Objectives
To determine whether the Charlson Comorbidity Index (CCI) predicts short‐ and long‐term mortality.
Design
Prospective cohort study.
Setting
The medical department of two university ...hospitals and one community‐based hospital.
Participants
Acutely hospitalized individuals aged 65 and older with a mean age of 77.8 ± 7.9, 45.8% male (n = 1,313).
Measurements
In eligible persons, information on demographic characteristics, activities of daily living (modified Katz ADL Index score), and disease‐related measures was collected within 48 hours after admission. Follow‐up using self‐reporting questionnaires was performed at 3 months and 1 year. Functional decline was defined as a decline of at least 1 point on the modified Katz ADL Index score at 12 months from baseline. Mortality data at 3 months and 1 and 5 years were collected from the municipal database.
Results
Logistic regression analysis, adjusted for age and sex, showed that participants with a CCI of 5 or more had higher 3‐month (odds ratio (OR) = 3.6, 95% confidence interval (CI) = 2.1–6.4), 1‐year (OR = 7.1, 95% CI = 4.2–11.9), and 5‐year (OR = 52.4, 95% CI = 13.3–206.4) mortality than those with a CCI of 0. Participants with CCI scores between 1 and 4 also had greater mortality risk at 3 months and 1 and 5 years.
Conclusion
The CCI independently predicts short‐ and long‐term mortality in acutely ill hospitalized elderly adults.
Summary Comprehensive geriatric assessment (CGA) is done to detect vulnerability in elderly patients with cancer so that treatment can be adjusted accordingly; however, this process is time-consuming ...and pre-screening is often used to identify fit patients who are able to receive standard treatment versus those in whom a full CGA should be done. We aimed to assess which of the frailty screening methods available show the best sensitivity and specificity for predicting the presence of impairments on CGA in elderly patients with cancer. We did a systematic search of Medline and Embase, and a hand-search of conference abstracts, for studies on the association between frailty screening outcome and results of CGA in elderly patients with cancer. Our search identified 4440 reports, of which 22 publications from 14 studies, were included in this Review. Seven different frailty screening methods were assessed. The median sensitivity and specificity of each screening method for predicting frailty on CGA were as follows: Vulnerable Elders Survey-13 (VES-13), 68% and 78%; Geriatric 8 (G8), 87% and 61%; Triage Risk Screening Tool (TRST 1+; patient considered frail if one or more impairments present), 92% and 47%, Groningen Frailty Index (GFI) 57% and 86%, Fried frailty criteria 31% and 91%, Barber 59% and 79%, and abbreviated CGA (aCGA) 51% and 97%. However, even in case of the highest sensitivity, the negative predictive value was only roughly 60%. G8 and TRST 1+ had the highest sensitivity for frailty, but both had poor specificity and negative predictive value. These findings suggest that, for now, it might be beneficial for all elderly patients with cancer to receive a complete geriatric assessment, since available frailty screening methods have insufficient discriminative power to select patients for further assessment.
Older patients reaching ESRD have a higher risk of adverse health outcomes. We aimed to determine the association of functional and cognitive impairment and frailty with adverse health outcomes in ...patients reaching ESRD. Understanding these associations could ultimately lead to prediction models to guide tailored treatment decisions or preventive interventions.
We searched MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, PsycINFO, and COCHRANE for original studies published until February 8, 2016 reporting on the association of functional or cognitive impairment or frailty with adverse health outcome after follow-up in patients reaching ESRD either with or without RRT.
Of 7451 identified citations, we included 30 articles that reported on 35 associations. Mean age was >60 years old in 73% of the studies, and geriatric conditions were highly prevalent. Twenty-four studies (80%) reported on functional impairment, seven (23%) reported on cognitive impairment, and four (13%) reported on frailty. Mortality was the main outcome measure in 29 studies (97%), and one study assessed functional status trajectory. In 34 of 35 (97%) associations reported, functional or cognitive impairment or frailty was significantly and independently associated with adverse health outcomes. The majority of studies (83%) were conducted in selected patient populations, mainly patients on incident dialysis.
Functional and cognitive impairment and frailty in patients reaching ESRD are highly prevalent and strongly and independently associated with adverse health outcomes, and they may, therefore, be useful for risk stratification. More research into their prognostic value is needed.
The aim of this systematic review is to summarise all available data on the effect of a geriatric evaluation on the multidisciplinary treatment of older cancer patients, focussing on oncologic ...treatment decisions, the implementation of non-oncologic interventions and the impact on treatment outcome.
A systematic search in MEDLINE and EMBASE for studies on the effect of a geriatric evaluation on oncologic and non-oncologic treatment decisions and outcome for older cancer patients.
36 publications from 35 studies were included. After a geriatric evaluation, the oncologic treatment plan was altered in a median of 28% of patients (range 8–54%), primarily to a less intensive treatment option. Non-oncologic interventions were recommended in a median of 72% of patients (range 26–100%), most commonly involving social issues (39%), nutritional status (32%) and polypharmacy (31%). Effect on treatment outcome was varying, with a trend towards a positive effect on treatment completion (positive effect in 75% of studies) and treatment-related toxicity/ complications (55% of studies).
A geriatric evaluation affects oncologic and non-oncologic treatment and appears to improve treatment tolerance and completion for older cancer patients. Fine-tuning the decision-making process for this growing patient population will require more specific and robust data on the effect of a geriatric evaluation on relevant oncologic and non-oncologic outcomes such as survival and quality of life.
physicians are frequently confronted with the question whether cardiopulmonary resuscitation (CPR) is a medically appropriate treatment for older people. For physicians, patients and relatives, it is ...important to know the chance of survival and the functional outcome after CPR in order to make an informed decision.
a systematic search was performed in MEDLINE, Embase and Cochrane up to November 2012. Studies that were included described the chance of survival, the social status and functional outcome after in-hospital CPR in older people aged 70 years and above.
we identified 11,377 publications of which 29 were included in this review; 38.6% of the patients who were 70 years and older had a return of spontaneous circulation. More than half of the patients who initially survived resuscitation died in the hospital before hospital discharge. The pooled survival to discharge after in-hospital CPR was 18.7% for patients between 70 and 79 years old, 15.4% for patients between 80 and 89 years old and 11.6% for patients of 90 years and older. Data on social and functional outcome after surviving CPR were scarce and contradictory.
the chance of survival to hospital discharge for in-hospital CPR in older people is low to moderate (11.6-18.7%) and decreases with age. However, evidence about functional or social outcomes after surviving CPR is scarce. Prospective studies are needed to address this issue and to identify pre-arrest factors that can predict survival in the older people in order to define subgroups that could benefit from CPR.
To develop and internally validate prediction models for future hospital care utilization in patients with multiple chronic conditions.
Retrospective cohort study.
A teaching hospital in the ...Netherlands (542 beds).
All adult patients (n = 18.180) who received care at the outpatient clinic in 2017 for two chronic diagnoses or more (including oncological diagnoses) and who returned for hospital care or outpatient clinical care in 2018. Development and validation using a stratified random split-sample (n = 12.120 for development, n = 6.060 for internal validation).
≥2 emergency department visits in 2018, ≥1 hospitalization in 2018 and ≥12 outpatient visits in 2018.
Multivariable logistic regression with forward selection.
Evaluation of the models' performance showed c-statistics of 0.70 (95% CI 0.69-0.72) for the hospitalization model, 0.72 (95% CI 0.70-0.74) for the ED visits model and 0.76 (95% 0.74-0.77) for the outpatient visits model. With regard to calibration, there was agreement between lower predicted and observed probability for all models, but the models overestimated the probability for patients with higher predicted probabilities.
These models showed promising results for further development of prediction models for future healthcare utilization using data from local electronic health records. This could be the first step in developing automated alert systems in electronic health records for identifying patients with multimorbidity with higher risk for high healthcare utilization, who might benefit from a more integrated care approach.
Introduction.
Cancer societies, research cooperatives, and countless publications have urged the development of clinical trials that facilitate the inclusion of older patients and those with ...comorbidities. We set out to determine the characteristics of currently recruiting clinical trials with hematological patients to assess their inclusion and exclusion of elderly patients.
Methods.
The NIH clinical trial registry was searched on July 1, 2013, for currently recruiting phase I, II or III clinical trials with hematological malignancies. Trial characteristics and study objectives were extracted from the registry website.
Results.
Although 5% of 1,207 included trials focused exclusively on elderly or unfit patients, 69% explicitly or implicitly excluded older patients. Exclusion based on age was seen in 27% of trials, exclusion based on performance status was seen in 16%, and exclusion based on stringent organ function restrictions was noted in 51%. One‐third of the studies that excluded older patients based on age allowed inclusion of younger patients with poor performance status; 8% did not place any restrictions on organ function. Over time, there was a shift from exclusion based on age (p value for trend <.001) toward exclusion based on organ function (p = .2). Industry‐sponsored studies were least likely to exclude older patients (p < .001).
Conclusion.
Notably, 27% of currently recruiting clinical trials for hematological malignancies use age‐based exclusion criteria. Although physiological reserves diminish with age, the heterogeneity of the elderly population does not legitimize exclusion based on chronological age alone. Investigators should critically review whether sufficient justification exists for every exclusion criterion before incorporating it in trial protocols.
The purpose of this study was to determine the characteristics of currently recruiting clinical trials with hematological patients to assess inclusion and exclusion of elderly patients. Notably, 27% of currently recruiting clinical trials for hematological malignancies use age‐based exclusion criteria. Investigators should critically review whether sufficient justification exists for every exclusion criterion before incorporating it in trial protocols.
Decision aids have been overall successful in improving the quality of health decision making. However, it is unclear whether the impact of the results of using decision aids also apply to older ...people (aged 65+). We sought to systematically review randomized controlled trials (RCTs) and clinical controlled trials (CCTs) evaluating the efficacy of decision aids as compared to usual care or alternative intervention(s) for older adults facing treatment, screening or care decisions.
A systematic search of (1) a Cochrane review of decision aids and (2) MEDLINE, Embase, PsycINFO, Cochrane library central registry of studies and Cinahl. We included published RCTs/CCTs of interventions designed to improve shared decision making (SDM) by older adults (aged 65+) and RCTs/CCTs that analysed the effect of the intervention in a subgroup with a mean age of 65+. Based on the International Patient Decision aid Standards (IPDAS), the primary outcomes were attributes of the decision and the decision process. Other behavioral, health, and health system effects were considered as secondary outcomes. If data could be pooled, a meta-analysis was conducted. Data for which meta-analysis was not possible were synthesized qualitatively.
The search strategy yielded 11,034 references. After abstract and full text screening, 22 papers were included. Decision aids performed better than control resp. usual care interventions by increasing knowledge and accurate risk perception in older people (decision attributes). With regard to decision process attributes, decision aids resulted in lower decisional conflict and more patient participation.
This review shows promising results on the effectiveness of decision aids for older adults. Decision aids improve older adults' knowledge, increase their risk perception, decrease decisional conflict and seem to enhance participation in SDM. It must however be noted that the body of literature on the effectiveness of decision aids for older adults is still in its infancy. Only one decision aid was specifically developed for older adults, and the mean age in most studies was between 65 and 70, indicating that the oldest-old were not included. Future research should expand on the design, application and evaluation of decision aids for older, more vulnerable adults.
Background
Postoperative cognitive dysfunction (POCD) is a common complication in older patients with cancer and is associated with decreased quality of life and increased disability and mortality ...rates. Systemic inflammation resulting in neuroinflammation is considered important in the pathogenesis of POCD. The aim of this study was to explore the association between the early surgery‐induced inflammatory response and POCD within 3 months after surgery in older cancer patients.
Methods
Patients ≥65 years in need of surgery for a solid tumor were included in a prospective cohort study. Plasma levels of C‐reactive protein (CRP), interleukin‐1 beta (IL‐1β), IL‐6, IL‐10, and Neutrophil gelatinase‐associated lipocalin (NGAL) were measured perioperatively. Cognitive performance was assessed preoperatively and 3 months after surgery. POCD was defined as a decline in cognitive test scores of ≥25% on ≥2 of five tests within the different cognitive domains of memory, executive functioning, and information processing speed. Logistic regression analysis was performed.
Results
POCD was observed in 44 (17.7%) of 248 included patients. Age >75, preoperative Mini‐Mental State Examination (MMSE) score ≤26 and major surgery were independent significant predictors for POCD. In multivariate logistic regression analysis, no significant associations were shown between the early surgery‐induced inflammatory response and either POCD or decline within the different cognitive domains.
Conclusions
This study shows that one out of six older patients with cancer developed POCD within 3 months after surgery. The early surgery‐induced inflammatory response was neither associated with POCD, nor with decline in the separate cognitive domains. Further research is necessary for better understanding of the complex etiology of POCD.
Background
Frailty is an important concept for risk stratification in clinical practice, but it is hardly acknowledged at all in mental healthcare settings. This paper aims to assess the impact of ...frailty on the course of depression and anxiety, and the impact of these affective disorders on the course of frailty.
Methods
Lifelines, a prospective population‐based cohort study, evaluated 167,729 people living in the northern Netherlands. Frailty was based on the deficit accumulation model, which resulted in a 60‐item frailty index (FI) at baseline and a 35‐item FI at baseline and 5‐year follow‐up. Current depressive and anxiety disorders were assessed with the Mini International Neuropsychiatric Interview according to DSM‐IV criteria. Bidirectional associations between frailty and affective disorders were investigated using separate multivariable regression analyses in younger (<60 years) and older adults (≥60 years).
Results
The FI was associated with the onset of a depressive disorder (younger adults: odds ratio OR = 1.12; 95% confidence interval CI 1.11–1.13; older adults: OR = 1.13; 95% CI 1.09–1.16) as well as any anxiety disorder (younger adults: OR = 1.10; 95% CI 1.09–1.10; older adults: OR = 1.07; 95% CI 1.04–1.09). The other way around, depressive disorder and anxiety disorders were associated with an accelerated increase of frailty over time (depressive disorder: younger adults: beta β = 0.03, p < 0.001; older adults: β = 0.04, p < 0.001; and any anxiety disorder: younger adults: β = 0.02, p < 0.001; older adults: β = 0.01, p < 0.142), although the effect of anxiety disorders was less equivocal among older adults.
Conclusions
Affective disorders are reciprocally related to frailty. Results with respect to the impact of anxiety disorders on frailty suggest most impact at lower levels of frailty. Our results might imply that interventions to slow biological aging should be broadened towards younger and middle‐aged people as well as non‐frail older patients. To develop targeted treatment, future clinical and epidemiologic studies on the underlying pathways of this bidirectional association are needed.
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