The organisation and responsibility for care for older people in Denmark, Finland and Sweden: outline and comparison of care systems.

AIM: To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden. METHODS: Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation. RESULTS: In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services - a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes. CONCLUSIONS: Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population.

The role of geriatric syndromes in predicting unplanned hospitalizations: a population-based study using Minimum Data Set for Home Care.

BACKGROUND: The predictive accuracies of screening instruments for identifying home-dwelling old people at risk of hospitalization have ranged from poor to moderate, particularly among the oldest persons. This study aimed to identify variables that could improve the accuracy of a Minimum Data Set for Home Care (MDS-HC) based algorithm, the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale, in classifying home care clients' risk for unplanned hospitalization. METHODS: In this register-based retrospective study, factors associated with hospitalization among home care clients aged ≥ 80 years in the City of Tampere, Finland, were analyzed by linking MDS-HC assessments with hospital discharge records. MDS-HC determinants associated with hospitalization within 180 days after the assessment were analyzed for clients at low (DIVERT 1), moderate (DIVERT 2-3) and high (DIVERT 4-6) risk of hospitalization. Then, two new variables were selected to supplement the DIVERT algorithm. Finally, area under curve (AUC) values of the original and modified DIVERT scales were determined using the data of MDS-HC assessments of all home care clients in the City of Tampere to examine if addition of the variables related to the oldest age groups improved the accuracy of DIVERT. RESULTS: Of home care clients aged ≥ 80 years, 1,291 (65.4%) were hospitalized at least once during the two-year study period. Unplanned hospitalization occurred following 15.9%, 22.8%, and 33.9% MDS-HC assessments with DIVERT group 1, 2-3 and 4-6, respectively. Infectious diseases were the most common diagnosis within each DIVERT groups. Many MDS-HC variables not included in the DIVERT algorithm were associated with hospitalization, including e.g. poor self-rated health and old fracture (other than hip fracture) (p 0.001) in DIVERT 1; impaired cognition and decision-making, urinary incontinence, unstable walking and fear of falling (p < 0.001) in DIVERT 2-3; and urinary incontinence, poor self-rated health (p < 0.001), and decreased social interaction (p 0.001) in DIVERT 4-6. Adding impaired cognition and urinary incontinence to the DIVERT algorithm improved sensitivity but not accuracy (AUC 0.64 (95% CI 0.62-0.65) vs. 0.62 (0.60-0.64) of the original DIVERT). More admissions occurred among the clients with higher scores in the modified than in the original DIVERT scale. CONCLUSIONS: Certain geriatric syndromes and diagnosis groups were associated with unplanned hospitalization among home care clients at low or moderate risk level of hospitalization. However, the predictive accuracy of the DIVERT could not be improved. In a complex clinical context of home care clients, more important than existence of a set of risk factors related to an algorithm may be the various individual combinations of risk factors.

Agreement Between Self-Reported Information and Health Register Data on Chronic Diseases in the Oldest Old.

Purpose: To study the agreement on disease prevalence between survey data and national health register data among people aged over 90. Patients and Methods: The survey data were from the Vitality 90+ Study conducted among 1637 community dwellers and persons in long-term care aged 90 and over in Tampere, Finland. The survey was linked with two national health registers, including hospital discharge data and prescription information. The prevalence of 10 age-related chronic diseases was calculated for each data source and the agreement between the survey and the registers was estimated using Cohen's kappa statistics and positive and negative percent agreement. Results: The prevalence of most diseases was higher in the survey than in the registers. The level of agreement was highest when the survey was compared with information combined from both registers. Agreement was almost perfect for Parkinson's disease (ĸ=0.81) and substantial for diabetes (ĸ=0.75) and dementia (ĸ=0.66). For heart disease, hypertension, stroke, cancer, osteoarthritis, depression, and hip fracture, the agreement ranged from fair to moderate. Conclusion: Self-reported information on chronic diseases shows acceptable agreement with health register data to warrant the use of survey methods in population-based health studies among the oldest old. It is important to acknowledge the gaps in health registers when validating self-reported information against register data.

Regional variation of potentially inappropriate medication use and associated factors among older adults: A nationwide register study.

BACKGROUND: Certain medications should be used with caution in older persons, which challenges rational prescribing. Potentially inappropriate medications (PIMs) are defined as medicines whose potential risk of harm typically outweighs the clinical benefits in geriatric population. Earlier studies have found regional differences in PIM use, but the factors underlying this phenomenon are unclear. OBJECTIVE: To compare prescription PIM prevalence among Finnish hospital districts and determine which population characteristics and factors related to social and health care are associated with regional variation. METHODS: This nationwide register study was based on the Prescription Centre data on all people aged ≥75 years in 2017-2019. Hospital district (n = 20) characteristics were drawn from the Finnish Institute for Health and Welfare's, Finnish Medical Association's, and Finnish Medicines Agency's publicly open data. PIMs were defined according to the Finnish Meds75+ database. A linear mixed-effect model was used to analyze potential associations of regional characteristics with PIM prevalence. RESULTS: Prevalence of PIMs varied between 16.4% and 24.8% across regions. The highest prevalence was observed in the southern regions, while the lowest prevalence was on the west coast. Hospital district characteristics associated with higher PIM prevalence were higher share of population living alone, with excessive polypharmacy, or assessed using the Resident Assessment Instrument, shortage of general practitioners in municipal health centers, and low share of home care personnel. Waiting time in health care or share of population with morbidities were not associated with PIM use. Of the total variance in PIM prevalence, 86% was explained by group-level factors related to hospital districts. The regional variables explained 75% of this hospital-district-level variation. CONCLUSIONS: PIM prevalence varied significantly across hospital districts. Findings suggest that higher PIM prevalence may be related to challenges in the continuity of care rather than differences in health care accessibility or share of the population with morbidities.

Prevalence of potentially inappropriate medication use in older population: comparison of the Finnish Meds75+ database with eight published criteria.

BACKGROUND: There are several national and international criteria available for identifying potentially inappropriate medications (PIMs) for older people. The prevalence of PIM use may vary depending on the criteria used. The aim is to examine the prevalence of potentially inappropriate medication use in Finland according to the Meds75+ database, developed to support clinical decision-making in Finland, and to compare it with eight other PIM criteria. METHODS: This nationwide register study consisted of Finnish people aged 75 years or older (n = 497,663) who during 2017-2019 purchased at least one prescribed medicine considered as a PIM, based on any of the included criteria. The data on purchased prescription medicines was collected from the Prescription Centre of Finland. RESULTS: The annual prevalence of 10.7-57.0% was observed for PIM use depending on which criteria was used. The highest prevalence was detected with the Beers and lowest with the Laroche criteria. According to the Meds75+ database, annually every third person had used PIMs. Regardless of the applied criteria, the prevalence of PIM use decreased during the follow-up. The differences in the prevalence of medicine classes of PIMs explain the variance of the overall prevalence between the criteria, but they identify the most commonly used PIMs quite similarly. CONCLUSION: PIM use is common among older people in Finland according to the national Meds75+ database, but the prevalence is dependent on the applied criteria. The results indicate that different PIM criteria emphasize different medicine classes, and clinicians should consider this issue when applying PIM criteria in their daily practice.

The Association of Long-Term Opioid Use With Health Care and Home Care Service Use Among Aged Home Care Clients.

OBJECTIVES: To compare health care and home care service utilization, mortality, and long-term care admissions between long-term opioid users and nonusers among aged home care clients. DESIGN: A retrospective cohort study based on the Resident Assessment Instrument-Home Care (RAI-HC) assessments and electronic medical records. SETTING AND PARTICIPANTS: The study sample included all regular home care clients aged ≥65 years (n = 2475), of whom 220 were long-term opioid users, in one city in Finland (population base 222,000 inhabitants). METHODS: Health care utilization, mortality, and long-term care admissions over a 1-year follow-up were recorded from electronic medical records, and home care service use from the RAI-HC. Negative binomial and multivariable logistic regression, adjusted for several socioeconomic and health characteristics, were used to analyze the associations between opioid use and health and home care service use. RESULTS: Compared with nonusers, long-term opioid users had more outpatient consultations (incidence rate ratio 1.26; 95% CI 1.08-1.48), home visits (1.23; 1.01-1.49), phone contacts (1.38; 1.13-1.68), and consultations without a patient attending a practice (1.22; 1.04-1.43) after adjustments. A greater proportion of long-term opioid users than nonusers had at least 1 hospitalization (49% vs 41%) but the number of inpatient days did not differ after adjustments. The home care nurses' median work hours per week were 4.3 (Q1-Q3 1.5-7.7) among opioid users and 2.8 (1.0-6.1) among nonusers. Mortality and long-term care admissions were not associated with opioid use. CONCLUSIONS AND IMPLICATIONS: Long-term opioid use in home care clients is associated with increased health care utilization regardless of the severity of pain and other sociodemographic and health characteristics. This may indicate the inability of health care organizations to produce alternative treatment strategies for pain management when opioids do not meet patients' needs. The exact reasons for opioid users' greater health care utilization should be examined in future.

Dementia and Related Comorbidities in the Population Aged 90 and Over in the Vitality 90+ Study, Finland: Patterns and Trends From 2001 to 2018.

OBJECTIVES: To examine trends in the prevalence of dementia and related comorbidities among the oldest old. METHODS: Six repeated cross-sectional surveys were conducted between 2001 and 2018, each including all inhabitants aged over 90 in Tampere, Finland (n = 5386). Co-occurring conditions and their time trends among participants with dementia were examined using logistic regression and generalized estimating equations. RESULTS: The prevalence of dementia decreased from 47% in 2007 to 41% in 2018. Throughout the study period, depression was more common among people with dementia compared to those without. The prevalence of hypertension, diabetes, and osteoarthritis increased and the prevalence of depression decreased among people with dementia. The mean number of comorbidities increased from 2.0 in 2001 to 2.3 in 2018. DISCUSSION: Dementia remains highly prevalent among the oldest old and it is accompanied by an increasing burden of comorbidities, posing a challenge to people with dementia, their caregivers, and care systems.

The impact of interprofessional education on students' current and desired competence in diabetes care.

AIM: To explore the impact of interprofessional education (IPE) on undergraduate nursing and medical students' knowledge, competence and targeted competence in diabetes care. DESIGN: Mixed methods design. METHODS: A voluntary IPE course of diabetes management was organized for nursing (n = 15) and medical (n = 15) students, who performed a diabetes knowledge test and self-evaluation of diabetes competence before and after the course and were compared with non-participating students. The participating students' focus-group interviews were analysed using inductive content analysis. RESULTS: The IPE course improved nursing students' diabetes knowledge and self-evaluated competence among nursing and medical students. The baseline differences in self-evaluated competence between the groups disappeared. The non-participating students evaluated their competence higher than the participants, though they scored lower or equally in the knowledge test. In conclusion, IPE showed potential in increasing students' self-evaluated competence, motivation to learn more and nursing students' diabetes knowledge, offering better prospects for future interprofessional diabetes management.

Opportunities for transitional care and care continuity following hospital discharge of older people in three Nordic cities: A comparative study.

AIM: To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm. METHODS: Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared. RESULTS: In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm). CONCLUSIONS: Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves.

One-year functional outcomes of patients aged 80 years or more undergoing colonic cancer surgery: prospective, multicentre observational study.

BACKGROUND: Older patients are at high risk of experiencing delayed functional recovery after surgical treatment. This study aimed to identify factors that predict changes in the level of support for activities of daily living and mobility 1 year after colonic cancer surgery. METHODS: This was a multicentre, observational study conforming to STROBE guidelines. The prospective data included pre-and postoperative mobility and need for support in daily activities, co-morbidities, onco-geriatric screening tool (G8), clinical frailty scale (CFS), operative data, and postoperative surgical outcomes. RESULTS: A total of 167 patients aged 80 years or more with colonic cancer were recruited. After surgery, 30 per cent and 22 per cent of all patients had increased need for support and decreased motility. Multivariableanalysis with all patients demonstrated that preoperative support in daily activities outside the home (OR 3.23, 95 per cent c.i. 1.06 to 9.80, P = 0.039) was associated with an increased support at follow-up. A history of cognitive impairment (3.15, 1.06 to 9.34, P = 0.038) haemoglobin less than 120 g/l (7.48, 1.97 to 28.4, P = 0.003) and discharge to other medical facilities (4.72, 1.39 to 16.0, P = 0.013) were independently associated with declined mobility. With functionally independent patients, haemoglobin less than 120 g/l (8.31, 1.76 to 39.2, P = 0.008) and discharge to other medical facilities (4.38, 1.20 to 16.0, P = 0.026) were associated with declined mobility. CONCLUSION: Increased need for support before surgery, cognitive impairment, preoperative anaemia, and discharge to other medical facilities predicts an increased need for support or declined mobility 1 year after colonic cancer surgery. Preoperative assessment and optimization should focus on anaemia correction, nutritional status, and mobility with detailed rehabilitation plan.

Classifying home care clients' risk of unplanned hospitalization with the resident assessment instrument.

PURPOSE: To identify predictive case finding tools for classifying the risk of unplanned hospitalization among home care clients utilizing the Resident Assessment Instrument-Home Care (RAI-HC), with special interest in the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale. METHODS: A register-based, retrospective study based on the RAI-HC assessments of 3,091 home care clients (mean age 80.9 years) in the City of Tampere, Finland, linked with hospital discharge records. The outcome was an unplanned hospitalization within 180 days after RAI-HC assessment. The Area Under the Curve (AUC) and the sensitivity and specificity were determined for the RAI-HC scales: DIVERT, Activities of Daily Living Hierarchy (ADLh), Cognitive Performance Scale (CPS), Changes in Health, End-Stage Diseases, Signs, and Symptoms Scale (CHESS), and Method for Assigning Priority Levels (MAPLe). RESULTS: Altogether 3091 home care clients had a total of 7744 RAI-HC assessments, of which 1658 (21.4%) were followed by an unplanned hospitalization. The DIVERT Scale had an AUC of 0.62 (95% confidence interval 0.61-0.64) when all assessments were taken into account, but its value was poorer in the older age groups (< 70 years: 0.71 (0.65-0.77), 70-79 years: 0.66 (0.62-0.69), 80-89 years: 0.60 (0.58-0.62), ≥ 90 years: 0.59 (0.56-0.63)). AUCs for the other scales were poorer than those of DIVERT, with CHESS nearest to DIVERT. Time to hospitalization after assessment was shorter in higher DIVERT classes. CONCLUSION: The DIVERT Scale offers an approach to predicting unplanned hospitalization, especially among younger home care clients. Clients scoring high in the DIVERT algorithm were at the greatest risk of unplanned hospitalization and more likely to experience the outcome earlier than others.

Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings.

BACKGROUND: We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). METHODS: A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. RESULTS: Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or 'not eligible for intensive care' (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. CONCLUSION: Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.

Preoperative measures predicting outcome after pancreatic resection in aged patients.

BACKGROUND AND OBJECTIVE: High-risk surgery on aged patients raises challenging ethical and clinical issues. The aim of this study was to analyze the preoperative factors associated with severe complications and returning home after pancreatic resection among patients aged ⩾ 75 years. PATIENTS AND METHODS: Patients aged ⩾ 75 years undergoing pancreatic resection in 2012-2019 were retrospectively searched from the hospital database. Preoperative indices (Clinical Frailty Scale, Skeletal Muscle Index, Geriatric Nutritional Risk Index, Charlson Comorbidity Index, and National Surgical Quality Improvement Program risk for severe complications) were determined. Postoperative outcome was evaluated by incidence of Clavien-Dindo 3b-5 complications, rate of returning home, and 1-year survival. RESULTS: A total of 95 patients were included. American Society of Anesthesiologists Class 3-4 covered 50%, Clinical Frailty Scale > 3 22%, Charlson Comorbidity Index > 6 53%, and a sarcopenic Skeletal Muscle Index 51% of these patients. The National Surgical Quality Improvement Program risk for severe complications was higher than average among 21% of patients. Geriatric Nutritional Risk Index showed high risk among 3% of them. In total, 19 patients (20%) experienced a severe (Clavien-Dindo 3b-5) complication. However, 30- and 90-day mortality was 2.1%. Preoperative indices were not associated with severe complications. Most patients (79%) had returned home within 8 weeks of surgery. Not returning home was associated with severe complications (p = 0.010). CONCLUSIONS: The short-term outcome after pancreatic resection of fit older patients is similar to that of younger, unselected patient groups. In these selected patients, the commonly used preoperative indexes were not associated with severe complications or returning home.

Factors associated with daily opioid use among aged home care clients: a cross-sectional analysis of Resident Assessment Instrument data.

PURPOSE: To examine which client characteristics and other factors, including possible adverse effects, identified in the Resident Assessment Instrument-Home Care (RAI-HC) are associated with daily opioid use among aged home care clients. METHODS: The study sample comprised 2584 home care clients aged ≥ 65 years, of which 282 persons used opioids daily. Clients using opioids less than once daily were excluded. The cross-sectional data were gathered from each client's first assessment with the RAI-HC during 2014. Multivariable logistic regression was used to study associations of daily opioid use with the clients' characteristics and symptoms. RESULTS: Cognitive impairment was associated with less frequent opioid use after adjusting for pain-related diseases, disabilities and depressive symptoms (OR 0.43, 95% CI 0.32-0.58). The association was not explained by the estimated severity of pain. Osteoporosis, cancer within previous 5 years and greater disabilities in Instrumental Activities of Daily Living (IADL) were associated with daily opioid use regardless of the estimated severity of pain. Depressive symptoms and Parkinson's disease were associated with daily opioid use only among clients with cognitive impairment, and disabilities in Activities of Daily Living, cancer, arthritis, fractures and pressure ulcers only among clients without cognitive impairment. Constipation was the only adverse effect associated with daily opioid use. CONCLUSION: The pain of home care clients with cognitive impairment may not be treated optimally, whereas there might be prolonged opioid use without a sufficient evaluation of current pain among clients with osteoporosis, cancer within previous 5 years and disabilities in IADLs.

Incidence of cataract surgeries in people with and without Alzheimer's disease.

PURPOSE: To investigate the incidence of cataract surgeries in relation to Alzheimer's disease (AD) diagnosis and to compare it with that in people without AD. METHODS: The MEDALZ-study includes community-dwelling Finnish persons who received clinically verified AD diagnoses (n = 70718) during 2005-2011 and a matched comparison cohort without AD (n = 70718). The cataract surgeries were identified from the Care Register for Healthcare (1996-2015) using NOMESCO surgical procedure codes CJE (10,15,20,25,99), CJF (00,10,20,30,40,45,50,55,99) and CJG (00,05,10,15,20,25,99). The incidence rates for surgeries per 100 person-years were calculated from 10 years before to 3 years after the index date (date of AD diagnosis from the Special Reimbursement Register). RESULTS: 25 763 cataract procedures were performed on persons with AD and 26 254 on persons without AD during the follow-up. The incidence of surgery increased similarly in both groups before the index date of AD diagnosis, and the rate of surgery was similar in people with and without AD (3.5 and 3.3/100 person-years, respectively). The incidence diminished steeply in the AD group already one year after the index date, whereas the slow increase continued in the non-AD group. After the index date, the rates were 3.7 and 4.7/100 person-years in people with and without AD. CONCLUSION: The diminishing surgery rate very soon after AD diagnosis is concerning. The stigma of AD diagnosis may lead to fewer referrals to surgery, although these patients are expected to benefit from surgery.

Screening of community-dwelling older patients by the emergency medical services: An observational retrospective registry study.

BACKGROUND: Inadequate nutrition, falls, and cognitive impairment are common problems among acutely ill older people and are associated with complicated and prolonged health problems and mortality. OBJECTIVES: To assess if the emergency medical services can identify patients with nutritional risk, falls risk, and cognitive impairment by using simple screening tools and to assess the prevalence of risks and rate they are reported to the emergency department. SETTING: The study was carried out in Espoo, Finland to patients over the age of 70 requiring non-urgent ambulance transfer to the emergency department. OUTCOME MEASURES: A set of validated electronic screening tools was used to identify patients at nutritional risk, risk of falling and having cognitive impairment. MAIN RESULTS: A total of 488 (8%) out of 5792 patients were screened. Of the patients 60%, (n = 292) had at least one risk: 17% (n = 81) had nutritional risk, 43% (n = 209) falls risk, and 28% (n = 137) cognitive impairment. Twenty-two (5%) were screened positive in all three categories. The observed risk was reported to the emergency department staff in 59% (n = 173) of the patients. CONCLUSION: The emergency medical services can be used in preventive health care to identify patients having nutritional risk, falls risk, or cognitive impairment.

Surgical and functional outcomes and survival following Colon Cancer surgery in the aged: a study protocol for a prospective, observational multicentre study.

BACKGROUND: The number of colorectal cancer patients increases with age. The decision to go through major surgery can be challenging for the aged patient and the surgeon because of the heterogeneity within the older population. Differences in preoperative physical and cognitive status can affect postoperative outcomes and functional recovery, and impact on patients' quality of life. METHODS / DESIGN: A prospective, observational, multicentre study including nine hospitals to analyse the impact of colon cancer surgery on functional ability, short-term outcomes (complications and mortality), and their predictors in patients aged ≥80 years. The catchment area of the study hospitals is 3.88 million people, representing 70% of the population of Finland. The data will be gathered from patient baseline characteristics, surgical interventional data, and pre- and postoperative patient-questionnaires, to an electronic database (REDCap) especially dedicated to the study. DISCUSSION: This multicentre study provides information about colon cancer surgery's operative and functional outcomes on older patients. A further aim is to find prognostic factors which could help to predict adverse outcomes of surgery. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03904121 ). Registered on 1 April 2019.

Is the Preoperative Use of Antidepressants and Benzodiazepines Associated with Opioid and Other Analgesic Use After Hip and Knee Arthroplasty?

BACKGROUND: Mental health disorders can occur in patients with pain conditions, and there have been reports of an increased risk of persistent pain after THA and TKA among patients who have psychological distress. Persistent pain may result in the prolonged consumption of opioids and other analgesics, which may expose patients to adverse drug events and narcotic habituation or addiction. However, the degree to which preoperative use of antidepressants or benzodiazepines is associated with prolonged analgesic use after surgery is not well quantified. QUESTION/PURPOSES: (1) Is the preoperative use of antidepressants or benzodiazepine medications associated with a greater postoperative use of opioids, NSAIDs, or acetaminophen? (2) Is the proportion of patients still using opioid analgesics 1 year after arthroplasty higher among patients who were taking antidepressants or benzodiazepine medications before surgery, after controlling for relevant confounding variables? (3) Does analgesic drug use decrease after surgery in patients with a history of antidepressant or benzodiazepine use? (4) Does the proportion of patients using antidepressants or benzodiazepines change after joint arthroplasty compared with before? METHODS: Of the 10,138 patients who underwent hip arthroplasty and the 9930 patients who underwent knee arthroplasty at Coxa Hospital for Joint Replacement, Tampere, Finland, between 2002 and 2013, those who had primary joint arthroplasty for primary osteoarthritis (64% [6502 of 10,138] of patients with hip surgery and 82% [8099 of 9930] who had knee surgery) were considered potentially eligible. After exclusion of another 8% (845 of 10,138) and 13% (1308 of 9930) of patients because they had revision or another joint arthroplasty within 2 years of the index surgery, 56% (5657 of 10,138) of patients with hip arthroplasty and 68% (6791 of 9930) of patients with knee arthroplasty were included in this retrospective registry study. Patients who filled prescriptions for antidepressants or benzodiazepines were identified from a nationwide drug prescription register, and information on the filled prescriptions for opioids (mild and strong), NSAIDs, and acetaminophen were extracted from the same database. For the analyses, subgroups were created according to the status of benzodiazepine and antidepressant use during the 6 months before surgery. First, the proportions of patients who used opioids and any analgesics (that is, opioids, NSAIDs, or acetaminophen) were calculated. Then, multivariable logistic regression adjusted with age, gender, joint, Charlson Comorbidity Index, BMI, laterality (unilateral/same-day bilateral), and preoperative analgesic use was performed to calculate odds ratios for any analgesic use and opioid use 1 year postoperatively. Additionally, the proportion of patients who used antidepressants and benzodiazepines was calculated for 2 years before and 2 years after surgery. RESULTS: At 1 year postoperatively, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for any analgesics than were patients without a history of antidepressant or benzodiazepine use (adjusted odds ratios 1.9 [95% confidence interval 1.6 to 2.2]; p < 0.001 and 1.8 [95% CI 1.6 to 2.0]; p < 0.001, respectively). Similarly, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for opioids than patients without a history of antidepressant or benzodiazepine use (adjusted ORs 2.1 [95% CI 1.7 to 2.7]; p < 0.001 and 2.0 [95% CI 1.6 to 2.4]; p < 0.001, respectively). Nevertheless, the proportion of patients who filled any analgesic prescription was smaller 1 year after surgery than preoperatively in patients with a history of antidepressant (42% [439 of 1038] versus 55% [568 of 1038]; p < 0.001) and/or benzodiazepine use (40% [801 of 2008] versus 55% [1098 of 2008]; p < 0.001). The proportion of patients who used antidepressants and/or benzodiazepines was essentially stable during the observation period. CONCLUSION: Surgeons should be aware of the increased risk of prolonged opioid and other analgesic use after surgery among patients who were on preoperative antidepressant and/or benzodiazepine therapy, and they should have candid discussions with patients referred for elective joint arthroplasty about this possibility. Further studies are needed to identify the most effective methods to reduce prolonged postoperative opioid use among these patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does chronic kidney disease affect implant survival after primary hip and knee arthroplasty?

AIMS: To investigate whether chronic kidney disease (CKD) is associated with the risk of all-cause revision or revision due to a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty. METHODS: This retrospective cohort study comprised 18,979 consecutive hip and knee arthroplasties from a single high-volume academic hospital. At a median of 5.6 years (interquartile range (IQR) 3.5 to 8.1), all deaths and revisions were counted. To overcome the competing risk of death, competing risk analysis using the cumulative incidence function (CIF) was applied to analyze the association between different stages of CKD and revisions. Confounding factors such as diabetes and BMI were considered using either a stratified CIF or the Fine and Gray model. RESULTS: There were 2,111 deaths (11.1%) and 677 revisions (3.6%) during the follow-up period. PJI was the reason for revision in 162 cases (0.9%). For hip arthroplasty, 3.5% of patients with CKD stage 1 (i.e. normal kidney function, NKF), 3.8% with CKD stage 2, 4.2% with CKD stage 3, and 0% with CKD stage 4 to 5 had undergone revision within eight years. For knee arthroplasty, 4.7% with NKF, 2.7% with CKD stage 2, 2.4% with CKD stage 3, and 7% of CKD stage 4 to 5 had had undergone revision. With the exception of knee arthroplasty patients in whom normal kidney function was associated with a greater probability of all-cause revision, there were no major differences in the rates of all-cause revisions or revisions due to PJIs between different CKD stages. The results remained unchanged when diabetes and BMI were considered. CONCLUSION: We found no strong evidence that CKD was associated with an increased risk of all-cause or PJI-related revision. Selection bias probably explains the increased amount of all-cause revision operations in knee arthroplasty patients with normal kidney function. The effect of stage 4 to 5 CKD was difficult to evaluate because of the small number of patients. Cite this article: Bone Joint J 2021;103-B(4):689-695.

The Clinical Frailty Scale is a useful tool for predicting postoperative complications following elective colon cancer surgery at the age of 80 years and above: A prospective, multicentre observational study.

AIM: Identification of the risks of postoperative complications may be challenging in older patients with heterogeneous physical and cognitive status. The aim of this multicentre, observational study was to identify variables that affect the outcomes of colon cancer surgery and, especially, to find tools to quantify the risks related to surgery. METHOD: Patients aged ≥80 years with electively operated Stage I-III colon cancer were recruited. The prospectively collected data included comorbidities, results of the onco-geriatric screening tool (G8), Clinical Frailty Scale (CFS), Charlson Comorbidity Index (CCI) and Mini Nutritional Assessment-Short Form (MNA-SF), and operative and postoperative outcomes. RESULTS: A total of 161 patients (mean 84.5 years, range 80-97, 60% female) were included. History of cerebral stroke (64% vs. 37%, p = 0.02), albumin level 31-34 g/l compared with ≥35 g/l (57% vs. 32%, p = 0.007), CFS 3-4 and 5-9 compared with CFS 1-2 (49% and 47% vs. 16%, respectively) and American Society of Anesthesiologists score >3 (77% vs. 28%, P = 0.006) were related to a higher risk of complications. In multivariate logistic regression analysis CFS ≥3 (OR 6.06, 95% CI 1.88-19.5, p = 0.003) and albumin level 31-34 g/l (OR 3.88, 1.61-9.38, p = 0.003) were significantly associated with postoperative complications. Severe complications were more common in patients with chronic obstructive pulmonary disease (43% vs. 13%, p = 0.047), renal failure (25% vs. 12%, p = 0.021), albumin level 31-34 g/l (26% vs. 8%, p = 0.014) and CCI >6 (23% vs. 10%, p = 0.034). CONCLUSION: Surgery on physically and cognitively fit aged colon cancer patients with CFS 1-2 can lead to excellent operative outcomes similar to those of younger patients. The CFS could be a useful screening tool for predicting postoperative complications.