Frailty is an aging syndrome caused by exceeding a threshold of decline across multiple organ systems leading to a decreased resistance to stressors. Treatment for frailty focuses on multi-domain ...interventions to target multiple affected functions in order to decrease the adverse outcomes of frailty. No systematic reviews on the effectiveness of multi-domain interventions exist in a well-defined frail population.
This systematic review aimed to determine the effect of multi-domain compared to mono-domain interventions on frailty status and score, cognition, muscle mass, strength and power, functional and social outcomes in (pre)frail elderly (≥65 years). It included interventions targeting two or more domains (physical exercise, nutritional, pharmacological, psychological, or social interventions) in participants defined as (pre)frail by an operationalized frailty definition.
The databases PubMed, EMBASE, CINAHL, PEDro, CENTRAL, and the Cochrane Central register of Controlled Trials were searched from inception until September 14, 2016. Additional articles were searched by citation search, author search, and reference lists of relevant articles. The protocol for this review was registered on PROSPERO (CRD42016032905).
Twelve studies were included, reporting a large diversity of interventions in terms of content, duration, and follow-up period. Overall, multi-domain interventions tended to be more effective than mono-domain interventions on frailty status or score, muscle mass and strength, and physical functioning. Results were inconclusive for cognitive, functional, and social outcomes. Physical exercise seems to play an essential role in the multi-domain intervention, whereby additional interventions can lead to further improvement (eg, nutritional intervention).
Evidence of beneficial effects of multi-domain compared to mono-domain interventions is limited but increasing. Additional studies are needed, focusing on a well-defined frail population and with specific attention to the design and the individual contribution of mono-domain interventions. This will contribute to the development of more effective interventions for frail elderly.
Comprehensive geriatric assessment for older patients admitted to dedicated wards has proven to be beneficial, but the impact of comprehensive geriatric assessment delivered by mobile inpatient ...geriatric consultation teams remains unclear. This review and meta-analysis aims to determine the impact of inpatient geriatric consultation teams on clinical outcomes of interest in older adults.
An electronic search of Medline, CINAHL, EMBASE, Web of Science and Invert for English, French and Dutch articles was performed from inception to June 2012. Three independent reviewers selected prospective cohort studies assessing functional status, readmission rate, mortality or length of stay in adults aged 60 years or older. Twelve studies evaluating 4,546 participants in six countries were identified. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies.
The individual studies show that an inpatient geriatric consultation team intervention has favorable effects on functional status, readmission and mortality rate. None of the studies found an effect on the length of the hospital stay. The meta-analysis found a beneficial effect of the intervention with regard to mortality rate at 6 months (relative risk 0.66; 95% confidence interval 0.52 to 0.85) and 8 months (relative risk 0.51; confidence interval 0.31 to 0.85) after hospital discharge.
Inpatient geriatric consultation team interventions have a significant impact on mortality rate at 6 and 8 months postdischarge, but have no significant impact on functional status, readmission or length of stay. The reason for the lack of effect on these latter outcomes may be due to insufficient statistical power or the insensitivity of the measuring method for, for example, functional status. The questions of to whom IGCT intervention should be targeted and what can be achieved remain unanswered and require further research.
CRD42011001420 (http://www.crd.york.ac.uk/PROSPERO).
Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation ...of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs.
For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months.
This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention.
Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618.
Purpose
Insomnia is highly prevalent in older persons and significantly impacts quality of life, functional abilities, and health status. It is frequently treated with benzodiazepines or Z-drugs. Due ...to adverse events, an increased use of alternative sedative medications has been observed in older adults. We aimed to study the efficacy and safety of alternative sedative medications for treating insomnia in older people, excluding benzodiazepines and Z-drugs.
Methods
We conducted a systematic search of MEDLINE (PubMed), EMBASE, and the Cochrane Central register of Controlled Trials databases. We included randomized controlled trials and prospective and retrospective quasi-experimental studies, conducted in patients older than 65 years, without psychiatric or neurological comorbidities.
Results
The systematic search yielded 9483 articles, of which 24 were included in this review, describing nine different sleep medications in total. No clear beneficial impact on sleep could be demonstrated in studies investigating the impact of melatonin (
n
= 10), paroxetine (
n
= 1), diphenhydramine (
n
= 1), tiagabine (
n
= 2), and valerian (
n
= 1). Ramelteon slightly improved sleep latency (
n
= 4), while doxepin was found to provide a sustained sleep improvement with a safety profile that was comparable to placebo (
n
= 3). Suvorexant showed an improved sleep maintenance with only mild side effects (
n
= 1). One study detected increased adverse effects of trazodone after 3 months but did not evaluate the effect on sleep.
Conclusions
The overall level of evidence was limited, making it difficult to draw robust conclusions. Preliminary evidence points towards suvorexant, doxepin, and possibly ramelteon as effective and safe pharmacological alternatives for treating insomnia in older adults.
Abstract 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 ≥ 65 years. 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.
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.
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.
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.
International Standard Randomised Controlled Trial Number (ISRCTN) Registry: ISRCTN20491828. Registered on October 11, 2021, https://www.isrctn.com/ISRCTN20491828.
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.
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.
Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017.
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.
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.
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.
Falls are a common, costly global public health burden. In hospitals, multifactorial fall prevention programs have proved effective in reducing falls' incidence; however, translating those programs ...accurately into daily clinical practice remains challenging. This study's aim was to identify ward-level system factors associated with implementation fidelity to a multifactorial fall prevention program (StuPA) targeting hospitalized adult patients in an acute care setting.
This retrospective cross-sectional study used administrative data on 11,827 patients admitted between July and December 2019 to 19 acute care wards at the University Hospital Basel, Switzerland, as well as data on the StuPA implementation evaluation survey conducted in April 2019. Data were analysed using descriptive statistics, Pearson's coefficients and linear regression modelling for variables of interest.
The patient sample had an average age of 68 years and a median length of stay of 8.4 (IQR: 2.1) days. The mean care dependency score was 35.4 points (ePA-AC scale: from 10 points (totally dependent) to 40 points (totally independent)); the mean number of transfers per patient -(e.g., change of room, admission, discharge) was 2.6 (range: 2.4- 2.8). Overall, 336 patients (2.8%) experienced at least one fall, resulting in a rate of 5.1 falls per 1'000 patient days. The median inter-ward StuPA implementation fidelity was 80.6% (range: 63.9-91.7%). We found the mean number of inpatient transfers during hospitalisation and the mean ward-level patient care dependency to be statistically significant predictors of StuPA implementation fidelity.
Wards with higher care dependency and patient transfer levels showed higher implementation fidelity to the fall prevention program. Therefore, we assume that patients with the highest fall prevention needs received greater exposure to the program. For the StuPA fall prevention program, our results suggest a need for implementation strategies contextually adapted to the specific characteristics of the target wards and patients.
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