Comprehensive geriatric assessment in older people: an umbrella review of health outcomes

Healthcare workers' experience of screening older adults in emergency care settings: a qualitative descriptive study using the Theoretical Domains Framework

BACKGROUND

In emergency care settings, screening for disease or risk factors for poor health outcomes among older adults can identify those in need of specialist and early intervention. The aim of this study was to identify barriers and facilitators to implementing older person-centred screening in emergency care settings in the Mid-West of Ireland.

METHODS

This study employed a qualitative descriptive design underpinned by the theoretical domains framework (TDF). This design informs implementation strategy by establishing a theoretical foundation for focused objectives. One on one semi-structured interviews were conducted with a purposive sample of healthcare workers (HCWs) to explore their screening experiences with older adults in emergency care settings. Information power guided sample size calculation. In data analysis, verbatim interview transcripts were deductively mapped to TDF constructs forming meta-themes that revealed specific barriers and facilitators to person-centred screening for older individuals. These findings will directly inform implementation strategies.

RESULTS

Three themes were identified; Preconditions to Implementing Older Person-Centred Screening; Knowledge and Skills Required to Implement Older Person-centred Screening and Motivation to Deliver Older Person-Centred Screening. Overall, screening in emergency care settings is a complicated process which is ideally undertaken by knowledgeable and skilled practitioners with a keen awareness of team dynamics and environmental challenges in acute care settings. These practitioners serve as champions and sources of specialist knowledge and practice. Less experienced clinicians seek supervision and support to undertake screening competently and confidently. Education on frailty and aged related syndromes facilitates screening uptake. Recognition of the value of screening is a clear motivator and leadership is vital to sustain screening practices.

CONCLUSIONS

Screening serves as an entry point for specialist intervention, necessitating a specialist multidisciplinary team (MDT) approach for effective implementation in emergency care settings. Strengthening screening practices for older adults who attend emergency care settings involves employing audit, supervision and tailored supports. Skilled and experienced practitioners play a key role in mentoring and supporting the broader MDT in screening engagement. Long-term and sustainable implementation relies on utilising existing managerial, practice development and educational resources to underpin screening practices. Communication between Emergency Department (ED) staff, the specialist team and wider geriatric team is vital to ensure a cohesive approach to delivering older person-centred care in the ED.

The Integrated Care Team: A primary care based-approach to support older adults with complex health needs

Many older adults have complex needs and experience high rates of acute care use and institutionalization. Comprehensive Geriatric Assessment (CGA) is a specialized multidimensional interprofessional intervention to prevent such outcomes, but access to CGA in the community is limited. The Integrated Care Team (ICT) is a proactive case-finding intervention to support older adults with complex needs in primary care. The ICT provides nurse practitioner-led shared-care supported by a pharmacist, family physician, and geriatrician. Patients undergo a CGA, and a person-centred plan of care is implemented. We conducted a mixed-methods evaluation of the ICT. Patients were 81 ± 9.2 years old, 71% were women. Patients had a high burden of dementia and multimorbidity and received 12.8 ± 5.8 prescriptions daily. The ICT improved prescribing and reduced emergency department visits by 49.5% (P = 0.0001). Patients, care partners, and referring physicians reported high satisfaction with care. The ICT is currently being expanded to support additional primary care providers.

Application of the world guidelines for falls prevention and management's risk stratification algorithm to patients on a frailty intervention pathway and the potential utility of sensory impairment information

BACKGROUND

The 2022 world guidelines for falls prevention and management suggest measuring sensory function including dizziness, vision, and hearing. These variables are not included in the falls risk stratification algorithm. This study sought to investigate the utility of the guidelines and potential avenues for improvement. This study applied the falls risk stratification recommendations and reviewed the individual sensory impairment risk factor variables predictive of falls and falls risk grouping in those assessed by a frailty intervention team (FIT) based in an emergency department (ED).

METHODS

Patients over 65 years old who attended the ED and had a comprehensive geriatric assessment carried out by FIT over a period of four months were included in this retrospective cross-sectional study. Patient characteristics, medication, physical and sensory function status data was retrieved and analysed with respect to falls and falls risk grouping.

RESULTS

Data was gathered retrospectively from 392 patients. Excluding those with missing data, almost all attendees were in the high-risk of falls category (n = 170, 43.4%), or the low-risk category (n = 149, 38.0%). Few people were in the intermediate-risk category (n = 19, 4.8%). Hearing loss and dizziness were significantly associated with falls incidence, whereas vision and balance were not. Hearing loss, balance and dizziness were significantly associated with risk grouping, whereas vision was not.

CONCLUSIONS

Most older adults included in the analysis fell into the low- or high-risk categories, with a minority in the intermediate-risk category. This suggests that the inclusion criteria for the intermediate category could be altered for greater sensitivity. While impaired balance and vision were the most common impairments, hearing status, balance and dizziness were associated with risk group. These results, through a practical application of the world guidelines for falls to an acute clinical sample, raise the possibility of refining the falls risk stratification criteria, and highlight the capacity for additional sensory intervention to mitigate falls risk.

Clinician's Guide to Geriatric Assessment

The population of older adults is rapidly growing worldwide. Because of the substantial shortage of geriatricians, all clinicians need basic fluency in older adult care. In our approach to evaluating an older adult in the clinic or at the bedside, we apply the "Geriatric 5Ms" framework to manage the patient's care. The Geriatric 5Ms consist of the following key steps. First, consider the mind: the cognitive and psychological domains of a patient's health. Second, evaluate mobility and fall risk. Third, review and reconcile medications, particularly high-risk medications. Fourth, ask what matters most to the patient. Fifth, assess multicomplexity: how the intersection of multiple chronic conditions and social determinants of health influence the patient's health care management. Herein, we provide clinicians with practical suggestions and resources for quickly and effectively applying the Geriatric 5Ms to the care of older adults.

Comprehensive Geriatric Assessment, Treatment Decisions, and Outcomes in Older Patients Eligible for Pancreatic Surgery

INTRODUCTION

Periampullary cancer has a poor prognosis. Surgical resection is a potentially curative but high-risk treatment. Comprehensive geriatric assessment (CGA) can inform treatment decisions, but has not yet been evaluated in older patients eligible for pancreatic surgery.

METHODS

This prospective observational study included patients ≥ 70 years of age eligible for pancreatic surgery. Frailty was defined as impairment in at least two of five domains: somatic, psychological, functional, nutritional, and social. Outcomes included postoperative complications, functional decline, and mortality.

RESULTS

Of the 88 patients included, 87 had a complete CGA. Sixty-five patients (75%) were frail and 22 (25%) were non-frail. Frail patients were more likely to receive nonsurgical treatment (43.1% vs. 9.1% p = 0.004). Fifty-seven patients underwent surgery, of which 52 (59%) underwent pancreaticoduodenectomy. The incidence of postoperative delirium was three times higher in frail patients (29.7% vs. 0%, p = 0.005). The risk of mortality was three times higher in frail patients (HR: 3.36, 95% CI: 1.43-7.89, p = 0.006).

CONCLUSION

Frailty is common in older patients eligible for pancreatic surgery and is associated with treatment decision, a higher incidence of delirium and a three times higher risk of all-cause mortality. CGA can contribute to shared decision-making and optimize perioperative care in older patients.

A multicomponent personalized prevention program in the primary care setting: a randomized clinical trial in older people with noncommunicable chronic diseases (Primacare_P3 study)

BACKGROUND

Multicomponent interventions based on a comprehensive geriatric assessment (CGA) could promote active aging and improve health status in older people with Noncommunicable Chronic Diseases (NCDs), but conflicting evidences are available.

AIM

To evaluate the efficacy of a CGA-based multicomponent personalized preventive program (PPP) in reducing unplanned hospitalization rates during 12-month follow-up in community-dwelling older people with NCDs.

MATERIALS AND METHODS

In this randomized clinical trial (RCT), 1216 older adults recruited by 33 general practitioners (GPs) will be randomly allocated to intervention group (IG) or usual care control group (CG). The IG will receive a multicomponent PPP developed on the findings of the CGA-based Multidimensional Prognostic Index short-form (Brief-MPI), including structured interventions to improve functional, physical, cognitive, and nutritional status, to monitor NCDs and vaccinations, and to prevent social isolation. Participants in the CG will receive usual care. Brief-MPI, resilience, and health-related quality of life will be assessed after 6 and 12 months. Moreover, saliva samples will be collected at baseline in IG to measure biomarkers of oxidative stress, inflammatory cytokines, and oral microbiome.

EXPECTED RESULTS

The CGA-based PPP might reduce unplanned hospitalization rates and potentially institutionalization rates, emergency department (ED) and unplanned GP visits, and mortality. Further outcomes explored in the IG will be the adherence to PPP, resilience, health-related quality of life, and multidimensional frailty as assessed by the Brief-MPI.

CONCLUSIONS

Results will suggest whether the CGA-based multicomponent PPP is able to improve specific outcomes in a primary care setting.

TRIAL REGISTRATION

ClinicalTrials.gov; identifier: NCT06224556 ; Registered January 25, 2024.

Impact of a geriatric intervention based on the Comprehensive Geriatrics Assessment on avoidable admissions in older patients at risk evaluated in the Emergency Department

OBJECTIVE

To know the impact of a geriatric intervention based on the Comprehensive Geriatric Assessment (CGA) on avoidable admissions in older patients at risk evaluated in the Emergency Department.

METHOD

Prospective observational unicenter study. We included patients, from October 1, 2018 to January 31, 2020, over 75 years who were attended at the Emergency Department with a Triage Risk Screening Tool (TRST) score≥2. All patients were evaluated by a geriatrician through the CGA. The reasons for going to the Emergency room were collected and also the main intervention carried out by Geriatrics, whether admission or discharge was indicated and whether the admission was avoidable. We did a cost analysis calculating this by (bed/day×average stay×number of admissions avoided).

RESULTS

We included 260 patients, 66% were women and the mean age was 86 years. 73.5% patients had polypharmacy, the mean Charlson index was 2.5 (5.6). 63.3% were independent for walking and 20.8% independent for basic activities of daily living. 59% had cognitive impairment. 91.5% lived at home. The most frequent reason for visiting the Emergency room was decline of general state in 22% and the most frequent intervention carried out by Geriatrics was assistance in the decision making process in 35.4% followed by referral to a preferential outpatient geriatric care circuit in 32.7%. Other interventions carried out by Geriatrics was assistance in clarifying diagnosis (4.2%), assistance in pharmacological adjustment (8.5%), referral to a standard geriatric care pathway (13.1%), telephone follow-up (4.2%) and/or coordination with Social Services for care planning (11.2%). Including all patients, 29.2% required hospital admission and 70.8% were discharged. 40% admissions were avoided, which meant more than 540 thousand euros saved.

CONCLUSIONS

A standardized CGA coordinated by Geriatrics in older patients at risk of suffering adverse events in the Emergency room reduces admissions and costs, so it should therefore be established as a recommendation of good clinical practice.

Preoperative comprehensive geriatric assessment and multidisciplinary team input in older people undergoing elective orthopaedic surgery: A feasibility trial

OBJECTIVE

To determine the feasibility of preoperative comprehensive geriatric assessment (CGA) and multidisciplinary team (MDT) input for older people undergoing elective orthopaedic surgery in a tertiary New Zealand setting.

METHODS

This single-centre retrospective study included elective orthopaedic patients older than 65 years (and Māori/Pasifika aged greater than 55 years) with hyperpolypharmacy, frailty, neurocognitive disorders and poor functional status. Patients attended a preoperative clinic where they had a geriatrician-led CGA along with MDT input. The feasibility of this preoperative model was assessed using outcomes of acceptability, accessibility and adherence. A qualitative description of patient demographics along with clinic assessment and interventions further describes this pilot experience.

RESULTS

Sixty patients met inclusion criteria. This group were vulnerable older people (median age 77 years), with a high incidence of hyperpolypharmacy (85%), frailty (80%) and neurocognitive disorders (30%). Acceptability was high (97%), along with CGA accessibility (100%); however, MDT accessibility varied (53-90%). Adherence to MDT intervention was low; with only 26% of patients completing physiotherapy sessions and only 29% adhering to dietary advice. Accurate recall was a significant factor contributing to poor adherence. Comprehensive geriatric assessment was demonstrated to be a broad and flexible intervention.

CONCLUSIONS

CGA with MDT input is an acceptable and accessible intervention to be utilised as part of improved preoperative care for the older person undergoing elective orthopaedic surgery. Further consideration around methods to increase adherence in this patient group should be explored. Future research should focus on refining the intervention, and quantifying impact on patient outcomes.

Unleashing frailty from laboratory into real world: A critical step toward frailty-guided clinical care of older adults

Understanding patients' degree of frailty is crucial for tailoring clinical care for older adults based on their physiologic reserve and health needs ("frailty-guided clinical care"). Two prerequisites for frailty-guided clinical care are: (1) access to frailty information at the point of care and (2) evidence to inform decisions based on frailty information. Recent advancements include web-based frailty assessment tools and their electronic health records integration for time-efficient, standardized assessments in clinical practice. Additionally, database frailty scores from administrative claims and electronic health records data enable scalable assessments and evaluation of the effectiveness and safety of medical interventions across different frailty levels using real-world data. Given limited evidence from clinical trials, real-world database studies can complement trial results and help treatment decisions for individuals with frailty. This article, based on the Thomas and Catherine Yoshikawa Award lecture I gave at the American Geriatrics Society Annual Meeting in Long Beach, California, on May 5, 2023, outlines our group's contributions: (1) developing and integrating a frailty index calculator (Senior Health Calculator) into the electronic health records at an academic medical center; (2) developing a claims-based frailty index for Medicare claims; (3) applying this index to evaluate the effect of medical interventions for patients with and without frailty; and (4) efforts to disseminate frailty assessment tools through the launch of the eFrailty website and the forthcoming addition of the claims-based frailty index to the Centers for Medicare and Medicaid Services Chronic Conditions Data Warehouse. This article concludes with future directions for frailty-guided clinical care.

A transitional care program in a technologically monitored in-hospital facility reduces the length of hospital stay and improves multidimensional frailty in older patients: a Randomized Clinical Trial

BACKGROUND

Longer length of hospital stay (LOS) negatively affects the organizational efficiency of public health systems and both clinical and functional aspects of older patients. Data on the effects of transitional care programs based on multicomponent interventions to reduce LOS of older patients are scarce and controversial.

AIMS

The PRO-HOME study aimed to assess the efficacy in reducing LOS of a transitional care program involving a multicomponent intervention inside a technologically monitored in-hospital discharge facility.

METHODS

This is a Randomized Clinical Trial on 60 patients (≥65 years), deemed stable and dischargeable from the Acute Geriatrics Unit, equally assigned to the Control Group (CG) or Intervention Group (IG). The latter underwent a multicomponent intervention including lifestyle educational program, cognitive and physical training. At baseline, multidimensional frailty according to the Multidimensional Prognostic Index (MPI), and Health-Related Quality of Life (HRQOL) were assessed in both groups, along with physical capacities for the IG. Enrolled subjects were evaluated after 6 months of follow-up to assess multidimensional frailty, HRQOL, and re-hospitalization, institutionalization, and death rates.

RESULTS

The IG showed a significant 2-day reduction in LOS (median days IG = 2 (2-3) vs. CG = 4 (3-6); p < 0.001) and an improvement in multidimensional frailty at 6 months compared to CG (median score IG = 0.25(0.25-0.36) vs. CG = 0.38(0.31-0.45); p = 0.040). No differences were found between the two groups in HRQOL, and re-hospitalization, institutionalization, and death rates.

DISCUSSION

Multidimensional frailty is a reversible condition that can be improved by reduced LOS.

CONCLUSIONS

The PRO-HOME transitional care program reduces LOS and multidimensional frailty in hospitalized older patients.

TRIAL REGISTRATION

ClinicalTrials.gov n. NCT06227923 (retrospectively registered on 29/01/2024).

Implementation status of comprehensive geriatric assessment among older inpatients: A nationwide retrospective study

AIM

The importance of comprehensive geriatric assessment (CGA) is increasing in aging societies worldwide. However, there are few comprehensive studies on CGA, resulting in a limited understanding of its implementation rate, temporal changes and factors associated with its implementation. We aimed to investigate the implementation status of CGA and its regional variance in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we investigated CGA trends, and identified the patient, hospital and regional factors associated with its implementation. We identified patients aged ≥65 years who were admitted for the first time between 2016 and 2020 with a diagnosis of stroke, heart failure, pneumonia, bone fracture or colorectal cancer. We examined the CGA implementation rate according to patient and hospital characteristics. We also investigated temporal changes and tendencies to carry out CGA in different prefectures.

RESULTS

A total of 1 974 817 patients were analyzed, of whom 570 696 (28.9%) underwent CGA. The implementation trend increased steadily from 25.3% in fiscal year 2016 to 33.4% in fiscal year 2019. The implementation rate also increased with patient age (30.3% in patients aged ≥95 years). Regional variations in its implementation status were observed, with a higher tendency to be implemented in areas near major metropolitan regions. A trend toward carrying out CGA for colorectal cancer, but not for other diseases, has been observed in eastern Japan.

CONCLUSION

Although CGA is increasingly carried out, considerable regional differences remain in its implementation status. Initiatives to reduce variations are necessary. Geriatr Gerontol Int 2024; ••: ••-••.

Trajectories of Frailty and Clinical Outcomes in Older Adults With Atrial Fibrillation: Insights From the Shizuoka Kokuho Database

BACKGROUND

The increasing prevalence of frailty has gained considerable attention due to its profound influence on clinical outcomes. However, our understanding of the progression of frailty and long-term clinical outcomes in older individuals with atrial fibrillation remains scarce.

METHODS

Using data from 2012 to 2018 from a comprehensive claims database incorporating primary and hospital care records in Shizuoka, Japan, we selected patients aged ≥65 years with atrial fibrillation who initiated oral anticoagulant therapy. The trajectory of frailty was plotted using Sankey plots, illustrating the annual changes in their frailty according to the electronic frailty index during a 3-year follow-up after oral anticoagulant initiation, along with the incidence of clinical adverse outcomes. For deceased patients, we assessed their frailty status in the year preceding their death.

RESULTS

Of 6247 eligible patients (45.1% women; mean age, 79.3±8.0 years) at oral anticoagulant initiation, 7.7% were categorized as fit (electronic frailty index, 0-0.12), 30.1% as mildly frail (>0.12-0.24), 35.4% as moderately frail (>0.24-0.36), and 25.9% as severely frail (>0.36). Over the 3-year follow-up, 10.4% of initially fit patients transitioned to moderately frail or severely frail. Conversely, 12.5% of severely frail patients improved to fit or mildly frail. Death, stroke, and major bleeding occurred in 23.4%, 4.1%, and 2.2% of patients, respectively. Among the mortality cases, 74.8% (N=1183) and 3.5% (N=55) had experienced moderately or severely frail and either a stroke or major bleeding in the year preceding their death, respectively.

CONCLUSIONS

In a contemporary era of atrial fibrillation management, a minor fraction of older patients on oral anticoagulants died following a stroke or major bleeding. However, their frailty demonstrated a dynamic trajectory, and a substantial proportion of death was observed after transitioning to a moderately or severely frail state.

[Frailty in Oncology: Updated Recommendations for Clinical Practice]

Frailty is a clinical condition associated with aging and resulting in increased risk of adverse outcomes upon exogenous or endogenous stressors. In oncology, cancer treatment itself can be a stressor event. In older cancer patients, frailty therefore not only enhances the probability of age-related health events such as institutionalization or falls, but also of treatment complications such as toxicity and interruption or discontinuation of therapy. As demonstrated by recent randomized-controlled trials conducted in older cancer patients receiving systemic treatment, the evaluation of frailty by geriatric assessment (GA) followed by an adjustment of the oncological therapy as well as targeted frailty interventions help to improve cancer treatment tolerability and feasibility. Based on these data, the American Society of Clinical Oncology (ASCO) updated the clinical practice guidelines for the assessment and management of vulnerabilities in older adults receiving systemic cancer therapy. The guideline recommends the use of a new GA-tool named 'practical geriatric assessment' (PGA) to foster the implementation of GA-based frailty assessment and management in routine cancer care. This article describes the background and key aspects of these recent advances.

Clinical prognostic factors for older people: A systematic review and meta-analysis

OBJECTIVE

To explore the accuracy and precision of prognostic tools used in older people in predicting mortality, hospitalization, and nursing home admission across different settings and timings.

DESIGN

Systematic review and meta-analysis of prospective and retrospective studies.

DATA SOURCES

A systematic search from database inception until 01st February 2023 was run in Medline, Embase, Cinhal, Cochrane Library.

ELIGIBILITY CRITERIA

Studies were eligible if they reported accuracy (area under the curve [AUC]) and/or precision (C-index) for the prognostic index in relation to any of the following outcomes: mortality, hospitalization, and nursing home admission.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data. Data were pooled using a random effects model. The risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. If more than three studies for the same setting and time were available, a meta-analysis was performed and evaluated using the GRADE tool; other data were reported descriptively.

RESULTS

Among 16,082 studies initially considered, 159 studies with a total of 2398856 older people (mean age: 78 years) were included. The majority of the studies was carried out in hospital or medical wards. In the community setting, only two tools (Health Assessment Tool and the Multidimensional Prognostic Index, MPI) had good precision for long-term mortality. In emergency department setting, Barthel Index had an excellent accuracy in predicting short-term mortality. In medical wards, the MPI had a moderate certainty of the evidence in predicting short-term mortality (13 studies; 11,787 patients; AUC=0.79 and 4 studies; 3915 patients; C-index=0.82). Similar findings were available for MPI when considering longer follow-up periods. When considering nursing home and surgical wards, the literature was limited. The risk of bias was generally acceptable; observed bias was mainly owing to attrition and confounding.

CONCLUSIONS

Several tools are used to predict poor prognosis in geriatric patients, but only those derived from a multidimensional evaluation have the characteristics of precision and accuracy.

Prognosticating the outcome of intensive care in older patients-a narrative review

Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.

Predictors of Hospital Readmission, Institutionalization, and Mortality in Geriatric Rehabilitation Following Hospitalization According to Admission Reason

BACKGROUND AND PURPOSE

Older adults following an inpatient geriatric rehabilitation (GR) program commonly experience adverse health outcomes such as hospital readmission, institutionalization, and mortality. Although several studies have explored factors related to these outcomes, the influence of admission reason on the predictive factors of adverse health outcomes in the rehabilitation process remains unclear. Therefore, this study aimed to identify predictive factors for adverse health outcomes in inpatients attending GR according to their admission reason.

METHODS

This retrospective study included patients with orthogeriatric (OG) conditions and patients with hospital-associated deconditioning (HAD) admitted to GR after an acute hospitalization between 2016 and 2020. Patients were evaluated by a comprehensive geriatric assessment at admission, including sociodemographic data, social resources, clinical data, cognitive, functional and nutritional status, and physical performance measurements. Adverse health outcomes were collected (hospital readmission, institutionalization, and mortality). Univariate analyses and multivariate backward binary logistic regressions were used to determine predictive factors.

RESULTS AND DISCUSSION

In this study, 290 patients were admitted for OG conditions, and 122 patients were admitted due to HAD. In patients with OG conditions, lower Mini-Mental State Examination (MMSE) predicted institutionalization and mortality. Lower Mini Nutritional Assessment-Short Form predicted institutionalization, whereas lower Barthel Index and lower Tinetti-Performance-Oriented Mobility Assessment scores were associated with higher mortality. In patients with HAD, higher age-adjusted comorbidity index predicted hospital readmission and mortality, and lower Short Physical Performance Battery scores predicted institutionalization and mortality. Finally, lower MMSE scores, worse values in Older Americans Resources and Services Scale and male gender were associated with a higher risk of institutionalization.

CONCLUSIONS

Predictive factors for hospital readmission, institutionalization, and mortality in patients with OG conditions and HAD during GR were different. Some of those predictors, such as nutritional status and physical performance, are modifiable. Understanding predictive factors for adverse outcomes, and how these factors differ by admission diagnosis, improves our ability to identify patients most at risk. Early identification of these patients could assist with prevention efforts and lead to a reduction of negative outcomes.

Intra- and inter- rater reliability of the face‑to‑face assessment and tele‑assessment of performance-based tests in older adults

PURPOSE

This study aimed to assess Timed-Up and Go (TUG), Five Times Sit-to-Stand Test (5xSST), and 4-Meter Walk Test (4MWT) intra- and inter-rater reliability between face-to-face and tele-assessment tools in older adults.

METHODS

A total of 54 older adults (aged ≥ 65 years) were included in the study. Measurements (TUG, 5xSST, and 4MWT) were carried out face-to-face and tele-assessment. The intraclass correlation coefficients (ICCs), and Bland-Altman plots was used determine intra- and inter-rater reliability.

RESULTS

The mean age of the participants, 53% of whom were female, was 69.59 years. Inter-rater reliability between face-to-face and tele-assessment was as following: excellent for TUG (ICC = 0.931) and 5STS (ICC = 0.908), and good for 4MWT (ICC = 0.803). In addition, intra-rater reliability between the two tele-assessments was excellent for all tests. The ICC values for TUG, 5STS, and 4MWT were 0.973, 0.948, and 0.934, respectively.

CONCLUSION

To conclude, the TUG, 5xSST, and 4MWT seem to be reliable tools of tele-assessment in older adults. These practical assessment tools can be used in home settings for older adults as tele-health interventions.

Interventions to prevent and treat delirium: An umbrella review of randomized controlled trials

Delirium is a common condition across different settings and populations. The interventions for preventing and managing this condition are still poorly known. The aim of this umbrella review is to synthesize and grade all preventative and therapeutic interventions for delirium. We searched five databases from database inception up to March 15th, 2023 and we included meta-analyses of randomized controlled trials (RCTs) to decrease the risk of/the severity of delirium. From 1959 records after deduplication, we included 59 systematic reviews with meta-analyses, providing 110 meta-analytic estimates across populations, interventions, outcomes, settings, and age groups (485 unique RCTs, 172,045 participants). In surgery setting, for preventing delirium, high GRADE evidence supported dexmedetomidine (RR=0.53; 95%CI: 0.46-0.67, k=13, N=3988) and comprehensive geriatric assessment (OR=0.46; 95%CI=0.32-0.67, k=3, N=496) in older adults, dexmedetomidine in adults (RR=0.33, 95%CI=0.24-0.45, k=7, N=1974), A2-adrenergic agonists after induction of anesthesia (OR= 0.28, 95%CI= 0.19-0.40, k=10, N=669) in children. High certainty evidence did not support melatonergic agents in older adults for delirium prevention. Moderate certainty supported the effect of dexmedetomidine in adults and children (k=4), various non-pharmacological interventions in adults and older people (k=4), second-generation antipsychotics in adults and mixed age groups (k=3), EEG-guided anesthesia in adults (k=2), mixed pharmacological interventions (k=1), five other specific pharmacological interventions in children (k=1 each). In conclusion, our work indicates that effective treatments to prevent delirium differ across populations, settings, and age groups. Results inform future guidelines to prevent or treat delirium, accounting for safety and costs of interventions. More research is needed in non-surgical settings.

Hypomagnesemia may be related to frailty, gait and balance problems, and basic activities of daily living in older adults

OBJECTIVES

The study aims to investigate the relationship between hypomagnesemia, preclinical hypomagnesemia, and normomagnesemia as along with geriatric syndrome and comprehensive geriatric parameters(CGA).

METHODS

217 patients who applied to the geriatric clinic between November 2022 and December 2023 were included in the study. All patients underwent CGA. Patients were categorized into three groups: Magnesium (Mg) level ≤ 1.5 mg/dL, Mg level 1.5-1.8 mg/dL, and Mg level > 1.8 mg/dL. These three groups were compared in terms of demographic characteristics, comorbidities, CGA parameters, and geriatric syndromes. Regression analyses was conducted for significant parameters, adjusting for confounders.

RESULTS

74.9% of all participants were female, with an average age of 76.5 ± 6.6 years. The frequency of hypomagnesemia was 14.2%. Demographic characteristics and medication use, including proton pump inhibitors and diuretics, were similar in these three groups. While the FRIED frailty scale and the duration of the timed-up-and-go test were higher in the hypomagnesemia group, the Basic Activities Daily of Living (ADLs) and the Tinetti-POMA(performance-oriented mobility assessment) scores were lower in the hypomagnesemia group. When normomagnesemia was accepted as the reference category, FRIED frailty scale, Basic ADLs, and POMA score were more significant in the hypomagnesemia group (p = 0.025, p = 0.013 and p = 0.011,respectively), but there was no significance in the preclinical hypomagnesemia group regardless of the covariates.

CONCLUSION

Hypomagnesemia, particularly serum Mg levels below 1.5 mg/dL, may be associated with frailty, basic ADLs, gait, and balance tests. In geriatric practice, patients with hypomagnesemia should be evaluated in terms of the risk of the mentioned disorders.

The Italian guideline on comprehensive geriatric assessment (CGA) for the older persons: a collaborative work of 25 Italian Scientific Societies and the National Institute of Health

BACKGROUND

The guideline was promoted by the Italian General Practitioners-Primary Care and Geriatrics Hospital-Community Societies and was carried out involving the National Institute of Health and an Expert Panel including representatives from 25 Scientific and Health-Professional Organizations. The aim of the Guideline was to develop evidence-based recommendations on the efficacy of CGA in older people across different clinical settings and the accuracy and utility of CGA-based tools to assess prognosis.

METHODS

According to the methodological handbook of the Italian National System of Guidelines and NICE criteria (National Institute for Health and Care Excellence in England), the Guideline was produced based on the Grading of Recommendations Assessment, Development and Evaluation. Over 20,000 records gathered through databases searches were initially selected. Sixteen recommendations on CGA efficacy were defined based on 117 studies that met the inclusion criteria and were performed in general practices and primary care (26 studies included), medical and surgical clinics (16 studies), emergency departments (17 studies), hospital medical and surgical wards (53 studies), long-term care facilities and nursing homes (5 studies), hospices and palliative care networks (no studies). Nine recommendations on CGA-based prognostic tools were issues based on 42 included studies carried out in general practices and primary care (5 studies), medical and surgical clinics (4 studies), and hospital wards (33 studies).

RESULTS

Using CGA can be useful to reduce hospitalization, mortality, institutionalization, the risk of delirium, and improve appropriateness in drug prescription and maintain functional activities in different settings. Further research on the efficacy of CGA in rehabilitative facilities, nursing homes, and hospice and palliative-care settings is recommended. CGA-based tools, particularly the Multidimensional Prognostic Index, should be used to predict some negative outcomes in different settings.

CONCLUSIONS

This Guideline may be useful in clinical practice and as a tool to support research on the use of CGA in older people.

Uncovering sarcopenia and frailty in older adults by using muscle ultrasound-A narrative review

Muscle ultrasound is a valuable non-invasive and cost-effective method in assessing muscle mass and structure, both of which are significant indicators for the development of sarcopenia and frailty in elderly individuals. Sarcopenia refers to the loss of muscle mass and strength that occurs with age, whereas frailty is a complex geriatric syndrome characterized by reduced physical function and an increased susceptibility to negative health outcomes. Both conditions are prevalent in older adults and are associated with higher risks of falls, disability, and mortality. By measuring muscle size and structure and several other ultrasound parameters, including muscle thickness, cross-sectional area, echogenicity (brightness in the ultrasound image), pennation angle, and fascicle length ultrasound can assist in identifying sarcopenia and frailty in older adults. In addition, ultrasound can be used to evaluate muscle function such as muscle contraction and stiffness, which may also be affected in sarcopenia and frailty. Therefore, muscle ultrasound could lead to better identification and tracking of sarcopenia and frailty. Such advancements could result in the implementation of earlier interventions to prevent or treat these conditions, resulting in an overall improvement in the health and quality of life of the elderly population. This narrative review describes the benefits and challenges when using ultra-sound for the evaluation of frailty and sarcopenia.

Clinimetric Properties of the "FIND-NEEDS" to Screen Geriatric Conditions

INTRODUCTION

Comprehensive geriatric assessment (CGA) is used to thoroughly assess and identify complex healthcare problems among older adults. However, administration of CGA is time-consuming and labor intensive. A simple screening tool with the mnemonic "FIND-NEEDS" was developed to quickly identify common geriatric conditions. The present study was to evaluate the clinimetric properties of the FIND-NEEDS.

METHODS

The participants comprised first-visiting older adults aged 65 years and above (and who were able to communicate by themselves or with the help of a caregiver) who were assessed (October to December, 2021) using the FIND-NEEDS and CGA at geriatric outpatient clinics of a tertiary, referred medical center. The FIND-NEEDS was examined for its criterion-related validity and compared with the CGA results. Two types of scoring (summed score and binary score) of FIND-NEEDS and CGA were analyzed using Spearman correlation, sensitivity and specificity, and area under receiver operating characteristic curve (AUC).

RESULTS

The mean age of the 114 outpatients was 78.3 ± 7.6 years, and 79 (69.3%) were female. The internal consistency was excellent when using all FIND-NEEDS items, and was acceptable when using domain scores. Exploratory factor analysis showed that most of the FIND-NEEDS domain scores had factor loadings higher than 0.3. Intercorrelations of binary scores between domains of FIND-NEEDS and CGA showed most domains were moderately correlated. The overall correlation of summed scores between FIND-NEEDS and CGA was high. The FIND-NEEDS summed score was moderately correlated with CGA score (r = 0.494; p < 0.001), and the binary score showed excellent correlation (r = 0.944; p < 0.001). When using the CGA score as the gold standard, the FIND-NEEDS showed excellent AUC (0.950), sensitivity (1.00), and specificity (0.90).

DISCUSSION/CONCLUSION

The present study demonstrated that the FIND-NEEDS had acceptable clinimetric properties to screen for geriatric problems among older adults. Further in-depth assessment and care plan can then be conducted afterwards.

Immunotherapy use in older adults with cancer with frailty: A young SIOG review paper

Immune checkpoint inhibitors (ICIs) became a treatment option in most tumor types and improved survival in patients with cancer in the last decade. Older patients with cancer are underrepresented in the pivotal clinical trials with ICIs. Older patients with cancer often have significant comorbidities and geriatric syndromes like frailty, which can complicate cancer care and treatment decisions. Frailty is among the most prevalent geriatric syndromes in patients with cancer and could lead to inferior survival and a higher risk of complications in patients treated with chemotherapy. However, the effect of frailty on the efficacy and safety of ICIs is understudied. This review focuses on the available evidence regarding the association between frailty and ICI efficacy and safety. Although the survival benefits of ICIs have generally been shown to be independent of age, the available real-world data has generally suggested higher rates of immune-related adverse events (irAEs) and treatment discontinuation in older patients. While international organizations recommend conducting a comprehensive geriatric assessment CGA to assess and address frailty before the start of anti-cancer therapies, an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher is frequently used in clinical practice as synonymous with frailty, albeit with significant limitations. The available data has generally demonstrated diminished ICI efficacy in patients with an ECOG 2 or higher compared to patients with better performance status, while the incidence of high-grade irAEs were similar. Whilst evidence regarding outcomes with ICI in older patients and in those with sub-optimal performance status is growing, there is very limited data specifically evaluating the role of frailty with ICIs. These studies found a shortened overall survival, yet no evidence of a lower response rate to ICIs. These patients experienced more AEs, but they did not necessarily have a higher incidence of irAEs.

Older persons' experiences of frailty: A systematic review

OBJECTIVES

The objective of this study was to synthesise the evidence of older persons' experiences of frailty.

BACKGROUND

The world's population is ageing with those aged over 60 years expected to total 2 billion by 2050. Although not exclusive to ageing, there is a higher prevalence of frailty in older adults, with corresponding demand for related healthcare. While definitions of frailty are debated, there is emerging consensus that sole reliance on biomedical conceptualisations is inadequate to capture the complex needs of older persons living with frailty. In addition, the voices of older persons have largely been excluded from frailty discourses. There is a consequent need for an expanded approach.

METHODS

A meta-synthesis was conducted of the literature on older persons' experiences of frailty. CINAHL, Medline, Embase and ASSIA databases were systematically searched up to January 2024. Reference lists of retrieved sources and grey literature were also searched. Studies were independently evaluated for inclusion by two reviewers using predetermined inclusion criteria. Included studies were quality appraised using a standardised tool, and extracted data were thematically analysed and synthesised.

RESULTS

Eight hundred and thirteen studies were identified as potentially relevant. Following title and abstract review, 52 studies were selected for full-text review. Thirty-four studies were subsequently excluded as they did not address the systematic review question, leaving 17 included in the final review. An additional two studies were identified via grey literature sources. Older persons' experiences of frailty were synthesised with reference to three themes: (i) living with frailty: a multidimensional experience; (ii) living with frailty: acceptability and associations; and (iii) living with frailty: resisting and adapting and losing control.

CONCLUSIONS

Older persons' experiences of frailty revealed a resistance to the biomedical use of the term generally used in clinical practice. Instead, a more nuanced and multidimensional understanding of frailty was identified in the experiences of older persons.

IMPLICATIONS FOR PRACTICE

Health and social care personnel should therefore consider an expanded approach in practice that incorporates the perspective of older people who strive to maintain independence and control when living with frailty. Doing so may enhance shared understanding and person-centred care planning between older persons and professionals.

Value of a multidisciplinary geriatric oncology committee on patient care in a community-based, academic cancer center

INTRODUCTION

The heterogeneity in health and functional ability among older patients makes the management of cancer a unique challenge. The Geriatric Oncology Program at the University of Maryland Baltimore Washington Medical Center (BWMC) was created to optimize cancer management for older patients. This study aimed to assess the benefits of the implementation of such a program at a community-based academic cancer center.

MATERIALS AND METHODS

We analyzed patients aged ≥80 years presenting to the Geriatric Oncology Program between 2017 and 2022. A multidisciplinary team of specialists collectively reviewed each patient using geriatric-specific domains and stratified each patient into one of three management groups- Group 1: those deemed fit to receive standard oncologic care (SOC); Group 2: those recommended to receive optimization services prior to reassessment for SOC; and Group 3: those deemed to be best suited for supportive care and/or hospice care.

RESULTS

The study cohort consisted of 233 patients, of which 76 (32.6%) received SOC, 43 (18.5%) were optimized, and 114 (49.0%) received supportive care or hospice referral. Among the optimized patients, 69.8% were deemed fit for SOC upon re-evaluation following their respective optimization services. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) score was implemented in 2019 (n = 90). Patients receiving supportive/hospice care only had an average score of 5.8, while the averages for those in the optimization and SOC groups were 4.6 and 4.1, respectively (p ≤0.001). Patients receiving SOC had the longest average survival of 2.71 years compared to the optimization (2.30 years) and supportive care groups (0.93 years) (p ≤0.001). For all patients that underwent surgical interventions post-operatively, 23 patients (85%) were discharged home and four (15%) were discharged to a rehabilitation facility.

DISCUSSION

The present study demonstrates the profound impact that the complexities in health status and frailty among older individuals can have during cancer management. The Geriatric Oncology Program at BWMC maximized treatment outcomes for older adults through the provision of SOC therapies and optimization services, while also minimizing unnecessary interventions on an individual patient-centric level.

Application, knowledge and training needs regarding comprehensive geriatric assessment among geriatric practitioners in healthcare institutions: a cross-sectional study

BACKGROUND

This study aimed to investigate the actual application, knowledge, and training needs of comprehensive geriatric assessment (CGA) among geriatric practitioners in China.

METHODS

A total of 225 geriatric practitioners attending the geriatric medicine or geriatric nursing training were recruited for this cross-sectional study. The questionnaire included demographics, healthcare institution characteristics, the actual application, knowledge, training needs, and barriers to CGA and geriatric syndromes (GS).

RESULTS

Physicians and nurses were 57.3% and 42.7%, respectively. 71.1% were female, with a median age was 35 years. Almost two-thirds (140/225) of geriatric practitioners reported exposure to CGA in their clinical practice. The top five CGA evaluation items currently used were malnutrition risk (49.8%), fall risk (49.8%), activity of daily living (48.0%), pain (44.4%), and cognitive function (42.7%). Median knowledge scores for the management procedures of GS ranged from 2 to 6. Physicians identified medical insurance payment issues (29.5%) and a lack of systematic specialist knowledge and technology (21.7%) as the two biggest barriers to practicing geriatrics. Nurses cited a lack of systematic specialist knowledge and technology (52.1%) as the primary barrier. In addition, physicians and nurses exhibited significant differences in their knowledge of CGA-specific evaluation items and management procedures for GS (all P < 0.05). However, there were no significant differences in their training needs, except for polypharmacy.

CONCLUSIONS

The rate of CGA application at the individual level, as well as the overall knowledge among geriatric practitioners, was not adequate. Geriatric education and continuous training should be tailored to address the specific roles of physicians and nurses, as well as the practical knowledge reserves, barriers, and training needs they face.

Frailty and spatialization of older adults in the city of Uberlândia with IVCF-20

OBJECTIVE

To describe the functional clinical profile of elderly people linked to primary health care, using the Functional Clinical Vulnerability Index (IVCF-20) and to spatialize those with the greatest functional decline by primary health care units in the municipality of Uberlândia, in the state of Minas Gerais (MG), in the year 2022.

METHODS

A cross-sectional study with secondary data from the Municipal Health Department of Uberlândia-MG. The variables were compared using Student's t-test, Mann Whitney test, Pearson's chi-square, and multinomial logistic regression to obtain the independent effect of each variable. The significance level adopted was 5% (p < 0.05). The georeferenced database in ArcGIS® was used.

RESULTS

47,182 older adults were evaluated with a mean age of 70.3 years (60 to 113 years), 27,138 of whom were women (57.52%), with a clear predominance of low-risk or robust older adults (69.40%). However, 11.09% are high-risk older adults and 19.52% are at risk of frailty. Older men had independently lower odds of moderate and high risk compared to older women (OR = 0.53; p < 0.001). A high prevalence of polypharmacy was observed, 21.40% of the older adult population, particularly in frail older adults, with a prevalence of 63.08%. There was a greater distribution of frail older adults around the central region of the municipality and in health units with a larger coverage area. The IVCF-20 made it possible to screen frailty in primary health care.

CONCLUSION

The instrument is capable of stratifying the risk of older adults in health care networks through primary health care, enabling the application of individualized preventive, promotional, palliative, or rehabilitative interventions, according to the clinical functional stratum of the older adult and the compromised functional domains. Risk stratification and spatial distribution of the frailest older adults can be a good strategy for qualifying health professionals with the aim of maximizing the autonomy and independence of the older adults.

Social and clinical predictors of perianal colonisation by multidrug-resistant bacteria for geriatric patients in the internal medicine service

BACKGROUND

Colonisation by multidrug-resistant (MDR) bacteria is a global health issue. The identification of patients with a higher risk of colonisation is essential. Patients admitted to internal medicine services might represent a vulnerable population with a high risk of colonisation. This study was the first to assess social and clinical variables associated with a higher risk of perianal colonisation by MDR bacteria in a Spanish cohort of patients admitted to internal medicine service.

METHODS

Patients admitted to an internal medicine service during 12 months of recruitment (1 March 2022 to 1 March 2023) were included in the study. Perianal swabs were performed at admission to identify the presence of MDR bacteria. Social and clinical variables were collected following a directed acyclic graph. A cluster analysis was performed to identify clinical profiles of higher risk. Bivariate analyses and multivariable logistic regression models were fitted to identify potential predictors of MDR bacteria colonisation.

RESULTS

A total of 245 patients, according to the required sample size, were included. Of them, 46 (18.8%) were colonised by MDR bacteria in perianal swabs. Female sex, age > 80 years, dependency on activities of daily living, cognitive deterioration and living in long-term care facilities constituted the highest risk clinical profile. After adjustments, living in long-term care facilities and malnutrition remained the main risk factors identified.

CONCLUSION

Patients admitted to internal medicine services presented a high frequency of perianal colonisation by MDR bacteria. Social and clinical variables associated with bio-psycho-social susceptibility were associated with colonisation. Special surveillance is needed in internal medicine services to control the transmission.

Effectiveness of a randomized intervention by a geriatric team in frail hospital inpatients in non-geriatric settings: FRAILCLINIC project

BACKGROUND

Little research has been undertaken on the benefits of frailty management within different hospital settings. The objective of this study is to provide evidence on the viability and effectiveness of frailty management in non-geriatric hospital settings on mortality and functional decline after discharge.

METHODS

Data from the FRAILCLINIC (NCT02643069) study were used. FRAILCLINIC is a randomized controlled trial developed in non-geriatric hospital inpatient settings (emergency room, cardiology and surgery) from Spain (2), Italy (2) and the United Kingdom (1). Inpatients must met frailty criteria (according to the Frailty Phenotype and/or FRAIL scale), ≥75 years old. The control group (CG) received usual care. The intervention group (IG) received comprehensive geriatric assessment (CGA) and a coordinated intervention consisting in recommendations to the treating physician about polypharmacy, delirium, falls, nutrition and physical exercise plus a discharge plan. The main outcomes included functional decline (worsening ≥5 points in Barthel Index) and mortality at 3 months. We used multivariate logistic regression models adjusted by age, gender and the Charlson index. Intention-to-treat (ITT) and per-protocol (PP) analyses were used.

RESULTS

Eight hundred twenty one participants (IG: 416; mean age 83.00 ± 4.91; 51.44% women; CG: 405; mean age 82.46 ± 6.03; 52.35% women) were included. In the IG, 77.16% of the participants followed the geriatric team's recommendations as implemented by the treating physicians. The intervention showed a benefit on functional decline and mortality [OR: 0.67(0.47-0.96), P-value 0.027 and 0.29(0.14-0.57), P-value < 0.001, respectively) when fully followed by the treating physician. A trend to benefit (close to statistical significance) in functional decline and mortality were also observed when any of the recommendations were not followed [OR (95% CI): 0.72 (0.51-1.01), P-value: 0.055; and 0.64 (0.37-1.10), P-value: 0.105, respectively].

CONCLUSIONS

An individualized intervention in frail in-patients reduces the risk of functional deterioration and mortality at 3 months of follow-up when a care management plan is designed and followed.

Development and implementation of multicomponent homecare interventions for multimorbid and frail older people based on Information and Communication Technologies: The MULTIPLAT_AGE project

The prevention and treatment of frailty condition among multimorbid older adults, in community and hospital settings, is becoming a healthcare priority. Growing evidence suggests that a multidimensional approach could help not only in the early identification of older patients' needs but also in designing personalized preventive interventions. However, in clinical practice, the effectiveness of such interventions is limited by a lack of continuity of care and poor compliance of patients. The widespread diffusion of the information and communication technology (ICT) could offer an excellent way to implement and monitor multidimensional and personalized interventions for multimorbid older adults. In this scenario, the MULTIPLAT_AGE, is a network project involving five research centers with the main objective to supply multidimensional interventions targeted to cognitive, motor, pharmacological, and functional domains including ICT-based: i) transitional care model from the hospital to a protected home area; ii) automatic home-care system to improve activities of daily living; iii) program to improve appropriate drug prescription in nursing-home residents; iv) tele-rehabilitation program to reduce the risk of falls and v) cognitive stimulation delivered by remote in older adults with neurological disorders. Each project is linked to the others by employing a shared online platform, in a perspective of technological-supplied multicomponent interventions according to the concept of "aging in place" as the best solution for the treatment and healthcare of older people. Here we describe the general framework of the MULTIPLAT_AGE, and we examine every single project, pointing out innovative aspects, and discussing the expected results.

The PRO-HOME Project. A multicomponent intervention for the protected discharge from the hospital of multimorbid and polytreated older individuals by using innovative technologies: A pilot study

BACKGROUD

Discharge planning from the hospital of frail older patients is an important step to avoid inappropriate long-stay hospitalizations and to prevent the risks related to the prolonged hospitalization. In this frame, we developed an experimental trial-'PRO-HOME', a multicomponent programme of interventions for multimorbid and polytreated hospitalized older patients.

AIM

The main aim of the study was to develop a protected discharge facility using a mini apartment equipped with advanced architectural and technological components to reduce the length of hospital stay of older participants (aged 65+ years old) admitted to the hospital for an acute event, deemed stable and dischargeable.

MATERIALS AND METHODS

This is a pilot randomized controlled study, comparing 30 hospitalized participants included in a multidimensional, transitional care programme based on information and communication technologies to 30 patients in standard usual care until hospital discharge.

RESULTS

We presented the study design of the PRO-HOME programme, including architectural and technological components, the enrolment procedures, the components of the intervention that is physical activity, cognitive training and life-style education and the evaluation method of the intervention based on the Comprehensive Geriatric Assessment to explore the changes in the individual domains that are target of the multicomponent intervention.

CONCLUSIONS

The final results will suggest whether the PRO-HOME programme represents a useful and feasible intervention to reduce the length of hospital stay of multimorbid and polytreated hospitalized older patients and improve their physical and cognitive performances and overall quality of life.

PATIENT OR PUBLIC CONTRIBUTION

Due to the characteristics of the population of interest of the PRO-HOME study, we involved in the study design and programme of the activities the participants enrolled in a previous smart home-based project named MoDiPro carried-out during a 3-year period. The elderly participants from the local population involved were asked, by means of focus groups, for feedback on their experience in MoDiPro, and their suggestions were integrated into the design phase of the current PRO-HOME project. The focus groups included open group interviews with a qualitative collection of the patients' feedback so that the participants could interact with each other.

The outcomes of considering goals of care in medication reviews for older adults: a systematic review

INTRODUCTION

This is a systematic review of prescribing, clinical, patient-reported, and health utilization outcomes of goal-directed medication reviews in older adults.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, SCOPUS and CINAHL databases to identify studies examining outcomes of goal-directed medication reviews in humans, with mean/median age ≥ 60 years and in English.

RESULTS

Seventeen out of 743 articles identified were included. Whilst there were inconsistent findings regarding changes in the number of medications between groups or post-intervention in one group (n = 6 studies), studies found reductions in drug-related problems (n = 2) and potential to reduce anticholinergics and sedatives (n = 2). Two out of seven studies investigating clinical outcomes found improvements, such as reduced hospital readmissions and improved depression severity. One study found 75% of patients achieved ≥ 1 goals and another found 43% of goals were achieved at six months. Four out of five studies found significant improvements in patient-reported quality of life between groups (n = 2) or post-intervention in one group (n = 2). Both studies investigating cost-effectiveness reported the intervention was cost-effective.

CONCLUSIONS

There is evidence of positive impact on medication rationalization, quality of life and cost-effectiveness, supporting goal-directed medication reviews. Larger, longitudinal studies, exploring patient-focused outcomes may provide further insights into the ongoing impact of goal-directed medication reviews.

Challenging Diagnosis of Invasive Sinus Aspergillosis Mimicking Gradenigo's Syndrome in an Elderly Patient with T-Cell Lymphoma

(1) Background: Gradenigo's Syndrome (GS) is a rare complication of acute otitis media characterized by the triad of diplopia, otitis, and facial pain. The widespread use of antibiotics has significantly reduced its occurrence. (2) Case summary: We present the case of an elderly patient with T-cell lymphoma who developed neurological deficits resembling GS. The patient was ultimately diagnosed with invasive sinus aspergillosis. The diagnostic process was challenging due to the atypical clinical presentation and the lack of specific imaging findings. A biopsy was the most important test for clarifying the diagnosis. (3) Conclusions: The prognosis for this complication is extremely poor without surgery, and the patient died despite adequate antifungal coverage. Therefore, maintaining high clinical suspicion is paramount to avoid adverse outcomes in similar cases, particularly in the geriatric population, wherein this syndrome's occurrence may not be expected.

Comprehensive geriatric assessment-where are we now, where do we need to be in the context of global ageing?

Comprehensive geriatric assessment (CGA) is the cornerstone of modern geriatric medicine and the framework around which conventional and new models of care for older people are developed. Whilst there are a substantial number of reviews synthesising the evidence on patient and service outcomes from CGA, as an intervention it remains poorly described. There is a lack of detail on how a CGA plan is coordinated, delivered and followed up, especially outside of acute care. This commentary reflects on the authors' experience of extracting data from 57 published studies on CGA. CGA as an intervention is akin to a 'black box' in terms of describing and measuring participants' interactions with CGA activity in terms of time, frequency and amount (dose) received. There is also a lack of detail on how newly established CGA teams become effective, interdisciplinary, high functioning and sustainable teams. The CGA knowledge-do gap persists with a need to draw from complex system theory and implementation science frameworks to better describe the intervention and understand the influence of the organisation and health service within which CGA is operationalised. Equally, the voice of older people, families and staff is critical in the conduct and evaluation of CGA, and how it evolves as a model to meet the growing needs of ageing populations.

Seeing the forest (plot) for the trees-the importance of evidence synthesis in older adult care

Systematically reviewing all the available evidence and then creating summary analyses of the pooled data is the foundation of evidence-based practice. Indeed, this evidence synthesis approach informs much of the care of older adults in hospital and community. It is perhaps no surprise that the journal Age and Ageing is a frequent platform for publishing research papers based on systematic review and synthesis. This research has evolved substantially from the early days of evidence-based medicine and the Cochrane Collaboration. The traditional approach would be a quantitative summary, calculated using pair-wise meta-analysis of randomised controlled trials of drug versus placebo, or a synthesis of observational studies to create summaries of prevalence, associations and outcomes. Methods have evolved and newer techniques such as scoping reviews, test accuracy meta-analysis and qualitative synthesis are all now available. The sophistication of these methods is driven in part by the increasingly complex decisions that need be made in contemporary older adult care. Age and Ageing continues to champion established and novel evidence synthesis approaches, and in the accompanying Collection exemplars of these differing methods are presented and described. Whilst there is marked heterogeneity in the techniques used, the consistent and defining feature of all these papers is the desire to comprehensively, and critically summarise the evidence in order to answer the most pertinent questions regarding older adult care.

Effectiveness of holistic assessment-based interventions for adults with multiple long-term conditions and frailty: an umbrella review of systematic reviews

Holistic assessment-based interventions (HABIs) are effective in older people admitted to hospital, but it is unclear whether similar interventions are effective in adults with multiple long-term conditions or frailty in the community. We conducted an umbrella review to comprehensively evaluate the literature on HABIs for adults (aged ≥18 years) with multiple long-term conditions, and frailty. We searched eight databases for systematic reviews reporting on experimental or quasi-experimental studies. Of 9803 titles screened, we identified 29 eligible reviews (14 with meta-analysis) reporting on 14 types of HABIs. The evidence for the effectiveness of HABIs was largely inconsistent across different types of interventions, settings, and outcomes. We found evidence of no benefit from hospital HABIs on health-related quality of life (HRQoL) and emergency department re-attendance, and evidence of no benefit from community HABIs on overall health-care utilisation rates, emergency department attendance, nursing home admissions, and mortality. The best evidence of effectiveness was for hospital comprehensive geriatric assessment (CGA) on nursing home admissions, keeping patients alive and in their own homes. There was some evidence of benefit from community CGA on hospital admissions, and from CGA spanning community and hospital settings on HRQoL. Patient-centred medical homes had beneficial effects on HRQoL, mental health, self-management, and hospital admissions.

Predictive Strategies to Reduce the Risk of Rehospitalization with a Focus on Frail Older Adults: A Narrative Review

Frailty is a geriatric syndrome that has physical, cognitive, psychological, social, and environmental components and is characterized by a decrease in physiological reserves. Frailty is associated with several adverse health outcomes such as an increase in rehospitalization rates, falls, delirium, incontinence, dependency on daily living activities, morbidity, and mortality. Older adults may become frailer with each hospitalization; thus, it is beneficial to develop and implement preventive strategies. The present review aims to highlight the epidemiological importance of frailty in rehospitalization and to compile predictive strategies and related interventions to prevent hospitalizations. Firstly, it is important to identify pre-frail and frail older adults using an instrument with high validity and reliability, which can be a practically applicable screening tool. Comprehensive geriatric assessment-based care is an important strategy known to reduce morbidity, mortality, and rehospitalization in older adults and aims to meet the needs of frail patients with a multidisciplinary approach and intervention that includes physiological, psychological, and social domains. Moreover, effective multimorbidity management, physical activity, nutritional support, preventing cognitive frailty, avoiding polypharmacy and anticholinergic drug burden, immunization, social support, and reducing the caregiver burden are other recommended predictive strategies to prevent post-discharge rehospitalization in frail older adults.

Characterization of patients admitted to specialized geriatric acute care hospital units with the German version of the Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening-instrument: a cross-sectional study

BACKGROUND

The Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening tool records major geriatric problems, originally applied in the emergency department. Particularly, the distinction of compensated and uncompensated problems is an interesting and new approach. Therefore, we translated the SEISAR in German language and used it to characterize patients in specialized geriatric hospital wards in Germany and to gather initial experience regarding its usability and practicability.

METHODS

The tool was translated by three independent specialists in geriatric medicine and backtranslated for quality-assurance by a non-medical English native speaker. In a second step, 8 acute care geriatric hospital departments used the translated version to characterize all consecutive patients admitted over a period of one month between December 2019 and May 2020 at time of admission.

RESULTS

Most of the 756 patients (78%) lived in an own apartment or house prior to hospital admission. Participants had on average 4 compensated and 6 uncompensated problems, a Barthel-Index of 40 pts. on admission with a median increase of 15 points during hospital stay, and a median length of stay of 16 days in the geriatric hospital department.

CONCLUSION

SEISAR is an interesting standardized brief comprehensive geriatric assessment tool for the identification of compensated and uncompensated health problems in older persons. The data of this study highlights the number, variability, and complexity of geriatric problems in patients treated in specialized acute care geriatric hospital wards in Germany.

TRIAL REGISTRATION

German Clinical trial register (DRKS-ID: DRKS00031354 on 27.02.2023).

Co-Creating a Digital Life-Integrated Self-Assessment for Older Adults: User Experience Study

BACKGROUND

Older adults are at increased risk of developing health disorders and functional decline. However, owing to time constraints and considerable effort, physicians rarely conduct comprehensive assessments to detect early signs of negative trajectories. If designed properly, digital technologies could identify health risks already at a preclinical stage, thereby facilitating preventive efforts and targeted intervention. For this purpose, a Life-integrated Self-Assessment (LiSA) tablet system will be developed through a structured co-creation process.

OBJECTIVE

This study aims to investigate older adults' perceptions of different self-assessment domains, components affecting user experience, risks and benefits associated with LiSA, characteristics of potential LiSA users, and the LiSA concept in general.

METHODS

A total of 10 community-dwelling older adults aged ≥70 years were recruited. In total, 6 co-creation workshops were held and started with expert input followed by semistructured discussion rounds. Participants performed hands-on activities with a tablet, including testing of preinstalled self-assessment apps. All workshops were audio recorded and additionally documented by the researchers using flipcharts, notes, and photos. Qualitative content analysis was used to analyze the data following a deductive-inductive approach guided by the Optimized Honeycomb Model for user experience.

RESULTS

The group (mean age 77.8, SD 5.1 years) was heterogeneous in terms of previous technology experience and health status. The mean workshop duration was 2 hours (122.5, SD 4.43 min), and an average of 8 (SD 1.15) participants attended each workshop. A total of 11 thematic categories were identified, covering results on all research questions. Participants emphasized a strong interest in conducting a digital self-assessment of physical activity and function and sensory and cognitive functions and requested additional features such as recommendations for actions or reminders. LiSA was perceived as empowering and a motivator to engage in active health care planning as well as enabling shared and informed decision-making. Concerns and barriers included the lack of technical competence, feelings of frustration, and fear of being left alone, with negative assessment results. In essence, participants expressed a positive attitude toward using LiSA repeatedly and identified it as an option to increase the chances of maintaining independence when growing older.

CONCLUSIONS

The co-creation participants supported the LiSA approach and were interested in performing regular self-assessments on a long-term basis. In their opinion, LiSA should include relevant assessments capturing physical activity and function and sensory and cognitive functions as well as recommendations for actions. It should be customizable to individual needs. These results will form the basis for a prototype. Iterative development and validation will aim to make LiSA accessible in the public domain as a reliable tablet-based system for self-assessment.

Comprehensive Geriatric Assessment and Quality of Life Aspects in Patients with Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma (HNSCC)

To define frailty in older cancer patients, the aim of this study was to assess the geriatric status and quality of life (QoL) aspects in patients suffering from recurrent/metastatic head and neck squamous cell carcinoma (r/m HNSCC) under palliative treatment. A comprehensive geriatric assessment (CGA) was performed on 21 r/m HNSCC patients at two defined assessments, and the QoL aspects and the impact of descriptive data were evaluated. The Kolmogorov-Smirnov test, Spearman's rho correlation, and two-way mixed ANOVA were used for statistical analysis. All patients were found to be "frail". Pain, fatigue, and the burden of illness were the highest-rated symptoms. Oral function and orofacial appearance were highly impaired. A significant impact of descriptive data on the CGA and QoL results was found (all p ≤ 0.05). Thus, the CGA results revealed high frailty, severe comorbidities, and high impairments in QoL aspects. The CGA and QoL results were negatively affected by the primary HNSCC treatment approach, the need for prosthetic treatment, and worse oral functional capacity. Therefore, frailty in r/m HNSCC patients seems to be multidimensional. The evaluation of the CGA and QoL aspects in r/m HNSCC patients can be recommended to detect special needs, organize aftercare, and improve the support for frail and vulnerable cancer patients to create a multidisciplinary treatment approach.

Challenges in anti-aging medicine-trends in biomarker discovery and therapeutic interventions for a healthy lifespan

We are facing a growing aging population, along with increasing pressure on health systems, caused by the impact of chronic co-morbidities (i.e. cancer, cardiovascular and neurodegenerative diseases) and functional disabilities as people age. Relatively simple preventive lifestyle interventions, such as dietary restriction and physical exercise, are important contributors to active and healthy aging in the general population. However, as shown in model organisms or in 'in vitro' conditions, lifestyle-independent interventions may have additional health benefits and can even be conceived as possible reversers of the aging process. Thus, pharmaceutical laboratories, research institutes, and universities are putting more and more effort into finding new molecular pathways and druggable targets to develop gerotherapeutics. One approach is to target the driving mechanisms of aging, some of which, like cellular senescence and impaired autophagy, we discussed in an update on the biology of aging at AgingFit 2023 in Lille, France. We underline the importance of carefully and extensively testing senotherapeutics, given the pleiotropism and heterogeneity of targeted senescent cells within different organs, at different time frames. Other druggable targets emerging from new putative mechanisms, like those based on transcriptome imbalance, nucleophagy, protein phosphatase depletion, glutamine metabolism, or seno-antigenicity, have been evidenced by recent preclinical studies in classical models of aging but need to be validated in humans. Finally, we highlight several approaches in the discovery of biomarkers of healthy aging, as well as for the prediction of neurodegenerative diseases and the evaluation of rejuvenation strategies.

Geriatric Assessment of Older Adults With Cancer During Acute Hospitalizations: Challenges and Opportunities

Introduction Geriatrics is a discipline that covers all adult healthcare, and oncology is no exception. The global geriatric assessment process plays a crucial role, impacting research, funding, resource allocation, as well as therapeutic decision-making. Thus, greater knowledge of the epidemiology of the frailty and functionality of elderly patients with cancer will allow for the development of a global care strategy. This study aimed to assess the prevalence of geriatric conditions in elderly cancer patients admitted to a medical geriatric unit following unplanned hospitalisation. Methods A retrospective, single-centre cohort study was conducted of patients aged ≥ 75 with an active oncological disease who were admitted to a geriatric medicine unit over a two-year period. Results A total of 65 patients were included. The median age was 85 (IQR 81-88), and 86% were aged ≥ 80. A moderate-to-high functional dependence was found: 67.7% on ≥ 3 basic activities of daily living (Katz ≥ D), with the majority classified as severely dependent based on the Barthel Index (mean 49.0 ± 33.7). Frailty was found in 90.7%. A high prevalence of geriatric syndromes was observed: malnutrition (84.6%), polypharmacy (64.6%), urinary incontinence (58.5%) and pressure ulcers (33.8%). The mortality rate was 36.9% during hospitalisation and 13.8%, 30 days post-discharge. Conclusions The study revealed a high prevalence of geriatric conditions, emphasising the importance of comprehensive assessment in managing elderly patients at different stages of the disease. This multidimensional and multidisciplinary approach optimises patient care throughout admission, hospitalisation and discharge.

Fear of Falling Score Is a Predictor of Falls in Community-Dwelling Pre-Frail and Frail Older People

Identifying frail older people at risk of falling is a priority in order to apply preventive strategies. This cross-sectional study included community-dwelling pre-frail and frail people (Fried's criteria) aged 70 years and older to assess the prevalence of falls and identify screening strategies based on comprehensive geriatric assessments to detect an increased risk of falling and recurrent falling in community-dwelling frail and pre-frail old people. Of the 229 participants, 121 (54.9%) had fallen in the previous 12 months, and 20 of these (16.5%) were recurrent fallers (≥2 falls). A score of 20 points or more on the Falls Efficacy Scale International was predictive of falling (area under the receiver-operating characteristics curve 0.67, 95% confidence interval: 0.61-0.74, p < 0.001) with a sensitivity of 51.7% and a specificity of 73.9%. Polypharmacy, Short Physical Performance Battery score of 8 points or less, and Falls Efficacy Scale International score of 20 points or more show an area under the curve of 0.78 (95% confidence interval: 0.67-0.89, p < 0.001) for recurrent falling.

Detecting Comparative Features of Comprehensive Geriatric Assessment through the International Classification of Functioning, Disability, and Health Linkage: A Web-Based Survey

Multidimensional assessments are important in evaluating the overall health of older adults. The comprehensive geriatric assessment (CGA) is a representative framework; however, the burden associated with the CGA has led to the development of simplified multidimensional tools. Comparing these tools to the CGA can help utilize them effectively. However, a direct comparison is challenging owing to the conceptual nature of the CGA. In this study, we conducted a web-based survey to identify essential CGA components by linking International Classification of Functioning, Disability, and Health (ICF) category level 2 items and "not defined/not covered" (nd/nc) items. Healthcare professionals and individuals aged >65 years participated in a two-stage Delphi study. In total, 182 respondents (7 geriatricians, 22 nurses, 20 therapists, and 4 case managers) completed the survey. Sixty-one essential components for CGA were identified, including 55 ICF categories. Additionally, personal factors (i.e., proactiveness) and nd/nc items (i.e., subjective perceptions) were aggregated. The results suggest that the CGA includes objective conditions of intrinsic capacity, functional ability, and environment as well as subjective perceptions and proactiveness toward those conditions. Thus, CGA is not merely expected to assess geriatric syndrome but also to estimate broader concepts, such as interoception, resilience, and quality of life.

The use of the World Guidelines for Falls Prevention and Management's risk stratification algorithm in predicting falls in The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

the aim of this study was to retrospectively operationalise the World Guidelines for Falls Prevention and Management (WGFPM) falls risk stratification algorithm using data from The Irish Longitudinal Study on Ageing (TILDA). We described how easy the algorithm was to operationalise in TILDA and determined its utility in predicting falls in this population.

METHODS

participants aged ≥50 years were stratified as 'low risk', 'intermediate' or 'high risk' as per WGFPM stratification based on their Wave 1 TILDA assessments. Groups were compared for number of falls, number of people who experienced one or more falls and number of people who experienced an injury when falling between Wave 1 and Wave 2 (approximately 2 years).

RESULTS

5,882 participants were included in the study; 4,521, 42 and 1,309 were classified as low, intermediate and high risk, respectively, and 10 participants could not be categorised due to missing data. At Wave 2, 17.4%, 43.8% and 40.5% of low-, intermediate- and high-risk groups reported having fallen, and 7.1%, 18.8% and 18.7%, respectively, reported having sustained an injury from falling.

CONCLUSION

the implementation of the WGFPM risk assessment algorithm was feasible in TILDA and successfully differentiated those at greater risk of falling. The high number of participants classified in the low-risk group and lack of differences between the intermediate and high-risk groups may be related to the non-clinical nature of the TILDA sample, and further study in other samples is warranted.

Effectiveness of multi-professional educational interventions to train Comprehensive Geriatric Assessment (CGA) - a Systematic Review

Introduction

As the world population ages, health and social care professionals are increasingly confronted with patients with chronic long-term conditions and multimorbidity, requiring an extensive assessment and integrated care management strategy. The aim of this paper was to systematically collect and assess evidence of interprofessional education and training strategies for Comprehensive Geriatric Assessment (CGA) to build a competent health workforce.

Methods

A systematic review was conducted according to PRISMA guidelines and the databases Medline, CINAHL, Cochrane and Embase were searched for studies illustrating effectiveness of educational interventions for teaching and training CGA in an interprofessional context.

Results

Based on 21 identified studies, a great variability and heterogeneity in duration, setting and design of the interventions was identified. Promising results were found in the domains analysed, ranging from knowledge and skills; practices and behaviour; patient health outcomes; attitudes and perceptions to collaboration and quality of care.

Discussion

Education and training of transversal skills within a continuous learning approach is key to equip the health care workforce for successful CGA performance in an interprofessional environment.

Conclusion

Further research in this field is recommended to strengthen the evidence-base towards development of a resilient and integrated health care workforce for an ageing population.