Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies.

We conducted a randomized controlled trial in older adults with hematologic malignancies to determine the impact of geriatrician consultation embedded in our oncology clinic alongside standard care. From February 2015 to May 2018, transplant-ineligible patients aged ≥75 years who presented for initial consultation for lymphoma, leukemia, or multiple myeloma at Dana-Farber Cancer Institute (Boston, MA, USA) were eligible. Pre-frail and frail patients, classified based on phenotypic and deficit-accumulation approaches, were randomized to receive either standard oncologic care with or without consultation with a geriatrician. The primary outcome was 1-year overall survival. Secondary outcomes included unplanned care utilization within 6 months of follow-up and documented end-of-life (EOL) goals-of-care discussions. Clinicians were surveyed as to their impressions of geriatric consultation. One hundred sixty patients were randomized to either geriatric consultation plus standard care (n=60) or standard care alone (n=100). The median age of the patients was 80.4 years (standard deviation = 4.2). Of those randomized to geriatric consultation, 48 (80%) completed at least one visit with a geriatrician. Consultation did not improve survival at 1 year compared to standard care (difference: 2.9%, 95% confidence interval: -9.5% to 15.2%, P=0.65), and did not significantly reduce the incidence of emergency department visits, hospital admissions, or days in hospital. Consultation did improve the odds of having EOL goals-of-care discussions (odds ratio = 3.12, 95% confidence interval: 1.03 to 9.41) and was valued by surveyed hematologic-oncology clinicians, with 62.9%-88.2% of them rating consultation as useful in the management of several geriatric domains.

Computed tomography-based body composition profile as a screening tool for geriatric frailty detection.

OBJECTIVE: To assess prevalence of CT imaging-derived sarcopenia, osteoporosis, and visceral obesity in clinically frail and prefrail patients and determine their association with the diagnosis of frailty. MATERIALS AND METHODS: This cross-sectional study was constructed using our institution's pelvic trauma registry and ambulatory database registry. The study included all elderly pelvic trauma patients and ambulatory outpatients between May 2016 and March 2020 who had a comprehensive geriatric assessment and CT abdomen/pelvis within 1 year from the date of the assessment. Patients were dichotomized in prefrail or frail groups. The study excluded patients with history of metastatic disease or malignancy requiring chemotherapy. RESULTS: The study cohort consisted of 151 elderly female and 65 male patients. Each gender population was subdivided into frail (114 female [75%], 51 male [78%]) and prefrail (37 female [25%], 14 male [22%]) patients. CT-imaging-derived diagnosis of osteoporosis (odds ratio, 2.5; 95% CI: 1.2-5.5) and sarcopenia (odds ratio, 2.6; 95% CI: 1.2-5.6) were associated with frailty in females, but did not reach statistical significance in males. BMI and subcutaneous adipose tissue at L3 level were statistically lower in the frail male group compared to the prefrail group. BMI showed strong correlation with the subcutaneous area at the L3 level in both genders (Spearman's coefficient of 0.8, p < 0.001). Hypoalbuminemia and visceral obesity were not associated with frailty in either gender. CONCLUSION: This proof-of-concept study demonstrates the feasibility of using CT-derived body-composition parameters as a screening tool for frailty, which can offer an opportunity for early medical intervention.

Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients.

BACKGROUND: The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that unrecognized cognitive impairment in patients without a history of dementia is a risk factor for development of postoperative complications. METHODS: We enrolled 211 patients 65 yr of age or older without a diagnosis of dementia who were scheduled for an elective hip or knee replacement. Patients were cognitively screened preoperatively using the Mini-Cog and demographic, medical, functional, and emotional/social data were gathered using standard instruments or review of the medical record. Outcomes included discharge to place other than home (primary outcome), delirium, in-hospital medical complications, hospital length-of-stay, 30-day emergency room visits, and mortality. Data were analyzed using univariate and multivariate analyses. RESULTS: Fifty of 211 (24%) patients screened positive for probable cognitive impairment (Mini-Cog less than or equal to 2). On age-adjusted multivariate analysis, patients with a Mini-Cog score less than or equal to 2 were more likely to be discharged to a place other than home (67% vs. 34%; odds ratio = 3.88, 95% CI = 1.58 to 9.55), develop postoperative delirium (21% vs. 7%; odds ratio = 4.52, 95% CI = 1.30 to 15.68), and have a longer hospital length of stay (hazard ratio = 0.63, 95% CI = 0.42 to 0.95) compared to those with a Mini-Cog score greater than 2. CONCLUSIONS: Many older elective orthopedic surgical patients have probable cognitive impairment preoperatively. Such impairment is associated with development of delirium postoperatively, a longer hospital stay, and lower likelihood of going home upon hospital discharge.

Geriatric trauma: there is more to it than just the implant!

Geriatric trauma continues to rise, corresponding with the continuing growth of the older population. These fractures continue to expand, demonstrated by the incidence of hip fractures having grown to 1.5 million adults worldwide per year. This patient population and their associated fracture patterns present unique challenges to the surgeon, as well as having a profound economic impact on the health care system. Pharmacologic treatment has focused on prevention, with aging adults having impaired fracture healing in addition to diminished bone mineral density. Intraoperatively, novel ideas to assess fracture reduction to facilitate decreased fracture collapse have recently been explored. Postoperatively, pharmacologic avenues have focused on future fracture prevention, while shared care models between geriatrics and orthopaedics have shown promise regarding decreasing mortality and length of stay. As geriatric trauma continues to grow, it is imperative that we look to optimize all phases of care, from preoperative to postoperative.

Beyond Mortality: Severely Frail Femur Fracture Patients Can Regain Independence after Surgery.

Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79-92), and a median FI-CGA of 0.48 (IQR 0.43-0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.

A proposal for virtual, telephone-based preoperative cognitive assessment in older adults undergoing elective surgery.

OBJECTIVE: To assess the feasibility of administering the MoCA 5-minute test/Telephone (T-MoCA), an abbreviated version of the Montreal Cognitive Assessment to older adults perioperatively DESIGN: A feasibility study including patients aged ≥ 70 years scheduled for surgery from December 2020 to March 2021 SETTING: Preoperative virtual clinic PATIENTS: Patients ≥70 years undergoing major elective surgery INTERVENTION: A study investigator called eligible patients prior to surgery, obtained consent, and completed the preoperative cognitive assessment. Follow-up assessment was completed 1-month postoperatively, and participating clinicians were surveyed at the completion of the study. MEASUREMENTS: An attention test, T-MoCA, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and Generalized Anxiety Disorder 2-item (GAD-2) MAIN RESULTS: Overall, 37/40 (92.5%) patients completed the pre- and post-operative assessments. The cohort was 50% female, white (97.5%), with a median age of 76 years (interquartile range (IQR) 73-79), and education level was higher than high school in 82.5% of patients. Preoperatively, the median number of medications was 8 (IQR 7-11), 27/40 (67.5%) had medications with anticholinergic effects, and 6/40 (15%) had benzodiazepines. Median completion time of the phone assessment was 10 min (IQR 8.25-12) and 4 min (IQR 3-5) for the T-MoCA with a median T-MoCA score of 13 (IQR 12-14). Most patients (37/40) completed the post-operative assessment, and 6/37 (16.2%) reported they had experienced a change in memory or attention post-operatively. Clinician's survey reported ease and feasibility in performing T-MoCA as a preoperative cognitive evaluation. CONCLUSION: Preoperative cognitive assessment of older adults using T-MoCA over the phone is easy to perform by clinicians and had a high completion rate by patients. This test is feasible for virtual assessments. Further research is needed to better define validity and correlation with postoperative outcomes.

From research to bedside: Incorporation of a CGA-based frailty index among multiple comanagement services.

The comprehensive geriatric assessment (CGA) is the core tool used by geriatricians across diverse clinical settings to identify vulnerabilities and estimate physiologic reserve in older adults. In this paper, we demonstrate the iterative process at our institution to identify and develop a feasible, acceptable, and sustainable bedside CGA-based frailty index tool (FI-CGA) that not only quantifies and grades frailty but also provides a uniform way to efficiently communicate complex geriatric concepts such as reserve and vulnerability with other teams. We describe our incorporation of the FI-CGA into the electronic health record (EHR) and dissemination among clinical services. We demonstrate that an increasing number of patients have documented FI-CGA in their initial assessment from 2018 to 2020, while additional comanagement services were established (Figure 2). The acceptability and sustainability of the FI-CGA, and its routine use by geriatricians in our division, were demonstrated by a survey where the majority of clinicians report using the FI-CGA when assessing a new patient and that the FI-CGA informs their clinical management. Finally, we demonstrate how we refined and updated the FI-CGA, we provide examples of applications of the FI-CGA across the institution and describe areas of ongoing process improvement and challenges for the use of this tailored yet standardized tool across diverse inpatient and outpatient services. The process outlined can be used by other geriatric departments to introduce and incorporate an FI-CGA.

A Culture Change in Geriatric Traumatology: Holistic and Patient-Tailored Care for Frail Patients with Fractures.

ABSTRACT: Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients.

Team Approach: Preoperative Management of Metabolic Conditions in Total Joint Replacement.

¼: Total joint arthroplasties (TJAs) of the knee and hip have been considered 2 of the most successful surgical procedures performed to date. ¼: Frailty is defined as increased vulnerability to adverse outcomes with physiologic stress. ¼: Preoperative optimization of frailty and metabolic bone conditions, including osteoporosis, vitamin D deficiency, and diabetes, through a multidisciplinary approach can help improve outcomes and minimize costs after TJA.

Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement.

To prepare for the increasing numbers of older adults undergoing surgery, the American College of Surgeons (ACS) has recently launched the Geriatric Surgery Verification Program with the goal of encouraging the creation of centers of geriatric surgery. Meanwhile, the Society for Perioperative Assessment and Quality Improvement (SPAQI) has published recommendations for the preoperative management of frailty, which state that teams should actively screen for frailty before surgery and that pathways, including geriatric comanagement, shared decision-making, and multimodal prehabilitation, should be embedded in routine care to help improve patient outcomes. Both SPAQI and the ACS advocate for a multidisciplinary approach to improve the value of care for older adults undergoing surgery. However, the best way to implement geriatric services in the surgical setting is yet to be determined. In this statement, we will describe the SPAQI recommendations for launching a geriatric surgery center and the process by which its value should be assessed over time.

Incidental Durotomy Is Associated With Increased Risk of Delirium in Patients Aged 65 and Older.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the impact of incidental durotomy during spine surgery on the development of delirium in patients aged 65 and older. SUMMARY OF BACKGROUND DATA: Delirium after spine surgery has been shown to increase the risk of adverse events, including morbidity and readmissions. Durotomy has previously been postulated to influence the risk of delirium, but this has not been explored in patients 65 and older, the demographic at greatest risk of developing delirium. METHODS: We obtained clinical data on 766 patients, including 182 with incidental durotomy, from the Partners healthcare registry (2012-2019). Patients had their medical records abstracted and age, biologic sex, body mass index, smoking status, preoperative diagnosis, use of a fusion-based procedure, and number of comorbidities were recorded. Our primary outcome was the development of delirium. Our primary predictor was incidental durotomy. We used logistic regression techniques to adjust for sociodemographic and clinical confounders. We performed propensity score matching as a sensitivity test. We hypothesized that elderly patients would be at increased risk of delirium following durotomy. RESULTS: Delirium was identified in 142 patients (19%). Among patients with an incidental durotomy, 26% were diagnosed with delirium. The incidence of delirium was 16% in the control group. Following adjusted analysis, the likelihood of delirium was significantly greater in patients with a durotomy (odds ratio [OR] 1.91; 95% confidence interval [CI] 1.27, 2.88). After propensity score matching, durotomy remained significantly associated with delirium in multivariable adjusted analyses (OR 1.90; 95% CI 1.07, 3.39). CONCLUSION: This investigation is among the first to specifically evaluate an association between durotomy and delirium in elderly patients undergoing spine surgery. The increased association between durotomy and delirium in this cohort should prompt increased surveillance and interventions designed to minimize the potential for cognitive deterioration or impairment during postoperative management of a durotomy. LEVEL OF EVIDENCE: 3.

Reliability of Proxy-reported Patient-reported Outcomes Measurement Information System Physical Function and Pain Interference Responses for Elderly Patients With Musculoskeletal Injury.

BACKGROUND: Patient-reported Outcomes Measurement Information System (PROMIS) instruments are useful to evaluate health status, but its use can be challenging for some vulnerable elderly patients, requiring aid from their proxies. Whether the proxies could be accurate informants is unknown. The goal of this study was to compare elderly patients' and their proxies' answers with PROMIS physical function (PF) and pain interference (PI) computer adaptive test for the evaluation of patients' outcomes after musculoskeletal injury. In addition, to correlate patients' reported PF with the Timed Up and Go (TUG) test. METHODS: This prospective cohort study, from February to September 2016, in the Orthopaedic trauma clinic of two level I Trauma centers, included 273 patients aged 65 years or older, ambulatory, cognitively intact, with a discernible proxy. PROMIS PF and PI, TUG, and the "FRAIL" Questionnaire screening tool were performed. The correlation of PROMIS scores between patients and proxies, and also with the TUG score, was assessed using Spearman rank correlation. The Bland-Altman analysis served to check agreement and bias. Subgroup comparison was tested using probit transformations. RESULTS: The mean age of patients was 75.7 years, SD 7.5 (62.2 years; SD, 13.8 for proxies), 66.7% women, 57.1% married, and 34% with femoral fractures. A significant correlation and agreement of PROMIS PF and PI scores were found between patients and proxies (Spearman rho for both, PF and PI = 0.73), although proxies tended to overestimate the interference of pain on patient's performance (median difference, -1.7; P < 0.001). The correlation was markedly stronger in nonfrail patients and in those with faster TUG scores. There was also a correlation between patients' PROMIS PF and TUG test (Spearman rho = - 0.58). CONCLUSIONS: Proxies are good informants of the PF of ambulatory, cognitively intact elderly patients, as evaluated by the PROMIS PF instrument, after musculoskeletal injury, although they tend to slightly overestimate PI. The use of proxy-reported PROs might better characterize functional impairment and pain in a vulnerable patient population, and it could decrease selection bias in outcomes research. LEVEL OF EVIDENCE: Diagnostic level II.

Implementation of Routine Cognitive Screening in the Preoperative Assessment Clinic.

Traditional systems of anesthesia evaluation do not routinely incorporate cognitive screening into preoperative assessments of vital organ systems. Increasing recognition of the importance of preoperative cognitive assessment of the elderly surgical patient has resulted in a "call to action" from experts in this area. A paradigm shift will be necessary to make this screening routine and not just a research tool. We describe our preliminary experience with developing a training program and implementing routine cognitive screening in a preoperative evaluation clinic. We outline a process showing our successful clinical implementation of sustainable cognitive stratification and documentation of routine cognitive screening.

Function, Survival, and Care Utilization Among Older Adults With Hematologic Malignancies.

BACKGROUND/OBJECTIVES: Cancer-focused organizations now recommend routine assessment of instrumental activities of daily living (iADLs) for all older patients with cancer, along with assessment of basic activities of daily living (ADLs) if possible. However, little is known regarding the role of iADLs in predicting survival and acute-care utilization in populations of older adults with different hematologic malignancies. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: A screening geriatric assessment was conducted for adults 75 years and older with hematologic malignancies (n = 464) presenting for initial consultation at a large tertiary cancer hospital in Boston, MA. MEASUREMENTS: Univariable and multivariable analyses assessed the association of dependency in ADLs and dependency in iADLs with survival and care utilization (emergency department [ED] visits and unplanned hospitalizations). RESULTS: Subjects were a mean age of 79.7 years and had a mean follow-up of 13.8 months. Overall, 11.4% had dependency in ADLs and 26.7% had dependency in iADLs. Only iADL dependency was associated with higher mortality (hazard ratio = 2.34 [95% confidence interval [CI] = 1.46-3.74]) independently of age, comorbidity, cancer aggressiveness, and treatment intensity. The effect was dose dependent, and impairments in shopping, meal preparation, and housework were all independently associated with a higher hazard of death. iADL dependency was also associated with higher odds of ED visits (odds ratio [OR] = 2.76 [95% CI = 1.30-5.84]) and hospitalizations (OR = 2.89 [95% CI = 1.37-6.09]). Several geriatric domain impairments, including probable cognitive impairment and physical dysfunction, were associated with iADL dependency. CONCLUSION: These findings suggest that older adults with hematologic malignancies and iADL dependency experience higher mortality and acute-care utilization, arguing that iADLs should be formally assessed as part of routine oncology care. J Am Geriatr Soc 67:889-897, 2019.

Recommendations for Preoperative Management of Frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

Frailty is an age-related, multi-dimensional state of decreased physiologic reserve that results in diminished resiliency and increased vulnerability to stressors. It has proven to be an excellent predictor of unfavorable health outcomes in the older surgical population. There is agreement in recommending that a frailty evaluation should be part of the preoperative assessment in the elderly. However, the consensus is still building with regards to how it should affect perioperative care. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in the fields of gerontology, anesthesiology and preoperative assessment to outline practical steps for clinicians to assess and address frailty in elderly patients who require elective intermediate or high risk surgery. These recommendations summarize evidence-based principles of measuring and screening for frailty, as well as basic interventions that can help improve patient outcomes.

FRAIL Questionnaire Screening Tool and Short-Term Outcomes in Geriatric Fracture Patients.

OBJECTIVES: There are limited screening tools to predict adverse postoperative outcomes for the geriatric surgical fracture population. Frailty is increasingly recognized as a risk assessment to capture complexity. The goal of this study was to use a short screening tool, the FRAIL scale, to categorize the level of frailty of older adults admitted with a fracture to determine the association of each frailty category with postoperative and 30-day outcomes. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PARTICIPANTS: A total of 175 consecutive patients over age 70 years admitted to co-managed orthopedic trauma and geriatrics services. MEASUREMENTS: The FRAIL scale (short 5-question assessment of fatigue, resistance, aerobic capacity, illnesses, and loss of weight) classified the patients into 3 categories: robust (score = 0), prefrail (score = 1-2), and frail (score = 3-5). Postoperative outcome variables collected were postoperative complications, unplanned intensive care unit admission, length of stay (LOS), discharge disposition, and orthopedic follow-up after surgery. Thirty-day outcomes measured were 30-day readmission and 30-day mortality. Analysis of variance (1-way) and Kruskal-Wallis tests were used to compare continuous variables across the 3 FRAIL categories. Fisher exact tests were used to compare categorical variables. Multiple regression analysis, adjusted by age, sex, and Charlson index, was conducted to study the association between frailty category and outcomes. RESULTS: FRAIL scale categorized the patients into 3 groups: robust (n = 29), prefrail (n = 73), and frail (n = 73). There were statistically significant differences between groups in terms of age, comorbidity, dementia, functional dependency, polypharmacy, and rate of institutionalization, being higher in the frailest patients. Hip fracture was the most frequent fracture, and it was more frequent as the frailty of the patient increased (48%, 61%, and 75% in robust, prefrail, and frail groups, respectively). The American Society of Anesthesiologists preoperative risk significantly correlated with the frailty of the patient (American Society of Anesthesiologists score 3-4: 41%, 82% and 86%, in robust, prefrail, and frail groups, P < .001). After adjustment by age, sex, and comorbidity, there was a statistically significant association between frailty and both LOS and the development of any complication after surgery (LOS: 4.2, 5.0, and 7.1 days, P = .002; any complication: 3.4%, 26%, and 39.7%, P = .03; in robust, prefrail, and frail groups). There were also significant differences in discharge disposition (31% of robust vs 4.1% frail, P = .008) and follow-up completion (97% of robust vs 69% of the frail ones). Differences in time to surgery, unplanned intensive care unit admission, and 30-day readmission and mortality, although showing a trend, did not reach statistical significance. CONCLUSIONS: Frailty, measured by the FRAIL scale, was associated with increase LOS, complications after surgery, and discharge to rehabilitation facility in geriatric fracture patients. The FRAIL scale is a promising short screen to stratify and help operationalize the perioperative care of older surgical patients.

Abnormal Mini-Cog Is Associated with Higher Risk of Complications and Delirium in Geriatric Patients with Fracture.

BACKGROUND: The Mini-Cog test is a validated and simple tool to screen for dementia. The purpose of this study was to investigate the relationship of cognitive impairment as measured by Mini-Cog testing as a predictor for in-hospital complications and mortality in geriatric patients with fracture. METHODS: From 2011 to 2014, patients who were seventy years of age or older, had a fracture, and were admitted to co-managed orthopaedic trauma and geriatrics services embedded at two Level-I trauma centers were enrolled in our study. As part of the patients' routine admission evaluation, the Mini-Cog examination was performed. An observational cohort study was completed documenting pre-injury functional status, in-hospital complications, length of stay, thirty-day readmission, and mortality. All patients in the study were followed for at least one year. RESULTS: Seven hundred and thirty-nine patients (median age, eighty-three years) attempted Mini-Cog testing. Of those, 513 were able to complete the test, demonstrating a 35.1% prevalence of cognitive impairment. The cohort's rate of in-hospital medical complications was 28.6%. Patients with an abnormal Mini-Cog test or those unable to complete the test had significantly higher odds of in-hospital complications (2.16 and 2.27, respectively) compared with patients with a normal Mini-Cog test (p < 0.001). Delirium was significantly increased in patients with an abnormal Mini-Cog test (odds ratio, 3.22; p = 0.001). The all-cause, one-year mortality rate after fracture in our population was 18.1%. Adjusted for age, sex, comorbidity, and fracture type, only the patients unable to complete the Mini-Cog test showed a higher risk of mortality at one year (hazard ratio, 2.26; p < 0.001). CONCLUSIONS: The Mini-Cog examination is a quick, easily administered screening test for cognitive impairment that is useful in identifying high-risk geriatric patients with fracture. With this tool, we found more than one-third of our elderly patients with fracture were cognitively impaired at the time of admission. These patients had higher rates of in-hospital complications and a trend toward early mortality. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.