Surgical assessment of the geriatric oncology patient

BACKGROUND: The aging population in the United States will correlate with an increased number of cancer diagnoses as cancer is primarily a disease of the elderly. Providing this ever-growing group of individuals with quality surgical management, while taking into account the unique needs and desires of this cohort, is a great challenge facing both geriatricians and surgeons going forward. The best approach to ensure that oncogeriatric patients receive the best tailored treatment is through the completion of a pre-surgical geriatric assessment. However, only a minority of oncogeriatric patients is undergoing a comprehensive pre-surgical geriatric assessment despite the majority of geriatricians and surgeons acknowledging its importance in order to properly risk stratify their patients. LITERATURE REVIEW FINDINGS: Multiple theories exist as to why geriatric assessments are not being utilized more frequently, but the most probable answer is that these assessments are very time-consuming, making it virtually impossible for incorporation into a healthcare provider’s busy schedule. Comprehensive literature review regarding geriatric assessments amongst the oncogeriatric population found that the most sensitive and specific domains of the geriatric assessments predicting morbidity and mortality include Frailty Index, Social Support Survey, Mini-Nutritional Assessment, and Geriatric Depression Screening. PROPOSED METHODS: A novel educational intervention will be proposed to teach Physician Assistant and Medical Students about the domains of the geriatric assessment most predictive of post-surgical risk during their surgical clerkship. The curriculum will utilize both simulation- and competency-based education training under the guidance of geriatricians and surgeons. Students will first learn the necessary skills in a controlled classroom environment and then proceed to incorporate these skills during their clerkship with patients on their service. CONCLUSIONS: The goal of the proposed method is to instill the confidence and skills necessary to provide an accurate geriatric assessment for oncogeriatric patients in future clinicians. The field of geriatric oncology is going to grow exponentially in the up-coming years and familiarizing future clinicians with the most predictive domains regarding surgical outcome will improve treatment outcomes for oncogeriatric patients in the immediate and foreseeable future

Polypharmacy and potentially inappropriate medication use in geriatric oncology.

Polypharmacy is a highly prevalent problem in older persons, and is challenging to assess and improve due to variations in definitions of the problem and the heterogeneous methods of medication review and reduction. The purpose of this review is to summarize evidence regarding the prevalence and impact of polypharmacy in geriatric oncology patients and to provide recommendations for assessment and management. Polypharmacy has somewhat variably been incorporated into geriatric assessment studies in geriatric oncology, and polypharmacy has not been consistently evaluated as a predictor of negative outcomes in patients with cancer. Once screened, interventions for polypharmacy are even more uncertain. There is a great need to create standardized interventions to improve polypharmacy in geriatrics, and particularly in geriatric oncology. The process of deprescribing is aimed at reducing medications for which real or potential harm outweighs benefit, and there are numerous methods to determine which medications are candidates for deprescribing. However, deprescribing approaches have not been evaluated in older patients with cancer. Ultimately, methods to identify polypharmacy will need to be clearly defined and validated, and interventions to improve medication use will need to be based on clearly defined and standardized methods

Psychobiological factors of resilience and depression in late life.

In contrast to traditional perspectives of resilience as a stable, trait-like characteristic, resilience is now recognized as a multidimentional, dynamic capacity influenced by life-long interactions between internal and environmental resources. We review psychosocial and neurobiological factors associated with resilience to late-life depression (LLD). Recent research has identified both psychosocial characteristics associated with elevated LLD risk (e.g., insecure attachment, neuroticism) and psychosocial processes that may be useful intervention targets (e.g., self-efficacy, sense of purpose, coping behaviors, social support). Psychobiological factors include a variety of endocrine, genetic, inflammatory, metabolic, neural, and cardiovascular processes that bidirectionally interact to affect risk for LLD onset and course of illness. Several resilience-enhancing intervention modalities show promise for the prevention and treatment of LLD, including cognitive/psychological or mind-body (positive psychology; psychotherapy; heart rate variability biofeedback; meditation), movement-based (aerobic exercise; yoga; tai chi), and biological approaches (pharmacotherapy, electroconvulsive therapy). Additional research is needed to further elucidate psychosocial and biological factors that affect risk and course of LLD. In addition, research to identify psychobiological factors predicting differential treatment response to various interventions will be essential to the development of more individualized and effective approaches to the prevention and treatment of LLD

Implementing Geriatric Frailty Screening in Acute Care

Practice Problem: Frailty is a syndrome of age-related physiologic decline characterized by an increased burden of symptoms and higher susceptibility to adverse health, including higher functional decline rates, pressure ulcers, falls, and delirium. In the general medicine unit of this project, geriatric patients were not screened for frailty. PICOT: The PICOT question that guided this project was: In hospitalized patients 65-years-of-age and older (P), how does implementing a geriatric frailty screening tool (I), compared to standard assessments (C), influence frailty identification and personalized plans of care (O) over eight weeks (T)? Evidence: Literature supports screening for frailty in the hospitalized geriatric population. Intervention: For eight weeks, a group of four RN clinicians piloted the CFS and collected data on patient appropriateness for screening, completion of screening, CFS scores, and influence of CFS scoring on personalized patient care plans. Outcome: Statistical analysis results suggest that completing the CFS and adjusting the individualized plan of care were related to one another. Conclusion: Applying best practices to identify frailty during hospitalization demonstrated a measurable influence on health promotion in acutely ill geriatric patients

Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools.

BACKGROUND: There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment. METHODS: We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach. RESULTS: We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations. CONCLUSIONS: There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence

Capturing patients’ needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems

STROBE. (PDF 28 kb

Cognitive Impairment and Age-Related Vision Disorders: Their Possible Relationship and the Evaluation of the Use of Aspirin and Statins in a 65 Years-and-Over Sardinian Population

Neurological disorders (Alzheimer’s disease, vascular and mixed dementia) and visual loss (cataract, age-related macular degeneration, glaucoma, and diabetic retinopathy) are among the most common conditions that afflict people of at least 65 years of age. An increasing body of evidence is emerging, which demonstrates that memory and vision impairment are closely, significantly, and positively linked and that statins and aspirin may lessen the risk of developing age-related visual and neurological problems. However, clinical studies have produced contradictory results. Thus, the intent of the present study was to reliably establish whether a relationship exist between various types of dementia and age-related vision disorders, and to establish whether statins and aspirin may or may not have beneficial effects on these two types of disorders. We found that participants with dementia and/or vision problems were more likely to be depressed and displayed worse functional ability in basic and instrumental activities of daily living than controls. Mini mental state examination scores were significantly lower in patients with vision disorders compared to subjects without vision disorders. A closer association with macular degeneration was found in subjects with Alzheimer’s disease than in subjects without dementia or with vascular dementia, mixed dementia, or other types of age-related vision disorders. When we considered the associations between different types of dementia and vision disorders and the use of statins and aspirin, we found a significant positive association between Alzheimer’s disease and statins on their own or in combination with aspirin, indicating that these two drugs do not appear to reduce the risk of Alzheimer’s disease or improve its clinical evolution and may, on the contrary, favor its development. No significant association in statin use alone, aspirin use alone, or the combination of these was found in subjects without vision disorders but with dementia, and, similarly, none in subjects with vision disorders but without dementia. Overall, these results confirm the general impression so far; namely, that macular degeneration may contribute to cognitive disorders (Alzheimer’s disease in particular). In addition, they also suggest that, while statin and aspirin use may undoubtedly have some protective effects, they do not appear to be magic pills against the development of cognitive impairment or vision disorders in the elderly

Targeting complexity of geriatric emergency department visitors: Comprehensiveness in a high-paced and efficiency-focused medical setting

The emergency department (ED) is one of the most important access points to medical care worldwide and a central link between out- and inpatient care. The demographic development is predicted to change the age distribution of patients in the German health system over the next few decades which could strongly affect the ED as a multidisciplinary centre of the health system. Many EDs in Germany have already observed an increase in the number of older and clinically complex patients that bind more resources and personnel capacities. Geriatric patients in the ED are a particularly vulnerable group with an increased risk of clinical complications compared to younger age groups. The higher prevalence of frailty, atypical symptoms, multimorbidity, polypharmacy, neuropsychiatric and cognitive impairments impede fast diagnosis and therapy. The integration of an elaborate and time-consuming assessment of older patients in an otherwise fast-paced and efficiency-driven environment is a major challenge of present-day and future EDs. Therefore, an effective screening for older patients who would benefit from further evaluation will be paramount. Common standardized triage systems of EDs or existing screening instruments like the Identification of Seniors at Risk (ISAR) score show major difficulties in effectively identifying vulnerable older patients. The Multidimensional Prognostic Index (MPI), which is based on a comprehensive geriatric assessment (CGA), has already been tested in numerous settings and might be an alternative to grasp the complexity of older ED patients. An important but rarely evaluated clinical outcome parameter is health-related quality of life (HRQOL). It is a central component of patient-related treatment concepts and plays a crucial role in the care for geriatric patients. Existing literature shows a strong influence of the health status on HRQOL of older people. The results of the study by Rarek et al., on which this thesis is based upon, were able to show that the HRQOL of geriatric ED patients is significantly associated with clinical prognosis at ED admission and up to 6 months after. Attention to the association between patient-related outcome factors such as HRQOL and objective clinical prognosis can improve a holistic approach for allocation decisions in future concepts of geriatric ED care. Various innovative concepts for the improvement of detection and management of geriatric and patients in the ED have been tested and evaluated in the USA in recent years. The initial experience about advantages and disadvantages of approaches that were tested can help to create adapted concepts for the German health care system. First responses to the increasing number of geriatric patients already exist in Germany and range from new screening tools to specialized ED units and an improved linking of different health care providers. Adapting EDs to the complexities and needs of geriatric patients will be a major challenge in an aging society. The global outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic has threatened the health systems of numerous nations and at the time of this publication, the end is still unforeseeable. Many aspects and challenges of the complexity in geriatric patients in clinical practice have been illustrated by the impact of the pandemic on geriatric care. Older, multimorbid and frail patients are particularly affected by this disease due to an increased risk of a severe course of disease and higher mortality. The need to effectively identify vulnerable patients in the ED with a poor clinical prognosis has become more important due to the pandemic-related scarcity of resources. In addition, it has been observed that the COVID-19 pandemic had a negative impact on HRQOL of older people and the treatment of chronic illnesses. Given that geriatric patients have a higher risk for the development of chronic remnants of COVID-19, the pandemic could have unforeseeable influence on future health of the aging society. In the face of demographic changes, present and future challenges for health systems, effective identification and management of frail and vulnerable patients in the ED and structural changes to obtain geriatric-friendly EDs are important steps to guarantee adequate geriatric care and improve the clinical outcome as well as HRQOL

Using practice effects for targeted trials or sub-group analysis in Alzheimer\u27s disease: How practice effects predict change over time

OBJECTIVE: To describe the presence of practice effects in persons with Alzheimer disease (AD) or mild cognitive impairment (MCI) and to evaluate how practice effects affect cognitive progression and the outcome of clinical trials. METHODS: Using data from a meta-database consisting of 18 studies including participants from the Alzheimer disease Cooperative Study (ADCS) and the Alzheimer Disease Neuroimaging Initiative (ADNI) with ADAS-Cog11 as the primary outcome, we defined practice effects based on the improvement in the first two ADAS-Cog11 scores and then estimated the presence of practice effects and compared the cognitive progression between participants with and without practice effects. The robustness of practice effects was investigated using CDR SB, an outcome independent the definition itself. Furthermore, we evaluated how practice effects can affect sample size estimation. RESULTS: The overall percent of practice effects for AD participants was 39.0% and 53.3% for MCI participants. For AD studies, the mean change from baseline to 2 years was 12.8 points for the non-practice effects group vs 7.4 for the practice effects group; whereas for MCI studies, it was 4.1 for non-practice effects group vs 0.2 for the practice effects group. AD participants without practice effects progressed 0.9 points faster than those with practice effects over a period of 2 years in CDR-SB; whereas for MCI participants, the difference is 0.7 points. The sample sizes can be different by over 35% when estimated based on participants with/without practice effects. CONCLUSION: Practice effects were prevalent and robust in persons with AD or MCI and affected the cognitive progression and sample size estimation. Planning of future AD or MCI clinical trials should account for practice effects to avoid underpower or considers target trials or stratification analysis based on practice effects