Integrating advance care planning as part of comprehensive geriatric assessment for hospitalised frail elderly patients: findings of a cross-sectional study

INTRODUCTION@#The integration of advance care planning (ACP) as part of the comprehensive geriatric assessment (CGA) of hospitalised frail elderly patients, together with the clinical and demographic factors that determine successful ACP discussion, has not been previously explored.@*METHODS@#A cross-sectional study on patients and family caregivers admitted under the geriatric medicine department of a tertiary hospital was conducted from October 2015 to December 2016.@*RESULTS@#Among 311 eligible patients, 116 (37.3%) patients completed ACP discussion while 166 (53.4%) patients declined, with 62 (37.3%) of the decliners providing reasons for refusal. Univariate logistic regression analysis showed that older age, higher Charlson Comorbidity Index, poorer functional status and cognitive impairment had statistically significant associations with agreeing to ACP discussion (p < 0.05). On multivariate logistic regression analysis, only poorer functional status was significantly associated (odds ratio 2.22 [95% confidence interval 1.27-3.87]; p = 0.005). Among those who completed ACP discussion, a majority declined cardiopulmonary resuscitation (79.3%), preferred limited medical intervention or comfort care (82.8%), and opted for blood transfusion (62.9%), antibiotics (73.3%) and intravenous fluid (74.1%) but declined haemodialysis (50.9%). Decision-making was divided for enteral feeding. Among decliners, the main reasons for refusal were 'not keen' (33.9%), 'deferring to doctors' decision' (11.3%) and 'lack of ACP awareness' (11.3%).@*CONCLUSION@#The feasibility and utility of integrating ACP as part of CGA has been demonstrated. Poorer functional status is significantly associated with successful ACP discussion. Greater public education on end-of-life care choices (besides cardiopulmonary resuscitation) and follow-up with decliners are recommended.

Improving prescribing for older patients - 'Yes S-I-R-E!'

INTRODUCTION@#Polypharmacy and inappropriate prescribing are associated with negative health outcomes in the elderly. Several prescribing tools have been developed to assess medication appropriateness. Explicit (criteria-based) tools often do not take into account patients' preferences and comorbidities, and have little room for individualised clinical judgement.@*METHODS@#A cross-sectional observational study was conducted in 243 elderly patients admitted to the Geriatric Medicine service in a Singapore tertiary hospital over one month. We incorporated an implicit (judgement-based) tool developed by Scott et al into a mnemonic, 'S-I-R-E', to assess medication appropriateness: S = symptoms ('Have symptoms resolved?'), I = indication ('Is there a valid indication?'), R = risks ('Do risks outweigh benefits?') and E = end of life ('Is there short life expectancy limiting clinical benefit?').@*RESULTS@#Inappropriate prescribing was present in 27.6% of patients. The most common reason for inappropriateness of medications was lack of valid indication (62.2%), followed by high risk-benefit ratio (20.7%). The most common medications that lacked valid indication were supplements and proton pump inhibitors. Polypharmacy was found in 93% of patients and was significantly associated with inappropriate prescribing (p = 0.047).@*CONCLUSION@#Inappropriate prescribing and polpharmacy are highly prevalent in the hospitalised elderly. The 'S-I-R-E' mnemonic can be used as a memory aid and practical framework to guide appropriate prescribing in the elderly.