Recognition of cognitive dysfunction in hospitalised older patients: a flash mob study.

BACKGROUND: It is important that healthcare professionals recognise cognitive dysfunction in hospitalised older patients in order to address associated care needs, such as enhanced involvement of relatives and extra cognitive and functional support. However, studies analysing medical records suggest that healthcare professionals have low awareness of cognitive dysfunction in hospitalised older patients. In this study, we investigated the prevalence of cognitive dysfunction in hospitalised older patients, the percentage of patients in which cognitive dysfunction was recognised by healthcare professionals, and which variables were associated with recognition. METHODS: A multicentre, nationwide, cross-sectional observational study was conducted on a single day using a flash mob study design in thirteen university and general hospitals in the Netherlands. Cognitive function was assessed in hospitalised patients aged ≥ 65 years old, who were admitted to medical and surgical wards. A Mini-Cog score of < 3 out of 5 indicated cognitive dysfunction. The attending nurses and physicians were asked whether they suspected cognitive dysfunction in their patient. Variables associated with recognition of cognitive dysfunction were assessed using multilevel and multivariable logistic regression analyses. RESULTS: 347 of 757 enrolled patients (46%) showed cognitive dysfunction. Cognitive dysfunction was recognised by attending nurses in 137 of 323 patients (42%) and by physicians in 156 patients (48%). In 135 patients (42%), cognitive dysfunction was not recognised by either the attending nurse or physician. Recognition of cognitive dysfunction was better at a lower Mini-Cog score, with the best recognition in patients with the lowest scores. Patients with a Mini-Cog score < 3 were best recognised in the geriatric department (69% by nurses and 72% by physicians). CONCLUSION: Cognitive dysfunction is common in hospitalised older patients and is poorly recognised by healthcare professionals. This study highlights the need to improve recognition of cognitive dysfunction in hospitalised older patients, particularly in individuals with less apparent cognitive dysfunction. The high proportion of older patients with cognitive dysfunction suggests that it may be beneficial to provide care tailored to cognitive dysfunction for all hospitalised older patients.

The effect of prehabilitation on long-term survival and hospital admissions in older patients undergoing elective colorectal cancer surgery.

INTRODUCTION: There is a growing body of evidence for a beneficial effect of prehabilitation on short-term outcomes after colorectal cancer (CRC) surgery in older patients. However, long-term effects on survival or hospital admissions have not been investigated. This study reports these long-term outcomes from a previously published observational cohort study. METHODS: We compared patients ≥75 years who received elective CRC surgery in Reinier de Graaf Hospital before (2010-2013: standard care) and after implementation of a multimodal prehabilitation program (2014-2015; prehabilitation). With a six-year follow-up period, we analyzed survival using the Kaplan-Meier method and the occurrence of one or more hospital admissions using logistic regression analyses. RESULTS: Overall, 137 patients were included in the standard care group and 86 patients in the prehabilitation group. There were no differences in patients, tumor and treatment characteristics. After six years, 51.1% in the standard care group and 59.3% in the prehabilitation group (p = 0.167) were still alive. When corrected for confounders in the prehabilitation group less patients had one or more hospital admissions during follow-up (odds ratio (OR) 0.43 (95% CI 0.24-0.77). CONCLUSIONS: Unfortunately these limited historical cohorts did not allow for strong conclusions concerning long-time survival. However, after prehabilitation less patients had hospital admissions during follow up. Hopefully, this first study into the long-term effects of multimodal prehabilitation will trigger more future research.

Age-specific impact of comorbidity on postoperative outcomes in older patients with colorectal cancer.

INTRODUCTION: Age and comorbidity are considered the strongest predictors for adverse events after colorectal cancer (CRC) surgery. We aimed to study the interaction of age and comorbidity and to gain better insight in options to improve care for the growing group of older patients. MATERIALS AND METHODS: We included all patients ≥70 years undergoing elective surgery for non-metastatic CRC between 2011 and 2019 in the Netherlands. Baseline characteristics, surgical and non-surgical complications, readmission, and short-term mortality were collected from the Dutch Colorectal Audit (DCRA). The cohort was stratified by 70-79, 80-89, and ≥ 90 years. Comorbidity prevalence and postoperative outcomes were determined per age group. We analyzed the interaction (age-group*comorbidity) with all outcomes using multivariate logistic regression analysis. Age-stratified analysis was indicated if the interaction was significant. RESULTS: We included 25,727 patients of 70-79 years, 12,198 patients of 80-89 years, and 713 of ≥90 years. Non-surgical complications and mortality increased with older age, while surgical complications significantly decreased. However, the association of a Charlson Comorbidity Index (CCI) score ≥ 3, cardiovascular, and cardiopulmonary disease with adverse postoperative outcome decreased with older age. For example, the odds ratio (OR) of a CCI score ≥ 3 for non-surgical complications was 1.79 (confidence interval [CI] 95% 1.66-1.94), 1.50 (CI 95% 1.36-1.65), and 1.21 (CI 95% 0.80-1.81) for, respectively, 70-79, 80-89, and ≥ 90 years. DISCUSSION: The rate of non-surgical complications after CRC surgery increased with older age, although older age itself became less associated with comorbidity. Perhaps risk assessment in the oldest patients should shift towards other predictors, such as frailty.

Differences in characteristics and outcomes of older patients hospitalized for COVID-19 after introduction of vaccination.

PURPOSE: The aim of the present study was to investigate characteristics and outcomes in vaccinated and unvaccinated older patients hospitalized for COVID-19 infection. METHODS: A retrospective multicentre cohort study among patients aged ≥70 years hospitalized for COVID-19 infection. RESULTS: 263 vaccinated and 82 unvaccinated patients were included. Vaccinated patients were older (median age 79 vs. 76 years; p < 0.001), more patients were male (66.2% vs. 53.7%; p = 0.040), had more comorbidities [median Charlson Comorbidity Index (CCI) 2 vs. 1; p 0.016] and were frailer [Clinical Frailty Scale (CFS) ≥ 4 68% vs. 49%; p 0.015]. Vaccinated patients were admitted earlier after symptom onset (median 5 days vs. 7 days) but were equally ill at time of hospital admission. After correction for frailty, comorbidity and disease severity, risk of in-hospital mortality was three times lower for vaccinated patients (HR 0.30 95% CI 0.16-0.56; p < 0.001) compared to unvaccinated patients. CONCLUSION: Vaccinated patients had lower risk of in-hospital mortality than unvaccinated patients with COVID-19 infection. These findings suggest that vaccinated patients benefit from the protective effect of the vaccine against death during hospital stay, outweighing the increased mortality risk that is associated with older age, greater frailty and more numerous comorbidities. This could be an encouragement for older people to receive age-appropriate vaccines, although no definite conclusions can be drawn for this was no intervention study.

Preparing for future pandemics: frailty associates with mortality in hospitalised older people during the entire COVID-19 pandemic, a Dutch multicentre cohort study.

PURPOSE: Viral mutations and improved prevention or treatment options may have changed the association of frailty with mortality throughout the COVID-19 pandemic. We investigated how associations of frailty with in-hospital mortality changed throughout the pandemic in older people hospitalised for COVID-19. METHODS: The COVID-OLD study included COVID-19 patients aged ≥ 70 years hospitalised during the first (early 2020), second (late 2020), third (late 2021) or fourth wave (early 2022). Based on the clinical frailty scale, patients were categorised as fit (1-3), pre-frail (4-5) or frail (6-9). Associations of frailty with in-hospital mortality were assessed with pairwise comparisons with fit as reference category and modelled using binary logistic regression adjusted for age and sex. RESULTS: This study included 2362 patients (mean age 79.7 years, 60% men). In the first wave, in-hospital mortality was 46% in patients with frailty and 27% in fit patients. In-hospital mortality decreased in each subsequent wave to 25% in patients with frailty and 11% in fit patients in the fourth wave. After adjustments, an overall higher risk of in-hospital mortality was found in frail (OR 2.26, 95% CI: 1.66-3.07) and pre-frail (OR 1.73, 95% CI: 1.27-2.35) patients compared to fit patients, which did not change over time (p for interaction = 0.74). CONCLUSIONS: Frailty remained associated with a higher risk of in-hospital mortality throughout the entire COVID-19 pandemic, although overall in-hospital mortality rates decreased. Frailty therefore remains a relevant risk factor in all stages of a pandemic and is important to consider in prevention and treatment guidelines for future pandemics.