Delirium in frail surgical oncology patients

Een delier is een veelvoorkomende en ernstige complicatie na een operatie bij oudere patiënten. Deze acute verwardheidtoestand verhoogt het risico op complicaties en overlijden. In dit proefschrift werd aangetoond dat geheugenproblemen voorafgaand aan de operatie en de zwaarte van de operatie, het risico op het doormaken van een delier na de operatie verhogen bij kwetsbare ouderen met kanker. Om te onderzoeken hoe dit risico beperkt kan worden, werden verschillende studies vergeleken waarin enerzijds gebruik werd gemaakt van medicatie en anderzijds van verpleegkundige maatregelen (non-medicamenteus) ter voorkoming van een delier. Globaal bleken beide methodes effectief te zijn, waarbij meer effect werd gezien van interventies bij hoogrisico patiënten. Een belangrijk onderdeel van dit proefschrift vormen de resultaten van de Liaison Intervention in Frail Elderly (LIFE) studie. Hierin werd begeleiding van een geriatrisch team rondom de operatie vergeleken met reguliere zorg bij kwetsbare ouderen die geopereerd werden in verband met kanker. We hebben ondervonden dat het doen van onderzoek bij kwetsbare ouderen een extra tijdsinvestering vergt, gepaard gaande met hogere personeelskosten. Bij 31 van de 260 patiënten (11.9%) trad een delier op. Extra geriatrische zorg rondom de operatie bleek het aantal delieren niet te verminderen in vergelijking met reguliere zorg. Na drie maanden werd voor geen van de lange termijn uitkomsten een verschil aangetoond tussen de interventie groep en de controle groep. Een delier vergrootte het risico op functionele achteruitgang na de operatie. Mogelijk kunnen in de toekomst hoogrisicopatiënten (grote operatie en/ of geheugenproblemen) wel profiteren van extra geriatrische zorg rondom de operatie

Long Term Outcomes of a Geriatric Liaison Intervention in Frail Elderly Cancer Patients

Background The aim of this study was to evaluate the long term effects after discharge of a hospital-based geriatric liaison intervention to prevent postoperative delirium in frail elderly cancer patients treated with an elective surgical procedure for a solid tumour. In addition, the effect of a postoperative delirium on long term outcomes was examined. Methods A three month follow-up was performed in participants of the Liaison Intervention in Frail Elderly study, a multicentre, prospective, randomized, controlled trial. Patients were randomized to standard treatment or a geriatric liaison intervention. The intervention consisted of a preoperative geriatric consultation, an individual treatment plan targeted at risk factors for delirium and daily visits by a geriatric nurse during the hospital stay. The long term outcomes included: mortality, rehospitalisation, Activities of Daily Living (ADL) functioning, return to the independent pre-operative living situation, use of supportive care, cognitive functioning and health related quality of life. Results Data of 260 patients (intervention n = 127, Control n = 133) were analysed. There were no differences between the intervention group and usual-care group for any of the outcomes three months after discharge. The presence of postoperative delirium was associated with: an increased risk of decline in ADL functioning (OR: 2.65, 95% CI: 1.02-6.88), an increased use of supportive assistance (OR: 2.45, 95% CI: 1.02-5.87) and a decreased chance to return to the independent preoperative living situation (OR: 0.18, 95% CI: 0.07-0.49). Conclusions A hospital-based geriatric liaison intervention for the prevention of postoperative delirium in frail elderly cancer patients undergoing elective surgery for a solid tumour did not improve outcomes 3 months after discharge from hospital. The negative effect of a postoperative delirium on late outcome was confirmed

Delirium in older COVID-19 patients:Evaluating risk factors and outcomes

Objectives: A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID-19). We aimed to identify determinants of delirium, including the Clinical Frailty Scale, in hospitalized older patients with COVID-19. Furthermore, we aimed to study the association of delirium independent of frailty with in-hospital outcomes in older COVID-19 patients. Methods: This study was performed within the framework of the multi-center COVID-OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID-19 in the Netherlands between February and May 2020. Data were collected on demographics, co-morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In-hospital outcomes included length of stay, discharge destination, and mortality. Results: A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio [OR] 8.9 [95% CI 2.3–33.6] p = 0.001), and pre-existent memory problems (OR 7.6 [95% CI 3.1–22.5] p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 [95%CI 1.40–1.90] p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C-reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 [95% CI1.71–4.72] p < 0.001), but not in multivariable analyses. Conclusions: A previous delirium and pre-existent memory problems were associated with delirium risk in COVID-19. Delirium was not an independent predictor of mortality after adjustment for frailty

Frailty is associated with in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands:the COVID-OLD study

BACKGROUND: During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome have been conflicting. OBJECTIVE: The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands. METHODS: This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality. RESULTS: A total of 1,376 patients were included (median age 78 years (interquartile range 74-84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6-9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1-3, patients with CFS 4-5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3-3.0)) and patients with CFS 6-9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8-4.3)). CONCLUSIONS: The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms

Melatonin, temazepam and placebo in hospitalised older patients with sleeping problems (MATCH): A study protocol of randomised controlled trial

Introduction Hospitalised older patients frequently suffer from inadequate sleep, which can lead to patient distress and delayed recovery from acute illness or surgical procedure. Currently, no evidence-based treatments exist for sleeping problems in hospitalised older patients. Benzodiazepines, such as temazepam, are regularly prescribed by physicians, although they have serious side effects; for older patients in particular. Melatonin is proposed as a safe alternative for sleeping problems in hospitalised older patients, but the efficacy of melatonin is unclear in this population. Therefore, the aim of this study is to investigate the effects of melatonin and temazepam compared with placebo on sleep quality among hospitalised older patients with sleeping problems. Methods and analysis This study is a multicentre, randomised, placebo-controlled trial. A total of 663 patients will be randomised in a 1:1:1 fashion to receive either melatonin (n=221), temazepam (n=221) or placebo (n=221). The study population consists of hospitalised patients aged 60 years and older, with new or aggravated sleeping problems for which an intervention is needed. The primary outcome is sleep quality measured with the Leeds Sleep Evaluation Questionnaire (LSEQ). Secondary outcomes include sleep parameters measured with actigraphy and medication-related adverse effects. Ethics and dissemination This study was approved by the Medical Ethics Committee of the Academic Medical Centre Amsterdam, (No 2015-302). Study findings will be disseminated through presentations at professional and scientific conferences and publications in peer-reviewed journals. Trial registration number NTR6908; Pre-results

Logistic regression analyses (intervention group versus control group).

*<p>No Care Dependency Score was available for 3 patients.</p>†<p>No data were available about domestic help for 8 patients.</p>‡<p>No data were available about care assistance for 8 patients.</p>∫<p>No data were available about informal care for 11 patients.</p

Univariate logistic regression analyses for the influence of postoperative delirium on 3-month outcomes.

<p>Univariate logistic regression analyses for the influence of postoperative delirium on 3-month outcomes.</p

CONSORT diagram for the study.

<p>CONSORT diagram for the study.</p