Comprehensive Geriatric Assessment, Treatment Decisions, and Outcomes in Older Patients Eligible for Pancreatic Surgery.

INTRODUCTION: Periampullary cancer has a poor prognosis. Surgical resection is a potentially curative but high-risk treatment. Comprehensive geriatric assessment (CGA) can inform treatment decisions, but has not yet been evaluated in older patients eligible for pancreatic surgery. METHODS: This prospective observational study included patients ≥ 70 years of age eligible for pancreatic surgery. Frailty was defined as impairment in at least two of five domains: somatic, psychological, functional, nutritional, and social. Outcomes included postoperative complications, functional decline, and mortality. RESULTS: Of the 88 patients included, 87 had a complete CGA. Sixty-five patients (75%) were frail and 22 (25%) were non-frail. Frail patients were more likely to receive nonsurgical treatment (43.1% vs. 9.1% p = 0.004). Fifty-seven patients underwent surgery, of which 52 (59%) underwent pancreaticoduodenectomy. The incidence of postoperative delirium was three times higher in frail patients (29.7% vs. 0%, p = 0.005). The risk of mortality was three times higher in frail patients (HR: 3.36, 95% CI: 1.43-7.89, p = 0.006). CONCLUSION: Frailty is common in older patients eligible for pancreatic surgery and is associated with treatment decision, a higher incidence of delirium and a three times higher risk of all-cause mortality. CGA can contribute to shared decision-making and optimize perioperative care in older patients.

Cluster-Based White Matter Signatures and the Risk of Dementia, Stroke, and Mortality in Community-Dwelling Adults.

BACKGROUND AND OBJECTIVES: Markers of white matter (WM) injury on brain MRI are important indicators of brain health. Different patterns of WM atrophy, WM hyperintensities (WMHs), and microstructural integrity could reflect distinct pathologies and disease risks, but large-scale imaging studies investigating WM signatures are lacking. This study aims to identify distinct WM signatures using brain MRI in community-dwelling adults, determine underlying risk factor profiles, and assess risks of dementia, stroke, and mortality associated with each signature. METHODS: Between 2005 and 2016, we measured WMH volume, WM volume, fractional anisotropy (FA), and mean diffusivity (MD) using automated pipelines on structural and diffusion MRI in community-dwelling adults aged older than 45 years of the Rotterdam study. Continuous surveillance was conducted for dementia, stroke, and mortality. We applied hierarchical clustering to identify separate WM injury clusters and Cox proportional hazard models to determine their risk of dementia, stroke, and mortality. RESULTS: We included 5,279 participants (mean age 65.0 years, 56.0% women) and identified 4 distinct data-driven WM signatures: (1) above-average microstructural integrity and little WM atrophy and WMH; (2) above-average microstructural integrity and little WMH, but substantial WM atrophy; (3) poor microstructural integrity and substantial WMH, but little WM atrophy; and (4) poor microstructural integrity with substantial WMH and WM atrophy. Prevalence of cardiovascular risk factors, lacunes, and cerebral microbleeds was higher in clusters 3 and 4 than in clusters 1 and 2. During a median 10.7 years of follow-up, 291 participants developed dementia, 220 had a stroke, and 910 died. Compared with cluster 1, dementia risk was increased for all clusters, notably cluster 3 (hazard ratio [HR] 3.06, 95% CI 2.12-4.42), followed by cluster 4 (HR 2.31, 95% CI 1.58-3.37) and cluster 2 (HR 1.67, 95% CI 1.17-2.38). Compared with cluster 1, risk of stroke was higher only for clusters 3 (HR 1.55, 95% CI 1.02-2.37) and 4 (HR 1.94, 95% CI 1.30-2.89), whereas mortality risk was increased in all clusters (cluster 2: HR 1.27, 95% CI 1.06-1.53, cluster 3: HR 1.65, 95% CI 1.35-2.03, cluster 4: HR 1.76, 95% CI 1.44-2.15), compared with cluster 1. Models including clusters instead of an individual imaging marker showed a superior goodness of fit for dementia and mortality, but not for stroke. DISCUSSION: Clustering can derive WM signatures that are differentially associated with dementia, stroke, and mortality risk. Future research should incorporate spatial information of imaging markers.

Delirium in older patients with COVID-19: Prevalence, risk factors and clinical outcomes across the first three waves of the pandemic.

OBJECTIVES: Delirium is a serious condition, which poses treatment challenges during hospitalisation for COVID-19. Improvements in testing, vaccination and treatment might have changed patient characteristics and outcomes through the pandemic. We evaluated whether the prevalence and risk factors for delirium, and the association of delirium with in-hospital mortality changed through the pandemic. METHODS: This study was part of the COVID-OLD study in 19 Dutch hospitals including patients ≥70 years in the first (spring 2020), second (autumn 2020) and third wave (autumn 2021). Multivariable logistic regression models were used to study risk factors for delirium, and in-hospital mortality. Differences in effect sizes between waves were studied by including interaction terms between wave and risk factor in logistic regression models. RESULTS: 1540, 884 and 370 patients were included in the first, second and third wave, respectively. Prevalence of delirium in the third wave (12.7%) was significantly lower compared to the first (22.5%) and second wave (23.5%). In multivariable-adjusted analyses, pre-existing memory problems was a consistent risk factor for delirium across waves. Previous delirium was a risk factor for delirium in the first wave (OR 4.02), but not in the second (OR 1.61) and third wave (OR 2.59, p-value interaction-term 0.028). In multivariable-adjusted analyses, delirium was not associated with in-hospital mortality in all waves. CONCLUSION: Delirium prevalence declined in the third wave, which might be the result of vaccination and improved treatment strategies. Risk factors for delirium remained consistent across waves, although some attenuation was seen in the second wave.

New horizons in cognitive and functional impairment as a consequence of cerebral small vessel disease.

Cerebral small vessel disease (cSVD) is a frequent finding in imaging of the brain in older adults, especially in the concomitance of cardiovascular disease risk factors. Despite the well-established link between cSVD and (vascular) cognitive impairment (VCI), it remains uncertain how and when these vascular alterations lead to cognitive decline. The extent of acknowledged markers of cSVD is at best modestly associated with the severity of clinical symptoms, but technological advances increasingly allow to identify and quantify the extent and perhaps also the functional impact of cSVD more accurately. This will facilitate a more accurate diagnosis of VCI, against the backdrop of concomitant other neurodegenerative pathology, and help to identify persons with the greatest risk of cognitive and functional deterioration. In this study, we discuss how better assessment of cSVD using refined neuropsychological and comprehensive geriatric assessment as well as modern image analysis techniques may improve diagnosis and possibly the prognosis of VCI. Finally, we discuss new avenues in the treatment of cSVD and outline how these contemporary insights into cSVD can contribute to optimise screening and treatment strategies in older adults with cognitive impairment and multimorbidity.

Quality of Life and Kidney Function in Older Adults: Prospective Data of the SCOPE Study.

A longitudinal alteration in health-related quality of life (HRQoL) over a two-year period and its association with early-stage chronic kidney disease (CKD) progression was investigated among 1748 older adults (>75 years). HRQoL was measured by the Euro-Quality of Life Visual Analog Scale (EQ-VAS) at baseline and at one and two years after recruitment. A full comprehensive geriatric assessment was performed, including sociodemographic and clinical characteristics, the Geriatric Depression Scale-Short Form (GDS-SF), Short Physical Performance Battery (SPPB), and estimated glomerular filtration rate (eGFR). The association between EQ-VAS decline and covariates was investigated by multivariable analyses. A total of 41% of the participants showed EQ-VAS decline, and 16.3% showed kidney function decline over the two-year follow-up period. Participants with EQ-VAS decline showed an increase in GDS-SF scores and a greater decline in SPPB scores. The logistic regression analyses showed no contribution of a decrease in kidney function on EQ-VAS decline in the early stages of CKD. However, older adults with a greater GDS-SF score were more likely to present EQ-VAS decline over time, whereas an increase in the SPPB scores was associated with less EQ-VAS decline. This finding should be considered in clinical practice and when HRQoL is used to evaluate health interventions among older adults.

Frailty in Non-geriatric Patients With Head and Neck cancer.

OBJECTIVE: Patients with head and neck cancer (HNC) are characterized by a poor lifestyle and comorbidity. The Geriatric 8 (G8) is an established screening tool to identify frail older patients with cancer. However, studies evaluating frailty in younger HNC patients are lacking. The aim of this study is to evaluate if the G8 can identify frailty and if it is related to mortality in younger HNC patients. STUDY DESIGN: Case-control study design. SETTING: Tertiary cancer center. METHODS: We studied patients <70 years with HNC. Patients with G8 ≤ 14 were considered frail. Patients were matched to nonfrail (G8 > 14) control patients. Patients were matched according to sex, age, smoking, tumor location, and period of first consultation. Baseline health characteristics were compared between frail patients and nonfrail controls. Second, the treatment plan and adverse outcomes were compared. RESULTS: Forty-five patients with G8 ≤ 14 were included and matched to 90 nonfrail controls. The median follow-up time was 357 days. Frail patients had a significantly lower body mass index and level of education, a worse World Health Organization performance status, and reported lower experienced overall health. 28.9% of the frail patients died after 1 year versus 10% of the nonfrail control patients (hazard ratio: 3.87 [95% confidence interval: 1.32-11.36], p = 0.014). CONCLUSION: The G8 is a valid screening tool to identify frail patients in younger HNC patients.

Validation of the ADFICE_IT Models for Predicting Falls and Recurrent Falls in Geriatric Outpatients.

OBJECTIVES: Before being used in clinical practice, a prediction model should be tested in patients whose data were not used in model development. Previously, we developed the ADFICE_IT models for predicting any fall and recurrent falls, referred as Any_fall and Recur_fall. In this study, we externally validated the models and compared their clinical value to a practical screening strategy where patients are screened for falls history alone. DESIGN: Retrospective, combined analysis of 2 prospective cohorts. SETTING AND PARTICIPANTS: Data were included of 1125 patients (aged ≥65 years) who visited the geriatrics department or the emergency department. METHODS: We evaluated the models' discrimination using the C-statistic. Models were updated using logistic regression if calibration intercept or slope values deviated significantly from their ideal values. Decision curve analysis was applied to compare the models' clinical value (ie, net benefit) against that of falls history for different decision thresholds. RESULTS: During the 1-year follow-up, 428 participants (42.7%) endured 1 or more falls, and 224 participants (23.1%) endured a recurrent fall (≥2 falls). C-statistic values were 0.66 (95% CI 0.63-0.69) and 0.69 (95% CI 0.65-0.72) for the Any_fall and Recur_fall models, respectively. Any_fall overestimated the fall risk and we therefore updated only its intercept whereas Recur_fall showed good calibration and required no update. Compared with falls history, Any_fall and Recur_fall showed greater net benefit for decision thresholds of 35% to 60% and 15% to 45%, respectively. CONCLUSIONS AND IMPLICATIONS: The models performed similarly in this data set of geriatric outpatients as in the development sample. This suggests that fall-risk assessment tools that were developed in community-dwelling older adults may perform well in geriatric outpatients. We found that in geriatric outpatients the models have greater clinical value across a wide range of decision thresholds compared with screening for falls history alone.

Atypical presentation of COVID-19 in older patients is associated with frailty but not with adverse outcomes.

PURPOSE: Older patients with COVID-19 can present with atypical complaints, such as falls or delirium. In other diseases, such an atypical presentation is associated with worse clinical outcomes. However, it is not known whether this extends to COVID-19. We aimed to study the association between atypical presentation of COVID-19, frailty and adverse outcomes, as well as the incidence of atypical presentation. METHODS: We conducted a retrospective observational multi-center cohort study in eight hospitals in the Netherlands. We included patients aged ≥ 70 years hospitalized with COVID-19 between February 2020 until May 2020. Atypical presentation of COVID-19 was defined as presentation without fever, cough and/or dyspnea. We collected data concerning symptoms on admission, demographics and frailty parameters [e.g., Charlson Comorbidity Index (CCI) and Clinical Frailty Scale (CFS)]. Outcome data included Intensive Care Unit (ICU) admission, discharge destination and 30-day mortality. RESULTS: We included 780 patients, 9.5% (n = 74) of those patients had an atypical presentation. Patients with an atypical presentation were older (80 years, IQR 76-86 years; versus 79 years, IQR 74-84, p = 0.044) and were more often classified as severely frail (CFS 6-9) compared to patients with a typical presentation (47.6% vs 28.7%, p = 0.004). Overall, there was no significant difference in 30-day mortality between the two groups in univariate analysis (32.4% vs 41.5%; p = 0.173) or in multivariate analysis [OR 0.59 (95% CI 0.34-1.0); p = 0.058]. CONCLUSIONS: In this study, patients with an atypical presentation of COVID-19 were more frail compared to patients with a typical presentation. Contrary to our expectations, an atypical presentation was not associated with worse outcomes.

Inflammaging and Blood Pressure Profiles in Late Life: The Screening for CKD among Older People across Europe (SCOPE) Study.

The neutrophil-to-lymphocyte ratio (NLR) is a marker for systemic inflammation. Since inflammation plays a relevant role in vascular aging, the aim of this study was to investigate whether NLR is associated with blood pressure profiles in older adults. This study was performed within the framework of the SCOPE study including 2461 outpatients aged 75 years and over. Mean blood pressure values, namely systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse pressure (PP) were investigated across tertiles of NLR. Change in blood pressure levels in 2 years of follow-up were compared across categories of baseline NLR. Data of 2397 individuals were used, of which 1854 individuals had hypertension. Mean values of blood pressure did not differ across categories of baseline NLR in individuals without hypertension. Individuals with hypertension with a high-range NLR had lower SBP and PP when compared to those in low-range NLR (mean difference SBP -2.94 mmHg, p = 0.032 and PP -2.55 mmHg, p = 0.030). Mean change in blood pressure in 2 years did only slightly differ in non-clinically relevant ranges, when compared across tertiles of baseline NLR. NLR as a marker of inflammaging was not associated with unfavorable blood pressure profiles in older individuals with or without hypertension.

Delirium in older COVID-19 patients: Evaluating risk factors and outcomes.

OBJECTIVES: A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID-19). We aimed to identify determinants of delirium, including the Clinical Frailty Scale, in hospitalized older patients with COVID-19. Furthermore, we aimed to study the association of delirium independent of frailty with in-hospital outcomes in older COVID-19 patients. METHODS: This study was performed within the framework of the multi-center COVID-OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID-19 in the Netherlands between February and May 2020. Data were collected on demographics, co-morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In-hospital outcomes included length of stay, discharge destination, and mortality. RESULTS: A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio [OR] 8.9 [95% CI 2.3-33.6] p = 0.001), and pre-existent memory problems (OR 7.6 [95% CI 3.1-22.5] p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 [95%CI 1.40-1.90] p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C-reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 [95% CI1.71-4.72] p < 0.001), but not in multivariable analyses. CONCLUSIONS: A previous delirium and pre-existent memory problems were associated with delirium risk in COVID-19. Delirium was not an independent predictor of mortality after adjustment for frailty.

Clusters of risk factors in metabolic syndrome and their influence on central blood pressure in a global study.

The effect of metabolic syndrome (MetS) and clusters of its components on central blood pressure (CBP) has not been well characterized. We aimed to describe the effect of MetS and clusters of its components on CBP in a large population and to identify whether this effect differs in men and women. We studied 15,609 volunteers (43% women) from 10 cohorts worldwide who participated in the Metabolic syndrome and Artery REsearch Consortium. MetS was defined according to the NCEP-ATP III criteria (GHTBW, glucose, high-density lipoprotein cholesterol, triglyceride, blood pressure, waist circumference). CBP was measured noninvasively and acquired from pulse wave analysis by applanation tonometry. MetS was associated with a 50% greater odds of having higher CSBP. After controlling for age, male sex, non HDL cholesterol, diabetes mellitus, and mean arterial pressure, only specific clusters of MetS components were associated with a higher CSBP; and some of them were significant in women but not in men. We identified "risky clusters" of MetS variables associated with high CSBP. Future studies are needed to confirm they identify subjects at high risk of accelerated arterial aging and, thus, need more intensive clinical management.

The recognition and management of neuropsychiatric symptoms in early Alzheimer's disease: a qualitative study among Dutch memory clinic physicians.

BACKGROUND: Timely recognition and treatment of neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) dementia may improve quality of life, reduce caregiver burden, and delay disease progression. However, management of NPS in early AD dementia remains challenging. To date, little is known about the specific challenges for memory clinic-based physicians. The aims of this qualitative study were to obtain insights regarding the recognition and treatment of NPS in AD dementia in the memory clinic, to identify challenges experienced by physicians while managing NPS, and to examine the attitudes of memory clinic physicians on the role of the memory clinic in the care for NPS in early AD dementia. METHODS: Semi-structured interviews were conducted with 13 physicians working at a memory clinic in the Netherlands (n = 7 neurologist, n = 6 geriatrician, 46% female). The data were analyzed by two independent researchers using thematic analysis. RESULTS: We observed large variation among Dutch memory clinic physicians regarding care practices, expertise, and attitudes on the role of the memory clinic considering NPS in AD dementia. The most prominent challenges that memory clinic physicians experienced while managing NPS included that the outpatient setting complicates the recognition and treatment of NPS, a lack of experience, knowledge, and/or resources to adequately apply non-pharmacological interventions, and a lack of consensus among physicians on the role of the memory clinic in NPS recognition and management. CONCLUSIONS: We identified challenges that need to be addressed to improve the early recognition and adequate management of NPS in AD dementia at the memory clinic.

The Multidimensional Prognostic Index Predicts Mortality in Older Outpatients with Cognitive Decline.

Since the heterogeneity of the growing group of older outpatients with cognitive decline, it is challenging to evaluate survival rates in clinical shared decision making. The primary outcome was to determine whether the Multidimensional Prognostic Index (MPI) predicts mortality, whilst assessing the MPI distribution was considered secondary. This retrospective chart review included 311 outpatients aged ≥65 years and diagnosed with dementia or mild cognitive impairment (MCI). The MPI includes several domains of the comprehensive geriatric assessment (CGA). All characteristics and data to calculate the risk score and mortality data were extracted from administrative information in the database of the Alzheimer's Center and medical records. The study population (mean age 76.8 years, men = 51.4%) was divided as follows: 34.1% belonged to MPI category 1, 52.1% to MPI category 2 and 13.8% to MPI category 3. Patients with dementia have a higher mean MPI risk score than patients with MCI (0.47 vs. 0.32; p < 0.001). The HRs and corresponding 95% CIs for mortality in patients in MPI categories 2 and 3 were 1.67 (0.81−3.45) and 3.80 (1.56−9.24) compared with MPI category 1, respectively. This study shows that the MPI predicts mortality in outpatients with cognitive decline.

A Systematic Review of Strategies for Preventing Delirium in Patients Undergoing Vascular Surgery.

BACKGROUND: Elderly patients undergoing vascular surgery are at a risk of developing postoperative delirium, which is associated with high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. METHODS: This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery,' 'prevention,' and 'delirium' and was last run on October 21, 2021 in the electronic databases PubMed, MEDLINE, Embase, Web of Science, the Cochrane library, and Emcare. Risk of bias was assessed using the Cochrane risk of bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies. RESULTS: Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group vs. 11% in the intervention group, P = 0.018) and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group vs. 8.2% in the intervention group, P = 0.043, Odds Ratio = 0.56). A nonsignificant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group vs. 14.6% in the intervention group, P = 0.17). The study concerning the impact of the type of anesthesia on delirium in 11 older vascular surgical patients, of which 3 developed delirium, did not differentiate between the different types of anesthesia the patients received. CONCLUSIONS: Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients.

Anticholinergic Drug Use on Admission and the Risk of In-Hospital Falls in Older Hospitalized Patients.

Purpose: In-hospital falls, especially among older patients, are a major and underestimated problem. Several studies have suggested a possible association between anticholinergic drug use and falls, but the results are inconclusive and studies focusing on in-hospital falls are scarce. The aim of the present study was to investigate whether anticholinergic drug exposure on admission is associated with in-hospital falls. Patients and Methods: This retrospective chart review study was conducted in the Erasmus MC University Medical Center, Rotterdam, the Netherlands. Patients aged 65 years and older, who were acutely admitted to the geriatric ward between 2012 and 2015, were included. Anticholinergic drug exposure was determined with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew. Logistic regression was used to investigate the possible association between anticholinergic drug exposure and in-hospital falls. Analyses were adjusted for age, sex, fall history, fall as reason for admission, number of drugs on admission, use of a mobility aid and delirium. Results: A total of 905 patients were included, of which 94 patients experienced one or more in-hospital falls. Each additional anticholinergic drug in use, according to the ARS, was associated with an increased odd of experiencing a fall (OR = 1.49, 95% CI: 1.06-2.10). Other measures, ie anticholinergic drug use (yes/no) and different categories of anticholinergic drug burden, measured with the ARS, ACB and list of Chew, were all not associated with in-hospital falls. Conclusion: Anticholinergic drug exposure on admission is possibly not a main risk factor for in-hospital falls among older patients.

Characteristics and outcomes of older patients hospitalised for COVID-19 in the first and second wave of the pandemic in The Netherlands: the COVID-OLD study.

BACKGROUND: as the coronavirus disease of 2019 (COVID-19) pandemic progressed diagnostics and treatment changed. OBJECTIVE: to investigate differences in characteristics, disease presentation and outcomes of older hospitalised COVID-19 patients between the first and second pandemic wave in The Netherlands. METHODS: this was a multicentre retrospective cohort study in 16 hospitals in The Netherlands including patients aged ≥ 70 years, hospitalised for COVID-19 in Spring 2020 (first wave) and Autumn 2020 (second wave). Data included Charlson comorbidity index (CCI), disease severity and Clinical Frailty Scale (CFS). Main outcome was in-hospital mortality. RESULTS: a total of 1,376 patients in the first wave (median age 78 years, 60% male) and 946 patients in the second wave (median age 79 years, 61% male) were included. There was no relevant difference in presence of comorbidity (median CCI 2) or frailty (median CFS 4). Patients in the second wave were admitted earlier in the disease course (median 6 versus 7 symptomatic days; P < 0.001). In-hospital mortality was lower in the second wave (38.1% first wave versus 27.0% second wave; P < 0.001). Mortality risk was 40% lower in the second wave compared with the first wave (95% confidence interval: 28-51%) after adjustment for differences in patient characteristics, comorbidity, symptomatic days until admission, disease severity and frailty. CONCLUSIONS: compared with older patients hospitalised in the first COVID-19 wave, patients in the second wave had lower in-hospital mortality, independent of risk factors for mortality.The better prognosis likely reflects earlier diagnosis, the effect of improvement in treatment and is relevant for future guidelines and treatment decisions.

Health outcome priorities in older patients with head and neck cancer.

OBJECTIVES: Older patients with head and neck cancer often have comorbidity, have reduced life-expectancy and await intensive treatment. For the decision-making process, knowledge of a patient's health outcome prioritization is of paramount importance. We aim to study the health outcome priorities of older patients with head and neck cancer, and to evaluate whether general health, markers of physical, cognitive, and social functioning, and quality of life are associated with health outcome prioritization. MATERIALS AND METHODS: Patients aged ≥70 years with head and neck cancer received a Comprehensive Geriatric Assessment and their priorities were assessed using the Outcome Prioritization Tool (OPT). Distribution of first priority, and associations with general health, markers of physical, cognitive, and social functioning, and quality of life were evaluated using ANOVA or chi-square. RESULTS: Of the 201 included patients, the OPT was available in 170 patients. The majority prioritized maintaining independence (n = 91, 53.3%), followed by extending life (n = 58, 34.1%), reducing pain (n = 14, 8.2%), and reducing other symptoms (n = 7, 4.1%). Housing situation, Body Mass Index, presence of musculoskeletal diseases, and quality of life were significantly related to prioritization of health outcomes. Reducing pain or other symptoms was more often prioritized by patients who lived alone, had a history of musculoskeletal problems, or had poor perceived quality of life. Age, sex, comorbidity, and markers of physical and cognitive functioning were not associated with health prioritization. CONCLUSION: Maintaining independence is most often prioritized by older patients with head and neck cancer. In addition, we found that health outcome priorities of older patients are only limited based on general and specific health characteristics. We suggest to systematically discuss patients' priorities in order to facilitate complex treatment decisions in older patients with cancer.

The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review.

BACKGROUND: Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients. METHODS: A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003). RESULTS: Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41. CONCLUSION: Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice. LEVEL OF EVIDENCE: Systematic review, Level II.