Preoperative geriatric assessment and follow-up of patients older than 75 years undergoing elective surgery for suspected colorectal cancer.

OBJECTIVES: We investigated the predictive value of specific tools used in a Comprehensive Geriatric Assessment (CGA) with regard to postoperative outcome in patients 75 years and older undergoing elective colorectal cancer (CRC) surgery. Furthermore, recovery was followed over the first postoperative year using the same assessment tools. MATERIAL AND METHODS: Baseline clinical and CGA variables including functional and nutritional status, pressure sore risk, fall risk, cognition, depression, polypharmacy, comorbidity, and health-related quality-of-life (HRQoL) were prospectively recorded. Outcome variables were postoperative complications and length of stay (LOS). Patients were likewise followed up at one, three and twelve months postoperatively. RESULTS: Forty-nine patients underwent surgery (median age 81 years). Forty-three per cent had ASA (American Society of Anesthesiologists) class 2 47% had ASA class 3. Postoperative complications occurred in 32.7%. Median LOS was eight days. In univariate analyses, none of the parameters tested predicted postoperative complication or LOS. During follow-up, all patients recovered to baseline values apart from HRQoL which was still reduced at three and twelve months (p = .017). Nutritional status had improved twelve months after surgery (p = .011). CONCLUSIONS: No association could be found in this study between the results of a comprehensive geriatric assessment and prolonged length of stay or postoperative complication rate after elective surgery for colorectal cancer. Patients recovered well during the first year after surgery. Quality of life, however, was still lower than prior to surgery.

The older patient's experience of the healthcare chain and information when undergoing colorectal cancer surgery according to the enhanced recovery after surgery concept.

AIMS AND OBJECTIVES: To describe how older patients experience the healthcare chain and information given before, during and after colorectal cancer surgery. BACKGROUND: Most persons with colorectal cancer are older than 70 years and undergo surgery with subsequent enhanced recovery programmes aiming to quickly restore preoperative function. However, adaptation of such programmes to suit the older patient has not been made. DESIGN: Qualitative descriptive study. METHOD: Semi-structured interviews were conducted on 16 patients undergoing colorectal cancer surgery at a Swedish University Hospital. The inductive content analysis was employed. RESULTS: During the period of primary investigation and diagnosis, a paucity of information regarding the disease and management, and lack of help in coping with the diagnosis of cancer and its impact on future life, leads to a feeling of vulnerability. During their stay in hospital, the patient's negative perception of the hospital environment, their need for support, and uncertainty and anxiety about the future are evident. After discharge, rehabilitation is perceived as lacking in structure and individual adaptation, leading to disappointment. Persistent difficulty with nutrition delays recovery, and confusion regarding division of responsibility between primary and specialist care leads to increased anxiety and feelings of vulnerability. Information on self-care is perceived as inadequate. Furthermore, provided information is not always understood and therefore not useful. CONCLUSION: Information before and after surgery must be tailored to meet the needs of older persons, considering the patient's knowledge and ability to understand. Furthermore, individual nutritional requirements and preoperative physical activity and status must be taken into account when planning rehabilitation. RELEVANCE TO CLINICAL PRACTICE: Patient information must be personalised and made understandable. This can improve self-preparation and participation in the own recovery. Special needs must be addressed early and followed up.

Cohort Effects in the Prevalence and Survival of People with Dementia in a Rural Area in Northern Sweden.

BACKGROUND: Recent studies suggest that trends in cardiovascular risk may result in a decrease in age-specific prevalence of dementia. Studies in rural areas are rare. OBJECTIVES: To study cohort effects in dementia prevalence and survival of people with dementia in a Swedish rural area. METHODS: Participants were from the 1995-1998 Nordanstig Project (NP) (n = 303) and the 2001-2003 Swedish National study on Aging and Care in Nordanstig (SNAC-N) (n = 384). Overall 6-year dementia prevalence and mortality in NP and SNAC-N were compared for people 78 years and older. Logistic regression analyses were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for dementia occurrence using the NP study population as the reference group. Cox regression models were used to analyze time to death. RESULTS: The crude prevalence of dementia was 21.8% in NP and 17.4% in SNAC-N. When the NP cohort was used as the reference group, the age- and gender-adjusted OR of dementia was 0.71 (95% CI 0.48-1.04) in SNAC-N; the OR was 0.47 (0.24-0.90) for men and 0.88 (0.54-1.44) for women. In the extended model, the OR of dementia was significantly lower in SNAC-N than in the NP cohort as a whole (0.63; 0.39-0.99) and in men (0.34; 0.15-0.79), but not in women (0.81; 0.46-1.44). The Cox regression models indicated that the hazard ratio of dying was lower in the SNAC-N than NP population. CONCLUSIONS: Trends toward a lower prevalence of dementia in high-income countries seem to be evident in this Swedish rural area, at least in men.

The relationship between number of drugs and potential drug-drug interactions in the elderly: a study of over 600,000 elderly patients from the Swedish Prescribed Drug Register.

BACKGROUND: Drug-drug interactions (DDIs) are of great concern, as they are known to be related to adverse drug reactions and hospitalisations. In addition, many DDIs are regarded as predictable and avoidable; therefore, they may be considered as targets for education and interventions. OBJECTIVE: To analyse the relationship between number of dispensed drugs and the probability of potential DDIs among the elderly by using the new Swedish Prescribed Drug Register. METHODS: We analysed data on age, sex and dispensed drugs for people aged > or = 75 years who were registered in the Swedish Prescribed Drug Register from October to December 2005, and constructed a list of current prescriptions for every individual on the arbitrarily chosen date of 31 December 2005. Thereafter, we included those who had at least two dispensed drugs to capture the elderly population at risk of being exposed to DDIs (n = 630 743). The main outcome measures were potentially clinically relevant DDIs (type C), which may require dose adjustment, and potentially serious DDIs (type D), which should be avoided. RESULTS: The prevalence of type C potential DDIs was 26% and of type D potential DDIs 5% in the study population. There was a strong association between number of dispensed drugs and the probability of type C potential DDIs and an even stronger association for type D potential DDIs, after adjustment for age and sex. In addition, the probability of type D potential DDIs decreased with increasing age, and women had a lower probability of type D potential DDIs than men. CONCLUSION: There seems to be a strong relationship between number of dispensed drugs and potential DDIs, especially for potentially serious DDIs, which has implications for the importance of trying to minimise the number of drugs prescribed in the elderly. Our findings that the probability of potentially serious DDIs decreases with increasing age among the elderly and that elderly women have a lower probability of potentially serious DDIs than elderly men need to be verified and investigated by further research.

The use of angiotensin-converting enzyme inhibitors and other drugs with cardiovascular effects by non-demented and demented elderly with a clinical diagnosis of heart failure. A population-based study of the very old.

OBJECTIVES: The aim of this study was to investigate drug treatment patterns for heart failure (HF) in the very elderly and, in particular, to determine if angiotensin-converting enzyme inhibitors (ACEIs) were under-used by demented persons. METHODS: The 265 participants investigated in this study were all 75 years and older, with HF and using cardiovascular drugs, and were part of the Nordanstig cohort (919 persons) of the population-based Kungsholmen project. Data on demographics, medical conditions, including dementia and HF from the baseline investigation 1995-1998, and drug use data from the baseline and follow-up (1999-2001) investigations were used. RESULTS: ACEIs were used by 25.7% of the participants. After adjustment for sociodemographic and medical background factors, there was no significant difference in ACEI use by dementia status, but use was lower with increasing age: the odds ratio (OR) was 0.11 and the 95% confidence interval (95%CI) was 0.01-0.95 between participants 90 years and older and those 75-79 years old (p=0.045). Use was also lower in those persons living in an institution compared to community-living elderly (OR: 0.28; 95% CI: 0.09-0.91; p=0.034). Only 15.8% of the participants used beta-blockers. Of the 12.8% using calcium channel blockers, 82% used preparations with negative inotropic effects. Non-steroid antiinflammatory drugs (NSAIDS), contraindicated in HF, were used by 10.6%. CONCLUSIONS: No significant difference in ACEI utilization related to dementia diagnosis was shown, but the study did reveal a significantly lower use in the oldest age group and in elderly persons living in institutions. The low utilization rates of ACEIs and beta-blockers, the high proportion of calcium channel blockers with negative inotropic effects, and the fairly frequent use of NSAIDs in the study cohort suggest that the quality in drug treatment of very old people with HF can be improved.

Heart failure and risk of dementia and Alzheimer disease: a population-based cohort study.

BACKGROUND: Heart failure has been linked to cognitive impairment in several previous studies, but to our knowledge, no investigations have explored the relationship between heart failure and the risk of dementia. We sought to examine the hypothesis that heart failure is a risk factor for dementia and Alzheimer disease. METHODS: A community-based cohort of 1301 individuals 75 years or older and without dementia in Stockholm, Sweden, was examined 3 times over a 9-year period to detect patients with dementia and Alzheimer disease using the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Heart failure was defined according to the guidelines of the Task Force on Heart Failure of the European Society of Cardiology by integrating clinical symptoms and signs with inpatient register entries and use of cardiac medications. Data were analyzed using Cox proportional hazards models with adjustment for major potential confounders. RESULTS: During the 6534 person-years of follow-up (mean, 5.02 years per person), 440 subjects were diagnosed as having dementia, including 333 with Alzheimer disease. At baseline, heart failure was identified in 205 subjects. Heart failure was associated with a multi-adjusted hazard ratio (HR) of 1.84 (95% confidence interval [CI], 1.35-2.51) for dementia and 1.80 (95% CI, 1.25-2.61) for Alzheimer disease. Use of antihypertensive drugs (83% of which are diuretics) seemed to reduce dementia risk due to heart failure (HR, 1.38; 95% CI, 0.99-1.94). Heart failure and low diastolic pressure (< 70 mm Hg) had an additive effect on the risk for dementia (HR, 3.07; 95% CI, 1.67-5.61). CONCLUSIONS: Heart failure is associated with an increased risk of dementia and Alzheimer disease in older adults. Antihypertensive drug therapy may partially counteract the risk effect of heart failure on dementia disorders.

The association of inappropriate drug use with hospitalisation and mortality: a population-based study of the very old.

BACKGROUND AND OBJECTIVE: Inappropriate prescribing is an important and possibly preventable risk factor for adverse drug reactions (ADRs) in the elderly, and hospital-based studies have shown that a large proportion of admissions is a result of ADRs. However, little is known about how inappropriate drug use (IDU) affects the elderly at the population level. The aim of this study was to explore possible associations of IDU with acute hospitalisation and mortality in an elderly population during 3 years of follow-up. PATIENTS AND METHODS: Data from a rural, population-based, longitudinal cohort study within the Kungsholmen Project, Sweden, were used. 785 participants, > or=75 years of age, had complete data on drug use and selected covariates collected during baseline investigation from 1995 to 1998, and were included in the study. Hospitalisation and mortality data during 3 years after inclusion were collected. IDU was assessed at baseline using consensus-based criteria applicable to available data (derived from Beers' criteria, Canadian criteria and clinical indicators of drug-related morbidity in older adults) with the addition of potentially dangerous drug duplication and additional potentially hazardous drug-drug interactions. IDU was defined as presence of at least one inappropriate drug regimen according to the study criteria. Logistic regression and proportional hazard models were used, respectively, to study the association of IDU with hospitalisation and mortality. RESULTS: Drugs were used on a regular or 'as needed' basis by 91.6% of the study population, with a mean of 4.4 drugs per person. IDU was common, with a prevalence of 18.6% and was associated with increased risk of at least one acute hospitalisation in community-living elderly, after adjustment for age, sex, education, comorbidity, dependency in activities of daily living (ADL) and smoking. The odds ratio was 2.72 (95% CI 1.64, 4.51). No association with mortality was found, after adjustment for age, sex, housing, education, comorbidity, ADL-dependency, smoking and body mass index. CONCLUSION: Polypharmacy and IDU are common among the elderly and IDU is associated with acute hospitalisation in community-living elderly. Although causality cannot be established with this study design, the results are consistent with the high prevalence of drug-related hospital admissions found in hospital-based studies. Our results indicate that it is desirable with current knowledge, to reduce IDU through information to physicians and careful prescribing.

A population-based study of drug use in the very old living in a rural district of Sweden, with focus on cardiovascular drug consumption: comparison with an urban cohort.

PURPOSE: To describe drug use among the elderly, with focus on cardiovascular drugs and regional differences. METHODS: Cross-sectional data from a Swedish population-based study on ageing and dementia were used. In rural Nordanstig, drug-use data for 918 participants, 75 years and older (N1), were collected during the period 1995-1998. The data for 335 participants, 84 years and older (N84+), were compared with 418 subjects of the same age group in urban Kungsholmen (K5), data collected 1997-1998. RESULTS: Over 90% of the participants were using drugs regularly or 'as needed'. The most common were cardiovascular drugs, nervous system drugs and drugs for the alimentary tract and metabolism. Polypharmacy (five drugs or more) was common, especially among the oldest, 46% (N84+) and 50% (K5). ACE-inhibitors were used by only 24% of the N1 participants with heart failure. Significantly fewer of cognitively impaired participants were treated with ACE-inhibitors (OR: 0.44) and beta-blockers (OR: 0.50). Significant regional differences among the oldest old were found, with more cardiovascular (OR: 2.72) and less antithrombotic drugs (OR: 0.43) in the rural 84+ group. CONCLUSIONS: The extensive drug consumption, high prevalence of polypharmacy and regional differences stress the need for rigorous monitoring of drug use in the elderly. The data also indicate undertreatment of some cardiovascular diseases in the elderly with cognitive impairment.