Geriatric surgical service interventions in older emergency general surgery patients: Preliminary results.

BACKGROUND: Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. We sought to identify geriatric surgical service interventions most relevant to EGS patients. METHODS: We prospectively identified patients ≥75 years admitted to the EGS service at an urban tertiary care hospital from January 2020-March 2021 who screened positive for frailty (FRAIL score ≥3 [scale 0-5, higher being worse]) or with cognitive impairment. A pilot geriatric surgical service, led by a dually-board certified geriatric and palliative care specialist, conducted a comprehensive geriatric assessment and modified Rockwood Frailty Index calculation for each eligible patient. Patient, hospital admission, and geriatric consultation characteristics were collected via chart review. RESULTS: Fifty consecutive patients (median age 82 years [IQR 78-90], 56% female) received geriatric consultation (median time 3 days [IQR 1-6] from admission). The most common admission diagnosis was bowel obstruction (32%). Sixty-four percent of patients underwent ≥1 surgical procedure. Using the Frailty Index, 64% were moderately or severely frail. Interventions most frequently performed by the geriatric team included delirium prevention and management (66%), consideration of swallowing function (52%), individualized pain management (50%), and facilitation of serious illness conversations (58%). CONCLUSIONS: Geriatric service involvement addresses a high burden of both geriatric and palliative care needs in older EGS patients. Geriatric recommendations may direct interventions for surgical education in fundamental geriatric and palliative care knowledge to maximize geriatric resources for the most high-risk patients.

[Medical oncological treatment of colorectal cancer in the elderly]. / Traitement oncologique médical du cancer colorectal chez la personne âgée.

Medical treatment with chemotherapy is discussed in several situations in the treatment of colon cancer. In the adjuvant setting, chemotherapy with 5FU±oxaliplatin for six months should be considered in the case of lymph node involvement. In the metastatic setting, several protocols exist. The choice of treatments should be based on the expected objectives in terms of response and survival gain, but also of tolerance and quality of life for the patient. A thorough oncogeriatric assessment helps to better define the therapeutic programme. The continuation of geriatric follow-up throughout the treatment process shows a benefit for the patient in terms of quality of life and tolerance of treatments.

Impact of a delirium prevention project among older hospitalized patients who underwent orthopedic surgery: a retrospective cohort study.

BACKGROUND: Postoperative delirium (POD) is a common clinical syndrome with significant negative outcomes. Thus, we aimed to evaluate the feasibility and effectiveness of a delirium screening tool and multidisciplinary delirium prevention project. METHODS: A retrospective cohort study was conducted at a single teaching center in Korea. A cohort of patients who underwent a delirium prevention program using a simple delirium screening tool from December 2018 to February 2019 (intervention group, N = 275) was compared with the cohort from the year before implementation of the delirium prevention program (December 2017 to February 2018) (control group, N = 274). Patients aged ≥65 years who were admitted to orthopedic wards and underwent surgery were included. The incidence rates of delirium before and after implementation of the delirium prevention program, effectiveness of the delirium screening tool, change in the knowledge score of nurses, and length of hospital stay were assessed. RESULTS: The sensitivity and specificity of the screening tool for the incidence of POD were 94.1 and 72.7%, respectively. The incidence rates of POD were 10.2% (control group) and 6.2% (intervention group). The odds ratio for the risk reduction effect of the project related to the incidence of POD was 0.316 (95% confidence interval: 0.125-0.800, p = 0.015) after adjustment for possible confounders. The delirium knowledge test score increased from 40.52 to 43.24 out of 49 total points (p < 0.001). The median length of hospital stay in the intervention and control groups was 6.0 (interquartile range, 4-9) and 7.0 (interquartile range, 4-10) days, respectively (p = 0.062). CONCLUSION: The screening tool successfully identified patients at a high risk of POD at admission. The POD prevention project was feasible to implement, effective in preventing delirium, and improved knowledge regarding delirium among the medical staff. TRIAL REGISTRATION: None.

Integration of Geriatric Assessment in the Care of Patients with Gastrointestinal Malignancies.

BACKGROUND: The majority of patients with gastrointestinal (GI) malignancies are older. Recently, it has become evident that elements from a geriatric assessment (GA) are powerful predictors of outcomes such as postoperative morbidity and mortality, length of stay, type of treatment received, and survival across several GI tumor types in older adults. A GA is a systematic evaluation of functional status, comorbidities, polypharmacy, cognition, nutritional status, emotional status, and social support. METHODS: A PubMed search was performed in order to identify clinical studies investigating the association between GA and outcomes in patients with GI malignancies. RESULTS: A total of 31 studies were included in this review. For colorectal cancer, the evidence linking GA variables and frailty to negative outcomes is substantial and consistent. The data regarding other GI malignancies is more limited, but generally shows the same findings. CONCLUSION: Increasing data shows that elements from a GA and frailty are consistently associated with negative short- and long-term treatment outcomes in older patients with GI malignancies. Future studies should investigate the impact of geriatric interventions on outcomes.

[Geriatric intervention in elderly hip fracture patients admitted to University Hospital of Guadalajara: Clincal, healthcare and economical repercussions]. / Intervención geriátrica en el anciano ingresado por fractura de cadera en el Hospital Universitario de Guadalajara: repercusión clínica, asistencial y económica.

OBJECTIVE: To evaluate the healthcare outcomes and economic impact of geriatric intervention in patients over 75 years old with hip fracture in acute phase. MATERIAL AND METHODS: Retrospective study of patients admitted to the University Hospital of Guadalajara (HUGU) due to hip fracture. An analysis was made of the number of cases per year, preoperative period, hospital stay, and mortality of all the patients over 75 years admitted to the HUGU due to hip fracture between 2002 and 2013. RESULTS: A total of 2942 patients were included. Comparing the activity of 2013 to that of 2006, the mean hospital stay fell from 18.5 to 11.2 days (-39.2%), and mortality from 8.9% to 6.8% (-23%). In contrast, the mean preoperative stay remained at a mean of 2.7 days versus 2.4 in previous years in the early post-intervention period. Hospital stay decreased, despite a progressive annual increase in the daily cost of hospitalisation due to hip fracture surgery, the reduced stay led to a reduction of the total cost by more than 900,000 euros each year. Geriatric intervention has gradually reduced mean hospital stay and mortality, although with a tendency to increase mean preoperative stay. CONCLUSIONS: Geriatric intervention in patients with hip fracture reduces mortality and length of hospital stay, and decreasing costs.

Role of geriatric intervention in the treatment of older patients with cancer: rationale and design of a phase III multicenter trial.

BACKGROUND: In the general geriatric population, programs linking geriatric evaluation with interventions are effective for improving functional status and survival of the patients. Whether or not these interventions improve health related quality of life (HRQoL) or overall survival (OS) in older patients with cancer is not yet clear. Indeed, randomized data on the effect of such interventions on survival and HRQoL are rare and conflicting. We describe the rationale and design of a phase III multicenter trial aimed at assessing the efficacy of geriatric intervention in the management of elderly patients with cancer. METHODS/DESIGN: Approximately 1200 patients, 70 years and older, considered in need of a geriatric intervention based on the G8 screening tool will be randomized into two intervention arms. The 'Usual-care' arm involves standard oncological care based on pre-defined oncological protocols. In addition to the standard oncological care, the 'Case-management' arm involves a multidimensional geriatric assessment and interventions tailored for the patient. Efficacy will be assessed using a co-primary endpoint encompassing OS and HRQoL. DISCUSSION: This trial has been designed to assess whether focused geriatric case management can either improve OS or HRQoL in elderly cancer patients considered in need of geriatric assessment. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT02704832 .

[Geriatric intervention in oncology for elderly patients]. / Place du gériatre dans la prise en charge des patients âgés atteints de cancer.

Half of all cancers occur in patients older than 70 years. National cancer plans in France promote the emergence of geriatric oncology, whose aim is that every elder cancer patient receives a pertinent treatment, according to his frailty. Geriatric intervention has been evaluated in various conditions or patients since 30 years. Meta-analysis has shown the benefits on autonomy and mortality. But benefits are related to the organization of geriatric care, especially when integrated care is provided. Literature on geriatric oncology is relatively poor. But it is certain that a geriatric comprehensive assessment provided a lot of important information for the care of cancer patients, leading to a modification of cancer treatment in many cases. Randomized trials will soon begin to evaluate the benefits of geriatric integrated care for elder cancer patients, in terms of mortality and quality of life. Actually, in oncogeriatic coordination units, pilot organizations are developed for the satisfaction of patients and professionals.

Early interdisciplinary hospital intervention for elderly patients with hip fractures : functional outcome and mortality

OBJECTIVES: Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: This observational, retrospective study was performed in an orthogeriatric care unit on patients aged >70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7 + 6.4 years. RESULTS: On admission to the unit, the average Barthel score of these patients was 77.2 + 27.8 points, and the average Charlson index score was 2.14 + 2.05. The mean length of stay was 8.9 + 4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay. CONCLUSIONS: Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery.