Multidisciplinary palliative care of the older adult: a narrative review.

BACKGROUND AND OBJECTIVE: The aging of society has contributed to individuals living longer with chronic illnesses. This places them at risk to develop cancer. Treating older adults with chronic illnesses and cancer, places strain on oncologists as this group of individuals is heterogenous in nature, differing in their functional status, co-morbidities, etc. Integrating geriatrics into the care of the older adult with cancer has proven to be beneficial in helping to ameliorate the effects of aging and honing oncologic treatment regimens to be effective and efficient. The purpose of this unsystematic review is to demonstrate the importance that geriatricians can have, when participating on a multidisciplinary team (MDT) with oncology, in the administration of holistic palliative cancer care to the older adult; to present geriatric specific issues that are imperative to consider when managing the older adult with cancer; and to consider other members of the MDT inclusive of social work, pharmacy, and nursing. METHODS: Data were identified by searching PubMed (January 2005 to July 2023) using the following search terms: multidisciplinary care and older adults and cancer care. The search was repeated using geriatrics, MDTs, chronic diseases, elderly. Non-English articles and observational studies were excluded. An additional review of literature was undertaken using relevant references of identified articles. KEY CONTENT AND FINDINGS: Older adults are heterogenous in the aging process and thus using a geriatrician to perform comprehensive geriatric assessments (CGAs) can help to tailor the palliative care of the older adult with cancer. Providing for better predictions of the success of the proposed treatment. The overarching goal is to maintain the individual's quality of life and independence. MDTs, consisting of nursing, pharmacy and social work in addition to geriatricians and oncologists are instrumental in providing his level of care. CONCLUSIONS: Utilizing geriatricians on an MDT with oncology can help to provide the older adult with cancer palliative care that is holistic, effective and efficient in its delivery. While intellectually these models of multidisciplinary care are effective for the older adult with cancer, future research is needed as to the quality, cost-effectiveness and impact this care can have.

Palliative care in the older adult with cancer and the role of the geriatrician: a narrative review.

BACKGROUND AND OBJECTIVE: Palliative care can offer individuals improved quality of care and life. While many individuals would benefit from palliative care, only a minority will receive it. Integrating palliative care with geriatrics can help relieve this deficit, help with basic symptom management, advanced care planning (ACP) and develop goals of care to assure that the care provided is congruent with the individual's priorities. The purpose of this narrative review is to demonstrate the importance that the geriatrician can have when participating in the administration of palliative care; to present geriatric-specific issues that are imperative to manage when palliatively treating the older adult with cancer. METHODS: Data were identified by searching PubMed (January 2000 to July 2023) using the following search terms: palliative care, older adults, and cancer care. The search was repeated using geriatrics, pain, fatigue, anxiety, and depression. Non-English articles and observational studies were excluded. Additional review of literature was undertaken using relevant references of identified articles. KEY CONTENT AND FINDINGS: Providing the right service at the right time for older adults with undergoing palliative care is imperative. It is important that clinicians, especially geriatricians, have basic skills in providing this level of care to older patients while working in conjunction with palliative care teams. Older adults are a heterogeneous group, thus utilizing comprehensive geriatric assessment helps the palliative care team to successfully treat individuals. Addressing goals of care, symptom management and ACP can help to maintain quality of life and independence of the older adult. The aging process can affect how the individual perceives and manage their symptoms related to their cancer care including pain, fatigue, anxiety/ depression, etc. CONCLUSIONS: Embedding primary care geriatrics in the palliative care arena helps to provide more access to this care. This integration helps providers address basic symptom management, advance care planning and work with individuals on goals of care to assure the care being provided is congruent individual's priorities. Older adults respond to symptoms different than their younger counterparts. Management of these symptoms has to be addressed in a manner commiserate with their age.

Palliative care in dementia.

Dementia is one of the leading causes of death in the US. Approximately, 6 million elderly people in the US had dementia in 2020. Advanced dementia is complicated by multiple problems that can lead to distress in both the patient and their caregivers. With the increase in aging population, physicians will be expected to take care of patients with dementia. Palliative and hospice care can play an important part in helping to alleviate physical symptoms as well as address non-medical/spiritual needs. In this review article, we highlight the patient-centered approach to treat symptoms and patient's needs to improve their quality of life. We discuss the most important and persistent challenges in advanced dementia with the aim to provide excellent care at the end-of-life and caregiver experience. Data were identified by using PubMed, EBSCO, and Google Scholar databases (January 1980 to present) using the following search terms: dementia, palliative care, advanced dementia, and hospice care. The search was repeated using geriatrics, end-oflife, decision making, advanced care, capacity evaluation, nutrition, infections, pain management, dyspnea, delirium, de-prescribing, and spiritual care. Additional review of literature was undertaken using relevant references of identified articles. There are many missed opportunities to improve care in this vulnerable patient population that when addressed can lead to peaceful and dignified death.

Doppler Ultrasound Assessment of Tumor Vascularity in Locally Advanced Breast Cancer at Diagnosis and following Primary Systemic Chemotherapy.

Aim: The primary goal of this research is to compare the morphological response, as determined by clinical and sonographic examination, to the gold standard, histology, in assessing the effectiveness of major systemic chemotherapy in patients with locally advanced breast cancer (LABC). Materials and Methods: During the check and before each example of chemotherapy (FAC schedule), 54 patients with privately progressed, non-metastatic breast disease underwent a comprehensive clinical assessment, ultrasonography of the breast and axillae, and assortment and spooky Doppler appraisal to evaluate response to therapy. Results: In 90% of instances, Doppler provided early insight into how a patient might respond to treatment. Disappearance of all vascular signals inside the tumor was shown to be the strongest predictor of full pathological response. Conclusion: Patients with LABC may benefit from using color Doppler to determine how well chemotherapy is working.

A Study on Urinary Isolates of Candida Species Isolated from Hospitalized Patients with Special Reference to Speciation, Antifungal Susceptibility, and Comparison of Rapid and Conventional Methods of Speciation.

Aim: In order to determine which species of Candida were isolated from hospitalized patients' urine, which risk factors they were linked to, and which antifungal drugs were effective against them, the current investigation was carried out. Materials and Methods: One hundred inpatients were part of the study group. Urine samples were collected from each subject and spun at 3000 rpm for 10-15 minutes in individual sterile centrifuge tubes. Color, size, texture, and the presence of color diffusion into the surrounding agar were used to identify the distinct Candida species, presumably in 48 hours. Results: A total of 86.7% of the Candida spp. were found to be non-albicans. Major inaccuracies occurred because of differences between methodologies; thus, MBD is the best way to determine antifungal susceptibility to itraconazole and amphotericin B. Conclusion: To help clinicians decide on an empirical treatment in an emergency, accurate identification of Candida down to the species level is crucial.

Body water percentage from childhood to old age.

BACKGROUND: Total body water (TBW) increases with growth, but the body water percentage (TBW%) decreases with aging. The objective of our study was to delineate TBW% in males and females by bioelectrical impedance analysis (BIA) from early childhood to old age. METHODS: We enrolled 545 participants aged 3 to 98 years (258 male, 287 female). Among the participants, 256 had a normal weight and 289 were overweight. The TBW was measured by BIA, and TBW% was derived by dividing the TBW (L) value by body weight (kg). For analysis, we divided participants into the four age groups of 3-10, 11-20, 21-60, and ≥61 years. RESULTS: In normal-weight subjects, the TBW% was similar at 62% between males and females in the 3-10-year group. It remained unchanged in males until and through adult life, then decreased to 57% in the ≥61-year group. In normal-weight female subjects, the TBW% decreased to 55% in the 11-20-year group, remained relatively unaltered in the 21-60-year group, then decreased to 50% in the ≥61-year group. In overweight subjects, the TBW% values in males, as well as females, were significantly lower as compared to those with normal weight. CONCLUSION: Our study showed that the TBW% in normal-weight males changes very little from early childhood to adult life compared to that of females, who showed a decrease in TBW% during the pubertal years. In normal-weight subjects of both sexes, the TBW% decreased after the age of 60 years. Overweight subjects had significantly lower TBW% as compared to those with normal weight.

Impact of pre-operative transjugular intrahepatic portosystemic shunt on post-operative outcomes following non-transplant surgeries in patients with decompensated cirrhosis.

Background: Patients with cirrhosis have a high risk for morbidity and mortality in relation to abdominal surgery. Despite improvements in surgical techniques and intensive care, major abdominal surgery still remains a challenge. Major factors determining short- and long-term survival and perioperative complications in this patient population include severity of liver dysfunction, degree of portal hypertension (PHTN), and the presence of related complications such as ascites. Elective transjugular intrahepatic portosystemic shunt (TIPS) placement prior to surgery has been reported to improve perioperative outcomes, but available data is limited to case reports and small case series. We aimed to determine the impact of elective TIPS placement on perioperative outcomes after abdominal-pelvic surgeries in patients with cirrhosis. Methods: We performed a retrospective chart review of patients who underwent elective TIPS and compared these patients with a cohort of cirrhotic patients who underwent any abdominal surgeries without TIPS placement. The primary outcomes were mortality at 30 days and 1 year following surgery. Other post-operative outcomes compared between the two groups, included: blood loss, worsening ascites, wound leak, infections, encephalopathy, liver decompensation, and length of hospitalization. Results: Among 38 patients with cirrhosis who underwent abdominal surgery, 20 patients underwent pre-operative elective TIPS placement. Demographic characteristics of the two groups were comparable including age, gender, and body mass index (BMI). The median age was 62 years with a male predominance (62.5%). Both groups had similar etiologies of cirrhosis with hepatitis C virus (HCV) (34.2%) being most common. The most frequent indications for surgery were strangulated hernia (50%) in the TIPS group and acute cholecystitis (55.6%) in the non-TIPS group. Mean pre-TIPS hepato-venous portal gradient (HVPG) was 16.5 mmHg and mean post-TIPS HVPG was 7.0 mmHg. Mortality at 1 month was not statistically different between the groups (20% vs. 5.6%, respectively, P=0.19). The 1-year mortality was also not statistically different between the two groups (20% vs. 11.1%, P=0.36). Conclusions: We found no statistically significant difference in mortality or rate of post-operative complications between patients who received pre-operative TIPS and those who did not in our age-matched cohort.

Diagnostic Delays and Psychosocial Outcomes of Childhood-Onset Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that manifests in affected individuals with a variety of clinical features and involves multiple organs. Despite recent advances over the past decades, higher morbidity and mortality have been reported by studies in patients with childhood-onset systemic lupus erythematosus (cSLE) compared to patients with adult-onset. The interplay of several factors can cause diagnostic delays resulting in worse disease activity, multiple organ damage, increased risk of hospitalization, and management with aggressive treatment. Significant factors include demographic, clinical, and socioeconomic characteristics of patients with cSLE. Moreover, despite recent advances in lupus treatment, prolonged disease duration in these young patients can result in debilitating psychosocial outcomes and can significantly impact their health-related and general quality of life (QOL). Important domains affected include patient self-esteem, education, employment, healthcare utilization, and mental health. In this review, we examined the barriers that lead to a delay in diagnosing lupus in the pediatric population and addressed cSLE morbimortality and its long-term impact on patient health-related and general QOL.

The Association of Epstein-Barr Virus With Cancer.

Epstein-Barr virus (EBV) is classified as a herpesvirus and is known for being one of the few viruses that can lead to the development of cancer. This study has gathered several studies to provide evidence as to this association as well as some of the mechanisms specific to EBV that allow this to happen. The development of EBV into cancer as well as the proteins involved in this oncogenesis play a crucial role in understanding this problem as well as creating a solution for mitigating this disease process in the future. This study summarized three of the most common malignancies caused by EBV in order to consolidate information about each of them. Additional emphasis was placed on finding which EBV serum markers were seen to be most indicative of prognosis and likelihood of developing malignancy. Higher serum EBV viral DNA loads were seen to be a useful indicator in assessing the risk of various cancers and should be studied further in relation to cancers that were not mentioned in this review.

Cardiovascular Complications in Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is an auto-immune disease of a relapsing-remitting nature that can cause multiorgan damage depending on several factors, mainly the disease activity. Young age women are the most likely to be affected by the disease and the female-to-male prevalence ratio is approximately 1:10. As the number of SLE patients has been increasing in the last few decades, the annual number of deaths due to the disease and its complications has increased as well, and one of the most important systems to which high mortality is attributed is the cardiovascular system, leading to premature atherosclerosis and other events such as endocarditis and valve disease. In addition to the classical cardiovascular risk factors, studies have found a positive correlation between SLE and other cardio-harmful diseases such as metabolic syndrome and dyslipidemia. Moreover, some of the medications used in the treatment of SLE place a heavy burden on the heart. The article reviews the shared pathophysiology of SLE and cardiovascular disease along with the most common SLE- associated cardiac risks, events, and management.

The Effect of Sepsis on Myocardial Function: A Review of Pathophysiology, Diagnostic Criteria, and Treatment.

Sepsis remains a worldwide challenge for physicians with many patients admitted to ICUs with septic shock. Septic shock management involves targeted treatment to control infections, reduce end-organ damage, and reverse the injury. Sepsis-induced myocardial dysfunction or septic cardiomyopathy remains an avenue to be explored with regard to underlying pathophysiology and definite treatment guidelines. This article has compiled various studies to explain the possible mechanisms involved in the development of septic cardiomyopathy and the existing diagnostic criteria including radiological and laboratory tests to assess septic cardiomyopathy. Furthermore, the article highlights management options currently available for physicians dealing with myocardial dysfunction secondary to sepsis.

Maternal and Neonatal Outcomes of Adolescent Pregnancy: A Narrative Review.

Adolescent pregnancy is the pregnancy of girls aged 10-19 years, leading to many maternal and neonatal adverse effects. These pregnancies have been a global concern for many decades and yet are still prevailing. This article has reviewed the significant determinants of adolescent pregnancy and various maternal adverse effects, including preeclampsia, preterm premature rupture of the membrane (PPROM), maternal anemia, sexually transmitted diseases, postpartum depression, and maternal deaths, and adverse neonatal outcomes, including low birth weight (LBW), prematurity, stillbirths, early neonatal demise, and low Apgar score. Various pathophysiologic events that lead to such adverse consequences have been briefly discussed in the article and how such occurrences can be overcome. This article has also emphasized the need to implement various modalities such as sex education, availability of contraceptives, and bringing community-level awareness to lower the prevalence of adolescent pregnancy.

Updating the landmark literature for the practice of geriatrics: Notable articles from 2012-2019.

BACKGROUND: Remaining current on the latest advances in the peer-reviewed literature is a basic tenant of medical education and evidence-based practice. We updated an important prior publication (Vaughan, et al.) identifying landmark articles in geriatric medicine by considering the influence of altmetrics and updating the list with notable articles published between 2012 and 2019. METHODS: Articles were identified by searching Web of Science and Scopus for highly cited articles clinically relevant to geriatrics or gerontology and by searching the Altmetric Explorer database for relevant articles with high altmetric scores. The results of the literature search were screened and evaluated using a bibliometric score consisting of an adjusted journal impact factor, citation count, and altmetric score. RESULTS: The top 12 notable articles in geriatrics were selected by a consensus panel and ranked using an expert opinion survey. This process reinforces the concept of combining subjective and objective measures to identify notable articles to be used for the education of healthcare professionals in geriatrics principles of care for older adults. CONCLUSIONS: While our update was performed approximately 9 years after the initial identification of landmark articles, we propose that future updates are conducted at an interval of every 5 years by the governance of a national professional society.

Trends in Incidence, and Mortality of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the United States Emergency Department (2010-2018).

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%; p < 0.001), VT/VF (0.14% vs 0.06%; p < 0.001), STEMI (0.22% vs 0.11%; p < 0.001) and NSTEMI (0.65% vs 0.2%; p < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%; p < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (p-trend 0.004 and 0.0003) and the trend of mortality had improved (p-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (p-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.

Merkel Cell Carcinoma in the Setting of Chronic Lymphocytic Leukemia and Diffuse Large B-Cell Lymphoma.

Merkel cell carcinoma (MCC) is a rare, rapidly growing, and highly malignant cutaneous tumor that typically presents in elderly males as an erythematous or violaceous plaque or nodule in sun-exposed areas. Risk factors include long-term ultraviolet (UV) exposure, Merkel cell polyomavirus (MCV) infection, immunosuppression, and lymphoproliferative disorders such as chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Given the aggressive nature of this tumor, patients may present with nodal and distal metastasis. Locoregional disease can be managed with definitive radiotherapy or surgery with or without adjuvant radiotherapy, depending on the case. Disseminated disease, on the other hand, often requires a multidisciplinary tumor board consultation to individually tailor the treatment. Possible treatments include systemic therapy with chemotherapy or immunotherapy, radiotherapy, and surgery. Here we report a case of a patient with a medical history significant for chronic lymphocytic leukemia and diffuse large B-cell lymphoma who presented with a rapidly growing lesion that contained neighboring MCC and CLL/SLL on biopsy. Management included immunotherapy with pembrolizumab and radiotherapy to limit the tumor's growth and spread. To the best of our knowledge, the coexistence of all three malignancies in a person is rare and has not been reported previously.

Letter to the editor: Vitamin D levels in acute illness and clinical severity in COVID-19 patients.

We would like to comment on the recently published article titled: "Circulating Vitamin D levels status and clinical prognostic indices in COVID-19 patients" by Ricci et al. The authors grouped the patients into two groups according to the vitamin D levels measured at the time of admission into the hospital and reported that lower vitamin D levels are associated with elevated D-dimer and IL-6 levels, low CD4/CD8 ratio and compromised clinical findings with elevated LIPI and SOFA scores. However, review of recent literature shows this association to be debatable. The 25-hydroxyvitamin D levels in the initial phase of critical illness have been reported to drop rapidly and hence consideration of the time of measurement from symptom onset would have enhanced the clinical relevance of these findings. Inferred association between vitamin D levels and disease severity based on SOFA score in COVID-19 patients, needs to be further explored in the light of the recent literature which casts doubt on using SOFA score at admission to predict mortality in COVID-19.

Impact of Malnutrition on Hospitalization Outcomes for Older Adults Admitted for Sepsis.

BACKGROUND: Malnutrition is a major determinant of health outcomes among the older adult population. Our goal was to evaluate the impact of malnutrition on hospitalization outcomes for older adults who were admitted with a diagnosis of sepsis. METHODS: The National Inpatient Sample was queried for all patients who were admitted with a primary diagnosis of sepsis from January to December 2016. These patients were identified using the International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code A419. Patients who were diagnosed with malnutrition were identified using ICD-10 codes E43, E440, E441, E45, and E46. Outcomes of hospitalization were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. RESULTS: Overall, a total of 808,030 patients were admitted for sepsis. Those diagnosed with malnutrition were 15.6% (126,335) of the total. The mean age (standard error of the mean) was 78 years (0.03). On multivariate analysis, malnutrition correlated with increased odds for mortality: adjusted OR (aOR) 1.20; 95% confidence interval [CI], 1.15-1.26; P < .001; septic shock: aOR 1.50; 95% CI, 1.44-1.57; P < .001; and intubation: aOR 1.45; 95% CI, 1.38-1.52; P < .001. It was also associated with higher odds for acute kidney injury and stroke. Malnutrition correlated with a 53% increase in the length of stay, with mean ratio 1.53; 95% CI, 1.51-1.56; P < .01; and a 54% increase in cost, with mean cost ratio 1.54; 95% CI, 1.51-1.58; P < .001. CONCLUSION: Among the geriatric population diagnosed with sepsis, malnutrition is an independent predictor for poor hospitalization outcomes.

Cardiovascular Risk Among Patients ≥65 Years of Age with Parkinson's Disease (From the National Inpatient Sample).

In this study, we aimed to investigate the relationship between Parkinson's disease (PD) and vascular disease and risk factors using a nationally representative sample. The National Inpatient Sample was queried for all patients aged ≥65 who were diagnosed with PD during the year 2016. Patients were identified using the International Classification of Diseases-Tenth Revision (ICD-10) diagnosis code: "G20." Each patient diagnosed with PD was frequency-matched to controls at a 1:4 ratio by age and gender. Study outcomes were hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, and stroke. Outcomes were modeled using logistic regression analysis and further validation was obtained using a propensity score-matched analysis. A total of 57,914 patients (weighted: 289,570) with PD were included. Most patients were of Caucasian race (80.8%). Females were 42.4% and the mean age was 79 years, standard error of the mean (0.03). PD correlated with lower odds for hyperlipidemia adjusted odd ratio (a-OR): 0.77 (95% confidence interval [CI]: 0.75 to 0.79) p <0.001, diabetes mellitus a-OR 0.73 (95% CI 0.71 to 0.75) p <0.001, hypertension a-OR 0.68 (95% CI: 0.67 to 0.70) p <0.001, coronary artery disease a-OR 0.64 (95% CI: 0.63 to 0.66) p <0.001 and higher odds for stroke a-OR: 1.27 (95% CI: 1.24 to 1.31) p <0.001. Following propensity score matching, identical findings were found. In conclusion, patients with PD have a distinct cardiovascular profile with higher rates of stroke and lower rates of coronary artery disease and vascular disease risk factors.

A Case of COVID-19 Infection With Delayed Thromboembolic Complication on Warfarin.

Novel coronavirus disease 2019 (COVID-19) pandemic has posed an unprecedented threat to humanity with more than eight million infections and 450,000 deaths reported worldwide so far. The spectrum of the disease varies from mild asymptomatic infection to severe disease with rapid progression to acute respiratory distress syndrome and multiorgan failure. It is associated with a prothrombotic state and hence there is a risk of thromboembolic complications in critically ill patients, even after recovery. However, the duration of prothrombotic risk after recovery is yet to be determined. We present the case of a 78-year-old man with a history of atrial fibrillation on warfarin who had been recently discharged to a nursing home after recovering from COVID-19 pneumonia and presented to the emergency department a month later with worsening shortness of breath and cough. He was found to have worsening respiratory failure with multiple segmental pulmonary emboli, despite being on warfarin, and supratherapeutic international normalized ratio (INR). He required mechanical ventilation and was started on steroids and therapeutic enoxaparin anticoagulation. This case highlights the risk of delayed thromboembolic complications in patients with COVID-19 infection and the need to identify the subgroup of patients with a higher risk of thromboembolism, such as discharges to nursing homes and those in need of oxygen requirement; and those with underlying comorbid conditions that may require anticoagulation for a longer duration. The role of heparin is being increasingly investigated in patients with COVID-19 infection; however, the role of other anticoagulants such as warfarin is yet to be defined.