Assessment Of Older Patients Research Articles

Simplified Geriatric Assessment in Older Patients With Diffuse Large B-Cell Lymphoma: The Prospective Elderly Project of the Fondazione Italiana Linfomi.

To prospectively validate the use of a simplified geriatric assessment (sGA) at diagnosis and to integrate it into a prognostic score for older patients with diffuse large B-cell lymphoma (DLBCL). We conducted the prospective Elderly Project study on patients with DLBCL older than 64 years who underwent our Fondazione Italiana Linfomi original geriatric assessment (oGA) (age, Cumulative Illness Rating Scale for Geriatrics, activities of daily living, and instrumental activities of daily living) before treatment. Treatment choice was left to the physician's discretion. The primary end point was overall survival (OS) (ClinicalTrials.gov identifier: NCT02364050). We analyzed 1,163 patients (median age 76 years), with a 3-year OS of 65% (95% CI, 62 to 68). Because at multivariate analysis on oGA, age > 80 years retained an independent correlation with OS, we also developed a new, simplified version of the GA (sGA) that classifies patients as fit (55%), unfit (28%), and frail (18%) with significantly different 3-year OS of 75%, 58%, and 43%, respectively. The sGA groups, International Prognostic Index, and hemoglobin levels were independent predictors of OS and were used to build the Elderly Prognostic Index (EPI). Three risk groups were identified: low (23%), intermediate (48%), and high (29%), with an estimated 3-year OS of 87% (95% CI, 81 to 91), 69% (95% CI, 63 to 73), and 42% (95% CI, 36 to 49), respectively. The EPI was validated using an independent external series of 328 cases. The Elderly Project validates sGA as an objective tool to assess fitness status and defines the new EPI to predict OS of older patients with DLBCL.

Protocol for a multi-site, cluster\u2010randomized, phase III, comparative clinical trial of geriatric assessment of older patients with non\u2010small\u2010cell lung cancer: the ENSURE-GA study

BackgroundIn Japan, approximately half of all lung cancer patients are aged > 75 years, and the proportion of older patients is increasing. In older patients, it is necessary to consider comorbidities and concomitant drug use to ensure optimal cancer treatment; however, geriatric assessment (GA) is not widely performed. We plan to conduct a study (ENSURE-GA) of GA in older lung cancer patients to determine whether GA with intervention improves patient satisfaction with their treatment.MethodsThe study will be a phase III comparative clinical trial with a cluster-randomized design, and it will be conducted at 81 sites distributed throughout Japan. Approximately 1000 lung cancer patients aged ≥ 75 years will be enrolled in the study. All participants will undergo a standardized GA before starting treatment (using an iPad). At the intervention sites, the GA results and intervention method recommended on the basis of the GA results will be returned as an instant report to guide the physician’s choice of intervention. At the control sites, the physician will decide on interventions based on standard practice. All participants will complete a patient satisfaction survey before treatment initiation (after the GA) and 3 months later.DiscussionThe purpose of the ENSURE-GA study is to evaluate whether GA with interventions improves patient satisfaction with treatment outcomes. The study may lead to the increased use of GA and improved treatment of cancer in older adults. The results will also be used to prepare guidelines for treating older cancer patients and will provide a foundation for the development of a standardized geriatric oncology system.Trial registrationThe study has been registered in the University Hospital Medical Information Network database (no. UMIN000037590). The registration date is August 4, 2019, and the protocol version is 2.0. (https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000042853.)

Delirium, Dementia, & Depression (3D) Assessment of Older Patients in the Emergency Department: 5-Year Survival Analysis

Delirium, Dementia, & Depression (3D) Assessment of Older Patients in the Emergency Department: 5-Year Survival Analysis

Do The Oncologists Systematically Follow Treatment Recommendations And Protocol Adaptations Suggested By Prior Comprehensive Geriatric Assessment In Older Patients With Colorectal Cancer?

In order to assess the ability of older patient with Colorectal Cancer (CRC) to receive chemotherapy, a Comprehensive Geriatric Assessment (CGA) is recommended before the final therapeutic decision.

Interprofessional medication assessment among home care patients: any impact on functioning? Results from a randomised controlled trial

BackgroundMultimorbidity and polypharmacy are related to the use of potentially inappropriate medicines and negative clinical outcomes including drug-related adverse events and functional declines. Home care clients are a vulnerable patient group often exposed to these risks. The aim of this study was to examine whether an interprofessional medication assessment can influence the functioning of home care patients.MethodsThe FIMA study was a randomised controlled intervention study comparing a general practitioner-led interprofessional medication assessment conducted at the baseline of the study with usual care with a six-month follow-up. We used linear mixed models (LMM) with a random subject effect to detect differences between the usual care and intervention groups in the following outcome measures; Katz index of Activities of Daily Living (ADL), Lawton and Brody scale of Instrumental Activities of Daily Living, Timed up and go-test (TUG), Mini-Mental State Examination, Geriatric Depression Scale and the 3-level version of EQ-5D.ResultsHome care patients (n = 512) had major disease burdens and functional limitations. Regarding TUG times, the LMM detected a one second improvement in the FIMA group and 2.4 s worsening in the usual care group. However, the result was not statistically significant. The ADL revealed an interaction across time, treatment and sex (p = 0.026). The ADL score decreased in both groups; the decline being the steepest among women in the intervention group.ConclusionsIn general, medication assessments may have limited impact on functioning of older people. Nonetheless, the FIMA intervention may prevent worsening of mobility among older home care patients.Trial registrationThe Interprofessional Medication Assessment for Older Patients, Clinical Trials.gov. NCT02398812. First registration, 26 March 2015. Retrospectively registered.

Medication Reconciliation Associated with Comprehensive Geriatric Assessment in Older Patients with Cancer: ChimioAge Study.

BackgroundPolymorbidity induces polypharmacy in older patients may lead to potential drug–drug interactions (DDI) which can modify the tolerance and safety of oncological treatments and alter the intended therapeutic effect. The objective of our study was to describe the decision-making process for oncological treatment and related outcomes, in a population of older adults undergoing a comprehensive geriatric assessment (CGA) associated to a comprehensive medication reconciliation (CMR) prior to initiating oncological treatment.MethodsChimioAge is a prospective observational study conducted between 01/2017 and 07/2018 at Marseille University Hospital and approved by the French National Ethics Committee. It comprised all consecutive patients aged 70 years and over who were referred for a CGA as part of CMR, before initiating systemic treatment.ResultsOne hundred and seventy-one cancer patients were included. Mean age was 79.2 years, over half had metastatic cancers, 75% had an ECOG performance status zero or one, and two-thirds were independent in daily activities. Two-thirds of the patients had polypharmacy and the CMR identified potential DDI with systemic treatment in 43.3% of patients. Following the CGA, the CMR and the hospital oncologists decision, 30% of the patients received adapted systemic treatment with reduced doses at initiation. They presented fewer toxicities – irrespective of grade and type – than patients who received standard treatment (p<0.001) and had comparable overall survival (Log rank p=0.21).ConclusionThis is one of the first studies to highlight the value in conducting CMR and a CGA simultaneously before initiating systemic treatment in older patients with cancer. These two evaluations could give oncologists decisive information to personalize cancer treatment of older patients and optimize treatment dose to offer the best efficacy and minimize toxicity.

Frailty assessment tools and geriatric assessment in older patients with hepatobiliary and pancreatic malignancies

BackgroundThe majority of patients with hepatobiliary and pancreatic (HBP) malignancies are older than 65 years. Due to the heterogeneity of this older population, decisions regarding surgical treatment cannot rely solely on treatment guidelines, but have to take into account patient frailty, geriatric impairments and resilience as well as patient preferences. In the few studies of older patients with HBP malignancies that have included a preoperative geriatric assessment (GA), frailty and elements from the GA such as reduced functional status have emerged as powerful predictors of postoperative morbidity and mortality, length of stay, type of treatment received and survival. A GA is a systematic evaluation of functional status, comorbidities, polypharmacy, cognition, nutritional status, emotional status, and social support. Materials and methodsA Pubmed search identifying clinical studies investigating the association between frailty, GA and outcomes in patients with HBP malignancies. ResultsA total of 20 studies were included in this review. For HBP malignancies, the evidence linking frailty and GA variables to negative outcomes is limited, but generally shows that frailty, functional dependency, comorbidity, and sarcopenia predict postoperative complications and survival. ConclusionAlthough scarcely investigated, frailty and elements from a GA seem to be associated with negative short- and long-term treatment outcomes in older patients with HBP malignancies. Future studies should investigate the impact of geriatric interventions and prehabilitation on outcomes.

Comprehensive geriatric assessment in older patients with cancer: an external validation of the multidimensional prognostic index in a French prospective cohort study

BackgroundOlder patients with cancer require specific and individualized management. The 3-group Multidimensional Prognostic Index (MPI) based on the Comprehensive Geriatric Assessment (CGA) has shown a predictive interest in terms of mortality. The objective of our study was to assess the prognostic value of MPI for 1-year mortality in an external prospective French cohort of elderly patients with cancer.MethodsFrom March 2015 to March 2017 a prospective single-center cohort study enrolled all patients with cancer, aged 75 years and older referred to the geriatric oncology clinic. We used a proportional hazard model for 1-year mortality adjusted for age, sex, tumor sites and metastatic status. C-statistics were used to assess the incremental predictive value of MPI index to these risk factors.Resultsoverall, 433 patients underwent CGA with MPI (women 42%; mean age 82.8 ± 4.8 years). The most common tumor sites were prostate (23%), skin (17%), colorectum (15%) and breast (12%); 29% of patients had a metastatic disease; 231 patients (53%) belonged to the “MPI-1” group, 172 (40%) to the “MPI-2” group and 30 patients were classified in the “MPI-3” group. One-year mortality rate was 32% (23% in MPI-1, 41% in MPI-2 and 53% in MPI-3, p = 0.024). All domains of MPI except cognition and living status were significantly associated with mortality at one-year, as well as tumor sites and metastatic status. Higher MPI was associated with a higher mortality risk (adjusted HR 1.56 [95%CI 1.70–2.09] and 1.72 [1.33–2.22] for MPI groups 2 and 3 compared to 1; p < 0.0001).ConclusionsIn addition to established risk factors, MPI improves risk prediction of 1-year mortality. This practical prognostic tool may help to optimize management of these vulnerable patients.

Evaluation of comprehensive geriatric assessment in older patients undergoing pacemaker implantation

BackgroundThis study evaluated the use of comprehensive geriatric assessment (CGA) in older patients undergoing pacemaker implantation.MethodsIn this prospective cohort, CGA was performed in 197 patients ≥75 years at pacemaker implantation and yearly thereafter. CGA embraced the following domains: cognition, mobility, nutrition, activities of daily living (ADLs), and falls (with or without loss of consciousness). Based on comorbidities, the Charlson comorbidity index (CCI) was calculated. For predictive analysis, logistic regression was used.ResultsDuring a mean follow-up duration of 2.4 years, the incidence rates of syncope decreased from 0.46 to 0.04 events per year (p < 0.001), and that of falls without loss of consciousness from 0.27 to 0.15 (p < 0.001) before vs. after implantation. Sixty-three patients (32.0%) died. Impaired mobility (OR 2.60, 95%CI 1.22–5.54, p = 0.013), malnutrition (OR 3.26, 95%CI 1.52–7.01, p = 0.002), and a higher CCI (OR per point increase 1.25, 95%CI 1.04–1.50, p = 0.019) at baseline were significant predictors of mortality. Among 169 patients who survived for more than 1 year and thus underwent follow-up CGA, CGA domains did not deteriorate during follow-up, except for ADLs. This decline in ADLs during follow-up was the strongest predictor of later nursing home admission (OR 9.29, 95%CI 1.82–47.49, p = 0.007). Higher baseline age (OR per year increase 1.10, 95%CI 1.02–1.20, p = 0.018) and a higher baseline CCI (OR per point increase 1.32, 95%CI 1.05–1.65, p = 0.017) were associated with a decline in ADLs during follow-up.ConclusionsCGA is useful to detect functional deficits, which are associated with mortality or nursing home admission after pacemaker implantation. The present study seems to support the use of CGA in older patients undergoing pacemaker implantation as functional deficits and falls are amenable to geriatric interventions.

The impact of a tailored follow-up intervention on comprehensive geriatric assessment in older patients with cancer - a randomised controlled trial

PurposeComprehensive Geriatric Assessment (CGA) can identify health problems in older persons. In addition, CGA includes intervention towards the identified problems. With follow up, more problems may be identified and the interventions can be adjusted. We wanted to compare CGA with or without tailored follow-up in a randomised design. Patients and MethodsPatients 70+ years referred for oncology treatment with four primary tumour sites. Participants were randomised 1:1 to either control group with no follow-up or intervention group with a tailored follow-up by a multidisciplinary team. Primary outcome was adherence to cancer treatment. Secondary outcomes were daily life activities, physical performance and hospitalisation. ResultsIn total, 363 participants were randomised. After randomisation only 301 were planned to receive specific cancer treatment. Median age was 75 years. Among the 301 participants, 52% of control group vs. 61% of intervention group completed treatment. Risk Rate (RR): 1.16 (95% Confidence Interval (CI): 0.95–1.42), p = .14. The impact varied between the included tumour-sites, p < .01. We found no difference in 90 days physical performance or daily life activities between groups. During the study period, 55% of controls vs. 47% in the intervention group were admitted to hospital, RR: 0.86 (95%CI: 0.69–1.07), p = .19. ConclusionIn frail and vulnerable patients with cancer, a tailored follow-up on CGA showed no differences in ability to complete initially planned cancer treatment. The impact varied between the included tumour sites. We did not find any impact of tailored follow-up on daily life activities, physical performance or hospitalisation.

Geriatric assessment in older patients with a hematologic malignancy: a systematic review.

The aim of this systematic review is to give an update of all currently available evidence on the relevance of a geriatric assessment in the treatment of older patients with hematologic malignancies. A systematic search in MEDLINE and EMBASE was performed to find studies in which a geriatric assessment was used to detect impaired geriatric domains or to address the association between geriatric assessment and survival or clinical outcome measures. The literature search included 4,629 reports, of which 54 publications from 44 studies were included. Seventy-three percent of the studies were published in the last 5 years. The median age of the patients was 73 years (range, 58-86) and 71% had a good World Health Organization (WHO) performance status. The median prevalence of geriatric impairments varied between 17% and 68%, even in patients with a good WHO performance status. Polypharmacy, nutritional status and instrumental activities of daily living were most frequently impaired. Whereas several geriatric impairments and frailty (based on a frailty screening tool or summarized geriatric assessment score) were predictive for a shorter overall survival, WHO performance status lost its predictive value in most studies. The association between geriatric impairments and treatment-related toxicity varied, with a trend towards a higher risk of (non-)hematologic toxicity in frail patients. During the follow-up, frailty seemed to be associated with treatment non-completion, especially when patients were malnourished. Patients with a good physical capacity had a shorter stay in hospital and a lower rate of hospitalization. Geriatric assessment, even in patients with a good performance status, can detect impaired geriatric domains and these impairments may be predictive of mortality. Moreover, geriatric impairments suggest a higher risk of treatment-related toxicity, treatment non-completion and use of healthcare services. A geriatric assessment should be considered before starting treatment in older patients with hematologic malignancies.

Frailty score of older patients with haematological malignancies: unsuspected role of mild cognitive impairment

Frailty assessment in older patients with haematological malignancies is extremely beneficial in order to optimize treatment decisions and supportive interventions. A comprehensive geriatric assessment can provide a better understanding of the functional age than clinical judgement by evaluating several skills domains such as physical function, autonomy, comorbidities, nutrition, cognition, psychological status and social support. However, the use of a multidisciplinary geriatric assessment may fail to detect unsuspected vulnerability such as mild cognitive impairment among so-called "clinically fit" patients. The objective of this paper is to update the current knowledge about predictive factors for toxicity and "frailty scoring" in older patients with haematological malignancies. The unsuspected major role of cognitive impairment and how to detect it will be emphasized.

The relevance of a multidomain geriatric assessment in older patients with heart failure.

AimsPhysical frailty screening is more commonly performed at outpatient heart failure (HF) clinics. However, this does not incorporate other common geriatric domains. This study assesses whether a multidomain geriatric assessment, in comparison with HF severity or physical frailty, is associated with short‐term adverse outcomes.Methods and resultsThis is a prospective cohort study of 197 patients with HF (mean age 78, 44% female) attending outpatient HF clinics. HF severity was assessed with New York Heart Association class (I‐II versus III‐IV) and N‐terminal pro b‐type natriuretic peptide levels. Physical frailty was assessed with the Fried frailty criteria (not frail, pre‐frail, and frail). The following geriatric domains were assessed: physical function, nutrition, polypharmacy, cognition, and dependency in activities of daily living. Logistic regression analyses adjusted for age, sex, diabetes and kidney function assessed 3 month risk of adverse health outcomes (emergency department visits, hospital admissions, and/or death) according to HF severity, physical frailty, and number of affected domains. Number (%) of patients with HF with no, 1, 2, and ≥3 domains affected were 36 (18%), 61 (31%), 58 (29%), and 42 (21%). Seventy‐four adverse outcomes were experienced in 50 patients at follow‐up. Severity of HF and physical frailty were not significantly associated with an increased risk of adverse health outcomes. However, increasing number of affected domains were significantly associated with an increased risk of adverse outcomes. Compared with no domains affected, odds ratios (95% confidence interval) for 1, 2, and ≥3 domains were 1.8 (0.5–6.5), 4.5 (1.3–15.4), and 7.2 (2.0–26.3) (P‐trend <0.01). Further adjustment for HF severity and frailty status slightly attenuated the effect estimates (P‐trend 0.02).ConclusionsHaving limitations in multiple domains appears more strongly associated with short‐term adverse outcomes than HF severity and physical frailty. This may illustrate the potential added value of a multidomain geriatric assessment in the evaluation and treatment of patients with HF with respect to relevant short‐term health outcomes.

Discharge Planning and Home Care Needs Assessment for Older Patients in a Nursing Hospital.

Background and objectives: Following the accumulation of a sufficient amount of scientific evidence, it is now possible to appeal for changes in the organization of nursing services. Our aims are to assess the health status of patients discharged from nursing hospitals and to identify their home care needs by applying the international InterRAI Home Care (HC) assessment form. Material and methods: 152 geriatric patients (older than 65 years of age) discharged after a 90–120-day stay at a nursing hospital were examined using face-to-face interviews. The data from the medical records were also assessed. The capacities of patients were discussed with the patients themselves, nursing personnel, and relatives of the patients. Results: The analysis revealed that 45.4% of the respondents had severely impaired cognitive skills, while 27.6% had moderately impaired cognitive skills for decision making in daily living. People with greater cognitive difficulties were more dependent during daily instrumental activities and ordinary daily activities. The strongest relationship was established among the cognitive skills and management of medications, management of finances, and ordinary housework. For the greater part of respondents, a special need for permanent nursing (57.9%) or assistance (25.7%) was determined, i.e., official, state-funded nursing at home was appointed. The remaining respondents (16.4%) were not appointed further state-funded nursing or assistance at home, but an assessment of the independence of these patients based on the InterRai Activities of Daily Living Hierarchy Scale indicated that these skills varied from moderate independence (decision making was difficult only in new situations) to severely impaired skills (made no independent decisions or they were scarce). Despite the low independence of respondents, the majority of them would prefer nursing services at home to institutional nursing. Conclusions: The low independence observed in all participants, as well as their limited capacities, prove the need for nursing services at home and the necessity of their continuity. Despite the low independence of respondents, the majority of them would prefer nursing services at home to institutional nursing.

To assess the feasibility of a therapeutic radiographer completing the brief geriatric assessment in lung cancer patients during routine radiotherapy practice

Keywords: Frailty, Brief Geriatric Assessment (BGA), Primary Lung Cancer, Radiotherapy, Occupational Therapist (OT), Therapeutic Radiographer. Introduction: The number of older people living with cancer will treble by 20401. Age-related decline in health deems radiotherapy as an attractive treatment option for people with cancer compared with surgery or chemotherapy2. However, even low-grade side effects may significantly impact older patients3. BGA4,5 is a multidisciplinary assessment that identifies the medical, psychosocial and functional needs of older people. This project aimed to assess the feasibility of therapeutic radiographers undertaking the BGA5, identifying skills required and impact on the service and the patient pathway. Method and Materials: The researcher (a therapeutic radiographer) undertook measurements using a modified version of the BGA on 15 patients under guidance from an OT. The first nine patients were assessed under direct supervision and the remaining six independently. On completion of each assessment, the researcher liaised with the OT, together making decisions based on clinical reasoning as to appropriate interventions, such as referral to community support services like Macmillan Cancer Support, OT, physiotherapist, GP and social services. The primary measure of feasibility is the time taken and skills required to complete the BGA effectively. Results: 67% of the 15 patients were identified as having unmet needs, ranging from cognitive, psychosocial, fatigue and functional deficits. BGAs ranged from 20-90 minutes and an additional 60-300 minutes were spent undertaking actions post BGA. The longest time was spent with the patient on the palliative pathway. Examples of actions implemented: referral to community services for falls prevention, rehabilitation and psychological support. Due to complex needs, 33% of patients were directed to be case managed by the OT. Conclusion and Discussion: This exploration has highlighted challenges of time constraints and limited assessment skills in incorporating the full BGA into the current radiotherapy service in one large department. However, it is possible to adopt a universal, targeted and specialist strategy by incorporating a multidisciplinary working arrangement, where low level needs are addressed by upskilling radiographers and complex cases managed by appropriate allied health professionals. Such an approach could provide appropriate and timely interventions to enhance patient pathways. Numerical References [1] Maddams, J., Utley, M., & Møller, H. (2012). Projections of cancer prevalence in the United Kingdom, 2010–2040. British Journal of Cancer, 107(7), 1195-1202. [2] Borras JM, Lievens Y, Barton M, Corral J, Ferlay J, Bray F, et al. (2016). How many new cancer patients in Europe will require radiotherapy by 2025? An ESTRO-HERO analysis. Radiotherapy and Oncology, 119(1), 5-11. [3] O'Donovan, A., Leech,M., Gillham, C. (2017). Assessment and management of radiotherapy induced toxicity in older patients. Journal of Geriatric Oncology, 8 (6), pp. 421-427. [4] Keenan, L. G., O'Brien, M., Ryan, T., Dunne, M., & McArdle, O. (2017). Assessment of older patients with cancer: Edmonton Frail Scale (EFS) as a predictor of adverse outcomes in older patients undergoing radiotherapy. Journal of geriatric oncology, 8(3), 206-210. [5] NHS ENGLAND MARCH 2017 DOCUMENT: Toolkit for general practice in supporting older people living with frailty. https://www.england.nhs.uk/publication/toolkit-for-general-practice-in-supporting-older-people- living-with-frailty.

17 Evidence for Combined Falls and Syncope Assessment in Older Patients

Abstract Syncope is a transient loss of consciousness due to cerebral hypoperfusion (reduced blood flow through the brain). Thirty percent of older persons who have syncope are unaware of loss of consciousness and the majority of events are not witnessed. In these cases, the patient presents with non-accidental/unexplained falls (Parry SW et al., 2005). Many of these events are not recognised. Given that most causes of syncope can be treated and further events prevented, the new ESC guidelines for syncope recommends inclusion of falls in syncope risk stratification (Brignole M et al., 2018) in older patients. These new risk stratification recommendations will be reviewed coupled with new prevalence and comorbidity information for falls in community samples and the long term consequences of hypotensive syndromes on cerebral function.

Integrating Geriatric Assessment for Older Patients Diagnosed With Acute Myelogenous Leukemia

Integrating Geriatric Assessment for Older Patients Diagnosed With Acute Myelogenous Leukemia

Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture.

Geriatricians have been increasingly involved in the pre-operative process in frail elderly patients with a hip fracture which can benefit re-hospitalization, post-operative functional performance, and mortality. The objective of this study was to compare the number of older patients with hip fractures who opted for non-surgical management after the addition of pre-operative comprehensive geriatric assessment (CGA) with shared decision making by a geriatrician to usual care. Secondary objectives were: reasons for non-surgical management, duration of life, and location of death. A single-center, with a level 2 trauma center, retrospective study comparing care before and after introducing pre-operative CGA with shared decision making in September 2014. Patients ≥ 70years with a hip fracture, admitted from January 2014 to September 2015, were included. The percentages of patients elected for non-surgical management and palliative care without or with CGA were compared. Differences in secondary objectives (age, sex, medical history, medication use, functional, and social status) were compared descriptively and qualitatively. With pre-operative CGA significantly more patients (or representatives) elected the non-surgical management option after hip fracture (respectively, 9.1% vs 2.7%, p = 0.008). Patient characteristics were comparable. Reported reasons not to undergo surgery include aversion to be more dependent on others, and severe dementia. The geriatrician can have an important role in decisions for non-surgical management by shared decision making in the pre-operative period in patients ≥ 70years with a hip fracture in the emergency room.

Cost-Effectiveness Analysis of Frailty Assessment in Older Patients Undergoing Coronary Artery Bypass Grafting Surgery

BackgroundIn perioperative settings, frailty assessment has been shown to reduce mortality. This study examined the cost effectiveness of frailty assessment among patients aged 65 with coronary artery disease under consideration for coronary artery bypass grafting surgery. MethodsA combined decision tree and Markov model was developed to estimate costs and quality-adjusted life years (QALYs) over a 21-year time horizon. Clinical parameters were obtained from published literature. Utilities were derived from the literature and the Canadian Community Health Survey. Costs were obtained from the Ontario fee schedule and published literature. Sensitivity and scenario analyses were conducted to assess the robustness of the results. Expected value of perfect information (EVPI) analysis was conducted to estimate the value of further research. ResultsThe frailty assessment initiative had a lower average cost than no frailty assessment ($19,567 compared with $20,062). QALYs with frailty assessment were 0.47 years more than with no frailty assessment. Thus, frailty assessment was dominant compared with no frailty assessment. Results were robust to changes in the input parameters. At a willingness to pay (WTP) threshold of $50,000/QALY, there was 100% probability of frailty assessment being cost-effective, and the EVPI per patient was $0. Scenario and sensitivity analysis showed frailty screening remained cost effective when changing the cohort average age, removing health benefits for nonfrail patients, and using subjective judgement to modify effectiveness parameters. ConclusionsFrailty assessment may be good value for money. However, limited availability of geriatric consultation services, may hinder implementation. Thus, the estimated benefits of frailty screening may not be achievable in practice.

Quality of Life Assessment in Older Patients with Newly-Diagnosed Multiple Myeloma

Multiple myeloma is a malignant plasma cell disease, which typically affects older patients, with a median age at diagnosis of 70 years. Following initial diagnosis and prognostication, selected 'fit' older adults may be eligible for high dose therapy with autologous stem cell transplant (SCT), whereas those less 'fit' will be deemed transplant ineligible (Non-SCT). Although there is a paucity of randomized controlled trial data, observational studies continue to support the role of SCT in older patients.