Outcomes of critically ill older adults with COVID-19: a multicentre retrospective cohort study.

PURPOSE: Older adults with COVID-19 have a high prevalence of complications and mortality during hospitalization. Given the large proportion of older adults requiring admission to an intensive care unit (ICU), we aimed to describe the management and outcomes of older adults with COVID-19 requiring ICU care and identify predictors of hospital mortality. METHODS: We included consecutive patients ≥ 65 yr of age who were admitted between 11 March 2020 and 30 June 2021 to one of five Toronto (ON, Canada) ICUs with a primary diagnosis of SARS-CoV-2 infection in a retrospective cohort study. Patient characteristics, ICU treatment, and outcomes were recorded. We used multivariable logistic regression to identify predictors of in-hospital mortality. RESULTS: Of the 273 patients, the median [interquartile range] age was 74 [69-80] yr, 104 (38.1%) were female, and 164 (60.1%) required invasive mechanical ventilation. One hundred and forty-two patients (52.0%) survived their hospital stay. Compared with survivors, nonsurvivors were older (74 [70-82] yr vs 73 [68-78] yr; P = 0.03), and a smaller proportion was female (39/131, 29.8% vs 65/142, 45.8%; P = 0.01). Patients had long hospital (19 [11-35] days) and ICU (9 [5-22] days) stays, with no significant differences in ICU length of stay or duration of invasive mechanical ventilation between the two groups. Higher APACHE II score, increasing age, and the need for organ support were independently associated with higher in-hospital mortality while female sex was associated with lower mortality. CONCLUSIONS: Older critically ill COVID-19 patients had long ICU and hospital stays, and approximately half died in hospital. Further research is needed to identify individuals who will benefit most from an ICU admission and to evaluate posthospitalization outcomes.

RéSUMé: OBJECTIF: Les personnes âgées atteintes de la COVID-19 ont une prévalence élevée de complications et de mortalité pendant l'hospitalisation. Compte tenu de la forte proportion de personnes âgées nécessitant une admission dans une unité de soins intensifs (USI), nous avons cherché à décrire la prise en charge et les devenirs des personnes âgées atteintes de COVID-19 nécessitant des soins intensifs et à identifier les prédicteurs de mortalité hospitalière. MéTHODE: Nous avons inclus des patient·es consécutif·ves âgé·es de ≥ 65 ans admis·es entre le 11 mars 2020 et le 30 juin 2021 dans l'une des cinq unités de soins intensifs de Toronto (ON, Canada) avec un diagnostic primaire d'infection par le SRAS-CoV-2 dans une étude de cohorte rétrospective. Les caractéristiques des patient·es, le traitement en USI et les devenirs ont été enregistrés. Nous avons utilisé une régression logistique multivariable pour identifier les prédicteurs de mortalité hospitalière. RéSULTATS: Parmi les 273 patient·es, l'âge médian [écart interquartile] était de 74 [69-80] ans, 104 (38,1 %) étaient des femmes et 164 (60,1 %) ont nécessité une ventilation mécanique invasive. Cent quarante-deux personnes (52,0 %) ont survécu à leur séjour à l'hôpital. Comparativement aux personnes survivantes, les personnes qui n'ont pas survécu étaient plus âgées (74 [70-82] ans vs 73 [68­78] ans; P = 0,03), et une plus faible proportion était de sexe féminin (39/131, 29,8 % vs 65/142, 45,8 %; P = 0,01). Les séjours des patient·es à l'hôpital (19 [11-35] jours) et à l'USI (9 [5-22] jours) étaient longs, sans différence significative dans la durée du séjour en USI ou la durée de la ventilation mécanique invasive entre les deux groupes. Un score APACHE II plus élevé, un âge plus avancé et le besoin de mesures de soutien d'organes étaient indépendamment associés à une mortalité plus élevée à l'hôpital, tandis que le sexe féminin était associé à une mortalité plus faible. CONCLUSION : Les personnes plus âgées gravement malades atteintes de la COVID-19 ont eu de longs séjours en soins intensifs et à l'hôpital, et environ la moitié sont décédées à l'hôpital. D'autres recherches sont nécessaires pour identifier les personnes qui bénéficieraient le plus d'une admission à l'USI et pour évaluer les devenirs post-hospitalisation.

Characteristics, treatment and delirium incidence of older adults hospitalized with COVID-19: a multicentre retrospective cohort study.

BACKGROUND: The COVID-19 pandemic has affected older adults disproportionately, and delirium is a concerning consequence; however, the relationship between delirium and corticosteroid use is uncertain. The objective of the present study was to describe patient characteristics, treatments and outcomes among older adults hospitalized with COVID-19, with a focus on dexamethasone use and delirium incidence. METHODS: We completed this retrospective cohort study at 7 sites (including acute care, rehabilitation and long-term care settings) in Toronto, Ontario, Canada. We included adults aged 65 years or older, consecutively hospitalized with confirmed SARS-CoV-2 infection, between Mar. 11, 2020, and Apr. 30, 2021. We abstracted patient characteristics and outcomes from charts and analyzed them descriptively. We used a logistic regression model to determine the association between dexamethasone use and delirium incidence. RESULTS: During the study period, 927 patients were admitted to the acute care hospitals with COVID-19. Patients' median age was 79.0 years (interquartile range [IQR] 72.0-87.0), and 417 (45.0%) were female. Most patients were frail (61.9%), based on a Clinical Frailty Scale score of 5 or greater. The prevalence of delirium was 53.6%, and the incidence was 33.1%. Use of restraints was documented in 20.4% of patients. In rehabilitation and long-term care settings (n = 115), patients' median age was 86.0 years (IQR 78.5-91.0), 72 (62.6%) were female and delirium occurred in 17 patients (14.8%). In patients admitted to acute care during wave 2 of the pandemic (Aug. 1, 2020, to Feb. 20, 2021), dexamethasone use had a nonsignificant association with delirium incidence (adjusted odds ratio 1.38, 95% confidence interval 0.77-2.50). Overall, in-hospital death occurred in 262 (28.4%) patients in acute care settings and 28 (24.3%) patients in rehabilitation or long-term care settings. INTERPRETATION: In-hospital death, delirium and use of restraints were common in older adults admitted to hospital with COVID-19. Further research should be directed to improving the quality of care for this population with known vulnerabilities during continued waves of the COVID-19 pandemic.

Mortality in hospitalized older adults with COVID-19 during three waves: A multicenter retrospective cohort study.

Background: The waves of COVID-19 infections in Ontario, Canada, were marked by differences in patient characteristics and treatment. Our objectives were to (i) describe patient characteristics, treatment, and outcomes of hospitalized older adults with COVID-19 between waves 1, 2, and 3, (ii) determine if there was an improvement in in-hospital mortality in waves 2 and 3 after adjusting for covariates. Methods: This retrospective cohort study was done in five acute care hospitals in Toronto, Ontario. Consecutive hospitalized older adults aged ≥65 years with confirmed COVID-19 infection were included. Wave 1 extended from March 11 to July 31, 2020, wave 2 from August 1, 2020 to February 20, 2021, and wave 3 from February 21 to June 30, 2021. Patient characteristics and outcomes were abstracted from charts. A logistic regression model was used to determine the association between COVID-19 and in-hospital mortality in waves 2 and 3 compared with wave 1. Results: Of the 1671 patients admitted to acute care, 297 (17.8%) were admitted in wave 1, 751 (44.9%) in wave 2, and 623 (37.3%) in wave 3. The median age of our cohort was 77.0 years (interquartile range: 71.0-85.0) and 775 (46.4%) were female. The prevalence of frailty declined in progressive waves. The use of dexamethasone, remdesivir, and tocilizumab was significantly higher in waves 2 and 3 compared with wave 1. In the unadjusted analysis, in-hospital mortality was unchanged between waves 1 and 2, but it was lower in wave 3 (18.3% vs. 27.4% in wave 1). After adjustment, in-hospital mortality was unchanged in waves 2 and 3 compared with wave 1. Conclusion: In-hospital mortality in hospitalized older adults with COVID-19 was similar between waves 1 and 3. Further research should be done to determine if COVID-19 therapies have similar benefits for older adults compared with younger adults.

Does Physician Retirement Affect Patients? A Systematic Review.

OBJECTIVES: Older patients that have aged with their doctors will likely experience their physician retiring. It is unclear if this interruption in continuity of care leaves patients at risk for adverse events or whether a new physician improves care. We sought to identify and synthesize findings from all articles examining the association between physician retirement and patient outcomes. DESIGN: Systematic review. We searched English-language articles cataloged in Medline, Embase, Cochrane, and PsycINFO, from database inception to May 4, 2018. PARTICIPANTS: Any patient whose physician (generalist or specialist) retired. INTERVENTION: Physician retirement, defined as voluntary practice closure, death, or departure. MEASUREMENTS: Articles were categorized as anecdotes, qualitative studies, or quantitative studies. Each patient outcome was indexed under one of 11 themes (eg, adverse event, difficulty accessing care) and classified as favorable, neutral, or unfavorable. Patient outcomes included but were not limited to clinical (eg, death), resource utilization (eg, hospitalization), treatment plan adherence (eg, access to medications), and patient satisfaction (eg, expressed frustration). Two reviewers independently assessed study quality. RESULTS: Of 2099 articles screened, 17 met inclusion criteria: 12 anecdotes, 2 qualitative studies, and 3 quantitative studies. Most patient outcomes described were unfavorable. These included feelings of loss, difficulties with transition to a new provider, adverse clinical outcomes, and increased use of high-cost services. The quality of qualitative studies was high, but that of quantitative studies was poor or moderate. CONCLUSION: Current evidence from qualitative studies suggests physician retirement affects patients unfavorably and that patients are vulnerable during this transition of care. High-quality quantitative research is lacking to identify whether this disproportionately affects older adults and whether physician retirement has significant consequences for the broader healthcare system. J Am Geriatr Soc 68:641-649, 2020.

Management of Sleep Disorders in Community-Dwelling Older Women and Men at the Time of Diagnosis.

OBJECTIVES: Sedative and hypnotic medications are associated with harm, and guidelines suggest limiting their use. Only limited evidence has described how older adults are managed following an initial sleep disorder diagnosis. We aimed to describe clinical management patterns of sleep disorders in older women and men at the time of initial diagnosis. DESIGN: Population-based retrospective cohort study using linked administrative databases. SETTING: Ontario, Canada. PARTICIPANTS: Community-dwelling adults aged 66 and older, diagnosed with a new sleep disorder by a primary care provider (n = 30 729; 56% women and 44% men). We compared women and men for each outcome. MEASUREMENTS: The primary outcome was prescription of a medication used for sleep within 30 days of a new sleep disorder diagnosis. Additional analysis included medical investigations such as sleep studies and visits to specialists who manage obstructive sleep disorders within 90 days of diagnosis. RESULTS: Among the 30 729 older adults with a new sleep disorder diagnosis, 5512 (17.9% total; 18.8% of women and 16.9% of men) were prescribed a medication used for sleep. Compared with men, women were somewhat more likely to be prescribed at least one sedative medication (adjusted odds ratio = 1.09; 95% confidence interval = 1.03-1.16). A total of 2573 (8.4%) older adults underwent a sleep study, and 3743 (12.2%) were evaluated by a specialist; both occurred more commonly in men. CONCLUSION: In our cohort, almost 1 in 5 older adults with a new sleep disorder diagnosis were prescribed a medication used for sleep; of these, a higher proportion were women. Comparatively few older adults were further evaluated; of these, a higher proportion were men. Our study highlights the high rates at which medications are prescribed to older adults with a new sleep disorder diagnosis and identifies potential sex differences in the management of such diagnoses. J Am Geriatr Soc 1-8, 2019. J Am Geriatr Soc 67:2094-2101, 2019.

Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners.

BACKGROUND: Cancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses. METHODS: This was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important). RESULTS: Between July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37%). The most important barriers to GoC discussions were patient and family factors. They included family members' difficulty accepting poor prognoses (mean score 5.9, 95% CI [5.7, 6.2]), lack of family agreement in the goals of care (mean score 5.8, 95% CI [5.5, 6.1]), difficulty understanding the limitations of life-sustaining treatments (mean score 5.8, 95% CI [5.6, 6.1]), lack of patients' capacity to make goals of care decisions (mean score 5.7, 95% CI [5.5, 6.0]), and language barriers (mean score 5.7, 95% CI [5.4, 5.9]). Participants viewed system factors and healthcare provider factors as less important barriers. CONCLUSIONS: Oncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions.

Role of allied health care professionals in goals-of-care discussions with hospitalized patients and perceived barriers: a cross-sectional survey.

BACKGROUND: Allied health care professionals can contribute meaningfully to goals-of-care discussions with seriously ill hospitalized patients and their families. We sought to explore the perspective of hospital-based allied health care professionals on their role in goals-of-care discussions and to identify barriers to their participation. METHODS: We surveyed allied health care professionals (social workers, physiotherapists, occupational therapists, registered dietitians, speech-language pathologists and pharmacists) on internal medicine, hematology-oncology, medical oncology and radiation oncology wards at 2 tertiary care hospitals in Hamilton, Ontario, from April 2013 to May 2014. We modified a validated questionnaire originally designed to assess barriers to discussing goals of care from the perspective of nurses, residents and staff physicians on hospital medical wards. Respondents rated the questionnaire items on a 7-point Likert scale. RESULTS: Of the 47 allied health care professionals invited, 32 (68%) participated: 9 physiotherapists, 7 social workers, 6 occupational therapists, 4 registered dietitians, 3 pharmacists and 2 speech-language pathologists; in 1 case, the profession was unknown. The greatest perceived barriers to engaging in goals-of-care discussions were lack of patient decision-making capacity (mean rating 5.9 [standard error (SE) 0.3]), lack of awareness of patients' previous discussions with other team members (mean rating 5.7 [SE 0.3]) and family members' difficulty accepting a poor prognosis (mean rating 5.6 [SE 0.2]). Although the respondents felt it was most acceptable for staff physicians, residents and advanced practice nurses to exchange information and reach a final decision during goals-of-care discussions, they felt it was acceptable for a broader range of allied health care professionals to initiate discussions (mean rating 4.7-5.8) and to act as decision coaches (clarifying values, weighing options) with patients and families (mean rating 5.3-6.1). INTERPRETATION: Allied health care professionals are willing to initiate goals-of-care discussions and to act as a decision coach with seriously ill hospitalized patients and their families. By improving interprofessional collaboration, we can engage the entire health care team in this process.

Looking for lithotripsy: accessibility and portability of Canadian healthcare.

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) is a definitive, ambulatory and non-invasive modality for treating kidney stones. ESWL is not available in all urban centres and many Canadians must either travel, sometimes out of province, or wait to have this procedure performed. We sought to evaluate the variability in access to ESWL treatment. METHOD: We compiled a comprehensive list of ESWL centres in Canada and contacted all centres in 2011 to assess their wait times, out-of-province patient fees, and roles and responsibilities of the referring physician. RESULTS: We contacted all 23 ESWL facilities across Canada (100% response rate). Wait times for elective ESWL procedures ranged from one day to over one year, with a mean of 8.4 weeks (SD, 16.76 weeks). No centres refused out-of-province patients, although five discouraged travel to their centre owing to their prolonged wait times. No facilities charged extra fees for out-of-province patients. Ten (43%) facilities required a secondary consultation by a urolo-gist at the centre before booking. Twelve (52%) of the centres indicated the waiting time could be shortened if the referring physician were to advocate on the patient's behalf. Contact was repeated one year later in 2012 with five centres, and the results were similar. INTERPRETATION: There is marked variation in wait times across Canada for ESWL but there are few barriers to care. Patients' waits may be shortened by physician advocacy.