Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial.

BACKGROUND: Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions. METHODS: This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis. DISCUSSION: The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.

Moral distress - a threat to dementia care? A qualitative study of nursing staff members' experiences in long-term care facilities.

BACKGROUND: Dementia is a public health priority worldwide due to its rapidly increasing prevalence and poses challenges with regard to providing proper care, including end-of-life care. This study is part of a research project about nursing staff members' experiences with providing palliative care for people with severe dementia in long-term care facilities. In an earlier study, we found that structural barriers that complicated the provision of palliative care led to moral distress among nursing staff. In this study, we performed a secondary analysis of the same data set to gain a deeper understanding of nursing staff members experiences of moral distress while providing palliative care for residents with severe dementia in long-term care facilities. METHODS: A qualitative, descriptive design was used. Data were collected during in-depth interviews with 20 nursing staff members from four Norwegian long-term care facilities. Content previously identified as moral distress was reanalysed by thematic text analysis, as described by Braun and Clarke, to gain a deeper understanding of the phenomenon. RESULTS: The nursing staff members' experiences of moral distress were generally of two types: those in which nursing staff members felt pressured to provide futile end-of-life treatment and those in which they felt that they had been prevented from providing necessary care and treatment. CONCLUSION: The findings indicate that nursing staff members' experiences of moral distress were related to institutional constraints such as time limitations and challenging prioritizations, but they were more often related to value conflicts. Nursing staff members experienced moral distress when they felt obligated to provide care and treatment to residents with severe dementia that conflicted with their own values and knowledge about good palliative care. Both education interventions focused on improving nursing staff members' skills regarding communication, ethical judgement and coping strategies; in addition, supportive and responsive leadership may have significant value with regard to reducing moral distress. Our findings indicate a need for further research on interventions that can support nursing staff members dealing with ethical conflicts in providing palliative care to residents with dementia.

A practitioner behaviour change intervention for deprescribing in the hospital setting.

BACKGROUND: hospital deprescribing trials have demonstrated marginal increases in deprescribing activity that are not sustained beyond the trial period. The hospital deprescribing implementation framework (hDIF) links barriers and enablers of deprescribing in hospital with 44 potential intervention components. This study aimed to support geriatricians and pharmacists to select and characterise hDIF components according to affordability, practicability, effectiveness, acceptability, safety and equity (APEASE) to design a deprescribing intervention in the English hospital setting. METHODS: we convened a modified Nominal Group Technique with a panel of nine geriatricians and pharmacists representing five English hospitals. Panel members selected and characterised intervention components from the hDIF based on the APEASE criteria. We set a consensus threshold of 80% agreement per APEASE criterion in order for the intervention component to be included. RESULTS: the panel selected five intervention components supporting engagement with deprescribing: an organisational action plan to prioritise deprescribing, two training activities to address pharmacists' beliefs about negative deprescribing consequences, restructuring pharmacists' working patterns to facilitate their contribution to deprescribing decisions, and sharing experiences of successfully engaging patients/family in deprescribing conversations to support others to do the same. A sixth component was selected to sustain engagement with deprescribing through measuring and sharing deprescribing activity achieved between teams. CONCLUSIONS: deprescribing interventions targeting geriatricians' and pharmacists' behaviour in the English hospital context should include the six characterised components. A component to sustain deprescribing activity is a notable omission from previously reported deprescribing interventions and may explain their failure to maintain efficacy beyond the short-term trial period.

Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists.

BACKGROUND: over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians' and pharmacists' barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing. METHODS: fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains. RESULTS: geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists' working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. CONCLUSION: the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.

Attitudinal predictors of older peoples' and caregivers' desire to deprescribe in hospital.

BACKGROUND: Deprescribing is a partnership between practitioners, patients and caregivers. External characteristics including age, comorbidities and polypharmacy are poor predictors of attitude towards deprescribing. This hospital-based study aimed to describe the desire of patients and caregivers to be involved in medicine decision-making, and identify attitudinal predictors of desire to try stopping a medicine. METHODS: Patients and caregivers recruited from seven Older People's Medicine wards across two UK hospitals completed the revised Patients'Attitudes Towards Deprescribing (rPATD) questionnaire. Patients prescribed polypharmacy and caregivers involved in medication decision-making of such patients were eligible. A target of 150 patients and caregivers provided a 95% confidence interval of ±11.0% or smaller around rPATD item agreement. Descriptive statistics characterised participants and rPATD responses. Responses to items regarding desire to be involved in medication decision-making and desire to try stopping a medicine were used to address the aims. Binary logistic regression provided the adjusted odds ratios (OR) for predictors of desire to try stopping a medicine. RESULTS: Patient participants (N = 75) were a median (IQ) 87.0 (83.0, 90.0) years old and the median (IQ) number of pre-admission medication was 8.0 (6.0, 10.0). Caregiver participants (N = 76) were a median (IQ) 70.0 (57.0, 83.0) years old and the majority were a spouse (63.2%). For patients and caregivers respectively, the following were reported: 58.7 and 65.8% wanted to be involved in medication decision-making; 29.3 and 43.5% reported a desire to try stopping a medicine. Attitudinal predictors of low desire to try stopping a medicine for patients and caregivers are a perception that there are no unnecessary prescribed medicines [OR = 0.179 (patients) and 0.044 (caregivers)] and no desire for dose reduction [OR = 0.199 (patients) and 0.024 (caregivers)]. A perception of not being prescribed too many medicines also predicted low patient desire to try stopping a medicine [OR = 0.195]. CONCLUSION: A substantial proportion of patients and caregivers did not want to be involved medication decision-making, however this should not result in practitioners dismissing deprescribing opportunities. The three diagnostic indicators for establishing desire to try stopping a medicine are perceived necessity of the medicine, appropriateness of the number prescribed medications and a desire for dose reduction.

Perceived barriers and facilitators in providing palliative care for people with severe dementia: the healthcare professionals' experiences.

BACKGROUND: Dementia has become a major public health issue worldwide due to its rapidly increasing prevalence and an increasing number of dementia-related deaths in long-term care facilities. The aim of this study was to examine health professionals' experiences of potential barriers and facilitators in providing palliative care for people with severe dementia in long-term care facilities. METHODS: This was a qualitative descriptive study. The data were collected from four focus groups and 20 individual in-depth interviews with healthcare professionals from four Norwegian nursing homes. The data were analysed by thematic text analysis, as described by Braun and Clarke. RESULTS: The major findings indicate that healthcare professionals experience a lack of continuity as the main barrier to facilitating palliative care. Time pressure and increased efficiency requirements especially affect the weakest and bedridden residents with dementia. The healthcare professionals feel conflicted between wanting to spend more time caring for each individual resident and feeling pressure to help everyone. Although resources are scarce, dying residents are always given priority by healthcare professionals, either by the hiring of extra personnel or the reorganization of tasks in a way that facilitates someone staying with the terminal resident. Advanced care planning was highlighted as a facilitator in providing palliative care, but the extensive use of temporary staff among nurses and doctors and the relocation between the sheltered and long-term wards threaten the continuity in planning and providing palliative care. CONCLUSIONS: The findings indicate that healthcare professionals experienced several structural barriers that prevented the provision of palliative care to people with severe dementia in long-term care facilities. Increasing demands for economic rationality lead to a lack of continuity of care. Organizational changes, such as measures to increase the competence and the proportion of permanent employees and the prevention of burdensome end-of-life transitions, should be implemented to improve continuity and quality of care.

A painful experience of limited understanding: healthcare professionals' experiences with palliative care of people with severe dementia in Norwegian nursing homes.

BACKGROUND: People dying with dementia have significant healthcare needs, and palliative care, with its focus on comfort and quality of life, should be made available to these patients. The aim of this study was to explore and increase knowledge of healthcare professionals' experiences with palliative care to people with severe dementia in nursing homes. METHODS: To describe the phenomenon under investigation, we used a phenomenological research approach grounded in the philosophy of Husserl. Data were collected using in-depth interviews with 20 healthcare professionals from four Norwegian nursing homes. RESULTS: The general meaning structure of the healthcare professionals' experiences with providing palliative care to people with severe dementia is painfulness, due to their limited understanding of patients' individual modes of expression. The painfulness is illustrated by the following themes: challenges related to "reading" the patients' suffering, coming up short despite occasional success, handing the patients over to strangers, and disagreeing on the patients' best interests. The healthcare professionals struggled to understand patients by "reading" their suffering. Occasionally, they succeeded and were able to calm the patients, but they often had the feeling of coming up short in situations related to pain relief and coping with behavioural symptoms, such as aggression and rejection of care. They also found it painful when the weakest patients were moved from the sheltered unit to a somatic long-term unit and were handed over to strangers who did not know the patients' ways of expression. Although the healthcare professionals emphasized the importance of good collaboration with the patients' relatives to ensure the best possible palliative care, they frequently found themselves in difficult situations when they disagreed with the family on the patients' best interests. CONCLUSIONS: We found healthcare professionals' experiences of providing palliative care to people with severe dementia to be painful. To be able to understand the patients better, long-term familiarity and knowledge of how to "read" and observe patients with severe dementia are necessary. Openness in cooperation with the patients' relatives and with the professional team may increase healthcare professionals' understanding of the patients' situations and hence improve the quality of care.

Addressing inequalities in eye health with subsidies and increased fees for General Ophthalmic Services in socio-economically deprived communities: a sensitivity analysis.

OBJECTIVES: Poor knowledge of eye health, concerns about the cost of spectacles, mistrust of optometrists and limited geographical access in socio-economically deprived areas are barriers to accessing regular eye examinations and result in low uptake and subsequent late presentation to ophthalmology clinics. Personal Medical Services (PMS) were introduced in the late 1990 s to provide locally negotiated solutions to problems associated with inequalities in access to primary care. An equivalent approach to delivery of optometric services could address inequalities in the uptake of eye examinations. STUDY DESIGN: One-way and multiway sensitivity analyses. METHODS: Variations in assumptions were included in the models for equipment and accommodation costs, uptake and length of appointments. The sensitivity analyses thresholds were cost-per-person tested below the GOS1 fee paid by the NHS and achieving break-even between income and expenditure, assuming no cross-subsidy from profits from sales of optical appliances. RESULTS: Cost per test ranged from £ 24.01 to £ 64.80 and subsidy required varied from £ 14,490 to £ 108,046. Unused capacity utilised for local enhanced service schemes such as glaucoma referral refinement reduced the subsidy needed. CONCLUSIONS: In order to support the financial viability of primary eye care in socio-economically deprived communities, income is required from additional subsidies or from sources other than eye examinations, such as ophthalmic or other optometric community services. This would require a significant shift of activity from secondary to primary care locations. The subsidy required could also be justified by the utility gain from earlier detection of preventable sight loss.

Do older patients find multi-compartment medication devices easy to use and which are the easiest?

BACKGROUND: multi-compartment medication devices (MMDs) are widely used, primarily by older people, to aid correct-medication taking. Several MMD types are available yet little is known about the ease with which patients with varying functional ability use these devices and whether some types are easier than others. Such knowledge would assist healthcare practitioners in advising patients on a suitable choice of device. OBJECTIVE: this study investigates the ease with which patients with differing functional ability use three types of MMD. METHOD: participants were recruited from an older person's medical ward. Demographic and medication information, cognitive function, visual acuity and manual dexterity were recorded. The Venalink®, Nomad Clear® and Dosett® MMDs were tested. Participants rated each MMD according to text readability, ease of opening, ease of medication removal, transportability and overall rating. These ratings were compared between MMDs for all patients and for subgroups with differing functional abilities. RESULTS: the MMDs were trialled by 50 patients; the majority rated text readability well but rated MMDs poorly according to the other criteria. Cognitively impaired participants may encounter difficulties in opening and removing medication from Venalink® and Nomad®. The Dosett® consistently rated better across all criteria. Transportability was the most influential criterion for overall MMD usability. CONCLUSION: the poor patient rating of MMDs which are widely used in practice is of concern. Some MMDs may be difficult to open and access, especially for patients with cognitive impairment. This offers some guidance to health professionals in advising patients on MMD choice however, overall MMD rating appears dominated by transportability.

Drawing on emotions: the evolving role of art therapy.

Art therapy is a form of psychotherapy that uses art media to improve well-being. This article explores the history and development of art therapy, from the first description of art therapy in the 1940s, to the two main approaches still in use today. The benefits of art therapy with regard to its delivery, patient population, and cost are then broadly discussed. The use of art therapy in psychiatric conditions, specifically in schizophrenia and schizophrenia-like conditions, is highlighted, as well as its role in chronic and physical conditions like asthma and cancer. Furthermore, the potential for art therapy to be more broadly implemented using technological novelties, such as virtual reality, is considered, especially in light of the COVID-19 pandemic.

Barriers and Facilitators When Implementing Electronic Patient-Reported Outcome Measures at a Municipal Cancer Care Unit: A Qualitative Study.

BACKGROUND: Few qualitative studies of barriers and facilitators when implementing electronic patient-reported outcome measure (ePROM) in municipal cancer care exist within the large body of symptom assessment research. Such data, gathered from healthcare professionals' (HCPs) perspective, are central to the development and design of sustainable interventions aiming for a systematic and patient-centered symptom assessment to patients with cancer. OBJECTIVE: The aim of this study was to identify and explore barriers and facilitators, as described by HCPs, in the implementation of the ePROM application "Eir" at a municipal cancer care unit in Norway. METHODS: The study applies a qualitative method, conducting an inductive data inquiry of semistructured individual interviews and focus groups with 14 Norwegian HCPs. Analysis was inspired by thematic analysis as described by Braun and Clarke. RESULTS: The analysis revealed 3 main themes affecting the implementation of ePROM in municipal cancer care: "achieving patient-centered care," "crucial management and training," and "technological barriers." CONCLUSION: The results from this study suggest that HCPs' motivation plays a significant role when implementing ePROM. Motivation of HCPs was strongly influenced by whether the application added value to previously used symptom assessment. Hands-on management and a multiprofessional approach enabled the implementation by facilitating adaptations, training, and resources. IMPLICATIONS FOR PRACTICE: The findings show that adapting the implementation of ePROMs to patient population could be of major importance. Early integration of ePROMs in cancer care could facilitate use throughout the disease trajectory.

Improving recruitment of older people to research through good practice.

There is widespread evidence both of the exclusion of older people from clinical research, and of under-recruitment to clinical trials. This review and opinion piece provides practical advice to assist researchers both to adopt realistic, achievable recruitment rates and to increase the number of older people taking part in research. It analyses 14 consecutive recently published trials, providing the number needed to be screened to recruit one older participant (around 3:1), numbers excluded (up to 49%), drop out rates (5-37%) and whether the planned power was achieved. The value of planning and logistics are outlined, and approaches to optimising recruitment in hospital, primary care and care home settings are discussed, together with the challenges of involving older adults with mental incapacity and those from minority groups in research. The increasingly important task of engaging older members of the public and older patients in research is also discussed. Increasing the participation of older people in research will improve the generalisability of research findings and inform best practice in the clinical management of the growing older population.

Continuous glucose monitoring in older people with diabetes and memory problems: a mixed-methods feasibility study in the UK.

OBJECTIVES: Older people with diabetes are at increased risk of harm from hypoglycaemia, particularly where there are coexisting memory problems. Continuous glucose monitoring (CGM) offers important benefits in terms of detecting hypoglycaemia, but the feasibility of use and extent of data capture has not been tested in this patient group. Our objective was to investigate the feasibility of trialling a CGM intervention in the community setting in older people with diabetes and memory problems. DESIGN: Mixed-methods feasibility study. SETTING: Community dwellings in the UK. PARTICIPANTS: Patients aged ≥65 with diabetes and abbreviated mental test score ≤8 or known dementia. INTERVENTION: FreeStyle Libre CGM. PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility criteria were numbers of eligible patients, recruitment, attrition, extent of capture of glucose readings and adverse events. Qualitative interview. RESULTS: We identified 49 eligible participants; 17 consented, but 5 withdrew before recording of data because they or their carers felt unable to manage study procedures. 12 participants (mean age 85 years) completed the study without adverse events. Data capture across 14 days ranged between 3% and 92% (mean 55%); 6 participants had <60% capture. Hypoglycaemic events were recorded in six out of nine insulin users. Qualitative interviews found: the device does not interfere with daily activities, usability and comfort was positive, and it was helpful for carers in monitoring participants' glucose concentrations. CONCLUSIONS: The device was acceptable to participants, and carers reported greater ease in monitoring the participant's glucose concentrations. However, completeness of data capture varied considerably with this device due to the need for users to conduct ≥3 scans per day. Real-time devices with automated data transfer may be more suitable in older people with memory problems.

Prevalence, characteristics and outcomes of people aged 65 years and over with an incidental rise in cardiac troponin I. An observational prospective cohort study.

BACKGROUND: Cardiac troponin I (cTnI) is a sensitive and specific marker of acute cardiac damage. We examined the prevalence, characteristics and outcome of incidental cTnI rises in older patients. METHODS: One hundred and eighty-seven consecutive patients aged 65 years or over with a raised cTnI on admission at least 8 h after symptom onset were categorised into: (1) ST-elevation myocardial infarction, (2) other acute coronary syndromes (ACS), (3) other recognised non-ACS causes of cTnI rise and (4) non-ACS with no other identifiable cause (an incidental finding). The number of readmissions and deaths for each group was measured at 30 and 90 days. RESULTS: Age range = 65-98 years. Male = 55.6%. Fifty-four percent had a raised cTnI due to non-ACS illnesses, whilst in 18% it was an incidental finding. The latter group was relatively older and had a significantly lower degree of cTnI rise (U = 1718.5, p = 0.002), but a higher readmission and mortality rate compared to the other groups (categories 1-3) for both follow-up periods. CONCLUSIONS: Incidental cTnI rise is common in older patients and is associated with a poorer prognosis compared to ACS or a recognised non-ACS condition. Future research should attempt to evaluate the significance of such incidental rises in elderly patients.

Validation and Feasibility of the Medication Acceptability Questionnaire to Investigate Tablet and Liquid Alendronic Acid with Older Hospital Patients.

The effects of formulation characteristics on acceptability are poorly understood. This study evaluated the validity and feasibility of using the Medication Acceptability Questionnaire (MAQ) to investigate factors influencing acceptability of tablet compared with liquid alendronic acid. Written consent was obtained from eligible patients on Older People's Medicine wards. MAQ face and content validity were evaluated through cognitive interviews while internal consistency and criterion validity were investigated by calculating Cronbach's alpha and correlation of MAQ items with visual analogue scale (VAS) responses. MAQ data were obtained from 33 and 25 participants for tablet and liquid formulations respectively. Cognitive interviews indicated MAQ face and content validity. The domains of appearance, efficacy, and tolerability demonstrated adequate internal consistency and suitable refinements were identified for the domains of convenience and taste with Cronbach's alpha <0.7. Significant positive correlations were identified between all MAQ domains and VAS. The liquid trended towards performing better for taste, appearance and tolerability and the tablet for convenience and efficacy. It is feasible to capture patient acceptability of a medication by questionnaire. Interpatient variation in acceptability for two formulations indicates that medication characteristics should be considered during prescribing and medication reviews to match patient preference with the appropriate formulation.

Deprescribing admission medication at a UK teaching hospital; a report on quantity and nature of activity.

Background Deprescribing medication may be in response to an adverse clinical trigger (reactive) or if future gains are unlikely to outweigh future harms (proactive). A hospital admission may present an opportunity for deprescribing, however current practice is poorly understood. Objective To quantify and describe the nature of deprescribing in a UK teaching hospital. Method Prescribing and discontinuation data for admission medication from a hospital's electronic prescribing system were extracted over 4 weeks. The rationale for discontinuation of a random sample of 200 was determined using medical records. This informed categorisation of deprescribing activity by clinicians into 'proactive' or 'reactive'. Data were extrapolated to estimate the proportion of admission medications deprescribed and the proportion which were reactive and proactive. Results From 24,552 admission medicines, 977 discontinuations were recorded. Of the 200 discontinuations sampled for review, only 44 (22.0%) were confirmed deprescribing activities; categorised into 7 (15.9%) proactive and 37 (84.1%) reactive. Extrapolation yielded 0.6% (95% CI 0.5-0.7%) of all admission medications deprescribed. Conclusion Limited deprescribing activity, dominated by reactive behaviour was identified, suggesting prescribers require a clinical trigger to prompt deprescribing. There may be scope for increasing proactive deprescribing in hospital, however the extent to which this is feasible is unknown.

CT diagnosis and outcome of primary brain tumours in the elderly: a cohort study.

BACKGROUND: The incidence of primary brain tumours (PBT) increases with age. Survival outcome depends on the treatment modality and histological type of the tumour. OBJECTIVES: To compare the survival outcome between those who had brain biopsy and those who did not among those who had PBT diagnosed by computerised tomography (CT). METHODS: We analysed data from 82 elderly patients who were admitted to a UK centre with close links to a neurosurgical unit. RESULTS: Age range was 62-99 years (median 74 years); 49 males and 33 females. 44 cases (54%) had brain biopsies of which 2 (5%) were not PBT. Both cases were malignant conditions, 1 case of metastasis and 1 leiomyosarcoma. Of 42 PBT, 34 (77%) were malignant gliomas. The remaining 8 cases were 4 astrocytomas, 2 meningiomas, 1 cerebellar tumour and 1 cerebral lymphoma. Initial clinical misdiagnosis of cerebrovascular disease (CVA) or transient ischaemic attack (TIA) was very common, 70% in our cohort. Those who had brain biopsy were younger (median age 72, range 62-81) compared to those who did not have brain biopsy (median age 77, range 65-91). A survival analysis for those who died comparing biopsy-proven malignant tumours (combined gliomas and astrocytomas (n = 37)) and those who did not have a biopsy (n = 37) showed that the latter had a shorter median time to receive definitive treatment after diagnosis, 8.0 days (95% CI; 5.4, 8.6) (n = 20) compared to 40.0 days (95% CI; 32.5, 47.5) (n = 26) but shorter median length of survival, 47.0 days (95% CI; 32.3, 61.7) compared to 81.0 days (95% CI; 66.7, 95.3) for those who had brain biopsy. Subgroup analysis of malignant gliomas between patients aged < or =70 years and those >70 years showed no significant difference in median length of survival, 74.0 days (95% CI; 54.0, 94.0) vs. 85.0 days (95% CI; 59.0, 111.0), respectively. CONCLUSIONS: Our findings suggest that the older elderly are less likely to have aggressive therapy, and more likely to be diagnosed initially as cerebrovascular event (CVA/TIA). However, when they were given similar definitive treatment, their survival is comparable with their younger counterparts and therefore, age alone should not contraindicate radical treatment. Elderly patients should be selected for radical treatment on existing criteria, but age itself should not preclude radical treatment where it is otherwise appropriate to offer it.