From research to daily clinical practice: implementation of orthogeriatric co-management in the trauma ward.

Introduction: Evidence strongly suggests that orthogeriatric co-management improves patient outcomes in frail older patients with a fracture, but evidence regarding how to implement this model of care in daily clinical practice is scarce. In this paper, we first describe the implementation process and selection of implementation strategies for an orthogeriatric co-management program in the traumatology ward of the University Hospitals Leuven in Belgium. Second, we report the results of a multi-method feasibility study. This study (1) measures the fidelity towards the program's core components, (2) quantifies the perceived feasibility and acceptability by the healthcare professionals, and (3) defines implementation determinants. Methods: Implementation strategies were operationalized based on the Expert Recommendations for Implementing Change (ERIC) guidelines. In the feasibility study, fidelity towards the core components of the program was measured in a group of 15 patients aged 75 years and over by using electronic health records. Feasibility and acceptability as perceived by the involved healthcare professionals was measured using a 15-question survey with a 5-point Likert scale. Implementation determinants were mapped thematically based on seven focus group discussions and two semi-structured interviews by focusing on the healthcare professionals' experiences. Results: We observed low fidelity towards completion of a screening questionnaire to map the premorbid situation (13%), but high fidelity towards the other program core components: multidimensional evaluation (100%), development of an individual care plan (100%), and systematic follow-up (80%). Of the 50 survey respondents, 94% accepted the program and 62% perceived it as feasible. Important implementation determinants were feasibility, awareness and familiarity, and improved communication between healthcare professionals that positively influenced program adherence. Conclusions: Fidelity, acceptability, and feasibility of an orthogeriatric co-management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning. Clinical trial registration: [https://www.isrctn.com/ISRCTN20491828], International Standard Randomised Controlled Trial Number (ISRCTN) Registry: [ISRCTN20491828]. Registered on October 11, 2021.

Orthogeriatric co-management for older patients with a major osteoporotic fracture: Protocol of an observational pre-post study.

BACKGROUND: Osteoporotic fractures are associated with postoperative complications, increased mortality, reduced quality of life, and excessive costs. The care for older patients with a fracture is often complex due to multimorbidity, polypharmacy, and presence of geriatric syndromes requiring a holistic multidisciplinary approach based on a comprehensive geriatric assessment. Nurse-led geriatric co-management has proven to prevent functional decline and complications, and improve quality of life. The aim of this study is to prove that nurse-led orthogeriatric co-management in patients with a major osteoporotic fracture is more effective than inpatient geriatric consultation to prevent in-hospital complications and several secondary outcomes in at least a cost-neutral manner. METHODS: An observational pre-post study will be performed on the traumatology ward of the University Hospitals Leuven in Belgium including 108 patients aged 75 years and older hospitalized with a major osteoporotic fracture in each cohort. A feasibility study was conducted after the usual care cohort and prior to the intervention cohort to measure fidelity to the intervention components. The intervention includes proactive geriatric care based on automated protocols for the prevention of common geriatric syndromes, a comprehensive geriatric evaluation followed by multidisciplinary interventions, and systematic follow-up. The primary outcome is the proportion of patients having one or more in-hospital complications. Secondary outcomes include functional status, instrumental activities of daily living status, mobility status, nutritional status, in-hospital cognitive decline, quality of life, return to pre-fracture living situation, unplanned hospital readmissions, incidence of new falls, and mortality. A process evaluation and cost-benefit analysis will also be conducted. DISCUSSION: This study wants to prove the beneficial impact of orthogeriatric co-management in improving patient outcomes and costs in a heterogenous population in daily clinical practice with the ambition of long-term sustainability of the intervention. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number (ISRCTN) Registry: ISRCTN20491828. Registered on October 11, 2021, https://www.isrctn.com/ISRCTN20491828.

Geriatric care for surgical patients: results and reflections from a cross-sectional survey in acute Belgian hospitals.

PURPOSE: To explore geriatric care for surgical patients in Belgian hospitals and geriatricians' reflections on current practice. METHODS: A web-based survey was developed based on literature review and local expertise, and was pretested with 4 participants. In June 2021, the 27-question survey was sent to 91 heads of geriatrics departments. Descriptive statistics and thematic analysis were performed. RESULTS: Fifty-four surveys were completed, corresponding to a response rate of 59%. Preoperative geriatric risk screening is performed in 25 hospitals and systematically followed by geriatric assessment in 17 hospitals. During the perioperative hospitalisation, 91% of geriatric teams provide non-medical and 82% provide medical advice. To a lesser extent, they provide geriatric protocols, geriatric education and training, and attend multidisciplinary team meetings. Overall, time allocation of geriatric teams goes mainly to postoperative evaluations and interventions, rather than to preoperative assessment and care planning. Most surgical patients are hospitalised on surgical wards, with reactive (73%) or proactive (46%) geriatric consultation. In 36 hospitals, surgical patients are also admitted on geriatric wards, predominantly orthopaedic/trauma, abdominal and vascular surgery. Ninety-eight per cent of geriatricians feel that more geriatric input for surgical patients is needed. The most common reported barriers to further implement geriatric-surgical services are shortage of geriatricians and geriatric nurses, and unadjusted legislation and financing. CONCLUSION: Geriatric care for surgical patients in Belgian hospitals is mainly reactive, although geriatricians favour more proactive services. The main opportunities and challenges for improvement are to resolve staff shortages in the geriatric work field and to update legislation and financing.

How to implement geriatric co-management in your hospital? Insights from the G-COACH feasibility study.

BACKGROUND: Geriatric co-management is advocated to manage frail patients in the hospital, but there is no guidance on how to implement such programmes in practice. This paper reports our experiences with implementing the 'Geriatric CO-mAnagement for Cardiology patients in the Hospital' (G-COACH) programme. We investigated if G-COACH was feasible to perform after the initial adoption, investigated how well the implementation strategy was able to achieve the implementation targets, determined how patients experienced receiving G-COACH, and determined how healthcare professionals experienced the implementation of G-COACH. METHODS: A feasibility study of the G-COACH programme was performed using a one-group experimental study design. G-COACH was previously implemented on two cardiac care units. Patients and healthcare professionals participating in the G-COACH programme were recruited for this evaluation. The feasibility of the programme was investigated by observing the reach, fidelity and dose using registrations in the electronic patient record and by interviewing patients. The success of the implementation reaching its targets was evaluated using a survey that was completed by 48 healthcare professionals. The experiences of 111 patients were recorded during structured survey interviews. The experiences of healthcare professionals with the implementation process was recorded during 6 semi-structured interviews and 4 focus groups discussions (n = 27). RESULTS: The programme reached 91% in a sample of 151 patients with a mean age of 84 years. There was a high fidelity for the major components of the programme: documentation of geriatric risks (98%), co-management by specialist geriatrics nurse (95%), early rehabilitation (80%), and early discharge planning (74%), except for co-management by the geriatrician (32%). Both patients and healthcare professionals rated G-COACH as acceptable (95 and 94%) and feasible (96 and 74%). The healthcare professionals experienced staffing, competing roles and tasks of the geriatrics nurse and leadership support as important determinants for implementation. CONCLUSIONS: The implementation strategy resulted in the successful initiation of the G-COACH programme. G-COACH was perceived as acceptable and feasible. Fidelity was influenced by context factors. Further investigation of the sustainability of the programme is needed. TRIAL REGISTRATION: ISRCTN22096382 (21/05/2020).

Risk factors for severe COVID-19 disease and death in patients aged 70 and over: a retrospective observational cohort study.

OBJECTIVES: The COVID-19 pandemic resulted in rapid reorganisations of hospital care. In our hospital, the geriatrics team introduced the Clinical Frailty Scale (CFS) on the non-ICU COVID-19 units during these reorganisations. A retrospective analysis was performed to investigate the CFS as a risk factor for severe COVID-19 disease and in-hospital death in older patients with COVID-19. METHODS: In patients aged ≥70 years, an online geriatric assessment questionnaire was launched, from which the CFS was scored by the geriatrics team. Additional clinical data were collected from the electronic medical records. Risk factors related to ageing, such as the CFS, age-adjusted Charlson Comorbidity Index, living situation and cognitive decline, were examined alongside frequently reported risk factors in the general population. Outcomes were in-hospital death (primary outcome) and oxygen need of ≥6 litres and early warning score ≥7, as parameters for severe disease (secondary outcomes). Baseline characteristics were described with descriptive statistics. Associations were analysed with uni- and multivariable analyses. RESULTS: One hundred and five patients were included, median age 82 years. CFS scores were 1-4 in 43, 5-6 in 45, and 7-9 in 17 patients. In multivariable analysis, CFS and cognitive decline were the only risk factors that were independently associated with in-hospital mortality. Chronic obstructive pulmonary disease, presence of respiratory symptoms on admission and male gender showed and independent association with severe disease. CONCLUSION: A retrospective analysis shows that CFS and cognitive decline have added value for predicting in-hospital mortality in older patients with COVID-19 disease.

Late complications of biliopancreatic diversion in an older patient: a case report.

BACKGROUND: In the mid-seventies, biliopancreatic diversion became popular as weight-loss surgery procedure. This bariatric procedure combines distal gastric resection and intestinal malabsorption, leading to greater weight loss and improvement of co-morbidities than other bariatric procedures. Nowadays, biliopancreatic diversion has become obsolete due to the high risk of nutritional complications. However, current patients with biliopancreatic diversions are aging. Consequently, geriatricians and general practitioners will encounter them more often and will be faced with the consequences of late complications. CASE PRESENTATION: A 74-year old female presented with weakness, recurrent falls, confusion, episodes of irresponsiveness, anorexia and weight loss. Her medical history included osteoporosis, herpes encephalitis 8 years prior and a biliopancreatic diversion (Scopinaro surgery) at age 52. Cerebral imaging showed herpes sequelae without major atrophy. Delirium was diagnosed with underlying nutritional deficiencies. Biochemical screening indicated vitamin A deficiency, vitamin E deficiency, zinc deficiency and severe hypoalbuminemia. While thiamin level and fasting blood glucose were normal. However, postprandial hyperinsulinemic hypoglycemia was observed with concomitant signs of confusion and blurred consciousness. After initiating parenteral nutrition with additional micronutrient supplementation, a marked improvement was observed in cognitive and physical functioning. CONCLUSIONS: Long-term effects of biliopancreatic diversion remain relatively underreported in older patients. However, the anatomical and physiological changes of the gastrointestinal tract can contribute to the development of metabolic and nutritional complications that may culminate in cognitive impairment, functional decline and delirium. Therefore, it is warranted to evaluate the presence of metabolic disturbances and nutritional complications in older patients after biliopancreatic diversion.

Urinary retention on an acute geriatric hospitalisation unit: prevalence, risk factors and the role of screening, an observational cohort study.

PURPOSE: Urinary retention (UR) is common in older patients. The aim of this observational cohort study was to measure the prevalence of UR in patients aged ≥ 75 years on admission to an acute geriatric hospitalisation unit and to determine which at risk group would benefit from screening. METHODS: Post-void residual volumes (PVR) were measured within 3 days of admission with an ultrasound bladder scan. Uni- and multivariable analysis were used to determine risk factors associated with PVR ≥ 150 and ≥ 300 millilitres. RESULTS: Ninety-four patients, mean age 84.6 years, were included. The male/female ratio was 0.7. Patients with PVR ≥ 150 (29.8%) had more urological comorbidities, symptoms of overflow incontinence, voiding difficulties, subtotal voiding, faecal impaction, urinary tract infection (UTI) and were more frequently referred because of urinary symptoms. Patients with PVR ≥ 300 lived less at home, had more urological comorbidities, dysuria, voiding difficulties, subtotal voiding, constipation, faecal impaction, UTI, detrusor relaxants, and were more frequently referred because of urinary symptoms. Voiding difficulties and referral because of urinary symptoms were independently associated with PVR ≥ 150. Not living at home, reporting subtotal voiding, constipation, and referral because of urinary symptoms were independently associated with PVR ≥ 300. CONCLUSION: Screening for UR on admission to an acute geriatric hospitalisation unit is most indicated in patients with urinary and defaecation problems. However, because the prevalence was high, because UR was also observed in patients without these problems, and history taking may be difficult, the threshold for PVR measurement in acutely ill geriatric patients should be low. TRIAL REGISTRATION: Clinicaltrials.gov NTC04715971, January 19, 2021 (retrospectively registered).

Geriatric co-management for cardiology patients in the hospital: A quasi-experimental study.

BACKGROUND/OBJECTIVES: Older patients admitted to cardiac care units often suffer functional decline. We evaluated whether a nurse-led geriatric co-management program leads to better functional status at hospital discharge. DESIGN: A quasi-experimental before-and-after study was performed between September 2016 and December 2018, with the main endpoint at hospital discharge and follow-up at 6 months. SETTING: Two cardiac care units of the University Hospitals Leuven. PARTICIPANTS: One hundred and fifty-one intervention and 158 control patients aged 75 years or older admitted for acute cardiovascular disease or transcatheter aortic valve implantation. INTERVENTION: A nurse from the geriatrics department performed a comprehensive geriatric assessment within 24 h of admission. The cardiac care team and geriatrics nurse drafted an interdisciplinary care plan, focusing on early rehabilitation, discharge planning, promoting physical activity, and preventing geriatric syndromes. The geriatrics nurse provided daily follow-up and coached the cardiac team. A geriatrician co-managed patients with complications. MEASUREMENTS: The primary outcome was functional status measured using the Katz Index for independence in activities of daily living (ADL; one-point difference was considered clinically relevant). Secondary outcomes included the incidence of ADL decline and complications, length of stay, unplanned readmissions, survival, and quality of life. RESULTS: The mean age of patients was 85 years. Intervention patients had better functional status at hospital discharge (8.9, 95% CI = 8.7-9.3 versus 9.5, 95% CI = 9.2-9.9; p = 0.019) and experienced 18% less functional decline during hospitalization (25% vs. 43%, p = 0.006). The intervention group experienced significantly fewer cases of delirium and obstipation during hospitalization, and significantly fewer nosocomial infections. At 6-month follow-up, patients had significantly better functional status and quality of life. There were no differences regarding length of stay, readmissions, or survival. CONCLUSION: This first nurse-led geriatric co-management program for frail patients on cardiac care units was not effective in improving functional status, but significantly improved secondary outcomes.

A retrospective observational study of enhanced recovery after surgery in older patients undergoing elective colorectal surgery.

BACKGROUND: Enhanced recovery programs (ERPs) in colorectal surgery have demonstrated beneficial effects on postoperative complications, return of bowel function, length of stay, and costs, without increasing readmissions or mortality. However, ERPs were not specifically designed for older patients and feasibility in older patients has been questioned. AIM: The aim of this study was to assess ERP adherence and outcomes in older patients and to identify risk factors for postoperative complications and prolonged length of stay. METHOD: Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017. RESULTS: Ninety-six patients were included. Adherence rates were above 80% in 18 of 21 ERP interventions considered. The lowest adherence rates were noted for preoperative carbohydrate loading and cessation of intravenous fluids. Postoperative complications (Clavien-Dindo ≥2) and prolonged postoperative length of stay (>75th percentile) were observed in 39.6% and 26.3%, respectively. Median length of stay was 7 days. The 30-day mortality, readmission and reoperation rates were 2.1%, 12.6% and 8.3%, respectively. Multivariable analysis indicated that polypharmacy and site of surgery were independent risk factors for postoperative complications, while higher age, American Society of Anesthesiologists class and preoperative radiotherapy were independent risk factors for prolonged postoperative length of stay. CONCLUSION: ERP adherence in older patients undergoing colorectal resection is high and ERP is therefore considered feasible. Postoperative complications and prolonged postoperative length of stay are common, so at risk patients should be targeted with tailored geriatric interventions.

Predicting hospitalisation-associated functional decline in older patients admitted to a cardiac care unit with cardiovascular disease: a prospective cohort study.

BACKGROUND: Up to one in three of older patients who are hospitalised develop functional decline, which is associated with sustained disability, institutionalisation and death. This study developed and validated a clinical prediction model that identifies patients who are at risk for functional decline during hospitalisation. The predictive value of the model was compared against three models that were developed for patients admitted to a general medical ward. METHODS: A prospective cohort study was performed on two cardiac care units between September 2016 and June 2017. Patients aged 75 years or older were recruited on admission if they were admitted for non-surgical treatment of an acute cardiovascular disease. Hospitalisation-associated functional decline was defined as any decrease on the Katz Index of Activities of Daily Living between hospital admission and discharge. Predictors were selected based on a review of the literature and a prediction score chart was developed based on a multivariate logistic regression model. RESULTS: A total of 189 patients were recruited and 33% developed functional decline during hospitalisation. A score chart was developed with five predictors that were measured on hospital admission: mobility impairment = 9 points, cognitive impairment = 7 points, loss of appetite = 6 points, depressive symptoms = 5 points, use of physical restraints or having an indwelling urinary catheter = 5 points. The score chart of the developed model demonstrated good calibration and discriminated adequately (C-index = 0.75, 95% CI (0.68-0.83) and better between patients with and without functional decline (chi2 = 12.8, p = 0.005) than the three previously developed models (range of C-index = 0.65-0.68). CONCLUSION: Functional decline is a prevalent complication and can be adequately predicted on hospital admission. A score chart can be used in clinical practice to identify patients who could benefit from preventive interventions. Independent external validation is needed.

Case report: an aortic aneurysm as cause of pseudoachalasia.

BACKGROUND: Pseudoachalasia is a rare disorder which has clinical, radiographic, and manometric findings that are often indistinguishable from primary achalasia. It is usually associated with malignancy. Few reports describe vascular compression as a cause of pseudoachalasia. CASE PRESENTATION: Here we present a case of a 84-year-old woman with anorexia, dysphagia and unintentional weight loss initially diagnosed as achalasia. Upon further investigation a rare cause of pseudoachalasia due to vascular compression of the esophagus was found. It could have been overlooked due to the fact that the initial work-out with a barium swallow, manometry and endoscopy was suggestive for primary achalasia. CONCLUSION: Particularly in older patients with a manometric diagnosis of achalasia, additional investigation to rule out pseudoachalasia is warranted. Although malignant involvement of the esophagus is the most common cause of pseudoachalasia, benign origins have also been described.

A systematic review of the intervention components, adherence and outcomes of enhanced recovery programmes in older patients undergoing elective colorectal surgery.

BACKGROUND: Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery. METHODS: Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines. RESULTS: Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%. CONCLUSIONS: ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence. TRIAL REGISTRATION: PROSPERO 2018 CRD42018084756 .

Conservative treatment of non-aneurysmal infectious aortitis: a case report and review of the literature.

BACKGROUND:  Non-aneurysmal infectious aortitis is a rare clinical entity with most often lethal complications when surgical intervention is delayed. OBJECTIVES:  This report describes the case of a non-aneurysmal infectious aortitis complicated with a penetrating aortic ulcer in an elderly woman, caused by a methicillin-sensitive Staphylococcus aureus. Surgery was deemed contra-indicated and treatment was limited to the administration of intravenous vancomycin (2 grams daily), followed by flucloxacillin (6 times 2 grams daily). She remains well after one year. METHODS: The Internet databases Medline and Embase were searched. Articles were selected based on relevanceof abstract, article type and impact of the journal. RESULTS:  A literature review addresses current insights in the pathogenesis, diagnosis, and treatment of non-aneurysmal infectious aortitis.

Geriatric CO-mAnagement for Cardiology patients in the Hospital (G-COACH): study protocol of a prospective before-after effectiveness-implementation study.

INTRODUCTION: Although the majority of older patients admitted to a cardiology unit present with at least one geriatric syndrome, guidelines on managing heart disease often do not consider the complex needs of frail older patients. Geriatric co-management has demonstrated potential to improve functional status, and reduce complications and length of stay, but evidence on the effectiveness in cardiology patients is lacking. This study aims to determine if geriatric co-management is superior to usual care in preventing functional decline, complications, mortality, readmission rates, reducing length of stay and improving quality of life in older patients admitted for acute heart disease or for transcatheter aortic valve implantation, and to identify determinants of success for geriatric co-management in this population. METHODS AND ANALYSIS: This prospective quasi-experimental before-and-after study will be performed on two cardiology units of the University Hospitals Leuven in Belgium in patients aged ≥75 years. In the precohort (n=227), usual care will be documented. A multitude of implementation strategies will be applied to allow for successful implementation of the model. Patients in the after cohort (n=227) will undergo a comprehensive geriatric assessment within 24 hours of admission to stratify them into one of three groups based on their baseline risk for developing functional decline: low-risk patients receive proactive consultation, high-risk patients will be co-managed by the geriatric nurse to prevent complications and patients with acute geriatric problems will receive an additional medication review and co-management by the geriatrician. ETHICS AND DISSEMINATION: The study protocol was approved by the Medical Ethics Committee UZ Leuven/KU Leuven (S58296). Written voluntary (proxy-)informed consent will be obtained from all participants at the start of the study. Dissemination of results will be through articles in scientific and professional journals both in English and Dutch and by conference presentations. TRIAL REGISTRATION NUMBER: NCT02890927.

Quality indicators for in-hospital geriatric co-management programmes: a systematic literature review and international Delphi study.

OBJECTIVE: To find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes. DESIGN: An international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers). SETTING: Western Europe and the USA. PARTICIPANTS: Thirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate). MEASURES: Participants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method. RESULTS: In the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications. CONCLUSION: The indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Feasibility of optimizing pharmacotherapy in heart failure patients admitted to an acute geriatric ward: role of the clinical pharmacist.

PURPOSE: Heart failure is associated with high mortality and (re)hospitalization rates. Multidisciplinary teams involving pharmacists are effective in preventing disease-related adverse outcomes such as heart-failure-related hospitalizations. We aimed to investigate the impact of integrating clinical pharmacists into a multidisciplinary care team on drug therapies in geriatric heart failure patients. Additionally, we wished to standardize the clinical pharmacy intervention by developing a comprehensive algorithm. METHODS: A prospective feasibility study was conducted in which systematic pharmaceutical recommendations in a geriatric heart failure population were given. Inclusion criteria were admission to the acute geriatric ward, a minimum age of 75 years and a diagnosis of heart failure. The number of pharmaceutical recommendations, the acceptance rate by the treating physician and the patients' clinical tolerability of the recommendations were registered. Six months after discharge, the general practitioner was contacted to determine drug therapy and heart-failure-related clinical outcomes. We developed a comprehensive algorithm to provide a structured, step-by-step approach for the pharmacotherapeutic evaluation of older heart failure patients. RESULTS: Thirty patients were included over a 5-month period; one patient dropped out. Sixty-one pharmaceutical recommendations were formulated for the treating physicians of which 43 were accepted. Five recommendations were not tolerated by the patients. The majority of the recommendations regarded diuretic therapy. The final algorithm was considered to contain the basic items needed to provide a comprehensive pharmacotherapeutic evaluation. CONCLUSIONS: A clinical pharmacist can play an important role in the optimization of therapy for HF patients in a geriatric ward. TRIAL REGISTRATION: Clinicaltrials.gov NCT02149940.

Value of geriatric screening and assessment in predicting postoperative complications in patients older than 70 years undergoing surgery for colorectal cancer.

OBJECTIVES: This study examines the association between geriatric screening and geriatric assessment (GA) and the risk of 30-day postoperative complications (30d-POCs) in older patients undergoing surgery for colorectal cancer (CRC). MATERIALS AND METHODS: Patients were identified from a prospectively collected database (2009-2015). All patients underwent geriatric screening with the G8 screening tool and the Flemish version of the Triage Risk Screening Tool (fTRST). The patients with an abnormal G8 score (G8≤14) received a GA, including living situation, basic and instrumental activities of daily living (ADL and I-ADL), falls, fatigue, cognition, depression, nutrition, comorbidities, and polypharmacy. 30d-POCs were retrospectively collected from the medical records and classified into Clavien-Dindo severity grades. The primary endpoint was the occurrence of Clavien-Dindo grade 2 and above (CD≥2) 30d-POCs. To identify predictive variables, logistic regression analyses were used. RESULTS: 190 patients, aged ≥70years, were included. Seventy-eight (41.1%) had CD≥2 30d-POCs, and the 30-day mortality was 1.6%. In univariable logistic regressions, the following variables were associated with CD≥2 30d-POCs (PWald<0.05): age, G8, ECOG-performance status (ECOG-PS), tumor location, and surgical approach. Age and surgical approach independently predicted 30d-POCs. In the G8≤14 patients (receiving a complete GA, n=115), ADL was the only GA variable associated with CD≥2 30d-POCs. CONCLUSION: In this study examining the predictive value of geriatric screening and GA in predicting CD≥2 30d-POCs, the G8 screening tool was associated in univariable analysis, but did not remain in multivariable analysis. In the G8≤14 group receiving GA, ADL was the only predictive GA variable.

Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis.

Background: geriatric consultation teams have failed to impact clinical outcomes prompting geriatric co-management programmes to emerge as a promising strategy to manage frail patients on non-geriatric wards. Objective: to conduct a systematic review of the effectiveness of in-hospital geriatric co-management. Data sources: MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to 6 May 2016. Reference lists, trial registers and PubMed Central Citations were additionally searched. Study selection: randomised controlled trials and quasi-experimental studies of in-hospital patients included in a geriatric co-management study. Two investigators performed the selection process independently. Data extraction: standardised data extraction and assessment of risk of bias were performed independently by two investigators. Results: twelve studies and 3,590 patients were included from six randomised and six quasi-experimental studies. Geriatric co-management improved functional status and reduced the number of patients with complications in three of the four studies, but studies had a high risk of bias and outcomes were measured heterogeneously and could not be pooled. Co-management reduced the length of stay (pooled mean difference, -1.88 days [95% CI, -2.44 to -1.33]; 11 studies) and may reduce in-hospital mortality (pooled odds ratio, 0.72 [95% CI, 0.50-1.03]; 7 studies). Meta-analysis identified no effect on the number of patients discharged home (5 studies), post-discharge mortality (3 studies) and readmission rate (4 studies). Conclusions: there was low-quality evidence of a reduced length of stay and a reduced number of patients with complications, and very low-quality evidence of better functional status as a result of geriatric co-management.

Functional decline in older patients with cancer receiving chemotherapy: A multicenter prospective study.

OBJECTIVES: This study aims to evaluate the evolution of functional status (FS) 2 to 3months after initiation of chemotherapy, to identify factors associated with functional decline during chemotherapy treatment and to investigate the prognostic value of functional decline for overall survival (OS). PATIENTS AND METHODS: Patients ≥70years with a malignant tumor were included when chemotherapy was initiated. All patients underwent a geriatric assessment (GA) including FS measured by Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). FS of patients was followed by repeating ADL and IADL to identify functional decline. RESULTS: From 10/2009 until 07/2011, 439 patients were included. At follow-up, ADL and IADL data were available for 387 patients. Functional decline in ADL and IADL was observed in 19.9% and 41.3% of the patients respectively. In multivariable logistic regression analysis, baseline factors associated with decline in ADL are abnormal nutritional status (OR:2.02) and IADL dependency (OR:1.76). Oncological setting (disease progression/relapse vs new diagnosis) (OR:0.59) is the only determinant of decline in IADL. Functional decline in ADL is strongly prognostic for OS (logrank p-value<.0001; Wilcoxon p-value<.0001) with HR 2.34 and functional decline in IADL is also prognostic for OS but less prominent with HR 1.25. CONCLUSIONS: Functional decline occurs in about a third of older patients with cancer receiving chemotherapy and is associated with GA components. It strongly predicts survival, the most prominent for ADL. This knowledge can be used to identify older persons with cancer receiving chemotherapy eligible for interventions to prevent functional decline.

The impact of frailty on postoperative outcomes in individuals aged 65 and over undergoing elective surgery for colorectal cancer: A systematic review.

Colorectal cancer surgery is frequently performed in the older population. Many older persons have less physiological reserves and are thus more susceptible to adverse postoperative outcomes. Therefore, it seems important to distinguish the fit patients from the more vulnerable or frail. The aim of this review is to examine the evidence regarding the impact of frailty on postoperative outcomes in older patients undergoing surgery for colorectal cancer. A systematic literature search of Medline Ovid was performed focusing on studies that examined the impact of frailty on postoperative outcomes after colorectal surgery in older people aged ≥65years. The methodological quality of the studies was evaluated using the MINORS quality assessment. Five articles, involving four studies and 486 participants in total, were included. Regardless of varying definitions of frailty and postoperative outcomes, the frail patients had less favourable outcomes in all of the studies. Compared to the non-frail group, the frail group had a higher risk of developing moderate to severe postoperative complications, had longer hospital stays, higher readmission rates, and decreased long-term survival rates. The results of this systematic review suggest the importance of assessing frailty in older persons scheduled for colorectal surgery because frailty is associated with a greater risk of postoperative adverse outcomes. We conclude that, although there is no consensus on the definition of frailty, assessing frailty in colorectal oncology seems important to determine operative risks and benefits and to guide perioperative management.