Comparison of Various Functional Assessment Tools to Identify Older Patients Undergoing Aortic Aneurysm Repair at Risk for Postoperative Complications.

BACKGROUND: To estimate whether the benefits of aortic aneurysm repair will outweigh the risks, determining individual risks is essential. This single-center prospective cohort study aimed to compare the association of functional tools with postoperative complications in older patients undergoing aortic aneurysm repair. METHODS: Ninety-eight patients (≥65 years) who underwent aortic aneurysm repair were included. Four functional tools were administered: the Montreal Cognitive Assessment (MoCA); the 4-Meter Walk Test (4-MWT); handgrip strength; and the Groningen Frailty Indicator (GFI). Primary outcome was the association between all tests and 30-day postoperative complications. RESULTS: After adjusting for confounders, the odds ratio for MoCA was 1.39 (95% confidence interval [CI] 0.450; 3.157; P = 0.723), for 4-MWT 0.63 (95% CI 0.242; 1.650; P = 0.348), for GFI 1.82 (95% CI 0.783; 4.323, P = 0.162), and for weak handgrip strength 4.78 (95% CI 1.338; 17.096, P = 0.016). CONCLUSIONS: Weak handgrip strength is significantly associated with the development of postoperative complications after aortic aneurysm repair. This study strengthens the idea that implementing a quick screening tool for risk assessment at the outpatient clinic, such as handgrip strength, identifies patients who may benefit from preoperative enhancement with help from, for example, Comprehensive Geriatric Assessment, eventually leading to better outcomes for this patient group.

Cost-effectiveness of the FindMyApps eHealth intervention vs. digital care as usual: results from a randomised controlled trial.

OBJECTIVES: Despite growing interest, the cost-effectiveness of eHealth interventions for supporting quality of life of people with dementia and their caregivers remains unclear. This study evaluated the cost-effectiveness of the FindMyApps intervention, compared to digital care-as-usual. FindMyApps aims to help people with dementia and their caregivers find and learn to use tablet apps that may support social participation and self-management of people with dementia and sense of competence of caregivers. METHOD: A randomised controlled trial (Netherlands Trial Register NL8157) was conducted, including people with mild cognitive impairment (MCI) or mild dementia and their informal caregivers (FindMyApps n = 76, digital care-as-usual n = 74). Outcomes for people with MCI/dementia were Quality-Adjusted Life-Years (QALYs), calculated from EQ-5D-5L data and the Dutch tariff for utility scores, social participation (Maastricht Social Participation Profile) and quality of life (Adult Social Care Outcomes Toolkit), and for caregivers, QALYs and sense of competence (Short Sense of Competence Questionnaire). Societal costs were calculated using data collected with the RUD-lite instrument and the Dutch costing guideline. Multiple imputation was employed to fill in missing cost and effect data. Bootstrapped multilevel models were used to estimate incremental total societal costs and incremental effects between groups which were then used to calculate Incremental Cost-Effectiveness Ratios (ICERs). Cost-effectiveness acceptability curves were estimated. RESULTS: In the FindMyApps group, caregiver SSCQ scores were significantly higher compared to care-as-usual, n = 150, mean difference = 0.75, 95% CI [0.14, 1.38]. Other outcomes did not significantly differ between groups. Total societal costs for people with dementia were not significantly different, n = 150, mean difference = €-774, 95%CI [-2.643, .,079]. Total societal costs for caregivers were significantly lower in the FindMyApps group compared to care-as-usual, n = 150, mean difference = € -392, 95% CI [-1.254, -26], largely due to lower supportive care costs, mean difference = €-252, 95% CI [-1.009, 42]. For all outcomes, the probability that FindMyApps was cost-effective at a willingness-to-pay threshold of €0 per point of improvement was 0.72 for people with dementia and 0.93 for caregivers. CONCLUSION: FindMyApps is a cost-effective intervention for supporting caregivers' sense of competence. Further implementation of FindMyApps is warranted.

[Managing multimorbidity is more than counting the number of conditions]. / Zorg voor multimorbiditeit is meer dan het tellen van ziektes.

The prevalence of patients with multimorbidity, defined by two chronic conditions is rapidly increasing. Defining multimorbidity remains challenging, with varying criteria in research. A recent study by MacRae et al. examined the impact of the number and selection of conditions on estimated multimorbidity prevalence, revealing significant variations from 4.6% to 40.5%. To standardize the definition for research, MacRae et al. recommend using three measurement instruments (Ho always + usually, Barnett, or Fortin condition-lists) to consistently measure prevalence over time. Multimorbidity's complexity is not adequately captured by dichotomous definitions, as this depends on context and purpose. Chronic diseases profoundly affect daily life, leading to reduced physical function and adverse psychosocial outcomes. Patients often experience increased stress, anxiety, and depression, which can further exacerbate somatic conditions. To assess multimorbidity from a patient perspective, considering experienced health and quality of life indicators like ADL functioning, mobility, mood, memory, and social factors is crucial. Effectively managing multimorbidity requires a holistic, tailored approach, including identifying and prioritizing key health issues, promoting self-management, proactive care planning, and coordinating treatments. Understanding the potential for differential treatment effects and considering individual life expectancy is vital. Multimorbidity also places a significant burden on healthcare systems, leading to fragmented care, communication gaps, and increased costs. Identifying complex disease clusters with high mortality and resource utilization can guide integrated care efforts. In less complex cases, primary care physicians can collaborate to provide comprehensive care. Multimorbidity remains a priority in healthcare, necessitating appropriate measurement and tailored interventions for diverse populations.

DeltaScan for the Assessment of Acute Encephalopathy and Delirium in ICU and non-ICU Patients, a Prospective Cross-Sectional Multicenter Validation Study.

OBJECTIVES: To measure the diagnostic accuracy of DeltaScan: a portable real-time brain state monitor for identifying delirium, a manifestation of acute encephalopathy (AE) detectable by polymorphic delta activity (PDA) in single-channel electroencephalograms (EEGs). DESIGN: Prospective cross-sectional study. SETTING: Six Intensive Care Units (ICU's) and 17 non-ICU departments, including a psychiatric department across 10 Dutch hospitals. PARTICIPANTS: 494 patients, median age 75 (IQR:64-87), 53% male, 46% in ICUs, 29% delirious. MEASUREMENTS: DeltaScan recorded 4-minute EEGs, using an algorithm to select the first 96 seconds of artifact-free data for PDA detection. This algorithm was trained and calibrated on two independent datasets. METHODS: Initial validation of the algorithm for AE involved comparing its output with an expert EEG panel's visual inspection. The primary objective was to assess DeltaScan's accuracy in identifying delirium against a delirium expert panel's consensus. RESULTS: DeltaScan had a 99% success rate, rejecting 6 of the 494 EEG's due to artifacts. Performance showed and an Area Under the Receiver Operating Characteristic Curve (AUC) of 0.86 (95% CI: 0.83-0.90) for AE (sensitivity: 0.75, 95%CI=0.68-0.81, specificity: 0.87 95%CI=0.83-0.91. The AUC was 0.71 for delirium (95%CI=0.66-0.75, sensitivity: 0.61 95%CI=0.52-0.69, specificity: 72, 95%CI=0.67-0.77). Our validation aim was an NPV for delirium above 0.80 which proved to be 0.82 (95%CI: 0.77-0.86). Among 84 non-delirious psychiatric patients, DeltaScan differentiated delirium from other disorders with a 94% (95%CI: 87-98%) specificity. CONCLUSIONS: DeltaScan can diagnose AE at bedside and shows a clear relationship with clinical delirium. Further research is required to explore its role in predicting delirium-related outcomes.

Risk assessment for postoperative outcomes in a mixed hospitalized gynecological population by the Dutch safety management system (Veiligheidsmanagementsysteem, VMS) screening tool 'frail elderly'.

PURPOSE: Frailty is associated with a higher risk for negative postoperative outcomes. This study aimed to determine the association between the screening tool of the Dutch safety management system, Veiligheidsmanagementsysteem (VMS) 'frail elderly' and postoperative complications in a gynecological population. METHODS: This cohort study included women aged 70 years or older, who were scheduled for any kind of gynecological surgery. VMS screening data (including risk for delirium, falling, malnutrition, and functional impairment) were extracted from the electronic patient records. VMS score could range between 0 and 4 patients with a VMS score of one or more were considered frail. Data on possible confounding factors and complications within 30 days after surgery, classified with the Clavien-Dindo classification, were collected. Regression analysis was performed. RESULTS: 157 women were included with a median age of 74 years (inter quartile range 71-79). Most patients underwent prolapse surgery (52%) or hysterectomy (31%). Forty-one patients (26%) experienced any postoperative complication. Sixty-two patients (39%) were considered frail preoperatively by the VMS screening tool. Frailty measured with the VMS screening tool was not independently associated with postoperative complications in multivariable analysis (Odds ratio 1.18; 95% CI 0.49-2.82). However, a recent fall in the last 6 months (n = 208) was associated with postoperative complications (Odds ratio 3.90; 95% CI 1.57-9.66). CONCLUSION: An independent association between frailty, determined by the VMS screening tool 'Frail elderly', and postoperative complications in gynecological surgery patients could not be confirmed. A recent fall in the last 6 months seems associated with postoperative complications.

Development of a new tool for the assessment of patient-defined benefit in hospitalised older patients: the Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP).

OBJECTIVES: To support the shift from disease-oriented towards goal-oriented care, we aimed to develop a tool which is capable both to identify priorities of an individual older hospitalised patient and to measure the outcomes relevant to him. DESIGN: Mixed-methods design with open interviews, three step test interviews (TSTIs) and a quantitative field test. SETTING: University teaching hospital and a regional teaching hospital. PARTICIPANTS: Hospitalised patients ages 70 years and older. RESULTS: The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) consists of a baseline questionnaire and an evaluation questionnaire. Items were based on 15 qualitative interviews with hospitalised older patients. Feedback from a panel of four community-dwelling older persons resulted in some adaptations to wording and one additional item. Twenty-six hospitalised older patients participated in TSTIs with Version 1 of the baseline questionnaire, revealing indications for a good content validity and barriers in completion behaviour, global understanding and understanding of individual items, which were solved with several adaptations. Four additions were made by participants. After TSTIs with ten patients with the evaluation questionnaire, one adaptation was made. A field test with 91 hospitalised older patients revealed a small number of missing values.To enhance the feasibility, the number of items was reduced from 32 to 22, based on correlations and mean impact score. The field test was repeated with 104 other patients in a regional teaching hospital. To enhance the understanding, the tool was split into two phases. This version was tested with TSTIs with eight patients and appeared to be understandable. The final version was an interview-based tool and took about 11 min to complete. CONCLUSIONS: The P-BAS HOP is a potentially suitable tool to identify priorities and relevant outcomes of the individual patient. Further research is needed to investigate its validity, reliability and responsiveness.

[Assessment instruments in frail older patients; a call for more standardisation]. / Meetinstrumenten bij kwetsbare ouderen: een pleidooi voor meer standaardisatie.

OBJECTIVE: To determine the frequency and background of the use of assessment instruments for the Comprehensive Geriatric Assessment by clinical geriatricians and internists in geriatric medicine; the secondary aim was to make an inventory of the willingness to standardise the assessment instruments used. DESIGN: A descriptive questionnaire study. METHOD: In December 2016, we sent out a digital questionnaire (Survey Monkey) to all the hospitals in the Netherlands. Respondents were asked which instruments they used for specific domains of the Comprehensive Geriatric Assessment, what their choice of instruments was based on, if these instruments had added value, and if they were prepared to change the instruments they used. RESULTS: We received 66 responses (response: 82%). The most frequently-used instruments were: Mini Mental State Examination in combination with the clock drawing test (21%), Geriatric Depression Scale-15 (45%), Katz Index of Independence in Activities of Daily Living-6 (75%), Lawton and Brody (48%), Mini Nutritional Assessment(-short form) (outpatient; 56%) and Short Nutritional Assessment Questionnaire (inpatient: 36%), Experienced Burden Informal Care (46%), Charlson Comorbidity Index (35%), Timed Up and Go (76%), and the Safety Management System (VMS) fall risk question (21%). The most frequently used instruments were used in a large number of hospitals (35-97%).The variation of tests was the greatest in the domains of cognition, malnutrition, and mobility/physical functioning. Many respondents saw the added value of a consensus set of instruments (median: 70%; interquartile range (IQR): 50-86), and most were willing to change the instruments they use (median: 80%; IQR: 65-90). CONCLUSION: This inventory shows that the instruments used in most domains were reasonably uniform. Taking the willingness to change into account, a national set of basis instruments seems to be an achievable aim.

Validation of the Charlson Comorbidity Index in acutely hospitalized elderly adults: a prospective cohort study.

OBJECTIVES: To determine whether the Charlson Comorbidity Index (CCI) predicts short- and long-term mortality. DESIGN: Prospective cohort study. SETTING: The medical department of two university hospitals and one community-based hospital. PARTICIPANTS: Acutely hospitalized individuals aged 65 and older with a mean age of 77.8 ± 7.9, 45.8% male (n = 1,313). MEASUREMENTS: In eligible persons, information on demographic characteristics, activities of daily living (modified Katz ADL Index score), and disease-related measures was collected within 48 hours after admission. Follow-up using self-reporting questionnaires was performed at 3 months and 1 year. Functional decline was defined as a decline of at least 1 point on the modified Katz ADL Index score at 12 months from baseline. Mortality data at 3 months and 1 and 5 years were collected from the municipal database. RESULTS: Logistic regression analysis, adjusted for age and sex, showed that participants with a CCI of 5 or more had higher 3-month (odds ratio (OR) = 3.6, 95% confidence interval (CI) = 2.1-6.4), 1-year (OR = 7.1, 95% CI = 4.2-11.9), and 5-year (OR = 52.4, 95% CI = 13.3-206.4) mortality than those with a CCI of 0. Participants with CCI scores between 1 and 4 also had greater mortality risk at 3 months and 1 and 5 years. CONCLUSION: The CCI independently predicts short- and long-term mortality in acutely ill hospitalized elderly adults.

Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review.

Comprehensive geriatric assessment (CGA) is done to detect vulnerability in elderly patients with cancer so that treatment can be adjusted accordingly; however, this process is time-consuming and pre-screening is often used to identify fit patients who are able to receive standard treatment versus those in whom a full CGA should be done. We aimed to assess which of the frailty screening methods available show the best sensitivity and specificity for predicting the presence of impairments on CGA in elderly patients with cancer. We did a systematic search of Medline and Embase, and a hand-search of conference abstracts, for studies on the association between frailty screening outcome and results of CGA in elderly patients with cancer. Our search identified 4440 reports, of which 22 publications from 14 studies, were included in this Review. Seven different frailty screening methods were assessed. The median sensitivity and specificity of each screening method for predicting frailty on CGA were as follows: Vulnerable Elders Survey-13 (VES-13), 68% and 78%; Geriatric 8 (G8), 87% and 61%; Triage Risk Screening Tool (TRST 1+; patient considered frail if one or more impairments present), 92% and 47%, Groningen Frailty Index (GFI) 57% and 86%, Fried frailty criteria 31% and 91%, Barber 59% and 79%, and abbreviated CGA (aCGA) 51% and 97%. However, even in case of the highest sensitivity, the negative predictive value was only roughly 60%. G8 and TRST 1+ had the highest sensitivity for frailty, but both had poor specificity and negative predictive value. These findings suggest that, for now, it might be beneficial for all elderly patients with cancer to receive a complete geriatric assessment, since available frailty screening methods have insufficient discriminative power to select patients for further assessment.

Longitudinal assessment of serum anticholinergic activity in delirium of the elderly.

BACKGROUND: Delirium, a frequently occurring, devastating disease, is often underdiagnosed, especially in dementia. Serum anticholinergic activity (SAA) was proposed as a disease marker as it may reflect delirium's important pathogenetic mechanism, cholinergic deficiency. We assessed the association of serum anticholinergic activity with delirium and its risk factors in a longitudinal study on elderly hip fracture patients. METHOD: Consecutive elderly patients admitted for hip fracture surgery (n = 142) were assessed longitudinally for delirium, risk factors, and serum markers (IL-6, cortisol, and SAA). Using a sophisticated statistical design, we evaluated the association between SAA and delirium in general and with adjustments, but also the temporal course, including the events fracture, surgery, and potential delirium, individual confounders, and a propensity score. RESULTS: Among elderly hip fracture patients 51% developed delirium, these showed more risk factors (p < 0.001), and complications (p < 0.05). Uncontrolled SAA levels (463 samples) were significantly higher in the delirium group (4.2 vs. 3.4 pmol/ml) and increased with delirium onset, but risk factors absorbed the effect. Using mixed-modeling we found a significant increase in SAA concentration (7.6% (95%CI 5.0-10.2, p < 0.001)) per day, which was modified by surgery and delirium, but this effect was confounded by cognitive impairment and IL-6 values. Confounder control by propensity scores resulted in a disappearance of delirium-induced SAA increase. CONCLUSIONS: Delirium-predisposing factors are closely associated with changes in the temporal profile of serum anticholinergic activity and thus neutralize the previously documented association between higher SAA levels and delirium. An independent relationship of SAA to delirium presence is highly questionable.

Systematic comprehensive geriatric assessment in elderly patients on chronic dialysis: a cross-sectional comparative and feasibility study.

BACKGROUND: Elderly dialysis patients are prone to disabilities and functional decline. This aggravates their last period of life. It would be valuable to be able to preserve daily function and quality of life. Identification of domains requiring additional attention is not common practice in standard care. Therefore, we performed a systematic Comprehensive Geriatric Assessment (CGA) to assess physical and psychosocial function and tested its feasibility in daily practice. The CGA is used more frequently in the assessment of elderly cancer patients, and we therefore compared the outcomes to this group. METHODS: A cross-sectional, multicenter study, between June 1st and September 31st, 2009, in four Dutch outpatient dialysis units. Fifty patients aged 65 years or above who received dialysis because of end-stage renal disease (ESRD) were randomly included. We assessed the CGA during a systematic interview with patients and their caregivers. The cancer patients had had a similar CGA in an earlier study. We compared prevalences between groups. RESULTS: In the dialysis population (68.0% 75 years or above, 76.6% on haemodialysis) caregivers often observed behavioral changes, such as deviant eating habits (34.0%) and irritability (27.7%). In 84.4%, caregivers felt overburdened by the situation of their family member. Somatic and psychosocial conditions were frequently found (polypharmacy (94.6%), depression (24.5%)) and prevalence of most geriatric conditions was comparable to those in elderly cancer patients. CONCLUSIONS: Geriatric conditions were highly prevalent among elderly dialysis patients and prevalences were comparable in both populations. The CGA proved feasible for recognition of these conditions and of overburdened caregivers. This could prevent further functional decline and preserve quality of life.

The value of a comprehensive geriatric assessment for patient care in acutely hospitalized older patients with cancer.

INTRODUCTION: A comprehensive geriatric assessment systematically collects information on geriatric conditions and is propagated in oncology as a useful tool when assessing older cancer patients. OBJECTIVES: The objectives were: (a) to study the prevalence of geriatric conditions in cancer patients aged ≥ 65 years, acutely admitted to a general medicine ward; (b) to determine functional decline and mortality within 12 months after admission; and (c) to assess which geriatric conditions and cancer-related variables are associated with 12-month mortality. METHODS: This was an observational cohort study of 292 cancer patients aged ≥ 65 years, acutely admitted to the general medicine and oncology wards of two university hospitals and one secondary teaching hospital. Baseline assessments included patient characteristics, reason for admission, comorbidity, and geriatric conditions. Follow-up at 3 and 12 months was aimed at functional decline (loss of one or more activities of daily living [ADL]) and mortality. RESULTS: The median patient age was 74.9 years, and 95% lived independently; 126 patients (43%) had metastatic disease. A high prevalence of geriatric conditions was found for instrumental ADL impairment (78%), depressive symptoms (65%), pain (65%), impaired mobility (48%), malnutrition (46%), and ADL impairment (38%). Functional decline was observed in 8% and 33% of patients at 3 and 12 months, respectively. Mortality rates were 38% at 3 months and 64% at 12 months. Mortality was associated with cancer-related factors only. CONCLUSION: In these acutely hospitalized older cancer patients, mortality was only associated with cancer-related factors. The prevalence of geriatric conditions in this population was high. Future research is needed to elucidate if addressing these conditions can improve quality of life.