Management Of Older Patients Research Articles

Four types of old patients in the emergency department : A geriatric medicine qualitative and economic viewpoint

Lack of clinical management of old patients in the emergency department. How can we manage old patients in the emergency department more effectively, medically and economically? Evaluation of current selection and screening methods and recommendations for old patients in the emergency department. Acute inpatient treatment needs, presence of dysfunction in at least two core areas and assessment of advance care needs are examined. The identification of old patients in the emergency department as geriatric patients alone shows no control potential. Combining the three test criteria of acute inpatient need for treatment, the presence of dysfunction in at least two core areas and the assessment of advance care needs generates four old patient types that have interesting control potential: the medical traumatology patient, the acute geriatric patient, the rehabilitative geriatric patient, and the ambulatory patient. in addition to identifying geriatric patients, screening should map acute inpatient treatment needs, assessment of dysfunction, and analysis of advance care needs to define clinically steerable old patients.

The impact of home quarantine during COVID-19 lockdown on neurological hospitalizations, in-hospital mortality, and acute ischemic stroke management in older patients without COVID-19

IntroductionThis study aimed to investigate the impact of home quarantine in older patients without COVID-19 hospitalized due to neurological disorders. MethodsWe consecutively enrolled 255 elderly patients(median age: 75 years, female: 54%), including 180 (70%) in the pre-home quarantine period and 75 (30%) home quarantine period from January to May 2020 (ten weeks before and ten weeks after the March 21, 2020, lockdown for older patients in Turkey) in a tertiary referral neurological center. ResultsIn the home quarantine period, we documented a fall in the number of neurological admissions by 58.3%, but an increased need for intensive care in older patients. Patients in the home quarantine period were younger [73 (65−91) vs 76 (65−95), p = 0.005], had worse Glasgow Coma Scores (12.3 ± 3.6 vs 13.7 ± 2.5, p = 0.007), higher in-hospital mortality rate (21.3% vs. 6.7%, p = 0.001), had a lower prevalence of comorbidities such as diabetes mellitus, hypertension, and cardiovascular disease, and chronic neurologic disease, albeit had a higher prevalence of the acute cerebrovascular disease (hemorrhagic/ ischemic stroke)(90.7% vs 78.9, p = 0.025). In this period, even there was an increase in the proportion of the patients undergoing reperfusion therapy, it wasn’t statistically significant (20.3% vs. 10.1%, p: 0.054). Multivariate analysis revealed that high NIHSS (The National Institutes of Health Stroke Scale) score (OR=1.25; p < 0.001) and hospitalization in the home quarantine period (OR=3.21; p = 0.043) were independently associated with in-hospital mortality. ConclusionOur study indicated that during the COVID-19 home quarantine period, despite a significantly fewer number of patients admitted to the hospitalization, there was a higher percentage of those hospitalized needing intensive care and an overall worse prognosis.

Geriatric assessment with management for older patients with cancer receiving radiotherapy. Protocol of a Norwegian cluster-randomised controlled pilot study

About 50% of patients with cancer are expected to need radiotherapy (RT), and the majority of these are older. To improve outcomes for older patients with cancer, geriatric assessment (GA) with management (GAM) is highly recommended. Evidence for its benefits is still scarce, in particular for patients receiving RT. We report the protocol of a cluster-randomised pilot study designed to test the effect, feasibility and health economic impact of a GAM intervention for patients ≥65 years, referred for palliative or curative RT. The randomising units are municipalities and city districts. The intervention is municipality-based and carried out in collaboration between hospital and municipal health services from the start of RT to eight weeks after the end of RT. Its main constituents are an initial GA followed by measures adapted to individual patients' impairments and needs, systematic symptom assessments and regular follow-up by municipal cancer nurses, appointed to coordinate the patient's care. Follow-up includes at least one weekly phone call, and a house call four weeks after the end of RT. All patients receive an individually adapted physical exercise program and nutritional counselling. Detailed guidelines for management of patients' impairments are provided. Patients allocated to the intervention group will be compared to controls receiving standard care. The primary outcome is physical function assessed by the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire C-30. Secondary outcomes are global quality of life, objectively tested physical performance and use of health care services. Economic evaluation will be based on a comparison of costs and effects (measured by the main outcome measures). Feasibility will be assessed with mixed methodology, based on log notes and questionnaires filled in by the municipal nurses and interviews with patients and nurses. The study is carried out at two Norwegian RT centres. It was opened in May 2019. Follow-up will proceed until June 2022. Statistical analyses will start by the end of 2021. We expect the trial to provide important new knowledge about the effect, feasibility and costs of a GAM intervention for older patients receiving RT.Trial registration: ClinTrials.gov, ID NCT03881137, initial release 13th of March 2019.

Is There a “Weekend Effect” in Intertrochanteric Fracture Surgery?

Introduction: Numerous studies reported poorer outcomes for patients who were admitted at weekends or off-hour, which relates to the underlying concept called the “weekend effect.” We aimed to assess the effect of adverse outcomes in older patients with intertrochanteric fracture surgery. Methods: A retrospective cohort study of patients aged ≥65 years with intertrochanteric fracture surgery. Data were collected from computerized medical records and all patients had a long-term follow-up. The association between weekend effect with adverse outcomes and factors for all-cause mortality was studied by 3-group comparison, Spearman and partial correlation analysis, univariate analysis, and multivariate Cox proportional-hazard model. Results: Our results showed no evidence supporting the existence of a weekend effect on adverse outcomes, including mortality rates (p = 0.950, log-rank), length of hospital stay, total hospital costs, rate and volume of transfusion, visual analog scale score, Harris Hip Score, and specific complications (all p > 0.05), except for an average of 0.5 days longer surgical delay found in patients admitted on Fridays relative to other days (p = 0.013). Instead, only age group (with a 10-year interval, HR 1.43, 1.28–1.59 95% CI, p < 0.001) and surgical delay (HR 1.05, 1.02–1.07 95% CI, p < 0.001) were identified as significantly associated with all-cause mortality. Conclusions: Older patients with intertrochanteric fracture surgery have similar mortality and adverse outcomes rates when admitted on weekends or holidays compared with weekdays. Our findings suggest that collaborative multidisciplinary team care seems both effective and efficient in the management of older patients with intertrochanteric fractures on any day of the week.

PORTRET, a more inclusive portrait of the older population with breast cancer

PORTRET, a more inclusive portrait of the older population with breast cancer

Association between body mass index and the risk of atrial fibrillation and ischemic stroke according to age: a nationwide population-based cohort study

Abstract Background Atrial fibrillation (AF) and ischemic stroke (IS) are two significant cardiovascular diseases that confer an enormous healthcare burden. A limited study comprehensively evaluated the association between full ranges of body mass index (BMI), including underweight, and AF or IS risks, especially in the different age subgroups. Purpose We investigated the association between BMI and AF and IS incidence according to the Korean population's age groups. Methods This was a nationwide population-based cohort study using data from the Korea National Health Insurance Service, including 9 194 477 healthy adults who underwent a medical examination in 2009. We stratified the study population into three age subgroups: age 20–39 (young, 33.1%), age 40–64 (middle-aged, 56.3%), and age over 65 years (elderly, 10.6%). In each age group, the individuals were categorized based on BMI (kg/m2) into underweight (&amp;lt;18.5), normal (18.5 to &amp;lt;23), overweight (23 to &amp;lt;25), obese I (25 to &amp;lt;30), and obese II (≥30). The first occurrences of AF and IS were followed up until December 31, 2018. According to BMI in each age group, the risks of AF and IS were analyzed by Cox proportional hazards regression with 95% confidence intervals (CI) by adjusting age, sex, lifestyle behaviors, and comorbidities. Results Overall, both underweight and higher BMI were associated with an increased risk of AF and stroke across all age groups. The increased risk of AF for patients with obese II was slightly accentuated compared to patients with normal BMI in the young population than elderly population (hazard ratio [HR] 1.78, 95% CI 1.63–1.94 for age 20–39 years; HR 1.55, 95% CI 1.48–1.61 for age ≥65 years, respectively). For underweight individuals, however, the increased risk of AF became more prominent in the elderly: HR and 95% CI was 1.12 (1.07–1.17) in the age over 65 years old, and 1.05 (0.94–1.16) in the age 20–39. Regarding IS, the young group presented a considerable increment in the magnitude of HRs in both underweight and higher BMI groups. However, the association between the BMI and stroke risk became attenuated in the elderly: HRs and 95% CI in underweight and obese II individuals were 1.10 (0.93–1.30) and 2.223 (1.99–2.49) in the age 20–39 group, whereas 0.97 (0.93–1.01) and 1.03 (0.98–1.08) in the age over 65 years old. Conclusions Underweight as well as obesity was associated with increased risks of AF and IS in the general population. In both AF and IS, the gradient of risks according to BMI was apparent at young ages; thus, maintaining normal body weight should be warranted in early life. An interplay of several factors other than BMI may contribute to ischemic stroke in the old ages, requiring integrated risk management in older patients. Funding Acknowledgement Type of funding sources: None.

Chronic obstructive pulmonary disease and asthma management in older patients.

How can I optimize chronic obstructive pulmonary disease (COPD) and asthma management in my older patients? The prevalence of COPD increases with age (20% to 30% in patients > 70), and asthma in the elderly is also common (> 10% of patients older than 60).[1][1] Accurate diagnosis is crucial but

1827P European Society for Medical Oncology (ESMO)/International Society of Geriatric Oncology (SIOG) Joint Working Group (WG) survey on management of older patients with cancer

ESMO and SIOG created a joint WG in 2019. Their goals are to improve management of the older cancer patients through education, dedicated resources and guidelines and to raise awareness on their specific needs and requirements. Therefore, the WG initiated a survey to describe the practice patterns worldwide.

Masseter muscle defined sarcopenia and survival in head and neck cancer patients

Sarcopenia is increasingly recognised as a poor prognostic factor in older patients undergoing cancer treatment. Recently, masseter muscle cross sectional area (MMCSA) has been shown to accurately identify sarcopenic patients. We aimed to apply this novel technique to a head and neck cohort to identify any potential relationship with survival. A retrospective review was undertaken of patients over 65 years, diagnosed with squamous cell carcinoma of the head and neck and treated with curative intent in our unit between October 2009 and October 2017. MMCSA was measured on staging CT scans using a validated technique. Patients were categorised into tertiles and also high and low MMCSA groups based on gender based tertile and mean MMCSA values. Survival analysis was performed using the Kaplan-Meier and Cox regression methods. A total of 111 patients were included in the study. The average age was 74 years (range 65-92 years) and 69% were male. The majority of patients had malignancies of the oral cavity (41%) or larynx (37%). The overall survival was 46% with a follow-up between 24 and 60 months. MMCSA was significantly associated with worse overall survival when defined using a gender based mean cut-off point (p=0.038) or tertile groupings (p=0.026), but did not maintain significance in multivariable analysis. Masseter muscle defined sarcopenia was associated with worse survival in our cohort in univariate analysis.Opportunistic measurement of this new factor on staging scans may aid prognostication and management in older patients.

Calcified Leg Ulcers in Older Patients: Clinical Description, Morphology, and Chemical Characterization.

Chronic wounds, including leg ulcers, constitute an important medical problem among older patients. Dystrophic calcifications (DC) are associated with a variety of disorders, including leg ulcers. The aim of this study was to report the clinical and biological characteristics of older patients with DC in leg ulcers and to determine the morphology and chemical composition of these calcifications. We conducted a prospective monocentric study in our Geriatric-Wound and Healing ward, Rothschild Hospital, Paris, from January 2018 to December 2019. Patients with leg ulcers were screened for DC by palpation. Patients' clinical, biological, and radiological findings were collected. DC morphology was analyzed using field-emission scanning electron microscopy and chemical composition was analyzed using µFourier transform infra-red spectroscopy and X-ray Fluorescence. Ten (7%) of the 143 patients hospitalized for leg ulcers presented DC. Older patients with DC were more likely to have leg ulcers with venous insufficiency (p = .015), colonized by Pseudomonas aeruginosa (p = .026), with a longer healing evolution (p = .0072) and hypercalcemia (p = .041). Five DC were extracted from ulcers: 2 presented 500 nm lacunar spheres and intermingled fibrils of about 10 nm in diameter, consistent with bacterial and biofilm imprints. DC were always composed of calcium-phosphate apatite and associated to the presence of zinc. Our analyses were consistent with the involvement of microorganisms and inflammatory process in DC formation. Early management of venous insufficiency, treatment of chronic bacterial colonization and use of calcium-solubilizing drugs seem to be rational strategies for calcified leg ulcer management in older patients.

Rationally decreasing the number of drugs seems to be a useful therapeutic approach in older adults: 6-month follow-up study

AimsOlder adults are at risk for polypharmacy, which has multidimensional safety, clinical and economic implications. Therefore, the optimization of drug therapy is one of the critical components of geriatrics clinical practice. This study is aimed to investigate the effect of drug rationalization on comprehensive geriatric assessment(CGA) parameters. Materials and MethodsThe study was a retrospective and longitudinal study examining the effect of change in drug number on functionality and physical performance. A total of 515 patients were included in the study. Detailed medication history, laboratory findings, CGA parameters were recorded in the first admission. Polypharmacy was accepted as concurrent usage of five or more drugs. Medications of each patient were reviewed with the guidance of CGA and Beers Criteria. ResultsThe mean age of patients was 74.13 ± 7.29 years, and 68.7% were female. The baseline mean number of drugs was 5.11 ± 3.34. The polypharmacy group(269 patients) had a higher rate of geriatric syndromes and lower CGA scores in the first admission. After optimization of medications, the mean drug number decreased to 4.76 ± 2.72. Depression, mobility and nutritional scores improved at the end of six months in the patients whose total number of drugs decreased, while global cognition, activities of daily living scores, and gait speed were preserved. Increasing the number of drugs was associated with lower mobility and functionality. ConclusionDrug rationalization guided with CGA improves the nutritional, physical, and psychosocial status of geriatric patients. Thus, medication reviews have key importance in the management of older patients.

Treatment Patterns of Hypomethylating Agents in Older (≥65 Years) Acute Myeloid Leukemia Patients Who Did Not Receive Intensive Chemotherapy: A Retrospective Claims Database Analysis

BACKGROUND: Acute myeloid leukemia (AML) and therapy for patients with AML represent a striking example of age-related outcome disparity in oncology. Older patients experience shorter overall survival, have usually more comorbidities, and are at greater risk for treatment-related mortality. Consequently, a substantial portion of older patients are considered “unfit” for standard intensive chemotherapy and are offered less intensive regimens or best supportive care. In recent years, hypomethylating agents (HMAs), namely azacitidine (AZA) and decitabine (DEC), have emerged as standards of care for patients with AML unfit for intensive chemotherapy. The objective of this study was to identify and describe HMA utilization in older patients with AML (≥65 years) not receiving intensive chemotherapy in a real-world claims database.METHODS: AML patients were retrospectively identified in the MarketScan® Research Database (Truven Health) including both Commercial and Medicare Supplemental claims databases between 01/2011 to 07/2016. Patients ≥ 65 years old with a minimum of two claims with an AML diagnosis, ≥ 1 bone marrow procedure (the first AML diagnosis following the bone marrow diagnosis procedure was defined as the index date), and ≥ 12 months of continuous eligibility (baseline period) prior to the index date were included. Exclusion criteria were the following: ≥ 1 diagnosis for AML relapse or remission on or before the bone marrow diagnosis procedure, ≥ 2 diagnoses for another blood cancer, ≥ 1 allogeneic hematopoietic stem cell transplantation before the bone marrow diagnosis procedure, or ≥ 1 claim for intensive chemotherapy at any time. We recorded the percentages of HMA usage (AZA and DEC) among patients treated with ≥ 1 antineoplastic agent (excluding hormonal therapy agents) overall and in first and second lines of therapy, and treatment duration (i.e., cumulative duration of AZA- or DEC-based lines of therapy) along with the corresponding number of 28-day treatment cycles obtained by dividing the treatment duration by 28. In patients using HMAs in first- or second-line therapy, the percentages of monotherapy and blood transfusion use were tabulated and the proportion of patients who initiated a subsequent line of therapy was recorded.RESULTS: After applying the selection criteria, 1,492 patients were identified for inclusion in our study population. Mean (standard deviation [SD]) patient age was 76.8 (7.0) years, 36.6% were ≥ 80 years old, and 61.0% were male. The mean (SD) Quan-Charlson Comorbidity Index (CCI) was 3.4 (2.4), with 33.5% of patients having a prior diagnosis of myelodysplastic syndrome. Among 610 (40.9%) patients treated with an antineoplastic agent, 449 (73.6%) patients received HMAs at any time during the observation period: 250 (55.7%; Table 1) of them used AZA (mean [SD] age = 77.3 [6.4] years; 59.6% male; mean [SD] CCI = 3.2 [2.3]) and 230 (51.2%; Table 1) used DEC (mean [SD] age = 76.5 [6.3] years; 60.0% male; mean [SD] CCI = 3.4 [2.4]). Mean (SD) total treatment duration was 134.8 (150.6) days with AZA and 139.8 (128.6) days with DEC, which is equivalent to a mean (SD) number of 28-day treatment cycles of 4.8 (5.5) for AZA and 4.9 (4.6) for DEC (Table 1). Among the 436 (71.5%) patients that received HMAs in first line, 232 (53.2%) used AZA, 204 (46.8%) used DEC, 395 (90.6%) used them in monotherapy, 379 (86.9%) had ≥ 1 blood transfusion during the first line of therapy, and 91 (20.9%) initiated a second line of therapy (Table 1). Of 120 (19.7%) patients with a second-line therapy, 65 (54.2%) received HMAs. Among them, 28 (43.1%) used AZA, 39 (60.0%) used DEC, 38 (58.5%) used them as monotherapy, 54 (83.1%) had ≥ 1 blood transfusion during the second line of therapy, and 10 (15.4%) patients proceeded to a third line of therapy (Table 1).CONCLUSION: This study confirms that HMAs are commonly used in older (≥65 years) patients with AML who did not receive intensive chemotherapy, following National Comprehensive Cancer Network guideline recommendations. Utilization and treatment patterns were similar between both HMAs. A large proportion of patients received blood supportive products during their therapy and few of them initiated a subsequent line of therapy suggesting the need for additional treatment options. Additional studies with detailed evaluation of HMA use (including sequencing) are needed to further evaluate the important unmet need in the management of older patients with AML. [Display omitted] DisclosuresSundaram:Johnson & Johnson, LLC: Equity Ownership; Janssen: Employment. Lafeuille:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Ltd: Research Funding; Janssen Scientific Affairs, LLC: Research Funding. Hoehn:Johnson & Johnson, LLC: Equity Ownership; Janssen: Employment. Emond:Janssen Scientific Affairs, LLC: Research Funding. Romdhani:Janssen Scientific Affairs, LLC: Research Funding. Lefebvre:Janssen Scientific Affairs, LLC: Research Funding.

Multimorbidity patterns in old adults and their associated multi-layered factors: a cross-sectional study

BackgroundInfluenced by various factors such as socio-demographic characteristics, behavioral lifestyles and socio-cultural environment, the multimorbidity patterns in old adults remain complex. This study aims to identify their characteristics and associated multi-layered factors based on health ecological model.MethodsIn 2019, we surveyed a total of 7480 participants aged 60+ by using a multi-stage random cluster sampling method in Shanxi province, China. Latent class analysis was used to discriminate the multimorbidity patterns in old adults, and hierarchical regression was performed to determine the multi-layered factors associated with their various multimorbidity patterns.ResultsThe prevalence of multimorbidity was 34.70% among the old patients with chronic disease. Over half (60.59%) of the patients with multimorbidity had two co-existing chronic diseases. “Degenerative/digestive diseases”, “metabolic diseases” and “cardiovascular diseases” were three specific multimorbidity patterns. Behavioral lifestyles-layered factors had the most explanatory power for the three patterns, whose proportions of explanatory power were 54.00, 43.90 and 48.15% individually. But the contributions of other multi-layered factors were different in different patterns; balanced diet, medication adherence, the size of family and friendship network, and different types of basic medical insurance might have the opposite effect on the three multimorbidity patterns (p < 0.05).ConclusionsIn management of old patients with multimorbidity, we should prioritize both the “lifestyle change”-centered systematic management strategy and group-customized intervention programs.

Updated recommendations regarding the management of older patients with breast cancer: a joint paper from the European Society of Breast Cancer Specialists (EUSOMA) and the International Society of Geriatric Oncology (SIOG)

Breast cancer is increasingly prevalent in older adults and is a substantial part of routine oncology practice. However, management of breast cancer in this population is challenging because the disease is highly heterogeneous and there is insufficient evidence specific to older adults. Decision making should not be driven by age alone but should involve geriatric assessments plus careful consideration of life expectancy, competing risks of mortality, and patient preferences. A multidisciplinary taskforce, including members of the European Society of Breast Cancer Specialists and International Society of Geriatric Oncology, gathered to expand and update the previous 2012 evidence-based recommendations for the management of breast cancer in older individuals with the endorsement of the European Cancer Organisation. These guidelines were expanded to include chemotherapy toxicity prediction calculators, cultural and social considerations, surveillance imaging, genetic screening, gene expression profiles, neoadjuvant systemic treatment options, bone-modifying drugs, targeted therapies, and supportive care. Recommendations on geriatric assessment, ductal carcinoma in situ, screening, primary endocrine therapy, surgery, radiotherapy, adjuvant systemic therapy, and secondary breast cancer were updated.

Appendiceal adenocarcinoma found by surgery for acute appendicitis is associated with older age

BackgroundAppendectomy for acute appendicitis is the most common procedure performed emergently by general surgeons in the United States. The current management of acute appendicitis is increasingly controversial as non-operative management gains favor. Although rare, appendiceal neoplasms are often found as an incidental finding in the setting of appendectomy. Criteria and screening for appendiceal neoplasms are not standardized among surgical societies.MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent appendectomy over a 9-year period (2010–2018). Over the same time period, patients who underwent appendectomy in two municipal hospitals in The Bronx, New York City, USA were reviewed.ResultsWe found a 1.7% incidence of appendiceal neoplasms locally and a 0.53% incidence of appendiceal tumors in a national population sample. Both groups demonstrated an increased incidence of appendiceal carcinoma by age. This finding was most pronounced after the age of 40 in both local and national populations. In our study, the incidence of appendiceal tumors increased with each decade interval up to the age of 80 and peaked at 2.1% in patients between 70 and 79 years.ConclusionsAppendiceal adenocarcinomas were identified in patients with acute appendicitis that seem to be associated with increasing age. The presence of an appendiceal malignancy should be considered in the management of older patients with acute appendicitis before a decision to embark on non-operative therapy.

Pain, functional disability and mental disorders as potential mediators of the association between chronic physical conditions and suicidal ideation in community living older adults

Objectives To examine the associations between chronic physical conditions and suicidal ideation and to assess whether associations are mediated by pain, anxiety, depression, post-traumatic stress syndrome (PTSS), and functional disability. Methods The study sample includes 1533 older adults aged 65+ recruited in primary care clinics between 2011–2013 and participating in Quebec’s Health Survey on Services “Étude sur la Santé des Aînés-Services” (ESA-S) study. Path analysis was used to assess the associations. The presence of suicidal behaviour was ascertained using 4 questions. PTSS was based on a validated scale for primary care older adults. Anxiety and depression were assessed according to DSM-IV criteria. Pain was self-reported on an ordinal scale and functional disability was based on the presence of disability in 8 dimensions of activities of daily living. The main predictors included a list of 13 physical disorders identified by diagnostic codes. Suicidal ideation was also controlled by a number of socio-demographic and psychosocial factors. Results PTSS, depression, and functional disability mediate the association between various chronic conditions and suicidal ideation. Although pain and anxiety are associated with many physical disorders, they did not mediate the association with suicidal ideation. Conclusions Chronic physical disorders are associated with suicidal ideation, either directly or indirectly through PTSS, depression, and functional disability. The findings underscore the importance of early identification and management of older patients with specific chronic disorders in primary care as they may be most at risk for suicidal ideation.

Improving Effective Mental Health Consultation for Rural Older Adults Living With Depression and Pain: Learning From the Experiences of Rural Primary Care Physicians.

Novel approaches are needed to assist rural primary care physicians (PCPs) in caring for older patients living with depression and pain who are at an elevated suicide risk. To refine and improve a model of care (PREDICTOR: Pharmacy Identification and Primary Care Intervention of Older Adults at Risk for Suicide), we conducted qualitative interviews with rural PCPs about (1) caring for seniors with depression, pain, and suicidality and (2) their favored procedures for working with psychiatric consultants and the professional characteristics desired in an effective consultant. The study utilized a best-practice approach (including double coding) for qualitative interviews with 10 PCPs practicing in rural Pennsylvania. PCPs were interviewed about 3 themes related to caring for older adults with depression, pain, and suicidal ideation and working with psychiatric consultants. The study was conducted from January 2019 to May 2019. Four primary themes emerged from the interviews. (1) Rural PCPs become comfortable managing depression in older adults out of necessity, but desire collaboration on more complex mental health care. (2) Comorbid depression and pain are universally described as related through a vicious cycle in older adults. (3) Rural PCPs experience varying comfort with prescribing opioids for pain management in older patients, but most prefer not to prescribe opioids, and some refuse to do so. (4) PCPs endorsed the PREDICTOR remote consultation model as potentially beneficial to themselves and their older patients, but strongly desired that the consultant work with them as collaborators and for a collegial professional relationship with the mental health specialist. Rural PCPs are comfortable with remote consultation for older patients living with depression but desire collegial relationships with these consultants, supporting a collaborative approach. We describe explicit plans for implementing these findings as we refine PREDICTOR, in efforts to promote PCP practice change.

151 Optimising Bone Health on Sheffield Frailty Unit Through Quality Improvement

Abstract Introduction NICE and the National Osteoporosis Guidance Group (NOGG) advise on evaluation of fracture risk and osteoporosis treatment1,2, with evidence suggesting that screening and treatment reduces the risk of fragility fractures 3,4,5. However, it is often overlooked in the management of older patients within secondary care. Audit data from Sheffield Frailty Unit (SFU) in 2018 showed that national guidance was not routinely followed. Fracture Risk Assessment Tool (FRAX®) scores were not calculated and bone health was poorly managed. Therefore, we undertook a quality improvement project aiming to optimise bone health in patients presenting to SFU. Method &amp; Intervention In January 2019 we collaborated with Sheffield Metabolic Bone Centre (MBC) to develop a pathway aiming to improve bone health assessment and management in patients presenting to SFU with a fall or fragility fracture. This included a user-friendly flow chart with accompanying guidelines, alongside education for staff. Performance was re-evaluated in May 2019, following which a tick box prompt was added to post take ward round documentation. A re-audit was performed in March 2020. Results In March 2018 0% of patients presenting with a fall had a FRAX® score calculated and only 40% of those with a new fragility fracture were managed according to guidelines. In May 2019, this had improved to 18% and 100% respectively. In March 2020 86% of patients had a FRAX® score calculated appropriately and 100% of fragility fractures were managed according to guidelines. In both re-audits 100% of FRAX® scores were acted on appropriately. Conclusions There has been a significant increase in the number of patients who have their bone health appropriately assessed and managed after presenting to SFU. However, achieving optimum care is under constant review with the aim to deliver more treatment on SFU, thereby reducing the need for repeat visits to the MBC.

Impact of age in critically Ill infected patients: a post-hoc analysis of the INFAUCI study

Older patients are the fastest expanding subgroup of intensive care units (ICU) and are particularly susceptible to bacterial infections and sepsis. The aim of this study was to address the epidemiology and the main determinants of outcome of infection in old and very old patients admitted to ICU. We performed a post hoc analysis of all infected patients admitted to ICU enrolled in a 1-year prospective, observational, multipurpose study. Patients aged < 65, 65-74 and ≥ 75years were compared. Of the 1652 patients included, 50% were older than 65years. There were no significant differences between young, old and very old patients in either ICU, hospital length of stay, or nosocomial infection. All-cause mortality was significantly higher in participants aged ≥ 75. Increased Gram-negative microorganisms' isolates occurred in > 65years (25% versus 31%; p = 0.034). Multidrug-resistant (MDR) microorganisms were directly associated to inappropriate empiric antibiotic therapy (OR 4.73; 95% CI 2.99-7.47) and inversely associated with community-acquired infection (OR 0.39; 95% CI 0.19-0.83). Age (65-74years: OR 1.10; 95% CI 0.64-1.90 and ≥ 75years: OR 1.52; 95% CI 0.89-2.59) and sepsis severity (sepsis: OR 0.67; 95% CI 0.18-2.46; severe sepsis: OR 1.17; 95% CI 0.40-3.44; septic shock: OR 0.77; 95% CI 0.27-2.24) were not associated to MDR bacteria. Patients > 65years accounted for 50% of infected patients admitted to an ICU. ICU and hospital length of stay, and nosocomial infection did not increase with age. Age did predispose to increased risk for infection by Gram-negatives. These findings may optimize strategies for infection management in older patients.

Abstract P38: Pooled Analysis of Long and Short Term Outcomes After Subarachnoid Hemorrhage - International Stroke Outcomes Study (INSTRUCT)

Background: Outcomes after subarachnoid hemorrhage (SAH) have been rarely examined in large cohorts. Methods: This is an extension of the International Stroke Outcomes Study (INSTRUCT) pooling 13 ‘ideal’ stroke incidence studies (n=657 with SAH from 1993-2017, median age 56 years; 46% men). The primary outcomes were mortality and functional outcome (mRS score 3-5). Harmonized study factors included age, sex, behaviors (current smoking, alcohol intake), comorbidities (history of hypertension, ischemic heart disease, atrial fibrillation), stroke severity (e.g. NIHSS score) and year of stroke. In the pooled dataset, we estimated predictors of mortality using Poisson regression, to estimate incidence rate ratio (IRR) at 1 month (11 studies), 1 year (12 studies) and 5 years (7 studies). Generalized equation estimates in the log-binomial family were used to calculate risk ratios (RRs) for predictors of poor functional outcome at 1 month (5 studies) and 1 year (8 studies). Results: Mortality was 33% at 1 month, 43% at 1 year, and 47% at 5 years (Fig 1). Poor functional outcome was 25% at 1 month and 15% at 1 year (Fig 1). In multivariable analysis, age and stroke severity were associated with mortality at all time points, together with current smoking at 1 and 5 years, and history of hypertension at 5 years (Fig 2). Poor functional outcome was predicted by age (RR 1.03; 95% CI 1.01-1.04) at 1 month and by age (RR 1.04; 95% CI 1.00-1.08) and stroke severity (RR 1.94; 95% CI 1.02-2.87) at 1 year. Conclusion: Risk factors that predict SAH incidence including hypertension and smoking make outcomes worse. Better management of older patients and those with severe strokes could improve outcomes after SAH.