Exploring the Impact of Age, Frailty, and Multimorbidity on the Effect of ICU Interventions: A Systematic Review of Randomized Controlled Trials.

OBJECTIVES: To date, age, frailty, and multimorbidity have been used primarily to inform prognosis in older adults. It remains uncertain, however, whether these patient factors may also predict response to critical care interventions or treatment outcomes. DATA SOURCES: We conducted a systematic search of top general medicine and critical care journals for randomized controlled trials (RCTs) examining critical care interventions published between January 1, 2011, and December 31, 2021. STUDY SELECTION: We included RCTs of critical care interventions that examined any one of three subgroups-age, frailty, or multimorbidity. We excluded cluster RCTs, studies that did not report interventions in an ICU, and studies that did not report data examining subgroups of age, frailty, or multimorbidity. DATA EXTRACTION: We collected study characteristics (single vs. multicountry enrollment, single vs. multicenter enrollment, funding, sample size, intervention, comparator, primary outcome and secondary outcomes, length of follow-up), study population (inclusion and exclusion criteria, average age in intervention and comparator groups), and subgroup data. We used the Instrument for assessing the Credibility of Effect Modification Analyses instrument to evaluate the credibility of subgroup findings. DATA SYNTHESIS: Of 2037 unique citations, we included 48 RCTs comprising 50,779 total participants. Seven (14.6%) RCTs found evidence of statistically significant effect modification based on age, whereas none of the multimorbidity or frailty subgroups found evidence of statistically significant subgroup effect. Subgroup credibility ranged from very low to moderate. CONCLUSIONS: Most critical care RCTs do not examine for subgroup effects by frailty or multimorbidity. Although age is more commonly considered, the cut-point is variable, and relative effect modification is rare. Although interventional effects are likely similar across age groups, shared decision-making based on individual patient preferences must remain a priority. RCTs focused specifically on critically ill older adults or those living with frailty and/or multimorbidity are crucial to further address this research question.

Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: a systematic review and meta-analysis.

BACKGROUND: Cholinesterase inhibitors are commonly used to treat patients with neurocognitive disorders, who often have an elevated risk of falling. Effective use of these medications requires a thoughtful assessment of risks and benefits. OBJECTIVE: To provide an update on previous reviews and determine the association between cholinesterase inhibitors and falls, syncope, fracture and accidental injuries in patients with neurocognitive disorders. METHODS: Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature and AgeLine were systematically searched through March 2023 to identify all randomised controlled trials of cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in patients with cognitive impairment. Corresponding authors were contacted for additional data necessary for meta-analysis. Inclusion criteria consisted of adults ≥19 years, with a diagnosis of dementia, Parkinson's disease, mild cognitive impairment or traumatic brain injury. Data were extracted in duplicate for the aforementioned primary outcomes and all outcomes were analysed using random-effects meta-analysis. RESULTS: Fifty three studies (30 donepezil, 14 galantamine, 9 rivastigmine) were included providing data on 25, 399 patients. Cholinesterase inhibitors, compared to placebo, were associated with reduced risk of falls (risk ratio [RR] 0.84 [95% confidence interval [CI] = 0.73-0.96, P = 0.009]) and increased risk of syncope (RR 1.50 [95% CI = 1.02-2.21, P = 0.04]). There was no association with accidental injuries or fractures. CONCLUSION: In patients with neurocognitive disorders, cholinesterase inhibitors were associated with decreased risk of falls, increased risk of syncope and no association with accidental trauma or fractures. These findings will help clinicians better evaluate risks and benefits of cholinesterase inhibitors.

Sleep monitoring challenges in patients with neurocognitive disorders: A cross-sectional analysis of missing data from activity trackers.

Background and Aims: Activity monitors, such as Fitbits®, are being used increasingly for research purposes and data have been validated in healthy community-dwelling older adults. Given the lack of research in older adults with neurocognitive disorders, we investigated the consistency of sleep data recorded from a wrist-worn activity monitor in this population. Methods: Fitbit® activity monitors were worn by hospitalized older adults as part of a parent study investigating sleep and step count in patients recovering from hip fracture surgery in a tertiary care academic hospital in Hamilton, Canada between March 2018 and June 2019. In this secondary analysis, we compared the proportion of missing sleep data between participants with and without a neurocognitive disorder and used a multivariable model to assess the association between neurocognitive disorder and missing sleep data. Results: Of 67 participants included in the analysis, 22 had a neurocognitive disorder (median age: 86.5 years). Sleep data were missing for 47% of the neurocognitive disorder group and 23% of the non-neurocognitive disorder group. The presence of a neurocognitive disorder was associated with an increased likelihood of missing sleep data using the Fitbit® activity monitors (adjusted odds ratio: 3.41; 95% confidence interval: 1.06-11.73, p = 0.04). Conclusion: The inconsistent nature of sleep data tracking in hospitalized older adults with neurocognitive disorders highlights the challenges of using interventions in patient populations who are often excluded from validation studies. As opportunities expand for activity monitoring in persons with neurocognitive disorders, novel technologies not previously studied in this group should be used with caution.

Comparison of perceived educational value of an in-person versus virtual medical conference.

PURPOSE: Though prior literature has shown that virtual conferences improve accessibility and provide a comparable educational experience, further research is required to characterize their educational value. METHODS: In this repeated cross-sectional study, demographic and survey data were compared between attendance perspectives for the in-person student-led internal medicine conference held in 2019 and subsequent virtual conference held in 2020. RESULTS: There were 146 attendees at the in-person conference and 200 attendees at the online conference, in which 32 (22% response rate) and 52 responses (26% response rate) were gathered, respectively. Comparison of Likert Scale data via Mann-Whitney U Test revealed that learning objectives were better met in-person for the overall conference (p < 0.01) and didactic sessions (p < .05), but not for workshops, in which there was no significant difference. Survey takers noted the virtual conference to be more accessible on multiple factors, but felt as though their potential for interaction with other participants was more limited. CONCLUSIONS: Results indicate that though the virtual conference appeared more accessible to attendees, overall learning objectives for the conference and didactic sessions were better met in-person. Interestingly however, there was no observed difference in perceived educational value for small group workshops.

OBJECTIF: Bien que la littérature existante montre que les conférences virtuelles améliorent l'accessibilité et offrent une expérience éducative comparable à celles qui sont tenues en personne, des recherches plus approfondies s'imposent pour mieux qualifier leur valeur éducative. MÉTHODES: Dans cette étude transversale répétée, on compare les données démographiques et les données d'enquête concernant la perception des participants à une conférence en médecine interne tenue par des étudiants dans un lieu physique en 2019 et les données analogues concernant une conférence virtuelle qui s'est tenue en 2020. RÉSULTATS: Des 146 participants à la conférence en personne, 32 ont répondu au sondage (taux de réponse de 22 %); parmi les 200 participants à la conférence en ligne, les répondants étaient au nombre de 52 (taux de réponse de 26 %). Les données recueillies selon une échelle de Likert ont été comparées par le biais du test U de Mann-Whitney. Le résultat montre que tandis que les objectifs d'apprentissage étaient mieux atteints lors de la participation en personne pour la conférence en général (p <0,01) et les séances didactiques (p <0,05), pour les ateliers, il n'y avait pas de différence significative. Les participants à l'enquête ont noté que la conférence virtuelle était plus accessible à divers niveaux, mais ils ont trouvé que la possibilité d'interagir avec les autres participants y était plus limitée qu'à la conférence tenue en personne. CONCLUSIONS: D'après les résultats, bien que la conférence virtuelle ait semblé plus accessible aux participants, les objectifs d'apprentissage généraux pour la conférence et les séances didactiques ont été mieux atteints en personne. Il est toutefois intéressant de noter qu'aucune différence n'a été relevée en ce qui concerne la valeur éducative perçue des ateliers en petits groupes.