Frailty in Diabetic Population: A Study From Northern India.

Introduction Frailty, a key issue in geriatric health, signifies heightened vulnerability due to the decline in various physiological systems, exacerbated by conditions such as diabetes. Diabetes and frailty together lead to significant disabilities and higher mortality, necessitating early screening and targeted interventions. The relationship between frailty and diabetes remains under-researched, prompting this study to explore their association in individuals over 50 years of age using the Edmonton Frail Scale (EFS). Methods and materials The study was an observational cross-sectional study conducted at MM Institute of Medical Sciences & Research (MMIMSR), Mullana, India, among 102 diabetic and 100 non-diabetic individuals aged more than 50 years, with data collected through interviews using a pre-validated proforma. Frailty was assessed using the EFS, categorizing patients into fit, vulnerable, and various levels of frailty based on their scores. Results The study found a higher prevalence and severity of frailty among diabetic individuals (61.8%) compared to non-diabetics (29%), with frailty being more pronounced across all age groups and both genders in diabetics. The severity of frailty increased with the duration of diabetes but showed no significant correlation with glycemic control (HbA1c). Strengths and limitations The study prospectively collected data, including middle-aged participants starting from age 50, and uniquely used the EFS to assess frailty in diabetic patients, excluding those with other chronic diseases (end-stage renal disease (ESRD), malignancy, etc.). However, limitations included a small sample size, recruitment from a single institution in India, and some EFS questions being less relevant to the Indian diabetic population. Conclusion The study found a 61.8% prevalence of frailty in diabetics compared to 29% in non-diabetics, with frailty being more severe and positively correlated with the duration of diabetes but not with glycemic control (HbA1c).

Frailty, Body Composition, and Glycemic Control in Older Adults with Type 2 Diabetes.

The relationship between frailty and glycemic control in older adults with diabetes remains uncertain, mainly due to the fact that previous studies have not accounted for measures of body composition. In older adults with diabetes, we examined the association between three types of frailty measures and glycemic control, while accounting for fat-free mass (FFM) and waist circumference (WC). Eighty older adults (age ≥65, 27 women and 53 men, mean age 80.5 ± 0.6 years) had gait speed, Cardiovascular Health Study Index (CHSI), Rockwood Clinical Frailty Scale (RCFS), and glycosylated hemoglobin (HgA1C) measured. HgA1C showed a negative association only with CHSI (standardized ß = -0.255 ± 0.120, p = 0.038), but no association with gait speed or the RCFS. Even after accounting for FFM and WC, we demonstrated a negative association between glycated hemoglobin and increasing frailty in older adults with diabetes.

A narrative overview of undergraduate geriatric medicine education worldwide.

There is a mismatch between the healthcare needs of the ageing population worldwide and the amount of education medical students receive in geriatric medicine. In 2014, Mateos-Nozal et al. published a systematic review of all undergraduate education surveys in geriatric medicine-a decade on, it is timely for an up-to-date overview of the state of undergraduate geriatric medicine education globally. In this review, we outline the international evidence in the field, exploring the results of national and multi-national teaching surveys, and discussing the relative strengths and weaknesses of nationally recommended curricula. We set these findings in the context of ageing population demographics, concluding with recommendations for the future of education and educational research in geriatric medicine, that aims to build capacity in the healthcare workforce and improve quality of care for older people.

Hyponatremia Among Elderly Hospitalized Patients: An Observational Study.

Aim The aim of this study is to analyze the demographic distribution (age and gender distribution), presenting symptoms, and evaluate the underlying etiology of hyponatremia among the study population. The presence of comorbidities and the volume status (hypovolemia, euvolemia, or hypervolemia) of elderly hyponatremic patients with varying severity of hyponatremia were assessed. Methods This cross-sectional, observational study was conducted in Dr. D. Y. Patil Hospital and Research Centre, Pune, India. After approval from the Institutional Ethics Sub-Committee (approval number: IESC/PGS/2022/09), it was conducted during the period between September 2022 and June 2024. The minimum sample size was calculated to be 96 with a confidence interval of 95% using WINIPEPI software (version 11.38). The lab values of serum sodium of all patients aged above 60 years admitted in wards and intensive care units (ICUs) were studied. Out of these hyponatremic patients, a sample size of 100 patients was randomly selected. Patients above 60 years and the patients who were on diuretic therapy were excluded from the study. Results The study included 100 elderly patients with a mean age of 73.25 ± 7.03 years, ranging from 64 to 86 years. Males predominated (63%), and severe hyponatremia (<125 mEq/L) was the most common, affecting 61% of patients. Generalized weakness (22%) and disorientation (17%) were the most frequently reported symptoms. Post-operative conditions (13%) and gastroenteritis (10%) were the leading causes. Most participants had no comorbidities (53%). Hypovolemia was present in 67% and euvolemia in 29% of the study subjects. Among hypovolemic patients, severe hyponatremia was present in 83.5% of patients. Conclusion This study highlights the significant burden of severe hyponatremia among elderly patients, particularly in male subjects and those with hypovolemia. Majority of the participants did not have any comorbidities. Additionally, the study emphasizes the need for heightened clinical vigilance in elderly patients presenting with generalized weakness and disorientation, as these were the most common symptoms associated with hyponatremia. The identification of post-operative conditions and gastroenteritis as leading causes further supports the need for comprehensive management strategies in elderly inpatients to prevent the occurrence and complications of hyponatremia.

Which stakeholders should be addressed to promote Geriatric Medicine among healthcare professionals, educationalists and policy-makers in European countries? - the PROGRAMMING COST 21,122 action experience.

BACKGROUND: Geriatric Medicine (GM), concerned with well-being and health of older adults, can play a crucial role in the alignment of healthcare systems to the needs of the aged populations. However, countries have varying GM development backgrounds. The goal of PROGRAMMING- COST 21,122 Action is to propose the content of education and training activities in GM for healthcare professionals across various clinical settings, adapted to local context, needs, and assets. Defining relevant stakeholders and addressing them on both an international as well as a country-specific level is crucial for this purpose. In this paper we are describing the methods used in the PROGRAMMING Action 21,122 to map the different categories of stakeholders to be engaged in the Action. METHODS: Through conceptualizing a model for stakeholders by literature research, and online discussion group meetings, a synthesis for the potential stakeholders was defined as a template, and pilot applications were requested from participant countries. RESULTS: There were 24 members from 14 countries (6 males/18 females) of multidisciplinary professions involved in this study. A model for the list of stakeholders to be addressed was developed and, after seven online discussion meetings, a consensus framework was provided. Invited countries completed the templates to pilot such operationalization. CONCLUSION: Our framework of stakeholders will support the research coordination and capacity-building objectives of PROGRAMMING, including the participation into the assessment of educational needs of healthcare professionals. Identified stakeholders will also be mobilized for purposes of dissemination and maximization of the Action's impact. By defining and mapping multidisciplinary stakeholders involved in older people's care specific to countries, particularly where GM is still emerging, GM tailored educational activities will be facilitated and optimally targeted.

Investigation of the knowledge, attitude and practice regarding nutrition in older adults with tuberculosis and diabetes: a cross-sectional study in Eastern China.

OBJECTIVES: Older adults with tuberculosis and diabetes have special needs regarding dietary nutrition. This study aimed to investigate the knowledge, attitude and practice (KAP) regarding dietary nutrition among older adults with those two conditions. DESIGN: Cross-sectional study. SETTING: Three tertiary medical centres in China. PARTICIPANTS: Adults over 60 year old diagnosed with tuberculosis and diabetes. INTERVENTIONS: Between July 2023 and October 2023. PRIMARY AND SECONDARY OUTCOME MEASURES: Demographic characteristics and KAP scores collected by self-designed questionnaire. RESULTS: A total of 456 valid questionnaires were analysed, with 261 (57.24%) participants being over 70 years old. The mean scores were 6.84±3.16 (possible range: 0-24) for knowledge, 23.23±2.23 (possible range: 8-40) for attitude and 22.73±3.14 (possible range: 8-40) for practice, respectively. Correlation analysis revealed significant positive correlations between knowledge and attitude (r=0.287, p<0.001), knowledge and practice (r=0.189, p<0.001) and attitude and practice (r=0.176, p<0.001). Structural equation modelling demonstrated that knowledge significantly influenced attitude (ß=0.343, 95% CI (0.257 to 0.422), p<0.001) and practice (ß=0.245, 95% CI (0.101 to 0.405), p<0.001) and attitude significantly influenced practice (ß=0.274, 95% CI (0.146 to 0.405), p<0.001). CONCLUSIONS: The study highlights a need for improvements in dietary nutrition practices for older adults with tuberculosis and diabetes. Findings emphasise the urgency of enhancing dietary education among this population in China. Implementation of targeted educational programmes is warranted to improve knowledge, foster positive attitudes and encourage healthier dietary practices, ultimately leading to improved patient outcomes and well-being.

Professional identity formation of medical students in relation to older persons' healthcare: exploring the views of older persons living in the Netherlands - a qualitative study.

OBJECTIVES: Given the growing population of older persons, medical students need to develop an appropriate professional identity to comply with older persons' healthcare needs. In this study, we explored the needs and expectations of older persons regarding their doctor to gain more insight into the characteristics of this professional identity. DESIGN: A qualitative study based on a constructivist research paradigm was conducted, based on individual semistructured, in-depth interviews using a letter as a prompt, and focus groups. Thematic analysis was applied to structure and interpret the data. SETTING AND PARTICIPANTS: Our study population consisted of older persons, aged 65 years and above, living at home in the South-West of the Netherlands, with no apparent cognitive or hearing problems and sufficient understanding of the Dutch language to participate in writing, talking and reflecting. The in-depth interviews took place at the participant's home or the Leiden University Medical Center (LUMC), and the focus groups were held at the LUMC. RESULTS: The older persons shared and reflected on what they need and expect from the doctor who takes care of them. Four major themes were identified: (1) personal attention, (2) equality, (3) clarity and (4) reasons why. CONCLUSION: Increasing complexity, dependency and vulnerability that arise at an older age, make it essential that a doctor is familiar with the older person's social context, interacts respectfully and on the basis of equality, provides continuity of care and gives clarity and perspective. To this end, the doctor has to be caring, involved, patient, honest and self-aware. Participation in a community of practice that provides the context of older persons' healthcare may help medical students develop a professional identity that is appropriate for this care.

Risk Factors for Loss to Follow-up of Elderly Patients After Hip Fracture Surgery: A Retrospective Cohort Study.

Introduction: Non-attendance with scheduled postoperative follow-up visits remains a common issue in orthopaedic clinical research. The objective of this study was to identify the risk factors associated with loss to follow-up among elderly patients with hip-fracture postoperatively. Methods: A retrospective analysis of 1-year post-surgery was performed on patients aged over 60 years who underwent hip-fracture surgery from January 2017 to March 2019. Based on their completion of the appointed follow-up schedule, the patients were classified into 2 groups: the Loss to Follow-up (LTFU) Group and the Follow-up (FU) Group. Clinical outcomes were evaluated by Functional Recovery Score (FRS) questionnaires. Telephone interviews were conducted with patients lost to follow-up to determine the reasons for non-attendance. A comparative analysis of baseline characteristics between the 2 groups was implemented, with further exploration of statistical differences through logistic regression. Results: A total of 992 patients met the inclusion criteria were included in this study, of which 189 patients, accounting for 19.1%, were lost to follow-up 1 year postoperatively. The mean age of the patients in the LTFU Group was 82.0 years, significantly higher than the 76.0 years observed in the FU Group (P < 0.001). The FRS for the LTFU Group was marginally higher than that of the FU group (84.0 vs 81.0), with no significant difference (P = 0.060). Logistic regression analysis identified several significant predictors of noncompliance, including advanced age at surgery, femoral neck fracture, hip arthroplasty, long distance from residence to hospital, and the reliance on urban-rural public transportation for reaching the hospital. Conclusion: Postoperative follow-up loss was prevalent among elderly patients with hip fractures. Our study indicated a constellation of risk factors contributing to noncompliance, including advanced age, transportation difficulties, long travel distance, femoral neck fracture and hip arthroplasty surgery.

Doxycycline-associated acute pancreatitis: a rare adverse effect of a commonly prescribed antibiotic.

In this case, a woman in her 80s presented to the emergency department with signs and symptoms of acute pancreatitis that began after starting a course of doxycycline. Common aetiologies of acute pancreatitis, including alcohol use, gallstones and hypertriglyceridaemia were ruled out. Less common aetiologies, including recent Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure, hypercalcaemia, malignancy, infection and trauma, were also ruled out, making drug-induced acute pancreatitis the most likely aetiology. After consideration of her medication list, doxycycline was determined to be the offending medication. On discontinuation and treatment with fluids and analgesics, her condition slowly improved.This case illustrates a rare but severe complication of doxycycline use. Determining the aetiology of drug-induced acute pancreatitis is more difficult in older patients due to high rates of polypharmacy. Recognition of doxycycline as an aetiology of drug-induced pancreatitis may allow earlier recognition and intervention in cases of suspected pancreatitis without a clear common aetiology in older patients with polypharmacy.

The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: A systematic review and meta-analysis.

The aim of this study was to investigate whether interventions to discontinue or down-titrate heart failure (HF) pharmacotherapy are feasible and associated with risks in older people. A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. Electronic databases were searched from inception to 8 March 2023. Randomized controlled trials (RCTs) and observational studies included people with HF, aged ≥50 years and who discontinued or down-titrated HF pharmacotherapy. Outcomes were feasibility (whether discontinuation or down-titration of HF pharmacotherapy was sustained at follow-up) and associated risks (mortality, hospitalization, adverse drug withdrawal effects [ADWE]). Random-effects meta-analysis was performed when heterogeneity was not substantial (Higgins I2 < 70%). Sub-analysis by frailty status was conducted. Six RCTs (536 participants) and 27 observational studies (810 499 participants) across six therapeutic classes were included, for 3-260 weeks follow-up. RCTs were conducted in patients presenting with stable chronic HF. Down-titrating a renin-angiotensin system inhibitor (RASI) in patients with chronic kidney disease was 76% more likely than continuation (risk ratio [RR] 1.76, 95% confidence interval [CI] 1.14-2.73), with no difference in mortality (RR 0.64, 95% CI 0.30-1.64). Discontinuation of beta-blockers were feasible compared to continuation in preserved ejection fraction (RR 1.00, 95% CI 0.68-1.47). Participants were 25% more likely to re-initiate discontinued diuretics (RR 0.75, 95% CI 0.66-0.86). Digoxin discontinuation was associated with 5.5-fold risk of hospitalization compared to continuation. Worsening HF was the most common ADWE. One observational study measured frailty but did not report outcomes by frailty status. The appropriateness and associated risks of down-titrating or discontinuing HF pharmacotherapy in people aged ≥75 years is uncertain. Evaluation of outcomes by frailty status necessitates investigation.

Multi-Stakeholder Validation of an Entrustable Professional Activities Framework for Canadian Geriatrics Residency Programs.

Background: Entrustable Professional Activities (EPAs) have become a cornerstone for an increasing number of competency-based medical education programs. Today, frameworks of EPAs are being used in most, if not all, medical specialties. These frameworks can break a discipline down to its constituting tasks, and structure the training and evaluation of residents. In 2018, The Royal College of Physicians and Surgeons of Canada created an EPA framework for Geriatric Specialty residency programs nationwide. The present study aims to evaluate this EPA framework through focus groups consisting of several stakeholder groups. Methods: Participants were recruited to be part of one of five focus groups-one for each stakeholder group of interest. The five focus groups consisted of: physician faculty, residents, allied health professionals, administrators/managers, and patients. Each focus group met once virtually over ZOOM® for no longer than 90 minutes. Meeting transcripts were iteratively coded based on emerging themes, and were compared for similarities and gaps between stakeholder perspectives. Results: Multi-stakeholder consultation yielded feedback on many specific EPAs, suggestions for new EPAs, and additional input which gave rise to four themes: (i) EPA scope, (ii) Operationalization, (iii) Interprofessional Collaboration, and (iv) Patient Advocacy. Lastly, we received their thoughts on how the framework defines Geriatrics relative to the work of Care of the Elderly physicians in Canada. Conclusions: Consulting a variety of stakeholder groups generates a robust and diverse supply of feedback that holistically augments EPA frameworks to be more practical, appropriate, socially accountable and patient-centred.

Racial and ethnic minority representation in dementia risk factor research: a scoping review of cohort studies.

BACKGROUND: Despite a potentially greater burden of dementia, racial and ethnic minority populations around the world may be more likely to be excluded from research examining risk factors for incident dementia. We aimed to systematically investigate and quantify racial and ethnic minority representation in dementia risk factor research. METHODS: We performed a two-stage systematic search of databases-MEDLINE (Ovid SP), Embase (Ovid SP) and Scopus-from inception to March 2021 to identify population-based cohort studies looking at risk factors for dementia incidence. We included cohort studies which were population-based and incorporated a clinical dementia diagnosis. RESULTS: Out of the 97 identified cohort studies, fewer than half (40 studies; 41%) reported the race or ethnicity of participants and just under one-third (29 studies; 30%) reported the inclusion of racial and ethnic minority groups. We found that inadequate reporting frequently prevented assessment of selection bias and only six studies that included racial and ethnic minority participants were at low risk for measurement bias in dementia diagnosis. In cohort studies including a multiethnic cohort, only 182 out of 337 publications incorporated race or ethnicity in data analysis-predominantly (90%) through adjustment for race or ethnicity as a confounder. Only 14 publications (4.2% of all publications reviewed) provided evidence about drivers of any observed inequalities. CONCLUSIONS: Racial and ethnic minority representation in dementia risk factor research is inadequate. Comparisons of dementia risk between different racial and ethnic groups are likely hampered by significant selection and measurement bias. Moreover, the focus on 'adjusting out' the effect of race and ethnicity as a confounder prevents understanding of underlying drivers of observed inequalities. There is a pressing need to fundamentally change the way race, ethnicity and the inclusion of racial and ethnic minorities are considered in research if health inequalities are to be adequately addressed.

Medicine communication from hospital to residential aged care facilities: a cross-sectional survey of aged care facility staff.

BACKGROUND: Continuity of medicines management can be compromised when older people are transferred between hospital and residential aged care facilities. AIM: This study explored medicines management practices at facilities during patients' transfer of care from hospital, and staff experiences with medicines information handover from hospitals. METHOD: An electronic cross-sectional questionnaire sent to all residential aged care facilities within a metropolitan region in Australia, in February 2022. The questionnaire comprised 23 questions covering facilities' profiles, medicines management practices, and medicines management at transfer of care from 2 public hospitals. RESULTS: Of 53 listed facilities, 31 [58.5%] responded. Facilities varied in size ranging between < 50 and up to 200 beds. Twenty-seven [87.1%] facilities offered more than one level of care. Of those 27 facilities, 26 [96.3%] offered dementia care, and 23 [85.2%] offered palliative care. Six (19.4%) solely used hardcopy medication charts. Handover from hospitals to manage patients' medicines at transfer was inconsistent with only 15 [48.4%] reporting consistently receiving appropriate documentation. CONCLUSION: Residential aged care facilities varied in size and level of care. Diverse processes exist for medicines management. There is inconsistency in information received when residents transfer from hospital to facilities, potentially compromising patient safety.

Cross-Sectional Study Comparing Activities of Daily Living Using Barthel Index Within a Geriatric Population Having Non-Communicable Diseases.

Introduction Disabilities and non-communicable diseases (NCDs) are prevalent among the elderly, significantly affecting their quality of life. Comprehensive population-based data are essential for effective healthcare planning and rehabilitation. This study aims to determine the prevalence of self-reported disabilities and compare Barthel Index scores among elderly individuals with and without NCDs. Methods A cross-sectional study was conducted at Dr. D. Y. Patil Medical College, Pune, involving 102 patients aged 60 years and above. Patients with a history of strokes or limb amputations were excluded. Data on demographics, comorbidities, and functional status were collected using a structured questionnaire designed based on Barthel Index scoring to assess the activities of daily living (ADL). Results The study included 102 participants: 58 males (56.9%) and 44 females (43.1%). Age distribution showed 73.5% in the 60-74 age group, 22.5% in the 75-84 age group, and 3.9% in the 85+ age group. Comorbidity data revealed that 37.3% had no comorbidities, 26.4% had one comorbidity, and 36.3% had two or more comorbidities. The mean Barthel Index scores were 87.11 for those without comorbidities, 83.89 for those with one comorbidity, and 82.30 for those with two or more comorbidities. The most affected activities were stair climbing (75.7%), bowel control (48.5%), and mobility (47.1%). Conclusion NCDs significantly impact daily activities in the elderly, underscoring the need for targeted healthcare interventions to improve their quality of life. This study highlights the importance of comprehensive care strategies to address the specific needs of elderly patients with comorbidities.

Prevalence of dermatoses in geriatric singaporeans in the community - a cross-sectional study.

BACKGROUND: Little is known about the prevalence of dermatoses in "skin-well" geriatric Singaporeans. We aim to identify the prevalence of dermatoses and their associations within the geriatric population in Singapore, and to understand the distribution of dermatological encounters presenting to primary care physicians, and the resultant referral behaviour. METHODS: A joint quantitative-qualitative study was performed across 8 months. Patients aged 65 years and above who visited a local polyclinic for management of non-dermatological chronic diseases were recruited. They were administered questionnaires, and underwent full skin examinations. Online surveys were disseminated to polyclinic physicians under the same healthcare cluster. RESULTS: 201 patients and 53 physicians were recruited. The most common dermatoses identified in patients were benign tumours and cysts (97.5%), and asteatosis (81.6%). For every 1-year increase in age, the odds of having asteatosis increased by 13.5% (95% CI 3.4-24.7%, p = 0.008), and urticarial disorders by 14.6% (95% CI 0.3-30.9%, p = 0.045). Patients who used any form of topical preparations on a daily basis had higher odds of having eczema and inflammatory dermatoses (OR 2.51, 95% CI 1.38 to 4.56, p = 0.003). Physicians reported dermatological conditions involving 20% of all clinical encounters. Eczema represented the most commonly reported dermatosis within the first visit. 50% of dermatology referrals were done solely at the patient's own request. CONCLUSION: The prevalence of dermatoses in the elderly in Singapore is high, especially asteatosis. Prompt recognition by the primary healthcare provider potentially prevents future morbidity. Outreach education for both primary care physicians and the general public will be key. ETHICS APPROVAL: National Healthcare group (NHG) Domain Specific Review Board (DSRB), Singapore, under Trial Registration Number 2020/00239, dated 11 August 2020.

A 10-Year Experience of an Integrated Geriatric Hip Fracture Treatment Protocol: Outcomes at a Minimum 2-Year Follow-Up.

Introduction: Increasing incidence of fragility fractures has spurred development of protocols, largely focused on peri-operative care, with numerous proven benefits. The purpose of this investigation was to evaluate outcomes of our hip fracture treatment program regarding successful protocol implementation, compliance, effect on subsequent fracture rates, and mortality during the first decade of adoption. Methods: A retrospective review identified patients >65 years old with fragility hip fractures between 2010 and 2022. The HiROC (+) cohort consisted of patients who received a "High-Risk Osteoporosis Clinic" (HiROC) referral for bone health evaluation and bisphosphonate initiation as indicated. Additional fracture rates and mortality at 3 years were calculated. Protocol implementation and compliance over the first 10 years was analyzed in the four identified cohorts. Results: A total of 1671 fragility hip fractures were identified, with 386 excluded due to insufficient follow-up, with an average age of 81.6 years and a median follow-up of 36.4 months. Of the 1280 included cases, 56% (n = 717) had a HiROC referral placed. HiROC(+) groups had lower subsequent fracture rates at two years, compared to those without referral (28% vs 13%, P < 0.0001) and those completing more steps of the protocol had lower subsequent fracture rates (28% vs 15% vs 13% vs 5%, P < 0.0001). No statistically significant difference was observed between the cohorts for anatomic site of subsequent fractures. Discussion: Greater than half of all eligible patients were successfully captured by the protocol. Patients completing more steps of the protocol had lower subsequent fracture rates. Captured patients demonstrated reduced mortality rates when compared to current literature. Conclusion: Successful implementation of this geriatric hip fracture protocol was associated with reduced additional fractures and mortality rates. Identifying steps of process failures in the protocol can provide opportunities for increased compliance and reduction in future fracture occurrences.

DOSAGE study: protocol for a phase III non-inferiority randomised trial investigating dose-reduced chemotherapy for advanced colorectal cancer in older patients.

INTRODUCTION: Treating older adults with chemotherapy remains a challenge, given their under-representation in clinical trials and the lack of robust treatment guidelines for this population. Moreover, older patients, especially those with frailty, have an increased risk of developing chemotherapy-related toxicity, resulting in a decreased quality of life (QoL), increased hospitalisations and high healthcare costs. Phase II trials have suggested that upfront dose reduction of chemotherapy can reduce toxicity rates while maintaining efficacy, leading to fewer treatment discontinuations and an improved QoL. The DOSAGE aims to show that upfront dose-reduced chemotherapy in older patients with metastatic colorectal cancer is non-inferior to full-dose treatment in terms of progression-free survival (PFS), with adaption of the treatment plan (monotherapy or doublet chemotherapy) based on expected risk of treatment toxicity. METHODS AND ANALYSIS: The DOSAGE study is an investigator-initiated phase III, open-label, non-inferiority, randomised controlled trial in patients aged≥70 years with metastatic colorectal cancer eligible for palliative chemotherapy. Based on toxicity risk, assessed using the Geriatric 8 (G8) tool, patients will be stratified to either doublet chemotherapy (fluoropyrimidine with oxaliplatin) or fluoropyrimidine monotherapy. Patients classified as low risk will be randomised between a fluoropyrimidine plus oxaliplatin in either full-dose or with an upfront dose reduction of 25%. Patients classified as high risk will be randomised between fluoropyrimidine monotherapy in either full-dose or with an upfront dose reduction. In the dose-reduced arm, dose escalation after two cycles is allowed. The primary outcome is PFS. Secondary endpoints include grade≥3 toxicity, QoL, physical functioning, number of treatment cycles, dose reductions, hospital admissions, overall survival, cumulative received dosage and cost-effectiveness. Considering a median PFS of 8 months and non-inferiority margin of 8 weeks, we shall include 587 patients. The study will be enrolled in 36 Dutch Hospitals, with enrolment scheduled to start in July 2024. This study will provide new evidence regarding the effect of dose-reduced chemotherapy on survival and treatment outcomes, as well as the use of the G8 to choose between doublet chemotherapy or monotherapy. Results will contribute to a more individualised approach in older patients with metastatic colorectal cancer, potentially leading to improved QoL while maintaining survival benefits. ETHICS AND DISSEMINATION: This trial has received ethical approval by the ethical committee Leiden Den Haag Delft (P24.018) and will be approved by the Institutional Ethical Committee of the participating institutions. The results will be disseminated in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT06275958.

Initial and Long-Term Prescribing of Opioids and Non-steroidal Anti-inflammatory Drugs Following Total Hip and Knee Arthroplasty.

Introduction: Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA. Materials and Methods: This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models. Results: The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants. Discussion: Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures. Conclusions: Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing.

Effect of home-based and remotely supervised combined exercise and cognitive intervention on older adults with mild cognitive impairment (COGITO): study protocol for a randomised controlled trial.

INTRODUCTION: Mild cognitive impairment (MCI) is an intermediate phase between normal cognitive ageing and dementia and poses a serious threat to public health worldwide; however, it might be reversible, representing the best opportunity for secondary prevention against serious cognitive impairment. As a non-pharmacological intervention for those patients, interventions that combine physical exercise and cognitive training, whether delivered simultaneously or sequentially, may have superior effects on various cognitive domains, including global cognition, memory, executive function and attention. The supportive evidence remains incomplete. This study aims to assess the effectiveness of a combined exercise and cognitive intervention in Chinese older adults with mild cognitive impairment (COGITO), empowered by digital therapy and guided by the Health Action Process Model and the Theory of Planned Behaviour (HAPA-TPB theory) in a home-based setting. METHODS AND ANALYSIS: This study is a randomised controlled, assessor-blinded multi-centre study. Four parallel groups will include a total of 160 patients, receiving either a combined exercise and cognitive intervention, an isolated exercise intervention, an isolated cognitive intervention or only health education. These interventions will be conducted at least twice a week for 50 min each session, over 3 months. All interventions will be delivered at home and remotely monitored through RehabApp and Mini-programme, along with an arm-worn heart rate telemetry device. Specifically, supervisors will receive participants' real-time training diaries, heart rates or other online monitoring data and then provide weekly telephone calls and monthly home visits to encourage participants to complete their tasks and address any difficulties based on their training information. Eligible participants are community-dwelling patients with no regular exercise habit and diagnosed with MCI. The primary outcome is cognitive function assessed by the Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog) and Community Screening Instrument for Dementia (CSI-D), with baseline and three follow-up assessments. Secondary outcomes include quality of life, physical fitness, sleep quality, intrinsic capacity, frailty, social support, adherence, cost-effectiveness and cost-benefit. ETHICS AND DISSEMINATION: The study was approved by the Institutional Review Board of Peking University. Research findings will be presented to stakeholders and published in peer-reviewed journals and at provincial, national and international conferences. TRIAL REGISTRATION NUMBER: ChiCTR2300073900.