Screening In Older Patients Research Articles

The inter-rater reliability of emergency department and paramedic frailty screening in older patients following a fall

BackgroundScreening for frailty in the emergency setting may be useful in directing patients to appropriate management pathways. The main aim of this study was to assess the inter-rater reliability of the Clinical Frailty Scale between paramedics and emergency department staff (doctors and allied heath) for patients after a fall. Secondarily, to assess how these scores correlate with patient outcomes. MethodsA prospective study of older patients arriving by ambulance to a single hospital in Western Australia following a fall. The inter-rater reliability was assessed using a weighted Cohen’s κ. The relationship between Clinical Frailty Scale and secondary outcomes were assessed using chi-squared and Kruskal-Wallis tests. ResultsData from 94 patients were included, the mean age was 82 years and 64 % were female.The inter-rater reliability between paramedics and emergency department staff using the Clinical Frailty Scale was moderate (κ 0.48 (95 % CI 0.36–0.59)). ConclusionsThere is only moderate agreement between emergency department staff and paramedics when screening for frailty in patients who present after a fall. The findings indicate the need to improve reliability as a pre-requisite to the use of frailty screening in emergency settings.

The clinical implications of using a low threshold for computed tomography scans in older patients presenting with a proximal femur fracture

Key summary pointsAimWe evaluated the number of computerized tomography (CT) scans performed as well as the traumatic and non-traumatic clinical implications of using a low threshold for performing CT scans as part of the initial trauma screening in older patients presenting at the ED with a proximal femur fracture following a low-energy trauma (LET).FindingsApproximately one in five patients received a CT scan as part of the trauma screening in older patients with a proximal femur fracture after a LET. Results show no traumatic clinical implications, two non-traumatic clinical implications, and two initially missed injuries.MessageIn this subgroup of older trauma patients admitted with a proximal femur fracture, a restrictive policy can be used instead of using a low threshold for CT scans as part of the initial trauma screening at the emergency department (ED).

Preoperative nutritional status and postoperative health outcomes in older adults undergoing spine surgery: Electronic health records analysis

AimTo examine whether a high nutritional risk status, assessed via the Geriatric Nutritional Risk Index (GNRI), is independently associated with postoperative health outcomes, including unplanned intensive care unit (ICU) admissions, infectious complications, and prolonged length of stay in older patients undergoing spine surgery. MethodsWe conducted a retrospective descriptive study analyzing electronic health records from a tertiary hospital, including data from 1,014 patients aged ≥70 undergoing elective spine surgery between February 2013 and March 2023. ResultsHigh nutritional risk patients had significantly higher odds of unplanned ICU admission, infectious complications, and prolonged length of stay compared to low-risk patients. For each one-point increase in GNRI, there was a significant 0.91- and 0.95-fold decrease in the odds of unplanned ICU admission and infectious complications, respectively. ConclusionGNRI screening in older patients before spine surgery may have potential to identify those at elevated risk for postoperative adverse outcomes.

Geriatric nutritional risk index has a prognostic value for recovery outcomes in elderly patients with brain abscess.

The Geriatric Nutritional Risk Index (GNRI) is a straightforward and objective tool for nutritional screening in older patients and has been demonstrated to possess prognostic predictive value in several diseases. Nonetheless, there is a lack of research on the nutritional risk associated with brain abscess in the older. This study aimed to evaluate the prevalence of nutritional risk among these patients by GNRI and to investigate its potential prognostic value for clinical outcomes. From August 2019 to April 2023, 100 older patients diagnosed with brain abscess were enrolled in this single-center prospective cohort study, which evaluated the prognostic value of the Geriatric Nutritional Risk Index (GNRI) in elderly brain abscess patients. Data collected included demographic, and clinical characteristics at admission and calculated the GNRI, and the Glasgow Outcome Scale (GOS) score 6 months post-discharge. A GOS score of 5 was considered indicative of a good recovery, whereas scores ranging from 1 to 4 were classified as poor recovery. The results revealed that 48% of older brain abscess patients were at risk of malnutrition according to the GNRI. These patients had significantly higher post-admission C-reactive protein (CRP) levels (p = 0.017), more comorbidities (p < 0.001), and higher age-adjusted Charlson Comorbidity Index (aCCI) scores (p < 0.001) compared to those without nutritional risk. Spearman correlation analysis showed that GNRI scores were negatively correlated with CRP levels, comorbidities, and aCCI scores, and positively correlated with Glasgow Outcome Scale (GOS) scores (Spearman's ρ = 0.624, p < 0.001). Multivariate logistic regression revealed that lower GNRI values were linked to reduced GOS levels (OR = 0.826, 95% CI: 0.775-0.880). ROC analysis determined a GNRI threshold of 97.50 for predicting poor recovery, with 90.57% sensitivity and 87.23% specificity. The older brain abscess patients exhibited a high malnutrition risk. GNRI showed an important predictive value for recovery in older patients, which could be helpful in clinical intervention and rehabilitation.

Development and Feasibility Assessment of a Nutrition Screening Guideline in Older Patients for Use by Healthcare Staff in Health Clinic Setting: An Action Research Study

Introduction: Older persons are more susceptible to malnutrition. However, malnutrition identification through nutrition screening is not routinely performed in Malaysia’s health clinics due to no specific nutrition screening guideline and validated tool in this setting. This study aimed to develop a nutrition screening guideline for older patients and assess its feasibility for use by healthcare staff in health clinic setting. Methods: This study was conducted in three phases. In Phase I, needs assessment was conducted amongst healthcare staff. Development of nutrition screening guideline in Phase II involved scoping review and validation amongst six experts and twelve healthcare staff. In Phase III, twenty-two healthcare staff participated in feasibility assessment using in-depth interviews after completing nutrition screening in older patients. Interview data was analysed thematically using NVivo Software 12.0. Results: A Malay language version of nutrition screening guideline in A4-sized with 31 pages was developed and validated. Items with a content validity index ≥0.83 from experts review were retained, while &lt;0.83 were revised accordingly. Validation amongst healthcare staff showed positive responses. The guideline was then assessed for feasibility, where 110 older patients (mean age= 68.7±6.1 years) were screened by healthcare staff using the newly developed nutrition screening guideline. Four themes emerged from in-depth interviews: 1) Ease of use; 2) Identification and management of malnutrition; 3) Acceptability; and 4) Implementation of nutrition screening. Conclusion: The newly developed and validated nutrition screening guideline is well-accepted and feasible for healthcare staff to screen older patients in health clinic setting for timely malnutrition identification and management.

A comparative study of the sarcopenia screening in older patients with interstitial lung disease

BackgroundThe Asian Working Group for Sarcopenia 2019 (AWGS 2019) is the gold standard diagnostic criteria for sarcopenia in Asian populations. The calf circumference (CalF), the strength, assistance in walking, rising from a chair, climbing stairs, and falls (SARC-F) and the SARC-CalF questionnaires for sarcopenia screening have been used by AWGS 2019. The aim of this study was to assess accuracy of these three sarcopenia screening tools in patients with interstitial lung disease.MethodsIn this cross-sectional study, stable patients with interstitial lung disease were enrolled. The SARC-F, SARC-CalF, and CalF, used in patients with interstitial lung disease, were compared to the diagnostic criteria proposed by AWGS 2019. The accuracy of screening tools was compared using sensitivity and specificity. Moreover, areas under the receiver operating characteristic curves (AUC) were computed.ResultsSeventy eight patients were analyzed, and sarcopenia was identified in 25 (32.1%) patients with interstitial lung disease by the AWGS 2019 criteria. The sensitivity of the CalF was highest (96%) of the three screening tools, while the specificity was 60%. The sensitivity of SARC-F and SARC-CalF were 24% and 68%, while the specificity were 92% and 66%, respectively. The AUCs of CalF, SARC-F, and SARC-CalF in all patients were 0.78, 0.58, and 0.67, respectively.ConclusionsThe CalF is most suitable for screening sarcopenia in patients with interstitial lung disease, while SARC-F and SARC-CalF are not.

Benefit of Sarcopenia Screening in Older Patients Undergoing Surgical Aortic Valve Replacement

BackgroundSarcopenia, known as physical frailty, is highly prevalent in older patients and is related to adverse outcomes after cardiac surgery. However whether sarcopenia assessment can reclassify an individual patient’s risk, which is estimated by Society of Thoracic Surgeons–predicted risk of mortality scores in patients who undergo surgical aortic valve replacement, is unclear. MethodsThis retrospective, single-center, cohort study comprised 874 patients aged ≥65 years who underwent surgical aortic valve replacement between 2009 and 2016. Total skeletal muscle area was calculated using height squared (cm2/m2) and was measured by preoperative computed tomography at the third lumbar vertebra inferior border using machine learning–based analysis. Sex-specific Z-scores were calculated, and patients in the lowest Z-score tertile were considered to have sarcopenia. The primary endpoint was 30-day mortality, and secondary endpoints were in-hospital events, 1-year mortality, and long-term mortality. ResultsThirty-day mortality, 30-day in-hospital events, and 1-year mortality rates were 4.7%, 17.6%, and 8.0%, respectively. As the Z-score decreased, the odds of an early adverse event showed a stepwise increase. Sarcopenia was independently associated with higher 30-day mortality, 30-day in-hospital events, and 1-year mortality. Reclassification analyses showed improvements in the ability to predict early adverse events after adding the Z-scores over and above The Society of Thoracic Surgeons–predicted risk of mortality scores (all P < .005). ConclusionsSarcopenic patients had significantly higher risks of early adverse events and long-term mortality after undergoing surgical aortic valve replacement than nonsarcopenic patients. Sarcopenia determined by preoperative computed tomography can enhance the prediction of postoperative outcome risk.

Carotid plaque in STEMI: evidence of a missed opportunity to reclassify risk

Abstract Funding Acknowledgements Type of funding sources: None. Background The presence of carotid plaque has been associated with an increased risk for acute coronary events, and can be assessed with a low-cost and readily available study such as carotid ultrasound. This has a class IIa recommendation to reclassify patients with intermediate risk, but little is known about the prevalence of carotid disease in patients with acute coronary syndromes. Methods Observational study in patients admitted for STEMI in a tertiary care center, performing a carotid ultrasound before hospital discharge. We analyzed the differential characteristics according to the presence of carotid plaque, as well as the atherosclerotic burden assessed by the number of diseased vessels. Results We included 191 patients with STEMI, and 57 (29.8%) had carotid plaque. Their basal characteristics and outcomes are listed in the table. Patients with subclinical atherosclerotic disease were older, but other risk markers were similar, as was the use of aspirin and statins. The prevalence of carotid disease increased with the number of diseased vessels, as seen in the figure. Conclusion About 1 in 3 patients with STEMI had carotid plaque detectable by ultrasound. Most were young with an intermediate basal risk for cardiovascular disease, with only a minority treated with statins or aspirin, and could have been reclassified as high risk with a timely ultrasound. No other risk factors but age was associated with the presence of carotid plaque, emphasizing the importance of carotid ultrasound screening in older patients. Characteristics by carotid plaqueOverallCarotid plaque absentCarotid plaque presentpn17011357Age56.63 ± 10.9254.36 ± 9.9361.12 ± 11.48&amp;lt;0.001Males146 (85.9%)98 (86.7%)48 (84.2%)0.833Diabetes30 (17.8%)18 (16.1%)12 (21.1%)0.556Hypertension95 (55.9%)61 (54.0%)34 (59.6%)0.590Smoker122 (72.2%)85 (75.9%)37 (64.9%)0.185Obesity31 (18.2%)23 (20.4%)8 (14.0%)0.425LDL-cholesterol (mg/dl)115.97 ± 42.51117.84 ± 44.02110.78 ± 38.720.550Statin use31 (18.6%)19 (17.0%)12 (21.8%)0.585Aspirin use38 (22.6%)24 (21.2%)14 (25.5%)0.677GRACE score105.66 ± 29.30100.61 ± 27.63115.66 ± 30.250.005Stroke1 (0.6%)0 (0.0%)1 (1.8%)0.723Hospital mortality5 (3.1%)2 (1.9%)3 (5.5%)0.441Abstract Figure. Carotid plaque by diseased vessels.

Diagnostic Performance of the 4-Item Geriatric Depression Scale for Depression Screening in Older Patients with Cancer: The ELCAPA Cohort Study.

In older patients with cancer, depression is difficult to assess because of its heterogeneous clinical expression. The 4-item version of the Geriatric Depression Scale (GDS-4) is quick and easy to administer but has not been validated in this population. The present study was designed to test the diagnostic performance of the GDS-4 in a French cohort of older patients with cancer before treatment. Our cross-sectional analysis of data from the Elderly Cancer Patient cohort covered all patients with cancer aged ≥70 years and referred for geriatric assessment at two centers in France between 2007 and 2018. The GDS-4's psychometric properties were evaluated against three different measures of depression: the geriatrician's clinical diagnosis (based on a semistructured interview), the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, and a cluster analysis. The scale's sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver operating characteristic curve (AUROC) were calculated. In a sample of 2,293 patients (median age, 81 years; women, 46%), the GDS-4's sensitivity and specificity for detecting physician-diagnosed depression were, respectively, 90% and 89%. The positive and negative likelihood ratios were 8.2 and 0.11, and the AUROC was 92%. When considering the subset of patients with data on all measures of depression, the sensitivity and specificity values were, respectively, ≥90% and ≥72%, the positive and negative likelihood ratios were, respectively, ≥3.4 and ≤ 0.11, and the AUROC was ≥91%. The GDS-4 appears to be a clinically relevant, easy-to-use tool for routine depression screening in older patients with cancer. Considering the overlap between symptoms of cancer and symptoms of depression, depression is particularly difficult to assess in older geriatric oncology and is associated with poor outcomes; there is a need for a routine psychological screening. Self-report instruments like the 4-item version of the Geriatric Depression Scale appears to be a clinically relevant, easy-to-use tool for routine depression screening in older patients with cancer. Asking four questions might enable physicians to screen older patients with cancer for depression and then guide them toward further clinical evaluation and appropriate care if required.

Validation of the Thai version of SARC-F, MSRA-7, and MSRA-5 questionnaires compared to AWGS 2019 and sarcopenia risks in older patients at a medical outpatient clinic

ObjectivesTo validate the Thai Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F), and 2 Mini Sarcopenia Risk Assessment (MSRA-5, and MSRA-7) questionnaires for sarcopenia screening in older patients in the medical outpatient setting, and to assess the improvements of the diagnostic accuracy by adapting the parameters in the SARC-F, MSRA-7, and MSRA-5 questionnaires. Risk factors for sarcopenia are also investigated. MethodsThai SARC-F, MSRA-7, and MSRA-5 questionnaires were translated backwards and forwards. Content validity and test–retest reliability were analyzed. Reliability analysis was used for SARC-F, MSRA-7, and MSRA-5 scores to increase the sensitivity and specificity. The sensitivity, specificity, likelihood ratio, and area under the receiver operating characteristic curves (AUCs) were analyzed. ResultsThe prevalence of sarcopenia was 22.7% (65 of 286 patients). The sensitivity of the SARC-F, MSRA-7, and MSRA-5 questionnaires was 21.5%, 72.3%, and 61.5%, respectively. The specificity was 93.7%, 43%, and 67.4%, respectively. The AUCs were 0.58, 0.58, and 0.65, respectively. After weighting and adjusting the scores for the least responded-to items of the MSRA-5, the sensitivity increased to 82.6%, specificity to 43.4%, and AUC to 0.65. Multivariate analysis showed that the associated factors of sarcopenia were age [odds ratio (OR) = 5.92], body mass index < 18.5 [OR = 9.59], and currently working [OR = 0.11]. ConclusionsThe modified MSRA-5 improved the sensitivity and diagnostic accuracy for screening for sarcopenia. It is potentially useful for screening for sarcopenia in settings with limited resources for bioelectrical impedance analysis, time, or health personnel.

Determining the optimal value of the Geriatric Nutritional Risk Index to screen older patients with malnutrition risk: A study at a university hospital in Japan.

The Geriatric Nutritional Risk Index (GNRI) can predict nutritional risk. However, just a few studies have validated the optimal cut-off value of GNRI for nutrition screening in older patients. Hence, this study aimed to determine the optimal value of GNRI to screen the risk of malnutrition among older patients. This retrospective cross-sectional study was carried out with 5867 consecutive older adult patients who were admitted to an academic hospital in Japan. Receiver operating characteristic curve analyses were carried out to obtain the optimal cut-off value of GNRI, and the results were compared against the Mini Nutritional Assessment - Short Form and Malnutrition Universal Screening Tool. The validation of the obtained cut-off value was examined on the concordance rate of malnutrition diagnosis based on the European Society of Clinical Nutrition and Metabolism criteria. The mean age of the patients was 76.0 ± 7.0 years. The optimal cut-off value of GNRI for Mini Nutritional Assessment - Short Form ≤11 points was 95.92 (area under the curve 0.827 [0.817-0.838], P < 0.001), and that for Malnutrition Universal Screening Tool ≥1 point was 95.95 (area under the curve 0.788 [0.776-0.799], P < 0.001). By adapting GNRI <96 points as an initial screening cut-off in the European Society of Clinical Nutrition and Metabolism-defined malnutrition process, the concordance rates of comparisons were 98.5% and 98.5% for Mini Nutritional Assessment - Short Form-based and MUST-based diagnosis, respectively. The study showed GNRI <96 points as the optimal cut-off value for nutritional screening. GNRI might be one of the easy-to-use tools for nutritional screening and for diagnosing malnutrition in older adults. Geriatr Gerontol Int 2020; 20: 811-816.

A Decision Aid to Promote Appropriate Colorectal Cancer Screening among Older Adults: A Randomized Controlled Trial

Concerns have been raised about both over- and underutilization of colorectal cancer (CRC) screening in older patients and the need to align screening behavior with likelihood of net benefit. The purpose of this study was to test a novel use of a patient decision aid (PtDA) to promote appropriate CRC screening in older adults. A total of 424 patients ages 70 to 84 y who were not up to date with CRC screening participated in a double-blinded randomized controlled trial of a PtDA targeted to older adults making decisions about whether to undergo CRC screening from March 2012 to February 2015. Patients were randomized to a targeted PtDA or an attention control. The PtDA was designed to facilitate individualized decision making-helping patients understand the potential risks, benefits, and uncertainties of CRC screening given advanced age, health state, preferences, and values. Two composite outcomes, appropriate CRC screening behavior 6 mo after the index visit and appropriate screening intent immediately after the visit, were defined as completed screening or intent for patients in good health, discussion about screening with their provider for patients in intermediate health, and no screening or intent for patients in poor health. Health state was determined by age and Charlson Comorbidity Index. Four hundred twelve (97%) and 421 (99%) patients were analyzed for the primary and secondary outcomes, respectively. Appropriate screening behavior at 6 mo was higher in the intervention group (55% v. 45%, P = 0.023) as was appropriate screening intent following the provider visit (61% v. 47%, P = 0.003). The study took place in a single geographic region. The appropriate CRC screening classification system used in this study has not been formally validated. A PtDA for older adults promoted appropriate CRC screening behavior and intent. Clinicaltrials.gov, registration number NCT01575990. https://clinicaltrials.gov/ct2/show/NCT01575990?term=epic-d&rank=1.

Are there regional tendencies toward controversial screening practices? A study of prostate and breast cancer screening in a Medicare population

IntroductionProstate and breast cancer screening in older patients continue to be controversial. Balancing the desire for early detection with avoidance of over-diagnosis has led to competing and contradictory guidelines for both practices. Despite similarities, it is not known how these screening practices are related at the regional level. In this study, we examined how screening PSA and mammography are related within healthcare regions, and, to better understand what may be driving these practices, whether they are associated with local intensity of care. MethodsWe performed a retrospective cross-sectional study of fee-for-service Medicare beneficiaries in 2012. For each of 306 hospital referral regions (HRRs), we calculated rates of PSA screening for men aged ≥68 years, as well as rates of screening mammography for women aged ≥75 years, adjusted for age and race. Additionally, we determined regional rates of “healthcare intensity”, including spending on tests and procedures, and intensity of end-of-life care. Pearson correlations of adjusted rates were calculated within HRRs. ResultsThe mean adjusted rate of PSA screening was 22%. The mean age of screened and unscreened patients was 75.0 and 77.4 years, respectively (p<0.0001). The mean adjusted rate of screening mammography was 23%; mean ages of screened and non-screened women were 79.95 and 83.67, respectively (p<0.0001). HRR-level PSA screening rates were independent of screening mammography rates (r=0.06, p=0.31). PSA screening rates were associated with spending on testing and procedures (r=0.42, p<0.0001) and various measures of intensity of EOL care (e.g. r=0.40, p<0.0001 for mechanical ventilator use). Screening mammography had low correlation with both health care spending and EOL care intensity measures (all r-values <0.3). ConclusionsRegional rates of PSA screening rates were independent of screening mammography, thus these practices appear to be driven by different factors. Unlike mammography, PSA screening was associated with local enthusiasm for testing and treatment. Efforts to reduce over-testing should contemplate these practices differently, and future research should examine the factors motivating these screening practices.

Cognitive Impairment Is Very Common in Elderly Patients With Syncope and Unexplained Falls

ObjectivesTo evaluate the prevalence of cognitive impairment (CI), including mild CI and dementia, in elderly patients with syncope and unexplained falls. In this population, we compared the use of the Mini-Mental State Examination (MMSE) with a cognitive screening test that assesses executive dysfunction typical of subcortical (vascular) CI, that is, the Montreal Cognitive Assessment (MoCA). DesignObservational cohort study. SettingOutpatient fall and syncope clinic. ParticipantsConsecutive patients aged ≥65 years with syncope and unexplained falls without loss of consciousness. MeasurementsBaseline characteristics, functional status, MMSE, MoCA, and magnetic resonance imaging scans of the brain. Main outcome: prevalence of CI, comparing the MMSE with the MoCA. CI was defined as an MMSE/MoCA score <26. Secondary outcomes: MMSE/MoCA overall and subdomain scores, Fazekas and medial temporal lobe atrophy scores. ResultsWe included 200 patients, mean age 79.5 (standard deviation 6.6) years (Syncope Group: n = 101; Fall Group: n = 99). Prevalence of CI was 16.8% (MMSE) versus 60.4% (MoCA) in the Syncope Group (P < .001) and 16.8% (MMSE) versus 56.6% (MoCA) in the Fall Group (P < .001). Prevalence of CI did not differ between the Syncope Group and Fall Group with either method. Executive dysfunction was present in both groups. ConclusionCI is as common in elderly patients with syncope as it is in patients with unexplained falls, with an overall prevalence of 58%. The MMSE fails as a screening instrument for CI in these patients, because it does not assess executive function. Therefore, we recommend the MoCA for cognitive screening in older patients with syncope and unexplained falls.

Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE.

Introduction: routine cognitive screening for in-patients aged ≥75 years is recommended, but there is uncertainty around how this should be operationalised. We therefore determined the feasibility and reliability of the Abbreviated mental test score (AMTS/10) and its relationship to subjective memory complaint, Montreal Cognitive Assessment (MoCA/30) and informant report in unselected older admissions.Methods: consecutive acute general medicine patients aged ≥75 years admitted over 10 weeks (March–May 2013) had AMTS and a question regarding subjective memory complaint (if no known dementia/delirium). At ≥72 h, the 30-point Montreal Cognitive Assessment (MoCA) and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) were done. Cognitive impairment was defined as AMTS < 9 or MoCA < 26 (mild impairment) and MoCA < 20 (moderate/severe impairment) or IQCODE ≥ 3.6.Results: among 264 patients (mean age/SD = 84.3/5.6 years, 117 (44%) male), 228 (86%) were testable with AMTS. 49/50 (98%) testable patients with dementia/delirium had low AMTS compared with 79/199 (44%) of those without (P < 0.001). Subjective memory complaint agreed poorly with objective cognitive deficit (39% denying a memory problem had AMTS < 9 (kappa = 0.134, P = 0.086)) as did informant report (kappa = 0.18, P = 0.15). In contrast, correlation between AMTS and MoCA was strong (R2 = 0.59, P < 0.001) with good agreement between AMTS < 9 and MoCA < 20 (kappa = 0.50, P < 0.01), although 85% of patients with normal AMTS had MoCA < 26.Conclusions: the AMTS was feasible and valid in older acute medicine patients agreeing well with the MoCA albeit with a ceiling effect. Objective cognitive deficits were prevalent in patients without known dementia or delirium but were not reliably identified by subjective cognitive complaint or informant report.

Suboptimal vitamin D screening in older patients with compromised skeletal health

Increasing number of primary care visits for osteoporosis by older patients combined with new vitamin D screening recommendations necessitate primary care providers (PCPs) to identify and screen at-risk patients. We described prevalence and determinants of vitamin D screening among older patients treated for osteopoenia, osteoporosis and related fractures in academic outpatient primary care clinics (family medicine and geriatric medicine) in Houston, TX. Electronic chart review collected data on patients ≥50 years old from January 2008 to December 2010. Orders for serum 25-hydroxy vitamin D indicated vitamin D screening. Differences in patient characteristics were described between the groups with and without vitamin D screening. Age, body mass index, racial/ethnic background, bone-promoting medication (BPM) use and clinic types (family medicine versus geriatric medicine) were determinants for vitamin D screening in the regression analysis. Patients were mostly women (95%), Caucasian (65%) and had a mean age of 69 ± 12 years. Twenty-two per cent of the family medicine clinic patients (total n = 78) and 51% of the geriatric medicine clinics patients (total n = 70) were screened. Older age (odds ratio, 0.94 confidence interval = 0.90-0.99) and BPM use (2.58, 1.03 to 6.45) were significant positive determinants for vitamin D screening. In primary care clinics, vitamin D screening remains low among patients diagnosed with osteopoenia, osteoporosis and fractures. In light of new guidelines, suboptimal screening in the vulnerable older patients is disturbing. We recommend increased PCPs' awareness about vitamin D screening guidelines for improving skeletal health in older patients.

Beyond Lung Cancer

Low-dose computed tomography screening in older patients with a heavy-smoking history can be viewed as an opportunity to screen for smoking-related illnesses and not just for lung cancer. Within the National Lung Screening Trial, 24.1% of all deaths were attributed to lung cancer, but there were significant competing causes of mortality in this patient population. Cardiovascular illness caused 24.8% of deaths. Other neoplasms were listed as the cause of death in 22.3%, and respiratory illness was the cause of death in 10.4%. All of these illnesses might be attributed to smoking. Low-dose computed tomography of the thorax may provide information about these diseases, which could be used to guide therapeutic intervention and, hopefully, alter the courses of these diseases. Information about coronary artery calcification, chronic obstructive pulmonary disease, and potential extrapulmonary malignancy should be provided in the report of the screening examination. This must be balanced against the risk of the burden of false-positive findings and the costs, both psychological and financial, associated with additional investigative evaluations.

Abstract NS16: The Discriminant Validity of the AD8 in Detecting Post-stroke Vascular Cognitive Impairment

Background: The AD8 is an informant-based brief cognitive screening instrument, which can be administered to the patient in the absence of an informant in detecting patients with dementia at the memory clinic or in the community. However, its discriminant validity in detecting post-stroke Vascular Cognitive Impairment (VCI) has not been reported. Purpose: Our aims were to examine the discriminant validity of the AD8 for the detection of VCI by comparing the AD8 (both informant-rated and patient-rated) to the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). Method: Patients with ischemic stroke and TIA were recruited from the stroke neurology service of the National University Health System in Singapore. Their consensus diagnoses of VCI and no cognitive impairment (NCI) were established by clinical assessment including formal neuropsychological evaluation and neuroimaging according to the internationally accepted criteria. Patients received the AD8, MMSE and MoCA whilst their informants received AD8. Area under the receiver operating characteristic curve (ROC) analysis was employed to examine the discriminant validity of the informant AD8 in detecting VCI. Results: Sixty patient-informant dyads were recruited (34 VCI and 26 NCI). There were no significant differences in age between patients with VCI and NCI (69.5 ±9.4 vs 66.8±6.8, p&gt;.05). Informant AD8 had shown a trend of superior discriminant validity compared to patient AD8 in detecting VCI (Area Under the Curve (95% Confident Interval): .81 (.70- .93), .67 (.54- .81), p=.06). At the respective optimal cutoff points, the informant AD8 (≥1) had acceptable sensitivity and specificity whilst the patient AD8 (≥3) had poor sensitivity and good specificity (sensitivity: .79 vs .32; specificity: .73 vs .96, correctly classified 76.7% vs 60.0%). In addition, the informant AD8 was equivalent to the MMSE and inferior to the MoCA in detecting VCI. Conclusions: The informant AD8 has demonstrated a trend of superior discriminant validity compares to the patient AD8 in detecting post-stroke VCI. Stroke nurses may adopt this brief instrument for targeted cognitive screening of older patients with stroke/TIA.

Pilot shows need for targeted screening of older patients

Pilot shows need for targeted screening of older patients

Malnutrition screening in older patients undergoing cardiac surgery: Both in preoperative patients not having an increased weight and in postoperative overfilled patients

Malnutrition screening in older patients undergoing cardiac surgery: Both in preoperative patients not having an increased weight and in postoperative overfilled patients