European Union Geriatric Medicine Society Research Articles

P-273: Body mass index, nutrition and rehabilitation outcome in elderly patients with cognitive impairment

This journal suppl. entitled: Abstracts of the 11th International Congress of the European Union Geriatric Medicine Society - Geriatric medicine for future Europeans - Successful aging creates new challenges

P-274: Should patients with severe cognitive impairment be offered rehabilitation after acute illness?

This journal suppl. entitled: Abstracts of the 11th International Congress of the European Union Geriatric Medicine Society - Geriatric medicine for future Europeans - Successful aging creates new challenges

European postgraduate training in geriatric medicine: data of a systematic international survey.

High-quality education and training standards in geriatric medicine are important to develop the profession of geriatric medicine. The objective of the study was to give a structured update on postgraduate specialty training in geriatric medicine throughout Europe to assess the need for further developments in postgraduate education. The study was performed as a cross-sectional structured quantitative online survey with qualitative comments. The survey content covered organization, content and educational aspects of specialty training in geriatric medicine in European countries. After piloting, the questionnaire was sent to experts in geriatric medicine with a special interest in postgraduate training who are members of one of the following organizations; European Union of Medical Specialists (UEMS), European Academy for the Medicine of Aging (EAMA), and European Union Geriatric Medicine Society (EUGMS). Respondents to the survey represented 31 European countries. Geriatric medicine is recognized as an independent postgraduate specialty in 61.3% (19/31) and as a subspecialty in 29.0% (9/31) of the countries. In 5 of the 31 countries geriatric medicine is not recognized at all. Nearly all countries offering postgraduate training in geriatric medicine have written, competence-based curricula covering different learning domains. 20/31 countries (64.5%) have some kind of specialist assessment. The survey tries to give an actual condensed picture of postgraduate specialty training in geriatric medicine across Europe. Results show a consistent improvement in the recognition of geriatric medicine as independent specialty over the last decade. Continuous development of specialty training in geriatric medicine is required to medical address the public health needs of an aging population. Competence-based educational models including adequate forms of assessment should be targeted throughout Europe. To emphasize the importance of postgraduate geriatric training, it should be a mission to harmonize training standards across Europe.

33 * INTERVENTIONS TO PREVENT NON-CRITICAL CARE HOSPITAL ACQUIRED PNEUMONIA-A SYSTEMATIC REVIEW

Background: Hospital-acquired pneumonia is a significant burden to healthcare systems around the world. Although there is a considerable body of evidence on prevention of ventilator associated pneumonia, less is known about strategies to prevent hospital-acquired pneumonia in non-critical care settings. Objective: To systematically review the randomised controlled trial evidence for prevention of hospitalacquired pneumonia in non-critical care settings. Methods: We searched EMBASE, CINAHL+, MEDLINE and the Cochrane Library. Seventeen different searches were conducted in parallel through each database. Studies were included if they were randomised controlled trials reporting hospital-acquired pneumonia as an endpoint. Studies were excluded if they were performed in critical care or community settings. All studies published up to the end of December 2014 were considered, with no language restrictions. Data were independently extracted by two authors and the Delphi risk of bias tool was applied to assess trial quality. Results: Five thousand one hundred and one titles were identified across 17 searches. Only two studies were eligible for inclusion in the final review, one from a search of physical therapy interventions and one from a search of enteral feeding. The heterogeneity of the interventions did not permit metaanalysis. One trial suggested possible benefits to early mobilisation; the other trial suggested no benefit or harm from early enteral feeding via nasogastric tube. Both trials enrolled patients with acute stroke. No trials in non-stroke, non-critical care populations were eligible for inclusion in the review. Conclusions: There is currently insufficient trial evidence on preventing non-critical care hospitalacquired pneumonia to make recommendations on practice. 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. Available online at

The value of comprehensive geriatric assessment in elderly patients with severe aortic stenosis – a position statement of the European Union Geriatric Medicine Society (EUGMS)

Severe symptomatic aortic stenosis is a serious condition of elderly, mostly geriatric patients with a poor prognosis if the valve is not replaced. Since geriatricians are able to provide major expertise in the prognostic assessment as well in the clinical management of these patients, they need to be more closely involved in the decision making process. For this reason the European Union Geriatric Medicine Society (EUGMS) represented by the authors phrased three propositions: (1) geriatricians need to be aware of the impact of severe aortic stenosis on patients’ outcomes and should be encouraged to take an active role in aortic stenosis management; (2) they need to be aware of treatment options and are required to support multidisciplinary teams with their expertise in assessing geriatric patients; (3) they should routinely perform a comprehensive geriatric assessment in patients with severe aortic stenosis scheduled to undergo surgical or transcatheter aortic valve replacement and during long-term follow-up.

Can we identify patients with high risk of osteoarthritis progression who will respond to treatment? A focus on epidemiology and phenotype of osteoarthritis.

Osteoarthritis is a syndrome affecting a variety of patient profiles. A European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis and the European Union Geriatric Medicine Society working meeting explored the possibility of identifying different patient profiles in osteoarthritis. The risk factors for the development of osteoarthritis include systemic factors (e.g., age, sex, obesity, genetics, race, and bone density) and local biomechanical factors (e.g., obesity, sport, joint injury, and muscle weakness); most also predict disease progression, particularly joint injury, malalignment, and synovitis/effusion. The characterization of patient profiles should help to better orientate research, facilitate trial design, and define which patients are the most likely to benefit from treatment. There are a number of profile candidates. Generalized, polyarticular osteoarthritis and local, monoarticular osteoarthritis appear to be two different profiles; the former is a feature of osteoarthritis co-morbid with inflammation or the metabolic syndrome, while the latter is more typical of post-trauma osteoarthritis, especially in cases with severe malalignment. Other biomechanical factors may also define profiles, such as joint malalignment, loss of meniscal function, and ligament injury. Early- and late-stage osteoarthritis appear as separate profiles, notably in terms of treatment response. Finally, there is evidence that there are two separate profiles related to lesions in the subchondral bone, which may determine benefit from bone-active treatments. Decisions on appropriate therapy should be made considering clinical presentation, underlying pathophysiology, and stage of disease. Identification of patient profiles may lead to more personalized healthcare, with more targeted treatment for osteoarthritis.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention

OBJECTIVE: To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN: Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING: Transnational registry in Spain. SUBJECTS: We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS: Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES: All-cause death. RESULTS: Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION: Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

The Impact of an Aging Population on Palliative Care

ABSTRACTBy 2050, it is predicted that 26% of the population will be aged 80 and over. Although older people have much to contribute, one challenging aspect of an aging population is the increasing rate of dementia. Palliative care is now included as part of the care pathway of a wide variety of nonmalignant diseases. The European Association for Palliative Care (EAPC) and the European Union Geriatric Medicine Society (EUGMS) have jointly called for every older citizen with chronic disease to be offered the best possible palliative care approach wherever they are cared for.This report is adapted from paineurope 2013; Issue 2, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International LTD. and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication.

Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group

New evidence shows that older adults need more dietary protein than do younger adults to support good health, promote recovery from illness, and maintain functionality. Older people need to make up for age-related changes in protein metabolism, such as high splanchnic extraction and declining anabolic responses to ingested protein. They also need more protein to offset inflammatory and catabolic conditions associated with chronic and acute diseases that occur commonly with aging. With the goal of developing updated, evidence-based recommendations for optimal protein intake by older people, the European Union Geriatric Medicine Society (EUGMS), in cooperation with other scientific organizations, appointed an international study group to review dietary protein needs with aging (PROT-AGE Study Group). To help older people (>65 years) maintain and regain lean body mass and function, the PROT-AGE study group recommends average daily intake at least in the range of 1.0 to 1.2 g protein per kilogram of body weight per day. Both endurance- and resistance-type exercises are recommended at individualized levels that are safe and tolerated, and higher protein intake (ie, ≥ 1.2 g/kg body weight/d) is advised for those who are exercising and otherwise active. Most older adults who have acute or chronic diseases need even more dietary protein (ie, 1.2-1.5 g/kg body weight/d). Older people with severe kidney disease (ie, estimated GFR <30 mL/min/1.73 m(2)), but who are not on dialysis, are an exception to this rule; these individuals may need to limit protein intake. Protein quality, timing of ingestion, and intake of other nutritional supplements may be relevant, but evidence is not yet sufficient to support specific recommendations. Older people are vulnerable to losses in physical function capacity, and such losses predict loss of independence, falls, and even mortality. Thus, future studies aimed at pinpointing optimal protein intake in specific populations of older people need to include measures of physical function.

Palliative care in acute geriatric care units across Europe: Some reflections about the experience of geriatricians

PurposeLittle is known about geriatricians’ knowledge, training and attitudes towards end-of-life issues as well as about how their experience concerning end-of-life decisions in the older patient. The aim of this survey was to explore the experience and the attitudes of geriatricians across Europe towards end-of-life care of patients dying in acute geriatric care units. Subjects/Materials and methodsA quantitative online survey was sent to the 21 members of the full board of the European Union Geriatric Medicine Society (EUGMS). These representatives had the possibility to forward it to colleagues from their countries, if they were not working in a geriatric acute care unit. ResultsThirty-five geriatricians representing nine countries of Europe responded to the survey. The results highlighted a mortality rate in these units (between 10 and 30%). More than half of the geriatricians described few resources to help them deal with issues of end-of-life care (guidelines, ethics committee, and palliative care consultation). Twenty-four geriatricians had to take a decision to withhold or withdraw life-prolonging treatment in their patient. They reported a high level of burden associated with this decision-making and also the need of more training in palliative care. Discussion and conclusionThese results highlight a number of needs of geriatricians working in acute geriatric care units that should encourage an action plan on palliative care and geriatric medicine to improve the quality of life of older patients with chronic diseases and to avoid moral distress in caregivers.

A call to action - Geriatricians’ experience in treatment of aortic stenosis and involvement in transcatheter aortic valve implantation

Aortic stenosis (AS) represents a significant healthcare burden in the elderly population. For inoperable patients or those at high-risk for surgery, transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option. The recently conducted European Union Geriatric Medicine Society (EUGMS) TAVI survey found that the involvement of geriatricians in the management of patients undergoing TAVI is generally low. Because of the complexity and rapidly progressive nature of severe AS, a geriatrician should be involved because of the need for a comprehensive geriatric patient assessment that may ameliorate or delay disability, cognitive dysfunction or nutritional status and their impact on clinical outcomes. Therefore, the EUGMS is currently setting up a prospective, observational study, designed to evaluate the effectiveness of TAVI from the perspective of the geriatrician (Transcatheter Aortic Valve Implantation Registry with Comprehensive Geriatric Assessment, CGA-TAVI). CGA-TAVI will investigate the prognostic relevance of clinical, cognitive, functional, nutritional, and social parameters and is carried out using six standardized scales and information on medications and social support network. Taken together, there is considerable potential for increased involvement of geriatricians in the management of elderly patients with severe asymptomatic AS. The input of geriatricians is invaluable to informed decision-making related to the prognosis and risk status of frail and/or elderly patients. The EUGMS recommends that geriatricians should be involved at an early stage of patient management, and should have a substantial impact on decision-making, rehabilitation and long-term care of elderly patients with AS, requiring valve replacement therapy.

Am I a Gerontologist or Geriatrician?

Am I a Gerontologist or Geriatrician?

Geriatric care in Europe – the EUGMS Survey part I: Belgium, Czech Republic, Denmark, Germany, Ireland, Spain, Switzerland, United Kingdom

Quality of geriatric care depends on institutional resources e.g. hospitals, medical departments engaged in acute medicine, rehabilitation and long term care but especially in quality and quantity of well educated and trained specialists, i.e. “geriatricians”. This survey initiated by the Academic Board of the European Union Geriatric Medicine Society (EUGMS) aimed to give an European overview by mapping the current situation in number and geographical distribution of geriatricians in relation to national demographic data. The discussion focuses on special national aspects including information about the national training tenure circumstances as well as political and historical influences on the geriatric care situation. The need for an European consensus concerning training curriculum is clearly stated, but also the need for fostering geriatric medicine with look on the demographic background, which is very similar in European countries. Last but not least: The survey can function as a benchmark, which every country may use in it's own medical and political environment.

Quality of life, characteristics and metabolic control in diabetic geriatric patients

Objectives To describe the characteristics, metabolic control and health-related quality of life (HRQL) of type 2 diabetes mellitus (T2DM) geriatric patients. Study design Cross-sectional descriptive study of consecutive patients attended at a geriatric outpatient clinic in a tertiary hospital over three months. Sociodemographic, geriatric assessment variables, HRQL (using the EuroQol instrument) and comorbidity (Charlson and CIRS-G indexes) were measured. The presence of macrovascular and microvascular complications and cardiovascular risk factors were investigated. To assess the degree of metabolic control, the European Union Geriatric Medicine Society (EUGMS) criteria were followed with patients under 80 years old being considered as young elderly and disability as dependence on more than 2 ADLs or need of aid in ambulation. Results We included 112 patients with an average age of 81.4 ± 5.7 years, a Charlson comorbidity index of 4.3 ± 1.57 and a CIRS-G index of 9.7 ± 3. Seventy four per cent of patients were dependent on none or only one ADL, 38.5% presented cognitive impairment and 40% depression. Appropriate control of basal glucose and glycosylated haemoglobin was seen in 43.2% of the patients. HRQL indicated a high frequency of involvement with a significant relationship with functional dependence, cognitive impairment, and depression but not with metabolic control. Conclusions Geriatric patients with T2DM treated on an outpatient basis have a heavy load of comorbidity and an insufficient level of metabolic control even when individually adapted to age and functional state. HRQL is greatly impaired and related to their functional, cognitive and affective derangements.

Adverse effects of the herd immunity or when childhood vaccination becomes deleterious for the epidemiology of infectious diseases in adults

The irremediable ageing of the world population, the aged-related increasing in the prevalence of infectious diseases the fear of any influenza pandemic rife have recently led the European Union Geriatric Medicine Society (EUGMS) et the International Association of Geriatric and Gerontology European Regions (IAGG-ER) of establishing vaccine recommendations dedicated to individuals aged of 60years or above and promoting a life-course vaccination programme. This approach is mainly motivated by the herd immunity-associated effect on the epidemiology of infectious diseases observed within the adult and old adult population. This review (1) after a presentation of the concept and its demonstrated beneficial effects; (2) will detail that herd immunity acts with adverse effects on the epidemiology of the infectious diseases in the adult and aged individual population; (3) in order to demonstrate that maintaining a vaccine pressure in every age groups is imperative.

Variability of nutritional practice by geriatricians across Europe

Introduction Older people are at risk of malnutrition. As this adversely affects clinical outcome, screening should be performed routinely. Our aim was to learn more about the knowledge and attitudes of geriatricians across Europe towards nutrition and their interest in receiving training. Methods A qualitative online survey of members of the European Union Geriatric Medicine Society (EUGMS) was conducted in spring 2010. It contained 47 questions using four case studies to illustrate clinical scenarios. Results Two hundred and eight responses were received from 20 countries. Twenty-six percent of the respondents had more than 25 years of experience and the majority worked in acute care. Only 20% had received any formal nutrition training, although nearly all indicated to consider nutrition when promoting healthy ageing. The majority recognised that a weight loss of 5–10% over the previous 6 months was indicative of malnutrition risk, whereas ∼20% use a Body Mass Index cut-off of 18.5 kg/m 2 to initiate nutritional intervention. MNA ® and ‘MUST’ were the nutritional tools most frequently used. Adequate protein and vitamin D intake were seen as important, but knowledge regarding oral nutritional supplements was limited. The majority (63%) indicated a training need and identified E-learning modules as the preferred method. Conclusions A survey in EUGMS has identified good awareness of the relevance of nutritional status for clinical outcome, but knowledge of appropriate identification of malnutrition and intervention was suboptimal. Participants showed high interest in attending specific nutrition training. E-learning modules should be considered as a means of educating healthcare professionals involved in geriatrics.

Palliative care for the geriatric patient in Europe

Knowledge about the quality of end-of-life care in the elderly patient in Europe is fragmented. The European Union Geriatric Medicine Society (EUGMS) Geriatric Palliative Medicine (GPM) Interest Group set as one of its goals to better characterize geriatric palliative care in Europe. The goal of the current study was to map the existing palliative care structures for geriatric patients, the available policies, legislation, and associations in geriatric palliative medicine in different countries of Europe. A questionnaire was sent to Geriatric and Palliative Medicine Societies of European countries through contact persons. The areas of interest were (1)availability of services for the management of geriatric patients by using vignette patients (advanced cancer, severe cardiac disease, and severe dementia), (2)policies, legislation of palliative care, and (3)associations involved in geriatric palliative medicine. Out of 21 countries contacted, 19 participated. Palliative care units and home care palliative consultation teams are available in most countries. In contrast, palliative care in long-term care facilities and in geriatric wards is less developed. A disparity was found between the available services and those most appropriate to take care of the three cases described in the vignettes, especially for the patient dying from non-malignant diseases. The survey also demonstrated that caregivers are not well prepared to care for the elderly palliative patient at home or in nursing homes. One of the challenges for the years to come will be to develop palliative care structures adapted to the needs of the elderly in Europe, but also to improve the education of health professionals in this field.

Updated vaccine guidelines for aging and aged citizens of Europe

There is a high burden of infectious diseases in the older population, which is associated with increased morbidity and mortality compared with younger age groups. Too many of these diseases are vaccine preventable yet there is a low vaccine coverage rate across Europe. These findings led the European Union Geriatric Medicine Society and the International Association of Gerontology and Geriatrics – European Region to convene an expert Working Group to address the issue of why vaccination programs have failed to provide adequate protection in older European populations and to recommend immunization guidelines to ensure that they contribute to a healthy aging strategy. This review addresses some of the main issues relating to poor vaccine uptake in older adults and presents the recommendations of the joint Working Group regarding the optimal use of the following vaccines: tetanus–diphtheria–pertussis, influenza, pneumococcal (PV23) and herpes zoster. To improve vaccine coverage, communication and awareness of vaccine preventable diseases in the general community is an important starting point, and all healthcare professionals and public health/social workers can play a key role in this regard.

Silver paper: The future of health promotion and preventive actions, basic research, and clinical aspects of age-related disease

BACKGROUND. In September 2008, under the French Presidency of the European Union and with the support of the Polish Minister of Health, a European Summit on Age-Related Disease was organised inWroclaw (Poland). At this meeting, European politicians, gerontologists and geriatricians gathered to discuss a common approach to future challenges related to age-related disease. Politicians and decision-makers from the European Union and Ministers of Health and their deputies from many European countries raised the problems and difficulties to be tackled in a growing population with a high burden of disease, and asked scientists to write a consensus document with recommendations for future actions and decisions. Scientists and clinicians worked in parallel in three different groups, on health promotion and preventive actions, basic research in age-related disease, and clinical aspects of disease in older people. Beforehand, the format of the paper with recommendations was discussed, and it was finally agreed that, for a better understanding by decision- makers, it would be divided in two different columns: one with facts that were considered settled and agreed by most experts (under the heading We know), and a second with recommendations related to each fact (We recommend). No limit on the number of topics to be discussed was settled. After careful and detailed discussion in each group, which in most cases included the exact wording of each statement, chairpersons presented the results in a plenary session, and new input from all participants was received, until each of the statements and recommendations were accepted by a large majority. Areas with no consensus were excluded from the document. Immediately after the Summit, the chairpersons sent the document both to the main authors and to a list of experts (see footnote) who had made presentations at the summit and agreed to review and critically comment on the final document, which is presented below. As regards the scientific aspects of the planning of the Summit, several organisations, under the leadership of the EUGMS, were asked both to review the program and to suggest names of speakers and participants. After the Summit, the Boards of these organizations (European Union Geriatric Medicine Society (EUGMS), International Association of Gerontology and Geriatrics-European Region (IAGGER), European Association of Geriatric Psychiatry (EAGP), International Society of Gerontechnology (ISG) and International Society for the Study of the Aging Male (ISSAM) agreed to consider the document as an official paper, and help with its dissemination. The name Silver Paper was used, recalling the grey or silvery hair of our older citizens, as an easy reference. It has been sent officially to several bodies of the European Union and to Health Ministers of most European countries; and will be published in other languages in local journals. Its declared intention is to foster changes in policies which may, in the future, reduce the burden of disease in old age.

P88 Geriatric palliative care interest group of the European Union Geriatric Medicine Society (EUGMS)

P88 Geriatric palliative care interest group of the European Union Geriatric Medicine Society (EUGMS)