Operational Definition of Active and Healthy Ageing (AHA): A Conceptual Framework

"Think positive and don't die alone" - Foreign-born, South Asian older adults' perceptions on healthy aging

South Asians are the largest and fastest-growing racialized group in Canada, yet there are limited data on various aspects of health and well-being within this population. This includes the South Asian older adults' ethnoculturally informed perceptions of ageing. The study aimed to understand how social and cultural forces impact the meaning assigned to healthy ageing amongst older South Asians in Canada. We recruited with purposeful and snowball sampling strategies in Southern Ontario. We conducted in-depth focus group and individual interviews (n = 19) in five South Asian languages, employing a multilingual and cross-cultural qualitative approach. In our analysis, we identified three central themes: (a) taking care of body (b) taking care of mind and heart and (c) healthy ageing through the integration of mind and body. Our study demonstrates that older immigrants are a diverse and heterogeneous population and that their conception of healthy ageing is strongly influenced by their country of origin. This study also demonstrates how racialized foreign-born older adults might provide distinctive perspectives on the ageing process and on social theories of ageing due to their simultaneous immersion in and belonging to global majority and global minority cultures. This research also adds to the limited body of literature on the theories of ageing, despite migration trends, still has a white-centric lens.

Feasibility and Effectiveness of a Personalized Home-Based Motor-Cognitive Training Program in Community-Dwelling Older Adults: Protocol for a Pragmatic Pilot Randomized Controlled Trial

BACKGROUND

Exergame-based motor-cognitive training in older adults has been associated with improvements in physical, cognitive, and psychological functioning. The novel Cocare system (Dividat GmbH), developed through a user-centered design process, allows motor-cognitive training in a telerehabilitation setting. It includes (1) a stationary stepping platform for supervised exergame training (Dividat Senso; Dividat GmbH), (2) a home-based version (Dividat Senso Flex, which is a rollable pressure-sensitive mat; Dividat GmbH), (3) an assessment system (including motor-cognitive tests), and (4) a rehabilitation cockpit for remote training supervision and management.

OBJECTIVE

The aim of this study is to test the feasibility and effectiveness of this novel training system.

METHODS

A total of 180 older adults from Switzerland, Italy, and Cyprus aged ≥60 years with a prescription for rehabilitation are randomly allocated to an intervention group or a control group. Both groups continue with their usual care, whereas participants in the intervention group additionally perform a 2-week supervised exergame training program at rehabilitation centers, followed by a 10-week home training program under remote supervision. The assessment system is used to indicate the start level of each participant, and, in both intervention periods, standardized progression rules are applied. The measures of feasibility include adherence, attrition, exergame enjoyment, willingness to perform such a training program, and the number and types of help requests. Effectiveness is assessed in terms of cognitive and physical functioning, balance confidence, and quality of life.

RESULTS

Data collection started in February 2023 and is ongoing. Final measurements are expected to be performed in January 2024.

CONCLUSIONS

Owing to the user-centered design approach, the Cocare system is expected to be user-friendly and offers several novel features to cover the whole continuum of care. This pragmatic trial will provide valuable information regarding final necessary adaptations and subsequent implementation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05751551; https://www.clinicaltrials.gov/study/NCT05751551.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49377.

60 years of healthy aging: On definitions, biomarkers, scores and challenges

BACKGROUND AND OBJECTIVE

As the proportion of aging people in our population increases steadily, global strategies accompanied by extensive research are necessary to tackle society and health service challenges. The World Health Organization recently published an action plan: "Decade of healthy aging 2020-2030", which calls for concerted collaboration to prevent poverty of older people to provide quality education, job opportunities, and an age-inclusive infrastructure. However, scientists worldwide still struggle to find definitions and appropriate measurements of aging per se and healthy aging in particular. This literature review aims to compile concepts of healthy aging and provide a condensed overview of the challenges in defining and measuring it, along with suggestions for further research.

MATERIALS AND METHODS

We conducted three independent systematic literature searches covering the main scopes addressed in this review: (1) concepts and definitions of healthy aging, (2) outcomes and measures in (healthy) aging studies and (3) scores and indices of healthy aging. For each scope, the retrieved literature body was screened and subsequently synthesized.

RESULTS

We provide a historical overview of the concepts of healthy aging over the past 60 years. Furthermore, we identifiy current difficulties in identifying healthy agers, including dichotomous measurements, illness-centered views, study populations & designs. Secondly, markers and measures of healthy aging are discussed, including points to consider, like plausibility, consistency, and robustness. Finally, we present healthy aging scores as measurements, which combine multiple aspects to avoid a dichotomous categorization and display the bio-psycho-social concept of healthy aging.

DISCUSSION AND CONCLUSION

When deducting research, scientists need to consider the diverse challenges in defining and measuring healthy aging. Considering that, we recommend scores that combine multiple aspects of healthy aging, such as the Healthy Ageing Index or the ATHLOS score, among others. Further efforts are to be made on a harmonized definition of healthy aging and validated measuring instruments that are modular, easy to apply and provide comparable results in different studies and cohorts to enhance the generalization of results.

Socio-economic status and trajectories of a novel multidimensional metric of Active and Healthy Ageing: the English Longitudinal Study of Ageing

Healthy ageing research largely has a unidimensional focus on physical health, negating the importance of psychosocial factors in the maintenance of a good quality-of-life. In this cohort study, we aimed to identify trajectories of a new multidimensional metric of Active and Healthy Ageing (AHA), including their associations with socio-economic variables. A latent AHA metric was created for 14,755 participants across eight waves of data (collected between 2004 and 2019) from the English Longitudinal Study of Ageing (ELSA), using Bayesian Multilevel Item Response Theory (MLIRT). Then, Growth Mixture Modelling (GMM) was employed to identify sub-groups of individuals with similar trajectories of AHA, and multinomial logistic regression examined associations of these trajectories with socio-economic variables: education, occupational class, and wealth. Three latent classes of AHA trajectories were suggested. Participants in higher quintiles of the wealth distribution had decreased odds of being in the groups with consistently moderate AHA scores (i.e., 'moderate-stable'), or the steepest deterioration (i.e., 'decliners'), compared to the 'high-stable' group. Education and occupational class were not consistently associated with AHA trajectories. Our findings reiterate the need for more holistic measures of AHA and prevention strategies targeted at limiting socio-economic disparities in older adults' quality-of-life.

Privacy by design in systems for assisted living, personalised care, and wellbeing: A stakeholder analysis

Privacy by design within a system for assisted living, personalised care, and wellbeing is crucial to protect users from misuse of the data collected about their health. Especially if the information is collected through audio-video devices, the question is even more delicate due to the nature of these data. In addition to guaranteeing a high level of privacy, it is necessary to reassure end users about the correct use of these streams. The evolution of data analysis techniques began to take on an important role and increasingly defined characteristics in recent years. The purpose of this paper is twofold: on the one hand, it presents a state of the art about privacy in European Active Healthy Ageing/Active Healthy Ageing projects, with a focus on those related to audio and video processing. On the other hand, it proposes a methodology, developed in the context of the European project PlatfromUptake.eu, to identify clusters of stakeholders and application dimensions (technical, contextual, and business), define their characteristics, and show how privacy constraints affect them. From this study, we then generated a Strengths, Weaknesses, Opportunities, and Threats analysis in which we aim to identify the critical features connected to the selection and involvement of relevant stakeholders for the success of a project. Applying this type of methodology to the initial stages of a project allows understanding of which privacy issues could be related to the various stakeholder groups and which problems can then affect the correct development of the project. The idea is, therefore, to suggest a privacy-by-design approach according to the categories of stakeholders and project dimensions. The analysis will cover technical aspects, legislative and policies-related aspects also regarding the point of view of the municipalities, and aspects related to the acceptance and, therefore, to the perception of the safety of these technologies by the final end users.

Listening to the patients' voice: a conceptual framework of the walking experience

BACKGROUND

walking is crucial for an active and healthy ageing, but the perspectives of individuals living with walking impairment are still poorly understood.

OBJECTIVES

to identify and synthesise evidence describing walking as experienced by adults living with mobility-impairing health conditions and to propose an empirical conceptual framework of walking experience.

METHODS

we performed a systematic review and meta-ethnography of qualitative evidence, searching seven electronic databases for records that explored personal experiences of walking in individuals living with conditions of diverse aetiology. Conditions included Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease, hip fracture, heart failure, frailty and sarcopenia. Data were extracted, critically appraised using the NICE quality checklist and synthesised using standardised best practices.

RESULTS

from 2,552 unique records, 117 were eligible. Walking experience was similar across conditions and described by seven themes: (i) becoming aware of the personal walking experience, (ii) the walking experience as a link between individuals' activities and sense of self, (iii) the physical walking experience, (iv) the mental and emotional walking experience, (v) the social walking experience, (vi) the context of the walking experience and (vii) behavioural and attitudinal adaptations resulting from the walking experience. We propose a novel conceptual framework that visually represents the walking experience, informed by the interplay between these themes.

CONCLUSION

a multi-faceted and dynamic experience of walking was common across health conditions. Our conceptual framework of the walking experience provides a novel theoretical structure for patient-centred clinical practice, research and public health.

Impact of chronic stress exposure on cognitive performance incorporating the active and healthy aging (AHA) concept within the cross-sectional Bern Cohort Study 2014 (BeCS-14)

Purpose

This study aims to verify that the mental-cognitive domain of the validated generic bio-functional status (BFS)/bio-functional age (BFA) assessment tool, incorporating the concept of Active and Healthy Ageing (AHA), reflects cognitive performance. In addition, the effects of chronic stress exposure on the mental-cognitive BFS/BFA should be investigated.

Methods

The study was carried out as a monocenter, cross-sectional, observational, non-interventional trial (Bern Cohort Study 2014, BeCS-14) with the participation of 147 non-pediatric, non-geriatric subjects. All participants followed a standardized battery of biopsychosocial assessments consisting of BFS/BFA, a validated cognitive performance test battery (Inventar zur Gedächtnisdiagnostik; IGD) and a validated questionnaire for the assessment of chronic stress (Trier Inventory for the assessment of Chronic Stress; TICS), respectively.

Results

Mean cognitive performance was average and higher in younger or better educated individuals. The BFA of the participants was 7.8 ± 7.8 year-equivalents below their chronological age. The mental-cognitive BFS/BFA assessment correlated well with the validated questionnaire for cognition assessment, the IGD. Further, three TICS subdomains (work overload (r =  − 0.246, p = 0.003), work discontent (r =  − 0.299, p = 0.006) and pressure to succeed (r =  − 0.274, p < 0.001)), reflecting mainly work-related stress, showed a significant negative correlation with the mental-cognitive BFS/BFA.

Conclusions

Our study shows that the BFS/BFA assessment tool follows European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) requirements. Further, we could demonstrate that higher levels of chronic work-related stress may be associated with poorer mental-cognitive performance and a pro-aging state indicating that cognitive impairments can be reduced by stress management interventions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06289-z.

Towards a Redefinition of Cognitive Frailty

Background:

The progressive aging of the population will dramatically increase the burden of dementia related to Alzheimer’s disease (AD) and other neurodegenerative disorders in the future. Because of the absence of drugs that can modify the neuropathological substrate of AD, research is focusing on the application of preemptive and disease-modifying strategies in the pre-symptomatic period of the disease. In this perspective, the identification of people with cognitive frailty (CF), i.e., those individuals with higher risk of developing dementia, on solid pathophysiological bases and with clear operational clinical criteria is of paramount importance.

Objective/Methods:

This hypothesis paper reviews the current definitions of CF, presents and discusses some of their limitations, and proposes a framework for updating and improving the conceptual and operational definition of the CF construct.

Results:

The potential for reversibility of CF should be supported by the assessment of amyloid, tau, and neuronal damage biomarkers, especially in younger patients. Physical and cognitive components of frailty should be considered as separate entities, instead of part of a single macro-phenotype. CF should not be limited to the geriatric population, because trajectories of amyloid accumulation are supposed to start earlier than 65 years in AD. Operational criteria are needed to standardize assessment of CF.

Conclusion:

Based on the limitations of current CF definitions, we propose a revised one according to a multidimensional subtyping. This new definition might help stratifying CF patients for future trials to explore new lifestyle interventions or disease-modifying pharmacological strategies for AD and dementia.

Home Monitoring System for Comprehensive Geriatric Assessment in Patient's Dwelling: System Design and UX Evaluation

Population aging threatens the sustainability of welfare systems since it is not accompanied by an extended healthy and independent period in the last years of life. The Comprehensive Geriatric Assessment (CGA) has been shown to be efficient in maintaining the healthy period at the end of the life. Frailty monitoring is typically carried out for an average period of 6 months in clinical settings, while more regular monitoring could prevent the transition to disability. We present the design process of a system for frailty home monitoring based on an adapted CGA and the rationale behind its User eXperience (UX) design. The resulting home monitoring system consists of two devices based on ultrasound sensors, a weight scale, and a mobile application for managing the devices, administering CGA-related questionnaires, and providing alerts. Older users may encounter barriers in their usage of technology. For this reason, usability and acceptability are critical for health monitoring systems addressed to geriatric patients. In the design of our system, we have followed a user-centered process, involving geriatricians and older frail patients by means of co-creation methods. In the iterative process of design and usability testing, we have identified the most effective way of conducting the home-based CGA, not just by replicating the dialogue between the physician and the patient, but by adapting the design to the possibilities and limitations of mobile health for this segment of users. The usability evaluation, carried out with 14 older adults, has proved the feasibility of users older than 70 effectively using our monitoring system, additionally showing an intention over 80% for using the system. It has also provided some insights and recommendations for the design of mobile health systems for older users.

Functioning profiles in a nationally representative cohort of Spanish older adults: A latent class study

Ageing well involves individuals continuing participating in personal, social and civic affairs even in older age. From this standpoint, limitations in individual's functioning (beyond the mere absence of disease) may drastically impact on how well people becoming older. This study aimed to identify functional status profiles in a nationally representative sample of older adults, using latent class analysis methods. Moreover, it intended to study the how identified classes would be related to health-related outcomes later in life, as a way to provide some evidence on predictive validity. Data from a nationally representative sample of Spanish older adults (N = 2,118; 56.18% women; M = 71.50 years, SD = 7.76), were used. Profiles were identified according to a large set of functioning indicators from multiple domains using latent class analysis. Outcomes were studied over a 3-year follow-up, considering both the individual (quality of life, well-being and mortality) and institutional level (health service utilisation). As a result, seven profiles were identified: normative profile (showed by most participants), limited cognitive functioning class, limited global functioning class, limited mental and mobility functioning class, poor self-reported health class, limited sensory functioning class and limited objective functioning class. All the profiles with limitations across domains showed poor outcomes. Multidimensional limitations were related to the worst outcomes, especially when psychosomatic complaints and high feelings of loneliness were reported. To sum up, latent class analysis constitutes a suitable alternative to study population heterogeneity, providing relevant evidence to help making decision in public and community health.

What Does "Successful Aging" Mean to you? - Systematic Review and Cross-Cultural Comparison of Lay Perspectives of Older Adults in 13 Countries, 2010-2020

Successful aging is a concept that has gained popularity and relevance internationally among gerontologists in recent decades. Examining lay older adults' perspectives on successful aging can enhance our understanding of what successful aging means. We conducted a systematic review of peer reviewed studies from multiple countries published in 2010-2020 that contained qualitative responses of lay older adults to open-ended questions such as "What does successful aging mean to you?" We identified 23 studies conducted in 13 countries across North America, Western Europe, the Middle East, Asia, and Oceania. We identified no studies meeting our criteria in Africa, South America, Eastern Europe, North Asia, or Pacific Islands. Across all regions represented in our review, older adults most commonly referred to themes of social engagement and positive attitude in their own lay definitions of successful aging. Older adults also commonly identified themes of independence and physical health. Least mentioned were themes of cognitive health and spirituality. Lay definitions of successful aging varied by country and culture. Our findings suggest that gerontology professionals in fields including healthcare, health psychology, and public health may best serve older adults by providing services that align with older adults' priority of maintaining strong social engagement as they age. Lay perspectives on successful aging acknowledge the importance of positive attitude, independence, and spirituality, in addition to physical and cognitive functioning.

Health-related Work Limitations Among Older Workers-the Role of Flexible Work Arrangements and Organizational Climate

BACKGROUND AND OBJECTIVES

Given their increasing prevalence with age, chronic health conditions (CHCs) are substantially affecting older workers and organizations. An important question is whether and how flexible work arrangements and organizational climates may help to reduce the work limitations experienced by older workers. Grounded on the Job Demand-Resource model, we hypothesize that access to flexible work arrangements (working-time flexibility, workplace flexibility, phased retirement) and supportive organizational climates (healthy ageing climate, psychological safety climate) are vital job resources that are associated with fewer health-related work limitations among older workers experiencing CHCs.

RESEARCH DESIGN AND METHODS

Multilevel data were collected among 5,419 older workers (60-65 years) in 624 organizations in the Netherlands. Perceived health-related work limitations of older workers diagnosed with arthritis (N = 2,330), cardiovascular disease (N = 720), and sleep disorders (N = 816) were analyzed.

RESULTS

Multilevel ordered logistic regression analyses revealed that perceived access to flexible working hours and a psychologically safe organizational climate was associated with fewer health-related work limitations among older workers with CHCs.

DISCUSSION AND IMPLICATIONS

Facilitating longer working lives is a key policy challenge within organizations, in particular if older workers are constraint by CHCs. This study shows that offering flexible working hours and ensuring a psychologically safe climate, where older workers with health issues are inclined to share their work needs and preferences, are likely to contribute to healthy ageing in the workplace.

Pilot study assessing the Rotterdam Healthy Aging Score in a cohort of HIV-positive adults in Toronto, Canada

Objective:

The Rotterdam Healthy Aging Score (HAS) is a validated multidimensional index constructed from five health domains. We describe the HAS distribution in a cohort of HIV-positive adults and correlate it with health outcomes.

Design:

A cross-sectional pilot study of 101 adults aged at least 40 years, on suppressive antiretroviral therapy attending a tertiary HIV clinic in Toronto, Canada.

Methods:

Participants completed questionnaires to calculate their HAS (range 0–14). Demographics, HAS and sub-scores were compared by age and sex. The HAS was compared with results of the Fried Frailty Score, Short Performance Physical Battery score (SPPB) and measures of health utilization. Kruskal--Wallis Rank-Sum and Fisher's exact tests were used for all comparisons.

Results:

Median (IQR) age was 56 (50--62), 81 (80%) men and 50 (50%) born in Canada. Median (IQR) CD4⁺ cell count was 574 (417--794) cells/μl. Median (IQR) HAS was 12 (10--13) with 39 (39%) achieving a score more than 12 (considered healthy aging). Younger participants experienced more depression, whereas women had greater pain. The HAS score correlated with the Fried Frailty Score (P = 0.008) and trended with the SPPB Score (P = 0.077). Those with the poorest HAS scores were more likely to have been hospitalized in the preceding 6 months (P = 0.034).

Conclusion:

The HAS ranged from 5 to 14 in this cohort of older HIV adults with 39% attaining scores in the ‘healthy’ range. The HAS correlated with measures of physical performance and health utilization. Further validation of an objective outcome in HIV-positive patients will facilitate evaluation of interventional studies to improve healthy aging.

n-3 Polyunsaturated Fatty Acids and Their Derivates Reduce Neuroinflammation during Aging

: Aging is associated to cognitive decline, which can lead to loss of life quality, personal suffering, and ultimately neurodegenerative diseases. Neuroinflammation is one of the mechanisms explaining the loss of cognitive functions. Indeed, aging is associated to the activation of inflammatory signaling pathways, which can be targeted by specific nutrients with anti-inflammatory effects. Dietary n-3 polyunsaturated fatty acids (PUFAs) are particularly attractive as they are present in the brain, possess immunomodulatory properties, and are precursors of lipid derivates named specialized pro-resolving mediators (SPM). SPMs are crucially involved in the resolution of inflammation that is modified during aging, resulting in chronic inflammation. In this review, we first examine the effect of aging on neuroinflammation and then evaluate the potential beneficial effect of n-3 PUFA as precursors of bioactive derivates, particularly during aging, on the resolution of inflammation. Lastly, we highlight evidence supporting a role of n-3 PUFA during aging.

Academic Leadership Roles and the Promotion of Research, Education, and Practices That Reframe Aging

Healthy aging represents an aspect of nursing science where there is accelerating academic interest in a topic that is of great public interest. Thus, an opportunity presents to consider how best to leverage academic leadership roles to assure a forward-looking curriculum, foster relevant research, and communicate results to the public. There are many roles that academic nursing leaders can play in advancing transformational ideas such as healthy aging, including acting as incubator and resource, hub and bridge, educational futurist, and public advocate. Nursing brings to this transformational task knowledge of the need for evidence-based research to guide policy and decision making as it relates to aging, clinical experience, and an ability to convey to a non-professional audience the clinical experience and research results. [Journal of Gerontological Nursing, 45(12), 28-32.].

Conceptualising and operationalising resilience in older adults

Context: As a result of increases in life expectancy and decreases in fertility, the proportion of the population entering later life has increased dramatically in recent decades. When faced with age-related challenges, some older adults respond more positively to adversity than would be expected given the level of adversity that they have experienced, demonstrating 'resilience'. Objectives: Having a clear conceptual framework for resilience is a prerequisite to operationalising resilience in a research context. Methods: Here we compare and contrast several approaches to the operationalisation of resilience: psychometric-driven and data-driven (variable-centred and individual-centred) methods. Results: Psychometric-driven methods involve the administration of established questionnaires aimed at quantifying resilience. Data-driven techniques use statistical procedures to examine and/or operationalise resilience and can be broadly categorised into variable-centred methods, i.e. interaction and residuals, and individual-centred methods, i.e. categorical and latent class. Conclusions: The specific question(s) driving the research and the nature of the variables a researcher intends to use in their adversity-outcome dyad will largely dictate which methods are more (or less) appropriate in that circumstance. A measured approach to the ways in which resilience is investigated is warranted in order to facilitate the most useful application of this burgeoning field of research.

Creating a Culture of Health in Planning and Implementing Innovative Strategies Addressing Non-communicable Chronic Diseases

Ongoing demographic changes are challenging health systems worldwide especially in relation to increasing longevity and the resultant rise of non-communicable diseases (NCDs). To meet these challenges, a paradigm shift to a more proactive approach to health promotion, and maintenance is needed. This new paradigm focuses on creating and implementing an ecological model of Culture of Health. The conceptualization of the Culture of Health is defined as one where good health and well-being flourish across geographic, demographic, and social sectors; fostering healthy equitable communities where citizens have the opportunity to make choices and be co-producers of healthy lifestyles. Based on Antonovsky's Salutogenesis model which asserts that the experience of health moves along a continuum across the lifespan, we will identify the key drivers for achieving a Culture of Health. These include mindset/expectations, sense of community, and civic engagement. The present article discusses these drivers and identifies areas where policy and research actions are needed to advance positive change on population health and well-being. We highlight empirical evidence of drivers within the EU guided by the activities within the thematic Action Groups of the European Innovation Partnership on Active and Healthy Aging (EIP on AHA), focusing on Lifespan Health Promotion and Prevention of Age-Related Frailty and Disease (A3 Action Group). We will specifically focus on the effect of Culture on Health, highlighting cross-cutting drivers across domains such as innovations at the individual and community level, and in synergies with business, policy, and research entities. We will present examples of drivers for creating a Culture of Health, the barriers, the remaining gaps, and areas of future research to achieve an inclusive and sustainable asset-based community.

Digital Services Landscape in Primary Care Setting in City of Zagreb; an EIP-AHA Reference Site Case Study

European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) brings together partners to create innovative solutions to the challenges of aging. Reference Sites (RS) of the Partnership act as hubs of innovation and assist the scale-up of identified solutions. "Blueprint on Digital Transformation of Health and Care for the Ageing Society" (The Blueprint) is guiding the shift towards ICT enabled patient-centered care. To further inform its development, a tool has been created and piloted across RS, to explore the digital services landscape and find services that address the needs of the personas developed for this tool, that represent the needs of the populations. The aim of this case study was to explore the digital services ecosystem in primary care in Zagreb from the services availability and accessibility perspective, using the personas needs tool. The total of 23 digital services was identified out of which 21 matched at least one persona need. Each service-need match was scored against usefulness and accessibility criteria and the resulting matrix was evaluated using original methods. The results point to several underperforming services and provide insight into possible improvement strategies. Several "workhorse" services were identified that are heavily dependent on the health workforce. The services adopted through EIP on AHA twinning schemes performed well against set criteria. The persona based tool, along with the original service assessment methodology based on the tool's framework provides a new perspective to the digital services landscape, useful for planning the areas for improvement and detecting underperforming services on a system level.

Health tourism: an opportunity for sustainable development

In February 2017, the "Programma Mattone Internazionale Salute" (ProMis), that is the Italian Program for Internationalization of Regional Health Systems of the Ministry of Health (MoH), presented the first version of its Position Paper on Health Tourism, which embeds a first shared approach to the recommendations expressed by the European Committee of Regions (CoR) on "Age-Friendly" tourism. The CoR stresses the importance of local and regional authorities in the coordination of multi-sectoral policies such as healthcare, social assistance, transport, urban planning and rural development in relation to the promotion of mobility, security, accessibility of services, including health care and social services. "Age-friendly" tourism is an example of an innovative tourist offer that strives to meet the health needs of the entire "traveling" population, with an integrated and cross-sector approach that involves various organizations operating in sectors such as healthcare, accessibility and transport. The aim of the workshop was to explore the interest of the stakeholders to participate in a systemic action in the field of "health" tourism, and to identify priority implementation areas that offer opportunities to take advantage of validated, innovative experiences that strengthen the accessibility to health and social services in regional, national and international contexts. This effort provides the opportunity to take advantage of aligning the European Structural and Investment Funds (ESIF) to the development of tourism, coherently with the needs and resources of local and regional health authorities.

Healthy Aging: American Geriatrics Society White Paper Executive Summary

In July 2015, the Journal of the American Geriatrics Society published a manuscript titled, "Failing to Focus on Healthy Aging: A Frailty of Our Discipline?" In response, the American Geriatrics Society (AGS) Clinical Practice and Models of Care Committee and Public Education Committee developed a white paper calling on the AGS and its members to play a more active role in promoting healthy aging. The executive summary presented here summarizes the recommendations from that white paper. The full version is published online at GeriatricsCareOnline.org. Life expectancy has increased dramatically over the last century. Longer life provides opportunity for personal fulfillment and contributions to community but is often associated with illness, discomfort, disability, and dependency at the end of life. Geriatrics has focused on optimizing function and quality of life as we age and reducing morbidity and frailty, but there is evidence of earlier onset of chronic disease that is likely to affect the health of future generations of older adults. The AGS is committed to promoting the health, independence, and engagement of all older adults as they age. Geriatrics as an interprofessional specialty is well positioned to promote healthy aging. We draw from decades of accumulated knowledge, skills, and experience in areas that are central to geriatric medicine, including expertise in complexity and the biopsychosocial model; attention to function and quality of life; the ability to provide culturally competent, person-centered care; the ability to assess people's preferences and values; and understanding the importance of systems in optimizing outcomes. J Am Geriatr Soc 67:17-20, 2019.

Prevalence and related factors of Active and Healthy Ageing in Europe according to two models: Results from the Survey of Health, Ageing and Retirement in Europe (SHARE)

BACKGROUND

Active and Healthy Ageing (AHA) is the process of optimizing opportunities related to health, participation, and safety in order to improve quality of life. The approach most often used to measure AHA is Rowe and Kahn's Satisfactory Ageing model. Nonetheless, this model has limitations. One of the strategic objectives of the WHO Global Strategy and Action Plan (2016) is to improve Healthy Ageing measurement. Our objectives were to compare two models of assessing AHA and further compare the results by country and sociodemographic variables.

METHODS

This was a cross-sectional, observational analysis of a representative sample of the general population aged 50 years and older in Europe. The data analysed were obtained by the Study of Health, Ageing and Retirement in Europe (SHARE). The dependent variable was AHA and its dimensions, measured using the Rowe and Kahn AHA model (AHA-B) and the authors' model based on the WHO definition (AHA-BPS). A descriptive analysis and multivariate models of binary logistical regression were developed.

RESULTS

The sample consisted of 52,641 participants (mean age 65.24 years [SD = 10.18; Range = 50-104], 53.2% women). Healthy Ageing prevalence in the AHA-B model was 23.5% (95%CI = 23.1%-23.9%). In the AHA-BPS model, this prevalence was 38.9%. In both models, significant variations were observed between countries, and were distributed along a north-western to south-eastern gradient. The sociodemographic variables associated with the absence of AHA were advanced age, female sex, death of spouse, low educational level, lack of employment, and low financial status. Comparing the two models, the strength of association between absence of AHA and advanced age (85 years and older) was four times greater in the AHA-B model.

CONCLUSIONS

Our results showing differences between these two models provide evidence that the AHA-BPS model does not penalize older age and is more likely to characterize AHA from a health promotion perspective.

Serial circulating omega 3 polyunsaturated fatty acids and healthy ageing among older adults in the Cardiovascular Health Study: prospective cohort study

OBJECTIVE

To determine the longitudinal association between serial biomarker measures of circulating omega 3 polyunsaturated fatty acid (n3-PUFA) levels and healthy ageing.

DESIGN

Prospective cohort study.

SETTING

Four communities in the United States (Cardiovascular Health Study) from 1992 to 2015.

PARTICIPANTS

2622 adults with a mean (SD) age of 74.4 (4.8) and with successful healthy ageing at baseline in 1992-93.

EXPOSURE

Cumulative levels of plasma phospholipid n3-PUFAs were measured using gas chromatography in 1992-93, 1998-99, and 2005-06, expressed as percentage of total fatty acids, including α-linolenic acid from plants and eicosapentaenoic acid, docosapentaenoic acid, and docosahexaenoic acid from seafoood.

MAIN OUTCOME MEASURE

Healthy ageing defined as survival without chronic diseases (ie, cardiovascular disease, cancer, lung disease, and severe chronic kidney disease), the absence of cognitive and physical dysfunction, or death from other causes not part of the healthy ageing outcome after age 65. Events were centrally adjudicated or determined from medical records and diagnostic tests.

RESULTS

Higher levels of long chain n3-PUFAs were associated with an 18% lower risk (95% confidence interval 7% to 28%) of unhealthy ageing per interquintile range after multivariable adjustments with time-varying exposure and covariates. Individually, higher eicosapentaenoic acid and docosapentaenoic acid (but not docosahexaenoic acid) levels were associated with a lower risk: 15% (6% to 23%) and 16% (6% to 25%), respectively. α-linolenic acid from plants was not noticeably associated with unhealthy ageing (hazard ratio 0.92, 95% confidence interval 0.83 to 1.02).

CONCLUSIONS

In older adults, a higher cumulative level of serially measured circulating n3-PUFAs from seafood (eicosapentaenoic acid, docosapentaenoic acid, and docosahexaenoic acid), eicosapentaenoic acid, and docosapentaenoic acid (but not docosahexaenoic acid from seafood or α-linolenic acid from plants) was associated with a higher likelihood of healthy ageing. These findings support guidelines for increased dietary consumption of n3-PUFAs in older adults.

The private healthcare market and the sustainability of an innovative community nurses programme based on social entrepreneurship - CoNSENSo project

Background

CoNSENSo is a project funded by the European Union, which is aimed at developing an innovative care model based on community nurses to support active ageing in mountain areas. The planned sustainability of this innovative approach relies on social entrepreneurship on the healthcare market, and this work highlights the necessary conditions for the successful implementation of these entrepreneurial initiatives.

Methods

Considering municipalities in the Piedmont Region and those aged 65 or older as target population, the authors propose several negative binomial regression models to estimate the effectiveness of current private healthcare services in supporting the active aging process. Such effectiveness may represent the ex-ante (positive) reputation of these new social entrepreneurial initiatives on the market.

Results

According to our results, the private supply of healthcare services can effectively support the aging process. Indeed, given that the other predictor variables in the model are held constant, there are statistically significant negative relations between the number of hip fractures and the private supply of healthcare services by dental practitioners and psychologists (p-value < 0.05), as well as the private supply of opportunities for social interaction by coffee bars (p-value < 0.05).

Conclusions

The authors expect a favourable environment for the entrepreneurial initiatives of community nurses in mountain areas. Accordingly, policy makers cannot reject the hypothesis that the goals reached by the CoNSENSo project may be maintained for the sake of the future generations, avoiding its collapse as soon as public funding shifts to new programmes.

Relationships between socio-clinico-demographic factors and global cognitive function in the oldest old living in the Tokyo Metropolitan area: Reanalysis of the Tokyo Oldest Old Survey on Total Health (TOOTH)

BACKGROUND

Despite a steady increase in life expectancy, a few studies have investigated cross-sectional correlates and longitudinal predictors of cognitive function, a core domain of the successful aging, among socio-clinico-demographic factors in the oldest-old exclusively.

OBJECTIVES

The aims of this study were to examine socio-clinico-demographic characteristics associated with global cognition and its changes in the oldest-old.

METHODS

We reanalyzed a dataset of cognitively preserved community-dwelling subjects aged 85 years and older in the Tokyo Oldest Old Survey on Total Health, a 6-year longitudinal observational study. This study consisted of (1) baseline cross-sectional analyses examining correlates of global cognition (n = 248) among socio-clinico-demographic factors and (2) longitudinal analyses examining baseline predictors for changes of global cognition in 3-year follow-up (n = 195). The Mini-Mental State Examination was used as a screening test to assess global cognition.

RESULTS

At baseline, higher weights were related to higher cognitive function in the oldest-old. The baseline predictors of global cognitive decline in 3-year follow-up were higher global cognition, shorter education period, and lower sociocultural activities and lower instrumental activity of daily living, in this order.

CONCLUSIONS

The present study suggests that it is crucial to attain higher education during early life and avoid leanness or obesity, participate in sociocultural cognitive activities during late life, and maintain instrumental activity of daily living to preserve optimal cognitive function in the oldest-old, which will facilitate developing prevention strategies for cognitive decline and promoting successful aging in this increasing population.

Selfie Aging Index: An Index for the Self-assessment of Healthy and Active Aging

Introduction

Governments across Europe want to promote healthy and active aging, as a matter of both public health and economic sustainability. Designing policies focused on the most vulnerable groups requires information at the individual level. However, a measure of healthy and active aging at the individual level does not yet exist.

Objectives

This paper develops the Selfie Aging Index (SAI), an individual-level index of healthy and active aging. The SAI is developed thinking about a tool that would allow each person to take a selfie of her aging status. Therefore, it is based entirely on self-assessed indicators. This paper also illustrates how the SAI may look like in practice.

Methods

The SAI is based on the Biopsychosocial Assessment Model (MAB), a tool for the multidimensional assessment of older adults along three domains: biological, psychological, and social. Indicators are selected and their weights determined based on an ordered probit model that relates the MAB indicators to self-assessed health, which proxies healthy and active aging. The ordered probit model predicts the SAI based on the estimated parameters. Finally, predictions are rescaled to the 0–1 interval. Data for the SAI development come from the Study of the Aging Profiles of the Portuguese Population and the Survey of Health, Aging, and Retirement in Europe.

Results

The selected indicators are BMI, having difficulties moving around indoors and performing the activities of daily living, feeling depressed, feeling nervous, lacking energy, time awareness score, marital status, having someone to confide in, education, type of job, exercise, and smoking status. The model also determines their weights.

Conclusion

Results shed light on various factors that contribute significantly to healthy and active aging. Two examples are mental health and exercise, which deserve more attention from individuals themselves, health-care professionals, and public health policy. The SAI has the potential to put the individual at the center of the healthy and active aging discussion, contribute to patient empowerment, and promote patient-centered care. It can become a useful instrument to monitor healthy and active aging for different actors, including individuals themselves, health-care professionals, and policy makers.

Age-dependent increase of oxidative stress regulates microRNA-29 family preserving cardiac health

The short-lived turquoise killifish Nothobranchius furzeri (Nfu) is a valid model for aging studies. Here, we investigated its age-associated cardiac function. We observed oxidative stress accumulation and an engagement of microRNAs (miRNAs) in the aging heart. MiRNA-sequencing of 5 week (young), 12–21 week (adult) and 28–40 week (old) Nfu hearts revealed 23 up-regulated and 18 down-regulated miRNAs with age. MiR-29 family turned out as one of the most up-regulated miRNAs during aging. MiR-29 family increase induces a decrease of known targets like collagens and DNA methyl transferases (DNMTs) paralleled by 5´methyl-cytosine (5mC) level decrease. To further investigate miR-29 family role in the fish heart we generated a transgenic zebrafish model where miR-29 was knocked-down. In this model we found significant morphological and functional cardiac alterations and an impairment of oxygen dependent pathways by transcriptome analysis leading to hypoxic marker up-regulation. To get insights the possible hypoxic regulation of miR-29 family, we exposed human cardiac fibroblasts to 1% O₂ levels. In hypoxic condition we found miR-29 down-modulation responsible for the accumulation of collagens and 5mC. Overall, our data suggest that miR-29 family up-regulation might represent an endogenous mechanism aimed at ameliorating the age-dependent cardiac damage leading to hypertrophy and fibrosis.

Is Technology Present in Frailty? Technology a Back-up Tool for Dealing with Frailty in the Elderly: A Systematic Review

This study analyzes the technologies used in dealing with frailty within the following areas: prevention, care, diagnosis and treatment. The aim of this paper is, on the one hand, to analyze the extent to which technology is present in terms of its relationship with frailty and what technological resources are used to treat it. Its other purpose is to define new challenges and contributions made by physiotherapy using technology. Eighty documents related to research, validation and/or the ascertaining of different types of hardware, software or both were reviewed in prominent areas. The authors used the following scales: in the area of diagnosis, Fried's phenotype model of frailty and a model based on trials for the design of devices. The technologies developed that are based on these models accounted for 55% and 45% of cases respectively. In the area of prevention, the results proved similar regarding the use of wireless sensors with cameras (35.71%), and Kinect™ sensors (28.57%) to analyze movements and postures that indicate a risk of falling. In the area of care, results were found referring to the use of different motion, physiological and environmental wireless sensors (46,15%), i.e. so-called smart homes. In the area of treatment, the results show with a percentage of 37.5% that the Nintendo® Wii™ console is the most used tool for treating frailty in elderly persons. Further work needs to be carried out to reduce the gap existing between technology, frail elderly persons, healthcare professionals and carers to bring together the different views about technology. This need raises the challenge of developing and implementing technology in physiotherapy via serious games that may via play and connectivity help to improve the functional capacity, general health and quality of life of frail individuals.

Do Aging Factors Influence the Clinical Presentation and Management of Chronic Rhinosinusitis?

Objective/Hypothesis Chronic rhinosinusitis (CRS) is a complex inflammatory disease of the upper respiratory airways resulting from the dysregulation of immunity and epithelial defenses. More recently, the contribution of an altered nasal microbiome to the development of CRS has also been proposed. However, the impact of aging on the development of CRS has been long overlooked. Here we propose, in a hypothesis piece, that aging can influence the physiopathology of CRS and its subsequent management in an elderly population. Data Sources We summarize the recent literature findings supporting that elderly patients with CRS could be a distinct population from those with adult CRS and might require different or adjunct therapeutic approaches. Methods Review of recent literature of the effect of aging and its possible effects in CRS using 3 different databases. Conclusions Age-dependent decrease in the levels of the S100 family proteins involved in epithelial proliferation, repair, and defenses combined with chronic inflammation might lead to an increased risk of abnormal microbial colonization and loss of microbiota diversity. Ultimately, these changes could have the potential to alter the physiopathology of CRS in the elderly. Implications Unlike in adults, in whom CRS T_h2-skewed responses with eosinophilia are thought to play a critical role, in aging populations, a microbiome and epithelial barrier dysfunctions may instead be the pivotal agents of disease development and persistence. This supports that therapies for elderly patients may require a different management or additional targeted therapies to control the disease. Prospective studies, however, are necessary to validate this concept.

Cognitive Frailty in Italian Community-Dwelling Older Adults: Prevalence Rate and Its Association with Disability

Cognitive frailty is the simultaneous clinical manifestation of both physical frailty and cognitive impairment. This paper aimed to propose and test an operational definition of cognitive frailty. The following specific aims were pursued: (i) to rate the prevalence of cognitive frailty; (ii) to evaluate differences in cognitive functioning among robust, pre-frail, and frail individuals; (iii) to examine the association of cognitive frailty with disability, in a sample of Italian community-dwelling older adults. Five hundred and ninety-four older adults (mean age 73.6 years, SD=5.8) were involved in this cross-sectional study. Cognitive frailty was operationalized using the Mini Mental State Examination (cut-off score equal or less than 25) for the evaluation of cognitive functions and the five criteria of the Cardiovascular Health Study (cut-off score equal or higher than 3) for the evaluation of physical frailty. Participants positive for both instruments were classified as cognitively frail. The outcome was disability measured with the Groningen Activity Restriction Scale. Descriptive statistics, one-way and two-way analysis of covariance (ANCOVA) were carried out. The prevalence rate of cognitive frailty was 4.4%. The one-way ANCOVA, controlling for age and gender, showed a significant difference (p< .001) among robust, pre-frail, and frail participants for the cognitive functioning. Moreover, cognitively frail individuals showed a difference (p<.001) in disability in comparison with non-frail participants. Our results are significant and provide empirical evidence about the usefulness of the cognitive frailty concept.

Measuring Active and Healthy Ageing: Applying a GENERIC Interdisciplinary Assessment Model Incorporating ICF

OBJECTIVES

In this study we compared the chronological and bio-functional age between two German speaking cohorts 30 years apart applying a comprehensive and generic Active and Healthy Aging (AHA) assessment model incorporating ICF.

METHODS

Single-centre, cross-sectional, observational, non-interventional, non-randomized trial at an University based women's hospital, division of Gynecological Endocrinology and Reproductive Medicine. All participants followed a standardized, holistic battery of biopsychosocial assessments consisting of bio-functional status (BFS), bio-functional age (BFA) and additional validated psychometric questionnaires.

RESULTS

462 non-pediatric, non-geriatric females were in the BeCS-14 cohort. The measured mean BFA was lower than the chronological age within the BeCS-14 cohort (regression coefficient 0.58) and comparable in the female LeCS-84 subcohort (regression coefficient age 0.85, communality age 76%). In detail, within the decades 35-45 years and 55-65 years the gradient of BFA increase (aging rate) was similar in both cohorts (decade 35-45 years: LeCS-84 4.08 ± 1.03 year equivalents and BeCS-14 4.78 ± 1.67 year equivalents; decade 55-65 years: LeCS-84 6.21 ± 1.29 year equivalents and BeCS-14 5.25 ± 1.18 year equivalents). Remarkably, within the LeCS-84 cohort the mean aging rate within the decade 45-55 years was significantly different from all other aging rates in both cohorts: 13.02 ± 1.05 year equivalents. However, within the BeCS-14 cohort the corresponding value was 4.83 ± 1.02 year equivalents thus indicating a continuous aging process across the adult life course. In BeCS-14, there was a significant age-related effect for cardiovascular performance and social stress exposition and younger age was associated with better cardiovascular performance while level of social stress exposition decreased in aging women.

CONCLUSION

When comparing BeCS-14 and LeCS-84, the aging process seemed to be accelerated in women in LeCS-84 between 45 and 54 years of age. We can only speculate on the reasons, such as differences in the health care, political and social system. However, the differences observed support the use of our BFS/BFA assessment tool not only on an individual level (strengths/resources) but also population level following EIP-AHA requirements. Yet, it remains to be developed how the assessed health strengths/resources-profile may be integrated into AHA management.

Health Promotion and Preventive Care Intervention for Older Community-Dwelling People: Long-Term Effects of a Randomised Controlled Trial (RCT) within the LUCAS Cohort

OBJECTIVES

An RCT of a health promotion and preventive care intervention was done in 2001-2002. Here, long-term analyses based on 12 years of follow-up of survival and of change in functional competence between intervention and control group are presented. Positive 1-year results (significantly higher use of preventive services and better health behaviour) were presented earlier.

DESIGN

Parallel group randomised controlled trial (RCT) with 878 participants in the intervention and 1,702 participants in the control group.

SETTING

The study took place in Hamburg, Germany and made use of health care structures and professionals of a geriatrics centre.

PARTICIPANTS

Study participants were initially community-dwelling, aged 60 years and older and without B-ADL-restrictions, cognitive impairment, or need of nursing care, with sufficient command of the German language.

INTERVENTIONS

Health promotion and preventive care interventions relied on an extensive health questionnaire and the subsequent offer to participate in multi-topic personal reinforcement performed in small group sessions or at preventive home visits.

MEASUREMENTS

Primary outcome: Survival time; in some analyses, adjustments were made for gender, age and self-perceived health. Secondary outcome: Functional competence (LUCAS Functional Ability Index) based on responses to self-administered questionnaires at 1-year follow-up and 12 years after 1-year follow-up (2013/2014).

RESULTS

Mean time under observation was 10.3 years. 38.3% (987/2,580) of the participants died; intervention group (IG): 35.7% (313/878), control group (CG): 39.6% (674/1,702); HR=0.89; p=0.09. Functional competence at 1-year follow-up: IG: ROBUST 67.4% (391/580), FRAIL 11.9% (69/580) vs. CG: ROBUST 62.9% (861/1,368), FRAIL 14.8% (203/1,368); p=0.12. 12-years after 1-year follow-up: IG: ROBUST 50.0% (160/320), FRAIL 30.9% (99/320) vs. CG: ROBUST 48.9% (307/628), FRAIL 34.1% (214/628); p=0.56.

CONCLUSIONS

Insignificant but consistent effects on survival and the dynamics of functional competence suggest effectivity of the complex intervention. We plan to take a closer look at the effect of each reinforcement separately.

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5)

Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.

Operational Definition of Active and Healthy Aging (AHA): The European Innovation Partnership (EIP) on AHA Reference Site Questionnaire: Montpellier October 20-21, 2014, Lisbon July 2, 2015

A core operational definition of active and healthy aging (AHA) is needed to conduct comparisons. A conceptual AHA framework proposed by the European Innovation Partnership on Active and Healthy Ageing Reference Site Network includes several items such as functioning (individual capability and underlying body systems), well-being, activities and participation, and diseases (including noncommunicable diseases, frailty, mental and oral health disorders). The instruments proposed to assess the conceptual framework of AHA have common applicability and availability attributes. The approach includes core and optional domains/instruments depending on the needs and the questions. A major common domain is function, as measured by the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). WHODAS 2.0 can be used across all diseases and healthy individuals. It covers many of the AHA dimensions proposed by the Reference Site network. However, WHODAS 2.0 does not include all dimensions proposed for AHA assessment. The second common domain is health-related quality of life (HRQoL). A report of the AHA questionnaire in the form of a spider net has been proposed to facilitate usual comparisons across individuals and groups of interest.