Coping review of dementia fear studies among middle-aged and elderly people in the community

This study used Arksey and O’Malley’s scoping review methodology as a framework and searched the following databases:PubMed,Embase,EBSCO,CINAHL,Web of Science,Cochrane Library,Scopus,CNKI,Wanfang,VIP,and the Chinese Biomedical Literature Database.The database is open to December 20,2023,and documents related to the fear of dementia among the elderly in the community are described and analyzed to provide a reference for future research in this field.At the same time,we screened,extracted,and summarized relevant information from 21 included documents(16 in English and 5 in Chinese),which consisted of 16 cross-sectional studies,2 quasi-experimental studies,2 randomized controlled studies,and 1 longitudinal study.Sixteen of the included documents mentioned the incidence or level of dementia fear among the elderly in the community,2 addressed the adverse effects of dementia fear,and 4 reported prevention and intervention measures for dementia fear.In total,there are 8 assessment tools,and the influencing factors are categorized into sociodemographic characteristics,psychological and behavioral characteristics,sociocultural background factors,and health and dementia-related factors.The final conclusion is that the fear of dementia is common among the elderly in the community.In the future,the application of research tools should be expanded among middle-aged individuals,with considerations for other types of dementia in mind.It is recommended to conduct large-scale,multi-center randomized controlled trials while confirming the intervention’s effect on different types of middle-aged and elderly individuals,focusing on the long-term impact of these intervention measures to promote healthy aging.

Strengthening Active Aging through Older People’s Association and Economic Activity of the Older People in Nepal

Aging is a natural lifelong process ending in death. Many older people are living in poverty. Older people are generally considered dependent on others as they grow older. The purpose of this article is to explore the entrepreneurship activities of Nepalese older adults. Data for this study were collected from the project Help Age International (HAI) implemented in Nepal. Qualitative data observations and interviews were used to collect data. The findings of this study show the formation of the Older People’s Association (OPA) has supported many older people to participate outside the home in various social activities. Moreover, regular deposits through OPAs offer little help. OPAs support older people in their need of financial support to implement minor entrepreneurship. Older people who received support were pleased and were actively involved in their activities and also regularly deposited money in them. Subsequently, older people’s participation in social activities has increased and also helped to lower elderly abuse, loneliness, and depression. Local governments should promote such activities which will help with healthy aging.

The Relationship Between Social Isolation, Psychological Resilience, and Psychological Well- Being Among Older People in the Community

Objective:To explore the relationship between social isolation,psychological resilience,and psychological well-being in community-dwelling older adults.Methods:A questionnaire survey was conducted with 265 community-dwelling older adults using the Social Isolation Scale for the Elderly(C-SIS),the 10-item Brief Psychological Resilience Scale,and the Comprehensive Happiness Questionnaire(MHQ).The results were statistically analyzed using SPSS 27.0.Results:The highest score on the Social Isolation Scale for Community Elderly was 23,with a mean entry score of 2.36±0.62.A score of 14 was the cut-off point,with scores of≤14 classified as social isolation.There were 136 cases with scores below 14,resulting in a social isolation incidence rate of 51.3%.The median(P50)psychological resilience score was 27,indicating a higher level of resilience.The total score on the Psychological Well-being Scale was 161,suggesting a moderate to slightly higher level of well-being.Social isolation had a direct negative effect on psychological well-being,while psychological resilience had a positive effect.Conclusion:Older adults should be supported in reducing the incidence of social isolation and increasing psychological resilience to enhance psychological well-being and promote successful aging.

Correlation between psychological traits and the use of smart medical services in young and middle-aged adults: An observational study

BACKGROUND Psychological problems affect economic development.However,there is a huge gap between mental health service resources and mental health service needs.Existing mental health service technology and platforms cannot meet all the diverse mental health needs of people.Smart medicine is a new medical system based online that can effectively improve the quality and efficiency of medical services and make mental health services accessible.AIM To explore the level of intelligent medical use among young and middle-aged people and its correlation with psychological factors.METHODS Convenience sampling was used to select 200 young and middle-aged patients with medical experience at the Third People's Hospital of Chengdu between January 2022 and January 2023 as the research subjects.The general condition Questionnaire,Eysenck Personality Questionnaire,Symptom Checklist-90,General Health Questionnaire,and Smart Medical Service Use Intention Questionnaire were used to collect data.Pearson’s correlation was used to analyze the correlation between the participants’willingness to use smart medical services and their personality characteristics,psychological symptoms,and mental health.RESULTS The results revealed that the mental health of young and middle-aged people was poor,and some had psycho-logical problems such as anxiety,depression,and physical discomfort.Familiarity,acceptance,and usage of smart healthcare in this population are at a medium level,and these levels correlate with psychological characteristics.Acceptance was positively correlated with E,and negatively correlated with P,anxiety,fear,anxiety/insomnia,and social dysfunction.The degree of use was negatively correlated with P,obsessive-compulsive symptoms,depression,anxiety,hostility,paranoia,and somatic symptoms.CONCLUSION The familiarity,acceptance,and usage of smart medical services among the middle-aged and young groups are related to various psychological characteristics.

Aging Experiences among Older People in Conakry/Guinea: Towards an Age-Friendly City and Community

Older people are a demographically significant group, who represent a vulnerable layer within conditions for active and healthy aging that may be lacking in both urban and rural areas. Objective: To identify the main barriers and opportunities for the establishment of age-friendly cities and communities in a low-income country. Methods: This was a qualitative study that involved focus group discussions with older people, and service providers (health and social services) in the city of Conakry. The older people were purposively selected with the support of older people associations, and men and women were equally represented in the sample. Results: The analysis focused on the experience of old age as well as the barriers and opportunities for active healthy aging specific to the sub-Saharan context. The results indicate that a good quality of life for older adults boils down to the acquisition of good health and decent housing. Other concerns frequently reported were food and education problems for their children and security. Conclusion: This study contributes to strengthening the understanding of the age-friendly cities and communities’ approach in the context of sub-Saharan African countries.

Advance care planning readiness for Chinese older people:An integrative review and conceptual framework

Advance care planning is a process of discussion in which patients can communicate their end-of-life care preferences to family members and health care providers for consideration.Readiness for advance care planning is a patient's preparedness to engage in advance care planning.This review aims to develop the conceptual framework for advance care planning readiness for Chinese older people.The current knowledge from the published studies was identified and synthesized by an integrative review.The conceptual framework was developed based on the social-ecological model and the theory of planned behavior.The factors from the social environment/community,health care professionals,and individual/family layers were defined.These factors may influence an individual's medical decision-making,which in turn triggers individual behavioral mechanisms that arise from interactions between motivations,attitudes,and beliefs.Relevant factors should be considered when assessing the behavior of personnel engaged in advance care planning or formulating appropriate intervention measures to improve advance care planning par ticipation in China.This framework can be used to guide studies that explore how the social/familial/individual factors predict the readiness for advance care planning among Chinese older people,and to design intervention studies to test the effect of family function on the readiness for advance care planning.

Public Square Dancing Intervention on Subjective Well-Being of Middle-Aged and Elderly People:A Meta-Analysis

Objective:To understand the influence of public square dancing on the subjective well-being of middle-aged and elderly people.Methods:According to the principle of Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)guidelines,we search Chinese databases,such as CNKI,Wanfang Data,and VIP,and English databases,such as Proquest,Web of Science,Pubmed,Cochrane,and ScienceDirect,and collect relevant articles at home and abroad from 2006 to December 2019 for meta-analysis in January 2020.Result:A total of 10 articles were included.The meta-analysis results showed that the well-being of middle-aged and elderly people in the public square dancing intervention group was significantly higher than that of the other exercise group and control group(both P<0.01).The results of the subgroup analysis showed the following:Different durations of intervention significantly influence the intervention effect(P<0.01).No difference was found between the effect of the mixed-gender intervention and the individual female intervention(P>0.05).No significant difference was found between the groups with weekly intervention frequency(P>0.05).Conclusion:Public square dancing intervention is effective for middle-aged and elderly people’s subjective well-being.Neither mixed intervention nor the times of weekly intervention have an impact on the intervention effect.However,the length of duration of intervention influences the intervention effect.

The Relationship between Mental Health Literacy and Subjective Well-Being of Young and Middle-Aged Residents: Perceived the Mediating Role of Social Support and Its Urban-Rural Differences

This study investigates mental health literacy among young and middle-aged urban and rural residents and the differences in mental health literacy,perceived social support and subjective well-being.From January to February 2022,620 participants(320 rural and 300 urban residents)from three provinces of China were selected by con-venience sampling.A general data questionnaire,mental health literacy scale,perceived social support scale and subjective well-being scale were administered.The mental health literacy scores of urban residents were 3.34±0.57 and those of rural residents were 2.73±0.79.The results of multiple regression analysis showed that the mental health literacy scores of rural residents were more significant than those of urban residents in terms of sex and age,while urban residents’mental health literacy scores were more significant than those of rural resi-dents in terms of monthly income.Mental health literacy,perceived social support and subjective well-being of young and middle-aged urban and rural residents were all positively correlated(P<0.01).While the level of mental health literacy is better among urban residents than rural residents,perceived social support plays a partial mediating role between mental health literacy and subjective well-being of both urban and rural residents,and should be the focus of researchers seeking to improve the level of well-being of residents.

A descriptive-comparative study of medications used by older people prior to and following admission to a continuing care facility

Medications are beneficial for curing or managing acute and chronic illnesses. Medications typically have positive outcomes, although older people are prone to drug-related problems. Community-dwelling seniors are at particularly high risk of polypharmacy, as they tend to receive many prescriptions over time and from different care providers. Continuing-care facility admission presents an excellent opportunity for a comprehensive medication review. A research study was conducted to describe and compare medications taken by community-dwelling seniors prior to and following admission to a continuing-care facility. This pilot project involved data being gathered from the charts of deceased residents, as required by a University Health Research Ethics Board, who had been cared for at one large local continuing-care facility. The facility administrators also approved this study, in part to evaluate their policy to conduct a medication review for all new residents within six weeks of entry. This study revealed a slight but statistically significant reduction in the number of medications following this review. Other issues such as medication interactions and required dosage changes were addressed by this medication review. Although this study was confined to one continuing-care facility and a small number of residents, the findings suggest medication reviews would be beneficial upon admission to all continuing-care facilities, and annually perhaps through other means for older persons living in the community.

Relationship between Waist Circumference, Waist-Height Ratio, Body Fat Percentage, Visceral Fat and Bone Mineral Density in Middle-Aged and Elderly Zhuang of China

Objective: To understand the correlation between different degrees of obesity and bone mineral density (BMD). Methods: 772 cases (300 men and 472 females) of Zhuang over 40 years old were randomly selected. The BMD and T score were calculated by measuring the right heel bone using a quantitative-ultrasound densitometer. Body composition index of body weight, waist circumference (WC), waist height ratio (WtHR), body fat percentage (BFP) and visceral fat (VF) were measured using a bioelectrical impedance method. Results: The BMI, WC, and WtHR of the male osteoporosis group were lower than those of the normal bone mass (NBM) group (P Conclusion: BMI is positively correlated with BMD in Zhuang. BFP has a greater correlation with female BMD, and a small reduction in BFP can result in a significant decrease in BMD. BMD of male was positively correlated with abdominal obesity indicators (WC, WtHR, VF). However, abdominal obesity has no obvious effect on the promotion of BMD in women, and increased WtHR can lead to a decrease in BMD. Zhuang can appropriately increase the amount of fat within the normal weight range. At the same time, reasonable exercise and balanced nutrition to avoid excessive obesity or low body weight can reduce the incidence of osteoporosis and osteoporosis fractures.

Thai Psychiatric Nurses’ Experiences and Perceptions of the Professional Role When Caring for Older People Displaying Depressive Symptoms

Purpose:?The aim of this study was to describe Thai psychiatric nurses’ experiences and perceptions of their professional role when caring for older people whom displayed symptoms of clinical depression.?Methods:?A qualitative descriptive research design was used. Thirteen psychiatric nurses working in the field of mental health and psychiatric nursing at a rural district hospital were purposively included. The data were collected through in-depth,?face to face interviews and analyzed using qualitative latent content analysis.?Results:?All participants were female, and the mean age was 43 years, and the mean experience of caring for mentally ill patients was 8.3 years. The psychiatric nurses’ experiences and perceptions of their professional role were mirrored in the following themes:?1) managing a central role in the care of the patients;?2) conflicting interests between the professional needs of caregiving and other requests;and?3) being compassionate beyond the profession.?Conclusion: The psychiatric nurses were challenged by the complexity of the caregiving situations and the partners involved in the process of caring for older people with depression. Professionally, the psychiatric nurses played an important role in preventive care and managerial work. They underwent stress under the influence of stakeholders, but they also contributed to the holistic patient care.?Health service authorities may use these results to develop plans for psychiatric nurses in managing a central role and in advocating for holistic care to mitigate the influence of stakeholders to enhance quality of caring for older?individuals with depression.

Improving wellbeing of community-dwelling people with mild cognitive impairment: the SENIOR (SystEm of Nudge theory based ICT applications for OldeR citizens) project

Population aging with longer life expectancy represents one of the most relevant challenges of the next future,also because of a significant proportion of older adult people may present with dementia.Motivating senior citizens with mild cognitive impairment to maintain their independence and functional abilities,improve health status and quality of life as well as social interactions,constitutes the main target of preventive medicine.According to a nudge theoretical approach,the SENIOR(SystEm of Nudge theory based ICT applications for OldeR citizens)project–developed thanks to the collaboration among Catholic University of the Sacred Heart,Bicocca University and IRCCS Auxiologico Institute in Milan(Italy)–has been designed to adopt an advanced information and communication technology coaching system able to collect and integrate physiological,psychological and behavioral data,with the final aim of interacting with community-dwelling elderly people suffering from mild cognitive impairment and of providing them personalized feedback on lifestyle management.The SENIOR project proposes to use a smart-watch app for alerting family doctors,sharing information with family members in specific cases and monitoring patients at higher risk in hospital Units,in order to ameliorate health of senior citizens with mild cognitive impairment.

Bowel preparation experiences and needs before follow-up colonoscopy in older adult postoperative colorectal cancer patients: A qualitative study

BACKGROUND The bowel preparation process prior to colonoscopy determines the quality of the bowel preparation,which in turn affects the quality of the colonoscopy.Colono-scopy is an essential procedure for postoperative follow-up monitoring of colorec-tal cancer(CRC)patients.Previous studies have shown that advanced age and a history of colorectal resection are both risk factors for inadequate bowel prepara-tion.However,little attention has been paid to the bowel preparation experiences and needs of predominantly older adult postoperative CRC patients.AIM To explore the experiences and needs of older adult postoperative CRC patients during bowel preparation for follow-up colonoscopy.METHODS Fifteen older adult postoperative CRC patients who underwent follow-up colonoscopy at a tertiary hospital in Shanghai were selected using purposive sampling from August 2023 to November 2023.The phenomenological method in qualitative research was employed to construct an interview outline and conduct semi-structured interviews with the patients.Colaizzi's seven-step analysis was utilized to organize,code,categorize,summarize,and verify the interview data.RESULTS The results of this study were summarized into four themes and eight sub-themes:(1)Inadequate knowledge about bowel preparation;(2)Decreased physiological comfort during bowel preparation(gastrointestinal discomfort and sleep deprivation caused by bowel cleansing agents,and hunger caused by dietary restrictions);(3)Psychological changes during different stages of bowel preparation(pre-preparation:Fear and resistance due to previous experiences;during preparation:Irritation and helplessness caused by taking bowel cleansing agents,and post-preparation:Anxiety and worry while waiting for the colonoscopy);and(4)Needs related to bowel preparation(detailed instructions from healthcare professionals;more ideal bowel cleansing agents;and shortened waiting times for colonoscopy).CONCLUSION Older adult postoperative CRC patients'knowledge of bowel preparation is not adequate,and they may encounter numerous difficulties and challenges during the process.Healthcare professionals should place great emphasis on providing instruction for their bowel preparation.

Associations of short-term ambient temperature exposure with lung function in middle-aged and elderly people:A longitudinal study in China

The short-term associations of ambient temperature exposure with lung function in middle-aged and elderly Chinese remain obscure.The study included 19,128 participants from the Dongfeng-Tongji cohort's first(2013)and second(2018)follow-ups.The lung function for each subject was determined between April and December 2013 and re-assessed in 2018,with three parameters(forced vital capacity[FVC],forced expiratory volume in 1 s[FEV1],and peak expiratory flow[PEF])selected.The China Meteorological Data Sharing Service Center provided temperature data during the study period.In the two follow-ups,a total of 25,511 records(average age:first,64.57;second,65.80)were evaluated,including 10,604 males(41.57%).The inversely J-shaped associations between moving average temperatures(lag01–lag07)and FVC,FEV1,and PEF were observed,and the optimum temperatures at lag04 were 16.5C,18.7C,and 16.2C,respectively.At lag04,every 1C increase in temperature was associated with 14.07 mL,9.78 mL,and 62.72 mL/s increase in FVC,FEV1,and PEF in the lowtemperature zone(<the optimum temperatures),whereas 5.72 mL,2.01 mL,and 11.64 mL/s decrease in the high-temperature zone(the optimum temperatures),respectively(all P<0.05).We observed significant effect modifications of gender,age,body mass index,body surface area,smoking status,drinking status,and physical activity on the associations(all Pmodification<0.05).Non-optimal temperatures may cause lung function decline.Several individual characters and lifestyles have effect modification on the temperature effects.

Effect of hydrotherapy on sleep deficiency among older people in integrated community health services in Pandak Ⅰ Bantul

Objective: Relaxation technique is a nonpharmacological treatment applied to increase sleep efficiency and the quality of sleep.Hydrotherapy is one of the relaxation techniques and uses warm water to decrease stress and muscle stiffness, as well as to warm the body. The incidence of sleep deficiency among older people in Integrated Community Health Services, Pandak I Bantul, has slightly increased year by year. This research aims to evaluate the effect of hydrotherapy on sleep deprivation among older people.Methods: The research was a quasi-experimental study with a pre-post test design. Purposive sampling was used to enroll 66 older people from the Integrated Community Health Services, Pandak I Bantul, Yogyakarta, Indonesia, as a sample, and we divided them into two groups: 33 people formed the intervention group, and 33 people comprised the control group. The intervention group did hydrotherapy once a day for a total of 7 days. First, they soaked their feet in warm water for 10 minutes. The water temperature was adjusted according to the body temperature, to approximately 40.0℃-43.0℃. Then, the intervention group took a bath using warm water. The level of sleep quality was measured using the Pittsburgh Sleep Quality Index(PSQI) questionnaire. Data analysis was done using the Wilcoxon test.Results: The mean score for sleep quality in the pretest in the intervention group was 9.04(standard deviation [SD]: 2.57) and the score on the posttest was 42(SD: 1.43). The mean score for sleep quality in the intervention group was 4.67, with P=0.05.Meanwhile, the research found that the difference between the pretest and posttest scores for quality of sleep in the control group was 0.42, with P=0.059. Wilcoxon analysis found that in the intervention group, there was a significant difference after intervention using hydrotherapy, with P<0.05. In the control group, there was no significance difference between the pretest and posttest scores,with P> 0.05.Conclusions: According to the results of the present study, it appears that the practice of hydrotherapy is effective in reducing sleep deficiency and hence can be considered an effective method of intervention.

Influence of Proxies on the Reported Frequency of Falls, Fear of Falling and Activity Restriction in Older People

Introduction: In older populations, the help of a third person may be necessary for a certain number of individuals in order to fill in questionnaires. The influence of this assistance on the collected information can raise questions, among others concerning the concordance between the information provided by the persons themselves and by their proxies, or the introduction of a potential bias. Our study’s objective is to examine, among older people, the differences in the reported frequency of falls, fear of falling and activity restriction due to fear of falling, according to the fact that people had filled in a questionnaire with or without the help of a third person. Methods: The data used come from the secondary analysis of a cross-sectional survey using a self-administered questionnaire and conducted in 2006 in a Belgian semi-rural town among non-institutionalised persons aged 65 years and over. Results: Among the 501 questionnaires, 16.4% were filled in with the help of another person. In bivariate analysis, the persons who needed help reported fall history, fear of falling and activity restriction significantly more often. In multivariable analysis, when considering concurrently the covariates (sex, age, living alone and fall history for fear of falling and for activity restriction), the influence of having received help to fill in the survey was only significant for activity restriction. Conclusion: Our study shows that it is important to know whether or not a person has received help to fill in a questionnaire. This can actually influence the reported frequency of certain outcomes, even, for activity restriction, when considering simultaneously the effect of other covariates. Given the current and future ageing of our populations, it seems that more extensive exploration is needed of the influence of proxies on the collected information about falls, fear of falling and activity restriction among older people.

Clarifying Problems with Emergency Healthcare Systems in Japanese Long-Term Care Facilities for Older People

Background: Long-term care facilities for older people play an important role as alternatives to family care in an aging society. This study aimed to assess staffing problems linked to emergency healthcare for residents of these facilities, and to investigate the relationship between these problems and the characteristics of the facilities. Methods: The study surveyed managers of long-term care facilities for older people in a Japanese urban area between September and December 2014. The type of care facility, the number of staff and any problems providing or accessing emergency healthcare for the residents were evaluated. Multiple logistic regression analysis was used to explore the factors common to facilities reporting staffing problems linked to emergency healthcare of residents. Results: In total, 321 long-term care facilities were eligible for this study and 226 (70%) returned the questionnaire. We compared the characteristics of facilities reporting and not reporting staffing problems in emergency healthcare of residents. The type of care facility was significantly associated with staffing problems in emergency healthcare of residents both during the day (p < 0.01) and at night (p = 0.04). The facilities most likely to report problems were group homes for older people with dementia, because of staffing shortages. Conclusions: Problems in emergency healthcare systems in Japanese long-term care facilities for older people varied by type of care facility. Our data underscore the need for telemedicine and consideration of mergers between smaller facilities such as group homes for older people with dementia.

Cancer risk in older people receiving statin therapy： a meta-analysis of randomized controlled trials

Background Although statins are well tolerated by most aged people, their potential carcinogenicity is considered as one of the big-gest factors limiting the use of statins. The aim of the present study was to determine the risk of cancer in people aged over 60 years receiving statin therapy. Methods A comprehensive search for articles published up to December 2015 was performed, reviews of each randomized controlled trials （RCTs） that compared the effects of statin mono-therapy with placebo on the risk of cancer in people aged 〉 60 years were conducted and data abstracted. All the included studies were evaluated for publication bias and heterogeneity. Pooled odds ratios （OR） estimates and 95% confidence intervals （CIs） were calculated using the random effects model. Results A total of 12 RCTs, involving 62,927 patients （31,517 in statin therapy group and 31,410 in control group）, with a follow-up duration of 1.9-5.4 years, contributed to the analysis. The statin therapy did not affect the overall incidence of cancer （OR = 1.03, 95% CI： 0.94-1.14, P = 0.52）; subgroup analyses showed that neither the variety nor the chemical properties of the statins accounted for the incidence of cancer in older people. Conclusions Our meta- analysis findings do not support a potential cancer risk of statin treatment in people over 60 years old. Further targeted researches with a longer follow-up duration are warranted to confirm this issue.

Oral health status of older people in residential homes in Saudi Arabia

The aim of the study was to de-termine the oral health status and treatment needs of elderly residents of residential homes in Riyadh, Saudi Arabia. Methods: Among 129 elderly residents, 83 (51 males, and 32 females) of them were interviewed and clini-cally examined according to WHO criteria by two calibrated dentists. Results: The mean age of the subjects was 72 ± 8.5. Male subjects had a higher smoking rate than females. Among elderly subjects below 74 years old, 20.8% had a functional dentition (> or = 20), while only 6.7% for those aged greater or equal to 75 years (p = 0.0004). Mean number of the sound teeth in all subjects was 6.7 ± 8.5. The mean number of DMFT was 18.6 ± 12.6. The missing component was the highest (16 ± 13) for both genders. The mean number of decayed roots was 2.75 ± 3.95 in males and 0.63 ± 1.96 in females. Overall, males had more sound and decayed teeth and less filled and missed teeth than females. There was no significant difference between males and females in periodontal problems except the calculus scores. The majority of subjects in need for tooth extraction were male subjects. With no gender difference 63% were in need for restorations, 40% needed upper and lower full dentures. Need for partial dentures was 38% upper and 48% lower. Conclusion: The oral health of the institutionalized elderly population in Saudi Arabia is generally poor and their treatment needs are high.

Physical activity in older people with cardiac co-morbidities

The World Health Organisation （WHO） launched a global action plan on physical activity to provide a frame- work of policy actions to increase physical activity in June 2018. Physical activity is an effective intervention for pre- vention and management of non-communicable diseases including cardiac disease, regardless of age. We hoped this letter would remind readers of the importance of physical activity in older people, particularly those with cardiac co-morbidities.