Geriatric Assessment Research Articles

Comprehensive geriatric assessment for predicting postoperative delirium in oral and maxillofacial surgery: a prospective cohort study.

Identifying high-risk patients for developing postoperative delirium (POD) is essential for optimizing the medical field's human and financial resources through specialty-relevant geriatric assessments that can aid in establishing prehabilitation strategies. This study aims to identify geriatric screening tools to predict preoperative delirium and explore the high-risk elderly patients undergoing oral maxillofacial surgery. A comprehensive geriatric assessment encompassing 23 instruments was used to evaluate inpatients undergoing surgery under general anaesthesia, preoperatively and postoperatively. Selective intraoperative and postoperative variables were also assessed for their relation to POD occurrence. This prospective study included 90 patients (mean age 79.0 years) from August 2022 to August 2023. The POD rate in this cohort was (8.9% n = 8). The Clock-Drawing Test (CDT) was significantly associated with POD occurrence (p = 0.005). Significant associations were found between POD occurrence and operation type (p = 0.018), duration (p = 0.026), length of stay ( p = 0.002), and postoperative hemoglobin levels (p = 0.027). This study highlights the importance of comprehensive geriatric assessments in predicting POD in elderly patients. Future research should build on these findings to enhance preoperative care strategies and improve outcomes.Trial registration: German Register of Clinical Studies, DRKSID DRKS00028614.

Circulating BMP-7 Level is Independent of Sarcopenia in Older Asian Adults.

In vitro and animal studies have demonstrated that BMP-7, renowned for its osteogenic properties, also exerts beneficial effects on muscle metabolism by enhancing myogenesis and reversing muscle atrophy. Despite being proposed as a common regulatory factor for both muscle and bone, the impact of BMP-7 on human muscle health has not been thoroughly investigated. This cross-sectional study involved 182 community-dwelling older adults who underwent a comprehensive geriatric assessment in South Korea. Sarcopenia was diagnosed using Asian-specific cutoffs, and serum BMP-7 levels were quantified via enzyme immunoassay. The mean age of the participants was 72.2 ± 7.3 years, with 62.6% being female. After adjustments for confounders, serum BMP-7 levels were not significantly different between individuals with and without sarcopenia, nor were there differences based on skeletal muscle mass, strength, or physical performance levels (P = 0.423 to 0.681). Likewise, no correlations were detected between circulating BMP-7 levels and any sarcopenia assessment metrics such as skeletal muscle index, grip strength, gait speed, or chair stand completion times (P = 0.127 to 0.577). No significant associations were observed between increases in serum BMP-7 concentrations and the risk of sarcopenia or poor muscle phenotypes (P = 0.431 to 0.712). Stratifying participants into quartiles based on serum BMP-7 levels also indicated no differences in sarcopenia-related parameters (P = 0.663 to 0.996). Despite experimental evidence supporting BMP-7's role in muscle metabolism, this study found no significant association between serum BMP-7 levels and clinical indicators of muscle health in older adults. These findings challenge the utility of serum BMP-7 as a biomarker for sarcopenia in this demographic.

Improving health outcomes among older adults in India: effectiveness and implementability of a novel comprehensive geriatric assessment based intervention

Background There is significant evidence on the benefits of comprehensive assessment in older adults. But this evidence is primarily from western countries and in secondary care settings. National policies in India recognize this need and envision community-based screening and facility-based assessment programs integrated into the care pathways for the elderly. However, this is yet to translate into specific interventions, primarily due to lack of complex interventions necessary and evidence of their effectiveness. This study aims to design and pilot an integrated (Community + Facility) Elderly Health Status Assessment and Screening (EHSAS) intervention to improve health outcomes of older adults and assess its feasibility for implementation in Indian rural settings. Methods We propose a hybrid design where we will build the complex intervention, develop and validate the tools needed, pilot it using an exploratory cluster randomized trial and evaluate its implementatbility using the Exploration-Preparation-Implementation-Sustainment (EPIS) framework. Conclusions This study will fill critical gaps in evidence regarding the effectiveness of geriatric screening and assessment in community and primary care settings in low-middle income countries and provide validated tools and implementation models for adoption into national programs. Registration CTRI/2023/07/055661

Prediction of Fragility Fractures and Mortality in a Cohort of Geriatric Patients.

Risk factors of refracture after fragility fractures include osteoporosis, female gender and advanced age among others. We hypothesized that the assessment of functionality, muscle health and nutrition status contribute to the risk prediction for further fractures and death. We assessed 334 patients admitted to the department of acute geriatrics for sociodemographic data, bone fragility, selected laboratory tests, body composition and data on functionality using the comprehensive geriatric assessment. Patients had follow-ups until the occurrence of further fractures or death. Dual-energy X-ray absorptiometry and pulse echo measurements were performed to assess bone mineral density. Fracture risk was assessed using the FRAX score and muscle strength according to published guidelines on sarcopenia. The mean age was 81 years (70-95), and 82.3% (275/334) were women. An incidence of 10.4% (35/334) new fragility fractures was observed within 24 months, and the mortality rate was 12.2% (41/334). A significantly higher rate of further fractures was associated with lower BMI (body mass index) (HR 0.925, CI 0.872-0.98; p = 0.009), lower parathyroid hormone levels (HR 0.986, CI 0.973-0.998; p = 0.026) and with the diagnosis of osteoporosis (HR 2.546, CI 1.192-5.438; p = 0.016). No significant associations were present in patients with previous fractures, with higher age, higher FRAX scores, sarcopenia, in women, sarcopenic obesity, frail patients, lower grip strength, lower walking speed, lower Barthel index or lower DI (density index) values. The predictive power for further fractures was 10.7% higher adding osteosarcopenia, BMI and parathyroid hormone levels to standard assessment parameters osteoporosis, age and the status of previous fractures. Mortality was significantly higher with advanced age (HR 1.101, CI 1.052-1.151; p < 0.001), in men (HR 6.464, CI 3.141-13.305; p < 0.001), in smokers (p = 0.002), higher FRAX score (HR 1.039, CI 1.009-1.070; p = 0.010), lower renal function (HR 0.987, CI 0.976-0.997; p = 0.010), lower Tinetti test scores (HR 0.943, CI 0.900-0.987; p = 0.012), lower walking speed (HR 0.084, CI 0.018-0.382; p = 0.001), lower hand grip (HR 0.876, CI 0.836-0.919; p < 0.001) and lower Barthel index scores (HR 0.984, CI 0.971-0.997; p = 0.015). In a cohort of geriatric patients, the addition of BMI, low parathyroid hormone levels and osteosarcopenia increases the predictive power for further fractures by 10.7%. These parameters are a valuable addition to the standard assessment parameters age and history of sustained fractures. Mortality is partly associated with potentially treatable functional parameters.

Association of Limited Health Literacy With Frailty, Health-Related Quality of Life, and Health Care Utilization Among Older Adults With Cancer: The Cancer and Aging Resilience Evaluation Registry.

Limited health literacy-ability to obtain, process, and understand health information-can hinder communication, access to medical treatment, and identification and management of comorbidities. Older adults have high rates of poor health literacy, but its role in aging-related outcomes among older adults with cancer is understudied. We included 876 older adults age 60 years and older with cancer from the Cancer and Aging Resilience Evaluation Registry completing self-reported geriatric assessment, including health literacy, at first visit to medical oncology. The exposure was limited health literacy. Outcomes were frailty, physical/mental health-related quality of life (HRQOL), and health care utilization. We used modified Poisson regression to examine the association of exposure on outcomes adjusting for age, race-ethnicity, sex, and cancer type/stage. Median age at enrollment was 68; 57.8% were male; 20.2% were non-Hispanic Black. The most prevalent cancers were advanced-stage (46.8% stage IV) colorectal (26.9%) and pancreatic (19.0%). Those with limited health literacy were older (70 v 68 years; P < .001), male (63.0% v 55.1%; P = .026), non-Hispanic Black (28.8% v 16.1%; P < .001), ≤high school educated (62.3% v 28.1%; P < .001), and retired/disabled (86.3% v 71.2%; P < .001). In multivariable analysis, limited health literacy was associated with higher prevalence of frailty (prevalence ratio [PR], 2.64 [95% CI, 2.15 to 3.26]), impaired physical (PR, 1.90 [95% CI, 1.59 to 2.27]) and mental (PR, 2.08 [95% CI, 1.76 to 2.47]) HRQOL, and hospitalization in the last year (PR, 1.28 [95% CI, 1.10 to 1.48]) versus adequate health literacy. Older adults with cancer and limited health literacy had higher adjusted prevalence of frailty, impaired physical and mental HRQOL, and recent hospitalization. Interventions to address limited health literacy should be explored in this vulnerable and growing cancer population.

Correlation Between Reduced Daily Living Competence and the Risk of Postoperative Delirium in Orthopedics and Trauma Surgery

Background/Objectives: Postoperative delirium is a prevalent and serious complication among elderly patients following surgical procedures. Prior research indicates that reduced competence in daily living, as evidenced by limitations in performing Activities of Daily Living (ADL), is directly associated with reduced patient mobility. This study aimed to investigate the potential role of preoperative mobility as a risk factor for the development of postoperative delirium. Methods: To assess preoperative mobility, a comprehensive geriatric evaluation of daily living competence was conducted. This included the Katz Index of Independence in ADL, which assessed basic daily activities over the preceding 14 days, and the Instrumental Activities of Daily Living Scale (IADL). Postoperatively, delirium monitoring was performed twice daily for seven days using validated delirium screening tools, including the Nursing Delirium Screening Scale, the Confusion Assessment Method, and the 4ATest. Results: A significant correlation was observed between the incidence of delirium and the IADL scores in all patients, with p &lt; 0.001 for men and p = 0.001 for women. Among emergency patients, the Katz Index scores significantly differed between those who developed delirium and those who did not (p = 0.015). Additionally, a significant correlation was found between the Katz Index and the incidence of delirium in both groups (p &lt; 0.001). Conclusions: The findings of this study emphasize the necessity of preoperative geriatric assessment using tools such as the Katz Index or IADL to identify patients at risk of delirium. The results confirm the importance of enhanced postoperative monitoring for potential delirium. For elective patients, prehabilitation should be considered when reduced daily living competence is identified. For emergency patients, immediate postoperative interventions, including intensive mobilization and orthogeriatric co-management, are recommended.

Evaluating the Diagnosis of Malnutrition Based on Global Leadership Initiative on Malnutrition (GLIM) Criteria in Community-Dwelling Older Adults (Singapore Longitudinal Aging Study)

Background: A minority of studies using the GLIM criteria for malnutrition diagnosis have performed formal empirical validation. Objectives: To evaluate the concurrent and predictive validity of GLIM criteria with and without prior screening among community-dwelling older adults in Singapore. Method: In the Singapore Longitudinal Aging Study (SLAS-2, n = 2477), malnutrition was diagnosed using single-step and two-step GLIM procedures using the Mini Nutritional Assessment Short Form (MNA-SF) and Elderly Nutritional Index for Geriatric Malnutrition Assessment (ENIGMA) for initial screening. Criterion validity was evaluated using MNA-Full Form (MNA-FF) as reference malnutrition diagnosis. Prognostic validity was evaluated using logistic and Cox regression analyses with respect to impaired quality of life (QoL) and 10-year mortality. Results: GLIM malnutrition with and without MNA-SF or ENIGMA screening showed significant associations with known clinical correlates; single-step GLIM malnutrition: sensitivity = 80%, specificity = 83%; two-step MNA-SF-GLIM malnutrition: sensitivity = 80%, specificity = 85%; two-step ENIGMA-GLIM malnutrition: sensitivity = 74%, specificity = 88%; positive predictive values of around 20% and negative predictive values above 98%. Cohen’s kappa values of agreement were uniformly low (0.26 to 0.32). All showed significant associations with about 50% increased odds of impaired QoL and 10-year mortality, adjusted for age, sex, ethnicity, education levels, and housing type, with the ENIGMA-GLIM malnutrition showing the highest risk estimates. Compared to MNA-FF malnutrition prevalence of 4.1%, GLIM-based malnutrition increased prevalence (14.6% to 19.7%) estimates. Conclusions: The GLIM criteria showed good construct and criterion validity. It increased the number of individuals diagnosed with malnutrition. The agreement between diagnoses of malnutrition was low. Diagnostic and prognostic accuracy vary with the screening instrument used. Early identification of malnutrition using appropriate tools can provide opportunities to delay or prevent the risk of important adverse outcomes such as impaired QoL and mortality.

Sleep quality, daytime sleepiness, and risk of falling: results from an exploratory cross-sectional study.

There is growing recognition of the importance of managing sleep disorders in the elderly, particularly given their complexity within a multidimensional framework. The aim of the present study is to investigate whether sleep quality and daytime sleepiness are associated with the risk of falls in older adults. This study included patients aged 75years or older who were consecutively evaluated at the Geriatric Service, University Hospital of Monserrato, Cagliari, Italy. Participants underwent geriatric assessment, including sleep analysis using the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale (ESS), as well as an assessment of risk of falls with Performance Oriented Mobility Assessment (POMA). The study included 206 subjects, of whom 70.4% were women, with a median age of 83years. A total of 141 participants (68.4%) had poor sleep quality, and 43 (20.9%) had excessive daytime sleepiness (EDS). Among people at high risk of falls, 85 participants had bad sleep quality, and 24 a satisfying one (χ2: 8.23, p = 0.0029); additionally, 77 participants did not exhibit daytime sleepiness, while 32 did (χ2: 9.03, p = 0.0027). To further explore these results, we designed logistic regressions, considering dichotomized PSQI and dichotomized ESS as independent variables, and dichotomized POMA as the dependent variable, and finally adjusted them for confounders. The adjusted model for PSQI yielded OR: 2.04 (95%CI 1.02-4.10), and the adjusted model for ESS yielded OR: 2.56 (95%CI 1.17-5.91). Our study demonstrated that an increased estimated risk of falling is associated with poor sleep quality and EDS in older adults, independently of the confounders.

Assessing palliative care needs in patients with dementia: A cross-sectional analysis of an predominantly oldest-old population from a geriatric memory clinic.

In this cross-sectional study, we assessed palliative care (PC) needs in older adults with dementia. Using the NECPAL CCOMS-ICO© 3.1 tool and comprehensive geriatric assessment, 16.25% of the 554 evaluated patients required PC, which had clinical frailty and a moderate stage of dementia. Advanced frailty was associated with the poorest prognosis, according to the PC-based stratification. Our findings support the use of PC assessment in dementia care, which focuses on a person-centered approach while minimizing unnecessary or ineffective treatments and meeting the real-world patient's needs. PC care may fulfill the multidimensional nature of dementia, shifting towards personalized palliative approaches.

The Association between Psychotropic Medication Use and Gait and Mobility Impairment in Community-Dwelling Older People. Data from The Irish Longitudinal Study on Ageing (TILDA).

Little work to date has quantified the effect of psychotropic medications (antidepressants, benzodiazepines, 'Z' drugs, antipsychotics, anticholinergics) on mobility and gait in later life. The aim of this study is to examine the relationship between these medications and mobility/gait parameters in a large cohort of community-dwelling older people. Participants were included if they were ≥60 years at TILDA Wave 1 and underwent gait and mobility assessment (Gaitrite system), with follow-up at Wave 3 (4 years). Medication lists were examined for psychotropic medications. Regression models assessed the relationship between psychotropic medications and mobility, using the following parameters: Timed Up and Go (TUG), gait speed, step length / width, double support phase. Multilevel modelling assessed trajectories of mobility/gait variables over time by psychotropic use. Of 2620 patients, 12% were prescribed ≥1 psychotropic medication, 3% prescribed ≥2 psychotropics. Cross-sectionally, psychotropic medication was independently associated with prolonged TUG (β=0.50 (95% CI 0.27-0.73); p<0.001), slower gait speed (β=-5.65 (95% CI -7.92 - -3.38); p<0.001), shorter step length (β=-2.03 (95% CI -2.93 - -1.42); p<0.001) and increased double support phase (β=0.47 (95% CI 0.19-0.75); p=0.001).Longitudinally, psychotropic use was independently associated with transition to abnormal TUG (OR 2.68 (95% CI 1.55-4.64), p<0.001), while using ≥2 psychotropics was associated with transition to slower gait speed (OR 2.59 (95% CI 1.01-6.68); p=0.048). Psychotropic use was associated with significantly poorer mobility and gait performance, both cross-sectionally and longitudinally. It is imperative that psychotropic medication use is reviewed as part of comprehensive geriatric assessment.

Early Telephone-Based Frailty Screening With the Vulnerable Elders Survey in Adults Aged 75 Years and Older With Lung and Gynecological Cancer.

The International Society of Geriatric Oncology recommends that all older people with cancer have a geriatric evaluation before beginning treatment. To determine the prevalence of frailty in people 75 years and older diagnosed with lung or gynecological cancer and evaluate the adaptation of standard therapeutic strategies based on frailty, following the implementation of telephone-based frailty screening with the Vulnerable Elders Survey (VES-13). We performed a retrospective observational study in 362 people screened by an advanced practice nurse before their first oncology appointment. We collected secondary data from electronic medical records. The main variables were degree of frailty (according to VES-13 and comprehensive geriatric assessment), type of cancer treatment (standard and prescribed), treatment completion, sociodemographic characteristics, and comorbidities. The VES-13 detected 186 people (51.4%) at risk of health deterioration, and the comprehensive geriatric assessment confirmed some degree of frailty in 157 people (43.4%), with a κ coefficient of 0.84. People with more comorbidities, greater frailty, and more geriatric syndromes were more likely to need treatment readjustment ( P < .001). Telephone-based frailty screening by an advanced practice nurse showed high applicability, with very good agreement between the proportion of people classified as frail before the initial visit and in the subsequent geriatric assessment. A protocol for establishing frailty risk through telephone screening by an advanced practice nurse facilitates the care process and helps clinicians adapt therapeutic decision-making to the needs of each patient and their family.

Development of a Leg And Walking Self-exercise (LAWS) program for older adults during cancer treatment.

We developed a self-directed Leg And Walking Self-exercise (LAWS) program informed by the Exercise is Medicine initiative and evaluated the feasibility and acceptability of this program in older adults with cancer. Over a 1-year period, we prospectively enrolled 40 older adults who received a comprehensive geriatric assessment (CGA) at a geriatric oncology service and initiated a new line of systemic therapy for advanced cancer as inpatients. LAWS is a tailored, self-directed exercise program consisting of leg resistance training and walking. Exercise adherence was recorded using an exercise diary to assess feasibility. Patient perspectives on this program were evaluated using the Feasibility of Intervention Measure (FIM) and Acceptability of Intervention Measure (AIM), with a score range of 1-5, higher being better. Overall, 28% of patients were fit, 53% pre-frail, and 20% frail based on the CGA. During hospitalization (average 12days), 63% of the patients adhered to exercises at lowest intensity during more than 50% of their inpatient stay: on average, 2.8 leg exercises, 23 repetitions a day, 5.6days/week, and 19min of walking a day, 4.9days/week. Patients rated their perceived exertion at 3.0 for leg exercise and 3.0 for walking on a 1-10 Likert scale. During the period between discharge and their first outpatient appointment (average 11days), 71% of patients adhered to the LAWS program. Mean scores of FIM and AIM were 4.2 (SD = 0.5) and 4.2 (SD = 0.7), respectively. For older adults undergoing cancer treatment, LAWS is a feasible and acceptable self-directed exercise program.

Geriatric Oral Health and Quality of Life Among the Indigenous Irula Tribes of Tamil Nadu.

This study aims to assess the oral health-related quality of life (OHRQoL) among the Irula tribes and to know the factors influencing quality of life among the elderly irula tribes of Tamil Nadu. This cross-sectional study was conducted in the Northern district of Tamil Nadu, including 486 Irula individuals aged 65 and above. Participants were selected using a multistage sampling method. Data were collected through a structured questionnaire, including the Geriatric Oral Health Assessment Index (GOHAI) to evaluate OHRQoL. The study tool covered demographics, medical history, and oral health issues. Data analysis was performed using SPSS version 23, with logistic regression applied to account for confounders. The sample primarily consisted of individuals aged 65-69 years (55.6%), with a predominance of females (76.3%). The majority were Hindu (94.9%) and lived in nuclear families (88.3%). Educational levels were low, with 66.5% being illiterate. Most participants were agricultural laborers (64.6%) and had low monthly incomes. GOHAI results revealed that many respondents faced significant oral health challenges, including difficulties with eating, speaking, and discomfort. Multivariate analysis showed that educational level significantly affected OHRQoL, with higher education correlating with better quality of life. Arthritis was associated with poorer OHRQoL, while other health conditions did not show significant impacts. The study highlights severe oral health issues among the Irula community, with significant physical and psychological impacts. Educational attainment plays a crucial role in OHRQoL, while arthritis notably affects quality of life. The findings emphasize the need for targeted oral health interventions and increased awareness in tribal communities to improve overall health outcomes. Further research in larger populations is necessary to comprehensively understand and address geriatric oral health needs.

Exploring geriatric assessment-driven rehabilitation referral patterns and its influence on functional outcomes and survival in older adults with advanced cancer.

Older adults with advanced cancer experience functional disability that warrants rehabilitation services; however, evidence indicates inconsistencies in referral. The purpose was to (1) identify predictors of geriatric assessment (GA)-driven referrals to rehabilitation services and (2) explore associations between referral and change in function, health-related quality of life (HRQoL), and overall survival among older adults with advanced cancer. This was a secondary analysis (NCT020107443, UG1CA189961) of a nationwide GA clinical trial. Patients were older adults with advanced cancer who had at least one GA-defined physical performance or functional status impairment. Primary outcomes were oncologist-initiated discussion about or referral to rehabilitation services after the GA (Aim 1) and decline in activities of daily living (ADL), Instrumental ADL (IADL), and HRQoL within 3 months, and overall survival at 1 year (Exploratory Aims). Analyses included multivariable logistic regression and Cox proportional hazards models. Demographic and clinical factors were controlled for by using 1:1 propensity score matching. In total 265 patients were analyzed. After adjustment, impaired cognition (odds ratio [OR] = 2.25, p = 0.01), Karnofsky score indicating disability (OR = 2.86, p < 0.01), and receipt of monoclonal antibodies (OR = 1.95, p = 0.04) were associated with higher odds of referral. In contrast, polypharmacy was associated with lower odds of referral (OR = 0.31, p < 0.01). Referred patients were less likely to decline in ADL (OR 0.30, p = 0.07) and IADL (OR 0.64, p = 0.35), but more likely to decline in HRQoL (OR 1.20, p = 0.67) and have worse survival (HR 1.18, p = 0.62). Cancer treatment, polypharmacy, cognition, and disability status likely influence oncologists' decision to refer for rehabilitation. Referral was not independently associated with change in functional disability, HRQoL, or survival. Future studies should evaluate patients' utilization of rehabilitation services post-referral and determine whether dose/timing of rehabilitation services influence clinical outcomes.

TAVIGER : Intérêt d’une expertise coordonnée gériatrique et cardiologique dans le bilan d’éligibilité des patients âgés à un remplacement valvulaire aortique par voie percutanée

BackgroundTranscatheter aortic valve implantation (TAVI) is the gold standard treatment for aortic stenosis in the elderly. Pre-identification of patients likely to benefit from this procedure remains crucial. A standardised geriatric assessment is used to identify the major geriatric syndromes likely to influence postoperative outcomes. ObjectiveTo identify factors associated with lack of TAVI management and to compare one-year survival in TAVI vs. non-TAVI patients. MethodsRetrospective study, between 2016 and 2020, at the Arras hospital. Patients aged 70 years and older with symptomatic severe aortic stenosis who had undergone geriatric assessment were included. ResultsOne hundred and ninety-two (192) patients, mean age 82.3 years. The 1-year mortality rate was 18% in the TAVI group and 44% in the non-TAVI group (p < 0.001).Parameters associated with no TAVI were Euroscore (ESL) 1 (19.6 ± 10.9 vs. 23.2 ± 13.5, p = 0.020), malnutrition (14% vs. 35%, p = 0.004), walking speed < 0.8 m/s (39% vs. 75%, p = 0.001), Activities of Daily Life (ADL) score (5.4 ± 1 vs. 4.2 ± 1. 6, p < 0. 001) and Instrumental Activities of Daily Life (IADL) score (2.6 ± 1.2 vs. 1.8 ± 1.4, p = 0.002), Mini Geriatric Depression Scale (mini GDS) ≥ 1 (16% vs. 38%, p = 0.045), Mini Mental State Examination (MMSE) score (25.1 ± 3.5 vs. 21.6 ± 4.3 < 0.001). ConclusionsGeriatric syndromes are important determinants of TAVI candidacy. Cardiological surgical risk scores are not effective in discriminating between patients. Coordinated assessment may optimise selection. Therefore, geriatric assessment should be systematically performed as part of the pre-TAVI evaluation.

Implementation of ePROs Into Multidisciplinary Tumor Board Discussions for Patients With Pancreatic Cancer: The INSPIRE Intervention.

The incorporation of electronic patient-reported outcomes (ePROs), such as the Geriatric Assessment (GA) and treatment preferences, into decision-making for pancreatic cancer has been limited by clinician- and system-level barriers concerning workflow. We hypothesized that ePRO inclusion within multidisciplinary tumor boards (MDTBs) would circumvent barriers and provide a venue for systematic consideration of critical patient-provided information. The INtegrating Systematic PatIent-Reported Evaluations (INSPIRE) intervention consists of (1) patient survey completion, including GA and patient preferences, and (2) screensharing patient ePROs during MDTBs. Proctor et al's implementation outcomes were assessed, with penetration (the proportion of consented patients who were presented at MDTBs) acting as the primary outcome (considered successful at 70%). Secondary outcomes included adoption, feasibility, acceptability, appropriateness, cost, and sustainability, assessed by clinician post-MDTB exit surveys, clinician postintervention surveys, clinician postintervention semistructured interviews, and time-coding analysis of recorded and transcribed historical (November 2021-February 2022) and intervention (September 2022-June 2023) MDTBs. A total of 50 patients completed surveys and all were presented at MDTBs (penetration=100%). All eligible clinicians (n=9) enrolled patients (adoption=100%) and reported that ePROs were useful in 90% and led to a change in treatment plan in 30% of cases. In postintervention surveys and interviews, clinicians primarily responded positively to feasibility, acceptability, and appropriateness questions. Time-coding analysis found a modest time cost of an additional 51.1 seconds in mean discussion time-per-patient between preintervention (mean [SD], 172.7 [111.4] seconds) and intervention patients (mean [SD], 223.8 [107.1] seconds); 86% of clinicians reported the intervention did not take too much time. All surveyed clinicians reported interest in continuing the intervention and suggested adaptations to further promote sustainability. The integration of ePROs into pancreatic MDTBs was feasible and acceptable, providing a potential approach to increase the utilization of ePROs by clinical teams in their management of patients with pancreatic cancer.

Condiciones geriátricas y estrategia invasiva en pacientes frágiles con IAMSEST. Análisis de subgrupos de un ensayo clínico aleatorizado

Introduction and objectives Invasive management in frail patients with non–ST-segment elevation myocardial infarction (NSTEMI) remains controversial. We investigated the impact of various geriatric conditions.Methods The MOSCA-FRAIL trial included 167 adults aged ≥ 70 years with frailty (Clinical Frailty Scale [CFS] ≥ 4 points) and NSTEMI, who were randomized to either an invasive (n = 84) or conservative (n = 83) strategy. In addition to frailty, we measured activities of daily living (Barthel index), cognitive impairment (Pfeiffer test), and comorbidities (Charlson index). The primary endpoint was the difference (invasive minus conservative) in restricted mean survival time (RMST) for all-cause mortality at a median follow-up of 3.9 years.Results A total of 93 patients died. The RMST difference favored invasive management at the CFS 25th percentile (CFS = 4; 157 days, 95%CI, 18-295; P = .027), which changed to a nonsignificant effect at the 50th and 75th percentiles. The RMST difference remained nonsignificant, irrespective of the severity of other geriatric assessments. In time-to-event analysis, invasive management was associated with an initially lower life expectancy, peaking at around 1 year, among all subgroups. However, patients with CFS = 4 experienced a benefit at the end of follow-up (181 days, 95%CI, 19-343), whereas those with CFS > 4 did not (−16 days, 95%CI, −217 to 186; interaction P = .16). Subgroups defined by other geriatric markers showed a similar time-dependent trend, albeit with weaker statistical interaction.Conclusions Among adults with frailty and NSTEMI, the CFS might be useful for evaluating the relative risks and benefits of invasive management. A CFS > 4 could serve as a valuable threshold for decision-making.

Predictive ability of the Cancer and Aging Research Group chemotherapy toxicity calculator in hematologic malignancy

IntroductionChemotherapy toxicity tools are rarely studied in patients with hematologic malignancy (HM). The primary aim of this pilot study was to determine the predictive ability of the Cancer and Aging Research Group (CARG) chemo-toxicity calculator in estimating grade 3–5 toxicity in patients with HM. Materials and MethodsPatients 60 years and older with HM were prospectively evaluated using the CARG chemo-toxicity calculator. Discrimination and calibration were checked by applying the published model in our data. Additionally, a full geriatric assessment (GA), the Short Physical Performance Battery (SPPB), and health related quality of life (HRQoL) were captured longitudinally at the start of treatment and at end of study. Secondary aims explored the association of GA metrics with chemo-related toxicities and survival. ResultsOne hundred forty-five patients were approached, 118 patients consented, and 97 patients were evaluable. Most patients were newly diagnosed (n = 91). The median CARG score was 9 (range 4–18). The CARG score was not validated in our cohort of older patients with HM, with area under the receiver operation characteristic curve being 0.53 (95 % CI: 0.41–0.65). In multivariable analysis, after controlling for disease type, risk factors associated with grade 3–5 toxicity included living alone (hazard ratio [HR] 4.24, 95 %CI: 2.07–8.68, p < 0.001), increase in body mass index (HR 1.06, 95 %CI: 1.01–1.12, p = 0.03) and a higher social activities score (HR 1.27, 95 %CI: 1.06–1.51, p = 0.01). In multivariable analysis of overall survival, the only prognostic factor was an objective marker of physical function (SPPB score HR = 0.85, 95 %CI:0.78–0.93, p < 0.001). DiscussionThe CARG chemo-toxicity calculator was not predictive of grade 3–5 toxicity in patients with hematologic malignancy. The SPPB was associated with overall survival in multivariable analysis, suggesting future use as an objective biomarker in HM. We also report a comprehensive trajectory of function, QoL, psychosocial well-being, and cognition among older adults with HM. The predictive accuracy of the CARG chemo-toxicity calculator may be affected by the diverse range of HM treatment options that are not traditional chemotherapy.

Risk Factors Analysis and Nomogram Conduction for Major Adverse Events After Lumbar Fusion Surgery in Older Patients: A Prospective Cohort Study

This study aimed to identify risk factors for major adverse events (AEs) after lumbar fusion surgery in patients aged 75 and over and evaluate the role of several common geriatric comprehensive assessment items in predicting postoperative major AEs. This is a prospective cohort study of patients aged ≥75 years who underwent open lumbar fusion for degenerative spine disease from August 2019 to August 2022. The primary outcome measure was the incidence of major postoperative AEs within 90 days after surgery. Clavien-Dindo III-IV complications and unplanned readmission were defined as major AEs. Patients' characteristics, laboratory tests, assessment results, and surgery-related variables were compared between the major AEs and the non-major AEs groups. Multivariable logistic regression analysis was used to identify independent risk factors for major AEs. The logistic regression model was evaluated in another prospective cohort of patients from October 2022 to October 2023. A total of 301 patients (mean [SD] age, 79.7 [3.5] years; 60.5% male) were included in the study. Five features, including female (OR 1.99, p = 0.040), higher body mass index (BMI) (OR 1.090, p = 0.024), frailty (OR 2.043, p = 0.032), hypoalbuminemia (OR 2.489, p = 0.040), and higher Charlson comorbidity index (CCI) (OR 1.397, p = 0.024), were independently associated with major AEs and were selected to develop a predictive nomogram of major AEs. The area under the curve values for the development set and validation set were 0.75 and 0.71, respectively. Preoperative frailty, hypoalbuminemia, female sex, greater BMI, and higher CCI grade were risk factors for 90-day major AEs after lumbar fusion surgery in older patients. The predictive nomogram that we developed using this data can enhance preoperative risk counseling and optimization for older patients.

Frailty screening with comprehensive geriatrician-led multidisciplinary assessment for older adults during emergency hospital attendance in Ireland (SOLAR): arandomised controlled trial.

Multidisciplinary comprehensive geriatric assessment (CGA) improves outcomes in hospitalised older adults but there is limited evidence on its effectiveness in the emergency department. We aimed to assess the benefits of CGA in the emergency department for older adults living with frailty. In this randomised controlled trial, we enrolled older adults (≥75years) who presented to the emergency department with medical complaints at University Hospital Limerick (Limerick, Ireland). Participants screened positive for frailty on the Identification of Seniors at Risk screening tool (score ≥2). Patients requiring resuscitation as well as those with COVID-19, psychiatric, surgical, or trauma complaints were excluded. Participants were randomly allocated 1:1 to geriatrician-led multidisciplinary CGA and management or usual care. Outcome assessors were masked to treatment allocation. The primary efficacy outcome was time spent in the emergency department, defined as the time from registration on the computer database until time of discharge or admission to an inpatient ward in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT04629690. Between Nov 9, 2020, and May 13, 2021, we recruited 228patients. 113participants were included in theintervention group (mean age 82·4years [SD 4·9]; 63 [56%] women; 113 [100%] White Irish) and 115in the control group (83·1[5·6]; 61 [53%]; 112 [97%]). Median time in the emergency department was 11·5h (IQR 5-27) in the intervention group and 20h (7-29) in the control group (median difference [Hodges-Lehmann estimator] 3·1 h [95%CI 0·6-7·5]; p=0·013). There were no adverse events related to the intervention. Geriatrician-led multidisciplinary assessment of older adults living with frailty was associated with reduced time spent in the emergency department setting at index visit and lower rates of nursing home admission, greater increases in quality of life, and lower decreases in function at both 30days and 180days. Multicentre trials are needed to confirm the external validity of the findings. This study provides an evidence base for similar teams in an emergency department setting. Health Research Board (ILP-HSR-2017-014).