Gill Livingston

Background: Key daily physical activities (e.g., standing and walking), postures (sitting and lying), and sleep constitute the 24-h day and have distinct health effects and functional implications. Traditionally studied separately, the distribution of these movement behaviours and sleep across the cognitive spectrum remains insufficiently characterised. We aimed to describe and compare the distribution of 24-h movement behaviours and sleep across the cognitive spectrum. Methods: We analysed cross-sectional, population-based data from 4,699 community-dwelling older adults (≥ 70 years) participating in the HUNT4 70 + study. Cognitive status was classified as mild cognitive impairment (MCI, n = 1,690) or dementia ( n = 360) according to DSM-5 criteria. Participants not classified with MCI or dementia were categorised as cognitively unimpaired. Accelerometers worn on the thigh and lower back (≤ 7 days) were used to assess standing, walking, sitting, lying awake, and sleep using validated machine-learning models. Inverse probability weighting and multiple imputation by chained equations were used to address selection bias. Group differences were examined using survey-weighted regression models adjusted for potential confounders including age, sex, education, marital status, self-rated health, obesity, depression, alcohol consumption, and smoking. Results: In fully adjusted models, older adults with MCI spent less time sitting (ß -12.4 [95% CI -20.0, -4.4] min/ 24 h) and more time lying awake (ß 10.3 [95% CI 2.7, 17.9]) and sleeping (ß 3.9 [95% CI 0.8, 7.0] min/24 h) than their cognitively unimpaired peers (all p < 0.05), while time spent standing and walking was similar between the two groups. In fully adjusted models, older adults with dementia spent less time standing (ß -29.0 [95% CI -41.3, -16.5] and ß -30.3 [95% CI -42.5, -18.2] min/24 h) and walking (ß -16.1 [95% CI -19.9, -12.4] and ß -17.2 [95% CI -20.9, -13.4] min/24 h), and more time lying awake (ß 36.3 [95% CI 17.1, 55.4] and ß 46.5 [95% CI 28.7, 64.5] min/24 h), than those with MCI and cognitively unimpaired peers (all p ≤ 0.001), and more time sleeping (ß 7.5 [95% CI 0.9, 14.9] min/24 h) than their cognitively unimpaired peers ( p = 0.04). Conclusion: Across the cognitive spectrum, older adults exhibit distinct distributions of 24-h movement behaviours and sleep. The clinical importance of the observed differences remains unknown, and future research on the independent and compositional effects of these behaviours is warranted.

Background: Most studies of delirium occurrence are based on selected hospitalised populations or administrative data. We aimed to estimate the incidence rate of in-hospital delirium in older adults and to assess use of the International Classification of Diseases, 10th Revision (ICD-10) delirium code (F05) in electronic health records. Methods: This population-based cohort study included 9956 participants aged ≥70 years from HUNT4 70+. Participants were followed from the date of study participation (2017–19) until 31 December 2023. In-hospital delirium was identified by retrospective chart review of all admissions during follow-up, using Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria. Incidence rates were estimated using the first delirium episode per participant, weighted for non-participation. Results: During follow-up, 1507 participants (15.1%) experienced ≥1 in-hospital delirium episode. The weighted incidence rate was 33.1 (95% CI 31.5–34.9) per 1000 person-years and increased with age from 11.4 (age 70–74) to 109.0 (age ≥90) per 1000 person-years. Men had higher incidence rates than women across age groups. Among admissions with delirium, 11.9% had an ICD-10 discharge delirium diagnosis code (F05). Conclusion: In-hospital delirium was common, increased markedly with age and was rarely captured by diagnostic coding. Low coding rates suggest that routine health-care data substantially underestimate delirium burden. Under-recognition of delirium may limit opportunities for follow-up in a group at high risk of adverse outcomes. With an ageing population, the burden of delirium is likely to increase for individuals and health-care systems. Our findings support systematic approaches to improve identification and management.

Background: The global ageing and surge in cognitive impairment (CI) and dementia has triggered an unprecedented long-term care crisis. Although Long-Term Care Insurance (LTCI) systems are expanding globally, their eligibility assessments are overwhelmingly anchored in physical functioning. We aimed to evaluate the causal impact of China’s national LTCI pilot programme on unmet care needs and family caregiving burden among older adults with CI, with a specific focus on identifying structural inequities in its policy design.Methods: In this nationwide quasi-experimental study, we utilised nationwide longitudinal data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS, 2011-2021). We included 12,065 older adults (aged ≥60 years) with CI and varying degrees of care dependency. Exploiting the staggered geographical rollout of LTCI across pilot cities, we applied a difference-in-differences (DID) model to compare outcomes between pilot and non-pilot areas. The primary outcome was unmet care needs (defined as lacking caregivers or receiving insufficient assistance for daily living activities). The secondary outcome was family caregiving burden, measured as log-transformed weekly hours of informal care provided by family members. Causal robustness was comprehensively assessed using advanced event-study designs and Rambachan-Roth sensitivity bounds.Findings: Following LTCI implementation, the absolute prevalence of unmet care needs in the intervention group decreased by 6.2 percentage points (95% CI 1.9–10.5; p=0.005), representing a 15.5% relative reduction from the pre-policy baseline. Pathway analysis revealed that LTCI facilitated a significant formal-for-informal care substitution, reducing weekly family caregiving time by 26.7% (p=0.032). The causal effect on unmet care needs and caregiving burden was supported by event-study estimates confirming the parallel trends assumption. Subgroup analysis revealed that, for unmet care needs, significant reductions were confined to individuals with high dependency (β=–0.107, p=0.001), urban residents (β=–0.076, p=0.003), women (β=–0.080, p=0.001), and those who were well educated (β=–0.075, p=0.007); individuals with moderate or low dependency, rural populations, men, and illiterate individuals showed no significant improvement. For caregiving burden, the largest reductions occurred among those with moderate dependency (β=–0.583, p<0.001), younger-old adults (β=–0.963, p=0.002), and married individuals (β=–0.957, p=0.002); men and those who were well educated also benefited, whereas women and illiterate individuals did not.Interpretation: While overall LTCI successfully mitigates unmet care needs and relieves “invisible” family carers, current physical-function-centric eligibility assessments create a profound “dementia penalty”. This structural blind spot systematically excludes CI individuals during critical early-to-moderate stages of decline and compounds socioeconomic disparities. Transitioning towards dementia-inclusive policy designs, incorporating behavioural and psychological symptoms into eligibility tiers, is urgently required to eliminate health inequities in global long-term care systems.

Background and ObjectivesCentral and general adiposity have been linked to dementia risk, but their relation to blood-based Alzheimer disease (AD) biomarkers is unclear. We examined life course adi...

Objective: To examine whether menopausal women who initiate systemic menopausal hormone therapy (MHT) around menopause (45-60 years old) have a different risk of developing dementia than those not taking MHT. Design: Systematic review and meta-analysis of randomised controlled trials and longitudinal observational studies. Risk of bias was assessed using ROB-2 and ROBINS I-V2. Data sources: MEDLINE, Web of Science, EMBASE, and Cochrane Library to 27 March 2026. Eligibility criteria for selecting studies: Studies which measured dementia or cognitive decline in women who initiated systemic MHT between ages 45-60 or within 5 years of menopause, compared with placebo or no MHT. Authors contacted for additional details if needed. Main outcome measures: Dementia, Alzheimer’s disease (AD), cognitive decline. Results: 10 studies totalling 213,678 participants (189,525 in studies with the primary population). There was no significant increased risk in women with a uterus for all cause dementia (pooled hazard ratio (HR): 1.12; 95% CI 0.91-1.31, N=78,613, I ² = 96.9%), but increased AD risk (HR: 1.14; 95% CI 1.02, 1.29, N=134,865, I ² = 35.6%). Results were similar in sensitivity analyses including women with or without a uterus. Results for cognitive decline were variable. Conclusions: MHT initiated around the age of menopause should not be prescribed for cognition or dementia prevention. It is not protective against dementia and may increase risk slightly. The magnitude of risk was similar in AD and dementia, but the latter with larger confidence intervals. Studies which followed up individuals rather than on health records lost people to follow up. This may account for difference in cognitive decline outcomes between studies, as people with cognitive impairment and dementia are more likely not to attend. MHT prescribing should balance benefits against risks, including evidence of a small increased dementia risk. There are few high-quality studies, so further research would inform recommendations. Systematic review registration Prospero CRD420251010663 What is already known on this topic?: Menopausal hormone therapy (MHT) is effective for alleviating vasomotor symptoms. Contemporary guidelines recommend treatment should be initiated for such symptoms under age 60 and or within 10 years of menopause onset. A large randomised trial on the topic found increased risk of dementia in women initiating MHT after the age of 65. It is unknown whether initiating MHT around the age of menopause impacts the risk of dementia or cognitive decline. What this study adds: There was no evidence that taking MHT around the time of menopause decreases the risk of dementia or cognitive impairment. They should not be prescribed for these indications. We were able to find more studies which examine this question by contacting authors for additional data. Initiating MHT in women with a uterus around the age of menopause increased the risk of Alzheimer’s disease slightly, by over 10%, and there is a similar but not significant effect in the fewer studies of all cause dementia. Women with or without a uterus show similar results. We found no significant difference shown in cognitive decline, possibly due to loss to follow up. This may be because most studies of cognitive decline follow up

START (STrAtegies for RelaTives) is an evidence-based manualised psychological intervention to improve mood and increase quality of life for family caregivers of people with dementia. A trained facilitator delivers eight sessions to individuals. The contents include psychoeducation, behavioural management, thought analysis, communication, relaxation strategies, planning for the future, and behavioural activation. This study aimed to culturally adapt START, train facilitators, and test its feasibility in India. The adaptation process followed the Medical Research Council guidelines for five phases adaptation of complex interventions. The Cultural Treatment Adaptation Framework (CTAF) was used to analyse professional and caregiver stakeholder qualitative interviews (N = 21) about cultural changes for the intervention. The manual incorporated the changes and was translated into Tamil. The intervention was adapted for virtual delivery using Zoom due to COVID-19. Feasibility was tested through recruitment, retention, attendance, and adverse effects. Modifications informed by stakeholder interviews (N = 21) involved cultural changes in materials, semantics, pictures and vignettes. The manual did not require modification of core therapeutic elements. Twenty-two caregivers were recruited, of whom eighteen completed all sessions. The feedback from the participants on START was positive, reporting that the intervention enabled them to express their emotions and increased their knowledge and skills in caring for people with dementia. START was feasible and acceptable for virtual delivery in India with the potential to improve the well-being of caregivers of people with dementia.

Idiopathic normal pressure hydrocephalus (iNPH) is a treatable condition characterized by impaired gait, cognition, and bladder function. Neuropsychiatric symptoms may be important in iNPH but are poorly understood. We report the first systematic review and meta-analysis estimating the prevalence, severity, and treatment responsiveness of neuropsychiatric symptoms and diagnoses in iNPH. We searched PubMed, CINAHL, Embase, Ovid, MEDLINE, Cochrane, and PsycINFO from inception until October 23, 2024, for peer-reviewed, original studies in adults with definite, probable, or possible iNPH that reported neuropsychiatric features using validated tools or clinician diagnosis (PROSPERO CRD42021287293). Case studies and series, as well as studies where diagnostic criteria for iNPH were unclear, were excluded. Study quality assessment and data extraction were independently performed by 2 authors, according to a proforma developed iteratively. Random-effects meta-analysis was used to pool proportions and standardized mean differences. Meta-regression, subgroup analysis, and sensitivity analysis were performed. Twenty-two studies were included, of which 1 was a randomized-controlled trial. For our primary outcome, we found a high prevalence of apathy (69.2%, 95% CI 63.1–74.6, n = 293) and depression (30.1%, 20.1–42.3, n = 7,670) in iNPH. Agitation (22.6%, 11.8–39.1), anxiety (21.9%, 13.2–34.2), disinhibition (21.0%, 11.8–34.7), and psychotic syndromes (8.0%, 3.3–18.3) were relatively less prevalent. Depression scores were higher in patients with iNPH than in controls (Hedge's g 1.31, 0.39–2.23). Treatment of iNPH was associated with a reduction in depression scores (−0.30, −0.62 to 0.01), although the confidence interval contained the null. A total of 12 of 22 studies were rated 'low' quality. Apathy and depression are highly prevalent in iNPH, maybe more so than in other neurodegenerative conditions. Little is known about other neuropsychiatric features in iNPH. Treatment of iNPH may reduce neuropsychiatric symptoms, particularly depression. However, our study was limited by heterogeneity in populations and assessment tools and a lack of baseline data on neuropsychiatric symptoms before iNPH diagnosis. These findings highlight the urgent need for further research into neuropsychiatric features in iNPH, their mechanisms, and their potential response to treatment.

Background: People living with dementia (PLWD) and mild cognitive impairment (MCI), and their family carers, often experience sleep disturbance which can impair daily living and care. There are limited options for effective long-term pharmacological management of sleep disturbance, yet recent advances in non-pharmacological approaches offer promising alternatives. TIMES is a novel, complex intervention, which aims to improve wellbeing for PLWD/MCI and their carers in primary care, by developing whole-person, tailored care plans that optimise management of sleep disturbance in context. Methods: Two-arm cluster-randomised (1:1), single-blinded, feasibility trial in 10 general practice sites in England, recruiting 64 patient–carer dyad participants (32 intervention + 32 treatment as usual). Co-primary objectives are to assess the feasibility and acceptability of conducting a subsequent definitive cluster-randomised controlled trial (cRCT) of the TIMES intervention. Secondary objectives include assessing the ability to collect data to address putative primary and secondary outcomes of a definitive cRCT. We will collect participant demographics at screening, and the following outcome measures at baseline, 9 and 15 week follow-ups: Sleep Disorders Inventory (SDI); Epworth Sleepiness Scale (ESS); Activities of Daily Living assessed with the Disability Assessment for Dementia (ADL DAD); Dementia Quality of Life Measure (DEMQOL); EQ-5D 5 level (EQ-5D-5L); ICEpop Capability measure for older people aged ≥ 65 (ICECAP-O); Neuropsychiatric Inventory Questionnaire (NPI-Q); Client Service Receipt Inventory (CSRI); Telephone Montreal Cognitive Assessment (T-MoCA); patient medical records review; patient serious adverse events (SAEs). We will conduct Process Evaluation interviews and Discrete Choice Experiments to inform refinement of the intervention content and delivery. Discussion: Our findings will inform the refinement and delivery of a subsequent definitive cRCT that tests the clinical and cost-effectiveness of the TIMES intervention compared with usual care. Trial registration: This study received approval from the Health Research Authority (HRA) and London–Harrow Research Ethics Committee (Reference: 24/LO/0123), and is sponsored by the University of Exeter (Reference: 2021–22-38). Trial registration: ISRCTN, ISRCTN54051676, registered 20 March 2024, https://www.isrctn.com/ISRCTN54051676 .

BACKGROUND Socially assistive robots have increasingly been explored as 1 means of supporting people with cognitive impairment, but evidence on their benefits has been lacking. ElliQ is a commercially available AI-driven companion robot designed to support independent living through proactive speech-based interaction. Its functions span social companionship (conversation, jokes), cognitive stimulation (quizzes, audiobooks, podcasts), entertainment (music, virtual tours, games), daily organisation (reminders, timers, shopping lists), health and well-being (guided physical exercise, mindfulness activities), and social connectedness (video calls, messaging). While it has been positively received by cognitively intact older adults in the United States, its use among people with cognitive impairment remains unexplored. OBJECTIVE To evaluate the feasibility and usability of deploying ElliQ with older adults with mild dementia or mild cognitive impairment (MCI) in the home and identify potential adaptations to support use in this population. METHODS This study recruited older adults with mild dementia or MCI and their caregivers living at home in England. All participants were shown ElliQ’s functions and provided think-aloud feedback while learning to use it. Older adults with caregivers kept ElliQ for 1 week, during which, we collected robot usage logs to contextualize and substantiate self-reported engagement. Following this, the older adults and caregivers discussed their experience in semistructured interviews. Think-aloud and interview data were analyzed using reflexive thematic analysis. RESULTS Thirteen participants (8 older adults with mild dementia or MCI, 5 with caregivers) took part. All participants were able to learn to operate key robot functions, and usage logs suggested reduced interactional effort across the week. Four interrelated themes described participants’ experiences: (1) conversational misalignment (speech recognition errors, pacing and timing, and cultural mismatch disrupted interaction quality); (2) the paradox of plenty (features were experienced as simultaneously engaging and burdensome); (3) adapting and learning (participants developed new strategies to use ElliQ, with some forming emotional connections with it); and (4) finding the right fit (most did not view themselves as needing ElliQ given their existing supports and preferences, although those with limited social engagement perceived it as suitable). CONCLUSIONS Older adults with mild dementia or MCI living at home found ElliQ feasible and usable, with older adults, finding it easier to use the robot over time. Refinements should target communication accessibility, cultural localization, and personalization of prompts and onboarding to improve usability, and position ElliQ as a tool for promoting independence rather than assisting decline to better align the robot with users’ needs and expectations. CLINICALTRIAL N/A – this study was not a registered clinical trial