Comprehensive geriatric assessment for older adults admitted to hospital

Psychiatry and the geriatric syndromes - creating constructive interfaces

Integrating mental and physical healthcare is difficult to achieve because of professional and organisational barriers. Psychiatrists recognise the problems resulting from fragmentation of services and want continuity of care for patients, but commissioning and service structures perpetuate these problems. One way forward may be to follow the syndromic model employed by geriatricians as a means of avoiding over-emphasis on diagnosis above the pragmatics of implementing multi-component, coordinated care. Commissioners need to be made aware of the overlap and complementarity of skills possessed by old age psychiatry and geriatric medicine to create joint services for people vulnerable to dementia and delirium. A re-forged alliance between the two specialties will be necessary to turn integrated care for frail, elderly people from rhetoric into reality.

Frailty, Aging, and Cardiovascular Surgery

Older adults make up an ever-increasing number of patients presenting for surgery, and a significant percentage of these patients will be frail. Frailty is a geriatric syndrome that has been conceptualized as decreased reserve when confronted with stressors, although the precise definition of frailty has not been easy to standardize. The 2 most popular approaches to define frailty are the phenotypic approach and the deficit accumulation approach, although at least 20 tools have been developed, which has made comparison across studies difficult. In epidemiologic studies, baseline frailty has been associated with poor outcomes in both community cohorts and hospitalized patients. Specifically in cardiac surgery (including transcatheter aortic valve implantation procedures), frailty has been strongly associated with postoperative mortality and morbidity, and thus frailty likely improves the identification of high-risk patients beyond known risk scores. For perioperative physicians then, the question arises of how to incorporate this information into perioperative care. To date, 2 thrusts of research and clinical practice have emerged: (1) preoperative identification of high-risk patients to guide both patient expectations and surgical decision-making; and (2) perioperative optimization strategies for frail patients. However, despite the strong association of frailty and poor outcomes, there is a lack of well-designed trials that have examined perioperative interventions with a specific focus on frail patients undergoing cardiac surgery. Thus, in many cases, principles of geriatric care may need to be applied. Further research is needed to standardize and implement the feasible definitions of frailty and examine perioperative interventions for frail patients undergoing cardiac surgery.

Chronic Heart Failure Care Planning: Considerations in Older Patients

In developed countries, it is estimated that more than 10 % of adults aged over 70 years have heart failure (HF). Despite therapeutic advances, it remains a condition associated with significant morbidity and mortality. It is one of the commonest causes of unscheduled hospital admissions in older adults and data consistently show a lower uptake of evidence-based investigations and therapies as well as higher rates of HF hospitalisations and mortality than in younger adults. These rates are highest amongst patients discharged to 'skilled nursing facilities', where comorbidities, frailty and cognitive impairment are common and have a significant impact on outcomes. In this review, we examine current guidance and its limitations and offer a pragmatic approach to management of HF in this elderly population.

An evaluation of the comparative effectiveness of geriatrician-led comprehensive geriatric assessment for improving patient and healthcare system outcomes for older adults: a protocol for a systematic review and network meta-analysis

BACKGROUND

Comprehensive geriatric assessment (CGA) is an integrated model of care involving a geriatrician and an interdisciplinary team and can prioritize and manage complex health needs of older adults with multimorbidity. CGAs differ across healthcare settings, ranging from shared care conducted in primary care settings to specialized inpatient units in acute care. Models of care involving geriatricians vary across healthcare settings, and it is unclear which CGA model is most effective. Our objective is to conduct a systematic review and network meta-analysis (NMA) to examine the comparative effectiveness of various geriatrician-led CGAs and to identify which models improve patient and healthcare system level outcomes.

METHODS

An integrated knowledge translation approach will be used and knowledge users (KUs) including patients, caregivers, geriatricians, and healthcare policymakers will be involved throughout the review. Electronic databases including MEDLINE, EMBASE, Cochrane library, and Ageline will be searched from inception to November 2016 to identify relevant studies. Randomized controlled trials of older adults (≥65 years of age) that examine geriatrician-led CGAs compared to any intervention will be included. Primary and secondary outcomes will be selected by KUs to ensure the results are relevant to their decision-making. Two reviewers will independently screen the search results, extract data, and assess risk of bias. Data will be synthesized using an NMA to allow for multiple comparisons using direct (head-to-head) as well as indirect evidence. Interventions will be ranked according to their effectiveness using surface under the cumulative ranking curve (SUCRA).

DISCUSSION

As the proportion of older adults grows worldwide, the demand for specialized geriatric services that help manage complex health needs of older adults with multimorbidity will increase in many countries. Results from this systematic review and NMA will enhance decision-making and the efficient allocation of scarce geriatric resources. Moreover, active involvement of KUs throughout the review process will ensure the results are relevant to different levels of decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014014008.

Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery

BACKGROUND

Increasing numbers of older patients are undergoing vascular surgery. Inadequate preoperative assessment and optimization may contribute to increased postoperative morbidity and mortality.

METHODS

Patients aged at least 65 years scheduled for elective aortic aneurysm repair or lower-limb arterial surgery were enrolled in an RCT of standard preoperative assessment or preoperative comprehensive geriatric assessment and optimization. Randomization was stratified by sex and surgical site (aorta/lower limb). Primary outcome was length of hospital stay. Secondary outcome measures included new medical co-morbidities, postoperative medical or surgical complications, discharge to a higher level of dependency and 30-day readmission rate.

RESULTS

A total of 176 patients were included in the final analysis (control 91, intervention 85). Geometric mean length of stay was 5·53 days in the control group and 3·32 days in the intervention group (ratio of geometric means 0·60, 95 per cent c.i. 0·46 to 0·79; P < 0·001). There was a lower incidence of delirium (11 versus 24 per cent; P = 0·018), cardiac complications (8 versus 27 per cent; P = 0·001) and bladder/bowel complications (33 versus 55 per cent; P = 0·003) in the intervention group compared with the control group. Patients in the intervention group were less likely to require discharge to a higher level of dependency (4 of 85 versus 12 of 91; P = 0·051).

CONCLUSION

In this study of patients aged 65 years or older undergoing vascular surgery, preoperative comprehensive geriatric assessment was associated with a shorter length of hospital stay. Patients undergoing assessment and optimization had a lower incidence of complications and were less likely to be discharged to a higher level of dependency. Registration number: ISRCTN23142588 (http://www.controlled-trials.com).

The Association of Geriatric Syndromes with Hospital Outcomes

BACKGROUND

Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital.

OBJECTIVE

To study the association of frailty (≥6 points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery).

DESIGN

Retrospective observational study.

SETTING

Large university hospital in England.

PATIENTS

We analyzed 8202 first nonelective inpatient episodes of people aged 75 years and older between October 2014 and October 2015.

MEASUREMENTS

The outcomes studied were prolonged length of stay (LOS ≥10 days), inpatient mortality, delayed discharge, institutionalization, and 30-day readmission. Statistical analyses were based on multivariate regression models.

RESULTS

Independently of controlling variables, prolonged LOS was predicted by CFS ≥6: odds ratio (OR) =1.55; 95% confidence interval [CI], 1.36-1.77; P ⟨ 0.001; HoD: OR = 2.16; 95% CI, 1.79-2.61; P ⟨ 0.001; and ACS: OR = 3.31; 95% CI, 2.64-4.15; P ⟨ 0.001. Inpatient mortality was predicted by CFS ≥6: OR = 2.29; 95% CI, 1.79-2.94; P ⟨ 0.001. Delayed discharge was predicted by CFS ≥6: OR = 1.46; 95% CI, 1.27-1.67; P ⟨ 0.001; HoD: OR = 2.17; 95% CI, 1.80-2.62; P ⟨ 0.001; and ACS: OR = 2.29; 95% CI: 1.83-2.85; P ⟨ 0.001. Institutionalization was predicted by CFS ≥6: OR = 2.56; 95% CI, 2.09-3.14; P ⟨ 0.001; HoD: OR = 2.51; 95% CI, 2.00-3.14; P ⟨ 0.001; and ACS: OR 1.93; 95% CI, 1.46-2.56; P ⟨ 0.001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09-1.71; P = 0.006.

CONCLUSIONS

Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults. Journal of Hospital Medicine 2017;12:83-89.

The impact of age on complications, survival, and cause of death following colon cancer surgery

Background:

Given scarce data regarding the relationship among age, complications, and survival beyond the 30-day postoperative period for oncology patients in the United States, this study identified age-related differences in complications and the rate and cause of 1-year mortality following colon cancer surgery.

Methods:

The NY State Cancer Registry and Statewide Planning and Research Cooperative System identified stage I–III colon cancer resections (2004–2011). Multivariable logistic regression and survival analyses assessed the relationship among age (<65, 65–74, ⩾75), complications, 1-year survival, and cause of death.

Results:

Among 24 426 patients surviving >30 days, 1-year mortality was 8.5%. Older age groups had higher complication rates, and older age and complications were independently associated with 1-year mortality (P<0.0001). Increasing age was associated with a decrease in the proportion of deaths from colon cancer with a concomitant increase in the proportion of deaths from cardiovascular disease. Older age and sepsis were independently associated with higher risk of colon cancer-specific death (65–74: HR=1.59, 95% CI=1.26–2.00; ⩾75: HR=2.57, 95% CI=2.09–3.16; sepsis: HR=2.58, 95% CI=2.13–3.11) and cardiovascular disease-specific death (65–74: HR=3.72, 95% CI=2.29–6.05; ⩾75: HR=7.02, 95% CI=4.44–11.10; sepsis: HR=2.33, 95% CI=1.81–2.99).

Conclusions:

Older age and sepsis are associated with higher 1-year overall, cancer-specific, and cardiovascular-specific mortality, highlighting the importance of geriatric assessment, multidisciplinary care, and cardiovascular optimisation for older patients and those with infectious complications.

Modified Frailty Index Predicts Morbidity and Mortality After Pancreaticoduodenectomy

BACKGROUND

Pancreatic cancer is a disease of older adults, who may present with limited physiologic reserve. The authors hypothesized that a frailty index can predict postoperative outcomes after pancreaticoduodenectomy (PD).

METHODS

All patients who underwent PD were identified in the 2005-2012 NSQIP Participant Use File. Patients undergoing emergency procedures, those with an American Society of Anesthesiologists (ASA) classification of five, and those with a diagnosis of preoperative sepsis were excluded from the study. A modified frailty index (mFI) was defined by 11 variables within the National Surgical Quality Improvement Program (NSQIP) previously used for the Canadian Study of Health and Aging-Frailty Index. An mFI score of 0.27 or higher was defined as a high mFI. Uni- and multivariate analyses were performed to evaluate postoperative outcomes.

RESULTS

This study enrolled 9986 patients (age 65 ± 12 years, 48.8% female) who underwent PD. Of these patients, 6.4% (n = 637) had a high mFI (>0.27). Increasing mFI was associated with higher prevalence of postoperative morbidity (p < 0.001) and 30-days mortality (p < 0.001). In the univariate analysis, high mFI was associated with increased morbidity (odds ratio [OR] 1.68; 95% confidence interval [CI] 1.43-1.97; p < 0.001) and 30-days mortality (OR 2.45; 95% CI 1.74-3.45; p < 0.001). After adjustment for age, sex, ASA classification, albumin level, and body mass index (BMI), high mFI remained an independent preoperative predictor of postoperative morbidity (OR 1.544; 95% CI 1.289-1.850; p < 0.0001) and 30-days mortality (OR 1.536; 95% CI 1.049-2.248; p = 0.027).

CONCLUSIONS

High mFI is associated with postoperative morbidity and mortality after PD and can aid in preoperative risk stratification.

Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?

OBJECTIVE

The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit.

DESIGN

This is a clinical, prospective, randomized, controlled, one-center intervention study.

SETTING

This study was conducted in a large county hospital in western Sweden.

PARTICIPANTS

The study included 408 frail elderly patients, aged ≥75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female.

INTERVENTION

This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit.

MEASUREMENTS

The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs.

RESULTS

After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.14-0.79), ambulation (OR =0.19, 95% CI =0.1-0.37), dexterity (OR =0.38, 95% CI =0.19-0.75), emotion (OR =0.43, 95% CI =0.22-0.84), cognition (OR = 0.076, 95% CI =0.033-0.18) and pain (OR =0.28, 95% CI =0.15-0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] =0.55, 95% CI =0.32-0.96), and the two groups did not differ significantly in terms of hospital care costs (P>0.05).

CONCLUSION

Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost.

Health care professionals' readiness for an interprofessional orthogeriatric unit: A cross-sectional survey

An assessment of readiness for change can set the stage for the implementation by providing information regarding staff members' beliefs and attitudes prior to an organizational change. We conducted a cross-sectional survey to assess readiness for change (N = 113 employees) in a hospital on the verge of implementing an interprofessional, co-managed orthogeriatric unit. Staff members from three departments with roles related to orthogeriatric patients were invited to answer a web-based questionnaire. Our survey demonstrates that health care professionals are confident that interprofessional collaboration will be promoted by the implementation of orthogeriatric care. We found they were knowledgeable about the proposed orthogeriatric collaboration model and ready to engage in its implementation. Their concerns pertained to various practical aspects; those voiced by the nursing staff related to work strain and the work-related interests of their professional group whereas the physicians' reservations concentrated on the planning of the change. The exploration of readiness for organizational change among health care professionals offers managers an understanding of their motivations and concerns and provides a useful tool for the planning and implementation of a new interprofessional collaboration model.

Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study

AIM

Frail individuals may be at higher risk of death from a given acute illness severity (AIS), but this relationship has not been studied in an English National Health Service (NHS) acute hospital setting.

METHODS

This was a retrospective observational study in a large university NHS hospital in England. We analyzed all first non-elective inpatient episodes of people aged ≥75years (all specialties) between October 2014 and October 2015. Pre-admission frailty was assessed with the Clinical Frailty Scale (CFS) of the Canadian Study on Health & Aging, and AIS in the Emergency Department was measured with a Modified Early Warning Score (ED-MEWS<4 was considered as low acuity, and ED-MEWS≥4 as high acuity). A survival analysis compared times to 30-day inpatient death between CFS categories (1-4: very fit to vulnerable, 5: mildly frail, 6: moderately frail, and 7-8: severely or very severely frail).

RESULTS

There were 12,282 non-elective patient episodes (8202 first episodes, of which complete data was available for 5505). In a Cox proportional hazards model controlling for age, gender, Charlson Comorbidity Index, history of dementia, current cognitive concern, and discharging specialty (medical versus surgical), ED-MEWS≥4 (HR=2.87, 95% CI: 2.27-3.62, p<0.001), and CFS 7-8 (compared to CFS 1-4, HR=2.10, 95% CI: 1.52-2.92, p<0.001) were independent predictors of survival time.

CONCLUSIONS

We found frailty and AIS independently associated with inpatient mortality after adjustment for confounders. Hospitals may find it informative to undertake large scale assessment of frailty (vulnerability), as well as AIS (stressor), in older patients admitted to hospital as emergencies.

Improving outcomes for older women with gynaecological malignancies

The incidence of most gynaecological malignancies rises significantly with increasing age. With an ageing population, the proportion of women over the age of 65 with cancer is expected to rise substantially over the next decade. Unfortunately, survival outcomes are much poorer in older patients and evidence suggests that older women with gynaecological cancers are less likely to receive current standard of care treatment options. Despite this, older women are under-represented in practice changing clinical studies. The evidence for efficacy and tolerability is therefore extrapolated from a younger; often more fit population and applied to in every day clinical practice to older patients with co-morbidities. There has been significant progress in the development of geriatric assessment in oncology to predict treatment outcomes and tolerability however there is still no clear evidence that undertaking a geriatric assessment improves patient outcomes. Clinical trials focusing on treating older patients are urgently required. In this review, we discuss the evidence for treatment of gynaecological cancers as well as methods of assessing older patients for therapy. Potential biomarkers of ageing are also summarised.

New horizons: urgent care for older people with frailty

Urgent care for older people is a major public health issue and attracts much policy attention. Despite many efforts to curb demand, many older people with frailty and urgent care needs to access acute hospital services. The predominant model of care delivered in acute hospitals tends to be medically focussed, yet the evidence-based approaches that appear to be effective invoke a holistic model of care, delivered by interdisciplinary teams embedding geriatric competencies into their service. This article reviews the role for holistic care-termed Comprehensive Geriatric Assessment in the research literature-and how it can be used as an organising framework to guide future iterations of acute services to be better able to meet the multifaceted needs of older people.

Improving the quality of survivorship for older adults with cancer

In May 2015, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging through a U13 grant, convened a conference to identify research priorities to help design and implement intervention studies to improve the quality of life and survivorship of older, frailer adults with cancer. Conference attendees included researchers with multidisciplinary expertise and advocates. It was concluded that future intervention trials for older adults with cancer should: 1) rigorously test interventions to prevent the decline of or improve health status, especially interventions focused on optimizing physical performance, nutritional status, and cognition while undergoing cancer treatment; 2) use standardized care plans based on geriatric assessment findings to guide targeted interventions; and 3) incorporate the principles of geriatrics into survivorship care plans. Also highlighted was the need to integrate the expertise of interdisciplinary team members into geriatric oncology research, improve funding mechanisms to support geriatric oncology research, and disseminate high-impact results to the research and clinical community. In conjunction with the 2 prior U13 meetings, this conference provided the framework for future research to improve the evidence base for the clinical care of older adults with cancer. Cancer 2016;122:2459-68. © 2016 American Cancer Society.

A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital, Italy

Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4 days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover ("come'n'go") ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called "flow manager," with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient's needs according to lean methodology principles. In 2012-2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22 %) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.

Effective health care for older people living and dying in care homes: a realist review

Background

Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes.

Methods

We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group.

Results

Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change.

Conclusion

How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.

Geriatric assessment with management in cancer care: Current evidence and potential mechanisms for future research

Older adults with cancer represent a complex patient population. Geriatric assessment (GA) is recommended to evaluate the medical and supportive care needs of this group. "GA with management" is a term encompassing the resultant medical decisions and interventions implemented in response to vulnerabilities identified on GA. In older, non-cancer patients, GA with management has been shown to improve a variety of outcomes, such as reducing functional decline and health care utilization. However, the role of GA with management in the older adult with cancer is less well established. Rigorous clinical trials of GA with management are necessary to develop an evidence base and support its use in the routine oncology care of older adults. At the recent U-13 conference, "Design and Implementation of Intervention Studies to Improve or Maintain Quality of Survivorship in Older and/or Frail Adults with Cancer," a session was dedicated to developing research priorities in GA with management. Here we summarize identified knowledge gaps in GA with management studies for older patients with cancer and propose areas for future research.

Hepatocellular carcinoma in elderly patients: challenges and solutions

Hepatocellular carcinoma (HCC) is the second most common cause of death by cancer in the world. Due to the delayed HCC development in hepatitis C carriers and nonalcoholic fatty liver disease, the incidence of HCC in the elderly is increasing and is becoming a global health issue. Elderly patients with HCC should be assessed through proper oncologic approach, namely, screening tools for frailty (Geriatric-8 or Vulnerable Elders Survey-13) and comprehensive geriatric assessment. This review of the literature supports the same treatment options for elderly patients as for younger patients, in elderly patients selected as fit following proper oncogeriatric assessment. Unfit patients should be managed through a multidisciplinary team involving both oncological and geriatrician professionals. Specific studies and recommendations for HCC in the elderly should be encouraged.

Barriers and facilitators for implementing a new screening tool in an emergency department: A qualitative study applying the Theoretical Domains Framework

AIM

The aim was to identify the factors that were perceived as most important as facilitators or barriers to the introduction and intended use of a new tool in the emergency department among nurses and a geriatric team.

BACKGROUND

A high incidence of functional decline after hospitalisation for acute medical illness has been shown in the oldest patients and those who are physically frail. In Denmark, more than 35% of older medical patients acutely admitted to the emergency department are readmitted within 90 days after discharge. A new screening tool for use in the emergency department aiming to identify patients at particularly high risk of functional decline and readmission was developed.

DESIGN

Qualitative study based on semistructured interviews with nurses and a geriatric team in the emergency department and semistructured single interviews with their managers.

METHODS

The Theoretical Domains Framework guided data collection and analysis. Content analysis was performed whereby new themes and themes already existing within each domain were described.

RESULTS

Six predominant domains were identified: (1) professional role and identity; (2) beliefs about consequences; (3) goals; (4) knowledge; (5) optimism and (6) environmental context and resources. The content analysis identified three themes, each containing two subthemes. The themes were professional role and identity, beliefs about consequences and preconditions for a successful implementation.

CONCLUSIONS

Two different cultures were identified in the emergency department. These cultures applied to different professional roles and identity, different actions and sense making and identified how barriers and facilitators linked to the new screening tool were perceived.

RELEVANCE FOR CLINICAL PRACTICE

The results show that different cultures exist in the same local context and influence the perception of barriers and facilitators differently. These cultures must be identified and addressed when implementation is planned.

The geriatric management of frailty as paradigm of "The end of the disease era"

The sustainability of healthcare systems worldwide is threatened by the absolute and relative increase in the number of older persons. The traditional models of care (largely based on a disease-centered approach) are inadequate for a clinical world dominated by older individuals with multiple (chronic) comorbidities and mutually interacting syndromes. There is the need to shift the center of the medical intervention from the disease to the biological age of the individual. Thus, multiple medical specialties have started looking with some interest at concepts of geriatric medicine in order to better face the increased complexity (due to age-related conditions) of their average patient. In this scenario, special interest has been given to frailty, a condition characterized by the reduction of the individual's homeostatic reserves and increased vulnerability to stressors. Frailty may indeed represent the fulcrum to lever for reshaping the healthcare systems in order to make them more responsive to new clinical needs. However, the dissemination of the frailty concept across medical specialties requires a parallel and careful consideration around the currently undervalued role of geriatricians in our daily practice.

Application of qualitative response models in a relevance study of older adults' health depreciation and medical care demand

AIM

The effect of health depreciation in older people on medical care demand is not well understood. We tried to assess the medical care demand with length of hospitalization and their impact on profits as a result of health depreciation.

METHODS

All participants who underwent comprehensive geriatric assessment were from a prospective cohort study at a tertiary hospital. A total of 1191 cases between September 2008 to October 2012 were investigated. Three sets of qualitative response models were constructed to estimate the impact of older adults' health depreciation on multidisciplinary geriatric care services. Furthermore, we analyzed the factors affecting the composite end-point of rehospitalization within 14 days, re-admission to the emergency department within 3 days and patient death.

RESULTS

Greater health depreciation in elderly patients was positively correlated with greater medical care demand. Three major components were defined as health depreciation: elderly adaptation function, geriatric syndromes and multiple chronic diseases. On admission, the better the basic living functions, the shorter the length of hospitalization (coefficient = -0.35, P < 0.001 in Poisson regression; coefficient = -0.33, P < 0.001 in order choice profit model; coefficient = -0.29, P < 0.001 in binary choice profit model). The major determinants for poor outcome were male sex, middle old age and length of hospitalization. However, factors that correlated with relatively good outcome were functional improvement after medical care services and level of disease education.

CONCLUSIONS

An optimal allocation system for selection of cases into multidisciplinary geriatric care is required because of limited resources. Outcomes will improve with health promotion and preventive care services. Geriatr Gerontol Int 2017; 17: 645-652.

Comprehensive geriatric assessment of effects of hospitalization and long-term rehabilitation of patients following lower extremity arthroplasty

[Purpose] This study was performed to examine the effects of subacute physical therapy (PT) on activities of daily living (ADL), quality of life, and geriatric aspects of patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA). [Subjects] The subjects were TKA (n=56) and THA (n=39) patients who received PT on the first day of independent ADL (up to 2 weeks) and just prior to discharge (4 weeks). [Methods] The functional independence measure (FIM), grip strength, knee extension strength (KES), timed up and go (TUG) test, mini-mental state examination (MMSE), geriatric depression scale short form (GDS-15), fall efficacy scale (FES), and medical outcome study 8-item short-form health survey (SF-8) were used as outcome measure, and comorbidity involvement was also investigated. [Results] Improvements in FIM, KES, TUG, GDS-15, FES, and SF-8 scores were seen in both groups (effect size, 0.31-0.87). Poor PT effects were found for THA patients aged ≥65 years, for TKA and THA patients with an MMSE score ≤28, and for THA patients with two or more comorbidities. [Conclusion] Positive effects were seen in patients who received PT at 2-4 weeks after surgery. Thus, additional PT for approximately 2 weeks after the beginning of independent ADL may be beneficial.

Discharge interventions for older patients leaving hospital: protocol for a systematic meta-review

BACKGROUND

There is an increased need for additional care and support services for the elderly population. It is important to identify what support older people need once they are discharged from hospital and to ensure continuity of care. There is a large evidence base focusing on enhanced discharge services and their impact on patients. The services show some potential benefits, but there are inconsistent findings across reviews. Furthermore, it is unclear what elements of enhanced discharge interventions could be most beneficial to older people. This meta-review aims to identify existing systematic reviews of discharge interventions for older people, identify potentially effective elements of enhanced discharge services for this patient group and identify areas where further work may still be needed.

METHODS/DESIGN

The search will aim to identify English language systematic reviews that have assessed the effectiveness of discharge interventions for older people. The following databases will be searched: Medline, Embase, PsycINFO, HMIC, Social Policy and Practice, CINAHL, the Cochrane Library, ASSIA, Social Science Citation Index and the Grey Literature Report. The search strategy will comprise the keywords 'systematic reviews', 'older people' and 'discharge'. Discharge interventions must aim to support older patients before, during and/or after discharge from hospital. Outcomes of interest will include mortality, readmissions, length of hospital stay, patient health status, patient and carer satisfaction and staff views. Abstract, title and full text screening will be conducted independently by two reviewers. Data extracted from reviews will include review characteristics, patient population, review quality score, outcome measures and review findings, and a narrative synthesis will be conducted.

DISCUSSION

This review will identify existing reviews of discharge interventions and appraise how these interventions can impact outcomes in older people such as readmissions, health status, length of hospital stay and mortality. The review could inform practice and will help identify where further research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015025737.

New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap

In this paper, we outline the relationship between the need to put existing applied health research knowledge into practice (the 'know-do gap') and the need to improve the evidence base (the 'know gap') with respect to the healthcare process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in CGA; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base that requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.

Who benefits from orthogeriatric treatment? Results from the Trondheim hip-fracture trial

Background

Hip fracture patients are heterogenous. Certain patient characteristics are associated with poorer prognosis, but less is known about differences in response to treatment among subgroups. The Trondheim Hip Fracture trial found beneficial effects on mobility and function from comprehensive geriatric care (CGC) compared to traditional orthopaedic care (OC). The aim of this study was to explore differences in response to CGC among subgroups in this trial.

Methods

Secondary analysis of the complete dataset from Trondheim Hip Fracture Trial, a randomised controlled trial including 397 home-dwelling older adults (≥70 years) with a hip fracture. Subgroups were age (over/under 80 years), gender, fracture type (intra-/extracapsular), and pre-fracture instrumental ADL (i-ADL) (defined as over/under 45 on the Nottingham Extended ADL scale). Dependent variables were mobility (Short Physical Performance Battery), personal ADL (p-ADL) (Barthel Index), i-ADL (Nottingham Extended ADL scale), cognition (Mini-Mental Status Examination), four and 12 months after hip fracture. Data were analysed by linear mixed models with interactions (treatment, time, and subgroup), reporting treatment effects being clinically and statistically significant within and between subgroups.

Results

Analyses within subgroups showed beneficial effects of CGC on mobility and i-ADL either at four or twelve months in all subgroups except for males, extra-capsular fractures and patients with impaired pre-fracture i-ADL. Beneficial effect on p- ADL was found in patients < 80 years, intra-capsular fractures and patients with impaired pre-fracture i-ADL. Effects on cognition were found in patients < 80 years and men.

The interaction analyses showed that CGC had statistically significant better treatment effect on i-ADL for younger participants at four months (p = 0.004), on p-ADL both at four (p = 0.037) and twelve months (p = 0.045) and mobility at twelve months (p = 0.021), for participants with intracapsular as compared to extracapsular fractures, and on i-ADL at twelve months for participants with higher pre-fracture function (p = 0.012).

Conclusion

Contrary to our hypothesis that the most vulnerable patients would benefit the most from CGC, we found the intervention effect was most pronounced in younger, female participants with higher pre-fracture i-ADL function.

Trial rigistration

ClinicalTrials.gov registration number: NCT00667914.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0218-1) contains supplementary material, which is available to authorized users.

Embedding comprehensive geriatric assessment in the emergency assessment unit: the impact of the COPE zone

We introduced a geographically embedded frailty unit, the comprehensive older person's evaluation 'COPE' zone within our emergency assessment unit (EAU). We collated data for all medical patients over 75 years admitted non-electively for one month before and after this service change. Significantly more patients were seen by a geriatrician on the EAU earlier in their admission in 2014 (33.4 vs 19.3%, p<0.001; 11 vs 20 h, p<0.001). More patients had documented comprehensive geriatric assessment and discussion in a geriatrician multidisciplinary team meeting (relative risk (RR) 3.3, 95% confidence interval (CI) 2.35-4.73, p<0.001; RR 3.6, 95% CI 2.26-5.57, p<0.001, respectively). More patients with markers of frailty were discharged directly from EAU (42.2 vs 29.0%, p = 0.006) without increasing readmissions. Mean length of stay was reduced (9.5 vs 6.8 days, p = 0.02). The introduction of the COPE zone has improved service delivery at the point of access for older people admitted to hospital.

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Background

Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.

Objectives

To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.

Design

We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.

Participants

The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.

Results

The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.

Conclusions

Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text.

MAIN RESULTS

We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials).

AUTHORS' CONCLUSIONS

A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.

Geriatric patients with cognitive impairment

BACKGROUND

Hospitals are now faced with increasing numbers of cognitively impaired patients aged 80 and older who are at increased risk of treatment complications. This study concerns the outcomes when such patients are treated in a specialized ward for cognitive geriatric medicine.

METHODS

Observation of a cohort of 2084 patients from 2009 to 2014, supplemented by a sample of 380 patients from the hospital cohort of the Longitudinal Urban Cohort Ageing Study (LUCAS) for the years 2010 and 2011.

RESULTS

Geriatric inpatients with cognitive impairment tend to be multimorbid. Half of the patients studied (1031 of 2084 patients) were admitted to the hospital on an emergency basis. Complications arising on the ward that necessitated transfer elsewhere arose in 2.6% (51 of 2084 patients). Moreover, analysis of the sample of 380 patients from the LUCAS cohort revealed that the treatments they underwent during hospitalization were associated with an improvement of their functional state: their mean overall score on the Barthel index rose from 39.8 ± 24.3 (median, 35) on admission to 52.7 ± 27.0 (median, 55) on discharge. The percentage of patients being treated with 5 or more drugs fell from 98.2% (373/380) on admission to 79.3% (314/362) on discharge. The percentage receiving potentially inappropriate medications (PIM), as defined by the PRISCUS list, fell from 45% to 13.3%, while the percentage of drug orders and prescriptions involving PIM fell from 7.8 % (327/4181) to 2.0% (53/2600). 70% of the patients were discharged to the same living situation where they had been before admission.

CONCLUSION

In this study, structured geriatric treatment in a cohort of older acutely ill patients with cognitive impairment was associated with improvement of functions that are relevant to everyday life, as well as with a reduction of polypharmacy. Controlled studies are needed to confirm the observed benefit.

To Operate or Not: Prediction of 3-Month Postoperative Mortality in Geriatric Cancer Patients

Context: Appropriate selection of aging patient who fit for cancer surgery is an art-of-state.

Objectives: This study aimed to identify predictive factors pertinent to 3-month postoperative mortality in geriatric cancer patients.

Methods: A total of 8,425 patients over 70 years old with solid cancer received radical surgery between 2007 and 2012 at four affiliated hospitals of the Chang Gung Memorial Hospital were included. The clinical variables of patients who died within 3 months post-surgery were analyzed retrospectively. Recursive partitioning analysis (RPA) was performed by randomly selecting 50% of the patients (testing set) to identify specific groups of patients with the lowest and highest probability of 3-month postoperative mortality. The remaining 50% were used as validation set of the model.

Results: Patients' gender, Eastern Cooperative Oncology Group performance (ECOG scale), Charlson comorbidity index (CCI), American Society of Anesthesiologist physical status, age, tumor staging, and mode of admission were independent variables that predicted 3-month postoperative mortality. The RPA model identified patients with an ECOG scale of 0-2, localized tumor stage, and a CCI of 0-2 as having the lowest probability of 3-month postoperative mortality (1.1% and 1.3% in the testing set and validation set, respectively). Conversely, an ECOG scale of 3-4 and a CCI >2 were associated with the highest probability of 3-month postoperative mortality (55.2% and 47.8% in the testing set and validation set, respectively).

Conclusion: We identified ECOG scale and CCI score were the two most influencing factors that determined 3-month postoperative mortality in geriatric cancer patients.

A Belgian Survey on Geriatric Assessment in Oncology Focusing on Large-Scale Implementation and Related Barriers and Facilitators

OBJECTIVES

The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate.

RESULTS

Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration.

CONCLUSION

Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators.

Economic Evaluation of a General Hospital Unit for Older People with Delirium and Dementia (TEAM Randomised Controlled Trial)

BACKGROUND

One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months.

OBJECTIVE

To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care.

METHODS

Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%).

RESULTS

The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded.

CONCLUSIONS

The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01136148.

The long-term effect of being treated in a geriatric ward compared to an orthopaedic ward on six measures of free-living physical behavior 4 and 12 months after a hip fracture - a randomised controlled trial

Background

This study is part of the Trondheim Hip Fracture Trial, where we compared free-living physical behavior in daily life 4 and 12 months following hip surgery for patients managed with comprehensive geriatric care (CGC) in a geriatric ward with those managed with orthopedic care (OC) in an orthopedic ward.

Methods

This is a single centre, prospective, randomized controlled trial. 397 hip fracture patients were randomized to CGC (n = 199) or OC (n = 198) in the Emergency Department with follow-up assessments performed four and 12 months post-surgery. Outcomes were mean upright time, number and length of upright events recorded continuously for four days at four and 12 months post-surgery by an accelerometer-based activity monitor. Missing data were handled by multiple imputation and group differences assessed by linear regression with adjustments for gender, age and fracture type.

Results

There were no group differences in participants’ pre-fracture characteristics. Estimated group difference in favor of CGC in upright time at 4 months was 34.6 min (17.4 %, CI 9.6 to 59.6, p = .007) and at 12 months, 27.7 min (13.9 %, CI 3.5 to 51.8, p = .025). Average and maximum length of upright events was longer in the CGC (p’s < .042). No group difference was found for number of upright events (p’s > .452).

Conclusion

Participants treated with CGC during the hospital stay improved free-living physical behavior more than those treated with OC both 4 and 12 months after surgery, with more time and longer periods spent in upright. Results support findings from the same study for functional outcomes, and demonstrate that CGC impacts daily life as long as one year after surgery.

Trials registration

ClinicalTrials.gov, NCT00667914, April 18, 2008

Association of the clinical frailty scale with hospital outcomes

BACKGROUND

The clinical frailty scale (CFS) was validated as a predictor of adverse outcomes in community-dwelling older people. In our hospital, the use of the CFS in emergency admissions of people aged ≥ 75 years was introduced under the Commissioning for Quality and Innovation payment framework.

AIM

We retrospectively studied the association of the CFS with patient characteristics and outcomes.

DESIGN

Retrospective observational study in a large tertiary university National Health Service hospital in UK.

METHODS

The CFS was correlated with transfer to specialist Geriatric ward, length of stay (LOS), in-patient mortality and 30-day readmission rate.

RESULTS

Between 1st August 2013 and 31st July 2014, there were 11 271 emergency admission episodes of people aged ≥ 75 years (all specialties), corresponding to 7532 unique patients (first admissions); of those, 5764 had the CFS measured by the admitting team (81% of them within 72 hr of admission). After adjustment for age, gender, Charlson comorbidity index and history of dementia and/or current cognitive concern, the CFS was an independent predictor of in-patient mortality [odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.48 to 1.74, P < 0.001], transfer to Geriatric ward (OR = 1.33, 95% CI: 1.24 to 1.42, P < 0.001) and LOS ≥ 10 days (OR = 1.19, 95% CI: 1.14 to 1.23, P < 0.001). The CFS was not a multivariate predictor of 30-day readmission.

CONCLUSIONS

The CFS may help predict in-patient mortality and target specialist geriatric resources within the hospital. Usual hospital metrics such as mortality and LOS should take into account measurable patient complexity.

Pro-Active Fall-Risk Management is Mandatory to Sustain in Hospital-Fall Prevention in Older Patients--Validation of the LUCAS Fall-Risk Screening in 2,337 Patients

OBJECTIVES

Prevention of in-hospital falls contributes to improvement of patient safety. However, the identification of high-risk patients remains a challenge despite knowledge of fall-risk factors. Hence, objective was to prospectively validate the performance of the LUCAS (Longitudinal Urban Cohort Ageing Study) fall-risk screening, based on routine data (fall history, mobility, mental status) and applied by nurses.

DESIGN

Observational study comparing two groups of patients who underwent different fall-risk screenings; the LUCAS screening (2010 - 2011) and the STRATIFY (St. Thomas's Risk Assessment Tool In Falling Elderly Inpatients) (2004 - 2006).

SETTING

Urban teaching hospital.

PARTICIPANTS

Consecutively hospitalized patients (≥ 65 years old) were screened on admission; LUCAS n = 2,337, STRATIFY n = 4,735.

MEASUREMENTS

The proportions of fallers were compared between the STRATIFY and the LUCAS time periods. The number of fallers expected was compared to that observed in the LUCAS time period. Standardized fall-incidence recording included case-note checks for unreported falls. Plausibility checks of fall-risk factors and logistic regression analysis for variable fall-risk factors were performed.

RESULTS

The proportions of fallers during the two time periods were LUCAS n = 291/2,337 (12.5%) vs. STRATIFY n = 508/4,735 (10.7%). After adjustment for risk-factor prevalence, the proportion of fallers expected was 14.5% (334/2,337), the proportion observed was 12.5% (291/2,337) (p = 0.038).

CONCLUSIONS

In-hospital fall prevention including systematic use of the LUCAS fall-risk screening reduced the proportion of fallers compared to that expected from the patients' fall-risk profile. Raw proportions of fallers are not suitable to evaluate fall prevention in hospital because of variable prevalence of patients' fall-risk factors over time. Continuous communication, education and training is needed to sustain in-hospital falls prevention.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

Background

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

Methods

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

Results

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

Conclusion

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in “what should be done by whom, for which target group and at what moment”, in order to improve current practice in preventive elderly care.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

BACKGROUND

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

METHODS

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

RESULTS

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

CONCLUSION

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in "what should be done by whom, for which target group and at what moment", in order to improve current practice in preventive elderly care.

Quantifying the prevalence of frailty in English hospitals

OBJECTIVES

Population ageing has been associated with an increase in comorbid chronic disease, functional dependence, disability and associated higher health care costs. Frailty Syndromes have been proposed as a way to define this group within older persons. We explore whether frailty syndromes are a reliable methodology to quantify clinically significant frailty within hospital settings, and measure trends and geospatial variation using English secondary care data set Hospital Episode Statistics (HES).

SETTING

National English Secondary Care Administrative Data HES.

PARTICIPANTS

All 50,540,141 patient spells for patients over 65 years admitted to acute provider hospitals in England (January 2005-March 2013) within HES.

PRIMARY AND SECONDARY OUTCOME MEASURES

We explore the prevalence of Frailty Syndromes as coded by International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-10) over time, and their geographic distribution across England. We examine national trends for admission spells, inpatient mortality and 30-day readmission.

RESULTS

A rising trend of admission spells was noted from January 2005 to March 2013 (daily average admissions for month rising from over 2000 to over 4000). The overall prevalence of coded frailty is increasing (64,559 spells in January 2005 to 150,085 spells by Jan 2013). The majority of patients had a single frailty syndrome coded (10.2% vs total burden of 13.9%). Cognitive impairment and falls (including significant fracture) are the most common frailty syndromes coded within HES. Geographic variation in frailty burden was in keeping with known distribution of prevalence of the English elderly population and location of National Health Service (NHS) acute provider sites. Overtime, in-hospital mortality has decreased (>65 years) whereas readmission rates have increased (esp.>85 years).

CONCLUSIONS

This study provides a novel methodology to reliably quantify clinically significant frailty. Applications include evaluation of health service improvement over time, risk stratification and optimisation of services.

Treatment of colorectal cancer in the elderly

Colorectal cancer has a high incidence, and approximately 60% of colorectal cancer patients are older than 70, with this incidence likely increasing in the near future. Elderly patients (> 70-75 years of age) are a very heterogeneous group, ranging from the very fit to the very frail. Traditionally, these patients have often been under-treated and recruited less frequently to clinical trials than younger patients, and thus are under-represented in publications about cancer treatment. Recent studies suggest that fit elderly patients can be treated in the same way as their younger counterparts, but the treatment of frail patients with comorbidities is still a matter of controversy. Many factors should be taken into account, including fitness for treatment, the wishes of the patient and family, and quality of life. This review will focus on the existing evidence for surgical, oncologic, and palliative treatment in patients over 70 years old with colorectal cancer. Careful patient assessment is necessary in order to individualize treatment approach, and this should rely on a multidisciplinary process. More well-designed controlled trials are needed in this patient population.

Emergency surgery in the elderly: challenges and solutions

Elderly patients frequently present with surgical emergencies to health care providers, and outcomes in this group of patients remain poor. Contributing factors include frailty, preexisting comorbidity, polypharmacy, delayed diagnosis, and lack of timely and consultant-led treatment. In this review, we address common emergency surgical presentations in the elderly and highlight the specific challenges in caring for these patients. We summarize 20 years of reports by various medical bodies that have aimed to improve the care of these patients. To improve morbidity and mortality, several aspects of care need to be addressed. These include accurate and timely preoperative assessment to identify treatable pathology and, where possible, to consider and correct age-specific disease processes. Identification of patients in whom treatment would be futile or associated with high risk is needed to avoid unnecessary interventions and to give patients and carers realistic expectations. The use of multidisciplinary teams to identify common postoperative complications and age-specific syndromes is paramount. Prevention of complications is preferable to rescue treatment due to the high proportion of patients who fail to recover from adverse events. Even with successful surgical treatment, long-term functional decline and increased dependency are common. More research into emergency surgery in the elderly is needed to improve care for this growing group of vulnerable patients.