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Background/Objectives Older patients admitted to cardiac care units often suffer functional decline. We evaluated whether a nurse-led geriatric co-management program leads to better functional status at hospital discharge. Design A quasi-experimental before-and-after study was performed between September 2016 and December 2018, with the main endpoint at hospital discharge and follow-up at 6 months. Setting Two cardiac care units of the University Hospitals Leuven. Participants One hundred and fifty-one intervention and 158 control patients aged 75 years or older admitted for acute cardiovascular disease or transcatheter aortic valve implantation. Intervention A nurse from the geriatrics department performed a comprehensive geriatric assessment within 24 h of admission. The cardiac care team and geriatrics nurse drafted an interdisciplinary care plan, focusing on early rehabilitation, discharge planning, promoting physical activity, and preventing geriatric syndromes. The geriatrics nurse provided daily follow-up and coached the cardiac team. A geriatrician co-managed patients with complications. MEASUREMENTS The primary outcome was functional status measured using the Katz Index for independence in activities of daily living (ADL; one-point difference was considered clinically relevant). Secondary outcomes included the incidence of ADL decline and complications, length of stay, unplanned readmissions, survival, and quality of life. RESULTS The mean age of patients was 85 years. Intervention patients had better functional status at hospital discharge (8.9, 95% CI = 8.7-9.3 versus 9.5, 95% CI = 9.2-9.9; p = 0.019) and experienced 18% less functional decline during hospitalization (25% vs. 43%, p = 0.006). The intervention group experienced significantly fewer cases of delirium and obstipation during hospitalization, and significantly fewer nosocomial infections. At 6-month follow-up, patients had significantly better functional status and quality of life. There were no differences regarding length of stay, readmissions, or survival. CONCLUSION This first nurse-led geriatric co-management program for frail patients on cardiac care units was not effective in improving functional status, but significantly improved secondary outcomes. Onderzoeksraad, KU Leuven, Grant/Award Number: REF22/15/028 Deschodt, M (corresponding author), UZ, Dept Gerontol & Geriatr, AGSF, Herestr 49 Box 7003 35, B-3000 Leuven, Belgium. mieke.deschodt@kuleuven.be

BackgroundCombining observation principles and geriatric care concepts is considered a promising strategy for risk-stratification of older patients with emergency care needs. We aimed to map the structure and processes of emergency observation units (EOUs) with a geriatric focus and explore to what extent the comprehensive geriatric assessment (CGA) approach was implemented in EOUs.MethodsThe revised scoping methodology framework of Arksey and O'Malley was applied. Manuscripts reporting on dedicated areas within hospitals for observation of older patients with emergency care needs were eligible for inclusion. Electronic database searches were performed in MEDLINE, EMBASE and CINAHL in combination with backward snowballing. Two researchers conducted data charting independently. Data-charting forms were developed and iteratively refined. Data inconsistencies were judged by a third researcher or discussed in the research team. Quality assessment was conducted with the Methodological Index for Non-Randomized Studies.ResultsSixteen quantitative studies were included reporting on fifteen EOUs in seven countries across three continents. These units were located in the ED, immediately next to the ED or remote from the ED (i.e. hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72h. Most studies focused on medical and functional assessment. Four studies reported to assess a patients' medical, functional, cognitive and social capabilities. If deemed necessary, post-discharge follow-up (e.g. community/primary care services and/or outpatient clinics) was provided in eleven studies.ConclusionThis scoping review documented that the structure and processes of EOUs with a geriatric focus are very heterogeneous and rarely cover all elements of CGA. Further research is necessary to determine how complex care principles of 'observation medicine' and 'CGA' can ideally be merged and successfully implemented in clinical care. The authors did not receive grants, institutional or corporate support to conduct this study. PH is holder of a PhD fellowship granted by Research Foundation - Flanders (FWO) (1133320 N). The authors would like to thank Magdalena Jans for her contribution to development of the search strings. This work was presented at the first virtual congress of the European Society for Emergency Medicine (EUSEM) (19-22 September, 2020).

Key Summary points Aim To determine the prevalence of urinary retention and the role of screening for urinary retention on admission to an acute geriatric hospitalisation unit. Findings A post-void residual volume (PVR) ≥150 ml was present in 29.8% of patients and was independently associated with reporting voiding difficulties or referral to the hospital because of urinary symptoms. A PVR ≥300 was present in 16.0% of patients and was independently associated with not living at home, reporting subtotal voiding, having constipation, and referral to the hospital because of urinary symptoms. Message Screening for urinary retention is most indicated in patients with urinary and defaecation problems, but a low threshold for screening is recommended in all acutely ill geriatric patients Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00495-3., Purpose Urinary retention (UR) is common in older patients. The aim of this observational cohort study was to measure the prevalence of UR in patients aged ≥ 75 years on admission to an acute geriatric hospitalisation unit and to determine which at risk group would benefit from screening. Methods Post-void residual volumes (PVR) were measured within 3 days of admission with an ultrasound bladder scan. Uni- and multivariable analysis were used to determine risk factors associated with PVR ≥ 150 and ≥ 300 millilitres. Results Ninety-four patients, mean age 84.6 years, were included. The male/female ratio was 0.7. Patients with PVR ≥ 150 (29.8%) had more urological comorbidities, symptoms of overflow incontinence, voiding difficulties, subtotal voiding, faecal impaction, urinary tract infection (UTI) and were more frequently referred because of urinary symptoms. Patients with PVR ≥ 300 lived less at home, had more urological comorbidities, dysuria, voiding difficulties, subtotal voiding, constipation, faecal impaction, UTI, detrusor relaxants, and were more frequently referred because of urinary symptoms. Voiding difficulties and referral because of urinary symptoms were independently associated with PVR ≥ 150. Not living at home, reporting subtotal voiding, constipation, and referral because of urinary symptoms were independently associated with PVR ≥ 300. Conclusion Screening for UR on admission to an acute geriatric hospitalisation unit is most indicated in patients with urinary and defaecation problems. However, because the prevalence was high, because UR was also observed in patients without these problems, and history taking may be difficult, the threshold for PVR measurement in acutely ill geriatric patients should be low. Trial registration Clinicaltrials.gov NTC04715971, January 19, 2021 (retrospectively registered). Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00495-3.

Background URGENT is a comprehensive geriatric assessment (CGA) based nurse-led care model in the emergency department (ED) with geriatric follow-up after ED discharge aiming to prevent unplanned ED readmissions. Methods A quasi-experimental study (sequential design with two cohorts) was conducted in the ED of University Hospitals Leuven (Belgium). Dutch-speaking, community-dwelling ED patients aged 70 years or older were eligible for enrolment. Patients in the control cohort received usual care. Patient in the intervention cohort received the URGENT care model. A geriatric emergency nurse conducted CGA and interdisciplinary care planning among older patients identified as at risk for adverse events (e.g. unplanned ED readmission, functional decline) with the interRAI ED Screener© and clinical judgement of ED staff. Case manager follow-up was offered to at risk patients without hospitalization after index ED visit. For inpatients, geriatric follow-up was guaranteed on an acute geriatric ward or by the inpatient geriatric consultation team on a non-geriatric ward if considered necessary. Primary outcome was unplanned 90-day ED readmission. Secondary outcomes were ED length of stay (LOS), hospitalization rate, in-hospital LOS, 90-day higher level of care, 90-day functional decline and 90-day post-hospitalization mortality. Results Almost half of intervention patients (404/886 = 45.6%) were categorized at risk. These received on average seven advices. Adherence rate to advices on the ED, during hospitalization and in community care was 86.1, 74.6 and 34.1%, respectively. One out of four at risk patients without hospitalization after index ED visit accepted case manager follow-up. Unplanned ED readmission occurred in 170 of 768 (22.1%) control patients and in 205 of 857 (23.9%) intervention patients (p = .11). The intervention group had shorter ED LOS (12.7 h versus 19.1 h in the control group; p

In implementation science (IS), conducting well-targeted and reproducible literature searches is challenging due to non-specific and varying terminology that is fragmented over multiple disciplines. A list of journals that publish IS-relevant content for use in search strings can support this process. We conducted a cross-sectional online survey of 56 Australian, European, and North American IS experts to identify and prioritize relevant journals that publish IS articles. Journals' relevance was assessed by providing each with a list of 12 journals, to which they were encouraged to add additional journal names and comments as free text. We also assessed which journals had published special IS-focused issues-identified via PubMed and Google searches-over the last 20 years. Data were analyzed descriptively. Between February 28 and March 15, 2020, a purposive sample of 34/56 experts participated in the survey (response rate: 60.7%). Implementation Science and BMC Health Services Research were perceived as relevant by 97.1% of participants; other journals' relevance varied internationally. Experts proposed 50 additional journals from various clinical fields and health science disciplines. We identified 12 calls and 53 special issues on IS published within various journals and research fields. Experts' comments confirmed the described challenges in identifying IS literature. This report presents experts' ratings of IS journals, which can be included in strategies supporting searches of IS evidence. However, challenges in identifying IS evidence remain geographically and interdisciplinary. Further investment is needed to develop reproducible search strings to capture IS evidence as an important step in improving IS research quality. The authors would like to thank all implementation science experts for participating in the survey, as well as Chris Shultis for manuscript editing.

Introduction: Implementation science methods and a theory-driven approach can enhance the understanding of whether, how, and why integrated care for frail older adults is successful in practice. In this study, we aimed to perform a contextual analysis, develop a logic model, and select preliminary implementation strategies for an integrated care model in newly created information and advice centers for older adults in Canton Basel-Landschaft, Switzerland.Methods: We conducted a contextual analysis to determine factors which may influence the integrated care model and implementation strategies needed. A logic model depicting the overall program theory, including inputs, core components, outputs and outcomes, was designed using a deductive approach, and included stakeholders' feedback and preliminary implementation strategies.Results: Contextual factors were identified (e.g., lack of integrated care regulations, existing community services, and a care pathway needed). Core components of the care model include screening, referral, assessment, care plan creation and coordination, and follow-up. Outcomes included person-centred coordinated care experiences, hospitalization rate and symptom burden, among others. Implementation strategies (e.g., nurse training and co-developing educational materials) were proposed to facilitate care model adoption.Conclusion: Contextual understanding and a clear logic model should enhance the potential for successful implementation of the integrated care model. This study is part of the INSPIRE research project which was funded by Swisslos Fond Baselland, Velux Stiftung/Velux Foundation, the Swiss National Science Foundation (NRP74) and Amt für Gesundheit Kanton Basel-Landschaft/Health Department Canton Basel-Landschaft. Additionally, this project has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 801076 (through the SSPH+ Global PhD Fellowship Programme in Public Health Sciences [GlobalP3HS] of the Swiss School of Public Health) and grant agreement No 812656 as it also forms part of the TRANS-SENIOR Project. The funding bodies had no role in the design, execution, analysis and interpretation of the data, or writing of the study.

Background: The COVID-19 pandemic resulted in a rapid reorganization of hospital care. In our hospital, the Clinical Frailty Scale (CFS) was introduced as a result of these reorganizations. A retrospective analysis was performed to investigate whether typical geriatric risk factors, such as frailty, comorbidity, living situation and cognitive decline, have added value compared to conventional risk factors in predicting severe COVID-19 disease and in-hospital death.Methods: In patients aged 70 years and over, an online geriatric assessment questionnaire was launched, from which the CFS was scored by the geriatrics team. Additional clinical data were collected from the electronic medical records. Baseline characteristics were described with descriptive statistics. Associations were analysed with uni- and multivariable analyses.Results: One hundred and five patients were included, median age 82 years. CFS scores were 1-4 in 43, 5-6 in 45, and 7-9 in 17 patients. Univariable analysis showed age, CFS, Charlson Comorbidity Index (CCI), age-adjusted CCI and cognitive decline associated with in-hospital mortality. Male gender, obesity, cardiovascular disease, chronic pulmonary disease, diabetes, cancer and hypertension were not significantly associated. In multivariable analysis, CFS and cognitive decline were independent predictors for in-hospital mortality. Chronic obstructive pulmonary disease, presence of respiratory symptoms on admission and male gender were associated with severe disease (univariable analysis). Conclusion: Through action of the geriatrics team at the time of rapid changes in the hospital, the frailty concept was introduced in the COVID-19 hospitalization units. A retrospective analysis shows that geriatric risk factors exceed conventional risk factors for predicting in-hospital mortality.

Key summary points Aim We evaluated the adherence to recommendations of inpatient geriatric consultation teams and the team and recommendation characteristics impacting the adherence rates. Findings The overall adherence rate to the recommendations was 69.7%. Adherence rate increased if recommendations were given to allied health professionals or by more experienced consultation teams and when fewer recommendations were given. Message Replication is needed in an international multicenter study with a specific attention given to the quality of the recommendations and the follow-up by the teams. Electronic supplementary material The online version of this article (10.1007/s41999-020-00397-w) contains supplementary material, which is available to authorized users., Purpose Inpatient geriatric consultation teams (IGCTs) provide recommendations for the care of older patients hospitalized on non-geriatric wards based on comprehensive geriatric assessment. The lack of adherence to their recommendations hinders the potential impact of IGCTs. We evaluated the adherence to IGCT recommendations and determined which team and recommendation characteristics are related to higher adherence rates. Methods Multicenter observational study in older adults aged ≥ 75 years admitted to an acute non-geriatric ward. Demographic and adherence data were collected for 30 consecutive patients. A cross-sectional survey mapped team and organizational characteristics of the participating IGCTs. Results Analyses were conducted in 278 patients (51.4% male, mean age 82.5 years, and median length of stay 10 days). There was a median number of 3 recommendations (range 1–13) per patient. The overall adherence rate was 69.7%. Recommendations related to ‘social status’ (82.4%) and ‘functional status/mobility’ (73.3%) were best adhered to. Recommendations related to ‘medication’ (53.2%) and ‘nutritional status’ (59.1%) were least adhered to. Adherence rates increased if recommendations were given to allied health professionals (OR = 6.37, 95% CI = 1.15–35.35) or by more experienced IGCTs (OR = 1.34, 95% CI = 1.04–1.72) and decreased when more recommendations were given (OR = 0.51, 95% CI = 0.33–0.80). Conclusion Adherence rate to IGCT recommendations increased if given to allied health professionals or by more experienced IGCTs and when fewer recommendations were given. Study replication in an international multicenter study with a larger number of centers and evaluating the quality of the recommendations is suggested. Electronic supplementary material The online version of this article (10.1007/s41999-020-00397-w) contains supplementary material, which is available to authorized users.

Background Regaining pre-hospitalization activity levels is only achieved in 30–50% of older patients. Extra physiotherapy time has been proven to improve functional outcome and shorten length of stay, but is costly. Considering their key role in caring for older people, involving informal caregivers in rehabilitation might further improve functional performance. Aim To determine if in-hospital or post discharge caregiver involvement can increase functional performance in older adults. The secondary aim was to determine if caregiver involvement can influence, quality of life of patient and caregiver, medical costs, readmission rate, discharge location, and mortality. Design Systematic review with narrative synthesis. Methods The electronic bibliographic databases MEDLINE, Embase, CINAHL, Cochrane and Web of Science were searched for (quasi) experimental and observational studies, with the following inclusion criteria; caregiver involvement regarding functional performance, mean age over 65 years, admitted to a hospital unit and subsequently discharged to their home setting. Risk of bias was assessed with the Rob 2 (randomized trials) and the ROBINS-1 tool (non-randomized studies). Results Eight studies of an initial 4683 were included: four randomized controlled trials, one prospective cohort study, one non-randomized controlled trial, one subgroup analysis of an RCT and one prospective pre-post study. All but one study included patients with stroke. Three types of caregiver interventions could be distinguished: a care pathway (inclusion of caregivers in the process of care), education on stroke and teaching of bed-side handling-skills, and caregiver-mediated exercises. The one study evaluating the care pathway reported 24.9% more returns home in the intervention group. Studies evaluating the effect of education and bed-side handling-skills reported higher effect sizes for several outcomes with increasing session frequency. All studies with caregiver-mediated exercises showed beneficial effects on functional performance, immediately after the intervention and within 3 months follow-up. Conclusion The findings of this review suggest that involvement of caregivers in the rehabilitation of older adults leads to better functional performance up to 3 months after initiation. However, evidence is low and mainly focusing on stroke.

OBJECTIVES: To compare the diagnostic accuracy of the Identification of Seniors at Risk, the Flemish version of Triage Risk Screening Tool, and the interRAI Emergency Department Screener for predicting prolonged emergency department (ED) length of stay, hospitalization (following index ED stay), and unplanned ED readmission at 30 and 90 days among older (aged ≥70 years) community-dwelling adults admitted to the ED. DESIGN: Single-center, prospective, observation study. SETTING: ED with embedded observation unit in University Hospitals Leuven (Belgium). PARTICIPANTS: A total of 794 patients (median age = 80 years; 55% female) were included. MEASUREMENTS: Study nurses collected data using semistructured interviews and patient record review during ED admission. Outcome data were collected with patient record review. RESULTS: Hospitalization (following index ED stay) and unplanned ED readmission at 30 and 90 days occurred in 67% (527/787) of patients and in 12.2% (93/761) and 22.1% (168/761) of patients, respectively. For all outcomes at cutoff 2, the three screening tools had moderate to high sensitivity (range = 0.71-0.90) combined with (very) low specificity (range = 0.14-0.32) and low accuracy (range = 0.21-0.67). At all cutoffs, likelihood ratios and interval likelihood ratios had no or small impact (range = 0.46-3.95; zero was not included) on the posttest probability of the outcomes. For all outcomes, area under the receiver operating characteristics curve varied in the range of 0.49 to 0.62. CONCLUSION: Diagnostic characteristics of all screening tools were comparable. None of the tools accurately predicted the outcomes as a stand-alone index. Future studies should explore the clinical effectiveness and implementation aspects of ED-specific minimum geriatric assessment and intervention strategies. J Am Geriatr Soc 68:1454-1461, 2020. ispartof: JOURNAL OF THE AMERICAN GERIATRICS SOCIETY vol:68 issue:7 pages:1454-1461 ispartof: location:United States status: published

The aim of this study was to determine the incidence and recovery of hospitalisation-associated disability (HAD), the associated risk factors, and the link with care processes in patients aged 70 years or older hospitalised with valvular heart disease (VHD).Prospective cohort study performed on the cardiology and cardiac surgery units of University Hospitals Leuven, Belgium. HAD was defined as the loss of independence to complete one of the Activities of Daily Living (ADLs) between hospital admission and discharge. Recovery of HAD at 30 days post hospital discharge was achieved when patients recovered their baseline ADL status (2 weeks before hospital admission) (ClinicalTrials.gov: NCT02572999).Eighty patients were enrolled in the study, 77 completed the assessment at discharge and 62 responded at 30 days follow-up. Forty patients (51.9%) developed HAD; 18 of them (45.0%) recovered their baseline ADL status. The risk of HAD increased when patients were physically restrained (relative risk (RR) 1.73, 95% confidence interval (CI) 1.20-2.49), had indwelling catheters (RR 1.80, 95% CI 0.85-3.80) and received preventive pressure ulcer measures (RR 1.71, 95% CI 1.07-2.74). Patients with HAD had longer hospital stays (+3 days, p = .011) and longer use of indwelling catheters (+2 days, p = .024).Half of the older adults with VHD developed HAD. The results indicate a potential association between HAD and care processes, which could be used as quality measures and intervention targets. Validation in larger cohort studies is recommended.

BACKGROUND: There is growing consensus that frailty, a state of vulnerability and a decline in functioning across multiple physiological body systems, is a valuable criterion to guide clinicians' risk prediction for poor outcomes in adult transplant candidates. In its 2016 listing criteria for heart transplantation the International Society for Heart Lung Transplantation recommends frailty assessment. We aimed to summarize the usefulness of frailty assessment in heart transplant candidates or recipients reported throughout the literature. METHODS: We performed a systematic literature search in PubMed to identify papers reporting on frailty in transplantation, chronic heart failure, and ventricualr assist device implantation published over the last 10 years in English. Additionally, a hand search was conducted, including manually searching the reference lists and a citation search of relevant papers. RESULTS: Eleven primary research articles were included in this systematic review. Frailty is a risk factor for morbidity, hospitalization, and mortality in patients with advanced heart failure and individuals being considered for ventricualr assist device implantation. Of the patients being considered for transplantation, 33% are frail. The Frailty Phenotype by Fried is a particularly useful tool to quickly identify higher risk patients for adverse outcomes. CONCLUSION: A lack of standardization and limited evidence on frailty in transplantation limit its use as a definitive listing criterion. Future research efforts should focus on systematic integration of frailty measures in transplant practice. publisher: Elsevier articletitle: Handle with care: A systematic review on frailty in cardiac care and its usefulness in heart transplantation journaltitle: Transplantation Reviews articlelink: http://dx.doi.org/10.1016/j.trre.2017.03.003 content_type: article copyright: © 2017 Elsevier Inc. All rights reserved. ispartof: Transplantation Reviews vol:31 issue:3 pages:218-224 ispartof: location:United States status: published

Background: Frailty is an aging syndrome caused by exceeding a threshold of decline across multiple organ systems leading to a decreased resistance to stressors. Treatment for frailty focuses on multi-domain interventions to target multiple affected functions in order to decrease the adverse outcomes of frailty. No systematic reviews on the effectiveness of multi-domain interventions exist in a well-defined frail population. Objectives: This systematic review aimed to determine the effect of multi-domain compared to mono-domain interventions on frailty status and score, cognition, muscle mass, strength and power, functional and social outcomes in (pre)frail elderly (≥65 years). It included interventions targeting two or more domains (physical exercise, nutritional, pharmacological, psychological, or social interventions) in participants defined as (pre)frail by an operationalized frailty definition. Methods: The databases PubMed, EMBASE, CINAHL, PEDro, CENTRAL, and the Cochrane Central register of Controlled Trials were searched from inception until September 14, 2016. Additional articles were searched by citation search, author search, and reference lists of relevant articles. The protocol for this review was registered on PROSPERO (CRD42016032905). Results: Twelve studies were included, reporting a large diversity of interventions in terms of content, duration, and follow-up period. Overall, multi-domain interventions tended to be more effective than mono-domain interventions on frailty status or score, muscle mass and strength, and physical functioning. Results were inconclusive for cognitive, functional, and social outcomes. Physical exercise seems to play an essential role in the multi-domain intervention, whereby additional interventions can lead to further improvement (eg, nutritional intervention). Conclusion: Evidence of beneficial effects of multi-domain compared to mono-domain interventions is limited but increasing. Additional studies are needed, focusing on a well-defined frail population and with specific attention to the design and the individual contribution of mono-domain interventions. This will contribute to the development of more effective interventions for frail elderly. ispartof: Clinical Interventions in Aging vol:12 pages:873-896 ispartof: location:New Zealand status: published

Purpose of review: To determine the impact of geriatric co-management programmes on outcomes in older patients undergoing a surgical procedure. Recent findings: Twelve programmes were identified. Time to surgery was decreased in two of four studies (pooled mean difference = -0.7 hours (95% CI, -3.1 to 4.4)). The incidence of complications was reduced in two of seven studies (pooled absolute risk reduction = -4% (95% CI, -10% to 2%)). Length of stay was reduced in four of eight studies (pooled mean difference = -1.4 days (95% CI, -2.7 to -0.1)). In-hospital mortality was reduced in one of six studies (pooled absolute risk reduction = -2% (95% CI, -4% to -0%)). Unplanned hospital readmissions at 30 days follow-up was reduced in two of three studies (pooled absolute risk reduction = -3% (95% CI, -5% to -0%)). Summary: There was a shorter length of stay, less mortality and a lower readmission rate. However, there was uncertainty whether the results are clinically relevant and the GRADE of evidence was low. It was uncertain whether the outcomes time to surgery and complications were improved. The evidence is limited to hip fracture patients. ispartof: Current Opinion In Anesthesiology vol:33 (1) issue:1 pages:114-121 ispartof: location:United States status: Published online

ispartof: Swiss Medical Weekly vol:150 pages:1-4 ispartof: location:Switzerland status: Published online

BACKGROUND: Enhanced recovery programs (ERPs) in colorectal surgery have demonstrated beneficial effects on postoperative complications, return of bowel function, length of stay, and costs, without increasing readmissions or mortality. However, ERPs were not specifically designed for older patients and feasibility in older patients has been questioned. AIM: The aim of this study was to assess ERP adherence and outcomes in older patients and to identify risk factors for postoperative complications and prolonged length of stay. METHOD: Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017. RESULTS: Ninety-six patients were included. Adherence rates were above 80% in 18 of 21 ERP interventions considered. The lowest adherence rates were noted for preoperative carbohydrate loading and cessation of intravenous fluids. Postoperative complications (Clavien-Dindo ≥2) and prolonged postoperative length of stay (>75th percentile) were observed in 39.6% and 26.3%, respectively. Median length of stay was 7 days. The 30-day mortality, readmission and reoperation rates were 2.1%, 12.6% and 8.3%, respectively. Multivariable analysis indicated that polypharmacy and site of surgery were independent risk factors for postoperative complications, while higher age, American Society of Anesthesiologists class and preoperative radiotherapy were independent risk factors for prolonged postoperative length of stay. CONCLUSION: ERP adherence in older patients undergoing colorectal resection is high and ERP is therefore considered feasible. Postoperative complications and prolonged postoperative length of stay are common, so at risk patients should be targeted with tailored geriatric interventions. ispartof: PLOS ONE vol:15 issue:5 ispartof: location:United States status: published

Atrial fibrillation (AF) is highly prevalent in older adults and has been associated with increased morbidity and mortality. To reduce this AF-related morbidity in older adults, antiarrhythmic drugs (AADs) are regularly used for rhythm control, assuming that increasing time in sinus rhythm reduces AF-related morbidity. However, whether AADs can improve clinical outcomes in older adults remains unclear because of the increased risk for adverse drug events compared with rate control. The aim of this study was to determine the impact of rhythm control versus rate control on clinical outcomes in older adults with AF. We conducted a systematic review and meta-analysis targeting patients aged ≥65 years with AF and using drugs to control rate or rhythm. Articles that met the following criteria were included: enrolled older patients (sample mean ≥75 years) with AF, compared pharmacological rate versus rhythm control, and reported all-cause mortality, cardiovascular mortality, or ischemic stroke. Five observational studies were included. In total, 86,926 patients with AF with a mean age ranging from 75 to 92 years were studied. No differences were found between rhythm and rate control for all-cause mortality (odds ratio [OR] 1.11; 95% confidence interval [CI] 0.78–1.59; I2 = 79.6%; n = 28,526; four studies) and cardiovascular mortality (OR 1.09; 95% CI 0.81–1.47; I2 = 0%; n = 2292; two studies). Rhythm control resulted in fewer strokes (OR 0.86; 95% CI 0.80–0.93; I2 = 0%; n = 59,496), although this was mainly determined by one study. All collected data were observational, which precluded making strong recommendations. Furthermore, all CIs were wide, increasing the uncertainty of the observed effects. As such, evidence was insufficient to recommend rhythm or rate control as the first-line therapy for AF in older adults. As AF is particularly prevalent in older people, more randomized controlled trials are needed in this population.

Insomnia is highly prevalent in older persons and significantly impacts quality of life, functional abilities, and health status. It is frequently treated with benzodiazepines or Z-drugs. Due to adverse events, an increased use of alternative sedative medications has been observed in older adults. We aimed to study the efficacy and safety of alternative sedative medications for treating insomnia in older people, excluding benzodiazepines and Z-drugs. We conducted a systematic search of MEDLINE (PubMed), EMBASE, and the Cochrane Central register of Controlled Trials databases. We included randomized controlled trials and prospective and retrospective quasi-experimental studies, conducted in patients older than 65 years, without psychiatric or neurological comorbidities. The systematic search yielded 9483 articles, of which 24 were included in this review, describing nine different sleep medications in total. No clear beneficial impact on sleep could be demonstrated in studies investigating the impact of melatonin (n = 10), paroxetine (n = 1), diphenhydramine (n = 1), tiagabine (n = 2), and valerian (n = 1). Ramelteon slightly improved sleep latency (n = 4), while doxepin was found to provide a sustained sleep improvement with a safety profile that was comparable to placebo (n = 3). Suvorexant showed an improved sleep maintenance with only mild side effects (n = 1). One study detected increased adverse effects of trazodone after 3 months but did not evaluate the effect on sleep. The overall level of evidence was limited, making it difficult to draw robust conclusions. Preliminary evidence points towards suvorexant, doxepin, and possibly ramelteon as effective and safe pharmacological alternatives for treating insomnia in older adults.

Background Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery. Methods Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines. Results Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%. Conclusions ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence. Trial registration PROSPERO 2018 CRD42018084756. Electronic supplementary material The online version of this article (10.1186/s12877-019-1158-3) contains supplementary material, which is available to authorized users.

Pneumococcal disease constitutes a major global health problem. Adults aged over 50 years and younger adults with specific chronic health conditions are at risk for invasive pneumococcal disease, associated with substantial morbidity and mortality. In Europe, two vaccine types are used in adults for pneumococcal immunization: pneumococcal polysaccharide vaccine (PPV23) and pneumococcal conjugate vaccine (PCV13). To provide an overview and to compare the national guidelines for pneumococcal immunization for adults in Europe. In November 2016, national guidelines on pneumococcal vaccination for adults of 31 European countries were obtained by Google search, the website of European Centre for Disease Prevention and Control, and contacting public health officials. In our analysis, we distinguished between age-based and risk-based guidelines. In October 2017, we used the same method to retrieve guideline updates. We observed great variability regarding age, risk groups, vaccine type, and use of boosters. In age-based guidelines, vaccination is mostly recommended in adults aged over 65 years using PPV23. Boosters are generally not recommended. An upper age limit for vaccination is reported in three countries. In the immunocompromised population, vaccination with both vaccines and administration of a booster is mostly recommended. In the population with chronic health conditions, there is more heterogeneity according vaccine type, sequence, and administration of boosters. Asplenia is the only comorbidity for which all countries recommend vaccination. The great variability in European pneumococcal vaccination guidelines warrants European unification of the guidelines for better control of pneumococcal disease. ispartof: European Journal Of Clinical Microbiology & Infectious Diseases vol:38 issue:4 pages:785-791 ispartof: location:Germany status: published

Background Up to one in three of older patients who are hospitalised develop functional decline, which is associated with sustained disability, institutionalisation and death. This study developed and validated a clinical prediction model that identifies patients who are at risk for functional decline during hospitalisation. The predictive value of the model was compared against three models that were developed for patients admitted to a general medical ward. Methods A prospective cohort study was performed on two cardiac care units between September 2016 and June 2017. Patients aged 75 years or older were recruited on admission if they were admitted for non-surgical treatment of an acute cardiovascular disease. Hospitalisation-associated functional decline was defined as any decrease on the Katz Index of Activities of Daily Living between hospital admission and discharge. Predictors were selected based on a review of the literature and a prediction score chart was developed based on a multivariate logistic regression model. Results A total of 189 patients were recruited and 33% developed functional decline during hospitalisation. A score chart was developed with five predictors that were measured on hospital admission: mobility impairment = 9 points, cognitive impairment = 7 points, loss of appetite = 6 points, depressive symptoms = 5 points, use of physical restraints or having an indwelling urinary catheter = 5 points. The score chart of the developed model demonstrated good calibration and discriminated adequately (C-index = 0.75, 95% CI (0.68–0.83) and better between patients with and without functional decline (chi2 = 12.8, p = 0.005) than the three previously developed models (range of C-index = 0.65–0.68). Conclusion Functional decline is a prevalent complication and can be adequately predicted on hospital admission. A score chart can be used in clinical practice to identify patients who could benefit from preventive interventions. Independent external validation is needed.

IntroductionAlthough the majority of older patients admitted to a cardiology unit present with at least one geriatric syndrome, guidelines on managing heart disease often do not consider the complex needs of frail older patients. Geriatric co-management has demonstrated potential to improve functional status, and reduce complications and length of stay, but evidence on the effectiveness in cardiology patients is lacking. This study aims to determine if geriatric co-management is superior to usual care in preventing functional decline, complications, mortality, readmission rates, reducing length of stay and improving quality of life in older patients admitted for acute heart disease or for transcatheter aortic valve implantation, and to identify determinants of success for geriatric co-management in this population.Methods and analysisThis prospective quasi-experimental before-and-after study will be performed on two cardiology units of the University Hospitals Leuven in Belgium in patients aged ≥75 years. In the precohort (n=227), usual care will be documented. A multitude of implementation strategies will be applied to allow for successful implementation of the model. Patients in the after cohort (n=227) will undergo a comprehensive geriatric assessment within 24 hours of admission to stratify them into one of three groups based on their baseline risk for developing functional decline: low-risk patients receive proactive consultation, high-risk patients will be co-managed by the geriatric nurse to prevent complications and patients with acute geriatric problems will receive an additional medication review and co-management by the geriatrician.Ethics and disseminationThe study protocol was approved by the Medical Ethics Committee UZ Leuven/KU Leuven (S58296). Written voluntary (proxy-)informed consent will be obtained from all participants at the start of the study. Dissemination of results will be through articles in scientific and professional journals both in English and Dutch and by conference presentations.Trial registration numberNCT02890927.

International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and especially prevent unplanned ED readmissions, the URGENT care model was developed. The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. A prospective single centre quasi-experimental study (sequential design with two cohorts) is used to evaluate its effectiveness on unplanned ED readmission compared to usual ED care. Secondary outcome measures are hospitalization rate, ED length of stay, in-hospital length of stay, higher level of care, functional decline and mortality. URGENT builds on previous research with adaptations tailored to the local context and addresses the needs of older patients in the ED with a special focus on transition of care. Although the selected approaches have been tested in other settings, evidence on this type of innovative care models in the ED setting is inconclusive. The study protocol is registered retrospectively with ISRCTN ( ISRCTN91449949 ).

Purpose Despite the beneficial impact of comprehensive geriatric assessment (CGA) for older patients in the hospital, it is not clear to what extent these models have been implemented in European hospitals. This study aims to map the implementation status of CGA-based models of care in general hospitals in Europe. Methods A cross-sectional survey study was conducted in autumn 2017 to map the implementation status of CGA-based care models in general hospitals (n = 178) in Belgium, Denmark, Estonia, Greece, Iceland, Ireland, Malta, and Slovenia. Results Acute geriatric units are implemented in all of the Belgian and the majority of Danish hospitals, but are scarce in Malta, Estonia, Slovenia and Greece. Geriatric rehabilitation units are most common in Ireland (63.6%) and Iceland (75%). In-hospital multidisciplinary geriatric consultation teams are widely implemented in Belgium (100%), Ireland (72.7%) and Denmark (59.1%), but are rare in Malta, Iceland, Estonia and Greece. Transitional care programs to ensure continuity of care after discharge are present in 60.1% of all hospitals. The intention to implement any of these care models in the next 5 years ranges from 10.3 to 25.4% and is the highest for co-management (36.5%), systematic screening of ED patients (36.2%) and transitional care programs (29.6%). Conclusions A great variety in the implementation of CGA-based care models was observed among the surveyed EU countries with the uptake being the highest in Belgium, Denmark and Ireland. A supportive legislative framework and a residency training in geriatrics favor the implementation of the geriatric care models. ispartof: European Geriatric Medicine vol:9 issue:6 pages:771-782 ispartof: location:Switzerland status: published

Medication nonadherence is a serious public health concern. Although there are promising interventions that improve medication adherence, most interventions are developed and tested in tightly controlled research environments that are dissimilar from the real-world settings where the majority of patients receive health care. Implementation science methods have the potential to facilitate and accelerate the translation shift from the trial world to the real world. We demonstrate their potential by reviewing published, high-quality medication adherence studies that could potentially be translated into clinical practice yet lack essential implementation science building blocks. We further illustrate this point by describing an adherence study that demonstrates how implementation science creates a junction between research and real-world settings. This article is a call to action for researchers, clinicians, policy makers, pharmaceutical companies, and others involved in the delivery of care to adopt the implementation science paradigm in the scale-up of adherence (research) programs. ispartof: ANNUAL REVIEW OF PHARMACOLOGY AND TOXICOLOGY, VOL 59 vol:59 pages:423-445 ispartof: location:United States status: published

Aim To determine if preoperative state anxiety is a risk factor for postoperative delirium in older hip fracture patients. Methods A secondary data analysis comprising data from a prospective non-randomized trial including 86 patients with a hip fracture aged 65 years and older was carried out. State anxiety was measured preoperatively using the State-Trait Anxiety Inventory. Delirium and its severity was measured pre- and postoperatively (day 1, 3, 5, 8) by trained research nurses using the Confusion Assessment Method and Delirium Index. Results A total of 24 patients (27.9%) developed delirium postoperatively. Preoperative state anxiety (State-Trait Anxiety Inventory) was not associated with postoperative delirium (rb = 0.135, P = 0.353), duration of postoperative delirium (rho = 0.038, P = 0.861) or severity of postoperative delirium (rho = 0.153, P = 0.160). Independent predictors of postoperative delirium were lower MMSE scores (OR 0.75, 95% CI 0.60–0.95, P = 0.015), osteosynthesis surgery (OR 3.66, 95% CI 1.02–13.15, P = 0,047) and lowest intraoperative diastolic blood pressure (OR 0.92, 95% CI 0.85–0.99, P = 0.031). Conclusion No relationship between state anxiety and postoperative delirium was found, but significant methodological hurdles were observed and discussed providing important groundwork for further research in this area. Further research should focus on reliable measurement of state anxiety in cognitively impaired older populations. Geriatr Gerontol Int ●●; ●●: ●●–●●.

As the number of care-dependent older people is projected to grow drastically, the number of individuals depending on long-term care services will increase significantly over the next 50 years, while the number of informal caregivers and healthcare professionals is decreasing (European Commission, Economic Policy Committee, 2012). One of the key challenges for healthcare systems therefore is to develop and implement effective long-term care programs that provide person-centered, efficient, safe, and sustainable care and living environments, as well as a corresponding work environment for healthcare workers. Although the majority of care-dependent older people are cared for in their own homes, about one fifth receive care in residential care facilities (Colombo, Llena-Nozal, Mercier, & Tjadens, 2011). Future long-term residential care needs to be able to adapt to older people's needs rather than coerce older people to adapt to the system. Moreover, long-term residential care cannot do without combining both health and social care, putting the evidence into practice to support older persons' best possible quality of life.While many initiatives and innovations have been launched and tested to optimize long-term care in recent years (Leichsenring, Billings, & Nies, 2013), four major challenges remain to ensure that healthcare workers are able to provide the best possible care at all times in safe and positive work environments. In tackling each of these challenges, residents' well-being should be kept on the forefront, focusing on residents' capacities, personal preferences, interpersonal relationships, involvement, and social needs.First, despite the great number of initiatives taken to improve long-term care, the actual implementation of evidence-based long-term care models has been scarce. The INTERLINKS research initiative listing European long-term care projects illustrated which elements have to be in place to construct an integrated long-term care system. However, from the 59 identified projects, only 8 had undergone a systematic mixed-method evaluation of processes and outcomes. Half of the project had no, minimal, or uncompleted evaluations and therefore failed to truly impact clinical practice and health policy, because the interventions aspects having the most or no impact could not be identified (Leichsenring et al., 2013). Successful implementation of effective and sustainable interventions in long-term care requires a systematic approach. Implementation research, which is intended to aid our understanding of what, why, and how interventions work in the real world setting, is therefore what is truly and urgently needed (Peters, Adam, Alonge, Ageypong, & Tran, 2013).Second, person-centered outcomes, such as improving quality of life or strengthening partnerships between resident and healthcare providers on the one hand, and system outcomes, such as reducing avoidable hospitalizations or costs on the other hand, should be equally important in evaluating the effectiveness of new models of long-term care. This is in line with the Institute for Healthcare Improvement triple aim of improving patient's experience of care and health while reducing costs (Berwick, Nolan, & Whittington, 2008). Ideally, the long-term care environment strives to create a living environment mirroring home as much as possible, while strengthening the residents and their relatives as active and empowered service users and not as passive recipients of care (Wagner, Austin, Davis, Hindmarsh, Schaefer, & Bonomi, 2001). Moreover, the development of new models should also address the building of supportive work environments for healthcare professionals that provide the basis to achieve excellence in care.Third, optimal coordination of care and well-founded care transitions between long-term care settings and healthcare providers are pivotal. Although multiple healthcare professions are involved in the care of older people, nurses are in a key position to ensure continuity of care. …

ObjectiveTo find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes.DesignAn international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers).SettingWestern Europe and the USA.ParticipantsThirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate).MeasuresParticipants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method.ResultsIn the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications.ConclusionThe indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Objectives: To assess the diagnostic characteristics of the get up and go test (GUGT) as a stand-alone test and in combination with the Flemish Triage Risk Screening Tool (fTRST) and Rowland questionnaire. One aim was to determine whether the diagnostic accuracy of these instruments could be improved for predicting unplanned emergency department (ED) readmission following ED discharge. Methods: We carried out a prospective cohort study at the ED of the University Hospitals Leuven, Belgium. All patients aged at least 75 years (n=380) completed fTRST, Rowland, and GUGT testing at the index ED admission. Diagnostic characteristics for unplanned ED readmission were determined for hospitalized and discharged patients 1 and 3 months after the index ED visit. Results: In both hospitalized and discharged patients, fTRST and Rowland (cut-off >=2) had good to excellent sensitivity and negative predictive value (NPV) but low to moderate specificity and accuracy; GUGT had low sensitivity and good to excellent NPV and specificity. The combined fTRST/GUGT or Rowland/GUGT had moderate to excellent NPV (56.3-94.3%). The combined fTRST (cut-off >=2)/GUGT had low sensitivity and moderate to excellent specificity. Sensitivity of the combined Rowland (cut-off >=4)/GUGT was good at the 1-month follow-up and moderate at the 3-month follow-up for hospitalized patients; it was low for discharged patients. Specificity was low for hospitalized patients and good for discharged patients. Conclusion: Neither the objective measure of mobility (GUGT) nor the combined fTRST/GUGT or Rowland/GUGT improved the results. Our analysis shows that the predictive accuracy of the stand-alone, self-reported screening instruments fTRST and Rowland (cut-off=2) is still good. This study also confirmed their previously known limitations. ispartof: European Journal of Emergency Medicine vol:25 issue:1 pages:46-52 ispartof: location:England status: published

Background: Education of healthcare workers is a core element of multicomponent delirium strategies to improve delirium care and, consequently, patient outcomes. However, traditional educational strategies are notoriously difficult to implement. E-learning is hypothesised to be easier and more cost effective, but research evaluating effectiveness of delirium education through e-learning is scarce at present. Aim is to determine the effect of a nursing e-learning tool for delirium on: (1) in-hospital prevalence, duration and severity of delirium or mortality in hospitalized geriatric patients, and (2) geriatric nurses’ knowledge and recognition regarding delirium. Methods: A before-after study in a sample of patients enrolled pre-intervention (non-intervention cohort (NIC); n = 81)and post-intervention (intervention cohort (IC); n = 79), and nurses (n = 17) of a geriatric ward (university hospital). The intervention included an information session about using the e-learning tool, which consisted of 11 e-modules incorporating development of knowledge and skills in the prevention, detection and management of delirium, and the completion of a delirium e-learning tool during a three-month period. Key patient outcomes included in-hospital prevalence and duration of delirium (Confusion Assessment Method), delirium severity (Delirium Index) and mortality (in-hospital; 12 months post-admission); key nurse outcomes included delirium knowledge (Delirium Knowledge Questionnaire) and recognition (Case vignettes). Logistic regression and linear mixed models were used to analyse patient data; Wilcoxon Signed Rank tests, McNemar’s or paired t-tests for nursing data. Results: No significant difference was found between the IC and NIC for in-hospital prevalence (21.5% versus 25.9%; p = 0.51) and duration of delirium (mean 4.2 ± SD 4.8 days versus 4.9 ± SD 4.8 days; p = 0.38). A trend towards a statistically significant lower delirium severity (IC versus NIC: difference estimate − 1.59; p = 0.08) was noted for delirious IC patients in a linear mixed model. No effect on patient mortality and on nurses’ delirium knowledge (p = 0.43) and recognition (p = 1.0) was found. Conclusion: Our study, the first in its area to investigate effects of delirium e-learning on patient outcomes, demonstrated no benefits on both geriatric patients and nurses. Further research is needed to determine whether delirium e-learning nested within a larger educational approach inclusive of enabling and reinforcing strategies, would be effective. ispartof: BMC Geriatrics vol:18 issue:18 pages:1-9 ispartof: location:England status: published

BACKGROUND: geriatric consultation teams have failed to impact clinical outcomes prompting geriatric co-management programmes to emerge as a promising strategy to manage frail patients on non-geriatric wards. OBJECTIVE: to conduct a systematic review of the effectiveness of in-hospital geriatric co-management. DATA SOURCES: MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to 6 May 2016. Reference lists, trial registers and PubMed Central Citations were additionally searched. STUDY SELECTION: randomised controlled trials and quasi-experimental studies of in-hospital patients included in a geriatric co-management study. Two investigators performed the selection process independently. DATA EXTRACTION: standardised data extraction and assessment of risk of bias were performed independently by two investigators. RESULTS: twelve studies and 3,590 patients were included from six randomised and six quasi-experimental studies. Geriatric co-management improved functional status and reduced the number of patients with complications in three of the four studies, but studies had a high risk of bias and outcomes were measured heterogeneously and could not be pooled. Co-management reduced the length of stay (pooled mean difference, -1.88 days [95% CI, -2.44 to -1.33]; 11 studies) and may reduce in-hospital mortality (pooled odds ratio, 0.72 [95% CI, 0.50-1.03]; 7 studies). Meta-analysis identified no effect on the number of patients discharged home (5 studies), post-discharge mortality (3 studies) and readmission rate (4 studies). CONCLUSIONS: there was low-quality evidence of a reduced length of stay and a reduced number of patients with complications, and very low-quality evidence of better functional status as a result of geriatric co-management. ispartof: AGE AND AGEING vol:46 issue:6 pages:903-910 ispartof: location:England status: published

Colorectal cancer surgery is frequently performed in the older population. Many older persons have less physiological reserves and are thus more susceptible to adverse postoperative outcomes. Therefore, it seems important to distinguish the fit patients from the more vulnerable or frail. The aim of this review is to examine the evidence regarding the impact of frailty on postoperative outcomes in older patients undergoing surgery for colorectal cancer. A systematic literature search of Medline Ovid was performed focusing on studies that examined the impact of frailty on postoperative outcomes after colorectal surgery in older people aged ≥ 65 years. The methodological quality of the studies was evaluated using the MINORS quality assessment. Five articles, involving four studies and 486 participants in total, were included. Regardless of varying definitions of frailty and postoperative outcomes, the frail patients had less favourable outcomes in all of the studies. Compared to the non-frail group, the frail group had a higher risk of developing moderate to severe postoperative complications, had longer hospital stays, higher readmission rates, and decreased long-term survival rates. The results of this systematic review suggest the importance of assessing frailty in older persons scheduled for colorectal surgery because frailty is associated with a greater risk of postoperative adverse outcomes. We conclude that, although there is no consensus on the definition of frailty, assessing frailty in colorectal oncology seems important to determine operative risks and benefits and to guide perioperative management.

BACKGROUND: There is increasing emphasis on promoting "homelike" residential care models enabling care-dependent people to continue living in a self-determined manner. Yet, little is known about the outcomes of homelike residential care models. PURPOSE: We aimed to (1) identify homelike residential care models for older care-dependent people with and without dementia, and (2) explore the impact of these models on resident-, family-, and staff-related outcomes. DESIGN AND METHODS: We applied a scoping review method and conducted a comprehensive literature search in PubMed, Embase, and CINAHL in May 2015. RESULTS: We included 14 studies, reported in 21 articles. Studies were conducted between 1994 and 2014, most using a quasi-experimental design and comparing the Eden Alternative (n = 5), nondementia-specific small houses (eg Green House homes) (n = 2), and dementia-specific small houses (n = 7) with usual care in traditional nursing homes. The studies revealed evidence of benefit related to physical functioning of residents living in dementia-specific small houses and satisfaction with care of residents living in nondementia-specific small houses compared with those living in traditional nursing homes. We did not find other significant benefits related to physical and psychosocial outcomes of residents, or in family- and staff-related outcomes. IMPLICATIONS: The current evidence on homelike residential care models is limited. Comparative-effectiveness research building on a clear theoretical framework and/or logic model and including a standardized set of resident-, family-, and staff-related outcomes, as well as cost evaluation, is needed to provide a stronger evidence base to justify the uptake of more homelike residential care models. publisher: Elsevier articletitle: “There's No Place Like Home”: A Scoping Review on the Impact of Homelike Residential Care Models on Resident-, Family-, and Staff-Related Outcomes journaltitle: Journal of the American Medical Directors Association articlelink: http://dx.doi.org/10.1016/j.jamda.2016.03.009 content_type: article copyright: © 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine. ispartof: Journal of the American Medical Directors Association vol:17 issue:8 pages:685-693 ispartof: location:United States status: published

Background and objectives Interdisciplinary geriatric consultation teams are implemented in the acute hospital setting in several high-income countries to provide comprehensive geriatric assessment for the increasing numbers of older patients with a geriatric profile hospitalized on non-geriatric units. Given the inconclusive evidence on this care model's effectiveness to improve patient outcomes, health care policy and practice oriented recommendations to redesign the structure and process of care provided by interdisciplinary geriatric consultation teams are needed. A scoping review was conducted to explore the structure and processes of interdisciplinary geriatric consultation teams in an international context. As nurses are considered key members of these teams, their roles and responsibilities were specifically explored. Design The revised scoping methodology framework of Arksey and O'Malley was applied. Data sources An electronic database search in Ovid MEDLINE, CINAHL and EMBASE and a hand search were performed for the identification of descriptive and experimental studies published in English, French or Dutch until April 2014. Review methods Thematic reporting with descriptive statistics was performed and study findings were validated through interdisciplinary expert meetings. Results Forty-six papers reporting on 25 distinct interdisciplinary geriatric consultation teams in eight countries across three continents were included. Eight of the 12 teams (67%) reporting on their composition, stated that nurses and physicians were the main core members with head counts varying from 1 to 4 members per profession. In 80% of these teams nurses were required to have completed training in geriatrics. Advanced practice nurses were integrated in eleven out of fourteen interdisciplinary geriatric consultation teams from the USA. Only 32% of teams used formal screening to identify patients most likely to benefit from their intervention, using heterogeneous screening methods, and scarcely providing information on the responsibilities of nurses. Nurses were involved in the medical, functional, psychological and social assessment of patients in 68% of teams, either in a leading role or in collaboration with other professions. Responsibilities of interdisciplinary geriatric consultation teams' nurses regarding in-hospital follow-up or transitional care at hospital discharge were infrequently specified (16% of teams). Conclusions This scoping review identified that the structure and processes of care provided to geriatric patients by interdisciplinary geriatric consultation teams are highly heterogeneous. Despite nurses being key team members, only limited information on their specific roles and responsibilities was identified. More research in this area is required in order to inform health care policy and to formulate practice oriented recommendations to redesign the interdisciplinary geriatric consultation team care model aiming to improve its effectiveness.

BACKGROUND: Integrated care models are highly recommended to overcome care fragmentation in the multimorbid older population. Nurses are potentially ideally situated to fulfil the role as care coordinator to guide integrated care. No systematic review has been conducted specifically focusing on the impact of nurse-led integrated care models for older people in community settings. OBJECTIVES: To identify core components of nurse-led integrated care models for the home-dwelling older population; to describe patient, service and process outcomes; and to evaluate the impact of these care models on quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions and mortality. DESIGN: Systematic review and meta-analysis. DATA SOURCES: English, Dutch, French, German and Spanish articles selected from PubMed and CINAHL, hand-search of reference lists of the included articles and grey literature. REVIEW METHODS: A systematic search was conducted to identify prospective experimental or quasi-experimental studies detailing nurse-led integrated care models in the older home-dwelling population. Study characteristics and reported outcomes were tabulated. The core components of the models were mapped using the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. A random effects meta-analysis was conducted to study the overall effectiveness of the included care models on health-related quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions or mortality. Risk of bias was appraised using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-I tool for non-randomized studies. RESULTS: Nineteen studies were included studying a total of 22,168 patients. Core components of integrated care for multimorbid patients such as the involvement of a multidisciplinary team, high risk screening, tailored holistic assessment and an individualized care plan, were performed in a vast majority of the studies; however variability was observed in their operationalisation. Twenty-seven different patient, provider and service outcomes were reported, ranging from 1 to 13 per study. The meta-analyses could not demonstrate a beneficial impact on any of the predefined outcomes. Most included studies were of high risk for several biases. CONCLUSION: The summarized evidence on nurse-led integrated care models in home-dwelling older people is inconclusive and of low quality. Future studies should include key components of implementation research, such as context analyses, process evaluations and proximal outcomes, to strengthen the evidence-base of nurse-led integrated care. ispartof: International Journal Of Nursing Studies vol:105 ispartof: location:England status: Published online