sticker on the sensor reports the correct orientation of the sensor with the help of two tags: "rodilla", which is the spanish word for knee, and "cabeza", which is the spanish word for head. the home care application was developed in java for android and was a user friendly evolution of the application in section 2.1.2.3. the application included a user-friendly interface specifically designed for older adults. once the default and the threshold values of the participants sitting and standing angles were calibrated for the first time, the application recorded the outcomes so it was not necessary to re-calibrate every time the participant took a test. the app provided explanatory pictures, audio, and video to help the participant in preparing for taking a test, and audio instructions were also available to guide him through the whole procedure. in order to assess the system acceptability, a semi-structured interview comprising the questions in the second column in table 2 was conducted. furthermore, the participants' general impressions were also collected by conducting another semi-structured interview, comprising the questions in the third column in table 2 . the first three questions in each questionnaire are related to the participant's opinions on the sensor. the remaining ones are related to the participant's opinions on the application in the tablet. table 2 . list of questions in the acceptability and general impressions questionnaires. the first three questions in each questionnaire ask about the participant's experience while using the sensor. whereas, the remaining ones ask about the participant's experience while using the home care application on the tablet. related to the sensor 1. what difficulties did you find while using the sensor? 1. was the device easy to put on? 2. what is your opinion on the sensor? 2. do you find the device comfortable? 3. how did you feel while using the sensor? 3. do you think you would be able to use the device at home on your own? related to the application 4. what difficulties did you find while using the tablet? 4. which activities did you find the most difficult to achieve while using the tablet? 5. what is your opinion on the tablet? 5. which features did you find the hardest to understand in the tablet? 6. how did you feel while using the tablet? 6. what are your general impressions on the tablet? 7. do you think you would be able to use the app at home on your own? a trained technician went to the participants' homes to set up the system and explain to them how to use it (only one user per home was configured). the technician delivered a tablet device with the home care application pre-installed. once in the participant's dwelling, the technician paired the sensor and the tablet via bluetooth and proceeded to calibrate the participant's default sitting and standing angles as described in section 2.1.2.3. the application recorded the values so the participant did not have to repeat this step every time he took a 30-s cst. the participants could contact the technician to get help to fix any technical issues that could arise over the course of the study. the participants used the system for a month. the participant initiates a test by entering into the "my medical tests" in the app. the participants had to follow the instructions of the home care application to complete a 30-s cst, without any supervision or further assistance, and according to the following procedure. the participant put the tablet on a nearby surface. the participant then had to put the device on over his knee, secure it with the strap, and click next on the tablet. then the participant had to switch on the device and click next on the tablet. after that, the participant had to fold his arms over his chest and wait for the start signal. then he had to stand up and sit down repeatedly until the stop signal. after that, the participant could switch the device off and take it off. once the 30-days period of study was over, a member of the research team went to the participants' homes to pick up the equipment and to conduct an interview to evaluate acceptability and general impressions by administering the corresponding questionnaires. the results of the acceptability and general impressions questionnaires were qualitatively assessed. table 3 summarizes the outcomes from the data collection process. most of the people in older populations are female, and this pattern was also reflected in the composition of the sample of volunteers recruited for the present study (5 female and 2 male). table 3 . data collected during the experimental procedure. each row in the table holds the data for one of the seven older adults in the experiment (age: m = 83.29 years old, sd = 4.19; gender: 5 female and 2 male). each participant took a single 30-s cst. the outcomes from the sensor automatic count match the outcomes from the trained professional's manual count for all the seven participants. all the 67 sist transitions that took place were correctly identified, and the mean absolute error was equal to zero. the mean absolute error for the automatic count of sist transitions was computed, as usual, according to the following expression: the mean absolute error was equal to zero because the sensor output was error-free in all the seven 30-s csts, i.e., all the 67 sist transitions were correctly identified. this means the high frequency noise in the estimated angle signal was not larger than the gap between the sitting and the standing thresholds for any of the sist transitions in the data set. therefore, the hysteresis thresholding mechanism had not been affected by said noise and no spurious transitions between states had taken place. additionally, the correlation between the manual and the automatic counts was studied to test the statistical significance of the perfect match in our observations. being two variables of the interval type, we chose pearson's r to study their correlation. before computing pearson's r, the normality of the two variables (manual count vs. automatic count) was studied with a shapiro-wilk test, as shown in table 4 . table 4 . results of the normality test for the manual count data set (left) and the automatic count data set (right). none of the tests were statistically significant. thus, we did not find statistical significance to state that any of the data sets were not normally distributed. therefore, we considered that they complied with the bivariate normality assumption, and proceeded to study their correlation with pearson's r. automatic count the data set complies with the bivariate normality assumption because the shapiro-wilk test resulted not statistically significant for both variables. therefore, we proceeded to study their correlation with pearson's moment-product correlation (r = 1, p = 0.00). this correlation estimate showed full correlation between the sensor automatic count and the manual count. the 95% ci was computed as a means to measure the accuracy of our estimation. the cor.test function in r computes the ci by applying fisher's transformation, and returned a 95% ci = (1, 1) . this result suggests that our observation was indistinguishable from a perfect correlation. however, the fisher transformation defines the lower and upper limits of the 95% ci as: where r is the pearson correlation coefficient and n is the sample size, which in this case equals the number of participants recruited for the study. the hyperbolic arc tangent function is defined only within the open interval (−1, 1), but not for the case when r equals one. since the hyperbolic arc tangent function tends to infinity as r tends to one, the contribution of the sample size to the value of the upper and lower values in fisher's expression becomes irrelevant. therefore, we think we are not getting much information about the impact of our sample size on the accuracy of our estimation. in order to tackle this issue and study the accuracy of our sensor, we studied the probability of finding a sist transition with harmless levels of noise; because the higher the number of transitions with harmless levels of noise, the more accurate the sensor outcomes will be. the situation was modeled as a binomial experiment (as described in section 2.1.4), which resulted in an estimated probability of success p = 1 with a 95% ci = (0.96, 1). therefore, the older adults in our sample are expected to produce sist transitions with harmless levels of noise at least 96% of the time. therefore, our sensor would need to observe 25 sist transitions in order to make a mistake due to a high level of noise. since the mean number of sist transitions per 30-s cst in our sample is 9.57, the sensor would make a mistake once every 2.61 tests; thus, in order to observe one wrong score, you need to conduct three tests. in other words, according to our estimated 95% ci, in the worst case scenario, our sensor would provide an error free score for at least 67% of the tests conducted, while the remaining 33% would miss the correct score by one sist transition. these results show our sensor to be very accurate, however, it could be argued that a sample of seven older adults is too small to be representative of the many interpersonal differences in the general older population and, therefore, the results might have been poorer if the device had been tested on a wider variety of cases. a larger sample might have shown cases with higher levels of noise; so we analyzed under which conditions angle signals would be noisier, and tested our algorithm behavior in those conditions. the noise in the angle signal is the result of the acceleration and deceleration forces applied to the sensor, especially upon reaching the upright and sitting positions. the faster, and the more sudden, the stand up and sit down moves are, the stronger these forces will be. on the one hand, subjects would have moved faster if they have completed a higher number of sist transitions within the 30 s in the test. on the other hand, given a fixed number of transitions, subjects need a larger momentum for those transitions with a wider range. therefore, the angle signal is expected to be noisier for 30-s csts with a higher number of sist transitions and a wider range for the thigh angle. rikli and jones identified the normative standard values to use the 30-s cst outcomes to compare an older adult's performance with the average population [41] . according to these standards, a subject's performance might be considered to be (i) within, (ii) below, or (iii) over the reference range of the average population [41] . however, the reference ranges have different values depending on gender and age [41] . thus, two people of the same gender with the same test score but belonging to different age groups need not be considered to have the same level of physical decline; and the same applies to two people of different gender but belonging to the same age group. according to these standards 90% of the men in the younger age group (between 60 and 64 years old) score below 22 [41] . the analogous scores for the remaining age groups in the case of men are lower than 22; as they are in the case of women of all age groups. on the other hand, rikli and jones also identified the critical values that predict physical independence until late in life [42] . an older adult scoring above the critical value is considered to be fit enough to remain independent until late in life; conversely an older adult scoring below the critical value is considered to be at risk of becoming dependent and requires taking action. these critical values depend on gender and age as well [42] . the critical value for men in the younger group (between 60 and 64 years old) is 17 [42] . the critical values for the remaining age groups in the case of men are lower than 17; as they are in the case of women for all age groups. thus, we took 22 sist transitions as a reference value for an extreme and highly demanding scenario, and 17 sist transitions for a critical and likely scenario. then, we conducted an exploratory study to inquire about the performance of our approach under those two scenarios. a member of the research team took ten 30-s csts scoring 22 or above (highly demanding scenario) and another ten 30-s csts scoring around 17 (critical scenario). the data for this exploratory study were collected with a smartphone (nokia 6 ta-1021 with android 9) on the subject's thigh and were processed with gnu octave 5.2.0; this was because the researchers were locked down at their homes, due to the covid-19 pandemic, and did not have access to the prototypes of the sensor devices. the experiment in the highly demanding scenario resulted in a total of 230 sist transitions. of which, 15 showed harmful noise. all 15 behaved like the transitions depicted around time = 20 and time = 25 s in figure 7 . both transitions show a strong and narrow inverse peak of noise (green line in figure 7 ) that tricks the algorithm into detecting a spurious stsi transition, and another spurious sist transition (red line in figure 7) . thus, an extra sist transition was detected for each valid transition affected by this kind of noise; in the case of figure 7 , the final score was overestimated by two points, i.e., 25 sist transitions were reported instead of 23. all the signals collected, and the code to process and visualize them, are available as supplementary materials. like in the case of the older adults' data set, we studied the probability of finding a sist transition with harmless levels of noise. again, it was modeled as a binomial experiment (as described in section 2.1.4) and the experiment resulted in an estimated probability of success p = 0.93, with a 95% ci = (0.89, 0.96). according to the lower limit of this ci, it would be necessary to observe 10 sist transitions in order to observe one of them with a high level of noise. the mean number of sist transitions per 30-s cst in our sample is 23; thus, between two and three high level noise transitions would be observed per test. on the other hand, according to the upper limit of the 95% ci, i.e., p (harmless noise) = 0.96, only one in two tests would miss the correct score, and would do so by a single point. finally, the experiment in the critical scenario resulted in a total of 173 sist transitions. the algorithm successfully identified all of them. in this case, the estimated probability of success is p = 1 with a 95% ci = (0.98, 1). therefore in the worst case (lower limit of the ci), it is necessary to observe 50 sist transitions in order to observe one error. since the mean number of sist transitions in our sample is 17.3, an error would be observed every 2.89 tests. thus, in order to observe one wrong score, you need to conduct three tests. therefore, according to the 95% ci, the noise pattern around the critical value would result in a single wrong transition in only one in three tests. under such a noise pattern our sensor would remain very accurate around the target critical value. all but one of the participants declared they did not find any major problems while using the device. one participant declared having experienced some pain in his knee due to osteoarthritis. the same participant also declared being worried about the possibility of the device falling out during the course of the 30-s cst. all the participants provided favorable answers to this question. they highlighted that the sensor is comfortable and easy to use. they also remarked that the labels on the sensor sticker were easy to follow and helped them to know how to correctly put the device on the leg. the participants declared that they felt comfortable using the device, and that they felt motivated to improve their performance over time. in line with the answers to question #1, one participant declared to be worried about the possibility of the device falling out during the course of the tests. six participants reported they found the device easy to put on. none of the participants reported that they did not find it easy, however, one of them reported the strap did not fit very well around his leg. all the participants felt able to use the app at home on their own. however, one of them highlighted that he would be able to do so as long as the application did not become more complex, and another one highlighted that technical support would be required. our sensor took advantage of the quasiperiodic variation of the thigh angle over time (i.e., the angle between the longitudinal axis of the subject's thigh and a horizontal plane perpendicular to gravity, e.g., the seat of the chair). the thigh angle was computed from acceleration readings from an accelerometer on the subject's thigh. previous works found in the literature have taken advantage of the quasiperiodic variation of some other variables such as the trunk pitch-angle [23] , vertical velocity [23, 24] , and vertical position [24] to study repetitive sts cycles in sts5 and 30-s cst tests. they estimated the values of these variables from the readings of an imu on the l3 region of the subject's lumbar spine. we think the thigh angle is a more convenient approach for two reasons. on the one hand, we think that older people might find it easier to correctly place the sensor on their thighs than on their lower backs, especially if they do not have any help to put them on. however, none of the papers studied their algorithm's sensitivity to misplacing of the sensor. the procedure for the estimation of the thigh angle described in the present paper (i.e., estimating the angle from the y-acceleration and z-acceleration components) requires the sensor x-axis to be aligned with the knee rotation axis. however, this constraint is easy to overcome by extending the angle estimation expression to its three-dimensional form. on the other hand, computing trunk pitch-angle, vertical velocity, and vertical position require integration and even double integration of the imu readings. due to the noisy nature of the latter, the result is distorted by drift and requires a lot of effort to estimate the original signal with computationally complex algorithms. millor et al., for instance, applied double integration, combined with fourth-level polynomial curve adjustment and cubic splines interpolation [24] . conversely, it is not necessary to integrate the acceleration readings to make an estimation of the thigh angle. such an estimation can be computed from the values of the different components of gravity in the accelerometer reference system; and these values can be estimated by filtering raw acceleration readings. we did not include any kalman or complementary filters in our design to avoid the extra hardware and computational load. instead, we estimated the thigh angle directly from raw acceleration readings; which resulted in noisy but drift-free angle estimations. in spite of the noisy nature of the angle estimations, the device showed an excellent performance. all the sist transitions were correctly identified in real time, and the device provided error-free outcomes for all the seven 30-s cst conducted with older adults. the narrow ci returned by the cor.test function in r suggests this observation is indeed statistically indistinguishable from a perfect correlation. however, the limitations described for the fisher transformation in section 3, to accommodate such an extreme value for pearson's r, make us think we are not getting much information about the impact of our sample size on the accuracy of our estimated correlation. looking at the results of our study from a different perspective, we studied the accuracy of our device based on the probability of observing noise levels high enough to exceed the gap between their personalized upper and lower thresholds in the hysteresis stage. since all the transitions were correctly identified in real time, we concluded that the participants in the study did not generate any transitions with such high levels of noise. according to the narrow 95% ci in our estimation, low levels of noise are expected to happen at least 96% of the time. which would result in very accurate sensor outcomes. this result can be generalized to the sist transitions generated by any population represented by our sample. however, our sample is limited because it could be argued that seven older adults are too few to be representative of the many interpersonal differences in the general older population and, therefore, signals with a higher level of noise might have been observed if the device had been tested on a wider variety of cases. nevertheless, we did not find any sist transitions with harmful levels of noise in our exploratory study for the critical scenario (around 17 transitions with high momentum). according to the narrow 95% ci obtained for that critical scenario (0.98, 1), even if any high noise transitions were to be observed, a single wrong transition would be observed in only one in three tests. since the 30-s cst is expected to be scheduled to be taken once or twice a week in a home care scenario, we did not observe any risks of missing anyone not fit enough due to sustained overestimated scores over time. we observed that a frequent overestimation of the scores is likely to happen in the highly demanding scenario (over 22 transitions with high speed and high momentum). however, we think that this result does not have a strong impact on the utility of our approach for two reasons. first, less than 10% of the older population are able to reach such high scores, and second, even in case of overestimation, people scoring over 22 are far away from the critical threshold, and therefore are undoubtedly fit enough not to require any immediate intervention. anyway, further experiments may be useful to characterize the noise profile between the scores of 17 and 22. we integrated the sensor into a home care app that guides the user throughout the process of taking a 30-s cst, and conducted an acceptability study with older adults in free-living conditions (i.e., using a home care app at home for several weeks to interact with the device without any assistance). all the participants kept using the system throughout the course of the study and none of them dropped out. this observation is in line with their favorable opinions about both the sensor and the application; and, in particular, corroborates the participants' positive answers to whether they feel able to use the system at home on their own. despite the excellent results of this acceptability study, further studies will be necessary to test, on the one hand, the long-term acceptability and adoption by older adults and their caregivers, and, on the other hand, to test the feasibility of this novel home care model for frailty in accommodating end-users' needs and expectations, not just on the older adults' side, but also on the health care professionals' side. we developed a system for older people to self-administer the 30-s chair stand test (cst) at home without supervision. the system comprises a low-cost sensor that automatically detects and counts sit-to-stand (sist) transitions in real time, and a home care application that guides older people through the whole procedure. we studied whether such a system was able to match older people's abilities and expectations so they can use it at home on their own without any supervision. the sensor automatic counts were perfectly correlated to the researcher's manual count, so we concluded that the signals generated by the participants did not push the device to its operational limits. this observation is supported by a very narrow 95% ci for the probability of finding a sist transition with a low level of noise. the small size of our sample limits our ability to generalize this result to the general older population because more demanding signals might have been observed if the device had been tested on a larger sample. however, we did not find harmful levels of noise in any of the signals in our exploratory study around the critical score. thus, we did not observe any risks of missing anyone not fit enough due to sustained overestimated scores over time. none of the participants in the unsupervised study of the complete system dropped out, and at the end of the study none of them reported any major problems in understanding the system and interacting with it. they declared they felt comfortable using it, and felt able to use it on their own. thus, the system is suitable to be used by older adults in their homes without professional supervision. supplementary materials: the data collected for the exploratory study on the demanding and the critical scenarios, together with the code used to process and plot the corresponding signals, are available online at http://www.mdpi.com/xxx/s1. beam, w.c. a 30-s chair-stand test as a measure of lower body strength in community-residing older adults frailty in older adults: evidence for a phenotype unstable disability and the fluctuations of frailty conceptualisation and measurement of frailty in elderly people frailty in elderly people frailty as a predictor of disabilities among community-dwelling older people: a systematic review and meta-analysis are we living longer and healthier? a physical activity intervention to treat the frailty syndrome in older persons-results from the life-p study frailty in the clinical scenario treating frailty-a practical guide accumulation of deficits as a proxy measure of frailty in relation to the accumulation of deficits frailty defined by deficit accumulation and geriatric medicine defined by frailty the clinical care of frail, older adults relationship between lower-limb muscle strength and frailty among elderly people a short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study sedentary behavior as a risk factor for physical frailty independent of moderate activity: results from the osteoarthritis initiative a tale of two pandemics: how will covid-19 and global trends in physical inactivity and sedentary behavior affect one another? kinematic parameters to evaluate functional performance of sit-to-stand and stand-to-sit transitions using motion sensor devices: a systematic review standardization and definitions of the sit-stand-sit movement cycle automated approach for quantifying the repeated sit-to-stand using one body fixed sensor in young and older adults automatic evaluation of the 30-s chair stand test using inertial/magnetic-based technology in an older prefrail population an evaluation of the 30-s chair stand test in older adults: frailty detection based on kinematic parameters from a single inertial unit validation of seat-off and seat-on in repeated sit-to-stand movements using a single-body-fixed sensor older adults with weaker muscle strength stand up from a sitting position with more dynamic trunk use a body-fixed-sensor-based analysis of stair ascent and sit-to-stand to detect age-related differences in leg-extensor power the instrumented sit-to-stand test (ists) has greater clinical relevance than the manually recorded sit-to-stand test in older adults gait velocity and chair sit-stand-sit performance improves current frailty-status identification sensor-based monitoring of sit-to-stand performance is indicative of objective and self-reported aspects of functional status in older adults development of an automated 30 second chair stand test using smartwatch application portable ultrasound-based device for detecting older adults' sit-to-stand transitions in unsupervised 30-second chair-stand tests human activity recognition using thigh angle derived from single thigh mounted imu data ability of thigh-worn actigraph and activpal monitors to classify posture and motion probabilistic identification of sit-to-stand and stand-to-sit with a wearable sensor quantifying sit-to-stand and stand-to-sit transitions in free-living environments using the activpal thigh-worn activity monitor mems based imu for tilting measurement: comparison of complementary and kalman filter based data fusion validation of thigh angle estimation using inertial measurement unit data against optical motion capture systems wearable goniometer and accelerometer sensory fusion for knee joint angle measurement in daily life functional fitness normative scores for community-residing older adults, ages 60-94 development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years we would like to thank feder funds for co-financing our home institutions. the authors would like to specially thank the volunteers in the study for their unselfish collaboration, enthusiasm, and dedication. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-261733-kc0d5pe8 authors: galili, uri title: why do we produce anti-gal: evolutionary appearance of anti-gal in old world primates date: 2017-09-15 journal: the natural anti-gal antibody as foe turned friend in medicine doi: 10.1016/b978-0-12-813362-0.00002-6 sha: doc_id: 261733 cord_uid: kc0d5pe8 the natural anti-gal antibody is one of the multiple natural anti-carbohydrate antibodies produced in humans against a wide range of carbohydrate antigens on gi bacteria. the antibody is unique to humans, apes, and old world monkeys, and it binds specifically to a mammalian carbohydrate antigen called the α-gal epitope that is synthesized in nonprimate mammals, lemurs (prosimians) and new world monkeys by the glycosylation enzyme α1,3gt. the α1,3gt gene (ggta1) appeared in mammals >100 million years ago, prior to the split between marsupial and placental mammals. this gene has been conserved in its active form, in all mammals, except for old world monkeys, apes, and humans. inactivation of the α1,3gt gene in ancestral old world primates occurred 20–30 million years ago and could have been associated with epidemics of enveloped viruses in the eurasia-africa continent. it is suggested that prior to such epidemics, few ancestral old world primates acquired deletion point mutations that inactivated the α1,3gt gene and eliminated α-gal epitopes. this resulted in loss of immune tolerance to the α-gal epitope and thus, in production of the anti-gal antibody against antigens on bacteria colonizing the gi tract. this accidental inactivation of the α1,3gt gene in very small populations is analogous to the highly rare blood type “bombay” individuals who do not synthesize blood group h (o antigen) because of inactivation of the α1,2-fucosyltransferase gene. the loss of immune tolerance to blood group h antigen has resulted in production of natural anti-blood group h antibodies in the blood group bombay individuals. it is suggested that anti-gal protected against infections by enveloped viruses presenting α-gal epitopes, which were lethal to the parental primate populations that conserved active α1,3gt and thus, synthesized α-gal epitopes. alternative causes for the elimination of old world primates synthesizing α-gal epitopes could be bacteria or protozoa parasites presenting α-gal or α-gal-like epitopes, and bacterial toxins, or detrimental viruses that used α-gal epitopes in these primates as “docking receptors.” ultimately, any of these proposed selective processes could result in extinction of old world primates synthesizing α-gal epitopes on their cells. these ancestral primates were replaced by offspring populations lacking α-gal epitopes and producing the anti-gal antibody, which continues to be produced by old world monkeys, apes, and humans. new world monkeys and lemurs were protected from pathogens of the old world by oceanic barriers, thus they continue to synthesize α-gal epitopes and lack the ability to produce the anti-gal antibody. this scenario of few individuals in a large population having a mutation(s) that inactivates a glycosyltransferase gene thus, resulting in production of evolutionary advantageous natural antibodies against the eliminated carbohydrate antigen, may reflect one of the mechanisms inducing changes in the carbohydrate profile of various mammalian populations. 1. background information on anti-gal and the α-gal epitope an evolutionary selective process in primate populations resulted in extinction of old world primates that synthesized α-gal epitopes. this extinction was followed by the expansion of monkey and ape populations with inactivated α1,3gt gene, which lacked α-gal epitopes, and thus could produce the natural anti-gal antibody. this transition from α-gal epitope synthesis to elimination of primates synthesizing this carbohydrate antigen and the appearance of primates producing an antibody against the α-gal epitope is observed only in old world primates. such observation raises the possibility that this evolutionary event was associated with a selection process mediated by a detrimental pathogen that was endemic to the old world. although it is practically impossible to indentify pathogens that affected evolution of primates millions of years ago, this chapter describes several scenarios that are most likely to explain these evolutionary events in ancestral old world primates. understanding anti-gal evolution requires a short discussion on production of the group of antibodies called "natural anti-carbohydrate antibodies" in response to antigenic stimulation by gastrointestinal (gi) bacteria. a schematic evolutionary tree describing the estimated evolutionary period in which α1,3galactosyltransferase and the α-gal epitope appeared in early mammals, and the period in which the selective pressure for elimination of primates synthesizing α-gal epitopes initiated (indicated by arrows). the estimated evolutionary periods for divergence events in mammals are indicated on the left. the absence of the α-gal epitope in vertebrates that are not mammals, and its synthesis in nonprimate mammals implies that α1,3gt and the α-gal epitope appeared in mammals prior to the split between marsupial and placental mammals. the absence of α1,3gt and α-gal epitopes only in old world monkeys, apes, and humans implies that inactivation of the α1,3gt gene (ggta1) and elimination of α-gal epitopes occurred after the split between new world monkeys and old world primates. the estimates of the evolutionary periods of divergence in mammals are based on several studies (dawkins, 2004; schrago, 2007; steiper and young, 2006) . adapted from galili, u., 2016 . natural anti-carbohydrate antibodies contributing to evolutionary survival of primates in viral epidemics? glycobiology 26, 1140 glycobiology 26, -1150 permission. one of the major sources for constant antigenic stimulation of the human immune system is the multiple bacteria that naturally colonize the gi tract. there are at least 400 different strains of bacteria in the gi tract, and they comprise >25% of the fecal material (stephen and cummings, 1980; gerritsen et al., 2011) . these bacteria present a wide range of antigens that can stimulate the human immune system. the multiple different polysaccharides and oligosaccharides on these bacteria serve as a source for many carbohydrate antigens that continuously stimulate the immune system to produce a wide variety of anti-carbohydrate antibodies, without the need for active vaccination by the carbohydrate antigens, i.e., natural anti-carbohydrate antibodies (wiener, 1951; springer, 1971) . anti-gal is one of these natural antibodies and it is produced in high amounts throughout life (galili et al., 1984; wang et al., 1995) . anti-gal was shown to bind to several gi bacteria, as well as to their lipopolysaccharide extracts, including klebsiella pneumoniae, serratia marcescens, and escherichia coli o86 (galili et al., 1988b) . in earlier studies, feeding killed e. coli o86 bacteria to patients with diarrhea was found to result in significant increase in the titer of anti-blood group b antibodies (springer and horton, 1969) . as detailed in chapter 3, >85% of anti-blood group b antibodies in humans are in fact anti-gal antibodies that can also bind to blood group b antigen (galili et al., 1987b) . accordingly, feeding α1,3galactosyltransferase knockout mice (gt-ko mice) with e. coli o86 was found to induce production of the anti-gal antibody in these mice (posekany et al., 2002) . furthermore, production of anti-gal in monkeys could be inhibited by administration of antibiotics that eliminate the gi bacterial flora (mañez et al., 2001) . although the natural anti-carbohydrate antibodies are primarily produced against bacterial carbohydrate antigens, some of these antibodies are capable of binding to mammalian carbohydrate antigens, as well (blixt et al., 2004; bovin et al., 2012; bovin, 2013; stowell et al., 2014) . accordingly, the natural anti-gal antibody is produced against bacterial carbohydrate antigens with terminal galactosyl units linked in an alpha anomeric linkage and is capable of binding to the mammalian α-gal epitope (galili et al., 1985; towbin et al., 1987) . anti-gal binds to various bacteria and bacterial lipopolysaccharides (galili et al., 1988b) ; however, the exact structure of bacterial carbohydrates inducing anti-gal production has not been identified, as yet. galα1-3glc and galα1-3gal epitopes were reported on both gram-positive and gram-negative bacteria (han et al., 2012; lüderitz et al., 1965) . additional examples of such antibodies in humans are anti-blood group a and b antibodies (springer and horton, 1969) , natural antibody to n-glycolylneuraminic acid (called anti-neu5gc), which is produced in humans, and not in other old world primates, or in nonprimate mammals (higashi et al., 1977; merrick et al., 1978; zhu and hurst, 2002; padler-karavani et al., 2008) , and natural anti-rhamnose antibody (chen et al., 2011; sheridan et al., 2014; long et al., 2014) . as detailed in chapter 3, the reason for the ability of anti-bacterial carbohydrate antibodies to bind mammalian carbohydrate antigens is that these antibodies are polyclonal, and different clones are capable of binding to various "facets" of a given carbohydrate antigen. some of these facets are likely to be shared between mammalian and bacterial carbohydrate antigens. as discussed below, mammals produce anti-carbohydrate antibodies against many carbohydrate epitopes, provided that these epitopes are not self-antigens. thus, if for any reason, a mammal stops synthesizing a certain carbohydrate epitope, there is high probability that it 1. background information on anti-gal and the α-gal epitope may start producing a natural antibody against that eliminated epitope, as part of the ongoing immune response against the many carbohydrate antigens on the bacteria of its natural gi flora. the one factor that limits the diversity of anti-carbohydrate antibodies is the immune tolerance that prevents production of antibodies to self-carbohydrate antigens. such production is prevented primarily by two mechanisms: (1) clonal deletion of immature b cell clones with b cell receptors, which can interact with self-antigens and (2) receptor editing in which the variable regions of immunoglobulin genes encoding antibodies to self-antigens are mutated so that the antibodies produced do not bind to self-antigens. the role of these mechanisms in prevention of anti-gal production in animals synthesizing the α-gal epitopes as selfantigen was demonstrated in transgenic wild-type and gt-ko mice. experimental studies in gt-ko mice indicated that the immune tolerance to the α-gal epitope is mediated by clonal deletion in which anti-gal b cell clones, even at the stages of mature and memory b cells, are deleted following interaction of their b cell receptors with α-gal epitopes as self-antigen mohiuddin et al., 2003; galili, 2004) . receptor editing mediating tolerance to α-gal epitopes was also observed in gt-ko mice in which an anti-gal encoding gene was introduced (i.e., "knocked in") (benatuil et al., 2008) . these mice continuously produce anti-gal without the need for their immunization. when such mice also acquired the active α1,3gt gene from wild-type mice, they ceased to produce anti-gal because the variable regions of immunoglobulin genes encoding for anti-gal b cell receptors were mutated at early stages of b cell development in the bone marrow. these mutations resulted in changes in the b cell receptor specificity, so it does not interact with α-gal epitopes (benatuil et al., 2008) . these immune tolerance mechanisms imply that once α-gal epitopes (and possibly other carbohydrate antigens) are eliminated because of inactivation of the gene encoding the corresponding glycosyltransferase, the immune tolerance mechanisms preventing production of antibodies against that self-antigen cease to function. thus, the immune system is stimulated by bacteria of the gi flora to produce antibodies against the eliminated selfantigen. a present day example of a scenario in which a glycosyltransferase gene is inactivated in small human populations, and the resulting production of a natural antibody against the eliminated carbohydrate antigen is the blood group "bombay" individuals, discussed at the end of this chapter. these rare individuals lack the blood group h (o) antigen and produce natural antibodies against this antigen. a specific present day example for de novo production of the natural anti-gal antibody following the elimination of α-gal epitopes was observed in recent years in α1,3gt knockout pigs (gt-ko pigs). as discussed in chapter 1, these pigs were generated by disruption ("knockout") of the α1,3gt gene, with the aim of providing pig xenograft organs and tissues that lack α-gal epitopes (lai et al., 2002; phelps et al., 2003; kolber-simonds et al., 2004; takahagi et al., 2005) . wild-type pigs present multiple α-gal epitopes as self-antigen on their cells, and thus, immune tolerance mechanisms prevent production of anti-gal antibodies in them. however, once the α-gal epitope is eliminated by "knockout" of the α1,3gt gene in the gt-ko pig genome, these pigs naturally produce anti-gal in high titers against gi bacteria, already at the age of 1.5-2 months (dor et al., 2004; fang et al., 2012; galili, 2013) . as discussed below, a similar production of anti-gal in primates, in which the α1,3gt gene was inactivated by mutations, might have prevented the extinction of old world primates that were exposed to highly detrimental enveloped viruses or other pathogens expressing α-gal epitopes. the selective process that eliminated α-gal epitopes from ancestral old world monkeys and apes (old world primates) and led to the appearance of anti-gal producing primates occurred after old world primates and new world monkeys diverged from a common ancestor. studies on the mutations inactivating the α1,3gt gene suggest that this selective process initiated 20-30 mya (see below). the lack of α-gal epitopes and production of the anti-gal antibody are uniformly observed in monkeys and apes, which evolved in all regions of the old world (i.e., the geographic area of eurasia-africa). the occurrence of this selective process throughout the vast regions of eurasia-africa suggests that it was mediated by a highly detrimental pathogen, such as enveloped virus (galili, 2016) . influenza virus is one current example of a virus, which potentially can become highly virulent, causing lethal infections and can effectively spread throughout human populations. intercontinental transportation can further enable its spread over geographic barriers. because enveloped viruses lack their own glycosylation machinery, they share the carbohydrate antigens on their envelope glycoproteins with the host cell. many of the glycosyltransferases within the host cells reside in the golgi apparatus. they synthesize the carbohydrate chains on cellular and viral glycoproteins in a manner similar to assembly lines in a car plant, in that there is a sequential buildup of the nascent carbohydrate chain at various compartments of the golgi apparatus. therefore, enveloped viruses infecting primates that synthesize α-gal epitopes are likely to have these epitopes on their envelope glycoproteins. the proposed scenario for elimination of α-gal epitopes in old world primates and the resulting appearance of the natural anti-gal antibody is based on the assumption that very rare mutation event(s) occurred accidentally and randomly in one or more of ancestral old world primate species. such a mutation could be single base frameshift deletion resulting in a premature stop codon, which completely inactivated α1,3gt catalytic activity. accordingly, a three amino acid deletion at the c-terminus of new world monkey α1,3gt was found to result in complete loss of catalytic activity of the enzyme (henion et al., 1994) . it is likely that offspring carrying such a mutation for several generations after it occurred were heterozygotes. they produced intact α1,3gt by the unmutated allele and synthesized α-gal epitopes (see the description of these mutations below). however, the mating of such heterozygotes resulted in homozygous offspring primates that carried two alleles of the inactivated α1,3gt gene, and therefore they lacked α-gal epitopes. as the α-gal epitope in these homozygotes became a nonself antigen, they naturally produced the anti-gal antibody in response to the constant antigenic stimulation by carbohydrate antigens with structures similar to that of the α-gal epitope, presented on gi bacteria. these anti-gal producing primates could evolve because the α-gal epitope turned out to be a nonessential carbohydrate epitope, similar to the observations with gt-ko pigs (phelps et al., 2003; kolber-simonds et al., 2004) . a scenario similar to the hypothetical one described above is presently observed in individuals of the rare blood group "bombay" who lack the enzyme producing blood group o (h) and who naturally produce anti-h (blood group o) antibodies (bhende et al., 1952; watkins, 1980; le pendu et al., 1986; balgir, 2005 balgir, , 2007 . the similarities between ancestral primate populations including small numbers of individuals lacking α-gal epitopes, prior to extinction of populations synthesizing α-gal epitopes, and present day human populations including small numbers of individuals lacking the ability to produce blood group o (i.e., blood group bombay individuals) are further discussed at the end of this chapter. as proposed in fig. 2 , early ancestral old world primates synthesized α-gal epitopes similar to new world monkeys. these old world primates could become extinct in epidemics of highly virulent enveloped viruses because they succumbed to the infections before these primates could mount a protective immune response against the infecting virus. the viruses mediating such epidemics carried α-gal epitopes on their envelope glycoproteins, world primates synthesizing α-gal epitopes and their replacement with offspring-lacking the α-gal epitope and producing the natural anti-gal antibody. few individuals in early old world primate populations, who carried mutations inactivating the α1,3gt gene, produced the natural anti-gal antibody. this antibody production is analogous to the present day rare blood type "bombay" individuals lacking blood group o (h antigen) and producing anti-h antibodies. epidemics by enveloped viruses presenting α-gal epitopes that were synthesized by α1,3gt of ancestral old world primates caused the extinction of these primates, whereas offspring-lacking α-gal epitopes were protected by the natural anti-gal antibody they produced. these offspring ultimately replaced the extinct primates that conserved active α1,3gt. ab-antibody. reprinted from galili, u., 2016 . natural anti-carbohydrate antibodies contributing to evolutionary survival of primates in viral epidemics? glycobiology 26, 1140 glycobiology 26, -1150 which were synthesized by α1,3gt in the infected host cells. however, the very few primates that were homozygous for the inactivated α1,3gt gene, lacked active α1,3gt enzyme, did not synthesize α-gal epitopes and produced the natural anti-gal antibody. these few primates could have been protected by this antibody against viruses expressing α-gal epitopes. anti-gal protection could be mediated by several mechanisms, including: (1) neutralization and destruction of the virus by anti-gal binding to the virus α-gal epitopes and activating the complement system, which induced complement-mediated lysis of the virus, (2) opsonization of the virus by anti-gal could induce effective uptake and destruction of the virus by macrophages following fc/fcγ receptor interaction between the opsonizing anti-gal and these cells, and (3) extensive uptake of anti-gal opsonized viruses by macrophages and dendritic cells via fc/fcγ receptor interaction could result in rapid processing and presentation of immunogenic viral peptides by these antigen presenting cells (apc) that effectively transport the virus antigens to regional lymph nodes. this apc-mediated mechanism would have resulted in induction of rapid, potent humoral and cellular protective anti-virus immune responses. thus, such an immune response could also protect against infecting viruses that "lost" their α-gal epitopes because of the initial infection of the host cells lacking α1,3gt. the ability of anti-gal to markedly increase immunogenicity of vaccinating viruses by targeting them for effective uptake by apc is further detailed in chapter 9 that describes the amplification of virus vaccine immunogenicity by α-gal epitopes linked to vaccinating viral glycoproteins (abdel-motal et al., 2006 , 2010 . overall, the combined effects of the anti-gal-mediated protective mechanisms could result in decrease in initial infecting virus burden, t cell-mediated destruction of cells infected by the virus, as well as destruction and neutralization of virus de novo produced in infected cells by elicited antibodies specific to virus protein antigens. the outcome of these protective mechanisms could be prevention of infective virus progression before it reaches lethal stages. anti-gal igg crosses the placenta into the fetal blood in humans (galili et al., 1984) . anti-gal is also present in colostrum and milk, as well as in other body secretions, primarily as the iga isotype (class) (hamadeh et al., 1995) . thus, it is possible that anti-gal-mediated protection against an infectious virus that presents α-gal epitopes also occurred in newborns. in the absence of competition from parental primate populations synthesizing α-gal epitopes, the small populations of offspring-lacking α-gal epitopes and producing the natural anti-gal antibody replaced the extinct parental old world primate populations that conserved active α1,3gt. it should be stressed that the proposed scenario could occur with any type of enveloped virus that presented α-gal epitopes, which was endemic to the eurasia-africa landmass because any enveloped virus propagated in cells containing active α1,3gt is likely to present α-gal epitopes. the process of selective evolutionary elimination of α-gal epitopes, which occurred in ancestral old world primates, may not be feasible in all mammalian species synthesizing α-gal epitopes. one example is gt-ko mice. these mice develop cataract at the age of 6-9 weeks in the absence of α-gal epitopes (thall, 1999; sørensen et al., 2008) . although gt-ko mice developing such cataract can survive in the protected environment of animal facilities, their survival would have been questionable in natural environments. in contrast, gt-ko pigs were not reported to develop the cataract observed in mice in the absence of α-gal epitopes. as indicated above, it is impossible to identify a pathogen(s) that exerted the selective pressure for evolution of primates lacking α-gal epitopes and producing the anti-gal antibody in earlier geological periods. however, there are several observations supporting the hypothesis proposed in fig. 2 . glycoproteins are an integral part of virus envelopes. the carbohydrate chains on such glycoproteins contribute to the formation of a hydration layer that protects the virus. carbohydrate chains of the complex type of glycoproteins ( fig. 2a in chapter 1) are synthesized on aspargines (-n-) that are part of the amino acid sequence -n-x-s/t-in proteins. because these carbohydrate chains are synthesized by the host cell glycosylation machinery, viruses propagated in cells containing α1,3gt usually present multiple α-gal epitopes. thus, propagation of eastern equine encephalitis virus in mouse cells resulted in production of virions carrying α-gal epitopes, whereas propagation of this virus in african green monkey vero cells (lacking active α1,3gt) resulted in production of virions with envelope glycoproteins lacking α-gal epitopes (repik et al., 1994) . accordingly, influenza virus propagated in embryonated chicken eggs lacks α-gal epitopes because birds, as other nonmammalian vertebrates, lack α1,3gt. in contrast, propagation of influenza virus in bovine mdbk cells or canine mdck cells resulted in production of virions with the envelope glycoprotein hemagglutinin carrying several α-gal epitopes per molecule . α-gal epitopes were also demonstrated on other viruses propagated in nonprimate mammalian cells, including: friend murine leukemia virus (geyer et al., 1984) , murine molony leukemia virus (rother et al., 1995) , porcine endogenous retrovirus (perv) (takeuchi et al., 1996) , lymphocytic choriomeningitis virus, newcastle disease virus, sindbis virus, vesicular stomatitis virus (welsh et al., 1998) , and measles virus (preece et al., 2002; dürrbach et al., 2007) . several of these studies further showed that incubation of the viruses expressing α-gal epitopes in human serum or with purified anti-gal antibody further resulted in anti-gal-mediated neutralization and complement-mediated lysis of the viruses, whereas no such effects were observed in viruses lacking α-gal epitopes. as suggested in fig. 2 , it may be possible that a similar protective effect was mediated by anti-gal in the few individuals among old world primates that had mutations inactivating the α1,3gt gene. in contrast, populations conserving α1,3gt activity produced virions presenting α-gal epitopes and were killed by such viruses in the absence of anti-gal. the observed anti-gal-mediated destruction and neutralization of viruses carrying α-gal epitopes further suggested that this antibody may contribute to prevention of cross-species viral transmission from nonprimate mammals to humans (repik et al., 1994; rother et al., 1995; takeuchi et al., 1996; welsh et al., 1998; preece et al., 2002) . as detailed in chapter 9, anti-gal-mediated targeting to apc of inactivated influenza virus engineered to present α-gal epitopes was found to increase anti-virus antibody response in gt-ko mice by ∼100-fold, in comparison with mice immunized with inactivated influenza virus lacking α-gal epitopes (abdel-motal et al., 2007) . intranasal challenge of the immunized mice with a lethal dose of live influenza virus lacking α-gal epitopes resulted in death of 90% of mice immunized with virus lacking α-gal epitopes, whereas only 10% of mice immunized with virus presenting α-gal epitopes died after such challenge (abdel-motal et al., 2007) . similarly, anti-gal-producing gt-ko mice immunized with gp120 of hiv carrying α-gal epitopes resulted in ∼100-fold higher anti-gp120 antibody response, ∼30-fold higher t cell response, and ∼40-fold increase in in vitro hiv neutralization activity in comparison to the immune responses measured in mice immunized with gp120 lacking α-gal epitopes (abdel-motal et al., 2006) . a similar increase in anti-virus cd8+ cytotoxic t cell response was reported in anti-gal-producing gt-ko mice that were immunized with a mouse cell line expressing murine leukemia virus proteins and α-gal epitopes, in comparison with cd8+ t cell response in wild-type mice (i.e., mice lacking the anti-gal antibody) and undergoing similar immunization (benatuil et al., 2005) . all these studies support the assumption that ancestral old world primates lacking α-gal epitopes and producing the anti-gal antibody could enhance the immune response against proteins of infecting viruses presenting α-gal epitopes, by anti-gal-mediated targeting of the virus to apc. the enhanced immune response might have been potent enough to prevent progression of the infection to lethal stages even when the virions lacked α-gal epitopes because of growth in cells lacking active α1,3gt in anti-gal producing hosts. the hypothesis on the role of enveloped viruses in mediating the selective pressure for evolution of primates lacking α1,3gt and producing anti-gal, includes the assumption that such viruses appeared in the old world only after the split from new world monkeys, i.e., new world monkeys were geographically isolated in the south american continent and thus were not affected by these viruses. this assumption is supported by observations of an enveloped virus, epstein barr virus (ebv), which is of the herpes virus family, and it is thought to have appeared among old world primates after the geographic separation from new world monkeys. therefore, this virus has influenced immune system evolution of only old world primates. when ebv infects old world primates, it immortalizes a proportion of their b cells. however, the immune system in old world primates evolved to mount an extensive t cell response against ebv antigens, which in humans results in the transient infectious mononucleosis disease (klein and masucci, 1982; callan, 2003) . the proliferating t cells kill the majority of b cells infected by the virus and immortalized. moreover, ebv-immortalized b cells residing in immunologic sanctuaries are destroyed upon detection by t cells if they leave such sanctuaries. as many as 90% of humans are infected by ebv. however, because of the effective t cell response against ebv infected b cells; these b cells are prevented from spreading throughout the body and from progressing into becoming lymphoma cells. in contrast, no significantly effective anti-ebv protective t cell response is observed in new world monkeys infected by ebv because the immune system in these primates was not evolutionarily exposed to infections by this virus. therefore, many of the ebv-immortalized b cells in new world monkeys are not destroyed and progress into lethal polyconal b cell lymphomas (epstein et al., 1973; shope et al., 1973; wang, 2013) . elimination of α-gal epitopes and production of the natural anti-gal antibody may represent an analogous selective pressure mediated by a virus endemic to the old world land mass, whereas new world monkeys evolving in south america or lemurs evolving in madagascar have not been subjected to evolutionary selective processes by such hypothetical viruses because of geographic isolation from the old world. the occurrence of mutations that result in elimination of major cell surface antigens, such as the α-gal epitope and the appearance of a natural antibody against it, are very rare events in evolution. there is only one other similar event known in the evolution of old world primates, the elimination of the sialic acid n-glycolylneuraminic acid (neu5gc) in hominins (ancestors of humans) and production of natural anti-neu5gc antibodies that are found only in humans (zhu and hurst, 2002; padler-karavani et al., 2008) . the rest of old world primates and nonprimate mammals synthesize neu5gc and lack anti-neu5gc antibodies (varki, 2010) . these selective processes were likely to be associated with extinction of the parental primate populations conserving the carbohydrate antigen and thus, lacking the natural antibody against it. although it is practically impossible to associate between the fossil record from previous geological periods and biochemical/immunological changes in primate populations, there is an interesting parallelism between the suggested hypothesis on extinction of apes that conserved α-gal epitopes and the fossil record of apes. apes were a very successful group of primates in the early miocene (∼20-23 mya) as implied from the multiple fossils of many ape species (hominoidea) dating to that period, which were found in eurasia-africa. however, the number and diversity of ape fossils from the middle miocene (∼11-16 mya) greatly declines. no fossils of apes from the late miocene (∼5-10 mya) have been found, suggesting an almost complete extinction of apes at that period (andrews, 1992; andrews et al., 1996; merceron et al., 2010; alba, 2012) . these changes in ape populations have been associated with dietary adaptations because of climatic changes (andrews and martin, 1991; agustí et al., 2003; ungar and kay, 1995) . an alternative cause for this almost complete extinction of ancestral apes could be associated with the selective pressure for the evolution of apes lacking α-gal epitopes and producing the anti-gal antibody (galili and andrews, 1995) , possibly mediated by epidemics of viruses carrying α-gal epitopes, as suggested above. the slow decline in ape populations during the middle miocene, toward their almost complete extinction in the late miocene, may further suggest that the extinction of primates by viral epidemics and expansion of subpopulations lacking α-gal epitopes throughout eurasia-africa could have been slow processes taking millions of years. the slow pace of these changes may have been the result of the great geographical distances between various ape populations. the fossil record of old world monkeys dating to those periods is sparse, and thus, it is difficult to determine the population changes in this group of primates during the miocene (miller et al., 2009 ). the efficacy of anti-gal in protecting against infections with viruses presenting α-gal epitopes may vary for different enveloped viruses. one example for insufficient protective activity is that of influenza virus. as indicated above, when this virus is grown is cells that have active α1,3gt (e.g., bovine mdbk cells or canine mdck cells), the virus carries α-gal epitopes on its hemagglutinin envelope protein . thus, it is likely to carry α-gal epitopes also when produced in porcine cells. indeed perv grown in porcine cells can be destroyed by anti-gal in human serum (takeuchi et al., 1996) . nevertheless, humans can be infected by influenza virus produced in pigs. once few virions succeed in penetrating into human cells of the respiratory tract, they proliferate and carry carbohydrate chains produced by the human glycosylation machinery, i.e., chains lacking α-gal epitopes. thus, additional scenarios for the evolutionary processes that could result in extinction of ancestral old world primates presenting α-gal epitopes should be considered, as well. three of these scenarios are as follows: 1. detrimental bacteria expressing α-gal-like epitopes-several bacterial strains bind the anti-gal antibody (galili et al., 1988b) , provide antigens that elicit production of anti-gal in humans (almeida et al., 1991) and in gt-ko mice (posekany et al., 2002) , and display carbohydrate antigens with terminal α-galactosyls in both gram-negative and grampositive bacteria (lüderitz et al., 1965; han et al., 2012) . it could be hypothesized that bacterial strains that were lethal to old world primates, which expressed antigens that elicit anti-gal production, could generate a selective pressure for survival of primates that produced this antibody as a protective antibody, i.e., selection for individuals with inactivated α1,3gt gene. could be that the lethal effects of the infecting bacteria were mediated by binding of their toxins to α-gal epitopes on host cells. a current example is enterotoxin a of clostridium difficile that causes severe diarrhea. this toxin can bind to various carbohydrate receptors; however, its primary receptor on nonprimate mammalian cells is the α-gal epitope (pothoulakis et al., 1996; teneberg et al., 1996) . it may be possible that epidemics among old world primates by bacteria producing lethal toxin(s) that used α-gal epitopes as receptor on target cells, exerted a selective pressure for survival of individuals that lacked the α-gal epitopes and thus, were not affected by the toxin. as discussed above, once the α-gal epitope was eliminated, the immune tolerance to this antigen was lost, resulting in production of the natural anti-gal antibody. a similar selective process may be envisaged if a detrimental virus "used" the α-gal epitope as a "docking receptor." influenza virus uses sialic acid on cells as a docking receptor that enables it to attach to cell membranes and penetrate into cells. if there was a virus that used the α-gal epitope as such a receptor, it could drive the selection of primates to survival only of those lacking α-gal epitopes along a pathway similar to that described in fig. 2 , without the involvement of antibodies in the selective process. however, anti-gal production would have been a by-product resulting from the loss of the α-gal epitope and of the immune tolerance to it. a current example for such a virus is bovine norovirus that was reported to use α-gal epitopes as a docking receptor for infecting bovine cells (zakhour et al., 2009 ). in addition, sindbis virus was found to preferentially infect cells that present α-gal epitopes and wild-type suckling mice synthesizing this epitope, in comparison with cells or suckling mice lacking α-gal epitopes (rodriguez and welsh, 2013) . chapter 4, several protozoa, which are parasitic in humans, were found to present cell surface carbohydrate epitopes with structures similar to the α-gal epitope. these include trypanosoma (ramasamy and field, 2012; milani and travassos, 1988; almeida et al., 1994) , leishmania (avila et al., 1989; mcconville et al., 1990; ilg et al., 1992) , and plasmodia (ramasamy and reese, 1986; yilmaz et al., 2014) . as argued above for bacteria, such protozoa pathogens could mediate the selective pressure for survival of individuals in which α-gal epitopes were eliminated and the natural anti-gal antibody produced (ramasamy and rajakaruna, 1997; yilmaz et al., 2014) . these antibodies could serve as protective antibodies against infections by protozoa presenting anti-gal-binding epitopes. indeed, anti-gal binding to trypanosoma cruzi was shown to induce complementmediated cytolysis of the parasite (milani and travassos, 1988; almeida et al., 1991 almeida et al., , 1994 as well as direct, complement-independent lysis (gazzinelli et al., 1991) . although bacteria and protozoa epidemics cannot be excluded as evolutionary causes for selection of old world primates with inactivated α1,3gt gene, the likelihood of these scenarios may be lower than the scenario of enveloped viruses mediating such a selective pressure. the complete elimination of old world monkeys and apes producing α-gal epitopes in all climatic regions of eurasia-africa suggests that the pathogen(s) had to have very high infectivity and may have not depended on secondary transmitting vectors (e.g., insects active only in certain climates). such are characteristics of viruses that spread directly from one infected individual primate to the other, regardless the large variety of climatic environments. the elimination of the α-gal epitope in ancestral old world primates was the result of mutations that inactivated the α1,3gt gene (ggta1) in few individuals, and subsequently in small populations of ancestral primates. α1,3gt activity was not essential in ancestral primates who were homozygous for the inactivated α1,3gt gene (galili et al., 1987a (galili et al., , 1988a . these observations raised the question of the mechanism that inactivated α1,3gt gene in old world primates. this question could be addressed following the cloning of the α1,3gt gene in mouse and bovine cells (larsen et al., 1989; joziasse et al., 1989) . the gene was found to be composed of ∼1110 base pairs divided into nine exons, of which exon ix (687 bp) is the largest. comparison of dna and derived protein sequences of exon ix in mouse and bovine α1,3gt and a cloned homologous human genomic sequences, indicated that in the human dna sequence, there are two frameshift mutations caused by single base deletions, corresponding to base 822 and base 904 of the mouse α1,3gt cdna (fig. 3) (larsen et al., 1989 (larsen et al., , 1990 joziasse et al., 1989; lantéri et al., 2002) . these mutations create premature stop codons, truncating the α1,3gt enzyme by 110 and 15 amino acids at the c-terminus, respectively. controlled truncation of a new world monkey α1,3gt cdna indicated that elimination of as few as the last three amino acids at the c-terminus of the enzyme was sufficient to cause complete loss of catalytic activity of α1,3gt (henion et al., 1994) . this implies that α1,3gt gene in humans is a pseudogene incapable of producing an active enzyme. sequencing of the homologous dna region in apes revealed that orangutan and gorilla have an α1,3gt pseudogene containing only one of the two deletions, at base 904, whereas chimpanzee has both deletions, similar to humans (fig. 3) (galili and swanson, 1991) . the absence of any of these two deletions in old world monkey α1,3gt pseudogenes (rhesus, african green, and patas monkeys in fig. 3) suggested that the deletions appeared in apes after they and old world monkeys diverged from a common ancestor, i.e., less than 28 mya. however, a third deletion was found in exon vii in rhesus monkey, in orangutan, and in humans (koike et al., 2002) . this mutation in an old world monkey, ape, and humans suggested that the inactivation of the gene occurred before divergence of old world monkeys and apes from a common ancestor (koike et al., 2002) . based on these studies, it is not clear at present whether the selective process for extinction of old world primates synthesizing the α-gal epitope and the emergence of primates lacking this epitope and producing anti-gal, initiated before or after the split between apes and monkeys of the old world, and thus, it is considered to initiate 20-30 mya (fig. 1) . aligned dna sequences of a 370-bp region in exon ix of the αl,3gt pseudogene from humans (larsen et al., 1990) , apes including: chimpanzee, gorilla and orangutan, and old world monkeys including: rhesus monkey, african green monkey, and patas monkey. these sequences are aligned with the active αl,3gt gene in new world monkeys including: spider monkey, squirrel monkey, and howler monkey, and with domestic cow (described by joziasse et al., 1989) . the base numbers in this figure are according to the open reading frame of the mouse αl,3gt cdna described by larsen et al. (1989) . the numbered base is under the second digit. dots represent sequences identical to those of the human αl,3gt pseudogene. note the two deletions c822 and g904 in humans and chimpanzees and g904 in humans and apes but not in other primates. reprinted from galili, u., swanson, k., 1991 . gene sequences suggest inactivation of α1-3 galactosyltransferase in catarrhines after the divergence of apes from monkeys. proc. natl. acad. sci. u.s.a. 88, [7401] [7402] [7403] [7404] with permission. the basic assumption in regard to the evolutionary elimination of ancestral old world primates producing α-gal epitopes is that prior to this elimination there have been few primates that were homozygous for mutations that inactivated the α1,3gt gene (ggta1) and thus produced the natural anti-gal antibody. this assumption is supported by a similar present day example of a very rare mutation in humans, which inactivates the α1,2 fucosyltransferase gene (α1,2ft also called fut1). individuals homozygous for this mutation belong to blood group "bombay" and are characterized by inability to synthesize the h antigen (fucα1-2gal-r that is blood group o) (bhende et al., 1952; watkins, 1980; le pendu et al., 1986; balgir, 2005 balgir, , 2007 . these individuals are designated as oh or h/h, in contrast to most humans who are h/h, i.e., they produce the blood group o carbohydrate antigen. in individuals who are blood group a or b, n-acetylgalactosamine (galnac) or galactose (gal) is added α1-3 to the penultimate gal of the h antigen, respectively. the structure of blood type "bombay" antigen oh is included in fig. 1 of chapter 3 that illustrates the α-gal epitopes and blood type abo antigens, as well. cloning and sequencing of the α1,2ft gene (fut1) in blood group bombay (oh) individuals demonstrated the presence of inactivating point mutations in the coding regions of both alleles of this gene (kelly et al., 1994; fernandez-mateos et al., 1998) . blood group bombay individuals are very rare. they are found in european populations as 1:1,000,000, whereas in india they are 1:10,000. in the absence of blood group o, blood group bombay individuals naturally produce anti-blood group h (o) antibodies (i.e., anti-fucα1-2gal-r antibodies). these natural antibodies are completely absent in all other human populations. blood group bombay individuals also produce natural anti-a and anti-b antibodies because in the absence of blood group h, they cannot synthesize blood groups a or b antigens. thus, blood group bombay individuals resemble the hypothesized ancestral old world primates who lived prior to the extinction of α-gal epitopes synthesizing primates, in the following characteristics: (1) individuals who are homozygous for the accidently acquired mutation(s) that inactivated the α1,2ft gene, and those primates with inactivated α1,3gt gene have been very rare within their corresponding populations. (2) the homozygous individuals for the inactivated glycosyltransferase genes lack the h antigen or the α-gal epitope and produce a natural antibody against the lost carbohydrate antigen. as indicated above, anti-gal can destroy or neutralize enveloped viruses presenting α-gal epitopes, following propagation in mammalian cells containing active α1,3gt. similarly, enveloped viruses including severe acute respiratory syndrome coronavirus (guillon et al., 2008) , measles virus (preece et al., 2002) , and hiv (neil et al., 2005) were found to present blood group a or b carbohydrate antigens when propagated in cells of containing α1,2ft and the corresponding a or b transferases. these viruses were further found to undergo complement-mediated inactivation in sera containing anti-a or anti-b antibodies, respectively. thus, it would be of interest to determine whether anti-blood group h (o) antibody in the serum of blood group bombay individuals can inactivate enveloped viruses propagated in blood group h human cells. such an anti-viral activity of anti-blood group h (o) antibody raises a hypothetical possibility that blood group bombay individuals may be immuno-protected better than other humans by the natural anti-blood group h (o), anti-a and anti-b antibodies against virulent enveloped viruses originating in any individual who is not blood group bombay. this protection may be in a manner analogous to the effects of anti-gal on enveloped viruses presenting α-gal epitopes, described in fig. 2 . the natural anti-gal antibody is one of the multiple natural anti-carbohydrate antibodies produced in humans against a wide range of carbohydrate antigens on gi bacteria. the antibody is unique to humans, apes, and old world monkeys, and it binds specifically to a mammalian carbohydrate antigen called the α-gal epitope that is synthesized in nonprimate mammals, lemurs (prosimians) and new world monkeys by the glycosylation enzyme α1,3gt. the α1,3gt gene (ggta1) appeared in mammals >100 million years ago, prior to the split between marsupial and placental mammals. this gene has been conserved in its active form, in all mammals, except for old world monkeys, apes, and humans. inactivation of the α1,3gt gene in ancestral old world primates occurred 20-30 million years ago and could have been associated with epidemics of enveloped viruses in the eurasia-africa continent. it is suggested that prior to such epidemics, few ancestral old world primates acquired deletion point mutations that inactivated the α1,3gt gene and eliminated α-gal epitopes. this resulted in loss of immune tolerance to the α-gal epitope and thus, in production of the anti-gal antibody against antigens on bacteria colonizing the gi tract. this accidental inactivation of the α1,3gt gene in very small populations is analogous to the highly rare blood type "bombay" individuals who do not synthesize blood group h (o antigen) because of inactivation of the α1,2-fucosyltransferase gene. the loss of immune tolerance to blood group h antigen has resulted in production of natural anti-blood group h antibodies in the blood group bombay individuals. it is suggested that anti-gal protected against infections by enveloped viruses presenting α-gal epitopes, which were lethal to the parental primate populations that conserved active α1,3gt and thus, synthesized α-gal epitopes. alternative causes for the elimination of old world primates synthesizing α-gal epitopes could be bacteria or protozoa parasites presenting α-gal or α-gal-like epitopes, and bacterial toxins, or detrimental viruses that used α-gal epitopes in these primates as "docking receptors." ultimately, any of these proposed selective processes could result in extinction of old world primates synthesizing α-gal epitopes on their cells. these ancestral primates were replaced by offspring populations lacking α-gal epitopes and producing the anti-gal antibody, which continues to be produced by old world monkeys, apes, and humans. new world monkeys and lemurs were protected from pathogens of the old world by oceanic barriers, thus they continue to synthesize α-gal epitopes and lack the ability to produce the anti-gal antibody. this scenario of few individuals in a large population having a mutation(s) that inactivates a glycosyltransferase gene thus, resulting in production of evolutionary advantageous natural antibodies against the eliminated carbohydrate antigen, may reflect one of the mechanisms inducing changes in the carbohydrate profile of various mammalian populations. increased immunogenicity of human immunodeficiency virus gp120 engineered to express galα1-3galβ1-4glcnac-r epitopes increased immunogenicity of influenza virus vaccine by anti-gal mediated targeting to antigen presenting cells increased immunogenicity of hiv-1 p24 and gp120 following immunization with gp120/p24 fusion protein vaccine expressing α-gal epitopes explaining the end of the hominoid experiment in europe fossil apes from the 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present in the human genome and partially transcribed isolation of a cdna encoding a murine udp-galactose:β-d-galactosyl-1,4-n-acetyl-d-glucosaminide α-1,3-galactosyltransferase: expression cloning by gene transfer frameshift and nonsense mutations in a human genomic sequence homologous to a murine udp-gal:β-d-gal(1,4)-d-glcnac α(1,3)-galactosyltransferase cdna on the specificity of human anti-h antibodies the immunochemistry of salmonella chemotype vi o-antigens. the structure of oligosaccharides from salmonella group u (o 43) lipopolysaccharides synthesis of α-l-rhamnosyl ceramide and evaluation of its binding with anti-rhamnose antibodies removal of bowel aerobic gram-negative bacteria is more effective than immunosuppression with cyclophosphamide and steroids to decrease natural α-galactosyl igg antibodies structures of the glycoinositolphospholipids from leishmania major. a family of novel galactofuranose-containing glycolipids ruminant diets and the miocene extinction of european 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biochemistry and genetics of the abo, lewis, and p blood group systems evaluation of the galα1-3gal epitope as a host modification factor eliciting natural humoral immunity to enveloped viruses origin of naturally occurring hemagglutinins and hemolysins; a review gut microbiota elicits a protective immune response against malaria transmission the αgal epitope of the histo-blood group antigen family is a ligand for bovine norovirus newbury2 expected to prevent cross-species transmission anti-n-glycolylneuraminic acid antibodies identified in healthy human serum key: cord-288392-khjo6j8u authors: davern, melanie; winterton, rachel; brasher, kathleen; woolcock, geoff title: how can the lived environment support healthy ageing? a spatial indicators framework for the assessment of age-friendly communities date: 2020-10-21 journal: int j environ res public health doi: 10.3390/ijerph17207685 sha: doc_id: 288392 cord_uid: khjo6j8u the age-friendly cities and communities guide was released by the world health organization over a decade ago with the aim of creating environments that support healthy ageing. the comprehensive framework includes the domains of outdoor spaces and buildings, transportation, housing, social participation, respect and inclusion, civic participation and employment, communication and information, and community and health services. a major critique of the age-friendly community movement has argued for a more clearly defined scope of actions, the need to measure or quantify results and increase the connections to policy and funding levers. this paper provides a quantifiable spatial indicators framework to assess local lived environments according to each age-friendly cities and communities (afc) domain. the selection of these afc spatial indicators can be applied within local neighbourhoods, census tracts, suburbs, municipalities, or cities with minimal resource requirements other than applied spatial analysis, which addresses past critiques of the age-friendly community movement. the framework has great potential for applications within local, national, and international policy and planning contexts in the future. research has long recognized that environmental factors play a significant role in determining health and wellbeing in older age [1] , and there are rising proportions of older people in the populations across the world. consequently, the recently released united nations decade of healthy ageing 2020-2030 calls for sustained global action to generate transformative change in four priority areas: addressing ageism; creating age-friendly communities; delivering integrated and person centered care; and providing long-term care [2, 3] . increased urbanization and policy discourses supporting ageing in place add to the urgency to create and plan for age-friendly environments. on a global scale, life expectancy has increased from 47 years in the mid-20th century to an expected 78 years by the mid-21st century [4] and 21% of the world's population is predicted to be aged over 60 years by 2050 [5] . the world health organization (who) world report on ageing and health [6] documented how age-friendly environments play a which often includes transportation systems, land development patterns, and microscale urban design (e.g., footpaths) [27, 28] . a lived environment reflects the importance of locality and access to good urban design, as well as human-made and natural environments to support health and wellbeing in the local neighbourhoods where people live. this is consistent with the argument regarding the narrow application of the term "built environment" where both human made and natural worlds are conceived as though there is no separation between them [29] . spatial indicators provide a quantitative measurement of local lived environments using geocoded data (defined by x and y co-ordinates) developed using geographic information systems (gis). data linked to a street address can be mapped using gis and calculated as spatial indicators, providing aggregated measures across a range of geographic areas, including neighbourhoods or census tracts, suburbs, municipalities, regions, or states. aggregated geocoded data can be drawn from a range of existing administrative data sources that assess the lived environment and a range of social, economic, and environmental issues. spatial afc indicators consequently provide objective and cost-effective assessments of age-friendliness that are easily replicated across large geographic areas using desktop spatial analysis. these indicators can also be made readily accessible to local governments using online digital planning portals and liveability indicator systems for cities, like the australian urban observatory (auo.org.au) [30] . the development of quantifiable spatial indicators of afc addresses the major critiques of the afc initiative-that it is too descriptive in approach [31] , not measured or monitored by indicators [31] , and without a clear understanding of an indicator framework [32] . this paper proposes spatial indicator tools that can be applied for the assessment of afc in local lived environments using a gis methodology. these afc spatial indicators can also be applied in a variety of international contexts with direct relevance to the healthy cities movement [33] , the new urban agenda, and the 2030 agenda for sustainable development [34] . the 2030 agenda provides a global framework for sustainable urban development up until 2030 signed by all 193 members states with 169 specific targets. these include sustainable development goals (sdgs) with specific mention of older people in targets for goal 10 reduced inequalities, goal 11 sustainable cities and communities, and goal 17 partnerships for the goals. in addition, the decade of healthy ageing [3] calls for disaggregated data in twenty-eight indicators across eleven goals. spatial indicators measuring afc in lived environments are noted by the united nations as being necessary for the measurement and monitoring of any actions contributing to sustainable development (goal 17) and multi-stakeholder partnership development and policy and institutional coherence. they have been developed to address segregation or siloed approaches in the current planning approaches and to encourage discussion and action that can promote integrated policy, planning, and practice across urban planning and public health. often the outcome of afc remains the sole responsibility of health or social planning with little integration across important portfolios, such as transport or statutory or strategic planning. the implementation of afc principles must extend beyond practitioners with interest in ageing and should ideally be integrated across policy portfolios with budget and legislative support. this paper aims to introduce a new set of afc spatial indicators that can be used to quantify and assess the age-friendliness of local lived environments and monitor changes in age-friendliness over time consistent with the sdgs and 2030 agenda. these indicators seek to support the decade of healthy ageing, which includes a commitment to action in the development of age-friendly environments and improved measurement, monitoring, and research [8] as well as tools to support planners and practitioners working within government settings. these spatial indicators of afc also identify the importance of older people and their lived environments in sustainable urban development and the 2030 agenda. eight interconnected domains are included in afc ( figure 1 ). the selection of specific spatial indicators to assess the lived environment of each afc domain was made following a workshop held with all five authors to identify the most relevant measures for each of these domains. the multidisciplinary experience of the research team spans gerontology, public health, urban planning, psychology, epidemiology, sociology, health geography, health policy, governance, and community development. with all five authors to identify the most relevant measures for each of these domains. the multidisciplinary experience of the research team spans gerontology, public health, urban planning, psychology, epidemiology, sociology, health geography, health policy, governance, and community development. potential indicators were then judged against the key criteria recommended by the who (box 1) as well as other best practice principles for indicator application [36] including: direct links to policy; connection to theory and existing research; available time series data; connection to budgeting and planning; relevance to most people; and connection to lived reality. these latter criteria being understood and relevant to most people, particularly older people, are particularly important and informed by previous research in the development of a specific indicator of access to services for older people [37] , which included focus groups of older people to determine the local needs and services of highest importance. the selected measures also needed to be relevant to the majority of older people living in a wide range of lived environments, and to measure the most critical requirements for places that support afc principles. box 1. the criteria suggested for defining local afc indicators [15] . will variations in the indicator be observable over time due to specific actions? disaggregation possible: can the indicator be disaggregated by gender, age group, or across neighbourhoods? there are also other strategies that could be important in the local context, including ethnicity, socioeconomic status, etc. aligns with local goals and targets: does the indicator link to a broader local agenda? can be linked to action: does the indicator provide an understanding of the various actions that might need to be undertaken? within local influence: does the local government or community have the mandate or authority to act on this indicator? for example, a federal insurance scheme is mostly beyond the influence of the municipal government. easy to collect: are the data required to produce the indicator easy to collect in a timely manner? socially acceptable: is the collection of this information acceptable to the communities and individuals concerned? the following section describes each of the selected afc spatial indicators with research evidence provided to support each indicator (table 1 ). potential indicators were then judged against the key criteria recommended by the who (box 1) as well as other best practice principles for indicator application [36] including: direct links to policy; connection to theory and existing research; available time series data; connection to budgeting and planning; relevance to most people; and connection to lived reality. these latter criteria being understood and relevant to most people, particularly older people, are particularly important and informed by previous research in the development of a specific indicator of access to services for older people [37] , which included focus groups of older people to determine the local needs and services of highest importance. the selected measures also needed to be relevant to the majority of older people living in a wide range of lived environments, and to measure the most critical requirements for places that support afc principles. box 1. the criteria suggested for defining local afc indicators [15] . will variations in the indicator be observable over time due to specific actions? disaggregation possible: can the indicator be disaggregated by gender, age group, or across neighbourhoods? there are also other strategies that could be important in the local context, including ethnicity, socioeconomic status, etc. aligns with local goals and targets: does the indicator link to a broader local agenda? can be linked to action: does the indicator provide an understanding of the various actions that might need to be undertaken? within local influence: does the local government or community have the mandate or authority to act on this indicator? for example, a federal insurance scheme is mostly beyond the influence of the municipal government. easy to collect: are the data required to produce the indicator easy to collect in a timely manner? socially acceptable: is the collection of this information acceptable to the communities and individuals concerned? the following section describes each of the selected afc spatial indicators with research evidence provided to support each indicator (table 1) . additional contextual factors for consideration include: the estimated resident population; proportion of population aged more than 60 years; population age distribution including proportions of older and younger populations in area; ethnicity; education; homeownership; residential density; remoteness e.g., accessibility/remoteness indices or the distance between towns in rural settings; the risk of natural disasters; climatic conditions; and the impact of climate change. * recommended as priority indicators for inclusion. the suggested spatial indicators for each afc domain are presented in table 1 with the priority indicators notated with asterisks. this provides flexibility for practitioners in identifying the key spatial indicators of importance to afc or additional optional indicators where resources are available. additional information is provided below explaining why these indicators are recommended for each afc domain with detailed explanations of the supporting research evidence. the indicators recommended in the following section were identified in accordance with indicators acting as icebergs and highlighting issues of major importance [37] . only after the major factors have been quantitively assessed should further qualitative assessment be completed, similar to a hierarchy of need. for example, if there are no public open spaces available there is little point in assessing the maintenance, shelter, or facilities available in public open spaces within an area. additional qualitative assessment could also include local consultation with older residents and relevant stakeholders. the priority indicators identified for this domain are walkability for transport [38, 39] and access to public open space within 400 m [22] . these indicators are directly related to walking [40] [41] [42] , specifically in older people [43] , and associated with physical health benefits [44] and mental health benefits [45] . walkable neighbourhoods are important for older people because, along with the fact that they enable people to reach destinations with commercial and social opportunities [43, 46] , walking is also associated with maintaining functional independence [47] and better cognitive function [48] . similarly, public open spaces that are easy to visit with walkable access are important for older people and important in reducing social isolation and increasing physical activity [49] . data required to create indicators of walkability are commonly available within municipal and planning contexts. road network analysis (a way to walk), land use mix (destinations to walk to), and housing density (people to service the destinations) are common key components of walkability assessments. similarly, public open space location data are also regularly held by most municipal governments. footpaths are an important infrastructure supporting walking in older people [50, 51] , and walkability can also be refined by superimposing footpath access where spatial data are available. an example of a walkability for transport assessment for the regional city of launceston in tasmania, australia was calculated and is provided in figure 2 to demonstrate the value of neighbourhood level walkability assessments. the results clearly suggest that the inner neighbourhoods of the city of launceston have good walkability while the outer neighbourhoods are less supportive of walking for transport, particularly those on the eastern side of town. additional spatial indicators for consideration include intersections with visual and auditory signalled pedestrian crossings that allow time for older people to cross over roads, and particularly busy intersections [53, 54] . in australia, many regional towns avoid the use of signalized pedestrian crossings and opt for roundabout intersections, which encourage continual traffic flow and can be frightening for people with reduced mobility. access to public seating is also recommended to be available within local public open spaces to encourage rest stops while walking (overlapping with the suggested measure of accessibility to public open space). clean and safe public toilets are also recommended, including those with accessibility features [51] and should also be included within high quality public open spaces. accessible buildings are italicised in table 1 due to the difficulty in sourcing data that measure buildings developed according to universal design principles. if possible, these are recommended, as older people experience difficulties associated with access to public buildings and the lack of handrails, narrow corridors, and steps [51] . post occupancy evaluations are generally more common in sustainability assessments [55] and are time and staff resource intensive but could be considered as an alternative measure if no other data are available to assess buildings. additional spatial indicators for consideration include intersections with visual and auditory signalled pedestrian crossings that allow time for older people to cross over roads, and particularly busy intersections [53, 54] . in australia, many regional towns avoid the use of signalized pedestrian crossings and opt for roundabout intersections, which encourage continual traffic flow and can be frightening for people with reduced mobility. access to public seating is also recommended to be available within local public open spaces to encourage rest stops while walking (overlapping with the suggested measure of accessibility to public open space). clean and safe public toilets are also recommended, including those with accessibility features [51] and should also be included within high quality public open spaces. accessible buildings are italicised in table 1 due to the difficulty in sourcing data that measure buildings developed according to universal design principles. if possible, these are recommended, as older people experience difficulties associated with access to public buildings and the lack of handrails, narrow corridors, and steps [51] . post occupancy evaluations are generally more common in sustainability assessments [55] and are time and staff resource intensive but could be considered as an alternative measure if no other data are available to assess buildings. there is a growing body of evidence showing a positive association between healthy ageing and blue space [56] . this is worthy of future consideration but is not accessible within all lived environments and, hence, has not been included as a recommended measure within the outdoor space and building domain but could be considered as second tier measures. blue space is defined as outdoor environments (natural or manmade) that prominently feature water and are accessible proximally (being located in, on, or near water) or distally/virtually (being able to see, hear, or sense water) [57] . therapeutic design of a built environment using urban green and blue infrastructure was shown to be protective for healthy ageing while supporting those with cognitive decline, or illness [58] . similarly, a study of largely older people in hong kong found that general health was significantly higher in people with a sea view from their home [59] , while, in ireland, older people had a lower risk of depression in those with more sea views [60] . in addition, nature-based solutions, there is a growing body of evidence showing a positive association between healthy ageing and blue space [56] . this is worthy of future consideration but is not accessible within all lived environments and, hence, has not been included as a recommended measure within the outdoor space and building domain but could be considered as second tier measures. blue space is defined as outdoor environments (natural or manmade) that prominently feature water and are accessible proximally (being located in, on, or near water) or distally/virtually (being able to see, hear, or sense water) [57] . therapeutic design of a built environment using urban green and blue infrastructure was shown to be protective for healthy ageing while supporting those with cognitive decline, or illness [58] . similarly, a study of largely older people in hong kong found that general health was significantly higher in people with a sea view from their home [59] , while, in ireland, older people had a lower risk of depression in those with more sea views [60] . in addition, nature-based solutions, through green and blue space urban management planning, can mitigate the health impacts of climate change while addressing the need for climate resilience in local communities [61] . future revisions of the afc principles could consider the inclusion of more detailed measures of green and blue spaces in the domain of outdoor spaces and buildings to address changing climates around the globe. these could include access to local blue spaces, public and private tree canopy coverage, public street tree canopy coverage and the associated shade capability, in combination with the currently recommended measures of walkability and accessibility to public open space. these measures are very worthy of consideration but bring their own challenges in terms of data access and spatial capability making them harder to produce. consequently, they are suggested as potential expanded, not essential, measures of the afc lived environment assessment. transport is an important determinant of health [62, 63] influencing access to local services, engagement in paid and non-paid productive activities (such as employment or volunteering), maintaining and developing social networks and supports, and engaging in social and recreational activities. public transport has also been identified as a critical influence of liveability in a community [19] and active transport important to older people [64] . policy-relevant spatial public transport indicators are typically based on 400 m access or a 5-min walk [20, 65] . another important factor that influences the use of public transport is service frequency. consequently, access to any public transport stop provides a high-level assessment while access to frequent public transport provides a more refined assessment. similar measures are also included in the australian government's national cities performance framework (https://www.bitre.gov.au/national-cities-performance-framework). for older people, mobility is essential for social participation and wellbeing [66] . public transport is particularly important for older people who might have a reduced ability to drive. older people tend to use public transport more frequently if there is easy access to public transport in neighbourhoods at a distance less than 5 min away [67] . this is also consistent with existing research that found that the frequency of public transport and wait time affected older people's willingness to travel [68] and that a high proportion of older people are no longer driving [69] . data for these indicators can most often be sourced from public access data portals, open street map or general transit feed specification (gtfs) where public transport data are provided by transport agencies into a computer readable format for web developers [70] . gaining access to more detailed data describing public transport that meets disability standards is another very valid indicator and has been associated with increased satisfaction and perceived useability in older people [71] . similarly, access to a bus stop with an accompanying shelter and seat is also important for older people's mobility, as well as dropped curves, footpaths, and pedestrian signals [54] . housing is central to living a productive, meaningful, and healthy life, and housing quality is an important influence on self-reported health [72] . unaffordable housing is detrimental to mental health in low to moderate income households [73] . unaffordable housing has also been associated with an increased risk of poor self-rated health, hypertension, and arthritis, and renting, rather than owing a home, increases associations between unaffordable housing and self-rated health [74] . consequently, housing costs and gentrification [75] are particularly important to consider, with housing stress in lower income households being a particularly important indicator for the assessment of age-friendly cities. housing needs, sizes, and types can change as people age. older people might consider downsizing to smaller homes with reduced maintenance needs or to be closer to extended family for support to age in place [76] . in rural and regional areas, older people might need to move from larger farms and back into towns where services are more readily available. alternatively, frail older residents might require the support of aged care providers to support high care needs. addressing these issues means that communities need to understand the available housing diversity options (e.g., larger houses, smaller houses, units, and apartments to serve broad community needs) as well as access to services for residents. afc supports multiple housing options that are beneficial to all residents with many municipalities thinking primarily about formal aged-care accommodation when addressing housing needs for older people. even more concerning in australia, it is common for aged care facilities to be built on the outskirts of cities and towns where there is an abundance of inexpensive and undeveloped land. this isolates older people from the rest of the community, makes it harder for people to access and visit, decreases access to other community services, and decreases intergenerational contact within communities. the 30/40 housing affordability indicator is recommended and describes the proportion of households in the bottom 40% of household incomes spending more than 30% of their income on housing costs [77] . this measure is also referred to as the ontario measure where the interest in housing affordability first identified the disproportionate impact of housing costs on lower income households [78, 79] . understanding community demographic profiles, particularly age, in combination with the high incidence of 30/40 housing affordability issues should raise concerns for any community wanting to support age-friendliness. specifically, older adults on an aged pension within the private rental market will face significant challenges in housing affordability [80] . the indicator of access to services for older people was developed with older people themselves [37] and includes hospitals, general practitioners, aged care facilities, public transport stops, supermarkets, community centres, libraries, and universities of the 3rd age, and could also include places of worship and parks. this indicator also provides a useful assessment for the afc domain of community support and health services but is included in the housing domain to reinforce the importance of urban planning that supports the co-locations of services and housing options. the proportion of government owned dwellings could also be investigated as an additional support measure of afc, particularly in lower income areas. meaningful social relationships and participation are essential for good health, with health defined as a social phenomenon in the social determinants of health [81] . social participation has been associated with physical activity [82] , mental health [83] , reduced psychological distress [84] , reduced risk of myocardial infarction [85] , and up to a 50% increased likelihood of survival in people with strong social relationships compared to lifestyle risk factors [86] . for older people, social participation provides greater life satisfaction [87] , is protective against cognitive decline [88] , and contributes to resilience in older people [89] , especially in rural communities [90] . social participation is also being taken seriously internationally, and the united kingdom appointed a new minister for loneliness and a national government action plan on loneliness [91] . the recommended spatial indicators supporting social participation connect to the access to services for older people [92] that are included in the housing domain. two indicators are recommended: access to community centres and neighbourhood houses; and access to recreational services that cater to the needs of older people. shared or 'third spaces' such as these are critical social infrastructure [25] and essential in supporting social participation for older adults [93] . recreational services also support physical and mental health through opportunities for physical activity designed for older people and supporting community connections. another indicator recommended for inclusion is access to a local library, which also supports the afc domains of respect and social isolation, communications and information, and community support and health services. libraries provide multiple community benefits beyond simply lending books [94, 95] , including multimedia borrowing, technology training, community classes, lectures, and opportunities for intergenerational and community connections. libraries also support the need for learning opportunities across the course of life with universities of the third age (u3as) providing social and learning benefits to older people [96, 97] . this is associated with better physical health and activity levels [98] . places of worship are also considered an important facilitator of social connections and social capital [99] , particularly in humanitarian arrivals [100] and different cultures [101, 102] . respect and social inclusion are essential to ensure social participation for older people. there is much debate on the definition of social inclusion, though most studies refer to an objective participation in society and a more subjective assessment of whether the actual participation meets an individual's preferences [103] . most definitions of social exclusion emphasise the importance of social activities as a core component [104] . however, the effects of cumulative disadvantage, decreasing social networks, and age discrimination magnify the negative health and wellbeing impacts of social exclusion in later life [105] . a local or lived environment must provide accessible buildings, housing and transport, along with opportunities for social activities to occur if social inclusion and social participation are supported and encouraged. previous research on the services deemed important for older people has emphasised the importance of local services, such as shops [37, 69] , and this is supported by the use of new spatial indicators that can access formal and informal places to meet. these include recommended indicators of access to social clubs/senior citizens clubs or participation in international clubs, like rotary or probus, that are more formally organised by older people themselves. alternatively, informal opportunities for social inclusion include an indicator of distance-based access to local cafes that support broader intergenerational social opportunities. older people need a range of venues to create opportunities for social activities as a foundation for community respect and social inclusion. empowerment, autonomy and control [63, 106] , and employment conditions [107] were all found to be important influences of actual and self-reported health. control over one's own destiny has also been proposed [106] , consistent with an understanding of health being simultaneously influenced at the individual (micro/personal), place and community context (meso/community) as well as the larger societal context (macro/societal level) [108] . civic participation and employment are important influences of agency and autonomy in a society. consequently, it is important to understand how many older people are engaged in paid and unpaid productive activity in the community. this is best measured through the proportion of people who remain employed past the official retirement age (66 years in australia noting there is no official retirement age and eligibility for the aged pension is currently 66 years increasing to 67 years by 2023) or people aged 60 years or more who are engaged in regular volunteering. these indicators of paid and unpaid productive activity are also important measures of social engagement and civic participation and could be separated into additional age brackets or deciles (e.g., 60-75 years) for more detailed information. it is important to note that employment is also not defined according to hours worked, acknowledging both the civic connections and benefits that come from any level of paid employment and that retirement is not a single event and includes a diverse range of retirement patterns [109] . there has been criticism regarding the dominance of volunteering in measures of collective civic social participation in older people [110] with voting participation argued as a better measure of civic participation [111] . however, voting participation is less relevant in countries like australia where electoral voting is compulsory and volunteering activities are measured every 4 years. volunteering is also particularly important in regional areas of australia where third sector or non-profit organisations rely on older people volunteering [112] with increasing proportions of older people residing in rural locations [113] . in countries where voting is not compulsory (e.g., the usa), then voting participation could be considered as an additional measure of civic engagement. in 2016, approximately 86% of australian households had access to the internet [114] . this proportion decreased to 77% in remote areas where it is common to have a high proportion of older people within populations, with entertainment, social networking, and banking the most commonly supported activities supported by internet connection. internet access is also becoming more necessary to access information about the government, health, banking, and community services as well as to maintain contact with friends and family. finding information on services like these is also critical for older people to age in place and is necessary to support independent living and the connection to communities [115] . th information provision also extends beyond essential services and includes services provided by local libraries, which includes online books, audio, audio-visual, and educational resources that can be made available online for people with physical or geographical mobility restrictions. online streaming (e.g., netflix) is another more recent example of recreational activities supporting social connection and information provision. however, all these online resources require household internet access. access to a national radio service is another important source of information and becomes particularly important in emergency management, including preparation and recovery from natural disasters, such as floods, droughts, and bushfires, which are becoming increasingly more commonplace in australia. emergency sms messaging systems are also deployed during emergency situations to inform residents of impending safety risks but are worthless without adequate mobile phone reception. climate change is predicted to increase the likelihood of these emergency situations making telecommunications assessment essential in the support of afc. it is also necessary for developing technologies, including passive surveillance of movement monitoring within the home, personal alarm devices, and telehealth [116] , which have become increasingly accessible and necessary during the 2020 coronaviruses 2019 (covid-19) pandemic. communication is an important influence on the wellbeing of older people [117] , and both household internet and mobile phone reception provide essential telecommunication systems that support both intergenerational communication with family and friends, the communication of essential information [118] , and the ongoing adoption of new technologies [119] , as well as influence the quality of life [120] . currently, there is a paucity of references or inclusion of technological solutions offered to support afc and healthy ageing and technology, and icts have recently been suggested as a new smart age-friendly ecosystem framework [118] . suggestions included in this new framework to assist afc include: the development of smart housing; the inclusion of ageing in smart cities and engagement with the internet of things (iot); the better use of digital assistants (e.g., alexa) in the home; the use of digital robots for deliveries; electronic camera enabled doorbells; and motion sensors to detect mobility. technological features like these require inclusion during new housing development and have benefits across multiple afc domains beyond communication. they also require a rethink and interdisciplinary collaboration between planners, architects, developers, computer science, industry, and the government. while the opportunities are waiting for action, they also require engagement with older people themselves and their families using qualitative and ethnographic research methods [121] . this is an important area of growth and future development in afc and requires further research. access to primary health support services is essential and necessary for people to age in place. it is also the preferred option for most older people to maximise their health and wellbeing [122] . within the local community, access to general practitioners has been identified by older people themselves as essential community support services [36, 69, 123] and the key access point for primary health care. consequently, access to general practitioners was identified as an indicator of primary importance within community support and health services. these practitioners also provide gateway services and referrals to any other medical specialists, including geriatricians, who specialise in treating conditions that affect older people, including dementia. additional indicators that should be included relate to housing support either as in-home support packages or residential aged-care accommodation. all of these services are also included within a complete definition of social infrastructure, which has an important influence on subjective wellbeing [25] and are important components of liveability [19] . the approaches and spatial measures described above were applied in a case study in a regional context and rural centre in north-eastern victoria, australia. the regional town is located over 200 km north-east of the capital city of melbourne in the centre of the state of victoria, south-eastern australia. the major industries are agriculture and manufacturing, with a population of over 9000 people. both the state government department of health and the local municipality/council were interested in analysing and understanding afc and broader liveability given an increasingly ageing rural population. the spatial measures used to assess this included: walkability (with and without footpaths); access to public open space; access to public transport; housing affordability; housing diversity; government owned dwellings (social housing); access to services for older people; libraries; universities of the 3rd age; places of worship; volunteering; households with internet access; aged care facilities; and access to general practitioners. the results were presented to the local health department officials, the local municipality, and as a community presentation to residents at the local library. many of the challenges and barriers to afc planning were identified in the spatial measures and were confirmed by the lived experiences of residents from the local community. these included: poor walkability on the outer areas of town; difficulty getting to doctors and medical services located at the regional hospital located on the outer town boundary with limited public transport and poor walkability; disconnection between the older people, families, and younger people in the town due to the location of residential aged care on the town boundary next to the hospital; the importance of cafes and social spaces in the centre of town to support community and social connections; the value of the town's library, art facilities, and public open spaces; and inequity in the disadvantaged areas of the town that had reduced access to public transport and lower levels of household internet connections. the use of mapped spatial measures of afc was hugely beneficial for inter-agency conversations and planning initiatives as well as community conversations, engagement, and validation of the spatial analyses. the results also highlight the future negative impact of the age-friendliness of the town if future residential aged care development is supported in the outer areas of the town. the original who global age-friendly cities guide was developed in response to the rapid population ageing and urbanisation across the world and was informed by interviews conducted with older people themselves in over 33 different countries [7, 15] . the ultimate aim of afc is to create environments that support healthy ageing. this paper provided detailed, objective, and functional spatial measures of age-friendliness across lived environments that can be used to assess, monitor, evaluate, and communicate age-friendliness refined to the neighbourhood level. objective spatial measures of the lived environment are critical for the following reasons: to simplify assessments of afc; to provide a foundation level of knowledge about the age-friendliness of an environment; to assist local and state government planning by informing and monitoring future actions and interventions needed to promote healthy ageing in communities; and to include older people into targets of the 2030 sustainable development goals and the new urban agenda. the movement has previously been criticised for a lack of objective measurements and the need to connect these ideals into functional measures connected to policy, planning, and financial levers [10] . previous attempts at developing indicators of age-friendliness have been non-specific, non-coordinated, and reliant on survey-based responses (e.g., world health organization [15] ). such assessments are also beyond the budget, resources, capabilities, and motivation of local planning agencies and municipalities. the proposed spatial measures of age-friendliness across lived environments is relevant to planners, policymakers, advocacy organisations, governments, architects, industry, citizens and research audiences. the suggested indicators are provided to guide and inform discussions and interventions to promote healthy ageing. the measures can also be adopted and customised to local environments ranging in geographic and population sizes, rurality, climate conditions, and resource limitations. the proposed spatial indicators of afc address these issues through the application of gis technology to produce an objective assessment of the age-friendliness of local lived environments, drawing on indicators from the liveability literature that are specifically relevant to the values, preferences, and needs of older adults. these indicators provide measurement and quantification of afc domains consistent with the idea that value comes with measurement and leads to knowledge production as argued by lord kelvin over 200 hundred years ago [124] . the more simplistic interpretation of this, is that what is measured, is valued, and consequently is done. one of the critical issues raised in the recommended afc spatial indicators is the connection of all indicators within existing policy and planning contexts [13] . all the recommended indicators can be linked to existing policy and planning environments regardless of whether these have a local/municipal, state, or national focus. the connection of indicators to policy has been long identified within social indicator research [125, 126] . these indicators can assist governments in meeting their commitments to the sustainable development goals in a way that is meaningful for a growing segment of their populations. there is also an increasing interest and development in public health digital observatories. for example, relevant liveability indicators for the 21 largest cities of australia are available in the australian urban observatory (auo.org.au) launched in 2020. there is an opportunity to make spatial indicators available through novel data visualisation and ease of communication providing an influence on the policies required for healthy ageing across communities. the spatial indicators recommended for assessing afc domains can all be influenced and improved through policy levers. this includes the indicators suggested for outdoor spaces, transport, housing, social participation, respect and social inclusion, civic participation and employment, communications and information, community support, and health services. the indicator results can be influenced though local and immediate strategies or applied in advocacy with the responsible higher government agencies. this can include reviewing afc assessments within the context of current policy contexts, existing public health planning, liveability planning, transport planning, strategic planning, land use, and statutory planning it is also important to acknowledge the limitations of afc spatial indicators and understanding that these aggregated area-based results effectively act as icebergs of knowledge [35] providing a tip of the iceberg assessment of what is occurring, with additional information required to understand why the result is happening and how it can be addressed. consequently, the objective afc spatial indicators should also be combined with additional sources of knowledge. these include consultation and engagement with local older people themselves to expand understanding, prioritise actions, and support the greatest social and economic benefits and returns on investments that support improved health and quality of life for older people. given the diversity of cities, communities, and places, it is recognised that the achievement of all suggested indicators might not be feasible across all geographic settings. this is particularly relevant to rural and regional locales, which often have a lower population density and reduced levels of physical or social infrastructure. consultations with older people and combining subjective understandings with more objective afc spatial indicators will also help to inform the understanding of unique community contexts, including regional and remote areas. for example, high levels of walkability might not be possible across an entire town in a rural area with a small population. alternatively, signaled pedestrian crossings might not be necessary. however, a walkability assessment using the recommended walkability indicator could identify walking and transport barriers (e.g., a major road or bridge across a rail line) or identify the best location for new community services. alternatively, the distances and measures of accessibility listed within indicators may vary across diverse rural and regional settings, but as noted above, these definitions of access within indicators must be determined through consultation with the older adults and communities to a reach consensus on what can be reasonably expected within this locale. consequently, in certain settings, these proposed indicators should act as a tool to prompt place-specific discussions around what is important in terms of measurement indicators, and what is achievable (particularly in relation to what should constitute reasonable access). a notable challenge of afc planning is the absence of the relevant climate change implications in the current afc principles and domains and inclusion of ict and new technology. we recommend that future revision of afc should expand and account for the challenges associated with climate change given the implications on the health and wellbeing of older people [127] and the ultimate afc goal of healthy ageing. the relationship between older people's physical health and mental health with the environment, urban design, architecture, and afc could also be considered in the development of future indicators [128] . understanding and expanding afc spatial indicators for unique contexts and environments is needed in the future and this current foundation of recommended indicators can be applied and tested across a range of different locations. this could include localities with climatic extremes (e.g., heat, cold, and snow), regional and rural locations, international comparisons, and cultural differences to explore how communities differ and what additional indicators should be included. the major aim of this research was to propose a foundational set of objective afc spatial indicators that can be applied in any location with minimal resources and are directly aligned for policy intervention. this is particularly relevant to planning and policymakers working in government and was neither previously available nor consistently applied within afc locations. further research should investigate 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social-demographic correlates of religious non-involvement in america: findings from three national surveys social integration and religious identity expression among dutch muslims: the role of minority and majority group contact a review of social inclusion measures social exclusion and mental health: conceptual and methodological review social exclusion of older persons: a scoping review and conceptual framework how could differences in 'control over destiny' lead to socio-economic inequalities in health? a synthesis of theories and pathways in the living environment health inequalities among british civil servants: the whitehall ii study european strategies for tackling social inequities in health: levelling up part 2. studies on social and economic determinants of population health evolving patterns of work and retirement fifty-five years of research into older people's civic participation: recent trends, future directions productive aging and civic participation healthy ageing in australia's rural places: the contribution of older volunteers does place matter? reviewing the experience of disadvantage for older people in rural australia household use of information technology, australia information provision for an age-friendly community ageing in place in the united kingdom interpersonal communication in older adulthood intergenerational effects on the impacts of technology use in later life: insights from an international, multi-site study connecting at local level: exploring opportunities for future design of technology to support social connections in age-friendly communities effects of technology use on ageing in place: the izi pilots who doesn't think about technology when designing urban environments for older people? primary health care and older people the ideal neighbourhood for ageing in place as perceived by frail and non-frail community-dwelling older people oxford essential quotations lessons learned from the history of social indicators; redefining progress disappointments and legacies of social indicators climate change in an ageing world. helpage international knowledge synthesis for environmental decisions: an evaluation of existing methods, and guidance for their selection, use and development: a report from the eklipse project the authors declare no conflict of interest. key: cord-018363-qr1pk78u authors: casey, ashley; conrad, kevin title: consultative and comanagement date: 2015-10-10 journal: absolute hospital medicine review doi: 10.1007/978-3-319-23748-0_2 sha: doc_id: 18363 cord_uid: qr1pk78u this chapter covers the role of the hospitalist as a consultant and their interaction with surgical specialties. included are discussions of perioperative care in the hospital and clinic. oral and parenteral nutrition for the hospitalized patient are examined. a special emphasis is placed on palliative care for the hospitalized patient. comanagement of surgical patients with an emphasis on orthopedics is reviewed. a 66-year-old male presents to the emergency room with a chief complaint of a severe headache that developed approximately 10 h ago. he describes the headache as the worst headache of his life. he has a history of myelodysplasia for which he has been followed as an outpatient. he reports no history of spontaneous bleeds and denies any spontaneous bruising. on physical examination, he is alert and oriented, and his speech is slightly slurred. the prothrombin time and activated partial thromboplastin time are within normal range. a ct scan is performed in the emergency room that shows an intracerebral bleed with a mild amount of extravasation of blood into the ventricular system. which of the following is the most appropriate minimum platelet threshold for this patient? a) 40,000 b) 60,000 c) 100,000 d) 150,000 answer: c thresholds for platelet transfusions are undergoing close examination. some areas continue to provoke debate especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding. guidelines recommend maintaining platelet count at 100,000 after a central nervous system bleeding event. this would also be the case immediately prior to and after surgery performed on the central nervous system. this patient has a potentially life-threatening intracranial bleeding. the bleeding source is probably secondary to hypertensive disease and not thrombocytopenia. however, the patient is at continued risk for extension of the intracerebral bleeding because of her thrombocytopenia. guidelines do not suggest additional benefi ts to maintaining platelet counts >100,000. a 44-year-old woman undergoes preoperative evaluation prior to surgery to repair a congenital defect of her pelvis. her expected blood loss is 2.0 l. she has a prior history of severe anaphylactic reaction to a prior erythrocyte transfusion that she received for postpartum hemorrhage at age of 27 years. in addition she has a history of rheumatoid arthritis. on physical examination, the temperature is 36.8 °c (98.5 °f), blood pressure is 140/70 mmhg, and heart rate is 76 bpm. laboratory studies indicate a hemoglobin level of 12.0 g/dl, a leukocyte count of 6500 μl, and a platelet count of 150,000 μl. previous laboratory studies indicate an igg level of 800 mg/dl and an igm level of 65 mg/dl. which of the following is the most appropriate erythrocyte transfusion product for this patient? a) leuko-reduced blood b) cytomegalovirus-negative blood c) irradiated blood d) phenotypically matched blood e) washed blood answer: e this patient has iga defi ciency. the most appropriate product to minimize the risk of an anaphylactic transfusion reaction in this case is washed erythrocytes. most patients with an iga defi ciency are asymptomatic. they are prone to gastrointestinal infections such as giardia. they also have an increased risk of autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. some patients with iga defi ciency have anaphylactic reactions to blood products containing iga. fresh frozen plasma (ffp) is the main blood component containing iga antibodies. anaphylaxis may occur with a variety of transfusions including ffp, platelets, and erythrocytes. washing erythrocytes and platelets removes plasma proteins and greatly decreases the incidence of anaphylaxis. a 34-year-old man with a history of superfi cial thrombophlebitis presents with bilateral foot pain of 3-days duration. over the 6 months, he has had several distinct episodes of severe burning pain of the foot and several toes. the pain persists at rest and is debilitating. the patient smokes one to two packs of cigarettes a day. on physical examination, he is thin; his feet are erythematous and cold. there are ulcerations noted distally on both feet. the femoral pulses are strong and intact, and the dorsalis pedis and posterior tibialis pulses are absent bilaterally. no discoloration is noted on his leg and a normal hair pattern is noted on his legs. the pain is not worsened by deep palpation. what is the most likely diagnosis for this patient? a) plantar fasciitis b) spinal stenosis c) thromboangiitis obliterans d) raynaud phenomenon e) atherosclerotic claudication answer: c this patient has thromboangiitis obliterans, also called buerger's disease. this results from infl ammatory blockage of arterioles in the distal extremities and is usually seen in male smokers who are typically less than 40 years of age. other typical features include a history of recurrent thrombophlebitis and rest pain. distal pulses are often absent. plantar fasciitis is usually relieved with rest. weight bearing and exercise exacerbate it. spinal stenosis usually occurs in older patients. it is exacerbated by standing or walking and is relieved by rest. atherosclerotic claudication is also seen in older patients. it has a steady progression. it starts with exercise-related pain and progresses slowly to pain at rest. raynaud phenomenon is seen mostly in women. it is caused by vasospasm of small arterioles. it more commonly occurs in the hands but can be seen in the feet. the vasospasm is precipitated by cold, temperature change, or stress. color changes, which can be profound, occur in the digits from white to blue to red. pain is usually not severe and peripheral pulses remain intact even during episodes of vasospasm. in buerger's disease, among patients who stop smoking, 94 % avoid amputation. in contrast, among patients who continue using tobacco, there is an 8-year amputation rate of 43 %. espinoza lr. buerger's disease: thromboangiitis obliterans 100 years after the initial description. am j med sci. 2009;337(4):285-6. olin jw, young jr, graor ra, ruschhaupt wf, bartholomew jr. the changing clinical spectrum of thromboangiitis obliterans (buerger's disease). circulation. 1990; 82 (5 suppl) : . preoperative malnutrition is associated with which outcome in patients undergoing gastrointestinal surgery? a) increased 30-day mortality b) increased 60-day mortality c) increased length of stay d) all of the above answer: d good nutritional status is an important factor in the outcome of gastrointestinal surgery. several studies have confi rmed this. preoperative malnutrition is an independent predictor of length of hospital stay, 30-day, and 60-day mortality, as well as minor medical complications, in patients undergoing gastrointestinal surgery. preoperative nutrition including total parenteral has been proven to be benefi cial in malnourished patients undergoing gastrointestinal surgery. reference burden s, todd c, hill j, lal s. pre-operative nutrition support in patients undergoing gastrointestinal surgery. cochrane database syst rev. 2012;(11):cd008879. a 52 year-old male presents with the chief complaint of daily seizures. he reports that he has had seizures weekly for the past several years since an automobile accident, but these have increased to nearly daily in the past few weeks. he states he takes levetiracetam, but is not certain of the dose. while in the emergency room, he has a generalized grand mal seizure and is given lorazepam. he has recently moved to the area and has no old records. he is admitted to the hospital medicine service and a 24 h eeg is instituted. on the fi rst night of his admission, he has an apparent seizure but no seizure activity is noted on the eeg. the next morning he develops an inability to move the left side of his body and dysar-thria. urgent mri of his head reveals no evidence of acute cerebrovascular accident. the most likely cause of his paralysis is? a) early cerebral infarction b) todd's paralysis c) malingering d) migraine variant e) conversion disorder answer: c this patient has several factors that suggest malingering. he presents with two relatively easy to mimic symptoms. first, he has a seizure with no eleptiform activity and then paralysis with a normal mri. his recent travel from another area is also suggestive of the diagnosis. malingering is not considered a mental illness and its diagnosis and treatment can be diffi cult. direct confrontation may not work best. hostility, lawsuits, and occasionally violence may result. it may be best to confront the person indirectly by remarking that the objective fi ndings do not meet the objective criteria for diagnosis. it is important to demonstrate to the patient that his abnormal behavior has been observed and will be documented. at the same time an attempt should be made to allow the patient who is malingering the opportunity to save face. obviously this can be a challenge. invasive diagnostic maneuvers, consultations, and prolonged hospitalizations often do more harm than good and add fuel to the fi re. people who malinger rarely accept psychiatric referral, and the success of such consultations is minimal. it may be considered to address a specifi c psychiatric complaint. the most common goals of people who malinger in the emergency department are obtaining drugs and shelter. it may be benefi cial to offer the patient some limited assistance in these areas. in the clinic or offi ce, the most common goal is fi nancial compensation. 259. a 60-year-old male with chronic obstructive pulmonary disease is admitted for a hip fracture sustained after a fall. he undergoes surgery without complication. on the second day of hospitalization, he develops some mild dyspnea and nonproductive cough. he is currently on 2 l of oxygen at home and states that he will often get somewhat short of breath with any change in his living situation. on physical exam, the patient appears comfortable. his temperature is 37.8 °c (100.1 °f), heart rate is 70 bpm, and respirations are 16 per minute. oxygen saturation is 96 % on pulse oximetry with 2 l. a chest x-ray shows no acute changes and white blood cell count is within normal limits. which of the following is the appropriate management of this patient? a) prednisone b) doxycycline plus prednisone c) levofl oxacin d) azithromycin answer: a american college of chest physician guidelines for chronic obstructive pulmonary disease exacerbation support inhaled beta agonists and steroids alone for mild fl ares. in this particular case, the patient is having a mild exacerbation of his typical chronic obstructive pulmonary disease. antibiotics should be reserved for moderate to severe cases. the criteria for moderate disease exacerbation include cough, change in color of sputum, and increased shortness of breath. 260. a 74-year-old man is admitted for cough, dyspnea, and altered mental status. the patient is noted to be minimally responsive on arrival. results of physical examination are as follows: temperature, 38.9 °c (102.1 °f); heart rate, 116 bpm; blood pressure, 96/60 mmhg; respiratory rate, 35 breaths/min; and o 2 saturation, 74 % on 100 % o 2 with a nonrebreather mask. the patient is intubated urgently and placed on mechanical ventilation. on physical exam, coarse rhonchi are noted bilaterally. a portable chest x-ray reveals good placement of the endotracheal tube and lobar consolidation of the right lower lobe. empirical broad-spectrum antimicrobial therapy is started. which is true concerning his nutritional management? a) enteral nutrition is less likely to cause infection than parenteral nutrition. b) parenteral nutrition has not consistently been shown to result in a decrease in mortality, compared with standard care. c) the use of oral supplements in all hospitalized elderly patients has been shown to be benefi cial. d) immune-modulating supplements are no better than standard high-protein formulas in critically ill patients. e) all of the above answer: e comparisons of enteral nutrition with parenteral nutrition have consistently shown fewer infectious complications with enteral nutrition. several studies have looked at specialized feeding formulas in the treatment of the critically ill. there is little evidence to support their use over standard high-protein formulas. in one study among adult patients breathing with the aid of mechanical ventilation in the icu, immune-modulating formulas compared with a standard high-protein formula did not improve infectious complications or other clinical end points. elderly patients require special consideration. a trial in 501 hospitalized elderly patients randomized to oral supplements or a regular diet showed that, irrespective of their initial nutritional status, the patients receiving oral supplements had lower mortality, better mobility, and a shorter hospital stay. 261. you are called to see a patient urgently in the postpartum ward. she is a 32-year-old female who, 20 min prior, had an uneventful vaginal delivery. in the past 20 min, the patient has become abruptly short of breath, hypoxic, and severely hypotensive with a blood pressure of 72/palpation mm hg. on physical exam, she is obtunded and in serve respiratory distress. she has no signifi cant past medical history documented and has had an uneventful pregnancy. mild wheezes with decreased breath sounds are heard. chest radiograph and arterial blood gasses are pending. the most likely diagnosis is? a) pulmonary embolism b) sepsis c) peripartum cardiomyopathy d) amniotic fl uid embolism e) eclampsia answer: d amniotic fl uid embolism is a rare complication of pregnancy. it presents acutely during and immediately after delivery, usually within 30 min. the exact mechanisms are unclear, but it is thought that amniotic fl uid gains entry into the maternal circulation. this triggers an intensive infl amma-tory reaction, resulting in pulmonary vasoconstriction, pulmonary capillary leak, and myocardial depression. patients present with acute hypoxemia, hypotension, and decreased mental status. treatment is supportive but may be improved by early recognition and cardiopulmonary resuscitation. the other answers do occur in pregnancy, but the severity, rapid onset, and timing to delivery strongly suggest amniotic fl uid embolism. the mortality rate may exceed 60 %. immediate transfer to an intensive care unit with cardiovascular resuscitation is recommended. over the past 4 days since surgery, she has been on parenteral nutrition. oral intake has been started gradually 2 days ago. diarrhea has occurred both at night and day. stool cultures and clostridium diffi cile polymerase chain reaction are negative. her current medications include low-molecular-weight heparin as well as loperamide two times daily. which of the following is the most appropriate management? a) increase loperamide. b) initiate cholestyramine. c) initiate omeprazole. d) stop oral intake. e) decrease lipids in parenteral nutrition. answer: c patients who have undergone signifi cant bowel resection should receive acid suppression in the postoperative period with a proton pump inhibitor. this patient has short-bowel syndrome. any process that leaves less than 200 cm of viable small bowel or a loss of 50 % or more of the small intestine as compared to baseline places the patient at risk for developing shortbowel syndrome. in short-bowel syndrome, there is an increase in gastric acids in the postoperative period. this can lead to inactivation of pancreatic lipase, resulting in signifi cant diarrhea. stopping the patient's oral intake may lead to temporary improvement. it is important that the patient continues her oral feedings, as this will eventually allow the gut to adapt and hopefully resume normal function. a 58-year-old female who underwent an elective cholecystectomy is noted to be in atrial fi brillation by telemetry. her heart rate is 108 bpm. she has a history of hypertension. her medications are verapamil and fullstrength aspirin. she states that several years ago, she had palpitations after exercise, but that has since resolved, and she has noticed no problems. you are consulted by the surgical team for management of her heart rate in preparing her for discharge. on physical exam she appears in no distress and is not short of breath. which of the following is the appropriate management of the patient's atrial fi brillation? a) maintain her current dose of verapamil. b) increase her dose of verapamil with a target rate of 80 beats per minute. c) add digoxin to control her heart rate to a target of 80 beats per minute. d) consult cardiology for possible cardioversion. answer: a a 2010 study compared lenient control of heart rate less than 110 beats per minute to more strict control of less than 80 beats per minute. the study found that achieving strict heart rate control resulted in multiple admissions with no perceivable benefi t outcomes. in this particular case, a heart rate of 108 bpm is acceptable, and patient the can be discharged on her current medications. follow-up with her primary care physician should be obtained to monitor heart rate. digoxin can be used in the acute setting but does little to control the ventricular rate in active patients. it is rarely used as monotherapy. caution should be exercised in elderly patients with renal failure due to toxicity. digoxin is indicated in patients with heart failure and reduced lv function. 266. you are called to the fl oor to see a patient who has developed acute onset of shortness of breath. she is a 56-year-old female who was admitted for upper gi bleed. she is currently receiving her fi rst unit of packed erythrocytes, which was started 1.5 h ago. on physical examination, temperature is 38.9 °c(102 °f), blood pressure is 110/65, pulse rate is 115 beats per minute, and respirations are 22 per minute. her current oxygenation is 83 %. she has been placed on 3 l by nasal cannula. no peripheral edema is noted. mild wheezes and diffuse crackles are heard throughout her lung fi elds. a stat x-ray is ordered which reveals diffuse bilateral infi ltrates. on review of her records, type and screen reveal an a+ blood type with a negative antibody screen. which of the following is the most likely diagnosis? a) transfusion-related acute lung injury b) acute hemolytic transfusion reaction c) febrile nonhemolytic transfusion reaction d) transfusion-associated circulatory overload e) transfusion-related sepsis answer: a this patient has likely developed transfusion-related acute lung injury (trali). the patient developed dyspnea, diffuse pulmonary infi ltrates, and hypoxia acutely during the blood transfusion. it usually occurs shortly after the transfusion or can be delayed for several hours. both the classic and delayed trali syndromes are among the most frequent complications following the transfusion of blood products. they are associated with signifi cant morbidity and increased mortality. antileukocyte antibodies in the donor blood product directed against the recipient leukocytes cause this reaction. trali can occur with any blood product. which of the following is most likely regarding cognitive function in patients such as this? a) return to baseline in an average of 5 days b) return to baseline in 2 weeks c) return to baseline in an average of 30 days d) return to baseline in an average of 6 months e) permanent loss of cognitive function answer: a postoperative cognitive dysfunction (pocd) is common in adult patients of all ages, recovery in the younger age group is usually within 5 days, and complete recovery is the norm for patients less than 60 years old. patients older than 60 years of age are at signifi cant risk for long-term cognitive problems, and in this group recovery from pocd may last as long as 6 months and may be permanent. patients with pocd in all age groups are at an increased risk of all-cause death in the fi rst year after surgery. most dizziness is benign and is self-limited. vertigo is often described as an external sensation such as the room is spinning. vertigo is most commonly from peripheral causes which affect labyrinths of the inner ear. focal lesions of the brainstem and cerebellum can also lead to vertigo. vertical nystagmus with a downward fast phase and horizontal nystagmus that changes direction with gaze suggest central vertigo. signifi cant non-accommodating nystagmus is most often a sign of central vertigo but can occur with peripheral causes as well. in peripheral vertigo, nystagmus typically is provoked by positional maneuvers. it can be inhibited by visual fi xation. central causes of nystagmus are more likely to be associated with hiccups, diplopia, cranial neuropathies, and dysarthria. 274. you are called to see a 43-year-old female who is 3 days postpartum. she has had a non-complicated pregnancy. she has not been discharged due to feeding issues with her child. she had a normal spontaneous vaginal delivery. this is her fourth vaginal delivery. on physical exam, she has nontender bilateral leg swelling, orthopnea, and a cough with frothy white sputum. her blood pressure is 150/87 mmhg. her temperature is 37.2 °c (99.0 °f). she has mild chest pain with inspiration. she has bilateral pulmonary crackles and pitting edema of her lower extremities. wbc is 16,000/μl. cxr is pending. which of the following is the most likely diagnosis? a) pulmonary embolism b) peripartum cardiomyopathy c) hospital-acquired pneumonia d) amniotic fl uid embolism e) acute myocardial infarction 275. a 65-year-old male presents with progressive shortness of breath over the past month. he has a 40-pack-year history of smoking. ct scan of the chest reveals a right middle lobe mass for which he subsequently undergoes biopsy, which reveals adenocarcinoma. magnetic resonance imaging of the brain reveals a 1-cm tumor in the left cerebral cortex, which is consistent with metastatic disease. the patient has no history of seizures or syncope. the patient is referred to outpatient therapy in the hematology/oncology service as well as follow-up with radiation oncology. the patient is ready for discharge. which of the following would be the most appropriate therapy for primary seizure prevention? a) seizure prophylaxis is not indicated. b) valproate. c) phenytoin. d) phenobarbital. e) oral prednisone 40 mg daily. answer: a there is no indication for antiepileptic therapy for primary prevention in patients who have brain metastasis who have not undergone resection. past studies have revealed no difference in seizure rates between placebo and antiepileptic therapy in patients who have brain tumors. antiepileptic therapy has high rates of adverse reactions and caution should be used in their use. 276. a 78-year-old male is admitted due to swelling over his chest wall. during discussion with the patient, he notes that he had an aicd implanted in the area of the swelling over 3 years ago. his postoperative course had been uneventful and he had never developed any wound dehiscence before. on physical examination, there are palpable swelling and fl uctuance over the right upper chest wall at the site of a well-healed incision. the patient notes some fevers and chills on and off the last few weeks. you are very concerned for a cardiovascular implantable electronic device (cied) infection. which of the following is appropriate in the care of your patient? a) draw two sets of blood cultures before beginning initiation of antimicrobial therapy. b) percutaneous aspiration of the generator pocket. c) attempt to preserve the placement of this aicd via empiric antibiotics. d) request removal of device and obtain gram stain and cultures of the tissue and lead tip. e) a and d. answer: e a patient with a suspicion of a cied infection should have two sets of peripheral blood cultures drawn before prompt initiation of antimicrobial therapy. the implantable device should be removed by an expert and the generator-pocket tissue and lead tip should be cultured on explanation. it is appropriate to obtain a transesophageal echocardiogram (tee) to assess for cied infection and valvular endocarditis. percutaneous aspiration is not needed, as the device will be removed. 277. which of the following occurs in the cognitive function following major cardiac surgery? a) all patients experience some transient cognitive decline. b) return to baseline can take as long as 6 months. c) greater declines will be seen in patients with postop delirium. d) most return to baseline at 5 days. e) all of the above. what is his expected postoperative risk of a major cardiac event? a) 0.5 % b) 1 % c) 5 % d) 10 % e) 20 % answer: d one of the most widely used preoperative risk assessment tools is the revised cardiac risk index (rcri). the rcri scores patients on a scale from 0 to 6. the patient here has a rcri score of 3. his score includes high-risk surgery, creatinine greater than 2 mg/dl, and diabetes mellitus requiring insulin. the six factors that comprise the rcri are high-risk surgical procedures, known ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus requiring insulin, and chronic kidney disease with a creatinine greater than 2 mg/dl. 0 predictor = 0.4 %, 1 predictor = 0.9 %, 2 predictors = 6.6 %, ≥3 predictors = >11 % 279. a 24-year-old woman is admitted with signifi cant fatigue, fever, and a sore throat. she reports due to throat pain she has been unable to swallow any liquids for the past 24 h. on physical examination, she is found to have anterior cervical lymphadenopathy, erythematous throat, and mild hepatosplenomegaly. she remembers having mononucleosis in high school. she has mild elevations of her transaminases. her heterophile antibody test is positive. which of the following is true concerning the heterophile antibody test? a) heterophile antibody testing would not be helpful for this patient because the results may be positive owing to her previous episode of mononucleosis. b) she has acute infectious mononucleosis from primary epstein-barr virus (ebv on physical exam, she has marked abdominal pain. her temperature is 39.5 °c (103.0 °f), heart rate is 100 beats per minute, and respirations are 15 per minute. her blood pressure is 100/62. she has marked hyperactive bowel sounds as well as signifi cant abdominal distention. laboratory studies include a leukocyte count of 28,000 and hematocrit of 25 %; and blood cultures are negative. stools are sent for clostridium toxin which is positive. which of the following is the most appropriate treatment for the patient's diarrhea? a) metronidazole orally b) metronidazole intravenously c) vancomycin oral d) vancomycin intravenously answer: c this patient has severe clostridium diffi cile -associated diarrhea (cdi). for patients with severe cdi, suitable antibiotic regimens include vancomycin (125 mg four times daily for 10 days; may be increased to 500 mg four times daily) or fi daxomicin (200 mg twice daily for 10 days). vancomycin has been shown to be superior to metronidazole in severe cases. fidaxomicin has been shown to be as good as vancomycin, for treating cdi. one study also reported signifi cantly fewer recurrences of infection, a frequent problem with c. diffi cile . other considerations in this case may be to obtain a ct scan and possible colorectal surgery consultation. 282. a 67-year-old man was admitted with a cerebrovascular accident. he has done well during his hospitalization and is preparing for discharge to a skilled nursing facility. a catheter, which was placed in the emergency room, has been in for 3 days. he reports no prior incident of urinary retention. it is removed, and patient has diffi culty voiding. which of the following would be considered an abnormal post-void residual (pvr) amount? a) 15 ml b) 50 ml c) 100 ml d) 200 ml e) 300 ml answer: c abnormal residual bladder volumes have been defi ned in several ways. no particular defi nition is clinically superior. some authorities consider volumes greater than 100 ml to be abnormal. others use a value greater than 20 % of the voided volume to indicate a high residual. in normal adults, the post-void residual volume should be less than 50 ml. over the age of 60, a range of 50 ml to 100 ml can be seen but is not known to cause signifi cant issues. post-void residual (pvr) volume increases with age but generally do not rise to above 100 ml unless there is some degree of obstruction or bladder dysfunction. urinary retention is common after several days of catheter placement, particularly in males. caution should be used when placing urinary catheters, as they are a signifi cant cause of urinary retention. whenever possible urinary catheters should be removed. bladder training and time may improve the retention. some consideration may be given to starting the male patient on medications to reduce benign prostatic hypertrophy as well. ultrasound can be used as a noninvasive means of obtaining pvr volume determinations, especially if a precise measurement is not required. the error using this formula, compared with the standard of post-void catheterization, is approximately 21 %. in patients with ascites bedside measurement by ultrasound of pvr can be inaccurate due to an inability to differentiate bladder fl uid from ascitic fl uid. lisenmeyer ta, stone jm. neurogenic bladder and bowel dysfunction. in: de lisa j, editor. rehabilitation medicine. philadelphia: lippincott-raven; 1998. p. 1073-106. a 37-year-old male has been admitted for alcohol-related pancreatitis. after six days, he continues with severe midepigastric pain that radiates to the back with nausea and vomiting. he has not been able eat or drink and has not had a bowel movement since being admitted. on physical examination, the temperature is 37.6 °c (99.5 °f), the blood pressure is 120/76 mmhg, the pulse rate is 90 bpm, and the respiratory rate is 20 breaths/ min. there is no scleral icterus or jaundice. the abdomen is distended and with hypoactive bowel sounds. laboratory studies show leukocyte count 12,400/ μl, amylase 388 μ/l, and lipase 924 μ/l. repeat ct scan of the abdomen shows a diffusely edematous pancreas with multiple small peripancreatic fl uid collections. some improvement from the ct scan 3 days ago is noted. he is now afebrile. which of the following is the most appropriate next step in the management of this patient? a) enteral nutrition by nasojejunal feeding tube b) intravenous imipenem c) pancreatic debridement d) parenteral nutrition e) continue with npo status answer: a this patient has ongoing moderate pancreatitis. with his possible underlying poor nutritional status due to alcoholism and expected inability to eat, the patient will need nutritional support. this patient will likely be unable to take in oral nutrition for several days.. enteral nutrition is preferred over parenteral nutrition because of its lower complication rate and proven effi cacy in pancreatitis. enteral nutrition is provided through a feeding tube ideally placed past the ligament of treitz so as not to stimulate the pancreas. broad-spectrum antibiotics such as imipenem therapy are primarily of benefi t in acute pancreatitis when there is evidence of pancreatic necrosis. randomized, prospective trials have shown no benefi t from antibiotic use in acute pancreatitis of mild to moderate severity without evidence of infection. pancreatic debridement is undertaken with caution and is not indicated here. eatock fc, chong p et al. a randomized study of early nasogastric vs. nasojejunal feeding in severe acute pancreatitis. am j gastroenterol. 2005;100:432-9. eckerwall ge, axelsson jb, andersson rg. early nasogastric feeding in predicted severe acute pancreatitis: a clinical, randomized study. ann surg. 2006; 244:959-65. 284 . a 64-year-old female with a past medical history signifi cant for type 2 diabetes mellitus is admitted with increasing shortness of breath. she is admitted for mild congestive heart failure and responds well to therapy. of note she reports increasing left knee pain. the pain is heightened when she tries to walk with physical therapy. three months ago she had left knee arthroplasty, and postoperative course was uneventful. her vital signs are stable. the patient's knee exam reveals a surgical scar but no joint effusion or redness. what should be done next? a) orthopedics consult b) arthrocentesis c) discharged with mild opioid d) order a knee mri e) discharged home with a trial of nsaids a 82-year-old female is admitted to the hospital service with urinary tract infection and sepsis. on admission she is noted to be lethargic and unable to swallow medicines. she develops progressive respiratory failure and is intubated. a cxr is consistent with ards. an ng tube is placed for administration of medicines. you are considering starting tube feeds in this patient. which of the following is the most accurate statement regarding enteral tube feeds in this patient? a) early enteral tube feeds can be expected to reduce her mortality risk. b) the use of omega-3 fatty acids will reduce her mortality risk. c) enteral tube feeds will increase the risk of infection. d) the benefi ts of early nutrition can be achieved with trophic rates. answer: d the benefi ts of early enteral tube feedings in the critically ill patient are uncertain. studies have revealed inconsistent results. there is some suggestion that the incidences of infection can be reduced, but there is no data to suggest long-term mortality improvement. in patients with ards, trophic tube feedings at 10 ml/h seem to concur the same benefi t as early full-enteral tube feedings. 286. which of the following is an acceptable indication for urinary catheter placement? a) a patient who has urinary incontinence and a stage ii pressure ulcer b) a patient who is under hospice care and requests a catheter for comfort c) a patient who is delirious and has experienced several falls d) a patient who is admitted for congestive heart failure whose urine output is being closely monitored answer: b urinary tract infections (utis) are the most common hospitalacquired infections. most attributed to the use of an indwelling catheter. there should always be a justifi able indication for placement of a urinary catheter, and whenever possible prompt removal should occur. this may be assisted by hospital protocols that trigger automatic reviews of catheter use. 287. an 88-year-old man in hospice care is admitted for dyspnea. he has advanced dementia, severe copd, and coronary artery disease. he has been in hospice for 2 months. he and his family would like to be discharged to home hospice as soon as possible. he is only on albuterol and ipratropium. on physical examination, he is afebrile, and his blood pressure is 110/76 mmhg, pulse rate is 110 beats/min, and respiratory rate is 28 breaths/min. oxygen saturation is 90 %. he is cachectic, tachypneic, and disoriented. he is in moderate respiratory distress. chest examination reveals decreased breath sounds and fi ne inspiratory crackles. in addition to continuing his bronchodilator therapy, which of the following is the most appropriate next step in the treatment of this patient? a) ceftriaxone and azithromycin b) morphine c) methylprednisolone d) haloperidol e) lorazepam answer: b this patient is enrolled in hospice. every effort should be made to ensure comfort and limit unnecessary treatments. dyspnea is one of the most common symptoms encountered in palliative care. opioids are effective in reducing dyspnea in patients with chronic pulmonary disease. a 5-mg dose of oral morphine given four times daily has been shown to help relieve dyspnea in patients with endstage heart failure. extended-release morphine, starting at a 20 mg given daily has been used to relieve dyspnea in patients with advanced copd. bronchodilator therapy should be continued to maintain comfort. antibiotics and corticosteroids are not indicated. 288. a 59-year-old man presents with fever and a diffuse blistering skin rash. he is recently started on allopurinol for gout. the patient also complains of sore throat and painful watery eyes. on physical examination, the patient is found to have blisters developing over a quarter of his body. oral mucosal lesions are noted involvement. the estimated body surface area that is currently affected is 15 %. which of the following statements regarding this patient's diagnosis and treatment are true? a) immediate treatment with intravenous immunoglobulin has been proven to decrease the extent of the disease and improve mortality. b) immediate treatment with glucocorticoids will improve mortality. c) the expected mortality rate from this syndrome is about 10 %. d) the most common drug to cause this syndrome is diltiazem. e) younger individuals have a higher mortality than older individuals with this syndrome. answer: c this patient has stevens-johnson syndrome (sjs). there is no defi nitive evidence that any initial therapy changes outcomes in sjs. early data suggested that intravenous immunoglobulin (ivig) was benefi cial, and this traditionally has been the recommended treatment. however, more recent studies have not shown consistent benefi t with ivig. immediate cessation of the offending agent or possible agents is necessary. systemic corticosteroids may be useful for the short-term treatment of sjs, but these drugs increase longterm complications and may have a higher associated mortality. therapy to prevent secondary infections is important. in principle, the symptomatic treatment of patients with stevens-johnson syndrome does not differ from the treatment of patients with extensive burns, and in many instances, these patients are often treated in burn wards. future studies are required to determine the role of ivig in the treatment of sjs. the lesions typically begin with blisters developing over target lesions with mucosal involvement. in sjs, the amount of skin detachment is between 10 and 30 % . mortality is directly related to the amount of skin detachment with a mortality of about 10 % in sjs. other risk factors for mortality in sjs include older age and intestinal or pulmonary involvement. the most common drugs to cause sjs are sulfonamides, allopurinol, nevirapine, lamotrigine, and aromatic anticonvulsants. 289. a 57-year-old woman with a history of diabetes and familial history of breast cancer is admitted with malaise, an appetite decline, and new-onset ascites. she denies having fevers, chills, diarrhea, nausea, and vomiting. on physical exam, there is no evidence of spider nevi or palmar erythema. her serum albumin is 3.4 g/ dl. on chest x-ray, a right-sided pleural effusion is noted. a diagnostic paracentesis reveals a glucose of 85 mg/dl, an albumin of 2.8 g/dl, and a wbc of 250/ ul, of which 45 % are neutrophils. based on the data provided, what is the most likely cause of her ascites? a) cirrhosis b) metastatic disease c) pelvic mass d) spontaneous bacterial peritonitis e) tuberculous peritonitis answer: c meigs' syndrome is the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. typical diagnostic paracentesis reveals a serum-ascites albumin gradient < 1.1 suggesting a nonportal hypertension-mediated process. of the possibilities for that, ovarian mass is the most likely here. transdiaphragmatic lymphatic channels are larger in diameter on the right. this results in the pleural effusion being typically classically located on the right side. the etiologies of the ascites and pleural effusion are poorly understood. further imaging is indicated. riker d, goba d. ovarian mass, pleural effusion, and ascites: revisiting meigs syndrome. j bronchology interv pulmonol. 2013;20(1):48-51. 290. a 77-year-old female patient presents with dizziness, headache, nausea, and vomiting for the past 48 h. she states that the fl oor feels like it is moving when she walks. the patient is alert, and she tells you she suffered from no recent trauma. on physical exam you note the patient's speech is slightly abnormal. during the neurological examination, the patient is able to understand your questions, respond appropriately, and repeat words, but her words are poorly articulated. she has a great deal of diffi culty walking across the room without assistance. what is your next step in the management of this patient? a) administer unfractionated heparin b) epley maneuver c) ct scan without contrast d) emergent mri or mra e) observation alone answer: d this patient has central vertigo possibly due to a cerebellar infarction. multiple cerebellar signs are noted which help distinguish this from benign peripheral vertigo. due to obstruction by a posterior fossa bone artifact, ct scan may not be of benefi t. emergent mri and mra if available are the tests of choice. this should be done to confi rm the diagnosis and followed for the development of an obstructing hydrocephalus, which can occur with cerebellar infarction. since the posterior fossa is a relatively small and nonexpandable space, hemorrhage or edema can lead to rapid compression. early neurosurgical consultation should be considered. on physical examination, temperature is normal. blood pressure is 147/83, pulse rate is 70 beats/min, and respiratory rate is 12 breaths/min. other physical examination fi ndings are within normal limits. which of the following is the most appropriate insulin therapy after surgery? a) continuous intravenous insulin infusion b) previous schedule of 70/30 insulin c) subcutaneous insulin infusion d) insulin glargine once daily and insulin aspart before each meal e) sliding-scale insulin alone f) insulin aspart before each meal alone answer: d this patient should receive basal insulin as well as scheduled insulin before each meal. this should be adjusted for conditions that occur in the hospital. a patient with longstanding type 1 diabetes makes no endogenous insulin and requires a maintenance dose of insulin postoperatively. it is expected that her po intake would be markedly decreased, and subsequently her insulin dose should be decreased. 293. you are urgently called to see in consultation of a 36-year-old woman who is in postop recovery. she has a sudden elevation of her temperature and is thought to be septic. her laparoscopic cholecystectomy was completed 45 min ago without complication. on physical exam her temperature is 40.5 °c (105 °f). she has respiratory rate of 28 breaths per minute. she is tachycardic, shaking, and confused. there is diffuse muscular rigidity noted. which of the following drugs should be administered immediately? a) acetaminophen b) haloperidol c) hydrocortisone d) ibuprofen e) dantrolene answer: e the patient has malignant hyperthermia. dantrolene should be given. physical cooling in addition to dantrolene with cooling blanket or iv fl uids should be used as well. dantrolene may be used in other central causes of extreme hyperthermic such as neuroleptic malignant syndrome. in this case, the episode was probably caused by succinylcholine and/or inhalational anesthetic. this syndrome occurs in individuals with inherited abnormality of skeletal muscle sarcoplasmic reticulum. more than 30 mutations account for human malignant hyperthermia. genetic testing is available to establish a diagnosis. the caffeine halothane contracture test remains the criterion standard. this is a muscle biopsy and performed at a designated center. the syndrome presents with hyperthermia or a rapid increase in body temperature that exceeds the ability of the body to lose heat. muscular rigidity, acidosis, cardiovascular instability, and rhabdomyolysis also occur. antipyretics such as acetaminophen, ibuprofen, and corticosteroids are of little use. the dantrolene dose is 2.5 mg/kg rapid iv bolus and may be repeated prn. occasionally a dose up to 30 mg/kg is necessary. which of the following is the most appropriate perioperative recommendation regarding anticoagulation in this patient? a) discontinue warfarin 5 days before surgery and bridge with full-dose iv heparin before and after surgery. b) discontinue warfarin 5 days before surgery and restart on the evening of the surgery. c) continue with warfarin. d) reverse anticoagulation with fresh frozen plasma transfusion 1 h before surgery and restart warfarin on the evening of the surgery. in patients with mechanical valves and at low risk for thromboembolism, low-dose low-molecular-weight heparin or no bridging is recommended. the short-term risk of anticoagulant discontinuation in this patient is small. the current recommendation is to stop warfarin 5 days before the procedure. the inr goal is 1.5. warfarin should be restarted within 24 h after the procedure. in patients with a mechanical valve and an increased risk of a thromboembolic event, it is recommended that unfractionated heparin be begun intravenously when the inr falls below 2.0. this should be stopped 4-5 h before the procedure and restarted after surgery. in patients with a mechanical heart valve who require emergent surgery, reversal with fresh frozen plasma may be performed. 297. an 88-year-old female who was admitted to the hip fracture service for a right hip fracture has currently become agitated and confused. she underwent hip fracture repair two days prior. she has a history of osteoporosis, dementia, and type 2 diabetes. her postoperative medicines include oxycodone 5 mg every 4 h as needed for pain as well as iv morphine 1-2 mg/h as needed for the pain. during the patient's fi rst night, she was calm and relatively free of pain. however, on her second night, she has become acutely agitated and is reported by the nurse to be screaming and pulling out lines and drains. her temperature is 99.1 °f. her pulse rate is 100 beats/min. her respirations are 20 per minute. her oxygenation is 92 % on room air. her hematocrit and hemoglobin are within normal limits as well as the rest of her electrolytes. which of the following is the appropriate response/ treatment for this patient's delirium? a) four-point restraints b) one 2 mg dose of intravenous lorazepam c) one 5 mg dose of oral haloperidol d) one 0.5 mg dose of oral haloperidol e) one 5 mg dose of intravenous haloperidol answer: d treatment of postoperative-induced delirium is a common issue confronted in the hospital setting. delirium that causes injury to the patient or others should be treated with medications. this can be a diffi cult management issue. no medication is currently approved by the food and drug administration for the treatment of delirium. current guidelines recommend using low-dose antipsychotics such as haloperidol. the use of benzodiazepines should be limited, unless concurrent alcohol withdrawal is present. a specifi c fda warning has been issued for intravenous haloperidol due to the risk of torsades de pointes in 2007. low-dose haloperidol, less than 2 mg, has a low incidence of extrapyramidal side effects. qtc prolongation monitoring is recommended for patients. if feasible, this patient should have had a baseline ekg as well as a follow-up ekg. haloperidol at doses greater than 4.5 mg increases the incidence of extrapyramidal side effects and should be avoided. the surgery was uneventful. on hospital day 2, she has a sudden onset of tachypnea and hypoxemia. a computed tomography pulmonary angiogram reveals a thrombus in the pulmonary artery to the right lower lobe. her inr is 1.0. what is the most likely cause of her thrombosis? a) surgery-induced thrombosis b) depletion of thrombin due to the surgical acutephase response c) thrombogenesis due to postoperative hypovolemia d) undetected prior thrombus e) rebound hypercoagulability and subsequent thromboembolism answer: e rebound hypercoagulability is the most likely cause. this may occur after abrupt cessation of warfarin. in addition, surgery increases the risk of thromboembolic events. following an abrupt withdrawal of warfarin, thrombin and fi brin formation increase and very high levels of thrombin activation are seen. if possible, warfarin withdrawal should be gradual which would not have been feasible in the current case. safely resuming anticoagulation after surgery should be a goal as well. a 60-year-old man who has metastatic lung cancer and painful bone metastases reports severe pruritus that started when he began to take morphine for his pain. pain in his chest wall and legs has been successfully treated with sustained-release morphine (80 mg every 12 h) and short-acting morphine (15 mg orally every 2 h as needed for breakthrough pain) which he uses two or three times daily, depending on his level of activity. on physical examination, the temperature is 37 °c (98.6 °f), pulse rate is 80 beats per minute, respirations are 16 per minute, and blood pressure is 115/70 mmhg. oxygen saturation by pulse oximetry is 95 % on room air. the patient is alert and oriented. his pupils are 4 mm initially and constrict to 2 mm with a light stimulus. the lungs are clear. cardiac examination shows a normal rate and regular rhythm. no rash is seen. examination of the abdomen is signifi cant for suprapubic dullness and sensitivity. neurological examination is nonfocal. which of the following should be done next? a) change to oxycodone, 40 mg every 12 h, and oxycodone, 5-10 mg every 2 h as needed b) lower the dosage of sustained-release morphine to 30 mg every 12 h c) continue with same morphine dose d) change to oxycodone, 60 mg every 12 h, and oxycodone, 15 mg every 2 h as needed answer: a oxycodone may cause somewhat less nausea, hallucinations, and pruritus than morphine. mild to moderate morphineinduced puritis may be managed by small-dose reductions or antihistamines. this patient has severe puritis which may be relieved by changing to oxycodone. the patient's baseline long-acting morphine daily dose was 160 mg, with a minimum short-acting morphine dose of 30 mg daily, which yields a total daily dose of 190 mg. the morphine-to-oxycodone ratio is 1.5:1. this patient's morphine-equivalent daily dose of oxycodone would be 120 mg. the daily dose of oxycodone would be 60 mg. thus, the every-12-h dose of long-acting oxycodone would be 40 mg. a 68-year-old female who has metastatic small cell lung cancer presents to the emergency room with shortness of breath. she is noted to be in marked respiratory distress and is intubated by emergency room personnel. she is admitted to the intensive care unit. on review of the medical records, you fi nd that the patient has an advanced directive, which indicates that the patient did not want to be intubated. this is noted both in a signed advanced directive as well as in the hospital records. you arrange a family meeting to discuss goals of care. the patient's daughter has recently quit her job and has moved in with her mother to provide care. you discuss the case with her, and she states that her mother has changed her mind recently and would like to be on the ventilator at all costs. which of the following is the correct course of action? a) follow the patient's written documentations and extubate the patient and provide comfort care. b) follow the daughter's instructions and have patient remain intubated. c) request an ethics consultation. d) consult the hospital's legal affairs department. answer: c it is of primary importance to follow the patient's wishes. in this particular case, there is some diffi culty in determining if the patient has recently changed her mind, as is suggested by the daughter. she has clearly documented her advance directives, and it would be appropriate to withdraw life support if the daughter did not provide the confl icting statement. financial confl icts of interest often interfere with the surrogates ability to act in the best interest of the patient. in this particular case, there are circumstances that suggest that fi nancial considerations may be infl uencing the statement. it would be diffi cult for an individual practitioner to make this determination, without the potential of liability. subsequently, an ethics consultation would be the correct course of action. as there are several factors, ethics and clinical, involved, an attorney alone would not be in a position to resolve the issue. 303. an 83-year-old female is admitted from a nursing home to the hospital for shortness of breath. on chest x-ray, she has a new-onset pleural effusion for which thoracentesis is indicated. on her medical record, it is reported that she has a history of dementia. on physical exam she is awake and alert. she knows that she is in the hospital, knows her name and address, but is confused about the current date. on review of her medical records, you discover that she has neither family members nor a durable power of attorney. in attempting to obtain consent for the procedure, which of the following is the next best step? a) proceed without consent. b) assign guardianship. c) determine capacity yourself. d) psychiatric consultation for competency. e) ethics consultation. answer: c there are four components of determining capacity in decision-making concerning a particular treatment or test: (1) an understanding of relevant information about proposed diagnostic tests or treatment, (2) appreciation of their medical situation, (3) using reason to make decisions, (and 4) ability to communicate their choice. in most instances, the primary physician should possess the ability to determine capacity. capacity is not the same measurement as competence. competence is determined by a court of law and uses issues of capacity in evaluating the legal ability to contract. a psychiatric consultation can determine competency but is usually not needed to determine capacity. assigning guardianship or an ethics consultation can be a lengthy process and should be reserved for cases with signifi cant issues to be resolve. a 65-year-old male is admitted to the hospital for elective total knee arthroplasty. he has a history of type 2 diabetes mellitus and is treated with metformin. he reports fair glucose control with diet and oral agents. he has never been on insulin. on physical examination he has mild edema of his lower extremities but otherwise is within normal range. preoperative laboratory studies have been done 1 week prior. his hemoglobin a1c revealed a concentration of 6.8 %. plasma glucose level measured on the day of surgery is 210 mg/l. which of the following is the most appropriate treatment for patients with elevated blood sugars preoperatively and postoperatively? a) metformin b) sliding-scale insulin c) iv hydration d) basal and sliding-scale insulin e) diet control alone answer: d the goal of glycemic control in the hospitalized patient is balancing the risks of hypoglycemia against the known benefi ts in morbidity and mortality. although tight control has been advocated in the past, current consensus guidelines recommend less stringent glycemic goals, typically between 80 and 150 mg/dl. the ultimate goal in the management of diabetic patients (dm) is to achieve outcomes equivalent to those in patients without dm. a meta-analysis of 15 studies reports that hyperglycemia increased both in-hospital mortality and incidence of heart failure in patients admitted for acute myocardial infarction. several other studies have also demonstrated the benefi ts of glycemic control in the perioperative area. type 2 diabetes mellitus often requires insulin while in the hospital. the requirements may be unpredictable. this may be due to the stress of hospitalization, dietary changes, glucose added to iv fl uids, and medicine interactions. sliding scale alone has often been traditionally used in the past. however, this method of control often results in wide fl uctuations in glycemic control. the optimal plasma glucose level postoperatively is not known, and certainly tight control has its risks. a 55-year-old female has been admitted for cellulitis. she has responded well to antibiotics and is ready for discharge. on admission she was noted to be in atrial fi brillation. she has been treated with low-molecularweight heparin in the hospital. she fi rst noted the irregular heartbeat 4 weeks ago. she denies chest pain, shortness of breath, nausea, or gastrointestinal symptoms. past medical history is unremarkable. there is no history of hypertension, diabetes, or tobacco use. her medications include metoprolol. on physical examination, she has a blood pressure of 124/76 mmhg and a pulse of 70 beats/min. an echocardiogram shows a left atrial size of 3.5 cm. left ventricular ejection fraction is 63 %. there are no valvular or structural abnormalities. which of the following would be the appropriate treatment of her atrial fi brillation? a) she requires no antiplatelet therapy or anticoagulation because the risk of embolism is low. b) lifetime warfarin therapy is indicated for atrial fi brillation in this situation to reduce the risk of stroke. c) she should be started on iv heparin and undergo electrical cardioversion. d) she should continue on sc low-molecular-weight heparin and transitioned to warfarin. e) her risk of an embolic stroke is less than 1 %, and she should take a daily aspirin. answer: e patients younger than 60 years of age without structural heart disease or without risk factors have a very low annual risk of cardioembolism of less than 0.5 %. therefore, it is recommended that these patients only take aspirin daily for stroke prevention. the risk of stroke can be estimated by calculating the chads2 score. older patients with numerous risk factors may have annual stroke risks of 10-15 % and must take a vitamin k antagonist or alternate indefi nitely. cardioversion may be indicated for symptomatic patients who want an initial opportunity to remain in sinus rhythm. a) peg tubes reduce aspiration as opposed to nasogastric tubes. b) in end-stage advanced malignancy with cachexia, peg tubes have been proven to improve survival and reduce morbidity. c) peg tubes have been proven to improve survival in end-stage dementia. d) mean survival after peg tube placement for failure to thrive is 6 months. answer: d the physician is often faced with this decision in a variety of end-of-life situations to consider placement of a peg tube. survival benefi ts of peg tube placement are often minimal at best. there is a wide range of cultural expectations in reference to this issue. it is important to understand the facts concerning the possible benefi ts or lack of benefi ts of peg tube placement when counseling the patient and family. as noted in this question, survival benefi ts for peg tube placement in a patient with failure to thrive to variety of conditions are modest at best. a 59-year-old man has been admitted for congestive heart failure. his symptoms have resolved. prior to discharge the cardiology service would like him to undergo placement of an automatic implantable cardiac converter defi brillator (aicd). he is on warfarin with an inr of 2.9. his other problems include rate-controlled atrial fi brillation and coronary artery disease. an echocardiogram performed 2 weeks ago showed a left ventricular ejection fraction of 25 % and a well-functioning mechanical mitral valve. trace edema is noted in the extremities. how should his warfarin be managed prior to placement of his aicd? a) continue warfarin, with a target inr of 3.5 or less on the day of the procedure. b) discontinue warfarin 5 days before the procedure and resume the day after the procedure. c) discontinue warfarin 5 days before the procedure and bridge with an unfractionated heparin infusion. d) discontinue warfarin 5 days before the procedure and bridge with low-molecular-weight heparin. answer: a not all procedures require warfarin to be stopped. in some cases, there is data to support continuing warfarin as opposed to bridging therapy. a randomized, controlled trial found that patients at high risk for thromboembolic events on warfarin who need a pacemaker or implantable cardioverter defi brillator (icd) can safely continue warfarin without bridging anticoagulation. continuing warfarin treatment at the time of pacemaker in patients with high thrombotic risk was associated with a lower incidence of clinically signifi cant device-pocket hematoma, as opposed to bridging with heparin. a 56-year-old male is admitted to the hospital with fever and cough. he was well until 1 week before admission when he noted progressive shortness of breath, cough, and productive sputum. on the day of admission, the patient's wife noted him to be lethargic. the past medical history is notable for alcohol abuse and hypertension. on examination, the patient is lethargic. temperature is 38.9 °c (102 °f), blood pressure is 110/85 mmhg, and oxygen saturation is 86 % on room air. there are decreased breath sounds at the right lung base. heart sounds are normal. the abdomen is soft. there is no peripheral edema. chest radiography shows a right lower lobe infi ltrate with a moderate pleural effusion. the white blood cell count is 15,000/μl and 6 % bands. he is admitted and started on broad-spectrum antibiotics. on hospital day 3 he is not eating due to lethargy. a nasogastric tube is inserted, and tube feedings are started. the next day, plasma phosphate is found to be 1.2 mg/dl and calcium is 9.2 mg/dl. what is the most appropriate approach to correcting the hypophosphatemia? a) administer iv calcium gluconate 1 g followed by infusion of iv phosphate at a rate of 8 mmol/h for 6 h. b) administer iv phosphate alone at a rate of 4 mmol/h for 6 h. c) administer iv phosphate alone at a rate of 8 mmol/h for 6 h. d) stop tube feedings, phosphate is expected to normalize over the course of the next 24-48 h. e) initiate oral phosphate replacement at a dose of 1750 mg/day. answer: c severe hypophosphatemia occurs when the serum concentration falls below 2 mg/dl . in this circumstance, iv replacement is recommended. in this patient with a level of 1.2 mg/dl, the recommended infusion rate is 8 mmol/h over 6 h for a total dose of 48 mmol. levels should be checked every 6 h as well. malnutrition from fasting or starvation may result in depletion of phosphate. when nutrition is initiated, redistribution of phosphate into cells occurs. this is common in alcoholics. it is generally recommended to use oral phosphate repletion when the serum phosphate levels are greater than 1.5-2.5 mg/dl. a 58-year-old male is admitted to the hospital for elective hip replacement therapy. he has a history of chronic pulmonary disease and takes inhaled steroids as well as albuterol inhalers. he was admitted to the hospital 2 weeks ago for a moderate exacerbation of copd for which he recently completed a 10-day course of prednisone. he is currently asymptomatic, and his breathing is back to baseline. he states that he has not taken steroids within the past year other than his recent admission. you are asked to provide clearance for the orthopedic service of this patient. which of the following is the most appropriate treatment? a) obtain a cortrosyn stimulation test and begin steroids if there is evidence of cortisol defi ciency. b) administer intravenous hydrocortisone 50 mg on the morning of surgery. c) administer intravenous hydrocortisone 100 mg preoperatively and then 50 mg every 8 h for 2 days after surgery. d) proceed with surgery. e) postpone surgery for 2 weeks. 316. an 86-year-old male is admitted for cough, dyspnea, and dysphagia. he has a known large non-small cell cancer in the upper lobe of the right lung and is on week 4 of palliative irradiation. he reports anorexia, diffi culty swallowing solid food, and right shoulder pain. his wife and family are concerned about dehydration. they request iv fl uids and nutrition. on physical examination, the patient is thin and appears weak but alert. pulse rate is 120 beats per minute, respirations are 24 per minute, and blood pressure is 150/70 mmhg. there are temporal wasting and a dry oropharynx. the patient's breathing is shallow, with mild tachypnea. breath sounds are diminished in the upper lobe of the right lung. you convene a family meeting to discuss options. which of the following would be the most likely outcome of intravenous hydration or nutrition in this patient? a) reduced bun/serum creatinine ratio b) prolonged survival c) increased albumin level d) improved quality of life answer: a families feel an important obligation to provide nutrition and hydration to the dying patient. a randomized controlled trial found that parenteral hydration did not improve quality of life in advanced cancer. the intravenous fl uids would likely reduce this patient's prerenal azotemic state in the short term but would not have a benefi cial impact on his quality of life. these facts can guide counseling of patients and families in seeking noninvasive measures for this stage of advanced cancer. 318. a 26-year-old woman is evaluated in the emergency department for abdominal pain. she reports a vague loss of appetite for the past day and has had progressively severe abdominal pain at her umbilicus. the pain is collicky. she reports that she is otherwise healthy and has had no sick contacts. surgery has been consulted and recommends observation. you are consulted for admission. on physical exam her temperature is 38.2 °c (100.8 °f), heart rate 110 bpm, and otherwise normal vital signs. her abdomen is tender in the right lower quadrant and pelvic examination performed in the emergency room is normal. urine pregnancy test is negative. which of the following imaging modalities would you do next? a) colonoscopy b) pelvic ultrasound c) ct of the abdomen without contrast d) ultrasound of the abdomen e) transvaginal ultrasound f) plain fi lm of the abdomen answer: c ct scan is indicated for the diagnoses of acute appendicitis. it has been shown to be superior to ultrasound or plain radiograph in the diagnosis of acute appendicitis, the appendix is not always visualized on ct, but nonvisualization of the appendix on ct scan is associated with surgical fi ndings of a normal appendix 98 % of the time. this patient presented with classic fi ndings for acute appendicitis. initial anorexia progressed to vague periumbilical pain. this was followed by localization to the right lower quadrant. low-grade fever and leukocytosis may be present. acute appendicitis is primarily a clinical diagnosis. however, imaging modalities are frequently employed as the symptoms are not always classic and take time to evolve. plain radiographs are rarely helpful. ultrasound may demonstrate an enlarged appendix with a thick wall, but is most useful to rule out gynecological disease such as ovarian pathology, tuboovarian abscess, or ectopic pregnancy, which can mimic appendicitis. an abdominal and pelvic computed tomography scan shows a large amount of stool but no bowel obstruction. which of the following is the correct treatment for this patient's ongoing constipation? a) add lactulose. b) add n-methylnaltrexone. c) add docusate. d) place a nasogastric tube for bowel decompression. e) request a colorectal surgery consult for manual disimpaction. answer: a constipation is the most frequent side effect associated with long-term opioid therapy. osmotic laxatives, such as mannitol, lactulose, and sorbitol, are effective in the palliation of opioid-induced constipation. although expert consensus supports the use of prophylactic bowel regimens in all patients taking opioids, little evidence demonstrates the effi cacy of one regimen over another. bulk-forming laxatives increase stool volume but should be used with caution in patients with advanced cancer because they require adequate fl uid intake and physical activity to prevent exacerbation of constipation. docusate has very little effect when given alone for opioidinduced constipation. gastric motility is decreased in these patients and softening of the stool alone may not alleviate the symptom. in many situations, its effi cacy has been questioned. n-methylnaltrexone is used for the treatment of opioidinduced constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has been insuffi cient. in this patient adding, starting and continuing with lactulose is the next step. in addition a bowel diary may be beneficial to review on her follow-up appointment. pappagallo m. incidence, prevalence, and management of opioid bowel dysfunction. am j surg. 2001;182 (suppl 5a):11s-8s. a 53-year-old woman who has hepatitis c cirrhosis is admitted for worsening ascites. in addition to complaints of abdominal pain, she complains of severe puritis. she has been on cholestyramine for several months for the itching. on physical exam multiple excoriations of her skin are noted and she is unable to stop scratching. she is very anxious and fatigued. her serum laboratory results are stable from last admission, including a stable total bilirubin. ultrasonography shows no evidence of biliary ductal dilatation or changes in her liver. which of the following should you now recommend? a) ursodeoxycholic acid at 30 mg/kg daily b) diphenhydramine 50 mg every 6 h c) naltrexone 25 mg daily d) morphine 5 mg bid e) hydroxyzine 10 mg bid answer: c refractory itching is a common in end-stage liver disease patients. it may be severe leading to signifi cant excoriations. cholestyramine has been the mainstay of treatment. patients who do not respond to continued doses of cholestyramine probably will not respond to an antihistamine. naltrexone is tolerated well and is a reasonable option in these cases. patients started on naltrexone should be followed for signs of withdrawal. wolfhaqen fh, sternieri e, hop wc et al. oral naltrexone therapy for cholestatic pruritus: a double-blind, placebocontrolled study. gastroenterology. 1997; 113:1264-9. 322 . a 69-year-old female with osteoarthritis of the knees for many years and has been advised by her orthopedist that the timing is now right to undergo knee arthroplasty. she has a history of diabetes, high cholesterol, hypertension, and coronary artery disease. nine months ago, she underwent a drug-eluting stent placement for worsening angina, which she tolerated well. she has been angina-free since that time and is able to walk up several fl ights of stairs without angina. current medications are aspirin, clopidogrel, losartan, and metoprolol. your recommendations concerning surgery are the following: a) surgery can proceed as planned. b) surgery should wait for 2 months. c) surgery can occur in 3 months. d) surgery can occur in 9 months. answer: c elective surgery should be delayed at least 1 year after the placement of a drug-eluting stent. rapid thrombosis of a drug-eluting stent (des) is a catastrophic complication. the risk of stent thrombosis is increased in the perioperative setting and is strongly associated with the cessation of antiplatelet therapy. to avoid thrombosis with des, aspirin and antiplatelet agents should be continued throughout surgery. in spite of the increased risk of bleeding, this strategy is acceptable in many types of invasive surgical procedures with no change in outcome. in situations where surgery may be needed on a semi-urgent basis in patients who have received a drug-eluding stent within 1 year and the risk of bleeding is high. in these situations, consultation with cardiology is recommended. elective surgery with bare metal stents should be delayed for 30-90 days. a patient with severe dementia is admitted for worsening anorexia and nausea over the past 6 weeks. she lives at home with her family. the family would like to continue palliative care but are looking to improve her appetite and diminish her nausea. you and the family meet and agree on a conservative course of action. which of the following statements accurately characterizes the treatment of these complications of severe dementia? a) haloperidol has minimal effects against nausea. b) even though this patient has severe dementia, it would be unethical to withhold nutrition and hydration. c) a feeding tube will reduce the risk of aspiration pneumonia. d) a trial of antidepressants is indicated. e) impaction may explain all the symptoms. f) a trial of megestrol acetate. answer: e anorexia and gastrointestinal symptoms are common near the end of life. despite a nonaggressive approach, some simple measures may improve symptoms. haloperidol may be highly effective against nausea and may be less sedating than many commonly used agents, such as prochlorperazine. impactions are common and can present with a variety of symptoms. treatment can be relatively easy and can improve comfort. because of the terminal and irreversible nature of end-stage dementia and the substantial burden that continued lifeprolonging care may pose, initiating aggressive hydration and nutrition would not be indicated. appetite stimulants such as megestrol acetate have not been shown to be of any benefi t in the anorexia of end-stage dementia. hanson lc, ersek m, gilliam r, carey ts. oral feeding options for patients with dementia: a systematic review. j am geriatr soc. 2011;59(3):463-72. a 23-year-old female is admitted with a new deep venous thrombosis (dvt). she is pregnant and in her late second trimester. you are consulted for management of her dvt. in review of her labs, it is noticed that her liver functions are elevated. her ast is 120 units/l; her alt is 140 units/l. t. bili is 1.6 mg/dl. which of the following is the likely diagnosis? a) hyperemesis gravidarum b) hellp c) cholestasis of pregnancy d) acute fatty liver of pregnancy e) none of the above answer: c gestational age of the pregnancy is a great guide to the differential of liver disease in the pregnant woman. cholestasis of pregnancy is common and most typically presents in the late second trimester. approximately 1 % of pregnancies in the united states are affected by this condition. some hepatic diseases of pregnancy are mild, and some require urgent and defi nitive treatment. a common condition of the fi rst trimester is hyperemesis gravidarum and may result in elevated ast and alt; however this usually resolves by week 20 of gestation. acute fatty liver of pregnancy is a cause of acute liver failure that can develop in the late second or third trimester. elevated lfts and bilirubin are most commonly seen. although symptoms and signs are similar to those of preeclampsia and hellp syndrome, aminotransferase levels tend to be much higher. riely ca. liver disease in the pregnant patient. am j gastroenterol. 1999; 94:1728-32. 326 . a 66-year-old male is admitted with acute onset of left hemiplegia. he has a history of hypertension, nonvalvular atrial fi brillation, and thyroid disease. he has been lost to medical follow-up in recent years and has been on no anticoagulation. on physical exam, motor strength is 1/5 in the left arm and 2/5 in the left leg. electrocardiogram reveals atrial fi brillation with a heart rate of 70 beats per minute. mri performed on presentation reveals a right middle cerebral artery infarction. which of the following is appropriate treatment for stroke prevention? a) aspirin 350 mg daily alone b) clopidogrel 25 mg daily c) warfarin, adjusted to achieve an inr of 2-3 d) unfractionated heparin bolus, followed by infusion e) enoxaparin answer: c guidelines do not support the routine use of anticoagulation for acute ischemic stroke. in this particular case with a large territory middle cerebral artery infarct, any urgent anticoagulation may increase the risk of conversion to hemorrhage. several randomized, controlled trials that used heparin early after ischemic stroke failed to show a signifi cant overall benefi t of treatment over controls. an exception may be in patients with acute ischemic stroke ipsilateral to a severe stenosis or occlusion of the internal carotid artery. stroke prevention treatment for atrial fi brillation is most often determined according to the chads2/chads2vas system. warfarin continues to be the most commonly used agent, although a number of newer agents including dabigatran are increasingly being prescribed. current recommendation is that warfarin be started during the hospitalization. bridging with low-molecular-weight heparin is not usually needed but may be considered in certain circumstances. a 37-year-old male with a history of intravenous drug abuse is admitted with fever and hypertension. a diagnosis of mitral valve endocarditis is made by echocardiogram. he is noted to have a large lesion on his mitral valve with moderate regurgitation. he is started on broadspectrum antibiotics and has a clinically good response. when is surgery indicated in the presence of endocarditis? a) heart failure b) after several embolic events c) myocardial abscess d) confi rmed fungal endocarditis e) all of the above answer: e fifteen to twenty percent of the patients who have endocarditis will ultimately require surgical intervention. congestive heart failure in a patient with native valve endocarditis is the primary indication for surgery. the decision to proceed with surgery is often diffi cult due to patient comorbidities. traditional criteria include those listed above. it is suggested that surgery may be considered in patients with large lesions and signifi cant valvular disease. early surgery reduces the risk of embolic events, although this has not been proven to change overall mortality. failure of medical treatment is another indication for surgery, although guidelines are not specifi c. in addition surgery should be considered in patients with multiresistant organisms. endocarditis in many circumstances warrants early cardiothoracic surgery consultation. 328. which of the following patients with metastatic disease is potentially curable by surgical resection? a) a 22-year-old man with a history of osteosarcoma of the left femur with a 1-cm metastasis to his right lower lobe b) a 63-year-old woman with a history of colon cancer with one metastases to the left lobe of the liver c) operable non-small cell lung cancer with a single brain metastasis d) all of the above e) none of the above answer: d in colon, non-small cell lung and osteosarcoma cancer cures have been reported with resection of solitary metastatic lesions. metastases typically represent widespread systemic dissemination of disease and are associated with poor prognosis. palliative chemotherapy is generally the accepted method of treatment. over the last several years, numerous reports and studies have demonstrated long-term survival after resection of isolated metastasis. after extensive investigation for further metastatic sites, isolated metastasis should be considered for reaction in select cases. manfredi s, bouvier am, lepage c et al. incidence and patterns of recurrence after resection for cure of colonic cancer in a well defi ned population. br j surg. 2006; 93:1115-22. 329 . a 56-year-old white male with known clinical atherosclerotic disease is admitted with severe leg cramps. his past medical history is signifi cant for a myocardial infarction (mi) 4 years ago requiring stent placement. at the time of his mi, he was initiated on a high-intensity statin; since then he has developed severe leg cramps. what would be the next best alternative in lipid therapy for this patient? a) start atorvastatin 20 mg po daily. b) no longer a need for statin therapy since his mi was 4 years ago. c) start rosuvastatin 20 mg po qhs. d) start pravastatin 10 mg po qhs. answer: a he should be on a high-intensity statin, but he was unable to tolerate the side effects. according to american college of cardiology guidelines, patients with known clinical atherosclerotic disease should be on a moderate-intensity statin if not a candidate or cannot tolerate the highintensity regimen. atorvastatin 20 mg is a moderateintensity statin. the moderate-intensity daily dose will lower ldl-c by approximately 30 to <50 %, whereas the high-intensity therapy lowers ldl-c by approximately ≥50 %. lastly, pravastatin 10 mg is a low-intensity statin. 330. a 62-year-old man is admitted for dehydration. he also reports severe nausea and vomiting that began 24 h ago. he recently started chemotherapy for non-small cell lung cancer. his last dose was 48 h ago. on physical examination his abdomen is soft and nontender. bowel sounds are present. he is admitted and started in intravenous fl uids. despite several doses of ondansetron, he continues to have near constant nausea. what would be the next appropriate treatment for his nausea and vomiting? a) dexamethasone b) haloperidol c) lorazepam d) octreotide answer: a dexamethasone is recommended for the management of delayed chemotherapy-induced nausea and vomiting. delayed nausea and vomiting are any nausea and vomiting that occurred after the day that chemotherapy is infused. nausea and vomiting are two of the most feared cancer treatment-related side effects for cancer patients. dexamethasone has synergistic action with many antiemetic medications. its specifi c antiemetic mechanism of action is not fully understood. it is generally started at 8 mg once or twice daily. corticosteroids may be effective as monotherapy as well. a 63-year-old man is admitted to the hospital because of hematemesis. he has gastroesophageal refl ux disease and atrial fi brillation; he takes warfarin. he had felt well until this morning when nausea developed after eating. he vomited blood once and was brought to the hospital. on physical exam, the temperature is normal. pulse rate is 84 beats per minute and irregular, and blood pressure is 112/74 mmhg. abdominal examination is normal. hemoglobin is 11.8 g/dl, serum creatinine is 0.9 mg/dl, and egfr is greater than 60 ml/ min/1.73 m 2 . intravenous isotonic saline is given, and nasogastric lavage is subsequently performed. upper endoscopy reveals a duodenal ulcer, which is successfully cauterized. warfarin is discontinued, and intravenous pantoprazole is begun. no additional bleeding is noted after 48 h, and the patient is prepared for discharge. how long after the bleeding episode can this patient's warfarin be safely restarted? a) one week. b) one month. c) six weeks. d) three months. e) warfarin should not be restarted. answer: a gastrointestinal (gi) bleeding affects an estimated 4.5 % of warfarin-treated patients annually and is associated with a signifi cant risk of death. these patients present a dilemma for clinicians regarding when to restart warfarin. a recent study examined patients who had gi bleeds when on warfarin. they found that warfarin therapy resumption within 1 week after a gi bleed was, after 90 days, associated with a lower adjusted risk for thrombosis and death without signifi cantly increasing the risk for recurrent gi bleeding compared to those who did not resume warfarin. the median time to restart warfarin was 4 days. from this study, a reasonable period of 7 days is suggested. 332. an 82-year-old male is admitted for communityacquired pneumonia. during the fi rst 24 h of admission, he undergoes cardiopulmonary arrest. he was subsequently successfully coded on the fl oor. the family cannot be contacted, and full resuscitation measures are taken. he is transferred to the icu. which of the following will characterize the patient's post-arrest clinical course? a) increased intracranial pressure b) intact cerebrovascular autoregulation c) myocardial dysfunction d) minimal infl ammatory response answer: c the post-cardiac arrest syndrome (pcas) is an infl ammatory syndrome that best resembles sepsis. infl ammatory mediators are released, resulting in activation of the coagulation cascade. cerebral edema, ischemic degeneration, and impaired autoregulation characterize the brain injury pattern in the pcas. brain injury alone contributes greatly to overall morbidity and mortality in the resuscitated cardiac arrest patient. there is impaired autoregulation as well as impaired oxidative metabolism. there is predictable myocardial dysfunction. myocardial dysfunction in the pcas seems to be reversible and is characterized largely by global hypokinesis. elevations of intracranial pressure are not prominent. treatment during this period involves hemodynamic support and the use of inotropic and vasopressor agents if warranted. hyperthermia should be avoided at all costs in patients with the pcas. if aggressive therapy is pursued, consider sedation with hypothermia to improve neurological outcome in the icu setting. a 72-year-old female is admitted with abdominal distension. she has history of colon cancer. her last bowel movement was 4 days ago despite her taking scheduled polyethylene glycol. her cancer was diagnosed 2 years ago and has been treated with chemotherapy after her disease was determined to be surgically unresectable. on physical exam the bowel is distended with absent bowel sounds. lungs are normal. a nasogastric tube is placed with some mild improvement of distension. ct scan shows dilated loops of small bowel and colon with a transition point in the mid-descending colon. which of the following will most likely improve this patient's ability to eat and ensure adequate caloric intake and fl uids? a) referral for radiation b) placement of a colonic stent across the single site of obstruction c) fleet enema d) exploratory surgery e) placement of a venting percutaneous endoscopic gastrostomy (peg) tube answer: b a single-site bowel obstruction can be successfully palliated with colonic stent placement. most self-expandable metal stent (sems) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. this would be a reasonable approach in this patient as opposed to surgery. when performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. hand decontamination with either antisepticcontaining soaps, alcohol-based gels, or a combination has consistently been shown to reduce clabsi rates. skin antisepsis with chlorhexidine was found to be associated with a 50 % reduction in the subsequent risk of clabsi compared with povidone iodine. hypocalcemia has also been reported following massive transfusions due to the binding citrate agent. however, this is transient, and there is no evidence that calcium supplementation will be of benefi t. septic shock and severe sepsis are also associated with hypocalcemia. this is due to abnormalities of vitamin d and parathyroid hormone. there is no evidence that septic patients benefi t from calcium repletion. the optimum dietary protein intake in patients with pressure ulcers is unknown, but may be much higher than the current adult recommendation of 0.8 g/kg/day. increasing protein intake beyond 1.5 g/kg/day may not increase protein synthesis and may cause dehydration. it has been suggested that a reasonable protein requirement is therefore between 1.0 and 1.5 g/kg/day. zinc and vitamin c are often included in supplements but have not been shown to improve healing in decubitus ulcers. med. 1980; 133:485-92. 338 . a 35-year-old female is admitted with severe pain to her left foot. she states that she had a fracture of her ankle due to a fall 2 months ago. since that time, she has had limited mobility and has infrequently gotten out of bed. she has had a follow-up appointment with her orthopedist who reports the ankle is healing well. she states that for the past 2 weeks, she has been completely unable to ambulate and has been bed bound. she reports a past medical history of anxiety and fi bromyalgia. on physical exam, the ankle is noted to be painful to mild touch. she states that the pain has a burning quality. the affected area is also noted to have an increased temperature, but no erythema is noted. x-rays are negative for fracture or any other noted pathology. what test would be most likely to make the diagnosis? a) magnetic resonance imaging. b) computed tomography c) triple-phase bone scan d) electromyography e) depression screen answer: c this patient's symptoms are consistent with a complex regional pain syndrome. this was formerly known as refl ex sympathetic dystrophy. this condition often occurs following trauma or surgery that results in a extended immobilization of the affected limb. attempts have been made to quantify this syndrome. criteria have been established to make the diagnosis. this includes pain due to mild stimuli and burning quality as well as changes in temperature, hair, and color of the affected extremity. bone scan has been shown to reveal a typical pattern and can be a useful adjunct in confi rming the diagnosis. diffuse increased perfusion to the entire extremity is usually noted. therapy is directed toward nonnarcotic alternative medications that address neuropathic pain and increasing mobility to the affected area. prevention focuses on early physical therapy. on exam, her temperature is 37.1 °c (98.8 °f), pulse rate is 90 beats per minute, respirations are 18 per minute, and blood pressure is 158/74 mmhg. oxygen saturation by pulse oximetry is 96 %. the cardiopulmonary examination is normal. no edema is noted, but the left leg is shortened and externally rotated. complete blood count and basic metabolic panel are normal. chest radiograph is normal. electrocardiogram shows sinus rhythm. which of the following interventions is most likely to increase mortality in the postoperative period? a) proceeding to surgery urgently in the next 48 h b) prescribing a beta-adrenergic blocking agent within 24 h before surgery c) postoperative venous thromboembolism prophylaxis d) early postoperative mobilization e) nicotine patch answer: b a recent meta-analysis demonstrated that, despite a reduction in nonfatal myocardial infarction, perioperative betablockers started less than one day prior to noncardiac surgery were associated with an increased risk of death 30 days after surgery. proceeding to surgery within 48 h has been shown to be benefi cial in hip fracture patients. bouri s, shun-shin mj, cole gd, mayet j, francis dp. metaanalysis of secure randomised controlled trials of betablockade to prevent perioperative death in non-cardiac surgery. heart. 2014;100(6):456-64. 340. you are consulted to see a 36-year-old woman that has been admitted for shortness of breath to the obstetrics service. she is 4 months pregnant and has a prior history of asthma. she uses her albuterol inhaler several times per week to achieve symptomatic relief, but this has proven to be inadequate. history includes mild persistent asthma that was well controlled before her pregnancy with an as-needed short-acting β2-agonist and mediumdose inhaled glucocorticoids. on physical examination, vital signs are normal. the lungs have diffuse wheezes. she appears in minimal distress. cardiac examination shows normal s1 and s2 with no gallops or murmurs. no leg edema is noted. what is the correct treatment? a) prednisone. b) add a long-acting β2-agonist. c) add theophylline. d) double the dose of inhaled glucocorticoid. e) a and b. answer: e approximately one-third of patients with asthma experience worsening of symptoms during pregnancy. patients who present with mild exacerbations of asthma may be treated with bronchodilator therapy and steroids. severe asthma exacerbations warrant intensive observation. close monitoring of oxygen levels should be undertaken. inhaled beta2-agonists are the mainstay of treatment. in particular, beta-adrenergic blocking agents should be avoided due to a possible increased bronchospastic effect. the early use of systemic steroids has not been shown to be detrimental and should be given when indicated. intense follow-up care should occur. this may include referral to an asthma specialist. reference rey e, boulet lp. asthma in pregnancy. bmj. 2007; 334(7593):582-5. 341 . a 32-year-old male is evaluated in the emergency department for diffuse muscle aches. he reports starting an extremely intense "boot camp" exercise routine 3 days ago. on physical examination, the patient is diffusely tender to touch. he appears uncomfortable. arms and legs display moderate diffuse swelling. temperature is normal, blood pressure is 92/50 mmhg, pulse rate is 120 beats/min, and respiratory rate is 20 breaths/min. oxygen saturation is 97 %. skin is mottled on the posterior back. neurological examination fi ndings are nonfocal. creatinine is 2.2 units/l, bicarbonate is 17 meq/l, and creatinine kinase (cpk) is 36,000 units/l. which of the following is the most appropriate treatment for this patient? a) hemodialysis b) intravenous mannitol c) rapid infusion of intravenous 0.9 % saline d) rapid infusion of 5 % dextrose in water e) surgical consultation answer: c rhabdomyolysis is a syndrome caused by extensive injury to skeletal muscle. it involves leakage of potentially toxic intracellular contents into plasma. this can occur in both the trained and non-trained athlete. this often occurs with the initiation of a new intense exercise regimen. the most severe complication is acute kidney injury (aki). etiologies of aki may be related to hypovolemia, vasoconstriction, and myoglobin toxicity. compartment syndrome of infl amed muscles may be either a complication of or the inciting cause of rhabdomyolysis. mild diffuse swelling of muscle groups is common. recommendations for the treatment of rhabdomyolysis include fl uid resuscitation fi rst and subsequent prevention of end-organ complications. this is best achieved with 0.9 % saline. other measures to preserve kidney function may be considered after adequate volume has been given. other supportive measures include correction of electrolyte imbalances. fluids may be started at a rate of approximately 400 ml/h and then titrated to maintain a urine output of at least 200 ml/h. treatment should continue until cpk displays a marked reduction or until the urine is negative for myoglobin. a 34-year-old woman is admitted overnight for the acute onset of pain after 10 days of bloody diarrhea. the diarrhea has escalated to 15 times per day. she has ulcerative colitis that was diagnosed 5 years ago. she currently takes azathioprine. on physical examination, she appears ill. following aggressive fl uid resuscitation overnight, temperature is 38.6 °c (101.5 °f), blood pressure is 68/45 mmhg, pulse rate is 120 beats/min, and respiratory rate is 35 breaths/min. abdominal examination discloses absent bowel sounds, distention, and diffuse marked tenderness with mild palpation. radiographs on admissions reveal colonic distension of 5 cm. this am repeat radiographs reveal colonic distension of 8 cm. which of the following is the most appropriate management? a) ct scan b) immediate surgery c) start infl iximab d) start intravenous hydrocortisone e) immediate gastroenterology consult answer: b early surgical consultation is essential for cases of toxic megacolon (tm). indications for urgent operative intervention include free perforation, massive hemorrhage increasing toxicity, and progression of colonic dilatation which is the case here. most guidelines recommend colectomy if persistent dilatation is present or if no improvement is observed on maximal medical therapy after 24-72 h. the rationale for early intervention is based on a marked increase in mortality after free perforation. the mortality rate for perforated, acute toxic colitis is approximately 20 %. some recommend providing up to 7 days of medical therapy if the patient demonstrates clinical improvement despite persistent colonic dilatation. tm was fi rst thought to be the only complication of ulcerative colitis. it has been described in a number of conditions, including infl ammatory, ischemic, infectious, radiation, and pseudomembranous colitis. 345. an 85-year-old man with very poor functional status is admitted from the nursing home with severe shortness of breath. he has a history of a prior cerebrovascular accident that has resulted in right hemiparesis and aphasia. chest x-ray shows that he has severe pneumonia. before the entire family arrives, the patient is intubated immediately and transferred to the icu. after a joint conference, the family decides to remove life support. which of the following statements accurately characterizes ventilator withdrawal in this situation? a) you should suggest 24 more hours of observation. b) limit family interaction while the patient is extubated. c) pulse oximetry should be followed to help guide the family through the dying process. d) you should demonstrate that the patient is comfortable receiving a lower fraction of inspired oxygen (fio2) before withdrawing the endotracheal tube. e) such patients generally die within 30 min to an hour after the endotracheal tube is removed. answer: d the family should be given the opportunity to be with the patient when the endotracheal tube is removed. the decision should be theirs to make and be a part of hospital protocol. all monitors including oxygen saturation should be turned off. the patient's comfort should guide therapy. fio2 should be diminished to 20 %. the patient should be observed for respiratory distress before removing the endotracheal tube. distress and air hunger can be treated with opioids and benzodiazepines prior to endotracheal tube removal. the family often expects an immediate response when the ventilator is turned off. it is important to inform them that the patient may live for hours to days. also it is important to explain that you and staff will continue to follow and provide comfort during this period. end-of-life care is increasingly seen not as medical failure but a special time to assist the patient, family, and staff with the physical and emotional needs that occur with the dying of a patient. resources, protocols, and education should be provided to staff to enhance these efforts. answer: e the fat embolism syndrome typically presents 24-72 h after the initial injury. dyspnea, tachypnea, and hypoxemia are the earliest fi ndings. this may progress to respiratory failure and a syndrome indistinguishable from acute respiratory distress syndrome (ards) may develop. cerebral emboli produce neurological signs in up to 80 % of cases. this is often the second symptom to appear. the characteristic petechial rash may be the third component of the triad to occur. there is no specifi c therapy for fat embolism syndrome. early immobilization of fractures has been shown to reduce the incidence of fat embolism syndrome and should be of primary importance with extensive long bone fractures. the risk is reduced by operative correction rather than conservative management. the use of steroids has been extensively studied for both prevention and treatment. it is recommended by some, for the management of the fat embolism syndrome. on admission amylase is 235 units/l, lipase is 175 unit/l, and alkaline phospatase is 52 g/dl. he is started in intravenous fl uids and has a rapid resolution of his symptoms the following day. amylase on the second day is 38 units/l and lipase is 86 units/l. ultrasound of the abdomen reveals a gallbladder with several stones. no gallbladder wall thickening is appreciated. what is the correct management of this patient? a) discharge home with no further intervention. b) surgical follow-up for cholecystectomy c) cholecystectomy prior to discharge d) hida scan answer: c if possible, patients admitted with gallstone pancreatitis should undergo cholecystectomy before discharge, rather than being scheduled as an outpatient. patients discharged without a cholecystectomy are at high risk for recurrent bouts of pancreatitis. recurrent episodes may be more severe than the original presentation. in one study, patients with mild gallstone pancreatitis who underwent laparoscopic cholecystectomy within 48 h of admission resulted in a shorter hospital stay. there was no apparent impact on the technical diffi culty of the procedure or the perioperative complication rate. 353. which of the following will provide the best bowel preparation for a morning colonoscopy? a) 4 l polyethylene glycol-based preparation plus citric acid taken the evening before the procedure b) 2 l polyethylene glycol-based preparation taken the evening before the procedure c) 2 l of polyethylene glycol-based preparation on the evening before and 2 l of the same preparation on the morning of the procedure d) 1 l of polyethylene glycol-based preparation n the evening before and 1 l of the same preparation on the morning of the procedure answer: c signifi cant evidence exists that better colon preparation is associated with increased detection of colon polyps. split-dose bowel preparation remains an essential concept for enhancing the quality of colonoscopy. this limits the amount of agent remaining in the colon prior to examination. many bowel preparations for colonoscopy are available. no preparation has been shown to be superior to 4 l of a polyethylene glycol-based preparation split into two 2-l doses that are given the evening prior to and the morning of the procedure. a 67-year-old man with metastatic lung cancer is admitted for failure to thrive. during this admission, several end-of-life issues are addressed. he has chosen not to consider additional chemotherapy or radiation therapy. his cancer is unlikely to respond to such treatment. he and his family are focused on upcoming visits with his 4 children and 14 grandchildren over the next several weeks. however, the family reports that his lethargy, poor appetite, and depression will make this diffi cult. you estimate the patient's life expectancy to be weeks to several months. which of the following would be the best management of this patient's symptoms? a) initiation of a trial of a methylphenidate b) referral of the patient to a psychologist c) trial of a selective serotonin reuptake inhibitor d) initiation of enteral feedings through a nasogastric tube e) initiation of oral morphine answer: a the use of psychostimulants, such as methylphenidate, is an effective management for cancer-related fatigue, opioidinduced sedation, and the symptoms of depression in the setting of a limited prognosis. helping this patient achieve some of his end-of-life wishes is important. psychostimulants have the benefi t of providing more immediate response than conventional therapies. it is improbable that this patient will live long enough to benefi t from cognitive behavioral therapy, ssri, or nutritional support. starting methylphenidate 2.5 mg po bid is a reasonable choice when time is limited. li m, fitzgerald p, rodin g. evidence-based treatment of depression in patients with cancer. j clin oncol. 2012;30:1187-96. a 67-year-old man is admitted with severe right buttock pain. in the previous year, the patient underwent resection and laminectomy for metastatic renal cell tumor compressing his lower thoracic and upper lumbar spinal cord. the mass is inoperable, and he is receiving palliative chemotherapy. hospice has not been discussed yet. during his admission, the pain has been severe and refractory to intravenous opioids. his daily requirement of hydromorphone is 150-175 mg for the past 4 days. on physical examination, vital signs are stable. he is somnolent, and when he wakes up he is in severe pain. motor strength assessment is limited by pain. which of the following should you recommend now? a) trial of methylphenidate b) placement of an implanted intrathecal drug pump c) optimization of the opioid regimen d) a trial of intrathecal analgesia e) lidocaine patch answer: d this patient requires aggressive pain control measures. changing opioid regimens will probably be of little benefi t. evidence supports the use of intrathecal drug delivery systems compared with systemic analgesics in opioidrefractory patients. a trial of intrathecal medication is important, to determine the effect, prior to permanent placement of an implanted device. his previous laminectomy and associated scarring may limit the effect of intrathecal delivery as well as make catheter placement diffi cult. the use of palliative sedation therapy is indicated in patients with refractory symptoms at the end of life. although his pain is severe and unresponsive to systemic medications, she is not at the end of life, nor have all interventions been pursued to address her pain. deer tr, smith hs, burton aw et al. comprehensive consensus based guidelines on intrathecal drug delivery systems in the treatment of pain caused by cancer pain. pain physician. 2011;14(3):e283-312. a 56-year-old woman has widely metastatic breast cancer. she is admitted for sepsis. the decision has been made to withdraw care and to allow a natural death preferably as an inpatient. the family is at the bedside. oxygen saturation is 85 % with the patient receiving supplemental oxygen, 2 l/min by nasal cannula. on physical examination, she is nonverbal and restless in bed. her respirations have become more difficult. the family appears fatigued and anxious. which of the following should you do now? a) request a sitter. b) provide 100 % oxygen by face mask. c) administer a dose of parenteral haloperidol. d) administer a dose of parenteral morphine. e) administer a dose of parenteral dexamethasone. answer: d morphine is the drug of choice with air hunger at the end of life. it is preferred over other sedation. there is no evidence that supplemental oxygen is benefi cial at the end of life. in addition, many patients experience increased agitation when a mask is placed over the mouth and nose. family members may not desire a face mask for the patient as well during this special time. ben-aharon i, gafter-gvili a, leibovici l, stemmer sm. interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. acta oncol. 2012;51(8):996-1008. a 78-year-old woman who has recurrent breast cancer with metastasis is admitted for decreased appetite. her last bowel movement was 4 days ago. she is on longacting morphine with oxycodone for breakthrough pain. her bowel regimen is docusate, 100 mg twice daily. on physical examination, her abdomen is distended. a radiograph of the abdomen demonstrates a large amount of stool. she is given three enemas, which produce a small amount of stool. which of the following is the most appropriate next step in the management of this patient's constipation? a) administer lactulose. b) administer methylnaltrexone. c) administration of high-dose senna. d) placement of a nasogastric tube (ngt) for highvolume laxative. e) rotation to another opioid. answer: b methylnaltrexone is used for severe constipation in opioidinduced ileus. it is well tolerated in most instances. this patient has already shown an intolerance of stimulant laxatives; further measures are unlikely to be successful. an ngt would be uncomfortable. 358. a 68-year-old female is evaluated for preoperative clearance before she goes in for left knee elective surgery. she has a history of chronic hypertension. she has on amlodipine but has been noncompliant with her medicines. her knee pain limits her activities but she is able to walk up two fl ights of stairs with minimal diffi culty. on physical exam her blood pressure is 145/99 mmhg, heart rate is 55 bpm, and respiratory rate is 11 breaths/ min. extremities pulses are 2+ and bilateral. an echo done 7 months ago shows an ejection fraction of 30 %. the patient denies any new complaints. what is the next step? a) proceed with surgery without additional preoperative testing. b) control bp to ideal measurement of <130/85. c) delay elective surgery for further evaluation or treatment. d) exercise stress test. e) start metoprolol. answer: a preoperative hypertension is frequently a hypertensive urgency, not an emergency. in general, patients with chronic hypertension may proceed to low-risk surgery as long as the diastolic bp is <110 mmhg. there continues to be some debate over the use of betablockers preoperatively. current guidelines state that in patients with no risk factors, starting beta-blockers in the perioperative setting provides unknown benefi t. thomas dr, ritchie cs. preoperative assessment of older adults. j am geriatr soc. 1995;43 (7):811-21. 359. you are asked to admit a 32-year-old female for a 4-day history of lower abdominal pain that she describes as intermittent cramps. she denies nausea or vomiting. she also denies having urinary frequency, dysuria, and fl ank pain. her only medication is an oral contraceptive agent. on physical examination, her temperature is 38.5 °c (101.4 °f), blood pressure is 120/68 mmhg, pulse rate is 100 beats/min, and respiratory rate is 18 breaths/min. abdominal examination is normal. there is no fl ank tenderness. pelvic examination shows cervical motion tenderness. bilateral adnexal tenderness is appreciated on bimanual examination. she is in minimal distress and is tolerating liquids. the hematologic and serum chemistries are normal. urine and serum pregnancy tests are negative. what is the next best step in the management of this patient? a) consult for laparoscopic diagnosis and treatment. b) admit the patient to the hospital, obtain pelvic ultrasound, and start ceftriaxone. c) administer a single-dose im ceftriaxone and discharge the patient. d) administer a single-dose im ceftriaxone and oral doxycycline for 14 days. e) obtain pelvic and abdominal ultrasound and prescribe oral doxycycline with metronidazole. answer: d this patient's clinical fi ndings are compatible with pelvic infl ammatory disease (pid). women with mild to moderate pid may receive outpatient medical treatment without increased risk of long-term sequelae. laparoscopy is the criterion standard for the diagnosis of pid, but the diagnosis of pid in emergency departments is often based on clinical criteria, without additional laboratory and imaging evidence. she should receive intramuscular ceftriaxone and oral doxycycline for 14 days. all women with suspected pid should be tested for infection with gonorrhea and chlamydia. in severe cases, imaging should be performed to exclude a tuboovarian abscess. patients with pid should be hospitalized if there is (1) no clinical improvement after 48-72 h of antibiotics, (2) an inability to tolerate food or medicine, (3) severe symp-toms, (4) suspected abscess, (4) pregnancy, or (5) answer: b one of the most common predisposing factors for erythema multiforme is infection with herpes simplex virus, which may or may not be active at the time of the em eruption. em is an acute, self-limited, and sometimes recurring skin condition that is considered to be a type iv hypersensitivity reaction. it is associated with infections, medications, and other various triggers. patients with recurrent em are typically treated with acyclovir or valacyclovir. mycoplasma pneumonia, amoxicillin, ibuprofen, and cytomegalovirus may cause em, but are not as common. aurelian l, ono f, burnett j. herpes simplex virus (hsv)associated erythema multiforme (haem): a viral disease with an autoimmune component. dermatol online j. 2003;9:1. a 65-year-old male with a long history of type ii diabetes is admitted with the chief complaint of hematuria. his blood pressure is 130/65 mmhg. otherwise his physical exam is normal. urinalysis shows blood 3+ and protein 3+. no casts are seen. a 24-h urinary protein shows 8 g of protein and serum creatinine is normal. urine microscopy shows isomorphic red blood cells with no casts. renal and bladder ultrasound are normal. his hematuria is less by day 2 of his admission. what is the next most appropriate investigation? a) renal angiogram b) renal biopsy c) doppler ultrasound of the kidneys d) ct scan of the abdomen and thorax alone e) cystoscopy f) observation alone 364. a 33-year-old woman is admitted to the hospital for evaluation of blurry vision and new-onset paraparesis. she has been followed closely by neurology in the past for two recent episodes of optic neuritis in the past 2 years. her only other history is hypothyroidism. her only medication is levothyroxine. on physical examination vital signs are normal. visual acuity is 20/200 in the right eye and 20/30 in the left. per ophthalmology consult, optic disks display pallor. signifi cant spasticity is noted in her legs. the patient requires bilateral assistance to ambulate. laboratory studies including a complete blood count, liver chemistry and renal function tests, and erythrocyte sedimentation rate are normal. the antinuclear antibody is positive. anti-double-stranded dna and anti-ssa/ssb antibodies are negative. analysis of the cerebrospinal fl uid shows a normal igg index and no abnormalities in oligoclonal banding. an mri of the spinal cord reveals an increased signal extending over fi ve vertebral segments with patchy gadolinium enhancement. an mri of the brain shows no abnormalities. which of the following is the most appropriate next diagnostic test? a) electromyography b) serum antineutrophil cytoplasmic antibody test c) serum neuromyelitis optica (nmo)-igg autoantibody test d) testing of visual evoked potentials e) neuromyelitis optica (nmo)-igg autoantibody test f) csf to serum protein ratio answer: e neuromyelitis optica (nmo), the presentation of myelitis and optic neuritis, may be a variant of multiple sclerosis (ms) or a unique disease. this patient very likely has neuromyelitis optica (nmo). she should be tested for the autoantibody marker nmo-igg. differentiating between nmo and ms early in the disease may be important because the prognosis and treatment of the two diseases are different. nmo is a more severe disease treated with immunosuppressive drugs. ms is often initially treated with immunomodulatory therapies, such as β-interferon and glatiramer acetate. the mri is suggested of nmo. in typical ms, lesions are usually less than two segments in length. the nmo-igg test is approximately 75 % sensitive and more than 90 % specifi c for nmo. cognitive trajectories after postoperative delirium multifactorial index of cardiac risk in noncardiac surgical procedures derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery early surgery versus conventional treatment for infective endocarditis management of infective endocarditis: challenges and perspectives evidence that gabapentin reduces neuropathic pain by inhibiting the spinal release of glutamate gabapentin for acute and chronic pain constant observation in medicalsurgical settings: a multihospital study in their own time: the family experience during the process of withdrawal of life-sustaining therapy on day 3 she is started on tube feeds at 40 ml/h. her goal rate is 70 ml h. four hours after her tube feeds are started, gastric residuals are measured to be 375 ml. which of the following should you recommend now? a) withhold the feeding for 2 h c) continuing the feeding at the current rate advancing the feedings toward the patient's goal rate poor validity of residual volumes as a marker for risk of aspiration in critically ill patients what is the best method for assessing pain in the nonverbal patient? e in nonverbal patients, pain assessment relies less on vitalsign changes and more on observing behaviors fat embolism and the fat embolism syndrome 4-liter split-dose polyethylene glycol is superior to other bowel preparations, based on systematic review and meta-analysis a predictive model identifi es patients most likely to have inadequate bowel preparation for colonoscopy high-dose methylprednisolone in the treatment of active ulcerative colitis predicting outcome in severe ulcerative colitis on physical exam, he has moderate diffuse joint tenderness which is no different from his baseline. he has some nontender bumps palpated on the forearm bilaterally near to the olecranon process and displacement of metacarpal bones over the proximal phalanges with fl exion at proximal joints and with extension of distal interphalangeal joints. labs are within normal range ct scan of the neck prior to surgery c) avoidance of a paralytic drug during surgery d) radiograph of the neck in fl exion and extension a serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis the clinical course of neuromyelitis optica (devic's syndrome) answer: d in this patient, the feedings should be increased toward the goal rate. there is no correlation between gastric residual volume and the incidence of aspiration. evidence shows that checking gastric residuals doesn't provide reliable information on tube-feeding tolerance, aspiration risk, or gastric emptying. current guidelines recommend withholding feedings for gastric residual volumes greater than 500 ml.answer: e this man has hematuria without evidence of dysmorphic red cells or casts in urinary sediment. macroscopic hematuria in the absence of signifi cant proteinuria or rbc casts is an indication for imaging to exclude malignancy or cystic renal disease. approximately 80-90 % of patients with bladder cancer present with painless gross hematuria. urine cytology is extremely valuable but would not eliminate the need for cystoscopy, which is the standard for diagnosing bladder cancer. many bleeding urinary tract lesions arise in the bladder and lower urinary tract, and no imaging technique is completely satisfactory for ruling out disease at these sites. further imaging may be of use but cystoscopy will ultimately be needed. answer: e the american college of gastroenterology practice guidelines defi ne severe colitis as the passage of six or more stools per day with evidence of systemic toxicity. intravenous corticosteroids, which are essential in severe cases, are effective in the induction of remission in the majority of cases. a daily intravenous steroid dose of hydrocortisone 300 mg or methylprednisolone 60 mg is suggested. fortunately, most patients with severe uc respond to intravenous steroid therapy. however, 30 % of patients fail to respond after 5-7 days. these patients are considered to be steroid refractory. one of the simplest algorithms predicts that at the third day of intravenous steroid therapy, patients with a stool frequency of greater than eight per day or three per day plus a crp greater than 45 mg/dl have an 85 % likelihood of requiring colectomy. medical treatment of steroid-refractory severe uc has expanded with the availability of both cyclosporine and infl iximab as rescue agents. the need for colectomy may be reduced with the use of these agents. in addition, stool samples should be collected for culture and toxin analysis to rule out enteric infection.answer: d patients with -ra presenting for tkr represent those patients who have failed medical management and are a high-risk group for cervical spine involvement. radiographic screening of ra patients presenting for joint replacement surgery reveals cervical spine instability in 44 %, which is typically asymptomatic. lateral fl exion/extension views are more sensitive and are recommended. cervical spine subluxation is less likely in ra patients presenting for general surgery, and there is currently no consensus on who should be screened in this population. key: cord-310556-ebh59adi authors: flett, gordon l.; heisel, marnin j. title: aging and feeling valued versus expendable during the covid-19 pandemic and beyond: a review and commentary of why mattering is fundamental to the health and well-being of older adults date: 2020-06-15 journal: int j ment health addict doi: 10.1007/s11469-020-00339-4 sha: doc_id: 310556 cord_uid: ebh59adi the current commentary and review examines the potentially protective role of feelings of mattering among elderly people during typical times and the current atypical times associated with the covid-19 global pandemic. mattering is the feeling of being important to others in ways that give people the sense that they are valued and other people care about them. we contrast this feeling with messages of not mattering and being expendable and disposable due to ageism, gaps in the provision of care, and apparently economically focused positions taken during the pandemic that disrespect the value, worth, and merits of older persons. we provide a comprehensive review of past research on individual differences in mattering among older adults and illustrate the unique role of mattering in potentially protecting older adults from mental health problems. mattering is also discussed in terms of its links with loneliness and physical health. this article concludes with a discussion of initiatives and interventions that can be modified and enhanced to instill a sense of mattering among older adults. key directions for future research are also highlighted along with ways to expand the mattering concept to more fully understand and appreciate the relevance of mattering among older adults. this article is about the need to matter among older people. the quote above from nancy schlossberg from her seminal work on mattering versus marginalization reflects the fact that even though people can and do differ enormously, they share a need to feel valued and significant to other people who care about them. they also share a basic need to feel connected to other people and feel a sense of fit rather than feeling like a misfit. these common needs to matter to others and to belong fit well the general belief that people of all backgrounds are more similar than they are different, and that we should focus to a greater degree on commonalities and what brings us together than on apparent differences which can serve to divide us. the need to matter applies to people of all ages and of vastly different backgrounds and cultures. it is a feeling that is relevant from the cradle to the grave and it is a global and universal need. there is still room for individual differences, however; some people will always have a stronger need to matter than will others, just as some may be more sensitive to perceived social connections and support. moreover, at present, billions of people feel like they actually do matter, while billions of other people feel like they do not matter or they do not matter as much as they should. this sense of not mattering enough is especially common among people who feel marginalized and left behind for social, political, economic, or other reasons, rather than feeling cherished and valued as human beings. the current article is both a review and a commentary focused on mattering in older people. it is based on a thorough and systematic search using multiple search engines, including google scholar, to identify any relevant research conducted on mattering among older people. most of the review focuses on articles in refereed journals, but detailed empirical results found in two key chapters are also provided (see fazio 2009; pearlin and leblanc 2001) . our overarching goal was to be as contemporary and as up-to-date with both our review and our commentary as possible. in this regard, we also refer to national and international events pertaining to the treatment and care of older people that have quite recently occurred during the pandemic. so why our current focus on the need to matter among older adults? and why focus on this need now at this point in time? there are three interrelated reasons. first, in their work that introduced the mattering concept, rosenberg and mccullough (1981) observed astutely that mattering is particular relevant for two groups of people-young people and elderly people. specifically, they suggested that, "mattering may be relatively high among children and adults, among adolescents and old people. the young child feels that he matters because the world revolves around him, because he is the center of the universe. the adult matters because he runs the world" (p. 180). regarding the relevance of mattering to older people, rosenberg and mccullough (1981) went on to note that mattering is tied closely with the transition to retirement. here they addressed the core fear that haunts many retirees by noting that, "it has been suggested that one problem of retirement is that one no longer matters; others no longer depend upon us" (p. 180). second, the need for older people to feel like they matter and to wonder how much they actually do matter is a very salient theme right now as the covid-19 global pandemic continues. the messages from many political leaders are centered appropriately on urging people to engage in physical distancing, while awaiting development of vaccines and antibodies because this practice will help stop the spread of the virus and this is especially required to protect older and immunocompromised people who are more susceptible to the ravages of the coronavirus. this message is often wrapped around the theme that older people are cherished and we need to do whatever it takes to protect their health and well-being during this high-risk period. this focus includes the recognition that self-isolation practices implemented to counter covid-19, albeit well-intentioned, disproportionately impact older adults and urgent action is needed to limit the mental health and physical health impacts among isolated older people (see armitage and nellums 2020) . finally, it is generally accepted that there are many challenges that have been brought about by the covid-19 global health crisis and the requirement that people engage in physical isolation. anxiety is heightened due to concerns about personal safety and the uncertainty of how and when the pandemic will be resolved. moreover, as noted above, physical distancing has led to the experience of social isolation among some people, especially those who are living alone and those who may lack web-enabled smartphones or other electronic devices that could help them remain in contact with friends and loved ones. loneliness is already a profound public health concern, especially among older people, and physical isolation is adding exponentially to the social isolation that is typified by loneliness. it was a grave concern in the usa before the pandemic; this was illustrated by the us senate special committee on aging chaired in 2018 by susan collins, united states senator from maine. this committee held hearings on the topic "aging without community: the consequences of isolation and loneliness." the disruption to daily routines and restriction of usually pleasurable activities as a result of the pandemic, including visiting with friends, children, and grandchildren, is also having a strong impact on people. given these changes, flett and zangeneh (2020) outlined how and why mattering is an essential resource for coping with and adapting to the pandemic. it was argued that everyone needs a sense of significance and being important to others in the best of times, but this is especially the case in challenging times and in anxiety-provoking crisis situations that entail being separated from others. this argument is particularly germane to the life experiences of older people coping with this global health crisis. older members of society have many reasons to be fearful and many have already been grappling with loneliness and mental health problems. unfortunately, expressions of concern about the health and welfare of older people and apparent steps taken to ensure their well-being are at variance with current realities. global statistics are mounting in ways that confirm that concerns about older people and their mortality are not overstated. there is growing evidence from various parts of the world of the disproportionate death and dying among older people (see onder et al. 2020; promislow 2020) . over 90% of deaths related to covid-19 were of individuals 60 years or older, and more than 50% were over 80-an age group with a mortality rate 5 times that of the global average. residential care homes, including long-term care (ltc) and assisted living (al) homes, have been hit especially hard and account for more than half of pandemic-related deaths worldwide (see comas-herrera et al. 2020) , posing a realistic source of existential anxiety and distress for older residents and their families. close-quarters living and limited access to personal protective equipment increase the risk of transmission, which, together with healthcare challenges associated with staffing shortages, results in multiple fatalities. the numbers of deaths are troubling but even more disconcerting are seemingly endless stories of neglect and mismanagement that have appear to be costing people their lives. key needs, both tangible and emotional, have been neglected and this is relevant to our premise because neglect is regarded as a primary precipitant of feelings of not mattering (see flett et al. 2016a) . some of the more heinous incidents and situations involving apparent neglect of older adults in the context of the covid-19 pandemic are listed in table 1 . this table contains a chronology of select occurrences. comparable events have already resulted in a litany of class action lawsuits by family members and urgent calls for public health inquiries to not only increase accountability but lead to necessary systemic change and better practices and procedures going forward. in addition to the incidents and situations in table 1 , an exposé in the montreal gazette revealed one nursing home that apparently concealed the deaths of 31 residents and many of these people died after most staff members abandoned the facility (see feith 2020) . some seniors did not have dignified deaths; indeed, the report indicated that they had gone for days without water, food, or a diaper change (derfel 2020) . more generally, actual occurrences include refusals of hospitals to provide treatment, improper treatment of deceased elders, and sending patients confirmed to have the virus to nursing homes, thereby increasing the risk for elderly residents. physical distancing requirements are having additional impacts on the ability of long-term care homes and assisted living residences to care for their older residents; prohibitions against large group meetings mean that residents cannot eat in cafeterias and common rooms, further limiting social connection, and overwhelming staff members who now must deliver food individually, limiting the amount of time and attention that they can pay to residents. these subtler impacts of the pandemic on the health and well-being of older adults are likely not being evaluated. a more recent exposé by the globe and mail of the situation in ontario, canada, also paints an exceptionally unfavorable picture. this article about this investigation is titled "systematic failings fuelled care-home outbreak" (see howlett 2020) . it is based on an extensive series of interviews and a review of documents filed with the ontario supreme court, as well as ontario ministry of labour inspection reports, and internal corporate records. key shortcomings included having home inspections conducted by telephone and the chief table 1 chronology of select pandemic-related incidents and situations in 2020 connoting that older people do not matter or do not matter enough march 24, 2020-spanish military finds corpses and seniors abandoned in care homes (benavides 2020) april 26, 2020-italy's lombardy region wracked by exceptionally high number of deaths, totally about half of deaths in italy. deaths including thousands of elderly people described by one who official as a "massacre"; regional government makes decision on march 8th to place patients with covid-19 virus in nursing homes and staff in some homes instructed to not wear protective masks because masks will scare the residents (winfield 2020) may 1, 2020-horrific deaths in an australian nursing home reported after an infected nurse works six shifts despite having mild virus symptoms. family members of residents express upset about inconsistent communication (zishuo 2020) may 13, 2020-sweden's herd immunity strategy and failure to enact lockdown leads to mass deaths in swedish elder care homes; "terrible numbers" dramatically underestimated due to decision to only count deaths of persons who had covid-19 test (shilton 2020) may 14, 2020-decision of new york to send recovering covid-19 virus patients to nursing homes characterized as "a fatal error" (mathews 2020) may 15, 2020-elderly patients characterized as "sacrificial lambs" detected with coronavirus are released back to care homes in april; 12 elderly people at st. nicholas care home in liverpool, england, die after hospital discharge (kelly and coen 2020) may 18, 2020-hospitals in lima, peru, stop admitting elderly patients with coronavirus in part due to lower recuperation rates relative to younger patients (torres 2020) may 19, 2020-nurses in care homes in sweden allege that people ill with the virus and 65 or older are refused access to hospital and life-saving equipment despite potentially having many years to live (savage 2020) may 20, 2020-report surfaces that older people in hamilton, ontario nursing home were transferred to st. joseph's healthcare but one male patient was forgotten and left entirely by himself in the evacuated nursing home (frketich 2020) medical officer of health waiting until april 21st to issue the decree that everyone in longterm care homes is to be tested for covid-19. the deplorable conditions at sites in ontario were confirmed by a canadian military report that detailed conditions of severe neglect deemed to reflect "borderline abuse" or actual abuse in ontario care homes along with "blatant disregard" for basic infection control measures (see stephenson and bell 2020) . deplorable situations came to light in five residences once military personnel were deployed to assist in long-term care homes. ontario premier doug ford described these accounts as horrific and prime minister justin trudeau expressed his strong feelings, concluding that, "it is the elderly who are suffering the most in this pandemic." the stories that have emerged thus far underscore the lack of resources and planning that have left too many older people and staff members in vulnerable and potentially lifethreatening situations. for instance, in canada, the deaths continue to escalate across most provinces and this dovetails with years of concerned frontline people and academic scholars calling for improvements and more resources for the care system. these calls have been renewed and extended (see béland and marier 2020) . collectively, it has been estimated that four out of five covid-19-related deaths in canada have been linked with senior homes (see brean 2020) . given these emerging realities in canada and elsewhere, it would be reasonable for older people in many countries to feel that professed concerns about their well-being either represent "lip service" or implemented safeguards simply add up to "too little" and "too late" given strong evidence of widespread system failure. the circumstances listed in table 1 demonstrate some horrific situations in nursing homes and long-term care facilities in various parts of the world. second, some very troubling views about older people in general have been expressed during the pandemic. some views have come from political leaders, while others have come from members of the media and social media influencers. these views have led some authors to consider whether the pandemic will worsen the narrative about aging in terms of the proliferation of stereotypes. these are often signified by referring to the pandemic with harsh social media hashtags such as "#boomerremover" and "#grandmakiller" (see eisenberg 2020) . ironically, as many younger people are commenting that their grandparents' generation saved the world by fighting fascism and oppression, they are saving it by sitting around at home, and there is a lack of recognition that those same grandparents are now being sacrificed in panicked efforts to forestall an anticipated financial collapse. what is also being missed is the opportunity to learn and benefit from the survival resources and resiliency factors cultivated by older adults who have lived through times of war, oppression, discrimination, and financial collapse. as the statistics accumulate, it is natural for older people who are aware of these developments to become increasingly alarmed and demoralized not only about their health status prospects but also by the overarching question of whether they matter at all to other people. indeed, some older people have wondered openly about exactly when they became disposable (see socken 2020) . maria branyas, a 113-year old survivor of the 1918 spanish flu epidemic, stated that "the elderly are the forgotten ones of society" (the guardian 2020). this serves as a poignant counter-point to the quote attributed to gandhi that "the true measure of any society can be found in how it treats its most vulnerable members." older adults who have already felt marginalized and who have been subject to prejudice due to racism or classism may be particularly susceptible at present to feelings of not mattering to other people. unfortunately, some politicians have gone so far as to suggest that economic considerations must become the priority, even if it means the loss of lives. the argument here is that balance is needed and perhaps physical isolation and the shutdowns have gone too far or are now doing more harm than good from an economic perspective focused on costs versus benefits. it has been openly and crassly suggested by too many politicians that people who survive the pandemic will just have to live with the loss of other people, especially elderly people, because it is time to end social distancing in order to restart the economic engine as it is too dire to let it idle any longer. public calls to restart the economy, even if so doing confers health risks in vulnerable groups, can increase perceptions of lack of social worth among older adults, and this is especially among older adults who are sensitized to cues suggesting that they do not matter. another factor that has been identified as a factor during the pandemic that promotes the image of older people as being less important and contributes to ageism is that under certain circumstances, chronological age is listed as a deciding factor for determining which of two people in equal need are given a ventilator (for a discussion, see fraser et al. 2020) . they are also several instances of people being denied access to hospital treatment because of their age (see table 1 ). it has been observed that older people are made to feel less significant as individuals by policies that characterize all older people as the same and fail to reflect the heterogeneity and varying levels of functioning and vitality among them. this too is regarded as a contributor to ageism (see fraser et al. 2020) . bob seger reminded us in one of his classic songs that it is easy for some people to "feel like a number." it is not difficult to take it personally when someone contends that it is just too bad, but some people may need to be sacrificed and needed medical equipment and supplies should be deployed to protect younger people. but how does it feel? one woman responded on twitter in early may 2020 by expressing her emotions in a clear and undeniable way in response to a televised segment she had watched. anne reminded us how it feels by saying, "that man you just had on said my life doesn't matter, that i am expendable, that i don't matter. i am a mother, wife, grandmother, community activist, community volunteer, i knit, i matter! i matter! i can't be sacrificed so he can go to walmart!" when it comes to lived experiences during the pandemic, this feeling of being expendable is, of course, not limited to older adults, but extends to others who are socially disadvantaged. findings are accumulating of the heightened risk of covid-related morbidity and mortality among hispanic and african americans. there have additionally been numerous reports from people of varying ages who are either refusing to go to work or who have quit their jobs given worry about their personal safety; however, it should be evident to any observer that the feeling of not being valued by the employer is also very salient and very strong among these workers. acts of defiance and disengagement should not be surprising; there is growing research evidence of how being made to feel unimportant and insignificant in the work setting is tied to turnover, work disengagement, and various negative emotions (jung 2015; jung and heppner 2017; richards et al. 2017) . the importance of mattering versus not mattering extends to healthcare workers. although some retired healthcare workers experience a sense of mattering when called back into service, one recent study found that nurses with lower levels of work mattering reported more burnout and less engagement (haizlip et al. 2020) . in contrast, workers thrive and flourish when they are valued and they know they matter. even small gestures and individualized inquiries about the personal life of the employee can have a huge positive impact. these are important themes for further consideration, but the current review article focuses on the need to matter among older adults. our analysis examines relational mattering (i.e., mattering to other people) as described by rosenberg and mccullough (1981) . statements about what should or should not happen at a broader level in institutions are more a reflection of the type of mattering known as societal mattering, which was a theme introduced by fromm (1941). people can be evaluated in terms of how much they feel they matter to others and to society. societal mattering is also quite important; indeed, many older people could feel like they are experiencing "double jeopardy." the person who does not feel significant to specific others and who does not feel significant to the broader community or society is someone who is at considerable risk in terms of both one's mental health status and physical health status. there is a third type of mattering known as "existential mattering" that is also distinct and involves assessments of whether one's life matters (see george and park 2014) ; this issue is also of relevance to many older adults and will be addressed in our discussion of meaningcentered research with older people. as suggested above, people know how it feels to them when they have been treated like they do not matter, so it should be easy to understand how many older people are feeling right now. our interest in the health and well-being of older people and their concerns are longstanding; we have conducted research over the past two decades on the risk and resilience factors associated with suicide and suicide ideation among older adults (heisel and flett 2006, 2016; . this work has also resulted in the creation of the first measure of suicide ideation tailored specifically to the needs and lives of older people, the geriatric suicide ideation scale (heisel and flett 2006) , which assesses sociocultural and existential factors (i.e., its "loss of personal and social worth" and "perceived meaning in life" subscales) in addition to thoughts and wishes to die and for suicide. recently, concerns have been expressed about an anticipated spike in suicide behavior and deaths among older adults as a result of the pandemic (see wand et al. 2020) . the royal college of psychiatrists has just estimated that there could be a six-fold increase in suicide attempts among older adults (see hymas 2020) . suicide prevention researchers and public health experts have warned the public of a substantial increase in suicide rates among older adults, given covid-related increased fear and despair, restriction of physical access to social supports and mental healthcare programs, and financial anxiety due to the impact of stock market volatility on retirement savings. the spanish flu was associated with increased rates of suicide, and elevated suicide risk was reported for older adults in hong kong in the aftermath of the 2003 sars epidemic, due in part to the negative impact of physical distancing and isolation (see chan et al. 2006) . it is our contention that any increase will be fuelled not only by anxiety, stress, uncertainty, and isolation, but also the broader messages that convey to older people that perhaps they simply do not matter. one theme that has emerged from our research and from that of other investigators is that given the risks that face vulnerable older people, it is vitally important to promote positive protective factors and competencies that heighten their resilience and engagement and involvement. we agree with rosenberg and mccullough's (1981) contention that mattering is vital for everyone, but it may be especially vital for older people. however, mattering deserves much more focus among psychologists than it has received thus far; knowledge of whether an older person feels like she or he matters to others is fundamental to understanding this person and how life is going and how it is likely to go in the future. it is our hope that the current review and analysis will serve as a catalyst for a much greater emphasis on the role of mattering and its many potential benefits among scholars who conduct research with older adults and professionals who are in positions to implement practices and procedures to enhance their health and mental health. relevant research on mattering among older adults is summarized below. as is typically the case, these research investigations are mostly variable-centered studies that investigate levels of mattering and associations between mattering and other variables in large samples with participants who are either rapidly approaching or who have already reached the ages associated with being an older person. it is important to reiterate before launching into an overview about this research that mattering is about the individual person. that is, it is about the significance of the older person's individual story and life narrative. it is about whether the individual feels seen and heard and valued versus invisible and unheard and someone who does not count to the people in their lives and perhaps society as a whole. if mattering is as relevant as we claim it is, then it should be possible to identify themes related to feelings of not mattering or of feeling unimportant and expendable when the focus shifts to qualitative accounts of the experiences of individual people. this is clearly the case. for instance, a study of perceptions of preventive home visits yielded four categories including a mattering-based category centered around the theme "it made me visible and proved my human value" (see behm et al. 2013 ). berglund and narum (2007) interviewed 282 women ranging in age from 75 to 93 years old. six categories emerged including a relationships category with content reflecting both belonging and mattering. specifically, one participant observed, "being in the company of my dear ones gives me a sense of belonging. it's nice to know that someone cares and they in turn can count on me when they need help or someone to talk to" (p. 43). another analysis of long-term care environments by pope et al. (2006) resulted in residents identifying several things that made them feel significant (i.e., they mattered) versus insignificant (i.e., they did not matter). feelings of insignificance were trigged by events or treatment that evoked feelings of loss of control. feelings of insignificance are also rooted in insensitive treatment. an examination of factors contributing to loneliness included input from one longterm resident who said he was being shunned by his adult children (see roos and malan 2012) . his social pain is reflected in his statement that, "they don't want me anymore. i feel like i don't exist to them." other analyses point to feeling insignificant because of not being consulted about decisions that pertain directly to personal care and well-being (fetherstonhaugh et al. 2013) . a phenomenological analysis of suicidal tendencies among older adults by our colleague sharon moore identified themes of not mattering such as "no one cares" and "i am no longer needed" and the sorrow in the realization of "not being depended on anymore by other people" (see moore 1997) . these are commonly expressed themes among people who feeling insignificant and perhaps expendable. comments from participants in our study of meaning-centered men's groups (mcmg; see heisel and the meaning-centered men's group project team 2018) for men over the age of 55 who were concerned about or struggling with the transition to retirement further underscore the central role of mattering in the mental health and well-being of middle-aged and older adults moving into their later years. qualitative findings from study exit interviews highlighted general themes relevant to mattering in enhancing participant satisfaction with the group experience, including being valued and respected, mutual camaraderie, fellowship, and belonging. a looming sense of missing each other was at the heart of requests to extend the sessions and find ways for group members to remain in contact. finally, the need to feel a sense of mattering was clearly evident in the responses that 22 older people with mental health problems generated as part of a concept mapping exercise. this study by wilberforce et al. (2018) was conducted to inform the development of a new measure of quality of mental health services for older people. one category that emerged to characterize excellent services was labeled "personal qualities and relationships." this category included several references to the mattering construct such as care providers who are really interested and listen to and understand the older person (i.e., my care worker really listens to me). one elderly person made explicit reference to a worker who showed compassion and that they mattered. the essence of this concept category was a sense of humanity stemming from being treated as a real person by someone who is joining with the older person and is truly interested in spending time with her or him, and is not just passing through. collectively, these accounts underscore how mattering can be linked with joy and flourishing, but the feeling of not mattering can be associated with deep psychological pain. moreover, mattering needs to be embedded in therapy and counseling services. in general, the insights yielded from these accounts attest to the merits of future qualitative research that extensively examines the lived experience of feelings of mattering versus not mattering to others and perhaps to society. below, we describe the mattering construct in more detail and some elements that need to be added in order to more fully capture the relevance of mattering versus not mattering to older people. this description is then followed by a comprehensive overview of research conducted thus far that illustrates the benefits of mattering among older people. what is mattering? rosenberg and mccullough (1981) introduced mattering and the components that comprise this construct. mattering reflects our need to feel like we are significant and important to other people. rosenberg and mccullough (1981) focused on three components: (1) the sense that other people depend on us; (2) the perception that other people consider us to be important to them; and (3) the understanding that other people are actively paying attention to us. rosenberg (1985) added a fourth component reflecting the sense that other people have expressed that they would miss us if we were no longer around. subsequently, schlossberg (2009) identified a fifth element-feeling appreciated by someone. this component emerged following interviews with adult caregivers who indicated what made them feel like they mattered to those people receiving their care. prilleltensky (2020) sees mattering as involving both the sense of having value to other people and giving value to other people; thus, mattering reflects both giving and receiving in ways that provide feelings of personal significance and importance. the notion of enhancing the self by becoming someone who matters to others was shown in a case excerpt described by karp (1996) in his book about people struggling with the sadness of chronic depression. marco struggled for years with profound depression but nevertheless had to assume the caregiver role when his mother suffered a prolonged illness and it became clear that she would never get better. when asked whether there was anything in it for him, marco replied, "it made me feel important" (p. 153) and it forced him to put his own "stuff" aside for the time being. whereas a commonplace clinical response is to seek to alleviate stress from individuals struggling with depression, this example demonstrates the value in challenging clients to focus meaningfully on the needs of others rather than attending exclusively to their own emotional difficulty. most recently, killen and macaskill (2020) illustrated the relevance of giving value to others in a qualitative study of the positive life events reported by older adults. they conducted a revealing analysis of the diary entries of 88 elderly people in order to arrive at a revised model of positive aging. one category that emerged from their analysis was being of value to others. this category involved doing something to help friends or family members or the broader community and receiving notes of appreciation from others. some entries reflected expressions of mattering. for instance, one woman noted in her diary that, "husband coming downstairs after going to bed specifically to give me a hug and kiss goodnight, what could be better to confirm that one matters!' (f70) (p. 12). collectively, 468 diary entries reflected the positive affect stemming from having value to other people. the components of mattering outlined above likely vary in their relevance according to an individual's current life stage, albeit with the caveat that all components are important to some degree. the need to feel that others depend on them is critical for older people. this observation accords with conclusions from sage scholars who point to the benefits that accrue when older people feel needed and wanted because other people are relying on them. findings of great longevity among older adults in japan who continue working into their 8th or 9th decades of life further demonstrate the very real health benefits that can accrue from feeling valued and that one has a purpose (see jenkins and germaine 2019). erik erikson proposed in his developmental theory that a key stage for middle-aged and older people is generativity versus stagnation. the positive resolution of this stage is care. although they did not discuss mattering per se, erikson et al. (1986) emphasized in their analysis of vital involvement that older people who show caring and engage in nurturing of younger people, especially younger family members (e.g., grandchildren), will spread feelings that clearly resemble feelings of mattering. similarly, george vaillant's (2002) classic analysis of the lives of older people who took part in the longitudinal harvard study of adult development also emphasized giving to others in ways that foster positive and mutually caring relationships in ways that benefit the self. these acts of caring can be focused on young family members but of course, in many instances, also involve caring for disabled relatives and friends. vaillant (2002) warned that it is possible for dedicated younger adults to become so engaged in providing care to aging parents that it can amount to too much sacrifice if such caregiving activities become all-consuming; he suggested that this can result in depleting the self by "giving the self away" to others. vaillant (2002) suggested that the benefits of giving to others are better and more evident when a person is older because caring for others is more self-determined and does not feel like an overwhelming obligation. similarly, erikson et al. (1986) suggested that generative acts from elderly people directed at younger family members are more beneficial when other people are shouldering the daily responsibility for younger people and older people can focus on being generative. how protective can it be to feel a sense of mattering to younger people who have come to depend on an older person? erikson et al. (1986) described an elderly woman who acknowledged during her interview that she actually refrained from taking her own life because she knew how much she was loved and admired by her grandchildren (i.e., she mattered). the feeling of mattering provides a sense of connection and comfort and a source of resilience that is a strong buffer of life problems and feelings of stress and distress (for discussions, see flett 2018a; flett et al. 2019) , especially during the pandemic (see flett and zangeneh 2020) . we discuss this protective role in reducing suicide risk in more detail in a subsequent section of this article. we now turn to a discussion of ways to extend the mattering construct to more fully capture the relevance of mattering versus not mattering to older people. these additional ways of capturing individual differences in mattering are important from a conceptual perspective, but they also extend the potential focus of preventive interventions and open up additional directions for future research. the original conceptualization of mattering from rosenberg and mccullough (1981) focused on it as a feeling state and as a psychological need that is central to how people define themselves. a strong case can be made for the argument that the need to matter is just as important to people as are other key needs such as the need for autonomy, the need for competence, and the need for connection with others. rosenberg and mccullough (1981) discussed at length and demonstrated with their extensive data that mattering should not be equated with self-esteem. several researchers have confirmed that mattering goes beyond selfesteem when predicting key outcomes (e.g., flett and nepon 2020; flett et al. 2016a flett et al. , 2016b matera et al. 2020) . accordingly, any framework built around the notion that people need selfesteem should be modified to reflect that people need self-esteem but they also need to matter to other people. here it should be underscored that while the conceptual focus for the construct is on the need to matter, most existing measures of mattering such as the general mattering scale assess perceived levels of mattering to others and not the actual need to matter (for a discussion, see flett 2018b). accordingly, research must focus jointly on the need to matter to other people and perceptions of achieved levels of mattering to other people. we contend that some other elements of the mattering construct are missing from the literature and clearly must be added in order to more fully capture what mattering and not mattering means to everyone, but especially older people. additional elements of the mattering construct are identified below. some of these elements have been discussed elsewhere, but they have not received much emphasis from a conceptual perspective until now. flett (2018b) suggested originally that there is a key element of the mattering construct that has not been considered or measured thus far-the fear of not mattering to other people. flett (2018b) proposed that people with a strong need to matter to others and who are also characterized by an insecure attachment style could become preoccupied with the fear of losing connections with the people whom they matter to and who matter to them. research on this facet of the mattering construct is in an early phase. casale and flett (2020) discussed at length how this fear of not mattering is especially relevant during the pandemic and how it is seemingly more germane at present than other fears such as the fear of missing out or the fear of negative evaluation. this element seems especially relevant to older people who have become isolated or socially disconnected or fearful of being forgotten as this global health crisis unfolds. elderly people who are cognizant of public statements about the expendability of whole segments of the population or the use of age as a key criterion to determine the allocation of scarce medical resources could have their general worries and levels of anxiety exacerbated by this particular fear. people who fear being alone may have also developed this fear of not mattering, and it could add to feelings of helplessness and hopelessness and perhaps resentment. this particular aspect of mattering may be especially relevant among some people who are in the process of dying. it is common to hear of people who just wanted to know that they have mattered to someone who cared about them and they have worries that this was not the case. it is not uncommon, among end-of-life care providers, to witness older adults at the end of life provide reassurance and comfort to family members who are struggling emotionally with the thought of the older person's impending death. a need for reassurance of having some significance to others should be especially salient among people who fear that they have not really mattered to anyone. a reasonable question to ask is, "what is worse-never having the sense of mattering to others or feeling a sense of mattering to others but then losing it?" a key element of the mattering construct that has received almost no attention thus far is the loss of mattering to others. elderly people who live long enough to outlive others and, as a result, experience loss of mattering via their losses can become very dejected if they have not found ways to maintain a sense of mattering or to still feel good about having mattering to the departed. there are many ways for older people to experience a loss of mattering to others. this may take the form of becoming a caregiver to young grandchildren who have parents employed full-time outside the home and then feeling no longer needed when these grandchildren are old enough to take care of themselves. complex family situations involving divorce and conflict may also result in a reduction in opportunities to matter for those older people who are no longer included in family activities. alternatively, a loss of mattering could take the form of losing physical mobility and no longer being able to fulfill an active volunteer role. and, of course, it could involve the loss of perceived mattering that results when an older person transitions to retirement and no longer feels important and significant to others, perhaps along with a loss of a sense of purpose. these transitions can be felt acutely by the older people who still very much need the sense of validation that is derived through mattering to other people. the loss of mattering can contribute to depressions that are due not only to loss of mattering but also a perceived loss of self. this observation fits with the many case examples of extremely depressed people who acknowledge that they no longer feel like their old selves and their first goal is to feel like themselves again. although they may not realize it, this translates into again having a feeling of mattering to others. as noted earlier, our geriatric suicide ideation scale contains a component subscale that assesses the perceived loss of personal and social worth. this factor is highly associated with a host of negative psychological factors, including depression, hopelessness, loneliness, and suicide ideation (e.g., heisel and flett 2006 . pearlin and leblanc (2001) stand alone as the only researchers thus far to focus extensively on the loss of mattering. their focus was on bereaved caregivers. their research showed that the death of a dependent relative (a spouse or parent with dementia) among caregivers resulted in a loss of mattering and contributed to depression, and the greater the loss of mattering among caregivers, the greater their level of depression 1 year later (pearlin and leblanc 2001) . what is especially important about this finding is that it suggests that it is not simply a loss of activity or change in routine or sadness about having lost a loved one that is associated with depression, but rather the loss of connection, of feeling needed, and of mattering to others. we will conclude this segment by newly proposing another aspect of the mattering construct that applies universally but seems essential among older people. a fifth element of the mattering construct that is worth considering involves personal assessments of whether an individual who needs to matter sees herself or himself as someone who perhaps does not currently have a sense of mattering, but still feels that they are capable of engaging in behavior that will generate feelings of mattering to other people. this aspect of mattering can be regarded as a specific type of self-efficacy reflecting the perceived capacity to generate feelings of mattering by engaging with other people or contributing to the community in meaningful ways. this emphasis of a specific type of self-efficacy is suggested in general by research attesting to the protective role of other specific ways of framing self-efficacy among older adults (e.g., paggi and jopp 2015; stephan et al. 2011) . the concept of the capability to matter to others follows from a line of investigation in the personality field that began when wallace (1966) observed astutely that certain personality characteristics could be measured as abilities or capabilities. capabilities focus on what is possible or feasible versus what is typical, which is what personality traits tend to reflect. there has not been extensive research on personality capabilities despite their clear relevance to understanding people and the individual differences among them. one key exception is the work by martin (1987, 1988) , who illustrated the usefulness of assessing personality capabilities in the interpersonal domain. they showed that capability and trait ratings of interpersonal characteristics are relatively orthogonal, and both capability and trait ratings are associated with low self-esteem and anxiety. the implications of these findings are clear: individual differences in trait ratings and capability ratings are quite different in their nature. similarly, just as it is possible to distinguish such things as a person's usual level of agreeableness and their capability of being agreeable, both subjectively and objectively, it should also be possible to distinguish a person's degree of mattering to others and their capability of being someone who could matter to others. it is likely that the perceived capability to matter to others overlaps to a substantial degree with feelings of loss of mattering. conceptually, it stands to reason that believing that one can still matter to others should moderate the negative impact of diminished feelings of mattering on depression and other negative psychological outcomes. some people will feel both a loss of mattering and a diminishment in their perceived capability to matter to others, perhaps as a consequence of having physical or cognitive declines that impact their ability to interact with other people. fazio (2009) has discussed how mattering to others can be impacted by personal circumstances and limitations that can also limit the frequency of positive social interactions. hopefully, such individuals will have people in their lives to whom they matter, and these people will be able to continue to demonstrate that they care about them and will take care of them. the next segment of this article consists of a review of existing research with an emphasis on mattering among older people. there are now enough articles on mattering among older people to get a clear sense of how mattering protects older people who have it and disadvantages those older people who do not feel like they matter to others. we then conclude with an analysis of applications in the form of preventive interventions and a discussion of directions for future research. our research review focuses on four topics. first, we examine the role of mattering in protecting against loneliness and social disconnection. next, we summarize research confirming that there is a negative association between mattering and depression. third, in keeping with a positive psychology orientation, we consider research illustrating the positive association between mattering and psychological well-being. finally, mattering is examined in terms of its role in positive physical health outcomes. results linking mattering with greater life satisfaction are also highlighted. most of the research investigations conducted on mattering in the elderly fit into these themes with the exception of some work examining the role of religiosity and mattering among older people (see lewis and taylor 2009; schieman et al. 2010) . loneliness is a serious problem facing many elderly people, and there are indications from extensive research that loneliness exacts both a devastating mental toll and a physical toll on older people. empirical research has supported the position that loneliness not only contributes to health problems, it may actually be a causal factor in early mortality (see holt-lunstad et al. 2015; luo et al. 2012) . fromm (1941) first discussed the association between being and feeling isolated and feelings of not mattering in his book escape from freedom. he proposed that individuals who achieve a sense of freedom from others also pay a price in terms of feeling both isolated and insignificant (see fromm 1941) . combined feelings of loneliness and of not mattering can be dangerous; this should especially be the case for exceptionally lonely older people who feel like they do not matter. this is just one of the many reasons why the situations brought about or exacerbated by the global health crisis may prove lethal for many older people. research on mattering and loneliness is quite limited. the most extensive study was conducted by flett et al. (2016a, b) . this research with a sample of university students showed that lower scores on the general mattering scale (gms) were associated with loneliness and this association was quite robust (r = − 0.62). moreover, feelings of not mattering and loneliness were both associated with reports of various forms of childhood maltreatment. other analyses of this cross-sectional data yielded support for mattering as a mediator of the link between childhood maltreatment and loneliness. work is continuing in our lab on the link between feelings of not mattering and loneliness and the initial evidence continues to suggest a strong link between these interpersonally-based psychological factors. how are these factors associated among the elderly? initial evidence of a strong negative association between feelings of mattering and loneliness came from an investigation by kadylak (2020) of 675 adult internet users 65 years or older with a mean age of 73.93 years. the main focus of this work was to examine reactions to "phubbing" which is the tendency to focus on technology in a way that also involves ignoring someone else. low mattering would exist if an elderly person (or anyone) was being ignored by someone absorbed in technology. mattering was assessed by the 24-item mattering index by elliott et al. (2004) . the measures also included an eight-item loneliness scale and measures of self-reported health, depression, and the five-item satisfaction with life scale (diener et al. 1985) . the depression results from this study are reported in the next section. analyses established that mattering was linked robustly with lower levels of loneliness and higher levels of life satisfaction. interestingly, although it was not associated significantly with self-reported health status, levels of mattering were significantly lower among participants with lower levels of socioeconomic status and among those who were widows or widowers. lower mattering was also linked with more frequent family phubbing expectancy violations (i.e., attention of others was expected but not obtained). finally, mattering mediated the link between intergenerational family phubbing expectancy violations and loneliness. evidence of a link between low mattering with less social connection was provided in a study by francis et al. (2019) . they examined how the frequent use of informational communication technology (ict) can enhance the functioning of older adults in retirement communities. this was an extensive project that was part of a randomized control treatment study with five waves of data collection. the participants were 199 older adults with a mean age of 81.61 years. mattering was assessed with the five-item gms (marcus and rosenberg 1987) . a negative link was found between mattering and assisted living, suggesting perhaps that mattering becomes diminished as a function of age-related declines in functioning. this interpretation seems consistent with the experience of older adults in residential care who are allowed to soil themselves before being assisted in toileting by on-site support workers; it is hard to conceive of a clearer message that one does not matter than to be subjected to this sort of indignity. the main analyses showed that higher levels of mattering were associated with more extensive ict use. it was also linked positively with a self-report measure of social network connectedness known as the lubben social network scale (see lubben and gironda 2004) . mediational analyses established further that social network connectedness mediated the association between ict use and mattering in this sample of elderly people. collectively, initial research with older people suggests that any links proposed between feelings of not mattering and feelings of isolation and social disconnection are well-founded. research with a lifespan perspective is now needed to examine mattering and loneliness from a longitudinal perspective. some complex associations likely exist, especially if mattering is studied with an extended scope that includes the fear of not mattering and the perceived loss of mattering. the predominant clinical research focus thus far in the mattering field has been on the negative association between mattering and depression. flett (2018b) summarized numerous reasons why lower mattering to others should be associated with higher levels of depressive symptoms. an association would be expected given the negative self-worth judgments that are common to both. also, people with low levels of perceived mattering should have less perceived and actual social support which could have provided a buffer from depression. dixon (2007) conducted the initial study of mattering and depression in the elderly. a sample of 167 older adults (39 men, 128 women) completed a 25-item measure of mattering developed by the author. the participants had a mean age of 83.5 years. dixon (2007) only reported the results for the overall score on this mattering measure even though it was comprehensive and assessed global mattering, but also mattering to significant others and friends and other family members, including any grandchildren. dixon (2007) found that mattering was linked robustly with less depression (r = − 0.64). other results from this study are reported in a subsequent segment of this article. chippendale (2013) also evaluated the link between mattering and depression on a smaller scale in a sample of 47 older adults from four senior's residences in new york city. mattering was assessed with a single but highly face valid item (i.e., i feel valued and important). this item was taken from the duke social support index (koenig et al. 1993) . participants also completed a brief one-item measure of self-reported health status and the full version of the geriatric depression scale (gds: yesavage et al. 1983 ). the one-item measure of mattering (i.e., feeling valued and important) was associated negatively with depression (r = − 0.56). secondary analyses indicated that among those people who were severely depressed according to the gds cutoffs, it was the case that none of these people indicated any level or degree of agreement with the mattering item (i.e., no person with depression felt a sense of mattering). another study by wight et al. (2015) of 315 gay identified men from the usa further illustrated the role of mattering in reduced levels of depression. the authors noted that their focus on mattering stemmed in part from reports found commonly among aging gay men of feeling invisible to other people. their participants had been part of a longitudinal study conducted over three decades, but wight et al. (2015) focused on data collected in 2012 and 2013. the average age of participants was 60.7 years with an age range of 48 to 78 years. overall, 61% of the participants were hiv-negative. mattering was assessed with the gms (marcus and rosenberg 1987) . other measures in the study included a measure of internalized gay ageism with items such as "aging is especially hard for me because i am a gay man." depression was assessed with the ces-d depression scale (radloff 1977) . the ces-d was administered many times over three decades and this enabled the researchers to identify five depression trajectories. these trajectories were controlled for in subsequent statistical analyses. the results of a regression analysis predicting the most recent ced-d score found that elevated depression scores were uniquely and significantly associated with lower levels of mattering and higher levels of internalized gay ageism. other analyses pointed to mattering as a mediator of the link between internalized gay ageism and depression; that is, higher levels of gay ageism were associated with lower mattering which, in turn, was associated with higher levels of depression. no support was found for mattering as a moderator variable. another study of functional limitations by redmond and barrett (2015) included data on mattering and depression. this longitudinal study of over 1300 adults from miami-dade county in florida found that lower scores on an extended version of the general mattering scale were associated with depression and increases in depression over time. this study is relevant because it had a broad representative sample with participants from three age groups (18-49 years, 50-69 years, and 70-93 years) who had a mean overall age of 57.03 years. finally, the study by kadylak (2020) described above on reactions to phubbing among 679 internet users also included a two-item depression scale. it was found once again that mattering was associated robustly with lower depression. as noted earlier, the study by dixon (2007) of 167 elderly adults also included indices of wellness and purpose in life. wellness was examined only as a total score. the correlational analyses conducted by dixon (2007) found that mattering was linked with purpose in life (r = 0.58) and with overall wellness (r = 0.62). it is especially noteworthy that a regression analysis predicting overall wellness showed that mattering, purpose in life, and depression all were significant, unique predictors, suggesting that mattering is neither simply a synonym for purpose in life or wellness, nor the opposite of depression, but is an unique variable in its own right. myers and degges-white (2007) examined mattering and levels of wellness among older adults in a retirement community. the participants were 142 residents (50 men, 92 women) who ranged in age from 73 to 101 years old and who had a mean age of 83 years old. perceived stress was also assessed. mattering was assessed with the five-item gms (marcus and rosenberg 1987) . wellness was assessed with the five-factor wellness scale (myers and sweeney 2005) which taps 5 domains of wellness and provides 23 measures in total. correlational analyses found that mattering was not associated with perceived stress, but it was associated significantly with overall levels of wellness (p < 0.002). overall, mattering had significant positive links with 11 of the 23 individual measures of wellness. a third study by piliavin and siegl (2007) reported findings from the wisconsin longitudinal study. this long-term study began decades earlier. the report from piliavin and siegl (2007) examined a large sample of participants who were assessed in 2004 when they were approximately 64 years old. the main focus of this work was to evaluate the potential benefits over time of volunteering. mattering was assessed with six items from the mattering index by elliott et al. (2004) . well-being was assessed with five-item or six-item subscale measure of ryff's (1989) well-being scale. it was a composite well-being measure comprised of four subscales tapping self-reported environmental mastery, purpose in life, personal growth, and self-acceptance. the results showed that even when controlling for levels of well-being when assessed in 1992, it was the case that greater subsequent psychological well-being was predicted by mattering and a host of other factors, including social integration, years of education, and being female. other analyses suggested that social integration mediated the link between volunteering and well-being, and mattering mediated the link between volunteering and well-being. it was concluded that when someone does not have a high level of social connection, direct engagement in volunteering can boost well-being and this is underscored, at least in part, by an enhanced feeling of mattering to others. mattering should be protective in terms of physical health because it should act as a stress buffer, especially following interpersonal stressors that involve negative social exchanges (for a discussion, see fazio 2009 ). similarly, mattering should be associated with positive health behaviors and self-care to the extent that people who perceive that they matter to others have internalized this perception and so feel that they matter to themselves. the study by chippendale (2013) described above that was conducted with 47 participants included a one-item assessment of self-reported health status. the one-item measure of mattering had a positive association with health status (r = 0.18), but this association did not achieve statistical significance. this could reflect the small sample size and the reliance on single-item measures. kadylak (2020) also did not find a link between mattering and a brief measure of health status. however, the study of ict frequency by francis et al. (2019) described earlier also included a one-item measure of self-reported health status; mattering was associated significantly with higher health status among these 199 participants. fazio (2009) described the results of the first assessment point from the aging, stress, and health study (ash) in a published chapter on mattering. the initial assessment was based on 1167 adults who were 65 years or older from washington and two counties in maryland. participants were categorized as young-old (65-74), old (75-84), and old-old (85 or older). four items were used to measure mattering in terms of importance to other people and another four items assessed other people depending on and counting on the person. it was found that levels of mattering decreased significantly with age; both mattering components were significantly lower in the old-old group versus the young-old group. most noteworthy for our purposes was the finding that better self-reported physical health status was linked positively with the two facets of mattering. also, engagement in volunteer roles was also associated with higher levels of mattering. hence, remaining engaged in physical activities and in doing for others overcome the negative impact of aging on perceptions of mattering. the most relevant research conducted thus far suggests that mattering may help reduce the impact of "the wear and tear" on the body at a precise time when people are increasingly susceptible to the onset of disease and major illnesses. a key investigation by taylor et al. (2019) examined 1026 adults from tennessee. they ranged in age from 22 to 69 year olds. the sample included 296 people between the ages of 47 and 57 years old and another 178 people who were 58 years old or older. they were evaluated on levels of allostatic load across 10 physiological indicators. these indicators contained various objective measures (e.g., blood pressure, cholesterol, high-density lipids, etc.). participants also reported chronic health conditions. the mean level of chronic health conditions for the sample was 2.76. the analyses found that age is associated with increased allostatic load, and this association is substantially greater among adults with low or moderate levels of mattering. these data suggest that a sense of not mattering plays an increasing role in poor physical health outcomes among older adults. ironically, with worsening health, the interpersonal others with whom older adults increasingly spend their time are healthcare providers; clinicians who work with older adults are thus strongly encouraged to be sensitive to, and seek to enhance, their older clients' feelings of mattering. analyses of chronic health conditions found that age was associated with more chronic health conditions, as would be expected, but mattering was associated with fewer reported chronic health conditions. however, levels of mattering did not interact with age to predict the number of chronic health conditions. while these findings need to be evaluated in future research to determine their replicability, employing multi-item measures and larger sample sizes, it does seem that mattering plays a protective role in health functioning, especially among older adults. taylor et al. (2019) went on to conclude that, "there is reason to believe that mattering may be a better predictor of health and well-being relative to other conceptualizations of social relationships" (p. 1842). in particular, they posited that mattering should outperform social support in terms of health and well-being. collectively, the results summarized above paint a positive image of the older person with a sense of mattering to others but a bleak image of the older person who feels insignificant, unimportant, or worthless to self and others. much more research is needed, but mattering is clearly protective in terms of being associated with less depression and greater well-being, and there are strong indications that mattering provides a platform for better health. also, initial data suggest that older people with a sense of mattering have lower loneliness and greater social connection. these findings combine to suggest that the older person who is able to maintain and extend a sense of mattering to others is someone who should cope reasonably well with the pandemic. once again, however, the situation is qualitatively different and untenable for elderly people who feel like they do not matter to others. these tendencies should be exacerbated if this is accompanied by the feeling of not mattering to the community or the broader society. flett et al. (2019) maintained that one of the key distinguishing features of mattering relative to other psychological constructs is that mattering translates well into actions and themes that can be incorporated into practical applications with a prevention and promotion focus. the potential relevance of mattering is considered below as part of a brief overview of some existing preventive interventions for older adults designed to enhance the sense of connection and relatedness to others and decrease social isolation and psychological distress. there now has been extensive research on the social isolation of older adults and the impact of loneliness and disconnection. the extent of this focus is reflected by there being at least two separate scoping reviews of research on isolation and social disconnection (see courtin and knapp 2017; o'rourke et al. 2018) . there is little doubt that anyone stands to gain from having more positive social interactions and a greater sense of interconnectedness with other people, but this is especially the case for older people who find themselves quite isolated. below we will provide a brief description of two interventions designed jointly to enhance social connections and improve mental health. mattering could be added as a key element in each instance. van orden et al. (2013) implemented a program in rochester, new york called the senior connection as a potential way of preventing suicide among elderly people. the essence of this program is that seniors who have expressed an interest in volunteering have that interest directed toward becoming a peer companion of another senior who is vulnerable and isolated, perhaps to the extent of becoming suicidal. the conceptual premise of this work is provided by the interpersonal theory of suicide by joiner and colleagues. this is a key element because ideally prevention attempts are guided by theory and conceptualization. two main themes are at the core of this interpersonal theory. people are suicidal because they feel like: (1) they do not belong with others; and (2) they have become a burden to other people. a program such as the senior connection will certainly address the sense of not belonging. moreover, the senior companion can openly discuss and refute the notion that their vulnerable partner is a burden to others. where could mattering enter this picture? there is a tendency to equate belongingness with mattering, but these two interpersonal constructs are distinct. someone can feel like they belong in a group yet still feel not valued or recognized within the group. flett (2018b) has also described empirical findings showing that belonging and mattering are distinct concepts in various research investigations. these results suggest that the senior connection could be reframed to place a specific emphasis on how the actions and verbal interactions that take place between companions can emphasize that both are valued. one premise guiding work on mentors and mentees is that the mentor gives value to the mentee, but the mentor also receives value as a result of having a role that makes a difference in the life of someone else. mattering is also relevant to another program being led by the second author. this intervention has received the support of the movember foundation and it is geared toward lowering suicide risk and enhancing the psychological resilience of men transitioning to retirement. it is rooted in the work conducted by the authors on the role of meaning in life in promoting psychological well-being and reducing risk for suicide among older adults (see heisel and flett 2014) . this program and its initial effectiveness are summarized in heisel et al. (2020) . this new paper outlines the preliminary results for the mcmg (also see heisel and the meaning-centered men's group project team 2018). the mcmg is a 12-session existentially oriented, community-based, psychological group intervention. delivery of the mcmg sessions is in community settings. recruitment is based on promoting this opportunity as a "men's group dealing with adjustment to retirement" rather than as a "psychotherapy group" in an attempt to normalize any concerns about retirement. two male facilitators lead the groups. the groups are comprised typically of 10 men who share the fact that are all facing the transition to retirement. a full description of positive initial findings is beyond the scope of this review article. it is worth noting, however, that heisel et al. (2020) made explicit reference to the potential role of mattering, and that the theme that each participant matters is implicit in the philosophy of this humanistic-existential group. our evaluation of the topics covered throughout the program identified many points where a more extensive focus on mattering could be implemented. for instance, of course, it is a simple matter when describing the purpose of the group in the initial meeting to emphasize the theme "you matter" as a reason for the existence of the program. mattering promotion can also be nonspecific in terms of providing opportunities to be seen and heard within a context where "everyone counts." some specific session themes fit naturally with the nature of the mattering construct and how to instill a feeling of mattering in a person facing retirement. for instance, one segment examines the benefits of volunteering and becoming a mentor for someone else; mattering through mentoring is quite viable. the role of mattering can also be highlighted in sessions seven and eight that collectively address meaning in relationships, friendships, business relations, and camaraderie, and meaning in love experiences with significant others, children, extended family, and even pets. one of the final sessions is focused on meaning in life and generativity. this session also represents a platform for the theme of giving a sense of mattering to the self by giving to others. the facilitators lead participants through the "clarence challenge"-named after the angel in the frank capra movie "it's a wonderful life"-asking them to imagine that an angel has materialized in front of them and shows them a movie reel of their life, specifically focusing on all of the contributions that they have made in life and the positive impact that they have had on others. after reflecting on these contributions, and listing them explicitly on paper, they are then asked to project themselves one decade into the future and imagine that clarence the angel reappears in 10 years' time and reveals to them all of the good that they can still do. they are specifically invited to "focus on the lives you will have touched, the value you will have contributed to the lives of those around you, whether your family, friends, neighbors, community, or even strangers. then mark down (below) the impact that you can still make on the world around you over the coming decade." this highlights the facet of mattering that involves the perceived capability or capacity to matter to others, both now and in the future. it goes without saying that positive group experiences should foster the development of bonds among group members who come to matter to each other. this appears to be the case, as some former group members have continued socializing with one another following the end of the group, including one group that has been meeting on a monthly basis for nearly 4 years following the end of their group; ironically, their most recent scheduled breakfast meeting was canceled due to covid-related prohibitions against group get-togethers. although it is beyond the scope of this review, the most recent mcmg group was temporarily halted due to covid; however, following receipt of research ethics approval, this group was reconvened online to positive effect. as suggested above, regardless of the specific content that comprises an intervention, we feel that there is much to be gained by highlighting the mattering theme prior to implementing an intervention so that participants understand that they are valued and their involvement is truly appreciated. it goes without saying that this value needs to be shown and lived rather than merely mentioned. this sense of being significant will resonate with those older people who have been feeling ignored or discounted. it should certainly be "music to the ears" of any older people who is troubled by messages and events during the pandemic that make them feel expendable and disposable rather than valued and cherished. numerous topics for future research have already been outlined in earlier segments of this article, so we will focus on only a few key themes that merit much more investigation. some of the work outlined below would benefit from a general approach that pits mattering versus other related constructs (e.g., belongingness, social support) in order to further establish the uniqueness and predictive utility of mattering. first, and foremost, the literature on the role of feelings of not mattering in suicide risk is beginning to build but, to our knowledge, there has not been research thus far focused on the potentially protective role of mattering among older people. research is imperative given growing concerns about suicidal tendencies among older people, especially during the pandemic. some studies have provided indirect evidence of the proposed association between mattering and lower suicidality, but programmatic research from a longitudinal perspective is urgently needed. regarding this indirect evidence, one study linked family connectedness with reduced suicide ideation among older adults (purcell et al. 2012) . measures of connectedness often include item content that assesses mattering (see flett 2018b) . in this instance, family connectedness was assessed with a four-itembased measure of family-based reasons for living. our anlysis indicated that one of these items is directly relevant to mattering (e.g., my family depends on me and needs me), while two of three remaining items constitute indirect indicators of mattering (i.e., would be missed by others). another investigation established links between measures of belongingness and reduced suicide ideation among older adults (mclaren et al. 2007 ). once again, however, the two belongingness measures each had a small subset of items reflecting mattering to others (e.g., have felt valued in the past). thus, the results actually signify that lower suicide ideation is linked with both mattering and belongingness. the study above on family connectedness was based on a four-item measure comprised of items designed to tap reasons for living. this is noteworthy because one way to frame mattering is to consider it as a core reason for living, and research findings support reasons for living in promoting optimism and reducing risk for suicide among older adults (e.g., britton et al. 2008; edelstein et al. 2009; hirsch et al. 2007 ). accordingly, one possibility for future research is to incorporate mattering as a key theme in existing measures of reasons for living. this fits with the results of a qualitative analysis indicating that the feeling of not mattering was identified as an overarching theme among elderly people with a desire for a hastened death (see van wijngaarden et al. 2015) . finally, rosenberg and mccullough (1981) observed that mattering is especially important when people are facing a transition, and as such, it seems evident that more research is needed on the role played by mattering as people continue to age and they undergo a variety of impactful transitions. the focus thus far has been on mattering and retirement and there is a clear need for programmatic research on mattering and retirement; additional important moments of transition can include downsizing one's home or moving into a residential care home; experiencing health-related changes, widowhood, or other significant interpersonal losses; and anticipation of one's own mortality. schlossberg (2009) also proposed "the mattering recipe." it has four ingredients: (1) getting involved and staying engaged, (2) harnessing the power of invitations, (3) taking initiative, and (4) doing your best to make others feel like they matter. initial evidence attests to the benefits of mattering for retired workers. froidevaux et al. (2016) described a longitudinal investigation with 178 retirees. gms scores were associated with positive affect, life satisfaction, and social support, and mattering was a mediator of the link between social support and positive affect. froidevaux et al. (2016) concluded that preventive efforts to enhance retirement adjustment should feature the mattering theme. in summary, the current article examined mattering and the need to feeling valued and significant and contrasted it with feelings of expendability among older people in usual times and in times of crisis such as the current global health pandemic. it has been mentioned often that the arrival of covid-19 has brought existing gaps and systemic problems into the light; we suggest that it has also illuminated a mattering gap. there is a clear need for older adults to be treated in ways that enhance their sense of mattering and enjoy the benefits of feeling significant and important rather than feeling expendable and disposable. this extends to the need to substantially increase the resources available to our older people, including training more mental health professionals to address the needs of older people who do not feel like they are priorities. humanistic approaches may be particularly consonant with such an approach, and we have outlined elsewhere the potential value of humanistically oriented interventions in enhancing well-being and reducing risk for suicide among older adults (heisel and duberstein 2016) . the facets of the mattering construct were described in this article and elements of the construct relevant to older people requiring much more attention were identified (e.g., the fear of not mattering and the loss of mattering). research was summarized which shows consistently the ways in which mattering is protective in terms of its links with higher levels of wellbeing and lower levels of depression and loneliness. mattering was also considered in terms of its link with physical health and its adaptive role as a buffer of the link between stress and physical health. the findings are generally in keeping with the premise advanced by rosenberg and mccullough (1981) that mattering is especially relevant among older people. it is vital for 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research in the general population the link between functional limitations and depressive symptoms: the explanatory role of self-conceptions understanding physical educators' perceptions of mattering: validating of the perceived mattering questionnaire-physical education the role of context and the interpersonal experience of loneliness among older adult people in a residential care facility self-concept and psychological well-being in adolescence mattering: inferred significance and mental health among adolescents happiness is everything, or is it? explorations on the meaning of psychological well-being coronavirus: what's going wrong in sweden's care homes? religious involvement, beliefs about god, and the sense of mattering among older adults marginality and mattering: key issues in building community revitalizing retirement: reshaping your identity, relationships, and purpose failure to halt covid-19 spread leads to mass deaths in swedish elder care homes when did elderly people like me become disposable? subjective health and memory self-efficacy as mediators in the relation between subjective age and life satisfaction among older adults military teams raise concerns about conditions at ontario care homes 113-year-old coronavirus survivor: the elderly are the forgotten ones of society hospitals in peru's capital won't admit elderly patients sickened with covid-19 into overcrowded icu wards due to their "risk of morbidity aging well: surprising guideposts to a happier life from the hallmark harvard study of adult development the senior connection: design and rationale of a randomized trial of peer companionship to reduce suicide risk in later life ready to give up on life: the lived experience of elderly people who feel life is completed and no longer worth living covid-19: the implications for suicide in older adults internalized gay ageism, mattering, and depressive symptoms among midlife and older gay-identified men the patient experience in community mental health services for older people: a concept mapping approach to support the development of a new quality measure many failures combined to unleash death on italy's lombardy development and validation of a geriatric depression screening scale: a preliminary report calls for inquiry into "horrific" covid-19 deaths at australian nursing home key: cord-258093-6fn8ei9f authors: hanania, nicola a.; king, monroe j.; braman, sidney s.; saltoun, carol; wise, robert a.; enright, paul; falsey, ann r.; mathur, sameer k.; ramsdell, joe w.; rogers, linda; stempel, david a.; lima, john j.; fish, james e.; wilson, sandra r.; boyd, cynthia; patel, kushang v.; irvin, charles g.; yawn, barbara p.; halm, ethan a.; wasserman, stephen i.; sands, mark f.; ershler, william b.; ledford, dennis k. title: asthma in the elderly: current understanding and future research needs—a report of a national institute on aging (nia) workshop date: 2011-08-25 journal: j allergy clin immunol doi: 10.1016/j.jaci.2011.06.048 sha: doc_id: 258093 cord_uid: 6fn8ei9f asthma in the elderly is underdiagnosed and undertreated, and there is a paucity of knowledge on the subject. the national institute on aging convened this workshop to identify what is known and what gaps in knowledge remain and suggest research directions needed to improve the understanding and care of asthma in the elderly. asthma presenting at an advanced age often has similar clinical and physiologic consequences as seen with younger patients, but comorbid illnesses and the psychosocial effects of aging might affect the diagnosis, clinical presentation, and care of asthma in this population. at least 2 phenotypes exist among elderly patients with asthma; those with longstanding asthma have more severe airflow limitation and less complete reversibility than those with late-onset asthma. many challenges exist in the recognition and treatment of asthma in the elderly. furthermore, the pathophysiologic mechanisms of asthma in the elderly are likely to be different from those seen in young asthmatic patients, and these differences might influence the clinical course and outcomes of asthma in this population. states is currently about 13% but is projected to grow from about 40 million in 2005 to more than 86 million by 2050, accounting for 25% of the population. the age group with the largest growth will be those older than 85 years, which is estimated to be more than 1 million by 2050. 1, 2 in 2004, the us prevalence of asthma for those 65 years or older was 7%, with 1,088,000 reporting an asthma attack in the previous 12 months. 3 older asthmatic patients are more likely to be underdiagnosed, undertreated, 4,5 and hospitalized than younger asthmatic patients. 3 they also have the highest death rate (51.3 per million persons) of any other age group. 6 older women are hospitalized more than twice as often as older men. asthma in older adults is superimposed on a background of aging-related changes in respiratory and immune physiology and often on multiple diseases and conditions common in older age. recognizing the paucity of research, the many challenges that exist in the recognition and treatment of asthma in older adults, and the opportunity to bridge geriatrics and the clinical specialties that focus on asthma, the national institute on aging (nia) sponsored a workshop on asthma in the elderly in herndon, virginia, on september 8 and 9, 2008. the workshop was planned by a committee of 6 physician-scientists from us academic institutions or from the division of geriatrics and clinical gerontology in the nia. the planning committee selected speakers and participants for their expertise in asthma, pulmonology, allergy/immunology, primary care, emergency medicine, geriatrics, and/or gerontologic science (see the list of participants in appendix 1). the immediate goals of this workshop were to summarize the current understanding of the mechanisms of asthma in older persons and to identify knowledge gaps and research opportunities leading to improved medical care and health outcomes for older persons with asthma. these research opportunities are discussed in the body of this report and summarized in table i . [7] [8] [9] in addition, the nia, in collaboration with the national heart, lung, and blood institute and the national institute of allergy and infectious diseases, recently issued a set of program announcements inviting research proposals on asthma in older adults (http:// grants.nih.gov/grants/guide/pa-files/pa-10-263.html, http://grants. nih.gov/grants/guide/pa-files/pa-10-264.html, and http://grants. nih.gov/grants/guide/pa-files/pa-10-265.html). it is a central principle of gerontology that aging itself is not a disease. 10 yet there are physiological changes within organs, tissues, and cells that result in diminished functional reserve and thereby increased susceptibility to stressors, disease, or both. a second principle is that these aging changes are highly variable and account for the great constitutional heterogeneity among older persons from very ''fit'' to very ''frail.'' in fact, the concept of frailty, both its causes and consequences, has become a focus of concentrated gerontologic investigation. at the root of age-associated physiological changes are a number of genetic, epigenetic, and environmental factors. 11 molecular damage accumulates over time, and the capacity for dna repair decreases. 12 cellular senescence, which is believed to be the consequence of accumulated dna and protein damage and reduced proliferative capacity, is becoming increasingly understood at the molecular level. 13 however, just how this correlates with the phenotypic changes of advanced age remains incompletely understood. 14 there has been much written about cellular senescence and the events that lead to cell death. [15] [16] [17] after a finite number of divisions, normal somatic cells invariably enter a state of irreversibly arrested growth, a process termed replicative senescence. 18 in fact, it has been proposed that escape from the regulators of senescence is the antecedent of malignant transformation. however, the role of replicative senescence as an explanation of organismal aging remains the subject of vigorous debate. the controversy relates, in part, to the fact that certain organisms (eg, drosophila species and caenorhabditis elegans) undergo an aging process, yet all of their adult cells are postreplicative. what is clear is that the loss of the proliferative capacity of human cells in culture is intrinsic to the cells and not dependent on environmental factors or even culture conditions. 18 unless transformation occurs, cells age with each successive division. the number of divisions turns out to be more important than the actual amount of time passed. thus cells held in a quiescent state for months, when allowed back into a proliferative environment, will continue approximately the same number of divisions as those that were allowed to proliferate without a quiescent period. 19 the question remains whether this in vitro phenomenon is relevant to animal aging. one suggestive observation is that fibroblasts cultured from samples of old skin undergo fewer cycles of replication than those from young skin. 20 furthermore, when various species are compared, replicative potential is directly and significantly related to lifespan. 21 an unusual b-galactosidase with activity peaks at ph 6 has proved to be a useful biomarker of in vitro senescence because it is expressed by senescent but not presenescent or quiescent fibroblasts. 22 this particular b-galactosidase isoform was found to have the predicted pattern of expression in skin from young and old donors, with measurably increased levels in dermal fibroblasts and epidermal keratinocytes with advancing age. 22 the nature of the expression of this in vivo biomarker of aging in other tissues will be important to discern. for clinical investigators, frailty has proved hard to define primarily because of the seemingly insurmountable heterogeneity inherent in geriatric populations on the basis of these variable rates of organ system decrease and the presence or absence of 1 or more diseases. 9 yet, regardless of the pathway taken to frailty, the clinical picture has common features, including a reduction in lean body mass (sarcopenia), loss of bone mass (osteopenia), cognitive impairment, functional decline, and anemia. on the basis of data derived from large cohorts of elderly patients, fried et al 23 have offered an operational definition of frailty incorporating an assessment of 5 specific characteristics to ascribe a frailty index. on this 5-point scale, a score of 3 or more has been shown to be independently predictive of a range of adverse clinical outcomes, including acute illness, falls, hospitalization, nursing home placement, and early mortality. [23] [24] [25] furthermore, simple performance measures, such as the assessment of walking speed, are predictive of important outcomes, including survival. 26 with the phenotype better defined, attention has shifted to pathophysiology. although frailty can occur in the absence of a diagnosable illness, the fact that some become frail and others do not suggests an inherent or acquired variability in homeostatic pathways. recent evidence from observational studies has raised suspicion that dysregulated inflammatory processes are involved in, if not central to, the variable patterns of aging. increased serum levels of certain proinflammatory cytokines, most notably il-6, are increasingly present with advancing age and to a greater extent with frailty. 27, 28 furthermore, the appearance of this and other inflammatory markers has been associated with a number of adverse clinical outcomes, including decreased strength and mobility, falls, dementia, and mortality. 27 life expectancy, lifespan, and maximum survival from the perspective of those who study aging, there is an important distinction made between median (life expectancy) and maximum lifespan. over the past several decades, with the advent of modern sanitation, refrigeration, and other public health measures, including vaccination and antibiotics, there has been a dramatic increase in median survival. 29 early deaths have been diminished, and more patients are reaching old age. in the united states today, life expectancy now approaches 80 years. 30 median survival is what concerns public health officials and health care providers, but for those studying the biology of aging, it is maximum survival that is the focus of greatest attention. it is worthwhile to note that it has been estimated that if atherosclerosis and cancer were eliminated from the population as a cause of death, about 10 years would be added to the average lifespan, yet there would be no change in maximum lifespan. 31 although several theories have been proposed, none suffice to account for the complexities of aging. lifespan is finite and varies generally from species to species and much less so within species. mice live, on average, 2½ years, monkeys 30 years, and human subjects about 90 years. among species, larger animals generally live longer than smaller animals, but within species, smaller animals are likely to live longer. it is clear that aging is not entirely explained by dna sequence. for example, mice and bats have only 0.25% difference in their primary dna sequence, but bats live for 25 years, 10 times longer than mice. a commonly held notion is that regulation of gene expression accounts for a longevity difference between species. the aging lung large, longitudinal, and more complete studies to determine the effects of aging on the function of the respiratory system improved knowledge about lung structure-function relationships in older age using techniques of imaging and measures of lung function not requiring effort (eg, high-resolution computed tomographic scanning and forced oscillation) improved assessment of lung processes underlying airflow limitation attributable to aging versus copd or asthma, especially in asthmatic patients who smoke studies to examine the effects of aging in ethnic groups and the role of gender epidemiology, effect, diagnosis, and management determine the true prevalence and cost of asthma in the older population develop a uniform definition of asthma to be applied to health care records that will distinguish asthma from copd and mixed asthma/copd evaluate evidence-based treatment algorithms for older asthmatic patients, such as those developed by the national heart, lung, and blood institute and global initiative for asthma guidelines 7 assess the effect of asthma treatment, including direct medical costs of care, indirect costs of care, and value of treatment in improving quality of life 8, 9 assess the effect of comorbid conditions, especially copd and congestive heart failure, on asthma 9 characterize phenotypes of elderly asthma with regard to responses to therapy and long-term outcomes based on age of onset, duration of disease, and environmental triggers develop algorithms for electronic medical record systems that are asthma-specific evaluate effects of current asthma medications in older patients compared with younger patients identify pharmacogenetic determinants of response to asthma medications in older adults identify simpler and safer drug delivery systems and schedules for older adults develop simple methods to differentiate copd from asthma exacerbations in older adults understand how environmental or aging-related factors affect epigenetic changes in asthma in older adults identify differences between older and younger asthmatic patients or between lsa and loa with regard to inflammation, remodeling, intracellular mechanisms, responses to environmental pollutants, and allergy sensitization and their effects on the metabolism and action of asthma drugs identify naturally occurring age-related changes in airway cellular patterns develop animal models of age-related airway inflammation understand the significance of allergy sensitization associated with asthma in older adults (eg, through larger prospective studies) identify the utility of allergy tests, either skin tests or serum specific ige measurement, in reflecting allergy sensitization in older adults identify the role of the microbiome in patients with loa understand the role of non-ige mechanisms in older adults' inflammatory responses to inhalant allergens or pollutants (eg, t h 17 lymphocytes producing il-17 or protease receptor responses to molds and dust mites) determine the roles of adaptive versus innate immune mechanisms on asthma development, progression, and response to treatment in older adults determine whether there are environmental pollutants peculiar to institutional settings identify viruses and other microbiological agents responsible for, and the mechanisms by which they cause, asthma exacerbations in older adults, which might lead to the development of vaccine-or antiviral drug-based interventions determine effects of asthma medications, viral or bacterial load, or allergy status on susceptibility to exacerbations in older patients define rates of infection and specific pathogens in older asthmatic patients distinguish roles of innate immunity in eosinophilic versus neutrophilic asthma it is now clearly established that certain specific genes can alter lifespan, at least in lower animals, but whether these same genes regulate ''aging'' is still in question. for example, transgenic drosophila species expressing increased copies of the free radical scavenging enzymes superoxide dismutase and catalase live on average a third longer than the appropriate controls. 32 in even lower species (eg, yeast and nematodes) the identification of specific genes that influence lifespan 33, 34 has led to the optimistic impression that analogous genes in higher organisms will lead greater insights into the aging process. yet the identification and functional analysis of analogous genes in human subjects remains elusive. the oldest human being alive today is approximately 120 years old. what is intriguing is that the record has remained stable and unchanged by the public health initiatives mentioned above. in fact, there has been some recent data presented that the maximum survival is actually decreasing in the united states. 35, 36 what is interesting is that, unlike the public health initiatives in human subjects in which median but not maximum survival has been enhanced, experimental interventions in lower species have resulted in prolongation of maximum survival. as mentioned above, transgenic drosophila species producing extra copies of superoxide dismutase and catalase survived about 33% longer than controls, 32 and similarly, the maximum survival in c57bl/6 mice fed a calorically restricted diet enhanced by 50% or more. 37, 38 the true mechanisms of aging might well be uncovered with a better understanding of how these interventions affect longer survival. future research in aging should attempt to improve our understanding of the basic biology of aging and interventions that retard the aging process. there is a need for the development and application of a standardized definition of frailty for future clinical investigation. investigations directed at the role of comorbidities in accelerating the aging process are important. furthermore, future research should focus on the development of cellular and animal models of typical, delayed, and accelerated aging and of large collaborative networks in which populations and resources can be shared to study aging and frailty. leveraging on well-characterized existing cohorts, when possible, is recommended. the lungs, like other organs, age and exhibit continued loss of function as a person grows old. lung function is traditionally assessed by means of a number of standardized methods. the most common measurement used is spirometry with the determination of fev 1 and forced vital capacity (fvc). fev 1 and fvc both show continuous decreases of between 25 and 30 ml with each year of life after about age 20 years. 39 the cause of this decrease is usually attributed to the loss of the driving forces for airflow as a result of reduced respiratory muscle performance, loss of static elastic recoil, or both. 39, 40 the decrease in fev 1 in asthmatic patients is largely a function of the decrease in fvc because of the increase in residual volume. 41 stiffening of the chest wall and reduced respiratory muscle performance result in a decrease in total lung capacity and an increase in residual volume because of ever-increasing closing volume. 42 accordingly, these aging processes lead to airflow limitation that might be hard to distinguish from an active disease process. not all older persons are able to perform spirometry, especially those with decreased cognition, coordination, and frailty. in addition, spirometry is effort dependent, and the very old can tire quickly. techniques of imaging and measures of lung function not requiring effort (ie, forced oscillation) should be used in future studies to extend our knowledge about lung structure-function relationships at the very end of life. bronchodilator responses are known to be less marked in the elderly, perhaps as a consequence of the aging effects attributed to the emphysema-like state of the senile lung 43 ; however, this would not explain the slow temporal response to bronchodilators. other studies do not find such age-related bronchodilator differences. furthermore, although methacholine responsiveness has been reported to increase with aging, the exact mechanism for this is not apparent. increased incidence and prevalence of many lung diseases occur with age. alterations in immune function increase the risk of many of these diseases. studies of systemic immunity suggest that sustained antigenic stress over a lifetime leads to a decrease in naive t-cell numbers, an accumulation of memory t cells, and a decrease in t-cell repertoire and b-cell functions but a lesser decrease in innate immunity. 43, 44 little is known about what happens to the immune/inflammatory pathways in older asthmatic patients. the immune system changes seen with aging will be discussed in more detail in the section on pathophysiology. in the united states the national health interview survey asks questions regarding lifetime history of asthma, current asthma prevalence, and asthma attacks in the last 12 months. 3 for all age groups, asthma prevalence has been steadily increasing since 1980. for the 65 years and older age group, asthma is consistently more prevalent in female than male subjects. 3 the national center for health statistics tracks data on physician encounters for asthma. the national ambulatory medical care survey reported that those 65 years or older have the second-highest rate of outpatient office visits after those aged 0 to 4 years. those 65 years and older did not have significantly different emergency department visits than the other adult groups. the 65 years and older age group accounts for a greater proportion of hospitalizations (23%) than the size of its population (13%) would indicate. not surprisingly, the elderly population is a high user of medical resources for the treatment of asthma. hospitalizations and emergency department visits are more common for these patients than for other adult cohorts. some of the increased costs are related to comorbid disease. for example, the presence of comorbid chronic obstructive pulmonary disease (copd) increases the risk of an asthma-related hospitalization in medicare patients 3.6-fold, respiratory medical costs almost 6-fold, and total medical costs 2-fold. elderly female subjects appear at greater risk than elderly male subjects. [45] [46] [47] [48] asthma mortality increased steadily from 1980 until it peaked in 1998. the highest mortality rates for asthma occur in the 65 years and older group. in fact, the increase in asthma mortality between 1979 and 1989 was primarily driven by the 65 years and older group. in addition, the decrease in asthma mortality between 1999 and 2005 was most evident in this age group. elderly women with asthma tend to have higher mortality rates than elderly men with asthma. one reason for the increasing prevalence of asthma in the elderly might be the improved longevity of the population. also, increased office visits for asthma in the elderly might be responsible for fewer attacks. increasing hospital admissions might account for decreased mortality. by continuing to gather surveillance data on asthma, reasons for these trends could become clearer. in addition, surveillance data help to focus intervention efforts in areas of greatest need. in the cardiovascular health study, a large community-based cohort of subjects older than 65 years, questions were asked that were relevant to asthma and provided more insight into the prevalence and effect of asthma in this population. 5, 49, 50 definite asthma was defined as a positive response to the questions indicating that the patient had current asthma and that a physician confirmed the diagnosis. probable asthma was defined as a history of wheezing in the past year associated with chest tightness or breathlessness. excluding smokers and those with a diagnosis of congestive heart failure, 4% of subjects had definite asthma, and 4% had probable asthma. among those who smoked, 11% had definite asthma, and 14% had probable asthma. among nonsmokers, 185 subjects were identified who had definite or probable asthma; 76% were women, and 20% were older than 80 years. the age of asthma onset was spread approximately evenly among decades. twenty-seven percent had late onset of disease after age 60 years, and 25% had onset of disease before age 20 years. as expected, respiratory symptoms in the older asthmatic subjects were more prevalent, with a 2-to 5-fold increase in cough, phlegm, wheezing, and dyspnea. dyspnea on exertion was 1.6-fold more likely to be present in asthmatic patients than in those without the diagnosis. lung function was reduced in those with a diagnosis of asthma. mean fev 1 was 77% of predicted value in those with definite asthma and 89% of predicted value in those with probable asthma compared with 96% in those who did not have asthma. forty-one percent of those with a diagnosis of asthma had airflow obstruction below the fifth percentile for the age group, and peak flow lability was increased. elderly asthmatic patients reported the most common trigger was a viral infection in 58% compared with animal allergies in 30%. two thirds reported seasonal worsening. asthma had a significant effect on quality of life, with 35% of patients with definite or probable asthma reporting a fair or poor health status compared with 17% of elderly patients without asthma. sixty percent of patients with definite asthma reported seasonal allergic rhinitis compared with only 30% in the nonasthma group. despite the high prevalence and morbidity of asthma in this population, inadequate treatment was common. only 40% of those with definite asthma had a rescue albuterol inhaler, and only 30% had inhaled corticosteroid use. 5, 49, 51, 52 the pathophysiology of asthma in the older adult is poorly understood and understudied. many questions about this issue remain: is asthma the same disease in older adults as it is in children and younger adults? is late-onset asthma (loa; asthma that starts in middle age or older) different from longstanding asthma (lsa; asthma of early onset that has persisted into older adulthood)? if loa and lsa are the same disease, then the diagnosis and treatment should be similar. however, if loa and lsa are different phenotypes or at least have a different cause and pathophysiology, then the diagnosis and treatment might differ (table ii) . the traditional view of disease susceptibility has been expanded to include epigenetics to account for the influence of environmental factors and aging on the genomic blueprint. epigenetics is defined as heritable changes in gene expression that occur without alterations in dna sequence. it is the process by which genotype interacts with environment to produce a phenotype and explains differences between cells, tissues, and organs despite identical genetic information. genes function in a milieu determined by the developmental and environmental history of the cell, which constitutes the epigenotype. 53, 54 epigenetic changes or marks can play a major role in human disease. 55, 56 the most common examples of epigenetic marks are dna methylation of cpg islands by dna methyltransferases and chromatin modification of histone proteins, particularly acetylation by histone acetyltransferases and histone deacetylases. 57, 58 the function of epigenetic changes is to regulate gene expression. epigenetic changes are known to contribute to cancer and autoimmune disease and are thought to contribute to common diseases, including cardiovascular disease, diabetes, and the loss of response to stress caused by aging. 59 asthma is a markedly heterogeneous disease, and recent evidence suggests that environmentally induced epigenetic changes contribute to asthma phenotypes and that airway inflammation in patients with asthma and copd might involve epigenetic regulation. 57, 58, 60 methylation patterns and chromatin structure change with age and are thought to contribute to the increase in the incidence of common diseases that begin in middle age. 55, 61 the incidence of asthma in the elderly resembles the incidence of common diseases. moreover, characteristics and asthma drug response in the elderly asthmatic patient differ from those seen in childhood asthma. compared with younger cohorts, elderly asthmatic patients have a higher prevalence, higher rates of bronchial hyperreactivity, more severe asthma, and a lower prevalence of atopy. the symptoms of elderly asthmatic patients are more difficult to control with drug therapy, and these patients have steroid resistance and might respond better to leukotriene receptor antagonists compared with inhaled corticosteroids. [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] the contribution of epigenetics to differences observed between elderly asthmatic patients and younger cohorts is unknown. unlike genetic variants that contribute to disease, epigenetic changes can be reversed and therefore represent potential drug targets. 72 older asthmatic patients are less responsive to albuterol treatments given in the emergency department and are more frequently admitted for hospitalization. 73 thus it appears that the responsiveness to treatment is diminished and the severity of asthma exacerbations is greater. the exact reason for these disparities is not known. immune cell function decreases with aging, a property often termed immunosenescence. 74 one often-confusing aspect of immunosenescence is the observation that aging might be associated with opposing immunologic effects. for example, t-cell secretion of il-2, il-4, or ifn-g has been shown to be both decreased with aging and also increased with aging. 75 it is likely that both phenomena are correct but are dependent on the context of the immune function. thus the effect of aging on t-cell function in the context of allergen stimulation might be different than the effects of aging on t-cell function in the context of viral infection. given that asthma is an inflammatory disorder of the airway, it is of interest to determine whether asthmatic airway inflammation of the elderly might differ from that of younger asthmatic patients and thus represent a distinct phenotype of asthma. these changes might have implications for susceptibility to exacerbations because of viruses or other pathogens, as well as response to treatment. the aging process has been shown to exhibit changes in airway inflammation. an examination of the cellular composition of bronchoalveolar lavage fluid from 19-to 83-year-old subjects without a history of allergies, pulmonary disease, or gastroesophageal reflux showed increased airway neutrophilia, as well as increased numbers of cd4 1 t cells. 76, 77 the t cells also appeared to be more activated in the elderly, with increased expression of hla-dr and cd69. the increase in airway neutrophils with aging has also been observed in asthmatic patients. 78 because there is a phenotype of severe asthma characterized by a predominantly neutrophilic airway inflammation, 79 the question arises as to whether the increased presence of neutrophils contributes to greater asthma severity in the elderly. some of the prominent inflammatory cells recruited into the airway in asthmatic patients are eosinophils, neutrophils, and t cells, which are capable of secreting numerous inflammatory mediators, including leukotrienes and cytokines. it is not known whether immunosenescence affects the production of these mediators in elderly asthmatic patients, either at baseline or during an exacerbation of symptoms. furthermore, it is not known whether age-related changes in their production would have any implication for the clinical presentation or management of asthma in the elderly. peripheral blood eosinophils were isolated from younger (20-40 years old) and older (55-80 years old) subjects for in vitro functional assays. the eosinophil effector functions of degranulation and superoxide production were diminished in the older compared with the younger asthmatic patients. 78 in another study examining the expression of neutrophil mediators in younger and older asthmatic patients, there was decreased baseline expression of leukotriene b 4 in the sputum of older asthmatic patients despite greater numbers of neutrophils. 80 whether these findings have implications during an asthma exacerbation has yet to be determined. nevertheless, the results demonstrate agerelated changes in the function of an inflammatory cell considered pathognomonic for allergic asthma and raise the question of whether additional effects of immunosenescence are relevant to airway inflammation in asthmatic patients. there have been several studies of animal models to address age-related changes in the airway inflammation induced by allergen challenge of sensitized aged animals (see experimental approaches section below). these studies yielded conflicting results, and there is concern that the animal models do not accurately represent the chronic features of human asthma with seasonal allergen exposure and intermittent exacerbations. the aged animals were both sensitized and challenged at old age, which is in contrast to the typical elderly human asthmatic patient who might be exposed to allergens for several decades. typically, nasal and ocular symptoms on exposure to allergens diminish with age. allergen-triggered asthma symptoms also diminish with age. the epidemiology and natural history of asthma (tenor) study examined the natural history of asthma in older (>65 years old) compared with younger patients and found that older asthmatic patients had lower total ige levels, fewer positive skin prick test responses, and less concomitant allergic rhinitis or atopic dermatitis. 81 several studies have demonstrated age-related decreases in total ige and allergen-specific ige levels, [82] [83] [84] [85] [86] [87] suggesting that this might be the explanation for the decrease in allergy symptoms. there is also evidence for an age-related decrease in skin prick test responses to allergens. 88 however, the relationship between total ige levels and allergic disease persists in the elderly, such that subjects with greater ige levels remain more likely to have allergic rhinitis or asthma. 89, 90 given the changes in allergic inflammation with aging, one might conclude that asthma in the elderly should be milder. however, there are several other common triggers for exacerbations of asthma, including irritants (eg, cold air) and respiratory tract infections. estimates suggest that up to 80% of asthma exacerbations in adults are caused by viral upper respiratory tract infections. 91 the role of environmental exposures and allergy in older asthmatic patients is largely unknown. in the general population, evidence regarding the effect of indoor pollution on asthma is summarized in ''clearing the air: asthma and indoor air exposure'' by the institute of medicine for the environmental protection agency published in 2000. 92 evidence was reported for asthma development related to house dust mites and for asthma development associated with environmental tobacco smoke in preschool children. the report also showed evidence for causation of asthma exacerbations for house dust mite, environmental tobacco smoke (in preschool children), cat, and cockroach; an association with exacerbations was found for dogs, fungi, formaldehyde, and rhinovirus. in addition, evidence associating exacerbation of asthma-related symptoms with self-reported damp air was reported in a review of damp indoor spaces and health. 93, 94 there are only a few studies that have evaluated the role of atopy in elderly patients with asthma. one large national study of allergy skin tests that included older adults 95 and several small studies of allergy skin tests in older adults with asthma 81,96-103 j allergy clin immunol volume 128, number 3 were reviewed. allergy skin test results were positive in 8% to 12% of all older adults. the prevalence of positive skin test results or specific ige levels to at least 1 allergen in older adults with asthma ranged from 0% to 75%. those whose asthma had an unknown age of onset ranged from 27% to 60%, those with onset before age 41 years ranged from 56% to 62%, and those with onset greater than age 41 years ranged from 0% to 24% (table iii) . 97, 101, 102 although there were no studies of allergen room exposure or bronchial challenge in older adults, neither prick-puncture skin test results nor specific ige levels predicted the nasal challenge response to dust mites. 104 safety concerns for allergen challenges in older adults are unresolved. technical limitations of allergens, environmental measurements, and age-specific norms and cutoff levels for laboratory and physiologic tests are needed. a few epidemiologic studies suggest an association between outdoor environmental exposures and emergency department or hospital admissions in older adults. 105, 106 in summary, studies of the general population suggest a causation or association between indoor air pollutants and allergy exposure and asthma. there are several small studies suggesting higher levels of positive allergy test results in older adults with asthma than in the general population of older adults. when age of onset is considered, asthma with an early onset (<41 years of age) has a much higher association with positive allergy test results than late-onset asthma. viral respiratory tract infections are common precipitants of asthma exacerbations during childhood. in approximately 80% of children with acute asthma exacerbations, a respiratory tract virus can be detected, with rhinovirus being the most frequent pathogen identified. 107 although it is likely that viruses also lead to exacerbations of asthma in older adults, comprehensive studies regarding the rates and specific pathogens are lacking. several issues have made defining the role of viruses in adult asthmatic patients problematic and include difficulty distinguishing copd from asthma, lack of sensitive diagnostic tests, and issues with asymptomatic infection. a number of investigators have explored the incidence of viral infection in adult asthmatic patients. 91, 108, 109 older studies using viral culture and serology for diagnosis demonstrated infection rates of 10% to 29%. 109 in contrast, more recent studies, which include rt-pcr, have shown significantly higher infection rates of 44% to 55%. 91, 108 similar to results found in children, rhinoviruses are the most frequently detected pathogen. few older persons were included in these studies, in which the mean ages of subjects were 30 to 39 years. the incidence of acute respiratory tract infections decreases steadily with advancing age, and rates of viral infection in older adults are influenced by place of residence. 110 among community-dwelling older adults, rates of acute respiratory tract infections are roughly 1% to 2% per year, whereas rates in senior day care centers and long-term care facilities are substantially higher at 6% to 11%. 111 in addition, the epidemiology of respiratory tract infections can be quite complex in these semiclosed populations, with multiple pathogens circulating simultaneously. 112 influenza a, respiratory syncytial virus (rsv), and human metapneumovirus (hmpv) are the most commonly identified viruses among older persons hospitalized with acute cardiopulmonary conditions. 113, 114 most patients who require hospitalization during a viral respiratory tract infection have underlying heart and lung conditions. although studies to date have largely focused on the role of viruses in copd exacerbations, it is reasonable to extrapolate infection rates and specific pathogens from these studies to older adults with asthma. johnston, 115 in ontario, canada, found a seasonal peak in emergency department visits for all acute respiratory tract infections, as well as exacerbations of both copd and asthma, for persons younger and older than 50 years. all the common respiratory tract viruses have been associated with copd exacerbations, and depending on the methodology and season of study, the specific rates of influenza, rsv, parainfluenza viruses, coronaviruses, hmpv, and rhinoviruses vary. 116, 117 wheezing appears to be a common symptom in older adults infected with any of the respiratory tract viruses, particularly rsv and hmpv, and 7% of adults hospitalized with rsv will have a discharge diagnosis of asthma. 114, 118 because most adult infections represent reinfection, the viral load in respiratory secretions tends to be low, making detection with conventional techniques difficult. viral culture and rapid antigen testing, which can be used successfully in children, have poor sensitivity in older adults. the use of molecular diagnostics has vastly improved the ability to detect a number of viruses, such as rsv, parainfluenza, and rhinoviruses, and allows the detection of hitherto uncultivable agents, such as hmpv and coronaviruses. viral infections appear to aggravate reactive airway disease through a number of different mechanisms. it has been postulated that viral infection disrupts the negative feedback loop of acetylcholine on the m2 receptor, leading to increased levels of acetylcholine and increased constriction of bronchiolar smooth muscle. 119 infection of the respiratory epithelium also induces chemokines, cytokines, and immune and growth factors, which result in a proinflammatory state. 120, 121 immunosenescence might affect the ability of older adults to clear viruses efficiently, and thus greater and more prolonged inflammation can result. in summary, respiratory viral tract infections are common among older adults and are likely precipitants of acute asthma exacerbations. furthermore, viral respiratory tract infections might likely precipitate the onset of loa, although this needs to be further examined. 122 comprehensive studies regarding the rates and specific pathogens are lacking in older adults. distinguishing copd from asthma, lack of sensitive diagnostic tests, and issues with asymptomatic infections make it difficult to define the role of infections in older adults. classic symptoms of asthma in the elderly are mostly similar to those seen in younger asthmatic patients. 4, 96 data on the clinical features of asthma in the elderly have been derived from both longitudinal community surveys and case studies. 5, 64, 97, 98, [122] [123] [124] most patients complain of episodic wheezing, shortness of breath, and chest tightness. these symptoms are often worse at night and with exertion and, like those in younger asthmatic patients, are often precipitated by an upper respiratory tract infection. in fact, the majority of elderly patients who have asthma after age 65 years have their first asthmatic symptom preceded immediately by or concomitant with an upper respiratory tract infection. 122 asthma can often be triggered by environmental exposures, such as aeroallergens, irritants (cigarette smoke, household aerosols, and paints), strong odors (perfumes), and inhalation of metabisulfites (found in beer, wine, and food preservatives). asthmatic symptoms can also be triggered by medications, such as aspirin, nonsteroidal anti-inflammatory agents, angiotensin-converting enzyme inhibitors, or b-blockers, which are commonly used by this patient population. this emphasizes the need for the physician to perform a comprehensive review of medications taken by the older asthmatic patient. studies have consistently shown that elderly patients and their physicians frequently overlook symptoms caused by asthma. 5, 73, 125 several factors contribute to the underdiagnosis and misdiagnosis of asthma. one reason, as shown in large community studies, is that most patients first have asthma in childhood or adolescence, and many physicians have had the misconception that asthma is a childhood disease. another important reason is that the symptoms of asthma are more commonly associated with other diseases seen in this age group. the symptoms of asthma in the elderly are therefore nonspecific and might be caused by conditions that mimic asthma. the differential diagnosis of asthma in the elderly is greater than seen in younger asthmatic patients and includes congestive heart failure, emphysema and chronic bronchitis (copd), chronic aspiration, gastroesophageal reflux disease (gerd), and tracheobronchial tumors. comorbid illnesses and the psychosocial effects of aging might also profoundly affect the diagnosis, clinical presentation, and care of asthma in the elderly. one particular diagnosis that is often difficult to detect and frequently overlooked by the patient and physician until the condition is advanced is upper airway obstruction, including the extrathoracic and intrathoracic central airways. common causes of upper airway obstruction include malignancy, infection, inflammatory disorders, trauma, and extrinsic compression related to enlargement of adjacent structures (eg, an enlarged thyroid gland). it appears that malignancy and benign strictures related to airway instrumentation (eg, endotracheal intubation and tracheostomy) are becoming increasingly more prevalent in the older age group. distinguishing chronic asthma from copd can be very challenging, and in some patients asthma cannot be distinguished from copd with widely available diagnostic tests. the management of these patients might have similarities to that of asthma. the distinction between loa and copd can be difficult to define precisely. the lung health study showed that methacholine-induced airways reactivity is present in many patients with mild-to-moderate copd (ie, 63% of men and 87% of women). approximately 85% of patients with tobacco-related copd demonstrate bronchodilator reversibility at least once on repeated testing sessions. the distinction between copd and asthma can be confounded by either the coexistence of the 2 common disease entities, the progression of common pathobiologic mechanisms induced by different environmental agents, or different disease mechanisms leading to an overlapping clinical syndrome. it has been known for more than a century that early-morning wheezing is a prominent symptom of congestive heart failure. it has been called cardiac asthma because it can mimic the clinical picture of typical asthma. the usual symptoms of gastroesophageal reflux in the elderly, such as vomiting and heartburn, might be absent. in a study of elderly patients with esophageal reflux proved by means of intraesophageal ph monitoring, chronic cough, hoarseness, and wheezing were present in 57% of patients. 126 in addition to causing asthma-like symptoms, there is also evidence that gerd might be a cause of worsening asthma. shortness of breath is a common symptom in the elderly and is most commonly caused by heart or lung diseases. it is usually experienced during exertion. shortness of breath at rest is not typical of heart disease or lung diseases, such as copd or interstitial lung disease, except in advanced stages. when present, it should prompt an investigation for asthma because sudden bronchospasm can cause respiratory distress at rest or exercise. paroxysmal nocturnal dyspnea, which is typical of congestive heart failure, is found in a smaller number of elderly patients with asthma. many elderly patients limit their activity to avoid experiencing dyspnea, and others assume that their dyspnea results from their aging process and thus avoid seeking medical attention early in their disease process. however, aging per se does not cause dyspnea, and a cause needs to be always pursued in assessing an elderly patient who complains of breathlessness. there are several other reasons why the diagnosis of asthma in the elderly might be delayed or not made at all. elderly patients have been shown to have a reduced perception of bronchoconstriction, 127 and this might delay medical intervention. many elderly patients are fearful of having an illness and dying and are reluctant to admit they are having symptoms. underreporting of symptoms in the elderly might have many causes, including depression, cognitive impairment, social isolation, denial, and confusing symptoms with those of other comorbid illnesses. cough is a very prominent symptom and might occasionally be the only presenting symptom. wheezing, on the other hand, might not be as prominent, and its presence is not very specific and does not correlate with severity of obstruction. physical examination in elderly patients with asthma is usually nonspecific and might misguide the diagnosis: a negative examination result does not rule out asthma, and wheezing can be found in a number of conditions, such as copd, recurrent aspiration, and ''cardiac asthma'' (congestive heart failure). two distinct clinical presentations have been described for asthma in the elderly. these are based on the onset and duration of the disease state. 97, 124, 128 patients with loa start having asthma symptoms for the first time when they are 65 years of age or older (some studies have suggested middle age or older). some studies of elderly asthmatic patients have shown that, as a group, as many as 40% will have their first attack after the age of 40 years. 97 patients belonging to this group tend to have fewer atopic manifestations, higher baseline fev 1 , and a more pronounced bronchodilator response than those with lsa. patients with lsa start having asthma symptoms early in life. patients belonging to this group tend to have a higher incidence of atopic diseases, more severe and irreversible or partially reversible airway obstruction, and more hyperinflation. the duration of the disease in this group is an important determinant of severity and of the development of irreversible airflow obstruction. 128 longitudinal studies of asthmatic populations, whether new onset or long standing, have shown that remission from asthma is uncommon in older groups, occurring in less than 20% of patients. 130 this contrasts with asthma in children and adolescents, in whom remission of asthma symptoms is common, especially in the second decade of life, and might be seen in as many as 60% to 70% of patients. objective measures to confirm the diagnosis of asthma are uncommonly performed in primary care settings. inhalers are prescribed for patients who are evaluated for asthma-like symptoms, and during a follow-up visit, the patient is asked whether the controller inhaler reduced the frequency of asthma symptoms or whether the albuterol inhaler quickly relieved the symptoms. such an empiric approach might work most of the time for young patients with mild asthma but is more likely to result in an incorrect diagnosis, poorly efficacious treatment, or unnecessary medication side effects in older patients. the onset of wheezing, shortness of breath, and cough in an elderly patient is likely to cause concern. although the adage ''all that wheezes is not asthma'' is true at any age, it is especially true in the elderly. diagnosis based on objective measures is essential. moreover, lung function testing, even in the presence of minimal symptoms, is especially important in this age group because there is thought to be an age-related reduction in the perception of exertional dyspnea in the elderly. 125 an older patient with chronic, untreated, severe airway obstruction caused by asthma might reduce activity to avoid dyspnea and stoically deny impairment of activity. this might reflect either neurocognitive function or changes in lifestyle that favor sedentary activities. there exist some barriers to lung function testing in the elderly. spirometry might be difficult to perform in some situations because of physical or cognitive impairments. however, 80% to 90% of elderly persons are able to perform goodquality spirometry when tested by skilled technologists. [129] [130] [131] [132] [133] the global initiative for obstructive lung disease guidelines for diagnosing the airway obstruction of copd by using a fixed fev 1 /fvc ratio of less than 0.70 caused a high misclassification rate in older persons. 134 however, almost all computerized spirometers automatically calculate the appropriate lower limit of the normal range for fev 1 /fvc ratio and for fev 1 by using race-specific national health and nutrition examination survey iii reference equations. in addition, it is hard to define the lower limits of predicted normal values in this age group. although complete reversibility of airflow obstruction is frequently seen with young asthmatic patients, most elderly asthmatic patients show incomplete reversibility despite continuous intense therapy, and many show fixed airflow obstruction as if they have copd. however, objective measures of lung function, such as spirometric and peak flow measurements, are generally underused in elderly patients, and this also contributes to the delay or absence of diagnosis. 134, 135 lung function testing is especially important in this age group because of the age-related reduction in the perception of dyspnea seen in the elderly. 127 spirometry is easily performed to determine that fev 1 and fev 1 /fvc ratio are demonstrated with the timed vital capacity maneuver. the flow-volume loop, which also measures inspiratory flow, is especially useful when the cause of respiratory tract symptoms is not known and an upper airway obstruction is in the differential diagnosis. although it might be difficult to perform spirometry in the elderly in some situations because of physical and poor cognitive impairment, studies have demonstrated that between 82% and 93% of elderly patients are able to perform the test properly. [131] [132] [133] [134] [135] on the other hand, it might be more difficult to define the lower limits of predicted normal values in this age group. traditionally, an fev 1 /fvc ratio of less than 70% increases the probability of asthma in an elderly patient with asthma symptoms, but this ratio normally decreases with age because of a decrease in elastic recoil, and a ratio lower that 70% might be a normal finding. 136 a brisk response to a short-acting bronchodilator might demonstrate the second cardinal feature of asthma: reversible airflow obstruction (ie, ''a responder''). when airflow obstruction is found in an elderly patient, attempts should be made to demonstrate reversibility after the inhalation of a short-acting b-adrenergic agent, such as albuterol. evidence of reversibility (postbronchodilator fev 1 or fvc increases of >12% and 200 ml) increases the probability of a diagnosis of asthma. elderly asthmatic patients, however, might have an impaired b-agonist bronchodilator response because the number of b-adrenergic receptors on smooth airway muscles is decreased with aging. 137 although the bronchodilator response to inhaled b-agonists decreases with age, 138 this is not the case with anticholinergic agents. 139 airway obstruction might be absent at the time of testing, and further testing might be needed to facilitate the diagnosis. bronchoprovocation testing with a methacholine challenge can be useful, and it is a safe and effective method to uncover asthma in older adults. 140, 141 a negative test result will rule out asthma; a positive test result must be interpreted and include an assessment of pretest probability. 142 in addition, some studies have shown that bronchial responsiveness is heightened in older adults, and therefore aging might be an independent factor that influences airway responsiveness. 143 there is a relationship between the degree of bronchial hyperresponsiveness and prechallenge pulmonary function; a low fev 1 predicts heightened responsiveness. 144 other factors that might contribute to heightened airway responsiveness in the older population are atopy and current or previous smoking history. peak expiratory flow variability might be helpful in the diagnosis and follow-up of younger patients with asthma, but poor coordination and muscle weakness in some elderly patients might lead to an inaccurate reading. 52, 145 a prospective study did not demonstrate any advantage of peak flow monitoring over symptom monitoring as an asthma management strategy for older adults with moderate-to-severe asthma when used in a comprehensive asthma management program. 146 other tests, such as measuring the carbon monoxide diffusing capacity of the lung, have been advocated to distinguish between asthma and copd because the diffusing capacity of the lung is reduced by parenchymal destruction found with emphysema. however, studies have shown that differences in lung function tests, although statistically significant, cannot be used clinically to separate the 2 groups of subjects because of a large overlap. 147 there is growing evidence that the airway function of young and middle-aged asthmatic patients decreases at a greater rate than that of healthy subjects. [148] [149] [150] the rate of decrease increases with increasing age and in those who smoke cigarettes. 149, 151 in patients with loa, there is evidence that lung function is reduced even before a diagnosis is made and decreases rapidly shortly after diagnosis. 98, 152 thereafter, it remains fairly stable. although the effect on older asthmatic patients with lsa is variable, in a random survey of 1200 elderly asthmatic patients older than 65 years, only 1 in 5 patients had normal pulmonary function (fev 1 >80% of predicted value), whereas a similar number showed moderate-to-severe airflow obstruction (fev 1 <50% of predicted value) after an inhaled short-acting bronchodilator. 153 because structural changes of emphysema are minimal in elderly asthmatic patients, except if they are previous smokers, airway remodeling is thought to be the main cause of fixed airflow obstruction. nitric oxide (no) is a gas generated by the action of no synthase from the substrates molecular oxygen and arginine. it was originally identified as a biologically important signaling molecule with the properties of an activity previously described as endothelial-derived relaxing factor. this molecule is important in regulating vascular integrity and blood flow and is thought to be a regulator of vascular smooth muscle relaxation. more recently, it has been found that no can be generated by a variety of inflammatory cells, including polymorphonuclear leukocytes, mononuclear cells, and, importantly, eosinophils. this finding led to the identification of no as a molecule present in exhaled breath. studies of no exhalation have found that it is increased in infection and inflammation of the airway. although high levels of no are found in nasally expired air, studies in pulmonary inflammation have avoided this by redirecting airflow through the oral airway. it has been found that exhaled no reflects airways inflammation and particularly eosinophilic inflammation. exhaled no levels are increased during the allergy season in atopic subjects. inhaled glucocorticoids promptly suppress exhaled no and do so in conjunction with suppression of eosinophilic inflammatory infiltrates. studies have demonstrated that monitoring exhaled no might permit better regulation of asthmatic symptoms, exacerbations, and total steroid use than treatments based on guidelines or symptoms. furthermore, increases in exhaled no levels might predict asthma exacerbations. 154 it is of interest that no levels in expired air decrease after bronchoconstrictive stimulation of asthmatic airways. little is known of the effects of age on no levels in the expired air. it appears that no production and vascular responses to no might be diminished in the elderly, but that effect might be overcome by exercise to increase fitness. an unanswered question in airways biology is whether no is causative of airways dysfunction, a marker for this dysfunction, or an ineffective homeostatic response to airways constriction. [155] [156] [157] [158] [159] challenges in defining asthma in the elderly there is agreement that asthma is both a common and underrecognized health problem for the elderly that leads to impairments of lung function and quality of health and life. the first question that needs to be addressed is why we need to make such a diagnosis rather than just treat the symptoms. there are reasons that physicians must strive to assign a diagnosis to a patient with a symptom complex. the patient is given relief by letting him or her know what is wrong by giving the illness a name, which implies a cause, establishes a prognosis, and initiates a treatment plan. moreover, advancement of the understanding of epidemiology, natural history, pathobiology, and treatment require a definable disease entity. whether the threshold for diagnostic criteria is set at a high level of sensitivity, a high level of specificity, or a high level of accuracy depends entirely on the costs and benefits of an incorrect diagnosis versus a missed diagnosis. for example, enumeration of a disease might require a high level of accuracy, whereas diagnosis of an uncommon and difficult-to-treat disease (eg, metastatic cancer) ought to be highly specific. the diagnosis of a common and easily treatable disease (eg, vitamin deficiency) ought to be highly sensitive, even if there is a risk of overdiagnosis. asthma tends to be one of those disorders that is relatively easy (although not inexpensive) to treat and has morbid consequences if left untreated, suggesting that the diagnostic criteria ought to be highly sensitive. although medical students are taught the rigorous discipline of data collection, differential diagnosis, and test confirmation, most physicians do not practice this way. in practice, physicians typically rely on a constellation of signs and symptoms along with demographic characteristics and recent experiences to establish diagnoses through the process of pattern recognition. there are no shortages of official definitions of asthma, and modifications seem to be added every year. most of these definitions involve the definition of a clinical syndrome (episodic cough, wheezing, and dyspnea), an underlying pathophysiology (airway hyperresponsiveness, variable, and reversible airflow obstruction), an underlying biological process (chronic eosinophilic or neutrophilic inflammation of the airways), and an associated morbid anatomy (basement membrane thickening, smooth muscle hypertrophy, and mucus cell metaplasia). given this, why is it so challenging to diagnose asthma in the elderly? first, the syndrome of asthma is often confused with other common diseases in the elderly, such as copd, congestive heart failure, paroxysmal arrhythmias, pulmonary emboli, recurrent aspiration, and gerd. second, asthma can often coexist with these other conditions, and it can be impossible to determine which of the 2 conditions is responsible for the patient's ill health. this diagnostic confusion can be amplified by the different manifestations of asthma in the elderly. elderly asthmatic patients can be insensitive to exertional dyspnea because of a sedentary lifestyle. they tend to be less atopic and have an incomplete response to bronchodilators. the elderly without asthma tend to show some signs suggestive of asthma: slower emptying of the lung during forced expiration, decreased lung elastic recoil, and a higher prevalence of nonspecific airways reactivity. the hope that formal testing of airways reactivity would prove useful in diagnosing asthma has led to disappointment. in young adults a history of asthma, wheeze, or treatment for asthma plus a positive methacholine challenge test result is highly specific for asthma (99%) but misses about half of the asthmatic population. 160 in epidemiologic studies that have examined various criteria for diagnosing asthma, it turns out that the solution is relatively j allergy clin immunol volume 128, number 3 simple. patients who answer yes to the question ''have you ever had asthma?'' have nearly 100% specificity and 48% to 100% sensitivity when compared with those receiving an independent expert's diagnosis. 161, 162 the problem of diagnosing asthma in the elderly is more complicated because of the overlap with copd. asthma is typically considered a disease of onset in youth driven by atopy and eosinophilic inflammation causing reversible airflow limitation. copd, in contrast, is considered to be a disease of onset in middle age driven by cigarette smoking and neutrophilic inflammation and leading to irreversible airflow limitation. as evidence presented in this workshop has shown, asthma in the elderly displays many of the features of copd. the disease can have its symptomatic onset late in life, often is only partially reversible, and is associated with neutrophilic inflammation. moreover, the current cohort of elderly patients has a high prevalence of past smoking, reflecting the health habits in the united states in the 1940s and 1950s. the failure to deal with the population of elderly patients who have overlapping signs of asthma and copd is not just a matter of classification of disease. it has significant health consequences in that such patients are systematically eliminated from clinical trials and are not covered by treatment guidelines. little is known about how best to treat the elderly patient with asthma who smokes or the elderly patient with copd who has reversible airflow limitation. this confusion is manifest by diagnostic coding in older medicaid patients. of those who were hospitalized with an initial diagnosis of copd, 43% had an asthma diagnosis within 3 years. of those who had an initial hospital diagnosis of asthma, 46% had a diagnosis of copd within 3 years. price et al 161 attempted to develop a discriminant function using clinical and demographic information that would separate patients with copd from those with asthma by using strict physiologic criteria. although several discriminating characteristics were found, the best diagnostic criteria were only 78% sensitive and only 75% specific. we need to ask whether it really is important to make the distinction between asthma and copd in the elderly in terms of prognosis or treatment. one study by hansen et al 136 suggests that regardless of whether a person is given a diagnosis of asthma or copd, the prognosis is mostly determined by the impairment in fev 1 . there are a number of ways to measure the effect of asthma in both young and elderly patients. assessments of symptoms, functional limitations, quality-of-life measures, and risk of adverse events are several that have been suggested by current asthma guidelines. 163 in addition, measuring a patient's satisfaction with his or her asthma symptom control and overall asthma care has been advocated. the use of objective measures of asthma control and satisfaction can be especially important in the elderly because the perception of symptoms might be impaired with advancing age. in addition, many elderly patients unconsciously accommodate to their symptoms or assume that the symptoms are a function of the aging process itself. because the number of unscheduled ambulatory visits, emergency department visits, and hospitalizations are high in elderly asthmatic patients, 164 ,165 and quality-of-life scores are low in elderly patients with persistent asthma when compared with those with mild asthma or no asthma at all, 5 careful assessment of asthma control is essential in this age group. despite severe symptoms and physiologic impairment, most elderly patients with asthma can lead active productive lives if their asthma is appropriately managed. in fact, when elderly patients with severe or difficult-to-treat asthma have been identified by a physician's assessment, they appear to do better than younger patients. in the tenor study, despite lower lung function, older asthmatic patients (mean age, 72 years) had lower rates of unscheduled office visits, emergency department visits, and corticosteroid bursts. 81 patients reported in the tenor study received more aggressive care than younger adults, including higher use of inhaled and oral corticosteroids, and this undoubtedly had an effect on outcomes. the tools to measure asthma outcomes include questionnaires and other self-report tools, such as diaries and standardized medical history forms. standardized questionnaires that assess asthma impairment include the asthma control test, 166, 167 the asthma control questionnaire, 168,169 the asthma therapy assessment questionnaire, 170, 171 and others. [172] [173] [174] [175] there are many tools available to clinicians to assess the quality of life of asthmatic patients. [176] [177] [178] [179] [180] [181] [182] [183] unfortunately, these psychometric instruments that claim to measure the same outcomes might produce disparate results, and none have been targeted for the elderly. in general, results that measure several domains are more accurate when a composite score is derived rather than when subscores of specific domains are compared. medical, administrative, and pharmacy records have also been used, especially to study larger asthmatic populations; these have proved useful for the assessment of a patient's change over time and to measure group differences. clinical trials of asthma therapy and educational, selfmanagement, and health services interventions have used psychometric instruments to assess elderly patients with asthma. in most of these studies, however, the majority of subjects are younger. there are no studies that have specifically determined the reliability and validity of these instruments in elderly persons. this is true of patient-satisfaction measures that have been used to assess asthma care. [184] [185] [186] this is much needed because using lung function testing to measure outcomes has potential limitations in this age group. there are difficulties in defining normal predicted values at a very advanced age, and many patients with physical or cognitive impairment cannot reliably perform these tests. it is hopeful that newer biomarkers of lung inflammation have a particular role to play in the assessment of asthma control in the elderly. tools assessing physical function: self-reported and objective a major goal of geriatric and gerontologic research is to reduce the decrease in cognitive and physical function and prevent disability among older adults. accordingly, many functional status measures have been developed and used to understand the disabling process, as well as to evaluate interventions to prevent functional decline. it is useful to identify instruments that measure functional limitations and disability to investigate the functional consequences of asthma in older adults and to understand the pathway from asthma to disability. functional limitations are restrictions in performing basic physical and mental actions at the whole-person level (eg, walking or climbing stairs), whereas disability refers to limitations or difficulty in performing socially defined roles or tasks of everyday living in a given environmental context (eg, grocery shopping or bathing). 187, 188 both self-reported and objective measures can be used to measure these different stages of disablement. 189 self-reported measures can provide an indication of how well a patient is functioning in daily life and provide an assessment of care needs. these measures incorporate self-perception of function and can assess adaptations made to compensate for decrements in function. 190 for disability assessment, self-reported difficulty or inability to perform basic activities of daily living (adl) is commonly used. for example, a composite score of 8 adl items has been used as an outcome to evaluate the efficacy of a program to prevent functional decline in frail older adults. 191 other composite scores assessing difficulty in ambulation, stair climbing, transferring, upper extremity function, and basic and instrumental adls have been developed. 192 these comprehensive instruments of function and disability are amenable to computer adaptive testing. 193 several objective measures of physical performance are used in studies of older adults and in disease-specific patient populations. tests of physical performance eliminate subjective attitudinal differences in the patient's reporting of physical function limitations. they have the advantage of providing an objective measure for comparisons across populations. 194 these tests are sensitive to change over time and can detect decrements in function that might not be observed with self-reported instruments. many studies in older adults have used physical performance tests as predictors of adverse health events, as well as outcomes. for example, the short physical performance battery, which consists of timed balance, walking, and chair-rise tasks, is a powerful predictor of disability, nursing home admission, and mortality. 195, 196 the short physical performance battery was also used as a screening instrument to identify functionally limited older adults and as an outcome in a randomized controlled trial of exercise. 197 increasingly, objective measures of physical function are used to summarize the effect of total disease burden, including subclinical conditions and impairments, and to identify physiologic reserve that might help some older adults cope with disease burden. clinically meaningful differences have been established for commonly used performance measures. 198 the goals of asthma therapy in elderly patients are not different from those for younger asthmatic patients. 96 they are to treat acute symptoms, prevent chronic symptoms, decrease emergency department visits and hospitalizations, preserve normal activity level, and optimize pulmonary function with a minimal adverse effect from medications. 163, 199, 200 optimal management should also focus on improving health status (quality of life) in these patients, which is often complicated by depressive symptoms and side effects from the drugs commonly used for asthma. 201 unlike many younger adults who might require no medication or just asneeded b-agonist therapy for occasional symptoms, most older asthmatic patients need continuous treatment programs to control their disease. at a time when memory loss is common and financial resources are often limited, many older patients require complicated and frequent dosing with multiple expensive drugs. unfortunately, this has led to a significant rate of noncompliance among the elderly population in general. 45 sex, socioeconomic factors, educational level, marital status, and severity of disease do not seem to be good predictors of compliance in elderly asthmatic patients. in summary, there are many challenges in the treatment of asthma in the elderly, which include a greater propensity to experience adverse events from medication use, as well as potential drug interactions with medications used for the treatment of comorbidities, 4,96 and thus it is particularly important to treat any disease in the elderly, including asthma, with a minimum of therapy while attaining maximum efficacy. a thorough understanding is required regarding which medications will be most effective in the treatment of asthma in the elderly to achieve this balance. because many current therapeutic options and those in development for asthma focus on specific inflammatory cells and mediators, any age-related changes in the airway inflammatory milieu will likely affect their therapeutic efficacy. therefore a rigorous characterization of age-related changes in airway inflammation will facilitate the management of asthma in the elderly. the therapeutic approach to asthma in elderly patients does not differ from what is recommended for young patients. statements on the standard of care for treating asthma have been published by the national institutes of health and are widely used as guidelines. 163, 199 treatment protocols use step-care pharmacologic therapy based on the intensity of asthma symptoms and the clinical response to these interventions. as symptoms and lung function worsen, step-up or add-on therapy is given. as symptoms improve, therapy can be stepped down. in this age group special attention should also be given to the potential adverse effects of commonly used medications. corticosteroids are capable of reducing airway inflammation, thereby improving lung function, decreasing bronchial hyperreactivity, reducing symptoms, and improving overall quality of life. oral corticosteroids should be avoided if possible because they place the patient at risk for bone fracture and increased likelihood of cataracts, muscle weakness, back pain, bruising, and oral candidiasis. 202 many studies have shown that inhaled corticosteroids are safe and effective treatment for persistent asthma, but none have specifically targeted the elderly population. long-term use of inhaled corticosteroids has been associated with a good safety profile, but higher doses of inhaled steroids (eg, >1000 mg/d) are capable of causing hypothalamicpituitary-adrenal axis suppression. local adverse effects, such as hoarseness, dysphonia, cough, and oral candidiasis, do occur but can usually be avoided by the use of a spacer or holding chamber with the metered-dose inhaler and by rinsing the mouth after each use. despite the pivotal role of inhaled corticosteroids in asthma, many elderly patients are undertreated with this group of medications. 5, 203 leukotriene-modifying agents (ltms) are also asthma controllers. these agents have been shown to be effective in preventing allergen-induced asthma, exercise-induced asthma, and aspirin-induced bronchospasm. studies on their use in the elderly are limited. when compared with ltms, low-dose inhaled corticosteroids have favored the latter. the ltms might also reduce asthma exacerbation rates and the need for steroid bursts. the ltms are generally very safe. 66, 204 b-adrenergic agents are important medications in the acute and chronic management of asthma. elderly patients with asthma j allergy clin immunol volume 128, number 3 might be less responsive to certain bronchodilators compared with younger patients. 73, 138 inhaled short-acting b 2 -adrenergic agonists are the treatment of choice for the acute exacerbation of asthma symptoms. despite the minimal systemic absorption seen with these agents, slight tachycardia might be observed. this is presumably because of vasodilatation, which results from the stimulation of b 2 -receptors in vascular smooth muscle. tremor can also occur and is especially troublesome in the geriatric patient. tremor is thought to be caused by stimulation of b 2 -receptors in skeletal muscle. in general, they have been proven to be safe and effective in all age groups. 205 however, b-agonists can cause (1) a dose-dependent decrease in serum potassium levels and (2) a dose-dependent increase in the qt interval on electrocardiography. because sudden death from ventricular arrhythmia can be caused by both of these mechanisms, as well as being a complication of ischemic heart disease, the use of b-agonists in the elderly should be closely monitored. short-acting b 2 -agonists should be used for rescue of symptoms, whereas long-acting agents should be used as maintenance medications only as an add-on to inhaled corticosteroids and never as stand-alone therapy. anticholinergics, such as inhaled ipratropium, a short-acting bronchodilator, and tiotropium, a bronchodilator with 24-hour action, have an excellent safety profile in the elderly. they should be considered when additional bronchodilator therapy is necessary; however, their role in long-term maintenance of asthma in the elderly has not been established. theophylline is an effective bronchodilator and has some antiinflammatory properties. however, its use has been greatly reduced over the past decade because of safety concerns, especially in the elderly. the narrow therapeutic range of theophylline, the frequency of concomitant illnesses that alter theophylline kinetics, and many drug interactions that affect the clearance of theophylline make it essential to closely monitor blood theophylline levels in older asthmatic patients. theophylline toxicity can cause seizures and cardiac arrhythmias, such as atrial fibrillation, supraventricular tachycardia, ventricular ectopy, and ventricular tachycardia. the most common cause for theophylline toxicity is a self-administered increase in medication. controlling triggers. measures should be taken to avoid triggers that can cause worsening of symptoms. as with asthma at any age, education concerning avoidance of aggravating factors that can lead to severe bronchospasm is very useful. although aeroallergens are less important in provoking symptoms in the elderly than in young patients, a program implementing environmental control measures, such as avoiding or minimizing aeroallergen exposure, should be instituted in patients with documented sensitivity to specific allergens. however, such programs might not be successful in all cases, especially because lifestyle changes in the elderly population might be difficult. the most important provocative factors include viral respiratory tract infections and irritants, such as cigarette smoke, paints, varnish, and household aerosols. pharmacologic agents that are often prescribed for concomitant illnesses (ischemic heart disease and hypertension), such as b-adrenoreceptor antagonists (b-blockers), can also provoke bronchospasm. 206 this includes both noncardioselective agents (propranolol, pindolol, and timolol) and, to a lesser extent, cardioselective agents (metoprolol and acebutolol). topical b-blockers are also widely used in the elderly to reduce intraocular pressure in wide-angle glaucoma. with such treatment, sufficient systemic absorption might cause fatal status asthmaticus. 207 the severity of b-blocker-induced bronchoconstriction correlates with the severity of underlying airflow obstruction and the degree of bronchial reactivity and might be reduced by the use of a cardioselective topical b-blocking agent, such as betaxolol. 208 aspirin and nonsteroidal anti-inflammatory agents might precipitate acute bronchospasm in certain asthmatic patients, and angiotensin-converting enzyme inhibitors might cause dry cough in some, worsening the symptoms of asthma. gerd should also be considered a cause of worsening asthma symptoms. asthma education. the complexity of the prescription regimen (number and frequency of medications), coupled with the memory loss and cognitive dysfunction that might be present in this group of patients, contribute partially to poor compliance with therapy. 4, 96 patient education is an effective tool and should be an integral part in the management of asthma. 209 active participation by a patient and family members in monitoring lung function, avoidance of provocative agents, and decisions regarding medications provide asthma management skills that give that patient the confidence to control his or her own disease. mastering the technique of an inhaled medication delivery device is a challenging problem in elderly patients, and the great majority of elderly patients are unable to properly use the metered-dose inhaler, even after proper instruction. [210] [211] [212] [213] use of dry powder devices, although simpler, requires the generation of an adequate inspiratory flow that might be suboptimal in frail patients and those with severe airway obstruction. in such situations the use of spacer devices or nebulizers might be beneficial. patients should recognize the rationale behind using the different medications, the correct way to use them, and their side effects, and polypharmacy should also be avoided. asthma in the elderly can be effectively managed, and despite severe symptoms and physiologic impairment, most patients can lead active and productive lives. a demographic study of 380 low-income elderly persons in chicago found that 26 (10%) without a previous diagnosis of asthma or emphysema had symptoms compatible with those of obstructive lung disease. 214 of patients with a previous diagnosis, only 18% were compliant with medications, and this was largely due to the cost of medications. in addition, health care use was high in this population. telephone intervention offers a simple option in the management of elderly patients with asthma. it has been shown that asthma care by means of telephone triage of adult asthmatic patients can lead to a higher percentage of asthmatic patients being reviewed at less cost per patient and without loss of asthma control when compared with usual routine care in the outpatient clinic. 215 however, it has not been determined whether such an intervention could improve asthma care specifically in persons aged 65 years or older. the following study was designed to evaluate this question. fifty-two elderly asthmatic patients who used their rescue inhalers more than twice a week and had at least 1 emergency department or urgent care visit in the previous year were randomized to an intervention or control group. 216 all patients received 2 telephone calls over a 12-month period. the intervention group received an asthma-specific questionnaire, and the control group received a general health questionnaire. medication use and health care use were evaluated at the beginning and end of a 12-month period. the study was completed by 23 control and 25 intervention subjects. baseline data were similar in both groups. after 12 months, 72% (n 5 18) of the intervention group was taking an inhaled corticosteroid compared with 40% (n 5 10) of the control group. the intervention group had fewer emergency department visits when compared with the control group. sixtyfour percent (n 5 16) of the intervention group had an asthma action plan compared with 26% (n 5 6) of the control group. this study provides evidence that using a simple telephone questionnaire can successfully improve asthma care in the elderly. by empowering the elderly with the appropriate knowledge regarding their asthma, an appropriate discussion about their asthma care can be initiated with their primary care physicians. pulmonary rehabilitation. although pulmonary rehabilitation is recommended as the standard of care for patients with copd, there are only a few studies that evaluate the benefit of rehabilitation for asthmatic patients, and none of these consider elderly asthmatic patients. one study looked at the effects of a 10-week outpatient rehabilitation program for 58 asthmatic patients after 3 years. [217] [218] [219] they found that 39 of 58 subjects continued to exercise regularly all 3 years; there was a decreased number of emergency department visits and a decrease in asthma symptoms. further studies are needed to assess empowerment strategies for elderly patients with asthma, as well as the potential benefits of pulmonary rehabilitation on morbidity and mortality. asthma pathogenesis is complex and incompletely understood. research into the pathophysiologic mechanisms is made more difficult by multiple factors, including the heterogeneity of the disease itself, variable presentations in different stages of life, and the lack of highly relevant animal models. [220] [221] [222] [223] [224] in the last decade, increasing interest in asthma in the elderly has triggered more intensive investigation in both human and animal systems by using ever more sophisticated immunologic methodologies. early investigation with rats revealed a lack of total and allergenspecific ige in response to ovalbumin. 225 this was born out by several later in vivo studies. [226] [227] [228] igg subset analysis (igg 1 vs igg 2 ) provided further support for this phenomenon. igg 1 , correlating in the mouse to a t h 2 response (vs igg 2 [t h 1]) was shown to follow a similar pattern. 227, 228 recent studies [226] [227] [228] of cytokine profiles in aged rodents compared with young control animals enhanced the paradigm that age resulted in less robust t h 2 cytokines, particularly il-4, il-5, and il-13, in favor of t h 1 gene and protein expression. 227, 228 this pattern was not fully supported in a recent chronic murine asthma model 229 wherein il-5 was greater in aged sensitized mice, making the picture more complex. ifn-g, a key t h 1 cytokine, has been consistently overexpressed in aged versus young rodents. [226] [227] [228] [229] eosinophilia, which is considered a key component of (allergic) asthma, was more pronounced in younger versus older animals (bronchoalveolar lavage fluid, lung tissue, or both) after most, [226] [227] [228] 230 although not all, 229 sensitization paradigms. molecular genetics and t-cell subset analysis has allowed further insight into possible mechanisms underlying the waning t h 2 response observed in most models. [227] [228] [229] specifically, elderly mice appear to have more memory t cells, less activated cd4 1 t h 2 cells, and less activated monocytes. 227, 228 resident goblet cells also appear to express upregulation of mucin and mucin gene expression. 229 a key to the impaired t h 2 response was recently found in the gata3 pathway. 228 elderly mice do not phosphorylate components of the extracellular signal-regulated protein kinase/mitogen-activated protein kinase pathway, resulting in lack of downstream signaling with gata3, with subsequent impairment of promoter regions for key t h 2 cytokines, including il-4. this could be an overarching explanation for many findings in the elderly asthmatic patient, including less ige (il-4 and il-13 are needed for opening switch regions for ige production); il-4 and il-13 are highly associated with airway hyperreactivity, and il-5 is associated with eosinophil activation, survival, and, to a lesser extent, trafficking. finally, airway hyperreactivity has been universally found to be greater in young versus aged animals. [226] [227] [228] [229] 231 the mechanisms might be complex, including both an altered key cytokine milieu and alterations in muscle function at the muscarinic receptor level. [231] [232] [233] clinical and translational research research into the pathogenesis of asthma in recent years has led to the discovery of a number of novel, potentially important targets for the development of new treatment options. much of this research has focused on t h 2 lymphocyte-driven processes underlying allergic asthma and its characteristic eosinophilic airway inflammation. abundant information supporting this research has been derived from bronchial biopsy and bronchoalveolar lavage studies largely carried out in a young adult population. it is recognized, however, that the role of allergy and allergic triggers in asthma diminishes with age. 69, 234 in addition, loa is often less reversible, more severe, and frequently occurs in response to a viral respiratory tract infection. 153 a distinct asthma phenotype characterized by normal airway eosinophil numbers has been described. 235 moreover, normal airway eosinophilia might also be associated with abnormal sputum neutrophilia. 236, 237 recent studies have shown that neutrophilic asthma might be associated with activation of innate immune pathways in contrast to the adaptive immune response associated with t h 2-mediated allergic asthma. 238 thus alternative immune pathways involving natural killer t or t h 17 lymphocyte subtypes have been hypothesized as being potentially important in the pathogenesis of asthma, particularly in adult-onset asthma. 239, 240 just as the discovery of t h 2-related pathways has led to important leads in drug discovery for allergic asthma, further clinical research into these alternative pathways should be carried out with the goal of identifying new and exciting targets for future drug discovery. this research should focus not only on the discovery of new molecular targets but also on the identification of noninvasive biomarkers that will help predict the success of any new therapy in an individual patient. asthma is an important disease in the older adult, affecting 7% of the population older than 65 years, which is understudied and frequently underdiagnosed. there are data to suggest that asthma in older adults is phenotypically different from that in young patients, with a potential effect on the diagnosis, assessment, and management in this population. this workshop brought together many disciplines to further our current understanding, resolve gaps in knowledge, and explore future areas of research and education. table i lists specific areas in need of research and study. the coming acceleration of global population ageing the census bureau on prospects for us population growth in the twenty-first century. population and development review national surveillance for asthma-united states asthma in the elderly: current knowledge and future directions underdiagnosis and undertreatment of asthma in the elderly. cardiovascular health study research group increasing u.s. asthma mortality rates: who is really dying? quality of care for older adults with chronic obstructive pulmonary disease and asthma based on comparisons to practice guidelines and smoking status economic burden in direct costs of concomitant chronic obstructive pulmonary disease and asthma in a medicare advantage population report of the national institute on aging task force on comorbidity a painful interface between normal aging and disease epidemiology of aging correlation between deoxyribonucleic acid excision-repair and life-span in a number of mammalian species executing cell senescence a systematic look at an old problem overview of biological mechanism of aging molecular biology of aging replicative senescence: a critical review the limited in vitro lifetime of human diploid cell strains cell culture aging: insights for cell aging in vivo? the relationship between in vitro cellular aging and in vivo human age evidence for a relationship between longevity of mammalian species and life spans of normal fibroblasts in vitro and erythrocytes in vivo a biomarker that identifies senescent human cells in culture and in aging skin in vivo frailty in older adults: evidence for a phenotype phenotype of frailty: characterization in the women's health and aging studies from bedside to bench: research agenda for frailty gait speed and survival in older adults age-associated increased interleukin-6 gene expression, late-life diseases, and frailty decreased cell proliferation and altered cytokine production in frail older adults determinants of longevity: genetic, environmental and medical factors united states life tables gains in life expectancy after elimination of major causes of death: revised estimates taking into account the effect of competing causes extension of life-span by overexpression of superoxide dismutase and catalase in drosophila melanogaster a genetic pathway conferring life extension and resistance to uv stress in caenorhabditis elegans divergent roles of ras1 and ras2 in yeast longevity can an improved environment cause maximum lifespan to decrease? comments on lifespan criteria and longitudinal gompertzian analysis longitudinal gompertzian analysis of stroke mortality in the u.s., 1951-1986: declining stroke mortality is the natural consequence of competitive deterministic mortality dynamics nutritional interventions in aging and ageassociated diseases caloric restriction and aging physiological changes in respiratory function associated with ageing sex and age differences in pulmonary mechanics in normal nonsmoking subjects elasticity of human lungs in relation to age flow and age dependence of airway closure and dynamic compliance human immunosenescence: the prevailing of innate immunity, the failing of clonotypic immunity, and the filling of immunological space inflamm-aging. an evolutionary perspective on immunosenescence patient factors and medication guideline adherence among older women with asthma refill adherence by the elderly for asthma/chronic obstructive pulmonary disease drugs dispensed over a 10-year period deaths: final data for asthma costs and utilization in a managed care organization asthma and its association with cardiovascular disease in the elderly. the cardiovascular health study research group the cardiovascular health study: design and rationale prevalence and correlates of respiratory symptoms and disease in the elderly. cardiovascular health study correlates of peak expiratory flow lability in elderly persons intra-individual change over time in dna methylation with familial clustering epigenetic reprogramming and imprinting in origins of disease aging by epigenetics-a consequence of chromatin damage? epigenetics at the epicenter of modern medicine the role of histone deacetylases in asthma and allergic diseases environmental epigenetics and asthma: current concepts and call for studies epigenetics, disease, and therapeutic interventions epigenetic regulation of airway inflammation epigenetic differences arise during the lifetime of monozygotic twins predictors of loss of lung function in the elderly: the cardiovascular health study overcoming gaps in the management of asthma in older patients: new insights allergic respiratory disease in the elderly the diagnosis and management of asthma is much tougher in older patients effect of age on response to zafirlukast in patients with asthma in the accolate clinical experience and pharmacoepidemiology trial (accept) is asthma in the elderly really different? diagnosis and severity of asthma in the elderly: results of a large survey in 1,485 asthmatics recruited by lung specialists asthma in the elderly asthma medications and their potential adverse effects in the elderly: recommendations for prescribing interleukin 1 genetics, inflammatory mechanisms, and nutrigenetic opportunities to modulate diseases of aging trichostatin a attenuates airway inflammation in mouse asthma model prospective multicenter study of acute asthma in younger versus older adults presenting to the emergency department immunosenescence: emerging challenges for an ageing population pathways to a robust immune response in the elderly variation of bronchoalveolar lymphocyte phenotypes with age in the physiologically normal human lung neutrophils and low-grade inflammation in the seemingly normal aging human lung age-related changes in eosinophil function in human subjects asthma: defining of the persistent adult phenotypes characterization of leukotrienes in a pilot study of older asthma subjects asthma in older adults: observations from the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) study ige mediated hypersensitivity in ageing influence of ageing on ige-mediated reactions in allergic patients the association of age, gender and smoking with total ige and specific ige total and specific serum ige levels in adults: relationship to sex, age and environmental factors aging and serum immunoglobulin e levels, immediate skin tests, rast age-related serum immunoglobulin e levels in healthy subjects and in patients with allergic disease longitudinal changes in allergen skin test reactivity in a community population sample chronic respiratory symptoms and airway responsiveness to methacholine are associated with eosinophilia in older men: the normative aging study serum total ige and specific ige to dermatophagoides pteronyssinus, but not eosinophil cationic protein, are more likely to be elevated in elderly asthmatic patients respiratory viruses and exacerbations of asthma in adults clearing the air: asthma and indoor air exposures meta-analyses of the associations of respiratory health effects with dampness and mold in homes damp indoor spaces /media/files/report%20files/2004/damp-indoor-spaces-and-health/dampin door2pagerforpdf.pdf. accessed is allergen skin test reactivity a predictor of mortality? findings from a national cohort asthma in older adults asthma in the elderly. a comparison between patients with recently acquired and long-standing disease characteristics of asthma among elderly adults in a sample of the general population asthma severity, atopic status, allergen exposure, and quality of life in elderly persons asthma in the elderly sensitization to cat allergen is associated with asthma in older men and predicts newonset airway hyperresponsiveness. the normative aging study the role of allergy and airway inflammation asthma in the elderly: cockroach sensitization and severity of airway obstruction in elderly nonsmokers prick puncture skin tests and serum specific ige as predictors of nasal challenge response to dermatophagoides pteronyssinus in older adults particulate air pollution and hospital admissions for cardiorespiratory diseases: are the elderly at greater risk? traffic and outdoor air pollution levels near residences and poorly controlled asthma in adults community study of role of viral infections in exacerbations of asthma in 9-11 year old children respiratory tract viral infections in inner-city asthmatic adults the incidence of respiratory tract infection in adults requiring hospitalization for asthma acute respiratory illness in an american community. the tecumseh study acute respiratory tract infection in daycare centers for older persons long-term care facilities: a cornucopia of viral pathogens respiratory syncytial virus infection in elderly and high-risk adults human metapneumovirus infections in adults: another piece of the puzzle the similarities and differences of epidemic cycles of chronic obstructive pulmonary disease and asthma exacerbations a community-based, time-matched, case-control study of respiratory viruses and exacerbations of copd viral infections in patients with chronic obstructive pulmonary disease respiratory syncytial virus infection in elderly adults virus-induced asthma attacks how viral infections cause exacerbation of airway diseases role of viral infections in asthma and chronic obstructive pulmonary disease incidence and outcomes of asthma in the elderly. a population-based study in rochester, minnesota the clinical outcome of asthma in the elderly: a 7-year follow-up study characteristics of asthma in the elderly asthma in the elderly: underperceived, underdiagnosed and undertreated; a community survey determinants of symptoms suggestive of gastroesophageal reflux disease in the elderly reduced subjective awareness of bronchoconstriction provoked by methacholine in elderly asthmatic and normal subjects as measured on a simple awareness scale duration of asthma and physiologic outcomes in elderly nonsmokers asthma in the elderly features of asthma in the elderly factors determining performance of bronchodilator reversibility tests in middle-aged and elderly quality of spirometric performance in older people study of respiratory function in the elderly with different nutritional and cognitive status and functional ability assessed by plethysmographic and spirometric parameters quality control of spirometry in the elderly. the sa.r.a. study. salute respiration nell'anziano 5 respiratory health in the elderly aging on quality of spirometry reversible and irreversible airflow obstruction as predictor of overall mortality in asthma and chronic obstructive pulmonary disease differential changes of autonomic nervous system function with age in man impaired bronchodilator response to albuterol in healthy elderly men and women influence of age on response to ipratropium and salbutamol in asthma bronchoprovocation testing an assessment of methacholine inhalation tests in elderly asthmatics guidelines for methacholine and exercise challenge testing-1999. this official statement of the american thoracic society was adopted by the ats board of directors airway hyperresponsiveness in the elderly: prevalence and clinical implications normal range of methacholine responsiveness in relation to prechallenge pulmonary function. the normative aging study peak flow lability: association with asthma and spirometry in an older cohort a randomized clinical trial of peak flow versus symptom monitoring in older adults with asthma differences in airway inflammation in patients with fixed airflow obstruction due to asthma or chronic obstructive pulmonary disease are chronic wheezing and asthma-like attacks related to fev1 decline? the cracow study rate of decline of lung function in subjects with asthma decline of lung function in adults with bronchial asthma effects of domestic gas cooking and passive smoking on chronic respiratory symptoms and asthma in elderly women findings before diagnoses of asthma among the elderly in a longitudinal study of a general population sample the natural history of asthma in adults: the problem of irreversibility physical activity prevents age-related impairment in nitric oxide availability in elderly athletes effect of natural grass pollen exposure on exhaled nitric oxide in asthmatic children exhaled nitric oxide (no) is reduced shortly after bronchoconstriction to direct and indirect stimuli in asthma height, age, and atopy are associated with fraction of exhaled nitric oxide in a large adult general population sample use of exhaled nitric oxide measurements to guide treatment in chronic asthma exhaled nitric oxide: the effects of age, gender and body size defining asthma in epidemiological studies symptom-based questionnaire for identifying copd in smokers asthma and asthma-like symptoms in adults assessed by questionnaires. a literature review national heart, lung and blood institute national institute of health. national asthma education and prevention program: expert panel report 2-guidelines for the diagnosis and management of asthma. bethesda: national heart, lung, and blood institute asthma in older patients: factors associated with hospitalization asthma exacerbations in north american adults: who are the ''frequent fliers'' in the emergency department? development of the asthma control test: a survey for assessing asthma control validity of the asthma control test completed at home development and validation of a questionnaire to measure asthma control identifying 'well-controlled' and 'not well-controlled' asthma using the asthma control questionnaire association of asthma control with health care utilization and quality of life association of asthma control with health care utilization: a prospective evaluation a new tool for monitoring asthma outcomes: the itg asthma short form perceived control of asthma: development and validation of a questionnaire a 6-item brief measure for assessing perceived control of asthma in culturally diverse patients how should we quantify asthma control? a proposal reliability and validity of the asthma quality of life questionnaire-marks in a sample of adult asthmatic patients in the united states the marks asthma quality of life questionnaire: further validation and examination of responsiveness to change an evaluation of an asthma quality of life questionnaire as a measure of change in adults with asthma a scale for the measurement of quality of life in adults with asthma validation of a standardized version of the asthma quality of life questionnaire development and validation of the mini asthma quality of life questionnaire american translation, modification, and validation of the st. george's respiratory questionnaire a self-complete measure of health status for chronic airflow limitation. the st. george's respiratory questionnaire patient characteristics relevant to effective self-management: scales for assessing attitudes of adults toward asthma applicability of the asthma opinion survey in the spanish population: distribution and relationship with sociodemographic and clinical variables a new treatment satisfaction measure for asthmatics: a validation study an epidemiology of disability among adults in the united states. milbank mem fund q the disablement process assessing the building blocks of function: utilizing measures of functional limitation preclinical mobility disability predicts incident mobility disability in older women a program to prevent functional decline in physically frail, elderly persons who live at home a randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. the fitness arthritis and seniors trial (fast) creating a computer adaptive test version of the late-life function and disability instrument variation in thresholds for reporting mobility disability between national population subgroups and studies a short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability effects of a physical activity intervention on measures of physical performance: results of the lifestyle interventions and independence for elders pilot (life-p) study meaningful change and responsiveness in common physical performance measures in older adults naepp working group: consideration for diagnosing and managing asthma in the elderly. bethesda: national institutes of health asthma: a six-part strategy for managing older patients drug treatment of asthma in the elderly adverse effects of oral corticosteroids in relation to dose in patients with lung disease underuse of inhaled steroid therapy in elderly patients with asthma loss of response to treatment with leukotriene receptor antagonists but not inhaled corticosteroids in patients over 50 years of age are there any detrimental effects of the use of inhaled long-acting beta 2-agonists in the treatment of asthma? beta-adrenergic-blocking agents in bronchospastic diseases: a therapeutic dilemma respiratory arrest following first dose of timolol ophthalmic solution the effect of topical ophthalmic instillation of timolol and betaxolol on lung function in asthmatic subjects asthma in the elderly: the importance of patient education a comparison of breath-actuated and conventional metered-dose inhaler inhalation techniques in elderly subjects acquisition and short-term retention of inhaler techniques require intact executive function in elderly subjects what determines whether an elderly patient can use a metered dose inhaler correctly? asthma in the elderly. a diagnostic and management challenge prevalence of obstructive airways disease in the disadvantaged elderly of chicago targeted routine asthma care in general practice using telephone triage improving asthma care for the elderly: a randomized controlled trial using a simple telephone intervention asthmatic patients' views of a comprehensive asthma rehabilitation programme: a three-year follow-up a 3-year follow-up of asthmatic patients participating in a 10-week rehabilitation program with emphasis on physical training high-intensity physical training in adults with asthma. a 10-week rehabilitation program animal models of asthma usefulness and optimization of mouse models of allergic airway disease murine models of asthma modeling allergic asthma in mice: pitfalls and opportunities promise and pitfalls in animal-based asthma research: building a better mousetrap van der straeten m. the effect of age on ige production in rats decreased expression of th2 type cytokine mrna contributes to the lack of allergic bronchial inflammation in aged rats induction and maintenance of airway responsiveness to allergen challenge are determined at the age of initial sensitization impaired gata3-dependent chromatin remodeling and th2 cell differentiation leading to attenuated allergic airway inflammation in aging mice effect of ageing on pulmonary inflammation, airway hyperresponsiveness and t and b cell responses in antigen-sensitized and -challenged mice failure of aged rats to accumulate eosinophils in allergic inflammation of the airway age differences in cholinergic airway responsiveness in relation with muscarinic receptor subtypes effect of ageing on nicotine-induced contraction of guinea-pig bronchial preparation effects of age on muscarinic agonist-induced contraction and ip accumulation in airway smooth muscle total serum ige is associated with asthma independently of specific ige levels. the spanish group of the european study of asthma analysis of induced sputum in adults with asthma: identification of subgroup with isolated sputum neutrophilia and poor response to inhaled corticosteroids evidence that severe asthma can be divided pathologically into two inflammatory subtypes with distinct physiologic and clinical characteristics heterogeneity of airway inflammation in persistent asthma: evidence of neutrophilic inflammation and increased sputum interleukin-8 innate immune activation in neutrophilic asthma and bronchiectasis persistent activation of an innate immune response translates respiratory viral infection into chronic lung disease il-17 is increased in asthmatic airways and induces human bronchial fibroblasts to produce cytokines fla co-chair: nicola a. hanania, md, ms section of pulmonary and critical care medicine asthma clinical research center baylor college of medicine houston, tex members sidney s. braman, md warren alpert medical school, brown university division of pulmonary, critical care, and sleep medicine rhode island hospital providence, ri carol saltoun we thank the nia for recognizing the need for this workshop, especially susan nayfield, md, who convened the workshop and provided tremendous support in moving this research field forward; evan hadley, md, the director of the division of geriatrics and clinical gerontology; and basil eldadah, md, who continued the work of dr nayfield and contributed valuable advice and encouragement to the authors in completing these proceedings. key: cord-253182-s60vzf3q authors: fang, evandro f.; xie, chenglong; schenkel, joseph a.; wu, chenkai; long, qian; cui, honghua; aman, yahyah; frank, johannes; liao, jing; zou, huachun; wang, ninie y.; wu, jing; liu, xiaoting; li, tao; fang, yuan; niu, zhangming; yang, guang; hong, jiangshui; wang, qian; chen, guobing; li, jun; chen, hou-zao; kang, lin; su, huanxing; gilmour, brian c.; zhu, xinqiang; jiang, hong; he, na; tao, jun; leng, sean xiao; tong, tanjun; woo, jean title: a research agenda for ageing in china in the 21st century (2nd edition): focusing on basic and translational research, long-term care, policy and social networks date: 2020-09-21 journal: ageing res rev doi: 10.1016/j.arr.2020.101174 sha: doc_id: 253182 cord_uid: s60vzf3q one of the key issues facing public healthcare is the global trend of an increasingly ageing society which continues to present policy makers and caregivers with formidable healthcare and socio-economic challenges. ageing is the primary contributor to a broad spectrum of chronic disorders all associated with a lower quality of life in the elderly. in 2019, the chinese population constituted 18 % of the world population, with 164.5 million chinese citizens aged 65 and above (65+), and 26 million aged 80 or above (80+). china has become an ageing society, and as it continues to age it will continue to exacerbate the burden borne by current family and public healthcare systems. major healthcare challenges involved with caring for the elderly in china include the management of chronic non-communicable diseases (cncds), physical frailty, neurodegenerative diseases, cardiovascular diseases, with emerging challenges such as providing sufficient dental care, combating the rising prevalence of sexually transmitted diseases among nursing home communities, providing support for increased incidences of immune diseases, and the growing necessity to provide palliative care for the elderly. at the governmental level, it is necessary to make long-term strategic plans to respond to the pressures of an ageing society, especially to establish a nationwide, affordable, annual health check system to facilitate early diagnosis and provide access to affordable treatments. china has begun work on several activities to address these issues including the recent completion of the of the ten-year health-care reform project, the implementation of the healthy china 2030 action plan, and the opening of the national clinical research center for geriatric disorders. there are also societal challenges, namely the shift from an extended family system in which the younger provide home care for their elderly family members, to the current trend in which young people are increasingly migrating towards major cities for work, increasing reliance on nursing homes to compensate, especially following the outcomes of the ‘one child policy’ and the ‘empty-nest elderly’ phenomenon. at the individual level, it is important to provide avenues for people to seek and improve their own knowledge of health and disease, to encourage them to seek medical check-ups to prevent/manage illness, and to find ways to promote modifiable health-related behaviors (social activity, exercise, healthy diets, reasonable diet supplements) to enable healthier, happier, longer, and more productive lives in the elderly. finally, at the technological or treatment level, there is a focus on modern technologies to counteract the negative effects of ageing. researchers are striving to produce drugs that can mimic the effects of ‘exercising more, eating less’, while other anti-ageing molecules from molecular gerontologists could help to improve ‘healthspan’ in the elderly. machine learning, ‘big data’, and other novel technologies can also be used to monitor disease patterns at the population level and may be used to inform policy design in the future. collectively, synergies across disciplines on policies, geriatric care, drug development, personal awareness, the use of big data, machine learning and personalized medicine will transform china into a country that enables the most for its elderly, maximizing and celebrating their longevity in the coming decades. this is the 2nd edition of the review paper (fang ef et al., ageing re. rev. 2015). the research agenda in response to rapid population ageing in china has been broad, covering areas including the study of the ageing process itself in laboratory and animal studies, to clinical-level studies of drugs or other treatments for common chronic diseases, and finally policy-level research for the care of the elderly in hospital, community and residential care settings, and its influence on health and social care policies . chinese population statistics taken between 1950-2050 show a reduction in crude death rate (cdr) and total fertility rate (tfr), accompanied by an increase in life expectancy at birth and an expansion of the population aged 65 and above (65+, termed the elderly) (fig. 1a) . as of 2019, the population of mainland china constitutes 18% of global total, with 164.5 million chinese citizens aged 65+, 26 million of whom are 80+. by 2050, it is expected that there will be 1.4 billion chinese, with 365 million aged 65+, a number representing 26.1% of the country's total population (fig. 1b) . furthermore, among this ageing population, 115 million are expected to reach an age of at least 80 and 0.6 million are expected to become centenarians (fig. 1b) . when compared with their counterparts born a decade earlier, the current 80+ generation has reduced annual mortality and disability rates, but has increased cognitive impairment and reduced objective physical performance capacity (zeng et al., 2017b) . to achieve what may be considered a 'healthy ageing society', it is first important to address and prepare for the challenges and issues that are associated with rapidly ageing populations. ageing is the primary driver of most, if not all, chronic diseases, including cancer, cardiovascular diseases, diabetes, and neurodegenerative diseases, particularly alzheimer's disease (ad) and parkinson's disease (pd) (kerr et al., 2017; lautrup et al., 2019; lopez-otin et al., 2013) . the most predominant diseases affecting the elderly in china (65+, data from 2017) include sensory diseases, other non-communicable diseases, digestive diseases, respiratory infections and tuberculosis, skin and subcutaneous diseases, neurological diseases, and musculoskeletal disorders, among others (fig. 1c) . from 1990 to 2017, there were dramatic increases in prevalence of all 21 diseases, excluding a very minor reduction in 'neglected tropical diseases and malaria' (fig. 1c) . the major diseases responsible for death of the elderly in china are cardiovascular diseases, neoplasms, chronic respiratory diseases, and neurological diseases, among others (figs. 1d and 2). compared to their younger counterparts, the elderly population are more fragile, and susceptible to conditions such as cardiovascular diseases, chronic respiratory diseases, diabetes, kidney diseases, unintentional injuries, hiv/aids and sexually transmitted diseases (stds), among others (fig. 2b ). in comparison with data from 1990, new patterns of disease mortality characterize the modern elderly, such as a dramatic reduction in the percentage of death contributed by 'neurological disorders' with an increase in deaths due to hiv/aids and stds (fig. 2b, d) . recognition of the current disease demographics in the elderly in china, and accurate prediction of future trends will enable us to be best prepared for different healthcare needs at different times. in wake of the expanding ageing society in china, and the formidable socio-economic and healthcare challenges, we offer the 2 nd edition of our previously published review . here, we aim to provide an update regarding the situation of the elderly in china using a range of expertise and suggestions from multiple fields which may further propel the exciting and ongoing reforms to china's healthcare system. we hope to explore different ageing care models that can be used to best produce a healthy ageing society (chen, 2009; yip et al., 2019; zhan et al., 2019) . the following sections highlight recent developments in the above areas as well as areas for future research. based on ageing phenotypes and the major disease demographics in the elderly in china (figs. 1 and 2), we chose to focus on frailty (including sarcopenia as an independent subsection), cncds (including cardiovascular disease as an independent subsection), mental health disorders, dental health challenges, elderly infections and immune diseases, as well as hiv, syphilis, and other stds. in view of recent reviews on other grand challenges, including cancer tsoi et al., 2017) , chronic respiratory diseases (zhu et al., 2018) , diabetes and kidney diseases (hu and jia, 2018; wei et al., 2019) , these areas will not explored here. frailty is a biologic syndrome characterized by deteriorating function across a broad spectrum of physiological symptoms (fried et al., 2001) . it can be thought of as a state of vulnerability. some have proposed an index approach to categorize different degrees of frailty; however, these attempts are complicated by the multidimensionality of the underlying causes of frailty, thus creating a dynamic, ever-changing value that is difficult to index (rockwood et al., 2006) . the term physical frailty has been applied to age-related loss of muscle mass and function, that is sarcopenia (detailed in the next section). in recent years, frailty research has increased rapidly in china as a strategy to prevent disability in response to an ageing population (chhetri et al., 2019) . research projects were showcased in the following scientific conferences: the 1 st and 2 nd international china conference on frailty in china, jointly organized by the who collaborating centre on frailty, clinical research and geriatric training at the gerontopole, toulouse, france, the chinese embassy in paris, and the national clinical centre for geriatric diseases, china, and the 4 th asian conference for frailty and sarcopenia in dalian in october 2018, organized by the chinese geriatrics society, beijing institute of geriatrics and gerontology and the chinese health promotion foundation. wide-ranging topics included basic science, epidemiology, definitions and measurements, management, as well as service models. such conferences greatly accelerate basic and clinical research on as well as clinical treatment for frailty. frailty may be used as a population indicator of ageing, and be a useful indicator of a need for treatment. research into prevalence, risk factors, prevention, and incorporation into service delivery models in community, hospital and residential care settings are an important part of the ageing research agenda for china. the importance of recognizing frailty in communitydwelling older people in china has been highlighted in a systematic review and meta-analysis by he et al. (he et al., 2019a) . risk factors for a worsening in frailty among community-living older adults include hospitalizations, older age, previous stroke, lower cognitive function, diabetes and osteoarthritis, while higher socioeconomic status and neighborhood green space were protective factors (lee et al., 2014; yu et al., 2018c) . a comparison of prevalence and incidence of frailty between populations may stimulate further research into prevention strategies and inform government policies. using data from a nationally representative study, wu et al. found that 7% of community-dwelling adults aged 60 years or above were frail in mainland china and the prevalence increased dramatically with age, reaching 32.5% for those aged 85 years or above ). substantial regional disparities exist in the prevalence as well as incidence of frailty in mainland china. for example, the incidence rate of frailty in the northeast was more than double than that in the southeast . furthermore, a comparison of frailty and its contributory factors across three chinese populations (hong kong, urban and rural populations of taiwan) using the ratio of frailty index (fi) to life expectancy (le) as an indicator of compression of morbidity showed higher fi/le in taiwan compared with hong kong. risk factors include low physical activity and living alone . the importance of protein intake to slow the decline in muscle mass and physical function over four years supports the importance of nutrition as an underlying factor for physical frailty .the role of inflammatory cytokines in the pathophysiology of sarcopenia is supported by the finding of slower decline in grip strength for those in the highest quartile of telomere length (woo et al., 2014b) . simple tools for frailty and sarcopenia may be used in a community setting as case finding, without the need for professionally trained personnel (woo et al., 2014a; woo et al., 2015b) . this may represent the first step in the approach to community-based intervention such as group exercises with or without nutritional supplementation for frailty and sarcopenia (yu et al., in press; . how community services may be developed to make frailty as a cornerstone of health and social care systems (woo, 2018) depends on the development of existing community infrastructures. two examples have been described previously: the tai po cadenza hub, and the jockey club e health project, where screening data based on the who integrated care for older people toolkit (who) were collected via ipad, followed by action algorithms for items where action is indicated: e.g., frailty, sarcopenia. this model emphasizes the empowerment of older people and their care-givers, societal-level behavioral changes, and the use of technology in the absence of a low cost primary care system orientated to meeting the needs of older people (woo, 2019) . in the hospital setting, detection of frailty may inform choice of therapies and prognosis, such as mortality and hospitalization in chronic heart failure . closely related to the concept of frailty, sarcopenia is an age-related gradual loss of mass and strength of skeletal muscles resulting in reduced physical performance. major pathological features include a loss of satellite cells and motor neurons, as well as less active neuromuscular junctions (cruz-jentoft et al., 2010) . following the publication of the european consensus group on sarcopenia (cruz-jentoft et al., 2019; cruz-jentoft et al., 2014) , an asian group including chinese researchers formed a panel to arrive at a consensus on the definition of sarcopenia, published in 2014 , and recently updated in 2019. the asian criteria differed from the european consensus definitions. an individual international statistical classification of diseases and related health problems code (m62.84) was assigned to 'sarcopenia' which has stimulated both diagnostic and therapeutic trials worldwide. in china, sarcopenia diagnosis requires some special considerations, including anthropometric and cultural differences. the 2019 guideline of asia working group of sarcopenia (awgs) provides updated guidelines on epidemiology, case-finding, the diagnostic algorithm, measurements of muscle mass, muscle strength and physical performance, and intervention and treatment. the prevalence of sarcopenia is estimated to be between 7.3-12.0% among the general older population and was over 25% in the oldest populations (85+) wang et al., 2018a; woo et al., 2015a; xu et al., 2020, in press; yu et al., 2014) . while old age is the primary risk factor for sarcopenia, other risk factors in the chinese population include household status, lifestyle, physical inactivity, poor nutritional and dental status, and some diseases (osteoporosis, metabolic diseases, etc.). in terms of longer-term clinical outcomes, awgs-defined sarcopenia was significantly associated with increased risks of physical limitations at 4 years, slowness at 7 years, and 10-year mortality, but not of hospitalization wang et al., 2018a; woo et al., 2015a; yu et al., 2014) . interventional strategies for the elderly of china have been the subject of recent research. for instance, an intervention for community-dwelling older adults yielded significant improvements in muscle function based on which when protein was offered as an oral nutritional supplement in combination with resistance exercises (kang et al., 2019) . similar findings were reported in j o u r n a l p r e -p r o o f major behavioral risk factors that are responsible for cncds are prevalent among the elderly in china. nearly 80% of deaths are attributable to unhealthy diet, high blood pressure, smoking, high glucose, air pollution (indoor and outdoor), and physical inactivity (who, 2014) . in china, 56.6% of adults aged 60+ have insufficient dietary balance (daily intake of <400g fruit and vegetables), 22.4% are current smokers, 45% use unclean fuel for cooking, 84% are physically inactive, and 11.4% have harmful alcohol use (who, 2012) . risk factors for major cncds, particularly smoking and alcohol use, are unevenly distributed among older men and women. the prevalence of cigarette smoking is substantially higher among men (41.5%) than women (4.3%). the prevalence of harmful alcohol use among men is more than three times as much as that among women (13.3% vs. 4%). substantial rural-urban disparities in the distribution of risk factors exist among older chinese adults. rural residents have a higher prevalence of smoking (23.7% vs. 19.9%), harmful alcohol use (13.3% vs. 7.5%), insufficient dietary intake (60% vs. 49.5%), and unclean fuel use (89% vs. 7.1%) than those in urban areas, while residents of urban areas have a substantially higher prevalence of physical inactivity than their rural counterparts. 2016, cvd was ranked first in mortality rates, higher than the mortality rates attributed to tumors and other prevalent diseases. studies have shown that in 2013, age-standardized cvd mortality in china was 21% lower than in 1990 (gbd, 2015; zhou et al., 2019) . although the age-standardized cvd mortality rate has declined, the absolute number of cvd deaths is still rising rapidly, and increased by 46% between 1990 and 2013. cvd is a large burden for the chinese healthcare system. with the development of medical technology, and the government's focus on chronic disease management, the problem of cvd in china has improved. however, due to the problems arising from population ageing, cvd still has a great impact on national health. major factors for cvd include hypertension, dyslipidemia, diabetes, air pollution, and excess weight (overweight and obesity). some risk factors are specific to china compared to other countries, however, this is changing as china's economy develops and the population ages. hypertension is an important public health problem in china. the prevalence of hypertension in china among those over the age of 18 is 23.2%, and the number of patients with hypertension in china is estimated to be 245 million . in 2013, 2.5 million deaths were attributed to hypertension in china, accounting for 27.5% of all causes of death (trammell et al., 2016) . with the rapid development of the economy and the ageing population, problems with blood lipid levels in china have gradually increased, and the prevalence of dyslipidemia has increased significantly. the main symptoms of dyslipidemia seen in china are low levels of low-density lipoprotein cholesterol (ldl-c) and hypertriglyceridemia (pan et al., 2016) , while dyslipidemia in the west is characterized by hypercholesterolemia and high levels of ldl-c (toth et al., 2012) . with the change of lifestyle following china's economic development, the number of chinese diabetic patients is growing. overall, 47% of adults in china have diabetes or pre-diabetes, which is slightly lower than the 49-52% in the united states . in recent years, there has been a significant increase in the prevalence of excess weight (bmi: 24.0-27.9kg/m 2 ) and obesity (bmi≥28.0 kg/m 2 ) in chinese residents, as noted over a five-year study period (he et al., 2017b) . the prevalence of combined overweight and obesity among men was 33.8%. air pollution is another important factor leading to cvd. among different particles, pm2.5 (an aerodynamic diameter of 2.5 μm or less ) is most closely related to cvd (brook et al., 2010) . a follow-up study of cohorts of elderly people 65+ in hong kong showed that for every 10 μg /m 3 increase in pm2.5 concentration, the risk of total cvd death increased by 22% (wong et al., 2015) . air pollution is also associated with increased blood pressure. for each 10 μg/m 3 increase in pm2.5 concentration, the per capita systolic blood pressure level increased by 1.30 mmhg, the per capita diastolic blood pressure level increased by 1.04 mmhg, and the risk of hypertension increases by 14% . coronary heart disease, atrial fibrillation (af), heart failure, and atherosclerosis are common forms of cvd. technological developments have allowed for an increase in treatment options and testing methods, including percutaneous coronary intervention (pci), radiofrequency ablation, implantable cardiac defibrillator (icd) and pacemaker implantation. since elderly patients are often associated with more complications, treatment decisions for cvd in elderly patients need to be adjusted individually based on an overall scoring of health. coronary heart disease is a common fatal cvd. for the treatment of coronary heart disease, the number of pci cases has steadily increased in china (zhao et al., 2018b) . the creative study explored antiplatelet treatment options for patients after pci in china, and studies have shown that for patients with low response to antiplatelet drugs after pci, a triple antiplatelet intensive therapy combined with cilostazol is safe and effective (tang et al., 2018) . bleeding events should be paid special attention when administrating dual antiplatelet treatment to acs patients aged 75 and older receiving pci (zhao et al., 2018a) . the risk of all-cause, cardiovascular, and stroke deaths in patients with af is significantly higher than in patients with sinus rhythm . the proportion of chinese patients receiving anticoagulation treatments is low. only 12.7% of patients with af and a chads2 score of 2 or more received anticoagulation treatment . patients with af aged 75+ tend to higher chads2 scores but receive less anticoagulation therapy. the risk of one-year follow-up deaths and adverse events in the elderly is more than doubled compared to other populations yang et al., 2014) . cases of af ablation procedures and icd implantation have steadily increased in china. however, european danish studies suggest that primary prevention through icd implantation has limited benefits in elderly patients with non-ischemic cardiac diseases (kober et al., 2016) . therefore, it is necessary to pay attention to the indications when expanding the population eligible for icd implantation in china. in recent years, the etiology of heart failure in china has changed significantly. the proportion of valvular disease (especially rheumatic valvular disease) has decreased. as china is becoming an ageing society, the number of elderly patients with heart failure has increased. at present, most studies suggest that coronary heart disease is a common cause of heart failure in the elderly, and the proportion of hypertension and pulmonary heart disease in elderly patients with heart failure increases with age. in recent years, the use of diuretics in hospitalized heart failure patients in china has not changed significantly, while the usage rate of digoxin has shown a downward trend. the use of acei, arb, aldosterone receptor antagonists and beta-blockers have shown a significant upward trend . lower extremity atherosclerotic disease (lead) is a common disease in the elderly and an important starting point for systemic atherosclerosis. early detection of lead is of great value in the diagnosis and treatment of systemic atherosclerosis (hiramoto et al., 2018) . to reduce the burden of cvd in china, we recommend interventions directed at altering lifestyles and programs dedicated to the detection and management of risk factors, especially for elderly people. research modeling has shown that if dyslipidemia and hypertension are effectively managed, medical expenses to the tone of $932 billion us from 2016-2030 (stevens et al., 2016) . controlling blood lipids and blood pressure of elderly people over 65 years of age represents the most cost-effective strategy (stevens et al., 2016) . mental health disorders, particularly dementia and depression, are major diseases in the elderly of china. alzheimer's disease international (adi) estimates that over 50 million people worldwide were living with dementia in 2019, and that this figure will rise to 152 million by 2050; the current annual cost of dementia is estimated at 1 trillion us dollars which will be doubled by 2030 (adi, 2019). it is estimated that the number of patients with dementia in china constitutes 25% of the dementia population worldwide, with the prevalence of dementia ranging from 5.14% (95% ci 4.71-5.57, in 2014) to 5.60% (95% ci 3.50-7.60, in 2019) for individuals aged 65+ jia et al., 2014; jia et al., 2020) . the patterns and spread of dementia in china vary geographically and between genders. women are 1.65 times more susceptible than men. western china has a higher prevalence at 7.2%, while central and northern china are lower at 5.2 and 5.5%, respectively, southern china has the lowest prevalence at 4.8%, this variation is possibly due to a variety of reasons including diet, exercise, social networks, healthcare, etc. (chan et al., 2013; jia et al., 2020; wu et al., 2018b) . the incidence of dementia in individuals aged 65+ ranged from 17.7 to 24.0 per 1000 person-years using 10/66 dementia research group criteria, while it was 12.14 per 1000 person-years using dsm-iv criteria (jia et al., 2020; prince et al., 2012; yuan et al., 2016) . while health conditions such as depression, diabetes mellitus, and insomnia correlate with dementia in a global fashion, epidemiological evidence from different regions in china also suggests smoking and heavy alcohol consumption as high risk factors (fan et al., 2019; pei et al., 2014; xue et al., 2019) . depression, a risk factor for dementia, is a common but often neglected disease in the elderly in china . data from a cross-sectional study suggest a prevalence of depression of 39% in the elderly which increases to 45% in the most elderly (yu et al., 2012) . in view of the stigma of mental illness in some areas of china coupled with inadequate health services in rural areas, depression is likely underdiagnosed suggesting the real prevalence may be higher. in addition to its contribution to dementia, depression aggravates the quality of life of the elderly and of their family members, brings the risk of death caused by different reasons, and accordingly is a heavy burden on the society and the healthcare system (zhang and li, 2011) . much effort should be made to address mental health disorders in china, including increasing government investment, the training of more geriatric care professionals with specialties in mental disorders, and raising public awareness, especially in conjunction with more active social activities and exercises. although there have been increased care facilities for citizens 65+ and improved access to health services, the diagnosis and management of dementia and depression are still inadequate, especially in rural areas (jia et al., 2020) . the inclusion of steps to manage dementia in the 13 th five-year plan of the central chinese government marked a major step forwards, and such efforts need to be continued. in view of the insufficiency of medical professionals in regards to mental disorders, especially in rural areas, we recommend increased training to such professionals, and the development of policies to encourage health professionals to work (at least for a short period) in rural areas . in recent years, the public awareness of mental disorders, especially ad, has greatly improved thanks to efforts from social media (e.g., drama shows on ad) and dementia organizations. professional interventions, comprising medicine and combined cognitivepsychological-physical intervention (e.g., family and community support plus playing mahjong and practicing taichi) can mitigate subclinical depression and improve overall mental health (kong et al., 2019; wang et al., 2019c; wong et al., 2014) . although no drug at present is available to cure ad, recent progress on the understanding of ad etiology, such as the involvement of impaired mitophagy and reduced grid-cell-like representations in the human ad brain, along with the development of novel stem cell models, and the use of artificial intelligence (ai), will undoubtedly propel the development of novel drugs (fang, 2019; fang et al., 2019; gilmour et al., 2020; kunz et al., 2015; lin et al., 2018) . the china brain project, covering studies on basic neuroscience, brain diseases, and brain-inspired computing, will greatly benefit the development of novel drugs for different neurological diseases (poo et al., 2016) . while oral health is an important part of the whole body, the prevalence of oral disease is high in the elderly in china, but is largely ignored, while here we focus on dental health. dental caries (tooth decay), periodontal disease and tooth loss in the elderly are issues of global health concern. the burden on healthcare cost and the quality of life of these dental diseases in the elderly remain high . maintaining good dental health is an integral part of healthy ageing. as such, developing effective preventive and therapeutic interventions are needed to protect and enhance dental health and well-being tonetti et al., 2017) . dental caries and periodontal diseases are common oral diseases in the elderly and often lead to tooth loss, edentulism (toothlessness), impaired masticatory function and poor nutrition. according to the 4 th national oral health epidemiological survey (fnohes, 2015 (fnohes, -2016 covering the whole of mainland china, caries and periodontal diseases are highly prevalent in the elderly in china; while the prevalence of caries was above 50% in all age groups (3-5, 12-15, 35-44, 55-64, and 65-74 years) , the rate was 98% in the 65-74 years groups (lu et al., 2018; si et al., 2019) . in adults aged 65-74 years, 90.7% had periodontal diseases, including gingival bleeding (82.6%), dental calculus (90.3%) and a deep periodontal pocket (14.7%) (lu et al., 2018; si et al., 2019) . human oral tissues naturally and gradually degrade with age; a fact also exacerbated by modern lifestyle choices, including the prevalence of sugary diets and a lack of oral hygiene (belibasakis, 2018; lamster et al., 2016) . more specifically, age-dependent changes include a reduction in periodontal support, loss of elastic fibers, and thickening and disorganization of collagen bundles in the connective tissue of the oral mucosa (belibasakis, 2018; lamster et al., 2016; wu et al., 2016b) . severe dental health challenges can cause loss of self-esteem, social difficulties, while also being drivers of common diseases, such as ad, pd, diabetes, and hypertension (belibasakis, 2018; bollero et al., 2017; dominy et al., 2019; lamster et al., 2016) . major risk factors of the high prevalence of dental diseases in the elderly in china include the scarcity of dental health knowledge in the general population, low frequency of daily oral hygiene practices, insufficiency of dental care services, and unhealthy diet habits. daily oral hygiene practices are effective for removing plaque and preventing gingivitis. the average awareness rate of dental health in the chinese elderly was 47.6%, only 30.1% of the elderly brush their teeth twice daily, and a mere 0.8% used dental floss (lu et al., 2018; si et al., 2019; . increased attention to the dental health needs of an ageing population urgently requires combined efforts by relevant stakeholders (lu et al., 2018; si et al., 2019; tonetti et al., 2017; . specifically in the case of older adults, knowledge and competence in oral care, awareness of medical comorbidities and of medications relevant to oral care should all be strengthened. epidemiological surveillance and monitoring of oral diseases and oral healthrelated quality of life in the elderly is needed. oral self-care, access to treatments and preventive services and assuring the affordability of dental care are critical for oral health. looking after teeth and gums by brushing twice a day with fluoride toothpaste and cleaning with dental floss are effective in achieving a good oral health status. likewise, the control of risk factors, such as refraining from the frequent consumption of foods and drink high in sugar, and refraining from smoking, are also important. provisions to expand services to older adults, to meet increasing oral healthcare needs in the ageing population, and to ensure the affordability of dental care should all be emphasized by policymakers. we suggest programmes that promote general oral health education as well as public outreach programmes directed towards the elderly via understandable brochures, and the use of television and other social medias. additionally, it is important to improve the country's dental care infrastructure by training more dentists and oral specialists and ensuring the provision of affordable dental healthcare. it has been well documented that altered immune system components and function are characteristic of ageing and form part of the causes of age-related diseases (nikolich-zugich, 2018) . in ageing, a significant decline in the homeostatic, defensive, and surveillance functions of the immune system is noted. prominent features of the ageing immune system include thymus involution, a decrease in naïve lymphocytes, and an accumulation of memory and senescent lymphocytes; more recently, the concept of 'inflammageing' has been developed (ferrucci and fabbri, 2018) . functionally, impaired immune defense, especially against new antigens for which no memory exists, makes older adults increasingly vulnerable to incident and more severe infections. in addition, a decline in immune surveillance hampers the elimination of premalignant cells, leading to cancer development. older adults also manifest a chronic low-grade inflammatory phenotype (clip), a manifestation of the inflammageing concept, that likely results from uncompensated inhibitory immune regulation and/or an inability to eliminate senescent cells (chen and yung, 2019; chen et al., 2019b) . as such, immune dysregulation is a general feature of ageing. here we provide an update on infectious diseases in the elderly in china. we carried out a comprehensive review on infections in china based on the following public databases: the chinese center for disease control and prevention (ccdc), the data-center of china public health science (ccdc, 2019), and the national bureau of statistics of china (nbsc, 2019). the three most common infectious diseases in 2017 were viral hepatitis, pulmonary tuberculosis (tb) and syphilis (detailed in section 2.8) while the three with the highest mortality rate were aids, tb, and viral hepatitis ( fig. 3a-d) . of note, pulmonary tb was more prevalent than the other two in older adults over 65 years of age (fig. 3c ). generally speaking, infectious diseases are more frequent and deadly in older adults, as seen with the recent 2019-ncov epidemic worldwide huang et al., 2020) ; thus, infectious diseases deserve more attention. viral hepatitis is caused by the hepatitis viruses a, b, c, d, and e (hav, hbv, hcv, hdv, hev) and is prevalent throughout the world, posing a significant threat to human health. china is a highly epidemic area of viral hepatitis with 86.6 million people infected with hbv and 7.6 million infected with hcvas of (who, 2018 . in 2018, there were 1.28 million new cases and 531 deaths among the chinese population (nbsc, 2018) . according to the chinese statutory infectious disease report, viral hepatitis mainly occurred in adults between 20 to 65 years old (83.68%, fig. 3e ). its morbidity in older adults was estimated to be 13.52% in 2016 ( fig. 3e ). however, compared with the morbidity, the mortality of viral hepatitis was higher (28.31%) in the aged population ( fig. 3e ). from the survey, the morbidity and mortality rate of viral hepatitis have ranked in the top five for many years. the morbidity of viral hepatitis was stable in last decade, which is likely due to the wide usage of the hepatitis vaccine ( fig. 3g , h). however, the morbidity of hepatitis in the elderly continues to increase yearly. since most cases of viral hepatitis developed into chronic hepatitis, the lifespan extension seen in china has contributed to a higher number of elderly hepatitis cases. luckily, the mortality of hepatitis has declined in both the aged population and the population at large (fig. 3h ). among the five hepatitis viruses, hdv is rarely detected and is not discussed here. hcv (20.13%) and hev (22.6%) demonstrated high morbidity in the aged population (fig. 3f) . however, the highest mortality is caused by two acute types, hav (60%) and hev (66.7%) (fig. 3f) , indicating a weakened immune responses against acute infection in the elderly. significantly, both the morbidity and mortality of hbv in the aged population were lowest among the four types ( fig. 3f ), further indicating the benefit of the hbv vaccine. however, prophylactic vaccines for hcv and other types of viral hepatitis are still lacking. for patients who have been infected, current treatments are still limited, especially for the elderly patients. one of the reasons for this is the lack of a long-term infection model for use in laboratory conditions (winer et al., 2017) . developing an elderly-representative model would be a useful tool for screening treatment options for those affected by hepatitis diseases. mycobacterium tuberculosis and is typically transmitted through coughs and sneezes. the lack of global tb control is the result of several factors, including hiv coinfection, limited vaccine efficacy, a lack of highly specific and sensitive diagnostic tests, and the rise of multidrug-resistant (mdr) and extensively drug-resistant (xdr) tb strains (venketaraman et al., 2015) . according to the who's 2019 global tuberculosis report, china is ranked third in terms of tb burden when compared with other countries (who, 2019a). pulmonary tuberculosis (p-tb) is the second highest ranked cause of morbidity and mortality among the 28 infectious diseases ranked in 2017 (fig. 3a, b) . however, it is the most frequent infectious disease in the elderly (fig. 3c ). the elderly occupied more than half (54.9%) of all deaths from p-tb (fig. 3e ). in the last decade, the incidence of p-tb has decreased year to year, however, the incidence and mortality rates of p-tb in the elderly remains high in china (fig. 3g , f). there are several reasons for the high incidence and mortality rates of p-tb in the elderly: i) an increasingly ageing population; ii) immune decline; iii) delay of diagnosis and treatment. with the increase of the number of elderly patients, p-tb is rapidly becoming a new public health challenge. several risk factors, such as immune decline, smoking, malnutrition, hiv infection and other chronic diseases, make the elderly susceptible to tb . compared with p-tb in the young, p-tb in the elderly has its own characteristics. elderly patients with p-tb are more contagious than the young, and elderly men are more likely to suffer from tuberculosis than elderly women (lee et al., 2017) . in the elderly, early symptoms of tb are atypical and insidious, and can result in misdiagnosis (rajagopalan, 2001) . furthermore, chronic fibrous cavitation and hematogenous disseminated tb are more common in the elderly population. most elderly patients with p-tb get tb in their youth at which time it is better controlled but, as they age, p-tb can result as immune function declines. moreover, elderly tb patients usually present with several complications, which further complicates diagnosis and treatment (nagu et al., 2017) . all these characteristics have brought special focus on the treatment and diagnosis of tb in the elderly. at present, there are several tb guidelines for high-risk groups (who, 2016b), but few for the elderly. previous studies in the elderly have also focused less on the evaluation of targeted strategies for control and prevention. thus it is necessary to pay more attention in the future to the production of control programs and evaluation of targeted interventions for tb in the elderly. aids is a chronic, potentially life-threatening infectious disease caused by hiv, which was first detected in the united states in 1983 ( barré-sinoussi et al., 1983) . in the last decade, the morbidity and mortality of hiv/aids has increased yearly ( fig. 3g, h) , and it has become the top cause of death by infectious disease in china, including in the elderly (fig. 3b, d) . the morbidity and mortality of hiv/aids in the elderly population is also rising significantly, and notably the mortality in the elderly is much higher than that seen in the young (ccdc, 2016). furthermore, because elderly people have many basic diseases and low awareness of selftesting after hiv infection, the elderly are more likely to already be aids patient at the time of diagnosis of their hiv infection (xing et al., 2014) . a study has shown that 35.5% of newly diagnosed elderly hiv infectors had already developed into the aids stage (liu et al., 2012) . with increasing use and efficacy of antiretroviral therapy for hiv infection, the lifespan of hiv/aids patients has been greatly extended, and more and more hiv/aids patients will enter old age (nizami et al., 2019) . the problem of hiv/aids in the elderly will become increasingly serious in the future. firstly, hiv infection is not commonly checked in the elderly in china upon visit to the hospital, which may lead to uncontrolled disease progression and infection to others. second, the treatment of aged hiv/aids patients may cause more adverse effects, such as cardiovascular disease (hanna et al., 2016; kramer et al., 2009) , ad (brousseau et al., 2009) , and diabetes (guaraldi et al., 2018) . furthermore, cognitive disorders, loneliness, shame and depression may increase the likelihood that they fail to follow their drug regimen, or refuse treatment altogether (greene et al., 2018; vincent et al., 2017) . interestingly, hiv infection is also likely a driver of early ageing, as aids patients age more rapidly than the general healthy population (he et al., 2019b; lin et al., 2019) . to address these problems, the diagnostic process in the aged population should be addressed more cautiously; therapeutic drugs and technologies suitable for the elderly patients should be developed. special attention should also be paid to psychological problems of elderly patients. the hiv epidemic as a sexually transmitted disease will be discussed further below. influenza is an acute viral infection caused by the influenza virus. at present, a total of four types of influenza viruses have been identified, including influenza a, b, c, and d (iav, ibv, icv and idv) (petrova and russell, 2018) . among them, only iav and ibv are able to cause seasonal epidemics and clinical disease. yearly, the extent of the influenza pandemic varies around the world, which causes high morbidity and mortality. because elderly individuals above 65 years of age are immunocompromised and may have preexisting conditions, they are more susceptible to influenza infection and its complications. data accumulated in the last decade showed that the morbidity of influenza has increased in both the general and aged populations (fig. 3g ). like other acute infections, the mortality of influenza in aged patients was higher than in younger population (fig. 3h ). during january 1, 2018 to september 28, 2019, a total of 1626 severe influenza cases were reported in hong kong, among which 1058 patients (65.07%) were over 65 years old (chp, 2019b). in 2018, a total of 5984 influenza cases were reported in macau, among which there were 188 cases were over 65 years (hbgm, 2019a) . however, only a small number of influenza cases acquires laboratory confirmation, as patients usually die of other related illnesses brought on by influenza. thus, the influenza-related mortality rate is greatly underestimated. in 2012, the ccdc estimated that the death rate caused by influenza was 18/100000 in northern china and 11.3/100000 in southern china, and most of the deaths occurred among people aged over 65 years (77.8% in southern cities and 69.6% in the northern) (feng et al., 2012) . the excess mortality of respiratory and circulatory diseases caused by influenza was 12.4/100000 and 8.8/100000, respectively, among which 86% occurred in people aged over 65 years (feng et al., 2012) . pneumonia is an acute respiratory infection that affects the lungs, which is especially deadly in children under 5 years and in the elderly (65+). pneumonia has become one of the major causes of death for the elderly over 65 years. the harm and mortality of pneumonia increases with age. the "2018 china health statistics yearbook" reported that the mortality rate (/100000) of urban residents aged 65-69, 70-74, 75-79, 80-84, and over 85 with pneumonia was 19.63, 34.48, 68.38, 219.07 and 865.53, respectively; and that of rural residents was 11.62, 23. 67, 48.61, 127.90 and 445.93, respectively (nbsc, 2018) . since 2003, pneumonia has been one of the top three causes of death in hong kong (chp, 2019a) . according to statists by the hong kong centre for health protection, the mortality rate of pneumonia was 39/100000 in 2017, with a total of 8032 pneumonia-related deaths. of these cases, 94.68% occurred in people aged over 65 years (chp, 2019c) . in macau, pneumonia also has been cited as one of the top three causes of death for many years (hbgm, 2019b). in summary, old age is known to affect the immune system negatively. immunocompromised elderly adults are more susceptible to common diseases such as influenza and pneumonia, both of which were responsible for many deaths in this age group. in some cases, these infections may lead to complications that then lead to death, and this likely contributes to underreporting, hiding the true effects of influenza and pneumonia. there are multiple methods for improving and maintaining healthy immune function in the elderly: physical activity and exercise are known to enhance the immune system, however effective ranges still need to be established and disseminated (venjatraman and fernandes, 1997) . additionally, the development of vaccines must be prioritized, although challenges exist such as finding suitable mass production methods. perhaps surprisingly, sexually transmitted diseases (stds) are becoming an increasing problem among older age groups. many people aged 50 years or older in china remain sexually active, and the shift towards nursing homes has led to an increase in exposure to possible sexual partners (yang and yan, 2016) . unfortunately, many older adults do not take precautions in their sex life, due to reasons such as a decreased worry about pregnancy (tht_uk, 2018) . high-risk sexual behaviors render them vulnerable to the transmission of hiv and other sexually transmitted diseases (stds), likewise low awareness of the potential risks and low use of sexual health services can result in late diagnosis and treatment of stds among older adults. we here describe the current situation of hiv/aids and other stds in older adults in china, and propose potential preventative measures. as mentioned before the incidence and proportion of older adults in the total number of reported hiv/aids cases is on the rise in china (fig. 3a-d) . the rise in both the number of absolute cases and the proportion of std infections was observed in both genders. the vast majority of cases in older adults resulted from heterosexual copulation, and has brought about an alarming increase in the rate of new infections. for example, in chongqing, the proportion of hiv infections reported in those aged 50 years and older increased dramatically from 27 to 58.4% between 2011 and 2019 (chinanews, 2019)at the same time, the overall number of male cases quadrupled, and the female cases tripled between 2012-2018 (wu, 2019) . among women newly diagnosed with hiv in china between 2010-2016, the proportion of those aged 50 years and older increased from 17.8% in 2010 (2 959/16 603) to 38.1% in 2016 (9 981/26 196) . this proportion is even higher in regions with larger rural populations. in guangxi, 46% of newly reported hiv cases in 2014 were men aged 50+ (hu et al., 2019a) . in addition to the increase in newly reported infection among older adults, people infected with hiv can now survive to an older age, increasing the proportion of advanced-age hiv cases. in addition to hiv other stds are increasing in prevalence among the elderly in china. from 2000 to 2013, the incidence of syphilis in people over 60 years of age increased by over 30%. the proportion of people aged 60 years and older among all syphilis cases was also on the rise, from 8.5% in 2004 to 22.0% in 2013 . between 2008-2016, the incidence of condyloma acuminate in china showed a downward trend, with an average annual decline of 2.2%. however, the incidence rate among people aged 50 and over increased by 4.8% annually (yue et al., 2017) . gonorrhea is not common in the elderly, and china saw an average annual decline of 7.9% in the incidence of gonorrhea. this trend was also seen in older adults (4.5%-10.9%) (gong et al., 2015) . this phenomenon may be related to the short incubation period of gonorrhea, the high self-medication rate of patients, the sensitivity of gonococcal bacteria to antibiotics, and the insignificant clinical symptoms of female patients (wang and ni, 2008) . there are several contributing factors behind hiv/stds transmission in older adults. ageing is associated with various physiological changes in the human body collectively known as frailty. however, physiological changes in sexual function often fail to attract societal attention. male sexual dysfunction and disorders often manifest in the slowing of penile erection, prolonged ejaculation, the dampening of sexual desire, impotence, etc. as women age, their vaginal tissue becomes thinner, drier, and less likely to become fertile. for the above reasons, the use of condoms in the elderly seems to be less important. older women may have less interest in or need for sexual intercourse; however, their male counterparts may continue to be sexually active for a long period of time. cravings for sex combined with loneliness may push men to resort to commercial sex to quench their desire for sex. in rural areas, the hiv prevalence is high among street-based female sex workers and female sex workers working at sex-on-premise venues with low quality of hygiene, such as hairdressing shops. use of condoms and other precautions in these scenarios is likely to be lacking . sexual education in older adults is nearly absent, and it is generally assumed that "age is a condom". embarrassment may discourage older adults from obtaining condoms and other precautions. in a survey in guangxi, although 87.9% of respondents were willing to accept condoms issued free of charge by healthcare services, 64.1% of the respondents were unwilling to take them of their own due to embarrassment (qi and pang, 2012) . despite the growing importance of sexual health among older adults, many of them do not seek health services for sexual problems. in china, data on sexual health in older adults are scarce. existing research focuses mostly on males (jiang, 2016) . few actions have been taken to accommodate older adults' sexual health needs in china. engaging older adults in health program development and policy changes is particularly challenging due to concurrent incidences of disability, frailty, and other comorbidities. conventional top-down strategies are often unappealing and less trusted by the target audience. innovative solutions are needed to develop contextualized sexual health services and ensure that they are inclusive, trusted, and reliable. collectively, hiv/stds are becoming an increasing problem in the elderly in china due to diminished precautions in their sex life, a lack of condom usage, and insufficient sexual education, among other issues. future research focuses should include a) routine sexual healthcare and screening for hiv/stds among older adults, especially those who have highrisk sexual behaviors; b) sexual health education and hiv/stds prevention among older adults; c) late diagnosis of hiv/stds among older adults; and d) healthcare providers' attitude on the sexual health of older adults. modifiable health-related behaviors (hrbs) are key contributors to chronic diseases and early mortality, such that by maintaining a vigorous lifestyle, the processes of frailty, disability, and dementia can be postponed or even prevented (lafortune et al., 2016; rizzuto and fratiglioni, 2014; who, 2019c) . similar public health recommendations for hrbs have been promoted worldwide, namely, refraining from smoking and excessive alcohol consumption, consuming a balanced diet, partaking in regular physical exercise, and maintaining frequent social engagements (who, 2015d ). an international comparison study revealed a large degree of consistency in hrb clustering across six nationally-representative ageing cohorts in the east and west, alongside considerable gender-and country-specific variations (liao et al., 2019b) . particularly, older chinese males were characterized by a much higher probability of being smokers (57%) than their counterparts in japan (28%), korea (38%), usa (17%), uk (15%), and in other european countries (21%~33%) (liao et al., 2019b) . comparable findings have been reported in the who's 2019 report on the global tobacco epidemic, which further indicates that the progress of smoking reduction tends to be noticeably slower in china than the global average (who, 2019d). nevertheless, positive developments of china's concerted tobacco control efforts, such as smoke-free public places, a strengthened ban on tobacco advertising, etc., should be acknowledged (li and galea, 2019) . these smoke-free movements have challenged and hope to gradually change social norms regarding smoking, though they may be less effective among older generations with poor health literacy (hu et al., 2016) . the implementation of the healthy china 2030 action plan provides an opportunity to increase tobacco control (li and galea, 2019) , as well as to address a range of risk factors via a population-based multi-sectoral approach (nhcprc, 2019a) . aiming to enhance the overall health of the chinese population, the plan prioritizes 15 major actions, including the promotion of health literacy, the improvement of nutrition, a new national exercise campaign, more tobacco control measures, the promotion of mental health and environmental health; and specific actions dedicated to four target populations (i.e. women and children, teenagers, older adults, and those undertaking special occupations) and five categories of diseases, i.e. cardiovascular and cerebrovascular diseases, cancer, respiratory diseases (e.g. copd), diabetes, and infectious diseases. besides health-related targets for the health promotion actions for older adults, the importance of building an elderly-friendly and engaging environment is highlighted, which embodies "ageing in place" with humane, equitable and sustainable health and social care resources. social engagement is a key determinant of active ageing (world health organization, 2002) , especially within china's collective cultural background (liao et al., 2019b; liao et al., 2020) . in tandem with physical exercise, social activities may generate health benefits not only for the body but also for the soul. chinese square dancing is a social group-based exercise performed to music in public squares or parks. this low-cost and easy-participation activity is highly popular among middle-aged and retired chinese women, estimated at 100 million participants in 2015 (fang, 2015) . square dancers can meet as often as every day, usually in the early morning or evening after dinner, and sometimes both, upon meeting they organize themselves into rank and file, and exercise for nearly two hours, led by the most proficient dancer (liao et al., 2019a) . as an aerobic exercise accompanied by a dance rhythm, square dancing mobilizes the participants' whole body, improving their balance and cardiopulmonary function (liu and guo, 2013) . it is also cognitively challenging, requiring participants to listen to and process the music, focus on movement and balance, and dance to the rhythm with coordinated body movements (kattenstroth et al., 2010) . moreover, square dancing creates a socially enriched environment for participants to interact with peers, keeping them socially engaged and dispelling loneliness (liao et al., 2019a; liao et al., 2020) . square dancing is a typical example of a grassroots group activity that may serve as inspiration for the design of culturally appropriate health promotion programs for older adults. one possibility is developing similar programs that can be implemented throughout the country, and possibly tailoring them to the local needs and/or cultures. in the past five years, central and local governments in china have made enormous efforts in establishing a multi-dimensional geriatric care system to support healthy ageing in chinese society. more than 30 national policies have been issued to drive the development of this care system, including cross-ministerial policy measures for promoting the growth of elderly services and the integrated development of medical, health and elderly care, through the guiding opinions on advancing the development of age-friendly livable environment (ndrc, 2016) , and the state council opinions on promoting the development of elderly care services (nhcprc, 2019b, c) . following the strategies of the national 5-year plan, provincial and municipal governments have all issued local implementation plans. in places such as shanghai, shandong, jiangsu, zhejiang and guangdong, political will has been accompanied by strong financial support (cnca, 2020). as compared to q3 2014, in q3 2019 there was an additional 2.4 million beds added in public and private nursing homes across china, resulting in a total national supply of 7.55 million beds (mcaprc, 2019a, b) . in 2018, the ministry of civil affairs allocated rmb 2.9 billion (usd 400 million) to support the local expansion of care beds in nursing homes as well as the development of community and home care services. in terms of service utilization, the occupancy rate of nursing home beds is at around 50%, i.e. at any time, there are less than 3.8 million residents in these facilities. 748,000 elderly benefited from nursing care subsidies while 5.22 million benefited from social care subsidies (mcaprc, 2019a, b) . in july 2016, the first national pilot of a long-term care insurance (ltci) program was announced in 15 cities across different regions of china (mhrssprc, 2016) . identification of elderly people with severe care dependency was carried out, and local models of financing care for them in nursing homes, community centers as well as at home were implemented. by june 2019 this pilot program covered a total of 88.54 million people, funding services for 426,000 beneficiaries at rmb 9,200 per year per person (nhsaprc, 2019). while geriatric care system development has attracted strong attention from stakeholders and become a major theme for policy, research and investment, the following challenges need to be understood and addressed before meaningful progress can be made to prepare the country for its rapid entrance into an ageing society. the first challenge is that care needs must be assessed comprehensively and should be subject to regular reassessment in order to develop personalized care plans and identify goals that are aligned among care recipients, providers and payers (who, 2017) . generally, there are currently two types of assessments in use in china: one conducted before admission into nursing homes, the other for entry into the ltci programs. the first type can be quite comprehensive but is often used to decide the charge levels associated with the care service. the second type uses a simple 6-item adl questionnaire and links its results to the funding schemes, e.g. maximum hours of care per month. as the assessment of care needs tends to be one-off and disconnected to care plans or goals (hua, 2019; ma, 2017) , it is difficult to allocate resources dynamically and to analyze care performance or economics. the second challenge involves problems with service capacity. on the one hand, 45% of nursing home beds are left unoccupied and, contrary to international best practice, for the beds that are occupied, only less than 20% are actually utilized by people with severe dependency; on the other hand, according to the national health commission, nearly 188 million seniors have chronic diseases, and 40 million have various levels of disabilities (nhcprc, 2019b, c) . among the over 40 million people with different degrees of care dependency and care needs, under 10% have been served by community and home, and the majority have yet to be cared for (mcaprc, 2019a, b) . some policies have been put in place to attempt to fill the huge gap in caregivers, stating that 10 million more caregivers are needed just to care for the existing group of dependent seniors. however, if the current mainstream model of "replacive care" is not changed, growing care service capacity will only lead to an accelerated rate of care dependency among the high-risk population. additionally, such a model of care is highly unattractive to potential workforce candidates. as a corrective move, the central government has now set a goal to train 2 million more caregivers by 2022 (mcaprc, 2019a, b) . the third challenge is distorted allocation of resources. up until the end of 2018, despite plans to establish a home care-dominant, community-backed and nursing home-supplemented system, investment has remained predominantly in heavy assets, i.e. the development of nursing homes as well as senior-living property projects, resulting in the above-mentioned "oversupply" of care beds (qiao, 2019) . since the 13 th five-year plan, the central government has committed to an annual funding of rmb 1 billion to support innovative pilots of home-or community-based care models (mcaprc, 2017 (mcaprc, -2019 . however, for many local governments, the first and foremost priority when developing local care capacity is to specify land for elderly care use and invest in care facilities construction before or while looking for operators of such facilities. in addition to resistance and reluctance from nursing homes and preexisting policymakers, difficulty in understanding senior population's care needs and evaluating care competency among community and home care providers have prevented financial support schemes from materializing in most parts of china. typical examples of the insufficient support for community and home care service development can be seen in the number of government purchase tenders that fell through without enough qualified bidders. while there is no lack of political will and resources to be invested in further developing the care system, there is an urgent need to pay for access and quality. a value-based resource allocation model focusing on improving population health rather than the current fee-for-service care model would provide china a rare opportunity to benefit from a healthily ageing society (gyurmey and kwiatkowski, 2019; mandal et al., 2017) . to address the above-mentioned challenges and seize the opportunity associated with them, pilots should be designed based on local evidence and should be established in four dimensions. firstly, development of care plans should be focused on individually centered goal based on comprehensive assessments. as highlighted in the latest who icope (integrated care for older persons) package, it is essential for countries and health systems to align the efforts of different stakeholders with a shared care plan that is customized to serve the individuals' priorities and goals. secondly, health and social care resources should be integrated to support the realization of personalized goals of care and, at the population level, to delay and reduce care dependency. rather than further developing passive care capacity to compensate for the increasing need for other fragmented services, devoting resources to the reaching of a consensus among care providers and receivers will serve to empower the population itself, and maximize the pooling of financial and human resources, decreasing the need for an expansion of passive services (who, 2019b). thirdly, the education and training of "integrated care managers" should be developed, whose job would be to work actively in primary care settings to identify care needs and coordinate care resources crucial to achieving societal and individual care goals. mobilizing talents with various backgrounds to understand and operate under the comprehensiveness of geriatric health needs, developing their capability to better communicate and coordinate care efforts across public and private sectors would not only facility the integration of various care services, but make the care work more attractive for those seeking long-term career opportunities (wang and song, 2019) . fourthly, a reform of the payment model used in elderly care services should be carried out, focusing on value rather than volume of care for populations at risk of care dependency. healthcare payments have long been moving from an inefficient, fragmented, fee-for-service model to a value-based capitation or bundled payment model. for geriatric care financing, this reform is likely to develop faster than the reform of payments for healthcare services. setting sustainable goals for care and allocating resources accordingly will be a viable realistic solution to caring for the millions of chinese citizens in need . we recognize the complexity of establishing such a health-oriented care system. for the four dimensions of an integrated care system to be aligned around common goals as discussed above, a pre-requisite should be the interconnectivity of data: linking results across personal health records, assessments of geriatric care needs, and total costs of care, including: social and commercial health insurance payment, out-of-pocket private payment, social welfare payment, as well as other sources of funding for elderly care (threapleton et al., 2017) . palliative care is emerging as a new alternative for hospitalized elderly with life-threatening illness. the who defines palliative care as the prevention and relief of suffering of adult and pediatric patients and their families facing the problems associated with life-threatening illness (including malignant and non-malignant diseases). these problems include physical, psychological, social and spiritual suffering of both patients and their family members the aim of palliative care is to enhance the quality of life, promote dignity and comfort, and may also positively influence the course of illness (who, 2016a). palliative care is the basic skill of medical staff in departments where medical care is provided to end-stage patients (e.g. icus, emergency rooms, geriatric and oncology departments) (ning, 2018) . the 2015 quality of death index survey showed that the death quality of mainland china ranked 71 st out of 80 countries, while taiwan and hong kong ranked 6 th and 22 nd , respectively (eiu, 2015) . while palliative care is widely available in western countries, it is limited in mainland china. according to a report in 2016, only 0.7% (146/22,000) of hospitals offered palliative care services. in china, the proportion of course in palliative medicine at medical schools is relatively low and, often only available as electives for undergraduates or postgraduates (liu and yuan, 2009) . questionnaire data of 5 th year medical students in 2017 and of geriatric nurses in 2016, showed that 58.7% of medical students and 55.7% of nurses had no training or education regarding death or terminal care, and 93% of medical students and 94.3% of nurses had not received any education about hospice and palliative care. thus the need for course education in hospice and palliative care at chinese medical schools is extremely urgent. palliative care is recommended to be introduced early in curative treatments when patients are diagnosed with a life-limiting disease or when the palliative care needs of patients are identified. current palliative care in mainland china is still mainly focused on patients with cancer, with only a few palliative care resources available for other chronic conditions such as copd, hiv and renal failure . therefore, in the future, palliative care should be extended to both patients with cancer, with other life-limiting diseases, and their families. many palliative care guidelines have emphasized that the discussion of advanced decisionmaking among patients and their families should be initiated when patients still possess decision-making capacity (cheng, 2018) . patients in mainland china sometimes fail to grasp or accept the truth of a diagnosis and limited survival time (cheng, 2018) . moreover, according to questionnaire reports from 1,084 patients in 2016, awareness of the concept of advance care planning or advance directives in china is still low (kang et al., 2017) . in mainland china, family members are often held responsible for making decisions for the elderly in their care, despite a lack of knowledge or training, and thus may resort to homeopathic remedies. healthcare professionals generally have to ''respect'' any decision made by the families and try their best to ''save'' patients' lives using many life-sustaining treatments, although they generally hold negative attitudes to useless treatments. such an approach is regarded as an appropriate measure in terms of protecting themselves from medical conflicts. misunderstanding of palliative care as 'giving up on treatment and waiting for the death of the patients' by family members of the patients as well as even by some doctors, should be corrected (hu et al., 2019b; ning, 2018; xiao et al., 2019) . there is an urgent need for the development of hospice and palliative care in china. in recent years, hospice and palliative care have witnessed rapid development. more and more patients, families, and health-care professionals come into contact with the concept and realize the benefit of hospice and palliative care, while more and more educators, organizations, government and other intermediary leaders have paid more attention to the promotion and development of hospice and palliative care. the current trend towards an ageing society poses difficulties due to the additional challenges seen in diseases in the elderly, including longer disease durations, more complications, underwhelming responses to treatment, and poor prognosis, thus in response to this trend, china has established the national clinical research center for geriatric disorders (ncrcgd) (o'meara, 2020; yu et al., 2018a) . funded by the central government, the ncrcgd aims to provide innovative models for the diagnosis, management and further research into geriatric diseases at a national level. the ncrcgd focuses mainly on comprehensive and systematic research into pathogenesis, prevention, diagnosis and treatment of age-related diseases such as ad, pd, and cerebrovascular disease (xwhosp, 2017b, 2019). at the same time, it is committed to building a national elderly medical service network and scientific innovation system by integrating resources of clinical and basic research. for instance, a health data management platform for the elderly could provide a scientific basis for management and decision making. furthermore, through the education and promotion of new theories and technologies of geriatrics to grassroots hospitals, the ncrcgd can build a better medical service system, improving the health of elderly people. the ncrcgd strives to promote the combination of academic and clinical research (xwhosp, 2017b, 2019). research on agerelated diseases has been carried on such various aspects as diagnosis, treatment, and prevention in fields such as immunology and molecular biology (o'meara, 2020). the characterization of the gene pool, a series of research findings and new technologies have been applied at the clinic, which promotes the development of gerontology in the direction of precision medicine for early diagnosis, early prevention, and early treatment. the ncrcgd also serves as an educational harbor to foster the training of geriatricians and promote academic exchange (frailty-china, 2019; xwhosp, 2017b, 2019). the organization also undertakes other social responsibilities, including partnerships with hundreds of institutions across the country, relying on their collaborative research network to successfully carry out a comprehensive assessment of multiple systems for the elderly (xwhosp, 2017a). through a comprehensive assessment of the multiple aspects of the elderly's diseases, fitness, cognition, psychology and society, it may be possible to develop a system for early identification of health imbalances in the elderly that characterize certain diseases, aiding in their early prevention, and helping to reduce the burden of the ageing chinese society, as well as improving the elderly health service system. prospectively, the ncrcgd will also play its essential role in guiding the research and clinical guidelines for elderly people care as well as making more contributions to improve elderly people's quality of life in china. in order to deal with the ongoing boom in the elderly population, the chinese government has put more effort into funding research on ageing and its related diseases in recent decades. during the recent (2019) outbreak of coronavirus in china, older patients with preexisting ageing-related diseases were found to have a much higher casualty rates than younger patients (chen n et al, 2019) , again highlighting the importance of preventing ageing-related diseases. in response to this, along with the growing need for improving the quality of life of the elderly in china, more attention has been placed on the development of pharmacological strategies against ageing, organ degeneration and major ageing-related diseases. in this section, we will discuss recent world-wide progress in pharmacological attempts to improve healthspan, and the significant contributions that chinese researchers have made. calorie restriction (cr) was first demonstrated as an effective way to extend lifespan in rodents (de cabo and mattson, 2019), however the physiological mechanisms behind its anti-ageing effectiveness were not fully understood at the time, and remain uncertain. later studies have suggested that cr might extend lifespan by regulating insulin-like growth factor (igf) and mammalian target of rapamycin (mtor) pathways. metformin is primarily known for treating type 2 diabetes, with its underlying molecular mechanisms leading to the to down-regulation of igf-1 signaling, and the inhibition of cellular proliferation, mitochondrial biogenesis, ros production, dna damage, activity of the mtor pathway, etc. . the anti-ageing effect of metformin is under investigation by the tame (targeting ageing with metformin) trial in the usa. acarbose, an antidiabetic drug, could also disrupt the igf pathway. acarbose has been shown to partially mimic the effects of cr and extend lifespan in mice by controlling blood sugar and slowing carbohydrate digestion (harrison et al., 2019) . a clinical trial on acarbose (clinicaltrials.gov identifier: nct02953093), named study of acarbose in longevity (sail), is in phase 2, and will hopefully shed some light on its pro-longevity effect in humans. mtor is a pivotal nutrition sensor that links cellular metabolism with proliferation, growth and survival by regulating amino acid metabolism, proteostasis, mitochondria dynamics, cellular senescence, etc. (liu and sabatini, 2020) . rapamycin, a well-known inhibitor of mtor, has shown life-extending effects in all model organisms and postpones the onset of age-associated diseases harrison et al., 2009; liu and sabatini, 2020) . despite the promising pro-longevity outcome of using rapamycin in animals, its clinical application in human has been obstructed by growing concern of potential side effects from immunosuppression and hyperglycemia (pallet and legendre, 2013) . whether the dosage can be fine-tuned to avoid these side effects will be the determining factor in whether or not rapamycin becomes a future pro-longevity drug. the application of induced pluripotent stem cells (ipscs) from healthy and pathological ageing individuals (liu et al., 2011) is also propelling further mechanistic studies and translational applications for cr. nicotinamide adenine dinucleotide (nad + ) is a fundamental molecule in human life and health; while there is an age-dependent reduction of nad + , nad + augmentation extends lifespan and improves healthspan in different animal models as well as shows potential to treat different neurodegenerative diseases based on phase i clinical trials (gilmour et al., 2020; lautrup et al., 2019; yoshino et al., 2018) . nad + precursors such as nicotinamide riboside (nr) and nicotinamide mononucleotide (nmn) have emerged as promising approaches for intervention against ageing phenotypes and age-related diseases. supplementation via these precursors can elevate nad + level in vivo and improve glucose metabolism, mitochondria biogenesis, dna repair, neovascularization and neuroprotection . additionally, more than five phase i clinical trials indicate that orally taking nr is well tolerated and able to elevate nad + in the blood (gilmour et al., 2020; lautrup et al., 2019) . several clinical trials are currently operating in parallel, investigating nr's effects on metabolic function in bones (nct03818802), in immunity (nct02812238), and nmn's effect in cardiometabolic function (nct03151239), with others also ongoing. in china, although nad + precursors have become widely available commercially as supplements, clinical trials exploring their disease-treating ability in humans are still lacking. senescent cells accumulate in aged tissues and this accumulation is considered one of the driving forces of ageing. senolytics are a class of molecules specifically designed to induce apoptosis of these senescent cells. clearing senescent cells in mice has been shown to substantially alleviate ageing phenotypes, producing potent therapeutic effects in ageingrelated diseases such as ad (bussian et al., 2018; zhang et al., 2019b) , atherosclerosis (childs et al., 2016) and osteoarthritis (jeon et al., 2017) . in 2016, a joint research team of chinese and american researchers found that the molecule abt263 reduced irradiationinduced senescent bone marrow hematopoietic stem cells (hscs) and muscle stem cells (muscs) in mice . abt263 (a bcl-2 family inhibitor), together with dasatinib (an anticancer drug) and quercetin (an apoptosis inducer) are the most commonly used senolytic drugs. the senolytic cocktail of dasatinib plus quercetin (dq) decreased naturally occurring senescent cells, improved mobility and reduced the risk of mortality . however, a small pilot clinical study using the same dq cocktail in patients with idiopathic pulmonary fibrosis (ipf) reported no change in pulmonary function, frailty index, clinical chemistries and reported health, though the beneficial effects on mobility were still noted (justice et al., 2019) . while clinical trials on senolytic drugs are mainly conducted in the usa, the concept of reducing senescent cells to delay the ageing progress has attracted interest from all over the world. since 2016, the national natural science foundation of china (nsfc) has set up special programs, providing millions of rmb to support research on cellular senescence and organ degeneration. as such, it is recommended that china further expand its investment in senolytics research. targeting the microbiota may also improve age-related diseases, including ad. in 2019, china approved the first domestically invented ad drug, oligomannate (gv-971) (wang et al., 2019d) . considering there has been no new approved anti-ad drugs in the past 17 years, this has been exciting news. despite the potential of these advances, more work is necessary to understand how gv-971 works. additionally, due to the relatively short clinical trial period, further investigation with longer lasting trials is highly recommended. most human trials for potential anti-ageing drug candidates are conducted in patients with certain age-related diseases. despite partial overlap of the pathologies of these diseases, the knowledge from these trials cannot be interpreted as treating ageing itself. therefore, to reach the goal of identifying anti-ageing compounds, a more comprehensive study on disease-free, healthily ageing groups with no obvious health issues is in immediate need. china has the advantage of a large and diverse population, providing an ideal subject pool for this type of study. the knowledge gained from such studies would likely open new avenues to better understand the fundamental aspects of ageing mechanisms, facilitating their treatment. from a public health and policy perspective, it can be seen that continuing research into prevention and management strategies will be important for both non-communicable diseases as well as geriatric syndromes, to ensure that it is not only life expectancy that is increased, but also the quality of life, by promoting independence and reducing reliance on elderly care services. regular monitoring of trends in incidence and case fatalities of common chronic diseases would enable estimates of future disease burdens and guide preventive health policies (chau et al., 2013a; chau et al., 2013b) . in addition, solutions to trends in the occurrence of disability and frailty are also needed (yu et al., 2018b) . such data would inform the design of elder-friendly service delivery models across the whole spectrum, from prevention to primary care, hospital and residential care settings (woo et al., 2013; yu et al., 2019) . currently, hong kong, a special administrative region (sar) of china, has the longest life expectancies in the world for both men and women, such that the need to redesign service models is particularly pressing. by 2064, it is predicted that 33% of the population in hong kong will be aged 65 years and over; 70% will have at least one chronic condition, with an increasing prevalence of disability also predicted (yeoh and lai, 2016) . while the health and social care systems are well developed, there is a mismatch of needs as those with chronic conditions are predominantly managed in the public hospital systems, whereas primary care is predominantly in the private sector. a recent review concluded that better integration of health and social care systems with a primary emphasis on the community could be the best way forward for the ageing population in hong kong (threapleton et al., 2017) , exemplified by the formation of nurse-led district health centers in 2019 (fhb, 2019). other community models with an emphasis on promoting group activities to prevent frailty and aid selfmanagement of chronic diseases have also been developed (cadenza). such developments have the potential to enhance the role of primary healthcare professionals in preventing functional decline (morley et al., 2017) , so that many can retain independence even as life expectancy increases. the who's integrated care for older people (icope), formally launched in october 2019, will form a useful blueprint for policymakers to build on their existing health and social care infrastructure (who, 2015c). experiences of elderly healthcare in the european union (eu) may provide useful tips for the situation in china (table 1 ). in the eu, elderly care is provided in each country based on its own social security system and cultural norms. in most european countries, the family and the state are the main providers of support to older people both in activities of daily living (adl) and in instrumental activities of daily living (iadl) (schmid et al., 2012) . europe is characterized by three types of care provision: 1) 'crowding out', whereby the state largely replaces family care; 2) 'crowding in', whereby the state promotes family care; 3) 'mixed responsibility', whereby both the state and the family take a joint responsibility for care, yet have separate functions (brandt et al., 2009) . in china, family is still the traditional provider for elderly care (wu et al., 2016a) . under current national and social developmental conditions of china, the chinese government encourages a '90/7/3' pattern of eldercare system, namely: 90% of all older people are cared for at home, 7% are cared for in communities, and 3% are cared for in institutions (mayston et al., 2017) . a 'crowd out' system dominates in the nordic countries (denmark, finland, norway, sweden, iceland) , where the government strives to create a comprehensive system of care services in order to reduce the care obligation of the family. in continental european countries such as austria, belgium, france, germany and the netherlands, systems are more mixed in their provision of elderly care, though tend towards a 'crowd out' approach (kasearu and kutsar, 2013) . in the island countries, i.e. the uk and ireland, the system is more mixed, and the private market is the dominant welfare provider, with the government providing two main social care services to older people, one being old age pensions and the other being healthcare . southern european countries (e.g. greece, italy, portugal, spain) have a 'crowd in' system whereby families have more responsibilities for care services to older people (kasearu and kutsar, 2013; wu et al., 2014) . eastern european countries have undergone dramatic political, social and economic changes after the soviet era and experienced a rapid change from 'crowd out' to a 'crowd in' system where family is the main care provider and the government provides basic formal care services (kasearu and kutsar, 2013; wu et al., 2014) . in china, owing to confucian culture and its emphasis on the family, it is taken for granted that the family, most notably adult children, has the responsibility to care for older parents, especially in the rural areas of china, thus older people rely mainly on their children or family for support (chen and silverstein, 2000; wu et al., 2016a) . rapid demographic ageing increases the demand for care in all ageing societies. currently, european countries face the enormous challenge of implementing major reforms to elderly care in order to ensure that the needs of older people can be continuously met in the future (brandt et al., 2009; broese van groenou and de boer, 2016) . to this end, european governments have increasingly relied on informal care in addition to regular and traditional formal care providers from professional home care services, day care units and nursing homes (broese van groenou and de boer, 2016; verbakel et al., 2017) . informal care for older people is generally provided by caregivers from both kin and non-kin groups, including spouses, children, relatives, neighbors, friends, etc. (swinkels et al., 2016) . in europe, around a third of people aged 50 years or older provide informal care to older people. however, shrinking family sizes, the increasing participation of females in the workplace, and rising retirement ages, may pose a drastic challenge to informal care in the future (verbakel et al., 2017) . china is currently facing challenges in its family-based elderly care model due to new family formation, the spread of individualistic values, and frequent internal migration from rural to urban areas encouraged by rapid economic development (wu et al., 2018a) . moreover, china's one-child policy has sped up the process of population ageing by accelerating the change of the fertility rate and, in turn, has weakened the family-based elderly care model in china . in europe, new elderly care arrangements have been gradually developing based on a new combination of family obligations, market provision and public support. in nordic countries, the state, family and market have been changing with regards to their roles in the provision of elderly care, specifically by increasing the provision of publicly funded care services in a forprofit capacity (marketization of elderly care) and increasing the importance of family care (szebehely and meagher, 2018) . in estonia, the idea of community-based support for older people has been increasingly set forth in order to postpone the need for institutional eldercare (tulva et al., 2016) (tulva et al., 2017) . when it comes to the current trend of eldercare in china, marketization has also been discussed to a large extent both at academic and policy levels. the 'public-private-partnership' (ppp) model may improve the efficiency of familybased eldercare. in the 13 th five-year plan for national economic and social development (2016-2020) , the opening-up of the market for elderly care services (e.g. purchase of services by the government) was clearly stated (du and wang, 2016) . elderly care reforms might create new challenges for both europe and china, an important challenge being an increase in inequality in eldercare service utilization among different social groups of older people. older people with higher socioeconomic status will be able purchase private care services whereas those with less social capital will have to rely on more family-based care. in addition, for the chinese government, there is a need to take into account larger inequalities derived from immense resource variations across regions during the development and reform of elderly care services. while mainland china can learn many successful experiences from hong kong, the eu, etc., there remains many unique features that demand the creation of an elderly care system tailored to mainland china. in addition to responding to changes and preparing to adapt to an ageing society at the societal and individual levels, understanding of the mystery of ageing at a molecular level will aid the development of novel strategies to slow ageing and to promote healthy longevity. in the below sub-sections, we will focus on how to use centenarians, the china national genebank database (cngbdb), and ai to further propel ageing research. in china, the numbers of the oldest-old individuals (those aged 80+), near-centenarians (95+), and centenarians are increasing at roughly 10% yearly (fig. 4a-b) , providing unique resources for both basic research and clinical studies. there were 3,384 centenarians in 1953, with the number rising to 35,934 by 2010 (abida and gu, 2008) . based on the un's medium variant projection, by 2050 over a quarter of the global oldest-old population will live in china. as the numbers of the most elderly have expanded, the gender structure of centenarians, the proportion from urban and rural areas, and differences in geographical distribution have formed "three-high" trends in china (data from china's 2010 population census, excluding hong kong, macau and taiwan) . first, there is a gender difference, with 75% of centenarians being female (peng, 2011) (fig. 4a) . data from the 6 th population census of china (2010) reported 27,082 (75.37%) female and 8,852 (24.63%) male centenarians. this could be due to both physiological (e.g., female hormone estrogen) and cultural differences (women often do more housework, pay more attention to healthcare) (austad and fischer, 2016; peng, 2011) . second, urban and rural disparities were clear, wherein more centenarians (56%) live in rural areas, possibly due to a healthier living environment, diet and lifestyle in these regions (cai, 2013; peng, 2011; zeng et al., 2017a) (fig. 4c ). and third, there was geographical difference in the distribution of centenarians. the distribution of longevity areas in china presents several significant characteristics, including province-specific: being majorly in hainan, guangxi, sichuan, yunnan, guangdong and xinjiang, and mostly distributed along river basins, with more centenarians along the pearl and yangtze rivers and the lancang river basins. these characteristics of the area distribution of centenarian suggest that areas beneficial to longevity can be divided into two types: 'natural' and 'economically developed' longevity areas (he et al., 2017; zeng et al., 2017a) (fig. 4d) . studies of centenarians can provide valuable information for early prevention of major diseases, premature ageing, and early death, thus providing the scientific support necessary to cope with the quickly approaching arrival of an ageing society in china. centenarians may represent a prototype of successful ageing. a longitudinal study of a danish 1905 cohort suggests exceptional longevity does not result in excessive levels of disability (christensen et al., 2008) . in fact, some centenarians experience a delayed onset of age-related illnesses (delayers), whereas others did not succumb to any age-related illnesses (escapers) (christensen et al., 2008; hitt et al., 1999) . in addition, one case-control study showed that older individuals had a delayed age of onset of cancer, cardiovascular disease, diabetes mellitus, hypertension and osteoporosis than their respective younger reference groups (ismail et al., 2016) . the china hainan centenarian cohort study (chccs) on 1,002 centenarians is now in progress, focusing primarily on examining biological indicators and medical aspects, and extensively examining psychological and sociological factors (he et al., 2017) . all in all, the study of centenarians is a topic of immense importance for population and health policymakers, as well as for the larger aim to achieve long, healthy lives. state-of-the-art technologies enable the 'big data'-based investigation of the molecular mechanisms of human ageing and its associated diseases, providing unique information for therapies and interventions. the cngbdb is a centralized 'big data' hub of biological data, providing data sharing, knowledge search, computational analysis, management authorization, and visualization services to the global research community. built and maintained by the china national genebank (cngb), cngbdb draws from 3 "banks": the living biobank, the biorepository, and the bioinformatics center, and from 2 "platforms": the digitization platform and the synthesis and editing platform. the research data system of cngbdb integrates molecular data from internal and external sources into nine sub-databases including literature, gene, variation, protein, sequence, project, sample, experiment, and assembly (https://db.cngb.org/news/2/). comparative analyses of species and tissues can identify the molecular causes of ageing phenotypes, corroborate or disprove theories on ageing, and help to understand differences in j o u r n a l p r e -p r o o f the mechanisms of ageing across species. genotype comparisons within a species at the level of individuals and populations can help identify genetic reason for differences in lifespan. this approach may be used to compare populations from different regions of china, or chinese and foreign populations, such as ashkenazi jews and okinawan centenarians in japan, two populations well-known for their longevity, facilitating the discovery of chinese-specific agemodifying genes. the identification of potential life-extending genes eases the design of therapeutics that can mimic the effect of these genes in people without those genes. likewise, treatments can be designed for age-related diseases that result from mutated or nonfunctional genes in specific populations. it is also possible to comparatively analyze gene expression at the tissue level, as tissues age at different speeds. since many age-related diseases, such as ad, occur within a specific tissue, understanding the speed at which tissues age can help chinese gerontologists assess the risk of and help to prevent tissue-specific age-related diseases (wieser et al., 2011) . the advent of 'big data' and machine learning have eased the collection and identification of biomarkers associated with biological age and may allow for the development of personalized clinical diagnostic tools for physicians in the near future (aman et al., 2019) . in the field of medicine, biomarkers refer to measurable indices capable of identifying a condition, state of being, disease, or environmental marker whose presence may reflect a pathophysiological state (naylor, 2003) . the use of biomarkers has been applied to the field of anti-ageing technologies, including the prevention and treatment of age-related disease, and has been used to explore methods to delay or offset the ageing process altogether, and will likely serve as key components to advances in the field (campisi et al., 2019) . in some cases biomarkers may more accurately represent a patient's 'biological age', as opposed to a patient's simple 'chronological age', the former of which is thought to be more clinically relevant (lopez-otin et al., 2013) . the following sections will review three applications of biomarkers at the molecular, individual and societal levels, including current findings as well as potential research directions. as stated above, there are multiple tests that can be used to obtain molecular biomarkers, and several have been validated to some degree by current research. molecular biomarker studies can be roughly separated into 2 classes: smaller scale studies attempting to determine the utility of a given biomarker, and machine learning studies involving thousands of samples with the intention of developing clinical assessment tools. as an example of this, a recent study involving elderly hypertensive patients was used to investigate a wide library of potentially useful biomarkers . here, 416 elderly chinese participants were matched with subjects from a pool of 9,000 normal volunteers. after adjusting for confounding covariate factors, the researchers found that only elevated triglyceride levels were strongly linked to high blood pressure (hong et al., 2017) . while these cross-sectional studies are certainly important for determining which biomarkers should be considered for clinical evaluation, one of the limitations, at least in comparison to machine learning studies, is that they have a low number of samples. in the above examples, most participant groups contained less than 500 people. while this is a surplus number in other medical contexts, one of the advantages of machine learning is its ability to process thousands of samples granting increased accuracy. fittingly, one of its primary uses is to draw meaningful conclusions from mass, simple, cheap, and non-invasive tests. another key limitation is that biomarker assessment studies using these 'smaller' cohorts tend to lack any external validation. perhaps one of the most easily accessible tests that comes to mind is a standard blood test, here the usefulness of machine learning has been demonstrated by putin and colleagues, who designed a modular ensemble of 21 deep neural networks (dnns) of varying depth, structure and optimization for the prediction of human chronological age using a basic blood test (putin et al., 2016) . the team trained the dnns using a collection of over 60,0000 samples from routine blood biochemistry and cell counting assays. the researchers reported that the accuracy of their results provided evidence to suggest that machine learning algorithms could be used to design minimally invasive biomarker tracking methods for ageing that would only improve with greater access to training samples (putin et al., 2016) . another study examined 19 serum biomarkers, and its results were externally validated using a separate data set from the framingham heart study (sebastiani et al., 2017) . such studies highlight the ability of machine learning techniques to infer conclusions from basic samples, and to externally validate such conclusions. still, this was one of the very few studies with this type of external validation and more are needed for clinical application. big data can also be used to assist geriatricians for personalized medicine, defined as a medical approach in which treatment is customized on an individual basis based upon disease subtype, genetics, risk, prognosis, or treatment response using specialized diagnostic tests (frohlich et al., 2018) . for instance, predictive biomarkers for the early detection of certain diseases, may help both patients and doctors to decide on appropriate treatment pathways. in addition, the 'internet of things' refers to the ability of technology to send and receive data via the internet. as wearable/compact technologies become more prevalent (i.e., phone pedometers, pacemakers, insulin trackers) and their data becomes easier to store and share, so too does it become easier to use life-logging data to track individual's wellbeing. unfortunately, while there is great potential for this type of technical approach, there are currently very few cases of applications within clinical practice (frohlich et al., 2018) , with many studies still in an exploratory phase, requiring further research. for example, one study shows that machine learning techniques have significant potential in developing personalized decision support for chronic disease tele-monitoring systems; however, it was noted that the system would be improved with a larger library of comprehensive predictive markers (finkelstein and jeong, 2017) . the use of radiomics, the high-throughput mining of quantitative image features from standard-of-care medical imaging that enables data to be extracted and applied within clinical-decision support systems, has also been proposed, especially within the realm of dementia prevention and detection . these studies have benefited from large sample sizes (>1,000 images) using machine learning. this brings us to the issue of noise reduction, which is crucial for effective use of big data and will enable a more robust extraction of features. given the immense amount of data expected to be handled in future projects, finding ways to store, process, and analyze this data also presents a challenge for future research. at the societal level biomarkers have numerous applications. monitoring population-level biomarkers will likely provide an accurate, real-time view of the health state of a given area. this will allow for targeted interventions catered to suit the specific needs of a population. as stated earlier in this piece, modern medicine has provided for major increases in both quality of life at old age, and life expectancy, however, this can also be considered a potential societal burden. earlier the use of federated systems with respect to online medical records and data sharing was discussed as a potential hurdle to some countries and medical systems in the world. china has recently embraced a centralized health informatics scheme, with over 80% of medical organizations above the county/district level, 27% of town level hospitals and all cdc above the county/district level capable of transmitting real-time reporting on the status of epidemics via the public health information system (zhang et al., 2007) . in the future, the data provided by a centralized medical record system has the capacity to train numerous machine learning algorithms for use with biomarkers. another challenge for population-level biomarker implementation is to select low-cost, minimally invasive testing that can be used at a large scale. with respect to china, great advances have been made in the use of medical informatics within the past 30 years. however one of the hurdles going forward for the country is that much of this investment has been driven by industry and the private sector, and a major priority for the country's future should be to divert resources to academic research (liang et al., 2017) . this is especially true for the poorer members of society, or those without ready access to healthcare, as biomarker are an asset in devising appropriate healthcare plans for populations in need . addressing rural areas may be a challenge both in terms of healthcare delivery and biomarker testing, as these regions may lack sufficient infrastructure for both, posing a challenge for the future . we recommend the use of mobile-equipped information technology services to reach more remote regions. in summary, biomarkers have a great deal of potential for how doctors can prevent, diagnose, and treat illness associated with ageing. while there are many hurdles going forward, the application of machine learning and big data to biomarker research will provide new opportunities to understand ageing at the molecular level, deliver personalized treatment at the individual level, and design influential and effective policy at the societal and population level. since the beginning of the 21 st century, china started to enter a period where it may be classified as an ageing society. at the same time, the compulsory healthcare insurance systems in china has undergone a comprehensive and rapid development, while still emphasizing the ideologies of health equity and social justice . three major health insurance schemes have been launched, achieving near-universal coverage in a short time, which gained early appraisal by emulating the goal of the provision of affordable and equitable basic healthcare for all by 2020 (yip et al., 2012) . after the establishment of the urban employee basic medical insurance (uebmi) in 1998, the chinese government implemented the new rural cooperative medical scheme (ncms) for rural residents in 2003, and the urban residents basic medical insurance (urbmi) for urban residents without employment in 2007. as a result, social health insurance coverage increased from 29.7 to 87.9% between 2003 and 2008, and further to 95.7% by 2011, and has been stable since (meng et al., 2012) . in order to further reform the fragmented health insurance system, the latter two of these schemes were combined into the basic medical insurance for rural and urban residents in early 2016, with a target of making the system less complicated, but more equitable for various social groups. in the past 10 years of the new round of healthcare reform beginning in 2009, the chinese government dramatically increased financial investment, with half of all investment in the form of funded premium subsidies for residents to be covered by the social health insurance system (yip et al., 2019) . universal coverage has since led to improved access to and utilization of healthcare (meng et al., 2019) , decreased the prevalence of catastrophic health expenditure (yip et al., 2019) , and reduced out-of-pocket expenditure as a proportion of total health expenditure, especially for vulnerable groups, including older adults (xu and mills, 2019) . however, the social health insurance system in china still faces the dual challenge of population ageing (demand) and inefficient delivery on the side of the healthcare system (supply), raising both health expenditures and individual disease burden. out-of-pocket expenditure as a proportion of disposable personal income increased from 4.98% in urban regions and 5.17% in rural areas in 2008 to 5.59% in 2017 (xu and mills, 2019) . concretely speaking, population ageing addressed the increasing health and social care needs of older people. according to the report on the fifth national health services survey, the prevalence of non-communicable disease had increased more than 20% between 2003-2012, from 50.1 to 71.8%, while the inpatient rate rose from 7.6 to 17.9% in between 2003-2013. the outpatient rate also increased to 49.7% in 2013 (nhfpc, 2015) . the reimbursement of social health insurance improved rapidly and accounted for 42% of total health expenditure in 2017, though while out-of-pocket payments dropped from 60% in 2000 to 28% to 2017, financial protection and services packages were insufficient for the elderly (meng et al., 2019) , especially for those in rural regions. reported a three times-higher risk of catastrophic health expenditure among the old population in rural regions . in 2013, expenditures on hospitalization for older people in urban areas were reimbursed 64% by social health insurance and 53% were covered for their rural counterparts (who, 2015b). regional disparity in health benefits for the elderly with insurance aside, a problem of inequity among different health insurance schemes on health outcomes for older adults is still a great challenge. uebmi recipients were found to have better physical and psychological health outcomes compared to those with urbmi or ncms insurance. this demonstrates a transformation in health insurance reform from an emphasis on the opportunity-oriented health equity measured by coverage and healthcare accessibility to stressing outcome-based equity composed of health outcomes for the elderly, namely "outcome-based health equity", giving priority to disadvantaged groups . in terms of supply-side deficiency and unsatisfied progress in the past 10 years, gaps in the public hospital and pharmaceutical reform have tremendously limited the effectiveness of social health insurance reform, even though the public hospital has removed mark-ups for drug sales, adjusted pricing mechanism, reformed provider payment systems and changed governance structures at the county level (yip et al., 2019) . the hospital-centered health delivery system has induced the growth of both health expenditure and health insurance expenses, which worsened the control of non-communicable diseases and health outcome improvement in ageing society. unexpectedly, the usage of outpatient and inpatient services in primary health facilities declined from 62% and 29% in 2009 to 54% and 18% in 2017 . due to the lack of qualified long-term care facilities, the length of hospitalization was longer for the old population aged 60 and over (who, 2015b), demanding higher expenditure input to cope while wasting health resources. we advocate the immediate application of an integrated health and social care-oriented, particularly in community settings, with the objective of increasing affordability and improving the quality of care for older people. population ageing, family structure shift, and migration, were three major challenges limiting the efficacy of traditional informal care provided by families and their networks. a large proportion of older people with functional disability or dementia will continue to create enormous challenges for an immature long-term care system in china . it was estimated about 40 million (19.5% of the elderly) older people had some sort of functional disability by 2015, among which 12.4 million (6.05% of old population) had a serious status of disability (nhfpc, 2015) . at the same time, china has become the largest country in the world to have over 9.5 million people with dementia (jia et al., 2020) . in response to the increasing need for social care of older people with disability, the central government of china has implemented a pilot practice of ltci policies in 15 cities, while some local governments were also encouraged by the central government to initiate county-level pilot experiments on ltci since 2016, in hopes of stimulating the growth of long-term care providers (luo and zhan, 2018) . most ltci schemes were based on the social health insurance system, though these pilots had distinct and diverse eligibility conditions, premium contributions, need assessment instruments, and benefit packages. the reason for carrying out a pilot practice rather than fully implementing a uniform nation-wide scheme reflected the complexity of ltci, and a worry about cost escalation noted ltci introduction in the more mature ageing societies of japan and germany. after two years of practice, a few evaluations were conducted to estimate the outcome of these pilot practices, identifying a host of problems. there are several characteristics and unique features present in the chinese ltci scheme. at first, coverage was narrow and limited only to older people with the most serious degrees of disability, and excluded older adults with dementia due to security issues and lower quality of care skills. by the end of 2017, less than 2% of the older population in the pilot cities were covered by ltci plans in qingdao (zhu and osterle, 2019) , which was the first city to launch the ltci scheme in china, a higher proportion of those 65 years and older was achieved in the ltci practice of the mature ageing populations in germany (11.7%) and japan (12.8%) (oecd, 2013) . secondly, the need assessment tools used by each pilot city were fragmented and biased. some pilot cities or counties only employed the barthel index to measure physically functional disability, but did not measure cognitive function with any scales, thus leading to the exclusion of older people with dementia from ltci coverage. more seriously, the results of need assessment were not applied to long-term care service provision, but only used as a "gate keeper" for receiving the fixed benefit package. assessment tools should be transformed from simple to comprehensive, from a physically oriented test to a multi-dimension health status one, even from health assessment to service assessment. thirdly, in most pilot plans, long-term care was provided by designated institutions through a contract, and a homeand-community-based caregiver was paid by the insurance scheme, however reimbursements were limited such that a large proportion of costs was still paid out-of-pocket by service users themselves, and unmet needs were still high among the disabled elderly . in addition, the inequality in access to long-term care services between advantaged and vulnerable elderly was enlarged. in most pilot schemes, higher numbers of benefit packages were allocated to insured groups living in nursing homes or receiving formal care than to those living at home receiving informal care. retired people with uebmi had higher affordability and preferred to live in the institutions and received higher reimbursements from insurance. rural residents could not access good quality long-term care facilities, and received fewer benefits. the inequality that remains in ltci practices highlights how policy reform ought to reevaluate and reconstruct the currently fragmented schemes and direct more attention to the disabled elderly with lower socio-economic status and without financial or family support. although china attempted the ltci scheme, its most urgent priority was to establish a unified meanstest public budget system to cover the most vulnerable social groups regardless of their living locations. through lu et al. (2017) 's projection, an investment as small as 0.25% of gdp (equivalent to about 1.25% of fiscal revenue) would greatly benefit the frail elderly and those with serious problems of functional disability and/or poor financial status . in 2016, the central committee of the communist party of china and the state council issued the healthy china 2030 plan. corresponding with the health-related sustainable development goal (sdg), this is a national mid-term and long-term strategic plan for moving towards universal health coverage and improving health equity, with emphases on health coverage for the whole life circle, including healthy ageing (prc, 2019). in 2018, china made a major restructuring of national healthcare governance. the national health commission (originally called the ministry of health) administers and regulates the healthcare delivery system and include two new areas of responsibility: elderly care and tobacco control (yip et al., 2019) . in addition, the national healthcare security administration was established. it is in charge of administering essential health insurances (urban employee basic health insurance, urban-rural resident basic health insurance, which integrated the original urban resident basic health insurance and new cooperative medical scheme) and medical assistance for the poor and vulnerable groups as well as deciding on pricing and drug procurement. rapid ageing and an alarming increase in non-communicable diseases (ncds) have arisen as major health concerns in china marten et al., 2014) . in 2009, the national basic public health service program was established, which included health management for elderly people, patients with major ncds (hypertension and diabetes), among others (nhfpc, 2017) . the program is financed by government funds, and the government's per capita allocation increased from 15 to 55 rmb between 2009 (nhfpc, 2017 . china's ongoing healthcare system reform prioritizes transforming hospital-centered treatment care to integrated and continued care through a tiered healthcare delivery system (meng et al., 2019) . a tiered healthcare delivery model defines the functions at each health facility level, and coordinates care across levels. a common model is that hospitals lead medical alliances to deliver integrated care, and provide support and training to strengthen primary health services wang et al., 2018b; wbwho, 2019) . in addition, residents are able to register with a family doctor team who provide preventive and basic healthcare as well as referral services. the government target is universal registration by 2020 (nhc, 2016) . china has made good progress in improving equal access to healthcare and financial risk protection for socially vulnerable people over the past decade (fu et al., 2018; meng et al., 2019; yip et al., 2019) , but challenges remain. there is a lack of qualified primary healthcare providers who are able to serve as gatekeepers, and the quality of primary healthcare is poorly characterized meng et al., 2019) . previous studies reported very low proportions of blood pressure and blood glucose control among patients with hypertension and diabetes seeking care from primary health facilities, and common over-prescription of antibiotics su et al., 2017; wang et al., 2014) . patients persistently bypass primary health facilities and seek perceived good quality of care in high level hospitals, despite many patients complaining of high medical costs and long wait times . on the other hand, most hospitals still largely rely on fee-for-service payment and tie doctors' salary to the hospital revenue generation, which gives hospitals an incentive to attract and retain patients rather than shifting them primary healthcare. overuse and overprovision of health services are common in china (meng et al., 2019; yip et al., 2019) . consequently, health expenditure has continued to escalate, a trend which threatens the long-term financial sustainability of basic health insurance schemes. the efficiency in using health resources is low (meng et al., 2019; yip et al., 2019) . as china continues to progress as an ageing society, strengthening primary healthcare system to provide integrated care will be fundamental to meet growing health needs and obtain the best value from existent health resources. it is difficult to shift from treatment-based intensive care to population-based preventive care and health management while perverse financial incentive for hospitals are not controlled or eliminated. this requires effective collaboration across related sectors led by a strong coordinating authority and needs to bridge policy dialogue to ensure health in all policies workable and achievable. china's prolonged demographic shift has led to decreased fertility, elevated sex ratios, rapid ageing, fast urbanization and major geographic redistributions (peng, 2011) , an interdisciplinary collaborative approach is necessary to prepare and face the challenges as society continues to age. we present a summary on ways to achieve a healthy ageing society in china at societal, individual, and molecular levels (fig. 5) . breaking knowledge gaps and eliminating boundaries among different sectors to further integrate and synergize different healthcarerelated parties at societal, individual, and molecular levels will optimize the outputs of the chinese healthcare system. the chinese government has adopted a positive stance to investment across the whole spectrum of ageing policies, medical education and training, basic ageing and geriatric research, prevention, primary care, and hospital and residential care. it is necessary to establish updated ageing policies on retirement age, to incentivize employment of the elderly, to encourage lifelong learning, and to invest in senior volunteer programmes (yeoh and lai, 2016) . the education and practice of geriatric medicine has been and will continue to be enhanced, including to further increase the teaching of geriatrics-related subjects in medical school, to design high-quality residency and fellowship programs, and to further integrate geriatric principles into general clinical practice (yu et al., 2018a) . the establishment of the national alliance of ncrcgd has been highly appreciated and welcomed and it will continue to serve as a national platform to educate and train geriatricians. while the achievement of healthy ageing and longevity is emerging as an important task for china as in many other countries, this may also be accompanied by socio-economic challenges. one of the major concern is that creating a society where healthy and active ageing and longevity are taken for granted may lead to a swelling of the elderly in the workforce, leading to limitations in job availability for the young, and proving to be a potent economic issue. countries like china and south korea are entering a society of population ageing, showing low birth rates and increased life expectancy, which changes the whole economy korea, 2017) . population ageing will likely have several macro-economic effects, touching various domains such as overall industrial structure, current account and inflation, output growth, household finance, labor markets, consumption, and even fiscal and monetary policy (korea, 2017) . it is therefore imperative to give a comprehensive assessment of population ageing in view of its effects on society and the economy in the long-term, to provide evidence to inform future policies. while a challenging task, some suggested responses to the early-emerging changes that could be taken to offset the effects of the ageing society include promoting the production of larger families in the young, finding ways to ensure jobs remain for the young should the elderly be able to continue longer in their positions, along with more general preparations on transform to an elderly-friendly society. it is delightful to witness the progress of basic and translational ageing research in china, as supported by increases in the number of grants and funding opportunities, as well as by rising numbers of high profile publications and discoveries (he et al., 2019c) . joint efforts from the government and stakeholders of each and every sector should be encouraged to nurture an elderly-friendly society, of most import are reforming the social support system to support china's ageing society, and the introduction of health service/investment interventions aimed at reducing inequalities in health among older people in china. we suggest current research focus on basic and translational gerontology to improve healthy longevity in the elderly, and on developing an integrated and affordable health and social care delivery system to meet the complex needs of a growing elderly population, and to finally transform china into an ageenabling country where well-being and healthy longevity can be celebrated for decades to come. in response to the ageing 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(per 10000 people) of viral hepatitis, pulmonary tuberculosis (p.tb), influenza, hiv infection and aids from 2004 to 2016 were extracted and presented as general (open) or aged (65 years or older, closed) population ), the 6 th population census of china (2010) and projection (2020-2050) of china's national bureau of statistics. c. women account for 75% of the total number of centenarians in china and the proportion of rural centenarians is far higher than that of urban area. data source: china's 2010 population census, excluding hong kong, macau and taiwan area. the map was made by r. d. geographical distribution of the relative number of centenarians. the proportion of centenarians in china's total population (centenarian ratio) has a significant regional imbalance the authors acknowledge the valuable work of the many investigators whose published articles they were unable to cite owing to space limitations. the authors thank dr. vilhelm bohr at the nia and university of copenhagen for reading of the manuscript. e.f. key: cord-011062-ukz4hnmy authors: nan title: poster date: 2020-03-11 journal: j frailty aging doi: 10.14283/jfa.2020.9 sha: doc_id: 11062 cord_uid: ukz4hnmy nan background: frail older adults are at increased risk of postoperative morbidity compared with robust counterparts. simple methods testing frailty such as grip strength have shown promising results for predicting post-operative outcome, but there is a debate regarding the most appropriate and precise frailty assessment method. objectives: we compared the predictive value of multidimensional frailty score (mfs) with grip strength or conventional risk stratification tool for predicting postoperative complications in older hip fracture patients. methods: from january 2016 to december 2018, 277 older hip fracture patients (age >= 65 years) who underwent surgery and comprehensive geriatric assessment (cga) were retrospectively included for analysis. hip-mfs was calculated based on the cga with component of sex, charlson comorbidity index, serum albumin, koval grade, cognitive function, risk of falling, mini-nutritional assessment and mid-arm circumference. grip strength was also measured before surgery. the primary outcome was a composite of postoperative complications (e.g. pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). results: among 277 patients (mean age 81.7 ± 6.8 years, 73. accordingly, grip strength could be used for screening tool to identify high-risk patients who need for further comprehensive geriatric assessment among older hip fracture patients. information and data suspected of post-operative infections. the diagnostic criteria of infection dealt with grade ii or more of clavien-dindo classification. diagnosis of infectious disease was made with reference to vital sign, blood test, imaging and bacterial test results. surgical site infection (ssi) was evaluated based on the infectious control team surveillance. results: 47 elderly patients were registered with necessary data. the average age was 77.0 years, 25 males and 22 females were included. in the sarcopenia evaluation, there were 15 cases without sarcopenia and 32 cases with it. 12 cases developed some infectious complications postoperatively. the types of infectious complications (including duplication) were 11 cases of some surgical site infections including suture failures, 5 of pneumonia, 2 of urinary tract infection, 4 of pneumonia and 2 cases of sepsis in 12 patients. infectious complications occurred in 4 cases in the non-sarcopenia group and 8 in the sarcopenia group (p = 0.903). the average postoperative hospitalization was 30.2 days overall, 20.8 in the group with postoperative infectious complications, and 61.9 in the group without sarcopenia. conclusion: in this study, there was no relation in the incidence of postoperative infections and preoperative sarcopenia. however, the postoperative hospitalization in the group with postoperative infectious complications was almost tripled. background: hypertension is one of the major risk factors for cardiovascular disease. lowering blood pressure is effective for preventing stroke, heart failure (hf), myocardial infarction and possibly dementia. in france, the prevalence of elderly people treated for hypertension rising leading to a possible increase of potentially inappropriate antihypertensive prescribing (piap) that may cause adverse drug events. objectives: to identify associated factors with potentially inappropriate antihypertensive prescribing (piap) in elderly people. methods: we conduct a retrospective observational study based on a cohort from geriatric day hospital for assessment of frailty and prevention of disability in toulouse, between january 2016 and april 2018. piap was defined with several explicit criteria: the european list of potentially inappropriate medications, alert and control of iatrogenesis (aci) criteria by the french health authority, the french society of hypertension guidelines, screening tool of older people's potentially inappropriate prescriptions (stopp) version two and summary of product characteristics. the piap has been considered as a binary variable (logistic regression) then as a counting variable by number of nonconformities on antihypertensive drugs (negative binomial regression). results: among the 1115 patients, 30% had piap. frailty, polypharmacy, history of angina and hf are associated with a higher risk of piap. similarly: frailty, polypharmacy and history of angina are associated with an increase in the number of non-conformities antihypertensive drugs. analysis of subgroup of patient hf -piap indicated that 42% had aci criteria whose 82% the aci criteria "4 antihypertensive drugs or more" and 68% the aci criteria "2 diuretics or more". analysis of subgroup of patient history of angina -piap indicated that 65% had stopp criteria, focused on loop diuretics. conclusion: our work suggests that some elderly people characteristics are associated with an increase likelihood of piap. targeting these patients would be beneficial in preventing medicine-related illness. background: social frailty was reported to be associated with age, sex, income, education, marital status, and household status. however, mood status including depression and emotion was relatively less investigated. objectives: the aim of this study is to clarify the association between depression and apathy status and social frailty in community-dwelling japanese elderly. methods: a health promotion project (teng tv project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. we ran a cross-sectional analysis using baseline characteristics of all participants (n=926). demographic data, socio-economic status, comorbidities, and nutrition evaluated by mininutritional assessment-short from (mna-sf) were recorded. functional capacity was assessed by the japan science and technology agency index of competence (jst-ic). mood status including depression, and emotion was measured by geriatric depression scale (gds-15) and apathy evaluation scale (aes). social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. we defined total deficit scores of 2 or more as social frailty, 1 as social pre-frailty, and 0 as robustness. we used a linear regression model to analyze the association between mood status and social frailty after adjusting for age, sex, education, marital status, comorbidities, bmi, mna-sf, jst-ic. results: at baseline, mean age of all participants (46.9% men) was 75±5.9 years. a total of 34.3% and 22% of all participants were categorized as social prefrailty and social frailty, respectively. the mean scores of gds-15 and aes were 3.4±3.3, 14.3±6.7, respectively. in linear regression model after full adjustment, participants with social pre-frailty and social frailty were associated with increased gds-15 scores (social pre-frailty vs. social robustness: b=0.58, 95%ci 0.01-1.15; social frailty vs. social robustness: b=2.49, 95%ci 1.68-3.29) and aes scores (social pre-frailty vs. social robustness: b=0.04, 95%ci -0.67-1.47; social frailty vs. social robustness: b=1.63, 95%ci 0.22-3.03). in addition, jst-ic was also associated with gds-15 and aes scores. conclusion: social pre-frailty and social frailty were associated with greater level of depression and apathy. future studies are warranted to determine the causal relationship among mood status and social participation. inthira roopsawang 1,2 , hilaire thompson 2 , oleg zaslavsky 2 , basia belza 2 ((1) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; (2) biobehavioral nursing and health informatics, school of nursing, university of washington, seatlle, usa) background: frailty is a common geriatric condition with an impact on surgical outcomes. no research has been published on frailty assessment in hospitalized orthopedic patients in thailand. having a valid frailty measure has the potential to improve screening and could enhance quality of care. objectives: to test the ability of the reported edmonton frailty scale-thai version (refs-thai) in predicting hospital outcomes compared with preoperative assessment measures, the american society of anesthesiologists physical status classification (asa) and the elixhauser comorbidity measure (emc) in older thai orthopedic patients. methods: a prospective study was conducted at a university hospital. the hospitalized patients aged 60 years or older scheduled for elective orthopedic surgery were recruited in this study. multiple firth logistic regression modeled the effect of frailty on postoperative complications, postoperative delirium (pod), and discharge disposition, while length of stay (los) was examined by poisson regression. the area under the receiver operating characteristic curve (auc) and mean squared errors (mse) were used to compare predictive ability of the instruments. results: two hundred participants with mean age of 72 (range 60-94 years) were mostly female , 23% were frail, and 58% underwent knee surgery; of which 26.5% had postoperative complications, 12.5 % developed pod, and 11% were unable to be discharged home. average los was 6 days. adjusting for other variables, frailty was significantly associated with postoperative complications (or = 2.38, p = 0.049), pod (or = 3.52, p = 0.034), and prolonged los (relative risk [rr] = 1.42, p = 0.043). applying the refs-thai alone shows good performance in predicting postoperative complications (auc = 0.81, 95% ci = 0.74-0.88) and pod (auc = 0.81, 95% ci = 0.72-0.90). the combination of refs-thai with asa and emc demonstrates improvement in predicting postoperative complications (auc = 0.81, 95% ci = 0.75-0.88 and 0.82 95% ci = 0.75-0.88, respectively) and pod (auc = 0.80, 95% ci = 0.71-0.89 and 0.81 95% ci = 0.72-0.90, respectively). conclusion: frailty assessment using the refs-thai was useful in predicting adverse outcomes in older adults undergoing orthopedic surgery. integrating the refs-thai for preoperative assessment may be useful for enhancing orthopedic care quality. anthony frioux 1 , matthieu faure 2 , margot de battista 2 , benoit roig 1 ((1) université de nîmes, france; (2) université de france) background: the attention of the scientific community to frailty has been drawn over the past several years. frailty is defined as a state of increased vulnerability that may lead to functional disability. if this state is managed soon enough it may be reversible. in parallel, the possibilities of monitoring health status through connected objects such as smartphones are increasing. similarly, it is possible to measure the activity of the inhabitants of a house collecting usage data (water and electricity consumption). our project is in the field of smart home and aging monitoring. objectives: therefore, the objective of our work is to develop an integrative model of frailty based on the contributions of existing scientific tools (fried et al., 2001 ; mitnitski, mogilner, & rockwood, 2001) and current sensors to measure a person's activity. eventually, we are aiming for the detection of the frailty trajectory early on. for example, real-time activity monitoring is used to detect a fall and alert rescue. in our case, these sensors will allow us to identify as soon as possible a dimension that would be abnormal in order to intervene and propose an appropriate intervention. methods: our tool will be able to measure the five fried's frailty criteria which are currently used in clinical practice. we compare the data from the sensors with the results of the evaluation of fried's frailty phenotype. results: we expect to obtain a correlation between our data and phenotype results. conclusion: the main contribution of our tool resides in the possibility to observe deviations from an individual's normal aging trajectory. thus, the evaluation we propose would be more ecological as it will enable us to consider the individual's habits and to have a more detailed assessment of his activity evolution. in conclusion, the holistic aspect of our work will allow the practitioners to base their intervention on a wide range of health data. l. van wagenberg, r.m. wösten-van asperen (department of paediatrics, paediatric intensive care unit. wilhelmina children's hospital, utrecht, the netherlands) background: a frail phenotype is recognized in the elderly population. frailty is associated with a higher mortality for adult intensive care (icu) patients. research in oncology suggests biological age is not the key contributor to frailty, since frailty is also found in the younger population. in paediatrics frailty is an unknown concept and as a consequence, the prevalence and meaning of being frail at young age are unknown. objectives: to assess whether a possible frail phenotype can be found in a critically ill paediatric oncological population. methods: a retrospective cohort study in a paediatric oncological icu population between january 2018 and september 2019. demographic data and need for icu resources (mechanical ventilation, inotropic support and s60 continuous renal replacement therapy (crrt)) were collected. since specific paediatric frailty scores are not available, we addressed patients as having a frail phenotype by textmining their electronic health records on the words "fatigue", "cachexia" and "diminished physical activities" before, during, and after paediatric icu admission. risk factors for a possible frail phenotype (cachexia, use of corticosteroids and lowest serum albumin levels) were collected. primary endpoint was mortality during icu treatment or course of illness. results: 479 admissions were included, of which 74 admissions had a possible frail phenotype. these admissions included 52 unique patients. 52% of patients was male and the median age was 5 years (iqr3-15). patients were predominantly treated for a haemato-oncological malignancy (52%). mortality during icu-admission was 8%, and 23% died subsequently during the course of disease after picu discharge. patients were severely ill, with a mean icu length of stay of 9.9 days (±17), 53% on ventilator support, 34% receiving vasopressor or inotropic support, and 5% on crrt. loss of muscle function or fatigue was present in 54% before icu admission and in 35% acquired atrophy or cachexia was documented during icu treatment. 67% were treated with corticosteroids during picu stay. in 28% a serum albumin ≤2 gram/dl was measured. conclusion: a possible frail phenotype is present in the oncological patient population of a paediatric icu. more research on the contributing factor of frailty on outcome of these patients is needed in the near future. john muscedere 1,2 , amanda lorbergs 1 , jayna holroyd-leduc 3 , anik giguere 4 , leah gramlich 5 , heather keller 6 , ada tang 7 , danielle bouchard 8 , donna fitzpatrick-lewis 7,9 , diana sherifali 7,9 ((1) canadian frailty network, kingston, on, canada; (2) queen's university, kingston, on, canada; (3) university of calgary, calgary, ab, canada; (4) laval university, quebec city, qc, canada; (5) background: despite research evidence related to nutritional and physical activity interventions, there is a gap in provision of evidence-based care focused on preventing and managing frailty among older adults. objectives: to systematically generate evidence-based nutrition and physical activity (pa) clinical practice guidelines to improve health and functioning in older adults with or at risk of frailty. methods: we are using the agree ii guideline development protocol to generate guidelines to improve health and functioning in older adults. for each guideline, systematic review of meta-analyses was conducted by searching three databases for english language citations published since 2001 that included adults aged 65y and older with frailty and/or pre-frailty. nutrition or pa interventions with a comparison group were considered eligible. acceptable study designs included rcts, quasi-experimental trials, and observational cohorts with a comparison group. in a face-to-face meeting with multidisciplinary content experts, healthcare professionals, and end-users we will further appraise the quality and strength of the evidence using the grade approach. this group will use this evidence to form recommendations related to nutrition and pa in this population. results: the nutrition and pa searches resulted in 3158 and 4709 citations, with 119 and 283 eligible for full-text review, respectively. the results will inform guideline recommendations. knowledge translation strategies will be developed to support guideline dissemination and implementation. conclusion: the guidelines will inform health professionals by providing evidence-based nutrition and pa interventions for adults with frailty. ( background: physical and psychosocial factors play important roles in the severity and progression of frailty. frailty screening tools include measures of the more common risk factors, including advanced age, comorbidities, poor diet, weight loss, lower socioeconomic status, and physical inactivity. however, there has been limited standardization in the us on specific frailty screening measures to include in national health surveys or frailty tools/protocols for community health settings. this makes it difficult to monitor frailty incidence/prevalence in the older adult population and to best identify and treat individuals at risk. results: we reviewed the most recent versions of 7 us national health surveys that include older adults, to identify whether frailty screening measures were included in. no national surveys had a battery of measures that would allow for frailty risk screening. most commonly, questions on weight, disability, mental health, physical functioning were included. however, physical functioning measurements such as grip strength or gait speed, measured height and weight, unintentional weight loss, dietary intake or appetite changes were not. further, we used the world health organization criteria for effective community screening programs to review published evidence of the validity, reliability, and feasibility of data-driven screening tools for frailty risk among community-dwelling older adults. of the 10 frailty screening tools reviewed, the frail scale was identified as the most promising, based on test characteristics and cost/ease of use. more community-level s61 research is recommended, particularly on predictive validity of favorable outcomes following physical activity/nutritional interventions. finally, because nutrition plays a significant role in frailty risk, we surveyed registered dietitian nutritionists who work with older adult populations (n=576) to identify their awareness/use of frailty screening protocols/tools and dietitians' potential role in frailty screening. dietitians practicing in the community recognized a potential role, but few dietitians were aware of (<6%) or using (< 4%) specific frailty screening tools. conclusion: future opportunities to better support healthy aging include: addition of frailty screening measures to national health surveys to help prioritize high-risk populations, conduct additional research to validate/recommend a common community-level screening tool, and promote engagement by dietitians and other health professionals who can establish protocols for community-based frailty screening. ming-yueh chou 1,3 , ying-hsin hsu 1 , yu-chun wang 1 , chih-kuang liang 1,3 , li-ning peng 2,4 , liang-kung chen 2,4 , yu-te lin 1 ((1) center for geriatrics and gerontology, kaohsiung veterans general hospital, kaohsiung, taiwan; (2) aging and health research center, national yang ming university, taipei, taiwan; (3) department of geriatric medicine, national yang ming university school of medicine, taipei, taiwan; (4) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, functional decline and mortality, and multi-domain intervention program may prevent those. objectives: the purpose of this study is to evaluate the effectiveness of multi-domain intervention program among those community-dwelling frail older people in southern taiwan. methods: a 12 week multi-domain intervention program were provided for all participants, including physical activity, high protein diet education, medical knowledge education and cognitive simulation activity for 2 hours per week. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds-5), cognitive condition (by mmse) and frailty status according to the definition by the cardiovascular health study (chs) . results: during jan 2018 and may 2019, totally 386 participants were invited for study (75.9% female, mean age 76.0±7.1 years). among them, 31 (9.4%) were clarified as frailty status and 190 (57.4%) as prefrailty status. after the multi-domain intervention program, their mood condition (0.35±0.83 to 0.23±0.71, p<0.001) and cognitive condition (24.40±5.75 to 25.14±5.70, p<0.001) improved significantly. in addition, the walking speed (0.89±0.28 to 0.98±0.49 m/s, p<0.001) and physical activity (13.42±14.51 to 16.31±15.99 mets/week, p<0.001) improved, but not handgrip strength (p=0.850). for the frailty status, those clarified as frailty status decreased from 9.4% to 5.2% and prefrailty status from 57.4% to 41.4% (p<0.001). conclusion: our results showed that through the 12 week multi-domain intervention program, those frail older people could improve their mood condition, cognitive condition, usual gait speed and frailty status. sarah b. lieber 1 , stephen a. paget 1,2 , jessica r. berman 1,2 , medha barbhaiya 1,2 , lisa sammaritano 1,2 , kyriakos a. kirou 1,2 , john a. carrino 3 , dina sheira 1 , mangala rajan 2 , yingtong lyu 2 , lisa a. mandl 1,2 ((1) division of rheumatology, hospital for special surgery, new york, ny, usa; (2) department of medicine, weill cornell medicine, new york, ny, usa; (3) department of radiology and imaging, hospital for special surgery, new york, ny, usa) background: frailty is a clinical phenotype that increases with age, but can occur in younger patients with chronic disease. based on few studies, frailty has been found in up to 27.5% of patients with systemic lupus erythematosus (sle) and is associated with increased mortality. whether frailty is prevalent in other sle cohorts and associated with objective and subjective factors is unknown. objectives: we aimed to determine the prevalence of frailty in a prospective cohort of women with sle and whether inflammatory biomarkers, body composition, and patient-centered domains differed between frail and non-frail women. methods: adult women <70 years old who fulfilled american college of rheumatology sle criteria were recruited from one center. exclusions included pregnancy, dialysis, active malignancy, overlap autoimmune syndromes, and severe sle disease activity. frailty was measured according to fried criteria. patient-reported outcomes (pros) were measured using pro measurement information system (promis) computerized adaptive tests; lupusqol; and disability based on valued life activities. physicianreported sle disease activity and damage indices were collected. inflammatory biomarkers and sarcopenia according to dual-energy x-ray absorptiometry were assessed. differences between frail and non-frail women were evaluated using chisquare tests and kruskal-wallis tests; the association between frailty and disability was determined using logistic regression. results: 71 women enrolled from 8/2018-9/2019. despite age under 70 years old, 21% were frail. frail women had greater disease damage (p=0.01) and were more often smokers (p=0.03). high-sensitivity c-reactive protein (p=0.05) and interleukin-6 (p=0.01) were higher and sarcopenia trended toward greater prevalence (p=0.07) in frail women. significant differences in promis mobility, physical function, pain interference and behavior, and fatigue and lupusqol physical health and pain (all p<0.01) were observed between frail and non-frail women, with frail women reporting consistently worse scores. frail women were 9.5x more likely to be disabled than non-frail women, including after adjustment for age, comorbid conditions, and disease activity/damage. conclusion: the prevalence of frailty was high in this cohort of mid-aged women with sle. frail women had poorer health-related s62 quality of life than non-frail women, including substantially higher disability. if frailty is associated with worse health outcomes, it could be a potential therapeutic target. chariya sumcharoen, supreeda monkong, nuchanad sutti (ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bangkok, thailand) background: bed bound older adults need caring of physical activities, mental, mood, and social from family caregivers. family caregivers usually gets the role strain from caregiving. there are many factors associate with the caregiver role strain but have been rarely reported in bed bound older adults at home. objectives: the study examined age, adequacy of incomes, mutuality, health status, preparedness, and social support influencing caregiver role strain from caregiving activities for bed bound older adults at home. methods: caregiver role strain concept by archbold and colleagues with literature review were used to guide this study. the sample was recruited by purposive sampling consisted of 117 caregivers aged 18 years or older, who have cared for bed bound older adults at home in thailand. data were collected by structured interview using the questionnaires including demographic data, preparedness, health perception, mutuality, social support, and caregiver role strain from the care activities. data was analyzed using descriptive statistics, pearson's product moment coefficients, and multiple regression analysis. results: the most of participants were women (78.33%), age ranging from 26 to 85 years (m= 56.23, sd=11.57) . the result showed that age, adequacy of incomes, mutuality, health status, preparedness, and social support jointly significantly explained 31.9 % of the variation in caregiver role strain from caregiving activities. the regression effects were strongest for health status (beta=-.285, p=.001), followed by preparedness (beta=-.254, p=.002), age (beta=.220, p=.008), and adequacy of incomes (beta=-.214, p=.014) respectively. conclusion: this finding suggests that healthcare providers should find strategies for promoting health status and preparedness of family caregivers for decrease caregiver role strain from caregiving activities. of life, and hospital admissions. objectives: we estimated the prevalence and describe the characteristics of the population with recurrent falls and fear of falling and their association with frailty, physical performance and cognitive fragility. methods: data came from the "salud, bienestar y envejecimiento" (sabe) colombia study, a cross-sectional study conducted in 2015 at the urban and rural research sites (244 municipalities) in colombia. sociodemographic, health, cognitive and anthropometric measures were collected from 23694 community-dwelling adults aged 60 years and older, representative form the total population. frailty was defined using the frailty phenotype proposed by fried. cognitive frailty was defined using the inaa/iagg consensus definition. low performance was evaluated with sppb (short physical performance battery). logistic regression analyses were used to identify factors associated with recurrent falls and fear of falls. results: our study identified 603 elderly who had recurrent falls and 1193 fear of falling (15.6% and 39.5% respectively). young elders (≤ 69 years) had more falls and greater probability for fear of falling compared to older ages. sex had no significant differences. the factor associated with an increased risk of recurrent falls and fear of falling in the elderly were low physical performance, fragility and polypharmacy. chronic illness such as osteoarticular disease, mental disease, diabetes and chronic pulmonary disease were significantly associated with recurrent falls and fear of falling. finally, when adjusted for age, sex, sociodemographic factors and comorbidities in a logistic regression model, frailty was associated with fear of falling and recurrent falls, while cognitive frailty and low physical performance only were associated with fear of falling. conclusion: recurrent falls have a significantly association with frailty. there are cognitive, physical performance and clinical factors associated with fear of falling that could be preventable and treatable. rubbieri gaia 1 , ceccofiglio alice 1 , mazzeo nicla 1 , pupo simone 2 , cartei alessandro 1 , rostagno carlo 1 , mossello enrico 2 ((1) department of perioperative medicine, careggi hospital and university of florence, italy; (2) department of geriatric medicine, careggi hospital and university of florence, italy) background: the prevalence of frailty in patients with hip fracture is high, but little is known about the choice of the best frailty tool in terms of prediction of functional recovery. objectives: the aim of this preliminary study was to determine the most predictive validated frailty tool in older people with hip fracture and to determine whether frailty can predict functional recovery during the hospital acute phase. methods: this study was observational prospective cohort study. participants aged 65+ admitted to hip fracture units in florence, were assessed pre surgery (t0), and post surgery. each participants underwent a comprensive geriatric assessment and frailty was defined using: clinical frailty scale (csf), frail scale (fs), reported edmonton frail scale (refs), postal frailty screening (pfs). the outcome was functional recovery, evaluated by a score of postoperative performance on the cumuleted ambulation score (cas). data recorded included pre-recovery barthel index (bi), charlson comorbidity index (caci), handgrip strenght test (hg), asa score, mini nutritional assessment short-form (mna-sf), delirium. results: sample included 114 patients (mean age 85±8 years, female 75.4 %). cfs was the most predictive frailty tool, with a 88% sensitivity and a 50% specificity (auc = 0.80, cut off >3). dividing the sample according to premorbid bi, while bi itself had the highest predictive value when premorbid level was <80%, cfs was the best predictor of functional outcome in the 80%+ subsample (auc= 0.67). conclusion: frailty defined by cfs can predict short-term functional recovery during acute phase following hip fracture. this appears particularly relevant for subjects with a higher pre-morbid functional independence. s64 52% were women. 385 individuals had data for all five frailty measures. nine percent of participants were non-frail by all instruments, 20 % were frail by all measures and thus 71 % had discordant frailty measurements. 91% were frail by at least one measure method. the prevalence of frailty ranged from 34 % to 75% for the different measures. those classified as frail by cfs and non-frail by bp were more likely to be men, be co-living, have lower cognitive function and a higher dependency in iadl compared to those classified as frail by bp and non-frail by cfs. conclusion: frailty measures cannot be used interchangeably. specifically the cfs might not identify physical frail women, with high cognitive ability who lives alone. factors contributing to the heterogeneity of groups classified as frail by different measures need to be further explored. background: polypharmacy is increasingly common amongst older, multimorbid adults. in these individuals, studies have shown a high prevalence of frailty. identification of frailty can be performed using comprehensive assessments registering accumulation of deficits like in the frailty index, or using single-trait markers of frailty like gait speed and handgrip strength. polypharmacy is recognized as an independent risk factor for the development of frailty, and the subgroup of psychotropic drugs may be particularly important in the development of this syndrome. objectives: our objectives were to study the relationship between the total burden of polypharmacy on frailty status using three different measurements of frailty, and specifically the influence of psychotropic drug use on frailty status. our overall aim was to explore whether either of these could be used as independent predictors of frailty. methods: we used data from a 2-year follow-up study of older people living in the community and receiving home care nursing, i.e. the cascade-study. data collection was completed in june 2018. all 210 participants were aged >65 years (mean 84 years). a 34 item frailty index was calculated based on results from a comprehensive geriatric assessment performed in the patients' own home. a fourmeter gait speed test was performed, as well as measurement of handgrip strength. information on regular medications was collected from the patients if they administered own medications, or from the home care nursing service if they were responsible for administering the patients' medications. psychotropic drugs were selected based on beers 2019 criteria. results: we found a significant association between the use of psychotropic drugs and frailty index, and frailty index increased by 0.03 for each psychotropic drug added (p<0.001). one additional psychotropic drug decreased gait speed by 0,03 m/s (p<0,05). there was no statistically significant association between psychotropic drug use and handgrip strength. conclusion: our study showed that psychotropic drug use was a significant predictor of increased frailty index and reduced gait speed. this was not the case for handgrip strength in our material. laetitia beernaert 1 , frédéric schuind 2 , sandra de breucker 1 ((1)department of geriatrics, hôpital erasme -université libre de bruxelles, belgium; (2) department of orthopedics, hôpital erasme -université libre de bruxelles, belgium) background: anemia is a condition whose prevalence might reach 50% in the geriatric population. anemia and frailty are two prognostic factors for patients admitted for a hip fracture. objectives: we analyzed retrospectively if preoperative frailty and anemia were independently predictive of postoperative complications and mortality in old patients admitted for hip fracture. methods: ninety-seven patients above 65 years old have been admitted for urgent surgery for a hip fracture during 2016 and 2017. we excluded patients with a pathological fracture or fractures due to high energy trauma. preoperative anemia was defined as an hemoglobin level under 12g/dl for women and 13g/dl for men. frailty was assessed with the isar (identification of seniors at risk) score. results: seventy-five percents of patients were considered as frail (isar score>2). the prevalence of preoperative anemia was 37%. we found no statistically significant correlation between anemia and frailty (r = -0.18-p = 0.071). in multiple regression logistic analysis, the only independent parameter associated with anemia was the presence of comorbidities (or 1.12 (1.04-1.20)-p = 0.02), and the only parameter associated with frailty was the presence of malnutrition (or 28.2 (2.8-28.9)-p = 0.005). neither anemia nor frailty was associated with postoperative complications and mortality. conclusion: preoperative anemia and frailty are not interrelated in patients admitted for hip fracture. anemia is associated with comorbidities, but not postoperative mortality. frailty is associated with preoperative malnutrition. the isar score may not be ideal to screen for frailty in old patients admitted for hip fracture, an item being attributed to the current loss of autonomy. settings. m martinez 2 , maria montoya 1,2 , davide angioni 1 , lizeth canchucaja 2 , natalia ronquillo 3 , maria luz gallego 2 , claudia bejar 4 , emmanuel gonzalez 2 , olga vazquez 2 , anna renom 2 ((1) institute de viellisement toulouse, france; (2) hospital del mar, barcelona, spain; (3) hospital de terrasa, barcelona, spain; (4) parc tauli, barcelona, spain) background: frailty is a common critical geriatric syndrome which has been associated with poor health outcomes.a wide variety of frailty indices (fis) have been developed. frail-vig («vig» is the spanish/catalan abbreviation for comprehensive geriatric assessment).it contains 22 simple questions that assess 25 different deficits. it has been inspired by the rapid geriatric assessment. objectives: the aim is to compare the prediction capacity of clinical rockwood index frailty (rif) and frail-vig index (vif) for poor health outcomes (pho) defined as: emergency department visits and/or hospital admission and/or mortalityamong elderly patients. methods: a retrospectiveobservational study was conducted with a followup up to 15 months or pho occurred. patients were admitted in acute geriatric unit care and geriatric day hospital at hospital del mar; barcelona; spain during august 2018 and march 2019. the inclusion criteria were the admission ones. frailty was measured at admission. survival analysis was conducted; cox proportional hazards regression was used to build a pho predictive model based on both indexes. best model according to contrast of hypothesis log-rank ,aic; bic and c harrel was selected.diagnoses of the chosen model was done. results: a total of 49 patients were included, mean age was 78 and 46.9% female. the mean of follow-up was 9.78 , 51% patients presented a pho. 24.4% died, 32% were admitted at emergency department, 26.5% were hospitalized and 22% presented more than one event.survival curves for frail and non-frail according to pho showed statistically significance for vif (x2=6.77 p=0.0093)but not for rif (x2=0.62 p=0.4315). cox proportional hazards regression showed vif hazard ratio 3.44 (p=0.0406) and rif hazard ratio 1.27 (p=0.607). predictive capability resulted in a model for vif containing cognition and sex, with harrel c of 0.735. as for rif the most parsimonious model rif would be absent and harrel c 0.503. the diagnoses of the model showed time covariate variable test with p=0.429, p=0.297, p=0.640 for each predictive variable; squared linear predictor with p=0.39 of and 2 outliners. conclusion: the vig frailty index performed better; compared to rockwood clinical index; in predicting a composite outcome composed by mortality, hospitalization and visits to emergency departments in patients admitted in acute and outpatient settings. after hospital discharge. methods: this study was conducted in the departments of internal medicine and neurology of the university hospital of araba (basque country, spain). participants were >=70 years, scoring >=20 on the mmse test and able to stand and walk independently for at least 4-meter. participants performed twice-weekly moderate intensity group sessions of multicomponent exercise at the hospital during 12-week, followed by a home-based intervention (12week) . both were focused on balance, aerobic capacity and strength. taking together both interventions, participants completed 24-week of physical exercise. at the beginning and the end of the program, frailty was measured though fried´s index1 and sarcopenia with different criteria2: muscle strength (5-chair stand), muscle quality (dxa) and physical performance (sppb). we compared the results before and after the intervention by mcnemar test. results: 55 patients (27 females, 49%) were enrolled, 26 were lost to follow-up at the 24-week time point and 29 people finished the intervention. the intervention decreased significantly the percentage of frail individuals (p<0.001) according to fried´s index, and the percentage of people who met sarcopenia criteria for sitto-stand (p=0.031) and sppb (p=0.031). however, there were no differences in the percentage of people with low appendicular muscle mass. conclusion: our study showed that a multicomponent exercise program is effective for posthospitalization patients because after 24-week intervention there were significant reductions in frailty and improving results in muscle strength and physical performance. we did not find changes related to muscle mass. references: 1. background: alcohol addiction can impact every part of the body, including bones. research shows that chronic heavy alcohol use, especially during adolescence and young adult years, can dramatically affect bone health and increase the risk of osteoporosis and bone fracture later in life. objectives: the purpose of this study is to compare data from international scientific literature with data from the study of patients admitted for alcohol dependence, to assess whether there are significant connections between alcohol dependence and unrecognized fractures. methods: we analyzed 34 meta-analysis's studies from the pubmed search engine to evaluate the association between bone fractures with alcohol use disorders. only humans studies from the last 5 years have been analyzed. subsequently, data related to patients admitted for an alcohol rehabilitation cycle were analyzed. results: scientific literature show that there is a close correlation between alcohol abuse and greater frequency of bone fractures. this is partly due to association between alcohol consumption and both osteoporotic fracture and bone density, and partly to the fact that there is an increased risk of falls in alcohol intoxicated patients compared to the general population. 1145 patients were considered: 71% male and 28.2% female. the average age was 48 years. of these 1145, 5.38%, 61 patients, had unrecognized fractures. conclusion: intoxicated patients admitted in alcoholic rehabilitation with recurrent falls anamnesis often did not perform any diagnostic assessment. this is due to the lack of pain perception in the patients or due to family members or emergency physicians who placed the state of drunkenness before any consequences caused by repeated falls. there is an increased risk of unacknowledged fracture in the patients admitted in alcohol rehabilitation this is partly due to the fact that alcohol intoxicated patients often do not perceive the pain and therefore do not investigate any falls that occurred in a state of drunkenness, in part it is due to the damages that alcohol causes on the bone. our data show that alcohol dependence and unrecognized fractures can often be associated. studies in the literature confirms that there is an increased risk of non-cone fractures in patients with alcohol dependence. zamudio-rodríguez, hélène amieva, luc letenneur, karine pérès (centre de recherche inserm u1219 université de bordeaux -isped, bordeaux, france) background: although conceptually distinct, frailty and disability are very common among older adults. both are multifactorial conditions and share some risk factors and pathophysiological mechanisms, such as inflammation or sympathetic-parasympathetic balance alteration. furthermore, each individual component of the frailty phenotype defined by the cardiovascular health study (chs) has been associated with disability in basic and instrumental activities of daily living. objectives: the present study aimed to determine whether pre-frail and frailty are part of the natural history of the disability process. methods: a sample of 894 people aged 75 of the three cities (3c) study in bordeaux were followed for four years. pre-frailty and frailty were defined according to the original phenotype proposed in the chs. disability was defined using the basic (adl) and instrumental (iadl) activity of daily living scales. seven mutually exclusive hierarchical groups were distinguished at inclusion: 1) robustness (no frailty or disability); 2) pre-frail (without disability); 3) frailty (without disability); 4) iadl (without pre or frailty or adl) 5) pre-frail with iadl (no adl); 6) frailty with iadl (no adl); 7) frailty with iadl and adl. results: 177 deaths (19.8%) occurred during the four years follow-up. compared to the robust group, all other hierarchical subgroups had an increased risk of death, with an increasing gradient: pre-frailty (hr= 1.84; ic 95 %= 1.00 -3.39); frailty (hr= 3.46; ic 95 %= 1, 53) , iadl disability (hr = 3.21; ic 95 %= 1.28 -8,05); pre-frailty with iadl disability (no adl) (hr= 4,08; ic 95%= 2,16 -7.70); frailty with iadl disability (no adl) (hr= 5,42; ic 95%= 2.84 -10.34); frailty with iadl and adl disability (hr= 10,58; ic 95%= 5.39 -20.77) were significant after adjustment by age and sex. conclusion: there is a gradual risk of mortality across the different groups ( i.e., 1) robust; 2) pre-frail; 3) frail; 4) iadl disability without pre or frailty; 5) pre-frail with iadl disability; 6) frail with iadl disability; 7) frail with iadl and adl disability) thus suggesting a hierarchical relationship. this study could have important clinical implications since pre-frailty and frailty are assumed more effectively reversible conditions in order to interrupt the continuum at the early phase of the disability processes. background: joint replacement provides significant improvement in pain, physical function, and quality of life in patients with osteoarthritis. with a growing body of evidence indicating that frailty can be treated, it is important to determine whether targeting frailty in joint replacement patients is feasible and improves post-operative outcomes. objectives: to examine the feasibility of a preoperative multi-modal frailty intervention (mmfi) compared to usual care in pre-frail/ frail older adults undergoing elective unilateral hip or knee replacements. methods: in this pilot randomized controlled trial (rct), participants who are 1)>=65 years old; 2) pre-frail (score of 1-2; (fried frailty phenotype (ffp)) or frail (score of 3-5; ffp); 3) having elective unilateral hip or knee replacement with surgery wait times between 3-10 months were recruited from the regional orthopaedic clinic mcmaster university, ontario canada. the mmfi included tailored exercise, protein (20-40 gm/day), vitamin d (1000 iu/day) supplementation, and medication review with recommendations sent to family physicians. frailty and mobility were assessed at baseline and 6-weeks post-operative using ffp, short performance physical battery (sppb) and oxford hip/knee score (ohs/ oks) respectively. results: we recruited and randomized 69 participants between september 2016 and may 2018. of those, 78.3% were referred for total hip replacement and 21.7% for knee replacement. the included participants' mean age (standard deviation (sd)) was 73.9 (7.5) years; 68.1% were women; 30.0% lived alone, body mass index was 31.9 kg/ m2 (7.2) and 44.9% were former smokers. at the baseline assessment, on the ffp, 64% were prefrail, 36% were frail and the sppb was 7.0 (2.2). for participants with hip osteoarthritis, ohs mean (sd) was 19.5 (7.3) and for participants with knee osteoarthritis, oks mean (sd) was 24.5 (7.2). the study recruitment rate was 54.8%, and the retention rate was 87%. eighty three percent of participants of the intervention group completed the intervention. self-reported adherence to the intervention components was as follow: 1) exercise sessions: 68.4%, 2) protein supplement: 87.5%, 3) vitamin d supplement: 85.7% and 4) medication review completion: 100%. conclusion: this is the first study to examine the feasibility of a multi-modal frailty intervention in pre-frail/frail older adults undergoing joint replacement. this study showed that frailty screening, assessment and management is feasible for older adults undergoing joint replacement in orthopaedic surgery clinics. results have informed the current multi-centre rct to determine effectiveness. christine tocchi 1 , sathya amarasekara 2 , michael cary 3 ((1) school of nursing, duke university durham, nc usa; (2) school of nursing, duke university durham, nc usa; (3) school of nursing, duke university durham, nc usa) background: inpatient rehabilitation facilities (irfs) provide intensive rehabilitation therapy to patients to reduce functional impairment, enhance independence and return patients to the community. determination of eligibility for irf is currently based on preadmission screening. subpopulations of older adults may require special consideration in determination of irf admission due to greater risk for poor functional recovery such as those with pre-existing functional limitations and those who are frail. frailty, a pervasive characteristic in older adults with hip fractures has not been examined as a clinical factor influencing discharge destination outcomes in irfs. objectives: 1) determine the prevalence of frailty among older adult with hip fracture receiving inpatient rehabilitation; and 2) determine the association between frailty and discharge destination among hip fracture patients receiving inpatient rehabilitation. methods: a retrospective cohort study design using cms 2014 inpatient rehabilitation facility-patient assessment instrument file. multivariate regression models were performed to examine the association between frailty and discharge destination. frailty status was measured using a frailty index of 30 items with the following cut-off points: 0 -0.20 robust/non-frail; 0.20 -0.35 pre-frail; and 0.35 or greater as frail. the final sample included 26,134 hip fracture patients. results: frailty, pre-frailty, and nonfrail were present in 0.33% (n=86), 7.6% (n=1976), and 92% (n=24071) of hip fracture patients, respectively. the majority (65%) of the frail hip fracture patients were discharged home. there were significantly greater proportion of females than males discharged home and those of white race, 65 to 74 years of age, and with higher functional status. regression analysis showed significantly lower functional status at discharge (p < .0001) for patients with these characteristics: males, non-white race, and older age. additional factors that influenced discharge destination included: marital status, living in the community prior hospitalization, and length of stay. conclusion: frailty was the most common frailty status on admission to irf. home is the most common discharge destination for all frailty status groups. frailty status could be used to identify hip fracture patients at high risk for adverse outcomes. future studies should be used to explore the potential of frailty to provide valueadded utility to clinical settings such as irfs. background: front-line care providers are seeking direction on how frailty measures may be integrated into existing or future care pathways to enhance the experience of individuals who live with it. multidimensional frailty measures such as the edmonton frail scale offer the potential for case-finding, estimation of severity, and definition of frailty components. objectives: test the feasibility of the implementation of a multidimensional frailty order set into acute care. methods: in 2016, we conducted a literature search to identify existing frailty guidelines and systematic reviews related to frailty in acute care. an expert panel graded the quality the evidence, then generated recommendations, graded by strength to inform the generation of a clinical knowledge and content management (ckcm) topic for dissemination throughout alberta health services (ahs). ahs is the largest province-wide, fullyintegrated health system in canada. this ckcm would include graded statements and recommendations, clinical decision support, electronic alerts, and a frailty order set. results: four guidelines, 60 systematic reviews, and one scoping review informed the development of the frailty ckcm. from this, we developed eight recommendations, covering topics such as prevention, case-finding, estimation of severity, definition of components, triggers for expert assessment, and linkage to care processes. the recommendations also addressed safeguards to avoid labelling and other unintended consequences. an order set employs the clinical frailty scale, electronic frailty index, and edmonton frail scale to support a clinician to develop a personalized care plan. the order set empowers front-line clinicians to administer these frailty measures, based on cut points that prompt personalized recommendations on diet, activity, fall prevention, bladder management, and infusions. depending on the frailty component of concern, clinicians are also prompted with specific options to address cognitive impairment, functional dependence, falls and immobility, social isolation, nutritional risk, polypharmacy, urinary incontinence, chronic pain, and constipation. in preparation for the conversion to a province-wide electronic medical record (emr) in november 2019, the ckcm was released in may 2018 and the frailty order set was built into the emr by september 2019. conclusion: development and implementation of a multidimensional frailty order set in the setting of acute care is feasible. masayo kojima 1 , toshihisa kojima 2 , yuko nagaya 3 , yasumoto matsui 1 ((1) national center for geriatrics and gerontology, obu, aichi, japan; (2) nagoya university, nagoya, aichi, japan; (3) nagoya city university, nagoya, aichi, japan) background: prevention programs for frailty at community usually target healthy older people. to further prolong healthy life expectancy, we need to approach those who already have got chronic diseases such as rheumatoid arthritis (ra). objectives: the aim of this study is to assess the prevalence and factors associated with frailty in japanese ra patients. methods: ra patients aged 40-79-yearold who visited two university hospitals between march and july 2019 were consecutively invited to join the study. those who agreed to participate the study provided written consent forms. frailty was assessed by the total score of the kihon checklist >=8. self-report questionnaires were used to evaluate patients' demographic characteristics, perceived degree of pain, depression (the beck depression inventory-ii) and physical function (the health assessment questionnaire, haq). rheumatologists' global assessment of disease severity, swelling and/or tender joint counts, years of ra duration, frequency of arthritis surgery and crp level were also measured. results: total of 389 ra patients were included in the study (312 women, average age: 64.5 ± 9.7 years, average disease duration: 15.8 ± 11.8 years), and the prevalence of frailty was 25.6%. the higher the age and the longer the duration of the disease, the higher percentage of ra patients with frailty was observed. 18.4% among ra patients of working age (40-64 years), were frail, whereas 28.0% and 39.3% were frail among those aged 65-74 years and >=75 years, respectively. stepwise logistic regression analysis revealed that age, haq, depression severity and trust in neighbors were independently associated with frailty in ra. no significant gender difference was observed. conclusion: frailty is common even among working age in ra patients. physical function, depression and social capital were suggested to be independently associated with frailty. on-going followup study will disclose the influence of frailty on fracture, dependency, and mortality among ra patients. background: frailty is an important modulator of ageing and might impact on clinical presentation and progression of parkinson's disease. objectives: to evaluate the prevalence of frailty and correlation with motor and non motor symptoms as well as mri atrophy and white matter hyperintensities in parkinson's disease. methods: consecutive parkinson's disease patients underwent a comprehensive motor and non motor evaluation and geriatric assessment using multidimensional prognostic index (mpi). a subset of 60 patients underwent mri with assessment of atrophy and white matter hyoperintensities by visual rating. results: 125 pd outpatients (mean age 69.5 y, mean disease duration 4.6 years) entered the study. pre-frailty assessed by mpi was presented by 20% of patients and correlated with age and disease duration. when adjusting for these ariables, mpi correlated with updrs-iii, non motor symptoms assessed by umsar, prevalence of prevalence of orthostatic hypotension, rbd and depression. the mri assessment showed a correlation between global atrophy and frailty indipendently from mmse and educational levels. no association between frailty and wm hyperintensities was found. conclusion: frailty is a possible important modulator of pathology and brain vulnerability in parkinson's disease and could explain different severity in motor and non motor symptoms. longitudinal studies are warrented to evaluate the impact of frailty in disease progression. background: accidental falls in older adults have been associated with worse health-related outcomes especially in the frailest individuals, such as nursing home (nh) residents. in this special population of older adults, falls have been related to greater morbidity and mortality, but their impact on nutritional status is still unclear. moreover, so far there are no data on the potential role of unmodifiable (e.g. cognitive impairment [ci] ) and modifiable factors (e.g. assistance from informal caregivers) in influencing the impact of falls on nutritional status in older residents. objectives: we aimed to evaluate the changes in body weight during the six months after the occurrence of a fall in nh residents, and the possible influence of severe cognitive impairment, depressive symptoms and of the assistance from informal caregivers on such variations over time. methods: the sample included 148 older residents who experienced at least one fall since nh admission. for each participant, we collected data on sociodemographic information, mean frequency of visits from informal caregivers, medical history, and cognitive and functional status at nh admission. severe ci was defined as the presence of a physician-based diagnosis of ci or a mini-mental state examination <18 points. the frequency of the visits from informal caregivers was categorized as none or 1 (low) vs >1 (high) per week. falls' date and characteristics were obtained from structured forms completed by physicians. monthly body weight in the six months before and after the fall were derived from the nh medical records based on nurses' assessments. linear mixed models were used to evaluate the body weight changes after a fall, as a function of the presence of severe ci and low visits' frequency from informal caregivers, alone or in combination. results: the mean age of our sample was 81.8±8.4 years and 72% were women. more than half (54.7%) of residents involved had severe ci and 51.7% had low visits' frequency from informal caregivers. after adjusting for potential confounders, the presence of severe ci (b=-0.4, se=0.1, p<0.001) and the report of low visits' frequency from informal caregivers (b=-0.2, se=0.1, p=0.03) were associated with steeper decline in body weight during the six months after the fall. when combining these variables, we found an additive effect of severe ci and low visits' frequency from informal caregivers in influencing weight loss (b=-0.44, se=0.13 for residents with severe ci and high visits' frequency, and b=-0.65, se=0.13 for those with severe ci and low visits' frequency; p<0.001 for all). conclusion: our results suggest that cognitive impairment may worsen the impact of falls on nutritional status in nh residents, and that this effect may be exacerbated by scarce assistance from informal caregivers. (2) tokyo women medical university, tokyo, japan, japan; (3) department of geriatic medicine, kyorin university medical hospital, tokyo, japan; (4) tokyo metropolitan institute of gerontology, tokyo, japan) background: in consideration of the future rapid aging of the society, to achieve healthy and active aging is indispensable. because especially the major issue is to prevent "multi-faceted frailty", it is necessary to reconsider regarding nutrition, physical activity and sociality/sociability in the elderly. sarcopenia is associated with adverse health outcomes, such as frailty, limited physical function, falls, disability and loss of independence. objectives: our aim to notice evidencebased new information, leading to frailty prevention, and let the community-based activity by elderly citizen only promote as a voluntary motion in each community. methods: we have already established many new evidences from our on-going japanese large-scale longitudinal study 'kashiwa study'. these evidences include the impact of overlapping of slight oral dysfunction, namely "oral frailty", as well as unbalanced diet and inadequate physical activity in early-stage sarcopenia. furthermore, we found the negative impact of several social disengagements including eating alone, so-called "social frailty", leading to subsequent sarcopenia. we developed a simple screening tool, ''frailty check-up activity'', which elderly citizen supporters only can operate in each small gathering place (e.g. community salon) via support by its local government. results: based on the concept of all-including three pillars, 1) nutrition (i.e. dietary food intake including diversity and adequate protein intake, and treatment/maintenance against oral frailty), 2) physical activity (not only exercises but also social daily activity) and 3) social participation, the newly citizen activity ''frailty check-up'' has developed. after elderly citizen supporters received training fully, they could implement this activity completely and repeatedly in each local municipality. elderly participants could learn how to improve/conquer by themselves with raising their self-awareness for the importance of early frailty/sarcopenia prevention and could change their behavior modification. in addition, using big data combined with preexisting database of new-onset regarding care needs and/or all-cause mortality, we found the new cut-off point in our frailty check-up activity. conclusion: we could confirm that our interdisciplinary "action-research" can raise the citizen's early awareness and affect their behavior modification via elderly citizen supporter system for frailty prevention, consequently leading to extend healthy life expectancy. saguez, carlos márquez, bárbara angel, mario moya, lydia lera (inta, universidad de chile, santiago, chile) background: physical phenotype of frailty has been associated with quality of life deterioration and some studies have calculated cost-effectiveness of interventions on frailty in quality-adjusted life years (qalys), however studies on the direct burden of frailty expressed in qualys lost in community dwelling older adults are scarce. objectives: to forecast qalys lost caused by frailty in older chileans and describe health profiles as determined by euroqol (eq-5d) in community-dwelling older chileans with and without frailty. methods: cross sectional study in 630 (72,4% women, mean age 72y±6.7) community dwelling people >=60years participants in alexandros cohorts. the frailty phenotype was defined as having >=3 from the 5 following criteria: weak handgrip dynamometry, unintentional weight loss, fatigue/ exhaustion, five chair-stands/slow walking speed and low physical activity. qol was evaluated trough euroqol (eq-5d) five dimensions: mobility, self-care, usual activities, pain/ discomfort and anxiety/depression and self-rated health trough eq5-visual analogue scale (eq-5d-vas). qualys were calculated by the eq5-d time trade-off (tto) method. to estimate life expectancies (le), multistate methods based on the follow-up of alexandros cohorts, were employed. results: frailty was identified in 31,7% of the sample. selfrated health according to eq-5d-vas was lower in frail than non-frail people (63.9±21.2 vs 73.6±18.0, p<0,01). after adjusted multinomial logistic regression, the eq-5d dimensions of anxiety/depression (very depressed rrr= 6.24;95%ci:2. moderate rrr=4.19; 95%ci:2, 23) and pain (much pain rrr=7.89; moderate pain rrr=2.44; had the highest association with frailty. the valorisation of years in qualys was lower in frail than in non-frail people (0.77±0.29 vs. 0.87±0.23 qalys per year, p<0,05) and among those frail, much lower in people >=80y than in the group 60-69y (0.48±0.30 vs. 0.83±0.26, p<0,05). the qualys remaining years were lower in frail people than in non-frail:total le at 60-69y was 22,5y corresponding to 18,8 qalys in frail and 20,5 qalys in the non-frail; in the group >=80y tle was 8,3y corresponding to 3,98 qalys in frail people and 6,72 in the non-frail. conclusion: the high burden of frailty on qalys, mostly related to pain and anxiety/depression makes compulsory its early detection and treatment. its knowledge allows calculating cost-effectiveness of interventions. background: + agil barcelona is a real-life a multicomponent intervention against frailty implemented in a primary care center, which promotes a comprehensive and coordinated approach between primary care, geriatrics teams and community resources, to detect and reverse frailty in the older adults. objectives: we aimed to assess the 3-months impact on physical function of +agil barcelona in community-dwelling frail older adults with cognitive impairment. methods: the study population was driven from the +agil barcelona program population. we included participants with cognitive impairment or dementia past history and those who performed a minicog test < 3 points. after frailty screening by the primary care team, a geriatric team performed the comprehensive geriatric assessment. according to cga results, a tailored and specific multidisciplinary intervention for each person was designed. the intervention could include a) multi-modal physical activity (pa) sessions, b) promotion of adherence to a mediterranean diet c) health education and d) medication review. the physical performance was assessed at baseline and at 3-omths follow-up by the short physical performance battery (sppb) and gait speed. the pre/post intervention analysis was done by a paired sample t-test for repeated samples for continuous variables and chi-square for categorical variables. results: we included 54 participants (mean age= 82.2±5.2, 70.2% woman and 29.8% lived alone). despite being independent in daily life, 36.8% had fallen the past year, 77.2% were vulnerable or frail according to the csf. physical performance was impaired: sppb=7.29±2.5 and gait sped=0.67±0.20m/sec and 46.9% had balance impairments. after 3 months, 73.2% of participants completed >=7.5 physical activity sessions. the mean improvements were +1.15±1.27 points (p<0.001) for sppb, +0.06±0.12 m/ sec (p<0.001) for gait speed, -4.4±8.53 sec (p<0.001) for chair stand test, and 47.6% (p 0.001) improved their balance. additionally, psychoactive treatment was withdrawn in 25.9%. conclusion: according to our results, a multidisciplinary and comprehensive geriatric intervention for frail elderly people with cognitive impairment of the community improves physical function and could reverse fragility at 3 months. clarence mwelwa patrick chikusu, amritha narayanan, joel james (ashford and st peter's nhs foundation trust, chertsey, uk) background: frailty and muscle strength are a critical component of walking ability and presence of these can result in high prevalence of falls. it also results in increased morbidity and mortality among the elderly. despite sarcopenia being very common and a reversible condition in its early stage it is a frequently overlooked and undertreated geriatric syndrome a greater understanding of sarcopenia and frailty among healthcare professionals could have a dramatic impact on outcome and quality of life of the elderly. objectives: this study aimed to assess the current knowledge about the concept of sarcopenia and frailty among the healthcare professionals working in an nhs district general hospital in surrey. methods: this longitudinal study included nhs healthcare professionals (n = 50) who were asked to complete a questionnaire regarding awareness of concept, risk, diagnostic strategy and management of frailty and sarcopenia. results: 63.27% of healthcare professionals stated to know the concept of sarcopenia, 20% indicated to know how to diagnose sarcopenia and 20% had seen patients with suspected sarcopenia in the last one month. only 20 % knew the risk associated with sarcopenia. 83.33% used sarc f questionnaire as diagnostic method for sarcopenia. 100 percent of the cohort experienced bottle necks during the implementation of diagnostic strategy. lack of awareness and time (41.76%) was the main reason for this .97.96 percent heard the term frailty and 76.16% knew that sarcopenia and frailty is not the same .77.55 percent was aware of the scoring methods for the frailty and 76.32 % used clinical frailty score as the method. 65.31% was aware of the frailty pathway but only 53.06% knew whom to contact regarding managing frailty. 57.14% heard the term comprehensive geriatric assessment. only 24.49% was aware of key recommendations of managing frailty in the acute settings. conclusion: although concept of sarcopenia and frailty is familiar to most nhs healthcare professionals, the practical and clinical application is limited due to a lack of awareness regarding the diagnostic methodology, risks as well as time constrains. as such the benefits and potential treatment options may be overlooked and we aim to improve awareness so that these measures can improve outcomes for patients. mahtab alizadeh-khoei 1 , fatemeh sadat mirzadeh 1 , reyhaneh aminalroaya 1 , fati nourhashemi 2 ((1) gerontology & geriatric department, medical school, tehran university of medical sciences, ziaeian hospital, tehran, iran; (2) department of internal medicine and clinical gerontology, toulouse, france) background: frailty is a potentially reversible geriatric syndrome associated with geriatric risk factors. detecting risk factors is a useful purpose to predict frailty levels incidence to plan for institutional or home care services. objectives: the aims were finding frail and prefrailty frequency in iranian geriatric outpatients' and determining demographics related factors and geriatric syndrome predictors on frailty levels, based on frailty fried index. methods: in this cross-sectional study 364 elderly >=60 years old, selected by convenience sampling from geriatric day clinics in the area of tehran university of medical sciences. the effect of risk factors (adl and iadl dependency, obesity, and polypharmacy) and geriatric syndromes (falling, chronic pain, sleep problems, vertigo, vision and hearing impairments, incontinence, dementia, and depression) were evaluated on frailty fried index. predictor factors by logistic regression model were analyzed, according to demographic risk factors and geriatric syndromes. results: the mean age was 67/3±6/2 years old, majority were male (62%). prefrailty was 37.6% in men and 47.1% in women based on fi. the significant risk factors in elderly prefrail women were depression (82.1%), polypharmacy (48.3%), visual impairment (47.2%), and chronic pain (56.6%); although, in prefrail men were vertigo (57.6%), falling (52%), sleep disorder (49.5%), and incontinence (52.1%). in prefrail older adults>=70 years, only sleep disorder was significant. in logistic regression model, six significant predicted factors were included depression, iadl dependency, falling, chronic pain, vertigo, and age. depression increased the risk of prefrailty by 2.8 times, dependency in iadl increased 3.5 times; moreover, chronic pain and vertigo increased prefrailty risk about 2 times. dependency on iadl increased the risk of frailty 5.8 times, and chronic pain and falling increased the risk of frailty about 1.65 times. by logistic regression model, 58% of prefrail outpatients elderly could be diagnosed. conclusion: geriatric syndromes in outpatients' elderly could predict prefrail more than frail elderly. in the iranian community dwellers prevalence of prefrailty was high, so the on-time screening and outpatients' interventions can help to prevent frailty. background: frailty is a key condition to be screened among elderly oncological patients. nevertheless, the use of the frailty index (fi) in onco-geriatrics is still limited. objectives: aim of our work is to measure the functional and prognostic value for 1-year mortality of the frailty index (fi) in a cohort of older women with gynecological cancer. methods: the prognostic value of fi was tested in 200 older women with gynecological cancer (mean age = 73.5 years). fi was retrospectively calculated following the rockwood model[1]. spearman's rho test was used for correlations with other oncological scales: eastern cooperative oncology group performance status (ecog); karnofsky performance status (kps); vulnerable elders scale-13 (ves-13). cox proportional hazard models and roc curve were performed to estimate prognostic role of 1-year mortality. sensitivity and specificity were also calculated. results: fi is normally distributed and descriptive statistics define our population as frail (mean = 0.25±0.11, range 0.08-0.51). 0.7 is confirmed as an upper limit compatible with life. fi doesn't significantly correlates with age, ecog and kps while it positively correlates with ves-13 (r=0.7, p < .01). fi is the strongest predictor for 1-year mortality confirmed after all adjustments for confounders (or 3.40; 95% ci 1.55-7.45, p < .01) and by roc curve analyses (0.66, 95% ci 0.51-0.81, p=.01). conclusion: frailty index is a useful tool to detect vulnerability in onco-geriatrics and it predicts 1-year mortality. it predicts negative health-related outcomes (mortality) better than other traditional scales. its adoption may support a more efficient identification of patients in the need of adapted and personalized care. further studies are needed to confirm and extend these findings. background: frailty has been studied in the old population due to its association with negative outcomes but more information is needed about frailty in very old samples. the fried frailty phenotype (ffp) has been widely used and includes a set of objective indicators: weakness, slowness, unintentional weight loss, exhaustion and low physical activity. objectives: to determine which sociodemographic, functional and health-related variables predict ffp in a sample of community-dwelling individuals aged 80+yrs. methods: data from 142 individuals living in the metropolitan area of porto were considered: sociodemographic information (age, sex, education level, living status), ffp (0-5), functionality (basic and instrumental activities of daily living), health information (nr. medicines, nr diseases, nr. falls, cognitive impairment, and self-perception of health). descriptive and correlational analysis were conducted and followed by a linear regression analysis (stepwise method) of variables significantly associated with ffp. results: participants' mean age was 88.1 years (sd=5.3), they were mainly women (73.9%), with 1-4 years of education (52.8%) and living with a relative (63.4%). high disability levels were found both for basic and instrumental activities of daily living. the mean of medicines intake was 6.8 (sd=3.5) and of diseases 6.4 (sd=2.1); 41.1% of the participants rated their health as poor. the median number of falls in the last year was 1 (iqr=2). participants scored on average 19.4 points (sd=6.4) in mmse. gender or age were not associated with ffp. basic and instrumental activities of daily living, selfperception of health and cognitive performance significantly predicted ffp. in the adjusted model (r2=0.311), the stronger predictor was the higher dependency for basic activities of daily living, followed by worst self-perception of health and lower scores of cognitive performance. the dependency for instrumental activities of daily living lost its significance in the adjusted model. conclusion: our results identify three main predictors of ffp (basic activities of daily living, selfperception of health, and cognitive performance) in participants with advanced age. these results provide relevant information for further understanding of frailty and the ffp among the oldest old. background: unplanned hospital readmissions are associated with poorer prognosis and increased risk of functional decline and dependence in older people. identifying major risk factors and assessing clinical risk scores can help to distinguish patients at risk of worse outcomes and rehospitalization, allowing the proposal of preventive measures. the aim of this study was to compare the accuracy of different instruments and risk factors in predicting readmission, functional decline and death in hospitalized older patients in a brazilian geriatric unit. methods: in a cohort study performed at a geriatric unit, 198 patients, 65 years old or over were included. demographic data, functional status, prisma 7 scale, geriatric depression scale, mini mental state examination, timed get up and go test, gait speed, mini nutritional assessment, palmar prehension strength, charlson comorbities index, frailty score of the cardiovascular health study and the senior index risk for rehospitalization were assessed at study admission. all patients received a follow-up telephone call at 90 days after discharge to assess potential readmissions, deaths and functional status. results: mean age was 79.1 years (sd +-8.63) and the mean barthel adl score was 71.43 (sd +-33.0). altered barthel (5.39; ci95% 2.6-11.4; p<0.001), chs score (11.57; ci95% 1.5-87.4; p<0.001), isar-hp (3.27; ci95% 1.1-9.9; p=0.02), tgug (7.85; ci95% 1.8-34.1; p<0.001), palmar prehension (3.84; ci95% 1.3-11.3; p=0.01) and gait speed (2.94; ci95% 1.6-6.9; p=0.01) were associated with higher mortality 90 days after discharge. the risk of functional decline at 3-month follow up evaluation was higher in patients with altered barthel (4.62; ci95% 1.54-13.9; p<0.001), lawton (5.66; ic95% 1.3-25.2; p=0.01), chs score (4.6; ci95% 1.9-11.0; p<0.001), isar-hp (3.88; ci95% 1.8-8.4; p<0.01), prisma 7 (2.23; ci95% 1.2-4.3; p=0.02), tgug (5.22; ci95% 2.36-11.55; p<0.001), palmar prehension (3.49; ci95% 1.7-7.0; p<0.01) and gait speed (1.98; ci95% 1.13.7; p=0.03). conclusion: altered iadl, frailty chs score, isar, tgug, palmar prehension strength and gait speed are predictive of functional decline and mortality 90 days after hospital discharge. these tools can be useful to pinpoint frailty in older patients, allowing the implementation of preventive interventions to avoid functional decline. more research is needed to evaluate the role of these tools in predicting rehospitalization. to limit the strain on available resources and prevent an unnecessary increase in patient burden. objectives: this study aimed to improve patient selection for multi-disciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients. methods: two-centre prospective cohort study in 537 patients aged >=70 years undergoing elective cardiac surgery. before surgery 11 frailty characteristics were investigated. outcome was disability at three months defined as world health organisation disability assessment schedule 2.0 >=25%. multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index were used to identify factors contributing patient selection. results: disability occurred in 91 (17%) patients. ten out of 11 frailty characteristics were associated with disability. a multivariable model including euroscore ii and preoperative haemoglobin yielded a c-statistic of 0.71 (95% ci 0.66 -0.77). after adding prespecified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health related quality of life, and living alone) to this model the c-statistic improved to 0.78 (95% ci 0.73 -0.83). net reclassification index was 0.32 (p<0.001) showing improved discrimination for patients at risk for disability at three months. conclusion: using preoperative frailty characteristics improves discrimination between elderly patients with and without disability at three months after cardiac surgery and can be used to guide patient selection for preoperative multi-disciplinary team care. fabiola valero 1,3 , henry tapia 1,3 , enrique valencia 1,3 , tania tello 1,2,3 ((1) facultad de medicina, universidad peruana cayetano heredia, lima, peru; (2) instituto de gerontología, universidad peruana cayetano heredia, lima, peru; (3) hospital cayetano heredia, lima, peru) background: frailty is increasingly recognized as a risk assessment to detect vulnerability and complexity. currently, there are limited tools to predict adverse perioperative outcomes for the geriatric population with hip fracture. objectives: to determine frailty and functional dependence as predictors of intrahospital adverse events in hospitalized older adults with hip fractures in the orthogeriatric unit of a general hospital in lima, peru. methods: we conducted a prospective cohort involving 218 patients aged 60 years or older who were admitted to the orthogeriatric unit with hip fracture from june 2017 to june 2019. data were obtained at the time of admission to our unit: frailty was assessed with the frail scale, function ability with the barthel scale, cognition with the short portable mental state questionnaire (spmsq) scale of pfeiffer, comorbidities, socio-family assessment and geriatric syndromes. patients were followed up to discharge, and adverse events were evaluated during this period. univariate models were performed, and logistic regression was done subsequently. results: 218 patients with hip fractures were evaluated, the mean age was 80.4 (8.9) years, 73.8% (161) were women and 2.7% (6) came from nursing homes. hypertension was the most frequent comorbidity in 41.2% (90). 56% (122) had a history of functional dependence on basic activities of daily living (abvd), 54% (104) had some degree of cognitive impairment, 13.7% (30) had social problems, polypharmacy in 21.5% (47) and 43.8% (139) history of falls in the last year. according to frail scale, 18.3% (n = 40) were robust, 29.3% (n = 64) were pre-frail and 52.3% were frail (n = 114). 31.8% (69) had an adverse event while hospitalized (pneumonia, uti, delirium, acute renal injury, pet), of whom 15% (6) were robust, 31.2% (20) pre-frail and 38% (43) frail (p = 0.02). 73.9% of patients with functional dependence on abvd presented adverse events. in the multivariate analysis, the factors associated with in-hospital adverse events were functional dependence in abvd, or: 2.72, (ci: 1.3-5.7); frailty with an or: 1.51 ic (0.5-4.5) and social problem, or: 2.72 ic (1.1-6.2). conclusion: older adult patients hospitalized for hip fracture who had frailty, functional dependence, and social problems had significant adverse events at a general hospital in lima, peru. aiko inoue 1 , chi hsien huang 1,2 , chiharu uno 1 , kosuke fujita 1,2 , tomoharu kitada 1,3 , joji onishi 2 , hiroyuki umegaki 2 , masafumi kuzuya 1,2 ((1) institutes of innovation for future society, nagoya university, japan; (2) department of community health and geriatrics, nagoya university graduate school of medicine, nagoya, japan; (3) department of business administration, seijoh university, aichi, japan) background: social frailty was associated with age, sex, income, education, marital status, and household status. however, the risk factors of social frailty relatively less investigated. objectives: the aim of this study is to clarify the risk factors of social frailty in community-dwelling japanese elderly. methods: a health promotion project (nagoya-teng project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. of all participants (n=926), 500 participants with complete baseline information (mean age 75.0±5.9 years, 242 men (46.9%)) were included in our cross-sectional analysis. at baseline, demographic data, socio-economic status, geriatric depression scale (gds-15), japanese version of european health literacy survey questionnaire (j-hls-eu-q47) were obtained. social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. total deficit scores of 2 or more were defined as social frailty,1 as social pre-frailty, and 0 as robustness. results: a total of 234 (46.8%), 172 (34.4%), and 94 (18.8%) of all participants were categorized as social non-frailty, pre-frailty and social frailty, respectively. in multivariable logistic regression model after adjusting for age, sex, bmi, and education level, living without a spouse is a significant risk factor (p<0.001) for social pre-frailty (or 2.95, 95% ci 1.78-4.88) and social frailty (or 4.31, ). low gds-15 scores were associated with high risk of social prefrailty (or 1.16, 95% ci 1.07-1.26) and social frailty (or 1.43, 95% ci 1.30-1.57). in addition, health literacy was inversely associated with social frailty (or 0.92, 95% ci 0.88-0.96). age, sex, and education level were not associated with social frailty. conclusion: regardless of age and sex, living with a spouse and depression which is associated with activity of daily living and quality of life are associated with social frailty. low health literacy is also a risk factor of social frailty. in literature, loneliness and social frailty were associated with functional decline and mortality in the elderly. future approaches incorporating health literacy interventions are warranted to prevent social frailty in the aged society with increasing number of physical frail older adults. background: frailty increases the risk for morbidity and mortality after cardiac surgery. the influence of frailty on postsurgical functional outcomes is largely unknown. objectives: the aim of this research was to study the association of preoperative frailty characteristics on adverse functional outcomes and to investigate the trajectory of functional recovery among frail and non-frail elderly patients up to one year after elective cardiac surgery. methods: a prospective two-centre observational cohort study in 555 elective cardiac surgery patients aged >=70 years. preanaesthesia assessment was supplemented with 11 frailty tests covering the physical, mental, and social domain. functional outcomes were assessed at one year and included change in health related quality of life (hrql) measured by the short form 36 and disability measured by the world health organisation disability assessment schedule 2.0. adverse functional outcome was considered when worse physical or mental hrql or disability was present after surgery. results: frailty characteristics were present in 468 (86%) patients of whom 406 (73%), 214 (39%) and 231 (42%) showed frailty in the physical, mental or social domain respectively. adverse functional outcome at one year after surgery occurred in 257 (46%) patients. patients with an adverse functional outcome were more often frail (92 (36%)) than patients without an adverse functional outcome (47 (16%) p<0.001). worse physical or mental hrql occurred in 134 (24%) and 141 (25%) patients respectively. the most important frailty characteristic associated with worse physical hrql was high preoperative physical hrql (β -0.56 per point (95% ci -0.7 to -0.5). preoperative mental hrql showed the strongest associations for worse mental hrql (β -0.55 per point (95% ci -0.7 to -0.4)). disability was reported by 120 (22%) patients and associated with preoperative polypharmacy, gait speed, health related quality of life, living alone or dependent living. gait speed had the strongest association (β 2.2 per second (95% ci 1.6 to 2.8)). conclusion: preoperative frailty characteristics were common and predictive for adverse functional outcome one year after cardiac surgery. frailty screening can be used to improve risk stratification and decision making in older cardiac surgery patients. background: frailty frailty has many elements and these can be characterised as physical, nutritive (including body composition), cognitive and sensory (including hearing and seeing). the relative prevalence and importance of these elements are not known. objectives: to estimate the prevalence of frailty and relative contribution of physical/ balance, nutritive, cognitive and sensory frailty to important adverse health states (falls, physical activity levels, outdoor mobility, problems in self-care or usual activities, and lack of energy or accomplishment) in an english cohort. methods: analysis of 9803 community-dwelling older people. the sample was drawn from a random selection of all people aged 70 or more registered with 63 general practices across england. data were collected by postal questionnaire. frailty was measured with the strawbridge questionnaire. we used cross sectional, multivariate logistic regression to estimate the association between frailty domains and adverse health outcomes. some models were stratified by sex and age. results: mean age of participants was 78 years (sd 5.7), range 70 to 101 and 47.5% (4653/9803) were men. the prevalence of overall frailty was 20.7% (2005/9671) and there was no difference in prevalence by sex (odds ratio 0.98; 95% confidence interval 0.89 to 1.08). sensory frailty was the most common and this was reported by more men (1823/4586) than women (1469/5056; odds ratio for sensory frailty 0.62, 95% confidence interval 0.57 to 0.68). men were less likely than women to have physical or nutritive frailty. physical frailty had the strongest independent associations with adverse health states. however, sensory frailty was independently associated with falls, less frequent walking, problems in selfcare and usual activities, lack of energy and accomplishment. conclusion: physical frailty was more strongly associated with adverse health states, but sensory frailty was much more common. the health gain from intervention for sensory frailty in england is likely to be substantial, particularly for older men. sensory frailty should be explored further as an important target of intervention to improve health outcomes for older people both at clinical and population level. background: it live independently. our goal is to encourage independent living, wellbeing and to relieve health and care services budget pressure. longevity is one of the biggest achievements of modern societies. by 2020, a quarter of europeans will be over 60 years of age. combined with low birth rates, this will bring about significant changes to the structure of european society, which will impact on our economy, social security and health care systems. the most problematic expression of population ageing is the clinical condition of frailty. frailty develops because of age-related decline in multiple physiological systems. it is estimated that a quarter to a half of people over 85 years are frail , and this is set to reach epidemic proportions over the next few decades. while frailty increases, the average amount of health spending increases as well with the frailty level in a range from 1,500 to 5,000 €/person year, depending upon the frailty status and the setting of care. frailty usually comes along associated with another risk facto; loneliness. then, ageing, frailty and loneliness constitute overlapping conditions submitted to multiple health and care interventions. ecare project aims to deliver disruptive digital solutions for the prevention and comprehensive management of frailty to encourage independent living, wellbeing and to relieve health and care services budget pressure, throughout the implementation of a pre-commercial procurement scheme. pre-commercial procurement is an ideal framework for the delivery of innovative solutions. the ecare network of procurers and the service providers are often on the frontline as new needs emerge. this pcp will allow the procurers to voice out their unmet needs, create a new demand to access sustainable products of higher quality, and develop new applications with lower life cycle costs. the demand and the supply side will work together to co-create and co-design the solutions and validate their functionalities against the specific challenges outlined in the pcp call for tender. this will clearly maximize the engagement of innovation in health and care services. solutions should improve outcomes for frailty in old adults entailing the physical and the psychosocial factors. the target group are the pre-frail/frail old adults with emphasis on those that feel lonely and/or isolated. the project will procure the development, testing and implementation of digital tools/services and communication concepts to facilitate the transition to integrated care models across health and social services and country-specific cross-institutional set-ups, including decentralised procurement environments and collaboration across institutions. objectives: the project objectives are: • newly development easy-to-use and reliable solutions that facilitate early detection of frailty based on the most efficient standards and methods. • improve the understanding of the factors affecting frailty and the feelings of loneliness and isolation, and how they do correlate (e.g.: gender dimension, social context, etc.). • deliver personalised intervention plans taking into account the end-user societal context. • innovative and meaningful means to tackle the feelings of loneliness and isolation. • new approaches to engage patients as active self-managers of their own health. • new technology developments designed and oriented to the target end-user. • and among all, investigate to deliver cost-efficient solutions, affordable to the payers involved. methods: ecare procurers will proactively organize the requirements of the demand for care solutions in a coherent way. the procurers (buyers' group) will assess the solution adequacy to the targets. the preferred partners will contribute with solid knowledge of innovative procurement paths to the innovation procurement tender. the project partners will do this by: • providing a solid and informed base for dialogue between stakeholders by determining a coherent picture of the market state of the art of the sector based on practical experience of customers and suppliers. • enabling a genuine and credible dialogue between the supply-chain and customers to determine the practical policy and procurement actions required to deliver the ecare solutions. • defining the common unmet needs, communicating these to stakeholders and initiating a mobilization plan for a pcp addressing ecare needs. the pcp may be summarized in a series of actions: • convey the relevance of innovation procurement to public procurers: encouraging suppliers to offer novel solutions to address ecare challenges rather than the lowest price solutions. • analyze the state of the art of the market with all potential suppliers, as well as the main problematic and barriers faced in the sector and that need to be overcome a set of actions involving both the supply and demand sides will be carried out: a coordinated first analysis of the state of the art conducted by all project members followed by a coordinated market sounding through all dissemination channels managed by the consortium will be undertaken to spread project results aiming to receive feedback from all key market players. for this, the role of procurers is vital to replicate and stretch the impact of the project. • providing public procurers with procurement know-how to improve public sector procurement efficiency and increase public sector market power by giving support to apply the methodologies of innovation procurement. market sounding will provide an opportunity for engagement and two-way dialogue with innovative companies that can offer solutions and guidance on how to overcome the procurement barriers. • launching an agreed, realistic and validated joint pcp tender. results: the ecare consortium is immerse in a deep process of unmet needs detection. our goal is to be extraordinarily concrete when defining what the end users and the healthcare professionals are willing for. those unmet needs will be critical for the definition of the requirements and uses cases that the it suppliers will have to follow to design the ict solutions. then… what a better way to know their needs that asking them personally? the vision of providing tailored fit solutions and tools to the end users led to the consensus in creating and facilitating focus group sessions across the 4 procurers regions -campania (italy), barcelona (spain), santander (spain) and wroclaw (poland)-. these sessions will be involving end users, health and social care professionals, and it internal departments of the procurers' organisations. -the focus group script for the end users sessions integrates as main topics the specific condition and related symptoms; experiences of services and care provided; experiences of managing condition when progressing rapidly ; needs for symptom management and how these can be met ; integration of it supportive tools in the management of frailty and loneliness. -the professionals are invited to reflect and discuss the topics of common symptoms and actual care model; experiences of monitoring elderly when condition is progressing rapidly; views about the supportive care needs of elderly and caregivers; early integration of the new care in the management of frailty and loneliness; integration of it supportive tools in the management of frailty and loneliness. -the identified and proposed topics for the it staff would be the state of the art of the relation in between it and social/healthcare; state of the art of interventions on frailty and loneliness. all the four procurers were challenged to organize, at least, 3 focus sessions, one with each specific target group. so far, all the procurers already organized and scheduled the sessions that will occur until the end of january. in terms of impact, 119 participants are expected to be involved (56 end users, 42 healthcare professionals and 21 it people). all the representative of the procurers reported so far that the participants have been considering the sessions so interesting and useful. in fact, new topics have been put in the table for discussion in all the different sessions, adding more important information for the definition of the unmet needs. the journey of the project so far has been providing very powerful insights and evidences that people and professionals appreciate to be involved and e(motionally) cared. conclusion: ecare will progress beyond the state of the art by approaching older people not just in terms of their diseases but also in terms of physical, cognitive and psychosocial care and support to prevent functional decline, frailty and disability. the project key components to address frailty are those that define also integrated care, with the addition of targeting high risk frail individuals, an enablement attitude and a focus on outcomes most relevant to frail individuals and their caregivers. for these, a multimodal comprehensive system able to provide the most effective care will need to be provided. background: maintaining autonomy as life progresses has become a challenge for the health systems. this objective can only be achieved by moving the axis of health policies and health care practice from the disease to the preservation of functional capacity. objectives: the aim of this study is to design and pilot a model for the assessment and support of functionality for community dwelling older people. methods: a space in which nurse and social worker jointly assess the functional capacity of older people and identify and provide responses to the detected deficits was proposed. this study was performed in osi donostialdea (gipuzkoa, spain). three main tasks were carried out: 1. definition of the joint assessment procedure of functionality. 2. identification of the existing resources and community assets to give answer to the identified needs. 3. piloting the model in a sample of older people. the identified needs and the availability of resources to respond to them were obtained from the pilot phase. results: in the initial version of this integral assessment were included, functional capacity, physical activity, cognitive capacity, sense organs, nutritional status, social assessment and housing and environmental conditions. a total of 49 individuals (69% women; mean age 82 years, sd=5.8; barthel index, mean 97.0, sd=4.2; 47% living alone; 76% without cognitive impairment) were recruited during the pilot. the following needs were identified: personalized workout routines, fine motor skill exercises, visual and efficient diets adjusted to each patient, make sure resources reach the community, promote the use and design of gadgets to assist the needs of basic and instrumental activities of daily living, improve strategies to prevent cognitive function impairment, ease loneliness and avoid or minimize physical and environmental barriers to access home, to walk the streets and, particularly, to use public transport. there were no resources available for all the identified needs. conclusion: this study will allow the development of a model for the integral assessment of functionality for the aged population, based in a multidisciplinary team, a space and a new way of working in primary care. mónica machón 1-3 , maider mateo-abad 2,3 , mercedes clerencia-sierra 2,4,5 , carolina güell 1,6 , beatriz poblador-pou 2,5 , kalliopi vrotsou 1-3 , antonio gimeno-miguel 2,5 , alexandra prados-torres 2,5 , itziar vergara 1-3 ( (1) background: multimorbidity and frailty are often present in older people and are found to be associated to increased risk of adverse health events. it is necessary to improve the knowledge of the characteristics of such populations to design adequate clinical guidelines seeking to avoid or delay the onset of dependence. objectives: the aim of this study was to identify clusters of chronic diseases in robust and frail individuals and compare sociodemographic and health characteristics between these clusters. methods: this was a cross-sectional study based on data from two longitudinal studies. the sample was composed of functionally independent community-dwelling older people with multimorbidity living in gipuzkoa (basque country, spain). information from electronic health records (diagnose diseases and medication) and a baseline assessment (sociodemographic characteristics, functional status, self-perceived health, cognitive status, sight and hearing impairments, history of falls and nutritional status) was used in the analysis. the timed up and go test of physical performance was included as a measure of frailty. multiple correspondence and cluster analyses were performed to identify groups. results: the study population consisted of 813 individuals (55.1% women; mean age 77.4 years, sd=5.0). frail individuals (n=244) were older, had a lower educational level and a poorer health status than robust individuals (n=569). three clusters were obtained in robust (rc1, n=348; rc2, n=139 and rc3, n=82) and four among the frail individuals (fc1, n=164; fc2, n=23; fc3, n=44 and fc4, n=13). in rc1 and fc1, none of the chronic diseases had a higher prevalence than in rc2-rc3 and fc2-fc3-fc4, respectively. individuals pertaining to rc2 and fc2 presented more frequently diseases related to mobility limitation or limb pain compare to the other clusters. higher rates of cardiovascular diseases and risk factors were seen in rc3 and fc3. in frail individuals a new cluster emerged, fc4, containing individuals with higher rates of cognitive and eye problems and a clearly poorer health status. conclusion: the findings obtained in this exploratory study may provide insight for the designing of more specific health interventions for older patients with multimorbidity, even though the chronic diseases cluster identified were similar in robust and frail individuals. background: older african americans (oaa) are at high risk for becoming frail in later life. interventions can reverse or delay frailty, yet oaa have largely been excluded from frailty intervention research. many interventions are also time and resource intensive, making them inaccessible to socially disadvantaged oaa. objectives: we present results of a feasibility trial of a low dose frailty prevention intervention among 60 community-dwelling, pre-frail oaa aged 55+ recruited from a primary care clinic between june 1st and october 31st 2018. methods: using a 2-arm rct, participants were assigned to the intervention, which was delivered by an occupational therapist (ot) and comprised of four sessions over four months (an ot evaluation, and sessions on healthy dietary practices, increasing physical activity, and maintaining a healthy lifestyle), or enhanced usual care (publicly available information about healthy lifestyle, home safety, and local elder services). feasibility criteria were set a priori at 75% for participant retention (including attrition due to death/ hospitalization), 80% for session engagement, 2 participants/ week for mean participant accrual, and 90% for program satisfaction. results: participants were 65% female with an average age of 76.58 years, 51.67% of which lived alone and 51.67% lived off of less than 15k per year. feasibility metrics were met. the study recruited 2.5 participants per week and retained 75% of participants who attended 95% of scheduled sessions. mean satisfaction scores were 93%. the treatment also resulted in positive trends in the expected direction in the treatment group for the following outcomes (d = effect size): global health (d = .45), mental health (d = .26), qol (d = .18), social functioning (d = .68), depression (d = .24), and pain reduction (d = .43). descriptively, treatment group participants were also less likely to experience a progression (deterioration) in three frailty status indicators at 4-months compared to controls: weight lost, walking speed slowness, and grip strength weakness. conclusion: the intervention was feasible to deliver. qualitative findings from exit interviews suggested changes to the program dose, structure, and content that could improve it for future use. background: it is well known that frail patients are potentially most at risk of functional decline following a hospital admission. objectives: to measure the effects of an augmented prescribed exercise programme versus usual care, on physical performance, quality of life and healthcare utilisation for frail older medical patients in the acute setting. methods: this was a parallel single-blinded randomised controlled trial. within two days of admission, older medical inpatients with an anticipated length of stay >=3 days, needing assistance/aid to walk, were blindly randomly allocated to the intervention or control group. until discharge, both groups received twice daily, monday-to-friday half-hour assisted exercises, assisted by a staff physiotherapist. the intervention group completed tailored strengthening and balance exercises; the control group performed stretching and relaxation exercises. length of stay was the primary outcome measure. blindly assessed secondary measures included readmissions within three months, and physical performance (short physical performance battery) and quality of life (euroqol-5d-5l) at discharge and at three months. time-to-event analysis was used to measure differences in length of stay, and regression models were used to measure differences in physical performance, quality of life, adverse events (falls, deaths) and negative events (prolonged hospitalisation, institutionalisation). results: of the 199 patients allocated, 190 patients' (aged 80 ±7.5 years) data were analysed. groups were comparable at baseline. in intention-to-treat analysis, length of stay did not differ between groups (hr 1.09 (95% ci, 0.77-1.56) p=0.6). physical performance was better in the intervention group at discharge (difference 0.88 (95% ci, 0.20-1.57) p=0.01), but lost at follow-up (difference 0.45 (95% ci, -0.43 -1.33) p=0.3). an improvement in quality of life was detected at follow-up in the intervention group (difference 0.28 (95% ci, 0.9 -0.47) p=0.004). overall, fewer negative events occurred in the intervention group (or 0.46 (95% ci 0.23 -0.92) p=0.03). conclusion: improvements in physical performance, quality of life and fewer negative events suggest that this intervention is of value to frail medical inpatients. its effect on length of stay remains unclear. background: to propose a simple frailty screening tool able to highlight frailty profiles, already since the initial screening phase. methods: a 9-item questionnaire (lorraine frailty profiling screening scale, lofpross), constructed by an experts' working group, was administered by health professionals to participants >70 years old (n=817) and living at home, in 3 different clinical settings: a primary care outpatient clinic (rural population, n=591), a geriatric day clinic (day-clinic population, n=76) and healthy volunteers (urban population, n=147). a multiple correspondence analysis (mca) followed by a hierarchical clustering of the results of the mca performed in each population was conducted to identify participant profiles based on their answers to lofpross. a response pattern algorithm was resultantly identified in the rural (main) population and subsequently applied to the urban and day-clinic populations and, in these populations, the two classification methods were compared. finally, clinically-relevant profiles were generated and compared for their ability to similarly classify subjects. results: the response pattern differed between the 3 subpopulations for all 9 items, revealing significant intergroup differences (1.2±1.4 positive responses for urban vs. 2.1±1.3 for rural vs. 3.1±2.1 for day-clinic, all p<0.05). five clusters were highlighted in the main rural population: "non-frail", "hospitalizations", "physical problems", "social isolation" and "behavioral", with similar clusters highlighted in the remaining two populations. identification of the response pattern algorithm in the rural population yielded a second classification approach, with 83% of tested participants classified in the same cluster using the 2 different approaches. three clinically-relevant profiles ("non-frail" profile, "physical frailty and diseases" profile and "cognitive-psychological frailty" profile) were subsequently generated from the 5 clusters. a similar double classification approach as above was applied to these 3 profiles revealing a very high percentage (95.6%) of similar profile classifications using both methods. conclusion: the present results demonstrate the ability of lofpross to highlight 3 frailty-related profiles, in a consistent manner, among different older populations living at home. such scale could represent an added value as a simple frailty screening tool for accelerated and better-targeted investigations and interventions. (3) homburg/saar/germany, saarland university medical center, neurology, homburg/germany) background: frailty is the most important short and long term predictor of disability in the elderly. no study to date evaluate the impact of frailty on short and long term independently from neurological outcome measures. objectives: the aim of the study was to evaluate whether diagnosis frailty predicts short and long-term mortality and neurological recovery in old patients who underwent reperfusion acute treatment in stroke unit. methods: consecutive patients were older than 65 years who underwent thrombectomy or thrombolysis in a single stroke unit from 2015 to 2018. predictors of stroke outcomes were assessed including demographics, baseline nihss, time to needle, treatment and medical complications. premorbid frailty was assessed with a comprehensive geriatric assessment (cga) including functional, nutritional, cognitive, social and comorbidities status. at 3 and 12months, all-cause of death and clinical recovery (using mrs) were evaluated. results: 102 patients, of whom 31 underwent mechanical thrombectomy and 71 venous thrombolysis (mean age 77.5, 65-94 years) entered the study. frailty was diagnosed in 32 out of 70 patients and associated with older age (p=0.001) but no differences in baseline nihss score or treatment strategies. at follow-up, frail patients showed higher incidence of death at 3 (25% vs 3%, p=0.008) and 12 (38% vs 7%, p=0.001) months. frailty was associated with worse neurological recovery at 3 month (mrs 3.4 + 1.8 vs 1.9 + 1.9, p=0.005) and one year followup (mrs 3.2 + 1.9 vs 1.9 + 1.9) for free survival patients. conclusion: frailty is an important predictor of efficacy of acute treatment of stroke beyond classical predictors of stroke outcomes. larger prospective studies are warranted in order to confirm our findings. background: frailty becomes increasingly common as adults age and has known associations with activity limitations and injurious falls among older adults. while it is believed that frailer older adults are less socially connected than their more functional counterparts, less is known about the relationship between frailty and social isolation among community-dwelling older adults. objectives: the purpose of this study was to examine associations of frailty indicators on self-reported social isolation risk among community-dwelling adults age 60 years and older. methods: the upstream social isolation risk screener (u-sirs) was developed to assess social isolation risk among older adults within clinical and community settings. comprised of 13 items (cronbach's alpha=0.80), the u-sirs assesses physical, emotional, and social support aspects of social isolation. using an internet-delivered survey, data were collected from a national sample of 4,082 adults age 60 years and older. participants completed the u-sirs and additional items on sociodemographics and other health risks. theta scores for the u-sirs serve as the dependent variable, which were generated using item response theory. an ordinary least squares regression model was fitted to identify frailty indicators associated with social isolation risk. results: participants' average age was 69.6 (±5.2) years. the majority of participants was female (58.5%) and lived with a partner/spouse (56.9%). twenty eight percent of participants reported difficulty walking or climbing stairs, 4.3% reported difficulty dressing or bathing, and 16.2% reported a fall in the past year. higher u-sirs theta scores were reported among males (b=3.82, p<0.001) and those with more chronic conditions (b=9.34, p<0.001). participants who reported difficulty walking or climbing stairs (b=3.96, p<0.001), difficulty dressing or bathing (b=3.43, p=0.001), or a fall in the past year (b=4.27, p<0.001) also reported higher u-sirs theta scores. further, higher u-sirs theta scores were reported among participants who had not left their home in the past three days (b=10.62, p<0.001). conclusion: findings suggest frailer older adults and those with functional limitations may have greater risk for social isolation. this highlights the critical demand for easy-to-administer and practical assessments for frail older adults that identify their social isolation risk and link them to needed resources and services. background: peak expiratory flow (pef) has been linked to several negative health-related outcomes in older people, but its association with frailty is still unclear. objectives: this study investigates the association between pef and prevalent and incident frailty in older adults. methods: data come from 2559 community-dwelling participants of the swedish national study on aging and care in kundgsholmen (snac-k), aged >=60 years. baseline pef was expressed as standardized residual (sr) percentiles. frailty was assessed at baseline and over six years, according to the fried criteria. associations between pef and frailty were estimated crosssectionally through logistic regressions, and longitudinally by multinomial logistic regression, considering death as alternative outcome. obstructive respiratory diseases and smoking habits were treated as potential effect modifiers. results: our crosssectional results showed that the 10th-49th and <10th pef sr-percentile categories were associated with three-and fivefold higher likelihood of being frail, than the 80th-100th one. similar estimates were confirmed longitudinally, i.e. adjusted or=3.11 (95%ci: 1.61-6.01) for pef sr-percentiles<10th, compared with 80th-100th. associations were enounced in participants without physical deficits, and tended to be stronger among those with baseline obstructive respiratory diseases, and, longitudinally, also among former/current smokers. conclusion: these findings suggest that pef is a marker of general robustness in older adults and its reduction, exceeding that expected by age, is associated with frailty development. background: as consistently reported in the literature, muscle strength (ms) decreases at a higher rate than muscle mass (mm) during aging resulting in a decreased muscle quality (mq). loss of mq has been associated with loss of mobility, falls, frailty and an increased risk of mortality. however, the degree of muscle declines is varying throughout the population leading to 3 states: successful, normal or pathological. it has been proposed that healthy life habits such as be physically active, having a healthy diet etc. could reduce the muscle aging decline. thus, identifying if life habits could counteract or maintain muscle quality during successful aging is important to better characterize aging and to intervene more specifically. objectives: the aim of the present study was to identify whether a physically active lifestyle could attenuate the effects of aging on mq. methods: active young were compared to active older men. to be considered active, young and older men need to practice voluntary physical activity at least 150min/week since 5yrs. body composition (dxa; mri) and maximum knee extension strength were measured. mq was calculated as the ratio of ms to mm. aerobic capacity (vo2max; moxus©) and muscle contractility (emg) were also measured. muscle biopsies were performed to determine fiber typing, size, intermuscular adipose tissue (imat) and intramyocellular lipid content (imcl). results: absolute mm (p<0.001) and ms (p=0.005) was greater in young participants compared to their older counterparts while mq was similar between them. even if total (p=0.04) and type iia (p=0.024) fiber size were greater in ya than in oa, muscle fiber proportion, muscle contractility and lower limb fat mass (imat, imcl) were similar between both groups (p>0.05). conclusion: mq was similar between younger and older physically active men suggesting that being physical activity may have mitigated the loss of mq with aging and delayed some physiological age-related changes (muscle composition, contractility). i r a t x e e g a ñ a , itxaso mugica 1,2 , nagore arizaga 2 , maider ugartemendia 1 , nagore zinkunegi 1 , janire virgala 2 , maider kortajarena 1 ( (1) and sppb test (p<0,01). similar results have been found in other researches. the parameters that have higher influence in cognition are handgrip test (p<0,01) and frailty (p<0,01). in other investigations, they got the same results; better cognition is related to better physical capacity and less fragility. in regards with functionality, the values of tug test (p<0,01) and gait speed (p<0,01) are the ones that show stronger relation. in other investigations, they observed that physical state and functionality were related. conclusion: the quality of life, the functionality and moca test are interconnected and the parameters that have the strongest statistical relationship are fragility and physical state. the greater the physical capacity of the older person is, the greater the functional capacity is too and the fragility decreases. in conclusion, the quality of life is better. kazuki kaji 1 , jun kitagawa 2 , takahiro tachiki 3 , naonobu takahira 2 , masayuki iki 4 , junko tamaki 5 , etsuko kajita 3 , yuho sato 6 , jpos study group 4 ((1) national center for geriatrics and gerontology, obu, aichi, japan; (2) nagoya university, nagoya, aichi, japan; (3) nagoya city university, nagoya, aichi, japan) background: the skeletal muscle mass index (smi), which is the appendicular skeletal muscle mass (asm) adjusted for height squared (kg/m2), is used to assess skeletal muscle mass. we reported at this conference last year that smi was overestimated by height loss due to aging in elderly women. furthermore, age-related changes in smi were inconsistent with changes in physical function such as grip strength and walking speed. objectives: the purpose of this cross-sectional study was to investigate the effects of height loss on agerelated changes in smi and physical function in japanese women aged 50 or older. methods: this study was part of the 15/16-year follow up survey of the japanese population-based osteoporosis (jpos) cohort study conducted in 2011/2012. the jpos study was started in 1996. the subjects of the 15/16year follow-up were 710 women (mean 65.3±10.0 years). we divided the subjects into quartiles based on 15 years of height loss (q1: the lowest, q2, q3 and q4: the highest). asm was measured by dual x-ray absorptiometry (qdr4500a, hologic, usa). grip strength, maximum walking speed, and timed up and go (tug) were also measured. results: the mean change in height during the 15/16-year follow-up was -1.6±1.6 cm. mean changes in height in q1 (n=191), q2 (n=171), q3 (n=172) and q4 (n=176) were -0.2±0.41 cm, -1.0±0.20 cm, -1.8 ±0.26 cm and -3.7±1.84 cm, respectively. the trend test demonstrated significant increases in the mean age and smi from q1 to q4. on the other hand, there was a significant decrease in asm from q1 to q4. the mean grip strength and maximum walking speed significantly decreased from q1 to q4. tug results were similar, suggesting that greater height loss led to longer times. conclusion: in japanese elderly women with height loss, asm and physical function decreased with age, but the smi adjusted for height increased. it may be necessary to establish a muscle mass parameter other than smi to investigate the relationship between muscle mass and physical function. kota tsutsumimoto 1 , takehiko doi 1 , sho nakakubo 1 , satoshi kurita 1 , hideaki ishii 1 , hiroyuki shimada 2 ((1) section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan; (2) center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: sarcopenia was defined as decline in skeletal muscle mass and muscle function, leading to serious health problems including disability. the modifiable risk factors of sarcopenia should be elucidated to contribute to develop intervention from sarcopenia. objectives: to examine the association between anorexia of aging and sarcopenia among community-dwelling elderly japanese individuals. methods: population-based, cross-sectional cohort study in japanese older adults was conducted and participants were identified from the database of the national center for geriatrics and gerontology-study of geriatric syndromes. anorexia of aging was assessed via a simplified nutritional appetite questionnaire. handgrip strength and walking speed were tested, and skeletal muscle mass was assessed using a bio-impedance analysis device. subjects with sarcopenia were defined as those who met the criteria of the asian working group for sarcopenia. the association between anorexia of aging and sarcopenia was then analyzed via multiple regression analysis. results: in total, 9,496 elderly japanese individuals were evaluated. the prevalence of sarcopenia and anorexia of aging was 4.0% and 9.8%, respectively. in multivariable logistic regression model adjusted for the covariates except for nutritional status such as albumin, anorexia of aging was independently associated with sarcopenia (or: 1.45, 95% ci: 1.07 to 1.95; p = 0.015). this significant association remained even after adjusting for all covariates including nutritional status (or: 1.42, 95% ci: 1.06 to 1.92, p = 0.020). conclusion: anorexia of aging is associated with sarcopenia among japanese older adults. further studies are needed to determine whether a causal association exists between anorexia and sarcopenia. background: low grip strength is consistently associated with higher rates of mortality, disability and other age-related health outcomes, and is a key characteristic of sarcopenia. grip strength has thus been proposed as a general biomarker of ageing. life expectancy in russia is substantially lower than in norway but whether this is reflected in differences in grip strength across adulthood, as observed in previous comparisons of older adults from russia, denmark and england, needs to be established and explained. objectives: we aimed to compare grip strength in norwegian and russian populations by age and gender, and investigate whether any observed differences were explained by contrasts in height, weight, smoking or education. methods: we used harmonised cross-sectional data on grip strength for 10,112 men and women aged 40-69 years. this comprised participants from the russian know your heart study (n=4,147) conducted in the cities arkhangelsk and novosibirsk in 2015-18, and from wave 7 of the norwegian tromsø study (n=5,965) conducted in 2015-16. grip strength was assessed using the jamar+ digital dynamometer in both studies, and the maximum of six measurements (three in each hand) was used. the association between grip strength and covariates was assessed using linear regression. results: norwegian males had stronger grip than russian males at all ages, for example they were an average of 3.2kg (95% confidence interval (ci) 2.3, 4.1) stronger at age 40 years and 3.3kg (95% ci 2.6, 4.0) stronger at age 69 years. among women, corresponding numbers were 2.0kg (95% ci 1.2, 2.8) at age 40 and 1.5kg (95% ci 0.9, 2.1) at age 69. adjustment for weight, education and smoking did not affect the results, but height attenuated the between country differences, especially at older ages. among women aged 60+, differences in height between countries fully explained the differences observed in grip strength. conclusion: norwegian 67-year-olds had the grip strength of 60-year-old russians suggesting that russians are ageing more rapidly in terms of muscular strength than their norwegian counterparts. the important role of height in explaining these differences, especially at older ages, suggest contrasts in early life circumstances may be of key importance. eleanor lunt 1,2 , paul greenhaff 2,3 , adam l gordon 2,4,5 , john rf gladman 1,2 ( (1) background: frailty is a state of vulnerability to stressors resulting in adverse clinical outcomes including falls and fragility fractures. identifying biomarkers associated with these outcomes may help target interventions. objectives: to compare parameters of body composition, muscle thickness and muscle strength between patients and healthy older and young volunteers. methods: six young (18-35 years) and 11 older (>= 70 years) healthy female volunteers were recruited by advert from community groups. 15 female patients (>=70 years) with an acute fragility fracture were recruited from hospital wards and measured during first week of admission (median 4th day (iqr 2-6)). frailty was determined by the 5-item frail scale. height, weight, handgrip (jamar dynamometer) and knee extension (lafayette manual muscle tester) were assessed. body composition was estimated using whole body bioelectrical impedance (bodystat quadscan 4000®). midpoint vastus lateralis (vl) muscle thickness and mid-thigh subcutaneous fat thickness were assessed using ultrasound (mylab gold, esaote biomedica, italy) with a 14hz linear-array probe. oneway anova and post hoc tukey's test were used to compare end-point measures between groups. results: frailty was significantly more prevalent in the patient group (53% frail, 40% pre-frail, 7% robust) than the healthy older group (100% robust, p<0.001). the patient group was older (83 ± 7 years vs 78 ± 6 years, p<0.05) and had more co-morbidities (p<0.001). there were no significant differences between the patient and healthy older group in weight, height, bmi, percentage body fat or subcutaneous fat thickness of lateral thigh. vl muscle thickness was lower in the patient group compared to healthy older and young volunteers (1.27±0.43cm, 1.75±0.30cm and 2.09±0.41cm respectively, p<0.01). the patient group also had lower handgrip strength (9.2±5.5kg, 19.9±5.8kg, 41.3±15.6kg respectively, p<0.001) and lower knee extension strength (4.3±1.4kg, 7.8±1.3kg, 9.5±1.3kg respectively, p<0.001). vl muscle thickness associated with muscle strength (knee extension r=0.70, p<0.001 and handgrip r=0.71, p<0.001) and was significantly lower in the frail compared to pre-frail or robust participants (0.98±0.30cm, 1.53±0.27cm, 1.76±0.29cm respectively p<0.001). conclusion: female patients presenting to hospital with a fall and fragility fracture have lower muscle thickness in the thigh compared to non-frail older women, despite no difference in other body composition variables. register, health technology assessment, nhs economic evaluation database) were searched from inception to april 12, 2019. cross-sectional and cohort studies that reported adjusted risk ratios with 95% confidence intervals (ci) for frailty with serum level of total testosterone, free testosterone, sex hormone-binding globulin (shbg) were selected. a metaanalysis was carried out by using fixed effects and random effects models to calculate the or of relationship between low level of testosterone and risk of frailty. results: the crosssectional study concluded 9 articles, there was statistically significant association between lower level of total testosterone and risk of frailty (or=1.59; 95%ci, 1.28-1.98, i2=80%), as well as free testosterone (or=1.59; 95%ci, 1.21-2.08,i2=78% ), the highest level of shbg was no significant associated with the risk of frailty(or=1.05; 95%ci, 0.84, 1.30; i2=62%). the prospective cohort studies obtain 4 articles, no significant were found between frailty and low total testosterone and frailty (pool or=1.12; 95%ci, 0.99-1.32, i2=14%). conclusion: the meta-analysis indicates that low level of serum testosterone is significantly associated with the risk of frailty in the crosssection studies. however, we found no significant relationship between low total testosterone and frailty in the cohort studies. more research is needed to address the underlying mechanisms to explain this relationship and to determine whether testosterone supplementation is effective for preventing frailty syndrome. background: although frailty and abdominal obesity are known risk factors for disability in older persons, few studies have investigated the interaction between both factors on the association with disability. objectives: to investigate the association of frailty and abdominal obesity with disability in older persons. methods: we used data from 13,787 participants (41% men) in the prospective, population-based singapore chinese health study cohort, who were interviewed and examined for frailty, abdominal obesity and disability at mean age of 74 (range 63 to 97) years from 2014-2017. we defined frailty as having three or more features of weak handgrip strength, slow timed-up-and-go test, low energy level, multiple comorbidities, and difficulty carrying out usual activities. we defined abdominal obesity by waist circumference using sexspecific cut-offs, and assessed disability using the lawton instrumental activities of daily living (iadl) scale. we used multivariable logistic regression models to compute the odds ratio (or) and 95% confidence interval (ci) for the association between frailty/abdominal obesity and disability. results: about 7.6% of participants were frail and 58.4% had abdominal obesity. frailty was associated with increased or (95% ci) of 7.78 (6.64-9.12) for disability. conversely, the or (95% ci) for the association between abdominal obesity and frailty was only 1.13 (1.01-1.27). compared to participants who were neither frail nor abdominally obese, the or (95% ci) for disability was 6.19 (4.71-8.14) in those who only had frailty, and 1.10 (0.98-1.24) in those who only had abdominal obesity. however, participants who were both frail and abdominally obese had markedly increased or (95% ci) of 9.57 (7.75-11.81) for disability; p-value for interaction between frailty and abdominal obesity was 0.047. furthermore, while men who were both frail and abdominally obese had increased or (95% ci) of 4.67 (3.27-6.67) for disability compared to their counterparts who were neither frail nor obese, the corresponding or (95% ci) was much higher at 14.92 (11.34-19.65) in women; p value for heterogeneity by sex <0.001. conclusion: frailty and abdominal obesity interacted synergistically to increase the risk of disability in older persons, and the combined effect of both factors on disability was much stronger in women than in men. background: as the world's population ages, the prevalence of cognitive impairment associated with age increases exponentially. objectives: objective of this study was to investigate the longitudinal association of physical activity and cognitive function in two deferentl populations; older adults from mexico representing latin america and south korea representing asia. based on two large population-based longitudinal studies. methods: this is a secondary analysis of two surveys, mhas and klosa, designed to study the aging process of adults living in mexico and south korea. participants>50 were selected from rural and urban areas. here we investigate the longitudinal association of exercise and cognition using the two waves of each study. cross cultural cognitive examination and mini-mental state examinarion were used to analyze the association between physical activity and cognition in mexican and korean older adults. multivariate logistic regression models were used to evaluate the said association. results: in mexico, the prevalence of physical activity was 40.68%, physical active older adults obtained a higher score in ccce (0.099 ± 1.01) p-value < 0.001. they also had more years of education (5.63 ± 4.61 vs. 5.10 ± 4.27) p-value <0.001, had depression (31.55% vs. 35.25%) 0.0090 and consumed less alcohol (89.91 vs. 93.03) p-value <0.001. in korea, the prevalence of physical activity was 35.57%. the physical active group performed better in mmse (-0.123 ± 1.05 vs. 0.046 ± 0.90) p-value <0.001. the no physical active group had a higher proportion of women, less alcohol consumption (50.01 vs. 55.22%) p-value <0.001, fewer years of education p-value < 0.001 and a higher prevalence of depression (5.12% vs 3.64%) p-value 0.0090. in the multivariate analysis an independent association was found in the korean population between physical activity and mmse score even after adjusting for confounders (0.0866 (0.0266 ; 0.1467) p value 0.0047). conclusion: physical activity could have a protective effect on the cognitive decline associated with ageing. background: aging is related to the increase of several chronic diseases, such as, osteoarthritis, osteoporosis, diabetes, hypertension and sarcopenia. sarcopenia (progressive loss of muscle mass and physical performance) is related to difficulties in treating other comorbidities, whether pharmacologically or non-pharmacologically. it's important to understand the relations between muscular strength (w), muscular mass and the phase angle (pa) of bioimpedance, in sarcopenic subjects to prescribe more accurate treatments. objectives: to study the relations of skeletal muscle index (smi) with w, pa and the presents of comorbidities (nc) in elderly subjects. methods: a prospective, observational secondary analysis of data from the "the sarcopenia screening and health related issues in the region of algarve", was performed. community independent living elderly subjects were recruited. body composition was measured by bioimpedance (seca analytics 115), knee flexion and extension isokinetic strength (60º/sec) (humac norm). a screening questionnaire was used to determine the presence of comorbidities. smi levels were assessed using european working group on sarcopenia in older people cut-off points. results: a total of 46 female and 12 males, were included, mean age 73,7 (± 7,64 sd). subject were divided into 3 groups according to smi: normal (n=21), moderated impairment (n=18) and severe impairment (n=19). pearson correlation were calculated within each group for w; pa and comorbidities. normal smi level, were correlated to knee extensors w in both legs (right: r=0,510, p<0,05 and left r=0,506, p<0,05) . no significant correlations were found with pa. moderate smi level: were correlated to knee extensors w in both legs (right: r=0,742, p<0,001 and left r=0,708, p≤0,001), and also with knee flexors w (right: r= 0,677, p< 0,005; left: r= 0,659, p<0,005). a moderate correlation was also found in this group with pa (r= 0,472, p< 0,05). severe smi level: no correlations were found, in this group, with w. a moderate correlation was found with pa (r= 0,565, p< 0,05). comorbidities did not have any correlations with smi levels. conclusion: our results seem to indicate that isokinetic strength (work) may have in the future a role in understanding sarcopenia, once it is related to smi. also, pa may indicate moderate and severe smi impairment. background: body characteristics as low muscle mass and high fat mass (fm) affect the physical function of older people. physical function is a fundamental component for the performance of daily activities and for the maintenance of the independence of older adults. however, the relationship between body composition and physical performance varies in different studies and still demands further research. objectives: this study aimed to investigate the association of fat mass index (fmi) determined by dual-energy x-ray absorptiometry (dxa) with physical performance in brazilian communitydwelling older adults. methods: a cross-sectional study with a sample of 55 participants aged 60 years and older, living in ribeirão preto, brazil, including both men and women, was conducted. fm was measured by dxa and fmi was calculated as fat mass/height2 (kg/m²). the physical performance was assessed by the 6-minute walk test, and walking distance was recorded as the main parameter, considering the distance predicted by sex. the kolmogorov-smirnov test was used to verify the normality of data distribution. the association of physical performance and fmi was analyzed using the pearson's correlation test and statistical significance was set at p ≤ 0.05 (two-sided). results: the participants were aged 70.13±6.3 years, fmi was 9.88±3.1kg/m2 and distance walked was 454.6±83.2m. there was a significant negative association (r = -277, p = 0.040) between fmi and distance walked, showing that higher fat mass index is associated with worse performance in the 6-minute walk test. conclusion: high fat mass index is associated with worse physical performance in brazilian older adults. background: sarcopenia and physical frailty have been shown to be risk factors for mortality and major morbidity in older adults suffering from various forms of cardiovascular disease. ultrasound measurement of quadriceps muscle thickness (qmt) is an emerging biomarker for sarcopenia, which we hypothesized could be conveniently acquired during the routine echocardiographic exam. objectives: to demonstrate the feasibility of measuring qmt at the time of echocardiography, and determine the association between qmt and clinical indictors of frailty. methods: adult inpatients and outpatients undergoing a clinically-indicated echocardiogram for known or suspected cardiovascular disease were recruited for this cross-sectional study at the jewish general hospital. prior to the echocardiogram, trained research assistants measured height, weight, and three clinical indicators of frailty: rockwood's clinical frailty scale, handgrip strength (jamar dynamometer), and bioimpedance phase angle (inbody 770). at the conclusion of the echocardiogram, cardiac sonographers blinded to the preceding assessments acquired a biplane image of the anterior thigh midway between the anterior superior iliac spine and knee, and measured qmt as the combined thickness of the rectus femoris and vastus intermedius muscles. a cardiac ultrasound machine and probe were used (ge vivid e9/e95, 1.5-4.5 mhz probe). results: the cohort consisted of 301 patients, of which 290 had an available measure of qmt. the acquisition and measurement of qmt added 1-2 minutes to the echocardiographic exam. the mean age was 65+/-15 years with 56% females. the mean qmt was 30+/-9 mm, similar in men and women, with the lowest quintile being <22.2 mm. higher age and lower body mass index were associated with lower qmt. after adjustment for age, sex, and body mass index, qmt was found to be associated with the multivariate composite of frailty indicators (p<0.001), particularly with the clinical frailty scale (beta -0.03 per mm; ci -0.04, -0.01) and bioimpedance phase angle (beta 0.02 per mm; ci 0.01, 0.03). additional adjustment for heart failure and inpatient status did not alter results. conclusion: qmt can be efficiently measured during a routine echocardiographic exam and can add incremental insights about frailty in a diverse group of patients with cardiovascular disease. background: frailty is a clinical syndrome whose signs and symptoms are predictors of health complications, making this a major public health problem. objectives: this study aims to evaluate the prevalence of frailty, in communitydwelling older adults enrolled in a physical exercise program in the north region of portugal, based on fried's phenotype, its association with other variables. methods: in this crosssectional analysis, we used data from 419 individuals who were enrolled in physical exercise programs. gender and age standardized prevalence and the association between frailty and sociodemographic (age, gender, marital status, education, shortage of money) physical (self-perceived health, polypharmacy, physical fitness, vision, hearing), cognitive (memory), social (emptiness, loneliness and abandonment) and psychological (depression and anxiety) variables were evaluated. results: of the 419 participants, the mean age was 72.4±5.5 years old, and 69.2% were female. prevalence of pre-frailty and frailty were of 46.8% and 5.0%, respectively. from the 5 fried's phenotype criteria, exhaustion is the most common reported by 58.2% of the pre-frail and 76.1% of the frail participants. age, marital status, self-perception of health, physical fitness, memory and depression were found to be independently associated with pre-frailty, while age, education, self-perception of health, physical fitness and anxiety were independently associated with frailty. conclusion: we reported lower prevalence of pre-frailty and frailty compared with other studies, showing that physical exercise may delay the progression of frailty. interventions aimed to prevent frailty must address the diversity of the associated variables. background: frailty is related with ethnicity and impaired physical capacity which is also affected by diabetes. however, little is known about how physical health indicators of frailty are associated with each other in older hispanics with diabetes. objectives: the goal of this study was to investigate the relationship between physical health indicators of frailty in older hispanics with diabetes. methods: thirty-eight older hispanics with diabetes (29 women, 9 men, age = 79±7 years) participated in the study. the variables included age, weight, body mass index, body composition (% of muscle mass and body fat -bio-impedance), fear of falls (falls efficacy scale international -fes-i), chair stands in 30 sec, grip strength (jamar® dynamometer), balance with eyes open and closed (force plate), preferred walking speed, gait velocity during regular and reduce time street crossing simulations (gaitrite®). results: characteristics: body mass = 75±16 kg, % of muscle mass = 25±5%, % of body fat = 40±11%, fes-i score = 29±11 points, chair stands = 8±4 repetitions, grip strength = 21±6 kg, center of pressure area with eyes open = 5±3 cm2 and with eyes closed = 8±6 cm2, preferred walking speed = 81±22 cm/s, gait velocity during regular = 100±29 cm/s and during reduced time street crossing = 124±34 cm/s. there were significant correlations (*p<0.05, **p<0.01) between age and gait velocity during regular street crossing (r = -0.34*); grip strength and % of body fat (r = -0.51**) and % of muscle mass (r = 0.56**); chair stands and preferred walking speed (r = 0.63**), gait speed during regular (r = 0.68**) and during reduced time street crossing (r = 0.60**) and center of pressure area with eyes closed (r = -0.36*), and between fear of falls and center of pressure area with eyes closed (r = 0.56**). conclusion: gait speed during street crossing simulations decreased with age. greater grip strength was associated with lower % of body fat and higher % of muscle mass. people who completed less chair stands in 30s also walked slower and had worse balance, and those with poor balance had increased fear of falls. britta c arends, lisa verwijmeren, peter g noordzij, douwe h biesma, leon timmerman, eric pa van dongen, heleen j blussévan oud-alblas (st. antonius hospital -nieuwegein, netherlands) background: chronic pain after cardiac surgery is common and has a negative impact on quality of life. frailty is an important risk factor for adverse surgical outcomes. the influence of frailty on chronic pain after cardiac surgery is unknown. objectives: this study aimed to address whether frailty characteristics were associated with chronic pain after cardiac surgery in an older population. methods: this study was based on the anesthesia geriatric evaluation (age) and quality of life after cardiac surgery study, which included 560 patients >= 70 years undergoing elective cardiac surgery. preoperatively, frailty was tested in physical, mental and social domains. pain was evaluated with the short form 36 questionnaire (sf-36) preoperatively and one year after surgery. multivariate logistic regression was used to investigate the association between frailty and chronic pain. change in health related quality of life (hrql) was analyzed to evaluate the impact of chronic pain. results: 426 (78%) patients were included in the analysis. 84/426 patients (20%) reported new or increased pain one year after surgery. in 356 patients (84%) at least one frailty characteristic was present and 118 patients (28%) were frail in two or more domains. after adjustment for possible confounders in multivariate analysis, patients with single status and polypharmacy were at increased risk for new or increased chronic pain (aors 1.86 (95% ci 1.01 -3.41) and 2.13 (95% ci 1.11 -4.11). new or increased chronic pain was associated with a worse hrql (aor 2.81; 95% ci of 1.61 -4.90). conclusion: frail patients are at risk for chronic pain and worse hrql after cardiac surgery. future research should focus on perioperative interventions to reduce chronic pain in elderly patients. background: frailty is a vulnerability state that is associated with negative outcomes such us falls, in-hospital admissions and mortality. many factors can contribute to the pathogenesis of frailty and nutritional status is playing and important role. that´s why undernutrition and frailty must be overview in older adults before surgical procedures in order to treat them earlier. objectives: identify the relationship between physical frailty and undernutrition in older adults undergoing elective abdominopelvic surgery in a general hospital in lima-perú. methods: this is a secondary database study from the original "physical frailty and adverse events in older adults undergoing elective pelvic abdominal surgery in a general hospital, lima-perú", it was realized between august 2017 and march 2019, using validated face to face questionnaires. physical frailty was determined with fried criteria, undernutrition by mini nutritional assesment (mna). in adition, they also evaluated functional status and cognition. univariate models were performed, and logistic regression was done subsequently. results: 171 older adult met inclusion´s criteria, the mean age was 68.7(+6.8) years old, 50,0% (86) were female, 29,7% (51) had hypertension, 12,2% (21) were diabetic, the mean number of comorbidities were 2.4 (+0.7), 11,1% (19) had functional impairment, 9,5%(16) had cognitive impairment. the mean bmi was 27.41 ± 4.80. 16,57% (28) were underweight, 49.70%(84) normal ,17.75%(30) overweigth and 15.98% (27) obese. by mna 31 % (53) had risk or undernutrition, 22.64% (12) of them had functional impairment in contrast with 5,9%(7) who weren´t at risk or undernutrition; p=0.002. also, 16.98 %(9) who had risk or undernutrition had cognitive impairment in contrast with 5.93%(7) who weren´t at risk or undernutrition; p=0.014. by fried criteria, 29% (49) were frailty, 66 % (113) prefrailty and 5,3% (9) robust. the frailty patients 53% (26) had risk or undernutrition vs 23,08%(26) in prefrailty and 1.11%(1) in robusts; p=0.000. conclusion: there is an increased risk of undernutrition in frail older adults undergoing abdominopelvic surgery at a general hospital in lima, peru. background: cognitive frailty increases the risk of dementia, dependency and mortality in older people. moderatevigorous physical activity (mvpa) improves frailty syndrome and cognitive functions in older people, but being physically inactive is still prevalent. walking is the most common and inexpensive form of physical activity in older people and brisk walking is a form of mvpa. m-health has been successful in changing health behaviours in many populations. however, its effect in treating cognitive frailty through promoting mvpa in older people is not known. objectives: the aims of this study were to examine the effects and feasibility of an m-health intervention. methods: a pilot randomized controlled trial was employed. eligibility criteria include 1) age > 60 years, 2) living in community, 3) having cognitive frailty, and 4) mobility at "outdoor walker" level. the study was conducted in community settings. subjects were recruited in the elderly community centres. subjects were randomized into either intervention or control at a 1:1 ratio. in the intervention groups, the subject received a smartphone pre-installed with physical activity tracking and social media applications. they received a course of brisk-walking in daily living training, health education, and a 12-week behavioural change intervention on the smartphone platform. in the control group, participants received a course of brisk-walking in daily living training, health education, and telephone follow-up. the outcomes were frailty (ffi), cognitive function (moca) and mvpa (actigraph). we targeted at recruiting totally 30 subjects. nonparametric tests were used to compare the effects within and between groups. missing values were replaced by last observed values. results: this study recruited 33 subjects (intervention: n=16, control: n=17). significant improvements in frailty (p<0.01), cognitive function (p<0.01), and mvpa (p<0.05) were observed in the intervention group after the completion of the intervention. only cognitive function was also observed to be improved in the control group (p<0.01). the compliance of wearing devices (i.e., smartphones and actigraphs) and the usage of the smartphone applications were highly satisfactory. three subjects withdrew from the study (intervention: n=1, control: n=2). conclusion: m-health intervention is feasible to treat cognitive frailty in older people. it is more effective to ameliorate frailty and increase mvpa in older people with cognitive frailty when compared to conventional training. background: the prevalence of dementia and associated healthcare cost increases with aging population. population health management and proactive screening with increased emphasis on primary risk reduction may reduce the overall prevalence of dementia. motoric cognitive risk syndrome (mcr) has been increasingly studied as a pre-dementia stage to identify older adults at risk of transiting to dementia while few studies explored the association between mcr and functional capabilities. objectives: the aims are to investigate the prevalence of mcr and its associated factors among community-dwelling older adult and also to examine possible impact of mcr on functional capabilities. methods: data for 546 older adults aged above 60 years old staying in northwest region of singapore was used. mcr was defined as slow gait speed over 4m (1 sd below population mean) with subjective memory complaints in the absence of dementia. functional capability was determined by administering the lawton instrumental activities of daily living (iadls). differences in demographics, socioeconomic and lifestyle factors between mcr positive and mcr negative groups were found using independent t-test and chi-square test. risk factors of mcr and impact of mcr on functional capability were examined using logistic regression. results: the prevalence of mcr in the studied population was 7.1%. after adjusting for demographics and socio-economic factors, indians (adjusted or = 5.79, 95% ci = 1.36-24.57, p = 0.017), increasing age (adjusted or = 1.09, 95% ci = 1.04-1.14, p <0.01), higher bmi (adjusted or = 1.12, 95% ci = 1.05-1.20, p <0.01) increased likelihood of mcr while increased years of education decreased likelihood (adjusted or = 0.91, 95% ci = 0.84-0.99, p = 0.028). the odds of having at least one impairment in iadl after adjusting for demographics, socio-economic and health factors amongst those with mcr were 3.65 (adjusted or = 3.65, 95% ci = 1.37-9.72, p = 0.01). conclusion: our study found 1 in 14 to have mcr, the pre-dementia stage. indian ethnicity, those with increased age and higher bmi are at greater risk of having mcr. as mcr is also associated with functional impairment, it can serve as a useful screening tool to identify those at risk of progressing to dementia. background: sleep disturbance has been found in older persons with dementia, which impact on the quality of life of older persons and on the caregiving burden of the family. little is known about the sleep patterns and sleep problems of older persons with dementia. exploring these data would provide basic information to develop interventions for this population. objectives: to explore sleep patterns and sleep problems in community-dwelling older persons with dementia. methods: the sample recruited by purposive sampling consisted of 88 community-dwelling older persons with any stage of dementia who used healthcare services at outpatient departments of a university hospital, thailand. data were collected using a demographic data questionnaire, a sleep diary recorded by caregivers, and an electronic wrist activity tracker to assess sleep data for 3 consecutive nights. the data had been collected for three months and were analyzed using descriptive statistics. results: the sample had an age range from 65 to 101 years (m= 82.33, sd = 7.15). the total sleep data of the 88 older persons with dementia consisted of 264 episodes. almost all of the sleep data showed the polyphasic sleep pattern (sleeps for several periods of time a day), but a few had monophasic and biphasic sleep patterns. the total sleep time per night ranged from 3 to 13 hours with a mean of 9 hours. the mean sleep latency was 35 minutes, by which two-thirds of them had sleep latency less than 30 minutes. three-quarters of the data woke up at night. the mean duration of waking up at night was 26 minutes. two-thirds of the data had sleep problems, including insomnia, waking after sleep onset, and excessive daytime sleeping. also, most of them had snoring (74%), followed by sleep talking (53%). conclusion: the polyphasic sleep pattern was found mostly in older persons with dementia. also, they had sleep problems of insomnia at night and excessive sleeping during the daytime. healthcare providers may use the results from this study to understand the sleep patterns and then find strategies to promote the sleep quality of older persons with dementia. yumi umeda-kameyama 1 , masashi kameyama 2 , taro kojima 1 , masaki ishii 1 , shinya ishii 1 , mitsutaka yakabe 1 , kiwami kidana 1 , tomohiko urano 1,3 , sumito ogawa 1 , masahiro akishita 1 ((1) department of geriatric medicine, the university of tokyo school of medicine, tokyo, japan; (2) department of diagnostic radiology, tokyo metropolitan geriatric hospital and institute of gerontology, tokyo, japan; (3) department of geriatric medicine, international university of health and welfare, narita, chiba, japan) background: «perceived age» of facial appearance in elderlies was shown to be a robust biomarker of aging that predicts survival, telomere length, and dna methylation. it is also reported to correlate with carotid atherosclerosis and bone status. objectives: this study aims to determine whether perceived age is a better biomarker than chronological age for a variety of aspects in dementia assessment, which includes general cognition, vitality, depressive state, and selfsupportability. methods: one hundred twenty-six patients admitted to the department of geriatric medicine, the university of tokyo hospital with suspect of cognitive decline were enrolled. mmse, vitality index, gds15, iadl, and barthel index were performed. ten geriatricians and clinical psychologists determined the perceived age of subjects based on their photographs. results: the average values of 10 rates showed excellent reliability (icc(3,10)=0.941). perceived age showed significantly better correlation with mmse (female), vitality index (total, female), and iadl (total) than chronological age by steiger's test, but not with gds15 and barthel index. conclusion: perceived age was demonstrated to be a better biomarker for cognitive assessment than chronological age. l a u r a t a y 1 , h u d a m u k h l i s 1 , jolene ho 1 , aisyah latib 2 , eeling tay 3 , shimin mah 3 , candy chan 4 , yeesien ng 1 ((1) department of general medicine, sengkang general hospital, singapore; (2) office of regional health system, singhealth, singapore; (3) department of physiotherapy, sengkang general hospital, singapore; (4) dietetics, sengkang general hospital, singapore) background: cognitive frailty is characterized by co-existence of physical frailty and cognitive impairment. earlier studies reported aggravated health outcomes attributable to cognitive frailty over physical frailty alone. objectives: we examine risk factors for cognitive frailty, and its impact on physical performance and health outcomes, compared with isolated occurrence of cognitive impairment or physical frailty. methods: cross-sectional analysis of 757 communitydwelling older adults who completed multi-domain geriatric screen assessing for social vulnerability, mood, cognition, functional performance, nutrition, physical frailty (frail) and sarcopenia (sarc-f). cognitive impairment was defined using locally validated education-adjusted cut-offs on modified-chinese mini-mental state examination. participants underwent physical fitness tests comprising grip strength, gait speed, lower limb strength and power, flexibility, balance, and endurance. health outcomes included hospitalization, emergency department visits, falls and self-rating of health. each participant was categorized as robust-cognitive intact (pf--/ ci-), pre-frail/ frail only (pf+/ ci-), cognitive impaired only (pf-/ ci+), and cognitive frailty (pf+/ ci+). results: mean age of study cohort was 67.6(6.7)years. 523 (69.0%) were pf-/ci-, 122 (16.1%) pf+/ci-, 73 (9.6%) pf-/ci+, and 39 (5.2%) pf+/ ci+. in multi-nomial logistic regression referenced to pf-/ci-, older age significantly increased risk for pf-/ci+ and pf+/ci+. cognitive frailty contributes to worse physical performance and poorer health outcomes compared to physical frailty and cognitive impairment in isolation. while social vulnerability and depression were differentially associated with isolated frailty status, malnutrition and sarcopenia should be targets for preventing frailty and cognitive impairment. osamu katayama, sangyoon lee, seongryu bae, keitaro makino, ippei chiba, kenji harada, yohei shinkai, hiroyuki shimada (department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, japan) background: cognitive frailty is a condition recently defined by operationalized criteria describing coexisting physical frailty and mild cognitive impairment (mci). however, there is no consensus on the definition of cognitive frailty for use in clinical and community settings. objectives: this study aimed to use latent class analysis (lca) to discover potential subtypes of cognitive frail older people. in addition, we explored the relationship between the identified cognitive frailty subtypes, and their demographical, neuropsychological, body composition, and lifestyle activity characteristics. methods: a total of 7309 community-dwelling older adults aged >= 60 years participated in the study. we characterized physical frailty as >= 3 of the following criteria: slow walking speed, muscle weakness, exhaustion, low physical activity, and weight loss. we used tests of word list memory, attention, and executive function, and processing speed to screen for cognitive impairment. the presence of >= 1 cognitive impairments were defined as mci. we defined the condition where physical frailty and mci coexist as cognitive frailty. lca was applied to characterize classes or subgroups with different cognitive frailty phenotypes. subsequently, we performed multinomial logistic regression analysis with cluster membership as dependent variable and dichotomized demographics and lifestyle activity characteristics as independent variables. results: lca identified eight distinct subgroups included three different cognitive frailty phenotypes: cognitive frailty composed of physical frailty and amnestic mci (acf), cognitive frailty composed of physical frailty and non-amnestic mci (nacf) and, cognitive frailty in which physical frailty and global cognitive impairment (gcf). cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. in particular, the acf cluster was associated with younger age and also related to the inactivity of productive and cognitive activities (p<0.05). the nacf cluster was related to the inactivity of social and cognitive activities (p<0.05). finally, the gcf cluster was associated with older age (p<0.05). conclusion: using lca, we identified eight distinct subgroups included three different cognitive frailty phenotypes in a large sample of community-dwelling older adults. cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. sara g aguilar navarro, alberto j mimenza alvarado, itzel aparicio gonzález, clarita cabrera juárez, alejandra samudio cruz, monsal alexa, ja avila funes, teresa juarez-cedillo (instituto nacional de ciencias médicas y nutrición salvador zubiran, ciudad de méxico, mexico) background: the prevalence of mild cognitive impairment (mci) ranges between 14-18% and is 4 times more frequent than dementia. the dcl has been associated with cardiovascular risk factors, mainly changes at the executive level. the apoe4 genotype, on the other hand, is a gene that confers susceptibility to alzheimer's disease in addition to participating in lipid metabolism, giving greater risk of atherosclerosis and cardiovascular risk. however, given the genetic heterogeneity of the mexican population, this association is not clear. objectives: to establish the strength of association between the different types of dcl (amnesic and non-amnesic) in mexican mestizo older adults according to their carrier status of the apoe4 allele and cardiovascular risk factors. methods: 83 patients in a memory clinic were evaluated from 2017 to 2019, older than 75 years, without sensory deficit, psychiatric diseases or uncontrolled metabolic pathology, separating them into 3 mutually exclusive groups: healthy controls, group with amnesic mci, group with nonamnesic mci, performing geriatric and neuropsychological evaluation. parametric and nonparametric statistics (x2, anova, multivariate linear regression analyzes) were used to find statistical differences between groups. results: multivariate linear regression analyzes were performed to examine the relationship between vascular risk factors, the presence of the apoe ε4 allele, and cognitive change. apoe genotype significantly modified the associations between both hypertension and cardiovascular disease and a decline in language abilities as well as diabetes and decline in verbal memory, attention, and visuospatial abilities in non-amnestic mci. associations between increased vascular risk burden and greater cognitive decline were observed among apoe ε4 carriers but not non-carriers with mci. conclusion: the present study revealed an increase in the association between non-amnestic mci (apoe ε4 carriers with vascular risk factors) and suggests that the treatment of vascular risk factors could contribute to reducing the risk of progression of cognitive impairment, particularly among patients with apoe ε4 mexicans. background: a number of cross-sectional and longitudinal studies have demonstrated an association between physical frailty and cognitive impairment (1). many mechanisms have been suggested to explain the presence of cognitive impairment in frail subjects, such as cardiovascular risk, hormonal disturbances, chronic inflammation or nutrition (2, 3). another hypothesis is that cognitive impairment in frail patient may be due to alzheimer's disease (ad) (1, 2, 3). however, the link between frailty and amyloid deposition has to date never been studied in vivo. objectives: (1) to examine the prevalence of cerebral amyloid pathology as measured with amyloid positron emission tomography (pet) or amyloid-β-1-42 level in cerebrospinal fluid, among frail and pre-frail individuals presenting an objective cognitive impairment (2) to characterize the cognitive and clinical progression of frail cognitively impaired patients according to the amyloid status. methods: cogfrail is a monocentric observational prospective study of 345 cognitive frail and prefrail older participants (according to fried criteria), aged >=70 years, with an objective cognitive decline (defined by a clinical dementia rating (cdr) scale scoreat 0.5 or 1). the participants will be followed up every 6 months, during 2 years. in addition to cerebral amyloid pathology (measured by amyloid positron emission tomography (pet) or amyloid-β-1-42 level in cerebrospinal fluid), measurements include cognitive performance, physical function, nutritional status, depressive symptoms biology, nutrition, magnetic resonance imaging (mri), and body composition to better understand the mechanisms and progression of cognitive frailty. results: the study is currently being recruited. to date, 272 patients were included. 156 mri 170 pet scan and 10 lumbar puncture have been performed. 43 subjects completed the study. conclusion: this study will allow us to determine, for the first time, the prevalence of amyloid pathology, a marker of ad, among frail and pre-frail patients presenting objective memory impairment. the results will help characterize the cognitive decline in frail and pre-frail patients, with important implications for the detection, management and ultimately prevention of neurocognitive disorders among frail old individuals references: 1) kojima g, taniguchi background: cognitive impairment is a well-known risk factor for falls in older adults. the risk of falls is increased in those with diminished executive function and reduced processing speed. while participants with cognitive deficits are more prone to falling, it is unknown whether risk of falling on cognitively intact individuals placing them at higher risk for future cognitive decline. objectives: to ascertain the incident development of cognitive decline in those at higher risk for falls using the center for disease control's fall risk assessment tool, steadi (stop elderly accidents, deaths, and injuries) in community dwelling individuals >65 years of age. methods: we identified individuals >=65 years old using the longitudinal national health and aging trends study (nhats) that consists of eight years of follow-up. these individuals did not have cognitive impairment at baseline. fall risk was defined using the algorithm from the center for disease control's steadi initiative. participants were classified at baseline in three categories of fall risk (low, moderate, severe). impaired global cognition was defined as nhats-defined impairment in either the alzheimer's disease-8 score, immediate/delayed recall, orientation, clock-drawing test, or date/person recall. the primary outcome was the risk of incident cognitive impairment over time. cox-proportional hazard models and linear mixed-effects modeling ascertained the incidence of cognitive impairment, adjusting for age, sex, smoking status, education, co-morbidities and an ability to walk. our referent variable was individuals at low steadi fall risk. results: of the 5,822 participants (55.7% female), median age category was 75-80 years. prevalence of baseline fall risk using the steadi measure in participants was low (55.2%), medium (36.2%) and high (8.5%). the rate of cognitive impairment in our sample was 45.7%. in our fully adjusted model, the risk of developing cognitive impairment was hr 1.12 [95%ci:1.00 -1.26] in the intermediate risk group, and hr 1.78 [95%ci: 1.51 -2.11] in the high risk group. using linear mixed-effects modeling yielded similar results. conclusion: steadi fall risk at baseline was predictive of higher rates of cognitive decline in those with normal cognition. elevated fall risk by steadi may suggest need for more thorough cognitive assessment. background: the concept of cognitive reserve (cr) has been developed as a potential factor able to describe individual differences in vulnerability to cognitive, functional, or clinical decline along aging. the progressive reduction of cognitive and functional performances represents an outcome commonly associated with aging. objectives: the aim of this crosssectional study is to investigate the association of cr with cognitive and functional outcomes in a sample of elderly outpatients. methods: subjects aged >=65 were consecutively recruited. patients who were unable to undergo the execution of required tasks due to severe cognitive, functional or sensory impairment were excluded. mini mental examination (mmse), brief intelligence test (tib) and cognitive reserve index questionnaire (criq) were administered. handgrip strenght, gait speed and daily life autonomy were measured; a frailty index (fi) was eventually calculated. results: data from 105 patients were analyzed. criq was significantly correlated with mmse (r = 0.378, p <0.01), handgrip (r = 0.347, p <0.01) and gait speed (r = 0.220, p= 0,024). furthermore, criq was correlated with badl (r = 0,270, p=0,005), iadl (r= 0,330, p= 0,001) and inversely with fi (r= -0.335, p <0.01). significant correlations were found between tib and mmse (r = 0.280, p <0.05), between tib and criq (r = 0.524, p <0.01), and between tib and iadl (r = 0,197, p= 0,043). conclusion: this preliminary report highlighted that patients with higher cr showed not only better overall cognitive functioning, but also better functional status and a lower degree of frailty. in the light of a multidimensional geriatric assessment, the integrative evaluation of cr in elderly might offer the opportunity to track possible trajectories of aging, since it appeared related either to cognitive status, either to functional oucomes and to frailty. background: the clinical syndrome of "physical" frailty has been conceived without regard for cognitive decline. nevertheless, it has been suggested that frail elders exhibit frailty-specific cognitive impairments, and that the cognitive correlates of frailty may be dementing in their own right. meanwhile, we have used confirmatory factor analysis (cfa) in a structural equation model (sem) framework to construct a latent dementia phenotype, "δ". our approach is modular and can be redirected to other clinical targets. objectives: in this analysis, we create a δ ortholog representing the "cognitive correlates of frailty" (df). methods: first, we constructed a frailty index (if) from wave-5 data collected as part of the hispanic established population for epidemiological studies in the elderly (h-epese). a δ ortholog targeting if was then constructed from a cognitive battery that included the mini-mental status exam (mmse) and clox: an executive clockdrawing task (clox). results: the model fit the data well and df exhibited factor determinance. dfrailty was strongly indicated (r = 0.64, p<0.001) by if and explained 41% of the index's variance. it was also significantly indicated by mmse and clox scores. df was strongly correlated (r = 0.90, p<0.001) with instrumental activities of daily living (iadl), independently of age, gender and education. the remaining 59% of if's variance had no significant association with iadl. the orthogonal latent variable "g'", df's residual in spearman's general intelligence factor "g", was strongly indicated by all three cognitive performance measures. nevertheless, it was weakly associated with iadl. measure specific cognitive performance, residual to both df and g', had no independent: association with iadl. conclusion: these results suggest that the frailty syndrome does indeed have specific cognitive correlates. these are strongly associated with iadl and therefore potentially "dementing". like δ, the cognitive correlates of frailty are extractable from spearman's g, which may constrain the biology and psychometric properties of frailty-specific cognitive changes. independently of df, cognition has little association with iadl. this suggests that frailty may be a major determinant of iadl performance in elderly ma, and possibly a major etiology of "all cause" dementia in that population. background: cognitive-frailty has been proposed as a distinctive entity which preludes dementia. objectives: we aimed to examine the relationship between physical frailty, cognitive status, and gait performance as predictors of cognitive decline and incident dementia. methods: cohort study of 252 community older adults free of dementia at baseline with a 5 year follow-up. inclusion criteria: > 65 years, english speaking, able to ambulate one city block. exclusion criteria: hip/knee joint arthroplasty in past 6 months, parkinsonism, major depression, and diagnosis of dementia (dsm-iv criteria). cognition was assessed using the moca, the mmse, and the clinical dementia rating (cdr) scale was performed. physical frailty was defined using the phenotypic criteria described by fried and walston. cognitive-frailty was defined as the simultaneous presence of physical frailty with objective cognitive impairment, and absence of concurrent dementia. the main outcome measure was all-cause dementia (dsm-iv criteria). cox proportional hazards models were used to estimate the risk of cognitive decline and incident dementia. results: over a 5-year follow-up, 53 participants experienced cognitive decline and 27 participants progressed to dementia (global incidence rate (ir): 73 per 1000-person/y). participants with frailty had a higher prevalence of cognitive impairment (77%) compared to those without (54%, p=0.02) but the risk of progression to dementia was not significant. adding cognitive impairment to the frailty phenotype (cognitive-frailty) predicted further cognitive impairment and progression to dementia. dementia ir for frailty was 61 per 1000 person/y and for cognitive-frailty, 80 per 1000 person/y. however, when slow gait was combined with baseline cognitive impairment, it showed the highest risk of progression to dementia (hr: 35.9, 95%ci: 4.0-319.2; p = 0.001) with an ir of 130 per 1000 person/y. conclusion: frailty and cognitive impairment are common and often coexist in the same individuals. however, slowing gait seems to be the frailty component driving the association with future dementia. background: assisted bathing requires the most hours of home care. for the frail elderly and their caretakers, the bathroom presents the most risk factors for falls and injury. bathroom adaptation is the primary reason for consultation in community occupational therapy and available resources cannot meet the increasing demand. the hygiene 2.0 (h2.0) website (https://algo.grismoir.com/) addresses this need by offering a structured questioning to identify bathing assistive technology for the frail elderly living at home. objectives: our actionresearch protocol aims to establish a partnership between actors in the home care social economy enterprises (eésad), the home care programs offered through the healthcare system and the private sector (e.g., assistive technology providers). this implies: 1) adapting h2.0 to the home care service workers' needs; 2) designing an implementation model for h2.0 in order to formalize a partnership in the community; 3) conducting pilot testing in two eésad. methods: 1) user-centered design and a multiple case study where a case represents a home care worker (n=9) from a eésad (québec, canada) offering bathing assistance for the elderly. during testing, the home care worker will explore the h2.0 prototype with an elderly in his or her home, sharing their thoughts out loud. the unit of analysis is the usability of h2.0, allowing improving to the prototype after every three participants. 2) all collaborators will participate in the iterative modification of a preliminary logic model for the implementation of h2.0. modifications suggested will be integrated to the model throughout three meetings, or until a consensus is reached. 3) the adapted version of h2.0 (obj. 1) will be tested according to the implementation model developed (obj. 2). a pilot project using mixed methods in collaboration with two eésad will be conducted with 20 older adults having difficulty bathing. results: anticipated results: responsive h2.0 website adapted to the users' needs, an implementation model and pilot data allowing scaling-up technology meeting needs of frail elderly and their caretakers issues during bathing. li-ning peng 1,2,3 , fei-yuan hsiao 4,5,6 , wei-ju lee 1,2,7 , shih-tsung huang 4 , liang-kung chen 1,2,3 ( (1) background: the theory of cumulative deficits using big data to develop the multimorbidity frailty index (mfi) has become a widely accepted approach in public health and healthcare services. however, constructing the mfi using the most critical determinants and stratifying different risk groups with dose-response relationships remain major challenges in clinical practice. objectives: this study aimed to develop the mfi by using machine-learning methods that select variables based on the optimal fitness of the model and to further establish four entities of risk using a machine-learning approach as well as to ensure the dose-response relationship and the best distinction between groups. methods: in this study, we used taiwan's national health insurance research database to develop a machine-learning multimorbidity frailty index (ml-mfi) using the theory of cumulative diseases/deficits of an individual older person. compared to the conventional mfi, in which the selection of diseases/deficits is based on expert opinion, we adopted the random forest method to select the most influential diseases/deficits that predict adverse outcomes for older people. to ensure that the survival curves showed a dose-response relationship with overlap during the follow-up, we developed the distance index and coverage index at any time point to classify the ml-mfi of all subjects into the categories of fit, mild frailty, moderate frailty and severe frailty. survival analysis was conducted to evaluate the ability of the ml-mfi to predict adverse outcomes, such as unplanned hospitalizations, intensive care unit (icu) admissions and mortality. results: the final ml-mfi model contained 38 diseases/deficits in this study. compared with conventional mfi, both indices had similar distribution patterns by age and sex; however, among people aged 65-69, the mean mfi and ml-mfi were 0.037 (standard deviation (sd) 0.048) and 0.0070 (sd 0.0254), respectively. the difference may result from discrepancies in the diseases/deficits selected in the mfi and the ml-mfi. a total of 86,133 subjects aged 65 to 100 years were included in this study and were categorized into 4 groups according to the level of the ml-mfi. both the kaplan-meier survival curves and cox models showed that the ml-mfi significantly predicted all outcomes of interest, including all-cause mortality, unplanned hospitalizations and all-cause icu admissions, at 1, 5 and 8 years of follow-up (p<0.01). in particular, a doseresponse relationship was revealed between the four ml-mfi groups and adverse outcomes. conclusion: the ml-mfi consists of 38 diseases/deficits that can successfully stratify risk groups associated with all-cause mortality, unplanned hospitalizations and all-cause icu admissions in older people, which indicates that precise, patient-centered medical care can be a reality in an aging society. to return home. understanding the home environment prior to discharge is crucial. occupational therapists (ots) often depend on client's verbal descriptions, pictures and sketches when planning rehabilitation exercises and suggesting adaptations. the information obtained is therefore partial. mapit is a new mobile application which scans a room producing a 3d representation with virtual measurements of environmental elements. this could provide a more complete representation of the home needed by inpatient rehabilitation ots. objectives: to target mapit's clinical applications for inpatient rehabilitation of the frail elderly. methods: multiple case study where mapit was introduced in three inpatient geriatric rehabilitation units over 40 days. five ots maintained a logbook and participated in four individual semi-structured interviews. a deductive thematic analysis of the logbooks and interview transcripts was corroborated by two additional ots. results: mapit is useful for ots in rehabilitation settings by allowing them to 1) see it: see the home environment, 2) measure it: take measurements of desired environmental elements, 3) document it: have a copy of the environment on hand, 4) communicate it : facilitate exchanges with the client and with colleagues. with mapit, ots gain a better understanding of the environment, which informs the rehabilitation intervention. better communication could also improve the client's implementation of the therapeutic strategies. conclusion: mapit is a useful resource to optimise intensive rehabilitation for the frail elderly. sonia jiménez-mola 1 , javier idoate-gil 1 , david idoate 2 , maría plaza carmona 3 ((1) geriatric department, complejo asistencial universitario, león, spain; (2) university of salamanca, salamanca, spain; (3) urgency department, complejo asistencial universitario, león, spain) background: as the age of the population increases, the incidence of osteoporosis and its direct consequence, fragility fractures, are also increasing. hip fractures are associated with the greatest number of complications, functional deterioration, and mortality of up to 30% one year after the fracture. objectives: the aim of this study is to determine the prevalence of previous diagnosis of osteoporosis in elderly patients who suffer hip fracture and its relationship with age distribution (75-84, 85-90 and >90 years old), gender, type of fracture and funtionality. methods: we enrolled 534 patients with hip fracture, aged 75 years or older in an orthogeriatric unit between december 2013 and november 2014. underwent comprehensive geriatric assessment that evaluates comorbidities, medication use, ability to perform basic activities of daily living, place of residence, anesthesia risk as measured by the asa score, type of fracture, type of surgery and anesthesia and in-hospital mortality. spss®, v.22.0. results: the mean age was 86.1±7.3 years (75-105 years). 75.4 % female. 55% pertrochanteric fractures. (93%) underwent surgery. only 11.6% received general anesthesia. 64% walked independently, 69% had barthel >60, 132 (25%) had a previous diagnosis of dementia, and 26% live in nursing home prior to fracture. we found a previous diagnosis of osteoporosis in 58 patients (10.9%). in these patients, statistically significant differences were shown for sex p<0.05 (12.8% female vs 5.2% male), age distribution p<0.05 (14.8%(75-84) vs 10.6% (85-89) vs 6.7% (>90) and the presence of anti-osteoporotic treatments p<0.001. all other measurements (barthel index, cognitive degree, type of fracture, asa score and type of surgery, did not show statistically significant differences (p>.05). conclusion: patients in very advanced age showed neither significantly higher percentage of diagnosed osteoporosis, not significantly higher amount of preexisting osteoporosis-related medication. although the prevalence of osteoporosis increases with age, the diagnosis and treatment prevalence decreased in higher age groups. background: aging is associated with a decrease in bone density, muscle mass and a gain in fat mass which increase physical disabilities and falls. nevertheless, the impact of obesity on bone density and architecture is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle and physical function, but also with bone density and architecture. however, the role of initial protein intake in osteopenic-obese older adults is still unclear. objectives: to examine the influence of initial protein intake on muscle and bone function in osteopenic-obese older adults. methods: cross-sectional a-posteriori matched study design. fourteen obese (total fat (%): men >25; women: >35) osteopenic (bmd t-score <-1.5) older adults (age >60 years old) were divided in 2 groups according to their initial protein intake (prot-(n=7): <1g/kgbw/d or prot+ (n=7): >1.2g/ kgbw/d) and were matched for age (±2years) and gender. body composition (fat, fat-free and bone masses, dxa), muscle composition and bone architecture (qpct), muscle function (grip strength, knee extension strength, muscle power), physical performance (walking speed (4m), tug (3m), unipodal balance, stair and chair tests), cardiorespiratory function (6min walking test) and lifestyle habits (physical activity level: 3-axial accelerometer and nutritional status: food record) were assessed. results: our groups (prot-vs. prot+) were similar (p>0.05) in terms of age (66.3±3.8 vs. 65.4±2.2 years), bmi (26.9±5.2 vs. 26.3±3.9 kg/m2), body fat (total(%): 33.4±5.9 vs. 37.6±4.0), muscle quantity (fat-free mass or limb muscle area) and quality (intra & submuscular adipose tissues), bone density (total hip or spine) and architecture (marrow, cortical or total area, and compressive or torsion strength), physical performance (walking speed(m/s): 0.75±0.13 vs. 0.75±0.06), cardiorespiratory function, lifestyle habits (steps: 7734±2867 vs. 8032±3418), except (by design) for the initial amount of protein intake (0.8±0.2 vs. 1.4±0.2 g/kgbw/d) respectively. conclusion: the initial protein intake does not seem to influence bone architecture, muscle function, or physical performance in elderly osteopenicobese. obesity but also the level of protein intake above the official recommendation (>0.8g/kgbw/d) could explain these conclusions. thus, future studies are needed to confirm our preliminary results. background: the glim definition of malnutrition is the first intended to be used globally. glim uses five criteria (two phenotypic and three etiologic) for the diagnosis of malnutrition, which is made when at least one etiologic and one phenotypic criterion are present. mna-sf is a validated widespread screening tool used in geriatric settings. glim and mna have not been compared in acute geriatric care. objectives: to measure the prevalence of malnutrition in older patients admitted to an acute geriatric unit using glim criteria and to assess the accuracy of the mna-sf in predicting glim defined malnutrition. methods: a prospective study was conducted among all patients older than 80 years old admitted to an acute geriatric unit. end-of-life situations and wearers of pacemakers were excluded. glim criteria and mna-sf were assessed on admission. muscle mass (one of the glim criteria) was estimated by bioimpedance (thresholds for low muscle mass: <21.4 kg in men; <14.1 kg in women). results: 171 patients were included (mean age 92.9±3.7 years, 72% women). on admission, 55.6% were malnourished according to the glim criteria (84.2% met at least one etiologic criterion, 63.2% met at least one phenotypic criterion). 53.8% were malnourished using mna-sf. however, there was no correlation between glim and mna-sf (correlation coefficient r=-0.05, p=0.076). mna-sf had low sensitivity (51.6%) and low specificity (43.4%) to detect malnutrition diagnosed with the glim criteria (roc curve auc=0.475). conclusion: more than half of the very old patients admitted to an acute geriatric unit were malnourished according to the glim diagnostic criteria. a very similar proportion of patients had a mna-sf suggesting malnutrition. however, mna-sf had a low reliability to detect patients with glim defined malnutrition. corina naughton 1 , rachel simon 2 , tj white 2 , darren daly 3 ( (1) background: hospitalised older adults are at risk of hospital associated decline (had). optimising nutrition intake is an important modifiable factor in protecting against had and promoting recovery, but food intake and the quality of mealtimes are frequently overlooked nursing activities. objectives: the study aim was to undertake an in-depth analysis of mealtime practices and to identify patient and mealtime factors associated with low food intake (<eating 50% of meal provided). methods: we carried out structured observation of mealtimes using a validated tool examining patient positioning, mealtime set up and assistance. the primary outcome was food consumption categorised as 0, 25%, 50% 75% or 100% based on visual inspection of food trays. data were also collected on patient characteristics. data analysis used descriptive statistics and univariate logistic regression to examine the association between low food intake and mealtime and patient factors. results: we included 295 mealtime observations on 63 patients aged 65 years and older. at 41% (n=122) of meals, patients ate half or less of the food provided. meal time factors with a weak association with low intake were: allocated red tray (an indicator of nutrition risk), modified diet, and needing assistance. breakfast time was the most important meal for food intake. nearly half of the patients (31/63) ate 50% or less of the food provided on two or more occasions over a 48-hour period. patient frailty and a moderate to high nutrition risk score were independently associated with low food intake. conclusion: patient factors are the strongest predictors of low food intake. increasing the quality of the mealtime experience and more tailored nutrition plans could improve nutrition intake in frail older adults. were hospitalized at least once, 149 (40.7%) fell at least once, and 35 (9.6%) had at least one fracture during the 4-year follow-up. no association was found between malnutrition and 4-year risk of institutionalization, hospitalization, falls, or fractures (p>0.05). conclusion: malnutrition according to glim criteria was associated with a 4.4-fold higher mortality risk; double that of the espen criteria, during a 4-year followup. no association was found between malnutrition according to these two criteria and incidence of other adverse health consequences. glim criteria anticipate outcome and might guide interventions, with important implications for clinical practice and research. background: older adults are at high risk of developing cardiovascular disease. pre-clinical studies indicate that resveratrol (rsv), a polyphenol present mostly in grapes and red wine, may prevent development of cardiovascular disease. objectives: our hypothesis was that rsv will reduce biomarkers of cardiovascular disease risk in obese, rather healthy older adults in a dose-dependent manner. methods: older participants (65 years and older) were randomized to a 90 day rsv treatment with 300mg (n=10), 1000mg (n=9) or placebo (n=10). we measured levels of atherosclerosis development risk biomarkers i.e. oxidized low-density lipoprotein (oxldl), soluble e-selectin-1 (se-selectin), soluble intercellular adhesion molecule-1 (sicam-1), soluble vascular cell adhesion molecule-1 (svcam-1), total plasminogen activator inhibitor (tpai-1). statistical significance was set at p<0.05. results: changes in svcam-1 300mg vs. 1000mg vs. placebo: (-10.4±43.8 ng/ml vs. 130.2±38.2 ng/ ml vs. 15.1±51.4 ng/ml) and tpai-1 300mg vs. 1000mg vs. placebo (-1.6±5.1 ng/ml vs. 15.2±3.5 ng/ml vs. 4.9±5.9 ng/ ml) indicate significantly higher levels in a 1000mg group compared to a 300mg and a placebo groups. other biomarkers (300mg vs. 1000mg vs. placebo: oxldl, seselectin-1 and sicam-1) followed the same trend toward higher levels in the 1000mg group compared to the 300mg and placebo groups, without reaching statistical significance. conclusion: this pilot project suggests that a higher dose of rsv may increase the levels of cardiovascular disease risk biomarkers in overweight older adults. given no change in the cardiovascular disease risk biomarkers in response to a lower dose, future studies should test the effects of different doses of rsv on reduction of cardiovascular disease biomarkers in overweight, rather healthy older adults. background: actual nutrition is a factor that continually effects physiological capacity and workability, the functional aging rate of an elderly persons. objectives: the purpose of this study was to determine the relationship between nutrition and physiological abilities, the work performance, functional aging rate, residual working capacity and frailty of the elderly. methods: it has been studied anthropometric and functional parameters of respiration, physical performance, mental capability, sensory skills, as well as the rate of functional aging in different aging groups: 20-30 years -43 persons, 60-89 years -120 persons, 90 -104 years -36 persons. we have also analyzed the professional history, social status, and factual nutrition (according to the questionnaire proposed by the who and adapted for ukraine) of the elderly. results: the nutrition or diet factors influence on the problems dealing with working capability, reduction of the hand grip strength and endurance, independence and frailty (for elderly) in overall 10.53% for all mentioned factors. right and left hand grip strength associate with protein consumption (r = 0.253; r = 0.248; p < 0.01 accordance) with variety of cereals (r =-0.224; r =-0.227 p < 0.05 accordance) also with variety of vegetables (r = 0.209; r = 0.196; p < 0.05 accordance)variety of fruits (r = 0.254; p < 0.01; r = 0.216; p < 0.05 accordance). it was studied features of an actual food at 36 centenarians of ukraine which not only have lived to this old age, but also have the relatives who have lived to age of centenarians. it was established, that meals of ukrainian centenarians include high percentage of vegetables, fruits and dairy products. meanwhile menu has been deprived practically all basic alimentary pathology risk factors which accelerates biological age, creates certain preconditions to preservation of health and longevity. conclusion: as a result of a comprehensive study and mathematical modeling was developed a quantitative method for assessing the residual working capacity for elderly persons. background: age-related decline in olfactory function has implications for health and nutrition due to reduced appetite and decreased sensory perception of food. several studies have investigated olfactory performance in the elderly, but studied mostly single odour components often less related to food and meals. food odours are composed of multiple odorants and compensation for specific perceptual losses among elderly may occur. therefore, it is relevant to study olfactory perception of complex food odours to improve understanding of odour perception in the context of foods and meals. objectives: to develop a test method to screen young and elderly (60+) subjects on their olfactory capacity for everyday food odours. the method included a series of sniffing sticks with relevant and familiar complex food odours from primarily essential oils. methods: the olfactory sniffing sticks test kit was developed in four steps: 1) selection and validation of relevant, familiar and diverse food odours, evaluated on perceived familiarity. 2) standardization of an iso intensity reference level for the food odours in relation to n-butanol. 3) assessment of shelf-life stability for the sniffing sticks within an 8 weeks period. 4) evaluation of test-retest reliability for intensity and identification of the odours within a 2 weeks period. results: 16 food odours were selected due to their diverse sensory characteristics. they were provided from a french manufacturer which may have compromised the familiarity in a danish context as only 12 out 16 obtained satisfactory familiarity score. however 14 out 16 showed reliable results in a test-retest procedure. n-butanol, in two concentrations provided a satisfactory reference frame for the iso intensity scaling. furthermore the food odours were overall shelf-life stable within an 8 weeks period. conclusion: a new odour test kit for everyday food odours was developed and validated for screening olfactory capacity (intensity perception, familiarity and identification) in elderly subjects. based on the evaluations, 15 odours were included in the final test kit. this olfactory test reflects the complex stimulation of the olfactory system, when stimulated by eating a food, compared to odour test kits with single or few components which makes it relevant when customizing of meals for elderly to improve nutrition and wellbeing. background: nordic nutrition recommendations (nnr) (2012) suggest protein intake >=1.1 g/kg body weight (bw) to preserve physical function in nordic older adults. however, no published study has used this cut-off to evaluate the association between protein intake and frailty. objectives: this study examined associations between protein intake, and sources of protein intake, with frailty status at the 3-year follow-up. methods: participants were 440 women aged 65-72 years enrolled in the kuopio osteoporosis risk factor and prevention -fracture prevention study. protein intake g/kg bw and g/d was calculated using a 3-day food record at baseline 2003. at the 3-year follow-up (2006), frailty phenotype was defined as the presence of three or more, and prefrailty as the presence of one or two, of the fried criteria: low grip strength adjusted for body mass index, low walking speed, low physical activity, exhaustion was defined using a low life satisfaction score, and weight loss >5% of bw. the association between protein intake, animal protein and plant protein, and frailty status was examined by multinomial regression analysis adjusting for demographics, chronic conditions, and total energy intake. results: at the 3-year follow-up 36 women were frail and 206 women were prefrail. higher protein intake >=1.1 g/kg bw was associated with a lower likelihood of prefrailty (or=0.45 and 95% confidence interval (ci) =0.01-0.73) and frailty (or=0.09 and ci=0.01-0.75) when compared to protein intake <1.1 g/kg bw at the 3-year follow-up. women in the higher. conclusion: protein intake >=1.1 g/kg bw and higher intake of animal protein may be beneficial to prevent the onset of frailty in older women. background: sarcopenia is a geriatric syndrome with increasing importance due to the aging of the population. progressive resistance training and protein supplementation are currently recommended for the prevention and treatment of sarcopenia. however, elderly are less responsive to these anabolic stimuli compared to healthy adults. inflammation is considered an important contributor to this age-related anabolic insensitivity. therefore, anti-inflammatory strategies, such as omega-3, are a promising strategy to combat sarcopenia. furthermore, omega-3 were also shown to improve muscle anabolism though activation of the mtor signalling pathway and reduction of insulin resistance. objectives: firstly, we performed a narrative review of literature that gives an overview of the current knowledge about omega-3 intake and sarcopenia defining parameters (grip strength, gait speed, muscle strength or physical performance). secondly, we provided an overview of data on omega-3 supplementation and sarcopenia defining parameters. methods: a literature search was conducted in november 2018, using electronic bibliographic databases (pubmed and embase). the reference lists of all full texts retrieved during the search process or as identified in already published (systematic) reviews were scanned. results were published in a narrative review (dupont j. et al. 2019 aging clin exp res.) results: seven observational studies described the associations between omega-3 intake and sarcopenia defining parameters. four interventional studies looked at the effect of omega-3 supplementation alone and suggested an improved muscle protein synthesis, improved gait speed and increased muscle strength and physical performance. three studies combining exercise with omega-3 supplementation suggested an enhancing effect of the supplement on the exercise-induced gains in muscle mass and strength. we found one study combining omega-3 and protein supplementation with exercise, but omega-3 dosage was too low for conclusive results. conclusion: observational data on omega-3 intake and sarcopenia remain conflicting. from current interventional data we conclude that there is growing evidence for a beneficial effect of omega-3 supplementation in sarcopenic elderly, which may add to the effect of exercise and/or protein supplementation. however, the exact dosage, frequency and use (alone or combined with exercise and/or protein supplementation) in the treatment and prevention of sarcopenia still need further exploration. background: with the growing incidence of cancer in older persons, malnutrition rates have increased. tumor-related malnutrition is a risk factor of treatment side effects. it reduces the quality of life and increases morbidity and mortality. therefore, malnutrition screening and diagnosis are mandatory to implement proper nutritional support. objectives: this study aimed to evaluate and compare the short form of mini nutritional assessment (mna-sf) nutritional screening tool with the new global leadership initiative on malnutrition (glim) diagnostic criteria for malnutrition among elderly patients with cancer. methods: patients >=70 years old, with a g8 screening tool ≤14, were referred to an oncogeriatrics consultation between february and september 2019. the data recorded comprehended, demographic variables (age, sex), type of tumor, functional (barthel, lawton index, fac) and mental (mmse, yesavage) status, nutritional (mna-sf, glim criteria) and social assessment and number of drugs. if-vig, cirs-g, rockwood-ms, cci-sf, sppb and handgrip strength were used to estimate frailty. the roc curve was used to evaluate the ability to accurately distinguish malnourished patients. to determine diagnostic concordance between the assessment and the new glim diagnostic criteria of malnutrition, retrospectively analyzed, cohen's к statistic was calculated. results: 34 patients were included, mean age 84.9±5.6, 41.2% were women. gastrointestinal (29.4%) and gynecological (26.5%) neoplasms were most prevalent. 91.2% were independent or had mild dependence on badl, 85.3% on iadl. 70.6% had no cognitive impairment and 50.4% had no depressive symptoms. frailty scales showed a pre-frail patient profile, with good social support and a 7.6±4 drugs on admission. according to the new glim diagnostic criteria for malnutrition, 50% of the patients were malnourished. with the use of mna-sf, 76.5% of the patients were found to be at risk of malnutrition. the roc curve of mna-sf had an area under the curve (auc) of 0.15. no concordance was found between the mna-sf and the malnutrition diagnostic results (к=0, p<0.001). conclusion: in this small sample, most cancer patients were male, >80 years old, with low frailty index, good functional and mental status and at risk of malnutrition. the mna-sf scale detected more risk cases so preconditioning and nutritional recommendations before specific oncological therapies could be made. concentration is associated with muscle mass and strength in healthy elderly. however, there are several confounders, including body composition, nutrient intake, physical activity level and blood parameters which may also influence muscle mass. previous studies have not thoroughly examined the relationship between serum 25(oh)d concentration and muscle indices by comprehensively considering the potential confounders in healthy elderly. objectives: the purpose of this study was to investigate the relationship of serum 25(oh) d concentration with muscle mass and strength in healthy japanese elderly. methods: this cross-sectional study included 100 healthy elderly in shiga prefecture in japan (age: 68.2 ± 5.2 years, m = 44, w = 56). total fat-free mass (tffm) and appendicular (affm) were measured using dual-energy x-ray absorptiometry. in addition, handgrip strength and leg extension power were measured. a blood sample was collected in an overnight fasted state, and serum 25(oh)d concentration was assessed. habitual dietary intake and physical activity were assessed. protein intake, carbohydrate, and vitamin d intakes were adjusted for energy by the residual method. association of serum 25(oh)d concentration with tffm, affm, handgrip strength, and leg extension power was assessed by hierarchical multiple regression analysis with adjustment for age, gender, weight, energy, energy-adjusted protein, carbohydrate, vitamin d intakes, serum albumin concentration, and physical activity. results: the mean serum 25(oh)d concentration of 100 participants was 88.3 ± 32.9 nmol/l. low serum 25(oh)d status (< 50nmol/l) was observed in 12.5% (8/100) of participants. the mean affm was 17.1 ± 3.7 kg, and handgrip strength was 29.3 ± 7.2 kg. serum 25(oh)d concentration was significantly associated with affm (β = 0.091, p = 0.033), but not with tffm (β = 0.071, p = 0.090), handgrip strength (β = 0.115, p = 0.081) and leg extension power (β = -0.022, p = 0.781). conclusion: serum 25(oh)d concentration is related to affm japanese healthy elderly people, even if confounders are comprehensively considered. background: muscle quality, often defined as force produced per area or mass of muscle, declines as people age. objectives: we hypothesized that dietary protein quality will better predict muscle quality than energy, carbohydrate, protein, fat, or leucine intakes when controlling for age, bmi, composition, and moderate to vigorous physical activity (mvpa). methods: strength was measured using isokinetic dynamometry at 60 degrees per second, leg composition (lc) was examined via dual-x-ray-absorptiometry, and mvpa was measured with accelerometry. dietary intake was estimated using three-day food logs and esha software. muscle quality was defined as right knee extensor peak torque relative to right leg lean mass. protein quality was the ratio of total leucine over total protein intake. multiple linear regression and stepwise linear regression models were used. results: ninety-four women (mean ± sd; age 40.6 ± 17.5 years; bmi 25.7 ± 5.18 kg/m2; lc 37.6 ± 6.63 % fat; mvpa 81.1 ± 31.7 min/day; energy 1,977 ± 528 kcal/day; carbohydrate 226.2 ± 73.3 g/ day; protein 86.3 ± 29.6 g/day; fat 79.3 ± 24.2 g/day; leucine 3.20 ± 2.52 g/day) completed the assessments. only protein quality (mean ± sem; beta = 45.131 ± 22.303; t = 2.023; p = 0.046) was significant to the full regression model containing all covariates (r = 0.495; adjusted r2 = 0.154; f (10, 83) = 2.688; p = 0.007). to verify the importance of protein quality, a stepwise regression analysis using the same variables was performed and resulted in a model (r = 0.422; adjusted r2 = 0.160; f (2, 91) = 9.869; p < 0.001) that included protein quality (mean ± sem; beta = 28.755 ± 8.720; t = 3.405; p = 0.001) and energy intake (mean ± sem; beta = 0.000730 ± 0.000269; t = 2.710; p = 0.008). conclusion: dietary protein quality is positively associated with muscle quality when controlling for bmi, lc, mvpa, and energy, protein, fat, carbohydrate, and leucine intakes. the most parsimonious model included protein quality and energy intake, suggesting that they are most related to muscle quality. background: it has been suggested that disruption of the apoptotic process may have an effect on the incidence of sarcopenia. on the other hand, one of the dietary recommendations for seniors is to increase their daily protein intake. however, the effect of protein intake on apoptosis is not well understood. objectives: the purpose of this study was to investigate the effect of eight weeks of protein whey supplementation on the expression of genes involved in the internal and external pathways of apoptosis of long extensor muscle of thumb of aged wistar rats. methods: this is an experimental studies. statistical sample of this study consisted of 14 male wistar rats (age: 20 months, weight: 200 ± 12 gr). they were randomly divided into supplement (n=7) and control (n=7) group. supplement group received 0.375 gr per body weigh protein whey daily for eight weeks. the left thumb extensor muscle of all subjects was carefully separated and after freezing in liquid nitrogen transferred to -80 ° c. quantitative real time-pcr was performed to measure bax, bcl-2, caspase 3, 8 and 9 gene expression levels. independent t-test and mann-whitney u test were used to compare the means and rankings. the hypotheses were tested at the significant level p<0.05. results: results showed that bax, caspase 3, caspase 8, and caspase 9 genes expression increased in all samples in training group compared to the control group but this increase was only significant for bax, caspase 9 and 3 gens (p < 0.05) and also bcl-2 gene expression significantly deceresed (p < 0.05) in comparison with control group. conclusion: it seems that protein supplementation lead to activation of the internal pathway of apoptosis by increasing mitochondria permeability. background: the presence of obesity alongside with impaired aging in general, and with impaired muscular performance in particular, may result in a unique and growing phenotype of obese frail/sarcopenic, which may be hardly diagnosed by simple observation. characterizing the nutritional intake of this phenotype is of a substantial relevance. objectives: to characterize the nutritional intake among frail prone (fp) and obese subjects in a sample of community dwelling older adults in israel. methods: in this cross sectional study we evaluate the nutritional intake of frail, frail prone and robust subjects (with and without the presence of obesity), as well as their adherence to the dietary reference intakes (dri). data were retrieved a series of national studies on the status of health and nutrition in different age groups in israel (mabat zahav) for [2005] [2006] . the frailty likelihood presented here is based on a previous study from our group suggesting a non-direct validated model estimating frailty based on 5 components. results: compared to the robust, fp subjects were more likely to have lower intake of several nutrients. among them are: iron (mg) (mean 8.47 vs. 10.43, p < 0.0001), vitamin c (mg) (mean 123.51 vs. 103.87, p < 0.0001), folate (μg) (mean 263.55 vs. 301.97, p < 0.0001), vitamin a (iu) (mean 1075.09 vs. 1474.29, p = 0.004). the average overall adherence score according to the dri (based on a sum of 8 nutritional components) was 1.62 among fp subjects, compared to 1.76 among robust subjects (p = 0.03). obesity either defined by bmi or by wc had a lower «effect» on the nutritional intake differences as compared to frailty status. this observation was seen when obese subject were compared to non-obese subjects and as fp subjects were more likely to show a poor nutritional status regardless of the presence of obesity. conclusion: our results show a clear association between frailty and poor nutritional intake, regardless of the presence of obesity. moreover, the functional status may better reflect nutritional gaps than obesity -challenging the concept of the frail -obese phenotype regarding to nutritional status. background: the loss of bone density during aging induces risks of falls, fractures and mobility decline. moreover, bone structure seems to be a better predictor of fractures than bone density. these phenomena are exacerbated in the presence of sarcopenia. however, dynapenia alone or in combination with obesity is more involved in falls and loss of mobility than sarcopenia. nevertheless, the impact of obesity on bone density and bone structure is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle, bone density and bone structure. to our knowledges, the impact of protein intake on bone density and bone structure among dynapenic-obese older adults is not known even if this condition reached around 20% of elderly. objectives: to assess the influence of protein intake on bone density and bone structure among dynapenic-obese older adults. methods: twenty-six older adults (>= 60 years), obese (%fat: men >25 ; women: >35) and dynapenic (relative to body weight grip strength: men <0.61 ; women <0.44) were divided into 2 groups according to their initial protein intake : prot-: < 1g/kg/d (n=13; 53.8% of women; 66.5±3.3 years) and prot+: >1.2g/ kg/d (n=13; 61.5% of women; 67.2±2,7 years). the following measurements were performed: relative to body weight grip strength using lafayette dynamometer, body composition using dxa, femoral bone structure using ct-scan, nutritional intake using the 3-day food record method. results: excepted, by design, for initial protein intake, both groups were comparable at baseline. the prot-group had a higher (p<0.05) marrow area (139 ± 54) than the prot + group (91 ± 38). in addition, the compressive loading strength was greater (p<0.05) in the prot-group (3019 ± 465) than in the prot + group (2604 ± 560). finally, the total bone area was larger (p<0.05) in the prot-group (650 ± 69) compared to the prot + group (579 ± 91). conclusion: surprisingly, a lower protein intake but higher than rda seems to protect bone structure but not bone density among dynapenic-obese older people. these results should be confirmed in larger studies designed to address this question. background: unintentional weight loss occurs in 15% to 20% of older adults and has been associated with morbidity, functional incapacity, risk of hip fracture, and overall mortality. while the impact of this condition is well established in frailty, studies involving sarcopenia are still insipient. objectives: to investigate the association between unintentional weight loss and sarcopenia in community-dwelling older adults. methods: a cross-sectional study was conducted among older adults (>=60 years) assisted in primary care. the unintentional weight loss was assessed by questions contained in three frailty assessment tools and one nutrition screening and assessment tool, described below: (1) "have you recently lost weight such that your clothing has become more loose?" [edmonton frail scale (efs)]; (2) "have you lost a lot of weight recently without wishing to do so? ('a lot' is: 6 kg or more during the last six months, or 3 kg or more during the last month)" [tilburg frailty indicator (tfi)]; (3) "in the last year, have you lost weight unintentionally (i.e., not due to dieting or exercise)? (unintentional weight loss is: more than 4.5 kg or of at least 5% of previous year's body weight)" [phenotype for frailty (pf)]; (4) «weight loss greater than 3 kg during the last 3 months" [mini nutritional assessment (mna®)]. sarcopenia was identified by european working group on sarcopenia in older people (ewgsop2) criteria. the data were analyzed with use of pearson chi-square test (p< 0.05). results: a total of 375 older adults were evaluated (69.9% female). the mean age was 72.7±7.2 years (61-95 y). sarcopenia was identified in 7.7% of the sample (n= 29). the frequency of unintentional weight loss in sarcopenics was 38% in tfi (n= 11; p=0.012), 31% in efs (n= 09; p=0.037), 34.5% in pf (n= 10; p=0.072) and 17.2% in mna® (n= 05; p=0.210). conclusion: we observed that the unintentional weight loss evaluated by tfi and efs (frailty assessment tools) was associated with sarcopenia. so, different ways to evaluate weight loss (amount and time) seems to influence this association. funding: this study was financed by fapergs (process number 1183-2551/13-4) and capes (finance code 001). background: half of older adults admitted to hospital are malnourished. malnutrition often leads to weight-loss and may lead to a loss of muscle mass, muscle strength and physical performance. nutritional interventions should individualise nutritional requirements, particularly energy and protein. objectives: to assess if energy requirements, determined by indirect calorimetry compared to usual care (predictive equations), can lead to a reduction in weight loss (primary outcome) and improvements in muscle mass, muscle strength and physical performance (secondary outcomes) in geriatric rehabilitation patients at risk of malnutrition. methods: geriatric rehabilitation inpatients were derived from the resort cohort (royal melbourne hospital, australia) and allocated by wards to either the indirect calorimetry or usual care group for the need study. energy requirements were measured using indirect calorimetry; the results were utilised by dietitians in the indirect calorimetry group and concealed for the usual care group. weights were obtained weekly. food intake assessment, muscle mass (bioelectrical impedance analyser), handgrip strength (hgs) and physical performance (short physical performance battery (sppb)) were measured at admission and discharge. within-group and betweengroup differences were calculated for the changes in outcome measures during hospitalisation. results: twenty-one patients (indirect calorimetry n=12; usual care n=9) were included (mean age 81.7 ± 11 years; 12 males, 9 females). preliminary results showed that in the indirect calorimetry group, five patients gained weight, four patients maintained weight and one patient lost weight during hospitalisation; the usual care group had four patients with weight gain and five patients maintaining weight. there were no significant within-group differences or between-group differences for changes in weight ( background: many older people have difficulties in performing daily living activities such as preparing meals and food shopping, which could be partly due to cognitive and physical decline [1]. these factors may influence food choice and represent a potential barrier to achieving good nutrition [2] . nevertheless, the association between mealrelated difficulties and nutritional risk, as well as dietary intake, has been understudied. objectives: (1) to examine the prevalence of autonomy in food-related activities, as measured with instrumental activities of daily living scale (iadl), among frail and pre-frail older subjects with an objective cognitive impairment (2) to characterize the association of food autonomy with an insufficient dietary intake and nutritional risk of cognitive frail older people. methods: this is a secondary cross-sectional analysis using baseline data from the cogfrail study, which is a monocentric observational study of 345 cognitive frail and prefrail older participants, aged >=70 years, with an objective cognitive decline. dietary intake is evaluated with a dietitian, using a diet history method. autonomy in food-related activities is assessed using iadl scale. nutritional status was categorized according to the mini nutritional assessment (mna). results: ongoing analyses. preliminary results show a mean energy intake of less than 1600 kcal and 65 g of protein per day, we considered all nutritional needs cannot be covered under this threshold. conclusion: frail older people, with cognitive impairment, are particularly at nutritional risk and insufficient dietary intake. food autonomy has to be evaluated systematically to prevent nutritional risk in this population. elderly aged 65 years or over, and this number will continue to increase. in order to extend the healthy life expectancy, disease prevention and health management of the elderly are important. preventive intervention of sarcopenia is considered to be an important issue in promoting care prevention for the elderly. objectives: the purpose of this study was to clarify the relationship of muscle weakness and physical characteristics with nutritional intakes. methods: subjects were 390 men and women (63 to 89 years old) in the nagoya longitudinal study for healthy elderly (nls-he) in 2018, excluding those who had missing values of the examinations. nutritional intakes were assessed by the food frequency questionnaire (ffq). low grip strength (gs) was diagnosed by asian working group for sarcopenia (awgs) criteria. the cut-off value of gs was 26 kg for men and 18 kg for women. results: the number of the subjects diagnosed with low gs was 64, (34 men and 30 women). comparison was made between the low gs group and the normal group. there were no significant differences between the two groups in age, sex, number of teeth, chewing ability and occlusal force, whereas mini nutritional assessment (mna) score, walking speed at the normal and maximum speed, exercise habits, and percent of body fat were significantly lower in the low gs group than the normal group. also, the rate of polypharmacy was significantly higher. in nutritional intakes, vitamin d and b12 were significantly lower in the low gs group. in the intakes by food groups, fish and meat intakes were significantly lower, but the intakes of snack were significantly higher. furthermore, the protein ratio and the amount of animal protein intakes were significantly lower in the low grip strength group. conclusion: in this study, muscle weakness was related to lower intake of specific nutrients such as vitamin d, b12, and animal protein, independent of number of teeth, chewing ability, and occlusal force. background: the status of calcium intake, the main mineral of the bone has no suitable biomarker to assess it. its evaluation is relevant in clinical practice as in research. postmenopausal women should be evaluated for risk factors for osteoporosis, including poor calcium intake. objectives: to develop and validate a food frequency questionnaire (ffq) to assess the calcium intake of mexican postmenopausal women. methods: after obtaining approval from the institutional ethics committee, a pilot study was performed including 25 mexican women whose calcium intake was assessed trough a 3 day food diary (3dfd). the ffq was designed including the foods reported by the participants of the pilot study that provided more than 1.5% of the calcium requirement and that were reported by at least 2 participants. the ffq was tested through a validation study that included 86 postmenopausal whom also completed the 3dfd. the validity of the ffq was assessed with the interclass correlation coefficient (icc) alongside a bland-altman analysis. results: 84 postmenopausal women were assessed from june 21, 2019 to january 18, 2020. participant's characteristics are shown in the table 1 . the ffq underestimated mean calcium intake compared to 3 day food diary (-210 mg ± 141.28, p<0.60). the two methods were strongly correlated by the icc (icc= 0.8204, ci 0.72-0.88). the ffq could identify individuals who consumed >=1200 mg/ day with a high sensitivity, and a reasonable specificity (table 2 ). figure 1 shows the agreement between the 3dfd and the ffq were plotted against the average of the two measurements (figure 1 ), the mean (solid line) and the 95% ci (broken lines) of the difference are shown. conclusion: conclusions: the ffq´s good sensitivity in identifying low calcium intake in postmenopausal women makes it useful also as an educational tool in diet counselling and for identifying subjects in need of supplementation. the difference between methods limits its utility as an epidemiological tool. helen yl chan 1 , winnie kw so 1 , regina cheung 2 , kc choi 1 , brenda ho 2 , francis li 2 , ty lee 2 , janet wh sit 1 , martin mh wong 1 , sy chair 1 ( (1) background: nutritional status has been recognized as a predictor of the level of frailty. however, little is known about how the eating habits and dietary preferences associated with frailty, especially in the chinese elderly population. objectives: this study aims to identify dietary factors in predicting frailty among community-dwelling older adults. methods: a multicentre cross-sectional correlational study was conducted in hong kong in 2018. frailty was defined by using fried's phenotype model. the frail scale was used to classify level of frailty and the mini-nutritional assessment (mna) was used to evaluate the nutritional status, in addition to anthropometric parameters. association between nutritional status (at risk or malnourished vs normal) and frailty status was examined using ordinal regression in a hierarchical fashion for adjusting participant socio-demographics, health status, lifestyle characteristics, eating behaviours and dietary habits. all the statistical analyses were performed using ibm spss 25.0. all statistical tests were two-sided with level of significance set at 0.05. results: a total of 610 chinese older adults participated in the study. the prevalence of robust, pre-frail and frail were 30.9%, 48.1% and 20.8% respectively. one third of the participants were malnourished or at risk of malnutrition. malnutrition and at-risk of malnutrition significantly increased the likelihood of frailty (or 2.6, 95% ci 1.7 -4.0). however, the level of frailty was not associated with age, gender, anthropometric measurements, eating behaviours, and use of dietary supplements. other nutritional factors significantly increased the likelihood of frailty were chewing difficulties (or 2.0, 95% ci 1.4 -2.9) and inadequate consumption of vegetables (or 2.2, 95% ci 1.4 -3.7). however, good appetite significantly reduced the likelihood of frailty (or 0.6, 95% ci 0.4 -0.9). conclusion: the findings showed that chewing difficulties and inadequate consumption of vegetables were associated with frailty, whereas good appetite was a protective factor. hence, interventions for addressing chewing problem and promoting appetite and consumption of vegetables are imperative to counter frailty in the older population. lack of energy was associated with nutritional status in nursing-home (nh) residents. methods: we performed a cross-sectional analysis of the incur study cohort. lack of energy was measured at baseline as part of the 10-items geriatric depression scale. nutritional status was evaluated according to mini nutritional assessment short-form (mna-sf). a 36-items frailty index (fi) was computed. logistic regression models were performed to test the association of lack of energy with nutritional status. results: a total of 573 nh residents were available for analysis. the median age (iqr) was 88 (83-91) years, with 411 (71.7%) females. at baseline, median mna-sf (iqr) was 11 (9-12) with 71 (12.4%) patients that were malnourished. among the patients included 42.9% (246 patients) reported lack of energy. at univariate logistic regression analysis mna was inversely associated with lack of energy. at multivariate logistic regression analysis, adjusted for age, sex nursing home years and fi, we found that mna was independently inversely associated with lack of energy (or 0.88, 95% ci 0.81-0.96). being malnourished is independently associated with lack of energy (or 2.10, 95% ci 1.22-3.63). among mna components we found that item a (decrease in food intake), item c (reduced motricity) and item d (psychophysical stress) were inversely associated with lack of energy (or 0.54, 95% ci 0.37-0.80; or 0.69, 95% ci 0.53-0.89; or 0.48 95% ci 0.31-0.74; for each point respectively), independently each one and from the other confounders. conclusion: in a cohort of very old nh residents, we found that an impaired nutritional status is associated with lack of energy. in particular, being malnourished bring a 2-fold risk of reporting lack of energy. more precisely, decrease in food intake, reduced motricity and psychophysical stress, each one were independently associated with lack of energy. a g e . m a r g u e r i t a s a a d e h 1,2 , f e d e r i c a p r i n e l l i 1,3 , anna-karin welmer 1,4 , weili xu 1 , davide l vetrano 1,5 , serhiy dekhtyar 1 , laura fratiglioni 1,6 , amaia calderón-larrañaga 1 ( (1) background: while declines in physical function are a common feature of ageing, the rate of the loss varies substantially between individuals, and has been attributed to intrinsic but also extrinsic (modifiable) factors such as diet, physical activity, and psychosocial well-being. objectives: (1) to assess the role of food and nutrient intake in the speed of functional decline over 12 years of follow-up. (2) to explore whether such an association differs between levels of physical activity and psychosocial well-being. methods: we analysed data from 2004 individuals aged 60+ from the population-based swedish national study on aging and care in kungsholmen (snac-k). the mediterranean diet score, mds (trichopoulou et al.) and the healthy diet indicator, hdi (who recommendations for saturated fatty acids, monodisaccharides, cholesterol, pufas, protein and fibre) were calculated for each participant, based on baseline data from a validated food frequency questionnaire and the corresponding transformation into nutrient intake. physical activity levels were assessed with questions about type, frequency, and intensity, and categorised as inadequate vs health/fitness-enhancing. we created a psychosocial well-being index by integrating variables linked to life satisfaction, positive/negative affect, social network and social participation. a global score of physical function was obtained by combining data on walking speed, balance, and chair stand tests. linear mixed models were used and adjusted for age, sex, education, smoking, baseline number of chronic diseases and impaired activities of daily living, total energy intake and time to death/drop-out. results: one standard deviation (sd) increase in the mds was associated with a lower functional decline both crosssectionally (β=0.03; p=0.02) and over the 12-year follow-up (β*time=0.004; p=0.02). higher scores of the hdi were also significantly associated with a lower functional decline, but only cross-sectionally (β=0.03; p=0.02 for one sd increase). when stratifying the analyses by levels of physical activity and psychosocial well-being, the protective effect of high mds was limited to subjects with health/fitness-enhancing physical activity (β*time=0.004, p=0.016) and high levels of psychosocial well-being (β*time=0.006, p=0.04), respectively. conclusion: a high adherence to a mediterranean dietary pattern, especially in combination with higher physical activity and psychosocial well-being, may slow down the age-relate decline in physical function. background: this cross-sectional study describes the application and follow-up of the self-care actions applied in a white male, 60 years old,1.80 m tall, a former athlete, currently sedentary, who in january 2018 presented 6% of glycated hemoglobin in medical consultation -between 5.7 and 6.4%: pre-diabetes; fasting glycemia 107 (mg / dl); (mg /dl) and the postprandial dose between 113 and 164 mg / dl. blood pressure between 140-150 mmhg; characterizing hypertension in stage. objectives: the objective was applying and follow-up a food re-education program associated with a resistance training program to reduce non-communicable diseases. methods: during 2019, a program of dietary reeducation was carried out, with a few complex carbohydrates, an increase in proteins of high biological value, associated with a program of resistance exercises, which was adapted and individualized, obeying the individual's particularities. a short physical performance battery (sppb) was also applied to assess walking speed, strength and muscle balance. this program was performed three times a week, under the supervision of a physical education professional. capillary blood glucose was collected and analyzed 69 times and blood pressure 231 times, respectively. it was carried out a basic training for 4 weeks aiming to rescue the muscular memory of the elderly, after beginning the adaptive phase of the physical valence training (cardiovascular endurance, localized muscular resistance); for 6 weeks and the specified. the loads corresponded to 80% of 1rm for 8-10 repetitions with three series and 2 to 3 minutes intervals at each stage of the training. we used the ibm spss statistics 22 program to perform descriptive statistics. results: the mean glycemia was 107 (mg / dl), the 3 glycated hemoglobin analyzes showed 5.5; low risk of diabetes. systolic blood pressure and diastolic blood pressure presented a mean of 113.95 ± 6.99 mmhg, and 78.32 ± 3.51 mmhg, respectively. we observed a gradual gain every 2 months of resistance training. the sppb score changed from 3 to 4 points; performance between intermediate to high. conclusion: dietary re-education associated with a well-designed strength training program can result in the reduction of diabetes and hypertension, as well as strengthening the muscular system of the elderly. background: diet can be an important non-pharmacological aspect in order to prevent and/or attenuate brain and frailty outcomes in older adfults. objectives: to investigate, by a systematic review, studies associating the dietary inflammatory index (dii) with brain and frailty outcomes in older adults. methods: we searched the publications in pubmed and lilacs databases up to june 2019. inclusion and exclusion criteria were formulated based on pi(e)cos strategy (population= older adults, >= 60 years; intervention/ exposition= dietary inflammatory index; comparison= not applied; outcomes= brain and muscle outcomes; study type= randomized clinical trials, cohorts, cross-sectional, casecontrol studies). results: searches resulted in 206 publications, and after exclusion due to duplicity (n=26) and not compliance with exclusion and inclusion criteria (n=172), eight studies were selected. these studies were published from 2017 to 2019, all of them were cross-sectional, with participants above 60 years old, and the outcomes investigated were frailty and frailty risk, survival free of disabilities (by fried's frailty criteria, sppb test, lawton and broady scales); memory, cognitive decline and risk of dementia (by meem, cerad, gds, prime-md, dsst and animal fluency test). conclusion: the data extracted from the articles showed significant association between dii and the outcomes investigated, namely, the more inflammatory diet was associated with higher odds to be frail and pre-frail, and to have any type of cognitive impairment. therefore, the dii showed to be associated to brain and frailty outcomes in older adults, however, to understand causality, longitudinal studies are still necessary. background: it is well established that reactive oxygen species (ros) are increased in skeletal muscle with age. we have recently shown that increased ros with age is associated with increased expression of the senescence-associated microrna mir-34a-5p (mir-34a) in skeletal muscle as well as in muscle-derived extracellular vesicles. these vesicles enriched in mir-34a are elevated in aged mouse serum, and can induce senescence in bone stem cells. the histone deacetylase sirt1 is a validated target of mir-34a, and sirt1 plays important roles in cell survival as well as in muscle hypertrophy with functional overload. importantly, we previously found that mir-34a expression was much higher in muscle from aged female mice compared to male mice, a phenomenon others have observed in mouse cardiac muscle. objectives: here we tested the hypothesis that pharmacological ablation of senescent cells could modulate mir-34a and sirt1 bioavailability in skeletal muscle of aged mice. we utilized the senescent drug abt-263 (navitoclax) since previous studies have shown that oral administration of abt-263 removed senescent satellite (stem) cells in mouse skeletal muscle. methods: ten male and ten female c57bl6 mice, 24 months of age, received either abt-263 (50 mg/kg bw, 100 ul) or vehicle by oral gavage for ten days. tibialis anterior muscles were removed at the end of the study for examination of mir-34 and sirt1 levels using rt-pcr and elisa, respectively. results: abt-263 reduced mir-34a expression in both male and female mice, although the effect was more pronounced in male mice compared to females. abt-263 significantly increased sirt1 levels in male skeletal muscle but not in females. the changes in sirt1 and mir-34a levels were not associated with significant differences in muscle fiber size over the treatment period. conclusion: these findings suggest that certain senolytic compounds can modulate levels of senescence-associated mirnas and their targets in aging skeletal muscle. these data also underscore the importance of considering sex differences in the molecular mechanisms underlying age-related muscle atrophy. background: the growth of the elderly population is a worldwide phenomenon and is associated with profound changes in body composition. the purpose of this study was to describe the magnitude of the problem, to evaluate the associated factors and the relation with functional capacity in the study population. objectives: to estimate the association between demographic factors, comorbidities and muscle mass index over time until functional disability or death appears in non-obese elderly individuals. methods: longitudinal study of 335 elderly individuals aged 65 years or over, non-obese and absence of functional disability at the beginning of the cohort on the epidoso project database. the variables gender, age, ethnicity, medical history, functional capacity and death were investigated. the low or normal muscle mass index (mmi) was obtained through anthropometric data and a predictive equation. the functional capacity was measured using a structured and validated multidimensional questionnaire. the deaths occurred in the period were investigated with relatives through household surveys, in registries and registries of the state system of data analysis foundation. estimates of eventfree survival (functional disability or death) were calculated using kaplan-meier curves using the log-rank test in the gross comparisons. a multiple cox proportional hazards model was used to identify the independent effect of time predictors until onset of functional disability or death. results: the mean time found for the onset of functional disability or death was 7.1 years (95%ci=[6.8; 7.5]). in the crude analysis, there were statistically significant differences in the time to occurrence of functional disability or death, by age group (p<0.001), arterial hypertension (p= 0.046), diabetes mellitus (p=0.007) and marginal statistical difference muscle mass level (p=0.105 background: a consequence of the ageing population is the increasing number of older adults with physical limitations. these limitations are mainly caused by decreased muscle mass and strength (sarcopenia). treatment or rather prevention of sarcopenia is necessary, as it may lead to lowered quality of life, hospitalization, loss of independence and even mortality. since older ethnic minorities are more likely to have an unfavourable health status compared to the majority population, variations in the prevalence of sarcopenia for ethnic minority groups are expected. further investigation seems imperative to be able to target preventive interventions to those at high risk of sarcopenia within the population. objectives: to examine the sarcopenia prevalence and its association with protein intake in an older multi-ethnic population in the netherlands. methods: we used cross-sectional data from the helius (healthy life in an urban setting) study, comprising the largest ethnic populations living in amsterdam, the netherlands. in total 5161 individuals from dutch, south-asian surinamese, african surinamese, turkish and moroccan origin aged 55 years and over were included. sarcopenia was defined according to the ewgsop2. in a subsample (n=1371), protein intake was measured using ethnic-specific food frequency questionnaires. descriptive analyses were performed to study sarcopenia prevalence across ethnic groups in men and women, and logistic regression analysis were used to study associations between protein intake and sarcopenia. results: sarcopenia prevalence was found to be sex-and ethnic specific, varying from 29.8% in turkish to 61.3% in south-asian surinamese men and ranging from 2.4% in turkish up to 30.5% in south-asian surinamese women. higher protein intake was associated with a 4% lower odds of sarcopenia in the total population (or= 0.96, 95% ci 0.92-0.99) and across ethnic groups. conclusion: ethnic differences in the prevalence of sarcopenia and its association with protein intake suggest the need to target specific ethnic groups for prevention or treatment of sarcopenia. background: few studies have evaluated the relationship between frailty and acute respiratory illness (ari), despite of increasing heavy burden of ari in older people. objectives: we conducted a prospective cohort study in communitydwelling older people in hong kong, to evaluate the impact of frailty on the risk of acute respiratory infections in the community setting and the potential modifying role of outdoor activities. methods: we recruited and followed up participants who were chinese and aged from 65 to 95 years, from december 2016 to may 2018. frailty was measured by fried frailty index (ffi) twice during the study period. daily hours of outdoor activities were collected by a monthly activity journal (n=225) during the whole period, and by wearable gps device from some participants for one week in summer (n=173) and winter (n=185), respectively. the ari incidence was collected by monthly phone calls to the participants. we used a logistic regression model to estimate the odds ratio (or) of ari associated with frailty status (robust as reference group). results: the participants were classified into three groups according to the ffi criteria: 56 (24.9%) as robust, 152 (67.6%) as pre-frail and 17 (7.6%) as frail groups. of them, 68 reported ari during the study period. according to the activity journals, daily hours of staying outdoors in the ari participants were slightly less than those in without ari (4.37 vs 4.46 in whole study period, 4.03 vs 4.60 in summer, 4.45 vs 4.84 in winter). while, the gps data showed that the participants with ari had longer daily hours of outdoors activities in summer (3.27 vs 3.14) but shorter in winter (4.20 vs 5.30), although none were statistically significant (p > 0.05). after adjustment for age, age, living alone or with family and daily hours of outdoor activities, we found that the frailty and pre-frailty groups had a higher risk of ari incidence compared with the robust group, with or 3.67 (p = 0.047) and 2.58 (p = 0.017), respectively. conclusion: frailty might be associated with a higher risk of ari among older people, but the role of outdoor activities remains inconclusive. background: previous studies have investigated the association between impaired muscle health and mortality. however, muscle health is a dynamic entity which change with time. objectives: to assess the effect of a short-term decline of muscle health (i.e., over 1 year) and its association with long-term mortality (i.e., over 4 years). methods: the sarcophage cohort follows up 534 older belgian adults to assess consequences of sarcopenia. an assessment of muscle mass (dxa), muscle strength (handheld dynamometer) and physical performance (by means of sppb, including gait speed) are performed annually. all-causes deaths are collected annually. the association between short term (i.e. after one year) decline in muscle parameters and 4-year occurrence of deaths was tested using cox model. roc analyses were performed to assess performance of prediction of the different muscle components and to find optimal cut-points. missing data were handled using multiple imputations. results: from the 534 subjects recruited (73.5±6.2 years, 60.5 % women), 7 were discarded from our sample because they died during the first year. therefore, the muscle decline was available on a sample of 527 subjects. 40 deaths occurred within the 3 first years of follow-up. a 1-point decrease in performance at sppb test resulted in 15% higher risk of dealth (hradjusted = 1.15 [95%ci 1.07-1.25]). for each decrease of 0.1 m/s of gait speed, we observed an 8% higher risk of death (hradjusted = 1.08 [1.02-1.14]). a 1-kg decrease of muscle strength resulted in 15 % higher risk of death in men and 46% higher risk of death in women (hradjusted = 1.15 [1.07-1.24] and hradjusted = 1.46 [1.21-1.77], respectively). we did not found any association between short-term loss of muscle mass and the occurrence of death (p=0.16). then, we tried to find cutoffs optimizing the sensitivity-specificity ratio and we found following results : over 1 year, a decline of sppb superior or equal to 1, of gait speed superior or equal to 0.15 m/s and of muscle strength superior or equal to 1.8 kg in men and 2.8 kg in women. conclusion: a short-term decline in muscle function is predictive of premature deaths. background: sarcopenia, the age-related progressive loss of muscle mass and function, is associated with an increased likelihood of adverse outcomes like falls, fractures, physical disability, and mortality. international consensus groups continue providing new definitions and clinical cut-off points despite over a decade of work in this area. objectives: we examined the prevalence of sarcopenia using two of the most current operational definitions (foundation of nih sarcopenia project (fnih) and the european working group on sarcopenia in older persons 2 (ewgsop2)) in a cohort of older adults (n=345, >= 65 yrs) hospitalized for an acute disease at utmb hospital in galveston (jan 2014-may 2019). methods: testing included measures of: demographics (age, gender, race, education), body composition (dexa), physical function tests (sppb, tug, grip), psychological wellbeing and independence questionnaires, and chart review (comorbidity, length of stay). results: we found 70% had low physical performance, 36% had low muscle strength, and 33% low lean mass. we compared multiple tests and cutoffs for each of the three groupings under the fnih and ewgsop2 and found there to be differences depending on the test usedespecially for low performance which varied from 29%-75%. in our cohort, the prevalence of sarcopenia was 15.79% by ewgsop2 and 13.59% by fnih. the subgroupings were found to be near identical across almost all measures despite the definitions' discrepancies in cutoff points between fnih and ewgsop2. conclusion: in conclusion, recent updates to the new ewgsop2 make it almost indistinguishable to the older fnih standard, but the new ewgsop2 algorithm does provide a grading system to identify different levels of severity of sarcopenia. background: the population is experiencing a fast growth in the number of older adults, therefore determine the prevalence of frailty could help to inform future strategies to reduce its social and health burden. objectives: determine the prevalence of frailty in chilean older adults. methods: 233 participants, aged >60 years, from the chilean national health survey 2016-2016 were included in this study. frailty was assessed by fried criteria modified, therefore people classified as frail should meet at least 3 out of the 5 criteria (low strength, low physical activity, low body mass index, slow walking pace and tiredness). results: the prevalence of frailty was 10.9% (7.7% for men and 14.1% for women). the prevalence of prefrailty was 59.0% whereas 30.1% was classified as normal. the prevalence of frailty increased with markedly with age, 58.2% and 62.4% of men and women, respectively, were frail at the age of 80. this prevalence increased to 89.9% and 86.9% for men and women at the age of 90. the prevalence of pre-frailty increased from 43.0% to 92.1% for men and from 76.4% and 77.5% for women from the age of 60 to 90 years, respectively. conclusion: the prevalence of frailty increased markedly with age. with the chilean population expected to increase their life expectancy and number of older adults, it is important to implement prevention strategies that allow for early identification of high-risk individuals. a 10 year follow-up. jair licio ferreira santos 1 , yeda aparecida de oliveira duarte 2 , tiago da silva alexandre 3 background: sarcopenia has been increasingly recognized as leading to poor prognosis in health outcomes. likewise, falls -although important at older ages -have not been studied frequently and may lead to an increased risk of death. we evaluated survival of elderly people living in são paulo -brasil in a 10-year follow-up, considering the presence of sarcopenia at baseline and the occurrence of falls before the interview. objectives: to investigate whether sarcopenia and/or falls increase mortality among brazilian older adults. methods: data came from the second (2006) and fourth (2015) rounds of the health, welfare and aging study (sabe), which begun in 2000, with a sample of the population over 60 years old in the city of são paulo, brazil. after the first round, follow-up was performed every five years. sarcopenia was defined according to the consensus of the european working group on sarcopenia in the elderly (ewgsop), and the occurrence of falls was assessed by direct questions answered by the elder or his caregiver. a multivariate analysis with robust estimation and control for exposure time was done using the poisson regression model. results: mortality rates (per thousand person years) were: 19.6 (non sarcopenic, no falls) ; 35.6 (non sarcopenic with falls); 75.1 (sarcopenic no falls) ); and 68.6 (sarcopenic with falls. the poisson regression resulted in incidence rate ratios (when compared to sarcopenic, no falls) of 1.7 for non sarcopenic with falls; 2.5 for sarcopenic elders with no falls and 2.2 for sarcopenic with falls. conclusion: sarcopenia and the occurrence of falls are important risk factors for mortality. this finding highlights the importance of considering sarcopenia in health risk assessment and developing educational programs to prevent falls. ecosse l. lamoureux, 1,2 , alfred t.l. gan 1 , ryan e.k. man 1,2 , eva k. fenwick 1,2 , bao lin pauline soh 3 , angelique chan 2 , david ng 2 , chong foong-fong mary 4 , preeti gupta 1 ((1) singapore eye research institute and singapore national eye centre, singapore; (2) duke-nus medical school, singapore; (3) singapore institute of technology, health and social sciences, singapore; (4) saw swee hock school of public health, national university of singapore, singapore) background: individually, sarcopenia and frailty are known risk factors for cognitive impairment (ci) in older adults, but information on their conjoint presence on the increased risk of ci is unavailable in this same population. objectives: we examined the association of the combined presence of sarcopenia and frailty with ci in elderly singaporeans. health profile in elderly singaporeans study (pioneer), a nationally-representative, population-based study of singaporean chinese, malays, and indians aged >=60 years. participants underwent body composition (dual energy x-ray absorptiometry -dxa); grip strength (hand dynamometer) and habitual 4m-walking speed assessments. sarcopenia was defined using the asian consensus as low appendicular lean mass (lalm; men <7 kg/m2, women <5.4 kg/m2) and low muscle strength (lms; men <26 kg, women <18 kg) or slow walking speed (sws; <0.8 m/s); and frailty was defined as meeting three or more of the following components: 1) unintentional weight-loss >= 4.5 kg in the past 6-12 months and/or bmi <18.5 kg/m2, 2) lms, 3) self-reported exhaustion in the past one month, 4) sws, and 5) low physical activity level. ci was determined using the montreal cognitive assessment (moca) basic scale. logistic regressionb models were used to determine the cross-sectional sarcopenia-frailty and ci relationship. results: of the 487 included participants (mean age [sd]: 73.1 [8.3] years; 50.5% females), 248 (51%); 176 (36%); and 63 (13%) had neither sarcopenia nor frailty, either sarcopenia or frailty, and both sarcopenia and frailty, respectively. ci was present in 8 (3.2%) individuals without sarcopenia and frailty; 19 (10.8%) with either sarcopenia or frailty; and 16 (25.4%) individuals with both sarcopenia and frailty. in multivariable-adjusted analyses, presence of either sarcopenia or frailty was not significantly associated with higher odds of ci (odds ratio (or) [95% confidence interval]: 1.84 [0.71-4.73]), while having both sarcopenia and frailty significantly increased the odds of ci by nearly 3.5 times (3.48 [1.19-10.12]). conclusion: the co-presence of sarcopenia and frailty is independently associated with a higher risk of ci, compared to one condition alone, although longitudinal studies are needed to confirm this finding. strategies to prevent the concomitant onset of sarcopenia and frailty may be warranted to potentially reduce the risk of ci in older adults. background: car accidents related to older adults increased with aging, particularly in japan. safety driving required robust of physical function. however, the association between frailty and car accidents was still unclear. objectives: the aim of this study was to examine the association between frail status and car accidents. methods: participants were 12,013 older adults (45.4% women, mean age: 71.7 years) enrolled current drivers in the national center for geriatrics and gerontology -study of geriatric syndromes. the criterion of frailty used in this study was j-chs index modified according to fried's criteria (chs index). the components of frailty in j-chs index were based on the original chs index: shrinking (weight loss), weakness, poor endurance (exhaustion), low activity level, and slowness. based on the presence numbers of these five components, our study defined "frailty" as 1 and over, i.e., including pre frail and frail. the data of car accidents were collected from self-reported history of car accidents during 2 years. results: among 12,013 participants, 1,117 participants (9.3%) had a history of car accident. higher proportion of car accidents group was observed in shrinking (9.0% vs 11.1%, p = 0.006), exhaustion (9.1% vs 10.8%, p = 0.033), physical inactivity (9.0% vs 10.4%, p = 0.035) and slowness (9.0% vs 10.5%, p = 0.032), but not weakness (9.2 vs 9.9, p = 0.447). in a logistic regression analysis, frailty was independently associated with car accidents in an adjusted model (or 1.26 [95%ci 1.11-1.43], p < 0.001). conclusion: this population study reveals frailty associated with car accidents. the findings have contribution of enhancing utility of risk assessments among older drivers. further studies were required to clarify risk of car accidents.model. background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty is associated with higher morbidity, mortality and healthcare utilization. the national prevalence of frailty among us older veterans was found to be as high a 45%. however, little is known about the incidence of frailty in older, community-dwelling veterans. objectives: determine the incidence over 5 years of frailty among robust or prefrail community-dwelling older veterans. methods: this is a retrospective cohort study of 16897 community-dwelling veterans 60 years and older who had determinations of frailty from july 2013-june 2014 and were followed until their last clinician visit before september 30, 2019. a 31-item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables (morbidity, function, sensory loss, cognition and mood and other) with data from electronic health records. the va-fi categorized veterans into robust (fi<.10), prefrail (fi=>.10, <.21) and frail (fi>=.21). using baseline and median duration of follow-up data based on event rates, incidence rates of frailty per 1000 person/years were calculated for robust, prefrail, combined (robust and prefrail) and gender groups. results: patients were 73.8% white, 90.6% non-hispanic, 97.1% male, mean age 72.11 (sd=9.32) years. the proportion of robust, pre-frail and frail patients at baseline was 42.4% (n=7158), 36.7% (n=6209) and 20.9% (n=3530) respectively. among robust veterans surviving a median follow-up of 4.85 (iqr 3.03) years, 14.87% (1065/7158) became frail with an incidence rate of 37.02 cases/per 1000 person-years. among prefrail veterans 47.02% (2920/6209) became frail and the incidence rate was 154.99 cases/per 1000 person-years. among the combined group, 30% became frail, with an incidence rate of 83.70 per 1000 person-years. the proportion of veterans becoming frail and the incidence rates were higher in women than men (32.64% vs. 29.73% and 106.20 vs 83.14 cases per 1000 person-years respectively). conclusion: this study shows a high incidence of frailty in community-dwelling older us veterans. identification of older veterans at high risk for frailty may assist in the development of interventions aimed at preventing frailty and its associated complications. background: anticholinergic drugs are prescribed to treat a variety of medical conditions through pharmacological actions opposing the actions of acetylcholine. anticholinergics and may contribute to frailty by causing cognitive, functional and physical impairment. frailty represents a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty may potentially make patients more susceptible to the deleterious effects of anticholinergic medications on cognition. objectives: determine the crosssectional association of anticholinergics with cognitive impairment according to frailty status among communitydwelling older veterans. methods: this is a cross-sectional study of 17,211 community-dwelling veterans 60 years and older whose frailty status was assessed october 2018-october 2019. the use of medications (active/inactive) with high anticholinergic burden scale (acb3) and cognitive impairment diagnoses (icd codes for mild cognitive impairment/dementia) were obtained from electronic health records. a 30-item va frailty index (va-fi) was generated as a proportion of all potential variables at the time of the assessment. we compared robust (fi≤.10), prefrail (fi=>.10, <.21) and frail (fi>=.21) patients. after adjusting for age, gender, race, marital status, median household income, and bmi, odds ratios (ors) and 95% confidence intervals (cis) were calculated using binomial logistic regression with cognitive impairment as the outcome variable and anticholinergics (acb3) as independent variables. we repeated the analysis according to frailty status. results: patients were 68% white, 97.6% male, mean age 75.45 (sd=7.98) years, 9.3% (1593) had cognitive impairment, 11.5% (n=1976) were taking acb3 medications, 30.8% (5308) took them in the past and 57.5% (9927) never used them. the proportion of robust, pre-frail and frail patients was 32.1% (n=5524), 37.6% (n=6476) and 30.3% (n=5211) respectively. in binomial logistic regression, active and inactive acb3 medications were associated with higher risk for cognitive impairment, adjusted or=3. background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. the national prevalence of frailty among us older veterans was found to be as high a 45%. multiple studies have shown a higher prevalence of frailty and mortality in african americans. however, little is known about racial-differences in all-cause mortality in older veterans who had just transitioned to frailty. objectives: determine racial differences in allcause mortality over 5 years among community-dwelling older us veterans who transitioned to frailty. methods: this is a retrospective cohort study of 3,756 community-dwelling veterans 60 years and older who transitioned to frailty from july 2013-september 2019 and were followed until death or september 2019. a 31-item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables with data from electronic health records. the va-fi categorized veterans into robust (fi≤.10), prefrail (fi=>.10,<.21) and frail (fi>=.21). at the end of follow-up, we aggregated data on mortality only on those veterans who transitioned to frailty (robust/prefrail at baseline) and compared whites and african americans. after adjusting for age, gender, ethnicity, marital status and median household income, the association of race with mortality was determined using a multivariate cox regression model. results: patients were 81.5% white, 18.5% african-american, 89.6% non-hispanic, 96.8% male, mean age at frailty transition was 73.59 (sd=8.677) years. over a median follow-up period of 1038 days (iqr=1047) from the time they transitioned to frailty, 760 deaths occurred (n=635, in whites vs. n=125 in african americans). african american veterans had a lower risk for all-cause mortality than white veterans, unadjusted hazard ratio (hr) =.595 (95%ci: .491-.721), p<.0005. however, these mortality differences disappeared after adjustment for covariates, adjusted hr =.777 (95%ci: .545-1.108), p=.164. conclusion: our study suggests that in community dwelling older us veterans who had transitioned to frailty, race is not significantly related to overall survival when adjusting for other covariates. background: previous studies show that sarcopenic obesity (so) is associated with higher risk of mortality. however, a consensus definition of so is lacking, and more information is needed on the validity of simple measures applicable at a regular health care visit, such as anthropometric measurements and hand-grip strength or chair stand test. objectives: to examine the association between so and mortality, defining so based on body mass index, waist circumference, hand-grip strength and chair stand test, in a representative sample of finnish population. methods: this study was based on 2,550 participants aged 55 years or over with data on anthropometrics, hand-grip strength and chair stand test from the nationally representative health 2000 survey. baseline sarcopenic obesity was defined as having bmi >=30 kg/m2 or waist circumference >=102 cm (men)/ 88 cm (women), and hand-grip strength <27 kg in men, <16 kg in women, or chair stand >15 s for five rises. register-based follow-up data of the statistic finland containing 1,115 deaths during the 15 years of follow-up were individually linked with the baseline data. survival analyses were based on cox proportional hazards models using age as the time scale. results: mean age was 68.0 years (sd 9.4) and 58.3% were females. overall prevalence of sarcopenic obesity was 24.4% at baseline. sarcopenic obesity was associated with higher risk of mortality (hr 1.35, 95%ci 1.19-1.54) in an age and sex adjusted model. further adjustments for education, smoking, alcohol use, and physical activity did not notably change the results (hr 1.27, 95%ci 1.10-1.46). conclusion: sarcopenic obesity, as defined based on anthropometric measurements as well as hand-grip strength or chair stand test, predicted higher mortality over 15 years of follow-up. background: malnutrition and sarcopenia have a negative impact on mobility, risk of falls, fractures, physical disability and mortality. currently, limited information is available on nutritional status and nutritional interventions in geriatric rehabilitation (gr) patients. objectives: to characterize nutritional status and evidence of nutritional interventions with and without physical exercise in gr patients. methods: eight electronic databases were screened for nutritional status and interventions in patients >= 60years, admitted to gr, one search string was used for both topics. pooled estimates were calculated for mean bmi and prevalence of (risk of) malnutrition (mna). meta-analyses were performed to quantify intervention effects on albumin, muscle mass, barthel index (bi), and hand grip strength (hgs). results: 62 observational and 12 intervention studies were included out of 1717 references. pooled estimates (95% confidence interval (ci)) for prevalence of malnutrition and risk of malnutrition were 13 (5-20)% and 47 (40-54)%. pooled estimate (95%ci) for bmi was 23.8 (23.2-24.5) kg/m². low protein and energy intake and vitamin d deficiency were prevalent. intervention studies were heterogeneous in interventions and outcomes. meta-analyses showed no significant effects on albumin (standardized mean difference (smd) 0.34, 95% ci -0.13:0.80), muscle mass (mean difference (md) 2.14 kg, 95% ci -2.17:6.45), bi (md 2.85 points, 95% ci -7.59:13.29) and hgs (smd -0.04, 95% ci -0.61-0.53), based on 3-4 studies. eight interventions tested oral nutritional supplements (ons) with protein, with or without exercise, 6 reported protein intake and showed an increase, 3/4 studies showed increased albumin levels and 4/7 reported improved functional outcomes. conclusion: a high percentage of gr patients was affected by reduced nutritional status. intervention studies were limited and heterogeneous, but studies with ons improved nutritional outcomes, and functional outcomes in the majority of reporting studies. the results emphasize the need for malnutrition and sarcopenia screening and show benefits of protein supplementation in this population. future well-designed, well-powered trials are needed to clarify existing controversial aspects. therefore, feasibility of an intervention with a high-whey protein, leucine and vitamin d enriched ons (fortifit®), combined with resistance-type exercise in gr hip fracture patients will be investigated in a new intervention study (empower-gr). background: sarcopenia is a progressive and generalized skeletal muscle disorder associated with an increased likelihood of adverse outcomes such as falls, fractures, physical disability and mortality. the geographical region of residence (urban and rural area) may affect the prevalence of sarcopenia due to physical and environmental conditions. in 2018, the european working group on sarcopenia in older people (ewgsop) updated the definition of sarcopenia (ewgsop2). objectives: to describe the prevalence of sarcopenia related to ewgsop and ewgsop2 criteria and to analyze the association between sarcopenia and geographical regions of residence. methods: this is a cross-sectional study involving elderly women (60 years old or more) that were undergoing dxa in a radiology facility located in palmeira das missões (southern brazil). sociodemographic data were collected through a questionnaire. for the diagnosis of sarcopenia, we used the criteria recommended by the ewgsop (low muscle mass plus low grip strength and/or low gait speed), and ewgsop2 (low grip strength plus low muscle mass and/or low gait speed). the study was approved by the university ethics committee. results: out of the 288 participants, 60.1% was married, 44.1% had education between 4 and 8 years of schooling, 71.2% was caucasian, and 93.1% was retired. the mean age was 67.6±5.8 years old (60-88). the frequency of sarcopenia in the total sample assessed by the ewgsop and ewgsop2 was 5.2% and 2.1%, respectively. the prevalence of sarcopenia by the ewgsop was 73% in the urban area and 26.7% in the rural area (p= 0.007) and by the ewgsop2 was 66.7% in the urban area and 33.3% in the rural area (p= 0.177). conclusion: in a sample of elderly women from the southern brazil, the prevalence of sarcopenia was low through both consensus (ewgsop and ewgsop2), and was higher among urban area. funding: this study was financed in part by the coordenação de aperfeiçoamento de pessoal de nível superior -brazil (capes) -finance code 001. background: patients with disuse syndrome have gradually increased with aging of inpatients in saitama medical university hospital. because these patients have been inactive in the acute phase, sarcopenia is likely to occur. sarcopenia was graded by three criteria in ewgsop2 ; muscle strength, muscle quantity and physical performance. muscle volume can be measured only in limited medical centers. many of patients with disuse syndrome can not walk even after the acute phase. for these reasons, muscle strength is the only quantitative factor reflecting sarcopenia, especially in old patients with disuse syndrome after the acute phase. objectives: to show 1) muscle strength in old patients with disuse syndrome after the acute phase, 2) effect of muscle strength on activities of daily living (adl). methods: subjects were old patients with disuse syndrome admitted in the department of rehabilitation medicine (rm) in saitama medical university hospital from january 2011 to december 2018. inclusion criterion were as follows; 1) patient age was 65 or older 2) patients could not walk independently at admission in the department of rm exclusion criterion were as follows; 1) patients with motor paresis, contracture of fingers 2) patients in inactivity before the onset of the disease causing disuse syndrome. grip strength (gs) was measured by handheld dynamometer. cut-off point of gs set by awgs in 2019 was adopted; 28kg for men and 16kg for women, adl was evaluated using functional independence measure motor scale (mfim) one week after admission in the department of rehabilitation medicine . percentage of gs below cut-off point was shown in men and women respectively. effect of gs on mfim was investigated using regression analysis. results: ninety nine out of 186 patients were subjects in this study. median age was 77.0 years in men (n=51), 79.0 years in women (n=48). only two in men and one in women were below gs cut-off point. correlation coefficient between gs and mfim was 0.379(p=0.0052) in men, 0.415(p=0.0025) in women respectively. conclusion: gs was below cut-off point in most of the subjects. gp may affect adl after the acute phase in old patients with disuse syndrome. death, whereas measures of functional ability, physical strength and morbidity were stronger associated with time to death than with chronological age. from the age of 70 and forwards participants have a high life-satisfaction in general, however, a decline is seen as persons get older and with proximity to death. measures of functional ability (e.g. going shopping) and morbidity (e.g. self-related health) had a significantly increasing effect on life-satisfaction with increasing age. whereas social function (e.g. living alone, meeting friends) did not significantly modify the decrease in life satisfaction with increasing age. conclusion: physical strength, functional ability and morbidity were measures mostly linked to biological aging, while social functioning was strongly correlated with chronological age. functional ability and self-related health are important factors to prevent age-related decrease in life satisfaction. background: previous studies mostly conducted in western countries support that physical frailty predicts future cognitive decline in general older populations. however, longitudinal evidence on this association is limited, especially among older japanese women. objectives: this study has investigated the prospective associations of frailty status with cognitive decline over two years among community-dwelling older japanese women, including which individual frailty components (i.e., slowness, weakness, exhaustion, low activity, and unintentional weight loss) could predict cognitive decline. methods: this study was a two-year population-based cohort study conducted in a metropolitan area of tokyo, japan. data were collected in october 2017 (baseline) and september 2019 (follow-up) and analyzed between december 2019 and january 2020. participants were community-dwelling older japanese women, aged 65 to 80 years at the baseline, without any neurological diseases or cognitive impairment as measured by a mini-mental state examination (mmse) score of >= 24 points. cognitive decline was defined as a drop of two points or more in the mmse score over two years. the physical frailty phenotype was classified by the japanese version of cardiovascular health study criteria. multiple poisson regression analyses with a robust error variance were applied to assess risk ratios (rrs) of two-year cognitive decline across the baseline frailty statuses (robust [reference category], prefrail, or frail). results: of the 522 women analyzed, 219 (42.0%) were prefrail (1 or 2 components), and 17 (3.3%) were frail (≥3 components) at the baseline. at the follow-up, 17 (5.9%) robust, 29 (13.2%) prefrail, and 6 (35.3%) frail women experienced cognitive decline. after being adjusted for various confounding factors including age, educational attainment, and baseline mmse score, the rrs of cognitive decline were 2.05 (95% confidence interval [ci]: 1.11, 3.80) in the prefrail and 3.68 (95%ci: 1.64, 8.27) in the frail women. among the five frailty components, slowness (rr: 2.19, 95%ci: 1.04, 4.62), weakness (rr: 2.85, 95%ci: 1.64, 4.94), and unintentional weight loss (rr: 1.78, 95%ci: 1.01, 3.14) were significantly associated with cognitive decline. conclusion: over the two-year period, approximately 10% of women experienced cognitive decline. baseline physical frailty status, particularly slowness, weakness, and unintentional weight loss, predicted this decline. intervention strategies targeting physical frailty may help delay cognitive decline in older japanese women. background: menopause leads to estradiol (e2) deficiency that is associated with decreases in muscle mass and strength. yet the mechanistic role of e2 in the loss of muscle mass has not been established. programmed cell death termed apoptosis has been proposed a key signaling route in skeletal muscle homeostasis, including muscle aging and sarcopenia. to date several micrornas (mirs) have been found to regulate key steps in apoptotic pathways. objectives: here we studied the effect of e2 deficiency on mir-signaling in skeletal muscle apoptosis. our aim was to reveal whether e2-responsive mirs have mechanistic role in inducing skeletal muscle apoptosis. methods: we utilized c57bl6 mice with three study groups; sham (normal estrous cycle, n=8), ovx (e2 deficiency, n=7) and ovx+e2 (high e2 supplemented by pellet, n=4). in our setup, ovx and ovx+e2 groups represent the extremes of e2 level. six weeks following the sham or ovx surgery, mice were sacrificed, gastrocnemius muscles were harvested and rna isolated. mir-profile was studied with ngs and candidate mirs verified using qpcr. the target proteins of the mirs were found using in silico analysis (target scan) and target proteins measured at mrna (qpcr) and protein levels (western blot). results: of the apoptosis-linked mirs found, four (122-5p, 133a-3p, 483-3p and 491-5p) indicated differential expression patterns between ovx and ovx+e2 groups. in qpcr verification, ovx had lower expression in all of the studied mirs compared with ovx+e2 (p=0.050). accordingly, ovx had higher expression of cytochrome c and caspases 3, 6 and 9 compared with ovx+e2 at the mrna level (p<0.050). at protein level, ovx had greater cytochrome c and active caspase 9 compared with ovx+e2 (p<0.050). conclusion: in muscle from e2 deficient mice (ovx vs. ovx+e2 group), several apoptosis-linked mirs were down regulated concomitant with higher mrna expression of the target proteins. furthermore, e2 deficiency was associated with higher cytochrome c and active caspase 9 protein levels. to conclude, e2 deficiency down regulated several mirs related to apoptotic pathways that may lead to increased apoptosis and reduced skeletal muscle mass. background: although sarcopenia's pathogenesis is multifactorial, with its major phenotypes, muscle mass and muscle strength, being highly heritable, its genetic underpinning is not well studied. objectives: summarize evidence for use of zebrafish as a model system to decode the sarcopenia's gwas findings. methods: several genome-wide association studies (gwas) of muscle-related traits were published recently, providing dozens of candidate genes, many of them with unknown function. therefore, animal models are required not only to identify causal mechanisms, but also to clarify the underlying biology and to translate this knowledge into new interventions. over the past several decades, small teleost fishes had emerged as a powerful system for modeling the genetics of human diseases. due to their amenability to rapid genetic intervention and the large number of conserved genetic and physiological features, small teleosts, such as zebrafish (d. rerio), are indispensable for skeletal muscle genomic studies. results: we summarize the evidence supporting the utility of small fish model for accelerating our understanding of human skeletal muscle in norm and disease. the following stable mutants (mostly knockouts) exist for the «monogenic muscle» diseases (human gene, fish mutant, disease): for duchenne and becker muscular dystrophy (md), sapje/dmd (homology of human dmd gene); for limb-girdle md, popdc1s191f (bves); for bethlem myopathy and ullrich congenital md, col6a1ama605003 (col6a1); for nemaline myopathy, froto27c (myo18b), and tmod4trg (tmod4); for merosin deficient congenital md, lama2cl501/cl501; candyfloss/lama2 (lama2); for limb-girdle md, bvesicl1/icl1 (popdc1), heltg287 (ttn), and «foie gras» (trappc11); for native american myopathy, stac3mi34 (stac3), as well as fish homologues of the acvr1, cacnb1, cavin4, cms, dag1, fhl1, flnc, vcp and other human genes. these models provide evidence of muscle-related gene's conservancy and similarity of skeletal muscle morphology and physiological phenotypes. we will outline challenges in interpreting zebrafish mutant phenotypes and translating them to human disease. conclusion: we conclude with recommendations of future directions to leverage. centenarians exhibit extreme longevity and a compression of morbidity. we showed previously that centenarians display a unique genetic signature, in terms of mrna and mirna profile, which is similar to that found in young people and different from that found in octogenarians. centenarian offspring seem to inherit centenarians' compression of morbidity, as measured by lower rates of age-related pathologies such as hypertension, diabetes, strokes, and heart attacks. we therefore hypothesized that they will also display a lower incidence of frailty. in this study, we aimed to ascertain whether centenarian offspring are endowed which such "genetic footprint" and a lower incidence of frailty, when compared to their contemporaries. for this purpose, we collected plasma and peripheral blood mononuclear cells from 88 septuagenarians, 88, age-matched centenarian offspring (but not sons or daughters of the centenarians included in this study) and 63 centenarians. mirna expression and mrna profiles were performed by the genechip mirna 4.0 array (affimetrix) and genechip clariom s human array (affimetrix), respectively. frailty phenotype was determined by meeting three or more of the following criteria: unintentional weight loss, low grip strength, exhaustion, slow gait speed, and low physical activity. we found that mirna and mrna expression patterns in centenarians are similar to centenarian offspring and different to non-centenarian offspring (p<0.01). importantly, we found a lower incidence of frailty among centenarians' offspring (p<0.01), when compared to their contemporaries. taken together, our results indicate that centenarian offspring resemble centenarian characteristics and that they enjoy significantly less frailty than their less fortunate contemporaries that are not sons or daughters of centenarians. this lower incidence of frailty may be a key feature to achieve extraordinary ageing. background: hypoglycemic episodes increase in older patients and their consequences are more significant. objectives: the aim of this prospective observational study is to explore unknown hypoglycemic episodes diagnosed by continuous glucose monitoring in older type 2 diabetic patients and to describe the link between the occurrence of hypoglycemia and glycosylated hemoglobin (hba1c) level. methods: we included 36 patients with type 2 diabetes aged 75 years or over hospitalized during 19 consecutive months in a geriatric acute care unit in tours university hospital in france. demographic characteristics, type of diabetic treatment, mini mental state examination, hba1c levels, albumin and creatinin level were recorded. continuous glucose monitoring (cgm) was used to detect hypoglycemia for a maximum of 5 days, and capillary blood glucose measurements (cbgm) were also performed 4 to 8 times a day. patients with at least one blood glucose measure lower than 70 mg/dl were compared with others for demographic, clinical and biological parameters. results: seventeen patients experienced hypoglycemia. these groups did not differ in demographic characteristics and in diabetic drug class. among these patients, 5 had an episode of severe hypoglycemia (< 40 mg/dl) and 14 patients had nocturnal episodes, more often between 4 and 8 am. twelve patients had unrecognized hypoglycemia by cbgm. the average duration of hypoglycemic episodes was 4.1 hours. there was no difference in the hba1c levels between the two groups (mean 7.5%, p=0.86). conclusion: the prevalence of hypoglycemia is underestimated in the oldest diabetic population receiving hypoglycemic drugs. measurements of cbgm and hba1c level in the target may overlook nocturnal and prolonged hypoglycemic episodes. our study showed the benefit of cgm in older diabetic patients in order to detect unknown hypoglycemia. more prospective studies are needed to explore factors that predict hypoglycemia. catenacci, sophie le-gonidec, alizée dortignac, ophélie pereira, romain madeleine, jean-philippe pradère, philippe valet, cedric dray (umr1048 inserm,universitéfédéral de toulouse -universitépaul sabatier toulouse iii, france) background: healthy lifespan does not increase proportionally compared to global lifespan leading to an increased number of disabled aged persons. to increase healthy lifespan, locomotion could be considered in the future as the main targetable outcome to fight against the frailty to dependency transition. the so-called sarcopenia, characterized as the loss of muscle mass and function, affects 6 to 22% of the populations over 65. mechanistically, sarcopenia is associated with an imbalance between protein synthesis and degradation, an increase of muscle inflammatory processes, a reduction of mitochondria-driven metabolism and an exacerbated fibrosis. several therapeutic strategies have been proposed such as hormonal replacement but, regarding the adverse effects, these strategies have been abandoned. in this context, we hypothesize that, through a modified secretory profile, adipose tissue could play a crucial role in the muscle loss of function. we previously promoted an unbiased proteomic study and identified haptoglobin as an up-regulated cytokine overproduced by the adipose tissue during aging. objectives: in this context, our project proposes to better understand the role of adipocyte haptoglobin in age-related muscle weakness. methods: to do so, we used complementary in vitro and in vivo models of haptoglobin supplementation and strategies of adipocyte haptoglobin over-expression/deletion. impacts of such interventions have been monitored by measuring myogenesic processes as well as muscle aging. moreover, a human cohort in progress will help to constitute a new biobank by collecting blood, adipose and muscle from sarcopenic individuals in order to evaluate the role of hapatoglobin on sarcopenia (inspire cohort). results: the results obtained in vivo and in vitro suggest that haptoglobin treatments induced an age-dependent decrease in muscle mass. moreover, these protocols indicated a muscle-specific role of haptoglobin when we measured the fiber diameter. in addition, a direct effect of haptoglobin on differentiation alteration was also observed in in vitro human muscle cells. conclusion: these results suggest that haptoglobin induces effects according to the age, the muscle type and the dose on muscle physiology. thus, a better knowledge of adipocyte haptoglobin production could help to better apprehend the age-related muscular complications. background: sarcopenia contributes to loss of independence and is increases risk of mortality. mitochondrial dysfunction and loss of proteostasis are two interrelated hallmarks of aging with well-established roles in skeletal muscle function. mitochondrial dysfunction increases cellular oxidative stress and impairs atp-generating capacity. consequentially, oxidatively-damaged proteins accumulate; however, a dysfunctional mitochondrial reticulum cannot sufficiently provide energetic resources to repair the proteome. in skeletal muscle, this impaired proteostasis and mitochondrial dysfunction promote sarcopenia. thus, improving mitochondrial function by increasing endogenous antioxidants could attenuate age-related loss of muscle function. objectives: using a phytochemical nrf2 activator (nrf2a), we sought to determine if upregulation of cytoprotective genes would improve mitochondrial function and gait, an integrative metric of musculoskeletal function. methods: we utilized dunkin-hartley (dh) guinea pigs that develop primary osteoarthritis and experiences age-related skeletal muscle dysfunction by 9 months of age (~20% of their maximal predicted lifespan). we treated young (2mo) and older (5mo) dh guinea pigs for 3 and 10 months, respectively, daily with a nrf2a. we assessed metrics of gait monthly to measure the effect of nrf2a on agerelated musculoskeletal dysfunction. we evaluated the effect of nrf2a on skeletal muscle protein turnover using the stableisotope deuterium oxide. we also assessed soleus mitochondrial function using high resolution respirometry. results: while nrf2a did not affect gait in young guinea pigs, 10 months of nrf2a treatment maintained stride length (p=0.067) in older male and stance width (p<0.05) in older female guinea pigs compared to untreated controls. nrf2a improved (p=0.089) adp vmax in young females and old males compared to their respective controls. nrf2a also increased uncoupled electron transport system capacity in both male and female guinea pigs of both ages (p<0.05). nrf2a augmented contractile protein synthesis in the soleus of old male and female guinea pigs (p=0.071), but did not prevent the age-related declines in the gastrocnemius. conclusion: in summary, long-term nrf2a treatment improved skeletal muscle mitochondrial function, increased contractile protein synthesis, and maintained aspects of gait. together, our findings provide evidence that targeting the transcription factor nrf2 mitigates the decline in musculoskeletal function in a model of osteoarthritis and sarcopenia, with concomitant improvements in mitochondrial function and protein turnover. . j a n n e k e v a n w i j n g a a r d e n 1 , francina j dijk 1 , miriam van dijk 1 , lisette cpgm d e g r o o t 2 , y v e s b o i r i e 3 , 4 , y v e t t e c l u i k i n g 1 background: sarcopenia is a muscle disease rooted in adverse muscle changes that accumulate across the lifespan. multiple factors cause or worsen sarcopenia, with aging as the primary factor and malnutrition, inactivity and diseases as secondary factors. objectives: to design a nutritional strategy to manage sarcopenia. methods: our research program investigated 1) specific nutrient deficiencies in sarcopenic older adults, 2) muscle protein synthesis (mps) response in cells and rodent models, and 3) effect of a specific nutrient combination (whey protein, leucine and vitamin d -actisyn(tm), present in the medical nutrition supplement fortifit(r), on mps in older adults. results: cross-sectional studies indicated a significantly lower intake of protein (-6%) and vitamin d (-36%) in sarcopenic versus healthy older adults (p<0.05) [verlaan, clin nutr 2017], and higher prevalence of sarcopenia among those with lower blood levels of leucine, total essential amino acids ( the specific combination of whey protein, leucine and vitamin d (actisyn(tm)) provides the right environment for muscle building in sarcopenia, where these nutrients are often deficient. this combination acts through a proven anabolic mode of action with optimal nutrient bioavailability for the muscle to stimulate mps. fortifit and actisyn are trademarks of n.v. nutricia. background: age-related sarcopenia is a major responsible for premature death, poor quality of life and several adverse outcomes, which lead to higher health care costs. despite its recent incorporation as a muscle disease (icd-10-cm m62.84), early identification of this disease remains challenging. mostly, due to classification and diagnostic criteria, which are predominantly based on technically advanced assessment tools, which may not be available in all clinic settings. recently, a non-invasive technique to analyze variations in biological tissues considering the effect of physiological and biological properties on microwave signals is being studied for its potential to determine muscle mass, with possible applications in the early diagnosis of this disease. objectives: therefore, the principal objective of this study is to preliminarily test the potential of this technique as a new tool for early diagnosis of age-related sarcopenia in a clinical setting. methods: muscle surface area are going to be assessed by abdominal computational tomography (ct) on the third lumbar spine vertebra (l3) and bioimpedance measurements among 50 men and women, aged >=60 years in the maastricht university medical center, the netherlands. participants will also be subjected to measurements done with the device under test (dut) (the proposed technique) in the same location. the data collected from the three different measurements are analyzed looking for correlation. laboratory experiments made from synthetic materials emulating human tissues and from ex-vivo porcine tissues are used for optimization and interpretation of the clinical measurements. results: up-tonow, the campaign has just started and there is no enough data to give a preliminary result. initial laboratory experiments prove that the thickness of the fat and muscle tissues is correlated to the system response. conclusion: this prospective device will estimate the muscle mass locally using microwave electromagnetic principles. the results of this study can contribute to reveal the potential of this approach as a tissueanalysis tool for early diagnosis and management of age-related sarcopenia. the results might also provide useful evidence to consider in a future planned prospective cohort study, which aims to examine the impact of dietary biomarkers and genetic factors on the incidence of age-related sarcopenia in older adults. background: sarcopenia has become a serious problem in this aging society. at present diagnosis of sarcopenia consist of physical performance and muscle quantity. dexa has been widely applied to examine muscle quantity in clinical but it's radioactive, inconvenient and unaffordable in remote area. as a result, there are more studies in ultrasound in replace of dexa. objectives: based on others researches csa might be a suitable parameter to evaluate the muscle quantity. we develop a cheaper ultrasonic imaging system to evaluate the cross-sectional area (csa) of rectus femoris (rf)muscle. methods: we use a cmos image sensor combing with digital signal processor to detect the displacement of single element ultrasonic transducer. therefore, we combine us a-mode signal with displacement into b-mode image. by circling region of interest (roi), we can obtain the csa of rf muscle. then, we use siemens s3000 evaluating the csa in the same region to testify the reliability. results: we recruited 10 young college students undergoing the experiment. the result shows that the correlation coefficient is up to 0.96. conclusion: in conclusion, our device can successfully evaluate the csa of rf muscle. moreover, our system using single element ultrasonic transducer is much cheaper than linear transducer in practice .it can be affordable in remote village or somewhere lacking in medical resource. a case-control study. camille nicolay 1 , sandra higuet 2 , sandra de breucker 1 ((1) geriatric department, hôpital erasme, brussels, belgium; (2) geriatric department, hôpital isppc-charleroi, charleroi, belgium) background: ten percents of belgian population are considered to be informal caregivers. little is known about their frailty status and their physical health. objectives: we compared the frailty status, the clinical and psychosocial status of old caregivers with controls (>65). we analyzed the association of frailty status according to fried's criteria and rockwood frailty index (fi) with the characteristics of caregivers and controls in multiple regression analysis. methods: eighty six caregivers and 105 gender and agematched controls were included. frailty was assessed by the frailty phenotype (fried) and the 40-deficit frailty index (fi). social data, sf-12 health survey, basic and instrumental adl, geriatric depression scale, mini nutritional assessment, mini-cog, cumulative illness rating scale-geriatric, usual gait speed, handgrip strength, and burden scale (zarit) were collected. results: the prevalence of frailty was similar in caregivers and controls with the fi (p=0.479) but higher with the fried's criteria (p=0.001). compared with the control group, caregiving was associated with a lower mental quality of life (p<0.001), a higher risk of depression (p<0.001), a higher consumption of antidepressant (p=0.02), a lower nutritional status (p=0.019), a more frequent help from health care providers (p=0.005), and more problems to maintain physical contacts with a social network (p=0.008). in multiple regression, the fried's criteria adjusted for age, gender, marital status and incomes were associated with the age, the grip strength, the physical quality of life, the gait speed and the nutritional status (r2=0.79 -p<0.0001), while fi was associated with the risk of depression, the use of antidepressants, the physical quality of life, the cognitive status and basal & instrumental adl (r2=0.85 -p <0.0001) in caregivers. conclusion: the prevalence of frailty is similar in caregivers and controls when using fi, but higher in caregivers with fried's criteria. compared with controls, caregiving is associated with poorer health and psychological issues. while fried's criteria focus on physical frailty, the fi is more related with geriatric syndromes like depression, cognitive disorders, loss of autonomy, and quality of life. this study could help researchers to choose between frailty scales before starting a study about older caregivers. background: nursing home (nh) residents are often undernourished and physically inactive contributing to sarcopenia and frailty. mobility is identified by older nh residents as being key to their quality of life and well-being. the combination of protein supplementation and physical exercise has been shown to be most effective to maintain and increase muscle mass. objectives: the older persons exercise and nutrition (open) study aimed to investigate the effects of sit-to-stand exercises (sts) integrated into daily care combined with a protein-rich oral nutritional supplement (ons), on physical function, nutritional status, body composition, healthrelated quality of life and resource use. methods: residents in eight nh were randomized by nh units into an intervention group (ig) or a control group (cg) (n=60/group). the ig was offered a combination of sts (four times/day) and ons (2 bottles/day providing 600 kcal and 36 g protein) for 12 weeks. the participants resided in nh units (dementia and somatic care), were >=75 years and able to rise from a seated position. the 30 seconds chair stand test (30scst) was the primary outcome. secondary outcomes were balance, walking speed, dependence in adl, nutritional status and body composition, health-related quality of life and resource use. data was analyzed using descriptive and inferential statistics including regression models. results: altogether 102 residents (86±5 years, 62% females) completed the study. no improvement in the physical function assessments was observed in the ig, whereas body weight increased significantly (2.05±3.5 kg, p=0.013) vs the cg. twenty-one (of 52) participants with high adherence to the intervention, i.e. at least 40% compliance to the combined intervention, increased their fat free mass (2.12 kg (0.13, 4.26 iqr), p=0.007 vs cg. logistic regression analyses indicated that the odds ratio for maintained/improved 30scst was 3.5 (ci 1.1, 10.9, p=0.034) among the participants with high adherence compared to the cg. waly dioh 1 , cendrine tourette 1 , carole margalef 1 , amy chen 2 , rené lafont 1,3 , pierre dilda 1 , stanislas veillet 1 , samuel agus 2 ((1) biophytis, sorbonne université -bc9, paris, france; ( background: sarcopenia is a geriatric condition characterized by loss of muscle mass and functions and can contribute to risks of falls, fractures and hospitalization. sara-obs is a multicenter, observational trial designed to better characterize age-related sarcopenia in a community dwelling population at risk of mobility disability. this is part of a clinical program that strives to provide more understanding of the target population in order to further develop a potential sarcopenia medical intervention. sara-obs study rationale, design and main baseline characteristics are presented. objectives: the objective is to characterize sarcopenia and sarcopenic obesity in older adults through evaluation of their physical performance and body composition. changes in baseline characteristics after a 6-month period will be assessed and used for development of a phase 2 interventional study on the efficacy and safety of an investigational drug, bio101. methods: participant recruitment was based on age (>=65 years), sppb score =<8 and body mass based on the fnih criteria. physical functions were assessed by two walking tests (400m walk test and the 6-minute walk test), the sppb, the handgrip strength test and the stair climb power test. patient reported outcomes were also assessed with the sf-36 and the sarqol questionnaires. results: 218 subjects were included in this study and the main screen failures were sppb scores and body mass criteria. baseline characteristics indicated that the average bmi was high, ~61 % of the participants were women and that the alm/bmi in men was lower than the fnih threshold (0.69 vs 0.789) but was similar in women (0.52 vs 0.52). 400m gait speed was 0.83 m/s, the mean total sppb score was 6.12 with the gait speed component of <0.8m/s and the chair stand sub-score of 1.73. conclusion: this population has a similar 400m gait speed as the populations in life and sprint-t studies at baseline. however, the sppb total score and the chair stand sub-score correspond more closely with the sprint-t study. addressing the loss of physical function and preventing mobility disability is still an unmet need of older adults. sara-obs included a population representative of a suitable target for subsequent interventional studies aimed to fulfill this need. yen-lung chen, hui-hua chiang (department of biomedical engineering, national yang-ming university, taipei, taiwan) background: in whole world, the elderly formally entered the aging society , and the patients with sarcopenia were highrisk groups in the fall. more than 20% of the elderly suffered moderate injuries due to falls. the sarcopenia as defined by the eu's sarcopenia working group was refers to progressive reduction in muscle mass and decreased muscle function. objectives: it is expected to provide diagnostic tools and techniques for the rapid determination of sarcopenia and muscle strength. at the same time, it will also be developed toward portable devices to facilitate the diagnosis of the aging of muscle function in the elderly at home to take care of the health and well-being of the elderly. methods: at present, the clinical measurement part is assisted by the radiation department of the veterans general hospital to collect and measure the subjects. clinical testing methods are mainly for older people over 65 years of age. the walking speed test is firstly performed on the method. if it is normal, then the grip strength test is performed. if the grip strength is too small, the femoral rectus femoris muscle volume test should be performed. generally, dual energy is used. dual-energy x-ray absorptiometry (dxa) is used for testing. if the walking speed is too slow, the dxa test should be performed directly. the test value is less than 6.0 (kg/m2) in woman and less than 7.0 (kg/m2)in man. that is, it is determined as a sarcopenia patient. since dxa has a small amount of free radiation, high cost, and a large space occupation, we expect to obtain a wide range of data through ultrasonic scans. back-end development algorithms are calculated to determine if there is sarcopenia and how severe it is. results: at present, the rectus femoris muscle volume obtained by using ultrasound has a highly linear relationship with the appendicular muscle mass measured by dxa (r2=0.87,p<0.001), and has the ability to distinguish whether it is sarcopenia. conclusion: the use of muscle volume of rectus femoris can improve the accuracy of sarcopenia prediction. in the near future, this plan will be used to develop automated ultrasonic scanners. background: although sarcopenia has multifactorial causes, the decline in physical activity has been considered a very important aspect for its development. since the promotion of higher levels of physical activity can attenuate the progression of sarcopenia, it is possible that the participation in a programmed training increases the spontaneous physical activity of the participants. objectives: to investigate if the participation of sarcopenic older women in a resistance training program and supplementation with fish oil leads to changes in the level of spontaneous physical activity (sedentary time and number of steps). methods: randomized, double-blind, placebo-controlled clinical trial. thirty-two older women, aged >= 65 years, participated in the study. all participants were classified as sarcopenic based on the criteria of the european consensus on sarcopenia 2010 (ewgsop). the participants were divided into two experimental groups: (1) exercise group + placebo (ep) and (2) exercise group + fish oil (efo). both groups underwent a resistance exercise program over 14 weeks, consisting of three weekly supervised sessions. all volunteers were instructed to take two capsules of food supplement at each main meal, lunch and dinner (4g/day). the ep group used capsules composed of sunflower oil as placebo, and the efo group fish oil capsules, (epa 440mg and dha 220mg). measurements of the level of spontaneous physical activity were made before and after the intervention by using the actipal® physical activity monitor (glasgow, uk), for a period of seven consecutive days, during which the volunteers were instructed to maintain their normal routine. the volume of the quadriceps muscle in the pre and post intervention periods was calculated from the images obtained by magnetic resonance imaging. for statistical analysis, a linear regression model with mixed effects was used to compare longitudinal data on mean intra-group differences between groups and moments. for all analyzes, a significance level of 0.05 was adopted. results: both groups showed an increase in muscle volume after the intervention (47.4 cm3 (13.5%) and 15.1 cm3 (4.9%), respectively). regarding the level of spontaneous physical activity, both groups had a similar sedentary time and number of steps, at both times (average 8.9h and 8,608 steps in the pre-intervention period and 8.3h and 8,844 steps in the postintervention period for the ep group, and 9.6hrs and 9,869 steps in the pre-period and 9.0h and 7,045 steps in the postintervention period in the eop group). conclusion: although sarcopenic older women supplemented with fish oil showed a higher increase in muscle volume, the level of spontaneous physical activity remained unchanged both in the pre and post intervention periods and between groups, indicating that the increase in muscle volume was not associated with significant changes in the level of spontaneous physical activity. background: regardless of improvements in surgical and anesthetic practices, older surgical patients often experience postoperative complications. the purpose of this study was to investigate the association between physical frailty and cognitive function using a validated upper-extremity function (uef) test with in-hospital outcomes in aging adults undergoing abdominal surgery. objectives: to recognize frailty and cognitive function as a risk factor for in-hospital adverse outcomes. methods: we administered pre-operative uef tests, within 24-hours after admission, among patients aged 40 years and older undergoing emergent/urgent abdominal surgery. the uef involved two tests; 20-and 60-sec of respectively fast and consistent elbow flexion, while angular velocity was measured via two wearable motion sensors applied to the wrist and upper-arm of the dominant arm. uef physical score was calculated, based on slowness, weakness, flexibility, and exhaustion (range: resilient=0-frail=1). uef cognitive score was assessed based on motor function variability within a dual-task performance that involved uef motor task and a cognitive task of counting backwards by threes (range: cognitive normal=0-cognitive impairment=1). adverse outcomes included: length of stay, complications, and death during their hospital stay. a logistic regression model was used to assess the association between uef physical and cognitive scores (independent variables) and in-hospital outcomes (dependent variable). results: a total of 75 participants (mean age 60.7±11.6 years) completed the preoperative uef assessment. thirty-six participants with an average age of 63.7±10.3 years experienced at least one adverse outcome while in the hospital. while age independently predicted in-hospital outcomes with receiver operating characteristic area under the curve (roc-auc) of 62%, this prediction improved by adding either the uef physical or the cognitive score. the physical score predicted in-hospital outcomes with a roc-auc of 80%, and the cognitive scores predicted in-hospital outcomes with a roc-auc of 77%. conclusion: the proportion of emergency surgical procedures increases with age, and population trends indicate that this demand will increase significantly. results from the current study showed that sensor-based measures of physical and cognitive function can provide an objective tool for predicting adverse outcomes, with potential applications for other surgical procedures. risk stratification can help to establish targeted management strategies to improve the healthcare system and patient-centered outcomes. background: while sensor-based daily physical activity (dpa) gait performance has been demonstrated to be an effective measure of physical frailty, it is not clear how repeatable the dpa gait parameters are between different days of measurement, especially across frailty groups. objectives: to evaluate the test-retest reliability (repeatability) of dpa gait performance parameters (stride time, variability, and irregularity) and quantitative measures (number of steps and walking duration) between two separate days of assessment among older adults. methods: dpa was acquired for 48-hours from older adults (age>=65 years) using a tri-axial accelerometer motion-sensor attached to the trunk. purposeful continuous walking bouts (>=60s) without long pauses (>1.7s) were identified from acceleration data and used to extract gait performance parameters, including stride time, power spectral density (psd) slope (representing the variability of walking cycles), dominant frequency of walking, and gait irregularity (sample entropy, representing predictability of walking cycles). to assess repeatability, intraclass correlation coefficient (icc) was calculated using two-way mixed effects f-test models for day-1 vs. day-2 as the independent random effect. repeatability tests were performed once for all participants and once within each frailty group (non-frail and pre-frail/frail). results: data from 63 older adults, 29 non-frail (age: 74.97±7.10 years) and 34 pre-frail/frail (age: 81.26±8.94 years) were analyzed. within all 63 participants with purposeful walking bouts on both the days, gait performance parameters of stride-time and gait variability parameters (slope and dominant frequency of walking) showed excellent test-retest reliability values (icc>=75%) while quantitative parameters, including number of steps and walking duration showed poor test-retest reliability results (icc<30%). among gait performance parameters (stride time, dominant walking frequency and sample entropy), we observed higher repeatability among the pre-frail/frail group with icc>78% compared to icc<53% for non-frail individuals. conclusion: from our study, it is evident that gait performance parameters including average step-and stride-time and frequency-domain gait variability parameters provided higher test-retest reliability compared to quantitative measures. further, gait performance parameters showed higher repeatability among pre-frail/frail volunteers between the two days compared to non-frail volunteers, which may be attributed to a lack of functional capacity among frail individuals for performing more intense and more variable physical tasks. background: while evaluation methods for skeletal muscle characteristics which are necessary to know the pathogenesis of sarcopenia are being considered, ultrasonography is attracting attention as a method simultaneously evaluate quantitative and qualitative evaluation of skeletal muscle. although we have found many, the statements that examined the relation between muscle thickness, echo intensity, physical function, and sarcopenia by quadriceps muscle ultrasonography in the previous report, there are few reports for the lower leg muscles. objectives: we conducted a study to examine whether the lower leg muscle ultrasonography is useful for evaluating sarcopenia index and muscle quality (muscle strength per unit muscle mass) evaluation in comparison with the quadriceps ultrasonography. methods: the participants were 52 patients over 65 years old (27 males, 25 females). the muscle thickness of the quadriceps muscle, tibialis anterior muscle, gastrocnemius muscle, soleus, and echo intensity were measured by ultrasonography, and the relationship between lower extremity muscle mass, muscle strength, physical function, and muscle quality was examined. results: the muscle thickness of quadriceps muscle, tibialis anterior muscle, soleus muscle was related to lower extremity muscle mass, grip strength, leg muscle strength, and only quadriceps muscle was related to gait speed. the echo intensity of the quadriceps, tibialis anterior, gastrocnemius was related to, grip strength, leg muscle strength, and only the tibialis anterior muscle was related to gait speed. the muscle thickness and the echo intensity of tibialis anterior muscle and soleus muscle are highly correlated with the quadriceps. the echo intensity of the tibialis anterior muscle, as well as that of the quadriceps muscle, showed a high correlation with the muscle quality of lower extremity. conclusion: concerning the assessment of sarcopenia using ultrasonography, muscle thickness and echo intensity evaluation by tibialis anterior muscle showed the same utility as them by the quadriceps muscle, and echo intensity of the tibialis anterior muscle can be a marker of muscle quality. lucena germano 1 , cristiano dos santos gomes 1 , juliana fernandes de sousa barbosa 1,2 , raysa freitas 1,3 , alvaro campos c. maciel 1 , ricardo oliveira guerra 1 ( (1 background: phase angle (pha) is emerging as a measure of great clinical relevance provided through bioimpedance assessment and its related to health adverse outcomes such as osteoporosis and sarcopenia. on the other hand, poor physical performance as gait speed and grip strength in elderly is associated with poor health conditions. we hypothesized it is plausible that those two measures might be related and can be used as a tool in clinical practice. objectives: to investigate the relationship between pha and physical performance measures in community-dwelling older adults from brazil. methods: this cross-sectional study enrolled 253 older adults of both sexes who had a comprehensive health evaluation including physical performance tests (gait speed and handgrip strength) and electrical bioimpedance screening. linear regression models were used to estimate the associations between pha and physical performance measures. results: the mean age of 72.06 ± 3.49 and 72.88 ± 4.90 for men and women respectively. hand grip strength (n: 0,248; p-value < 0,05) and gait speed (n: 0,212; p-value < 0,05) were independently correlated with pha. conclusion: pha could help to easily identify elderly on the onset of present heath adverse outcome and guide specific interventions by clinicians. shosuke satake 1,2 , kaori kinoshita 1 , yasumoto matsui 3 , background: in japan, we have a simple yes/no questionnaire to assess multiple functions in daily living for older adults; the kihon checklist (kcl). in the questionnaire, 5 questions to assess mobile functions are included. objectives: we examined whether the 5-item questions in the physical domain of the kcl (kcl-phys) could be a surrogate of validated measurements of physical functions. methods: subjects were 465 independent and ambulatory seniors aged 65 years or older who had been consulted in our frailty clinic. all of them received grip strength test, dual energy x-ray absorptiometry, physical performance tests, cognitive examination, and the kcl questionnaire. among them, we excluded 2 subjects with missing data, and 8 with moderate cognitive impairments. we examined the relationships between scores of the kcl-phys and usual gait speed, short physical performance battery (sppb), and timed up and go (tug) with the spearman's rank correlation. the score of the kclphys were counted when the subject meets any criteria with each question as previously reported. also, we evaluated the cutoff point of the kcl-phys equivalent to slow gait speed (<0.8m/s), low sppb score (sppb < 8), and slow tug (tug >= 20 sec) with the receiver operating characteristic (roc) curve analysis. results: the mean values of age, body mass index, and prevalence of sarcopenia were 77.4 years old (women 67.9%), 23.7 (kg/m2), and 22.9 (%), which were no differences between sexes. on the other hand, physical functions of gait speed, sppb, and tug were all worse in women than in men. relationships between the scores of the kcl-phys and usual gait speed, sppb, and tug were moderate with the coefficients of -0.595, -0.589, and 0.544, respectively (p<0.0001 for all). the area under the roc curve of the kcl-phys score equivalent to slow gait speed, low sppb score, and slow tug were 0.791, 0.820, and 0.792, respectively. the cutoffs were thought to be the best at 3 points of the kcl-phys to identify low physical functions based on the youden index. conclusion: physical domain of the kcl could be a surrogate of assessments of physical functions in older people. yuji hirano 1 , izumi kondo 1 , tetuya nemoto 1 , naoki itoh 1 , hidenori arai 1 ((1) national center for geriatrics and gerontology, japan; (2) nihon fukushi university, japan) background: we have developed a new type of grip strength measurement that addresses the time axis in evaluating physical function. it can measure the dynamic force, response in gripping performance, and maximum grip strength. the "kihon checklist" (kcl) is used to screening the frail elderly, based on the japanese long-term care insurance system. however, the relationship between the gripping performance and kcl has not been well investigated. objectives: the purpose of this study was to introduce a novel automatic reading method for dynamic force parameters in gripping performance and to evaluate their relationship with the kcl. methods: the subjects comprised 248 patients (94 men, 154 women, average age 78.2 ± 6.0 years) who visited the integrated healthy aging clinic (locomo-frail outpatient clinic in japanese) of our hospital. the four indices of grip force response measured were: reaction start time (rst), time constant (tc), maximum value of force (mvf), and force rising slope (frs). we examined the relationship between these four indices and seven categories of the kcl; activities of daily living (adl), physical functions and fall, nutrition state, oral functions, outdoor activities, cognitive functions and mood, using spearman's correlation coefficient. results: in the female right hand, the mvf was only significantly correlated with adl and overall scores; whereas, in the female left hand, the mvf and the frs were significantly correlated with many items (adl, physical functions and fall, nutrition state, outdoor activities, and cognitive functions). the time-dependent items (rst and tc) were significantly correlated with outdoor activities in the female left hand and significantly correlated with adl and oral functions in the male left hand. however, in the right hand, the time-dependent items were not correlated with any of items in kcl in both sexes. conclusion: our newly developed grip strength measurement system could automatically calculate not only the maximum grip strength but also the time response of the grip force. moreover, their relationship with kcl was clearly indicated. the relationship between detailed grip strength response indicators and kcl items differed between men and women, and the left hand was correlated with more items than the right hand. ranyah almardawi, rao gullapalli, michael terrin (university of maryland school of maryland, baltimore, usa) background: rotator cuff (rc) tear and shoulder pain are both highly prevalent in older populations. routine medical screening for shoulder dysfunction is uncommon for community-dwelling older adults. the disabilities of the arm, shoulder and hand (dash) survey estimates self-reported dysfunction of both upper limbs in a composite score. dash offers a quick method to identify older adults with potential dysfunction in either shoulder, which otherwise may go unrecognized during routine medical visits. objectives: 1. to determine if dash, american shoulder and elbow surgeons (ases) and simple shoulder test (sst) surveys are related to one another in older adults. 2. to assess dash, ases and sst score relationships to the sf-36 physical functioning (pf) subcomponent score, shoulder forward flexion range of motion (ff-rom) and shoulder abduction range of motion (abd-rom) in older adults. methods: cross-sectional study: twenty-three community-dwelling-older-adult volunteers [mean age, 69.7 ± 6.8 years; range, 61 to 84 years; female, 65%] with no history of rc surgery and no history of shoulder injury or shoulder physical therapy in the prior 3 months completed shoulder magnetic resonance imaging (mri) and dash, sf-36, charlson co-morbidity index (cci), katz activities of daily living (adls) and lawton instrumental adls (iadls) surveys. for the shoulder ipsilateral to mri, participants completed ases, sst, visual analog scale for pain (vas) surveys; and shoulder ff-rom and abd-rom. descriptive statistics and spearman rank order correlation (rho) were performed. results: frequencies: rc tear (supraspinatus tendon) on mri: 47.8%; shoulder pain >= 2 on vas: 56.5%; no limitation (score=6) on katz adls: 91.3%; no limitation (score=8) on lawton iadls: 95.6%. means: cci, 3.0 ± 1.0; dash, 16.6 ± 7.5; ases, 81.4 ± 19.2; sst 70.2 ± 29.4; 81.7 ± 19.7; 144.1 ± 31.4; 133.3 ± 31.7 . range of correlation among dash-ases-sst surveys: (|rho|=0.92-0.95, p<0.001). range of correlation for dash-ases-sst with sf-36 pf(|rho|=0.61-0.69, p<0.002), p<0 .001), abd-rom (|rho|=0.74-0.82, p<0.001). conclusion: dash, ases and sst correlate well, and all three surveys show a consistent relationship with sf-36 physical functioning, ff-rom and abd-rom. next steps would be to evaluate the feasibility of dash to identify older adults with shoulder dysfunction during routine medical visits. background: physical performance is closely associated with chronic diseases and dysfunction of numerous organ systems. old persons with chronic renal failure have shown the apparent decline in physical performance, especially in the end-stage. however, it is unclear whether the subclinical kidney dysfunction is associated with skeletal muscle function deficit in the elderly population. objectives: the aim of this study is to determine the association between renal function and skeletal muscle function deficit in old persons without nephropathy. methods: eight hundred fifty-four korean elderlies (female, 75.3%) aged 65 to 89 years were included in the cross-sectional analysis. of the participants, 135 elderlies (female 57.0%) were available for the 1-year follow-up test session. all participants were interviewed face-to-face and received measures of anthropometry, body composition and serum biomarkers of metabolic diseases. estimated glomerular filtration rate (egfr) was calculated using the chronic kidney disease epidemiology collaboration (ckd-epi) equation based on serum creatinine concentration. skeletal muscle function deficit was defined as a combination of weakness and slowness based on the handgrip strength to body mass index ratio (hs/bmi, men < 1.0, women < 0.56) and converted timed up-and-go to walking speed (tugspeed < 0.8 m/s). results: the subjects with 30 <= egfr < 45 ml/min/1.73m2 showed significantly lower physical performance for muscular strength and functional mobility than those with 45 <= egfr < 60 and egfr > 60 ml/min/1.73m2, respectively (all for p < 0.05). logistic regression analysis indicated the significant association between egfr and skeletal muscle function status even after adjustment for potential confounders (p for trend < 0.01). moreover, the prospective observational analysis by ancova showed the significant effects of enhancement in hs/bmi [f(2, 122) = 4.89, p = 0.009] and tugspeed [f(2, 122) = 9.50, p < 0.001] on the improvement in egfr during 1-year followup. conclusion: taken together, skeletal muscle function status is associated with even moderately reduced egfr in an older population. these results suggest that maintenance of physical and functional fitness may be a contributory factor for preserving renal function in elderly persons. rn, brazil) background: sarc-f is a brief and useful test to identify older people at risk of sarcopenia-associated adverse outcomes. previous studies with older populations have suggested that it may be useful to screen those with severe sarcopenia. its ability to screen sarcopenia among low-income brazilian older adults is still unknown and its association with sarcopenia diagnostic criteria may be useful to understand its utility among this population. objectives: this study aims to evaluate the validity of sarc-f in screening low muscle strength and low physical performance among a low-income sample of older adults. methods: in a cross-sectional study, 62 community-dwelling older-adults (>=60 years old; men and women) from santa cruz (northeast brazil) answered the sarc-f questionnaire and were classified as sarcopenic (>=4) and non-sarcopenic (<4) according to sarc-f scores. they were also evaluated in relation to the sarcopenia criteria of muscle strength (handgrip strength) and physical performance (sppb). the cutoff of <16 kg for women and <27 kg for men were used to classify those with low muscle strength. a sppb score of <=8 was used to classify low physical performance. a chi-square test was used to assess the association between the sarc-f and the objective parameters of sarcopenia. sensitivity and specificity of the sarc-f according to the objective functional parameters were also assessed. results: the sample was composed by 71% of women, with mean age of 72.4 (±1.06) years old. according to sarc-f, 24.2% of the sample was sarcopenic. low muscle mass and low physical performance were identified in 37.1% and 46.8% of the sample respectively. sarcopenia was significantly associated to low muscle mass (p<0.01) and low physical performance (p<0.001). the sensitivity of sarc-f in identifying those with low muscle mass was of 67% and specificity of 59%. for low physical performance, sensitivity and specificity were of 45% and 94% respectively. conclusion: sarc-f has a moderate ability to identify the sarcopenia criteria of low muscle mass and low physical function among older adults from a low-income setting. since it is a simple measure, it can be advantageous for low-income and rural communities. background: menopause marks a critical transition towards older adulthood for women and studies suggest that it is associated to several sarcopenia parameters, such as muscle mass and physical functioning. understanding how the menopausal transition associates to sarcopenia diagnostic criteria may help to direct screening tests for middle-aged populations and to identify earlier those at higher risk of sarcopenia. objectives: to evaluate the association between menopausal status and sarcopenia diagnostic criteria (muscle strength, muscle quantity and physical performance). methods: in a cross-sectional study, 389 communitydwelling women from northeast brazil (40-65 yearsold) were evaluated in relation to menopausal status using the stages of reproductive aging workshop classification (premenopausal, perimenopausal or postmenopausal) , and in relation to sarcopenia diagnostic criteria according to european working group on sarcopenia in older people (ewgsop2): muscle strength (grip strength -handheld dynamometer), muscle quantity (appendicular muscle mass adjusted for height through bioelectrical impedance) and physical performance (gait speed). association between menopausal status and sarcopenia criteria was evaluated with multiple linear regression models adjusted for covariates (current age, education, family income, walking, bmi, reproductive history). results: among the participants, 26.7% were classified as premenopausal, 39.1% as perimenopausal, and 34.2% as postmenopausal. menopausal status was significantly associated to grip strength, since premenopausal women were significantly stronger than perimenopausal or postmenopausal women, even in the fully adjusted analyses (b= 2.26; 95% ci= 0.39: 4.12). muscle quantity and gait speed were not significant according to menopausal status. conclusion: perimenopausal and postmenopausal status are associated with less muscle strength among middle-aged women. muscle weakness may be the first sarcopenia parameter that is affected by women's aging and should be tracked among middle-aged to women for early identification of sarcopenia risk.. background: we speculate maintaining good postural stability is the key to good adl in elderly patients. this is a preliminary study to evaluate which factor relates to good postural stability. objectives: we evaluated 69 patients (22 males and 47 females) over 65 years old. the average age was 75.8 years old ranging 65 to 97. methods: we measured index of postural stability(ips) using gravicoder gw-5000 manufactured by anima. the ips was adovocated by mochizuki in 2000. it was defined following this equation; ips=log[(area of stability limit + area of postural sway)/area of postural sway). larger ips means better postural stability. the average ips in each age was already known. ips was calculated automatically through gravicoda. we devided these patients into two groups by the results of ips. group a with the patients whose ips was larger, group b with the patients whose ips was smaller than the average in their age. we compared the following items between the two groups. nutrition(albumin, calcium, magnesium, ferritin, vitamin b1,b12, 1,25-d3, zinc in blood test) , bone status(bone density, % of yam), spinopelvic parameters (pelvic incidence(pi), lumbar lordosis(ll), pelvic tilt(pt) using whole spine x-ray photograph. results: ten patients were classified into group a and 59 patients were into group b. the average age was 77.6±6.1years old in group a and 75.5±5.7 in group b. in group a , ll and pt were respectively 49.7, 17.1. in group b, 36.1, 23.7. ll and pt were significantly different between the two groups. pi minus ll is an important indicator to determine the spino-pelvic balance. it is known that pi-ll<10 means good spino-pelvic balance. in group a, pi minus ll was 1.7±16.9. in group b, it was 15.7±17.0. according to nutrition and bone status, albumin was significantly higher in group b. conclusion: our results showed spino-pelvic alignment related to the postural stability. this suggests good spino-pelvic alignment is likely the key to good postural stability. background: physical performance is of main relevance for quality of life and independence in the community. identification of deterioration of physical performance helps to start early interventions to stay independently in old age. objectives: to determine physical performance of communitydwelling older adults above 70 years by using a comprehensive geriatric assessment to find most sensitive tests for functional decline. methods: older community-dwelling adults aged 70+. analysis of baseline and 6 (t1) and 24 months (t2) of followup data of hand grip strength (hgs), stair climb power test (scpt), timed up and go test (tug), short physical performance battery (sppb), 4m gait speed (4mgs), 5-time chair rise test (5tcr), 6 minute walking test (6mwt) and frailty categories according to fried. results are shown in mean (± sd) in total numbers and percentage. results: 251 participants (75,4 y.± 3,89) were included, 148 (59%) female. overall physical performance was on high level, above geriatric cut-offs for physical disabilities at baseline: (hgs female: 22, 13 (±4, 76) (-16,95 (± 11,55 )%) followed by scpt (-9,15 (± 16,84)%). all tests showed a decline except 5tcr (+2,78 (±14,24)%). conclusion: physically active, communitydwelling older people show a high level of functional performance, far from geriatric cut-offs indicating physical disabilities. nevertheless, after two years a clinically relevant reduction of strength in upper (handgrip) and lower extremities (stair climb) was detected. these data may be relevant for the identification of older individuals who may benefit from early intervention exercise programs to keep them physically independent as long as possible. 5tcr showed divergent results and could be of special interest for continuous measurements to identify gradual decreases in functional performance. background: sarcopenia is characterized by loss of skeletal muscle mass and strength and it is a frequent finding in oncology, being associated with reduced quality of life, impairment in the response to antineoplastic therapy and increased toxicity, especially in older patients. objectives: the aim of the present study was to evaluate the association between low muscle mass (lmm) assessed by computed tomography (ct) analysis and sarcopenia considering the revised european consensus published by the european working group on sarcopenia in older people (ewgsop2) with the variables of the comprehensive geriatric assessment (cga) in older oncological patients. methods: for this purpose, 67 patients (50.7% female; mean age of 76.8±7.9 years) followed at the oncogeriatric outpatient clinic of a university hospital were enrolled. clinical data were obtained from electronic medical records and the skeletal muscle mass evaluation was performed using ct (in the height of the third lumbar vertebra). for lmm and sarcopenia classification, specific cutoff points were adopted. cga variables were compared between lmm and normal skeletal muscle mass (nsmm) and between sarcopenic and non-sarcopenic individuals. groups were compared by the independent t test (r core team®, p<0.05). results: the most frequent tumors were breast, intestine, stomach and lung, at different stages of the disease. the prevalence of lmm was 78.6% and the prevalence of sarcopenia was 50%. of all cga variables evaluated, hand grip strength (16,53±6,46) and katz scale (4,87±1,68) were associated with lmm and sarcopenia. conclusion: the results highlight the importance of early geriatric clinical assessment of older cancer patients, considering the association of cga variables with low muscle mass and most important, to sarcopenia, for the possible reversal of functional and nutritional impairments and for the indication or appropriate planning of cancer therapy. lygia paccini lustosa 1 , patricia parreira batista 1 , jéssica rodrigues de almeida 1 , andré gustavo pereira de andrade 2 , aimée de araújo cabral pelizari 1 , stephanie aguiar 1 , leani de souza máximo pereira 1 ((1) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; (2) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: functional tests in the older person reflect the integrity of the interrelationship between muscle mass and function, vascular, endocrine and neurological aspects of central and peripheral command. the reduction in functionality, muscle mass and strength associated with advancing age is related to the increase of circulating proinflammatory cytokines in plasma, which in turn predisposes the individual to negative repercussions, such as the development of chronic diseases, falls and disability. they can identify changes in the intrinsic capacity of the older people. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated community older women (60 years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all responded to clinical and demographic information, performed the short physical performance battery (sppb), timed up and go (tug) and plasma tests of stnfr1 and il-6 (elisa method). correlation analysis by spearman test. 5% significance level. approval by the research ethics committee/ ufmg (caae: 14129513.7.1001.5149). results: 97 older women participated, with a mean age of 73.29 ± 6.3 y; number of comorbidities 2.55 ± 1.92 and medications in use of 3.06 ± 2.08. mean of body mass index were 27.18 ± 4.52 kg/m2. there was a significant negative relationship between the sppb test and stnfr1 (rho= 0.29; p= 0.003) and a significant positive relationship between tug and stnfr1 (rho= 0.57; p= 0.001). other relationships were not significant (p> 0.05). conclusion: older women with better functional capacity presented lower plasma dosage of stnfr1. the results suggest influence between these variables -functional capacity, mobility and inflammatory process -and no causal factor can be attributed. in these case, longitudinal studies are needed to verify functional performance vulnerability factors and their causal relationship with circulating inflammatory mediators in plasma. however, these results point to the importance of evaluating these variables in daily clinical practice. patricia parreira batista 1 , stephanie aguiar 1 , andré gustavo pereira de andrade 2 , jéssica rodrigues de almeida 1 , leani de souza máximo pereira 1 , lygia paccini lustosa 1 ((1) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; (2) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: perceptions of health and well-being in the older people are identified as subjective aspects by the international classification of functioning (icf), with direct and indirect interference with overall performance, activities of daily living, social relationships and independence. subjective well-being is associated with the form of coping adopted with a health condition, adaptability and resilience. positive and negative physiological repercussions on functionality and interaction with the family and social network may be consequences of inadequate adaptation and perception of subjective well-being. objectives: to explore the relationship between subjective well-being, functionality and plasma indices of inflammatory mediators in community older wowen. methods: participated community older women (60 years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive changes (mini-mental state examination). all answered about clinical and demographic data and information about subjective well-being. they performed tests of functional capacity (short physical performance battery -sppb) and mobility (timed up and go -tug). plasma dosages of stnfr1 and il-6 were by elisa method. correlation analysis by spearman test. significance level of 5%. approval by the research ethics committee/ ufmg (caae: 14129513.7.1001.5149). results: 97 elderly women participated, with a mean age of 73.29 ± 6.3 years; number of comorbidities 2.55 ± 1.92, final sppb score 9.6 ± 1.98, tug of 11.26 ± 3.96 seconds; body mass index of 27.18 ± 4.52kg/m2. there was a significant positive relationship between subjective well-being and sppb (rho= 0.27; p= 0.007) and tug (rho= 0.23; p= 0.02). other associations were not significant (p> 0.05). conclusion: the results showed a significant association of subjective well-being with functional capacity in the older women. however, this condition was not associated with inflammatory markers, suggesting the need for further studies. on the other hand, it can be thought that the identification of personal strategies and perception of health and well-being act as barriers and/ or facilitators in a functional rehabilitation process, indicating the need for a multidisciplinary approach. background: the united states census bureau projects a rise in the population aged 65 and over from 43.1 million in 2012 to 83.7 million by 2050. the projected rise in the elderly population represents an accompanying increase in geriatric syndromes. frailty is a common geriatric syndrome defined as a clinically recognizable state of increased vulnerability to adverse outcomes related to a decline in physiologic reserve. this decline in reserve places the individual at increased risk for poor health outcomes including falls, disability, hospitalization, institutionalization and mortality. various effective interventions for frailty are established in the literature. the body of knowledge on the role of technology in reducing frailty is less abundant. objectives: to summarize available evidence on frailty and technology use for community dwelling older adults. methods: a comprehensive search of computerized databases was conducted in the following databases published between 2013-2018: cinahl, pubmed, and academic search complete. the prisma search strategy was utilized for this review. articles were included if they met the following criteria: 1) focused on community dwelling adults aged 65 and over; 2) peer-reviewed; 3) published in the english language; 4) featured randomized controlled trials (rcts), cohort studies or qualitative research; and 5) included an operationalized definition for frailty. results: the database searches yielded a total of 183 articles. 41 duplicates were removed. 114 results were excluded based on title and abstract. 32 relevant articles were retrieved for full text examination. 18 articles were excluded based on inclusion/exclusion criteria. references of 14 included articles were hand searched for relevant works. four additional relevant articles were identified. the final analysis included 18 articles. conclusion: current research focuses on assessment and diagnosis as opposed to intervention studies. methodological weaknesses limit generalizability and validity of findings. few studies utilize frailty as an outcome measure thus, limiting available research directly related to frailty. emerging technologies represent potentially effective, flexible and integrative solutions for frailty assessment, monitoring and intervention in the home environment. more research is needed on the potential for technological tools as interventions for frailty in community dwelling elderly specifically, for the purpose of detection and prevention of pre-frailty. a study protocol. inae c. gadotti 1 , raquel aparicio ugarriza 2,3 , fernanda civitella 1 , jorge g. ruiz 2,4 , edgar ramos vieira 1 ( (1) background: there are several studies on the association of balance and gait impairments with frailty and falls in older adults. however, little is known about the associations between postural alterations, frailty and falls in older adults in general and among older veterans. also, inter-relations among postural alterations, balance, strength, gait impairments, falls and frailty in older adults are not well known. objectives: the objective of this study is to evaluate if postural alterations, gait and balance impairments are associated with falls and frailty in older veterans. methods: sixty veterans, 60 years old or older, will participate on a voluntary basis. one-hour long assessments will be completed at baseline, 6, and 12 months. participants will fill out a questionnaire including information on demographics (age, sex, height, and weight), health conditions, falls (history, characteristics, and fear of falls), mobility impairments, physical activity level, medication history, medication changes and adherence, and health care utilization. frailty status will be assessed based on fried's frailty phenotype. the following physical health variables will be assessed: sagittal head and neck posture using photogrammetry, spinal curvatures using flexicurve, deep neck flexors activation by performing the craniocervical flexion test with a pressure biofeedback, grip strength using a dynamometer, usual and fast gait analysis using a gaitrite, balance using a force plate, and lower limb functional strength based on chair stands in 30s. differences among the variables by frailty status and falls history will be assessed using manovas. results: the results will be presented at conferences and published in scientific journals. conclusion: the results of this study may inform interventions to reduce frailty and falls in older veterans and possible among non-veterans as well. background: the number of deaths caused by pneumonia is increasing. the guidelines for pneumonia recommend optimal application of antibiotics based on a pathogenoriented strategy. despite wide distribution of these guidelines, pneumonia demonstrates high mortality in aged people. thus, for developing the next strategy for pneumonia management in aged people, new targets are required. with aging, the loss of skeletal muscle mass and strength occurs, which is named sarcopenia. the sarcopenia phenotype is associated with malnutrition. little is known about relationship between muscles and pneumonia, however, we reported that aspiration pneumonia induced respiratory muscle atrophy. impaired swallowing and/or cough functions often induce pneumonia in aged people. the swallowing muscle weakness is associated with impaired swallowing function. the strong respiratory muscles generate effective cough, which clears the airways and prevents pneumonia. objectives: to investigate presently unknown relationships between onset or recurrence of pneumonia in aged people and; respiratory muscle strength; swallowing muscle strength; and malnutrition. methods: a cross-sectional cohort study consisted of 47 patients aged 70-year-old and older admitted to the hospital by pneumonia, and 35 controls. the respiratory muscle strength was measured by a hand-held multi-functional spirometer with a pressure sensing transducer. the swallowing muscle strength was evaluated by measuring tongue pressure. a bioelectrical impedance analysis evaluated muscle and body fat masses. malnutrition was evaluated by serum albumin level and body fat mass. results: the respiratory (both the inspiratory and the expiratory) and the tongue muscle strengths, body trunk muscle mass, serum albumin level, and body fat mass divided by height2 were lower in aged pneumonia patients than in controls. body trunk muscles include the respiratory and swallowing muscles. the multivariate logistic regression model showed the low inspiratory and expiratory respiratory muscle strengths, the low body trunk muscle mass divided by height2, and the low serum albumin level as risk factors for onset of pneumonia. for recurrence of pneumonia within 6 months after the onset of pneumonia, low body fat mass divided by height2 was a risk factor. conclusion: above findings suggest that the respiratory muscles and malnutrition as new targets of the new management strategy for pneumonia in aged people. background: more than 50% of the people with hiv are older than fifty years. data about this population are still scarce and mainly focused on comorbidity instead of on physical function and frailty. hiv-funcfrail cohort is one of the four european cohorts of older hiv adults launched in 2018. objectives: our main objective in this work was to know the factors associated to physical impairment. methods: longitudinal prospective cohort study. patients from the "hiv-funcfrail: multicenter spanish cohort to study frailty and physical function in 50 years or older hiv-infected patients" were included. eleven centers participated. we recorded sociodemographic data, comorbidities and variables related to hiv infection. physical function was measured by gait speed and sppb and frailty according to frailty phenotype. other components of the comprehensive geriatric assessment such as depression and cognitive impairment were evaluated too. results: 563 were included. median age was 56.2 (53.7-60.6). 25.8% were women. at baseline median cd4 count was 672.5 (473.5 -904.5). viral load was undetectable in 91.2%. 30% of the patients had > 4 comorbidities and 21.8% had polypharmacy. 97.5% of the patients were able to walk independently and 97% were completely independent for the activities of daily living. more than half were prefrail, 5.8% prefrail and 42.6% were robust according to frailty phenotype. 17.7% of the patients had a sppb score < 9 and 5.4% had a gait speed < 0.8m/sg. in the univariate analysis we found association between physical impairment defined as sppb score < 9 with: diabetes, copd, osteoarthritis, comorbidities number, moca test < 20, gds-sf >9 and age. but in the multivariate analyses the factors associated were just: polypharmacy ) p= 0.001], gds-sf >9 [3.09 (1.63-5.84) p=0.001]. conclusion: functional impairment was prevalent among older adults with hiv in their middleage. polypharmacy doubles the risk of functional impairment and depression increases the risk three-fold. therefore, polypharmacy, depression and physical function should be assessed in all the older adults with hiv in order to implement early prevention intervention to avoid physical impairment. sophie bastijns, anne-marie de cock, maurits vandewoude, stany perkisas (university of antwerp, antwerp, belgium) background: acute sarcopenia is defined as a decline in muscle mass and muscle function within 28 days after hospitalization or acute illnesses, sufficiently to meet the sarcopenia criteria. muscle ultrasound is an objective and non-invasive technique that can measure muscle quantity and quality. muscle elastography can furthermore measure muscle stiffness, which is regarded as an important qualitative parameter. objectives: the primary aim of the study is to assess the effect of acute hospitalization on muscle stiffness. the secondary aim is to evaluate other influencing parameters. methods: this study is a prospective, observational study. patients admitted for at least 7 days to one of the geriatrics departments of the zna antwerp hospitals are included. rectus femoris (rf) and vastus lateralis (vl) muscle stiffness are measured through elastography on day 1 of admission, and then every 7 days until discharge. results: preliminary results show significant differences between rf and vl values in men, but not in women. in rf, a non-significant downwards trend is seen for elastography between day 1 and day 8. in vl, a non-significant downwards trend is seen in women, but also a non-significant upwards trend is seen in men between day 1 and day 8. in rf, a non-significant trend of decreasing stiffness is seen with increasing age in men, but an increase is seen in women. a significant negative correlation is seen between elastography of rf and vl on day 1 and hand grip strength on day 1. conclusion: this study seeks to gain insight in parameters affecting muscle stiffness and of the evolution of muscle stiffness after acute illness or hospitalization. a trend of decreasing muscle stiffness is seen after seven days of hospitalization and illness. this study showed no direct relation between age and muscle stiffness. a decrease in muscle stiffness results in higher hand grip strength and therefore better muscle performance. more data and longer follow-up periods are needed and are expected by march 2020. ainhoa indurain 1,2 , jennifer linge 3 , mikael petersson 3 , thobias romu 3 , fredrik uhlin 1,4 , anders fernström 1 , mårten segelmark 1,6 , olof dahlqvist leinhard ((1) departments of nephrology and medical and health sciences, linköping university, linköping, sweden; (2) departments of acute internal medicine and geriatrics and medical and health sciences, linköping university, linköping, sweden; (3) background: sarcopenia is a prevalent condition in hemodialysis patients and it´s associated with poor quality of life, hospitalization and mortality. recent research using magnetic resonance imaging (mri) has demonstrated the importance of proper body size-adjustment in the assessment of muscle mass, and that the addition of muscle fat infiltration reflecting muscle quality, improves functional correlations and prediction of hospitalization in sarcopenia. it is not yet demonstrated if this new mri method, combining body sizeadjusted muscle volume and muscle fat infiltration, improves the evaluation of sarcopenia in hemodialysis patients. objectives: to investigate if adverse muscle composition, defined using mri, predicts survival and comorbidity in hemodialysis patients. methods: in 2014, 11 patients on hemodialysis were scanned using rapid whole body fat and water separated mri. following 5 years, survival and comorbidity index (nci) were recorded using electronic health care records. thigh muscle fat infiltration (mfi) and fatfree muscle volume (ffmv) normalized with height2 was assessed using amra research (amra medical, linköping sweden). a z-score describing the deviation from expected ffmv/height2 was calculated using sex and bmi-matched virtual controls (ffmvvcg) and mfi adjusted (mfiadj) was calculated using the sex-specific population mean. for these calculations, normative data from 9615 subjects in uk biobank was used. to estimate a combined muscle score (musclecomb), mfiadj and ffmvvcg were projected on the linear regression line describing the normal population relationship between mfiadj and ffmvvcg in the uk biobank dataset. spearman rank correlation was estimated comparing mfiadj, ffmvvcg and musclecomb to nci. wilcoxon signed-rank test was used to estimate the association to survival. roc values and confidence interval were also calculated. results: musclecomb (combined muscle score) was significantly correlated to comorbidity (p<0.05) and predicted survival (p<0.05) while mfiadj (adjusted muscle fat infiltration) and ffmvvcg (deviation from an individual´s expected muscle volume) did not reach significant level on either test. the roc values for predicting survival were 0.86 (0.61-1.00) for ffmvvcg, 0.82 (0.55-1.00) for mfiadj, and 0.89 (0.69-1.00) for musclecomb. background: frailty is a risk factor for cardiovascular disease (cvd). as declines in bone metabolism and impaired inflammatory response are often associated with frailty, bone analytes and inflammation markers involved in these signaling pathways may act as biomarkers of frailty-related disease progression. objectives: this study sought to examine differences in systemic bone analyte and inflammation marker concentrations based on cvd risk profile and frailty status. methods: 1030 females with no prior cvd were stratified into low or high cvd risk groups based on their framingham risk scores. frailty was assessed using the fried phenotype of frailty. greedy matching with pre-frailty as the exposure variable was used to identify a set of 26 closely matched pairs in both the low and high cvd risk groups for a total of 104 females in a case-control design. factorial anova was used to compare differences in log transformed concentrations of 15 bone and inflammation analytes based on frailty status, cvd risk, and their potential interaction. results: differences for il-6 (5.25 ± 14.30 vs. 1.35 ± 1.74 pg/ml, p=0.001), leptin (12628.48 ± 10472.90 vs 7562.96 ± 4972.25 pg/ml, p=0.023) and tnfα (1.41 ± 1.83 vs 0.89 ± 0.40 pg/ml, p=0.06) systemic concentrations were found with high cvd risk status compared to low. no differences in bone or inflammation analyte concentration were found based on frailty status, nor were any interaction effects. conclusion: there was a difference in inflammatory marker concentrations based on cvd risk status indicating that higher cvd risk is associated with impaired inflammatory response in females. there was no difference in bone or inflammation analytes in the pre-frail group compared to their robust peers as these females may be too early in the progression of frailty to have these signs of impaired bone health and inflammation. (2) pancreato-biliary cancer center, gangnam severance hospital, yonsei university college of medicine, seoul, korea) background: biliary tract cancer (btc) is a highly lethal disease, and improved prognostication methods should be sought. sarcopenia (low muscle mass), poor muscle quality (low muscle attenuation) and excess adiposity (subcutaneous and visceral) can be surrogate markers of sarcopenia and related frailty. however this hypothesis has not been demonstrated conclusively in btc patients. objectives: to evaluate associations of all four body composition measures, derived from clinically acquired ct at the time of initial diagnosis, with overall survival in advanced btc patients. methods: we measured skeletal muscle index (smi), mean muscle attenuation (ma), visceral adipose tissue index, and subcutaneous adipose tissue index via computed tomography at the level of the l3 vertebra. clinical data were extracted from patients' charts. results: a total of 601 patients (58% males, median age 67 [range 30-91]) were included in this study, 65% were metastatic and 35% were recurrent disease. during the follow-up duration (median of 9.4 months; range 0.1 month to 128 months), 570 patients (95%) died. sarcopenia, defined as low l3smi (lower than 39 cm2/m2 for women and lower than 55 cm2/m2 for men) was noted in 463 patients (77%), and 162 patients (27%) had low muscle radiodensity. for adiposity, 31% and 29% of patients had low subcutaneous and visceral fat, respectively. when we combined this four factors and grouped the patients, no risk group (n =67) had the best overall survival (median 14.6 months, 95% ci, 11.7-17.5), while the patients who suffered all the risk factors (n=12) showed the poorest survival (median 2.5 months, 95% ci, 0-5.7) which was statistically significant (log-rank test <0.001). this classification was independent factor for survival in multi-variate analysis along with other clinical factors, carcinoembryonic antigen (cea), neutrophil-to-lymphocyte ratio, white blood count, platelet, and cholesterol (hr 1.271, 95% ci 1.126-1.435). conclusion: sarcopenia, ma, and adiposity independently predict mortality in patients with btc and can be utilized as surrogate markers for prognosis. background: frailty is a clinical syndrome of reduced systemic physiological reserve that phenotypically overlaps with heart failure. nt-probnp is a cardiac-specific marker that increases with ventricular stress, whereas growth differentiation factor 15 (gdf-15) is a non-tissue specific systemic marker that increases with inflammation, tissue injury and possibly inflammageing. objectives: this study aims to determine if combination of nt-probnp and gdf-15 organised in a 2x2 matrix can classify cardiac dysfunction with and without frailty, non-cardiac frailty, and non-frailty. methods: this is a cross-sectional analysis of a prospective cohort study (phase 1), undiagnosed heart failure in older adults (ufo), that recruited community-living older adults aged >/=60 years in a ratio of 1:1:1 for robust, pre-frail and frail status classified by the frail scale. participants without a history of heart failure and meeting the eligibility criteria were entered into the study. nt-probnp and gdf-15 levels were measured using the roche cobas elecsys platform. echocardiography and 6-minute walk distance (6mwd) were documented. informed consent was obtained from all participants. the study was approved by the local institutional review board. ) was ascertained by correlation with abnormal echocardiographic diastology represented most prominently by increased left atrial volume index (r=0.37, p=5.8x10e-11). conclusion: a 2x2 dual biomarker approach utilising nt-probnp and gdf-15 may assist in subclassification of cardiac (diastolic) dysfunction and frailty. background: frailty was occurred frequently in elderly and known as higher risk of mild cognitive impairment (mci) and dementia than healthy elderly. hippocampus, parahippocampus and entorhinal cortex as memory system is considered one of the key regions of dementia especially alzheimer's disease. in addition, atrophy of these regions presumably related to higher risk of alzheimer's disease. on the other hand, it is poor understood about neural substrates of relationships frailty and higher incident rates of mci and dementia. objectives: the purpose of this study, therefore, to clarify differences of atrophy level of hippocampus, parahippocampus and entorhinal cortex and total gray matter between healthy, pre-frail and frail in elderly. methods: a total 1,220 elderly were measured brain structure with 3t-mri, and 1,117 were fulfilled inclusion criteria in this study. structural brain images were preprocessed and total hippocampal volume was estimated using freesurfer v6.0.0 and ubuntu 16.04 lts. we classified participants into three groups as healthy, pre-frail and frail characterized by 0, 1 or 2 and 3 or more of the following 5 domains respectively: low activity, slowness, weight loss, exhaustion and weakness. we compared total gray matter or hippocampal volume between healthy, pre-frail and frail in elderly with one way analysis of covariance (ancova) adjusted for sex, age, educational years, drinking and smoking habit, geriatric depression scale points and estimated total intracranial volume (etiv) and multiple comparison using bonferroni correction. results: the prevalence of pre-frail and frail was 49.2% and 5.9% respectively. hippocampus, parahippocampus and entorhinal cortex volume were significantly decreased in elderly with frail compared healthy and pre-frail (hippocampus: p=0.002 and p=0.014; parahippocampus: p=0.002 and p<0.001; entorhinal cortex: p=0.024 and p=0.043 respectively). in contrast, total gray matter volume was not significantly difference between three groups. conclusion: hippocampus, parahippocampus and entorhinal cortex were atrophied in elderly with frailty compared healthy or pre-frail elderly. it might be neural substrates of higher risk of dementia in elderly with frailty. rasekh kashkosh 1 , irina gringauz 1 , jonathan weissmann 2 , gad segal 3,4 , michael swartzon 5 , abraham adunsky 1,4 , dan justo 1,4 ((1) geriatrics division, sheba medical center, israel; (2) biomedical engineering department, israel; ( background: low alanine aminotransferase (alt) blood levels prior to rehabilitation are associated with poor rehabilitation outcomes in terms of low mobility and function in older adults following hip fracture. objectives: we have hypothesized that low alt blood levels prior to rehabilitation are also associated with 1-year mortality in this population. methods: included were 456 older adults (age >=60 years, median age 83 years, 82.5% women) admitted for rehabilitation following hip fracture. alt blood levels were documented between one and six months prior to rehabilitation. excluded were patients with alt blood levels over 40 iu/l possibly consistent with liver injury. the study group included patients with low (10 iu/l or lower) alt blood levels, and the control group included patients with high-normal (11-40 iu/l) alt blood levels. the main outcome was all-cause mortality one year following rehabilitation admission. results: the study group included 142 (31.1%) patients with low alt blood levels, and the control group included 314 (68.9%) patients with high-normal alt blood levels. overall, 52 (11.4%) patients died within one year following rehabilitation admission. compared with the control group, patients with low alt blood levels had significantly higher 1-year mortality rates (17.6% vs. 8.6%, or 2.27, 95%ci 1.27-4.08). cox regression analysis showed that low alt blood levels prior to rehabilitation were associated with 1-year mortality (hr 1.61, 95%ci 0.91-2.84) together with peripheral vascular disease (hr 2.69, 95%ci 1.08-6.68) -independent of age, gender, albumin serum levels, length of rehabilitation, and rehabilitation outcomes. conclusion: low alt blood levels prior to rehabilitation are associated with 1-year mortality in older adults following hip fracture. fawaz azizieh 1 , dia shehab 2 , khaled al jarallah 2 , renu gupta 2 , raj raghupathy 2 ((1) gulf university for science & technology, mubarak al-abdullah area, kuwait; (2) faculty of medicine, kuwait university, jabriya, kuwait) background: in addition to some well-characterized bone turnover markers, cytokines and adipokines have also been suggested to be linked to osteoporosis seen in menopause. however, there is much controversy on the possible association between these markers and bone mineral density (bmd). objectives: this study was aimed at measuring circulatory levels of selected cytokines and adipokines in postmenopausal women with normal and low bmd. methods: the study population included 71 post-menopausal women, 25 of whom 25 had normal bmd, 31 had osteopenia and 13 had osteoporosis. circulatory levels of selected pro-resorptive (tnf-a, il-1b, il-6, il-8, il-12, il-17), anti-resorptive (ifng, il-4, il-10, il-13, tgf-b) and five adipokine markers (adiponectin, adipsin, lipocalin-2/ngal, pai-1 and resistin) were measured using the multiplex system and read on the magpix elisa platform. further, two bone turnover markers (p1np, ctx) as well as estradiol levels were assayed from the same samples. results: while circulatory levels of cytokines were comparable between groups, women with low bmd had statistically significantly higher median circulatory levels of adipokines as compared to those with normal bmd. further, while levels of ctx were not different between the two groups; p1np, p1np/ctx ratio and estradiol levels were significantly lower in women with low bmd. levels of adiponectin, p1np, p1np/ctx ratio and estradiol correlated significantly with bmd of the hip and spine. conclusion: while the associations between the studied markers and bmd may be complex and multivariate, our data provide insights into the possible use of circulatory levels of cytokines, adipokines and bone turnover markers on the pathogenesis of postmenopausal osteoporosis. background: with the application of diffusion tensor imaging (dti), a few studies have found that some white matter (wm) structures were closely related to impaired gait speed. however, the evidence is still sparse and the wm structural association with overall lower-body physical function, which can be evaluated by short-physical performance battery (sppb), has never been investigated among older adults. objectives: the aim of this study is to explore the associations between wm structures (evaluated by dti parameters) and sppb scores among older adults. methods: data of 209 participants (75 ± 4 years old), who were recruited in the multidomain alzheimer's preventive trial (mapt) study and with no dementia at baseline level, were analysed in this study. based on the functional magnetic resonance imaging data, dti parameters of fractional anisotropy (fa), mean (md), axial (ad) and radial diffusivity (rd) were calculated in 48 wm structures that were annotated by the john hopkins university white matter parcellation atlas. linear regression was used to analyse the association between sppb score and each dti parameter while controlling for age, gender, body mass index, physical activity level, total intracranial volume, cardiovascular risk and time interval between the dti and sppb measurement. results: three dti parameters (the md and rd of left corticospinal tract, and the md of right cerebral peduncle) were associated with the sppb score at a p-value < 0.05. conclusion: the findings indicate that wm structures of corticospinal tract and cerebral peduncle might be related to overall lower-body physical function of older adults. further studies on the changes of these wm structures with physical function alterations during ageing will be more informative. background: ct-derived skeletal muscle index and skeletal muscle density (smd) have been independently associated with mortality in older adults. although smd is a commonly used measure of myosteatosis on ct images, more novel muscle texture (i.e., radiomic) features may provide an alternative measure of muscle quality, independent of smd. there have been no prior studies on the association of ct-derived muscle texture features and mortality. objectives: to examine the association of skeletal muscle texture features with all-cause mortality in older adults from the national lung screening trial (nlst). methods: the relationship between ct-derived skeletal muscle texture and all-cause mortality over 6 years was determined in 13,279 participants (39% women, age range 60-74 years, mean age 64.8) in the nlst. using ct images at the level of t12 vertebra, paraspinous muscle was automatically segmented using machine learning algorithm, and muscle texture features determined using pyradiomics. 75 second order (and higher) texture features were grouped into 5 categories: gray level dependence matrix (gldm), gray level co-occurence matrix (glcm), gray level run length matrix (glrlm), gray level size zone matrix (glszm), and neighbouring gray tone difference matrix (ngtdm). muscle texture features often indicate greater or lower heterogeneity/complexity of an image. associations between standardized muscle texture variables and all-cause mortality were determined using cox proportional hazards models, adjusted for age, sex, race, body mass index, pack years of smoking, presence of type 2 diabetes, chronic lung disease, cardiovascular disease, cancer at enrollment, and smd. multiple comparisons were accounted for using false discovery rate testing. results: after a mean 6.41 ± 1.11 years of follow-up, 1188 (8.95%) participants died. in fully adjusted models, the following muscle texture features were associated with mortality: gldm-dependenceentropy (hazzard ratio (hr) per standard deviation (sd)=0.88, p<0.001), gldm-dependencenonuniformity (hr per sd=0.91, p=0.011), gldmsmalldependencelowgraylevelemphasis (hr per sd=1.15, p<0.001), glrlm-graylevelnonuniformity (hr per sd=0.89, p<0.001), glszm-small area low gray level emphasis (hr per sd=1.08, p=0.003), ngtdm-coarseness (hr per sd=1.06, p=0.005), ngtdm-strength (hr per sd=1.06, p=0.003). each of these associations were in the direction that suggested greater heterogeneity of the image was associated with increased mortality. conclusion: in a large multicenter cohort of community-dwelling older adults, ct-derived muscle texture features indicating greater heterogeneity were associated with mortality, independent of common covariates including skeletal muscle density. background: growth differentiation factor 15 (gdf15) has been related with disease progression, mitochondrial dysfunction, and mortality. elevated gdf-15 level was recently reported to be associated with poorer physical performance in very healthy community-dwelling adults. however, until now, the relationship of serum gdf-15 level with sarcopenia in community-dwelling older adults has not been well characterized. objectives: this study aimed to investigate the association between serum gdf-15 levels and sarcopenia in community-dwelling older adults. methods: we analyzed 929 participants (mean age, 75.9±8.9 years; 48.0% men) who underwent measurement of serum gdf-15 level and sarcopenia parameters, using their baseline data from the korean frailty and aging cohort study. participants with reduced kidney function, specifically an estimated glomerular filtration rate (egfr) from creatinine of <60 ml/min/1.73 m2, were excluded. serum gdf-15 level was quantified with an enzyme-linked immunosorbent assay kit. appendicular skeletal muscle mass was measured using dual-energy x-ray absorptiometry. sarcopenia status was determined in accordance with the asian working group for sarcopenia (awgs) 2019 guidelines. results: according to the awgs 2019 algorithm, 154 (16.6%) of the participants in the whole study population were classified as having sarcopenia. gdf-15 concentration had significant negative correlations with appendicular lean mass (men, r = -0.183, p < 0.001 and women, r = -0.118, p = 0.009), grip strength (men, r = -0.150, p = 0.001 and women, r =-0.113, p = 0.013), and gait speed (men, r = -0.148, p = 0.002 and women, r = -0.137, p = 0.002). in the multivariate analysis adjusted for potential confounders, the highest gdf-15 quartile (>=1245 pg/ml) was associated with a greater risk of sarcopenia (odds ratio [or] = 1.95; 95% confidence interval [ci], 1.15-3.31) than the lowest quartile (<885 pg/ml). these associations remained unchanged (or = 1.90; 95% ci, 1.14-3.23) after further adjustment for potential biomarkers (e.g., myostatin, dehydroepiandrosterone, and insulin-like growth factor-1). the or per unit increase in log-transformed gdf-15 level was 3.59 (95% ci, 1.21-10.70). conclusion: higher circulating gdf-15 levels were independently associated with a greater risk of sarcopenia in community-dwelling older adults. gdf-15 may be considerate a promising biomarker of sarcopenia. background: frailty has been recognized as an emerging public health problem in rapidly aging populations worldwide. use of biomarkers to identify frailty has been suggested for early frailty screening. among multiple risk factors of frailty, inadequate nutrition such as inadequate intake of protein and vitamin d has been shown to be associated with increased risk of frailty. therefore, nutritional biomarkers could be useful for early screening of frailty. objectives: to review the evidence of potential biomarkers, especially nutritional biomarkers for early screening of frailty in community-dwelling older adults. methods: a literature search was conducted using pubmed and scopus databases. studies evaluating blood biomarkers and frailty in community-dwelling older adults from 2000 to 2019 were included. information on the definition of frailty, study design, characteristics of the study populations, and the associations between biomarkers and frailty was summarized. results: in total, 95 studies were identified in which 60 observational studies were published since 2015. majority of studies used physical frailty. other definitions such as multidimensional, social and frailty were also used. 123 biomarkers were identified. cross-sectional and longitudinal studies consistently showed that low level of vitamin d was associated with frailty. emerging scientific evidence suggested that abnormal level of albumin, low levels of high-density lipoprotein (hdl), beta-hydroxy beta-methylbutyrate (hmb), vitamin b6 (measured by pyridoxal-5-phosphate), carotenoids, or a-tocopherol (vitamin e), and high level of dp-ucmgp (marker of vitamin k) could have the potential for frailty screening. besides nutritional biomarkers, the evidence showed that inflammatory markers such as c-reactive protein (crp), interleukin-6 (il-6), and fibrinogen, and endocrine-related markers such as hemoglobin, dehydroepiandrosterone sulfate (dheas), and hemoglobin a1c could be useful for screening frailty. additionally, there is evidence suggesting that some oxidative or immune-related markers were associated with frailty. conclusion: vitamin d could be a useful nutritional biomarker for early frailty screening in the community setting. other nutritional biomarkers, inflammatory markers and endocrine-related markers could be associated with frailty. further research is needed to validate and refine other potential biomarkers. jonathan quinlan 1,2,3 , amritpal dhaliwal 2,3 , felicity williams 2,3 , matthew armstrong 3,4 , leigh breen 1,3,5 , ahmed elsharkawy 3,4 , carolyn greig 1,3,5 , janet lord 2,3,5 ( (1) background: end stage liver disease (esld) is associated with reduced muscle mass with a reported incidence of sarcopenia of 40-60% (bhanji, 2017). loss of muscle mass in esld patients has a negative impact on clinical outcomes including mortality and recovery rates from liver transplantation (montano-loza, 2014) . previous research has investigated loss of muscle mass in esld via appendicular skeletal muscle mass and psoas muscle cross sectional area (csa) using dxa and magnetic resonance imaging (mri) respectively. however, the quadriceps muscle group has high functional significance and thus should be investigated in esld patients in whom function may be limited. ultrasound (us) offers a non-invasive, bedside imaging assessment of quadriceps muscle mass. however, esld may be associated with increased subcutaneous fat which can present an operational challenge for us and thus its application in esld patients requires validation. objectives: the aim of this research is to validate the accuracy of ultrasonographic measures of quadriceps muscle mass by comparison with the gold standard of mri. methods: 24 parallel mri and us were collected from patients with an esld diagnosis and awaiting liver transplant (12 patients, age 52±10yrs, bmi 28.4±6.4). participants underwent us scanning of both left and right quadriceps followed directly by an mri. specifically, measures of vastus lateralis (vl) muscle thickness (mt) and quadriceps csa were obtained at 50% femur length during longitudinal and extended field of view us respectively. to enable direct comparison with quadriceps csa obtained during mri, an oil capsule was placed upon the leg to mark the exact location of us image collection. all procedures received research ethics committee approval and written informed consent from the participants. results: a significant (p<0.001, n=24) positive correlation was found between vl mt and quadriceps csa obtained via mri (r2=0.42). similarly, there was a significant positive correlation (p<0.0001, n=22) between csa obtained via extended field of view us and mri (r2=0.97). bland-altman plots demonstrated a bias of -0.07 ± 1.4cm2, with 95% limits of agreement of -2.96cm2 and 2.83cm2. conclusion: our data demonstrate that the assessment of quadriceps csa and vl mt via us may offer a suitable bedside alternative to mri in patients with esld. background: sarcopenia is defined as the gradual ageassociated loss of both muscle quantity and strength in older adults, and severe sarcopenia affects subject performance (such as reduced gait speed). it is a devastating condition, predicting an increase in mortality, falls, fractures and hospitalizations. current clinical criteria diagnose sarcopenia through dual x-ray absorptiometry (dxa) measures of muscle mass, a test that cannot be performed at the bedside and is rarely used to find this condition. point-of care ultrasound (pocus) is rapidly becoming a standard part of the physical exam, and has the potential to become a quick, noninvasive marker for both muscle mass and function. objectives: we examined the relationship between ultrasound measures of muscle mass (vastus medialis thickness, mt) and other measures of muscle quantity (appendicular skeletal mass, asm; mid-arm biceps circumference, mabc). we also examined the association between mt and measures of muscle strength (grip strength) and muscle performance (gait speed) in an older adult population. methods: 150 older adults (age >= 65; mean age 80.0±0.5 years, 66 women, 84 men) were recruited sequentially from geriatric medicine clinics. each subject had appendicular skeletal muscle mass (asm, by bioimpedance assay), grip strength, mid-arm biceps circumference (mabc), gait speed, and an ultrasonic measure of muscle quantity (mt, vastus medialis muscle thickness) measured. our initial models contained age, sex, bmi, and mt as predictor variables, and our outcome variables were asm, grip strength, mabc and gait speed. results: in our final parsimonious models, mt showed a strong significant correlation with all measures of muscle mass, including asm(standardized ß=0.204±0.058, r2 = 0.58, p<0.001) and mabc(standardized ß = 0.141±0.067, r2 = 0.77, p=0.038). with respect to measures of muscle quality, there was a strong significant correlation with grip strength (standardized ß = 0.156±0.058, r2 =0.51, p=0.008) but not with subject performance (gait speed). conclusion: mt showed strong correlations with both measures of muscle mass (asm and mabc) and with muscle strength (grip strength). riki kosugi 1 , yung-li hung 2 , toshiharu natsume 3 , shuichi machida 4 ((1) faculty of health and sports science, juntendo university, inzai, chiba, japan; (2) institute of health and sports & medicine, juntendo university, inzai, chiba, japan; (3) coi project center, juntendo university, bunkyo-ku, tokyo, japan; (4) graduate school of health and sports science, juntendo university, inzai, chiba, japan) background: loquat (eriobotrya japonica) leaves are commonly used in teas and folk medicines. recently, loquat leaf extract (lle) has been reported to promote muscle protein synthesis in vitro. additionally, resistance exercise has been shown to promote muscle protein synthesis in vivo. it is considered that lle and resistance exercise might have a synergistic effect on activating muscle protein synthesis. however, this has never been investigated. objectives: the purpose of the present study was to investigate whether lle enhances the muscle contraction-induced activation of muscle protein synthesis signaling in rats. methods: male wistar rats (12 weeks old, n=6-7/group) were categorized into a control (con) group, an lle-administered (lle) group, an electrical muscle stimulation (ems) group , and an ems with lle (ems+lle) group. rats were administered lle (1.5 g/kg/ day) or distilled water once in a day by oral gavage for 7 days. on the seventh day, 3 h post-lle administration, the gastrocnemius muscle of the right legs of ems group and ems+lle group rats were stimulated by ems (100 hz, 30 v) through 5 sets of 10 isometric contractions (7 s contraction, 3 s rest) with 3 min inter-set intervals. rats were then sacrificed and their gastrocnemius muscles were rapidly excised 3 h post-ems. expression levels of muscle synthesis-related proteins [protein kinase b (akt), mammalian target of rapamycin (mtor), and ribosomal protein s6 kinase beta-1 (p70s6k)] were determined by western blotting. results: no significant differences were observed in body weight, water intake, and diet intake among the groups. akt phosphorylation at ser473 was found to be significantly increased in the ems+lle group compared to that in con group; mtor phosphorylation at ser2448 did not show a significant difference. p70s6k phosphorylation at thr389 was found to be significantly increased in the ems group compared to that in con group, while the ems+lle group was observed to have significantly higher p70s6k phosphorylation at thr389 than the ems group. conclusion: our study suggests that lle enhances the muscle contraction-induced activation of p70s6k phosphorylation. background: metabolic aging has emerged as a new sedentarity related syndrome combining metabolic diseases and sarcopenia, a degenerative loss of skeletal muscle mass, quality, and strength associated with aging. it has been recently shown that kynurenic acid (ka), a key metabolite of tryptophan/ kynurenine pathway, improved glycemic control and lipid profile in rodents. objectives: to show that ka has a key role in metabolic aging, we have evaluated its effect on muscle function and mass in vitro and in vivo in muscle cell line and in a model of hindlimb immobilization in mouse. methods: in vitro in c2c12 muscle cells we measured the ability of ka to inhibit myostatin gene expression (endogenous inhibitor of muscle growth), stimulate protein synthesis and enlarge muscle cell size. differentiated cells were exposed to ka for 2h30 for protein analysis, 6h for gene study and the 5 days of differentiation for cell enlargement examination. in vivo, muscle mass (tibialis and soleus) was measured after a 1 week-hindlimb immobilization in mice treated or not with ka (3mg/kg.day per os). results: in vitro, ka significantly and dose-dependently inhibited myostatin gene expression, stimulated protein synthesis and enlarged c2c12 muscle cells. in mice, ka treatment significantly reduced tibialis and soleus muscle wasting induced by immobilization. conclusion: we demonstrated for the first time the positive impact of ka on muscle function and mass preservation offering a promising therapy for patients affected by metabolic aging, who do not currently benefit from relevant therapeutic solutions. â n g e l a m a r i a p e r e i r a 1 , 2 , 3 , a n a f r e i t a s 1 , a n a p a c i f i c o 1 , c a t a r i n a c o s t a 1 , m a r g a r i d a a l m e i d a 1 ((1) physiotherapy departement, escola superior de saúde egas moniz, portugal; (2) centro de investigação interdisciplinar egas moniz, monte da caparica, portugal; (3)hospital garcia de orta, almada; portugal) background: as people age they are more likely to fall. although most fall-related injuries are minor, they can cause significant pain and discomfort, affect a person's confidence and lead to loss of independence. some falls can cause serious long-term health problems. one strategy to promote greater adherence and motivation to intervention in physical therapy is the use of virtual environment (ve) programs associated with a balance exercise programs as an effective method of preventing falls. objectives: the purpose of this study was to analyze the benefit of a virtual environment exercise program in non-institutionalized elderly at the end of six weeks. methods: in this randomized controlled trial 80 non-institutionalized elderly were included. 40 subjects, age 81.6±7.9 yrs constituted the experimental group (eg); and 40, age, 81.9±76.1 yrs constituted the control group (cg). the eg was submitted to 6 weeks of a ve exercise program performed on a nintendo wii, and to a set of recreational activities. the cg only performed the activities. the instruments used in the present study to evaluate performance were tinetti's index, which evaluates the static balance and the gait to quantify the risk of fall, and the fullerton's functional fitness tests to assess physical parameters such as strength, aerobic endurance, flexibility and agility/ balance. results: at the end of the 6 weeks of intervention in a virtual environment, significant improvements in upper limb strength, agility and static balance were observed. in the intragroup comparison, it was possible to verify improvements in all physical fitness battery tests. the values of functional fitness tests were significantly different (p<.05) between eg and cg groups for the following variables: 30-second chair stand 15.1±3.1 vs. 10.8±2.9 times; arm curl 16.8±3.5 vs. 13.8±4.6 times; 8-foot up-and-go 9.7±2.3 vs. 15.8±5.1 sec; two min. step 126.8±34.9 vs. 75.7±34.8 steps, respectively; as well as for the tinetti index. conclusion: this study, suggests that exercise in ve context applied to non-institutionalized elderly, promotes improvements in mobility, in lower limbs muscular strength, and may help to reduce the risk of falls by improving the static and dynamic balance. background: the small non-coding micrornas (mirs) are endogenous regulators of gene expression. they bind to complementary sequence on target messenger rna transcripts resulting in translational repression or target degradation. they are involved in the skeletal muscle response to training in animals and humans (kirby, 2015) . objectives: the aim of our study was to measure the effects of high intensity interval training (hiit) associated or not with l-citrulline on the expression of serum and muscle mirs in a group of men. methods: we selected 9 men (mean age: 66.6 ± 2.9 years, 6 men in the placebo group and 3 in the l-citrulline group, 10 gr/day) from a cohort of 56 men and women submitted for 12 weeks to hiit (buckinx, 2018) . we evaluated the expression of serum and muscle mirs before and after training. the quantification of mir expression was performed using the next generation sequencing (ngs) technique (exiqon). for statistical analysis, the measurements were normalized with the tmm method (trimmed mean of m-values). results: we identified 225 mirs from serum and 379 mirs from muscle above the detection limit (>= 1 tpm, tags per million). after benjamini-hochberg correction, 5 serum mirs from the l-citrulline group had a significantly different level of expression before and after training: 744-5p, 106b -5p, 484, 151a-3p and -6511a-3p (p <0.05, 5% fdr). no mir of the placebo group had a significantly altered expression. in muscle, our approach revealed 59 mirs with a significantly different level of expression before and after training in the placebo group and 8 in the l-citrulline group, 7 of which were common to both groups. these mirs were different from those highlighted at the serum level. the 5 most-expressed muscle mirs with the greatest difference in expression before and after training were 483-5p, 504-5p, 542-3p, 483-3p and 146b-5p (p <0.05, 5% fdr). conclusion: with the ngs approach, we identified 65 mirs differentially expressed before and after hiit. expression of circulating mirs appears to be influenced by l-citrulline. the next validation step will be to measure these specific mirs in the entire cohort to determine the clinical utility of these markers. background: recent interventional studies on frailty used multicomponent programs (physical exercise, cognitive stimulation, and nutritional supplementation) with some promising results. however, these emerging programs developed to counter the multidimensional concept of frailty still need methodological improvements to be completely effective. objectives: the objective of this innovative project is to develop personalized multicomponent interventions that could be easily used by frail older adults in order to reverse physical, cognitive and psychosocial symptoms associated with frailty. three original and specific action levers will be used to insure a better effectiveness: 1/to target a key population (hospitalized frail older adults who will be discharged to home), 2/to use a real multicomponent program (physical exercises simultaneously associated with cognitive and social components that mimic daily gestures), and 3/to encourage adherence through medical prescription. methods: one hundred and twenty frail older adults (>= 75) will be recruited from the geriatrics unit of the university hospital of tours (france), and randomly assigned to one of the two study arms: the intervention group (ig), who will receive a medical prescription of an adapted multicomponent intervention, vs the control group (cg; no intervention). twelve-week programs will be adapted according to observed intrinsic capacities of the frail older adults. including exercises will be based on effective international physical programs, with original cognitive and social components added to the physical exercises. all participants will perform pre-and post-tests to compare their physical health (gait speed, balance, and strength), cognitive health (global cognition and executive functions), and psychosocial health (self-efficacy and quality of life) before and after the three-month program. results: a pilot study to this rct has already started in tours. the international conference on frailty and sarcopenia research would be the perfect opportunity to share preliminary results. the intervention will be considered as feasible if ig participants adhere to > 75% of the prescribed exercise and as effective if we observe significant improvements in all clinical outcomes for ig participants, compared to the cg. conclusion: final objective will be to disseminate to a large number of individuals the idea that several concrete ways exist to age well. amanika kumar, clarissa polen-de, gladys asiedu carrie langstraat, aminah jatoi (mayo clinic, rochester, minnesota, usa) background: frailty in patients with advanced stage ovarian cancer (oc) is common and associated with increased oncologic and surgical morbidity and mortality. prehabilitation is one option to reverse frailty in this subset of patients. objectives: our aim was to investigate potential barriers and facilitators of prehabilitation during neoadjuvant chemotherapy (nact) in oc patients. methods: we identified 16 patients who underwent nact from 2016-2018 at a large volume single institution. patients underwent a semi-structured one-on-one phone interview. transcripts from interviews were read by 4 independent reviewers to identify emerging themes related to patients' experience, functioning and exercise during chemotherapy. results: five primary themes emerged following analysis of the participants transcripts. participants were overall willing to participate in exercise during chemotherapy, with 12/16 patients stating they would walk or did walk at least 30 minutes daily during treatment; this was linked to a strong motivation to improve surgical and survival outcomes. only 1/16 patients stated they were not interested in exercise during treatment. most notable, patients' motivations were tied closely to physician recommendation. patients prominently identified a shift in health as a priority following their ovarian cancer diagnosis, which subsequently lead to an increase in daily activities and exercise. surgery and improvement in mental well-being were strong motivators for patients to start or continue an exercise program. participants also identified barriers to exercise during treatment including a variety of treatment related and nontreatment related concerns, including neuropathy, nausea, pain, program availability, time and most significantly fatigue. despite this, most retrospectively thought they would have been willing to exercise with modifications. almost all participants voiced the importance of a supportive treatment community, including their medical care team, family, friends and the local community. conclusion: patients with advanced ovarian cancer demonstrated high motivation and willingness to exercise during chemotherapy when there was a perceived benefit to overall survival. prehabilitation may be a helpful to improve outcomes, but a prehabilitation strategy should be designed specifically for the patients with the most need and designed with barriers and motivators in mind. randomized control trial. kosuke fujita 1,2 , hiroki umegaki 2 , aiko inoue 1 , huang chi hsien 1,2 , hiroyuki shimada 3 , masahumi kuzuya 1,2 ((1) institute of innovation for future society, nagoya university nagoya, japan; (2) department of community healthcare and geriatrics, nagoya university graduate school of medicine nagoya, japan; (3) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology obu, japan) background: gait disorder in older adults could lead fatal consequence following falling or reducing physical activity, especially in individual with pre-clinical / clinical cognitive decline. effectiveness of exercise intervention for the gait characteristics has been examined in previous studies, however, evidence about differences between exercise modality such as aerobic training (at) and resistance training (rt) for the acute and long phase is unclear. objectives: the aim of the present study was to compare the effect of different exercise modality on the gait characteristics of older adults with preclinical cognitive decline. methods: 415 individuals (mean age, 72.3 years) with self-reported cognitive decline were enrolled in randomized controlled trial. subjects assigned to at group (n = 104), rt group (n = 102) and at+rt group (n = 104) underwent exercise intervention 2 days a week for 26 weeks. subjects assigned to control group (n =105) were provided information about healthy aging. gait characteristics were examined before, just after the intervention and after the 26 weeks of follow-up period using an electronical walkway system. results: in the analyses about the change between pre and just after the intervention period, all of three exercise groups significantly improved gait velocity (at, p < 0.01; rt, p < 0.01; at+rt, p < 0.01), stride time (at, p < 0.01; rt, p = 0.03; at+rt, p < 0.01), cadence (at, p < 0.01; rt, p = 0.02; at+rt, p < 0.01), stride length (at, p < 0.01; rt, p = 0.04; at+rt, p < 0.01) and double support time (at, p < 0.01; rt, p < 0.05; at+rt, p < 0.01), and at+rt group improved significantly with cv of step width (p < 0.05). in the analyses about the change between pre and follow-up period, rt group only had improvements with gait velocity (p < 0.05), stride length (p = 0.03) and double support time (p = 0.04). conclusion: all exercise interventions could improve gait characteristics of older adults with pre-clinical cognitive decline. for the purpose of maintain improved gait characteristics for a long phase, rt is likely to be recommended. activity and a broader array of physical and psychological outcomes among nursing home residents. however, some limitation of this game should be acknowledged (e.g. too long, too bulky, exercises too simple). taking into account these weaknesses, we decided to develop and validate a new version of a giant exercising board game: the gamotion. objectives: to evaluate the impact of gamotion on physical capacity, motivation and quality of life among nursing home residents. methods: a one-month randomized controlled trial was performed in two comparable nursing homes. eleven participants (71.63±8.15 years; 7 men) meeting the inclusion criteria took part in the intervention in one nursing home, whereas 10 participants (84±7.57 years; 4 men) were assigned to the control group in the other institution. the gamotion required participants to perform strength, flexibility, balance and endurance activities. the assistance provided by an exercising specialist decreased gradually during the intervention in an autonomy-oriented approach based on the selfdetermination theory (ryan & deci, 2002) . physical capacity (i.e. quantitative evaluation of walking using locometrix; grip strength using jamar dynamometer; knee extensor isometric strength using microfet2; fall risk using tinetti test; dynamic balance using timed up and go test (tug) and physical abilities using sppb test), motivation (i.e. using behavioral regulation in exercise questionnaire-2) and quality of life (i.e. using eq-5d questionnaire) were assessed at baseline and at the end of the intervention. a two-way repeatedmeasure analysis of covariance (ancova) was used to assess time*group (intervention vs. control group) effects. results: globally, during the intervention period, the experimental group displayed a greater improvement in symmetry of steps (p=0.04), tinetti score (p<0.0001), tug (p=0.02), sppb (p<0.0001), knee extensor isometric strength (p=0.04), grip strength (p=0.02), 3 domains of the eq-5d (i.e. mobility, self-care, usual activities : p<0.0001) and intrinsic motivation (p=0.02) compared to the control group. conclusion: the effects of gamotion on physical capacity, motivation and quality of life of nursing home residents confirm the results obtained with the previous version of the giant exercising board game. in-hospital stay, even in short stays, is associated with functional impairment in older patients. objectives: the agecar plus study aims to evaluate the effectiveness of a program of physical exercise and health education to prevent the functional deterioration during the in-hospital stay. methods: randomized clinical trial. patients older than 74 years admitted to the ace of the general university hospital gregorio marañón were included and randomized at admission in control group (cg) or intervention group (ig). exclusion criteria were baseline barthel (15 days before admission) less than 20 points, severe cognitive impairment or unable to walk. both groups received usual care, and patients in intervention group also performed simple supervised exercises (strengthening of lower limbs, walking, and inspiratory muscle training). in the preliminary analysis, we analyzed the effect of the intervention on changes in short physical performance battery (sppb) and alusti test, at admission and discharge, by t-test of repeated measures in the 2 study periods. results: from may 2018 to february 2019, 55 patients were included: 28 gc and 27 ig. the cg and ig were homogeneous in sex (women 47.3%), age (86.5±5.1 vs. 87.6±4.5), comorbidities (charlson: 2.3±1.8 vs. 2.9±2.1), cognitive impairment (pfeiffer: 6.8 ± 2.7 vs. 7.5±1.6), fragility (fried >=3: 69% p=0.297), and functional-physical capacity (sppb: 3.6± 06 vs 3.9±3.4; alusti, 61.4±14.1 vs 60.2±13.0). p <0.05 for all variables. a significant effect of the intervention was found, with a higher mean score in the alusti test in the ig (cg: 63.5±12.4 vs 67.3±12.5; f(1,50)=4.6; p=0.038), not finding such differences with the sppb (4.0±2.3 vs 4.5±3.4; f(1,48) =0.47; p=0.496). conclusion: the preliminary analysis shows that the alusti test could be used as an evaluation test for functional capacity in hospitalized elderly patients. a physical exercise program during hospitalization in an acute unit improves the functional capacity assessed by the alusti test at discharge significantly. funding: instituto de la salud carlos iii (pi17/02021), ciberfes, fondo europeo de desarrollo regional (feder). the authors declare no conflicts of interest. a. sampaio 1 , i. marques-aleixo 1,2 , j. carvalho 2 ((1) ciafel -research center in physical activity, health and leisure, faculty of sport, university of porto, portugal; (2) faculty of psychology, education and sports, lusófona university of porto, portugal) background: cognitive impairment is a highly prevalent, poorly managed, and disabling consequence of dementia. exercise training that improves physical fitness can represent a promising approach for managing cognitive impairment in persons with dementia. objectives: the aim of this crosssectional study investigated the association of physical fitness and balance with cognitive function. methods: sixty-four institutionalized older adults, aged 78.0±8.4 years, with dementia, predominately female (70%) and with dementia due to alzheimer's disease (53.1%). regression analyses were used to examine associations between physical fitness components (senior fitness test), balance (tinetti index) and cognitive function (mini-mental state examination). results: univariate regression indicates a significant association between the strength of the upper body (p=0,047) and aerobic endurance (p=0,037) with the cognitive function in older people with dementia. conclusion: these results suggest an association between the specific dimensions of physical fitness and cognitive function. consequently, multicomponent exercisebased therapeutic strategies aiming to improve physical fitness could be an important nonpharmacological strategy for dementia management. satoshi kurita, takehiko doi, kota tsutsumimoto, sho nakakubo, hideaki ishii, hiroyuki shimada (section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: women had higher risk of cognitive impairment or dementia compared to men. although studies reported physical activity (pa) and/or cognitive activity (ca) had protective association with cognitive impairment among older adults, it is unknown whether the association is depended on sex or not. objectives: the purpose of the present study was to examine the sex differences in the association of pa and/or ca with cognitive impairment in community-dwelling older adults. methods: a community-based cohort survey was conducted in a total of 2726 participants (mean age 75.5 ± 3.9 years; 51.8% female) who met the study criteria. time of moderate-to-vigorous intensity pa was measured using an accelerometer. ca was assessed by the frequency of engaging in 6 activities using a ca scale including reading, doing crossword puzzles, and playing board games or cards. participants were categorized into four groups based on quartile 1 (low) and 2 to 4 (high) values of pa and ca. cognitive impairment was defined by at least 1 out of 4 neuropsychological tests having a result at least 1.5 standard deviation below the reference threshold. results: in both sex, the prevalence of cognitive impairments showed significant differences among 4 groups; that of low pa/low ca group, low pa/high ca group, high pa/low ca group, and high pa/high ca group were respectively 30.6%, 18.0%, 20.4%, and 14.1% for male (p <0.001) and 28.1%, 18.8%, 21.8%, and 15.4% for female (p <0.01). in binomial logistic regression models for male, all groups showed a low odds ratios of cognitive impairment compared to the low pa/low ca group (odds ratio = 0.50 to 0.66, all p <0.05), while for female, only high pa/high ca group had significant association with cognitive impairment (odds ratio = 0.53, 95% confidence interval = 0.32 to 0.88, p = 0.015). conclusion: in male, pa and ca are associated with cognitive impairment even in the case of low engagement in either pa or ca. in female, higher engaging in both activities are associated with cognitive impairment. female older adults may need to engage in more activities than male to acquire benefit on preventing cognitive impairment. (139 interventions) were included in the systematic review and 64 in the meta-analyses (86 interventions). there was considerable heterogeneity in the number for interventions that detected significant increases in muscle mass (50/139, 36%) and muscle strength (61/86, 71%). of those muscle strength interventions 9/24(38%), 52/74(70%), 20/26(77%) and 4/4 (100%) interventions reported a significant increase in handgrip strength, lower body muscle strength, upper body muscle strength and whole body muscle strength respectively. ret factors associated with the greatest gains in muscle mass and muscle strength were: use of combination of equipment, seven to eight exercises per session with three lower body exercises, a volume of three to four sets and 12 to 15 repetitions per exercise, a frequency of two-three days per week, intervention length of greater than six weeks, progressive intensity, intervention duration of 15-45 minutes, and in a supervised individually training structure. these results align with current guidelines provided by american, australian, japanese, british, canadian and japanese societies. conclusion: not all ret interventions are effective for improving muscle mass and strength, but our meta-analysis suggests that adhering to the current ret guidelines for older adults are likely to be most effective. duarte barros, andreia pizarro, arnaldina sampaio, joana carvalho (research center in physical activity, health and leisure, faculty of sports, university of porto, portugal) background: sedentary time (sed) and low physical activity (i.e. low levels of moderate-to-vigorous physical activity [mvpa] ) are different behaviours associated with negative health outcomes, but how synergetic combinations of these behaviours impact the risk of frailty are still unexplored. objectives: to examine the relationship between different combinations of sedentary time and mvpa in the risk of being frail. methods: a cross-sectional study including 152 community dwelling elders (74.37±6.29 years; 66.4% female) accessed frailty through the phenotype of frailty. daily sed and mvpa were objectively measured using accelerometry. sed and mvpa were ranked by the median and then participants were categorized into one of four groups: lowsed+lowmvpa, l o w s e d + h i g h m v p a , h i g h s e d + l o w m v p a a n d highsed+highmvpa. results: overall, 13.2% of the participants were frail. mvpa was associated with reduced odds of being frail (or 0.958 ic: 0.938-0.979, p < 0.001). moreover, compared to the highsed+lowmvpa, the groups lowsed+highmvpa (or 0.34 ic: 0.127-0.825, p = 0.018) and highsed+highmvpa (or 0.086 ic: 0.027-271, p < 0.001) were associated with reduced odds of being frail. conclusion: mvpa seems associated with reduced odds of being frail, irrespective of sedentary time. background: sarcopenia is central to frailty and the strongest evidence for reversal lies in the combination of resistance exercise and protein supplementation. unfortunately, uptake amongst older adults remains low, partly due to a lack of suitable exercise programs. delivery by health professionals alone will not achieve widespread participation. objectives: defrail aims to develop a novel exercise program (focused on resistance training), feasible for delivery to frail older adults in a group setting without the input of health professionals, and to examine its effect when combined with commercially-available protein-supplemented milk. methods: a multi-component exercise program was designed by expert consensus using a modified delphi process. participants were recruited from geriatric medicine clinics and primary care, with assessments at baseline, after eight weeks of regular activity and then after the eight-week intervention. the primary outcome measure was the change in the fried frailty criteria (ffc) during the intervention compared with the period of regular activity. secondary outcome measures included the timed up & go (tug) and 30-second sit-to-stand (30sts) tests. results: the first 12 participants to complete the program (7 females, 5 males, mean age 84, range 78-91) had a median ffc score of 3 (interquartile range (iqr) 3,3), i.e. frail, both at baseline and after the period of regular activity period, but had improved to 2 (iqr 1,2), i.e. pre-frail, following the intervention. similarly, the median tug was 17.5 (iqr 14.6, 19) at baseline, increasing to 18.8 (iqr 15,22.2) after the period of regular activity, improving to 15.5 (iqr 13.2,18.7) following the intervention. the median 30sts was 6 (iqr 3,8) at baseline, 6 (iqr 5,7) after the period of regular activity, improving to 8 (iqr 6,9) following the intervention. conclusion: median frailty improved from frail to pre-frail for the first 12 defrail participants. this program could allow increased community-based participation in resistance exercise for frail older adults. further work now includes completion of the intervention and analysis of data on a range of secondary outcome measures (assessments of cognition, mood, pain, body mass composition and biochemical markers of frailty). background: exercise interventions have been shown to improve functional status and quality of life of frail older people, and in some cases to reverse frailty status. it is important that such interventions are targeted to those people who would benefit the most. objectives: the objective of this pilot study was to assess the effectiveness of a physical activity intervention given to mildly frail older people, who were identified using electronic health records (ehr). methods: the electronic frailty index (efi) was used to identify mildly frail older people and offer them a physical activity intervention of their choice. the pilot study was offered in one area of luton (uk), with invitation letters sent by the participants gp. participants were tested before and after a 12-week programme of strength, balance and mobility, delivered in a weekly session lasting one hour. participants were assessed at baseline for motivation using the patient activation measure (pam), physical function using the short physical performance battery (sppb), and fear of falling using the falls efficacy scale international (fes-i). each test was carried out in a follow-up test after the programme had concluded. bootstrapped paired t-tests were used to assess the effect of the intervention. results: twenty-seven people aged 74.6 ± 5.4 years took part in the intervention. the pam scores improved from 74.5% to 83.6% (9.1, 95% ci: 2.9, 14.7), which is twice the minimal clinically important difference (mcid) of 4. for sppb, there was an improvement from 8.5 to 9.8 (1.27, 95% ci: 0.71, 1.86). the average increase was greater than the mcid for a substantial improvement of 1.0. when fes-i was assessed, only three people (11%) had high concern about falling. there was no significant improvement in fes-i after the intervention (-2.5, 95% ci: -5.3, -0.2). after the intervention, 62% of participants choose to pay for the continuation of the programme. conclusion: the findings of this study suggest that a targeted exercise programme including strength and balance training can significantly improve motivation and functional status among mildly frail older people identified using the efi, with the majority choosing to continue exercising. background: despite frailty has traditionally been examined from a physical standpoint, recent studies advocate for the existence of cognitive frailty (1), and suggest that both physical and cognitive frailty are interrelated. thus, interventions should aim to prevent or attenuate the effects of frailty from a multidimensional perspective. objectives: to evaluate the effects of three different exercise programs on frailty among older adults living in long-term nursing homes (ltnh). methods: 128 participants (67.3% female) met the following criteria: aged 70 years, scored 50 on the barthel index, scored 20 on mec test (an adapted version of mmse in spanish) and capacity to stand up and walk 10m independently. participants were randomly assigned to a progressive multicomponent group (mcg; n=43), a multicomponent dual-task group (dtg; n=42), or to a walking group (wg; n=43). the mcg underwent a 3-month moderate intensity strength and balance exercise program twice a week. the dtg performed simultaneous cognitive training (attention, inhibitory control, calculations and semantic memory) to the mc program. the wg walked up to 20 minutes per day for 7 days a week. frailty was measured though the following tests: fried frailty index (ffi), the tilburg frailty index (tfi) and the study of osteoporotic fractures (sof). results: the ffi revealed reductions in frailty in all groups, although only the mcg and the wg reached statistical significance (p<0.05). as for the tfi and sof tests, no statically significant differences were found in any of the groups. however, there was a positive trend in tfi in the dtg (p=0.07). no group-by-time interactions were found in any of the frailty tests used (p>0.05). conclusion: our study showed no differences between interventions regarding frailty. however, the mcg and the wg showed significant reductions in phenotypic frailty, whereas the dtg showed a positive trend in the tfi, which takes into account physical, psychological and social domains. therefore, further studies should explore the effects of different exercise modalities on frailty from a broad perspective in older adults living in ltnhs. references: kelaiditi et al 2013 . j nutr health aging. 2013 17(9) :726-34. noirez 1,2 , iraj hashemi 1 , deborah kopoin 1 , pierrette g a u d r e a u 3 , m a r c b é l a n g e r 2 , g i l l e s g o u s p i l l o u 2 , josé a morais 4 , aubertin-leheudre 1 ( (1) background: aging leads to a loss of muscle strength and functional capacity. these phenomena can be slow down by daily exercise practice or resistance training intervention. objectives: the aim of this study was to investigate in elderly men muscle fiber size and type after resistance training. methods: among sedentary older men who completed a 12-week mixed power training program, 8 were biopsied in the vastus lateralis before and after the program. cross sections were performed on these muscles, followed by triple immunohistochemical staining with antibodies directed against laminin, myosin heavy chain (myhc)-1 and myhc-2a coupled with staining with secondary fluorescent antibodies. immunostaining analysis of laminin allowed us to determine fiber size and these of myhcs to determine fiber type. results: the size of the muscle fibers remained the same between before and after the mixed power training (p=0.71).there was no significant difference in the percentage of expression of myhc-1, 2a, 2x (p= 0.67, p = 0.34, p = 0.5286) between before and after intervention. in addition, there was no difference in the size of fiber expressing myhc-1 between before and after the training (p = 0.97). however, significant increase in the sizes of fiber expressing myhc-2a and myhc-2x (respectively p = 2e-04, p <.0001) after the mixed power training was observed. conclusion: in elderly men, an increase of the size in fibers both expressing myhc-2a and myhc-2x in vastus lateralis muscle could explained the improvement on muscle mass observed previously (carvalho et al. acer 2019) . to confirm the mechanism explanation of this promising exercise modality, mitochondrial parameters should be also analyzed. background: muscle (in)activation related with sedentary behavior (sb) and physical (in)activity (pa) is a risk for sarcopenia in older adults. although age is not yet a risk factor for sarcopenia in adulthood, other factors such as lifestyle may significantly contribute to its progression. objectives: considering the primary and secondary prevention of sarcopenia, the aim of this study was to analyze associations of sb and pa with markers of muscle strength (lower limb muscle power) and muscle mass (fat mass (fm) to fat free mass ratio (ffm) in adult women and men with and without deficits in these markers. methods: participants were 225 apparently healthy adults (147 women) with a mean age 45.2±9.4yrs, employed in activities requiring office work. fm and ffm were evaluated by bioelectrical impedance analysis (bia, 50 khz bia 101 rjl, akern bioresearch, florence, italy akern). muscle power relative to body mass (pmax/mass) was assessed during a single two-legged jump on a force platform (leonardo mechanograph, novotec medical, pforzheim, germany) . sb and pa were assessed by accelerometry (actigraph, gt3x model, fort walton beach, fl, usa) during four consecutive days (2-week+2-weekend days). the variables analyzed were time spent per day in sb, in light-, moderate-, vigorous-, moderate to vigorous-intensity pa, total pa and breaks per day of sb. multiple linear regressions were performed by stepwise to examine associations of sb and pa with muscle power and fm/ffm, separately for men and women with and without muscular deficits. for the identification of deficits (<-0.5 sd), muscle power and fm/ffm were standardized separately for men and women having as reference their respective mean. results: linear regressions by stepwise evidenced an association of sb with muscle power in women with muscular deficit (β = -0.360, p = 0.017, adjr2 = 11,9%%) and an association of vigorous pa with fm/ffm in men without muscular deficit (β = 0.501, p < 0.001, adjr2 = 23,5%). no associations were observed between sb or pa with muscle power or fm/ffm in other groups. conclusion: sb was negatively evidenced in women with muscle power deficit while vigorous pa revealed to be associated with fm/ffm in men without ffm deficit. funded by portuguese science and technology foundation; project c mup-eri/hc i/0046/2013 patricia parreira batista 1 , andré gustavo pereira de andrade 2 , jéssica rodrigues de almeida 1 , aimée de araújo cabral pelizari 1 , leani de souza máximo pereira 1 , lygia paccini lustosa 1 ((1) physical therapy department, ufmg -eeffto, belo horizonte, brazil; (2) sports department ufmg -eeffto, belo horizonte, brazil) background: the practice of regular physical activity in the older people leads to the decreased of the loss of muscle mass and function with advancing age, and enhances the functionality in activities of daily living and social interaction. in addition, exercise promotes gains in the quantity and quality of muscle fibers and improves muscle strength and power, acting as a protective factor for negative health-related outcomes such as falls, frailty, and hospitalizations. regular practice of physical activity is known to modify the chronic proinflammatory condition common in the older people. probably, exercise reduces the drive of catabolic stimuli from this proinflammatory cascade, modifies the metabolism and production of cytones in tissues and organs, promoting protective and anti-inflammatory effect in the body. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated women (60 years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all informed clinical and demographic data and performed the tests short physical performance battery (sppb) and timed up and go (tug). plasma dosages of stnfr and il-6 were by elisa method. comparison was by independent student t test. approval by the research ethics committee / ufmg (caae: 14129513.7.1001.5149). results: fiftytwo sedentary older women participated (74.35 ± 6.97 ys.); number of comorbidities of 2.83 ± 2.07; body mass index of 26.81 ± 4.25 kg/m2. from the active group were 45 elderly women (72.07 ± 5.23 ys.); comorbidity number of 2.22 ± 1.67; body mass index of 27.6 ± 4.81 kg/m2. there was significant difference between groups in sppb (p = 0.017), tug (p = 0.001) and stnfr1 (p = 0.01). conclusion: the results showed that the active older women had better functional and mobility performance and worse plasma stnfr levels. in this case, one can think about the possible influence of body mass index in these older women, which should be explored in future studies. background: our research group designed a comprehensive geriatric intervention program (cgip) consisting of resistance exercise, physical activity increments, oral functional care, and a nutritional guide. we conducted a 12-week intervention and investigated the effects. after the short-term intervention, we followed up the all participants. we hypothesized that the follow-up could mitigate the loss of short-term intervention effects. objectives: the aim of this study was to compare physical functions before and after the 12-week intervention, and the end of the follow-up. methods: a total of 526 were willing to participate in the 12-week cgip. we encouraged them to increase their daily steps and to carry out the program by using daily self-monitoring logs. the participants were randomly assigned to two groups [class-styled session (cs) group 251; home-based (hb) group 275] based on their residential districts. while cs group attended 90-minute weekly sessions and independently executed the program on other days, hb group did not attend the weekly sessions but received instructions on program execution. after the shortterm intervention, all participants were instructed to carry out the gcip habitually. also, three optional sessions for all participants were held in order to recommend implementation of the program. physical functions, such as knee extension strength (kes), maximum walking speed (mws), and anterior thigh muscle thickness (mt) were measured before and after the short-term intervention, and the end of the follow-up. results: of the 526 participants identified, 312 (cs 153; hb 159) took part in the measurements after the follow-up. thus, we analyzed their data. a significant interaction were observed in mws (p=0.033). the 12-week cs intervention significantly improved mws (p<0.001). but, mws in cs group significantly decreased after the follow-up (p=0.003). there was no significant difference between before the intervention and after the follow-up in mws in cs group. on the other hand, no significant change was observed in hb group. significant time effects were observed in kes and mt (p<0.001). both 12-wk interventions significantly improved kes and mt. while kes was maintained even after the follow-up, mt was significantly decreased. conclusion: the results suggested that appropriate follow-up helps to preserve short-term intervention effects. background: with the increasing prevalence of alzheimer disease and the current absence of drugs therapeutic, nonpharmacological strategies are definitively necessary. physical intervention is often proposed to aid in preventing or slowing cognitive decline. recent studies suggest that combining physical exercise with cognitive stimulation may have more global effect. objectives: we aimed at assessing effect of aerobic exercise alone or combined to intellectual exercises on major cognitive functions: attention (stroop), problem solving (hanoi tower) and working memory (digit span). subjects were trained twice a week for eight weeks. cognitive functions were assessed before training (base line), at the fourth and at the eighth weeks. to evaluate persistency of the effect, subjects were assessed one month after the end of training. methods: two groups were randomly constituted mild cognitive impairment subjects (mci) and alzheimer disease moderate patients (adm). each group was subdivided into three sub groups according to the task to be performed. aerobic exercise (pedaling) alone or combined to cognitive games presented on screen. control groups performed a reading task. results: an effect of training on cognitive functions was observed in adm as well as in mci subjects. however, only adm patient's performances were further improved by adding cognitive games. after four weeks, the observed effects were still maintained in both groups. mci results were obviously better than those of adm. there was no significant change in performances for control groups. conclusion: aerobic exercise induce cognitive improvement in adm and mci patients. combined physical exercise and cognitive games potentiated this effect mainly in adm group. this procedure has long lasting beneficial effect. this supports the necessity of regular aerobic exercise to prevent cognitive deficits in aging cognitive deficits. background: increasing physical activity represent a key therapeutic intervention to prevent the loss of mobility disability for enhancing health related quality of life. hence, we have set up a primary and secondary prevention care path through exercise training and nutrition to improve mobility and physical performances. objectives: our primary goal is to integrate a prevention care path into daily life of elders who may present a mobility disability risk. we aim to improve quality of life and mobility. methods: our program includes 70 years or more who present a risk of developing a mobility disability. initially, we identify and screen a risk of mobility disability in wide elders communities. we diagnose mobility disability risk factors, sarcopenia and frailty, in day hospital (dietician, geriatrician and a kinesiologist). we use the ewgsop2 algorithm to diagnose sarcopenia. the patient then attend a 3-months training program, including 2 sessions per week. sessions combine resistance exercises and balance training during 60 minutes. we support the patient for his own project of long-term maintenance quality of life between physical activity and nutrition. results: 152 patients have been seen after 20 sessions. physical performance was significantly improved after 3 months of intervention (sppb p<0,001, gait speed p<0,001 and time-up-and-go p<0,001) likewise grip strength (p<0,001). the "sarqol" score was also significantly higher (p<0.001). sub-group sppb ≤8 with severe sarcopenia improve significantly more its score (+1.6±1.9 p<0,001) comparing to the overall population (+0.6±1.7). moreover, there was a significant difference (p<0,001) for sppb at baseline between responders (7.6±2.3) and nonresponders (9.8±2.0). conclusion: our intervention enhances mobility through physical performance benefits. we can make the assumption that adverse events will be occurring less and physical dependence will be delayed, regarding gait speed improvement. patients with lower physical performance are responding better than the overall population meaning that our intervention is more specially indicated for patients with severe sarcopenia. furthermore, our program sustains motivation for physical activity and exercise after 3 months. we were able to show that it was possible to set up a comprehensive and effective care path for frail and sarcopenic elderly people. background: middle-aged adults who are pre-sarcopenic are at the highest risk of developing sarcopenia due to the progressive nature of the syndrome. objectives: to determine whether high intensity interval training (hiit) results in greater improvements in body composition, compared to a control group, in middle-aged adults with pre-sarcopenia. methods: eighty-two sedentary adults (40-50 yrs) with a low appendicular skeletal muscle mass index (asmi) were randomized into control (n=41) or intervention group (n=41) using stratified randomization based on age, sex and bmi. low asmi (asm/ht2) was determined by dxa (lunar prodigy, ge healthcare) using age-and sex-specific cut-scores as proposed by prado. the control group received one education session on general physical activity recommendations. the intervention was supervised, group-based, high-intensity aerobic and resistance interval training (hitt), 3 times weekly for 20-weeks. an intention-to-treat mixed model linear regression, with a random effect, was used to analyse group differences for body composition. results: 85.4% of the sample were female, the mean age was 45.1 yrs (3.1) and the mean bmi at baseline was 25.8 kg/m2 (3.5). 71 people (87%) completed the intervention, 39 people in the hitt group and 32 in the control group. no adverse events were reported. significant group differences were observed for total muscle mass (0.73 kg, 95%ci: 0.065-1.398), leg muscle mass (0.40 kg, 95%ci 0.121-0.681), asmi (0.21 kg/m2, 95%ci 0.087-0.331) and visceral fat mass our study indicated that group-based hiit is an effective, tolerable and safe exercise modality to increase total body and appendicular muscle mass, and to decrease visceral fat, in middle-aged adults with pre-sarcopenia. background: aging is related to body composition modifications and functional capacities declines. it is recognized than being active can prevent these changes and improve quality of life. however, it is unclear if gender or age influence this relationship and if a sub-type of voluntary physical activity is more efficient to maintain these physical parameters. objectives: to assess the association between current physical activity level or type and functional capacities and body composition among elderly people and to examine if age (< or >= 65 yrs old) or sex modulate the relationship. methods: functional capacities using different validated tests (i.e. grip strength, timed up and go, sit-to-stand, muscle power, alternate step test, leg extension, vo2 max), body composition (fat & fat-free masses) using dxa were assessed. current global (total) and specific (aerobic, resistance or body and mind) physical activity levels (duration) were obtained through a questionnaire. multiple regressions, adjusted on age, sex and bmi, were performed to assess the relationship between current physical activity level and functional capacities or body composition. sub-group analysis, according to the sex and age (<65y vs. >= 65y) were also performed by means of pearson correlations. results: a total of 525 subjects (61.7±8.1years; women: 68.9%; bmi=26.4±4.8kg/ m²) were enrolled. after adjustment on confounding factors, total current physical activity level has positive impact on total fat mass (%; β=-2.09, p=0004) and balance (β=0.10; p=0.05). moreover, current body & mind activities influence total fat-free mass (kg; β=-0.22, p=0.02) and balance (β=0.17; p=0.001) whereas resistance activities influence fat-free mass (kg; β=0.17; p=0.05), fat mass (%; β=-0.16; p=0.04) and sitto-stand test (β=-0.10; p=0.05). sub-analysis shows that total physical activity level was significantly associated with fat mass, sit-to-stand test, balance and vo2 max in women but not in men. moreover, among people under 65 y, the time spent on cardio activities does not affect functional capacities and body composition. nonetheless, among people aged 65 y and over, the time spent on resistance activities is associated with functional capacities and body composition. conclusion: being active is associated with body composition and functional capacities, especially among women aged 65 years and over. itxaso mugica-errazquin 1 , nagore arizaga 3 , janire virgala 3 , julen gomez 1 , garbiñe lozano 1 , yune aranburu 4 , udane elordi 1 , maider kortajarena 1 , ana rodriguez-larrad 2 , jon irazusta 2 ( (1) background: low physical fitness, frailty and dependency are highly prevalent in people living in long term nursing homes (ltnh). multicomponent physical exercise, including strength, balance and endurance, has demonstrated to be effective for improving physical fitness and reducing frailty in ltnh. however, there is no evidence that this type of programs are capable to improve or even maintain the levels of autonomy in activities of daily living (adl) of this population. objectives: the major aim is to ascertain whether a new approach of 6 months, individualized and progressive multicomponent program focused on functioning maintains autonomy in older adults living in ltnhs; the secondary aim is to assess the effects on frailty and physical fitness. methods: 77 people living in ltnh, between 70 and 103 years, participated in this single group interventional study. inclusion criteria were: >=70years, >=50 barthel index, >=20 mec-35 and be able to stand up from a chair and walk 10 meters with or without one person/technical assistance. the intervention consisted of 3 months of a progressive multicomponent physical exercise program (ep) aiming to improve the physical condition, followed by 3 months of physical exercises focused on functional adl with the objective of maintaining/improving autonomy of the participants. barthel index was used to assess autonomy level in adl, frailty was measured by fried frailty index and short physical performance battery (sppb) was used to assess physical fitness. the study is registered in u.s clinical trial (nct04221724) and approved by the committee on ethics in research of the university of the basque country (m10/2018/171). results: during the 3 first months of ep participants lowered the score in the barthel index (p<0,001). however, participants showed significant improvements in frailty (fried frailty index p<0,01) and in physical fitness (sppb p<0, 001) . from the 3rd to 6th months, while physical fitness of participants did not change, they improved autonomy in adl, and decreased frailty non-significantly. when comparing the effects of the entire intervention, barthel index did not change significantly and physical fitness and frailty improved (sppb p< 0,001; fried p<0,005). conclusion: this new approach of 6 months of individualized and progressive multicomponent program focused on daily functioning maintains autonomy in activities of daily living, improves physical fitness and reduces frailty in older adults living in ltnhs. shuji sawada 1 , hayao ozaki 1,2 , toshiharu natsume 1 , daiki nakano 1 , pengyu deng 1 , toshinori yoshihara 1 , takuya osawa 3 , shuichi machida 1 , hisashi naito 1 ((1) juntendo university, chiba, japan; (2) tokai gakuen university, aichi, japan; (3) japan women 's college of physical education, tokyo, japan) background: in previous study, we found that low-load resistance training using own body weight and elastic band even only biweekly could induce muscle hypertrophy in older adults after 12 weeks of training. however, it is unclear whether levels of different blood parameters before training associated with the effects of training. objectives: this study aimed to clarify whether levels of different blood parameters before training influenced the effect of low-load resistance training on lower limb muscle thickness (mt). methods: sixty-nine communitydwelling japanese subjects aged 69.4±6.5 years (49 women and 20 men) volunteered for this study and participated in a lowload resistance training program using their own body weight and elastic band. the training was performed biweekly for 12 weeks. each participant's mt at the anterior aspects of the thigh (at) was measured using a b-mode ultrasound device. further, the levels of the following blood parameters were assessed before and after the training program: serum albumin (alb), hemoglobin (hb), total cholesterol (tc), and hemoglobin a1c (hba1c). we checked the first quartile value of each blood parameter to establish the cutoff criteria for reduced levelsserum alb = 4.1 g/dl, hb = 12.6 g/dl, tc = 181 mg/dl, and hba1c = 5.3%. participants were divided into low or normal groups in each blood parameter, and their data were analyzed using two-way analysis of variance. results: when using the abovementioned criteria, biweekly low-load resistance training increased mt at the at in every group after training. the interaction between time and groups was only detected with low (<4.1 g/dl) versus normal (>=4.1 g/dl) serum alb levels. in this case, there was no difference in mt at the at before training, but participants in the normal serum alb level group had greater mt after training than those in the low serum alb level group. conclusion: the effect of low-load resistance training on lower limb mt appears to be limited in participants with low pre-training serum alb level. objectives: it was to estimate the affect of complex 3-week treatment with 4 kinesiotherapy methods on body weight loss and muscle function in patients with obesity. methods: 80 men and women aged 21-69 years old with alimentary obesity were enrolled in the study (mean age 52.4±11 years, weight 111.3±24.5 kg, bmi 40.3±8.1 kg/m2, waist circumstance wc 113.4±16 cm, hip circumstance hc 124.2±16 cm). the complex kinesiotherapy administered daily for 3 week and included interactive sensorimotor trainings on double unstable platform, kinesiohydrotherapy in a pool, special complex of physical exercises in a gym and ergocycle trainings. weight, wc, hc, fall number for last 3 weeks were measured at baseline and after the treatment was completed. muscle strength and walking speed functional tests results assessment (10-meters-walk test, up-and-go test, 4 special tests for back and abdomen muscle endurance to static and dynamic loading) were performed at baseline and in 3 weeks. results: there was a significant reduction in body weight (111.3±24.4 kg at baseline vs 107.9±23.1 kg in 3 weeks; p=0,000), in bmi (40.3±8.1 vs 39.1±7.7 kg/m2; p=0.000), in wc (113.4±15.9 vs 109.2±15.1 cm; p=0.000) and in hc (124.1±15.5 vs 119.7±14.1 cm; p=0.000) in treated obese patients. 10-meters-walk speed increased from 0.84±0.15 m/sec at baseline to 0.88±0.17 m/ sec in 3 weeks (p=0.000). up-and-go test results improved from 8.4±2.1 to 7.9±2.09 sec (p=0.000). we registered statistically significant elevation of the endurance to static loading in abdomen muscles from 13.1±9.7 to 16.49±12.8 sec (p=0.000) and in back muscles from 14.8±11.9 sec to 18.6±14.9 sec (p=0.000). the endurance to dynamic loading increased in abdomen muscles from 29.9±11.2 to 34.84±11.93 times (p=0.000) and also in back muscles from 9.1±7.4 to 12.2±9.2 times (p=0.000). fall namber markably decreased from 0.14 ±0.34 at baseline to 0.0 (95%ci: 0.02; 0.25) after completion of treatment. conclusion: investigated complex treatment with 4 kinesiotherapy methods promotes body weight loss, wc and hc reduction in obesity. 3-week special training of obese patients is associated with increasing in gate speed and lower extremities muscle strength, and it also causes improvement in static and dynamic loading endurance of back and abdomen muscles. those changes may probably improve balance function and decrease risk of falling in obese patients. thaiana pacheco, candice medeiros, rummenigge dantas, inae c. gadotti, edgar r vieira, fabrícia costa cavalcanti (department of physical therapy, florida international university, miami, usa) background: integrating technological advances into clinical practice can be challenging. physical therapists have been developing serious games/exergames for a variety of rehabilitation purposes, but uptake has been slow. games with virtual scenarios are an engaging and affordable way to encourage and increase physical activity levels. serious games have been developed to adapt virtual gaming environments to patients' needs and evolving capabilities. games can improve adherence and therapy effectiveness. the sensory and motor stimulation while playing serious games can help geriatric rehabilitation to improve mobility and balance. objectives: this study analyzed the effects of a new serious game on the balance of older adults. methods: this was a pilot quasiexperimental design study in which older adults completed six sessions of dynamic balance training using the virtualter serious game that uses the kinect sensor for motion capture. this game was developed by researchers from the federal university of rio grande do norte in brazil. the game consists of static and dynamic tasks for training balance. it involves stationary walk, lateral reaching and climbing steps up and down. it has 3 phases with increasing the level of difficulty. the participants were evaluated before and after the program using the berg balance scale (bbs) and the short physical performance battery (sppb). t-test for dependent samples was used to analyze the pre vs. post data. results: twenty three participants participated in the study (age = 72±8; sex = 65% women). the results indicate improvement in bbs scores (pre: 50±6; post: 51.4±6; p = 0.006) and sppb scores (pre: 10±2; post: 11±2; p = 0.01). conclusion: playing the virtualter serious game improved balance in older adults. helen chan 1 , duncan wong 2 , cindy fan 2 ((1) the nethersole school of nursing, the chinese university of hong kong, hk; (2) silver yoga lab, hk) background: evidence showed that both frail and prefrail significantly increase the risk of developing or worsening disability in activities of daily living, poor quality of life and institutionalisation. yoga has been consistently reported as effective intervention in improving physical functioning in terms of balance, lower limb strength, mobility and body flexibility. objectives: to assess the feasibility of silver yoga in older adults and to examine the preliminary effects of silver yoga on their physical health. methods: this was a one group pre-test post-test study conducted in a community centre. people who aged 60 and above, were mentally competent, home-living, and classified as prefrail based on physical phenotypes using fried criteria, were eligible to the study. the silver yoga class included eight 1.5-hour weekly sessions delivered by two experienced yoga instructors with specialized training in silver yoga. senior fitness test (sft) was conducted to assess changes in physical health. paired t-test was used to compare the within-subject differences across 2-month time. results: a total of 25 older adults were recruited. there were significant improvement in six dimensions of the sft, including upper extremity muscle strength, lower extremity muscle strength, upper body flexibility, lower body flexibility, agility and dynamic balance, and aerobic endurance (ps < 0.001). all participants except one completed the yoga programme, with high level of satisfaction. in addition to the effects of physical conditions, the participants also appreciated it as mind-soothing and relaxing. conclusion: the findings showed that silver yoga is well-received by older adults generally, with significant effects in improving their physical fitness. more rigorous study is needed to examine its effects in a longer term and also in a more holistic manner. ku leuven, leuven, belgium; (2) physical activity, sports and health research group, department of movement sciences, ku leuven, leuven, belgium) background: with aging skeletal muscle tissue becomes less responsive to anabolic stimuli, eventually contributing to muscle wasting. inflammation is considered an important player in this age-related anabolic insensitivity. recent reports provide a promising role for omega-3 polyunsaturated fatty acids (ω-3) in (muscle) health, as they possess systemic anti-inflammatory properties and stimulate muscle anabolic signaling. objectives: we investigated whether ω-3 supplementation improves the systemic inflammation and muscular adaptations (i.e. strength, mass, molecular signaling) to resistance exercise in an elderly population. methods: twenty-three elderly (65-84y; 8♀) were randomized to receive either ω-3 (~3g/d) or an isocaloric amount of corn oil (plac) during 14 weeks. after two weeks of supplementation, participants engaged in resistance exercise (re; 3x/week) for 12 weeks. prior to and after completion of the intervention, muscle and blood tissue, parameters of body composition, muscle strength and functionality were assessed. results: upon re, 1-rm significantly improved in plac (+23.5%) and in ω-3 (+ 30.4%), irrespective of condition. isometric strength significantly improved in ω-3 (+12.2%), but not in plac (-0.3%). muscle volume did not change following re. plasma crp levels decreased, though not non-significantly, in ω-3 (-28.9%), whereas only a small increase was observed in plac (+6.9%). ω-3 supplementation nor re affected the muscle anabolic sensitivity (akt phosphorylation) in response to a protein bolus. conclusion: this study confirms that ω-3 pufas improve the gains in isometric but not in dynamic muscle strength upon re in elderly. however, this was not associated with changes in anabolic sensitivity or systemic inflammation. further analyses will investigate whether the ω-3 induced gains in strength can be related to systemic hormones or muscle molecular signaling (mtor signaling, inflammation). meera suresh, clarence chikusu, caroline goodger (nutrition and dietetics, st. peter's hospital, chertsey, uk) background: deconditioning is a common phenomenon in patients over 75 years old in acute settings. it is well known that poor nutritional status has a major impact on adverse outcomes in frailty and can exacerbate sarcopenia (1). currently, there is limited research exploring the impact of dietitians on optimising nutritional status in acute settings in older populations for frailty and sarcopenia. objectives: compare the impact of dietetic intervention on the change in frailty scores between a patient group (n=125; mean age 87.07 years) who received dietetic intervention (di) and a patient group (n=254; mean age 86.79 years) who did not receive dietetic intervention (ndi). methods: a 5-month retrospective study (august-december 2018) was undertaken at the older persons short stay unit at a district hospital in england. frailty scores were calculated based on the rockwood model of clinical frailty. dietary intake was recorded and analysed using a standardised nutritional profile of hospital meals. the di group was given standardised dietetic care including oral nutrition support and build up dietary advice. descriptive statistics were used to determine frequencies. results: the di had higher frailty scores (mean of 5.6; range: 3-8) and a higher mortality rate (35%).the ndi had a mean score of 4.73 (range: 1-8) and mortality rate of 18%. the average oral intake for energy and protein for patients in the di group prior to dietetic intervention was 40% lower than the espen recommendations. despite the higher frailty scores and mortality rates in the di group, progression in their frailty score was slower compared to the ndi group (24% vs 38%). conclusion: the results highlight the importance of a timely referral for early dietetic intervention which is crucial for optimisation of better clinical outcomes in these patients. a dietitian is a key member of the mdt and can prevent further deterioration in muscle mass and the impact on patients' frailty and independence and also slow down the progression of sarcopenia and frailty. this has long term impact on health and social services by reducing length of stay, hospital re-admissions and the increasing burden on social care. uz leuven, leuven, belgium) background: while the protein recommended dietary allowance (rda) for healthy adults is 0.8g protein/kg bodyweight (bw)/day (d), expert groups recommend a protein intake up to 1.5g protein/kg bw/d for older people with chronic diseases. in addition, at least 25-30g protein (whereof at least 2.5g of leucine) is recommended per meal. objectives: we aim to assess in (pre)sarcopenic older people the daily energy and protein quantity and quality intake, and their change due to supplementation. methods: dietary protein quantity, and quality (plant/animal source, amount of amino acids, amount of leucine and leucine distribution over a day) and dietary energy intake were calculated from four day estimated dietary records of (pre)sarcopenic participants of the enhance study (clinicaltrials.gov nct03649698) before and after a 12-week supplementation period. participants received an individualized protein supplement (resource® instant protein, nestlé) , to achieve a total (dietary + supplemental) intake of 1.5g protein/kg bw/d. results: 51 (pre)sarcopenic adults (73.61 ±6.47 years, 53% female) had an average dietary protein intake of 1.06 ±0.26 g/kg bw/d, which is higher than the rda, but below the 1.5g/kg bw/d recommended by experts. 20 (pre)sarcopenic adults were supplemented with protein powder, which improved the total protein intake to 1.55 ±0.26g/kg bw/d without affecting dietary protein or energy intake. moreover, supplementation increased the protein intake to at least 29 g protein/meal without affecting dietary intake. more than 60% of dietary protein intake was of animal origin. leucine intake at baseline was insufficient at all meals, but increased to at least 2.81 g at lunch and dinner by supplementation without affecting dietary leucine intake. conclusion: community-dwelling (pre)sarcopenic older people do not reach the recommended protein intake proposed by expert groups. individualized protein supplementation results in adequate intake of protein without substantial change in dietary intake. nutrition and dietetics, internal medicine, amsterdam university medical centers, amsterdam, the netherlands) background: weight loss is a main treatment goal in obese older adults with dm2. combined lifestyle interventions (cli) may be more effective in preserving muscle mass during weight loss. whether severe obese benefit similar to less obese is unknown. objectives: our probe-study showed an increase in muscle mass during cli in obese older adults (55+) with dm2. do severe obese (bmi > 35 kg/m2) benefit similarly to less obese. methods: in a post-hoc analysis, 97 out of 123 enrolled older adults had both body weight and protein intake data before and after a 3-month cli consisting of dietary advice (-600 kcal/day) and resistance exercise. a selection of assessments were appendicular skeletal muscle mass (asmm, by dxa), physical performance (wmax; by cycle ergometer steep ramp test), quality of life (rand-36 physical component summary score (pcs), visceral adipose tissue (vat, by dxa), crp, insulin sensitivity and resistance (matsuda, homa-ir; by ogtt), blood pressure (sbp, dbp). linear regression analysis was used with protein intake (g/kg, except for asmm being included in kg) as independent and assessments after 3-months as dependent (with assessment before intervention as confounder) for both groups bmi>35 (severe obese n=28) and bmi<=35 (n=69). results: mean age was 67, mean bmi was 33.3, sex 62m/35f and protein intake during intervention was 93+30 gram/day. mean weight loss was -2.6+2.9kg and fat loss -2.8+2.3kg. per 20g protein intake increase 175+62g muscle was preserved (p=0.006). however, this appeared 68+168 (p=0.686) vs 204+67g (p=0.003) for severe obese vs not severe obese. severe obese showed higher response for wmax (+60.9+26.3 (p=0.033) vs -4.3+8.3) and pcs (+10.5+5.3 (p=0.058) vs -1.7+1.7), for vat (-58.9+32.1 (p=0.079) vs +2.5+6.6) and crp (-2.5+1.4 (p=0.081) vs +0.3+1.3), for insulin sensitivity (matsuda +1.2+0.6 (p=0.044) vs +0.4+0.4) and insulin resistance (homa-ir -5.3+2.4 (p=0.034) vs +0.2+0.6), sbp (-19.1+9.4 (p=0.055) vs -1.3+4.2) and dbp (-16.7+6 .7 (p=0.022) vs +1.2+2.4). while whole group and not severe obese group showed no significant effect. conclusion: these results suggest that severe obese might benefit even more from combined lifestyle intervention compared to less obese older adults with dm2. further investigation is needed to confirm these findings and identify potential mechanisms. background: nutritional interventions have been shown to stimulate muscle protein synthesis. to optimize muscle mass preservation and gains, several factors, including type, dosage, frequency, timing, duration and compliance have to be considered. objectives: this systematic review and meta-analysis aimed to summarize these factors influencing the efficacy of nutritional interventions on muscle mass in older adults. methods: data sources: a systematic search was performed using the electronic databases medline, embase, cinahl, cochrane central register of controlled trials and sportdiscus, from inception date to 22nd november 2017, in accordance with the prisma guidelines. inclusion criteria included randomized controlled trials, mean/median age >=65 years and reporting muscle mass at baseline and post-intervention; exclusion criteria included genetically inherited diseases, anabolic drugs/hormone therapies, neuromuscular electrical stimulation, chronic kidney disease, kidney failure, neuromuscular disorders and cancer. data extraction: extracted data included study characteristics (population, sample size, age, sex), muscle mass measurements (method, measure, unit) , effect of the intervention versus the control group, and nutritional intervention factors i.e. type, composition, dose, duration, frequency, timing and compliance. data analysis: standardized mean differences and 95% confidence intervals were calculated from baseline to post-intervention for the intervention and control group. a meta-analysis was performed using a random-effects model and grouped by the type of intervention. results: twentyeight articles were included encompassing 2190 participants (mean age 75.7 years, sd 2.22). amino acids, creatine, betahydroxy-beta-methylbutyrate, and protein with amino acids supplementation significantly improved muscle mass. no effect was found for protein supplementation alone, protein and other components, and poly-unsaturated fatty acids. high inter-study variability was observed regarding the dose, duration and frequency, coupled with inconsistency in reporting timing and compliance. conclusion: overall, nutrition alone is an effective intervention to improve muscle mass in older adults. due to the substantial variability of the intervention factors among studies, the optimum profile is yet to be established. background: physical and functional capacities decline with age. one new potential intervention is oral citrulline supplementation (cit) since cit seems to increase muscle protein synthesis, mass, size and strength, improve mobility but also decrease adipose tissue mass, particularly visceral depot in old rats. furthermore, exercise is known to be another efficient intervention. however, studies assessing cit supplementation combined or not with exercise on muscle function and mobility in older human adults are emerging and literature conclusions are needed to help health professionals. objectives: establish the potential effectiveness of citrulline supplementation combined or not with exercise on muscle function and physical performance via a systematic review of randomized controlled trials (rcts) in human aged 50 years and older. methods: the preferred reporting items for systematic reviews and meta-analysis (prisma) statement has been followed. medline, cochrane central register for rcts and scopus databases have been searched. studies selection and data extraction have been performed by two researchers independently. methodological quality of each included studies was assessed using the quality assessment of diagnostic accuracy studies-2 (quadas-2) tool. results: based on prisma guideline, 103 references have been identified. among this number, only 6 rcts (250 participants) matched the inclusion criteria (e.g rcts, age>50yrs, human, cit supplementation, muscle or physical parameters) and were included in the systematic review. among these studies, 5/6 reported beneficial effects of cit on muscle mass. effects on muscle strength is reported on 4/6 studies but when cit is combined to exercise better improvements in upper muscle strength are observed. finally, 3/6 studies reported beneficial effect of cit on physical performance but suggested that cit with exercise displayed greater improvements in walking speed than exercise or cit alone. the overall quality of studies was rather high. conclusion: cit supplementation seems able to improve muscular and physical factors in specific elderly people (malnourished, women, hypertensive, obese, dynapenic-obese) compared to placebo. more importantly, cit with exercise is more efficient than exercise or cit alone. however, due to the small number (6) and heterogeneity (dose, duration, population) of the studies, further investigations are needed to confirm its promising intervention for health professionals. background: the medical nutrition supplement fortifit (r), containing the specific nutrient combination actisyn™, is designed to support muscle building in sarcopenia (muscle loss). actisyn (whey protein, leucine and vitamin d) provides high bioavailability of leucine and essential amino acids for the muscle; the nutrients in actisyn act together to optimize the muscle protein synthesis response in a state of sarcopenia where these nutrients are often deficient. preclinical and acute human studies confirmed this mode of action. objectives: to demonstrate the longer-term effects of fortifit supplementation on muscle building in healthy and sarcopenic older adults and on muscle preservation in obese (diabetic) older adults during a weight-loss lifestyle intervention. methods: our clinical research program investigated the effects on muscle mass, strength and function in healthy and sarcopenic older adults and in obese and type 2 diabetic patients. muscle mass was measured by dexa; strength and function by handgrip strength, 5-times chairstand test and short physical performance battery (sppb). all studies were randomized-controlled trials with an intervention duration of 6 to 13 weeks. results: a significant increase in appendicular lean mass and leg lean mass was observed in healthy older adults after 6 weeks supplementation (p<0.05 vs non-caloric control) [chanet, jnutr 2017]. in sarcopenic older adults, 13-week intervention increased appendicular lean mass (0.17kg, 95%ci 0.004-0.338kg; p=0.045 vs iso-caloric control) [bauer, jamda 2015] . moreover, during a 13-week lifestyle intervention of energy restriction and resistance exercise training in obese older adults with or without type 2 diabetes, fortifit preserved appendicular lean mass (p<0.05 vs iso-caloric control) [verreijen, ajcn 2015; memelink, clin nutr 2018] . a significant improvement was observed in chairstand time after 13-week intervention in sarcopenic older adults (-1.01s, 95%ci -1.77 to -0.19s; p=0.018 vs isocaloric control), but improvements in handgrip strength and sppb (primary outcomes) were only significant versus baseline (p<0.05) and not versus control [bauer, jamda 2015] . conclusion: the medical nutrition supplement fortifit effectively supports muscle building in healthy, sarcopenic and obese older adults. moreover, the improvement in chair-stand time observed in sarcopenic older adults is clinically relevant. background: chronic kidney disease (ckd) is commonly found in older persons and it affects the quality of life and economic burden. knowledge and health literacy have been reported as fundamental factors for persons with chronic illness to perform health behavior. however, from a literature review, relationships among knowledge, health literacy, and health behavior in older persons with non-dialysis ckd have rarely been reported. objectives: to examine relationships among knowledge, health literacy, and health behavior in older persons with chronic kidney disease. methods: nutbeam's conceptual framework of health literacy was used to guide the study. the sample recruited by purposive sampling consisted of 98 older persons with non-dialysis stage 4 to 5 ckd, who sought healthcare services at a ckd clinic in a university hospital, thailand. data were collected by interviews using the questionnaires about the demographic data, knowledge about care of ckd, health literacy, and health behavior of older persons with ckd and then were analyzed using descriptive statistics and spearman's rho correlation coefficients. results: the sample consisted of 52 men and 46 women with their age ranging from 60 to 88 years (m = 73.02, sd = 7.26). the analysis revealed that the sample had the mean scores of total knowledge about care of ckd, health literacy, and health behavior at a high level. health literacy was positively associated with health behavior (r = .30, p = .001), but knowledge about care of ckd was not significantly associated with health literacy (r = .13, p = .092), nor health behavior (r = .16, p = .057). conclusion: only health literacy was significantly positively related to health behavior. although knowledge is fundamental of health literacy, it was not significantly related to health literacy nor health behavior in this study. it is explained that health literacy is the ability and skills that might link knowledge of individuals to perform behaviors. thus, healthcare providers should find strategies for enhancing health literacy of older persons with ckd to promote appropriate health behavior, thereby delaying complications. background: handgrip strength (gs) is linked to the vitality domain of the intrinsic capacity (ic) construct and is a marker of sarcopenia and frailty. low gs is a predictor of adverse health outcomes like disability onset and mortality. small increases in gs have been reported after exercise interventions, suggesting that life-course determinants rather than short-term determinants influence gs. objectives: to assess social inequality in the distribution of gs and the association of gs levels with a proxy of social determinants of health (sdh) among adults and older adults. methods: secondary analysis from wave 1 (2007-2010) of the world health organization (who) study on global ageing and adult health (sage), which is nationally-representative of six countries, including 16,903 participants aged >=60 years and 20,168 <59y. gs was computed in kg. wealth quintiles were assigned according to ownership of household assets. the last level of education of the participant and his/her mother was self-reported (the latter was used as a marker of early life sdh). social inequality was estimated using pairwise comparisons among the average of gs of the extreme social groups; and gradient inequality by the slope index of inequality (multivariate linear regression to adjust for age, sex, body mass index). estimations were weighted to consider the complex design of the sample. results: average gs was 22.2 kg for participants >=60y and 29.8kg for <59y. participants >=60y who reported a postgraduate level of education or higher showed 51% (9.3kg) higher gs than their illiterate counterparts (34%, 8.0kg, for participants <59y). gs was on average 12% higher in participants >=60y in the most top wealth quintile compared to those in the lowest quintile (11% in <59y). in the multivariate models, gs was 2.5kg higher in urban than rural participants and 5.1kg higher among participants whose mothers had completed >=9 years of education compared to those whose mothers were illiterate. slope coefficients were significant after controlling for confounders. conclusion: grip strength displayed an unequal distribution among social groups and also among groups of early life exposures, which suggests that vitality as a domain of ic is shaped by the sdh and built through the life course. background: intrinsic capacity (ic) is the composite of the physical and mental abilities of an individual. the distribution and correlates of ic in older adults (oa) have not been reported using an integrative score with routinely-collected clinical data. it is not clear how ic is associated with multi-systemic biochemical age-related processes captured by alterations in standard clinical laboratory tests. objectives: to describe the distribution and correlates of ic in a population of older adults from the frailty day hospital of toulouse and to test its cross-sectional association with low or high haemoglobin or high crp, accounting for frailty status. methods: using routinely collected cross-sectional data of 2,324 first visits of oa aged 60+ to the frailty day clinic of toulouse (2011-2016), we calculated an index of ic (biomarkers and validated scales for five who domains). low/high haemoglobin levels or high crp levels served as indicators of acute and middleterm multisystem disruption. we used descriptive statistics to learn the distribution of ic across sex, age, education and fried frailty categories. multivariate linear models were used to test the hypothesis that higher ic holds a negative association with the multi-system deficits depicted by altered laboratory tests. results: 63% of the population was female, and 50% was frail. our ic score has theoretical limits (0-1). overall, the ic was: mean=0.65,sd=0.11,min=0.28, max=0.91. on average ic men scored 0.68 (ic95% 0.67, 0.69) and women 0.63 (ic95% 0.63, 0.64). the relationship found between ic and age was not linear. frail older adults displayed 25% less ic than their robust counterparts and 17% less ic than their pre-frail counterparts. if frail oa would return to robust in this population, the average ic would potentially* rise 19%. disruption in haemoglobin or crp was inversely and significantly associated with the ic score after adjusting for age2, sex, level of education and fried frailty status. conclusion: the population attending the toulouse frailty clinic displayed highly-heterogeneous ic levels, with frail oa showing significantly lower levels than robust oa. the association between ic and age is not linear. sex, age, education, frailty status and disruption in haemoglobin or crp levels were all significantly associated with ic in a multivariate model. background: older persons tend to be hospitalized increasingly because of the complex interaction among acute problems, age-related changed, and chronic diseases. qualified nursing care needs knowledge, understanding, and a positive attitude towards the care of older persons. however, little is known factors predict the caring behavior of nurses to care for hospitalized older persons. objectives: to examine the predictability of selected factors to explain intention to care and caring behavior for older persons of professional nurses. methods: the theory of reasoned action was used to guide the study. the proportionate stratified random sampling was used to recruit a sample of 150 professional nurses from clinical wards providing care for older patients in a university hospital. data were collected using 6 questionnaires and then, analyzed with descriptive statistics, pearson's product-moment correlation, and multiple regression analysis with the enter method. results: almost all of the sample were female, with their age ranged from 23 to 54 years (m = 30.4). factors related to professional nurses' intention to care were perceived caring climate in organization and attitude toward caring for older persons. also, factors related to caring behavior for older persons were perceived caring climate in an organization, intention to care, and attitude toward caring for older persons. through multiple regression analysis, perceived caring climate in an organization, attitude toward caring older persons, and basic knowledge about older persons jointly predicted 8.7% of the variance in intention to care. together, perceived caring climate in an organization, intention to care, attitude toward caring for older persons, and basic knowledge about older persons accounted for 32.3% of the variance in caring behavior for older persons of professional nurses. the perceived caring climate in an organization was the strongest predictor of caring behavior, whereas basic knowledge about older persons was not a significant predictor. conclusion: the findings support the notion of the theory of reasoned action. it is suggested that strategies to promote perceived caring climate in an organization, attitude toward caring for older persons, and intention to care should be established and maintained to promote caring behavior for older persons of professional nurses. background: environmental and social conditions play a major influence in the development and progression of negative health-related outcomes. they represent crucial elements when taking clinical decisions and planning the care plans of frail patients. nevertheless, they still often remain overlooked because priority is given to the clinical manifestations. objectives: the aim of this study is to explore the importance of social support in the definition of major health-related outcomes among hospitalized patients compared to other critical factors of older persons (i.e., frailty, age). methods: data were retrospectively collected from the medical records of patients aged 70 years and older admitted to the geriatric unit of the fondazione irccs ca' granda ospedale maggiore policlinico (milan, italy). a 42-items frailty index (fi) was computed from clinical variables recorded during the first days of hospitalization (i.e., medical history, cognitive, functional and social assessment, physical examination, laboratory tests). mortality, length of hospital stay above the median, and risk of institutionalization were the outcomes of interest. results: we included 87 patients (mean age 87.5, sd 6.3 years, women 75.9%). six patients died during the hospital stay (6.9%). the median duration of hospital stay was 12 (iqr 7-20) days. twenty-seven patients were discharged to other institutions (31%). the mean fi was 0.39 (sd 0.12). the fi showed a statistically borderline association with mortality (or 1.07, 95% c.i. 0.99-1.15, p=0.09), and was predictive of longer length of stay (or 1.05, 95% c.i. 1.00-1.09, p=0.05), even after adjustment for confounders. the presence of a caregiver was the only factor significantly associated with the discharge at home of patients (or 0.23, 95% c.i. 0.08-0.68, p=0.01) at the multivariate analysis. age had no significant association with the three studied outcomes. conclusion: health systems should be organized according to an integrated model of care in order to adequately address the complex health needs of older people. social and environmental context plays a critical role in determining the person's health trajectory. social factors (as the presence of a caregiver) may play a stronger role in clinical decisions than biological or clinical aspects. background: the acute therapy team was formulated after the integration of an older persons assessment and liaison team (opal) with medical ward therapists. the team was spread across all acute areas. this team worked closely with the acute geriatric and frailty clinical team and it was recognised that length of stay, and improved patient experience and overall outcomes would be improved with earlier assessment and cga planning at the front door allowing closer collaborative working between the clinicians and therapists. objectives: to enhance service improvement and prevent the impact of sarcopenia and frailty syndromes leading to greater hospital stay and disability as a consequence of a delay to assessment by clinicians and therapists in the acute setting. through the screening of frailty syndrome risk and sarcopenia risk patients by the ed geriatrician and junior doctor, there would be a speedier response to therapy led interventions thereby reducing the conversion rate from ed and also therefore improving overall outcomes in length of stay and reduced disability through prolonged hospital stay. methods: consultant geriatrician and junior doctor (opssu team) to go to the emergency department in the mornings and see up to 6 patients in cdu/a&e beds; the use of a the rockwood frailty score template identified those patients at risk of frailty syndrome and likely to benefit from early therapy intervention. these patients would have been highlighted as having the potential to be discharged within 24 hours. a 3 month data collection period from was chosen with data collected monday to friday only. data examined was categorised as follows: new patients, follow-ups; how many patients were seen on day of ed attendance vs after day of attendance?; number of patients seen by therapists same day of ed attendance number of patients not seen by therapists day of attendance; which team was looking after the patient from a clinically; how much time spent with patients; therapy led plan after initial assessment; an integrated assessment too was instrumental in the cga component of the therapy and clinical assessments. results: 88% of patients seen by therapists in ed are new patients referred. 28% of patients referred are seen on the actual date of ed attendance. the rest are seen later admission episode. 53% of therapy time is spent doing non-face to face tasks such as documentation. but up to 65% of patients have a discharge plan put in place after being seen by therapists in the ed. conclusion: a great deal of time is spent by therapists on documentation during assessment. this has a negative impact on the amount of time dedicated to clinical assessments and physiological and functional assessments required in the cga. there is a large number of patients referred by the clinical team to the therapists for review but a majority of patients are seen elsewhere during an admission episode and not in the ed. streamlined assessments and screening tools are recommended & planned for the future model of care. yi-chun cheng 1 , li-ning peng 1,2 ((1) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan; (2) aging and health research center, national yang ming university, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people, and integrated intervention program may prevent those. objectives: to evaluate the effectiveness of an integrated intervention program among those communitydwelling frail older people in north taiwan. methods: a total of 435 participants over 65 years old mild to moderate disability and mild cognitive impairment persons were recruited from a community-dwelling frail older people in north taiwan during august 2017 and july 2019, frail older people were invited for the study. a 12 weeks integrated intervention program was provided for all participants. they attended the 2 hours program once per two weeks and physical activity, high protein diet education, and cognitive stimulation activity were included in the integrated intervention program. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds-5), cognitive condition (by mmse), weakness (by handgrip strength), exhaustion (by self-report in chs) slowness (by gait speed) and time-up-go test. pretest on the 1st week before intervention and post-test on the 12th week to compare the difference between twice evaluate consequence. results: overall, 435 participants were identified as having pre-frailty (55.6%) and frailty ( background: low appendicular skeletal muscle mass (asm), an integral component of current sarcopenia definitions, is commonly measured using bioimpedance analysis (bia). bia equations for estimation of asm are not generalizable across population groups and instrument types, potentially giving rise to inaccurate results when applied inappropriately. there is a lack of bia prediction equations for asian populations, none of which have been developed or validated for singaporean older adults. objectives: to develop a bia prediction equation for estimation of asm in communitydwelling older singaporean adults. methods: we studied 230 healthy community-dwelling subjects (mean age 67.2 years) from the gerilabs-2 cohort. bia was performed using a single-frequency instrument. the reference method used for asm measurement was dual-energy x-ray absorptiometry (dxa). we first identified independent asm predictors by assessing the correlation of demographic, anthropometric and bia variables with dxa-measured asm. the best-fitting prediction equation was derived from these variables using stepwise (backward elimination and forward selection) linear regression with bootstrap validation. using asian working group for sarcopenia (awgs) cutoffs, we then compared anthropometric, strength and physical performance parameters between normal and low bia-derived asm groups. results: the derived bia equation incorporated 4 predictorsimpedance index, weight, gender and body mass index (bmi), i.e. asm(kg) = 2.098 + (0.155 x impedance index) + (0.202 x weight) + (-1.397 x gender) + (-0.252 x bmi), where males = 0, females = 1 and impedance index = height(cm2)/resistance. the r2 and standard error of the estimate of this regression model were 0.93 and 0.91kg respectively, with impedance index accounting for 87.3% of its variability. individuals with low bia-derived asm have significantly smaller mid-arm and calf circumference and weaker grip strength, compared to individuals with normal bia-derived asm (p<0.001). physical performance was similar in both groups. conclusion: we have developed a valid single-frequency bia prediction equation which can provide good estimates of asm in communitydwelling older singaporean adults. validation of this prediction equation in an independent sample of population is required to establish its accuracy and precision. (2) faculty of sport sciences, waseda university, tokorozawa, japan) background: it has been well known that appendicular lean mass (alm) and skeletal muscle mass index (smi), which is the ratio of alm to height 2 (m), is positively proportional to regional bone mineral density (bmd) in elderly men. however, there is limited information about these relationships in middleaged men. objectives: the purposes of this study were to investigate the difference in bmds (arms, lumbar spine, pelvis, legs, and subtotal: total body without head area) in middleaged men with low and normal smi (alm/height 2 ≤7.0 kg/ m 2 from asian working group for sarcopenia: awgs), and to determine the associations between alm, smi, and bmds. methods: three hundred and two middle-aged japanese men between 40 and 65 years of age participated in this study. alm and bmd measurements were taken using dual-energy x-ray absorptiometry (dxa, delphi a-qdr, hologic). results: based on the definition from awgs, the prevalence of low smi was approximately 7% in middle-aged men. the subjects with low smi (low smi group, n = 22, 6.6 kg/m 2 ) had significantly lower body weight (58.2 vs. 70.4 kg), bmi (19.9 vs. 23.9 kg/m 2 ), and fat mass (12.2 vs. 14.9 kg) compared to the normal group (n = 280, 8.2 kg/m 2 ), although there were no differences in age (51 vs. 52 years), standing height (170.9 vs. 171.4 cm), and body fat percentage (20.6 vs. 20.8 %) between the two groups. bmds were significantly lower in low smi group than normal group for regional body parts (arms 0.729 vs. 0.765 g/cm 2 ; lumbar spine 0.925 vs. 0.991 g/cm 2 ; pelvis 1.043 vs. 1.138 g/cm 2 ; legs 1.144 vs. 1.205 g/cm 2 ) and subtotal (0.916 vs. 0.972 g/cm 2 ). moreover, body weight, fat mass, alm, and smi were positively correlated with bmds using partial regression analysis controlling for age in all subjects, except for fat mass vs. lumbar spine bmd. in a stepwise multivariable model, alm was more closely related to bmds, except in the case of pelvis. conclusion: these results suggest that in order to maintain the regional bmd in middle-aged men, a key factor is to maintain or increase both alm and smi. background: the societies on sarcopenia have recently accepted the use of bioelectrical impedance analysis (bia) in the assessment of appendicular skeletal muscle mass (asm). several bia equations and devices have been introduced, which analyze the whole body composition, including the trunk and excluding the left arm and left leg at 50khz. it is necessary to measure the appendicular body segments of impedance parameters with a specific frequency (hz) that optimally analyze the muscle for valid assessment of asm. prior our study, literature-based bia equations and the two devices estimated asm at >75% of r2 (coefficient of determination) with the significant constant-errors rated as «poor». objectives: thus, the aims of this study were (1) externally cross-validate the equations and devices of bia on the appendicular skeletal muscle mass and (2) develop valid equations based on appendicular bioimpedance parameters at the specific frequency (khz) that reflects the muscle for estimating asm; methods: 201 community dwelling koreans over 70-year-old (77+4.4yrs, 107 females and 94 males) participated. asm was predicted using bia-based equations available in literature and bia devices and compared to dxa outcomes which is the gold standard. we conduct internal cross-validation and stepwise multiple linear regression to develop asmformulas with segmental multi-frequency bias. results: our new prediction formulas were developed by the appendicular impedance(z) index = height2 / (z of right arm + z of left arm + z of right leg + z of left leg)) at higher than 50khz and the appendicular reactance(xc) = xc of right arm + xc of left arm + xc of right leg + xc of left leg at 5khz. r2s were over 93%, see wes under 0.90kg of asm with the subject rating as «excellent» for men and «good» for women. conclusion: we found that our new protocol resulted in higher agreement with dxa and improved bia accuracy for this specific age group. clinicians can use this lower cost protocol and equations to better diagnose sarcopenia in larger cohorts with comparable to measurement of dxa. background: greater protein intake throughout the lifespan may be related to better body composition through the preservation of lean body mass during aging. objectives: we sought to determine whether an association between dietary protein intake (pi) and body fat percentage (bf) exists among women when controlling for dietary and lifestyle factors. methods: body composition and lean body mass were examined via dual-energy x-ray absorptiometry, grip strength (gs) was assessed using a hand grip dynamometer, and moderate-to-vigorous physical activity (mvpa) was measured by accelerometry. dietary intakes were estimated via threeday food logs and esha software. multiple linear regression and stepwise linear regression models were used. results: a total of 94 women (mean ± sd; age 40.6 ± 17.5 years) finished all assessments. a full regression model (i.e., containing all covariates; r = 0.863; adjusted r2 = 0.710; f(11,82) = 21.662; p < 0.001) was created using fat, carbohydrate, protein and leucine intake (g/day), protein quality (g/day of leucine over g/day of protein), energy intake (kcal/day), age (years), lean body mass (kg), bmi (kg/m2), gs (kg), and mvpa (min/day). only bmi (mean ± sem; beta = 1.244 ± 0.119; p < 0.001), gs (mean ± sem; beta = -0.401 ± 0.099; p < 0.001), and pi (mean ± sem; beta = -0.113 ± 0.048; p = 0.021) were significant to the full regression model. to verify their importance, a stepwise regression using the same variables was performed and resulted in a model (f(3,90) = 74.994; p < 0.001; r = 0.845; adjusted r2 = 0.714) that included bmi (mean ± sem; beta = 1.330 ± 0.093; p < 0.001), gs (mean ± sem; beta = -0.347 ± 0.079; p < 0.001), and pi (mean ± sem; beta = -0.048 ± 0.016; p = 0.003). conclusion: greater protein intakes are associated with lower bf in women when controlling for various covariates. we theorize that greater protein intakes preserve lean body mass which results in improved body composition. more specifically, a one gram per day increase in dietary protein is predicted to decrease bf by 0.113% when controlling for all other variables. background: muscle aging and the increased prevalence of obesity in the geriatric population create a new area of research: sarcopenic obesity. in prospective cohorts of nonhospitalized subjects, it is associated with an increased risk of developing physical limitation. hospitalization is an event with high risk of loss of independence. the impact of sarcopenic obesity during this episode isn't known yet. objectives: analyze the evolution of functional independence during a hospitalization in an acute geriatric ward, looking for a link between the presence of sarcopenic obesity and a decline of independence. early readmission, length of stay and changes in body composition during hospitalization were also examined. methods: prospective descriptive monocentric cohort study carried out in an acute geriatric ward of the pau hospital. sarcopenia was diagnosed using the european working group on sarcopenia in older people algorithm by an impedancemeter. a bmi over 30 was used to report obesity. functional independence was rated on the adl katz scale. results: 92 patients were included. sarcopenic obesity was diagnosed in 5.43% of cases, sarcopenia and obesity in 59% and 21% of patients, respectively. the greatest variation in functional independence during hospitalization was observed in sarcopenic obese patients (mean variation of 2 out of 6 points, p=0.046). a total of 15 early readmission at 1 month were counted, with the highest rate for sarcopenic obese (60%, but 16% at the sample level) (p=0.045). the average length of stay was 17.4 days. conclusion: sarcopenia is common in patients hospitalized in geriatrics, and when associated with obesity, there is greater variation in functional independence and more readmissions. background: known that is sarcopenic obesity, excessive accumulation of adipose tissue is detected, with a decrease in muscle mass and strength, which is already over the age of 30 years. modern diagnostic methods have their drawbacks for the diagnosis of sarcopenic obesity. bodpod quality and timeliness of diagnosis of signs of sarcopenia in obese patients is improved, which ultimately will contribute to an earlier targeted treatment of sarcopenia and an improvement in its prognosis. bodpod methodology can be recommended for use in complexes for the diagnosis of sarcopenic obesity. objectives: to compare the effectiveness of three methods of body composition assessment such as bioimpedans analysis (bia), air-replacement bodyplatismography (bodpod) and dual x-ray absorptiometry total body program (dxa total body) in the verification of reducing of skeletal muscle mass as sign of sarcopenic obesity in obese patients. methods: the study group included 95 patients aged 21-69 y.o. (average age 53,9±11,05 years) with bmi>=30.0 kg/m2. the control group included 37 patients aged 37-69 y.o (average age 50,73±10,6 years) of the same age without obesity with bmi 20.0-29.9 kg/m2. body composition was tested using bia, bodpod and dxa with calculating fat, lean and skeletal muscles mass (kg) and % in all the patients. (bodpod) is the most sensitive in the verification of skeletal muscle mass reduction in obese patients. this method shows that patients with obesity have a significantly reduced muscle mass compared with normal weight or overweight subjects. background: in overweight and obesity excess energy and changes in body composition may favor the onset of metabolic derangements. combined with excess adiposity, the age-related decline in lean body mass can accelerate the development of insulin resistance and the consequences in terms of cardiovascular risk. objectives: the aim of our study was to investigate the association between the phenotype of sarcopenic obesity and cardio-metabolic risk in postmenopausal women. methods: postmenopausal women were recruited among subjects admitted to the high specialization centre for the care of obesity (casco), at the sapienza university, rome, italy. fat mass (fm) and fat-free mass (ffm) were assessed by dxa. obesity was defined as body fat >= 35%. appendicular skeletal muscle mass (asmm) was calculated. sarcopenia was defined as asmm/weight < 2sd than the sex-specific mean of a young population. the cut-point was asmm/weight< 0.2347. the lipid accumulation product was calculated: lap = (waist circumference cm -58) × triglycerides mmol/l]. the estimated glucose disposal rate (egdr) was calculated. high-sensitivity c-reactive protein (hs-crp) was measured. results: 335 women were included (age: 58.7 ± 7.2 years, bmi: 37.1 ± 6.3 kg/m2). sarcopenia was diagnosed in 57.6% of study participants. sarcopenic obese women were older than nonsarcopenic women (59.4 ± 6.7 vs. 57.7 ± 7.7 years, p=0.04). lap was higher in sarcopenic obese women compared to their nonsarcopenic counterparts (96.8 ± 51.3 vs. 87.7 ± 55.8, p=0.03) after adjustment for age, body fat, and hs-crp levels. estimated gdr was significantly lower in sarcopenic obese women (4.02 ± 2.28 vs. 5.55 ± 2.36, p=0.03) after adjustment for age and body fat. an inverse association emerged between the index of sarcopenia, asm/weight, and lap (beta: -3.9*10-5, se: 1.9*10-5, p=0.03), independent of age, body fat, and hs-crp levels. a positive association was observed between asm/weight and egdr (beta: 1.4*10-3, se:4.7*10-4, p=0.004) adjusting for age, body fat, and hs-crp levels. conclusion: postmenopausal sarcopenic obese women exibithed a high lap and a low egdr, indicating increased cardiometabolic risk and decreased insulin sensitivity, respectively. l e a t h a a . c l a r k 1 , 4 , 5 , todd m. manini 2 , nathan p. wages 1,5 , janet e. s i m o n 1,3 , d a v i d w . r u s s 1,3 , b r i a n c . c l a r k 1,4,5,6 ( (1) background: muscle weakness strongly contributes to mobility limitations and physical disability. the role of neural mechanisms contributing to age-related weakness have not been fully delineated to sufficiently target interventions that enhance strength and physical function in older adults. objectives: we sought to compare differences in voluntary inactivation and measures of motor corticospinal excitability in older adults with clinically meaningful muscle weakness compared to young adults and stronger adults without muscle weakness. methods: maximal voluntary isokinetic and isometric leg extensor strength, electrical stimulation of the leg extensors, and transcranial magnetic stimulation (tms) of the motor cortex were performed in older adults and young adults. outcome measures of leg extensor strength relative to body weight, voluntary inactivation (via), motor evoked potential (mep) amplitude and silent period (sp) duration during isometric leg extension contractions at 5%, 20%, and 40% of maximum voluntary contraction (mvc) were obtained. older adults were classified into three weakness groups based on previously established isokinetic leg strength/ body weight cut points (severely weak, moderately weak, or not weak). group differences were examined after controlling for sex. results: the older adults had 63% lower isokinetic strength/body weight when compared to the young adults. the severely weak older adults were 33% and 84% weaker than the moderately weak and older adults who were not weak, respectively. severely weak older adults exhibited higher levels of leg extensor via than older adults who were not weak (14.2+1.7% vs. 6.1+1.8%). severely weak older adults exhibited 24% longer sp's compared to the older adults who were not weak, but this difference was not statistically significant (p=0.06). the severely weak older adults' mep's were approximately half the amplitude of the older adults who were not weak. regression analyses demonstrated that mep amplitude and sp duration -indices of hypoexcitability-were associated with relative strength. conclusion: weak older adults have significant deficits in their nervous systems' ability to fully activate their leg extensor muscles. additionally, motor corticospinal hypoexcitability is associated with age-related weakness, suggesting that interventions targeting the nervous system could be used to enhance muscle strength and prevent future health risks in older adults with muscle weakness. model. results: we evidenced oxidative stress in a mouse model of the pathology at different ages (4, 10 and 15 months) and aimed to identify the consequences of opa1 inactivation on redox homeostasis. increased ros levels were observed in cortices of the murine model opa1+/-as well as in opa1 down-regulated cortical neurons. this increase is associated to a decline in mitochondrial respiration and an increase of antioxidant enzyme levels. upon exogenous oxidative stress opa1-depleted neurons did not further up-regulated antioxidant defenses. finally, low levels of antioxidant enzymes were observed in fibroblasts from patients supporting their role as modifier factors. moreover, the simulations obtained with our mathematical model of complex i are able to reproduce biological experiments of quantification of ros production by complex i. conclusion: our study shows: (i) the prooxidative state induced by opa1 loss can be considered as a pathological mechanism (ii) differences in antioxidant defenses can contribute to the variability in expressivity and (iii) antioxidant defenses can be used as prognostic tools to gauge the severity and the evolution of the disease. (iv) furthermore, our mathematical model model of ros porduction by complex i will help to understand the dysfunctions of oxidative metabolism in opa1 gene related disorders. we will present the last results of our algorithm and wet laboratories experiments. amanika kumar, deepa m narasimhulu, michaela e. mcgree, amy l.weaver, aminah jatoi, nathan k lebrasseur (mayo clinic, rochester, mn, usa) background: patients with advanced ovarian cancer (eoc) are often frail and require multi-agent chemotherapy. objective: to evaluate the relationship between frailty and adjuvant chemotherapy tolerance and toxicity among women with advanced epithelial ovarian cancer. methods: women who underwent primary debulking surgery for stage iiic or iv eoc and received adjuvant chemotherapy at the same institution were identified. a frailty deficit index (fi) was derived from 30 items representing comorbidities and activities of daily living. frailty was defined as a fi ≥0.15. if data were unavailable for frailty index calculation, patients were excluded. relative dose intensity (rdi) for carboplatin and paclitaxel was calculated as the percentage of the standard dose that was actually administered and compared between frail and non-frail using the wilcoxon rank sum test. results: of the 169 women who met inclusion criteria, 17.2% (29/169) were frail. frail women were older (67.9 vs 62.3 years, p=0.01), had a higher bmi (29.6 vs 25.7 kg/m2, p=0.003), and were more likely to have american society of anesthesiologists (asa) score ≥3 (65.5 vs 35.0%, p=0.002) compared to nonfrail women. frail patients were less likely to complete 6 cycles of adjuvant chemotherapy, (76% versus 94%, p<0.008). despite the decrease in total cycles of chemotherapy, we did not observe significant differences in dose delays (34.5 vs. 42.1%), dose reductions (65.5 vs 68.6%), and severe neutropenia (44.8 vs. 39.3%) between frail and non-frail women. we analyzed a subset of 96 patients (19 frail and 77 non-frail) women received both intravenous carboplatin and paclitaxel. we observed that frail women were less likely to have a carboplatin rdi of 85% or higher (15.8% vs. 66.2%, p<0.001) and less likely to have a paclitaxel rdi of 85% or higher (57.9% vs. 80.5%, p=0.07). conclusion: frail women with advanced eoc undergoing adjuvant chemotherapy receive reduced rdi and are less likely to complete 6 cycles of chemotherapy despite no increase in dose reduction, delays, and neutropenia. physician bias and patient choice may influence chemotherapy intensity decisions. further studies are needed to explore the association between frailty, chemotherapy, and survival. background: gait speed is a core component of physical frailty (pf) and, as a single measure, is correlated with important health outcomes, including mortality. immune dysregulation has been previously associated with pf -including increased il-6 production in peripheral blood mononuclear cell (pbmc) lipopolysaccharide (lps) stimulation assays. it is not known whether gait speed is associated with lps-stimulated cytokine production. objectives: this pilot study evaluated whether gait speed is correlated with dysregulated immune response in two populations of older adults undergoing procedures -knee osteoarthritis (oa) scheduled for knee replacement, and chronic kidney disease (ckd) approaching hemodialysis initiation. methods: 10 older adults with ckd and 11 older adults with knee oa underwent preoperative evaluation including gait speed (usual pace, 4-meter walk, best of two trials) and immune stimulation testing (in vitro, thawed pbmcs stimulated with lps at doses 0, 0.1, and 10 ug/ml, with il-6 quantified by elisa at 2, 18, 24, and 48 hours; reported as area under the curve (auc)). correlation coefficient and p-value were calculated. results: for ckd, the il-6 auc of lps stimulated pbmcs was negatively associated with gait speed (lps 0.1 ug/ml r = -0.286, p=0.423; lps 10ug/ml r= -0.515, p=0.128). for oa, the correlation between il6 auc and gait speed was positively correlated for lps dose 0.1 ug/ml (lps 0.1 ug/ml r = 0.228, p=0.501; lps 10ug/ml r= 0.062, p=0.857). none of these associations were statistically significant. similar results were obtained when age was included as a covariate. conclusion: in people with ckd, increased cytokine production was correlated with decreased gait speed. in people with knee oa, results do not support this hypothesis. further studies with larger sample size are warranted. for participants with knee oa, future studies should account for severity of knee pain at time of gait speed assessment. background: skeletal muscle drives fuel utilization, and carbohydrate (cho) is a major fuel source. metabolic flexibility describes the ability to balance cho and fat oxidation efficiently in response to changes in metabolic demands or conditions. despite its role in long-term metabolic health, little is known about cho oxidation or metabolic flexibility in sarcopenic older adults. objectives: to examine resting metabolism and metabolic flexibility from a fasted to fed state after a cho-rich meal in sarcopenic versus nonsarcopenic older adults. methods: twenty-two men and women (age ± sd=77±9 y) were enrolled into this pilot study with either normal (non-sarcopenic, n=11) or low (sarcopenic, n=11) handgrip strength, gait speed and relative skeletal muscle index. resting metabolism was assessed in a fasted state at baseline, and metabolic flexibility was assessed after (180 min, post-prandial) consuming a meal containing 9 g of fat, 6 g of protein, and 51 g of a rapidly-digestible cho. respiratory quotient (rq), cho, and fat oxidation were measured with open-circuit spirometry, indirect calorimetry. fat and fat-free mass were measured with dual x-ray absorptiometry. blood glucose was assessed from venous samples using glucose oxidase methodology. results: rq was 5-9% higher (p=0.02-0.04) in sarcopenic participants throughout the experiment. after adjusting for fat-free mass, fat oxidation was 18% lower (p=0.02), while cho oxidation was 18% higher (p=0.04) at baseline for sarcopenic men and women. sarcopenic participants also exhibited delayed and limited (p<0.05) postprandial increases in cho oxidation, despite greater (p<0.05) increases in blood glucose. conclusion: sarcopenic individuals are more reliant on cho and less reliant on fat oxidation than non-sarcopenic adults, which is generally consistent with poorer metabolic health. when compared to non-sarcopenic adults, sarcopenia delayed and truncated cho utilization after a meal, indicating impaired metabolic flexibility in this population. impaired metabolic flexibility could be a mechanism underlying the losses of strength and physical function accompanying sarcopenia. anton de spiegeleer 1,2,3 , hasan kahya 1,2 , nele van den noortgate 2 , evelien wynendaele 3 , tine decruy 1 , srinath govindarajan 1 , dirk elewaut 1 ((1) unit for molecular immunology and inflammation, vib-center for inflammation research, ghent, belgium; (2) department of geriatrics, faculty of medicine and health sciences, ghent university hospital, ghent, belgium; (3) drug quality and registration (druquar) group, faculty of pharmaceutical sciences, ghent university, ghent, belgium) background: acute and chronic muscle wasting represent an important unmet clinical health problem. most pathophysiological studies suggest an effect of the immune system, primarily through catabolic cytokine productions such as il-6. also endoplasmic reticulum (er) stress is considered to be an important pathway favouring muscle wasting. er stress in turn plays an important role in innate-like t cells, particularly invariant natural killer t cells (inkt cells), by controlling their cytokine production [govindarajan et al., nat. commun. 2018 ]. as such we reasoned that inkt cells may play a pivotal role in muscle homeostasis through their excessive cytokine production. previous studies have already highlighted the importance of these cells in a wide range of diseases such as cancer and metabolic disorders such as obesity. objectives: the aim of this study was to investigate the in vivo role of inkt cells in muscle homeostasis. methods: we compared wild-type (wt) versus inkt cell depleted mice (jα18 ko) for clinical, histological and gene expression differences in lower limb skeletal muscle. results: interestingly, we found that inkt cell depleted mice (jα18 ko) had a lower relative muscle weight, i.e. a muscle wasting phenotype, compared to wt mice. this clinical muscle wasting was associated with a decrease in oxidative enzymatic activity (succinate dehydrogenase histology). moreover jα18 ko mice showed a decreased transcription of genes involved in skeletal muscle growth and differentiation (follistatin and myogenin), sarcomere assembly (myosin-3) and neuromuscular junction function (neuronal acetylcholine receptor subunit alpha-1). conclusion: taken together, our results suggest a role for inkt cells in muscle wasting diseases and put innate-like t cells at the centre stage of immune cells controlling skeletal muscle biology. a r m a n d a t e i x e i r a -g o m e s 1 , 2 , s o l a n g e costa 1,2 , bruna lage 1,2 , dietmar fuchs 3 , vanessa valdiglesias 1,4 , blanca laffon 4 , joão paulo teixeira 1,2 ( (1) background: frailty is a multidimensional geriatric syndrome characterised by increased vulnerability and functional decline that may be reversed if addressed early. it has been identified to be the most common condition leading to disability, institutionalisation and death in older adults. despite its known biological basis, no particular biological trait has been consistently associated with frailty syndrome so far. objectives: on this basis, the main objective of the present work was to evaluate the possible association between immunological: biomarkers and the frailty status in a group of community dwellers. methods: a group of older adults (>=65 years old) was engaged in this study. frailty status was assessed via fried's frailty model. the levels of several immune activation molecules -neopterin, tryptophan, kynurenine -were analysed. results: the classification of the study population was 47.5% robust, 49.2% pre-frail and 3.3% frail. no significant differences were found between robust and pre-frail groups regarding serum concentrations of neopterin. although, the kynurenine/tryptophan ratio was significantly higher in pre-frail individuals as compared with robust subjects. conclusion: the preliminary data obtained suggest the activation of immunobiochemical pathways and are in agreement with previous studies that report alterations of the immune response in frail older adults. nevertheless, further investigation is encouraged and required to consistently demonstrate these findings. in future studies physical activity, nutritional, psychological, sociological and clinical features should also be considered when evaluating changes in immune biomarkers and frailty. the work developed by armanda teixeira-gomes and solange costa is supported by fct under the grants sfrh/bd/121802/2016 and sfrh/ bpd/100948/2014, respectively. vanessa valdiglesias was supported by beatriz galindo research fellowship beagal18/00142. background: frailty and hemoglobin count, above what would be considered clinical anemia, are two common findings in older patients and lead to an increased risk of negative health outcomes. objectives: evaluate whether hemoglobin concentration is an independent predictor of frailty and investigate possibe causal pathways in particuliar the relationship between inflammation and nutrition with hemoglobin concentration. methods: 1829 communitydwelling participants aged 65 years or older who visited the toulouse frailty clinic between 2011 and 2016 were included in this analysis. patients underwent a comprehensive geriatric assessment and had a blood sample. a series of multivariate logistic regression models were perfomed after minimizing potential influence from age, gender, kidney function, inflammation, cognition, nutritionnal status and certain socioeconomic factors. results: hemoglobin count and frailty are significantly associated after minimizing potential influence from other covariates (p<0.005). an increase in one point of hemoglobin concentration is associated with a 14% risk decrease of being frail (or=0.79, 95%ic=0.71-0.89). there were no evidences of significant impact of inflammation and nutritional status in the relationship between hemoglobin concentration and frailty status (p>0.005). conclusion: hemoglobin concentration is strongly associated with frailty in older adults. these results can have potentially important implications for prevention policies targeting frailty, by identifying potential patients with high risk of adverse outcomes and functional outcomes. juliette tavenier 1 , line jee hartmann rasmussen 1 , jan nehlin 1 , morten baltzer houlind 1 , aino leegaard andersen 1 , ove andersen 1 , janne petersen 1,2 , anne langkilde 1 ( (1) background: chronic inflammation is thought to be involved in the development of frailty. we hypothesized that increased monocyte inflammatory activity plays a role in chronic inflammation and thereby in frailty. objectives: to study the potential role of chronic monocyte inflammatory activity in frailty. methods: two groups of elderly adults (>=65 years) were included: 52 patients with a recent admission to the emergency department (ed) and 52 age-and sex-matched controls, without recent ed admission. data was collected at baseline and after 1 year. participants were considered frail if they had 2 or more of the following: hand grip strength ≤26 kg for men or ≤16 kg for women, gait speed ≤0.76 m/s, unintentional weight loss of >1kg within the last 3 months. frailty was also assessed using the frailty index (fi)-outref. we measured cognitive function (mini mental state examination -mmse) and chronic inflammation (soluble urokinase plasminogen activator receptor -supar). monocyte inflammatory activity was assessed by nf-κb phosphorylation (pnf-κb) using flow cytometry. results: participants had a mean age of 76.6 years (range: 65.8-92.2) and 48% were women. preliminary results show that at baseline, the patient group had a greater proportion of frail individuals compared to the control group (21 vs. 1, p<0.0001). fi-outref was on average 1.5 points higher (p<0.0001) and supar levels 35% higher (p<0.0001) in the patient group, however, there was no difference in mmse score between the groups (p=0.17). at 1 year, although the proportion of frail individuals decreased in the patient group, it was still greater than in the control group (9 vs. 3, p=0.04). fi-outref remained elevated in the patient group (p=0.004), but there was no difference in supar levels (p=0.70). pnf-κb was positively associated with age in the control group (p=0.002), but not in the patient group (p=0.45). pnf-κb was 53% higher in the patient group compared to the control group (p<0.0001), and this was unchanged when adjusting for frailty, supar, and mmse. conclusion: the patient group was more frail and had elevated monocyte inflammatory activity compared to the control group. however, none of the frailty measures were confounders for the difference in monocyte inflammatory activity between groups. background: aging is most often accompanied by a loss of body weight: a decrease of fat deposits and muscle body weight. body mass index (bmi) in adults is considered normal if it is in the range of 18.5 to 24.9 kg / m2 (according to the who classification). bmi is widely used in the diagnosis of obesity. the association of bmi and cardiovascular and cerebrovascular diseases is known. objectives: the purpose of research is to identify the relationship of bmi with physical abilities and cognitive functions in long-livers. methods: 75 long-living subjects aged 93.7 ± 2.8 years were examined. in long-livers, height, body weight were measured, calculated bmi. the level and direction of cognitive disturbances was determined by the mmse test (mini mental state examination). physical abilities were determined by the questionnaire and physical tests (tests the muscular strength in forearms and of the hands, chair stand test). results: bmi in long-livers had a normal distribution. the median bmi was 24.7 kg / m2, the minimum value was 11.4 kg / m2, and the maximum value was 42.4 kg / m2. 37.9% of long-livers had a bmi ranging from 18.5 to 24.9 kg / m2. 34.8% of long-livers have lost weight during the past year, including 37.5% by 10 kg or more. 84.1% of long-livers could stand up of the chair. however, only 39.4% of long-livers were able to complete the test correctly. amongst them, 42.3% had a normal bmi. indicators of muscular strength in forearms and of the hand in long-livers who completed the chair stand test were significantly higher compared to long-livers who did not completed the chair stand test (r = 0.31, p <0.01). bmi had a positive correlation with the ability of a long-lived to wash without anyone's help (r = 0.24, p <0.05), go up and down the stairs (r = 0.30, p <0.05), do light housework (r = 0.44, p <0.001). mmse indicators also positively correlated with bmi (r = 0.54, p <0.001). the average mmse 27.8 ± 1.5 was observed with average bmi 26.1 ± 2.7. conclusion: against the background of a decrease in the bmi indicator in long-livers, a decrease in physical abilities and cognitive functions is observed. however, there is a problem in determining the boundaries of the ratio of height and body weight for elderly people. in all likelihood, there are not linear, but more complex dependencies between bmi and functional abilities of long-livers. suparb aree-ue 1 , inthira roopsawang 1 , jansudaphan boontham 2 , surinrat baurangtheinthong 2 , yuwadee phiboonleetrakun 2 ((1) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; (2) faculty of graduate studies, mahidol university, bkk, thailand) background: depressive symptom results in increasing poor outcomes and care dependency in older adults. the prevalence of depressive symptoms is common with its associated multiple factors. however, this conundrum problem is underestimated, particularly in older people living in rural areas. to promote healthy aging, understanding of the conundrum problem is essential in strengthening care quality and enhancing the quality of life in this population. objectives: to determine the relationships of the number of medication use, pain, frailty, and locomotive syndrome and their effects on depressive symptoms among community-dwelling thai older adults. methods: a cross-sectional study was employed. the sample consisted of 310 community-dwelling thai older adults who met the inclusion criteria. data were assessed by using demographics questionnaire, thai version 25-question geriatric locomotive function scale: glfs-25; numeric rating scale; the reported edmonton frailty scale: refs-thai version; and the 15-item geriatric depression scale, tgds-15. a path analysis was employed to determine the pathways linking the number of medication use, pain, locomotive syndrome, frailty to influence depressive symptoms. results: there were significant positive direct paths from pain (beta = 2.78, p <.001) to locomotive syndrome and from locomotive syndrome to the number of medication use (beta = -.03, p <.01). an inversely, the locomotive syndrome was a negative significant direct to depressive symptoms (beta = -.06, p <.01). pain had an indirect effect on depressive symptoms (beta = -.17, p <.01). additionally, the model explained 30.8% of the variability in depressive symptoms. conclusion: the locomotive syndrome is a major factor influencing depressive symptoms. the complex relationship among pain, number of medication use, locomotive syndrome, and depressive symptoms should be taken into account for designing an appropriate intervention to reduce depressive symptoms among community-dwelling thai older adults. background: total knee arthroplasty (tka) is a clinical curative treatment for severe knee osteoarthritis. however, the outcomes are differences in each patient's perception. preoperative patients' expectations to functional abilities are one of important factors influencing on postoperative outcomes and satisfaction. objectives: to investigate the association among preoperative patients' expectations, postoperative functional abilities, and satisfaction to functional abilities among older adults undergoing tka at 6-week after surgery. methods: participants were 97 older adults who were diagnosed with knee osteoarthritis and required to receive tka at a university hospital in bangkok, thailand. the sample was purposely selected based on the following criteria: were aged 60 years or over, received tka for the first time, and had no cognitive impairment. the data were collected at preoperative and postoperative tka by using the demographic data questionnaire, the hospital for special surgery knee replacement expectations survey, and the knee and osteoarthritis outcome score in the part of function in daily living (koos adl) thai version. the data analysis was performed by using descriptive statistics, paired t-test, and pearson product moment correlation coefficient. results: before surgery, patients' expectations to postoperative functional abilities had a high level with the total mean score of 70.21 (sd =13.86), and the item of improving ability to walk in a short distance was rated as the highest expectation. at 6-week after surgery, the overall functional ability had a significant improvement (t = -9.229, p = .000). satisfaction to functional ability also had a high level (mean ± sd = 71.15 ± 14.73), and the improving ability to walk in a short distance item had the highest. patients' expectations to functional abilities had a significantly low positive correlation to postoperative functional ability and satisfaction (r = .273, p < .05; r = .292, p < .01, respectively). moreover, there was a significant moderate positive correlation between functional abilities and satisfaction to functional abilities (r = .603, p < .01). conclusion: a better understanding of expectations may be beneficial in gaining knowledge, paving expectations on possible outcomes, and developing trust resulting in enhancing quality of care for thai older adults undergoing tka. background: identifying low muscle strength is a key step in many operational definitions of sarcopenia including the one recently proposed by the european working group on sarcopenia in older people-2 (ewgsop2). grip strength is widely used to identify people with low muscle strength. however, it is unclear what impact variation in the type of hand-held dynamometer used to measure grip strength has on the prevalence of low muscle strength. objectives: we aimed to assess the impact of estimated differences of between 4 and 5kg in the measurement of grip strength when using different types of hand-held dynamometer on the case-finding of low muscle strength. methods: study participants were 118 men and women aged 45-74 from a randomised, repeated measurements cross-over trial. maximum grip strength was assessed using four hand-held dynamometers (jamar hydraulic; jamar plus+ digital; nottingham electronic; smedley) in a randomly allocated order. ewgsop2 recommended cutpoints (<27kg men; <16kg women) were applied to estimate prevalence of low muscle strength for each device. agreement between devices was assessed using kappa statistics. results: prevalence of low muscle strength varied by dynamometer type ranging between 3% and 22% for men and, 3% and 15% for women. of the 13 men identified as having low muscle strength by at least one of the four dynamometers, only 8% were identified by all four and 54% by just one. of the 15 women classified as having low muscle strength by at least one of the four dynamometers, only 7% were identified by all four and 67% by only one. when comparing pairs of devices, kappa statistics ranged from 0.13 to 0.55 suggesting poor to moderate agreement. conclusion: case-finding of low muscle strength is influenced by the type of hand-held dynamometer used. it is important to identify the sources of variation in the measurement of grip strength and consider the implications of these for sarcopenia. further research is required to understand how best to standardise the assessment of each of the different components of commonly used operational definitions of sarcopenia and take account of sources of variation in these measures where standardisation cannot be achieved. background: sarcopenia is characterized by a progressive loss of skeletal muscle mass and strength associated with mortality and severe adverse events on health. for a healthy aging, the quality of life (qol) is essential and it is associated to autonomy of persons, social relations, and socioeconomic factors. objectives: to compare the qol of chilean older people with sarcopenia living in santiago de chile, according to an adapted version of the european working group on sarcopenia. methods: 562 community-dwelling older people (mean ± sd: 69.8 ± 6.2 years; 72.1% females) were interviewed, registering self-reported chronic diseases and the questions of short-form-12 health survey (sf-12). anthropometry, dynamometry and physical performance were measured. qol was measured using sf-12, validated in chilean older adults. norm-based score of 8 subscales and two summaries components -mental and physical (mcs and pcs; respectively)-were calculated using the chilean-specificscoring for older people. low score was defined as having a score ≤ 25th percentile of mcs and pcs. logistic regressions were estimated. results: sarcopenia was identified in 20.5% of the sample (20.5% women; 20.4% men; p=0.966). the average score of the 8 subscales were significantly higher in non-sarcopenic adults than sarcopenic. the average of mcs and pcs were also significantly higher in non-sarcopenic adults than sarcopenic (mcs: 48.2 vs 46.1; p=0.006; respectively; pcs: 47.2 vs 44.8; p<0.0001; respectively), and were significantly higher in men than women non-sarcopenic (mcs: 49.7 vs 47.7; p=0.006; respectively; pcs: 47.7 vs 47.1, p=0.0287; respectively). there were non-significant differences in sarcopenic adults by sex. logistic regressions demonstrated an association between sarcopenia and low mcs and pcs (or = 3.27; 95%ci: 1.77 -6.04; or = 2.70; 95%ci: 1.48 -4.93; respectively), adjusted by age, sex, multimorbidity, body mass index and lean/fat mass ratio. conclusion: sarcopenia was associated with a worse quality of life, which shows the impact of this pathology and the importance of developing programs for its prevention, delay or reversal. funded by fondef15i10053 p271-munich sarcopenia registry (idsar): first results. uta ferrari 1,3 , marina schraml 1 , ralf schmidmaier 1,3 , navina röcker 1,3 , sigrid adler-reichel 1,3 , christian lottspeich 1,3 , martin bidlingmaier 1,3 , benedikt schoser 1,3 , sabine krause 1,3 , martin reincke 1,3 , michael drey 1,3 ((1) department of medicine iv, university hospital, lmu munich, germany; (2) friedrich baur institute at the department of neurology, university hospital, lmu munich, germany; (3) preventive geriatrics study group, germany) background: since 2018 sarcopenia can be coded as disease in germany (icd-gm 62.50). in the same year we established the first sarcopenia registry linked with a biobank to identify modifiable, crucial risk factors for sarcopenia and its adverse outcomes. objectives: objectives of the registry are (i) how to optimize and standardize the diagnosis over in-and outpatient settings for musculoskeletal health, (ii) identification of clinical and molecular modifiable risk factors (iii) improvement of interdisciplinary treatment and prevention of sarcopenia as a new icd-code-based geriatric syndrome here we present the design as a practical approach for diagnosis in out-and inpatient care and a first descriptive analysis of influencing factors and comparison between in-and outpatients data. methods: patients older than 70 years of age from outpatient clinic and acute geriatric ward at munich university hospital were consecutively screened by the sarc-f questionnaire. patients with high risk (sarc-f score >= 4) were further assessed for sarcopenia in line with the european consensus definition 2 (ewgsop2). among further factors assessed in the registry, we retrieved presence of further comorbidities, daily medication, nutritional status, sppb, frailty, and quality of life. results: at time of analysis, 282 patients have been screened and within the first 50 patients with high risk (82% women) 16% had sarcopenia. patients screened positive for sarcopenia have lower quality of life, even in a subclinical condition (mean euroqol (eq5d-vas) = 47.4±16.5). lower bmi (22.1±2.8, p=0.010) and sex (p=0.029) were statistically significant different for sarcopenia status, but not age (mean 78.5±5.2 years, p=0.326) or number of medication (p=0.691) and comorbidities (p=0.691). but the latter two were the most significant factors for inpatient status (both p<0.001). the results underline the need for an early screening for sarcopenia in all patients older than 70 years of age, suggested by hand grip strength in inpatients and sarc-f for outpatients. sex differences and further laboratory factors are necessary to add in sarcopenia diagnosis for precision medicine approaches. hospitalised older adults. we consider acute sarcopenia to be the last remaining acute organ insufficiency, with potentially devastating impact on function. characterising this condition will enable development of targeted interventions to ameliorate these changes. mobility disability, and incident mobility disability over 2.2 + 0.3 years. factor 1 was associated with incident and prevalent mobility disability only, and factor 2 was associated with only prevalent mobility disability. conclusion: muscle mass by d3cr co-segregated with strength and physical performance measures, and together was associated with mobility and disability outcomes in older men. body composition measures (including dxa alm) did not co-segregate with strength and physical performance measures and together was associated with only mobility disability. background: currently, there are no registered drug treatments for the loss of skeletal muscle mass, strength and function that occurs during sarcopenia and cachexia. moreover, they are only limited relevant pharmacological screening options available. objectives: to improve in vitro pharmacological screening options, we developed a model of muscle wasting using donor primary muscle cells and our myoscreen™ platform that generates standardized myotubes for high-throughput phenotypic screening (young et al., slas discov. 2018 23(8) :790-806). methods: myoblasts from four donors aged 4, 20, 37 and 68 years were compared in terms of proliferation, differentiation, size of formed myotubes and achr cluster formation using imaging and high content analysis. we then established an assay for muscle wasting: in each of the four donors various molecular pathways implicated in the pathogenesis of sarcopenia were activated using tnfa, tgfb or dexamethasone. results: myotubes formed from elderly patient's myoblasts displayed a reduced capacity to proliferate and differentiate, thinner myotubes and fewer acetylcholine receptor clusters. therefore, myotubes cultured using the myoscreen system continue to reflect age-related properties of donor muscle. interestingly, we also found that myotube sensitivity to atrophy stimulation increased with increasing age. myotubes were then co-incubated with growth/ repair factor igf-1 or hdac inhibitor, trichostatin a (tsa). both agents attenuated tnfa-induced myotube atrophy and differentiation inhibition in a dose-dependent manner. the extent of fusion index and myotube size increase was highest in myotubes from elderly subjects while myotubes from young subjects were more resistant to the protective effects of igf-1 and tsa. conclusion: myoscreen can be exploited to quantify age-dependent modifications in skeletal muscle fibers in vitro and identify candidate compounds that counteract the muscle wasting phenotype. andreas friedberger 1 , alexandra grimm 1 , wolfgang kemmler 1 , klaus engelke 1,2 ((1) institute of medical physics, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany; (2) department of internal medicine; (3) friedrich-alexander-universität erlangen-nürnberg and university hospital erlangen, erlangen, germany) background: sarcopenia is characterized by a progressive loss of skeletal muscle mass, which is infiltrated by adipose tissue. dual energy x-ray absorptiometry can only differentiate overall lean and fat mass. a local muscle analysis requires 3d imaging like magnetic resonance imaging (mri). usually, t1 weighted images are used for a visual grading of the amount of intermuscular adipose tissue (imat). however, a quantitative analysis requires segmentation of the fascia lata (fl, deep fascia of the thigh). objectives: our aim was to develop a highly reproducible 3d segmentation method in oder to quantify imat and the fat fraction of the thigh muscles using a combination of t1 weighted turbo spin echo (t1wtse) and corresponding 6pt turbo spin echo (tse) dixon fat fraction (ff) images. methods: mri scans were acquired on a 3t scanner (magnetom skyrafit siemens) at the midthigh (length 10 cm, 34 slices, voxel size t1w 0.5x0.5x3.0 mm³, dixon 0.8x0.8x3.0 mm³). since the fl is difficult to detect in the ff images, the t1wtse images were used for segmentation. this process involved several steps, starting with a fuzzy c-mean clustering followed by several filtering steps to enhance 3d surface like structures representing the fl. finally, a level set algorithm was applied to obtain a closed 3d surface. if necessary, results were corrected manually. segmented masks were transferred from the t1w to the ff images by rigid registration. imat was then segmented using a threshold determined from the histogram of the ff values within the intra-fascia region. 15 sarcopenic (80±5 y) and 5 healthy (28±4 y) male subjects were analyzed by three operators once (interoperator reproducibility) and three times by one operator (intraoperator reproducibility). results: inter-and intra-operator variability results of imat are shown in the table as mean / root mean square of the standard deviation (rms-sd) in units of the measured variable / coefficient of variation (rms-cv) in %. overall precision was excellent with errors below 0.5 %. conclusion: a semi-automatic 3d segmentation for the fascia of the thigh was developed. the operator impact on imat was almost negligible. background: sarcopenia a muscle disease that causes muscle mass loss and weakness. the calf circumference is a good screening test for sarcopenia in older adults in primary care. the most commonly used cutoff point is 31 cm, but it is derived from north american studies and it may not be adequate for screening different populations that have lower height, weight and bmi. objectives: the objective of this study was to determine the ideal cutoff point for calf circumference for sarcopenia in community-dwelling older people in northeastern brazil. methods: this was a cross-sectional study of 538 community-dwelling older people with a mean age of 70±7 years (63% women). data on sociodemographics, anthropometrics, grip strength, gait speed, and skeletal muscle mass (bioimpedance) were collected. sarcopenia was assessed based on the diagnostic criteria suggested by european working group on sarcopenia in older people 2 (ewgsop2). the area under the roc curve (auc) was calculated for different calf circumferences to identify the best cutoff point to determine sarcopenia among the participants. results: the prevalence of sarcopenia was 15%. the most appropriate calf circumference cutoff point was 30 cm, with an auc of 0.68, 79% sensitivity and 45% specificity. conclusion: it was found that the most appropriate calf circumference cutoff point to diagnose sarcopenia in older northeastern brazilians was 30 cm. this is a more accurate cutoff point and will reduce the number of false positives and optimize health services in brazil. background: osteosarcopenia is a new geriatric syndrome defined as the presence of both sarcopenia and osteopenia or osteoporosis. this musculoskeletal disorder is related to higher prevalence of disabilities, falls and fractures and higher risk of mortality among community-dwelling older adults. therefore, the early diagnosis of this condition must be considered in order to reduce costs and negative impact on function. objectives: to explore the use of the infrared spectroscopy as a potential screening tool for osteosarcopenic older women (>=65 years old). methods: sarcopenia was identified by observing the presence of both reduction of muscle strength (grip strength) and mass (appendicular skeletal muscle mass) as suggested by the revised algorithm of the european working group on sarcopenia in older people (2019). reduction on bone mineral density was identified through bone densitometry and a t-score of <-1,0 was adopted to classify the older women as osteopenic/osteoporotic. infrared spectroscopy through attenuated total reflection-fourier transform infrared spectroscopy (atr-ftir) was used to collect the sample information and to perform a multivariate analysis model. vibrational spectrum was obtained from serum. six samples of each group (osteosarcopenic and non-osteosarcopenic) were used to test the model and thirteen ostesarcopenic samples and fifteen non-osteosarcopenic samples were used for training. results: the most suitable model was the ga-svm with an accuracy of 91.7%, 100% of sensibility and 83.3% of specificity to differ osteopenic to non-osteopenic women. the more important selected variables found in the model were at the spectral regions: ~900 cm-1 for carbs, ~1000 to 1150 cm-1 for nuclei acids and ~1500 to 1650 cm-1 for proteins. conclusion: infrared spectroscopy may be a promisor future method to early and easily diagnosis osteosarocopenia and prevent the harms this health condition may cause to the elderly population and minimizing costs to treat them. background: the modified european working group on sarcopenia in older people (ewgsop-2) algorithm to identify older people with sarcopenia contains three steps after initial clinical suspicion. the chair stand test, also known as the fivetimes sit-to-stand test (5sts), is one of two tests that can be used to assess muscle strength. the 5sts is also a component of the short physical performance battery (sppb), which is used as a measure of severity in the ewgsop-2 algorithm. objectives: the objective of this study was to determine whether the 5sts could be used to assess both muscle strength and physical performance in the ewgsop-2 algorithm to detect sarcopenia. methods: one hundred and ten older people aged 70.2 ± 5.4 years participated in the study. all participants were evaluated using the sppb score, as well as the timed-upand-go (tug). the ewgsop-2 algorithm specifies cut-off points of ≤8 points on the sppb, ≤ 0.8 m/s for gait speed, and ≥ 20 s for the tug. each participant was classified for tug and gait speed using the ewgsop-2 cut-offs, with stepwise discriminant function analysis used to predict the classification of 90 participants. the remaining 20 participants were used for cross-validation. prediction of sppb classification used the 5sts score in combination with predicted balance and sppb gait scores from stepwise linear regression. the total sppb score obtained using this method was used to predict sppb classification for the ewgsop-2 cut-off for sppb. results: the 5sts scores were able to predict tug and gait speed classification with 89% and 79% accuracy, respectively for the learning set of 90 participants. the predicted sppb score had a classification accuracy of 95%, with 100% sensitivity and 93% specificity. when the remaining 20 participants were evaluated, the sppb classification was correctly predicted for 19 participants (95%), with 100% sensitivity and 92% specificity. conclusion: the 5sts can be used to accurately predict sppb classification in the ewgsop-2 algorithm to detect sarcopenia, meaning that the 5sts test could be used as a standalone test in an initial screening for sarcopenia. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital , san josé, costa rica) background: obesity is a disease characterized by increased adiposity with negative impact on patient health. aging process is associated with a progressive loss in muscle function, that may lead to functional decline and frailty. there are only few studies that have compared the prevalence of sarcopenia and dynapenia in obesity. objectives: the aims of this study were to determine the prevalence of sarcopenic and dynapenic obesity in elderly using the european working group on sarcopenia in older people 2 criteria. methods: we conducted a cross-sectional study that included elderly patients with obesity from the obesity clinic since january 2018 to june 2018. sarcopenia was defined according to the european working group on sarcopenia in older people 2 (ewgsop2) criteria, and obesity with body mass index (bmi) > 28 kg/m2. handgrip strength was assess using a hydraulic dynamometer (jamar). bioimpedance analysis (bia) was performed. results: we evaluated 130 persons, but only 90 had bia data (70%). a total of 90 older (72.9 ± 6 years), 88% were women. mean body mass index, waist circumference, weight and calf circumference were 37.1±5.1 kg/m2, 119.4±11.6 cm, 89.2±15.5 kg and 39.4±4.2 cm respectively. all patients had elevated body fat (mean 51%) and 100% had abdominal obesity. patients showed higher frequency of hypertension (91%), diabetes (60%), dyslipidemia (56%). sedentary was present in 80% and falls in 5%. mean handgrip strength and muscle mass for men and women were 26.18±8.3 kg; 17.29±6.3kg and 29.7±4.5 kg; 22.5±5.5 kg respectively. there were 3 (3.3%) individuals fulfilling criteria for sarcopenic obesity, all women. but, dynapenic obesity was present in 4.4% men and 38% women. conclusion: although the loss of muscle mass is associated with the decline in strength during aging, the decline in strength is more prevalent than the loss in muscle mass in our obeses. a large difference in prevalence of the two conditions was observed, sarcopenia obesity 3.3% and dynapenic obesity 42%, respectively. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital, san josé, costa rica) background: sarcopenia is a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass, strength, and function. several operative definitions for sarcopenia have been proposed over the past two decades. objectives: the aim of this study was to determine the prevalence of sarcopenia in costa rican longevity and health aging study (creles) using the ewgsop and ewgsop2 criteria. methods: to carry out the analysis, all the available cases of the creles study database in 2005 which belong to the cohort that follows in the period 2005-2009 were used. we analyzed 2142 community-dwelling older adults. low muscle mass was assessed using calf circumference <31 cm and low strength if <30 kg in men or <20 kg in women (ewgsop) vs <27 kg in men or <16 kg in women (ewgsop2). results: according to the ewgsop 17.8% of the participants had sarcopenia, while according to the ewgsop2 sarcopenia was present in 9,7% of participants. there was an increasing trend of sarcopenia by age group, it was more prevalent in women. mean handgrip strength was 21,95 kg in men and 13,65 kg in women with sarcopenia. mean calf circumference was 28,4 cm. sarcopenia was positively associated with age (or=1.10; ci:1.06-1.15), incomplete primary education (or 4, 264; ic 1, 753) , perceived as unhealthy (or 1,691; ic 1,133-2,525), antecedent of ischemic vascular event (or 3,221; ic 1,566-6,628), arthritis (or 1,648; ic 1,044-2,601), and falls (0r 1,676; ic 1,143-2,458). conclusion: the overall prevalence sarcopenia were significantly lower in ewgsop2. prevalence of sarcopenia varies widely depending on the grip strength cut-off points applied. based on a 24-hour dietary recall, and poorer nutritional status as determined using must compared to their non-sarcopenia counterparts (all p<=0.0063). conclusion: the high prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition highlights the importance to devise targeted exercise and nutrition interventions to improve muscle health, physical performance and nutritional status. these interventions are essential to reduce the risk of progression to frailty and disability in this population group. v i n c e n z o m a l a f a r i n a 1 , l e t i z i a s u e s c u n p u e r t a 2 , a r a n t z a z u b i a i n u g a r t e 3 , i ñ a k i a r t a z a a r t a b e 4 , virtudes niño martín 5 ( (1) s o p h i e g u y o n n e t 1 , c a t h e r i n e t a k e d a 2 , philipe de souto barreto 3 , yves rolland 1 , sandrine andrieu 4 , bruno vellas 1 and the inspire study group ( (1) background: the new geroscience field should not only be focusing on preventing age-related diseases, but should investigate the optimal maintenance of intrinsic capacity (ic): mobility, cognition, psychological, vitality and sensorial (hearing and vision) capacities as defined by the w.h.o. a better understanding about how to measure biological aging is an indispensable step that may lead to the definition of the best putative markers of aging capable of predicting healthspan. objectives: the main objective of inspire bioresource research platform for healthy aging is to build a comprehensive research platform gathering biological, clinical (including imaging) and digital resources that will be explored to identify robust (set of) markers of aging, age-related diseases and ic evolution. methods: the inspire platform will gather clinical data and biospecimens from 1000 subjects in the occitania region of different ages (from 30 years or over -no upper limit for age) and functional capacity levels (from robust to frail to disabled) over 10 years (inspire human translational research cohort). data are collected annually. between two annual visits, ic domains are monitored (with or without the help of a caregiver) each 4-month. once ic declines are confirmed, participants have a thorough clinical assessment and blood sampling to investigate the response of markers of aging at the time declines are detected. biospecimens includes blood, urine, saliva, and dental plaque that are collected from all subjects at baseline and then, annually. nasopharyngeal swabs and cutaneous surface samples are collected from all subjects at 6 time-points (baseline visit and follow-up visits at m24, m48, m72, m96 and m120). feces, hair bulb and skin biopsy are collected optionally at the baseline visit. results: recruitment started in october 2019 for a two years period. the identification of markers of aging will take advantage of three complimentary approaches to look for the best markers of aging: without a priori approach (transcriptomics, proteomics, lipidomics); semi a priori approach (metabolism, inflammation, cell cycle, mitochondrial network…); and targeted approach (pre-identified targets). the inspire platform will also aim to develop an integrative approach to promote novel new technologies for the assessment and monitoring of functional capacities. *acknowledgments: the inspire plateform is supported by grants from the occitania region and the european regional development fund (erdf), and co-funding by the apoc, the ctad, and the edenis, korian, pfizer, and pierre fabre groups. the promotion of this study is supported by the university hospital center of toulouse. background: energy balance is usually regulated by silent information regulator 2 related enzyme 1 (sirt1) and adenosine monophosphate-activated protein kinase (ampk). caloric restriction (cr) can postpone the pathological process of aging-related diseases and has a neuroprotective effect on nervous system degenerative diseases, but the mechanism is complex and not yet fully elucidated, although some of the cr effects may be mediated by sirt1 and ampk. objectives: to evaluate the beneficial effects of a cr diet on learning and memory ability. methods: six-week-old male c57/bl mice were fed ad libitum for 1 week before the experiment began. animals were weight-matched and randomly divided into three different groups: normal control group (nc group, n = 30), high-energy group (he group, n = 30), and cr group (n = 30). the energy of nc diet, he diet and cr diet caloric ratio was 1:1.3:0.7. the total experimental duration was 10 months. results: cr improved spatial learning and memory ability and decreased body weight and serum glucose. nissle staining showed the cell density was significantly decreased in the he group and increased in the cr group. cr decreased the expression of insulin signal pathway-related proteins such as igf-1, ir, irs-1, pi3k, akt/pkb, and p-creb. more sirt1-immunoreactive cells and fewer mtor-and s6k1immunoreactive cells were observed in the hippocampal in the cr group than in the nc group. cr decreased hippocampal mtor and s6k1 protein activation and mrna expression. the expression of beclin1, lc3 and cat b was increased and p62 was decreased in the cr group. the number of gfap-positive and iba-1-positive cells in the cr group was significantly reduced compared to the nc group. conclusion: cr may prevent age-related learning and memory impairment via suppression of pi3k/akt pathway and activation sirt1/ ampk/ mtor pathway in brain. background: head-down (6°) bed rest (hdbr) is a wellaccepted model to understand the pathophysiology of disuseinduced sarcopenia. human centrifugation as a measure to counteract muscle wasting during spaceflight is discussed. previous studies have observed decreases in maximal voluntary contraction force of the knee and hip-extensors of up to 22% following 5 weeks of hdbr. muscle force is regulated by the recruitment of motor units (mus) and the modulation of mu firing rate. objectives: the aim of this study was to assess whether long-duration hdbr alters motor unit properties as one cause for disuse induced sarcopenia and whether human centrifugation can attenuate this decrement. methods: twelve healthy participants (35.9±9.7yr; 174±7cm & 76.8±6.7kg) were confined to 60-days 6° hdbr in the frame of the first campaign of the agbresa bedrest study. eight received 30mins of artificial gravity (ag) daily via human centrifugation whereas four belonged to a control group. estimations of mu number (munix) and size (musix) in the abductor digiti minimi (adm) and tibialis anterior (ta) muscles were made using the motor unit number index method from on day 5 preceding bed rest (bdc5) and on days 4 (hdt4) and 59 (hdt59). mean compound muscle action potential (cmap), munix and musix as a percent change from bdc5 were compared using repeated-measures anova, where muscle and time were ascribed as within-group factors and intervention a between-group factor. significance was denoted by p<0.05. results: both cmap and munix were unaltered over time in both muscles, irrespective of the intervention. although musix was also indifferent over time for both muscles, a significant muscle*time interaction was observed, indicating that the changes over time differed between the two muscles. conclusion: the preliminary data from the ongoing study indicate that neurodegeneration due to bedrest might affect muscles differently. there does not seem to be an effect of ag on mu number. analyses have to be repeated when the study is completed with a larger number of participants. additional histological and biochemical data will give further insight in the pathophysiology. living. soumaya msaad 1 , geoffroy cormier 2 , guy carrault 1 ((1) univ rennes, inserm, ltsi -umr 1099, f-35000 rennes, france; (2) neotec vision , rennes , france) background: several models have been proposed for elderly frailty detection. there is a consensus on two of them: the fried model, and the rockwood model. however, daily monitoring of the elderly is impossible with these models, whereas it is very important to detect any change as soon as possible to prevent dependency, since frailty is reversible only if early detected. objectives: the objective of this study is to propose a non-intrusive and low-cost method that anticipates frailty using depth images. crucial hypotheses are that regularity of daily activities is important for the elderly and that any prolonged change is considered as an indicator of frailty. methods: the proposed method consists in three steps: 1) extraction of parameters from depth images: lying and sitting time percentage during the day, walking speed, and number of falls, visits, and exits. 2) classification of the daily state using logistic regression and the extracted parameters. the daily state is considered as normal if the daily routine is maintained and abnormal if it is broken. 3) computation of the weekly percentage of maintaining routine based on the classification of the nature of the day. results: tracking frailty is a difficult task that requires recording data over several months. as real data has not been collected yet, the feasibility of our approach was assessed on simulated data. in the latter, we reproduced variations of the parameters we would have extracted from real images of a patient after investigating his or her daily life. the classification of the days (normal/abnormal) led to an accuracy of 99% (training dataset: 135 days, test dataset: 45 days). a patient is considered frail when the weekly percentage of maintaining routine decreases steadily. conclusion: the preliminary results prove that in addition to being non-intrusive, a depth-imaging based approach can be a promising tool for frailty detection. anna franke 2 , ellen freiberger 2 , robert kob 2 simon moskowitz 1 , david w. russ 1,2 , leatha a clark 1,3,4 , nathan p. wages 1,3 , dustin r. grooms 1,5 , brian c. clark 1,3,6 ( (1) background: one putative mechanism explaining mobility limitations (mls) in older adults (oas) is a reduction in the central nervous system's (cns) ability to rapidly drive muscle force/torque production. rapid movements can be mathematically expressed as the time derivative of force/ torque, also termed 'yank' (y). muscles are ultimately responsible for generating y, but cns input (ni) to the muscles clearly influences y. the time derivative of the voluntary electromyogram during maximal efforts is associated with gait speed (gs) and chair rise time (crt). however, since the electromyogram is influenced by non-physiological factors (e.g., subcutaneous adipose tissue acting as a low pass filter), it is difficult to fully ascribe this finding to cns deficits. theoretically, normalizing y to the time derivative of electrically evoked force/torque controls for musculoskeletal factors contributing to y (ymsk), which yields a value representing the cns's ability to rapidly produce force/torque (yni=y/ymsk). objectives: to better understand the role of the cns in mls in oas we 1) compared leg extensor yni between young and oas, and 2) examined the association between leg extensor yni and measures of mobility. methods: twenty-one young and fifty-nine oas (21.95 +/-1.8 and 75.07 +/-6.8yrs) were instructed to "kick out as fast and hard as possible" against a fixed lever arm attached to a torque motor, and we quantified y between onset and 100-msec. next, we quantified ymsk from a supramaximal electrically evoked torque-time recording (potentiated 100-hz doublet) and calculated yni as described. on a separate visit six-minute walk (6mw) gs, stair climb power (scp), and 5x crt were measured. results: oas had higher yni vs. young adults reflecting a 22% reduction in central neural activation during rapid torque development (0.503 +/-0.141 vs. 0.393 +/-0.148; p<0.001). significant associations were observed between yni and 6mwgs (r=0.30), scp (r=0.43), and 5x crt (r=-0.48). conclusion: oas have a slower rate of volitional neural activation during rapid leg extensor torque production relative to young adults. in addition, yni explained ~10-25% of the variability in measures of mobility, thereby supporting the notion that age-related reductions in the ability of the cns to rapidly activate muscles contribute to mls. background: opa1 mutations cause dominant optic atrophy (doa), an incurable retinopathy with variable severity and which mechanisms are still unknown. more than 20% of patients will endure a doa plus syndrome with ataxia, deafness or parkinsonism. the hypothesis of an oxidative stress has been proposed to explain the variability of these symptoms. objectives: that's why our goal is to improve understanding of the physiopathological mechanisms involved in this disease by developing mathematical models of the production of reactive oxygen species (ros) by the mitochondrial respiratory chain. methods: we monitored the levels of mitochondrial respiration, reactive oxygen species (ros), anti-oxidant defenses and cell death by biochemical and in situ approaches using in vitro and in vivo models of opa1related disorders and model the complex i functioning with a detailed stochastic background: the sarc-f is a 5-question screening tool for sarcopenia. we present results for reliability and validity of the german version of the sarc-f. objectives: translation, adaptation and validation of the german version of the sarc-f for community-dwelling older adults in germany. methods: design: cross-sectional. setting and participants: 117 community-dwelling outpatients with a mean age of 79.1 ± 5.2 years were included in the study, 94 (80.4%) of them were female. 63 (53.8%) had a positive sarc-f score of >= 4 points. according to the definition for sarcopenia from the european working group on sarcopenia in older people (ewgsop2), eight patients (6.8%) were identified as sarcopenic and 57 (48.7%) as probable sarcopenic. methods: translation and cultural adaption was composed of seven different steps that were in general based on the guidelines put forward by the world health organization. validation include test-retest and the inter-rater reliability (intra-class correlation coefficient) as well as internal consistency (cronbach's alpha). further, sensitivity, specificity, positive predictive value, and negative predictive value of the sarc-f were calculated. receiver operating characteristics (roc) analysis was performed to calculate the area under the curve. results: the translated and culturally adopted version of the sarc-f for the german language has shown excellent interrater reliability and good test-retest reliability. the internal consistency is acceptable. sensitivity (63%) and specificity (47%) for sarcopenia is low. for detecting patients with probable sarcopenia, the sarc-f in the german version has shown 75% sensitivity and 67% specificity. conclusion: due to a low sensitivity for detecting sarcopenia but an acceptable sensitivity for identifying probable sarcopenia, the german version of the sarc-f is a suitable tool for case finding of probable sarcopenia. background: skeletal muscle is a vital component of the locomotor system necessary for physical function. however, there is increasing evidence that skeletal muscle acts as a secretory organ in itself, communicating with other organ systems. acute sarcopenia is an emerging condition affecting adults following hospitalisation, which should be considered akin to organ insufficiency elsewhere. however, acute sarcopenia remains poorly characterised to date. objectives: • to characterise changes in muscle quantity, strength, physical performance, and patient-reported physical function in hospitalised older adults at one week and three months. • to determine what biological and clinical factors are predictive of changes to enable further research towards targeted interventions. methods: planned recruitment will include hospitalised patients aged 70 years and older; 56 elective colorectal surgery patients, 56 emergency surgery patients, and 56 general medical patients with acute bacterial infections. patients will be recruited to the elective cohort in pre-operative assessment clinic with repeat measures within 48 hours of surgery, at one week, and at three months. emergency surgery patients will be recruited pre-or post-operatively with repeat measures at one week, and at three months. medical patients will be recruited within 48 hours of admission, with repeat measures at one week, and at three months. muscle quantity will be measured by bilateral anterior thigh thickness using ultrasound and bioelectrical impedance. muscle function will be measured by handgrip strength and short physical performance battery. serum and plasma samples will be obtained prior to admission in the elective cohort, within 48 hours of surgery in both surgical cohorts, and within 48 hours of admission in the medical cohort. background: sarcopenia is common in old age and is associated with various diseases. as human life expectancy is projected to increase, this will pose a challenge for the global healthcare industry. since sarcopenia is highly heritable, study of its genetic underpinning can help its etiology. in the past decade genome wide association studies (gwas) have allowed the identification of new genetic markers for various conditions. identification of new genetic markers through gwas requires functional validation using cellular models in order to both prioritize and validate the potential loci/genes. objectives: demonstrate that a locus identified in gwas may affect muscle health, which is approximated by lean mass and hand grip strength. methods: gwas results are screened using a two-step scoring system which utilizes publicly available databases such as genecards, ensembl and coxpresdb to assess the relevance of a certain locus. relevant genes are then knocked out using crispr-cas9 in c2c12 mouse myotube cells which are induced to differentiate. after cell harvest rt-qpcr and western blot are performed to assess mrna and protein expression, respectively. knocked out cells are also examined against wild type cells for morphological phenotype. results: slc8a1 is a promising candidate based on: (a) muscle gwas results, (b) the expression of the gene in smooth and striated muscle tissue, (c) the lack of co-expression with other genes that have an effect on muscle; (d) mouse phenotypes associated with a mutation in the mouse ortholog slc8a1, (e) cell epigenetic data and (f) the topologically associated domain (tad) at chr. 2:40,097,270-40,611,053. rt-qpcr of wild type c2c12 cells showed a fast increase in the expression of slc8a1's mrna which remains constant during the entire differentiation process. conclusion: preliminary results indicate that slc8a1 might be a promising candidate to investigate for involvement in muscle health. there is a fast and stable increase of the gene's expression during myotube formation. positive results may suggest that slc8a1 is of importance to muscle health. to farther assess slc8a1 role, wild type cells will be compared to knocked-out cells. this might lead to a new genetic marker for muscle health, thus extending personalized medicine in the field of sarcopenia and muscle health. jesse zanker 1 , terri blackwell 2 , sheena patel 2 , kate d u c h o w n y 2,3 , s h a r o n b r e n n a n -o l s e n 1 , s t e v e n r . cummings 2,3 , william j. evans 4,5 , eric s. orwoll 6 , david scott 1,7 , sara vogrin 1 , gustavo duque 1 , peggy m. cawthon 2,3 ( (1) background: muscle mass, strength and physical performance are independent risk factors for disability and mobility disability in older adults. it is not known how measures of body composition (muscle, lean and fat mass), strength and physical performance are interrelated or how empirical groupings of these measures relate to disability and mobility disability. objectives: to determine the relationship between measures of body composition, strength and physical performance in older men and to examine how empirical groupings of these measures relate to adverse mobility and disability outcomes. methods: muscle mass was assessed by d3-creatine dilution (d3cr muscle mass) in 1345 men (84.1 + 4.1 years) enrolled in the osteoporotic fractures in men (mros) study. participants completed anthropomorphic measures, walk speed (6m), grip strength (kg), chair stands (s), and dual x-ray absorptiometry (dxa) appendicular lean mass (alm) (adjusted for weight, body mass index or height2) and body fat percentage. factor analysis was conducted to reduce variables into smaller components. men self-reported limitations in mobility (walking 2-3 blocks, climbing 10 steps, or carrying 10 pounds); activities of daily living (adls); and instrumental adls at initial and follow-up visits. negative binomial models adjusted for participant characteristics were used to determine the relative risk of factors with mobility and disability outcomes. results: factor analysis reduced 10 variables into four factors: factor 1, body composition, with strong loading by alm, body fat percentage, weight and muscle mass; factor 2, body size and lean mass, with strong loading by height, weight and alm; factor 3, muscle mass, strength and performance, with strong loading by walk speed, chair stands, grip strength, and muscle mass; and factor 4, lean mass and weight, with strong loading by alm and weight. only factor 3 was associated with prevalent disability and background: urinary incontinence(ui) is a prevalent and costly condition that affects ~40% of older communitydwelling women.one of the contributors of ui is decreased pelvic muscle strength. objectives: to determine the effect of additional oral glutamine supplementation to kegel-exercise on pelvic floor strength and clinical parameters of ui in females. methods: it is a randomized, double-blind study. females with ui were included. digital test and a vaginal manometer were used for measuring the strength of the pelvic floor muscles. 24 hours pad weight test was examined. participants were randomized into 2 groups as oral glutamine 30 gr/day and placebo. it was asked to use the supplementation and kegel-exercises to all participants for 3 months. basic and 3th month measurements were compared by paired sample t -test and wilcoxon tests in each group. the progression between measurements at basic and 3th months was compared between the groups by using mann-whitney-u test. (clinical trials protocol id: 2014 /1203 background: it is important to identify if middle-aged people are at risk for sarcopenia. a screening-tool identifying predictors of pre-sarcopenia early in the lifespan may inform prevention focused interventions. objectives: develop and validate a practical screening-tool to identify middle-aged adults at risk for pre-sarcopenia using data from the dunedin multidisciplinary health and development study (dmhds). methods: the dmhds is an ongoing longitudinal birth cohort study from the greater dunedin (nz) metropolitan area. the primary outcome of the screening-tool was low appendicular lean muscle index (almi) in middle-aged adults, at age 45. low almi was classified using prado's age-specific median cut-scores. the models were developed in 80% (n=720) of the cohort and cross-validated in the remaining 20% (n=179). possible predictors at age 38, were examined for associations with low almi, using univariate logistic regression. significant predictors were selected in a multivariate logistic regression to derive sex-specific prediction models. each individual in the cohort was allocated a risk-score and classified as low, medium and high risk, based on the quartile risk score. overall performance of the final models was estimated with nagelkerke r2 score, discrimination of the models with the area under the roc curve and calibration of the final models with hosmer-lemeshow tests. results: 49% of the development set and 51% of the validation set were female. the final models for both sexes included body mass index (b=-0.704, p=0.000; b=-0.746, p=0.000), vo2max (b=-0.137, p=0.000, b=-0.187, p=0.004) and grip strength (b=-0.067, p=0.000, b=-0.118, p=0.001). the final model for females also included creatinine (b=-0.187, p=0.016). nagelkerke's r2 showed that 56.7% and 67.6%, of the variance in low almi, is explained by the variables in the screening-tool for males and females, respectively. the area under the roc curve demonstrated good discrimination (0.827). sensitivity in the lowest quartile was 93.8%, specificity in the highest quartile was 97.8%. the hosmer-lemeshow p-values were respectively 0.539 and 0.617, showing goodness of fit. conclusion: this screening-tool was able to predict the sex-specific risk of pre-sarcopenia in a large birth cohort of early middle-aged adults. clinical utility and application of this screening-tool require further investigation. background: aging-associated changes in body composition include a decrease in skeletal muscle mass, which may predispose women to physical limitations and disabilities. in women, these changes may already be accelerated during menopause, when ovarian estradiol (e2) production ceases. e2, the main female sex hormone, is known to have beneficial effects on female skeletal muscle mass. objectives: the aim of this study was to investigate the effects of menopausal transition on lean body mass, lower limb muscle mass, muscle area and muscle fiber cross-sectional area in middle-aged women. methods: middle-aged women (n=199) were followed from perimenopause to postmenopause. menopausal state was defined based on repeated follicle-stimulating hormone (fsh) measurements and menstrual bleeding diaries. serum hormone levels (e2 and fsh; immulite2000), lean body mass (lbm), right leg lean mass (dxa, n=190), and thigh muscle cross-sectional area (computed tomography (ct), n=37) were measured in peri-and postmenopause. muscle biopsies for immunohistochemistry were obtained from 7 participants at peri-and postmenopausal phases, and muscle fiber crosssectional areas were measured. the level of physical activity (pa) from the previous 12 months was assessed with a questionnaire (met-hours/day, n=183). statistical differences were analyzed with paired t-test and wilcoxon signed rank test. gee-modeling was used to analyze the effects of covariates during follow-up. results: the average followup time was 1.2 years (range 0.4-3.6 years) and there was a significant difference in e2 and fsh levels during the transition (p<0.001 for both). lbm decreased 0.5% (p=0.027) and leg lean mass 1.2% (p=0.003) during the menopausal transition. no changes were found in the cross-sectional area of thigh muscles or muscle fibers. the level of pa declined during the transition (p=0.037). when individual menopausal transition time and pa were controlled, only systemic e2 levels were positively associated with lbm (b=0.675, p=0.031). conclusion: despite the relatively short follow-up time, significant declines were observed in lbm and leg lean mass during the menopausal transition. the decrease in lbm was associated with lower systemic e2 level. therefore, it seems that although pa might slow the decrease in muscle mass, estradiol loss is one key factor in whole body muscle loss during menopausal transition. hiroyuki shimada 1 , takehiko doi 1 , sangyoon lee 1 , kota tsutsumimoto 1 , seongryu bae 1 , sho nakakubo 1 , keitaro makino 1 , hidenori arai 2 ((1) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan;(2) national center for geriatrics and gerontology, aichi, japan)background: in 2018, the european working group on sarcopenia in older people met again (ewgsop2) to update the original definition of sarcopenia. ewgsop2 uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia. however, it is not clear that the relationships between the revised definition of the sarcopenia and disability incidence in japanese older adults. objectives: to examine the associations between sarcopenia for ewgsop2 criteria and disability incidence among community-dwelling older japanese individuals. methods: a total of 4561 older adults participated in the study (2301 women; average age, 71.9 ± 5.4 years) form a japanese national cohort study called the ncgg-sgs. skeletal muscle mass was assessed using a bioimpedance analysis device and handgrip strength and walking speed were measured as physical performance. we used the cut-points of the asian working group for sarcopenia to determine the low muscle mass and low physical performances. the participants were divided into non-sarcopenia, sarcopenia, and severe sarcopenia groups. the incidence of disability was determined using data collected by the japanese longterm care insurance system over 49 months. results: the prevalence rates of sarcopenia and severe sarcopenia were 2.6% and 1.4%, respectively. the participants with sarcopenia, included sarcopenia and sever sarcopenia, showed higher risk of disability incidence than those with non-sarcopenia (hazard ratio [hr]: 1.78, 95% confidence interval [95% ci]: 1.27-2.49). in analysis between non-sarcopenia and sarcopenia or severe sarcopenia, although the association between disability incidence and severe sarcopenia remained significant (hr: 2.00, 95% ci: 1.32-3.02), there was no significant association in sarcopenia (hr: 1.54, 95% ci: 0.97-2.46). conclusion: severe sarcopenia combined low muscle mass and low physical performance could have a higher risk of disability than healthy older adults or older adults with low muscle mass alone. further studies are needed to determine whether sarcopenia without poor physical performance is associated with disability incidence.background: sarcopenia is one of the biological hallmarks of frailty that has been associated with adverse events in older adults undergoing cardiac surgery. dual x-ray absorptiometry (dxa) is a recommended modality to measure muscle mass, however, dxa may be less accurate in acute cardiac patients due to the confounding effects of peripheral edema and fluid shifts. objectives: the study aims to determine if sarcopenia as measured by a combination of dxa and timed chair rises is associated with mortality in older adults referred for cardiac surgery. methods: a convenience sample of hospitalized older adults being evaluated for cardiac surgery was prospectively enrolled at the jewish general hospital. after a questionnaire and physical performance battery, patients underwent a dxa scan (ge lunar) to measure their appendicular muscle mass (amm). patients were categorized as sarcopenic based on the european working group guidelines if they had low amm defined as <7 kg/m2 in men or <6 kg/m2 in women and low muscle strength defined as 5 chair rises >15 seconds. multivariable logistic regression was used to test the ageand sex-adjusted association between sarcopenia and allcause mortality. results: the cohort consisted of 146 patients with a mean age of 70.1 ± 10.3 years and 22% females. the interventions were isolated coronary bypass in 60%, valve surgery in 30%, and decision not to proceed with surgery in 10%. the mean amm was 24.1 ± 5.2 kg in men and 21.1 ± 5.2 kg in women. the prevalence of sarcopenia was 15% (n=22), similar in men and women. sarcopenia was not associated with 1-year mortality (or 0.87, 95% ci 0.21-3.57) and, in a separate model, neither was low amm (or 1.00, 95% ci 0.28-3.61). slow chair rise time was associated with higher 1-year mortality (or 6.10, 95% ci 1.21-30.89). when patients with heart failure and reduced ejection fraction were excluded, sarcopenia appeared to be more prognostic (or 1.96, 95% ci 0.39-9.82) although it did not reach statistical significance. conclusion: lower-extremity muscle strength, but not dxa-based measures of muscle mass or sarcopenia, is predictive of survival in hospitalized older adults referred for cardiac surgery. background: the "blue zone" are limited areas with a high prevalence of centenarians, with rather homogeneous characteristics, life styles and environment." this blue zone, located in the nicoya peninsula, is in the province of guanacaste. even though costa rica has this blue zone, there are no studies that characterize the prevalence sarcopenia in the centenarians of the region. objectives: the aim of this study was to determine the prevalence of sarcopenia on centenarians from nicoya, costa rica, using the ewgsop2 criteria. methods: this is a cross-sectional study using a population base of 43 community-dwelling centenarians from guanacaste. antropometric measures, weight, height and strength were assessed. to assess the nutritional state, the mini nutritional assessment (mna) was used and activities of daily living (adl) scores. low muscle mass was assessed by calf circumference <31 cm and low strength if <27 kg in men or <16 kg in women. results: the mean age of the patients were 101.93±1.7 years. from this group, 18 (41.9%) were men and 25 (58.1%) were women. patients showed comorbilities: hypertension (55.5%), diabetes (11.6%), copd (20.9%), cancer (7%), osteoarthritis (25%) and depression (25%). mean body mass index, weight, brachial and calf circumference were 20.8±4.3 kg/m2, 44.3±10.5 kg, 22.6±3.3 cm and 27.2±4.6 cm. mean handgrip strength was 9.9±5.3 kg. the mean score for the mna test was 19.9±4.9 and adl score 54.65±33.9. with respect to sarcopenia prevalence, a total number of 20 (46.5%) subjects were detected, 8 (18.6%) men and 12 (27.9%) women fulfilled the criteria. according to the nutritional status, 3 patients with sarcopenia had malnourishment, 15 were on nutritional risk and 5 had a good nutritional state. from the sarcopenic centenarians, at least 55% of the subjects had dependency with adl. conclusion: we had high prevalence sarcopenia in centenarians from the "blue zone". there are few studies in centenarians, but using the ewgsop2 criteria, it is the first in latin america. background: sarcopenia is a geriatric syndrome characterized by low muscle mass and low muscle function and/or reduced physical performance. malnutrition is a major risk factor for sarcopenia. there is limited data on the prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition in singapore. objectives: the objectives were (i) to determine the prevalence of sarcopenia and its components i.e. low handgrip strength, low appendicular skeletal muscle mass index (asmi) and low gait speed based on the asian working group for sarcopenia consensus (chen et al., 2014) , (ii) to describe the characteristics and dietary intake of older adults with sarcopenia to those without sarcopenia. methods: a total of 811 community-dwelling older adults (>=65 years) who were at risk of malnutrition (malnutrition universal screening tool; must score >=1) took part in this study. sarcopenia was diagnosed by low muscle mass (asmi using bioelectrical impedance analysis) plus low muscle strength (handgrip strength) and/or low physical performance (4-meter usual gait speed). anthropometric measurements, dietary intake, and short physical performance battery (sppb) were also collected. results: over 90% of participants had a charlson comorbidity score of 0. the overall prevalence of sarcopenia was 70%; 81.3% had low asmi, 81.7% had low handgrip strength and 44.2% had low gait speed. participants with sarcopenia were significantly older, shorter, and with lower body weight and bmi, mid-upper arm circumference, calf circumference and bone mass compared to those without sarcopenia (all p<0.0001). they also had lower physical functions as measured using handgrip strength and endurance, leg strength, and sppb score than those without sarcopenia (all p<=0.0021). additionally, older adults with sarcopenia had lower total energy intake and energy-adjusted protein intake background: the prevalence of sarcopenia varies according to the diagnostic criteria used, however it is an important geriatric syndrome related to a worse functional state in the elderly. very older adults are often excluded from clinical trials. objectives: the aim of this observational prospective study is to describe the prevalence of sarcopenia in community very older adults with high comorbidity. methods: we included patients who enter the geriatric day hospital of the hospital of navarra, spain, aged more than 75 y, underwent bioelectrical impendance analisys (bia), measurement of hand grip strength (hgs), gait speed (gs), short physical performance battery (sppb), mini-nutritional assessment (mna-sf), barthel index and cumulative illness rating scale-geriatric (cirs-g). sarcopenia were defined according to ewgsop2 (2019). the study begining in 2017 and it is actually ongoing. we registered variables at baseline, and at the time 6, 12 and 24 months. all-cause mortality were registered. results: we present the preliminary results of baseline value. we icluded 302 patients (52.3% men, 87.4±4.6 y). sarcopenia were present in 173 participts, vithout sex differences. sarcopenic vs no-sarcopenic patiets were older (88.2±4.4 vs 86.2±4.4 y) (p<0.001) and they presented worse nutritional status (bmi 23.3±2.9 vs 28.7±4.7 kg/m2) (p<0.001), mna-sf 9 (95%ci 8-11) vs 11 (10-13) (p<0.001). sarcopenic patients presented lower barthel index (75, 95%ci 60-90 vs 85, 70-95) (p=0.022), but we have no observed differnces nor in the sppb 5, 95%ci 3-7 in sacropenic, vs 5, 4-8 in no-sarcopenic participats (p=0.139), neither in comorbididy index (cirs-g 16, 13-20 vs 17, 15-20 respectivelly) (p=0.552). sarcopenia is significantly associated with higher mortality (hr 0.623, 95%ci 0.388-0.999) (p=0.045). at the present time the mean follow-up is 15.7±8.6 months. at 6 months in 18 patients (17%) the sarcopenia reverted, and we have observed 20 new sarcopenic cases (22%) (incident sarcopenia). conclusion: sarcopenia is highly prevalent in very older adults with high comorbidity. sarcopenia is associated with malnutrition and with higher mortality. background: disability is a multifactorial trait that contributes substantially to decline of health/wellbeing and increases steeply with age after midlife. progress in genomewide sequencing has created the potential for discovering genes influencing various health-related traits. the vast majority of such studies focus on the genetic bases of different traits assuming that they have independent mechanisms. as conceptualized by geroscience age/aging are major risk factors of geriatric traits of distinct etiologies. accordingly, the same mechanisms can predispose not to just one, but to a large fraction of geriatric conditions. objectives: identify the common genetic architecture of various traits by discovering the genetic architecture of complex multifactorial trait such as disability. methods: genome-wide association study of disability in a sample of 24,068 subjects from five studies with 12,550 disabled individuals from the women's health initiative (whi) genomics and randomized trials network, whi memory study, cardiovascular health study, framingham heart study, and health and retirement study. disability was defined as having at least one of four basic activities of daily living impairments (bathing, dressing, getting out of bed, and walking). results: we identified 30 promising disability-associated single nucleotide polymorphisms (snps) in 19 loci at p<10-4. four of them attained suggestive level of significance, p<10-5. in contrast, polygenic risk scores (prs) aggregating effects of minor alleles of independent snps that were adversely or beneficially associated with disability showed highly significant associations in meta-analysis, p=3.13×10-45 and p=5.60×10-23, respectively, and were replicated in each study. the analysis of genetic pathways, related diseases, and biological functions supported the connections of genes for the identified snps with disabling and age-related conditions primarily through oxidative/nitrosative stress, inflammatory response, and ciliary signaling. we identified musculoskeletal system development, maintenance, and regeneration as important components of gene functions. conclusion: the discovery of adverse and beneficial prs for a multifactorial trait of distinct etiologies such as late life disability supports the concept of geroscience. the beneficial and adverse gene sets may be differently implicated in the development of musculoskeletal-related disability with the beneficial set characterized, e.g., by regulation of chondrocyte proliferation and bone formation, and the adverse set by inflammation and bone loss. 