BACKGROUND:Evidence on the optimal anaesthetic technique for hip fracture surgery is scarce. We evaluated the effects of spinal versus general anaesthesia on all-cause mortality and new-onset serious cardiac and pulmonary complications in older patients undergoing hip fracture surgery. METHODS:We conducted the pragmatic, randomised, two-arm parallel-group, open-label, multicentre Improve Hip Fracture Outcome in the Elderly Patient (iHOPE) trial across 22 German hospitals. Patients aged 65 years or older undergoing hip fracture surgery were randomly assigned (1:1) using a web-based system, stratified by centre, to general anaesthesia (n=389) or spinal anaesthesia (n=386). The primary outcome was time to first occurrence of a composite outcome comprising all-cause mortality and new-onset serious cardiac and pulmonary complications within 30 days post-surgery. The primary analysis followed the intention-to-treat principle and was based on the full analysis set. iHOPE was stopped early, after enrolment of 75% of the target sample size (n=1032), on the recommendation of the data and safety monitoring board, owing to slow recruitment and reduced staffing during the COVID-19 pandemic. iHOPE was registered with the German Clinical Trials Register (DRKS00013644). FINDINGS:Between April, 2018, and February, 2023, iHOPE enrolled 775 patients. Four patients were excluded before analysis because of erroneous randomisation, withdrawal of consent, death before anaesthesia, or postrandomisation ineligibility, leaving a full analysis set of 771 patients, of whom 528 (69%) were female. The primary endpoint occurred in 55 (14%) of 385 patients in the spinal anaesthesia group and 47 (12%) of 386 patients in the general anaesthesia group. Kaplan-Meier curves showed similar event-free survival in the two groups. The mean (SD) time to first occurrence of the composite outcome was 10·2 (9·7) days in the spinal anaesthesia group and 10·5 (10·4) days in the general anaesthesia group. The primary composite outcome did not differ between the two anaesthetic techniques (centre-stratified hazard ratio: 1·23, 95% CI 0·83-1·82; p=0·29). Adverse events occurred in 320 (83%) of 385 patients in the spinal anaesthesia group and 344 (89%) of 386 patients in the general anaesthesia group, whereas serious adverse events occurred in 109 (34%) of 319 patients in the spinal anaesthesia group and 105 (31%) of 344 patients in the general anaesthesia group. No treatment-related deaths occurred. INTERPRETATION:Our findings should be interpreted with caution given the premature trial termination, modest statistical power, and high treatment crossover. However, findings add to the evidence supporting an individualised anaesthetic approach, and suggest that there is no clinically meaningful difference between spinal anaesthesia and general anaesthesia for hip fracture surgery. FUNDING:German Federal Ministry of Education and Research.
Older adults (≥65 years) are a rapidly growing population that are experiencing a higher number of hospitalisation admissions, longer hospital stays, and greater hospitalisation-related costs than younger adults. There is an important gap in post-discharge care for older adults, and digital technologies, such as video visits, mobile health apps, and remote patient monitoring, may support follow-up and management after hospital discharge. This systematic review examined the effectiveness, feasibility, acceptability, and impact (ie, effects on rehospitalisation, quality of life, mental health, adherence, and patient satisfaction) of technology-based interventions used for the follow-up and management of older adults after hospital discharge. MEDLINE (via PubMed), Scopus, and Web of Science were searched from database inception to January, 2026. The search identified 1972 records, of which 46 studies met the inclusion criteria: older adult populations (aged ≥65 years), a technology-based intervention, post-discharge follow-up or management, and empirical data. Overall, digital post-discharge interventions were reported to be feasible, with good engagement, adherence, compliance, and retention; low dropout rates; and positive patient satisfaction. However, mixed findings were reported regarding rehospitalisation rates and mental health outcomes for virtual care compared with those for traditional care. Digital health technologies might represent a promising step towards improving post-discharge health care and continuity of care for older adults.
Older adults (ie, ≥65 years old) have disproportionate health impacts from climate change owing to age-associated physiological changes and higher prevalences of chronic diseases, functional impairment, and social isolation. Prioritising older adults in climate change adaptation plans is essential to ensure their needs are supported in future policy decisions. We identified 16 adaptation themes relevant to the health and wellbeing of older adults using a framework-based synthesis and examined their inclusion across national climate change adaptation plans from 204 countries. 125 countries (61·3%) included one to five themes, two (1·0%) included six to ten themes, one (0·5%) included 11 or more themes, and 77 (37·7%) included no themes. The most frequently included themes were strengthening responses to extreme temperatures, including older adults in decision-making processes, and improving disaster preparedness and response. 47 (23·0%) of 204 countries outlined concrete policies, programmatic actions, or funding commitments to support older adults. Our findings reflect substantial gaps in national climate adaptation for ageing populations.
BACKGROUND:Insomnia in later life has been associated with accelerated biological ageing; however, little is known about the effects of insomnia treatment on it. In this study, we evaluated the effects of cognitive behavioural therapy for insomnia (CBT-I), compared with sleep education therapy (SET), an active comparator condition, on epigenetic indicators of biological ageing in older adults with insomnia. METHODS:This secondary analysis was conducted within a larger single-site, investigator-initiated randomised controlled trial (ClinicalTrials.govNCT01641263) of adults aged 60 years or older meeting DSM-IV criteria for insomnia disorder recruited from the Los Angeles, CA, USA. Participants in the parent study were randomly assigned to CBI-T or SET according to a computer-generated random number sequence with block sizes ranging from 5-10. Analyses included participants with complete paired epigenetic data. Peripheral blood mononuclear cells were collected before treatment initiation (baseline) and at a follow-up visit occurring at 20-39 months after baseline. Follow-up times exceeding 30 months were winsorised to 30 months. Biological age was measured by use of DNA methylation-derived epigenetic clocks; Dunedin pace of ageing (DunedinPACE), GrimAge, and the principal component version of PhenoAge (PCPhenoAge). FINDINGS:Recruitment for the parent trial was conducted between July 1, 2012, and April 30, 2015. Participants from the CBT-I (n=47; mean age=69·5 [SD 7·0] years) and SET (n=45; mean age=69·4 [5·1] years) groups were randomly selected based on sample availability. Participants receiving CBT-I in the current analysis were more likely to have full remission following treatment than those receiving SET (34% [16 of 47] vs 13% [six of 45]). Compared with those receiving SET, older adults receiving CBT-I showed a significantly slower pace of biological ageing, as estimated by DunedinPACE (-0·02, 95% CI -0·04 to -0·01, false discovery rate [FDR]-adjusted p=0·03). No statistically significant differences were observed for GrimAge (-0·33, -0·68 to 0·03, FDR-adjusted p=0·11) and PCPhenoAge (-0·49, -1·34 to 0·36, FDR-adjusted p=0·26). INTERPRETATION:These findings indicate that a cognitive behavioural intervention for insomnia might slow the pace of biological ageing, as estimated using DunedinPACE. Treatment of insomnia in older adults could therefore represent a strategy for slowing biological ageing in this clinically vulnerable population. FUNDING:National Institute on Aging.
BACKGROUND:Statins are among the most widely used drugs; however, their benefits for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in individuals aged 75 years or older without the disease remain uncertain. We aimed to assess the non-inferiority of statin cessation in terms of all-cause mortality under real-life conditions in individuals aged 75 years or older who were prescribed statins for the primary prevention of ASCVD. METHODS:We performed a multicentre, open-label, parallel-group, phase 3 randomised controlled trial in 297 primary care offices. Individuals who were aged 75 years or older, were prescribed any statin for at least 1 year for the primary prevention of ASCVD, had no history of ASCVD, and could provide informed consent were randomly assigned (in an unbalanced 5:4 ratio) to continue or stop their statin treatment and were followed up for 36 months. Participants were excluded if they had a progressive disease with a life expectancy of 3 months or less, were diagnosed with dementia, had known homozygous or double heterozygous familial hypercholesterolaemia, or were unable to provide informed consent. Randomisation was computer-generated and implemented via a central electronic system; masking was not done. The primary endpoint was all-cause mortality at 3 years, analysed in participants according to the primary estimand (participants who met all key eligibility criteria and were randomly assigned to statin discontinuation or continuation less than 90 days after inclusion). Missing data were handled using multiple imputation. The non-inferiority margin was 5% for the absolute between-group difference in mortality. This trial is registered with ClinicalTrials.gov, NCT02547883 (completed). FINDINGS:Between June 15, 2016, and Jan 7, 2020, 1180 participants were randomly assigned, and 1160 participants were included in the analysis of the primary estimand. 639 participants were randomly assigned to the statin continuation group, and 521 participants were assigned to the statin discontinuation group. The median age was 80 years (IQR: 78-84), and 775 (66·8%) of 1160 participants were women; 342 (29·5%) of 1160 participants had diabetes, and 896 (77·2%) of them had hypertension. At 36 months, 48 (7·9%) of 604 participants in the statin continuation group and 35 (7·2%) of 484 participants in the statin discontinuation group had died. The absolute difference in all-cause mortality between groups was -0·68% (95% CI -3·95 to 2·60). Statin discontinuation was non-inferior to continuation for 3-year all-cause mortality as the upper bound of the between group difference 95% CI did not exceed the prespecified non-inferiority margin. Adverse events occurred in 461 (73·1%) of 631 participants in the continuation group, and in 390 (74·0%) of 527 in the discontinuation group. Non-cardiovascular adverse events occurred in 456 (72·3%) of 631 participants in the continuation group and 383 (72·7%) of 527 in the discontinuation group. INTERPRETATION:In persons aged 75 years or older receiving statins for primary prevention and with no previous history of ASCVD, discontinuation of statins was non-inferior to continuation in terms of all-cause mortality over 3 years. These findings support individualised decision-making regarding statin discontinuation in older adults. FUNDING:French Ministry of Health within the framework of the Medico Economical Research Program (PRME) 2014.
BACKGROUND:Little is known about dementia incidence and its risk factors in people older than 90 years, particularly in heterogeneous populations. We evaluated dementia incidence and examined the associations of sex, race and ethnicity, and APOE genotype with dementia risk after age 90 years using data from LifeAfter90, an ongoing prospective cohort study. METHODS:LifeAfter90 is a prospective cohort study that enrolled Kaiser Permanente Northern California members, who were at least 90 years old, from the San Francisco Bay Area and Sacramento, USA. Participants were clinically evaluated every 6 months from July 17, 2018, to Nov 9, 2024, in person or remotely. Incident all-cause dementia was diagnosed by a combination of physician assessment, Clinical Dementia Rating, and a Functional Activities Questionnaire. Sex, race and ethnicity, and education were captured during in-person assessments; APOE genotyping was performed using salivary DNA. We estimated age-standardised dementia incidence rates and used age-adjusted Cox and Fine-Gray competing-risk models to study the association between sex, race and ethnicity, APOE genotype, and dementia. The Fine-Gray subdistribution hazard ratio (sHR) models treated death as a competing risk. Models were adjusted for age (time-scale) and individuals were followed until dementia diagnosis or end of follow-up. FINDINGS:Of 1120 individuals initially available, 96 with prevalent dementia and 219 with only one clinical evaluation were excluded; 805 participants were included. Median age was 92 years (range 90-103), 494 (61%) were female, 209 (26%) Asian, 191 (24%) African American or Black, 157 (20%) Hispanic or Latinx, 228 (28%) White, and 20 (2%) from other racial or ethnic groups; 413 had APOE data. During mean follow-up of 2 years (SD 1·7), 138 (17%) developed dementia and 295 (37%) died. The age-standardised incidence rate was 116·82 cases per 1000 person-years (95% CI 93·69-139·96). In Fine-Gray models, dementia risk was higher in female than in male participants (subdistribution hazard ratio [sHR] 1·89, 95% CI 1·30-2·76) and Black than Asian participants (sHR 1·75, 1·07-2·88), lower in APOE ε2 carriers than in non-carriers (sHR 0·39, 0·17-0·88), and not significantly higher in APOE ε4 carriers than in non-carriers (sHR 1·51, 0·92-2·47). No significant differences were found by education. INTERPRETATION:Ethnoracial disparities in dementia risk appear to persist after 90 years, and the association between APOE ε4 and dementia might differ by sex. These findings reinforce the importance of dementia screening and surveillance, even among people with exceptional longevity. FUNDING:National Institute on Aging.
BACKGROUND:Frailty has been widely associated with poor outcomes in mixed stroke cohorts, but evidence specific to intracerebral haemorrhage, particularly from settings in low-income and middle-income countries and regarding treatment-effect modification, remains scarce. We aimed to evaluate the association between frailty and several clinical outcomes and to ascertain whether frailty modifies the treatment effect of a care bundle in individuals with acute intracerebral haemorrhage. METHODS:We conducted a post-hoc analysis of the third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral haemorrhage (INTERACT3) international, stepped-wedge, cluster-randomised controlled trial (NCT03209258; Chinese Clinical Trial Registry ChiCTR-IOC-17011787), which enrolled individuals with acute spontaneous intracerebral haemorrhage at 121 hospitals in nine low-income and middle-income countries and one high-income country. Frailty was quantified using a 30-item cumulative-deficit frailty index; individuals were categorised as non-frail (frailty index ≤0·10), pre-frail (frailty index >0·10 to <0·21), or frail (frailty index ≥0·21). The primary outcome was 6-month all-cause mortality. Mixed-effects regression models, adjusted for key prognostic variables and clustering by hospital site, were used to estimate associations and treatment interactions across frailty strata. FINDINGS:Of the 7036 individuals enrolled in INTERACT3, 7035 with available frailty data were included in this analysis (mean age 62·0 years; 2533 [36·0%] women and 4502 [64·0%] men). 3185 (45·3%) were non-frail, 3000 (42·6%) were pre-frail, and 850 (12·1%) were frail. Increasing frailty was associated with higher 6-month mortality and poorer functional outcomes. These associations were attenuated but persisted after multivariable adjustment (mortality: adjusted hazard ratio [HR] 1·48 [95% CI 1·20-1·83]; major disability among survivors: adjusted odds ratio 1·73 [1·40-2·14] for frail vs non-frail individuals). The care bundle was associated with lower mortality point estimates across frailty groups (non-frail adjusted HR 0·66 [95% CI 0·46-0·94], pre-frail adjusted HR 0·80 [0·61-1·05], and frail adjusted HR 0·65 [0·43-0·98]; p for interaction=0·30). Absolute mortality rate reductions were larger among individuals with frailty (116·9 events per 1000 person-years) than among individuals without frailty (44·1 events per 1000 person-years). No clear evidence of treatment-by-frailty interaction was observed for death or major disability at 6 months (p for interaction=0·27). INTERPRETATION:Frailty showed a graded association with poor prognosis in acute intracerebral haemorrhage, and these associations were attenuated but generally persisted after adjustment for age, baseline neurological severity, and other prognostic factors. We found no clear evidence that frailty modified the effect of the INTERACT3 care bundle on mortality. Mortality estimates favoured the care bundle across frailty strata, with larger absolute mortality reductions observed among individuals with frailty. These findings support offering protocolised acute care to individuals with imaging-confirmed spontaneous intracerebral haemorrhage who present within 6 h of symptom onset, irrespective of frailty status, while also maintaining individualised clinical judgement regarding prognosis and functional recovery. FUNDING:None.
BACKGROUND:Obesity in older adults is associated with functional decline and increased risk of disability. Lifestyle interventions improve physical function, but the role of metformin as an adjunct to lifestyle intervention in this population remains unclear. In this randomised clinical trial, we evaluated whether metformin enhances the effects of an intensive lifestyle intervention on physical function in older adults with obesity. METHODS:The Diet and Exercise plus Metformin to Treat Frailty in Obese Seniors (DEMFOS) trial (ClinicalTrials.gov: NCT04221750 [completed]) was a randomised, placebo-controlled trial conducted at the Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine (Houston, TX, USA). Older adults (aged 65-85 years) with obesity (BMI ≥30 kg/m2) were randomly assigned to intensive lifestyle intervention (weight-management and exercise training) plus placebo, intensive lifestyle intervention plus metformin, or healthy lifestyle (diet education) plus metformin groups. The primary outcome was change in the modified physical performance test score at 6 months. The primary analysis was by intention-to-treat. FINDINGS:Of 221 participants assessed for eligibility between March 30, 2021, and Dec 12, 2024, 114 were included in this study (mean age 72·8 years [SD 5·2]; 101 [89%] men and 13 [11%] women). 64 (56%) participants were White, 50 (44%) were Black, and 15 (13%) were Hispanic or Latino. Changes in physical performance test differed between groups (group-by-time interaction p<0·0001). At 6 months, physical performance test improvement was greater in the intensive lifestyle plus metformin group than in the healthy lifestyle plus metformin group (mean difference 2·5 points, 95% CI 1·2-3·8; p=0·0002), whereas there was no difference between the intensive lifestyle plus metformin and intensive lifestyle plus placebo groups (0·1 points, -1·2 to 1·4; p=0·92). Serious adverse events were infrequent and not attributed to the study interventions. INTERPRETATION:Our findings suggest that in older adults with obesity undergoing intensive lifestyle intervention, metformin does not provide additional improvement in physical function. These results support prioritising lifestyle-based strategies to improve functional outcomes in this population. FUNDING:US Department of Veterans Affairs.
BACKGROUND:The comparative efficacy and safety of high-dose inactivated influenza vaccine (HD-IIV) versus standard-dose inactivated influenza vaccine (SD-IIV) in adults 65 years or older remain uncertain. Hence, we aimed to compare the effects of HD-IIV versus those of SD-IIV for hospitalisation and mortality outcomes in this population by synthesising evidence from randomised controlled trials (RCTs). METHODS:In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Global Health, and ClinicalTrials.gov from inception to Sept 3, 2025, for randomised trials comparing HD-IIV (60 μg of haemagglutinin per strain) with SD-IIV (15 μg of haemagglutinin per strain) in adults aged 65 years or older. We excluded trials of adjuvanted or recombinant vaccines and those conducted during the 2009-10 H1N1 pandemic because the antigenic profile differed from seasonal strains. Pairs of reviewers independently screened studies and extracted aggregate data from eligible reports. Prespecified primary outcomes were hospitalisation for influenza or pneumonia, hospitalisation for influenza, hospitalisation for pneumonia, hospitalisation for laboratory-confirmed influenza, hospitalisation for cardiorespiratory disease, all-cause hospitalisation, and all-cause mortality; serious adverse events (SAEs) were the secondary outcome. We did random-effects meta-analyses and used risk ratio (RR) estimates and baseline risks to calculate absolute risk differences (ie, the difference in absolute number of events per 10 000 vaccinated individuals between SD-IIV and HD-IIV groups) for each outcome. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework. The protocol was registered with the OSF Registry. FINDINGS:A total of 1422 records were identified. After screening 813 titles and abstracts, from which 84 full texts were assessed for eligibility, 14 unique RCTs with 581 845 participants were eligible and included in the analyses. Of the 49 outcome results assessed, 32 were rated as low risk of bias and 17 as having some concerns. Compared with SD-IIV, HD-IIV reduced hospitalisation for influenza (RR 0·61 [95% CI 0·50-0·74]; I2=0%; absolute risk difference -4 events per 10 000 vaccinated individuals [95% CI -5 to -3]; high certainty), hospitalisation for laboratory-confirmed influenza (RR 0·68 [0·58-0·80]; I2=0%; absolute risk difference -4 events per 10 000 vaccinated individuals [-5 to -3]; high certainty), hospitalisation for cardiorespiratory disease (RR 0·92 [0·86-0·98]; I2=5·9%; absolute risk difference -15 events per 10 000 vaccinated individuals [-26 to -4]; high certainty), and all-cause hospitalisation (RR 0·97 [0·95-0·99]; I2=8·7%; absolute risk difference -29 events per 10 000 vaccinated individuals [-48 to -10]; high certainty). There was probably little or no difference between the effects of HD-IIV and SD-IIV on all-cause mortality (RR 0·98 [0·92-1·05]; I2=0·0%; absolute risk difference -1 event per 10 000 vaccinated individuals [-4 to 3]; moderate certainty). Compared with SD-IIV, HD-IIV might have little or no effect on hospitalisation for influenza or pneumonia (RR 0·83 [0·66-1·03]; I2=71·3%; absolute risk difference -7 events per 10 000 vaccinated individuals [-14 to 1]; low certainty), hospitalisation for pneumonia (RR 0·85 [0·66-1·08]; I2=72·0%; absolute risk difference -9 events per 10 000 vaccinated individuals [-21 to 5]; low certainty), or SAEs (RR 0·97 [0·93-1·01]; I2=16·4%; absolute risk difference -18 events per 10 000 vaccinated individuals [-41 to 6]; low certainty). INTERPRETATION:HD-IIV could be considered as a strategy to reduce hospitalisation burden in adults 65 years or older; however, the evidence does not support routine preferential use across all older adults irrespective of context. Absolute benefits were modest on average, and the value of HD-IIV is likely to depend on baseline risk, health-care context, and implementation considerations. FUNDING:National Natural Science Foundation of China Youth Science Fund and Shandong Provincial Natural Science Foundation Youth Science Fund.
