Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial.

AIM: Colorectal cancer (CRC) is prevalent in the older population, and surgery is the mainstay of curative treatment. A preoperative geriatric assessment (GA) can identify frail older patients at risk for developing postoperative complications. In this randomized controlled trial we wanted to investigate whether tailored interventions based on a preoperative GA could reduce the frequency of postoperative complications in frail patients operated on for CRC. METHOD: Patients > 65 years scheduled for elective CRC surgery and fulfilling predefined criteria for frailty were randomized to either a preoperative GA followed by a tailored intervention or care as usual. The primary end-point was Clavien-Dindo Grade II-V postoperative complications. Secondary end-points included complications of any grade, reoperation, length of stay, readmission and survival. RESULTS: One hundred and twenty-two patients with a mean age of 78.6 years were randomized. We found no statistically significant differences between the intervention group and the control group for Grade II-V complications (68% vs 75%, P = 0.43), reoperation (19% vs 11%, P = 0.24), length of stay (8 days in both groups), readmission (16% vs 6%, P = 0.12) or 30-day survival (4% vs 5%, P = 0.79). Grade I-V complications occurred in 76% of patients in the intervention group compared with 87% in the control group (P = 0.10). In secondary analyses adjusting for prespecified prognostic factors, there was a statistically significant difference in favour of the intervention for reducing the total number of Grade I-V complications (P = 0.05). CONCLUSION: A preoperative GA and tailored interventions did not reduce the rate of Grade II-V complications, reoperations, readmission or mortality in frail older patients electively operated on for CRC.

Using the Mini-Mental State Examination to screen for delirium in elderly patients with hip fracture.

BACKGROUND: The main aim of this paper was to examine the usefulness of the Mini-Mental State Examination (MMSE) for screening delirium in elderly patients with hip fracture. METHODS: The sample included 364 elderly patients with hip fracture admitted to two hospitals in Oslo. Delirium was assessed by the Confusion Assessment Method (CAM) as an approximation of the gold standard, DSM-IV. To evaluate the psychometric properties of the MMSE scale, we used the Mokken nonparametric latent trait model for unidimensional scaling. RESULTS: In total, 76 (21%) patients were diagnosed with delirium based on the CAM, and 141 (43%) had preexisting cognitive impairment. As a screening tool, the recommended MMSE cut-point of 24 showed an acceptable sensitivity of 88% with a specificity of 54%. The prediction of delirium, based on logistic regression on the MMSE total score and on the 5 items selected by the stepwise logistic regression procedure, gave clearly less acceptable results. CONCLUSIONS: Our study indicates that the MMSE may be useful in screening for delirium, but the high percentage of false positives shows that it does not have diagnostic potential in patients with hip fracture.

"Two per cent isn't a lot, but when it comes to death it seems quite a lot anyway": patients' perception of risk and willingness to accept risks associated with thrombolytic drug treatment for acute stroke.

BACKGROUND: Thrombolytic drugs to treat an acute ischaemic stroke reduce the risk of death or major disability. The treatment is, however, also associated with an increased risk of potentially fatal intracranial bleeding. This confronts the patient with the dilemma of whether or not to take a risk of a serious side effect in order to increase the likelihood of a favourable outcome. OBJECTIVE: To explore acute stroke patients' perception of risk and willingness to accept risks associated with thrombolytic drug treatment. DESIGN: Eleven patients who had been informed about thrombolytic drug treatment and had been through the process of deciding whether or not to participate in a thrombolytic drug trial went through repeated qualitative, semistructured interviews. RESULTS: Many patients showed a limited perception of the risks connected with thrombolytic drug treatment. Some perceived the risk as not relevant to them and were reluctant to accept that treatment could cause harm. Others seemed to be aware that treatment would mean exposure to risk. The patients' willingness to take a risk also varied substantially. Several statements revealed ambiguity and confusion about being involved in a decision about treatment. The patients' reasoning about risk was put into the context of their health-related experiences and life histories. Several patients wanted the doctor to be responsible for the decisions. CONCLUSION: Acute stroke patients' difficulties in perceiving and processing information about risk may reduce their ability to be involved in clinical decisions where risks are involved.

TOAST criteria applied in acute ischemic stroke.

BACKGROUND: Etiological subclassification of ischemic stroke has become increasingly important, as new therapeutic agents have been introduced. The aim of this study was to assess the inter-rater reliability of the TOAST classification applied in the acute setting, and further to evaluate the criterion validity of the TOAST classification in discriminating between small vessel disease and other etiologies. METHODS: From June to December 2001, 38 patients with acute ischemic stroke were included in the present study. All were classified according to the TOAST criteria by two junior registrars shortly after admission. Later, a consensus classification was made based on a comprehensive investigation programme. RESULTS: The inter-rater reliability between the two junior registrars was very good (kappa 0.88). The overall agreement between initial and consensus classifications was fair (kappa 0.30). The TOAST classification discriminated between small vessel disease and other subgroups in most patients (sensitivity 0.93, specificity 0.83). CONCLUSION: Etiological subclassification of ischemic stroke requires extensive cerebrovascular investigation. Normally, such resources are not available at admission. Nevertheless, the TOAST classification should be used in this setting to help physicians differentiate between small vessel disease and other etiologies of acute stroke, particularly when therapies with possible harmful side effects are considered an option.

Risk factors for serious fall related injury in elderly women living at home.

OBJECTIVES: To study whether balance, function, and other health status indicators can predict serious fall related injury in elderly women living at home. METHODS: In this prospective study, the authors took a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%), living in the community. Serious fall injuries which occurred over a period of during one year were recorded, together with baseline registrations of health, function, and tests of walking and balance. RESULTS: In all, 155 women (50.5%) fell one or more times. One hundred and fifty six (51%) of the 308 falls resulted in a fall related injury, 74 (24%) in a serious fall related injury, and 40 falls (13%) resulted in fractures. The presence of rheumatic disorders, inability to rise from the floor, arthrosis of the hip, having had more than one fall during the one year follow up period, and an increased tendency to sway in the frontal plane when doing a calculation task were independent and significant predictors for serious fall related injury (fractures included). The independent predictors of fall induced fractures were experiencing more than one fall in the follow up period, cognitive impairment, and receiving care from professional or other. CONCLUSION: The study suggests that rheumatic disorders and the inability to get up from lying on the floor were the strongest independent risk factors for serious fall related injury. Experiencing more than one fall in the follow up period and cognitive impairment are the strongest independent predictors for fall induced fractures. Age was not a significant predictor of serious fall related injury. Assessment of these markers is feasible in a clinical setting and is a useful way of identifying those who are at risk of serious fall related injuries.

Acute phase predictors of subsequent psychosocial burden in carers of elderly stroke patients.

The objective was to describe the psychosocial burden experienced by informal carers of elderly stroke victims, and to identify its predictors among baseline characteristics of the patients. From a prospective study of 171 elderly stroke patients admitted to a geriatric ward for rehabilitation in the acute phase, 68 patients living at home with a primary caregiver were identified 6 months after the stroke. At baseline, all the patients were assessed with respect to motor function, cognitive function, global handicap and activities of daily living, and after 6 months the caregivers were assessed, using the Relatives' Stress Scale. According to this, the most frequent impacts were worries that an accident might befall their relatives, that they had to reorganise their household routines and further, that their social life and ability to take holidays had been reduced. Impaired cognitive function was the only baseline patient characteristic that predicted a subsequent psychosocial burden on the carer. Special attention should be paid to elderly stroke patients initially assessed with impaired cognitive function and their caregivers.

Association between impairments, self-care ability and social activities 1 year after stroke.

PURPOSE: To explore how motor and cognitive impairments relate to physical activities of daily living (PADL) and social activities after stroke. METHOD: The data related to 65 patients (mean age 74.4 years, 43% females), assessed 1 year after stroke by means of the Sødring Motor Evaluation of Stroke patients and the Assessment of Stroke and other Brain damage instruments. The self-care and social activities scales applied were the Barthel ADL Index and the Frenchay Activities Index (FAI). The association between impairment variables on the one hand and PADL and FAI scores on the other was estimated using Kendall rank correlations. RESULTS: Arm motor function correlated most strongly with the Barthel score (tau = 0.76), and visuospatial function came second (tau = 0.58). Factor analysis of the FAI produced three subscales: a 'domestic' factor most strongly related to arm motor function (tau = 0.49); 'outdoor' related to visuospatial ability (tau = 0.48); and 'hobby' which had no significant correlates. CONCLUSION: In the chronic phase of stroke, self-care and involvement in social activities relate most strongly to arm motor function and visuospatial ability. Outdoor activities depend mainly on visuospatial function.

How does a cerebral stroke affect quality of life? Towards an adequate theoretical account.

PURPOSE: To contribute, through a hypothesis-generating, qualitative study, to a consistent theoretical account of the mechanisms by which strokes affect the quality of lives of patients. METHOD: A strategic subsample of six persons (65-85 years) was drawn from a larger sample of 60 stroke patients 3 years after stroke. They suffered from some, mostly mild, motor or cognitive impairments, and underwent a semi-structured interview, which was tape-recorded, transcribed and analysed. RESULTS AND CONCLUSION: Only one of the subjects had any familiarity with the QoL concept. When it was rephrased in familiar terms, all but one stated that their QoL had been reduced after the stroke. All the subjects reported considerable bodily changes. The reduced QoL was not, however interpreted as a direct consequence of these, but as a result of the individual's interpretation and evaluation of the changes. It was essential whether the patient compared the present situation to life prior to the stroke, or to a post-stroke reference point. These personal evaluations interacted with the interpretations of the situation by the patients' significant others.

Stroke and gender.

The literature regarding gender-specific aspects of cerebrovascular diseases is quite sparse. It is well-documented that the incidence of stroke is higher in men than in women in all age classes, and women are, on average, several years older than men when they suffer their first stroke. The prevalence of stroke is higher among men up to the age of approximately 80 years, after which it becomes higher in women. A majority of studies indicate that the case-fatality rate is higher in female than in male stroke patients; there is also some evidence, albeit relatively weak, indicating a better functional outcome in men. Gender differences in risk factor profile and treatment response appear to be weak. The burden of providing informal care to stroke patients seems to constitute a threat to the mental health of the caregivers, who are predominantly women.

Validation of the screening instrument for neuropsychological impairment in stroke.

BACKGROUND AND PURPOSE: Full neuropsychological assessment is time-consuming and exhausting for the patient in the early phase of stroke. The screening instrument for neuropsychological impairment in stroke (SINS) is a brief, bedside-applicable instrument designed to screen perceptual and cognitive dysfunction related to functional activities in stroke. It has been developed by physiotherapists to be incorporated in the general assessment of the patient. This study evaluates the validity of the method against a more extensive reference method assessing cognitive function. METHODS AND RESULTS: An unselected group of hospitalized stroke patients (N = 87) was assessed 10 days and 12 months after stroke. Factor analyses (52% explained variance), identified three factors: 'aphasia', 'apraxia' and 'visuocognitive dysfunction'. Receiver operating characteristics (ROC) curves demonstrated that for all factors, high specificity was maintained at the high sensitivity needed for a screening method. Kendall rank correlation coefficients between the scorings on the new instrument and the reference method were high. Effect size analysis showed that the ability of the new instrument to detect change in cognitive functioning during the first year was of the same magnitude as the reference method. CONCLUSIONS: SINS has a high sensitivity regarding cognitive dysfunction, as diagnosed by the more comprehensive and time-consuming reference method. The instrument would be useful as an initial step in the assessment of neuropsychological impairment in stroke patients.

[Use of antipsychotic drugs in a long-term care institution. Experiences with implementing clinical guidelines]. / Bruk av antipsykotiske legemidler i en langtidsinstitusjon. Erfaringer med innføring av kliniske retningslinjer.

Anti-psychotic drugs (neuroleptics) are useful for treating psychoses. However, non-psychotic patients, particularly patients with a deviant behaviour pattern, are often also treated with anti-psychotic drugs. The drugs may induce serious side-effects and should only be used on strict indications and at the lowest possible dosage. In a nursing home for deaf people with additional handicaps we introduced clinical guidelines for the use of anti-psychotic drugs and recorded their use during a two-year period. We found there was a reduction in the number of patients taking anti-psychotic drugs (from 32/54 to 26/54, p = 0.03), as well as a decrease in dosage per user (from median 2.4 mg to 1.7 mg equivalents of haloperidol, p = 0.05). Both the number of patients who were given depot injections and the number of different anti-psychotic drugs per patient were reduced. We conclude that it is possible to reduce the use of anti-psychotic drugs in institutions where long-term care is provided for disabled people.