Assessment of Frailty and Risk of Chemotherapy Toxicity at a Geriatric-Oncology Multidisciplinary Clinic.

BACKGROUND: Multidisciplinary Geriatric-Oncology (GO-MDC) clinic performed comprehensive geriatric assessment (CGA) to determine frailty and chemotherapy toxicity risk. METHOD: Retrospective cohort study of patients ≥65 years seen between April 2017 to March 2022. We compared Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) to CGA as a determinant of frailty and risk of toxicity from chemotherapy. RESULTS: Mean age of the 66 patients was 79 years. Eighty-five percent were Caucasian. Predominant cancers were breast (30%), and gynecological (26%). One-third were stage 4. The CGA identified fit (35%), vulnerable (48%), and frail (17%) patients whereas ECOG-PS classified 80% as fit. CGA assessed 57% of ECOG-fit patients as vulnerable or frail (p<0.001). High chemotherapy toxicity risk using CGA was 41% and using ECOG was 17% (p=0.002). CONCLUSION: At GO-MDC, CGA was a better predictor of frailty and toxicity risk than ECOG-PS. Treatment modification was recommended in one-third of patients.

Impact of Geriatric Trauma Co-Management on 1-Year Mortality in Older Adults with Multiple Rib Fractures.

BACKGROUND: Rib fractures in older adults are associated with higher morbidity and mortality. Geriatric trauma co-management programs have looked at in-hospital mortality but not long-term outcomes. METHODS: A retrospective study of multiple rib fracture patients 65 years and older (n=357), admitted from September 2012 to November 2014 comparing Geriatric trauma co-management (GTC) vs Usual Care by trauma surgery (UC). The primary outcome was 1-year mortality. RESULTS: 38.9% (139) were cared for by GTC. Compared to the UC, GTC patients were older (81.6±8.6 years vs 79±8.5) and had more comorbidities (Charlson 2.8±1.6 vs 2.2±1.6). GTC patients had 46% less chance of dying in 1-year compared to UC (HR 0.54, 95% CI [0.33-0.86]).  Conclusions: GTC showed a significant reduction in 1-year mortality even though patients were overall older and more comorbid. This shows multidisciplinary teams are crucial to patient outcomes and should continue to be further explored.

Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs.

BACKGROUND: Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs. METHODS: Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration). RESULTS: All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group. CONCLUSIONS: A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.

A Model of Care to Improve Survival of Older Trauma Patients: Geriatrics Comanagement.

BACKGROUND: Trauma patients older than 80 years of age have higher mortality rates compared to younger peers. No studies have investigated the effectiveness of geriatrics comanagement on mortality in general trauma. METHODS: A retrospective cohort study from 2015 to 2016 comparing overall and inpatient mortality in a geriatrics trauma comanagement (GTC) program versus usual care (UC). Demographic and outcome measures were obtained from the trauma registry at an 11-bed trauma critical care unit within a 719-bed Level 1 Trauma Center. One thousand five hundred and seventy two patients, 80 years and older, with an admitting trauma diagnosis were evaluated. Primary outcome was in-hospital mortality and overall mortality (defined as inpatient death or discharge to hospice). Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, discharge location, and medical complications. RESULTS: Three hundred and forty six patients (22%) were placed in the GTC program. Overall mortality was lower in the GTC (4.9%) when compared with UC (11.9%), representing a 57% reduction (95% odds ratio [OR] confidence interval [CI] 0.24-0.75, p value = .0028). There was a 7.42% hospital mortality rate in the UC group compared to 2.6% in the GTC group (95% CI 0.21-0.92, p value = .0285), representing a 56% decrease in in-hospital mortality. GTC patients had a longer mean LOS (6.4 days vs 5.3 days, p value < .0001). More GTC patients were sent to inpatient rehabilitation facilities or skilled nursing facilities (80% vs 60%, p value < .0001). CONCLUSION: Geriatrics trauma comanagement of trauma patients above the age of 80 may reduce mortality and deserves formal study.

Cardiac surgery as a stressor and the response of the vulnerable older adult.

In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including "cardiac surgery, frailty, and aged" in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes.