Comprehensive geriatric assessment for older hospital patients

The effectiveness of the comprehensive geriatric assessment for older adults with frailty in hospital settings: A systematic review and meta-analysis

BACKGROUND

Comprehensive geriatric assessment (CGA) is performed by a multidisciplinary team and includes systematic comprehensive team assessment and treatment. Comprehensive geriatric assessment has become a fundamental component of geriatric nursing, as a multidimensional approach is necessary to achieve the best diagnosis and therapy for older adults with frailty.

OBJECTIVE

The aim of our review was to analyze the effects of comprehensive geriatric assessment interventions on older adults with frailty in hospital settings.

METHODS

The PubMed, Web of Science, Embase, CINAHL and Cochrane Library databases were systematically searched from inception to February 28, 2024. Only randomized controlled trials were included in the analysis. The risk ratios (RRs) or standardized mean differences (SMDs) were calculated to determine the pooled intervention effects. Sensitivity analyses and publication bias analyses were also conducted. Methodological quality and evidence were assessed using the RoB2 tool and GRADE pro online tool.

RESULTS

A total of 18 randomized controlled trials were included in this review. The results showed that participants in the intervention group had a lower risk of having decreased activities of daily living than did those in the control group (RR = 0.55, 95 % CI: 0.33 to 0.92, P = 0.021, low certainty evidence). Comprehensive geriatric assessment was associated with a reduced mortality risk (RR = 0.85, 95 % CI: 0.73 to 0.99, P = 0.038, high certainty evidence).

CONCLUSION

In conclusion, this systematic review analyzed the available literature, and the results showed that comprehensive geriatric assessment had significant benefits in terms of increased independence and was associated with a reduced mortality risk for older adults with frailty in hospital settings. However, the evidence was limited. Thus, more research is needed in the future to further enrich the evidence in the field of comprehensive geriatric assessment interventions for older adults with frailty.

Comprehensive Geriatric Assessment in the era of telemedicine

The aging global population poses significant medical and social challenges, necessitating efforts to promote healthy aging. Comprehensive Geriatric Assessment (CGA) is a multidimensional diagnostic approach for older adults that aims to improve overall health. Remote CGA, facilitated by technological advancements, offers convenience and other potential advantages. It enables early disease detection, monitors chronic disease progression, delivers personalized care, and optimizes healthcare resources for better health outcomes in older individuals. However, remote CGA also has limitations, including technological requirements, data security, and the need for comprehensive evaluation and simplicity. Collaborative efforts are essential to developing a digital home-based CGA platform that addresses accessibility issues and tailors the assessment process to meet the needs of older adults. Continuous optimization of remote CGA can become a pivotal tool for advancing geriatric care and ensuring the well-being of the aging population. Geriatr Gerontol Int 2024; 24: 67-73.

What are the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population? A systematic review

AIMS

This review aims to identify the evidence base for the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population.

METHOD

In this systematic review, we searched MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library for studies from January 2001 to 15th August 2022. We included a variety of study types that assessed and reported frailty including patients ≥18 years old. Studies included those that reported the prevalence of over or undertreatment of diabetes mellitus in a frail population and those examining outcomes related to glucose control in frail older people living with diabetes. Data were extracted using a bespoke extraction table using a narrative synthesis approach.

RESULTS

A total of 4114 articles were identified with 112 meeting inclusion criteria. These included 15,130 participants across the 11 studies with sample sizes ranging from 101 to 11,140. Several areas were identified in the included studies where under or overtreatment of diabetes impacted outcomes for patients. These included hospital admissions, readmissions, length of stay, falls, mortality, cognitive impairment and cardiovascular disease outcomes.

CONCLUSION

The results showed that there was a high heterogeneity of outcomes between the studies and that many examined small numbers of participants. In this review, both over and undertreatment were shown to increase adverse outcomes in frail older people. Further research around optimal glycaemic control for frail older people living with diabetes is required with the aim to identify ideal target ranges and produce practical clinical guidelines to promote attainment of these.

Adjusting the Split: Examining Complications After Emergency Exploratory Laparotomy in Older Adults

INTRODUCTION

Older adults experience higher rates of complications after an emergency exploratory laparotomy (EEL). To better understand the shift to an aging population in the United States, identifying how age may influence these complications in older patients is important. The current standard age category for older adult patients is ≥65. We analyzed postlaparotomy complications using a lower age split.

METHODS

A retrospective analysis was done on patients who required an EEL from October 2015 to December 2019 at an academic medical center. Patient demographics and hospital course variables were collected. Differences in complications in patients aged ≥/<55 y and ≥/<65 y were measured using univariate and multivariable analyses.

RESULTS

A total of 481 patients were reviewed. Both patient groups of ≥55 and ≥65 were typically male, White, had 3+ comorbidities, Medicare insurance, were retired, and presented in extremis to the emergency department. Patients aged ≥55 y had significant rates of pulmonary complications and inpatient mortality (odds ratio 2.2, 2.7, respectively). Patients aged ≥65 y had significant rates of genitourinary and cardiac complications (odds ratio 2.3, 1.8, respectively).

CONCLUSIONS

Patients aged ≥55 y undergoing EEL had higher odds of experiencing pulmonary complications and death during their index hospitalizations, which was not present with the standard ≥/<65-y-old patient analysis. Those aged ≥65 y experienced index genitourinary and cardiac complications. The ≥/<55 age split has a unique set of complications that should be considered. Given the increased odds of inpatient mortality and types of complications in patients aged ≥55 y, the current age split for older adults should be reconsidered.

Effectiveness of a multicomponent activity and horticultural intervention for the hospitalized older adults: A randomized controlled trial: Effectiveness of Intervention for the Hospitalized Older Adults

This study evaluated the effectiveness of different intervention programs in improving function among hospitalized older individuals using the Comprehensive Geriatric Assessment (CGA). A randomized controlled trial consisted of three groups: routine care, horticulture, and multicomponent activities (n = 32 each). Horticultural and multicomponent activity interventions showed beneficial effects on the CGA in hospitalized older individuals, particularly regarding cognitive function and quality-of-life. Additionally, horticultural activities significantly contributed to the perception of older adults' health status. We recommend to select older patients in geriatric wards with long-term hospitalization and adjust the frequency of activities or choose a single intervention program to provide long-term and effective intervention effects.

Did the Acute Frailty Network improve outcomes for older people living with frailty? A staggered difference-in-difference panel event study

OBJECTIVES

To evaluate whether the Acute Frailty Network (AFN) was more effective than usual practice in supporting older people living with frailty to return home from hospital sooner and healthier.

DESIGN

Staggered difference-in-difference panel event study allowing for differential effects across intervention cohorts.

SETTING

All English National Health Service (NHS) acute hospital sites.

PARTICIPANTS

All 1 410 427 NHS patients aged 75+ with high frailty risk who had an emergency hospital admission to acute, general or geriatric medicine departments between 1 January 2012 and 31 March 2019.

INTERVENTION

Membership of the AFN, a quality improvement collaborative designed to support acute hospitals in England deliver evidence-based care for older people with frailty. 66 hospital sites joined the AFN in six sequential cohorts, the first starting in January 2015, the sixth in May 2018. Usual care was delivered in the remaining 248 control sites.

MAIN OUTCOME MEASURES

Length of hospital stay, in-hospital mortality, institutionalisation, hospital readmission.

RESULTS

No significant effects of AFN membership were found for any of the four outcomes nor were there significant effects for any individual cohort.

CONCLUSIONS

To realise its aims, the AFN might need to develop better resourced intervention and implementation strategies.

Association between the Neutrophil-to-Lymphocyte Ratio and Inpatient Mortality in Hospitalized Older Veterans with COVID-19 Infection

OBJECTIVES

Determine the association of high neutrophil-to-lymphocyte ratio (NLR) values with inpatient mortality and other outcomes in older veterans hospitalized with coronavirus disease 2019 (COVID-19).

METHODS

This was a retrospective, multicenter, cohort study of hospitalized adults, with laboratory-confirmed COVID-19 infection who were studied for 1 year after discharge or until death. The NLR was categorized into tertiles, and we determined frailty status with the 31-item Veterans Affairs Frailty Index. Multivariate logistic regression and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were performed to assess the association between NLR and clinical outcomes.

RESULTS

The study included 615 hospitalized adult veterans, mean age 66.12 (standard deviation 14.79) years, 93.82% (n = 577) male, 57.56% (n = 354) White, 81.0% (n = 498) non-Hispanic, median body mass index of 30.70 (interquartile range 25.64-34.99, standard deviation 7.13), and median length of stay of 8 days (interquartile range 3-15). Individuals in the middle and upper tertile groups had higher inpatient mortality (8.37%, n = 17 and 18.36%, n = 38, respectively) as compared with the lower tertile (2.93%, n = 6, P < 0.001). Compared with the lowest tertile, the middle and upper tertiles had a higher risk of inpatient mortality (aOR 3.75, 95% CI 1.38-10.21, P = 0.01, and aOR 8.13, 95% CI 3.18-20.84, P < 0.001, respectively). The highest tertile had a higher odds of intensive care unit admission (aOR 4.47, 95% CI 2.33-8.58, P < 0.001) and intensive care unit transfer (aOR 3.54, 95% CI 1.84-6.81, P < 0.001).

CONCLUSIONS

The NLR score is a clinically useful tool to predict in-hospital mortality in older patients with COVID-19.

Validation of a Brief Form of the Self-Administered Multidimensional Prognostic Index: The SELFY-BRIEF-MPI Project

In clinical practice, self-administered and brief tools to promptly identify older people at risk of frailty are required. The Multidimensional Prognostic Index (MPI), derived from the Comprehensive Geriatric Assessment (CGA) seems reliable enough to serve this purpose, but despite the several versions developed over the past 15 years, it lacks a self-administered and brief version. In this study, we aimed to evaluate the agreement between an abbreviated form of the SELFY-MPI (i.e., SELFY-BRIEF-MPI) and the standard version of the MPI. Four Italian hospitals consecutively enrolled outpatients and inpatients >65 years. The sample included 105 participants (mean age = 78.8 years, 53.3% females). Overall, the two versions showed non-statistically significant differences (Standard-MPI 0.42 ± 0.19 vs.. SELFY-BRIEF-MPI 0.41 ± 0.18; p = 0.104) and a very strong correlation (R = 0.86, p < 0.001). The Bland-Altman Plot revealed that only 5/105 measurements (4.76%) were outside the limits of agreement. The accuracy of the SELFY-BRIEF-MPI in identifying frail people (defined as a Standard-MPI > 0.66) was optimal (area under the curve, AUC = 0.90, p < 0.001). To predict multidimensional frailty, a SELFY-BRIEF-MPI score of 0.60 exhibited the greatest sensitivity/specificity ratio. In conclusion, the SELFY-BRIEF-MPI reported a good agreement with the standard version of the MPI, indicating its application in the screening of multidimensional frailty among older people.

Association between a Frailty Index from Common Laboratory Values and Vital Signs (FI-LAB) and Hospital and Post-Hospital Outcomes in Veterans with COVID-19 Infection

OBJECTIVES

Determine the association of higher FI-LAB scores, derived from common laboratory values and vital signs, with hospital and post-hospital outcomes in Veterans hospitalized with COVID-19 infection.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective, multicenter, cohort study of 7 Veterans Health Administration (VHA) medical centers in Florida and Puerto Rico. Patients aged 18 years and older hospitalized with COVID-19 and followed for up to 1 year post discharge or until death. Clinical Frailty Measure: FI-LAB.

MAIN OUTCOMES AND MEASURES

Hospital and post-hospital outcomes.

RESULTS

Of the 671 eligible patients, 615 (91.5%) patients were included (mean [SD] age, 66.1 [14.8] years; 577 men [93.8%]; median stay, 8 days [IQR:3-15]. There were sixty-one in-hospital deaths. Veterans in the moderate and high FI-LAB groups had a higher proportion of inpatient mortality (13.3% and 20.6%, respectively) than the low group (4.1%), p <0.001. Moderate and high FI-LAB scores were associated with greater inpatient mortality when compared to the low group, OR:3.22 (95%CI:1.59-6.54), p=.001 and 6.05 (95%CI:2.48-14.74), p<0.001, respectively. Compared with low FI-LAB scores, moderate and high scores were also associated with prolonged length of stay, intensive care unit (ICU) admission, and transfer.

CONCLUSIONS AND RELEVANCE

In this study of patients admitted to 7 VHA Hospitals during the first surge of the pandemic, higher FI-LAB scores were associated with higher in-hospital mortality and other in-hospital outcomes; FI-LAB can serve as a validated, rapid, feasible, and objective frailty tool in hospitalized adults with COVID-19 that can aid clinical care.

Efficacy of acute care pathways for older patients: a systematic review and meta-analysis

Meeting the needs of acute geriatric patients is often challenging, and although evidence shows that older patients need tailored care, it is still unclear which interventions are most appropriate. The objective of this study is to systematically evaluate the hospital-wide acute geriatric models compared with conventional pathways. The design of the study includes hospital-wide geriatric-specific models characterized by components including patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment, and follow-up after discharge. Primary and secondary outcomes were considered, including functional decline, activities of daily living (ADL), length-of-stay (LoS), discharge destination, mortality, costs, and readmission. A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A total of 20 studies reporting on 15 trials and acutely admitted patients with an average age of 79, complex conditions and comorbidities to acute geriatric-specific pathways (N = 13,595) were included. Geriatric-specific models were associated with lower costs (weighted mean difference, WMD =  - $174.98, 95% CI = -$332.14 to - $17.82; P = 0.03), and shorter LoS (WMD =  - 1.11, 95% CI =  - 1.39 to - 0.83; P < 0.001). No differences were found in functional decline, ADL, mortality, case fatalities, discharge destination, or readmissions. Geriatric-specific models are valuable for improving patient and system-level outcomes. Although several interventions had positive results, further research is recommended to study hospital-wide geriatric-specific models.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Background

Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care.

Methods

The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit.

Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively.

Discussion

Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT.

Trial registration

The trial was registered in Clinical Trials Protocols and Results System as of 21^st July 2021, with registration number NCT049836020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00954-5.

Effectiveness of acute geriatric unit care on functional decline and process outcomes among older adults admitted to hospital with acute medical complaints: a protocol for a systematic review

INTRODUCTION

Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints.

DESIGN

Updated systematic review and meta-analysis METHODS AND ANALYSIS: MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow-up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper.

PROSPERO REGISTRATION NUMBER

CRD42021237633.

Predictive ability of the G8 screening test to determine probable sarcopenia and abnormal comprehensive geriatric assessment in older patients with solid malignancies

Background

Pre-treatment evaluation for sarcopenia is recommended in cancer patients. New screening tests that are less time-consuming and can identify patients who will potentially benefit from geriatric assessment are being developed; the G8 geriatric screening test is one such example. We aimed to investigate whether the G8 screening test can detect probable sarcopenia and is valid and reliable compared to a comprehensive geriatric assessment (CGA) in Turkish older adults with solid cancers.

Methods

We included solid cancer patients referred to a single center. Probable sarcopenia and abnormal CGA were defined as low handgrip strength. Cut-offs for handgrip strength in the Turkish population have been previously determined to be 32 kg for males and 22 kg for females and impairment in at least one of the CGA tests, respectively. The CGA tests comprised KATZ Basic Activities of Daily Living Scale Lawton–Brody Instrumental Activities of Daily Living Scale, Mini-Mental-State Examination Scale, Geriatric Depression Scale-15, and Mini-Nutritional Assessment Short Form. Receiver operating characteristic curve analyses evaluated the test’s predictive ability. Intra-rater and inter-rater reliabilities were assessed.

Results

The median age of the 76 patients included was 72 (65–91) years. There was a moderate correlation between handgrip strength and the G8 test total score. The sensitivity and specificity of the G8 test to detect probable sarcopenia alone (cut off score = 12.5) were 50 and 92%, respectively (AUC: 0.747; p < 0.001); to determine abnormal CGA plus probable sarcopenia (cut off score = 13) were 93.33 and 86.89%, respectively (AUC: 0.939; p < 0.001); and to detect abnormal CGA alone (cut off score = 14) were 79.63 and 95.45%, respectively (AUC: 0.893; p < 0.001). The G8 test results agreed with those of CGA (κ = 0.638; p < 0.001). Both inter- and intra-rater assessments of G8 scores revealed a strong agreement (Interclass correlation coefficient = 0.979, p < 0.001 and ρ = 0.994, p < 0.001, respectively).

Conclusions

The Turkish version of the G8 test is a good screening tool to detect probable sarcopenia alone and in conjunction with abnormal CGA in older patients with solid malignancies. The G8 screening tool may thus be useful in detecting probable sarcopenia in Turkish older adults with solid cancers.

Does preoperative hemodynamic preconditioning improve morbidity and mortality after traumatic hip fracture in geriatric patients? A retrospective cohort study

INTRODUCTION

Dehydration is a major problem in the older population with traumatic hip fractures (THF). A preoperative hemodynamic preconditioning (PHP) protocol may help in achieving hemodynamic stability to ensure adequate perfusion and oxygenation using only clinical parameters to assess cardiovascular performance.

MATERIALS AND METHODS

A single-centre retrospective study in geriatric trauma patients was conducted in a Level 1 Trauma Centre in Switzerland. Patients over the age of 70 with THFs and with Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM) scores ≥ 5% who underwent surgical treatment between February 2015 and October 2017 were included. It was hypothesized that patients whose hemodynamic stability was optimised before surgery would have fewer complications and reduced mortality postoperatively. Primary outcomes were complications and mortality. Secondary outcomes were hospital length of stay (HLOS) and place of discharge.

RESULTS

100 patients were included in the PHP group and 79 patients were included in the non-PHP group. The median age was 86.5 (82-90) in the PHP group and 86 (82-90) in the non-PHP group. Patients who had been treated according to the PHP protocol showed a significant reduction in mortality at 30 days (p = 0.02). The PHP group showed an 8.1 and 3.5% reduced mortality at 90 days and at 1 year, respectively. The PHP group showed an 11.7% reduction of patients with complicated courses. No significant differences were seen in HLOS and discharge disposition.

CONCLUSIONS

The PHP group showed a significant reduction in short-term mortality, a reduction in long-term mortality, and a reduction in the number of patients with complicated courses. The PHP protocol is a safe, strictly regulated, non-invasive fluid resuscitation protocol for the optimization of geriatric patients with a THF that requires minimal effort.

LEVEL OF EVIDENCE

Level III, therapeutic.

Research into ageing and frailty

Research into ageing covers opportunities and challenges posed by an older population, and research to understand the ageing processes across the lifespan. The evidence base for Comprehensive Geriatric Assessment (CGA) is well established and efforts should now shift to understanding how to implement its principles across different healthcare contexts. Research around syndromes common in older people has progressed with variable success; while effective therapies for falls and cognitive impairment have been identified, older people with advanced frailty have commonly been excluded from Parkinson's disease and continence research. Research to understand the mechanisms of ageing has potential to mitigate against or treat emerging sarcopenia and cognitive impairment, and thus modify frailty trajectories. Pharmacogenetics could individualise therapeutics to reduce polypharmacy. These issues can only be addressed with development of infrastructure, capacity and expertise in ageing research. Commonly used research methodologies must be adapted to take account of frailty, cognitive impairment and functional dependency.

Managing older patients with heart failure calls for a holistic approach

AIMS

This study aims to assess the presence of geriatric domain impairments in an older heart failure (HF) outpatient population and to relate these domain impairments with 1 year mortality risk in comparison with a geriatric outpatient population without HF.

METHODS AND RESULTS

Data were used from two different prospective cohort studies: 241 outpatients with HF (mean age 78 ± 9 years, 48% female) and 686 geriatric outpatients (mean age 80 ± 7 years, 55% female). We similarly assessed the following geriatric domains in both cohorts: physical function, nutritional status, polypharmacy, cognitive function, and activities in daily living. Cox proportional hazards analyses were used to relate individual domains to 1 year mortality risk in both populations and to compare 1 year mortality risk between both populations. Of the patients with HF, 34% had impairments in ≥3 domains, compared with 38% in geriatric patients. One-year mortality rates were 13% and 8%, respectively, in the HF and geriatric populations; age-adjusted and sex-adjusted hazard ratio (95% confidence interval) for patients with HF compared with geriatric patients was 1.7 (1.3-2.6). The individual geriatric domains were similarly associated with 1 year mortality risk in both populations. Compared with zero to two impaired domains, age-adjusted and sex-adjusted mortality risk (hazard ratio, 95% confidence interval) for three, four, or five impaired domains ranged from 1.6 (0.6-4.2) to 6.5 (2.1-20.1) in the HF population and from 1.4 (0.7-2.9) to 7.9 (2.9-21.3) in the geriatric population.

CONCLUSIONS

In parallel with geriatric patients, patients with HF often have multiple geriatric domain impairments that adversely affect their prognosis. This similarity together with the findings that patients with HF have a higher 1 year mortality risk than a general geriatric population supports the integration of a multi-domain geriatric assessment in outpatient HF care.

Diagnostic and predictive accuracy of the Clinical Frailty Scale among hospitalised older medical patients: a systematic review and meta-analysis protocol

INTRODUCTION

Frailty is a common condition affecting older adults and is associated with increased mortality and adverse outcomes. Identification of older adults at risk of adverse outcomes is central to subsequent resource planning and targeted interventions. This systematic review and meta-analysis will examine the: (1) diagnostic accuracy of the Clinical Frailty Scale (CFS) in identifying hospitalised adults ≥65 years with frailty and a medical diagnosis compared with the reference standard Frailty Index or Frailty Phenotype and (2) predictive value of the CFS in determining those at increased risk of subsequent adverse outcomes.

METHODS AND ANALYSIS

We will include cross-sectional, retrospective and prospective cohort studies, and randomised controlled trials that assess either the diagnostic accuracy of the CFS when compared with the reference standard Frailty Index/Frailty Phenotype or the predictive validity of the CFS to predict subsequent adverse outcomes in hospitalised adults over 65 years with medical complaints. Adverse outcomes include falls, functional decline, unplanned Emergency Department attendance, emergency rehospitalisation, nursing home admission or death. A systematic search will be conducted in Embase, AMED, MEDLINE (Ebsco, Ovid, Pubmed), CINAHL, PsycINFO, Cochrane Library. Studies will be limited to those published from 2005 to 30 October 2019. Two independent reviewers will screen all titles and abstracts to identify relevant studies. The methodological quality of studies will be independently assessed using the Quality Assessment of Diagnostic Accuracy Studies-2. A CFS score of >4 will be used to identify frailty. We will construct 2×2 tables and determine true positives, true negatives, false positives and false negatives for each study when compared with the reference standard and for each adverse outcome. A bivariate random effects model will be applied to generate pooled summary estimates of sensitivity and specificity.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. We will disseminate our findings through a peer-reviewed journal.

A key role for comprehensive geriatric assessment in aortic valve replacement

As our population ages, the demand for surgical services in older people is increasing exponentially. Shown to be indispensable in the care of medical patients, use of the comprehensive geriatric assessment (CGA) is also growing in the perioperative setting. We present the case of a previously independent 82-year-old man who underwent a standard preoperative assessment and surgical aortic valve replacement. In the 7 months that followed, prior to his death, he suffered a rapid functional decline contributed to by slow postoperative recovery, delirium and recurrent falls. Post-mortem revealed cardiac amyloid deposition and extensive small vessel disease in the brain. This case highlights the importance of the CGA in the perioperative management of older patients, especially in identification and optimisation of geriatric syndromes and consideration of less-invasive alternative treatments. We review the existing literature on CGA use in cardiothoracic and vascular surgical settings, drawing on experiences learnt from the above case.

Multidimensional Prognostic Index (MPI) score has the major impact on outcome prediction in elderly surgical patients with colorectal cancer: The FRAGIS study

BACKGROUND

This study aims (I) to evaluate whether the Multidimensional Prognostic Index (MPI) score is associated with postoperative outcomes and (II) to develop a prognostic model for individual complication-risk prediction following colorectal cancer (CRC) surgery.

METHOD

This is a prospective multicentric cohort study. Consecutive ≥75-year-old candidates for elective CRC surgery were enrolled from October 2017 to August 2019. Patients underwent standardized preoperative geriatric assessment including the MPI. Patients with MPI score > 0.33 were classified as frail. Logistic regression models were employed to evaluate variables associated with major postoperative complications and mortality, using 10-fold cross-validated LASSO (least absolute shrinkage and selection operator) for model selection.

RESULTS

In all, 104 patients were included, 34 (33%) had MPI score > 0.33. Major postoperative complications occurred in 52% of frail versus 16% of fit (MPI score ≤ 0.33) patients (p < .01). Both 30-day (9% vs. 0%; p = .033) and 90-day mortality (18% vs. 1%; p < .01) were higher among frail patients. In multivariate analysis, MPI score was associated with adverse outcomes. A final postoperative complication predictive model was created, including MPI score, gait-speed test, ASA (American Society of Anesthesiology) score, surgical approach, and stoma creation.

CONCLUSION

MPI score is strongly associated with postoperative major complications in CRC elderly patients and it is a primary component of an individual prediction model.

An Automated Planning Model for HRI: Use Cases on Social Assistive Robotics

Using Automated Planning for the high level control of robotic architectures is becoming very popular thanks mainly to its capability to define the tasks to perform in a declarative way. However, classical planning tasks, even in its basic standard Planning Domain Definition Language (PDDL) format, are still very hard to formalize for non expert engineers when the use case to model is complex. Human Robot Interaction (HRI) is one of those complex environments. This manuscript describes the rationale followed to design a planning model able to control social autonomous robots interacting with humans. It is the result of the authors’ experience in modeling use cases for Social Assistive Robotics (SAR) in two areas related to healthcare: Comprehensive Geriatric Assessment (CGA) and non-contact rehabilitation therapies for patients with physical impairments. In this work a general definition of these two use cases in a unique planning domain is proposed, which favors the management and integration with the software robotic architecture, as well as the addition of new use cases. Results show that the model is able to capture all the relevant aspects of the Human-Robot interaction in those scenarios, allowing the robot to autonomously perform the tasks by using a standard planning-execution architecture.

Factors Determining the Choice of a Career in Geriatrics among Students in Geriatric in-Hospital Training: A Prospective Study of 74 Medical Students

To understand why students in the 2nd cycle of medical studies choose to complete a Diploma of Specialized Studies (DSS) in geriatrics, we conducted a study to identify the factors influencing the choice of a future specialty. In addition, we assessed the impact of clinical in-hospital training (CIHT) in a geriatric hospital on the students’ selection of their future specialty. We included all students who completed CIHT in the geriatric facility of our University Hospital between 1 May and 31 October 2018. Data were collected using a two-part questionnaire: one part was given before CIHT and the other after. The students were classified into two groups: those considering a career in geriatrics (CIG) before CIHT, forming the group DSS geriatrics+ (GDSSG+), and those not considering it, constituting the group DSS geriatrics− (GDSSG−). Seventy-four students aged 22 years old were included. Of these students, 26% were considering a CIG before CIHT. This rate increased significantly to 42% after CIHT (p = 0.04). However, none of the students who indicated that they were potentially interested in pursuing geriatrics before CIHT preselected geriatrics as their first option. For more than 92% of the students, the comprehensive care of geriatric patients was an asset. The main drawbacks were diagnostic and therapeutic limitations (60% of students), then managing aging, disability, and neurocognitive disorders (55% of students). After CIHT, the view of geriatrics improved by 74%. In conclusion, geriatric CIHT improves students’ opinions of geriatrics and increases the number of students considering a CIG. However, geriatrics still suffers from a lack of prestige.

Quality of Care Perceived by Older Patients and Caregivers in Integrated Care Pathways With Interviewing Assistance From a Social Robot: Noninferiority Randomized Controlled Trial

Background

Society is facing a global shortage of 17 million health care workers, along with increasing health care demands from a growing number of older adults. Social robots are being considered as solutions to part of this problem.

Objective

Our objective is to evaluate the quality of care perceived by patients and caregivers for an integrated care pathway in an outpatient clinic using a social robot for patient-reported outcome measure (PROM) interviews versus the currently used professional interviews.

Methods

A multicenter, two-parallel-group, nonblinded, randomized controlled trial was used to test for noninferiority of the quality of care delivered through robot-assisted care. The randomization was performed using a computer-generated table. The setting consisted of two outpatient clinics, and the study took place from July to December 2019. Of 419 patients who visited the participating outpatient clinics, 110 older patients met the criteria for recruitment. Inclusion criteria were the ability to speak and read Dutch and being assisted by a participating health care professional. Exclusion criteria were serious hearing or vision problems, serious cognitive problems, and paranoia or similar psychiatric problems. The intervention consisted of a social robot conducting a 36-item PROM. As the main outcome measure, the customized Consumer Quality Index (CQI) was used, as reported by patients and caregivers for the outpatient pathway of care.

Results

In total, 75 intermediately frail older patients were included in the study, randomly assigned to the intervention and control groups, and processed: 36 female (48%) and 39 male (52%); mean age 77.4 years (SD 7.3), range 60-91 years. There was no significant difference in the total patient CQI scores between the patients included in the robot-assisted care pathway (mean 9.27, SD 0.65, n=37) and those in the control group (mean 9.00, SD 0.70, n=38): P=.08, 95% CI –0.04 to 0.58. There was no significant difference in the total CQI scores between caregivers in the intervention group (mean 9.21, SD 0.76, n=30) and those in the control group (mean 9.09, SD 0.60, n=35): P=.47, 95% CI –0.21 to 0.46. No harm or unintended effects occurred.

Conclusions

Geriatric patients and their informal caregivers valued robot-assisted and nonrobot-assisted care pathways equally.

Trial Registration

ClinicalTrials.gov NCT03857789; https://clinicaltrials.gov/ct2/show/NCT03857789

Validation of the Pictorial Fit-Frail Scale in a memory clinic setting

OBJECTIVE

To assess the feasibility, reliability, and validity of the Pictorial Fit-Frail Scale (PFFS) among patients, caregivers, nurses, and geriatricians in an outpatient memory clinic.

DESIGN

Observational study.

SETTING

A Canadian referral-based outpatient memory clinic.

PARTICIPANTS

Fifty-one consecutive patients and/or their caregivers, as well as attending nurses and geriatricians.

MEASUREMENTS

Participants (patients, caregivers, nurses, and geriatricians) were asked to complete the PFFS based on the patient's current level of functioning. Time-to-complete and level of assistance required was recorded. Participants also completed a demographic survey and patients' medical history (including the Mini-Mental State Examination [MMSE], and Comprehensive Geriatric Assessment [CGA]) was obtained via chart review.

RESULTS

Patient participants had a mean age of 77.3±10.1 years, and average MMSE of 22.0±7.0, and 53% were female. Participants were able to complete the PFFS with minimal assistance, and their average times to completion were 4:38±2:09, 3:11±1:16, 1:05±0:19, and 0:57±0:30 (mins:sec) for patients, caregivers, nurses, and geriatricians, respectively. Mean PFFS scores as rated by patients, caregivers, nurses, and geriatricians were 9.0±5.7, 13.1±6.6, 11.2±4.5, 11.9±5.9, respectively. Patients with low MMSE scores (0-24) took significantly longer to complete the scale and had higher PFFS scores. Inter-rater reliability between nurses and geriatricians was 0.74, but it was lower when assessments were done for patients with low MMSE scores (0.47, p<0.05). The correlation between PFFS and a Frailty Index based on the CGA was moderately high and statistically significant for caregivers, nurses, and geriatricians (r=0.66, r=0.59, r=0.64, respectively), but not patients.

CONCLUSIONS

The PFFS is feasible, even among people with some slight cognitive impairment, though it may be less useful when patients with severe dementia administer it to themselves. Further, the PFFS may help inform clinicians about areas of concern as identified by patients, enabling them to contribute more to diagnostic and treatment decisions or helping with health tracking and care planning.

Frailty, geriatric assessment and prehabilitation in elderly patients undergoing urological surgery - is there a need for change of the daily clinical practice? Synthesis of the available literature

Introduction

The population of older people is heterogeneous and constantly growing. Over 50% of urological operations are performed in elderly patients. Some elderly patients present with frailty syndrome - a state of increased vulnerability to external stressors resulting in increased risk of hospitalizations, adverse treatment outcomes and death. Currently, there is no widely accepted system of qualification and preparation for surgical treatment developed specifically for elderly patients.

Material and methods

We searched Medline/Pubmed, Embase and Cochrane Libraries databases from 2000-2020 (week 5). The following medical subject headings (MeSH) terms were used to ensure the sensitivity of the searches: geriatric assessment, frailty, urology, and prehabilitation. Relevant articles were also identified through a manual search of the reference lists of potentially relevant articles.

Results

A total of 23 papers met the criteria and were included in the current study. Screening for frailty seems to be promising in predicting adverse outcomes, but frail patients should undergo detailed geriatric assessment (GA) which may indicate a need for preoperative intervention which can be unavailable during the hospitalization. The concept of prehabilitation is becoming increasingly discussed in thoracic and abdominal surgery, but only a few studies are available in the field of urology.

Conclusions

Geriatric assessment seems to be a valuable tool for urologists in daily clinical practice. A proper form of prehabilitation may provide enhanced recovery after surgery.

The cumulated ambulation score is superior to the new mobility score and the de Morton Mobility Index in predicting discharge destination of patients admitted to an acute geriatric ward; a 1-year cohort study of 491 patients

PURPOSE

To investigate the predictive value of New Mobility Score, de Morton Mobility Index, and Cumulated Ambulation Score regarding discharge destination, and to determine the feasibility of the tests in an acute geriatric ward.

MATERIALS AND METHODS

Observational 1-year cohort study of 491 geriatric patients admitted consecutively from own home. New Mobility Score (pre-hospital functional level), de Morton Mobility Index, and Cumulated Ambulation Score were recorded at the first physiotherapy contact.

RESULTS

Univariable logistic regression showed that the odds for not being discharged home were 7 times higher (odds ratio = 7.6, 95%CI; 4.5-12.7) for patients with a non-independent mobility level (Cumulated Ambulation Score ≤ 5) compared to independent (Cumulated Ambulation Score = 6). Corresponding ratios were 6.2 (3.8-10.0) for de Morton Mobility Index ≤ 41 points and 2.8 (1.8-4.5) for New Mobility Score ≤5 points. Adjustment for gender, age, cause of admission, and marital status improved the predictive value of the Cumulated Ambulation Score. Upon admission, 99% of the patients were assessed with New Mobility Score, 100% with Cumulated Ambulation Score, and 81% with de Morton Mobility Index.

CONCLUSION

Cumulated Ambulation Score is more feasible and superior in predicting discharge destination than de Morton Mobility Index and New Mobility Score in an acute geriatric ward.Implications for rehabilitationEasy, quick, and accurate measurement of mobility is essential for discharge planning and effective targeting of physiotherapy in an acute geriatric ward.The objectively assessed Cumulated Ambulation Score is superior to the de Morton Mobility Index and the pre-hospital New Mobility Score in predicting discharge destination in geriatric patients admitted from their own home.The Cumulated Ambulation Score and the New Mobility Score are more feasible and less time consuming to complete in an acute geriatric ward compared to the de Morton Mobility Index.

ADL-dependency, D-Dimers, LDH and absence of anticoagulation are independently associated with one-month mortality in older inpatients with Covid-19

Background: To assess factors associated with one-month mortality among older inpatients with Covid-19.

Results: The mean age was 78 ± 7.8 years, 55.5% were men, CT scan lung damage was observed in 76% of the patients (mild 23%, moderate 38%, extensive 22%, and severe 7%). The mortality rate was 26%. Dependency/Activities of Daily Living (ADL) score ≤ 5/6, D-Dimers, LDH, and no anticoagulation by reference for curative were independently associated with one-month mortality. A score derived from the multivariate model showed good calibration and very good discrimination (Harrell’s C index [95%CI] = 0.83 [0.79-0.87]).

Conclusion: ADL-dependency, high serum levels of D-Dimers and LDH and the absence of anticoagulation were independently associated with one-month mortality among older inpatients with Covid-19.

Methods: 108 consecutive older inpatients aged 65 and over with Covid-19 confirmed by RT-PCR and/or typical CT chest scan were prospectively included in a French single-centre cohort study from March to April 2020. A systematic geriatric assessment was performed. Covariates were lymphocyte count, serum levels of albumin, C-Reactive Protein, D-Dimers and Lactate Dehydrogenase (LDH), anticoagulation level, and exposure to the hydroxychloroquine and azithromycin combined therapy. Cox uni- and multivariate proportional-hazard regressions were performed to identify predictors of one-month mortality.

Assessments of frailty in bladder cancer

BACKGROUND AND AIMS

The incidence of frailty is increasing as the population ages, which has important clinical implications given the associations between frailty and poor outcomes in the bladder cancer population. Due to a multi-organ system decline and decreased physiologic reserve, frail patients are vulnerable to stressors of disease and have poorer mortality and morbidity rates than their nonfrail peers. The association between frailty and poor outcomes has been documented across multiple populations, including radical cystectomy, creating a need for frailty assessments to be used preoperatively for risk stratification. We aim to provide a review of the common frailty assessments and their relevance to radical cystectomy patients.

FINDINGS

A variety of assessments for frailty exist, from short screening items to comprehensive geriatric assessments. The syndrome spans multiple organ systems, as do the potential diagnostic instruments. Some instruments are less practical for use in clinical practice by urologists, such as the Canadian Study of Health and Aging Frailty Index and Comprehensive Geriatric Assessment. The tool most studied in radical cystectomy is the modified Frailty Index, associated with high grade complications and 30-days mortality. Frailty often coexists with malnutrition and sarcopenia, stressing the importance of screening for and addressing these syndromes to improve patient's perioperative outcomes.

CONCLUSIONS

There is no universally agreed upon frailty assessment, but the most studied in radical cystectomy is the modified Frailty Index, providing valuable data with which to counsel patients preoperatively. Alterations in immune phenotypes provide potential future diagnostic biomarkers for frailty.

Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study

Background

Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.

Aims

To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.

Design

Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.

Setting

Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.

Participants

Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.

Main outcome measures

Length of stay, quality of assessment and carer-rated experience.

Results

People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.

Limitations

The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.

Conclusions

If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.

Future work

Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.

Predicting hospitalisation-associated functional decline in older patients admitted to a cardiac care unit with cardiovascular disease: a prospective cohort study

BACKGROUND

Up to one in three of older patients who are hospitalised develop functional decline, which is associated with sustained disability, institutionalisation and death. This study developed and validated a clinical prediction model that identifies patients who are at risk for functional decline during hospitalisation. The predictive value of the model was compared against three models that were developed for patients admitted to a general medical ward.

METHODS

A prospective cohort study was performed on two cardiac care units between September 2016 and June 2017. Patients aged 75 years or older were recruited on admission if they were admitted for non-surgical treatment of an acute cardiovascular disease. Hospitalisation-associated functional decline was defined as any decrease on the Katz Index of Activities of Daily Living between hospital admission and discharge. Predictors were selected based on a review of the literature and a prediction score chart was developed based on a multivariate logistic regression model.

RESULTS

A total of 189 patients were recruited and 33% developed functional decline during hospitalisation. A score chart was developed with five predictors that were measured on hospital admission: mobility impairment = 9 points, cognitive impairment = 7 points, loss of appetite = 6 points, depressive symptoms = 5 points, use of physical restraints or having an indwelling urinary catheter = 5 points. The score chart of the developed model demonstrated good calibration and discriminated adequately (C-index = 0.75, 95% CI (0.68-0.83) and better between patients with and without functional decline (chi² = 12.8, p = 0.005) than the three previously developed models (range of C-index = 0.65-0.68).

CONCLUSION

Functional decline is a prevalent complication and can be adequately predicted on hospital admission. A score chart can be used in clinical practice to identify patients who could benefit from preventive interventions. Independent external validation is needed.

The implementation of a Geriatric Fracture Centre for hip fractures to reduce mortality and morbidity: an observational study

INTRODUCTION

The aim of this study was to evaluate the effect of an orthogeriatric treatment model on elderly patients with traumatic hip fractures (THF). The Geriatric Fracture Centre (GFC) is a multidisciplinary care pathway with attention for possible age-related diseases, discharge management and out-of-hospital treatment.

MATERIALS AND METHODS

A prospective cohort study with a historical cohort group was conducted at a level I trauma centre in Switzerland. Patients over the age of 70 years with THFs who underwent surgical treatment at GFC in 2013 and 2016 were included. Primary outcomes were mortality and complications. Secondary outcomes were hospital length of stay (HLOS), time to surgery and place of discharge.

RESULTS

A total of 322 patients were included in this study. In 2016, mortality showed a reduction of 2.9% at 30 days (p = 0.42) and 3.4% at 90 days (p = 0.42) and 0.1% at 1 year (p = 0.98). The number of patients with a complicated course showed a decrease of 2.2% in 2016 (p = 0.69). A significant increase in the diagnosis of delirium by 11.2% was seen in 2016 (p < 0.001). The median HLOS was significantly reduced by 2 days (p < 0.001). An increase of 21.1% was seen in patients who were sent to rehabilitation in 2016 (p < 0.001). Day-time surgery increased by 10.2% (p = 0.04).

CONCLUSION

The implementation of the GFC leads to improved processes and outcomes for geriatric patients with THFs. Increased awareness and recognition led to an increase in the diagnosis of complications that would otherwise remain untreated. Expanding these efforts might lead to more significant effects and an increase in the reduction of morbidity and mortality in the future.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

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

How do doctors choose treatment for older gynecological cancer patients? A Japanese Gynecologic Oncology Group survey of gynecologic oncologists

BACKGROUND

The proportion of elderly Japanese people (age ≥ 65 years) is currently 27.7%, and the average life span of women is 87.14 years, both of which are unprecedented. In gynecologic cancer, evidence of treatment for the elderly is scarce, and treatment policies are determined by each facility. The aim of the present study was to investigate the status of treatment policies for elderly patients with gynecologic cancer.

METHODS

A web-based questionnaire regarding how treatment strategies are currently determined for elderly patients with gynecologic cancer was conducted on gynecologic oncologists to develop a tool for the objective evaluation of treatment policy decisions for elderly patients.

RESULTS

The responses showed that 48% of the gynecologic oncologists were aware of comprehensive geriatric assessment (CGA), but only 6% had actually conducted CGA. Age, comorbidities, performance status, and pretreatment evaluations were regarded as important in determining the treatment strategy. Invasive treatments such as radical hysterectomy and para-aortic lymph node dissection tended to have age limits.

CONCLUSIONS

These findings suggest that awareness of CGA is low in Japan, and that elderly people may not be given standard therapy, which highlights the importance of building on these findings by gathering further evidence and developing a new tool for predicting treatment outcomes for elderly patients with gynecologic cancer.

Perioperative Medicine for Older People

Global demographic changes have resulted in an older, frailer surgical population with significant multimorbidity causing higher frequency of adverse postoperative outcomes. The need for restructuring of perioperative care pathways to address this issue has been recognised. Comprehensive geriatric assessment (CGA) and optimisation are emerging as innovative perioperative pathways. This paper describes one centre’s approach in applying CGA in the surgical setting and presents the evidence in support of this. Similar models are being established in Singapore in hip fracture, colorectal and vascular populations. The challenges in the widespread adoption of such models of care are similar across settings. The global nature of translation is also discussed in this paper. Key words: Comprehensive geriatric assessment, Geriatrician-led multidisciplinary team, Optimisation

Structured follow-up of frail home-dwelling older people in primary health care: is there a special need, and could a checklist be of any benefit? A qualitative study of experiences from registered nurses and their leaders

Aim

To identify experiences and opinions about the need for a structured follow-up and to identify potential benefits and barriers to the use of a checklist (Sub Acute Functional decline in the Older people [SAFE]) when caring for frail home-dwelling older people.

Background

The complexity of older peoples’ health situation requires more coordinated health care across health care levels and a better structured follow-up than is currently being offered, especially in the transitional phase between hospital discharge and primary care, but also in more stable phases at home.

Design

This was a qualitative study using focus group interviews.

Methods

Data were collected during six focus group interviews in three districts in a municipality. Nineteen registered nurses (RNs) and seventeen leaders responsible for the follow-up of frail home-dwelling older people participated. Participants were representatives of the RNs in homecare and their leaders.

Results

Our results highlight that although most RNs and their leaders saw a number of significant benefits to conducting a structured assessment and follow-up of frail older people home care recipients, a number of barriers made this difficult to realize on a daily basis.

Conclusion

There is no common perception that a structured follow-up of frail home-dwelling older people in primary health care is an important and contributing factor to better quality of health care. Despite this, most RNs and leaders found that the use of a structured checklist such as SAFE was a benefit to achieving a structured follow-up of the frail older people. We identified several factors of importance to whether a structured follow-up with a checklist is conducted in home care.

The proactive elderly care team: dementia screening of over 20 000 patients

The proactive elderly care team was introduced at Lancashire Teaching Hospitals NHS Foundation Trust in October 2012. This article describes how the team performed over 5 years (up to the end of December 2017). The proactive elderly care team had three broad aims related to all non-elective patients over the age of 75 years who either came to accident and emergency or were admitted into the hospital, irrespective of speciality: To screen all patients over the age of 75 years for delirium and dementia To identify patients over 75 years who were the most frail, and would benefit from a comprehensive geriatric assessment and targeted interventions To reduce length of stay for patients over the age of 75 years without any increase in their readmission rate. Following the introduction of the proactive elderly care team, length of stay and the readmission rate of patients who were seen by the service fell by about 50%. Almost £10 million has been saved and for every £1 invested in the proactive elderly care team service, over £12 was saved.

Role of muscle power output as a mediator between gait variability and gait velocity in hospitalized older adults

Acute illness requiring hospitalization is a sentinel event leading to functional decline and frequently, long-term disability in older adults. Although functional decline has become a key outcome during and after hospitalization, there is currently no gold standard for measuring functional impairment. The purpose of this study was to compare gait characteristics and muscle performance endpoints of hospitalized older adults based on the Short Physical Performance Battery (SPPB) score (0-12 points) obtained at admission, and to determine the association underlying the gait impairment. A total of 130 hospitalized older adults (aged ≥75) were included. The primary endpoints were differences in functional capacity between groups, assessed with the 6-m Gait Velocity Test (GVT), verbal and arithmetic GVT, followed by gait pattern data recorded using an inertial sensor unit. Maximal muscle strength (MS) and muscle power (MP) were also measured as muscle performance endpoints. A mediation analysis was performed to understand gait disorders. The walking parameters measured at admission were related to functional status and showed significant differences among phenotype groups (disabled, frail, and prefrail groups), as well as muscle performance endpoints (p < 0.05). Finally, the indirect effect was significant (-0.27; 95%CI, -0.59 to -0.05), confirming the mediation role of MP between gait variability and gait velocity in this model. MP slightly weakens the relationship between gait variability and gait velocity. In addition to MS and MP, gait velocity and gait pattern parameters are distinguishing factors among acutely hospitalized older adults.

Perioperative comprehensive geriatric assessment: what do we need to know?

As a consequence of an ageing population greater numbers of elderly patients are presenting for both elective and emergency surgery. These older patients typically present with an increased burden of age-related problems and multimorbidity, which is associated with an increased risk of adverse postoperative outcomes. Traditional preoperative assessment models are adept at discerning patients' suitability for anaesthesia and surgery, but there is minimal focus on improving postoperative outcomes.

Comprehensive geriatric assessment is a multidisciplinary approach used both to assess existing ‘known’ pathology and to screen for previously undiagnosed issues across medical, functional, social and/or psychological domains. This diagnostic phase then leads to the development and implementation of an individualized ‘optimization’ strategy across these domains. There is emerging evidence that comprehensive geriatric assessment and optimization in the surgical setting leads to improved outcomes, and it is reasonable to conclude that it would benefit the patient's long-term health.

Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review

OBJECTIVES

Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes.

DESIGN

Realist review.

SETTING

Care homes.

METHODS

The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute.

RESULTS

130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care.

CONCLUSION

The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings.

TRIAL REGISTRATION NUMBER

CRD42017062601.

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

Background

The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.

Objectives

To improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.

Methods

We used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.

Results

We included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.

Limitations

The risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.

Conclusions

The CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.

Funding

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

Frailty in people living with HIV

The life expectancy of people living with HIV (PLHIV) has dramatically improved with effective and well-tolerated antiretroviral therapy. This presents a new challenge in caring for this patient population, with up to 28% of older PLHIV being identified as frail. Studies suggest that the prevalence of frailty is higher in PLHIV compared to the general population, and that the onset of frailty occurs at an earlier age. Frail individuals often present with multiple and non-specific health complaints, fluctuating disability, falls and delirium, and are at higher risk for multiple adverse outcomes, post-operative complications, poor responses to vaccination and functional decline. They tend to require longer hospital admissions, are more likely to require nursing home care, and are at greater risk of mortality. The degree of frailty can fluctuate over time. Limited evidence exists to support the reversal of frailty, but epidemiological evidence suggests that interventions to assess and manage co-morbidities, reducing risk factors such as smoking, increasing exercise and optimising BMI, and improving personal and community resources, are all likely to reduce the risk of frailty. Physicians who care for PLHIV need to recognise and manage frailty in this patient population. This includes an understanding of: when to intervene aggressively in the management of an older patient with a new HIV diagnosis to delay or prevent permanent debility and frailty; when to acknowledge that the patient has become frail; and the role of geriatric medicine in addressing the specific issues and needs of this patient, such as maximising functional ability, preventing falls, reducing social isolation and improving quality of life.

Improving the personalisation of care in a district nursing team: a service improvement project

Service users can benefit in a variety of ways from a personalised approach to care. This service improvement project aimed to improve personalisation for patients being cared for by a community nursing team in the south of England. A plan, study, do, act (PDSA) approach to the project was undertaken with a community nursing team. Both quantitative and qualitative data showed improvement once the focus on personalisation had been improved. Patient and staff satisfaction scores improved and a documentation audit showed the focus on personalisation had increased. Qualitative data suggested that personalisation had also saved staff time, although this measurement was not included in the project. A focus on personalisation can be beneficial for staff and service users.

Geriatric CO-mAnagement for Cardiology patients in the Hospital (G-COACH): study protocol of a prospective before-after effectiveness-implementation study

INTRODUCTION

Although the majority of older patients admitted to a cardiology unit present with at least one geriatric syndrome, guidelines on managing heart disease often do not consider the complex needs of frail older patients. Geriatric co-management has demonstrated potential to improve functional status, and reduce complications and length of stay, but evidence on the effectiveness in cardiology patients is lacking. This study aims to determine if geriatric co-management is superior to usual care in preventing functional decline, complications, mortality, readmission rates, reducing length of stay and improving quality of life in older patients admitted for acute heart disease or for transcatheter aortic valve implantation, and to identify determinants of success for geriatric co-management in this population.

METHODS AND ANALYSIS

This prospective quasi-experimental before-and-after study will be performed on two cardiology units of the University Hospitals Leuven in Belgium in patients aged ≥75 years. In the precohort (n=227), usual care will be documented. A multitude of implementation strategies will be applied to allow for successful implementation of the model. Patients in the after cohort (n=227) will undergo a comprehensive geriatric assessment within 24 hours of admission to stratify them into one of three groups based on their baseline risk for developing functional decline: low-risk patients receive proactive consultation, high-risk patients will be co-managed by the geriatric nurse to prevent complications and patients with acute geriatric problems will receive an additional medication review and co-management by the geriatrician.

ETHICS AND DISSEMINATION

The study protocol was approved by the Medical Ethics Committee UZ Leuven/KU Leuven (S58296). Written voluntary (proxy-)informed consent will be obtained from all participants at the start of the study. Dissemination of results will be through articles in scientific and professional journals both in English and Dutch and by conference presentations.

TRIAL REGISTRATION NUMBER

NCT02890927.

Is care based on comprehensive geriatric assessment with mobile teams better than usual care? A study protocol of a randomised controlled trial (The GerMoT study)

INTRODUCTION

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process used to determine the medical, psychological and functional capabilities of frail older people. The primary aim of our current study is to confirm whether CGA-based outpatient care is superior than usual care in terms of health-related outcomes, resource use and costs.

METHODS AND ANALYSIS

The Geriatric Mobile Team trial is designed as a single-centre randomised, controlled, assessor-blinded (at baseline) trial. All participants will be identified via local healthcare registries with the following inclusion criteria: age ≥75 years, ≥3 different diagnoses and ≥3 visits to the emergency care unit (with or without admittance to hospital) during the past 18 months. Nursing home residency will be an exclusion criterion. Baseline assessments will be done before the 1:1 randomisation. Participants in the intervention group will, after an initial CGA, have access to care given by a geriatric team in addition to usual care. The control group receives usual care only. The primary outcome is the total number of inpatient days during the follow-up period. Assessments of the outcomes: mortality, quality of life, health care use, physical functional level, frailty, dependence and cognition will be performed 12 and 24 months after inclusion. Both descriptive and analytical statistics will be used, in order to compare groups and for analyses of outcomes over time including changes therein. The primary outcome will be analysed using analysis of variance, including in-transformed values if needed to achieve normal distribution of the residuals.

ETHICS AND DISSEMINATION

Ethical approval has been obtained and the results will be disseminated in national and international journals and to health care leaders and stakeholders. Protocol amendments will be published in ClinicalTrials.gov as amendments to the initial registration NCT02923843. In case of success, the study will promote the implementation of CGA in outpatient care settings and thereby contribute to an improved care of older people with multimorbidity through dissemination of the results through scientific articles, information to politicians and to the public.

TRIAL REGISTRATION NUMBER

NCT02923843; Pre-results.