The 2023 WSES guidelines on the management of trauma in elderly and frail patients.

BACKGROUND: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

The role of geriatricians in hospital palliative care units for elderly patients affected by end stage diseases.

OBJECTIVE: To show the importance of geriatricians in the assessment and treatment of patients with terminal illnesses requiring palliative care. METHODS: This was a retrospective epidemiological study, in which the authors used data relating to 229 patients with terminal stage cancer/advanced chronic diseases, which were evaluated by a palliative care team and collected from January to December 2018. RESULTS: The average age of the sample was 72 years. The sample was divided into two groups, called 'advanced cancer' (N=161, 70.3%) and 'advanced chronic diseases' (N=68, 29.6%). The authors found that patients with advanced chronic diseases had the highest age, highest number of comorbidities and higher indicators of complex care. The authors also showed that, in advanced chronic diseases, the factors that are associated with increased hospital death are: bedridden (OR=3,778; 95% CI=1,371-10,409), dysphagia (OR=2,038; 95% CI=1,005-4,133) and a higher number of diseases (OR=1,446; 95% CI=1,179-1,774). DISCUSSION: Given these findings, there is a high prevalence of elderly hospitalised patients with advanced chronic end-stage disease, a classic geriatric condition, who need access to palliative care services. CONCLUSION: The authors believe that an increase in geriatricians dedicated to palliative care services is needed to ensure that these patients have equal access to continuity of care services and optimal treatment.

Infections in hospitalised patients affected by end-stage diseases: a narrative overview.

AIM: To analyse the presence and treatment of infections in hospitalised terminal patients by identifying potential risk factors. METHODS: We conducted a retrospective study using health data from 229 terminally ill patients (evaluated by our hospital palliative care team (HPCT) hospitalised from January to December 2018. RESULTS: A total of two types of infections were identified: blood flow infection (through blood cultures) and pneumonia (through radiological examinations), while the other cases of infection remained unknown. The most frequently identified microorganism was Staphylococcus spp. The prevalence of infections was higher in patients with non-oncological diseases (n=47, 36.7%; p value 0.009). The potential risk factors identified for infections were the presence of: Parkinson's disease (n=15, 11.7%; p value 0.005), dysphagia (n=49, 38.3%; p value 0.007), bedding (n=15, 11.7%; p value 0.048), pressure ulcers (n=31, 24. 2%); p value 0.018), oxygen therapy (n=60, 46.9%; p value 0.050), urinary catheters (n=95, 74.2%; p value 0.038) and polypathology (2.3 vs 1.7; p value 0.022). Parkinson's disease (OR=5.973; 95% CI=1.292-27.608), dysphagia (OR=2.090; 95% CI=1.080-4.046) and polypathology (OR=1.220; 95% CI=1.015-1.466) were confirmed by a corrected logistic regression analysis. CONCLUSIONS: Infections and, consequently, antibiotic therapies, have a high prevalence in hospitalised patients with terminal disease. Potential risk factors for infections in these patients could be polypathology, dysphagia and Parkinson's disease. Patients with these conditions could benefit from prevention programmes.

The benefits of a hospital palliative care team.

AIM: To investigate the association between a hospital palliative care unit assessment and hospital outcome. METHODS: This was a prospective cohort study. Data were assessed from all patients treated and followed by the hospital palliative care team (HPCT) from November 2016 until December 2017. RESULTS: The mean age of the 588 patients was 73.15±13.6 years. All of the patients included in the study were referred to palliative care. A large proportion of patients were affected by cancer, 69.7% (410), while 30.3% (178) were affected by an advanced chronic illness. The three most frequent cancers were: gastrointestinal (n=81, 19.8%), gynaecological (n=66, 16.1%) and lung (n=63, 15.4%); the three most frequent chronic advanced diseases were: advanced dementia (n=45, 25.3%), severe ischaemic/haemorrhagic stroke (n=36, 20.2%) and severe heart failure (n=25, 15.3%). The majority of patients were in clinical wards (n=476, 81.0%) and the average length of stay was 22.9 days. Hospital outcome trends were evaluated in terms of length of stay and number of deaths that occurred in the hospital. In particular, length of stay decreased from 25.8 days to 18.1 days, hospital death from 13 to 0 during the time that the HPCT assessed patients for an appropriate discharge. CONCLUSION: The HPCT is an effective means of managing patients affected by severe illness, reducing the number of deaths that occur within the hospital, long periods of hospitalisation and instances of readmission. However, further studies are required to fully assess the impact of an HPCT on hospital outcomes.

Effects of hyperpolypharmacy and potentially inappropriate medications (PIMs) on functional decline in older patients discharged from acute care hospitals.

AIM: To comparatively investigate the effects of hyperpolypharmacy and potentially inappropriate medications (PIMs) on functional decline in older patients after hospital discharge. METHODS: Our series consisted of 733 patients aged ≥65 consecutively enrolled in a multicenter observational longitudinal study. PIMs were defined on the basis of updated versions of Beers and STOPP criteria. The occurrence of functional decline was defined as the loss of independency in at least 1 basic activity of daily living (BADL) from discharge through 3-month follow-up visit. RESULTS: After adjusting for several potential confounders, hyperpolypharmacy (OR = 2.20; 95%CI = 1.11-4.37) and Beers violations (OR = 1.99; 95%CI = 1.17-3.49) were significantly associated with functional decline, while STOPP (OR = 1.10; 95%CI = 0.64-1.88) and combined Beers + STOPP violations (OR = 1.72; 95%CI = 0.97-3.05) were not. In logistic regression models simultaneously including both hyperpolypharmacy and PIMs, hyperpolypharmacy was always associated with functional decline (OR = 1.98; 95%CI = 1.0-3.97 in the model including Beers violations; OR = 2.19; 95%CI = 1.11-4.35 in the model including STOPP violations; OR = 2.04; 95%CI = 1.02-4.06 in the model including combined Beers and STOPP violations). Beers violations (OR = 1.89; 95%CI = 1.09-3.28) also remained significantly associated with the outcome in this latter analysis, but not STOPP or combined Beers and STOPP violations. CONCLUSIONS: Hyperpolypharmacy, and to a lesser extent Beers violations predict functional decline in older patients discharged from acute care hospitals, whilst STOPP criteria are no longer associated with the outcome after adjusting for potential confounders. Hyperpolypharmacy is associated with functional decline independent of PIMs.

Impact of hospitalization on modification of drug regimens: Results of the criteria to assess appropriate medication use among elderly complex patients study.

AIM: To assess the impact of hospitalization on modification of drug burden among elderly patients. METHODS: The present prospective cohort study was carried out in acute care hospitals in Italy. The difference in the number of drugs used before hospital admission and those prescribed at discharge was calculated. The prevalence of (i) any increase (1 or more drugs); and (ii) an increase >50% in the number of drugs from admission to discharge was calculated, and the factors associated with these conditions were identified. RESULTS: The mean age of 1082 participants was 81.2 ± 7.3 years and 606 were women (56.0%), an increase in the number of drugs (1 or more drugs) between admission and discharge was observed in 672 participants (62.1% of study sample) and an "increase >50%" was observed in 372 participants (34.3%). "Any increase" was inversely associated with age and the number of drugs used before hospitalization, and it was positively associated with length of stay and diagnoses, including chronic obstructive pulmonary disease, ischemic heart disease and diabetes. "Increase >50%" was inversely associated with female sex, the number of drugs before hospitalization, involuntary loss of weight and intact cognitive status, and was positively associated with length of stay, chronic obstructive pulmonary disease, heart failure and diabetes. CONCLUSIONS: Not only disease, but also demographic factors (age and gender) and geriatric syndromes (weight loss and cognitive status) might influence pharmacological burden. These data might be useful in order to target interventions aimed at improving drug use and reducing iatrogenic illness. Geriatr Gerontol Int 2016; 16: 593-599.

Polypharmacy and health outcomes among older adults discharged from hospital: results from the CRIME study.

AIM: To investigate if older adults using multiple drugs have an increased risk of rehospitalization and mortality after hospital discharge. METHODS: This was a prospective cohort study carried out in acute care hospitals. The primary outcomes of the study were rehospitalization and mortality within 1 year after discharge from acute care hospitals. The study population was categorized in two groups according to the number of drugs prescribed at hospital discharge: no polypharmacy (<8 drugs) and polypharmacy (≥8 drugs). RESULTS: The mean age of 480 participants was 78.6±6.8 years ,and half of them (n=238; 49.6%) were using multiple drugs (≥8 drugs). Overall, 65 out of 242 participants (26.9%) in the no polypharmacy group and 92/238 (39.1%) in the polypharmacy group were rehospitalized (P=0.004), and 15 out of 242 (6.2%) in the no polypharmacy and 23 out of 238 (9.7%) in the polypharmacy group died during the 1 year follow up (P=0.16). After adjusting for potential confounders, participants in the polypharmacy group had an increased risk of 1-year rehospitalization as compared with those in the no polypharmacy group (RR=1.81, 95% CI=1.18-2.75). No significant association was observed between mortality and polypharmacy. CONCLUSIONS: Older persons using multiple drugs are at increased risk of rehospitalization. Further studies are required to assess the impact of programs aimed at reducing polypharmacy on health outcomes.