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About the Authors: Thomas A. Jackson * E-mail: t.jackson@bham.ac.uk Affiliations Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom ORCID http://orcid.org/0000-0001-6320-9600 John R. F. Gladman Affiliation: Division of Rehabilitation and Ageing, Queen’s Medical Centre, Nottingham, United Kingdom ORCID http://orcid.org/0000-0002-8506-7786 Rowan H. Harwood Affiliation: Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom Alasdair M. J. MacLullich Affiliation: Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, United Kingdom ORCID http://orcid.org/0000-0003-3159-9370 Elizabeth L. Sampson Affiliation: Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom Bart Sheehan Affiliation: Psychological Medicine, Rehabilitation and Cardiac Division, John Radcliffe Hospital, Oxford, United Kingdom Daniel H. J. Davis Affiliation: MRC Unit for Lifelong Health & Ageing, University College London, London, United Kingdom ORCID http://orcid.org/0000-0002-1560-1955Citation: Jackson TA, Gladman JRF, Harwood RH, MacLullich AMJ, Sampson EL, Sheehan B, et al. Competing interests: I have read the journal's policy and the authors of this manuscript have the following conflicts: JRFG is a researcher and clinician in the field covered by this paper, whose employing organisation holds research grant awards from The Alzheimer's Society and the NIHR (through CLAHRC and the PGfAR schemes) on which JRFG is an investigator. RHH holds research grants from the UK National Institute for Health Research (UK government) and is a member of The Alzheimer's Society, the topic review panel for the National Institute for Health Research, the National End of Life Care Intelligence Network steering committee, and the NHS...

Background/Objectives: Older adults with dementia have at least a twofold increased risk of falls. Multi-factorial interventions have failed to demonstrate a reduction in falls in this group. Improved understanding of specific cognitive factors and their relationship to gait, balance and falls is required. Methods: Systematic searches of Medline, Embase, PsycInfo, and CINAHL databases from inception to April 2011 were conducted to identify prospective studies in older adults examining executive function and its relationship with falls, balance and gait abnormalities. Two independent reviewers extracted data on study populations, executive function measures and study outcomes. Results: Of 8,985 abstracts identified, 14 studies met inclusion criteria. Eleven studies examined executive function and falls. The remaining studies examined executive function and gait speed decline. Nine studies examining executive function and falls found a relationship between poor executive function and increased fall risk. All 3 studies examining executive function and gait found an association between poor executive function and declines in gait speed. Impaired executive function was associated with more serious falling patterns. Conclusions: Executive function was associated with falls and gait speed slowing in older adults. Future research should consider executive dysfunction as a training target for fall prevention, or as a factor mediating the failure of conventional fall prevention interventions.

Background Pain and frailty are associated, but this relationship is insufficiently understood. We aimed to test whether there is a unidirectional or bidirectional relationship between joint pain and frailty. Methods Data were from Investigating Musculoskeletal Health and Wellbeing, a UK-based cohort. Average joint pain severity over the previous month was assessed using an 11-point numerical rating scale (NRS). Frailty was classified as present/absent using the FRAIL questionnaire. Multivariable regression assessed the association between joint pain and frailty, adjusted for age, sex, and BMI class. Two-wave cross-lagged path modelling permitted simultaneous exploration of plausible causal pathways between pain intensity and frailty at baseline and 1-year. Transitions were assessed using t -tests. Results One thousand one hundred seventy-nine participants were studied, 53% female, with a median age of 73 (range 60 to 95) years. FRAIL classified 176 (15%) participants as frail at baseline. Mean (SD) baseline pain score was 5.2 (2.5). Pain NRS ≥ 4 was observed in 172 (99%) of frail participants. Pain severity was associated with frailty at baseline (aOR 1.72 (95%CI 1.56 to 1.92)). In cross-lagged path analysis, higher baseline pain predicted 1-year frailty [β = 0.25, (95%CI 0.14 to 0.36), p  < 0.001] and baseline frailty predicted higher 1-year pain [β = 0.06, (95%CI 0.003 to 0.11), p  = 0.040]. Participants transitioning to frailty over one year had higher mean pain scores (6.4 (95%CI 5.8 to 7.1)) at baseline than those who remained non-frail (4.7 (95%CI 4.5 to 4.8)), p  < 0.001. Conclusions The bidirectional relationship between pain and frailty could lead to a vicious cycle in which each accelerates the other’s progression. This justifies attempts to prevent frailty by addressing pain and to include pain measures as an outcome in frailty studies.

Background In the inpatient rehabilitation of older patients, estimating to what extent the patient may functionally recover (functional prognosis), is important to plan the rehabilitation programme and aid discharge planning. Comorbidity is very common in older patients. However, the role of comorbidity in making a functional prognosis is not clearly defined. The aim of this study was to investigate a modified and weighted Functional Comorbidity Index (w-FCI) in relation to functional recovery and compare its predictive performance with that of the Charlson comorbidity index (CCI) and the original Functional Comorbidity Index (FCI). Methods The COOPERATION study (Comorbidity and Outcomes of Older Patients Evaluated in RehabilitATION) is a prospective observational cohort study. Data of patients that were admitted in an inpatient geriatric rehabilitation facility in the UK between January and September 2017, were collected. The outcome measures were: the Elderly Mobility Scale (EMS) and Barthel index (BI) at discharge, EMS gain/day and BI gain/day. Baseline comorbidity was assessed using the CCI, the FCI and the w-FCI. Correlations, receiver operating curves (ROC), and multiple linear regression analyses were performed. The models were adjusted for age, gender and EMS or BI on admission. Results In total, 98 patients (mean age 82 years; 37% male) were included. The areas under the ROC curves of the w-FCI (EMS at discharge: 0.72, EMS gain/day: 0.72, BI at discharge: 0.66 and BI gain/day: 0.60) were higher than for the CCI (0.50, 0.53, 0.49, 0.44 respectively) and FCI (0.65, 0.55, 0.60, 0.49 respectively). The w-FCI was independently associated with EMS at discharge (20.7% of variance explained (PVE), p  < 0.001), EMS gain/day (11.2PVE, p  < 0.001), and BI at discharge (18.3 PVE, p  < 0.001). The FCI was only associated with EMS gain/day (3.9 PVE, p  < 0.05). None of the comorbidity indices contributed significantly to BI gain/day (w-FCI: 2.4 PVE, p  > 0.05). Conclusions The w-FCI was predictive of mobility & function at discharge and mobility gain per day, and outperformed the original FCI and the CCI. The w-FCI could be useful in assessing comorbidity in a personalised way and aid functional prognosis at the start of rehabilitation.

Key summary points Aim To explore the link between polypharmacy, psychotropic medications, and falls risk in a cohort of UK care home residents. Findings Polypharmacy and psychotropic drugs are predictive of falls in UK care home residents. Message Deprescribing interventions relating to psychotropic drugs should continue to be encouraged. Purpose Falls and polypharmacy are both common in care home residents. Deprescribing of medications in residents with increased falls risk is encouraged. Psychotropic medications are known to increase falls risk in older adults. These drugs are often used in care home residents for depression, anxiety, and behavioural and psychological symptoms of dementia. However, a few studies have explored the link between polypharmacy, psychotropic medications, and falls risk in care home residents. Methods This was a prospective cohort study of residents from 84 UK care homes. Data were collected from residents’ care records and medication administration records. Age, diagnoses, gender, number of medications, and number of psychotropic medications were collected at baseline and residents were monitored over three months for occurrence of falls. Logistic regression models were used to assess the effect of multiple medications and psychotropic medication on falls whilst adjusting for confounders. Results Of the 1655 participants, mean age 85 (SD 8.9) years, 67.9% female, 519 (31%) fell in 3 months. Both the total number of regular drugs prescribed and taking ≥ 1 regular psychotropic medication were independent risk factors for falling (adjusted odds ratio (OR) 1.06 (95% CI 1.03–1.09, p  < 0.01) and 1.39 (95% CI 1.10–1.76, p  < 0.01), respectively). The risk of falls was higher in those taking antidepressants ( p  < 0.01) and benzodiazepines ( p  < 0.01) but not antipsychotics ( p  > 0.05). Conclusion In UK care homes, number of medications and psychotropic medications (particularly antidepressants and benzodiazepines) predicted falls. This information can be used to inform prescribing and deprescribing decisions.

Key summary points Aim Neuromuscular electrical stimulation is a potentially effective intervention to improve outcomes after fragility fracture, but its feasibility in this group has not been established. Findings The implementation of neuromuscular electrical stimulation is feasible in a small fraction of fragility fracture patients. Message Neuromuscular electrical stimulation should be considered as a supplementary intervention rather than a substitute, with the findings offering insights for future randomised clinical trial design, essential before NMES becomes routine in clinical care. Introduction Neuromuscular electrical stimulation (NMES) is a potentially effective intervention to improve outcomes after a fragility fracture, but its feasibility in this group has not been established. Methods A feasibility study was conducted in two phases: 1) in the hospital only, and 2) hospital, rehabilitation centres, and participants’ homes. Patients with fragility fracture were randomised to receive NMES for 6 weeks/discharge either to the right or left leg, with the other leg serving as control. Patients who had no mobility issues had contraindications to NMES and were unable to give consent were excluded. NMES was applied to quadriceps and tibialis anterior muscles for 30 min, 3 days/week. Sessions were progressed to achieve 60 min, 5–7 days/week. Feasibility outcomes included participant characteristics, recruitment rate, tolerability, and number of NMES sessions. Clinical outcomes included muscle strength, and ADL at six months. Results Overall, 1052 patients were identified, of whom 113 (11%) were eligible, and 29 (3%) were recruited (median Clinical Frailty Score 3, median Barthel ADL score 93/100). The recruitment rate was 0.45/week in phase 1 and 0.9/week in phase 2. Fifty-three percent achieved the target of 24 NMES sessions. However, 5/29 withdrew due to intolerance of NMES. Leg muscle strength improved in both treated and untreated legs, with marginally greater improvement observed in the tibialis anterior of treated legs. Conclusion Although it would be feasible to evaluate the specific effect of NMES in fragility fracture patients in a multi-centre trial using home-based NMES, this would be possible only in a minority of mildly frail fragility fracture patients with little premorbid disability.

Background From late February 2020, English care homes rapidly adapted their practices in response to the COVID-19 pandemic. In addition to accommodating new guidelines and policies, staff had to adjust to rapid reconfiguration of services external to the home that they would normally depend upon for support. This study examined the complex interdependencies of support as staff responded to COVID-19. The aim was to inform more effective responses to the ongoing pandemic, and to improve understanding of how to work with care home staff and organisations after the pandemic has passed. Methods Ten managers of registered care homes in the East Midlands of England were interviewed by videoconference or phone about their experiences of the crisis from a structured organisational perspective. Analysis used an adapted organisational framework analysis approach with a focus on social ties and interdependencies between organisations and individuals. Results Three key groups of interdependencies were identified: care processes and practice; resources; and governance. Care home staff had to deliver care in innovative ways, making high stakes decisions in circumstances defined by: fluid ties to organisations outside the care home; multiple, sometimes conflicting, sources of expertise and information; and a sense of deprioritisation by authorities. Organisational responses to the pandemic by central government resulted in resource constraints and additional work, and sometimes impaired the ability of staff and managers to make decisions. Local communities, including businesses, third-sector organisations and individuals, were key in helping care homes overcome challenges. Care homes, rather than competing, were found to work together to provide mutual support. Resilience in the system was a consequence of dedicated and resourceful staff using existing local networks, or forging new ones, to overcome barriers to care. Conclusions This study identified how interdependency between care home organisations, the surrounding community, and key statutory and non-statutory organisations beyond their locality, shaped decision making and care delivery during the pandemic. Recognising these interdependencies, and the expertise shown by care home managers and staff as they navigate them, is key to providing effective healthcare in care homes as the pandemic progresses, and as the sector recovers afterwards.

Key Summary Points Aim To explore the longitudinal associations between pain characteristics at baseline and subsequent falls risks, at 2-year follow-up, in community-dwelling adults aged ≥ 50 years, in the Survey of Health, Ageing and Retirement in Europe (SHARE). Findings Higher intensity of pain and number of pain sites at baseline were associated with an increased risk of subsequent falls in community-dwelling adults, in a dose–response way, independent of socio-demographic and clinical characteristics. The strength of the association between pain intensity and falls risk varied by age, being greater in middle-aged adults. Message The association between pain intensity and falls risk is of greater clinical significance in middle-aged adults versus older adults. Purpose To investigate the longitudinal associations between pain and falls risks in adults. Methods Prospective cohort study on data from 40,636 community-dwelling adults ≥ 50 years assessed in Wave 5 and 6 in the Survey of Health, Ageing and Retirement in Europe (SHARE). Socio-demographic and clinical information was collected at baseline (Wave 5). At 2-year follow-up (Wave 6), falls in the previous 6 months were recorded. The longitudinal associations between pain intensity, number of pain sites and pain in specific anatomic sites, respectively, and falls risk were analysed by binary logistic regression models; odds ratios (95% confidence intervals) were calculated. All analyses were adjusted for socio-demographic and clinical factors and stratified by sex. Results Mean age was 65.8 years (standard deviation 9.3; range 50–103); 22,486 (55.3%) participants were women. At follow-up, 2805 (6.9%) participants reported fall(s) in the previous 6 months. After adjustment, participants with moderate and severe pain at baseline had an increased falls risk at follow-up of 1.35 (1.21–1.51) and 1.52 (1.31–1.75), respectively, compared to those without pain (both p  < 0.001); mild pain was not associated with falls risk. Associations between pain intensity and falls risk were greater at younger age ( p for interaction < 0.001). Among participants with pain, pain in ≥ 2 sites or all over (multisite pain) was associated with an increased falls risk of 1.29 (1.14–1.45) compared to pain in one site ( p  < 0.001). Conclusions Moderate, severe and multisite pain were associated with an increased risk of subsequent falls in adults.

Key summary points Aim To identify care home manager’s experiences of working within and across organisational and regulatory boundaries of practice during the second wave of the COVID-19 pandemic. Findings Managers continued to experience challenges to resources which were predominantly system-led setbacks across the care home sector and external organisations. Managers deployed highly pragmatic and reflexive practices to ensure the safety and well-being of residents and staff. Message It is essential that key lessons, including expertise, respect, recognition and meaningful collaboration with the care home sectors are embedded across the statutory and regulatory organisations to maximise and build on previous gains for effective future workings. Objectives To explore care home managers’ experiences of systems working with various organisations, including statutory, third sector and private, during the second wave of the COVID-19 pandemic from Sept 2020 to April 2021 Design An exploratory qualitative interview study using a systems theory approach focussing on the intersections of relationship interdependencies with other organisations. Setting Conducted remotely with care home managers and key advisors who had worked since the start of the pandemic in/with care homes for older people across the East Midlands, UK. Participants 8 care home managers and 2 end-of-life advisors who participated during the second wave of the pandemic from Sept 2020. A total of 18 care home managers participated in the wider study from April 2020 to April 2021 Results Four organisational relationship interdependencies were identified: care practices, resources governance and wise working. Managers identified changes in their care practices as a shift towards the normalisation of care, with an emphasis on navigating pandemic restrictions to fit the context. Resources such as staffing, clinical reviews, pharmaceutical and equipment supplies were challenged, leading to a sense of precarity and tension. National polices and local guidance were fragmented, complex and disconnected from the reality of managing a care home. As a response a highly pragmatic reflexive style of management was identified which encompassed the use of mastery to navigate and in some cases circumvent official systems and mandates. Managers’ experience of persistent and multiple setbacks were viewed as negative and confirmed their views that care homes as a sector ere marginalised by policy makers and statutory bodies. Conclusions Interactions with various organisations shaped the ways in which care home managers responded to and sought to maximise residents and staff well-being. Some relationships dissolved over time, such as when local business and schools returned to normal obligations. Other newly formed relationships became more robust including those with other care home managers, families, and hospices. Significantly, most managers viewed their relationship with local authority and national statutory bodies as detrimental to effective working, leading to a sense of increased mistrust and ambiguity. Respect, recognition and meaningful collaboration with the care home sector should underpin any future attempts to introduce practice change in the sector.

Background In an ageing population, pain, frailty and disability frequently coexist across a wide range of musculoskeletal diagnoses, but their associations remain incompletely understood. The Investigating Musculoskeletal Health and Wellbeing (IMH&W) study aims to measure and characterise the development and progression of pain, frailty and disability, and to identify discrete subgroups and their associations. The survey will form a longitudinal context for nested research, permitting targeted recruitment of participants for qualitative, observational and interventional studies; helping to understand recruitment bias in clinical studies; and providing a source cohort for cohort randomised controlled trials. Methods IMH&W will comprise a prospective cohort of 10,000 adults recruited through primary and secondary care, and through non-clinical settings. Data collection will be at baseline, and then through annual follow-ups for 4 years. Questionnaires will address demographic characteristics, pain severity (0–10 Numerical Rating Scale), pain distribution (reported on a body Manikin), pain quality (McGill Pain Questionnaire), central aspects of pain (CAP-Knee), frailty and disability (based on Fried criteria and the FRAIL questionnaire), and fracture risk. Baseline characteristics, progression and associations of frailty, pain and disability will be determined. Discrete subgroups and trajectories will be sought by latent class analysis. Recruitment bias will be explored by comparing participants in nested studies with the eligible IMH&W population. Discussion IMH&W will elucidate associations and progression of pain, frailty and disability. It will enable identification of people at risk of poor musculoskeletal health and wellbeing outcomes who might be suitable for specific interventions, and facilitate generalisation and comparison of research outcomes between target populations. The study will benefit from a large sample size and will recruit from diverse regions across the UK. Purposive recruitment will enrich the cohort with people with MSK problems with high representation of elderly and unwell people. Trial registration Clinicaltrials.gov NCT03696134 . Date of Registration: 04 October 2018.