Developed countries and certain regions of economically emerging nations have displaying a rapidly growing population of the oldest-oldónonagenarians, centenarians, and supercentenarians. As this ...trend continues, we must redirect some of our research on aging to the experience of advanced old age and discovering individual and community factors that improve the quality of life during this life stage. This state-of-the science, multidisciplinary Annual provides a comprehensive discussion of the factors promoting healthy survival and/or ensuring a good quality of life for the oldest elderly. It features an international representation that includes Denmark, Finland, France, Italy, the Netherlands, the United Kingdom, Sweden, Japan, and North America. The Annual disseminates the most current research regarding this population and notes gaps in our knowledge. The book addresses ongoing demo-epidemiological changes regarding longevity, estimates of oldest-old populations, and prevalence of chronic and degenerative diseases, frailty, and old-age dependency. The meaning of healthy longevity as a theoretical concept is explored. Grounded in the fundamental issue of whether or not the prevalence of poor health or poor quality of life inevitably increases with age, recent research and ongoing studies from a variety of perspectives are presented from several nations. The book clarifies the known and hypothetical factors favoring healthy longevity, from genes to social integration. Additionally, chapters explore gender differences in age trajectories and changes over time. Special attention is given to the social and cognitive dimensions of healthy longevity. Key Features: * Disseminates new scholarly research about a rapidly growing segment of the populationóthe oldest old * Offers multidisciplinary and international perspectives about the factors that promote healthy survival and improve quality of life * Addresses the social and cognitive dimensions of healthy longevity * Provides important information regarding health care costs for this population * Includes the research of seasoned and emerging scholars
Summary Background Raised blood pressure is common after acute stroke and is associated with an adverse prognosis. We sought to assess the feasibility, safety, and effects of two regimens for ...lowering blood pressure in patients who have had a stroke. Methods Patients who had cerebral infarction or cerebral haemorrhage and were hypertensive (systolic blood pressure SBP >160 mm Hg) were randomly assigned by secure internet central randomisation to receive oral labetalol, lisinopril, or placebo if they were non-dysphagic, or intravenous labetalol, sublingual lisinopril, or placebo if they had dysphagia, within 36 h of symptom onset in this double-blind pilot trial. The doses were titrated up if target blood pressure was not reached. Analysis was by intention to treat. This trial is registered with the National Research Register, number N0484128008. Findings 179 patients (mean age 74 SD 11 years; SBP 181 SD 16 mm Hg; diastolic blood pressure DBP 95 SD 13 mm Hg; median National Institutes of Health stroke scale NIHSS score 9 IQR 5–16 points) were randomly assigned to receive labetolol (n=58), lisinopril (n=58), or placebo (n=63) between January, 2005, and December, 2007. The primary outcome—death or dependency at 2 weeks—occurred in 61% (69) of the active and 59% (35) of the placebo group (relative risk RR 1·03, 95% CI 0·80–1·33; p=0·82). There was no evidence of early neurological deterioration with active treatment (RR 1·22, 0·33–4·54; p=0·76) despite the significantly greater fall in SBP within the first 24 h in this group compared with placebo (21 17–25 mm Hg vs 11 5–17 mm Hg; p=0·004). No increase in serious adverse events was reported with active treatment (RR 0·91, 0·69–1·12; p=0·50) but 3-month mortality was halved (9·7% vs 20·3%, hazard ratio HR 0·40, 95% CI 0·2–1·0; p=0·05). Interpretation Labetalol and lisinopril are effective antihypertensive drugs in acute stroke that do not increase serious adverse events. Early lowering of blood pressure with lisinopril and labetalol after acute stroke seems to be a promising approach to reduce mortality and potential disability. However, in view of the small sample size, care must be taken when these results are interpreted and further evaluation in larger trials is needed. Funding UK National Health Service Research and Development Health Technology Assessment Programme.
Retirement ages are rising in many countries to offset the challenges of population ageing, but people's capacity to work for more years in their later working life (>50 years) is unclear. We aimed ...to estimate healthy working life expectancy in England.
This analysis included adults aged 50 years and older from six waves (2002–13) of the English Longitudinal Study of Ageing (ELSA), with linked mortality data. Healthy working life expectancy was defined as the average number of years expected to be spent healthy (no limiting long-standing illness) and in paid work (employment or self-employment) from age 50 years. Healthy working life expectancy was estimated for England overall and stratified by sex, educational attainment, deprivation level, occupation type, and region by use of interpolated Markov chain multi-state modelling.
There were 15 284 respondents (7025 men and 8259 women) with survey and mortality data for the study period. Healthy working life expectancy at age 50 years was on average 9·42 years (10·94 years 95% CI 10·65–11·23 for men and 8·25 years 7·92–8·58 for women) and life expectancy was 31·76 years (30·05 years for men and 33·49 years for women). The number of years expected to be spent unhealthy and in work from age 50 years was 1·84 years (95% CI 1·74–1·94) in England overall. Population subgroups with the longest healthy working life expectancy were the self-employed (11·76 years 95% CI 10·76–12·76) or those with non-manual occupations (10·32 years 9·95–10·69), those with a tertiary education (11·27 years 10·74–11·80), those living in southern England (10·73 years 10·16–11·30 in the South East and 10·51 years 9·80–11·22 in the South West), and those living in the least deprived areas (10·53 years 10·06–10·99).
Healthy working life expectancy at age 50 years in England is below the remaining years to State Pension age. Older workers of lower socioeconomic status and in particular regions in England might benefit from proactive approaches to improve health, workplace environments, and job opportunities to improve their healthy working life expectancy. Continued monitoring of healthy working life expectancy would provide further examination of the success of such approaches and that of policies to extend working lives.
Economic and Social Research Council.
Although the biological rationale for the association between folate, vitamin B12, and homocysteine with cognitive function seems plausible, conflicting results have been reported. This study aimed ...to determine the associations between 1-carbon (1-C) metabolism biomarkers (folate, vitamin B12, and homocysteine), and cognitive impairment at baseline and the rate of cognitive decline over 5 years in the very old.
The Newcastle 85+ Study was a prospective longitudinal study of people 85 years old and followed over 5 years in Northeast England.
Community-dwelling and institutionalized.
The analytical sample included 765 very old participants with 1-C metabolism biomarkers and cognitive measures.
Global cognition was measured by the Standardized Mini-Mental State Examination (SMMSE) at baseline, and at 3 and 5 years of follow-up and, attention-specific cognition with the Cognitive Drug Research (CDR) System at baseline, and at 1.5 and 3.0 years of follow-up. Baseline red blood cell folate (RBC folate), plasma vitamin B12, and total homocysteine (tHcy) concentrations were determined by immunoassay. Linear mixed models were used to estimate the associations between quartiles of 1-C metabolism biomarkers and cognition over 3 (CDR) and 5 years (SMMSE).
Compared with participants in the lowest quartile of RBC folate concentrations (<612 nmol/L), those in the highest quartile of RBC folate concentrations (>1280 nmol/L) had 1 more point on the SMMSE at baseline (β = +1.02, SE = 0.43, P = .02). Those in quartile 4 of tHcy (>21.4 μmol/L) had 1 point less in the SMMSE at baseline than those in the lowest quartile (<13.5 μmol/L) (β = −1.05, SE = 0.46, P = .02). Plasma vitamin B12 was not predictive of global or attention-specific cognition at baseline and at follow-up. None of the 1-C metabolism biomarkers except tHcy was associated with the rate of decline in attention scores over 3 years.
RBC folate and tHcy, but not plasma vitamin B12, were associated with better global cognition in the very old at baseline but were not predictive of rate of decline over 5 years.
Summary Background The prevalence of dementia is of interest worldwide. Contemporary estimates are needed to plan for future care provision, but much evidence is decades old. We aimed to investigate ...whether the prevalence of dementia had changed in the past two decades by repeating the same approach and diagnostic methods as used in the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS) in three of the original study areas in England. Methods Between 1989 and 1994, MRC CFAS investigators did baseline interviews in populations aged 65 years and older in six geographically defined areas in England and Wales. A two stage process, with screening followed by diagnostic assessment, was used to obtain data for algorithmic diagnoses (geriatric mental state–automated geriatric examination for computer assisted taxonomy), which were then used to estimate dementia prevalence. Data from three of these areas—Cambridgeshire, Newcastle, and Nottingham—were selected for CFAS I. Between 2008 and 2011, new fieldwork was done in the same three areas for the CFAS II study. For both CFAS I and II, each area needed to include 2500 individuals aged 65 years and older to provide power for geographical and generational comparison. Sampling was stratified according to age group (65–74 years vs ≥75 years). CFAS II used identical sampling, approach, and diagnostic methods to CFAS I, except that screening and assessement were combined into one stage. Prevalence estimates were calculated using inverse probability weighting methods to adjust for sampling design and non-response. Full likelihood Bayesian models were used to investigate informative non-response. Findings 7635 people aged 65 years or older were interviewed in CFAS I (9602 approached, 80% response) in Cambridgeshire, Newcastle, and Nottingham, with 1457 being diagnostically assessed. In the same geographical areas, the CFAS II investigators interviewed 7796 individuals (14 242 approached, 242 with limited frailty information, 56% response). Using CFAS I age and sex specific estimates of prevalence in individuals aged 65 years or older, standardised to the 2011 population, 8·3% (884 000) of this population would be expected to have dementia in 2011. However, CFAS II shows that the prevalence is lower (6·5%; 670 000), a decrease of 1·8% (odds ratio for CFAS II vs CFAS I 0·7, 95% CI 0·6–0·9, p=0·003). Sensitivity analyses suggest that these estimates are robust to the change in response. Interpretation This study provides further evidence that a cohort effect exists in dementia prevalence. Later-born populations have a lower risk of prevalent dementia than those born earlier in the past century. Funding UK Medical Research Council.
Summary Background Although life expectancy in the European Union (EU) is increasing, whether most of these extra years are spent in good health is unclear. This information would be crucial to both ...contain health-care costs and increase labour-force participation for older people. We investigated inequalities in life expectancies and healthy life years (HLYs) at 50 years of age for the 25 countries in the EU in 2005 and the potential for increasing the proportion of older people in the labour force. Methods We calculated life expectancies and HLYs at 50 years of age by sex and country by the Sullivan method, which was applied to Eurostat life tables and age-specific prevalence of activity limitation from the 2005 statistics of living and income conditions survey. We investigated differences between countries through meta-regression techniques, with structural and sustainable indicators for every country. Findings In 2005, an average 50-year-old man in the 25 EU countries could expect to live until 67·3 years free of activity limitation, and a woman to 68·1 years. HLYs at 50 years for both men and women varied more between countries than did life expectancy (HLY range for men: from 9·1 years in Estonia to 23·6 years in Denmark; for women: from 10·4 years in Estonia to 24·1 years in Denmark). Gross domestic product and expenditure on elderly care were both positively associated with HLYs at 50 years in men and women (p<0·039 for both indicators and sexes); however, in men alone, long-term unemployment was negatively associated (p=0·023) and life-long learning positively associated (p=0·021) with HLYs at 50 years of age. Interpretation Substantial inequalities in HLYs at 50 years exist within EU countries. Our findings suggest that, without major improvements in population health, the target of increasing participation of older people into the labour force will be difficult to meet in all 25 EU countries. Funding EU Public Health Programme.
Summary Background Whether rises in life expectancy are increases in good-quality years is of profound importance worldwide, with population ageing. We investigate how various health expectancies ...have changed in England between 1991 and 2011, with identical study design and methods in each decade. Methods Baseline data from the Cognitive Function and Ageing Studies in populations aged 65 years or older in three geographically defined centres in England (Cambridgeshire, Newcastle, and Nottingham) provided prevalence estimates for three health measures: self-perceived health (defined as excellent–good, fair, or poor); cognitive impairment (defined as moderate–severe, mild, or none, as assessed by Mini-Mental State Examination score); and disability in activities of daily living (defined as none, mild, or moderate–severe). Health expectancies for the three regions combined were calculated by the Sullivan method, which applies the age-specific and sex-specific prevalence of the health measure to a standard life table for the same period. Findings Between 1991 and 2011, gains in life expectancy at age 65 years (4·5 years for men and 3·6 years for women) were accompanied by equivalent gains in years free of any cognitive impairment (4·2 years 95% CI 4·2–4·3 for men and 4·4 years 4·3–4·5 for women) and decreased years with mild or moderate–severe cognitive impairment. Gains were also identified in years in excellent or good self-perceived health (3·8 years 95% CI 3·5–4·1 for men and 3·1 years 2·7–3·4 for women). Gains in disability-free years were much smaller than those in excellent–good self-perceived health or those free from cognitive impairment, especially for women (0·5 years 0·2–0·9 compared with 2·6 years 2·3–2·9 for men), mostly because of increased mild disability. Interpretation During the past two decades in England, we report an absolute compression (ie, reduction) of cognitive impairment, a relative compression of self-perceived health (ie, proportion of life spent healthy is increasing), and dynamic equilibrium of disability (ie, less severe disability is increasing but more severe disability is not). Reasons for these patterns are unknown but might include increasing obesity during previous decades. Our findings have wide-ranging implications for health services and for extension of working life. Funding UK Medical Research Council.
Existing models for forecasting future care needs are limited in the risk factors included and in the assumptions made about incoming cohorts. We estimated the numbers of people aged 65 years or ...older in England and the years lived in older age requiring care at different intensities between 2015 and 2035 from the Population Ageing and Care Simulation (PACSim) model.
PACSim, a dynamic microsimulation model, combined three studies (Understanding Society, the English Longitudinal Study of Ageing, and the Cognitive Function and Ageing Study II) to simulate individuals' sociodemographic factors, health behaviours, 12 chronic diseases and geriatric conditions, and dependency (categorised as high 24-h care, medium daily care, or low less than daily dependency; or independent). Transition probabilities for each characteristic were estimated by modelling state changes from baseline to 2-year follow-up. Years in dependency states were calculated by Sullivan's method.
Between 2015 and 2035 in England, both the prevalence of and numbers of people with dependency will fall for young-old adults (65–74 years). For very old adults (≥85 years), numbers with low dependency will increase by 148·0% (range from ten simulations 140·0–152·0) and with high dependency will almost double (increase of 91·8%, range 87·3–94·1) although prevalence will change little. Older adults with medium or high dependency and dementia will be more likely to have at least two other concurrent conditions (increasing from 58·8% in 2015 to 81·2% in 2035). Men aged 65 years will see a compression of dependency with 4·2 years (range 3·9–4·2) of independence gained compared with life expectancy gains of 3·5 years (3·1–4·1). Women aged 65 years will experience an expansion of mainly low dependency, with 3·0 years (3·0–3·6) gained in life expectancy compared with 1·4 years (1·2–1·4) with low dependency and 0·7 years (0·6–0·8) with high dependency.
In the next 20 years, the English population aged 65 years or over will see increases in the number of individuals who are independent but also in those with complex care needs. This increase is due to more individuals reaching 85 years or older who have higher levels of dependency, dementia, and comorbidity. Health and social care services must adapt to the complex care needs of an increasing older population.
UK Economic and Social Research Council and the National Institute for Health Research.
We aimed to estimate healthy working life expectancy (HWLE) at age 50 years by gender, cohort, and level of education in Australia.
We analysed data from two nationally representative cohorts in the ...Household Income and Labour Dynamics in Australia survey. Each cohort was followed up annually from 2001 to 2010 and from 2011 to 2020. Poor health was defined by a self-reported, limiting, long-term health condition. Work was defined by current employment status. HWLEs were estimated with Interpolated Markov Chain multi-state modelling.
We included data from 4951 participants in the cohort from 2001 to 2010 (2605 53% women and 2346 47% men; age range 50–100 years) and 6589 participants in the cohort from 2011 to 2020 (3518 53% women and 3071 47% men; age range 50–100 years). Baseline characteristics were similar between groups. Working life expectancy increased over time for all groups, regardless of gender or educational attainment. However, health expectancies only increased for men and people of either gender with higher education. Years working in good health at age 50 years for men were 9·9 years in 2001 (95% CI 9·3–10·4) and 10·8 years (10·4–11·3) in 2011. The corresponding HWLEs for women were 7·9 years (7·3–8·5) and 9·0 years (8·5–9·6). For people with low education level, HWLE was 7·9 years (7·3–8·5) in 2001 and 8·4 years (7·9–8·9) in 2011, and for those with high education level, HWLE rose from 9·6 years in 2001 (9·1–10·1) to 10·5 years in 2011 (10·2–10·9). Across all groups, there were at least 2·5 years working in poor health and 6·7 years not working in good health.
Increases in length of working life have not been accompanied by similar gains in healthy life expectancy for women or people of any gender with low education, and it is not unusual for workers older than 50 years to work with long-term health limitations. Strategies to achieve longer working lives should address life-course inequalities in health and encourage businesses and organisations to recruit, train, and retain mature-age workers.
Australian Research Council.
Summary Background Up to 50% of patients with acute stroke are taking antihypertensive drugs on hospital admission. However, whether such treatment should be continued during the immediate ...post-stroke period is unclear. We therefore aimed to assess the efficacy and safety of continuing or stopping pre-existing antihypertensive drugs in patients who had recently had a stroke. Methods The Continue Or Stop post-Stroke Antihypertensives Collaborative Study (COSSACS) was a UK multicentre, prospective, randomised, open, blinded-endpoint trial. Patients were recruited at 49 UK National Institute for Health Research Stroke Research Network centres from January 1, 2003, to March 31, 2009. Patients aged over 18 years who were taking antihypertensive drugs were enrolled within 48 h of stroke and the last dose of antihypertensive drug. Patients were randomly assigned (1:1) by secure internet central randomisation to either continue or stop pre-existing antihypertensive drugs for 2 weeks. Patients and clinicians who randomly assigned patients were unmasked to group allocation. Clinicians who assessed 2-week outcomes and 6-month outcomes were masked to group allocation. The primary endpoint was death or dependency at 2 weeks, with dependency defined as a modified Rankin scale score greater than 3 points. Analysis was by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Register , number ISRCTN89712435. Findings 763 patients were assigned to continue (n=379) or stop (n=384) pre-existing antihypertensive drugs. 72 of 379 patients in the continue group and 82 of 384 patients in the stop group reached the primary endpoint (relative risk 0·86, 95% CI 0·65–1·14; p=0·3). The difference in systolic blood pressure at 2 weeks between the continue group and the stop group was 13 mm Hg (95% CI 10–17) and the difference in diastolic blood pressure was 8 mm Hg (6–10; difference between groups p<0·0001). No substantial differences were observed between groups in rates of serious adverse events, 6-month mortality, or major cardiovascular events. Interpretation Continuation of antihypertensive drugs did not reduce 2-week death or dependency, cardiovascular event rate, or mortality at 6 months. Lower blood pressure levels in those who continued antihypertensive treatment after acute mild stroke were not associated with an increase in adverse events. These neutral results might be because COSSACS was underpowered owing to early termination of the trial, and support the continuation of ongoing research trials. Funding The Health Foundation and The Stroke Association.
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