Full-endoscopic spine surgery in oldest old patients aged over 90 years:A case report.

BACKGROUND: Transforaminal full-endoscopic spine surgery (FESS) is the least invasive spinal surgery and can be performed under local anesthesia. In Japan, the population is rapidly aging and the number of spinal surgeries performed in the elderly is also increasing. OBJECT: In this report, we describe 3 patients aged 90 years or older in whom we performed FESS under local anesthesia. CASE: The first case was a 90-year-old man who presented with severe leg pain. He had multiple medical comorbidities and was unsuitable for general anesthesia. We performed FESS. After surgery, the leg pain resolved with full recovery of muscle strength. He was discharged with no perioperative complications. The second case was a 90-year-old man who presented with severe leg pain. MRI showed a herniated nucleus pulposus and foraminal stenosis at L4/5. We performed FESS. The leg pain improved immediately after surgery. The third case was a 91-year-old woman in whom we diagnosed left L5 radiculopathy due to foraminal stenosis at L5/S1. After surgery, her leg pain was relieved. CONCLUSION: FESS is a good surgical procedure for elderly patients who are in a poor general condition because it is minimally invasive and can be performed under local anesthesia with early mobilization. J. Med. Invest. 71 : 169-173, February, 2024.

"Inspiratory muscle weakness in acutely hospitalized patients 75 years and over": a secondary analysis of a randomized controlled trial on the effectiveness of multicomponent exercise and inspiratory muscle training.

PURPOSE: The impact of hospitalization for acute illness on inspiratory muscle strength in oldest-old patients is largely unknown, as are the potential benefits of exercise and inspiratory muscle training (IMT) during in-hospital stay. DESIGN AND METHODS: This was a sub-study of a randomized clinical trial that evaluated the efficiency of a multicomponent exercise program in preventing hospitalization-associated disability. Patients were randomized into control (CG) and intervention (IG) groups. The intervention included two daily sessions of supervised walking, squat, balance, and IMT. Baseline and discharge maximal inspiratory pressure (MIP) and inspiratory muscle weakness (IMW) were determined. The effect of the intervention on inspiratory muscle strength was assessed by analyzing (1) the differences between groups in baseline and discharge MIP and IMW, (2) the association, patient by patient, between baseline and discharge MIP, and the improvement index (MIP discharge/baseline) in patients with or without IMW. RESULTS: In total, 174 patients were assessed (mean age of 87), 57 in CG and 117 in IG. Baseline MIP was lower than predicted in both sexes (women 29.7 vs 44.3; men 36.7 vs 62.5 cmH2O, P < 0.001, baseline vs predicted, respectively). More than 65% of patients showed IMW at admission. In women in IG, the mean MIP was higher at discharge than at admission (P = 0.003) and was the only variable that reached expected reference levels at discharge (Measured MIP 39.2 vs predicted MIP 45 cmH2O, P = 0.883). Patients with IMW on admission showed a statistically significant improvement in MIP after the intervention. CONCLUSION: IMW is very prevalent in oldest-old hospitalized with acute illness. Patients might benefit from a multicomponent exercise program including IMT, even during short-stay hospitalization. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NTC03604640. May 3, 2018.

Triglyceride glucose index predicts all-cause mortality in oldest-old patients with acute coronary syndrome and diabetes mellitus.

BACKGROUND: Acute coronary syndrome (ACS) and diabetes mellitus (DM) are the leading health risks for the elderly. Triglyceride-glucose (TyG) index is a novel and reliable indicator of insulin resistance (IR). This study aims to explore the relationship between the TyG index and all-cause mortality in oldest-old patients with ACS and DM. METHODS: Seven hundred twenty hospitalized patients with ACS aged ≥ 80 years were enrolled, and 699 patients signed informed consent for the study. During the follow-up period, 37 were lost to follow-up, and the follow-up rate was 94.7%. 231 ACS patients with DM were selected for the study's analyses. Kaplan-Meier curve, Cox regression model and receiver operating characteristic (ROC) curve were used to analyze the association between the TyG index and all-cause mortality. RESULTS: The mean age of participants was 81.58 ± 1.93 years, and 32.47% were women. Compared to TyG tertile 1, the Hazard Ratio (HR) [95% confidence interval (CI)] of all-cause mortality was 2.04 (1.09, 3.81) for TyG tertile 3 in the fully adjusted model. For the TyG index per standard deviation (SD) increment, the HR (95% CI) of all-cause mortality was 1.44 (1.13, 1.83). Further, the association between the TyG index and all-cause mortality was dose-response (P for trend = 0.026). ROC curve analyses indicated that the TyG index outperformed FBG and TG in the prediction of mortality risk and improved the prognostic value of the Gensini score combined with LVEF. CONCLUSION: The TyG index predicts the risk of all-cause mortality in the oldest-old ACS patients with DM.

Functional trajectories associated with acute illness and hospitalization in oldest old patients: Impact on mortality.

Background: The literature pays low attention to functional changes during acute illness in older patients. Our main objectives were to separately describe the different functional changes occurring before and after hospital admission in oldest old medical patients, to investigate their association with mortality, and identify predictors associated with in-hospital failure to recover function. Methods: Secondary analysis of data from a prospective cohort study conducted in a tertiary teaching hospital. The study followed the STROBE criteria. The sample included 604 consecutive patients aged 65 or older hospitalized for acute illness, discharged alive, and not fully dependent at baseline. Activities of daily living measured at baseline, admission, and discharge were used to classify patients into four functional trajectories depending on whether they decline or remain stable between baseline and admission (prehospital) and whether they decline, remain stable, or recover baseline function between admission and discharge (in-hospital). Multivariate models were used to test the association between functional trajectories with mortality, and predictors for in-hospital recovery. Results: Functional trajectories were: "stable-stable" (18%); "decline-recovery" (18%); "decline-no recovery" (53%); "in-hospital decline" (11%). Prehospital decline occurred in 75% and 64% were discharged with worse function than baseline. "In-hospital decline" and "decline-no recovery" trajectories were independently associated with higher 6- and 12-month mortality. Extent of prehospital decline and dementia were predictors of failure to in-hospital recovery. Conclusion: In acutely ill older people, differentiating between prehospital and in-hospital functional changes has prognostic implications. Lack of functional regain at discharge is associated with higher mortality at 6- and 12-months.

Adverse Drug Reactions Due to Opioid Use in Oldest-Old Patients Visiting the Emergency Unit of the Geneva Geriatric Hospital.

Opioid use has much increased in several countries during the last two decades, accompanied by a rise in associated morbidity and mortality, especially in the United States. Data on a possible opioid crisis are scarcer in Europe. We performed a study aiming to assess the frequency of adverse drug reactions (ADR) related to opioids in patients presenting to the emergency unit (EU) of a geriatric tertiary Swiss University Hospital. This particular setting is intended for patients aged 75 and older. Our retrospective, monocentric survey of opioid use and related ADR was conducted over two months in 2018. The main and secondary outcomes were the frequency of EU visits considered due to an opioid ADR and insufficient pain relief, respectively. Current opioid use was identified in 20.3% (n=99) of the 487 included EU visits (mean age 86). An ADR was the suspected cause of the EU visit in 22 opioid users, mainly fall-related injury and gastrointestinal disorders. All these patients had at least one comorbid condition. In 19/22 cases (86%) of ADR, a drug-drug interaction might have been involved. In 12 opioid users (12%), insufficient pain relief was suspected as the cause of the EU visit. In conclusion, one-third of opioid users visiting a geriatric EU consulted for a problem related to its use mainly adverse drug-related reaction (22%) followed by insufficient pain relief (12%).

Short- and mid-term outcomes of laparoscopic colorectal surgery in patients ≥ 85 years old: a multicenter study using a propensity score-matched analysis.

PURPOSE: The number of laparoscopic surgeries for colorectal cancer (CRC) in elderly patients has been increasing. We examined the short- and mid-term outcomes of laparoscopic surgery for CRC in oldest-old patients (≥ 85 years old) compared with the outcomes in younger patients (< 85 years old). METHODS: We retrospectively reviewed primary tumor resection for CRC from April 2015 to December 2020 at six hospitals. Short- and mid-term outcomes were compared after propensity score matching. RESULTS: From the 1374 patients, 126 matched pairs were selected. In the matched cohort, the duration of postoperative hospital stay was longer in the oldest-old patients than in the younger patients (15 days vs. 12 days, p = 0.001). There were no significant differences between the groups in the rate of Clavien-Dindo grade ≥ 2 postoperative complications (21.4% vs. 15.1%, p = 0.254). The oldest-old patients showed a poorer overall survival (OS) than the younger patients (3-year OS, 79.9% vs. 93.5%, p = 0.005) but comparable recurrence-free survival (RFS) (3-year RFS, 72.2% vs. 81.6%, p = 0.530) and cancer-specific survival rates (CSS) (3-year CSS, 90.1% vs. 99.0%, p = 0.124). CONCLUSION: Laparoscopic surgery for CRC in oldest-old patients was performed safely with comparable short-term outcomes to those in younger patients. Although the OS was poorer in the oldest-old patients than in the younger patients, the oncological mid-term outcomes were comparable. Laparoscopic surgery for CRC can be considered acceptable as a treatment in oldest-old patients.

Wound Management of Multi-Site Pressure Ulcer at Different Stages in Elderly Patients.

OBJECTIVE: The present study aims to explore the individualized treatment options for multisite pressure ulcer (PU) at various stages in elderly patients with multiple medical conditions. METHODS: Stages 1 and 2 PU at 146 sites were treated with closed negative pressure suction combined with continuous micro-oxygen perfusion and the local application of foam dressings, silver ion dressings, and moist burn cream. Stages 3 and 4 PU in the sacrococcygeal region were treated with skin or myocutaneous flap transplantation. RESULTS: Stages 1 and 2 PU healed after treatment with closed negative pressure suction combined with continuous micro-oxygen perfusion and dressing changes. One case died during hospitalization due to an illness. Skin or myocutaneous flap repair was conducted in 34 cases of stage 3 or 4 PU in the sacrococcygeal area. Of these cases, 28 achieved primary healing, and 6 required two or three surgeries, 5 of which received micro-skin implantation. In addition, 10 small deep PU at other sites were repaired by direct excision and suturing or local flap repair. Seven cases were transferred to other departments or hospitals due to concomitant diseases or were discharged automatically without surgical treatment. CONCLUSION: Home care for geriatric patients is difficult. PU often occur at multiple sites because of the duration of various pressures, and different sites may demonstrate different stages because of varying degrees of pressure. When actively treating stages 3 and 4 PU, the trauma management of stages 1 and 2 PU should not be neglected.

Clinical characteristics of sleep apnea in middle-old and oldest-old inpatients: symptoms and comorbidities.

BACKGROUND: Obstructive sleep apnea (OSA) is prevalent in older adults but still underdiagnosed for many reasons, such as underreported symptoms, non-specific ones because of the comorbidities and polypharmacy, or the social belief of sleep problems as normal with aging. OBJECTIVES: To identify salient symptoms and comorbidities associated with OSA, diagnosed by nocturnal respiratory polygraphy in geriatric inpatients. METHOD: We conducted a retrospective, cross-sectional study in a sample of 102 geriatric inpatients from a French Geriatric University Hospital. We reviewed medical records to collect demographic, medical information including comorbidities, the geriatric cumulative illness rating scale (CIRS-G), subjective sleep-related symptoms and data of overnight level three portable sleep polygraphy recording. RESULTS: Among classic OSA symptoms, only excessive daytime sleepiness (p = 0.02) and nocturnal choking (p = 0.03) were more prevalent in older inpatients with OSA (n = 64) than in those without (n = 38). The prevalence of comorbidities and mean CIRS-G scores were not different between groups except for the lower prevalence of chronic obstructive pulmonary disease and the higher level of creatinine clearance in OSA patients. Multivariate analysis showed OSA was associated with excessive daytime sleepiness (OR = 2.83, p = 0.02) in symptoms-related model and with composite CIRS-G score (OR 1.26, p = 0.04) in comorbidities-related model. CONCLUSIONS: Only excessive daytime sleepiness and comorbidity severity (composite CIRS-G score) were associated with the objective diagnosis of OSA, while other usual clinical OSA symptoms and comorbidities in geriatric inpatients were not. These findings emphasize the importance of excessive daytime sleepiness symptom, when reported in comorbid older patients, strongly suggesting OSA and requiring adequate nocturnal exploration.

General practitioners' views on (long-term) prescription and use of problematic and potentially inappropriate medication for oldest-old patients-A qualitative interview study with GPs (CIM-TRIAD study).

BACKGROUND: Potentially inappropriate medication (PIM) is defined as medication with uncertain therapeutic effects and/or potential adverse drug reactions outweighing the clinical benefits. The prescription rate of PIM for oldest-old patients is high despite the existence of lists of PIM (e.g. the PRISCUS list) and efforts to raise awareness. This study aims at identifying general practitioners' views on PIM and aspects affecting the (long-term) use of PIM. METHODS: As part of the CIM-TRIAD study, we conducted semi-structured, qualitative interviews with 47 general practitioners, discussing 25 patients with and 22 without PIM (according to the PRISCUS list). The interview guideline included generic and patient-specific questions. Interviews were digitally recorded and transcribed verbatim. We content analyzed the interviews using deductive and inductive category development. RESULTS: The majority of the general practitioners were not aware of the PRISCUS list. Agents deemed potentially inappropriate from the general practitioners' point of view and the PRISCUS list are not completely superimposable. General practitioners named their criteria to identify appropriate medication for elderly patients (e.g. renal function, cognitive state) and emphasized the importance of monitoring. We identified prescription- (e.g. benzodiazepines on alternative private prescription), medication- (e.g. subjective perception that PIM has no alternative), general practitioner- (e.g. general practitioner relies on specialists), patient- (e.g. "demanding high-user", positive subjective benefit-risk-ratio) and system-related aspects (e.g. specialists lacking holistic view, interface problems) related to the (long term) use of PIM. CONCLUSIONS: While the PRISCUS list does not seem to play a decisive role in general practice, general practitioners are well aware of risks associated with PIM. Our study identifies some starting points for a safer handling of PIM, e.g. stronger dissemination of the PRISCUS list, better compensation of medication reviews, "positive lists", adequate patient information, multifaceted interventions and improved communication between general practitioners and specialists.