Frail Elderly Patients Research Articles

Impact of age and comorbidities on short- and long-term outcomes of patients undergoing surgery for colorectal cancer

As the world population is progressively ageing, more and more elderly patients will require cancer surgery. Although curative surgery is the treatment of choice for resectable colorectal cancer (CRC), it is still debated whether elderly frail patients should undergo major cancer surgery due to the increased risk of postoperative and long-term mortality. The aim of this retrospective study was to evaluate the impact of age and comorbidities on postoperative mortality/morbidity and long-term outcomes, looking for potential age-related survival differences. A total of 1,482 patients operated for CRC at our institution between January 2005 and October 2020 were analysed. The independent effect of age and comorbidities on postoperative complications was assessed by a logistic model, while the effect on overall survival (OS) and cancer-related survival (CRS) was estimated by a Cox regression model. The median age in the cohort was 67.8 years. Postoperative mortality was very low in the whole cohort (0.8%) and contained even in older age groups (3.2% in patients aged 80-84 years, 4% in the 85-90-year age group). The cumulative incidence of postoperative complications was doubled in patients with comorbidities (32.8% vs. 15.1%, p = 0.002). With regard to OS, as expected, it exponentially decreased with advancing age. Conversely, differences in CRS were less pronounced between age groups and absent in patients with stage 0-I CRC. Analysis of all causes and cancer-related mortality revealed a peak within 2 years from surgery, suggesting a prolonged impact of surgery. In patients aged 75 years and above, all-cause mortality showed a steep increase 1 year after surgery, while cancer-related mortality plateaued at about 4 years after surgery. On multivariable analysis, OS, but not CRS, was significantly influenced by age. Although acceptable results of surgery in elderly patients, OS is strongly dependent on age: older people die more from competing causes than cancer-related treatments compared to younger age classes. The preoperative identification of risk factors for low OS may help the selection of those elderly patients who would benefit from curative CRC surgery.

Lack of Benefit of High Flow Nasal Oxygen Therapy as Ceiling of Treatment for Severe COVID-19 Pneumonitis in Elderly Frail Patients: A Single Centre Observational Study

Background: Severe COVID-19 pneumonitis in elderly frail patients is associated with poor outcomes, and therefore invasive mechanical ventilation is often deemed an inappropriate course of action. Some evidence suggests high-flow nasal oxygen (HFNO) may prevent the need for invasive ventilation in other groups of patients, but whether it is an appropriate ceiling of care for older frail patients is unknown. Methods: We retrospectively identified patients with severe COVID-19 pneumonitis requiring FiO2>60% who were deemed inappropriate for invasive ventilation or non-invasive continuous positive airway pressure ventilation (CPAP). Our local protocol based on national guidance suggested these patients should be considered for HFNO. We observed whether the patients received HFNO or standard oxygen therapy (SOT) and compared mortality and survival time in these groups. Results: We identified 81 patients meeting the inclusion criteria. From this group, 24 received HFNO and 57 received SOT. The HFNO group was similar in age, BMI and co-morbidities to the SOT group but less frail, as determined by the Clinical Frailty Scale (CFS). All 24 patients that received HFNO died in comparison to 46 patients (80.7%) in the SOT group. Mortality in the HFNO group was significantly higher than in the SOT group. Conclusion: Elderly frail patients with severe COVID-19 pneumonitis deemed inappropriate for invasive ventilation and did not benefit from HFNO. Further, HFNO may have been associated with harm in this group.

Pseudo-V1 ECG lead recording with quality smartwatches and medical interpretation may be necessary for timely and accurate remote detection of atrial flutter/fibrillation

Abstract Background Remote rhythm monitoring with wearable devices is increasingly used especially for early detection of atrial fibrillation/flutter (AF/Afl), being the access to hospital discouraged, especially for frail elderly patients, due to the burden and risk of COVID-19 pandemic. Whereas devices using photo plethysmography (PPG) may misinterpret as AF pulse irregularities due to extrasystoles, patient-directed recording of a single (usually wrist-to-wrist) lead ECG (LEAD I) with hand-held devices or smartwatches have been developed to increase accuracy in AF detection. However, although recent studies validating such devices single-lead ECG recording have shown high sensitivity and specificity, false negative findings such as those reported here are still possible and must be prevented [1]. Purpose Given previous experience of diagnostic uncertainty or failure of the smartwatch ECG (SW-ECG) LEAD I to detect AF/Afl, we have tested if false negative diagnosis could be avoided by recording in addition at least one right precordial (pseudo-V1) lead analyzed by a trained healthcare professional. Method Over one calendar year observation, five patients with previous history of ablated supraventricular arrhythmias suffering sudden palpitations suspected of paroxysmal AF/Afl were instructed to record with their smartwatch at least one precordial lead in addition to LEAD I, to monitor ECG until the termination of symptoms. The SW-ECG strips were sent by telephone for professional interpretation. Diagnostic accuracy based on LEAD I and pseudo-V1 were independently validated by two cardiologists (diagnostic goldstandard - DGS). Results 22 AF/Afl events occurred. Pharmacological cardioversion to sinus rhythm (SR) was obtained in 64%. 192 ECG strips were transmitted. 43,7% of the strips were automatically classified as “not significant” (or “not valid”). Compared to DGS, out of 108 “valid” strips, correct automatic identification of AF/Afl was obtained in 36,4% with LEAD I, in 33,3% with pseudo V1 and in 54,5% with combined leads, respectively. Interestingly, the SW algorithm has wrongly diagnosed as SR, not only LEAD I, but also 39,4% of pseudo-V1 strips, despite clear-cut evidence of typical flutter waves (Figure 1), when RR intervals were regular due to high degree (e.g., 4:1) A-V block. Conclusions With simple instructions, patients (or their relatives) can easily record an additional precordial (pseudo-V1) SW-ECG lead, that may enhance sensitivity and specificity for remote detection of AF/Afl. However, at present, visual interpretation of SW-ECG by a trained healthcare professional is still needed to guarantee 100% correct diagnosis of AF/Afl, crucial to reduce thromboembolic risk and timely initiate the appropriate treatments. The automatic interpretation of SW's ECG could be improved by appropriate training of a machine learning approach to detect and analyze the atrial waveform provided by an additional pseudo-V1 lead. Funding Acknowledgement Type of funding sources: None.

S2294 Endoscopic Management of Esophageal Cancer in a Patient with Decompensated Cirrhosis: The Importance of Multidisciplinary Collaboration and Peri-Procedure Planning in Complex Clinical Scenarios

Introduction: Endoscopic therapy is effective for management of early esophageal cancer (EC), however serious complications such as bleeding and perforation can occur. Patient selection, optimization of co-morbidities and peri-procedure management help mitigate risk and improve patient outcomes. We present a patient with decompensated cirrhosis who required complex peri-procedure planning prior to endoscopic treatment of early EC. Case Description/Methods: A 71-year male with decompensated cirrhosis (portal hypertension, esophageal varices, ascites) and recent DVT on apixaban was found to have a 1cm raised focal lesion at the GEJ; biopsies revealed high-grade dysplasia (HGD). He was referred for endoscopic mucosal resection (EMR). After extensive discussion with hematology, patient was admitted for anticoagulation management with intravenous (IV) heparin. EGD confirmed an 8mm nodule at the GEJ (Figure 1A,B,C). Grade 3 non-bleeding esophageal varices were noted at the GEJ and in the distal esophagus, prohibiting safe EMR. Biopsies again showed HGD. After multidisciplinary tumor board discussion, a transjugular portosystemic shunt (TIPS) was performed to decompress the portal system and reduce bleeding risk from the planned EMR. Doppler ultrasound a few weeks later confirmed patent TIPS. Repeat diagnostic EGD showed decompression of varices. EUS revealed a mucosal lesion with no lymphadenopathy. Biopsy revealed intramucosal adenocarcinoma. Based on this evaluation and after detailed discussion with the patient, EMR was planned with appropriate anticoagulation management. En-bloc multiband mucosectomy was performed (Figure 1D,E). Intraprocedural bleeding was controlled with band ligation and hemostatic spray (Figure 1F). Patient remained inpatient for observation on octreotide and IV pantoprazole drip without further bleeding. Apixaban 2.5mg was resumed on day 3 and he was discharged home on acid suppression. Pathology confirmed well-differentiated adenocarcinoma, pT1a. Tumor board discussion recommended continued endotherapy (cryotherapy) to the residual dysplastic Barrett’s mucosa which he is tolerating well. Discussion: Endoscopic treatment is effective for the management of early EC. However, when complex scenarios present in an elderly frail patient, multidisciplinary collaborative management and stepwise risk-mitigation strategies need to be in place to minimize morbidity and maximize success (Table). Tumor board and shared decision making are key patient centric strategies that reflect best practice.Figure 1.: A: Nodular distal esophageal lesion; B: Lesion in high-definition white light endoscopy (HDWLE); C: Lesion in narrow band imaging (NBI), D: Band placed at the base of the lesion, E: EMR defect, F: Hemostatic spray was used to achieve hemostasis of an area of focal bleeding after EMR. Table 1. - Risk Mitigation Strategies in Complex Endoscopy Practice – Best Practice Principles Pre-procedure consultation (nonemergent diagnostic/elective procedures) Pre-procedure planning (labs, imaging) Optimization of treatment for co-morbidities Anesthesia consultation Detailed high-risk informed consent Shared decision making Multidisciplinary GI tumor board discussion Medical record documentation Guideline-based anti-thrombotic management Appropriate procedure back-up and support (IR, surgery, radiology, critical care)

Extremity high-grade sarcomas in elderly patients, are they candidates for surgery? Experience in a sarcoma referral center.

The number of elderly patients diagnosed with cancer is increasing. However, knowledge regarding cancer in elderly patients is very scarce. The aim of this study is to analyze the differences in management and outcomes of high-grade extremity sarcomas between elderly and middle-aged patients. Two cohorts were made (> 70 and 30/50years old) among patients treated in a multidisciplinary unit of a national reference center between 2011 and 2017 with a minimum of 2years of follow-up. The management and outcomes between these two cohorts were compared. Seventy patients were included, 34 young patients and 36 elderly patients. The only difference between the treatment schemes was the chemotherapy used, 67.6% of the young patients received chemotherapy versus 16.7% of the elderly patients (p = 0.000015). There were no differences either in the overall survival or the progression-free survival between groups at 1 and 2-year follow-up. Deceases for other causes were nearly exclusive of elderly patients at a median of 45.57months. Surgery is the treatment of choice for sarcomas in both elderly and young patients having similar results in terms of progression-free survival, overall survival, and surgery outcomes. The use of chemotherapy is the only difference in the treatment schemes between both groups. In the elderly patient with minimal or no comorbidity and good functional reserve, surgical curative treatment should be chosen. As for frail elderly patients, the therapeutic objectives must be focused mainly on quality of life and palliation of symptoms.

What do orthopaedic nurses think about frailty? A qualitative analysis

<h2>ABSTRACT</h2><h3>Background</h3> Frailty is a complex geriatric syndrome. Frail people frequently experience orthopaedic problems such as falls and fractures. Therefore, orthopaedic nurses often care for frail elderly patients. <h3>Aim</h3> To provide deep insight into the orthopaedic nurses' perspectives regarding frailty. <h3>Method</h3> Data were collected using semi-structured interviews with 18 orthopaedic nurses in one institution in this descriptive qualitative study. The interviews were transcribed and analysed using the MAXQDA software. <h3>Findings</h3> Two main themes and six subthemes were identified. The main themes were: (i) conceptualisation of frailty and (ii) how to cope with frailty. The findings explicated nurses' awareness and perceptions about the frailty concept. <h3>Discussion</h3> Orthopaedic nurses heard the concept of frailty for the first time during this study. Understanding more about the perspectives of acute care providers such as orthopaedic nurses can help to guide care planning, improve care of frail people, and make better health care outcomes. <h3>Conclusion</h3> Knowing more about the perspectives of orthopaedic nurses can help identify frailty and activate multidisciplinary care. Educating nurses about frailty may promote caring strategies for frail people with complex care needs.

Prise en charge de l'insuffisance cardiaque chronique chez le sujet âgé fragile après hospitalisation pour décompensation aiguë ; apport d'une cellule de coordination ville-hôpital ; étude GERICCO-78

AimsHeart failure (HF) is the leading cause of hospitalisation in the elderly in France. Early rehospitalisations are common, often through an emergency department. The aim of this study was to assess the impact of a primary care-hospital coordination network, with interventions by coordination nurses (IDEC), on the rehospitalisations after a first hospitalisation for acute decompensation in frail elderly HF patients. MethodsFrom 01/10/2019 to 01/10/2021, 237 patients aged > 75 years with frailty criteria, hospitalised in 8 departments of 5 private or public hospitals in the Yvelines Sud health territory were followed by an IDEC (hospital visit, telephone contacts, home visit(s)) within 3 months of their return home. This prospective observational study analysed the rate of consultations to the emergency room, rehospitalisations (total and for acute HF), and the number of events avoided at 90 days after discharge. ResultsThe mean age of the patients was 87 years, 54% were women, 68% had a left ventricular ejection fraction > 40%, and 70% had atrial fibrillation. Non-cardiac comorbidities were very frequent. At 3-month follow-up, mortality was 9.3% (22/237), only 27 patients (11.3%) consulted the emergency room for acute HF, and the rehospitalisation rate for HF was 19.8%, without difference according to left ventricular ejection fraction. A consultation to the emergency room or a rehospitalisation for heart failure could be avoided for 10% of patients. ConclusionThis study suggests that a primary care-hospital coordination network with dedicated coordination nurses is useful for the management of very elderly frail patients following hospitalisation for heart failure, limiting visits to the emergency room and rehospitalisations.

338 Establishing Ceilings of Care in Elderly Frail Patients with Acute Fractures

Abstract Aim The British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) document ‘Care of the Older or Frail Orthopaedic Trauma Patient’ advocates early discussion and documentation of ceilings of care. The aim of the study was to assess whether cardiopulmonary resuscitation (CPR) status was being discussed and documented at the time of admission in this patient cohort. Method At two separate time points (September and October 2021), a sample of current inpatients admitted under the acute fractures service were selected who met inclusion criteria of having sustained a low-energy fracture and having a clinical frailty score of 5 or greater. Patient notes were examined to determine whether any decisions or discussions regarding CPR status had been documented at the time of admission. Between time points, a teaching presentation was sent to all FY2-CT2 doctors who covered acute fractures admissions and a reminder box was added to the fracture's admissions sheet template. Results The mean age was 82 years (range 65 to 97 years) and 85 years (range 70 to 94 years) at the first and second time point, respectively. Successful documentation regarding ceiling of care at the time of admission improved from 26% (5/19) to 64% (14/22) between study periods. Conclusions Early discussion and documentation of ceilings of care in elderly frail patients sustaining acute fractures is important to avoid unsuccessful, undignified attempts at resuscitation in the event of deterioration.

Poor outcome in frail elderly patient after severe TBI

ABSTRACT Objective To investigate the influence of frailty in elderly with severe TBI on mortality and functional outcome. Method 126 patients with TBI aged 60 years or older and with a presenting Glasgow Coma Scale score of 8 or lower were retrospectively included. To investigate frailty, we used the CSHA Clinical Frailty Scale. The primary outcome measures were mortality, and the secondary outcome measures were Glasgow Outcome Scale Extended (GOSE) at discharge and GOSE at 6 months after trauma. Results High frailty was a significant predictor for mortality (OR 2.38, p 0.047), if adjusted for the injury severity scale. High frailty was also a significant predictor for poor functional outcome after 6 months (OR 4.35, p 0.03). After 6 months, the GOSE of the low frailty group was significantly higher than in the high frailty group (p 0.019). Also, the improvement of the GOSE was significant in the low frailty group (p 0.007), while in the high frailty group there was no significant improvement of the GOSE (p 0.546) after 6 months. Conclusion Frailty has a significant impact on outcome in elderly with severe TBI. There is a higher mortality in the frail elderly and there is less recovery after TBI.

Ankle tibiotalocalcaneal nailing in elderly ankle fractures as an alternative to open reduction internal fixation: technique and literature review.

The use of tibiotalocalcaneal nails for unstable ankle fractures in low demand elderly patients has been introduced as an alternative to open reduction internal fixation to allow early weight-bearing and to decrease soft tissue complications and mechanical failures. This paper describes the technique of hindfoot nailing and reviews the current literature. Overall, it is a minimally invasive and expeditious procedure that provides stable fixation to withstand immediate ambulation of the frail elderly patient. Future high-quality randomized controlled trials will determine if complications and outcomes compare favorably to open reduction and internal fixation.

CACHET-CADB: A Contextualized Ambulatory Electrocardiography Arrhythmia Dataset.

ECG is a non-invasive tool for arrhythmia detection. In recent years, wearable ECG-based ambulatory arrhythmia monitoring has gained increasing attention. However, arrhythmia detection algorithms trained on existing public arrhythmia databases show higher FPR when applied to such ambulatory ECG recordings. It is primarily because the existing public databases are relatively clean as they are recorded using clinical-grade ECG devices in controlled clinical environments. They may not represent the signal quality and artifacts present in ambulatory patient-operated ECG. To help build and evaluate arrhythmia detection algorithms that can work on wearable ECG from free-living conditions, we present the design and development of the CACHET-CADB, a multi-site contextualized ECG database from free-living conditions. The CACHET-CADB is subpart of the REAFEL study, which aims at reaching the frail elderly patient to optimize the diagnosis of atrial fibrillation. In contrast to the existing databases, along with the ECG, CACHET-CADB also provides the continuous recording of patients' contextual data such as activities, body positions, movement accelerations, symptoms, stress level, and sleep quality. These contextual data can aid in improving the machine/deep learning-based automated arrhythmia detection algorithms on patient-operated wearable ECG. Currently, CACHET-CADB has 259 days of contextualized ECG recordings from 24 patients and 1,602 manually annotated 10 s heart-rhythm samples. The length of the ECG records in the CACHET-CADB varies from 24 h to 3 weeks. The patient's ambulatory context information (activities, movement acceleration, body position, etc.) is extracted for every 10 s interval cumulatively. From the analysis, nearly 11% of the ECG data in the database is found to be noisy. A software toolkit for the use of the CACHET-CADB is also provided.

Hospital Acquired Depressive Symptoms in Frail Elderly Patients and Its Associations with Zinc Level

Hospital Acquired Depressive Symptoms in Frail Elderly Patients and Its Associations with Zinc Level

PB2149: ZANUBRUTINIB IN COMBINATION WITH LENALIDOMIDE AND RITUXIMAB VERSUS R-MINICHOP IN UNFIT OR FRAIL PATIENTS WITH NEWLY DIAGNOSED DIFFUSE LARGE B-CELL LYMPHOMA AGED OVER OR EQUAL TO 70 YEARS

Background: The optimal treatment for elderly diffuse large B-cell lymphoma (DLBCL) patients needs to be further explored due to their comorbidities, intolerability of standard immunochemotherapy, and unfavorable genetic features. The balance of efficacy and safety is a major issue in the treatment of elderly patients. Rituximab in combination with attenuated CHOP (R-miniCHOP) is the standard treatment for unfit or frail elderly patients. However, the toxicity of chemotherapeutic drugs is still inevitable. In a phase 2 trial (NCT04460248), 40 patients aged 75 years or older with newly diagnosed DLBCL received zanubrutinib in combination with lenalidomide and rituximab (ZR2) regimen, and achieved similar treatment response rate as those of attenuated immunochemotherapy (manuscript in preparation). The promising preliminary results of ZR2 make the combination a potentially chemo-free option versus immunochemotherapy in unfit or frail elderly patients. Aims: PEARL study (NCT05179733) is a multicenter, prospective, randomized, open-label, controlled, non-inferiority trial to evaluate the efficacy and safety of ZR2 versus R-miniCHOP in the treatment of unfit or frail newly diagnosed DLBCL patients aged older than or equal to 70 years. Methods: Key eligibility criteria include patients aged ≥ 80 or 70-79 years with comprehensive geriatric assessment stratified as unfit or frail, histologically-confirmed DLBCL without central nervous system involvement, Eastern Cooperative Oncology Group performance status 0-3, and at least one measurable site of disease. Two hundred and eighty patients will be randomized 1:1 to receive either ZR2 or R-miniCHOP for 6 cycles. The primary endpoint is progression-free survival. Secondary endpoints include complete response rate, overall survival, safety, and quality of life. Response will be evaluated before treatment and repeated after 3 cycles and at the end of treatment. Disease response will be assessed by investigator according to Lugano 2014 criteria. Patients’ enrollment is ongoing. Results: N/A Summary/Conclusion: N/A

Reaching Frail Elderly Patients to Optimize Diagnosis and Management of Atrial Fibrillation (REAFEL): A Feasibility Study of a Cross-Sectoral Shared-Care Model.

Introduction: Atrial fibrillation (AF) management in primary care often requires a referral to cardiology clinics, which can be strenuous for frail patients. We developed “cardio-share” (CS), a new cross-sector collaboration model, to ease this process. General practitioners (GPs) can use a compact Holter monitor (C3 from Cortrium) to receive remote advice from the cardiologist. Objective: To test the feasibility and acceptability of the CS model to manage suspected AF in frail elderly patients. Methods: We used a mixed methods design, including the preparation of qualitative semistructured interviews of GPs and nurses. Results: Between MAR-2019 and FEB-2020, 54 patients were consulted through the CS model, of whom 35 underwent C3 Holter monitoring. The time from referral to a final Holter report was shortened from a mean (SD) of 117 (45) days in usual care to 30 days (13) with the CS model. Furthermore, 90% of the patients did not need to attend visits at the cardiology clinic. The GPs and nurses highlighted the ease of using the C3 monitor. Their perception was that patients were confident in the GPs’ collaboration with cardiologists. Conclusions: The CS model using a C3 monitor for AF is both feasible and seems acceptable to GPs. The elapsed time from referral to the Holter report performed for the diagnosis was significantly reduced.

1015 AN OBSERVATIONAL STUDY OF THE CORRELATION OF FRAILTY SEVERITY WITH MENTAL HEALTH

Abstract Introduction The eFI (electronic Frailty Index) is used to assess the severity of frailty in elderly frail patients using a cumulative deficit model based on routine interactions with their GP. Frailty is associated with an increased risk of falls, reduced mobility, hospitalisations, disability and death. Method Patients were selected for annual frailty assessments by searching the electronic clinical system (SystmOne) using the eFI tool. Patients were assessed using the Comprehensive Geriatric Assessment (CGA) framework. In addition, all patients were screened for coexisting anxiety and depression using the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder (GAD-7) questionnaire. Results Of the 118 patients who ranged from mild to severe frailty, we found there was a positive correlation of the frailty severity eFI scores with increased rates of anxiety and depression evidenced by higher scores on the PHQ-9 and GAD-7 scoring tools. We found a positive correlation of the eFI with the PHQ-9 depression scores of (r = 0.819 p &amp;lt; 0.001). Within the same data set, we found correlation coefficients of eFI and anxiety GAD-7 scores (r = 0.651 p &amp;lt; 0.001). Increasing frailty was found to be associated with a higher rate of depression and anxiety. Conclusion We found in this study higher (eFI) electronic frailty indices are associated with worsening physical impairment and higher rates of anxiety and depression. We would recommend annual frailty assessments in patients with high electronic frailty indices and this should include screening for mental health deterioration. Early detection of deterioration will enable patient centered supportive measures and targeted treatment strategies. Health maintenance programs should ensure patient centered holistic assessment of both physical and mental health needs for early identification to avoid deterioration of both physical and mental health.

981 FIONA STANLEY FREMANTLE HOSPITAL GROUP'S CHOICE PROJECT SUPPORTS EARLY DISCHARGES AND MINIMISES LENGTH OF STAY FOR FRAIL PATIENT

Abstract Background In 2019, Fiona Stanley Fremantle Hospital Group (Western Australia) launched a project to support earlier than usual discharges for frail elderly patients. This project was branded CHOICE—Consider Home Over Inpatient Care Every time. Introduction Evidence suggests that older adults admitted to hospital are at greater risk of further complications and declining health than those cared for at home. Our problem is that the decision to prolong admission can be influenced by our perception of risk which can delay discharges and increase risks for deconditioning, functional decline, hospital acquired complications and early entry into residential care. Method CHOICE implemented 2 key strategies improve patient outcomes and reduce health care costs by minimising LOS: 1. Promotion of a home-first culture began in April 2019 using staff education, training and positive reinforcement. A focus was on positive risk taking behaviours that keep the unique values of our patients at the forefront of all decisions. 2. The CHOICE Team launched in November 2019 to support early diversion of care and assessment into the community. Key elements included an Allied Health led Discharge to Assess service, rapid response Geriatrician clinic and a Nursing outreach service. Results Outcomes achieved in the 20/21 financial year were compared against pre CHOICE (2018) data for patients aged greater than 75 years on target wards 1,756 bed days were saved for patients returning home 22% reduction in discharges directly into care facilities 444 additional home discharges 91% of surveyed patients (n100) felt completely satisfied having their health assessments completed at home Readmission rates did not increase. Conclusion The CHOICE model has been shown to be more cost-effective and clinically effective than traditional practice. CHOICE is now embedded into the operational budget with workforce costs offset by bed day savings and an increase in activity based funding.

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial

BackgroundFrailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery.MethodsPatients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention.DiscussionPrehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery.Trial registrationClinicalTrials.gov NCT04418271. Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820

Ixazomib and daratumumab without dexamethasone (I-Dara) in elderly frail RRMM patients: A multicenter phase 2 study (IFM 2018-02) of the Intergroupe Francophone du Myélome (IFM).

8000 Background: Frail patients with multiple myeloma have an inferior outcome, especially in the relapse setting. This adverse prognosis is mainly related to a high discontinuation rate due to treatment (Tx) related adverse events. The aim of this phase 2 study is to evaluate efficacy and tolerability of Ixazomib-Daratumumab (I-Dara) without Dexamethasone in elderly frail patients with relapsed myeloma (RRMM) (NCT03757221). Methods: Ixa-Dara naïve RRMM patients received oral Ixazomib (4 mg: days 1, 8, 15), IV Daratumumab (16 mg/kg; days 1, 8, 15, 22, cycles 1-2; days 1, 15, cycles 3-6; days 1, cycles 7+) and IV Methylprednisolone before Daratumumab (100 mg at day 1, 8, cycle 1 and then 60 mg). They were enrolled after 1 or 2 prior therapy if their frailty score was ≥ 2 by IMWG score. The primary endpoint was ≥ very good partial response rate (VGPR) at one year. Secondary endpoints included ORR, PFS, OS &amp; toxicity according to NCI-CTCAE version 5. Results: Sixty-three patients were screened and 55 enrolled between 03/2018 and 09/2021. Patient were at first (n = 36) or second relapse (n = 19). Thirty-three patients (60%) were previously exposed to bortezomib, 37 (67%) were previously exposed to lenalidomide (Len) and 20 (36 %) were refractory to Len. Median age was 82 (72-93). All patients had a frailty score ≥2 and 13 (24 %) had a 3 or 4 frailty score. In 41 patients ISS at diagnosis was stage I (n = 11), II (n = 18) or III (n = 12). Seventeen (36%) patients harbored high-risk (HR) cytogenetic, including t(4;14) (n = 8) or del17p (n = 10). The median duration of Tx among 28 pts with ongoing Tx was 10 months [5-32] at data cutoff (February, 2)]. The median duration of Tx among 27 pts who stopped Tx was 6 months [0-18]: 18 had progressive disease. Nine patients died during the study: Daratumumab-related bronchospasm (D1C1); Ixazomib-related overdose (C2); sepsis (n = 4), progressive disease (n = 3). Regarding toxicity, 27 pts had a ≥grade 3 AE (49%). The most common grade 3-4 toxicities were thrombocytopenia (n = 9), other cytopenias (n = 4), infection (n = 8), hypertension (n = 3) and gastrointestinal disorders (n = 3). Fourteen out of 28 were SAE including 5 infections, 1 bronchospasm, 1 acute respiratory failure and 2 ixazomib overdoses. Overall response rate, including minimal response, was 86 % with a ≥VGPR rate of 32 % in the whole group. In Len refractory patients the ORR was 82 % and ≥VGPR 41%, in HR cytogenetic patients ORR was 85 % and ≥VGPR 46%. With a median follow-up of 11.6 months median PFS is 16 months and median OS NR (76% estimated at one year). Conclusions: In this elderly frail population Ixa-Dara is a feasible combination with favorable efficacy profile even in Len refractory and HR cytogenetic patients. Early toxicity remains a concern in this population eventhough more manageable with Dara SC. Clinical trial information: NCT03757221.

Sequential Intrathecal Injection of Hyperbaric and Isobaric Bupivacaine in Orthogeriatric Lower Limb Surgery, a Prospective Randomized Study.

The hemodynamic consequences of sympathetic blockade under spinal anesthesia remains a major concern especially in elderly frail patients. The baricity of the injected solution remains the principal factor controlling the diffusion of spinal anesthetics and the resulting sympathetic blockade. In this study, the sequential administration of isobaric and hyperbaric bupivacaine (HB) is evaluated regarding the incidence of hypotension during orthogeriatric surgery. Fifty elderly patients (age ＞ 60), scheduled for lower limb orthopedic surgery were randomly divided into two groups. In group HIB (n = 25), sequential injection of two syringes, 1.5 mL of 0.5% HB with 15 μ of fentanyl was injected, followed immediately by 1.5 mL of 0.5% isobaric bupivacaine, and in group HB (n = 25), 3 mL of 0.5% HB mixed with 15 μ of fentanyl citrate (0.3 mL of fentanyl 50 μg/mL) were used for spinal anesthesia. No statistical difference was found between the two groups regarding patient demographics, comorbidities, or preoperative laboratory data. The absolute incidence of hypotension (16% vs. 44%, P = 0.03) was statistically lower in the HIB group than the HB group. Also, the total number of hypotensive episodes and the need for vasopressor medications were statistically lower in the HIB group than the HB group (P = 0.02 vs. P = 0.01). Our results show a better hemodynamic profile of the sequentially injected mixture with a lower incidence of intraoperative hypotension and subsequent lower vasopressor requirements.

An Observational Study of the Mental Health Burden in Frail and Elderly Patients

AimsPsychiatric illnesses are common among older adults and are associated with increased mortality and physical comorbidities. It is suggested that patients with frailty have a higher prevalence of depressive symptoms. (1) The eFI (electronic Frailty Index) is a tool used to assess the severity of frailty in elderly frail patients using a cumulative deficit model based on routine interactions with their GP.MethodsPatients were selected for annual frailty assessments by searching the electronic clinical system (SystmOne) using the eFI tool. Patients were assessed using the Comprehensive Geriatric Assessment (CGA) framework. In addition, all patients were screened for coexisting anxiety and depression using the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) questionnaire.ResultsOf the 118 patients who ranged from mild to severe frailty, we found there was a positive correlation of the frailty severity eFI scores with increased rates of anxiety and depression evidenced by higher scores on the PHQ-9 and GAD-7 scoring tools. We found a positive correlation of the eFI with the PHQ-9 depression scores of (r = 0.819 p &lt; 0.001). Within the same data set, we found correlation coefficients of eFI and anxiety GAD-7 scores (r = 0.651 p &lt; 0.001). Increasing frailty was found to be associated with a higher rate of depression and anxiety.ConclusionWe found in this study higher (eFI) electronic frailty indices are associated with higher rates of anxiety and depression. We would recommend annual frailty assessments in patients with high electronic frailty indices and this should include screening for mental health deterioration. Early detection of deterioration will enable patient centered supportive measures and targeted treatment strategies. Health maintenance programs should ensure patient centered holistic assessment of both physical and mental health needs for early identification to avoid deterioration of both physical and mental health.