Geriatric assessment factors are associated with mortality after hospitalization in older adults with cancer.

PURPOSE: Survival in older adults with cancer varies given differences in functional status, comorbidities, and nutrition. Prediction of factors associated with mortality, especially in hospitalized patients, allows physicians to better inform their patients about prognosis during treatment decisions. Our objective was to analyze factors associated with survival in older adults with cancer following hospitalization. METHODS: Through a retrospective cohort study, we reviewed 803 patients who were admitted to Barnes-Jewish Hospital's Oncology Acute Care of Elders (OACE) unit from 2000 to 2008. Data collected included geriatric assessments from OACE screening questionnaires as well as demographic and medical history data from chart review. The primary end point was time from index admission to death. The Cox proportional hazard modeling was performed. RESULTS: The median age was 72.5 years old. Geriatric syndromes and functional impairment were common. Half of the patients (50.4 %) were dependent in one or more activities of daily living (ADLs), and 74 % were dependent in at least one instrumental activity of daily living (IADLs). On multivariate analysis, the following factors were significantly associated with worse overall survival: male gender; a total score <20 on Lawton's IADL assessment; reason for admission being cardiac, pulmonary, neurologic, inadequate pain control, or failure to thrive; cancer type being thoracic, hepatobiliary, or genitourinary; readmission within 30 days; receiving cancer treatment with palliative rather than curative intent; cognitive impairment; and discharge with hospice services. CONCLUSIONS: In older adults with cancer, certain geriatric parameters are associated with shorter survival after hospitalization. Assessment of functional status, necessity for readmission, and cognitive impairment may provide prognostic information so that oncologists and their patients make more informed, individualized decisions.

Geriatric assessment as predictors of hospital readmission in older adults with cancer.

BACKGROUND: Hospital readmission is a common, costly problem. Little is known regarding risk factors for readmission in older adults with cancer. This study aims to identify factors associated with 30-day readmission in a cohort of older medical oncology patients. SETTING/PARTICIPANTS: Adults age 65 and over hospitalized to an Oncology Acute Care for Elders Unit at Barnes-Jewish Hospital. MEASUREMENTS: Standard geriatric screening tests were administered in routine clinical care. Clinical data and 30-day readmission status were obtained through medical record review. RESULTS: 677 patients met the inclusion criteria. 77% were white and 53% were male. Thoracic (32%), hematologic (20%), and gastrointestinal (18%) malignancies were most common. The 30-day unplanned readmission rate was 35.2%. Multivariable analyses identified complete dependence in feeding (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.29-10.65), and some dependence (1.58, 1.04-2.41) and complete dependence (2.64, 1.70-4.12) in housekeeping, prior to admission, as associated with higher odds of readmission. Age<75 (1.49, 1.04-2.14), African-American race (1.59, 1.06-2.39), potentially inappropriate medications (1.36, 0.94-1.99), and higher-risk reasons for index admission (1.93, 1.34-2.78) also increased odds of readmission. These factors were organized into a prognostic index. CONCLUSION: Hospital readmission was common and higher than previously reported rates in general medical populations. We identified several previously unrecognized factors associated with increased risk for readmission, including some geriatric assessment parameters, and developed a practical tool that can be used by clinicians to assess risk of 30-day readmission.

The Dementia Friendly Hospital Initiative education program for acute care nurses and staff.

Individuals with Alzheimer's disease and other dementias have 3.2 million hospital stays annually, which is significantly more than older individuals without dementia. Hospitalized patients with dementia are at greater risk of delirium, falls, overwhelming functional decline that may extend the hospital stay, and prolonged or complicated rehabilitation. These risks highlight the need for staff education on the special care needs of this vulnerable population. This article describes a one-day education program, the Dementia Friendly Hospital Initiative, designed to teach staff how to provide the specialized care required by patients with dementia. Participants (N = 355) from five different hospitals, including 221 nurses, completed a pretest-posttest evaluation for the program. Changes in participants attitudes and practices, confidence, and knowledge were evaluated. Scores indicated significant improvement on the posttest. The evaluation provides further evidence for recommending dissemination of the Dementia Friendly Hospital Initiative.

Nutritional processes of care for older adults admitted to an oncology-acute care for elders unit.

BACKGROUND: Acute care for elders (ACE) units have been established in the United States to prevent functional decline in older hospitalized patients. PURPOSE: We sought to examine whether an ace unit that focused specifically on care of older oncology patients (OACE) compared with a usual care cancer ward (UCCW) demonstrated improved nutritional processes of care in patients who had documentation of nutritional deficits. METHODS: We conducted a retrospective chart review to examine whether orders had been placed for a nutritional consult or use of nutritional supplements. Logistic regression analyses, controlling for confounding variables, were conducted to evaluate differences between the wards. RESULTS: OACE unit patients were 2.1 times more likely than UCCW patients to have a nutrition consult placed and 2.5 times more likely to have nutritional supplements ordered. CONCLUSIONS: An OACE unit model of care resulted in increased nutritional interventions. Future work is warranted to evaluate outcomes of care.

Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit.

BACKGROUND: A novel Oncology-Acute Care for Elders (OACE) unit that uses an interdisciplinary team to enhance recognition and management of geriatric syndromes in hospitalized older adult cancer patients has been established at Barnes-Jewish Hospital (St. Louis, Missouri). The OACE team includes a clinical pharmacist whose primary role is to improve the appropriateness of prescribing. OBJECTIVE: Using polypharmacy as the prototypical geriatric syndrome addressed by the OACE team, the objective of this study was to document the processes of communication of an interdisciplinary team and the impact on polypharmacy when the treating physician did not participate in the daily interdisciplinary team rounds. METHODS: This was a prospective, observational study of older cancer patients admitted to the OACE unit. We tracked processes and outcomes of interdisciplinary communication regarding medications by prospectively recording OACE team recommendations and evaluating the frequency of implementation of these recommendations through a chart review. Treating physicians, who did not attend team rounds, received these recommendations on a communication form placed in the patient's chart. RESULTS: Forty-seven patients were included in the study. The mean (SD) age was 73.5 (7.5) years. Twenty-one percent (10/47) of patients were prescribed > or =1 Beers medication as part of their home-care regimen before admission to the OACE unit. The OACE team made 51 medication recommendations, and 42 of those recommendations (82%) were implemented. Twenty-five patients (53%) had an alteration in their medication regimen; 13 (28%) had a potentially inappropriate medication discontinued. A medication error was corrected in ~1 of every 8 patients (6/47 [13%]). CONCLUSIONS: We found that polypharmacy was common in older cancer patients and increased during hospitali-zation. We also found that most OACE team recommendations communicated to physicians were implemented even though the primary physicians were not members of the OACE team. Future randomized trials are needed to assess the impact of the OACE team model of care on adverse events, survival, and cost in hospitalized older adult cancer patients.

Geriatric syndromes in elderly patients admitted to an oncology-acute care for elders unit.

PURPOSE: The goal of this study was to characterize an elderly population admitted to a novel Oncology-Acute Care for Elders (OACE) unit, determine the prevalence of functional dependencies and geriatric syndromes, and examine their suitability for an interdisciplinary model of care. PATIENTS AND METHODS: We conducted a retrospective review of 119 patients age 65 years or older who had a primary oncologic or hematologic diagnosis and were admitted to the OACE Unit. Standard geriatric screens were administered to assess mood, functional, and cognitive status. Demographic and medical data were compiled by review of patients' medical records. RESULTS: The mean age of the patients was 74.1 years (standard deviation, 5.9 years). The sample was predominantly white, of equal sex, had limitations in instrumental and basic activities of daily living, and a mean length of stay of 6 days. Geriatric syndromes detected by the OACE interdisciplinary team included cognitive impairment (dementia and/or delirium), depression, weight loss, and use of high-risk medications. Adverse events such as falls, restraint use, and pressure sores were rare. CONCLUSION: In this descriptive study, many older cancer patients were found to have geriatric syndromes by the OACE team and these patients were considered appropriate for an interdisciplinary model of care. Additional studies are needed to compare the outcomes of hospitalized older oncology patients receiving an OACE intervention with those patients receiving usual care.