BACKGROUND: Hospital admissions may provide an opportunity to discontinue potentially inappropriate medications (PIMs) in older patients. Little is known about the effect of using the Screening Tool of Older People's potentially inappropriate Prescriptions (STOPP) in this context. This study aimed to test the hypothesis that specific STOPP recommendations from an inpatient geriatric consultation team (IGCT) to the hospital physician leads to reductions in PIMs for patients at discharge. METHODS: This was a randomised controlled study in 146 frail inpatients (in 2011). The intervention consisted of STOPP recommendations made by the IGCT to ward physicians to discontinue PIMs, in addition to the standard geriatric advice. RESULTS: Intervention ( n = 74) and control ( n = 72) groups were similar in terms of patient characteristics (median age 85 years; median number of daily drugs, seven) and PIM distribution (68 and 57 PIMs in 53 and 51 % of patients, respectively). At discharge, the reduction in PIMs was twice as high for the intervention group as for the control group (39.7 and 19.3 %, respectively; p = 0.013). The proportion of patients who still had one or more PIM at discharge did not differ between groups. In the 50 patients followed-up a year later, the majority of PIMs that had been stopped during hospitalisation had not been restarted after discharge (17/28; 61 %). The clinical relevance of PIMs identified at baseline in those patients was considered major (29 %), moderate (37 %), minor (5 %), deleterious (8 %), or not assessed (11 %). Discontinuation rate was not associated with clinical importance. CONCLUSION: Specific STOPP recommendations provided to hospital physicians doubled the reduction of PIMs at discharge in frail older inpatients. To further improve the appropriateness of prescribing in older patients, clinicians should focus on the STOPP criteria that are of major clinical importance, and general practitioners should be actively involved.
Objective During hospitalization older people often experience functional decline which impacts on their future independence. The objective of this study was to evaluate a multifaceted transitional care intervention including home-based exercise strategies for at-risk older people on functional status, independence in activities of daily living (ADLs) and walking ability. Methods A randomized controlled trial was undertaken in a metropolitan hospital in Australia with 128 patients (64 intervention, 64 control) aged over 65 years with an acute medical admission and at least one risk factor for hospital readmission. The intervention group received an individually tailored programme for exercise and follow-up care which was commenced in hospital and included regular visits in hospital by a physiotherapist and a registered nurse, a home visit following discharge and regular telephone follow-up for 24 weeks following discharge. The programme was designed to improve health-promoting behaviours, strength, stability, endurance and mobility. Data were collected at baseline, then 4, 12 and 24 weeks following discharge using the Index of ADL, Instrumental Activities of Daily Living (IADL) and the Walking Impairment Questionnaire (WIQ; modified). Results Significant improvements were found in the intervention group in IADL scores ( P < 0.001), ADL scores ( P < 0.001) and WIQ scale scores ( P < 0.001) in comparison to the control group. The greatest improvements were found in the first 4 weeks following discharge. Conclusions Early introduction of a transitional model of care incorporating a tailored exercise programme and regular telephone follow-up for hospitalized at-risk older adults can improve independence and functional ability.
Acute Care for Elders Units offer enhanced care for older adults in specially designed hospital units. The care is delivered by interdisciplinary teams, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. In a randomized controlled trial of 1,632 elderly patients, length-of-stay was significantly shorter-6.7 days per patient versus 7.3 days per patient-among those receiving care in the Acute Care for Elders Unit compared to usual care. This difference produced lower total inpatient costs-$9,477 per patient versus $10,451 per patient-while maintaining patients' functional abilities and not increasing hospital readmission rates. The practices of Acute Care for Elders Units, and the principles they embody, can provide hospitals with effective strategies for lowering costs while preserving quality of care for hospitalized elders.
UNLABELLED: Comprehensive geriatric assessment (CGA) is advocate to improved care of elderly with cancer but is not available in every hospital within a short delay. Therefore, a tool allowing gastroenterologist to detect rapidly specific abnormalities in elderly is needed.
PATIENTS AND METHODS: the aim of our pilot study was to evaluate feasibility of a mini geriatric assessment (MGA) to adapt the anticancer treatments. MGA was done by a gastroenterologist and was taken into account during the cancer multidisciplinary team meeting for making decision. Then, CGA was realised and suggested adaptation of care.
RESULTS: 21 patients over 75 years treated for different digestive cancers were enrolled. The treatments recommended by the cancer multidisciplinary team meeting after the GMA were: standard treatments in 9 (41%); modified in 10 (47%) and best supportive care in 2 (12%) patients. CGA led to an adaptation of the non-oncological treatment in 15 (72%) and of the social care in 8 (38%) patients, but never modified the oncological strategy.
CONCLUSIONS: MGA could help gastroenterologists for adaptation of anticancer treatment. The characteristics of the patients that should subsequently have a geriatric follow-up remain to be defined.
Quality of life (QOL) is a critical issue in elderly patients with cancer. In the geriatric population, cancer is often associated with other chronic conditions possibly affecting QOL. This prospective study aimed to evaluate the validity of two QOL questionnaires, EORTC QLQ-C30 and SF-36, in older cancer patients. Seventy-two of 87 male patients with genitourinary cancer (median age, 76 years) completed the questionnaires (83% response rate). Internal consistency reliability was high (α≥0.7), except for SF-36 cognitive function (α=0.62) and QLQ-C30 general health status (α=0.57). QLQ-C30 and SF-36 appear similarly reliable for QOL assessment in this population. However, cognitive function and functional status, two factors likely to influence the value of QOL self-assessment, are poorly taken into account whereas they are correctly explored by the comprehensive geriatric assessment (CGA) procedure. QOL assessment in elderly cancer patients should therefore be associated with CGA to better meet the expectations of clinicians.
OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission.
DESIGN: Controlled trial based on assignment by convenience.
SETTING: Trauma ward in a university hospital.
PARTICIPANTS: One hundred seventy-one people with hip fracture aged 65 and older.
INTERVENTION: Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture.
MEASUREMENTS: End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery.
RESULTS: Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between-group differences could be documented for mortality, new nursing home admission, or readmission rate.
CONCLUSION: This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more-intensive approach with more-direct control over patient management, more-specific recommendations, and more-intense education would be effective.
Oncologists usually base treatment decision on the assessment of patients' performance status (PS). This study was undertaken to explore the ability of KPS to correctly assess the PS of elderly cancer patients, comparing it to a validated geriatric tool named Physical Performance Test (PPT). One single examiner assessed elderly cancer patients' PS at registration in our institution and performed the PPT on patients with KPS ≥ 60. A sample of 152 patients actually underwent PPT. A low refusal rate was observed (<5%). Most patients (82%) had a high PS (KPS ≥ 80), whereas only 20% had no health impairment according to PPT scores. Patients' gender and disease stage did not correlate with PPT scores. The KPS seems to be a less accurate tool than the PPT to assess functional status of elderly cancer patients. Then PPT could be used as an inclusion criterion instead of KPS before cancer treatment decision.
INTRODUCTION: The Comprehensive Geriatric Assessment (CGA) is a key component of the treatment approach for older cancer patients. The goals of the current study were to develop a brief but non-self-administered cancer-specific geriatric assessment and to determine its feasibility, as measured by (1) the length of time to completion and (2) patient satisfaction.
METHODS: The literature was reviewed to select validated scales for geriatric assessment across the following domains: functional status, co-morbidity, cognition, social support and risk of malnutrition. Oncologic patients older than 70 years were included in the study.
RESULTS: The instrument was completed by 99 patients (mean age, 78.65 yrs). The mean time to completion of that was 12.9 min (range, 9.5-20.5 min). Most patients were satisfied with its length (63.6%), and most considered it fairly easy to complete (69.7%).
CONCLUSIONS: The designed CGA was accepted by most patients and was not perceived to be overly time-consuming.
OBJECTIVES: To determine whether a new multimodal comprehensive discharge-planning intervention would reduce emergency rehospitalizations or emergency department (ED) visits for very old inpatients.
DESIGN: Six-month prospective, randomized (Zelen design), parallel-group, open-label trial.
SETTING: Six acute geriatric units (AGUs) in Paris and its surroundings.
PARTICIPANTS: Six hundred sixty-five consecutive inpatients aged 70 and older (intervention group (IG) n = 317; control group (CG) n = 348).
INTERVENTION: Intervention-dedicated geriatricians different from those in the study centers implemented the intervention, which targeted three risk factors for preventable readmissions and consisted of three components: comprehensive chronic medication review, education on self-management of disease, and detailed transition-of-care communication with outpatient health professionals.
MEASUREMENTS: Emergency hospitalization or ED visit 3 and 6 months after discharge, as assessed by telephone calls to the participant, the caregiver, and the general practitioner and confirmed with the hospital administrative database.
RESULTS: Twenty-three percent of IG participants were readmitted to hospital or had an ED visit 3 months after discharge, compared with 30.5% of CG participants (P = .03); at 6 months, the proportions were 35.3% and 40.8%, respectively (P = .15). Event-free survival was significantly higher in the IG at 3 months (hazard ratio (HR) = 0.72, 95% confidence interval (CI) = 0.53-0.97, P = .03) but not at 6 months (HR = 0.81, 95% CI = 0.64-1.04, P = .10).
CONCLUSION: This intervention was effective in reducing rehospitalizations and ED visits for very elderly participants 3 but not 6 months after their discharge from the AGU. Future research should investigate the effect of this intervention of transitional care in a larger population and in usual acute and subacute geriatric care.
BACKGROUND: Pilot Oncogeriatric Coordination Units (UPCOGs) were created by the French National Cancer Institute (INCA) in order to implement routine geriatric assessment of all cancer patients over 75 years of age. This article examines the role of geriatric and oncologic tools in the organization of medical oncogeriatric activities, focusing on the role and place of geriatricians.
METHODS: We conducted a qualitative sociological survey in the West Paris Oncogeriatric Program (POGOP), one of the Pilot Oncogeriatric Coordination Units (UPCOGs) recently created in France. Various qualitative methods were used including a review of the literature, participative observational surveys, and semidirective interviews with medical staff managing elderly cancer patients.
RESULTS: The results show that the way in which geriatric assessment procedures are implemented confirms the role of the geriatrician in the diagnosis and prevention of vulnerabilities and fragility at the time of initial diagnosis and medical decision making. Nevertheless, the articulation of these different working methods gives rise to various organizational configurations.
CONCLUSIONS: The POGOP has largely contributed to clarifying medical activity in oncogeriatrics: identification of physicians, definition of shared goals, initiation, and structuring of new partnerships. Nevertheless, the geriatrician's tools, expertise, and know-how are often perceived ambiguously.
Hospital admissions may provide an opportunity to discontinue potentially inappropriate medications (PIMs) in older patients. Little is known about the effect of using the Screening Tool of Older People's potentially inappropriate Prescriptions (STOPP) in this context. This study aimed to test the hypothesis that specific STOPP recommendations from an inpatient geriatric consultation team (IGCT) to the hospital physician leads to reductions in PIMs for patients at discharge.
METHODS:
This was a randomised controlled study in 146 frail inpatients (in 2011). The intervention consisted of STOPP recommendations made by the IGCT to ward physicians to discontinue PIMs, in addition to the standard geriatric advice.
RESULTS:
Intervention ( n = 74) and control ( n = 72) groups were similar in terms of patient characteristics (median age 85 years; median number of daily drugs, seven) and PIM distribution (68 and 57 PIMs in 53 and 51 % of patients, respectively). At discharge, the reduction in PIMs was twice as high for the intervention group as for the control group (39.7 and 19.3 %, respectively; p = 0.013). The proportion of patients who still had one or more PIM at discharge did not differ between groups. In the 50 patients followed-up a year later, the majority of PIMs that had been stopped during hospitalisation had not been restarted after discharge (17/28; 61 %). The clinical relevance of PIMs identified at baseline in those patients was considered major (29 %), moderate (37 %), minor (5 %), deleterious (8 %), or not assessed (11 %). Discontinuation rate was not associated with clinical importance.
CONCLUSION:
Specific STOPP recommendations provided to hospital physicians doubled the reduction of PIMs at discharge in frail older inpatients. To further improve the appropriateness of prescribing in older patients, clinicians should focus on the STOPP criteria that are of major clinical importance, and general practitioners should be actively involved.
