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The article comments on a study which examined the clinical trial pathway to assess non-invitation and refusal rates among older cancer patients. It expresses disappointment with isolation, need for homecare, and low educational attainment as factors to noninvitation. It also points out that receiving radiotherapy as a barrier for participation should be subjected to bias in the Qualisage study. Emphasis is given on the need to improve reporting and include more appropriate outcome measures.

The article comments on a study which examined mortality risk among older patients with cancer and cardiovascular disease (CVD). It points out the greater likelihood for older patients with cancer to die from CVD, particularly those with good prognosis cancer types. It suggests further studies on the effect of anti-cancer treatment on CVD risk, as well as on age-related differences, quality of life and quality of death in CVD-related death risk in older adults with cancer.

Background The documentation of discussions about resuscitation status with patients and their relatives is an important part of medical care, but can be a time-consuming process. These discussions may be difficult, particularly for patients who have cognitive impairment or are acutely unwell. The National Consent Policy1 recommends that resuscitation decisions should be made with patients themselves, or with family members if the patient cannot participate. It also recommends decisions are made by the most senior decision maker with responsibility for the patient's care and discussions should be carefully documented. Methods The charts of all 106 inpatients in our hospital were audited on a single day. Documentation of resuscitation status in the medical and nursing notes was reviewed. Results The average age of inpatients was 79.8 years. 25.5% of patients had a DNACPR order. Of these, 92% had their DNACPR status documented in the nursing notes. 100% had a DNACPR form in their medical notes but none were fully completed. 48% had not had the decision endorsed by the consultant in charge of the patient's care. 74% had not been discussed with the patient or had not had a reason documented as to why the decision had not been discussed. 41% did not have any discussion documented in the medical notes. Conclusion The DNACPR form in use includes the details recommended by national guidelines but these forms are not being completed in their entirety. Discussions with patients themselves are possibly inappropriate at the time resuscitation status is being considered, but documentation of the reasons for this is still important. This, in particular is an area which needs to be highlighted to medical staff in our hospital. Results of this audit will be incorporated into an education session, with a view to changing practice. [ABSTRACT FROM AUTHOR]

Background Ascertaining and discussing resuscitation status should be a routine part of medical practice. However, it is frequently neglected until a patient is acutely unwell. The National Consent Policy1 recommends that discussion around "Do not attempt cardiopulmonary resuscitation" (DNACPR) orders should occur for patients with "an identifiable risk of cardiorespiratory arrest occurring". The Clinical Frailty Scale is a useful tool for providing predictive information about the risk of death in older patients2. Along with the presence of comorbidities, it can assist with determining prognosis and identifying patients for whom early discussion about resuscitation status is appropriate. Methods A chart review was carried out of all 106 inpatients in a model 3 hospital. Data was extracted on demographic information, frailty score and resuscitation status. Results The average age of inpatients was 79.8 years. On admission, the average Clinical Frailty Scale score was 5 (mildly frail), with 15% having a frailty score of 7 or more, and 28% a diagnosis of dementia. 25.5% of inpatients had a DNACPR order in place. It took an average of 32.4 days (range 0-224 days) from admission until this decision was made. Conclusion As we are caring for an older population with frailty; care planning, including resuscitation status should be discussed at an earlier stage. Ideally, this should occur on admission for certain patients, particularly those with high levels of frailty and multiple comorbidities. Our current practice, in which DNACPR decisions sometimes take place after a prolonged admission, is suboptimal. A change to the medical admission proforma, adding a prompt for discussion of DNACPR orders will be considered. [ABSTRACT FROM AUTHOR]

Background Hip fractures are an increasing phenomenon in the older population. Receiving post-operative rehabilitation is associated with better outcomes and a higher likelihood of returning to preexisting level of functioning. Best rehabilitation practices for people with dementia have not been established. Methods All patients >/= 60 years old with a hip fracture admitted under the orthopaedic team between March 2016-February 2018 were reviewed. Those with a diagnosis of dementia were extracted from the database. Clinical Frailty Scale (CFS), Zuckermann Functional Recovery Score (FRS) and New Mobility Score (NMS) were documented at baseline and at one year. Outcomes assessed included 1 year mortality, decline FRS/NMS, change in CFS and nursing home (NH) admission rates. Results 465 patients' hip fractures were recorded: 175 patients had dementia. 67 patients were dead at 1-year post fracture (38.285% mortality rate). Of the 108 patients with dementia who were living at 1-year; 30.5% (n=33) received offsite rehab. 58.4% (n=63) received routine in-patient rehab. 12 lost to follow-up. Of the 33 patients that received off-site rehab the mean FRS at baseline was 66 and decreased to 45.56 at 1 year (30.9% reduction). The mean CFS at baseline was 5.1, increasing to 6 at 1-year (17% increase). Mean NMS was 5.7 decreasing to 3.7 at 1-year. In those patients with dementia that did not receive off site rehab (n=63); baseline mean FRS was 38 reducing to 30 at 1 year (26.6 % reduction). Mean CFS was 6.25- increasing to 6.47 at 1 year. 41% of patients admitted from home who did not receive off-site rehab were discharged to NH. Of the group discharged to off-site rehab: at 1 year 33% were in a NH and 72% remained at home. Conclusion Both groups demonstrated decline in function. Those that received off-site rehab had higher premorbid functioning/mobility and reduced frailty. There was a reduced NH admission rate at 1-year in the group that received off-site rehab. [ABSTRACT FROM AUTHOR]

Background Hip fractures in the older person are associated with significant morbidity and mortality. Screening patients for frailty and assessing baseline mobility and function may help predict poorer outcomes Methods All patients >/= 60 years old with a hip fracture admitted under the orthopaedic team between February 2016-February 2018 were included. We assessed clinical frailty score(CFS), zuckermann functional recovery score(FRS) and new mobility score(NMS) on admission and at 1 year. Outcomes assessed included mortality rates and nursing home(NH) admission rates Results 541 patients were included; 533 underwent surgery, 4 died preoperatively and 4 of the periprosthetic fracture cohort were treated conservatively. 33 patients lost to follow-up. Overall mortality was 24.7%(n=134) at one year. In the severely frail cohort (CFS7-9)(n=72); 47.2% mortality rate at 1 year. 20.8%(n=15) came from home, 2 of those were discharged to NH. In the moderately frail cohort (CFS 5-6)(n= 184), mortality rate was 30.4% at 1 year. 77.2%(n=142) were admitted from home and 8%(n=15) of this cohort were discharged to NH. In the non-frail subgroup (CFS 1-4)(n=211), mortality rate was 11.8%(n= 25)at 1 year, 97.1% (n=205) were admitted from home and 7.5%(n=11) of the cohort admitted from home were living in a NH at 1 year. Regarding FRS; compared to those without frailty(FRS>75), those with FRS 30-75 had a two-fold increased risk of one year mortality [OR: 2.16 (95% CI: 1.24 to 3.78)]. This increased to a nearly six-fold increased risk in those with severe frailty (FRS<30); [OR 5.73 (95%CI : 3.16 -10.41)]. This effect was independent of age. A dementia diagnosis independent of age and frailty is associated with 2.5 fold increased risk of NH/mortality at 1 year Conclusion All three tools (CFS, NMS, FRS) can accurately predict mortality and NH admission at 1 year. Patients with higher CFS and poor baseline functioning and mobility have poorer outcomes. CFS is a simple tool that can be documented on admission with a hip fracture and help inform discussions with patients and families regarding potential outcomes/prognosis. [ABSTRACT FROM AUTHOR]

Radiotherapy is an effective, albeit underutilised, treatment for cancer in older adults, especially for those who are surgically inoperable or for whom chemotherapy poses too great a risk. It is estimated that approximately half of patients with cancer could benefit from radiotherapeutic management. This article synthesises the basics of how radiotherapy works, recent developments in the field and considers how this treatment modality may be adapted in an older patient population or may evolve in the future. Technological advances of relevance include Intensity Modulated Radiotherapy (IMRT), Volumetric Modulated Arc therapy (VMAT), Stereotactic Ablative Body Radiotherapy (SABR), proton therapy, MR guided radiotherapy, as well as better image guidance during irradiation in order to improve precision and accuracy. New approaches for better integration of geriatric medicine principles into the oncologic assessment and workup will also be considered, in order to provide more age attuned care. For more informed decision making, a baseline assessment of older radiotherapy patients should encompass some form of Comprehensive Geriatric Assessment. This can facilitate the optimal radiotherapy regime to be selected, to avoid overly toxic regimes in patients with frailty. The review discusses how these new initiatives and technologies have potential for effective oncologic management and can help to reduce the toxicity of treatment for older adults. It concludes by highlighting the need for more evidence in this patient population including better patient selection and support for treatment to enhance person-centred care. [ABSTRACT FROM AUTHOR]

The authors reflect on the relevance of oncological trials in the care and treatment of older people with cancer. Also cited are the practice of excluding older adults in randomized controlled trials (RCT) to determine the standard of care treatment for older people, the study showing the insufficiencies of cancer trial registration, and the challenges facing the geriatric oncology community.

The authors discuss the lack of attention paid to the implications of delirium identification and management in the public health response to the COVID-19 pandemic. Topics include evidence of high mortality rates linked with delirium in care homes, the impact of using personal protective equipment by hospital staff on older adults with underlying cognitive impairment, and a toolkit developed by the Hospital Elder Life Program to offer delirium prevention strategies for patients in isolation.

A letter to the editor is presented in response to the article "Human rights and healthcare: changing the culture," by J. Morris in the 2010 issue.