Trends, prescribing patterns, and determinants of initial antiepileptic drug treatment in older epileptic patients.

OBJECTIVES: There is no report on the initial antiepileptic drug (AED) treatment of older Thai epileptic patients. This study aimed to determine the trends, prescribing patterns, and determinants of initial AED treatment. METHODS: This cross-sectional study used data on older (≥60 years) epileptic patients gathered from one tertiary-care hospital's database from 2012 to 2022. We evaluated the trends and prescribing patterns for starting AED treatment. We used logistic regression to identify the determinants of the initial treatment with new-generation AEDs. KEY FINDINGS: This study comprised 919 participants (59.19% men, 70.99 ± 8.00 years old). Between 2012 and 2022, we observed a decreasing trend in starting therapy with old-generation AEDs, from 89.16% to 64.58%. In contrast, there was an increasing trend in initiating treatment with new-generation AEDs, from 10.84% to 35.72% (P for trend <0.001 for both). Each assessment year, the most prescribed treatment pattern was monotherapy. The determinants of initial therapy with new-generation AEDs included the year treatment began (adjusted odds ratios [AOR] = 1.0006; 95% confidence intervals [CI] 1.0003-1.0008), non-Universal Coverage Scheme (AOR = 1.94; 95% CI 1.26-3.00), liver disease (AOR = 6.44; 95% CI 2.30-18.08), opioid use (AOR = 2.79; 95% CI 1.28-6.09), and statin use (AOR = 0.59; 95% CI 0.36-0.95). CONCLUSIONS: There is a growing trend of initiating treatment with new-generation AEDs in older Thai patients with epilepsy. Factors positively associated with starting new-generation AEDs include the year treatment began, non-Universal Coverage Scheme, liver disease, and opioid use, while statin use is a negatively associated factor.

Mortality prediction models for community-dwelling older adults: A systematic review.

INTRODUCTION: As complexity and comorbidities increase with age, the increasing number of community-dwelling older adults poses a challenge to healthcare professionals in making trade-offs between beneficial and harmful treatments, monitoring deteriorating patients and resource allocation. Mortality predictions may help inform these decisions. So far, a systematic overview on the characteristics of currently existing mortality prediction models, is lacking. OBJECTIVE: To provide a systematic overview and assessment of mortality prediction models for the community-dwelling older population. METHODS: A systematic search of terms related to predictive modelling and older adults was performed until March 1st, 2024, in four databases. We included studies developing multivariable all-cause mortality prediction models for community-dwelling older adults (aged ≥65 years). Data extraction followed the CHARMS Checklist and Quality assessment was performed with the PROBAST tool. RESULTS: A total of 22 studies involving 38 unique mortality prediction models were included, of which 14 models were based on a cumulative deficit-based frailty index and 9 on machine learning. C-statistics of the models ranged from 0.60 to 0.93 for all studies versus 0.61-0.78 when a frailty index was used. Eight models reached c-statistics higher than 0.8 and reported calibration. The most used variables in all models were demographics, symptoms, diagnoses and physical functioning. Five studies accounting for eleven models had a high risk of bias. CONCLUSION: Some mortality prediction models showed promising results for use in practice and most studies were of sufficient quality. However, more uniform methodology and validation studies are needed for clinical implementation.

Frailty in Diabetic Population: A Study From Northern India.

Introduction Frailty, a key issue in geriatric health, signifies heightened vulnerability due to the decline in various physiological systems, exacerbated by conditions such as diabetes. Diabetes and frailty together lead to significant disabilities and higher mortality, necessitating early screening and targeted interventions. The relationship between frailty and diabetes remains under-researched, prompting this study to explore their association in individuals over 50 years of age using the Edmonton Frail Scale (EFS). Methods and materials The study was an observational cross-sectional study conducted at MM Institute of Medical Sciences & Research (MMIMSR), Mullana, India, among 102 diabetic and 100 non-diabetic individuals aged more than 50 years, with data collected through interviews using a pre-validated proforma. Frailty was assessed using the EFS, categorizing patients into fit, vulnerable, and various levels of frailty based on their scores. Results The study found a higher prevalence and severity of frailty among diabetic individuals (61.8%) compared to non-diabetics (29%), with frailty being more pronounced across all age groups and both genders in diabetics. The severity of frailty increased with the duration of diabetes but showed no significant correlation with glycemic control (HbA1c). Strengths and limitations The study prospectively collected data, including middle-aged participants starting from age 50, and uniquely used the EFS to assess frailty in diabetic patients, excluding those with other chronic diseases (end-stage renal disease (ESRD), malignancy, etc.). However, limitations included a small sample size, recruitment from a single institution in India, and some EFS questions being less relevant to the Indian diabetic population. Conclusion The study found a 61.8% prevalence of frailty in diabetics compared to 29% in non-diabetics, with frailty being more severe and positively correlated with the duration of diabetes but not with glycemic control (HbA1c).

Home-based cardiac rehabilitation in older adults: expert-recommendations for physiotherapist-led care to improve daily physical functioning and reduce comorbidity-related barriers.

Background: Cardiac rehabilitation (CR) can reduce mortality and improve physical functioning in older patients, but current programs do not support the needs of older patients with comorbidities or frailty, for example due to transport problems and physical limitations. Home-exercise-based cardiac rehabilitation (HEBCR) programs may better meet these needs, but physiotherapy guidelines for personalising HEBCR for older, frail patients with cardiovascular disease are lacking. Purpose: To provide expert recommendations for physiotherapists on how to administer HEBCR to older adults with comorbidities or frailty. Methods: This Delphi study involved a panel of Dutch experts in physiotherapy, exercise physiology, and cardiology. Three Delphi rounds were conducted between December 2020 and February 2022. In the first round panellists provided expertise on applicability and adaptability of existing CR-guidelines. In the second round panellists ranked the importance of statements about HEBCR for older adults. In the third round panellists re-ranked statements when individual scores were outside the semi-interquartile range. Consensus was defined as a semi-interquartile range of ≤ 1.0. Results: Of 20 invited panellists, 11 (55%) participated. Panellists were clinical experts with a median (interquartile range) work experience of 20 (10.5) years. The panel reached a consensus on 89% of statements, identifying key topics such as implementing the patient perspective, assessing comorbidity and frailty barriers to exercise, and focusing on personal goals and preferences. Conclusion: This Delphi study provides recommendations for personalised HEBCR for older, frail patients with cardiovascular disease, which can improve the effectiveness of CR-programs and address the needs of this patient population. Prioritising interventions aimed at enhancing balance, lower extremity strength, and daily activities over interventions targeting exercise capacity may contribute to a more holistic and effective approach, particularly for older adults.

Functional Impairments, Phenotypic Frailty and Sector-Specific Incremental Healthcare Costs in Older Adults.

BACKGROUND: This study quantifies incremental healthcare expenditures of functional impairments and phenotypic frailty in specific healthcare sectors. METHODS: Pooled 2023 analysis of 4 prospective cohort studies linked with Medicare claims including 4318 women and 3847 men attending an index examination (2002-2011). Annualized inpatient, skilled nursing facility (SNF), home healthcare (HHC) and outpatient costs (2023 dollars) ascertained for 36 months following index examination. Functional impairments (difficulty performing 4 activities of daily living) and frailty phenotype (operationalized using 5 components) derived from cohort data. Weighted multimorbidity index including demographics derived from claims. RESULTS: Mean age at index examination was 79.2 years. After accounting for multimorbidity and each other, average annualized incremental costs of 3-4 functional impairments versus no impairment in women (men) was $2838 ($5516) in inpatient, $1572 ($1446) in SNF and $1349 ($1060) in HHC sectors; average incremental costs of phenotypic frailty versus robust in women (men) was $4100 (not significant for men) in inpatient, $1579 ($1254) in SNF and $645 ($526) in HHC sectors. Incremental inpatient costs were primarily due to a higher hospitalization risk, while incremental SNF and HHC costs were related to both increased risks of utilization and higher costs among individuals with utilization. Neither geriatric domain was associated with outpatient costs. CONCLUSIONS: In this study of community-dwelling beneficiaries, functional impairments were independently associated with higher subsequent expenditures in inpatient, SNF and HHC sectors among both sexes. Phenotypic frailty was independently associated with higher subsequent inpatient costs in women, and higher SNF and HHC costs in both sexes.

Prehospital undertriage of older injured patients in western Switzerland: an observational cross-sectional study.

BACKGROUND: The ageing of the population is leading to an increase in the number of traumatic injuries and represents a major challenge for the future. Falls represent the leading cause of Emergency department admission in older people, with injuries ranging from minor to severe multiple injuries. Older injured patients are more likely to be undertriaged than younger patients. The aim of this study was to investigate the extent of undertriage in older patients with particular emphasis on access to trauma centres and resuscitation rooms. METHODS: Retrospective observational cross-sectional study based on data prospectively collected from prehospital electronic records including all patients ≥ 18 years for whom an ambulance or helicopter was dispatched between 1 January 2018 and 31 April 2023 due to a trauma. The primary outcome, admission to the resuscitation room of the regional trauma centre with trauma team activation, was assessed by age. Multivariate logistic regression was used to control for known confounders and to test for plausible effect modifiers. RESULTS: Emergency Medical Services treated 37,906 injured patients. Older patients ≥ 75 years represented 17,719 patients (47%). Admission to trauma centre with trauma team activation was lower in older patients, N = 121 (1%) compared to N = 599 (5%) in younger patients, p < 0.001; adjusted odds ratio: 0.33 (0.24-0.45); p < 0.001. Undertriage increased by twofold with age ≥ 75; OR: 1.81 (1.04-3.15); p value < 0.001. Undertriaged patients were older, more likely to be female, to have low energy trauma and to be located farther from the regional trauma centre. CONCLUSION: Older injured patients were at increased risk of undertriage and non-trauma team activation admission, especially if they were older, female, had head injury without altered consciousness and greater distance to regional trauma centre.

The Role of Frailty in the Treatment of Locally Advanced Rectal Cancer.

Owing to the gradual aging of today's population, an increase in the prevalence of frailty syndrome has been noticed. This complex state of health, characterized by decreased resilience and tolerance with concurrent increased vulnerability to stressors and adverse health-related factors, has drawn researchers' attention in recent years. Rectal cancer, which constitutes ~30% of all colorectal cancers, is a disease noticeably related to the elderly. In its locally advanced form, it is conventionally treated with trimodal therapy-neoadjuvant chemoradiotherapy followed by total mesorectal excision and adjuvant chemotherapy. Despite its good clinical outcomes and improvement in rectal cancer local control, as evidenced by clinical trials, it remains unclear if all frail patients benefit from that approach since it may be associated with adverse side effects that cannot be handled by them. As old patients, and frail ones even more noticeably, are poorly represented in the clinical trials describing outcomes of the standard treatment, this article aims to review the current knowledge on the trimodal therapy of rectal cancer with an emphasis on novel approaches to rectal cancer that can be implemented for frail patients.

[Frailty and adverse outcomes in patients over 65 years old with acute coronary syndrome in a hospital cohort in Medellin, Colombia]. / Fragilidad y resultados adversos en pacientes mayores de 65 años con síndrome coronario agudo en una cohorte hospitalaria en Medellín, Colombia.

Objective: Several studies have demonstrated an association between frailty and worse outcomes in patients with acute coronary syndrome (ACS); however, there is a lack of evidence from Colombia. This study aims to evaluate the association between frailty and the risk of adverse outcomes in patients over 65 years old diagnosed with ACS. Materials and methods: A prospective cohort study was conducted, including patients over 65 years old who underwent coronary angiography due to an ACS diagnosis at a hospital in Medellín, Colombia. Frailty was assessed using the FRAIL scale. The primary outcome was all-cause mortality at 30 days. Secondary outcomes included length of hospital stay and a composite outcome of in-hospital or 30-day mortality, contrast-induced nephropathy (CIN), acute heart failure, cardiogenic shock, hemorrhagic complications, and vascular complications. Results: A total of 112 patients were included. Frail patients (n=35, 31.3%) were older, had a lower socioeconomic status, higher GRACE scores, and more severely compromised coronary vessels. A significant association was observed between frailty and 30-day mortality (relative risk [RR] 19.00, 95% confidence interval [CI]: 5.04-72.61; p<0.001), the composite outcome (RR 4.57, 95% CI: 2.56-8.34; p<0.001), and longer hospital stays (9 days vs. 5 days in the non-frail group). Conclusions: A considerable number of patients over 65 years old with ACS were frail. Frailty was associated with adverse in-hospital and 30-day outcomes.

The Edmonton Frail Scale as a screening score for frailty in oncogeriatrics.

Introduction: The comprehensive geriatric assessment (CGA) is recommended for assessing frailty in older cancer patients but is time-consuming. The G8 screening tool was developed to select frail patients requiring CGA to optimize resources. The Edmonton Frail Scale (EFS) is another frailty scale validated for preoperative frailty screening, but scarcely studied in the field of oncogeriatrics. In this study, we examined the added value of the EFS in older cancer patients already considered as frail by the G8, by analyzing the association of EFS with CGA adjusted for age, gender, metastatic stage and comorbidity. We also analyzed the association of EFS with the one-year mortality rate after adjusting for cancer type and metastatic stage. Methodology: This retrospective study included patients aged over 70 years old with a new diagnosis of cancer, considered as potentially frail according to the G8 and who had had a CGA (N = 380). Results: The EFS identified 329 (86.58%) patients as frail and having a statistically significant predicted number of pathological components on the CGA (r = 0.64, p < 0.001). When adjusted for age, sex, comorbidity, and metastatic stage, the EFS was independently associated with the CGA (p < 0001), as well as with comorbidity (p = 0.004). The patients who died in the first year (43%) had a significantly higher mean EFS score (8/17) than living patients (6/17) (p < 0.0001). After adjustment for cancer type and stage, EFS independently predicted one-year mortality (OR 1.17; 95% CI 1.08-1.28; pseudo R 2 = 0.228, p < 0.001). Discussion: The EFS is a reliable tool for predicting frailty identified by the CGA in an older cancer population pre-selected as frail by the G8. EFS is an independent predictor of one-year mortality after adjustment for confounding factors. Validation of the EFS as a screening tool for frailty in cancer requires further studies to assess its performance in patients with normal G8 scores.

The impact of a multidisciplinary team intervention on medication prescription in nursing homes in Catalonia.

Background: In response to the rising population of nursing home residents with frailty and multimorbidity, optimizing medication safety through drug utilization review and addressing medication-related problems (MRPs) is imperative. Clinical decision support systems help reduce medication errors and detect potential MRPs, as well as medication reviews performed by a multidisciplinary team, but these combined assessments are not commonly performed. The objective of this study was to evaluate the impact on medication plans of a multidisciplinary team intervention in nursing homes, by analyzing the medication plan before and after the intervention and assessing whether the recommendations given had been implemented. Methods: A multicenter before-after study, involving five nursing homes, assessed the impact of a multidisciplinary team intervention, to estimate effectiveness related to the review of the prescribed medications. The follow-up period for each patient was 12 months or until death if prior, from July 2020 to February 2022, and involved 483 patients. The clinical pharmacologist coordinated the intervention and reviewed all the prescribed medications to make recommendations, focused on the completion of absent data, withdrawal of a drug, verification of whether a drug was adequate, the substitution of a drug, and the addition of drugs. Since the intervention was performed during the COVID-19 pandemic, optimization of psychotropic drugs and absorbent pads were limited. Results: The intervention had an impact with recommendations given for 398 (82.4%) of the patients and which were followed by 58.5% of them. At least one drug was withdrawn in 293 (60.7%) of the patients, with a mean of 2.3 (SD 1.7). As for the total of 1,097 recommendations given, 355 (32.4%) were followed. From the intervention, antipsychotics, antidepressants, benzodiazepines, statins, and diuretics were the most frequently withdrawn. Conclusion: The findings underscore the impact of targeted interventions to reduce inappropriate medications and enhance medication safety in nursing homes. The proposed recommendations given and followed show the importance of a multidisciplinary team, coordinated by a clinical pharmacologist, for a patient-centered approach to make medication reviews regularly, with the help of clinical decision support systems, to help reduce potential MRPs and polypharmacy.

[Rehabilitative subacute inpatient care-Optimizing posthospital care for geriatric patients with rehabilitation needs: results of the REKUP study]. / Rehabilitative Kurzzeitpflege ­ Optimierung der poststationären Versorgung von geriatrischen Patienten mit Rehabilitationsbedarf: Ergebnisse der REKUP-Studie.

BACKGROUND: Geriatric patients in subacute inpatient care (SC) with rehabilitation needs after hospitalization seldom utilize rehabilitative services and are often transitioned to long-term care (LTC), suggesting that their care in SC can be optimized. OBJECTIVE: To evaluate the effectiveness of rehabilitative subacute inpatient care (REKUP) in improving the care of geriatric patients in SC with rehabilitation needs after hospitalization. METHODS: The study was conducted as a nonrandomized intervention trial with an historical control group (CG). The intervention group (IG: n = 49) received REKUP (activating therapeutic care, functional rehabilitative therapy, psychosocial services, medical care), while the CG (n = 57) received usual care during SC. Primary outcomes were transition to inpatient rehabilitation, home, and LTC, deteriorated care setting, care level, and mortality within 3 months after SC. Secondary outcomes were functional, motor and psychological variables. RESULTS: The transition rate to inpatient rehabilitation (82% vs. 37%) and home (86% vs. 65%) was higher (p < 0.05) in the IG than in the CG. The proportion of persons utilizing LTC (12% vs. 35%) and with deteriorated care setting (35% vs. 60%) was lower (p < 0.01) in the IG than in the CG. The Barthel Index, visual analogue scale of the EQ-5D, and numerical pain scale improved (p < 0.05) during the SC stay in the IG but not in the CG. DISCUSSION: REKUP as a new care model for SC promotes the transition to inpatient rehabilitation, reduces the utilization of LTC and improves the chances of returning home and achieving greater independence in geriatric patients with rehabilitation needs after hospitalization.

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study.

BACKGROUND: Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs). OBJECTIVE: This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes. METHODS: A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements. RESULTS: A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025. CONCLUSIONS: This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/60099.

A Voice-Activated Device Exercise and Social Engagement Program for Older Adult-Care Partner Dyads: Pilot Clinical Trial and Focus Group Study Evaluating the Feasibility, Use, and Estimated Functional Impact of EngAGE.

BACKGROUND: Maintaining exercise is essential for healthy aging but difficult to sustain. EngAGE is a socially motivated exercise program delivered over a voice-activated device that targets older adult-care partner dyads. OBJECTIVE: This 10-week pilot study aimed to assess EngAGE feasibility and use, obtain user experience feedback, and estimate potential impact on function. METHODS: In total, 10 older adults aged ≥65 years were recruited from an independent living residence together with their self-identified care partners. EngAGE delivered National Institute on Aging Go4Life exercises to older adults daily, while care partners received progress reports and prompts to send encouraging messages that were read aloud by the device to the older adult. Older adults' use was tracked, and physical function was assessed at baseline and follow-up. Follow-up focus group data provided qualitative feedback. RESULTS: On average, participants completed 393.7 individual exercises over the 10-week intervention period or 39.4 exercises/wk (range 48-492, median 431, IQR 384-481, SD 112.4) without injury and used EngAGE on an average of 41 of 70 days or 4.1 d/wk (range 7-66, median 51, IQR 23-56, and SD 21.2 days). Mean grip strength increased nonsignificantly by 1.3 kg (preintervention mean 26.3 kg, SD 11.0; postintervention mean 27.6 kg, SD 11.6; P=.34), and 4 of 10 participants improved by a minimal clinically important difference (MCID) of 2.5 kg. Further, the time for 5-repeated chair stands significantly reduced by 2.3 seconds (preintervention mean 12, SD 3.6 s; postintervention mean 9.7, SD 2.7 s; P=.02), and 3 of 9 participants improved by an MCID of -2.3 seconds. Furthermore, 3-meter usual walk performance was brisk at baseline (mean 2.1, SD 0.4 s) and decreased by 0.1 seconds (postintervention 2, SD 0.4 s; P=.13), although 5 of 9 participants improved by a MCID of 0.05 m/s. Qualitative results showed perceived benefits, favored program features, and areas for improvement. CONCLUSIONS: We present a pilot study of a new voice-activated device application customized to older adult users that may serve as a guide to other technology development for older adults. Our pilot study served to further refine the application and to inform a larger trial testing EngAGE's impact on functional outcomes, a necessary step for developing evidence-based technology tools.

Pooled analysis of the MANTICO2 and MONET randomized controlled trials comparing drug efficacy for early treatment of COVID-19 during Omicron waves.

BACKGROUND: The clinical effectiveness of early therapies for mild-to-moderate COVID-19, comparing antivirals and monoclonal antibodies (mAbs) during the Omicron era, has not been conclusively assessed through a post-approval comparative trial. We present a pooled analysis of two randomized clinical trials conducted during Omicron waves. METHODS: The MANTICO2/MONET trial is a pooled analysis of two multicentric, independent, phase-4, three-arm, superiority, randomized, open-label trials. Nonhospitalized patients with early mild-to-moderate COVID-19 (≤5 days after symptoms' onset) and at least one risk factor for disease progression were randomized 1:1:1 to receive 500 mg of intravenous sotrovimab (SOT) or 600 mg of intramuscular tixagevimab/cilgavimab (TGM/CGM) or oral 5-days course of nirmatrelvir/ritonavir (NMV/r) 300/100 mg BID. Primary outcome was COVID-19-related hospitalization or death within 29 days after randomization. Fisher's exact test for pooled data and incidence of failure was reported as overall and by arm with respective 95% CI. Pairwise comparisons across the arms were conducted using unadjusted exact logistic regression. An analysis by means of a doubly robust marginal model using augmented inverse probability weighting (AIPW) was also conducted to estimate the potential outcomes (Pom) in each treatment group and their difference by the average treatment effect (ATE). Analysis of symptom persistence within 30 days after randomization was performed using a 2-level hierarchical mixed-effects logistic model with a random intercept at the patient's level. Point estimates and 95% confidence intervals were adjusted for age and sex and calculated using ANOVA-like methods for the mixed effects logistic model. These trials are registered with the European Clinical Trials Database, EudraCT2021-002612-31 (MANTICO2) and EudraCT2021-004188-28 (MONET) and ClinicalTrials.gov, NCT05321394 (MANTICO2). FINDINGS: Between March 2022 and February 2023, 991 patients (SOT = 332, TGM/CGM = 327, NMV/r = 332) were enrolled in 15 Italian centers. The overall mean age was 66 years; 482 participants (48.80%) were male, and 856 were vaccinated with at least a primary course (86%). Among the 8/991 hospitalizations observed, one resulted in death. The overall estimate of failure was 0.81% (95%CI; 0.35-1.58%). The odds ratio (OR) for the primary outcome in the NMV/r arm compared to the TGM/CGM and SOT arms was 8.41 (95% CI 1.21 to infinity; p = 0.015) and 2.42 (95% CI 0.19 to infinity; p = 0.499), respectively. No significant difference was observed between SOT and TGM/CGM (OR 0.32; 95% CI 0.032-1.83; p = 0.174). Results were similar when we applied the marginal weighted model accounting for potential residual confounding bias. There was no evidence for a difference in the prevalence of symptoms between treatment groups, except for cough, which was higher in the SOT group compared to the other two groups at the 21-day follow-up (P = 0.039) and a higher prevalence of nausea at the 7-day follow-up in the NMV/r group compared to the mAbs group (p = 0.036). INTERPRETATION: NMV/r was superior to TGM/CGM in reducing hospital admission or death in clinically vulnerable patients with SARS-CoV-2 infection treated within 5 days of symptoms' onset. No significant difference in symptom prevalence over time across the arms was found.

The association of frailty with morbidity and mortality following major mucosal head and neck surgery.

OBJECTIVES: Frailty refers to a state of reduced physiological reserve and functional decline. We sought to analyse whether frailty, assessed using the 5-item modified frailty index (5mFI), was associated with increased morbidity and mortality following major mucosal head and neck surgery. MATERIALS AND METHODS: We performed a retrospective study of patients undergoing major mucosal head and neck surgical resection over a 2-year period. Potential confounding variables were controlled by way of multivariable regression analysis. RESULTS: There were 310 patients included with 77 (24.8 %) classified as frail. Most patients were male (219/310, 70.7 %), had a history of smoking (246/310, 79.4 %) and 151 patients (48.7 %) were older than 65 at time of surgery. Most surgeries related to oral cavity or oropharyngeal subsites (227/310, 73.2 %) and 150 patients (48.4 %) underwent microvascular free tissue reconstruction. On multivariable analysis, frail patients were more likely to suffer adverse outcomes such as a return to theatre (OR 3.47, 95 % CI 1.82-6.62, p < 0.001), a Clavien-Dindo grade IV complication (OR 6.23, 95 % CI 2.55-15.20, p < 0.001) or medical complications, such as respiratory complications (OR 2.61, 95 % CI 1.45-4.69; p = 0.001) or delirium (OR 5.05, 95 % CI 2.46-10.33; p < 0.001). Additionally, hospital length of stay was increased among frail patients (ß 16.46 days, 95 % CI 9.85-23.07 days; p < 0.001). Neither 90-day nor 1-year post-operative mortality was increased in frail patients. CONCLUSION: Frailty assessed using the 5mFI was associated with greater post-operative morbidity, but not mortality following major mucosal head and neck surgery.

Geriatric patient at emergency department.

Emergency departments in the Czech Republic have been established in recent years. Seniors are typical patients of these departments. Emergency medicine´s approach is based on symptoms' evaluation and on deciding about the priority of the care needed. The approach to older patients is specific both in diagnostics and in therapy. The triage of geriatric patients is more accurate when we also evaluate patient´s cognition, when we use geriatric frailty scales and screening tools for detection of delirium. Comprehensive geriatric evaluation is a time demanding process and thus inadequate for emergency department however we must maintain its basic components. The therapeutical approach must be complex, and it must include biological, psychological, and social aspects and environmental risk analysis. Trauma management in seniors requires evaluation of different vital function´s values compared to common triage criteria, the influence of medication on adaptive mechanisms and the risk of low energy trauma mechanisms. Therapy of trauma must be timely and complex and the continuity of care between intensive and standard level and then rehabilitation must be ensured. Palliative approach is appropriate for terminally ill patients.

Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis.

Background: Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement. Objectives: To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect. Review design: Systematic review and network meta-analysis. Eligibility criteria: Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention. Main outcomes: Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year. Data sources: We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists. Review methods: Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis). Results: We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive. Limitations: High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts. Conclusions: Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence. Future work: Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further. Study registration: This study is registered as PROSPERO CRD42019162195. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Due to a lack of robust evidence, the benefits and risks of most types of community services for older people are unclear. Individualised care planning, where medication is adjusted and there are regular follow-ups, probably helps people stay living at home. There are many kinds of community services for older people. For example, in some services, everyone is given exercise and dietary advice or an individualised care plan. These often aim to help older people age independently. Maintaining independence is important in later life. We wanted to find out which community services work best: to help people stay living at home, and to do day-to-day activities independently. We reviewed findings from previous studies that have tested different community services for older people. We combined these findings and compared different types of service with one another. We rated our confidence in the evidence. We found 129 studies with 74,946 people. We found 63 different kinds of service have been studied. The studies were carried out in diverse populations around the world. Individualised care planning, where medication is adjusted and there are regular follow-ups, may help people age independently. It probably increases the chance of staying at home slightly. It may also help with doing day-to-day activities very slightly. Exercise and dietary advice may also help people stay living at home. However, there was some evidence that some services may reduce independence. We do not know what effect most services have. We generally had little confidence in the evidence because studies were small, and information was missing. The evidence is up to date to August 2021.

A multicenter retrospective study to assess feasibility, safety and efficacy of first-line carboplatin-paclitaxel versus carboplatin monotherapy in a frail, elderly epithelial ovarian cancer population.

OBJECTIVE: Underrepresentation of elderly ovarian cancer patients in clinical trials has led to lack of clarity regarding optimal first-line chemotherapy in this cohort. The Elderly Women with Ovarian Cancer (EWOC)-1 trial demonstrated that 3-weekly carboplatin (3wC) resulted in worse survival and feasibility compared with standard 3-weekly carboplatin-paclitaxel (3wCP) in frail, elderly ovarian cancer patients. Our retrospective study compares feasibility, safety, and efficacy of first-line 3wCP and 3wC in a frail ovarian cancer cohort. METHODS: Clinical data were retrospectively analyzed for newly-diagnosed, International Federation of Gynecology and Obstetrics (FIGO) stage III/IV, ≥70-year-old epithelial ovarian cancer patients, treated by clinician choice with 3wC or 3wCP at two London cancer centers over a 2 year period. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status provided surrogate markers of frailty. Common Terminology Criteria for Adverse Events v5.0 graded toxicity. RESULTS: A total of 107 patients were treated with 3wC (n=30) and 3wCP (n=77). Age, performance status, and CCI were significantly different between cohorts, with 3wC patients older (84 vs 75 years, p<0.001), with more comorbidities (median CCI 4 vs 3, p<0.001) and worse performance status (47% vs 17% PS ≥2, p=0.015). Surgical outcomes differed significantly between cohorts, with 20 (67%) 3wC patients not undergoing surgery, compared with 22 (29%) 3wCP patients (p<0.001). Median follow-up was 45.8 months (IQR 38.7-56.3 months). While we observed improved progression-free (HR 0.55, 95% CI 0.33 to 0.90, p=0.017) and overall survival (HR 0.44, 95% CI 0.27 to 0.73, p=0.001, log-rank test) in a univariate cox proportional hazards comparison between 3wCP and 3wC, this was not significant on multivariate analysis. Completion of six planned chemotherapy cycles was achieved by the majority, with similar discontinuation rates between groups (13% 3wC vs 8% 3wCP, p>0.05). Overall grade ≥3 hematological toxicity rates were similar between regimens (33% 3wC vs 44% 3wCP, p=0.37) with grade ≥3 neutropenia (p=0.019) and grade ≥3 thrombocytopenia (p=0.006) more common with 3wCP and 3wC, respectively. No treatment-related deaths occurred. CONCLUSION: Our data demonstrates that standard 3wCP is a well-tolerated, feasible first-line treatment for frail, elderly ovarian cancer patients. Improved survival with 3wCP was not significant when corrected for established clinical prognostic factors.

Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review.

OBJECTIVE: Many tools have been used to assess frailty in the perioperative setting. However, no single scale has been shown to be the most effective in predicting postoperative complications. We evaluated the relationship between several frailty scales and the occurrence of complications following different non-cardiac surgeries. METHODS: This systematic review was registered in PROSPERO (CRD42023473401). The search strategy included PubMed, Google Scholar, and Embase, covering manuscripts published from January 2000 to July 2023. We included prospective and retrospective studies that evaluated frailty using specific scales and tracked patients postoperatively. Studies on cardiac, neurosurgical, and thoracic surgery were excluded because of the impact of underlying diseases on patients' functional status. Narrative reviews, conference abstracts, and articles lacking a comprehensive definition of frailty were excluded. RESULTS: Of the 2204 articles identified, 145 were included in the review: 7 on non-cardiac surgery, 36 on general and digestive surgery, 19 on urology, 22 on vascular surgery, 36 on spinal surgery, and 25 on orthopedic/trauma surgery. The reviewed manuscripts confirmed that various frailty scales had been used to predict postoperative complications, mortality, and hospital stay across these surgical disciplines. CONCLUSION: Despite differences among surgical populations, preoperative frailty assessment consistently predicts postoperative outcomes in non-cardiac surgeries.

Characteristics of fragility hip fracture-related falls in the older adults: A systematic review.

BACKGROUND AND OBJECTIVES: With the global aging trend, the incidence of falls and hip fractures is projected to rise, leading to an increased associated burden. Over 90% of hip fractures result from falls, yet not all falls cause fractures, suggesting specific fall characteristics may contribute to hip fractures. This review provides insights into fragility hip fracture-related falls among the older adults, aiding in understanding and developing effective fall prevention strategies for this population. METHODS: Searches encompassed PubMed, OVID, EMBASE, Cochrane Library, and Web of Science, supplemented by citation checks. We included non-randomized studies detailing characteristics of fragility hip fracture-related falls in the older individuals, with or without a non-hip fracture control. Evaluated fall characteristics included height, location, direction, time, mechanism, activity during the fall, hip impact, protective responses, walking aid use, and impact surface. Results were analyzed using a narrative synthesis approach. The quality of these studies was assessed using the revised Risk of Bias Assessment tool for Non-randomized Studies 2 (RoBANS2). RESULTS: A total of 30 articles were reviewed, comprising 23 non-case control and 7 case-control studies, with a mean age of 75.6 years. Studies presented varied details on fall characteristics. Hip-fracture related falls typically occur indoors at or around standing height during daytime, often involving sideways or backward motions with inadequate protective responses. Slipping is predominant, yet lost balance and weakness/collapse are notable. Walking precedes many falls, but stationary activities (lack of forward motion, changing positions, sitting or standing still, transfer) also contribute. Low usage of walking aids and impact on hard surfaces are common features of these falls. CONCLUSIONS: This review underscores fall characteristics associated with fragility hip fractures in older adults, highlighting features more aligned with age-related physical frailty than general falls. Such insights can guide healthcare providers in implementing tailored interventions to reduce hip fractures and related challenges.