In-home preventive comprehensive geriatric assessment (CGA) reduces mortality--a randomized controlled trial

Does proactive care in care homes improve survival? A quality improvement project

BACKGROUND

NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered.

AIM

To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents.

DESIGN AND SETTING

Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival.

METHOD

All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP.

RESULTS

By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables.

CONCLUSION

A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.

IT-assisted comprehensive geriatric assessment for residents in care homes: quasi-experimental longitudinal study

BACKGROUND

Frailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We assessed if, in older care home residents, particularly those with severe frailty, i-CGA could improve access to advance care planning discussions and reduce unplanned hospitalisations.

METHOD

As a quality improvement project we progressively incorporated our i-CGA process into routine primary care for older care home residents, and used a quasi-experimental approach to assess its interim impact. Residents were assessed for frailty by General Practitioners. Proactive i-CGAs were completed, including consideration of traditional CGA domains, deprescribing and ACP discussions. Interim analysis was conducted at 1 year: documented completion, preferences and adherence to ACPs, unplanned hospital admissions, and mortality rates were compared for i-CGA and control (usual care) groups, 1-year post-i-CGA or post-frailty diagnosis respectively. Documented ACP preferences and place of death were compared using the Chi-Square Test. Unplanned hospital admissions and bed days were analysed using the Mann-Whitney U test. Survival was estimated using Kaplan-Meier survival curves.

RESULTS

At one year, the i-CGA group comprised 196 residents (severe frailty 111, 57%); the control group 100 (severe frailty 56, 56%). ACP was documented in 100% of the i-CGA group, vs. 72% of control group, p < 0.0001. 85% (94/111) of severely frail i-CGA residents preferred not to be hospitalised if they became acutely unwell. For those with severe frailty, mean unplanned admissions in the control (usual care) group increased from 0.87 (95% confidence interval ± 0.25) per person year alive to 2.05 ± 1.37, while in the i-CGA group they fell from 0.86 ± 0.24 to 0.68 ± 0.37, p = 0.22. Preferred place of death was largely adhered to in both groups, where documented. Of those with severe frailty, 55% (62/111) of the i-CGA group died, vs. 77% (43/56) of the control group, p = 0.0013.

CONCLUSIONS

Proactive, community-based i-CGA can improve documentation of care home residents' ACP preferences, and may reduce unplanned hospital admissions. In severely frail residents, a mortality reduction was seen in those who received an i-CGA.

Guidance for Treating the Older Adults with Colorectal Cancer

OPINION STATEMENT

The need for evidence-based data in the rapidly growing group of older patients is vast and more elderly-specific studies are desperately needed, for which there is clear demand from both patients and providers. Notably, many of the studies discussed in this review included unplanned subset analyses based on age and/or were not originally stratified by age; therefore, these data, particularly overall survival data, need to be interpreted with some caution as they may not be statistically valid based on the initial trial design and statistical plan. As we await data from ongoing elderly-specific trials, our recommendation for managing older patients with CRC should include geriatric screening tools (e.g., CSGA, VES-13, G8, CARG, CRASH) to help guide treatment adjustments for improved tolerability without sacrificing efficacy. For patients with a positive screen for significant geriatric concerns, a full geriatric assessment is recommended to guide treatment approach and supportive care. Prior data support the use of all approved medications for CRC in older adults who are fit; however, treatment breaks and dose attenuation with potential escalation are reasonable options for these patients. Ultimately, management decisions in the care of older adults with mCRC must be made through shared decision-making with the patient with consideration for the patient's functional status, comorbidities, goals of care, social support, as well as potential toxicities and possible effect on QoL.

The GIANT trial (ECOG-ACRIN EA2186) methods paper: A randomized phase II study of gemcitabine and nab-paclitaxel compared with 5-fluorouracil, leucovorin, and liposomal irinotecan in older patients with treatment-naïve metastatic pancreatic cancer - defining a new treatment option for older vulnerable patients

INTRODUCTION

Pancreatic cancer is the fourth leading cause of cancer-related death in the US with an increasing incidence in older adults (OA) over age 70. There are currently no treatment guidelines for OA with metastatic pancreatic cancer (mPCA) and selecting a chemotherapy regimen for these patients is subjective, based largely on chronologic age and performance status (PS). Geriatric screening tools provide a more objective and accurate evaluation of a patient's overall health but have not yet been validated in patient selection for mPCA treatment. This study aims to elucidate the optimal chemotherapy treatment of vulnerable OA with mPCA and understand the geriatric factors that affect outcomes in this population.

METHODS/DESIGN

The GIANT (ECOG-ACRIN EA2186) study is multicenter, randomized phase II trial enrolling patients over age 70 with newly diagnosed mPCA. This study utilizes a screening geriatric assessment (GA) which characterizes patients as fit, vulnerable, or frail. Patients with mild abnormalities in functional status and/or cognition, moderate comorbidities, or over age 80 are considered vulnerable. Enrolled patients are randomized to one of two dose-reduced treatment regimens (gemcitabine/nab-paclitaxel every other week, or dose-reduced 5-fluoruracil (5FU)/ liposomal irinotecan (nal-IRI) every other week). GA and quality of life (QoL) evaluations are completed prior to treatment initiation and at each disease evaluation. Overall survival (OS) is the primary endpoint, with secondary endpoints including progression free survival (PFS) and objective response rate (ORR). Enrolled patients will be stratified by age (70-74 vs ≥75) and ECOG PS (0-1 vs 2). Additional endpoints of interest for OA include evaluation of risk factors identified through GA, QoL evaluation, and toxicities of interest for older adults. Correlative studies include assessment of pro-inflammatory biomarkers of aging in the blood (IL-6, CRP) and imaging evaluation of sarcopenia as predictors of treatment tolerance.

DISCUSSION

The GIANT study is the first randomized, prospective national trial evaluating vulnerable OA with mPCA aimed at developing a tailored treatment approach for this patient population. This trial has the potential to establish a new way of objectively selecting vulnerable OA with mPCA for modified treatment and to establish a new standard of care in this growing patient population.

TRIAL REGISTRATION

This trial is registered with ClinicalTrial.gov Identifier NCT04233866.

Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people

BACKGROUND

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear.

OBJECTIVES

To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors.

SELECTION CRITERIA

We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest.

MAIN RESULTS

We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17).

AUTHORS' CONCLUSIONS

CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.

Gastric Mobility and Gastrointestinal Hormones in Older Patients with Sarcopenia

Sarcopenia has serious clinical consequences and poses a major threat to older people. Gastrointestinal environmental factors are believed to be the main cause. The aim of this study was to describe the relationship between sarcopenia and gastric mobility and to investigate the relationship between sarcopenia and the concentration of gastrointestinal hormones in older patients. Patients aged ≥ 75 years were recruited for this prospective study from August 2018 to February 2019 at the emergency department. The enrolled patients were tested for sarcopenia. Gastric emptying scintigraphy was conducted, and laboratory tests for cholecystokinin(CCK), glucagon-like peptide-1 (GLP-1), peptide YY (PYY), nesfatin, and ghrelin were performed during the fasting period. We enrolled 52 patients with mean age of 86.9 years, including 17 (32.7%) patients in the non-sarcopenia group, 17 (32.7%) patients in the pre-sarcopenia group, and 18 (34.6%) in the sarcopenia group. The mean gastric emptying half-time had no significant difference among three groups. The sarcopenia group had significantly higher fasting plasma concentrations of CCK, GLP-1, and PYY. We concluded that the older people with sarcopenia had significantly higher plasma concentrations of CCK, GLP-1, and PYY. In the elderly population, anorexigenic gastrointestinal hormones might have more important relationships with sarcopenia than orexigenic gastrointestinal hormones.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Geriatric Assessment-Driven Intervention (GAIN) on Chemotherapy-Related Toxic Effects in Older Adults With Cancer: A Randomized Clinical Trial

Importance

Although geriatric assessment-driven intervention improves patient-centered outcomes, its influence on chemotherapy-related toxic effects remains unknown.

Objective

To assess whether specific geriatric assessment-driven intervention (GAIN) can reduce chemotherapy-related toxic effects in older adults with cancer.

Design, Setting, and Participants

A randomized clinical trial enrolled 613 participants from a National Cancer Institute-designated cancer center between 2015 and 2019. Patients were 65 years and older with a solid malignant neoplasm, were starting a new chemotherapy regimen, and completed a geriatric assessment. Patients were followed up until chemotherapy completion or 6 months after initiation, whichever occurred first. Data analysis was done by intention-to-treat principle.

Interventions

Patients were randomized (2:1) to either the GAIN (intervention) or standard of care (SOC) arm. In the GAIN arm, a geriatrics-trained multidisciplinary team composed of an oncologist, nurse practitioner, social worker, physical/occupation therapist, nutritionist, and pharmacist reviewed geriatric assessment results and implemented interventions based on prespecified thresholds built into the geriatric assessment's domains. In the SOC arm, geriatric assessment results were sent to treating oncologists for consideration.

Main Outcomes and Measures

The primary outcome was incidence of grade 3 or higher chemotherapy-related toxic effects (graded using National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0). Secondary outcomes included advance directive completion, emergency department visits, unplanned hospitalizations, average length of stay, unplanned hospital readmissions, chemotherapy dose modifications, and early discontinuation. Overall survival analysis was performed up to 12 months after chemotherapy initiation.

Results

Among the 605 eligible participants for analysis, median (range) age was 71 (65-91) years, 357 (59.0%) were women, and 432 (71.4%) had stage IV disease. Cancer types included gastrointestinal (202 [33.4%]), breast (136 [22.5%]), lung (97 [16.0%]), genitourinary (91 [15.0%]), gynecologic (54 [8.9%]), and other (25 [4.1%]). Incidence of grade 3 or higher chemotherapy-related toxic effects was 50.5% (95% CI, 45.6% to 55.4%) in the GAIN arm and 60.6% (95% CI, 53.9% to 67.3%) in the SOC arm, resulting in a significant 10.1% reduction (95% CI, -1.5 to -18.2%; P = .02). A significant absolute increase in advance directive completion of 28.4% with GAIN vs 13.3% with SOC (P < .001) was observed. No significant differences were observed in emergency department visits, unplanned hospitalizations, average length of stay, unplanned readmissions, chemotherapy dose modifications or discontinuations, or overall survival.

Conclusions and Relevance

In this randomized clinical trial, integration of multidisciplinary GAIN significantly reduced grade 3 or higher chemotherapy-related toxic effects in older adults with cancer. Implementation of GAIN into oncology clinical practice should be considered among older adults receiving chemotherapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02517034.

Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore

BACKGROUND

The first Patient-Centered Medical Home (PCMH) demonstration in Singapore was launched in November 2016, which aimed to deliver integrated and patient-centered care for patients with bio-psycho-social needs. Implementation was guided by principles of comprehensiveness, coordinated care, shared decision-making, accessible services, and quality and safety. We aimed to investigate the impact of implementing the PCMH in primary care on quality of life (QoL) and patient activation.

METHODS

The study design was a prospective single-arm pre-post study. We applied the 5-level EuroQol 5-dimension (EQ-5D-5L) and Visual Analog Scale (EQ VAS) instruments to assess health-related QoL. The CASP-19 tool was utilised to examine the degree that needs satisfaction was fulfilled in the domains of Control, Autonomy, Self-realisation, and Pleasure. The 13-item Patient Activation Measure (PAM-13) was used to evaluate knowledge, skills and confidence in management of conditions and ability to self-care. Multivariable linear regression models with random intercepts were applied to examine the impact of the PCMH intervention on outcome measures at 3 months and 6 months post-enrolment, compared to baseline.

RESULTS

We analysed 165 study participants enrolled into the PCMH from November 2017 to April 2020, with mean age 77 years (SD: 9.9). Within-group pre-post (6 months) EQ-5D-5L Index (β= -0.01, p-value = 0.35) and EQ VAS score (β=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (β = 1.34, p-value = 0.05) and 6 months post-enrolment (β = 1.15, p-value = 0.08) that were marginally out of statistical significance. There was also a significant impact of the PCMH on the CASP-19 Pleasure domain (β = 0.62, p = 0.03) at 6 months post-enrolment, compared to baseline. We found improved patient activation from a 15.2 % reduction in the proportion of participants in lower PAM levels, and a 23.4 and 16.7 % rise in proportion for higher PAM levels 3 and 4, respectively, from 3 months to 6 months post-enrolment.

CONCLUSIONS

Preliminary demonstration of the PCMH model shows evidence of improved needs satisfaction and patient activation, with potential to have a greater impact after a longer intervention duration.

Estimating the effect of health assessments on mortality, physical functioning and health care utilisation for women aged 75 years and older

Health assessments have potential to improve health of older people. This study compares long-term health care utilisation, physical functioning, and mortality for women aged 75 years or over who have had a health assessment and those who have not. Prospective data on health service use, physical functioning, and deaths among a large cohort of women born 1921–26 were analysed. Propensity score matching was used to produce comparable groups of women according to whether they had a health assessment or not. The study population included 6128 (67.3%) women who had an assessment, and 2971 (32.7%) women who had no assessment. Propensity matching produced 2101 pairs. Women who had an assessment had more use of other health services, longer survival, and were more likely to survive with high physical functioning compared to women with no assessment. Among women who had good baseline physcial functioning scores, women who had an assessment had significantly lower odds of poor outcomes at 1000 days follow-up compared to women who had no assessment (OR: 0.67, 95%CI: 0.52, 0.85). This large observational study shows the real-world potential for assessments to improve health outcomes for older women. However, they also increased health service use. This increased healthcare is likely to be an important mechanism in improving the women’s health outcomes.

Utilisation of general practice health assessments around an aged care assessment is associated with lower mortality risk in older Australians

OBJECTIVE

(i) to describe the general practitioner utilisation of health assessments, management plans, coordination of team care arrangements and medication review item numbers within 6 months of an aged care eligibility assessment for home care packages (HCP) and (ii) investigate the impact of health assessments on the risk of mortality and entry into permanent residential aged care (PRAC) of individuals accessing HCP.

DESIGN AND SETTING

retrospective cohort study utilising data from the Registry of Senior Australians (ROSA) was conducted.

SUBJECTS

75,172 individuals aged ≥75 years who received HCP between 2011 and 2015.

OUTCOME MEASURE

for objective 1: the use of comprehensive assessments (Medicare Benefits Schedule (MBS) items 705 or 707), management plans (MBS 721), coordination of team care arrangements (MBS 723), and medication reviews (MBS 900). For objective 2: time to death and entry into PRAC.

RESULTS

of the 75,172 individuals, 28.2% (95% confidence interval (CI): 27.8-8.5%) had comprehensive assessments, 36.7% (95% CI: 36.3-37.0%) had management plans, 33.0% (95% CI: 32.7-33.3%) received coordination of team care arrangements and 5.4% (95% CI: 5.2-5.5%) had medication reviews. Individuals with a comprehensive assessment had a 5% lower risk of mortality (adjusted hazard ratio (aHR), 95% CI = 0.95, 0.92-0.98) but 5% higher risk of transition to PRAC (adjusted subdistribution HRs, 95% CI = 1.05, 1.02-1.08) compared to those who did not have these services.

CONCLUSION

the utilisation of health assessments was associated with a lower risk of mortality. There is an opportunity for increased use of item numbers in frailer individuals.

Developing an electronic geriatric assessment to improve care of older adults with cancer receiving radiotherapy

Older adults make up a substantial proportion of patients diagnosed with cancer. Gaps in evidence of care for older adults with cancer leads to treatment heterogeneity and poor outcomes. Medical and Surgical Oncology clinics throughout the world are increasingly using Geriatric Assessment (GA) based approaches to treatment that are beginning to improve care through treatment decision-making communication, health-related quality of life outcomes, and reducing chemotherapy toxicities. Yet, GA based approaches are not often used in radiation oncology clinics. This manuscript aims to describe the ongoing development of an electronic patient-reported GA with real-time data interpretation and recommendation delivery to help increase the use of a personalized GA based approach to the care of older adults within radiation oncology clinics. Future studies demonstrating the utility and benefit of GA based approaches to help older adults undergoing radiotherapy for their cancers are still sorely needed.

Older adults with cancer and their caregivers - current landscape and future directions for clinical care

Despite substantial improvements in the outcomes of patients with cancer over the past two decades, older adults (aged ≥65 years) with cancer are a rapidly increasing population and continue to have worse outcomes than their younger counterparts. Managing cancer in this population can be challenging because of competing health and ageing-related conditions that can influence treatment decision-making and affect outcomes. Geriatric screening tools and comprehensive geriatric assessment can help to identify patients who are most at risk of poor outcomes from cancer treatment and to better allocate treatment for these patients. The use of evidence-based management strategies to optimize geriatric conditions can improve communication and satisfaction between physicians, patients and caregivers as well as clinical outcomes in this population. Clinical trials are currently underway to further determine the effect of geriatric assessment combined with management interventions on cancer outcomes as well as the predictive value of geriatric assessment in the context of treatment with contemporary systemic therapies such as immunotherapies and targeted therapies. In this Review, we summarize the unique challenges of treating older adults with cancer and describe the current guidelines as well as investigational studies underway to improve the outcomes of these patients.

Handgrip strength, tumor necrosis factor-α, interlukin-6, and visfatin levels in oldest elderly patients with cognitive impairment

INTRODUCTION

Handgrip strength is associated with mild cognitive impairment. Tumor necrosis factor [TNF]-α and interleukin [IL]-6 were pro-inflammatory cytokines influencing the severity of initial neurological deficit. Visfatin is a novel adipokine and has a strong correlation with inflammation. The relationships of TNF-α, IL-6 and visfatin are not consistent, and no study has investigated them in the elderly patients with cognitive impairment.

METHODS

This study included patients aged ≥75 years at the emergency department from August 2018 to February 2019. All patients underwent comprehensive geriatric assessment and blood tests for fasting plasma TNF-α, IL-6 and visfatin levels.

RESULTS

We enrolled 106 elderly patients with a mean age of 87.3 years, including 62 (58.4%) patients in cognitive impairment group (Mini-Mental State Examination [MMSE] < 24) and 44 (41.5%) patients in the non-cognitive impairment group. Compared to the non-cognitive impairment group, the cognitive impairment group had significantly lower handgrip strength, and significantly higher TNF-α, IL-6 and visfatin levels. TNF-α positively correlated with IL-6. Both TNF-α and IL-6 negatively correlated with Barthel index and MMSE. Handgrip strength negatively correlated with TNF-α but positively correlated with Barthel index and MMSE scores. Backward and stepwise multiple logistic regression analyses showed that the independent predictor for cognitive impairment was handgrip strength and age.

CONCLUSION

The cognitive impairment group had significantly higher serum TNF-α, IL-6, and visfatin levels. The independent predictors of cognitive impairment were handgrip strength and age. Handgrip strength negatively correlated with TNF-α and IL-6 but positively with Barthel index and MMSE scores.

Geriatric assessment for older adults with sickle cell disease: protocol for a prospective cohort pilot study

Background

The life expectancy for people with sickle cell disease (SCD) has improved tremendously over the last 50 years. This population experiences hemolysis and vaso-occlusion in multiple organs that lead to complications such as cardiopulmonary disease, strokes, and avascular necrosis. These complications can limit mobility and aerobic endurance, similar to limitations that often occur in geriatric populations. These sickle-cell and age-related events lead to frequent hospitalization, which further increases the risk of functional decline. We have few tools to measure functional decline in people with SCD. The purpose of this paper is to describe a protocol to evaluate the feasibility of sickle cell disease geriatric assessment (SCD-GA).

Methods/design

We will enroll 40 adults with SCD (20 age 18–49.99 years and 20 age ≥ 50 years) in a prospective cohort study to assess the feasibility of SCD-GA. The SCD-GA includes validated measures from the oncology geriatric assessment enriched with additional physical and cognitive measures. The SCD-GA will be performed at the first study visit, at 10 to 20 days after hospitalization, and at 12 months (exit visit). With input from a multidisciplinary team of sickle cell specialists, geriatricians, and experts in physical function and physical activity, we selected assessments across 7 domains: functional status (11 measures), comorbid medical conditions (1 measure), psychological state (1 measure), social support (2 measures), weight status (2 measures), cognition (3 measures), and medications (1 measure). We will measure the proportion completing the assessment with feasibility as the primary outcome. Secondary outcomes include the proportion consenting and completing all study visits, duration of the assessment, acceptability, and adverse events.

Discussion

We present the protocol and rationale for selection of the measures included in SCD-GA. We also outline the methods to determine feasibility and subsequently to optimize the SCD-GA in preparation for a larger multicenter validation study of the SCD-GA.

Comprehensive geriatric assessment in the emergency department for the prediction of readmission among older patients: A 3-month follow-up study

BACKGROUND

Older people present to the emergency department (ED) with distinct patterns and emergency care needs. This study aimed to use comprehensive geriatric assessment (CGA) surveying the patterns of ED visits among older patients and determine frailty associated with the risk of revisits/readmission.

METHODS

This prospective study screened 2270 patients aged ≥75 years in the ED from August 2018 to February 2019. All patients underwent CGA. A 3-months follow-up was conducted to observe the hospital courses of admission and revisit/readmission.

RESULTS

A total of 270 older patients were enrolled. The independent predictors of admission at initial ED visit were the risk of nutritional deficit and instrumental activities of daily living (IADL). In the admission group, the independent predictors of revisit/readmission were a fall in the past year and mobility difficulties. In the discharge group, the independent predictors of revisit/readmission were frailty and insomnia. Regardless if older patients were either admitted or discharged at the initial ED visit, the independent predictor of revisit/readmission for older patients was frailty.

CONCLUSION

Our study showed that frailty was the only independent predictor for revisit/readmission after ED discharge during the 3-month follow up. For ED physicians, malnutrition and IADL were independent predictors in recognizing whether the older patient should be admitted to the hospital. For discharged older ED patients, frailty was the independent predictor for the integration of community services for older patients to decrease the rate of revisit/readmission in 3 months.

CAUSES, mortality rates and risk factors of death in community-dwelling Europeans aged 50 years and over: Results from the Survey of Health, Ageing and Retirement in Europe 2013-2015

OBJECTIVE

To determine mortality rates and to rank the causes and predictors of mortality using a wide range of sociodemographic and clinical variables.

MATERIALS AND METHODS

It is a prospective population-based cohort study of adults living in the community, 2013-15 N = 48,691, age ≥50; deceased = 1,944. Clinical and sociodemographic data were obtained from the Survey of Health, Ageing and Retirement in Europe SHARE: Age, Gender, Marital Status, Years of Schooling, Income, Loneliness, Cognition, Self-Rated Health, Diseases, Activities of daily living ADL, and Frailty. Mortality rates were calculated. A Cox proportional hazards model were used to determine risk-adjusted mortality ratios.

RESULTS

The crude mortality rate was 18.39 (1000 person-years at risk), (99 % CI, 18.37-18.42). The factors most associated with an increased mortality risk were older age, lower self-rated health, lower cognition, male gender, ADL deficits, higher comorbidity, frailty and loneliness. The diseases with a higher mortality risk were: cancer (Hazard ratio, HR = 2.67), dementia (HR = 2.19), depressive symptoms (HR = 2.10), fractures (hip, femur) (HR = 1.57), stroke (HR = 1.55), chronic lung disease (HR = 1.52), diabetes (HR = 1.36) and heart attack (HR = 1.21).

CONCLUSIONS

The main mortality risk factors, associated independently in the eight diseases were: older age, poor self-rated health, ADL deficits, male gender, lower cognition, comorbidity and the presence of depressive symptoms, with a different influence in the European regions. The need to evaluate and treat the depressive symptoms that accompanies diseases with higher risk of mortality is stressed.

The Effects of Preventive Home Visits on Older People’s Use of Health Care and Social Services and Related Costs

Background

We use data from a randomized controlled trial on preventive home visits exploring effectiveness on health-related quality of life. In this article, we examine the intervention’s cost-effectiveness and effects on quality-adjusted life years in older home-dwelling adults.

Methods

There were 422 independently home-dwelling participants in the randomized, controlled trial, all aged more than 75 years, with equal numbers in the control and intervention groups. The intervention took place in a municipality in Finland and consisted of multiprofessional preventive home visits. We gathered the data on health care and social services use from central registers and medical records during 1 year before the intervention and 2 years after the intervention. We analyzed the total health care and social services use and costs per person-years and the difference in change in health-related quality of life as measured using the 15D measure. We calculated quality-adjusted life years and incremental cost-effectiveness ratios.

Results

There was no significant difference in baseline use of services or in the total use and costs of health care and social services during the 2-year follow-up between the two groups. In the intervention group, health-related quality of life declined significantly more slowly compared with the control group (–0.015), but there was no significant difference in quality-adjusted life years gained between the groups. The cost-effectiveness plane showed 60% of incremental cost-effectiveness ratios lying in the dominant quadrant, representing additional effects with lower costs.

Conclusions

This multiprofessional preventive home visit intervention appears to have positive effects on health-related quality of life without accruing additional costs.

The clinical trial registration number

ACTRN12616001411437.

Five-year survival rate among older adults participating in the national geriatric screening program: A South Korean population-based cohort study

INTRODUCTION

This study aimed to assess the health benefits of a geriatric screening program comprising of physical function tests, screening questionnaires for depression and cognitive impairment, and bone mineral density measurements for women as a part of the National Screening Program for Transitional Ages (NSPTA). We compared the all-cause mortality between subjects who did and did not participate in the screening program.

METHODS

This was a nationwide longitudinal study with a 5-year follow-up based on a 10% sample of the National Health Insurance beneficiaries aged 60 years and older. Mortality records were obtained from the qualification dataset in the elderly cohort database of 2005-2013 provided by the National Health Insurance Service. A Cox proportional hazards model was used to analyze the mortality risk. We sampled 11,986 subjects each in the screened (intervention) and non-screened (control) groups after exact matching using propensity score.

RESULTS

After adjusting for demographic and socioeconomic characteristics (age, sex, household income, smoking, alcohol drinking, physical activity, body mass index, and the Charlson Comorbidity Index), all-cause mortality rates were found to be significantly lower (a) in the intervention group compared to the control group (hazard ratio = 0.73; 95% confidence interval: 0.65, 0.82) and (b) among women compared to men (hazard ratio = 0.50; 95% confidence interval: 0.44, 0.56). Lower hazard ratios were also observed among those with a higher body mass index, fewer comorbidities, and higher income.

CONCLUSION

A nationwide geriatric screening program might be helpful in reducing the incidence of premature deaths among older people.

Risk assessment during preventive home visits among older people

Background

Preventive home visits (PHV) may contribute to identify risks and needs in older people, and thereby delay the onset of functional decline and illness, otherwise often followed by home care or admission to hospital or nursing homes. There is a need to increase knowledge about which factors are associated with different risk areas among older people, so that the PHV questionnaire focuses on relevant tests and questions to make the PHV more specific and have a clear focus and purpose.

Objective

The objective of this study was to examine associations between five kinds of risks: risk of falls, malnutrition, polypharmacy, cognitive impairment, and risk of developing illness and factors related to lifestyle, health, and medical diagnoses among older people living at home.

Methods

A cross-sectional study design was applied. PHV were conducted by nurses among 77-year-old people in an urban municipality and among ≥75-year-old people in a rural municipality. A questionnaire including tests and a risk assessment score for developing illness was used. Descriptive and inferential statistics including regression models were analyzed.

Results

The total sample included 166 persons. Poor perceived health was associated with increased risk of developing illness and risk of fall, malnutrition, and polypharmacy. Lifestyle and health factors such as lack of social support, sleep problems, and feeling depressed were associated with risk of developing illness. Risk of falls, malnutrition, polypharmacy, and cognitive impairment were also associated with increased risk of developing illness. None of the independent factors related to lifestyle, health, or medical diagnosis were associated with risk of cognitive impairment.

Conclusion

Poor perceived health was associated with health-related risks in older persons living at home. Preventive health programs need to focus on social and lifestyle factors and self-reported health assessment to identify older people at risk of developing illnesses.

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology

Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .

Efficacy of nurse-led and general practitioner-led comprehensive geriatric assessment in primary care: protocol of a pragmatic three-arm cluster randomised controlled trial (CEpiA study)

INTRODUCTION

Older patients raise therapeutic challenges, because they constitute a heterogeneous population with multimorbidity. To appraise this complexity, geriatricians have developed a multidimensional comprehensive geriatric assessment (CGA), which may be difficult to apply in primary care settings. Our primary objective was to compare the effect on morbimortality of usual care compared with two complex interventions combining educational seminars about CGA: a dedicated geriatric hotline for general practitioners (GPs) and CGA by trained nurses or GPs.

METHODS AND ANALYSIS

The Clinical Epidemiology and Ageing study is an open-label, pragmatic, multicentre, three-arm, cluster randomised controlled trial comparing two intervention groups and one control group. Patients must be 70 years or older with a long-term illness or with unscheduled hospitalisation in the past 3 months (750 patients planned). This study involves volunteering GPs practising in French primary care centres, with randomisation at the practice level. The multifaceted interventions for interventional arms comprise an educational interactive multiprofessional seminar for GPs and nurses, a geriatric hotline dedicated to GPs in case of difficulties and the performance of a CGA updated to primary care. The CGA is systematically performed by a nurse in arm 1 but is GP-led on a case-by-case basis in arm 2. The primary endpoint is a composite criterion comprising overall death, unscheduled hospitalisations, emergency admissions and institutionalisation within 12 months after inclusion. Intention-to-treat analysis will be performed using mixed-effects logistic regression models, with adjustment for potential confounders.

ETHICS AND DISSEMINATION

The protocol was approved by an appropriate ethics committee (CPP Ile-de-France IV, Paris, France, approval April 2015;15 664). This study is conducted according to principles of good clinical practice in the context of current care and will provide useful knowledge on the clinical benefits achievable by CGA in primary care.

TRIAL REGISTRATION NUMBER

NCT02664454; Pre-results.

Geriatric assessment with management intervention in older adults with cancer: a randomized pilot study

BACKGROUND

Older adults receiving cancer therapy have heightened risk for treatment-related toxicity. Geriatric assessment (GA) can identify impairments, which may contribute to vulnerability and adverse outcomes. GA management interventions can address these impairments and have the potential to improve outcomes when implemented.

METHODS

We conducted a randomized pilot study comparing GA with management interventions versus usual care in patients with stage III/IV solid tumor malignancies (N = 71). In all patients, a trained coordinator conducted and scored a baseline GA with pre-determined cutoffs for impairment. For patients randomized to the intervention arm, an algorithm was used to identify GA management recommendations based upon identified impairments. Recommendations were relayed to the primary oncologist for implementation. GA was repeated at 3 months. The primary outcome was grade 3-5 chemotherapy toxicity. Secondary outcomes included feasibility, hospitalizations, dose reductions, dose delays, and early treatment discontinuation.

RESULTS

The mean participant age was 76 (70-89). The total number of GA management recommendations relayed was 409, of which 35.4% were implemented by the primary oncologist. Incidence of grade 3-5 chemotherapy toxicity did not differ between the two groups. Prevalence of hospitalization, dose reductions, dose delays, and early treatment discontinuation also did not differ between the two groups.

CONCLUSIONS

An algorithm can be used to guide GA management recommendations in older adults with cancer. However, reliance upon the primary oncologist for execution resulted in a low prevalence of implementation. Future work should aim to understand barriers to implementation and explore alternate models of implementing geriatric-focused care for older adults with cancer.

Incorporating Geriatric Medicine Providers into the Care of the Older Adult with Cancer

A significant proportion of cancer patients and survivors are age 65 and over. Older adults with cancer often have more complex medical and social needs than their younger counterparts. Geriatric medicine providers (GMPs) such as geriatricians, geriatric-trained advanced practice providers, and geriatric certified registered nurses have expertise in caring for older adults, managing complex medical situations, and optimizing function and independence for this population. GMPs are not routinely incorporated into cancer care for older adults; however, their particular skill set may add benefit at many points along the cancer care continuum. In this article, we review the role of geriatric assessment in the care of older cancer patients, highlight specific case scenarios in which GMPs may offer additional understanding and insight in the care of older adults with cancer, and discuss specific mechanisms for incorporating GMPs into oncology care.

The Older Adult With Locoregionally Advanced Head and Neck Squamous Cell Carcinoma: Knowledge Gaps and Future Direction in Assessment and Treatment

Older adults with head and neck squamous cell carcinoma (HNSCC) pose unique treatment and supportive care challenges to oncologists and other cancer care providers. The majority of patients with HNSCC present with locoregionally advanced disease, for which combined-modality treatment integrating chemotherapy and radiation therapy is often necessary to maximize tumor control. However, applying these approaches to an older population with concomitant comorbidities and a higher risk of functional impairments remains challenging and is exacerbated by the paucity of studies involving older adults. The purpose of this article is to identify knowledge gaps in the evaluation and management of older adults with HNSCC-particularly those undergoing concurrent chemoradiation therapy-and their caregivers through a review of the literature conducted by clinicians, researchers, and patient advocates. The findings highlight the importance of a geriatric assessment and the therapeutic paradigms and challenges relevant to this population. Furthermore, we identify the need for additional research and interventions related to key supportive care issues that arise during and after treatment in older adults with locoregionally advanced HNSCC. On the basis of our findings, we prioritize these issues to guide future patient-oriented research endeavors to address these knowledge gaps and thus better serve this growing patient population.

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.

A Frailty Instrument for primary care for those aged 75 years or more: findings from the Survey of Health, Ageing and Retirement in Europe, a longitudinal population-based cohort study (SHARE-FI75+)

OBJECTIVE

To create and validate a frailty assessment tool for community-dwelling adults aged ≥75 years.

DESIGN

Longitudinal, population-based study.

SETTING

The Survey of Health, Ageing and Retirement in Europe (SHARE).

PARTICIPANTS

4001 women and 3057 men aged ≥75 years from the second wave of SHARE. 3325 women and 2587 men had complete information for the frailty indicators: fatigue, low appetite, weakness, observed gait (walking without help, walking with help, chairbound/bedbound, unobserved) and low physical activity.

MAIN OUTCOME MEASURES

The internal validity of the frailty indicators was tested with latent class analysis, by modelling an underlying variable with three ordered categories. The predictive validity of the frailty classification was tested against 2-year mortality and 4-year disability. The mortality prediction of SHARE-FI75+ was compared with that of previously operationalised frailty scales in SHARE (SHARE-FI, 70-item index, phenotype, FRAIL).

RESULTS

In both genders, all frailty indicators significantly aggregated into a three-category ordinal latent variable. After adjusting for baseline age, comorbidity and basic activities of daily living (BADL) disability, the frail had an OR for 2-year mortality of 2.2 (95% CI 1.2 to 3.8) in women and 4.2 (2.6 to 6.8) in men. The mortality prediction of SHARE-FI75+ was similar to that of the other SHARE frailty scales. By wave 4, 49% of frail women (78 of 159) had at least one more limitation with BADL (compared with 18% of non-frail, 125 of 684; p<0.001); in men, these proportions were 39% (26 of 66) and 18% (110 of 621), respectively (p<0.001). A calculator is supplied for point-of-care use, which automatically replicates the frailty classification for any given measurements.

CONCLUSIONS

SHARE-FI75+ could help frailty case finding in primary care and provide a focus for personalised community interventions. Further validation in trials and clinical programmes is needed.

Prolonged impact of home versus clinic-based management of chronic heart failure: extended follow-up of a pragmatic, multicentre randomized trial cohort

OBJECTIVES

We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF).

METHODS

We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay.

RESULTS

280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n=143) or clinic-based (n=137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p=0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p=0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p=0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p<0.01 for rate and duration of hospital stay).

CONCLUSIONS

Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry number 12607000069459 (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803).

Influence of the geriatric oncology consultation on the final therapeutic decision in elderly subjects with cancer: analysis of 191 patients

OBJECTIVES

Evaluate the impact of the Geriatric Oncology Consultation on the final therapeutic management of cancer in elderly patients aged 70 and older.

DESIGN

Retrospective study.

SETTING

The Pilot Coordination Unit in Geriatric Oncology of Côte d'Or, Burgundy, France.

PARTICIPANTS

From January 2010 to December 2010, 191 patients with cancer aged 70 and older.

MEASUREMENTS

The concordance between the treatments proposed following the Tumor Board, those proposed following the Geriatric Evaluation (GE) and those actually given to the patients was evaluated using the Kappa agreement test.

RESULTS

One hundred and ninety-one patients were included. Mean age was 81.5. The most frequent cancer locations were breast (31.9%), colon-rectum (14.1%) and lung (10.5%). Concordance between the cancer treatments proposed by the Tumor Board and those suggested after the GE was excellent except for chemotherapy and targeted therapy, which were recommended less frequently by the geriatrician (Kappa = 0.67), and support care, which was more often proposed after the GE (Kappa = 0.61). However, concordance between treatments proposed by the geriatrician and treatment actually given was not so good for chemotherapy (Kappa = 0.58), and surgery (Kappa = 0.61), since both were often replaced by a less aggressive treatment.

CONCLUSION

Concordance between the therapies proposed during the Tumor Board or after the Geriatric Oncology Consultation and the treatment actually given was satisfactory. However, the role of the oncologist remains determinant in the final choice, especially for chemotherapy.

Geriatric assessment in undergraduate geriatric education - a structured interpretation guide improves the quantity and accuracy of the results: a cohort comparison

BACKGROUND

With regard to the growing proportion of elderly multimorbid patients, a sound undergraduate geriatric education becomes more important. Therefore we included the execution and interpretation of a comprehensive geriatric assessment (CGA) into a mandatory two-week clerkship at a general practitioner's office. The present study examined the effect of a guide structuring the students' considerations when interpreting a CGA on the quantity and accuracy of the documented findings and conclusions.

METHODS

We compared random samples out of two cohorts of fourth-year medical students (interpreting the CGA with and without using the structured interpretation guide) completing their clerkship between April 2006 and March 2008 with regard to the content of the CGA interpretation and the grades the students achieved for their clerkship documentation, which were substantially determined by the quantity and accuracy of the documentation and interpretation of the CGA.

RESULTS

The structured interpretation guide led to significantly more mentions of aspects that have to be considered in geriatric patient care and to a higher documentation rate of respective positive results. Furthermore, students who analysed the CGA by using the interpretation guide achieved significantly better grades.

CONCLUSIONS

An additional tool structuring medical students' considerations when interpreting a CGA increases the quantity and the accuracy of the documented findings and conclusions. This may enhance the students' learning gain.

Is comprehensive geriatric assessment recognized and applied in Southwest China? A survey from Sichuan Association of Geriatrics

OBJECTIVES

To investigate how health care providers in Southwest China conducted comprehensive geriatric assessment (CGA) in their clinical practices.

METHODS

One hundred twenty-two medical care providers who attended the 2012 Sichuan Association of Geriatrics (SAG) Continuing Medical Education participated in this cross-sectional survey. The instrument was divided into 2 parts, including respondents' demographics and information on their application of CGA.

RESULTS

Of the total 122 participants, 120 (73 physicians and 47 nurses) responded. Three-quarters of the respondents reported that they evaluated at least 1 item of CGA separately. Among them, 30/32 respondents from university-affiliated hospitals reported having performed CGA compared with 18/22 from community hospitals or retirement/nursing facilities and 42/66 from provincial or county hospitals (P < .001), respectively. Respondents who attended the SAG Continuing Medical Education were more likely to complete the CGA (86.5% vs 66.2%, P = .011) and the integrated CGA (48.9% vs 20.0%, P < .001). Physicians were more likely to assess the instrument daily living capacity and communication capacity. Nurses were more focused on the basic activities of daily living, economic support, and caregiver.

CONCLUSIONS

These findings showed that the application of CAG in the mainland of China is not adequate. The training program related to CGA held by the SAG was helpful in improving the proportion of effective use of CGA. More efforts should be made in the future to build the CGA work team.

Does the Multidimensional Prognostic Index (MPI), based on a Comprehensive Geriatric Assessment (CGA), predict mortality in cancer patients? Results of a prospective observational trial

OBJECTIVE

Despite the lack of definitive data on the impact of Comprehensive Geriatric Assessment (CGA) in the geriatric oncology setting, the broad use of any form of CGA is strongly recommended before any treatment decision in elderly cancer patients (ECP); currently there is no consensus about the best format for this geriatric assessment. The aim of this study was to firstly test the Multidimensional Prognostic Index (MPI) in ECP with locally advanced or metastatic disease.

MATERIALS AND METHODS

Patients aged ≥70years with inoperable or metastatic solid cancer consecutively admitted to our Program of Geriatric Oncology were assessed by a multidisciplinary team and received a basal CGA to calculate the MPI score.

RESULTS

A hundred and sixty patients entered the study. In the Cox's regression model, MPI, CIRS-SI, BSA, GDS, MMSE, chemotherapy and a diagnosis of primary lung cancer were associated with mortality at 6 and 12months. The ROC curves confirmed the prognostic value of MPI, with the best discriminatory power for mortality at both 6 and 12months.

CONCLUSION

The present study is the first to indicate that the MPI retains its prognostic value even in elderly cancer patients with advanced stage of disease. The CIRS-SI and the GDS may potentiate the prognostic value of MPI.