Management Of Older Patients Research Articles

1305 Management of older patients with newly diagnosed gastric and oesophageal cancers (GOC)

1305 Management of older patients with newly diagnosed gastric and oesophageal cancers (GOC)

Use of Opioid Analgesics in Older Australians.

To identify potential medication management issues associated with opioid use in older Australians. Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012. Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility. Patient characteristics in those taking regularly dosed opioids and not and those taking opioid doses >120 mg and ≤120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified. Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations. A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain.

Orthogeriatrics in the management of frail older patients with a fragility fracture

This review article examines the role of orthogeriatric management for frail older patients with a fragility fracture. The history of orthogeriatrics and its application in clinical practice around the world is reported, and an evidence-based evaluation for the effect of orthogeriatric management on patient morbidity and mortality is also provided. It has been more than 50 years since the role of the geriatrician in the management of patients with a hip fracture was first described. The evidence that supports an orthogeriatric model of care has grown exponentially over the last decade. This evidence base is primarily related to hip fractures and demonstrates reduced morbidity and mortality rates amongst patients managed with a recognised model of orthogeriatric care. The societal and economic burden of hip fracture has led to health economic evaluations within this field, many of which have concluded that orthogeriatric management results in cost-effective clinical practice. Based on existing clinical and economic research, national clinical practice guidelines have been developed in several countries which recommend orthogeriatric participation in the management of older patients with a hip fracture. Compliance with such guidance has already demonstrated improved patient outcomes. Although the pathogenesis and prognosis of other types of fragility fracture may be as poor, there is a dearth of clinical research that evaluates the effect of orthogeriatric management on such injuries. Looking to the future, orthogeriatric management is likely to become more widespread, and the robust collection and reporting of patient outcomes from national registries will provide a greater understanding of the impact of orthogeriatric models in the care of all frail older patients with any type of fragility fracture.

Primary eye care services offered to older adults

PurposeEye care services in long-term care facilities are not optimal and should be improved. In Canada, optometrists are the major providers of primary oculovisual examinations. Our objective was to evaluate the eye care services optometrists offer to older adults, in particular to frail older adults. Materials and methodsA questionnaire regarding older adult patients ≥ 65 years of age was designed and sent to optometrists in active practice throughout Canada. Questions related to the optometrist's personal and practice profiles, the treatment and management of older patients, and gerontology/geriatric education. ResultsThe overall average response rate for the entire country was 31.3%. About a third of all patients examined by optometrists in their office are ≥ 65 years of age. Optometrists examine about 2 to 4 older frail patients weekly in their office. Many optometrists are already examining older frail patients outside the office, and a greater proportion would accept to do so if they were asked, but on an exceptional basis. The main reasons for not seeing patients outside of the office relate to the lack of adequate fees, instrumentation and structural organization. Discussion/conclusionOptometrists examine a large proportion of older patients in their office, but only a small proportion of those are frail older adults. However, some optometrists examine older frail patients outside the office, and more would consider doing so if the working conditions and remuneration were improved. Solutions could therefore be implemented to improve accessibility to eye care services for older frail seniors in their living environment.

Delirium detection and improved delirium management in older patients hospitalized for hip fracture

Delirium is a common and potentially devastating problem for older patients following hip fracture. Although early detection is recommended, description and evaluation of standardized approaches are scarce. The aims of this quality improvement project were to: (1) implement a clinical algorithm for improving delirium detection and management and (2) assess the impact of the clinical algorithm on length of stay, discharge disposition and patient satisfaction. The pilot study was implemented on an orthopedic unit to evaluate the effectiveness of a clinical protocol for delirium detection and management to improve outcomes. Outcomes of 33 elderly post-operative hip fracture patients were compared to historical controls from the same unit. Delirium was detected in 18% of patients. Length of stay was reduced by 22% (P < .001), discharge disposition showed a 13% improvement (P = .17) and patient satisfaction scores showed a 15% (P = .15) improvement post-intervention. Implementation of a clinical algorithm to promote early detection and treatment of delirium in post-operative hip fracture patients is feasible and associated with improved outcomes.

Improved prognosis in Norwegian patients with glomerulonephritis associated with anti-neutrophil cytoplasmic antibodies.

BackgroundGlomerulonephritis associated with anti-neutrophil cytoplasmic antibodies (ANCA) is associated with increased mortality and a high risk of end-stage renal disease (ESRD). Here, we investigated whether the prognosis has improved over the last 25 years.MethodsPatients were identified in the Norwegian Kidney Biopsy Registry. We included all patients with pauci-immune crescentic glomerulonephritis and a positive ANCA test from 1988 to 2012. Deaths and ESRD in the cohort were identified through record linkage with the Norwegian Population Registry (deaths) and the Norwegian Renal Registry (ESRD). Outcomes of patients diagnosed in 1988–2002 were compared with outcomes of patients diagnosed in 2003–12.ResultsA cohort of 455 patients with ANCA-associated glomerulonephritis was identified. The mean follow-up was 6.0 years (range, 0.0–23.4). During the study period, 165 (36%) patients died and 124 (27%) progressed to ESRD. Compared with patients diagnosed in 1988–2002, those diagnosed in 2003–12 had higher mean initial estimated glomerular filtration rates (37 versus 27 mL/min/1.73 m2) and lower risk of ESRD (1-year risk: 13 versus 19%; 10-year risk: 26 versus 37%). The composite endpoint, ESRD or death within 0–1 year after diagnosis, was reduced from 34 to 25%. In patients over 60 years old, 1-year mortality fell from 33 to 20%.ConclusionsIn Norwegian patients with ANCA-associated glomerulonephritis, prognosis was significantly better in 2003–12 compared with 1988–2002. This improvement was probably partly due to a shorter diagnostic delay, and better therapeutic management in older patients.

Prognostic Value of Neuro-Psychological and Biological Factors in Clinically Fit Older Patients with Hematological Malignancies

BACKGROUND: A Comprehensive Geriatric Assessment (CGA) is recommended to detect vulnerable cancer patients for whom chemotherapy may lead to severe impairment on functionality, quality of life, or survival. Although CGA is useful for a better management of older patients with unsuspected problems, little is known about the reliability of CGA - or G8 screening tool - to optimize the therapeutic approach in a specific patient with a malignant hemopathy. Particularly, the prognostic value of cognitive functions, psychological status and other selected biological factors in older patients with hematological malignancies admitted to receive chemotherapy, are poorly investigated.AIM: To assess in clinically fit (go and slow go) patients with malignant hemopathies, the reliability of G8 screening and CGA as a prognostic tool to predict overall survival (OS) and particularly, the predictive value of neuro-psychological and biological factors, in terms of one-year OS.POPULATION AND METHODS: Between Oct 2010 and June 2013, G8 and CGA were proposed to 107 consecutive older patients (65+-yrs) with hematological malignancies, admitted to the hospital and judged clinically fit, by their refereeing physicians, to receive chemotherapy. An initial full-dose or reduced-dose chemotherapy has been administrated to these patients according to a multidisciplinary team decision. The nutritional status was screened by MNA and the cognitive functions by MMS and MoCARESULTS: Ninety patients -completely assessed for G8 and CGA- were evaluable for one year OS; Non Hodgkin’s Lymphoma (53%), Multiple myeloma (16%), Acute Myeloid Leukemia and Myelodysplastic Syndrome (15%), Chronic Lymphocytic Leukemia (14%) and Myeloproliferative Neoplasms (2%). Median age is 74 (65-89) yrs. 56% are males. 72% and 80%, were considered as “vulnerable” when evaluated with G8 (≤14.5) or CGA (≥2 impairments), respectively. The area under ROC-curve of G8 compared to CGA was 0.749 ± 0.051 (sensibility = 79.2% and specificity =55.6%). During the first year of follow-up, 28% (n=22) of older patients treated for hematological malignancies died. The leading cause of death (82%) was indeed the disease progression. Retrospectively, neither the G8 nor the CGA total score had an impact with the initial treatment choice and were not predictive for one-year OS. In addition, regarding patients characteristics, in a multivariate analysis (Cox proportional hazard model), age (p=0.015; HR=1.12) and diagnosis (p<0.001; HR=7.2), were major prognostic factors in terms of OS. Regarding specific CGA items, a multivariate analysis concluded that unsuspected cognitive impairment (evaluated with a MMS and a MoCA) had the strongest prognostic value (p=0.03; HR=3.560) in terms of OS.DISCUSSION: In our clinically fit hematological patients, a poor G8 or CGA score does not translate into a worse survival, more likely because of two reasons: the disease itself remains the major cause of death and malnutrition, a reversible impairment after effective treatments, strongly impacts on G8 and CGA. The objective of an effective screening tool should thus be the identification of the population who could benefit from optimal treatment combined with an comprehensive management of unsuspected specific problems.CONCLUSIONS: Our observations in “clinically fit” older hematological patients suggest that 1) the major cause of death is the disease itself and the priority should be to identify all patients susceptible to benefit from full dose chemotherapy 2) a poor G8 screening or an abnormal CGA are not specific enough and does not translate into a worse one year OS 3) some specific factors in the CGA (such as neuro-cognitive impairments) are highly correlated with one-year OS 4) age remain a continuous variable with a poor prognostic factor. Prospective trials are needed to further determine whether the combination of optimal treatment and improved management of impaired functions, including cognition, could lead to a better OS. DisclosuresNo relevant conflicts of interest to declare.

Clinicopathologic characteristics and management trends of cutaneous invasive and in situ melanoma in older patients: a retrospective analysis of the National Cancer Data Base.

The incidence of melanoma in older patients is on the rise. Prior studies have shown disparities in surgical management and poor survival of older patients with melanoma. This is a retrospective study of adult patients diagnosed with cutaneous invasive and in situ melanoma between 2000 and 2011 in the National Cancer Data Base. Characteristics and management of older patients (≥60 years) were compared with younger patients (20-59 years) using χ(2) testing. Of 476,623 total cases, 54% (n = 258,153) were diagnosed among older patients. The reported cases in the older patients increased by 1.74-fold between 2000 and 2011. The majority were white (96%), men (65%), with early-stage disease (76% stage 0-II), and superficial spreading melanoma histology (39%). Older patients, compared with younger patients, were more likely to be men (65% versus 49%, p < 0.0001), and have in situ melanoma (28% versus 21%, p < 0.0001); less likely to have nodal metastases (7% versus 9%, p < 0.0001), receive care in academic centers (30% versus 35%, p < 0.0001), undergo wide excision or major amputation for stage I-III disease (68% versus 72%, p < 0.0001) and systemic therapy for stage III (18% versus 45%, p < 0.0001) and IV disease (30% versus 50%, p < 0.0001). Older patients with melanoma are less likely to receive care in academic centers, undergo wide excision for stage I-III disease and receive systemic therapy for stage III-IV disease. Particularly, the utilization of systemic therapy is markedly low. This disparity is particularly important with the availability of less intense more effective therapies.

Home telehealth in older patients with heart failure &amp;ndash; costs, adherence, and outcomes

Home telehealth in older patients with heart failure &ndash; costs, adherence, and outcomes Susanna Spinsante Dipartimento di Ingegneria dell&#39;Informazione, Universit&agrave; Politecnica delle Marche, Ancona, Italy Abstract: This short review discusses the role of telehealth technologies in the management of older patients with heart failure, from different perspectives. Instead of providing a systematic overview of existing literature in the field, this paper provides evidence for a simple, but effective, paradigm upon which a telehealth system may be built, and highlights how such a model may successfully apply to heart failure management, to improve patients&#39; quality of life after discharge, increase independency, and reduce readmissions and costs for the public health institutions. A few examples are discussed, to show the real applicability of the proposed model and further confirm the effectiveness of telehealth, when properly designed and tailored to users&#39; needs. Keywords: remote health care, workflow, requirements

O4.09: Functional status, comorbidities and their impact on management of older patients with cancer in India

O4.09: Functional status, comorbidities and their impact on management of older patients with cancer in India

The Prevalence of Depression and Its Relevance to Clinical and Radiological Characteristics among Older Adults with Knee Osteoarthritis

In this study we assessed the prevalence of depression and its relevance to pain intensity, functional status (health related disability) and radiographic severity in older adults with knee osteoarthritis (OA).One hundred and thirty-eight elderly (sixty-five years or older) patients with knee OA and 82 age and sex matched healthy controls were included into the study. Beck depression scale was used to assess depressive disorders in all participants. The pain intensity, functional status and radiographic severity in patients were assessed with a Visual Analogue Scale (VAS), the Western Ontario and Mc-Master Universities Osteoarthritis Index (WOMAC), and the Kellgren-Lawrence grading system,respectively. Depression was detected in 49.3% of patients and 12.3% of controls. In patients group whose BDI scores were ≥17, the scores of VAS, WOMAC, and radiographic severity were found to be statistically significantly higher, compared to the group whose BDI scores were <17. A positive correlation was detected between BDI score and VAS, WOMAC and radiological classification scores in patients with knee OA. In linear regression analysis, the most significant determinant for the level of depression was WOMAC score. The present study shows that depression is a commonly encountered comorbidity in older adults with knee OA. The level of depression was correlated with the severity of the disorder, especially in patients whose WOMAC score was high. Therefore, coexisting depression should be taken into account in the assessment and management of older patients with knee OA.

Novel Telemedicine Technologies in Geriatric Chronic Non-Cancer Pain: Primary Care Providers’ Perspectives

We sought to identify primary care providers' interest in, as well as perceived barriers and facilitators to, using novel telemedicine technologies (e.g., smartphones) for managing chronic non-cancer pain (CNCP) in older adults. Six focus groups were conducted with 25 primary care providers. Two academically affiliated primary care practices serving older adults with CNCP in New York City. The investigators used content analysis to analyze transcribed focus group data and identify specific themes. While most providers reported limited use of telemedicine, they expressed substantial interest in trying devices such as smartphones in the management of older patients with CNCP. Perceived barriers to implementation of telemedicine tools included information overload, lack of mobile device usability among patients and clinicians, liability issues, and cost. To overcome these barriers, participants suggested implementing electronic or human-based pre-analysis of data (e.g., a computer or a person that triages patient data), creating a low-cost and user-friendly mobile device design, and targeting appropriate user populations. Primary care providers are interested in applying telemedicine when caring for older adults with CNCP. Although they perceived multiple barriers to device implementation, they offered innovative solutions to address these barriers. Providers felt that novel telemedicine technologies may improve the management of CNCP but wanted evidence that the devices were both cost- and time-efficient, and led to improved patient outcomes before adopting their use in practice.

ASCO leadership development group – geriatric oncology focus/Report from the ASCO Leadership Development Group in Geriatric Oncology

Abstract: Authors: Thomas W. Flaig, Beverly Moy, William Tse, T. Christopher Windham

Distinctive Features of Melanoma and Its Management in Elderly Patients

Life expectancy is increasing in most developed countries, and elderly people have the highest incidence of melanoma. To identify characteristics of melanoma and its management in the elderly compared with younger patients. Retrospective population-based study of incident cases of primary melanoma in 1621 patients with stage I or II melanoma in 2004 and 2008. Questionnaires administered to physicians and a survey of cancer registries and pathology laboratories were used to obtain data. The study was conducted in 5 regions in northeastern France. Characteristics of patients and tumors, circumstances of diagnosis, and further management in older patients (≥70 years, 487 patients [30.0%]) compared with younger ones (<70 years, 1134 [70.0%]). Older patients had more frequent melanomas of the head and neck (29.4% vs 8.7%; P < .001) and of the nodular, lentigo maligna, or acral lentiginous histologic subtypes. They had thicker and more frequently ulcerated tumors, categorized as T3 or T4 in 36.7% of cases vs 20.1% in younger patients. Diagnosis of melanoma occurred more frequently in a general practice setting and less frequently in direct consultation with a dermatologist or regular screening for skin cancer. Time to definitive excision was longer in older patients, and 16.8% of them compared with 5.0% of the younger population had insufficient excision margins (P < .001). A sentinel lymph node biopsy was performed in 23.3% of the older patients with melanoma thicker than 1 mm vs 41.4% in the younger patients (P < .001). Adjuvant therapy was less frequently started in older patients and was prematurely stopped in a higher proportion of that population. Age-related variations are observed at every step of melanoma management. The most important concerns are access of elderly people to settings for early diagnosis and excision with appropriate margins.

Geriatric interventions in the management of older patients with cancer

Geriatric interventions in the management of older patients with cancer

Medication Management of Chronic Heart Failure in Older Adults

Heart failure (HF) is a common problem in older adults. Individuals aged 65 years or older are at a higher risk for developing HF, especially diastolic HF or HF with preserved ejection fraction (HFpEF). HF can be seen in up to 20 % of adults aged 85 years or older. In contrast to middle-aged (40-64 years) HF patients, multiple cardiac, non-cardiac and geriatric syndrome co-morbidities are seen in elderly HF patients. Additionally, age-related changes in pharmacokinetics and pharmacodynamics influence medication therapy. Hence, the management of older patients with HF is challenging and treatment should be modified in the light of the above-mentioned conditions. This article discusses the current evidence for medication management in both systolic HF or HF with reduced ejection fraction (HFrEF) and HFpEF, noting, however, the limited data for HFpEF and HFrEF in those 80 years of age or older. The objective of this article is to discuss evidence-based and outcomes-driven pharmacologic management strategies for chronic HF in the older adults for whom functional and other patient-centered outcomes might be more than or as important as clinical outcomes. Optimal management would be expected to help to reduce illness burden, reduce mortality and hospitalizations, and improve function and quality of life.

Cognitive function and self-care management in older patients with heart failure

People with heart failure have difficulty with self-care management. We do not know if patients with heart failure have difficulty with self-care management due to underlying, mild cognitive impairment (MCI). The purpose of this study was to determine whether MCI, as identified on a simple screening tool, is significantly associated with self-care management in a sample of community dwelling older patients with heart failure. Using a cross-sectional design, heart failure patients (n=100, mean age 72 SD 10 years) attending an outpatient heart failure clinic completed the Montreal Cognitive Assessment tool (MoCA), Self-Care in Heart Failure Index (SCHFI) and Geriatric Depression Scale. The presence of MCI, as defined by a MoCA score <26, was present in 73% patients; 21% had an adequate self-care management SCHFI score; and 12% reported symptoms of depression. Participants with a MoCA score <26 vs. ≥ 26 scored significantly lower on the self-care management subscale of the SCHFI (48.1 SD 24 vs. 59.3 SD 22 respectively, p=0.035). Using backward regression, the final model was fitted to self-care management while controlling for age and sex and was significant, with (F= 7.04 df (3, 96), and p<0.001), accounting for 18% of the total variance in self-care management (R (2) = 18.03%). The MoCA score was the only variable which remained in the model significantly with p= 0.001. Findings from this study highlight the difficulty older heart failure patients have with self-care management and the need to include formal screening for MCI when exploring variables contributing to self-care management in heart failure patients.

Comparison of the use of anatomical compression plate and locking compression plate for the management of old patients with intertrochanteric fractures

Objective To compare the therapeutic effect between anatomical compression plate (ACP) and locking compression plate (LCP) in treatment of old patients with intertrochanteric fractures.Methods Selected 90 cases of intertrochanteric fractures experienced ACP internal fixation (47 cases) or LCP internal fixation (43 cases) from August 2006 to March 2011,and compare operation time,blood loss,fracture healing time,complications of the two groups.Results ACP group:operation time (98.8 ±31.2) min,blood loss (350.7 ± 123.9) ml,fracture healing time (95 ± 15) day,neck shaft angle (132.0 ± 4.9) °,cut-out (4 cases).LCP group:operation time (105.6 ± 36.3) min,blood loss (364.8 ± 119.5) ml,fracture healing time (93 ± 14) day,neck shaft angle (135.0 ± 1.5) °,cut-out (none).There was no statistical difference on operation time,blood loss,fracture healing time between the two groups (P ＞ 0.05).The difference was significant on neck shaft angle and cut-out between the two groups (P ＜ 0.01).Conclusion Compared with ACP internal fixation,LCP intemal fixation is good method for the treatment of old patients with intertrochanteric fractures. Key words: Intertrochanteric fractures ; Old patients; Anatomical compression plate ; Locking compression plate

Evaluation of Type 2 Diabetes Mellitus Medication Management and Control in Older Adults

The primary aims of this study were to characterize glycemic control and pharmacologic management in older patients and to compare glycemic control and pharmacological management in patients 65 to 79 years of age ("young-old") with those 80 to 89 years of age ("old-old"). We hypothesized that patients 80 to 89 years of age would be prescribed fewer medications and would have higher A1c values compared with younger patients. Retrospective medical record review. This study was conducted in outpatient clinics within a university hospital setting. This study included 400 adults 65 to 89 years of age with a diagnosis of type 2 diabetes mellitus and at least one A1c measurement over 12 months. A1c measurements and diabetes mellitus medications were assessed in these patients. The overall mean A1c was similar in the young-old compared with the old-old (7.1 ± 1.1% vs. 7.0 ± 1.1%; P = NS). There was no difference between groups for any of the A1c ranges studied. Fewer diabetes medications were prescribed in the old-old compared with the young-old (P = 0.003). In the young-old compared with the old-old, metformin (51.0% vs. 33.0%; P < 0.01), glucagon-like peptide-1 agonists (6.7% vs. 0%; P < 0.01), insulin glargine/detemir (24.7% vs. 13.0%; P < 0.05), and short-acting insulin (15.0% vs. 7.0%; P < 0.05) were more frequently prescribed. Our results indicate that glycemic control was similar between the young-old and old-old. However, the old-old required fewer diabetic medications for this same level of glycemic control.

Older Patients’ Experiences of Heart Failure—An Integrative Literature Review

Several literature reviews have been published summarizing objective knowledge about older patients with heart failure (HF). Although of vital importance to the treatment and diagnosis of HF, these reviews fail to explicate and summarize older patients' subjective and lived experience of the condition, which restrains us from providing a complete picture of the illness trajectory. The purpose of this integrative review was to explore and summarize the current literature examining self-reported symptoms, illness experience, and self-care management in older patients with HF. Combinations of search terms related to illness experience, symptoms, and self-care management in HF were used to search three electronic databases. Inclusion criteria were empirical studies, published in English between 2001 and 2011, in populations of older patients (≥ 75 years) investigated in relation to a self-reported subjective experience of HF. The search initially yielded 279 results; 23 qualitative and qualitative studies met the inclusion criteria. Older patients with HF have poor health-related quality of life compared with controls and experience severe and frequent symptoms of fatigue and dyspnea that limit several aspects of their life, making them dependent on others for survival. The variety of ways in which older patients cope with these consequences is determined by how they understand their illness, with the majority showing poor health literacy in relation to HF. Neither self-management nor symptom monitoring is ideal in older patients with HF, although person-centered interventions such as motivational interviewing show promising results in improving self-efficacy in this age group. Studies examining older patients' personal experiences of HF and the relationships between symptoms, situational antecedents, and social ties will fill a gap in the literature. Older patients have special care needs caused by their HF and other chronic conditions, coupled with those of great age. When symptoms of HF exacerbate, older patients are predominantly admitted to geriatric care rather than cardiac care units, implying restricted access to specialized treatment. Little is still known about the basis for self-care abilities from both healthcare provider and patient perspectives.