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

Evaluation and establishment of a ward-based geriatric liaison service for older urological surgical patients: Proactive care of Older People undergoing Surgery (POPS)-Urology.

OBJECTIVE: To assess the impact of introducing and embedding a structured geriatric liaison service, Proactive care of Older People undergoing Surgery (POPS)-Urology, using comprehensive geriatric assessment methodology, on an inpatient urology ward. PATIENTS AND METHODS: A phased quality improvement project was undertaken using stepwise interventions. Phase 1 was a before-and-after study with initiation of a daily board round, weekly multidisciplinary meeting, and targeted geriatrician-led ward rounds for elective and emergency urology patients aged ≥65 years admitted over two 1-month periods. Outcomes were recorded from medical records and discharge documentation, including length of inpatient stay, medical and surgical complications, and 30-day readmission and mortality rates. Phase 2 was a quality improvement project involving Plan-Do-Study-Act cycles and qualitative staff surveys in order to create a Geriatric Surgical Checklist (GSCL) to standardize the intervention in Phase 1, improve equity of care by extending it to all ages, improve team-working and streamline handovers for multidisciplinary staff. RESULTS: Phase 1 included 112 patients in the control month and 130 in the intervention month. The length of inpatient stay was reduced by 19% (mean 4.9 vs 4.0 days; P = 0.01), total postoperative complications were lower (risk ratio 0.24 [95% confidence interval 0.10, 0.54]; P = 0.001). A non-significant trend was seen towards fewer cancellations of surgery (10 vs 5%; P = 0.12) and 30-day readmissions (8 vs 3%; P = 0.07). In Phase 2, the GSCL was created and incrementally improved. Questionnaires repeated at intervals showed that the GSCL helped staff to understand their role better in multidisciplinary meetings, improved their confidence to raise issues, reduced duplication of handovers and standardized identification of geriatric issues. Equity of care was improved by providing the intervention to patients of all ages, despite which the time taken for the daily board round did not lengthen. CONCLUSION: This is the first known paper describing the benefits of daily proactive geriatric intervention in elective and emergency urological surgery. The results suggest that using a multidisciplinary team board round helps to facilitate collaborative working between surgical and geriatric medicine teams. The GSCL enables systematic identification of patients who require a focused comprehensive geriatric assessment. There is potential to transfer the GSCL package to other surgical specialties and hospitals to improve postoperative outcomes

Timely short-term specialised palliative care service intervention for frail older people and their family carers in primary care : study protocol for a pilot randomised controlled trial

Introduction There is limited evidence regarding the effectiveness of timely integration of short-term specialised palliative care services for older people in primary care. Using a Theory of Change approach, we developed such an intervention, the Frailty+ intervention. We present the protocol of a pilot randomised controlled trial (RCT) with a process evaluation that aims to assess the feasibility and preliminary effectiveness of the Frailty+ intervention. Methods and analysis We will conduct a pilot RCT in Flanders, Belgium. Frail older people who are discharged to home from hospital will be identified and recruited. Seventy-six will be randomly assigned either to the control group (standard care) or the intervention group (Frailty+ intervention alongside standard care). Data will be collected from patients and family carers. At the core of the Frailty+ intervention is the provision of timely short-term specialised palliative care facilitated by a nurse from the specialised palliative home care service over a period of 8 weeks. We will assess feasibility in terms of recruitment, randomisation, acceptability of the intervention, retention in the programme and data completion. The primary outcome for assessing preliminary effectiveness is a mean score across five key symptoms that are amenable to change (ie, breathlessness, pain, anxiety, constipation, fatigue), measured at baseline and 8 weeks post-baseline. The process evaluation will be conducted in the intervention group only, with measurements at 8-11 weeks post-baseline to evaluate implementation, mechanisms of change and contextual factors. Ethics and dissemination The study has been approved by the ethics committee of University Hospital Ghent. Results will be used to inform the design of a full-scale RCT and will be published in a peer-reviewed, open access journal

GERIATRIC CO-MANAGED CARE OF OLDER ADULTS ADMITTED TO A SURGICAL SERVICE FOR GASTROINTESTINAL CANCER. A PROPENSITY SCORE ANALYSIS

Surgery represents the key treatment for the majority of g.i. cancers and the advances in anaesthesia, perioperative medicine, pain medicine and postoperative critical care, as well as surgical techniques, have changed the risk-to-benefit balance of surgery in many high-risk patients. Many more medically complex patients have become eligible for surgical interventions, including those who are older, frail, or have multiple comorbidities, a decline in physiological reserve, impaired nutrition or cognition and are at higher risk for poor outcomes. Geriatric patients require multimodality and multispecialty interventions to improve their care geriatric but geriatric comanagement (GC) in general surgery is rarely implemented. A single-centre observational study was performed within an Italian teaching hospital with a tertiary referral practice for oncological surgery between January 2015 and December 2019. Eligibility criteria were patients aged at least 70 years, with colorectal, gastric, and hepatopancreaticobiliary cancer, admitted to the Oncological Surgery of Policlinico San Martino of Genoa, who underwent elective surgical procedures or palliative treatments and required a hospital stay of at least 1 day. This before and after study aimed to examine the effectiveness of the GC by comparing patient outcomes before and after the implementation of a dedicated geriatric service in November 2018. During the first three years older cancer patients underwent a CGA in order to stratify patients\u2019 frailty and performance status prior to surgery. Starting from November 1st 2018, a GC was implemented in the surgical ward following the appointment of a fulltime consultant geriatrician. This upgraded model of geriatric care consisted of the initiation of daily targeted geriatrician-led ward rounds focusing on older cancer patients. A total of 235 patients were admitted to the oncological surgery ward during the entire study period: 122 (52%) before November 1st 2018 (control group) and 113 (48%) between November 1st 2018 and November 1st 2019 (GC group). Comparison of the two cohorts demonstrated that patients in the control group were older (median age [IQR] 81.50 [78.00, 85.00] years vs 79.00 [76.00, 83.00] years; p\u2009<\u20090.004) and predominantly male (79 [64.8%] vs 59 [52.2%]; p\u2009<\u20090.05). Average Frailty Index scores were 0.12 in the control group and 0.18 in the intervention group (p <0.01), corresponding to a pre-frail phenotype in both cases. Patients from the GC group demonstrated a significant decrease in grade I-V postoperative complications (OR = 0.53 (95%CI 0.32, 0.87), p <. 0.012), which was also confirmed by our adjusted analysis according to the propensity score (weighted OR = OR = 0.37 (95%CI 0.27, 0.50), p < 0.001). Indeed, the GC group exhibited significantly lower CCI scores (\u3b2 coefficient [SE], GC vs control group -10.2 (95%CI -17.3, -3.8), p < 0.009) as compared to the patient from the control group. Specifically, in those patients who received GC, mean CCI score was lower by 12 points, which represents a statistically significant decrease after adjustment (\u3b2 coefficient [SE], intervention vs controls -15.6 (95%CI -23.8, -7.33), p < 0.001). No significant differences between the two groups were observed when considering 90-day and 1-year mortality. Of note, the majority of deaths in the GC group were cancer related (i.e., due to progression of disease). A higher number of patients were deemed eligible to start anticancer treatment in the GC group as compared to the patient from the control group [21 (48%) vs. 35 (69%), p = 0.063]. In conclusion, GC can improve the perioperative management of older cancer patients undergoing elective g.i. surgery by potentially reducing postoperative complications. To our knowledge, amongst the few studies analysing the effectiveness of GC in patient who are candidate to major oncological surgery, this is one of the few ones showing positive results in terms of reduction of postoperative complications

Multi-disciplinary and pharmacological interventions to reduce post-operative delirium in elderly patients: A systematic review and meta-analysis

Study objective: An estimated 80% of older people undergoing surgery develop postoperative delirium (POD) making them a high-risk group. Research in this area is growing fast but there is no established consensus on strategies for POD prevention or management. A systematic review and meta-analysis were conducted to synthesise data on clinical interventions used to reduce POD among older people undergoing elective and emergency surgery. Methods: A range of database searches generated 336 papers. A total of 25 studies met the inclusion criteria and were assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The studies were undertaken across the world. Results: This review identified a range of intervention approaches: comparisons between anaesthetic and sedatives agents, medication-specific interventions and multidisciplinary models of care. Results found more consistencies across multidisciplinary interventions than the pharmacological interventions. In pooled analyses, haloperidol (OR 0.74; 95% CI (confidence interval) 0.44, 1.26) was not statistically significantly associated with reduced POD incidence any more than a placebo. Conclusion: There is a need to implement multidisciplinary interventions, as well as collaboration between clinicians on pre- and postoperative care practices regarding pharmacological interventions to more effectively reduce and manage POD in older people

Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study

Background. Hip fracture is common in the elderly. Previous studies suggest that psychiatric illness is common and predicts poor outcome, but have methodological weaknesses. Further studies are required to address this important issue. Methods. We prospectively recruited 731 elderly participants with hip fracture in two Leeds hospitals. Psychiatric diagnosis was made within 5 days of surgery using the Geriatric Mental State schedule and other standardized instruments, and data on confounding factors was collected. Main study outcomes were length of hospital stay, and mortality over 6 months after fracture. Results. Fifty-five per cent of participants had cognitive impairment (dementia in 40% and delirium in 15%), 13% had a depressive disorder, 2% had alcohol misuse and 2% had other psychiatric diagnoses. Participants were likely to remain in hospital longer if they suffered from dementia, delirium or depression. The relative risks of mortality over 6 months after hip fracture were increased in dementia and delirium, but not in depression. Conclusions. Psychiatric illness is common after hip fracture, and has significant effects on important outcomes. This suggests a need for randomized, controlled trials of psychiatric interventions in the elderly hip fracture population

Can Comprehensive Geriatric Assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings

Introduction The aim of this study was to design an approach to improving care for frail older patients in hospital services where Comprehensive Geriatric Assessment (CGA) was not part of the clinical tradition. Methods The intervention was based on the principles of CGA, using quality improvement methodology to embed care processes. Qualitative methods and coproduction were used to inform development of the intervention, which was directed towards the health care professionals involved in peri-operative/surgical cancer care pathways in two large UK teaching hospitals. A formative, qualitative evaluation was undertaken; data collection and analysis were guided by Normalisation Process Theory. Results The clinicians involved agreed to use the toolkit, identifying potential benefits including improved surgical decision making and delivery of interventions pre-operatively. However, sites concluded that pre-operative assessment was not the best place for CGA, and at the end of the 12-month trial, implementation was still nascent. Efforts competed against the dominance of national time-limited targets, and concerns relating to patients’ immediate treatment and recovery. Some participants involved in the peri-operative pathway felt that CGA required ongoing specialist input from geriatricians, but it was not clear that this was sustainable. Conclusions Clinical toolkits designed to empower non-geriatric teams to deliver CGA were received with initial enthusiasm, but did not fully achieve their stated aims due to the need for an extended period of service development with geriatrician support, competing priorities, and divergent views about appropriate professional domains.NIH

Understanding cognition in older patients with cancer

Cancer and neurocognitive disorders, such as dementia and delirium, are common and serious diseases in the elderly that are accompanied by high degree of morbidity and mortality. Furthermore, evidence supports the under-diagnosis of both dementia and delirium in older adults. Complex questions exist regarding the interaction of dementia and delirium with cancer, beginning with guidelines on how best measure disease severity, the optimal screening test for either disorder, the appropriate level of intervention in the setting of abnormal findings, and strategies aimed at preventing the development or progression of either process. Ethical concerns emerge in the research setting, pertaining to the detection of cognitive dysfunction in participants, validity of consent, disclosure of abnormal results if screening is pursued, and recommended level of intervention by investigators. Furthermore, understanding the ways in which comorbid cognitive dysfunction and cancer impact both cancer and non-cancer-related outcomes is essential in guiding treatment decisions. In the following article, we will discuss what is presently known of the interactions of pre-existing cognitive impairment and delirium with cancer. We will also discuss identified deficits in our knowledge base, and propose ways in which innovative research may address these gaps

Can usual gait speed be used as a prognostic factor for early palliative care identification in hospitalized older patients? A prospective study on two different wards

Background Timely palliative care in frail older persons remains challenging. Scales to identify older patients at risk of functional decline already exist. However, factors to predict short term mortality in older hospitalized patients are scarce. Methods In this prospective study, we recruited patients of 75 years and older at the department of cardiology and geriatrics. The usual gait speed measurement closest to discharge was chosen. We used the risk of dying within 1 year as parameter for starting palliative care. ROC curves were used to determine the best cut-off value of usual gait speed to predict one-year mortality. Time to event analyses were assessed by COX regression. Results On the acute geriatric ward (n = 60), patients were older and more frail (assessed by Katz and iADL) in comparison to patients on the cardiology ward (n = 82); one-year mortality was respectively 27 and 15% (p = 0.069). AUC on the acute geriatric ward was 0.748 (p = 0.006). The best cut-off value was 0.42 m/s with a sensitivity and specificity of 0.857 and 0.643. Slow walkers died earlier than faster walkers (HR 7.456, p = 0.011), after correction for age and sex. On the cardiology ward, AUC was 0.560 (p = 0.563); no significant association was found between usual gait speed and survival time. Conclusions Usual gait speed may be a valuable prognostic factor to identify patients at risk for one-year mortality on the acute geriatric ward but not on the cardiology ward