Statins for primary and secondary prevention in the oldest old : an overview of the existing evidence

Hypercholesterolemia, although a modifiable risk factor for cardiovascular disease, is still one of the leading causes of death among older people in western countries. The use of statins among cholesterol reducing agents in both primary and secondary prevention has not been extensively studied in older patients in contrast to middle-aged patients. Despite a growing body of evidence in secondary prevention, statins are still under utilized in older patients with established vascular disease. On the other hand, the benefits of statins in primary prevention are not so clear. Therefore, the systematic use of statins in older patients with hypercholesterolemia needs to be further investigated

Symptom assessment and management at the end of life

As people age, the number and complexity of illnesses they develop increases. Symptoms during the last year of life in older persons are often a combination of the underlying life-threatening illness and other chronic conditions. These may be complicated by psychosocial and spiritual needs, related to life events such as bereavement. Geriatric palliative medicine involves the care and management of older patients’ progressive advanced disease, for whom the aim is quality of life. It focuses on detailed geriatric assessment, relief from pain and other symptoms such as anorexia, constipation, or delirium, and also management of psychological problems including depression or anxiety. This may be more challenging in people with cognitive impairment who may not be able to express whether they are in pain or otherwise suffering. Adequate pain and symptom management at the end of life emphasizes the need for a tailored multidisciplinary approach for patients and their family

Factors influencing ICU referral at the end of life in the elderly

Referral to the intensive care unit (ICU) and frequency of do-not-resuscitate (DNR) decisions at the end of life (EOL) in adult hospitalized patients a parts per thousand yen75 years and those < 75 years were examined and influencing factors in the elderly were determined. Data were prospectively collected in all adult patients who deceased during a 12-week period in 2007 and a 16-week period in 2008 at a university hospital in Belgium. Overall, 330 adult patients died of whom 33% were a parts per thousand yen75 years old. Patients a parts per thousand yen75 years old were less often referred to ICU at the EOL (42% vs. 58%, p=0.008) and less frequently died in the ICU (31% vs. 46%, p=0.012) as compared to patients < 75 years old. However, there was no difference in frequency of DNR decisions (87% vs. 88%, p=0.937) for patients dying on non-ICU wards. After adjusting for age, gender, and the Charlson comorbidity index, being admitted on a geriatric ward (OR 0.30, 95% CI 0.10-0.85, p=0.024) and having an active malignant disease (OR 0.39, 95% CI 0.19-0.78, p=0.008) were the only factors associated with a lower risk of dying in the ICU. Patients a parts per thousand yen75 years are less often referred to the ICU at the EOL as compared to patients < 75 years old. However, the risk of dying in the ICU was only lower for elderly with cancer and for those admitted to the geriatric ward

Factors associated with the goal of treatment in the last week of life in old compared to very old patients: a population-based death certificate survey

Background: Little is known about the type of care older people of different ages receive at the end of life. The goal of treatment is an important parameter of the quality of end-of-life care. This study aims to provide an evaluation of the main goal of treatment in the last week of life of people aged 86 and older compared with those between 75 and 85 and to examine how treatment goals are associated with age. Methods: Population-based cross sectional survey in Flanders, Belgium. A stratified random sample of death certificates was drawn of people who died between 1 June and 30 November 2007. The effective study sample included 3,623 deaths (response rate: 58.4%). Non-sudden deaths of patients aged 75 years and older were selected (N = 1681). Main outcome was the main goal of treatment in the last week of life (palliative care or life-prolonging/curative treatment). Results: In patients older than 75, the main goal of treatment in the last week was in the majority of cases palliative care (77.9%). Patients between 75 and 85 more often received life-prolonging/curative treatment than older patients (26.6% vs. 15.8%). Most patient and health care characteristics are similarly related to the main goal of treatment in both age groups. The patient's age was independently related to having comfort care as the main goal of treatment. The main goal of treatment was also independently associated with the patient's sex, cause and place of death and the time already in treatment. Conclusion: Age is independently related to the main goal of treatment in the last week of life with people over 85 being more likely to receive palliative care and less likely to receive curative/life-prolonging treatment compared with those aged 75-85. This difference could be due to the patient's wishes but could also be the result of the attitudes of care givers towards the treatment of older people

Validation of the supportive and palliative care indicators tool in a geriatric population

Background: Timely identification of patients in need of palliative care is especially challenging in a geriatric population because of prognostic uncertainty. The Supportive and Palliative Care Indicators Tool (SPICT (TM)) aims at facilitating this identification, yet has not been validated in a geriatric population. Objective: This study validates the SPICT in a geriatric patient population admitted to the hospital. Design: This is a retrospective cohort study. Setting: Subject were patients admitted to the acute geriatric ward of a Belgian university hospital between January 1 and June 30, 2014. Measurements: Data including demographics, functional status, comorbidities, treatment limitation decision (TLD), and one-year mortality were collected. SPICT was measured retrospectively by an independent assessor. Results: Out of 435 included patients, 54.7% had a positive SPICT, using a cut-off value of 2 for the general indicators and a cut-off value of 1 for the clinical questions. SPICT-positive patients were older (p = 0.033), more frequently male (p = 0.028), and had more comorbidities (p = 0.015) than SPICT-negative patients. The overall one-year mortality was 32.2%, 48.7% in SPICT-positive patients, and 11.5% in SPICT-negative patients (p < 0.001). SPICT predicted one-year mortality with a sensitivity of 0.841 and a specificity of 0.579. The area under the curve of the general indicators (0.758) and the clinical indicators of SPICT (0.748) did not differ (p = 0.638). In 71.4% of SPICT-positive cases, a TLD was present versus 26.9% in SPICT-negative cases (p < 0.001). Conclusion: SPICT seems to be valuable for identifying geriatric patients in need of palliative care as it demonstrates significant association with one-year mortality and with clinical survival predictions of experienced geriatricians, as reflected by TLDs given

Improving end-of-life care in acute geriatric hospital wards using the Care Programme for the Last Days of Life : study protocol for a phase 3 cluster randomized controlled trial

Background: The Care Programme for the Last Days of Life has been developed to improve the quality of end-of-life care in acute geriatric hospital wards. The programme is based on existing end-of-life care programmes but modeled to the acute geriatric care setting. There is a lack of evidence of the effectiveness of end-of-life care programmes and the effects that may be achieved in patients dying in an acute geriatric hospital setting are unknown. The aim of this paper is to describe the research protocol of a cluster randomized controlled trial to evaluate the effects of the Care Programme for the Last Days of Life. Methods and design: A cluster randomized controlled trial will be conducted. Ten hospitals with one or more acute geriatric wards will conduct a one-year baseline assessment during which care will be provided as usual. For each patient dying in the ward, a questionnaire will be filled in by a nurse, a physician and a family carer. At the end of the baseline assessment hospitals will be randomized to receive intervention (implementation of the Care Programme) or no intervention. Subsequently, the Care Programme will be implemented in the intervention hospitals over a six-month period. A one-year post-intervention assessment will be performed immediately after the baseline assessment in the control hospitals and after the implementation period in the intervention hospitals. Primary outcomes are symptom frequency and symptom burden of patients in the last 48 hours of life. Discussion: This will be the first cluster randomized controlled trial to evaluate the effect of the Care Programme for the Last Days of Life for the acute geriatric hospital setting. The results will enable us to evaluate whether implementation of the Care Programme has positive effects on end-of-life care during the last days of life in this patient population and which components of the Care Programme contribute to improving the quality of end-of-life care