A consensus statement on minimum operational standards for geriatric emergency care in Belgium: a modified Delphi study.

BACKGROUND: As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium. METHODS: A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards. RESULTS: Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards). CONCLUSIONS: This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries.

Flanders Nursing Home (FLANH) project: Protocol of a multicenter longitudinal observational study on staffing, work environment, rationing of care, and resident and care worker outcomes.

BACKGROUND: While the demand for high quality of care in nursing homes is rising, it is becoming increasingly difficult to recruit and retain qualified care workers. To date, evidence regarding key organizational factors such as staffing, work environment, and rationing of care, and their relationship with resident and care worker outcomes in nursing homes is still scarce. Therefore, the Flanders Nursing Home (FLANH) project aims to comprehensively examine these relationships in order to contribute to the scientific knowledge base needed for optimal quality of care and workforce planning in nursing homes. METHODS: FLANH is a multicenter longitudinal observational study in Flemish nursing homes based on survey and registry data that will be collected in 2023 and 2025. Nursing home characteristics and staffing variables will be collected through a management survey, while work environment variables, rationing of care, and care worker characteristics and outcomes will be collected through a care worker survey. Resident characteristics and outcomes will be retrieved from the Belgian Resident Assessment Instrument for long-Term Care Facilities (BelRAI LTCF) database. Multilevel regression analyses will be applied to examine the relationships between staffing variables, work environment variables, and rationing of care and resident and care worker outcomes. CONCLUSION: This study will contribute to a comprehensive understanding of the nursing home context and the interrelated factors influencing residents and care workers. The findings will inform the decision-making of nursing home managers and policymakers, and evidence-based strategies to optimize quality of care and workforce planning in nursing homes.

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.

End-of-Life Care in the Last Three Months before Death in Older Patients with Cancer in Belgium: A Large Retrospective Cohort Study Using Data Linkage.

This study aims to describe end-of-life (EOL) care in older patients with cancer and investigate the association between geriatric assessment (GA) results and specialized palliative care (SPC) use. Older patients with a new cancer diagnosis (2009-2015) originally included in a previous multicentric study were selected if they died before the end of follow-up (2019). At the time of cancer diagnosis, patients underwent geriatric screening with Geriatric 8 (G8) followed by GA in case of a G8 score ≤14/17. These data were linked to the cancer registry and healthcare reimbursement data for follow-up. EOL care was assessed in the last three months before death, and associations were analyzed using logistic regression. A total of 3546 deceased older patients with cancer with a median age of 79 years at diagnosis were included. Breast, colon, and lung cancer were the most common diagnoses. In the last three months of life, 76.3% were hospitalized, 49.1% had an emergency department visit, and 43.5% received SPC. In total, 55.0% died in the hospital (38.5% in a non-palliative care unit and 16.4% in a palliative care unit). In multivariable analyses, functional and cognitive impairment at cancer diagnosis was associated with less SPC. Further research on optimizing EOL healthcare utilization and broadening access to SPC is needed.

Long-term health-care utilisation in older patients with cancer and the association with the Geriatric 8 screening tool: a retrospective analysis using linked clinical and population-based data in Belgium.

BACKGROUND: Little evidence is available on the long-term health-care utilisation of older patients with cancer and whether this is associated with geriatric screening results. We aimed to evaluate long-term health-care utilisation among older patients after cancer diagnosis and the association with baseline Geriatric 8 (G8) screening results. METHODS: For this retrospective analysis, we included data from three cohort studies for patients (aged ≥70 years) with a new cancer diagnosis who underwent G8 screening between Oct 19, 2009 and Feb 27, 2015, and who survived more than 3 months after G8 screening. The clinical data were linked to cancer registry and health-care reimbursement data for long-term follow-up. The occurrence of outcomes (inpatient hospital admissions, emergency department visits, use of intensive care, contacts with general practitioner [GP], contacts with a specialist, use of home care, and nursing home admissions) was assessed in the 3 years after G8 screening. We assessed the association between outcomes and baseline G8 score (normal score [>14] or abnormal [≤14]) using adjusted rate ratios (aRRs) calculated from Poisson regression and using cumulative incidence calculated as a time-to-event analysis with the Kaplan-Meier method. FINDINGS: 7556 patients had a new cancer diagnosis, of whom 6391 patients (median age 77 years [IQR 74-82]) met inclusion criteria and were included. 4110 (64·3%) of 6391 patients had an abnormal baseline G8 score (≤14 of 17 points). In the first 3 months after G8 screening, health-care utilisation peaked and then decreased over time, with the exception of GP contacts and home care days, which remained high throughout the 3-year follow-up period. Compared with patients with a normal baseline G8 score, patients with an abnormal baseline G8 score had more hospital admissions (aRR 1·20 [95% CI 1·15-1·25]; p<0·0001), hospital days (1·66 [1·64-1·68]; p<0·0001), emergency department visits (1·42 [1·34-1·52]; p<0·0001), intensive care days (1·49 [1·39-1·60]; p<0·0001), general practitioner contacts (1·19 [1·17-1·20]; p<0·0001), home care days (1·59 [1·58-1·60]; p<0·0001), and nursing home admissions (16·7% vs 3·1%; p<0·0001) in the 3-year follow-up period. At 3 years, of the 2281 patients with a normal baseline G8 score, 1421 (62·3%) continued to live at home independently and 503 (22·0%) had died. Of the 4110 patients with an abnormal baseline G8 score, 1057 (25·7%) continued to live at home independently and 2191 (53·3%) had died. INTERPRETATION: An abnormal G8 score at cancer diagnosis was associated with increased health-care utilisation in the subsequent 3 years among patients who survived longer than 3 months. FUNDING: Stand up to Cancer, the Flemish Cancer Society.

A survey on the availability of geriatric-friendly protocols, equipment and physical environment across emergency departments in Flanders, Belgium.

BACKGROUND: The acquisition of geriatric-friendly resources is an important part of adapting emergency department (ED) care to the needs of vulnerable older patients. The aim of this study was to explore the availability of geriatric-friendly protocols, equipment and physical environment criteria in EDs and to identify related improvement opportunities. METHODS: The head nurse of 63 EDs in Flanders and Brussels Capital Region was invited to complete a survey in collaboration with the chief physician of the ED. The questionnaire was inspired by the American College of Emergency Physicians Geriatric ED Accreditation Program and explored the availability, relevance and feasibility of geriatric-friendly protocols, equipment and physical environment. Descriptive analyses were performed. A region-wide improvement opportunity was defined as a resource that was never to occasionally (0-50%) available on Flemish EDs and was scored (rather or very) relevant by at least 75% of respondents. RESULTS: A total of 32 questionnaires were analysed. The response rate was 50.8%. All surveyed resources were available in at least one ED. Eighteen out of 52 resources (34.6%) were available in more than half of EDs. Ten region-wide improvement opportunities were identified. These comprised seven protocols and three physical environment characteristics: 1) a geriatric approach initiated from physical triage, 2) elder abuse, 3) discharge to residential facility, 4) frequent geriatric pathologies, 5) access to geriatric specific follow-up clinics, 6) medication reconciliation, 7) minimising 'nihil per os' designation, 8) a large-face, analogue clock in each patient room, 9) raised toilet seats and 10) non-slip floors. CONCLUSIONS: Currently available resources supporting optimal ED care for older patients in Flanders are very heterogeneous. Researchers, clinicians and policy makers need to define which geriatric-friendly protocols, equipment and physical environment criteria should become region-wide minimum operational standards. Findings of this study are relevant to facilitate the development process of this endeavour.

Prognostic factors and prediction model for 1-year mortality after proximal humeral fracture.

The goal was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality after proximal humeral fracture (PHF). A clinical prediction model showed that the combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF. INTRODUCTION: Proximal humeral fractures (PFH) are the third most common major non-vertebral osteoporotic fractures in older persons and result in an increased mortality risk. The aim of this study was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality. METHODS: Retrospective study with 261 patients aged 65 and older who were treated for a PHF in University Hospitals Leuven between 2016 and 2018. Baseline variables including demographics, residential status, and comorbidities were collected. The primary outcome was 1-year mortality. A clinical prediction model was developed using LASSO regression and validated using split sample and bootstrapping methods. The discrimination and calibration were evaluated. RESULTS: Twenty-seven (10.3%) participants died within 1-year post-PHF. Pre-fracture independent ambulation (p < 0.001), living at home at time of fracture (p < 0.001), younger age (p = 0.006), higher BMI (p = 0.012), female gender (p = 0.014), and low number of comorbidities (p < 0.001) were predictors for 1-year survival. LASSO regression identified 6 stable predictors for a prediction model: age, gender, Charlson comorbidity score, BMI, cognitive impairment, and pre-fracture nursing home residency. The discrimination was 0.891 (95% CI, 0.833 to 0.949) in the training sample, 0.878 (0.792 to 0.963) in the validation sample and 0.756 (0.636 to 0.876) in the bootstrapping samples. A similar performance was observed for patients with and without surgery. The developed model demonstrated good calibration. CONCLUSIONS: The combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF. These findings can guide PHF treatment decisions.

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.

Linking clinical and population-based data in older patients with cancer in Belgium: Feasibility and clinical outcomes.

INTRODUCTION: Geriatric screening and geriatric assessment (GS/GA) have proven their benefits in the care for older patients with cancer. However, less is known about the predictive value of GS/GA for outcomes. To research this, clinical data on GS/GA can be enriched with population-based data. In this article we describe the methods and feasibility of data linkage, and first clinical outcomes (GS/GA results and overall survival). MATERIALS AND METHODS: A large cohort study consisting of patients aged ≥70 years with a new cancer diagnosis was established using linked data from clinical and population-based databases. Clinical data were derived from a previous prospective study where older patients with cancer were screened with G8, followed by GA in case of an abnormal result (GS/GA study; 2009-2015). These data were linked to cancer registration data from the Belgian Cancer Registry (BCR), reimbursement data of the health insurance companies (InterMutualistic Agency, IMA), and hospital discharge data (Technical Cell, TCT). Cox regression analyses were conducted to evaluate the prognostic value of the G8 geriatric screening tool. RESULTS: Of the 8067 eligible patients with a new cancer diagnosis, linkage of data from the GS/GA study and data from the BCR was successful for 93.7%, resulting in a cohort of 7556 patients available for the current analysis. Further linkage with the IMA and TCT database resulted in a cohort of 7314 patients (96.8%). Based on G8 geriatric screening, 67.9% of the patients had a geriatric risk profile. Malnutrition and functional dependence were the most common GA-identified risk factors. An abnormal baseline G8 score (≤14/17) was associated with lower overall survival (adjusted HR [aHR] = 1.62 [1.50-1.75], p < 0.001). DISCUSSION: Linking clinical and population-based databases for older patients with cancer has shown to be feasible. The GS/GA results at cancer diagnosis demonstrate the vulnerability of this population and the G8 score showed prognostic value for overall survival. The established cohort of almost 8000 patients with long-term follow-up will serve as a basis in the future for detailed analyses on long-term outcomes beyond survival.

Strategies to implement multifactorial falls prevention interventions in community-dwelling older persons: a systematic review.

BACKGROUND: One-third of the community-dwelling older persons fall annually. Guidelines recommend the use of multifactorial falls prevention interventions. However, these interventions are difficult to implement into the community. This systematic review aimed to explore strategies used to implement multifactorial falls prevention interventions into the community. METHODS: A systematic search in PubMed (including MEDLINE), CINAHL (EBSCO), Embase, Web of Science (core collection), and Cochrane Library was performed and updated on the 25th of August, 2022. Studies reporting on the evaluation of implementation strategies for multifactorial falls prevention interventions in the community setting were included. Two reviewers independently performed the search, screening, data extraction, and synthesis process (PRISMA flow diagram). The quality of the included reports was appraised by means of a sensitivity analysis, assessing the relevance to the research question and the methodological quality (Mixed Method Appraisal Tool). Implementation strategies were reported according to Proctor et al.'s (2013) guideline for specifying and reporting implementation strategies and the Taxonomy of Behavioral Change Methods of Kok et al. (2016). RESULTS: Twenty-three reports (eighteen studies) met the inclusion criteria, of which fourteen reports scored high and nine moderate on the sensitivity analysis. All studies combined implementation strategies, addressing different determinants. The most frequently used implementation strategies at individual level were "tailoring," "active learning," "personalize risk," "individualization," "consciousness raising," and "participation." At environmental level, the most often described strategies were "technical assistance," "use of lay health workers, peer education," "increasing stakeholder influence," and "forming coalitions." The included studies did not describe the implementation strategies in detail, and a variety of labels for implementation strategies were used. Twelve studies used implementation theories, models, and frameworks; no studies described neither the use of a determinant framework nor how the implementation strategy targeted influencing factors. CONCLUSIONS: This review highlights gaps in the detailed description of implementation strategies and the effective use of implementation frameworks, models, and theories. The review found that studies mainly focused on implementation strategies at the level of the older person and healthcare professional, emphasizing the importance of "tailoring," "consciousness raising," and "participation" in the implementation process. Studies describing implementation strategies at the level of the organization, community, and policy/society show that "technical assistance," "actively involving stakeholders," and "forming coalitions" are important strategies. TRIAL REGISTRATION: PROSPERO CRD42020187450.

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.

Stakeholders' experiences and perception on transitional care initiatives within an integrated care project in Belgium: a qualitative interview study.

BACKGROUND: In 2015, a plan for integrated care was launched by the Belgium government that resulted in the implementation of 12 integrated care pilot project across Belgium. The pilot project Zorgzaam Leuven consists of a multidisciplinary local consortium aiming to bring lasting change towards integrated care for the region of Leuven. This study aims to explore experiences and perceptions of stakeholders involved in four transitional care actions that are part of Zorgzaam Leuven. METHODS: This qualitative case study is part of the European TRANS-SENIOR project. Four actions with a focus on improving transitional care were selected and stakeholders involved in those actions were identified using the snow-ball method. Fourteen semi-structured interviews were conducted and inductive thematic analysis was performed. RESULTS: Professionals appreciated to be involved in the decision making early onwards either by proposing own initiatives or by providing their input in shaping actions. Improved team spirit and community feeling with other health care professionals (HCPs) was reported to reduce communication barriers and was perceived to benefit both patients and professionals. The actions provided supportive tools and various learning opportunities that participants acknowledged. Technical shortcomings (e.g. lack of integrated patient records) and financial and political support were identified as key challenges impeding the sustainable implementation of the transitional care actions. CONCLUSION: The pilot project Zorgzaam Leuven created conditions that triggered work motivation for HCPs. It supported the development of multidisciplinary care partnerships at the local level that allowed early involvement and increased collaboration, which is crucial to successfully improve transitional care for vulnerable patients.

The 20-valent pneumococcal conjugate vaccine (PCV20): expected added value.

OBJECTIVES: Currently existing pneumococcal vaccines have contributed to a major reduction in pneumococcal disease. However, there remains an unmet need for vaccine coverage of serotypes not included in PCV13 to further reduce the burden of disease. The objective of this review is to assess the potential impact of implementation of the investigational 20-valent pneumococcal conjugate vaccine (PCV20) in the childhood and adult immunization programme in Belgium and Europe. METHODS: A literature search was conducted to identify publications and surveillance reports concerning the effectiveness and safety of pneumococcal vaccines, epidemiological data on pneumococcal disease or serotype distribution dynamics after introduction of systematic vaccination. RESULTS: Serotypes included in PCV20 currently account for the majority of pneumococcal disease in Belgium and Europe. In Belgium, PCV20-serotypes accounted for 71.4% of invasive pneumococcal disease (IPD) cases across all age groups in 2019, of which 39.2% were caused by PCV20-non-PCV13-serotypes. In Europe, these seven serotypes accounted for 37,6% of IPD cases in 2018.  PCV20 has proven to be well tolerated in vaccine-naïve adults and elicits a substantial immune response against all serotypes included. CONCLUSION: Due to serotype replacement following the introduction of PCV7 and PCV13, a considerable proportion of pneumococcal disease is currently caused by PCV20-serotypes. PCV20 has the potential of preventing more pneumococcal disease in children and the adult population at risk than the existing conjugate vaccines. The available evidence on safety and immunogenicity of PCV20 is promising, but further research is needed to provide data about vaccine effectiveness, immune response duration and replacement phenomenon after introduction of PCV20.

Identifying vulnerable older adults at risk for functional decline in cardiac care wards: time to shift the paradigm.

OBJECTIVE: To determine whether routine screening with the Flemish version of the Triage Risk Screening Tool (fTRST) is a valid approach to determine which patients on cardiac care wards are at risk for inhospital functional decline and would benefit from geriatric expertise consultation. METHODS: A secondary data-analysis of the G-COACH before-cohort, describing patient profiles and routine care processes, in 189 older adults on two cardiac care wards in the University Hospitals Leuven between September 2016 and June 2017. Inhospital functional decline was defined as an increase of at least one point on the Katz Index of Activities of Daily Living or death between hospital admission and discharge. RESULTS: Nine in 10 patients had at least one geriatric syndrome and one-third developed functional decline. Based on the fTRST proposed cut-off of ≥2, 156 (82.5%) patients were at risk for functional decline (sensitivity of 95.2%, specificity of 23.8%, negative predictive value of 90.9% and Area Under the Curve of 0.60). Of the 156 'at risk' patients, 43 (27.6%) received a consultation by the geriatric consultation team after a median of four hospitalization days. A positive fTRST was not significantly related to geriatric consultations (x2 = 0.57; p = 0.45). CONCLUSION: The fTRST has a low discriminative value in identifying older cardiology patients at risk for functional decline. Given the high prevalence of geriatric syndromes, we propose a new paradigm were all older adults on cardiac care wards undergo a needs assessment upon hospital admission.

In-hospital rehabilitation with the Geriatric Activation Program Pellenberg improves functional performance in a heterogeneous geriatric population.

BACKGROUND: Regaining independent living can be challenging in patients undergoing inpatient geriatric rehabilitation. Given the paucity of evidence-based physiotherapy programs for this particular heterogeneous group, the Geriatric Activation Program Pellenberg (GAPP) was developed. PURPOSE: Investigate the evolution of functional performance, and predict detectable changes throughout 4 weeks of GAPP. Methods: Participants in this observational study (2017-2019) followed GAPP as part of their rehabilitation program. Functional balance (Berg balance scale (BBS)) and independence (Katz scale) were the primary outcomes, with gait speed, elbow and knee extension strength, cognitive processing speed, and mood as secondary outcomes. All outcomes were assessed at baseline, 2 weeks and 4 weeks later. Prediction analysis was conducted using logistic regression modeling. Previously reported minimal detectable change with 95% confidence interval (MDC95) was used as detectable change. RESULTS: We recruited 111 participants, with 83 completing 4 weeks of GAPP and all assessments. Over 4 weeks, all outcome measures showed a significant improvement (p ≤ .007). Detectable change was found for BBS (mean improvement of 12.8 points (95% CI: 10.9-14.8), MDC95 = 6.6) and gait speed (mean improvement of 0.24 m/s (95% CI: 0.19-0.29), MDC95 = 0.1 m/s). We found that baseline scores lower than 26 on the BBS (75% sensitivity, 65% specificity) and gait speed lower than 0.34 m/s (53% sensitivity, 81% specificity) were associated with participants achieving detectable change at 4 weeks on BBS and gait speed, respectively. CONCLUSION: Functional performance of a heterogeneous group of geriatric inpatients improved notably after 4 weeks of GAPP. Baseline scores on BBS and gait speed can partially predict detectable changes in functional performance.

Incidence of falls and fall-related injuries and their predictive factors in frail older persons with cancer: a multicenter study.

BACKGROUND: Falls and fall-related injuries are a major public health problem. Data on falls in older persons with cancer is limited and robust data on falls within those with a frailty profile are missing. The aim of this study is to investigate the incidence and predictive factors for falls and fall-related injuries in frail older persons with cancer. METHODS: This study is a secondary data analysis from data previously collected in a large prospective multicenter observational cohort study in older persons with cancer in 22 Belgian hospitals (November 2012-February 2015). Patients ≥70 years with a malignant tumor and a frailty profile based on an abnormal G8 score were included upon treatment decision and evaluated with a Geriatric Assessment (GA). At follow-up, data on falls and fall-related injuries were documented. RESULTS: At baseline 2141 (37.2%) of 5759 included patients reported at least one fall in the past 12 months, 1427 patients (66.7%) sustained an injury. Fall-related data of 3681 patients were available at follow-up and at least one fall was reported by 769 patients (20.9%) at follow-up, of whom 289 (37.6%) fell more than once and a fall-related injury was reported by 484 patients (62.9%). Fear of falling was reported in 47.4% of the patients at baseline and in 55.6% of the patients at follow-up. In multivariable analysis, sex and falls history in the past 12 months were predictive factors for both falls and fall-related injuries at follow-up. Other predictive factors for falls, were risk for depression, cognitive impairment, dependency in activities of daily living, fear of falling, and use of professional home care. CONCLUSION: Given the high number of falls and fall-related injuries and high prevalence of fear of falling, multifactorial falls risk assessment and management programs should be integrated in the care of frail older persons with cancer. Further studies with long-term follow-up, subsequent impact on cancer treatment and interventions for fall prevention, and integration of other important topics like medication and circumstances of a fall, are warranted. TRIAL REGISTRATION: B322201215495.

Functional status in older patients with cancer and a frailty risk profile: A multicenter observational study.

INTRODUCTION: Functional status (FS) and frailty are significant concerns for older adults, especially those with cancer. Data on FS (Activities of Daily Living [ADL]; Instrumental Activities of Daily Living [IADL]) and its evolution during cancer treatment in older patients and a frailty risk profile are scarce. Therefore, this study examines FS and its evolution in older patients with cancer and a frailty risk profile and investigates characteristics associated with functional decline. MATERIAL AND METHODS: This secondary data-analysis, focusing on FS, uses data from a large prospective multicenter observational cohort study. Patients ≥70 years with a solid tumor and a frailty risk profile based on the G8 screening tool (score ≤ 14) were included. A geriatric assessment was performed including evaluation of FS based on ADL and IADL. At approximately three months of follow-up, FS was reassessed. Univariable and multivariable logistic regression analyses were used to identify predictive factors for functional decline in ADL and IADL. RESULTS: Data on ADL and IADL were available at baseline and follow-up in 3388 patients. At baseline 1886 (55.7%) patients were dependent for ADL, whereas 2085 (61.5%) patients were dependent at follow-up. Functional decline was observed in 23.6% of patients. For IADL 2218 (65.5%) patients were dependent for IADL, whereas 2591 (76.5%) patients were dependent at follow-up. Functional decline in IADL was observed in 41.0% of patients. In multivariable analysis, disease stage III or IV, comorbidities, falls history in the past twelve months, and FS measured by IADL were predictive factors for functional decline in both ADL and IADL. Other predictive factors for functional decline in ADL were polypharmacy, Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) score 2-4, and cognitive impairment, and for functional decline in IADL were female sex, fatigue, and risk for depression. DISCUSSION: Functional impairments are frequent in older persons with cancer and a frailty risk profile, and several characteristics are identified that are significantly associated with functional decline. Therefore, FS is an essential part of the geriatric assessment which should be standard of care for this patient population. Next step is to proceed with directed interventions with the aim to limit the risk of functional decline as much as possible.

Integrated Care Components in Transitional Care Models from Hospital to Home for Frail Older Adults: A Systematic Review.

Introduction: Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit. Methods: This study is part of the European TRANS-SENIOR project. PubMed, CINAHL and Embase were searched for studies in English, German and Dutch that describe a TCM for frail older patients including both pre- and post-discharge components. Results: Seventeen studies, covering 15 TCMs were included. All TCMs describe a person-centred, tailored, pro-active and continuous transitional care service. Components like a small sized care team, intensive follow-up, shared decision making and informal caregiver involvement are likely to be associated with reduced hospital readmission and ED visits. Twenty-seven transitional care outcomes were reported: 19 service outcomes, six patient outcomes and two provider outcomes. Conclusion: Heterogeneity in content and outcomes complicates between-study comparison, yet several components were identified that improved care outcomes. Patient and provider outcomes should be included in future research.

The effect of a trAnSitional Pharmacist Intervention in geRiatric inpatients on hospital visits after dischargE (ASPIRE): Protocol for a randomized controlled trial.

BACKGROUND: Unplanned rehospitalizations occur frequently in older patients. Drug-related problems constitute a major and largely preventable cause with inappropriate prescribing being a substantial culprit. Solutions are needed to reduce this risk by targeting pharmacotherapy both during and after hospital stay. Therefore, we aim to perform a randomized controlled trial in geriatric inpatients to investigate the impact of a multifaceted clinical pharmacy intervention on health-related outcomes. METHODS/DESIGN: The study concerns a monocenter, non-blinded, randomized controlled trial that will take place at the acute geriatric wards of a large academic hospital. Patients being in a palliative stage with active therapy withdrawal or patients discharged to another ward within the same hospital or another hospital are excluded. In total, 828 patients will be randomized (1:1) to the usual care or intervention group. The multifaceted clinical pharmacy intervention comprises medication reconciliation at admission and discharge, medication review, patient/caregiver education, intensified communication with primary care providers and post-discharge follow-up, which also includes a telepharmacology service. The primary endpoint is defined as the time to an all-cause, unplanned hospital revisit within six months after discharge. Other health-related outcomes such as drug-related readmissions, quality of life and number of potentially inappropriate medications will be analyzed as secondary endpoints. Patient inclusion started in February 2021. DISCUSSION: This study will provide useful insights regarding the impact of clinical pharmacy interventions on geriatric wards with the goal to optimize health-related outcomes such as hospital revisits. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04617340.

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).