3745 Digital CGA: innovation, implementation, and audit-driven evaluation

Prior studies have shown that about half of critically ill patients in intensive care units (ICUs) have abnormal blood glucose. Both hyperglycemia and hypoglycemia increase the risk of death in critically ill patients; therefore, controlling blood glucose in such patients is crucial. There is a significant gap between clinical practice and the current best evidence regarding glycemic control in ICU. This best practice implementation project aimed to improve glycemic control for critically ill patients in a tertiary hospital in China by promoting best practices. This project was conducted according to the JBI Evidence Implementation Framework, which is based on an audit and feedback strategy. Four audit criteria were developed for the baseline and follow-up audits. An implementation protocol was designed based on the barriers and facilitators identified in the baseline audit. Nursing documentation from patients' medical records and interviews with nurses were used to assess the baseline and follow-up audit compliance rates. The results showed improved compliance with the four criteria in the follow-up audit. Except for only slight improvement in Criterion 2 (increasing from 15.3% to 26.6%), the three other criteria all achieved significant improvements. The compliance rate for Criterion 1 increased from 43.8% to 70.0%, Criterion 3 increased from 0% to 100%, and Criterion 4 increased from 46.8% to 65.8%. This evidence-based implementation project successfully increased nurses' compliance with best practice recommendations for glycemic control in critically ill patients. http://links.lww.com/IJEBH/A338.

Hypertension is highly prevalent in the elderly and represents a major risk factor for cardiovascular complications such as coronary heart disease, stroke, and cognitive dysfunction. Frailty is a common geriatric syndrome characterized by increased risk of disability, hospitalization, and mortality. However, little is known about the frailty status in older adults with hypertension. Thus, we aimed to explore the epidemiological characteristics and related factors of frailty in older Chinese adults with hypertension. The current study included data collected from participants in the China Comprehensive Geriatric Assessment Study. Frailty was defined using the frailty index. Hypertension was defined as SBP at least 140 mmHg, DBP at least 90 mmHg, current treatment with antihypertensive medication, or a self-reported diagnosis of hypertension. Frailty index was positively correlated with age. The prevalence of frailty was significantly higher in hypertensive patients than in normal controls. The prevalence of frailty in older adults with hypertension was 13.8% in China. The awareness and treatment of hypertension was higher in frail individuals than in nonfrail individuals. The control rate of hypertension did not differ significantly between the two groups. Logistic analysis showed that older age, poor marital status, coronary heart disease, chronic obstructive pulmonary disease, cerebrovascular disease, diabetic mellitus, osteoporosis, hearing loss, lack of exercise, depression, cognitive impairment, and higher white blood cell count were factors independently related with frailty in older participants with hypertension. The current study provides the first evidence regarding the status of frailty in older Chinese adults with hypertension.

The impact of comprehensive geriatric assessment on final treatment decisions

IntroductionThe incidence of most cancers increases with age and cancer is a leading cause of morbidity and mortality in the older population. Older cancer patients frequently have additional co-morbidities and functional decline, which can substantially affect treatment outcomes. Major oncology societies recommend a screening for geriatric impairments in patients at risk (e.g. G8), followed by a comprehensive geriatric assessment (CGA). Nevertheless, CGA is often not established in routine care. We describe the implementation process of CGA in patients with hematological cancers at the University Hospital of Zurich. We evaluate its benefits, its perception by physicians and patients, and identify potential obstacles and solutions to allow integration into daily clinical practice.Materials and MethodsThis retrospective, single-center observational study was conducted at the University Hospital of Zurich. Patients aged ≥65 years with hematological malignancies who underwent CGA within the last 5 years were included. Patients were referred for CGA based on physicians’ choice. All data were extracted from electronic medical records and later analyzed. Perception of the CGA by patients and physicians was assessed by a questionnaire.Results46 patients who underwent CGA between April 2019 and July 2023 were included in this study. 89.1% showed at least one impaired domain in the CGA. For 98% of patients, one or more interventions were suggested. Low G8 scores were significantly associated with detected CGA-impairments (p<0.05). 70% of patients found the CGA and its resulting recommendations useful and reported benefiting from the process. 75% of the physicians rated the resulting CGA report as helpful for their clinical assessment.ConclusionOur data support the use of a CGA in older patients with hematological cancers based on positive feedback on its implementation, from both patients and treating physicians. Our results emphasize the need for a dedicated geriatric assessment in an older cancer population as it contributes to a more comprehensive medical evaluation and potentially improves overall care and quality of life for patients.

Grip strength (GS) and the short physical performance battery (SPPB) have been shown to predict clinical outcomes in older adults with cancer. However, whether pre-treatment GS and SPPB impact treatment decisions following comprehensive geriatric assessment (CGA) is poorly understood. Our objective was to assess the impact of low GS and/or SPPB on treatment modification to initially proposed treatment plans in older adults with cancer following CGA. This was a retrospective cohort study of older adults who had undergone CGA before receiving cancer treatment. Data were retrieved from a prospective database in an academic cancer centre and medical records. Treatment modification following CGA was defined as reduced treatment intensity or transition from active treatment to supportive care. Multivariable logistic regression assessed the impact of pre-treatment GS and SPPB on treatment modification following CGA. In total, 515 older adults (mean age: 80.7y) who had undergone CGA prior to cancer treatment were included. Low muscle strength and/or physical performance was observed in 66.4% of participants. Treatment was modified in 49.5% of the cohort following CGA. Low GS and/or SPPB combined was predictive of treatment modification (OR = 1.77, 95%CI = 1.07-2.90, P = 0.025) in multivariable analysis. Additional predictors of treatment modification included palliative treatment intent, comorbidities and malnutrition. Low GS and/or SPPB combined prior to cancer treatment predicts treatment modification in older adults with cancer and may be useful in treatment decision-making. Management of poor muscle strength and physical performance should be offered to optimize patient care and potentially improve treatment outcomes.

Background: Older adults living in the Long Term Care facilities are frail and have complex care needs. Holistic assessment of resident’s health status is the key to delivering optimal care. Comprehensive Geriatric Assessment (CGA) is the validated gold standard tool to identify care needs for frail older people in order to develop a coordinated and integrated plan for treatment and long-term follow-up. There was no designated CGA available for the Pre-admission to Community Nursing Units (CNUs) only a Common Summary Assessment Report (CSAR). Therefore, the care needs are not clearly identified prior to being accepted in the care home. Purpose/Aim: The author aimed to present the Nursing Home Pre-Admission Comprehensive Geriatric Assessment (CGA) form developed in collaboration with the Integrated Care Team for Older Persons. The form captures the complex needs of frail older people entering nursing homes to ensure the care home has the scope to meet their needs. The form streamlines the assessment process, allowing multidisciplinary teams to address all important medical needs and functional issues in a focused and standardized fashion enabling comprehensive and dedicated clinical thinking to be applied to the resident’s care. Methodology: The pre-admission assessment form was initiated in collaboration with all members of the multidisciplinary team (MDT) across the Integrated Care Programme for Older Persons (ICPOP) service in Community Healthcare Organisation-Dublin North City and County (CHO-DNCC), using the CGA from the community ICPOP. This was modified to support the preadmission assessment of the older person in the Nursing Home (NH). Engagement from the NS’s stakeholders was paramount. The document was amended gradually after multiple meetings with ICPOP and NH teams. The final version of the CGA was validated for use in July 2023 and then implemented into practice across the Community Nursing units (CNUs) in CHO- DNCC. Outcome/Result: Preliminary data demonstrated that the pre-admission assessment tool is fit for purpose and accepted by the CNU staff as all information describes the individual’s clinical baseline health status prior their admission, enabling timely and informed clinical decision-making in caring for the frail older individual. The pre-admission assessment form is the best intervention to provide collaboration and integration working in practice and has the potential to greatly improve the quality of care and promote overall good health for older people in the nursing home. The staff became better understood the different care needs of the care home population. Conclusion: The Pre-admission Assessment From is a designated Assessment tool for the Nursing Home in which a holistic view of the resident’s medical, functional, and social issues is taken. CGA is therefore a structured approach to creating a unified view of many different parts of a resident’s clinical assessment providing all information required to plan and deliver the optimal, coordinated, patient-centred care for the frail older adult who lives in a care home. The Pre-admission CGA form is transferable to other agencies if requested.

Postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) is frequent in older adults and associated with multiple negative outcomes including a higher mortality. We aimed to investigate whether a comprehensive geriatric assessment (CGA) prior to TAVI reduces the odds of POD and results in a positive change in self-care ability, intended to lay a foundation for future geriatric comanagement. We used a retrospective, single-center study with a quasi-experimental design enrolling patients aged 70 years and older undergoing CGA before elective TAVI, and a nonrandomized comparison group without preoperative CGA. Data on POD occurrence during the first 5 days after TAVI (primary outcome) and change in self-care ability index (SPI) between admission and discharge (secondary outcome) were collected from electronic health records and CGA data (exposure) by clinical assessment. To explore associations between (1) CGA and POD, and (2) CGA and SPI, multivariate logistic regression and linear regression models were applied adjusting for age, sex, BMI, and number of medications. Among 435 patients (mean age 81.0 ± 5.6 years, 43.6% women, median [IQR] SPI at baseline 40 [39, 40] points), POD incidence was 14.3% in the CGA group vs 18.8% in the non-CGA group (P 0.219). Undergoing CGA before TAVI was not associated with the odds for POD (OR: 1.15; 95%CI: 0.65-2.04) or improved SPI (P 0.073). We observed no association of CGA prior to TAVI with POD incidence or postoperative self-care, highlighting the need for additional studies investigating the effect of POD preventive measures in older TAVI patients integrated into a comprehensive geriatric comanagement program.

Frailty is a common and important geriatric syndrome characterized by age-associated declines in physiologic reserve and function across multiorgan systems, leading to increased vulnerability for adverse health outcomes. Two major frailty models have been described in the literature. The frailty phenotype defines frailty as a distinct clinical syndrome meeting three or more of five phenotypic criteria: weakness, slowness, low level of physical activity, self-reported exhaustion, and unintentional weight loss. The frailty index defines frailty as cumulative deficits identified in a comprehensive geriatric assessment. Significant progress has recently been made in understanding the pathogenesis of frailty. Chronic inflammation is likely a key pathophysiologic process that contributes to the frailty syndrome directly and indirectly through other intermediate physiologic systems, such as the musculoskeletal, endocrine, and hematologic systems. The complex multifactorial etiologies of frailty also include obesity and specific diseases. Major clinical applications include risk assessment and stratification. This can be applied to the elderly population in the community and in a variety of care settings. Frailty may also be useful for risk assessment in surgical patients and those with cardiovascular diseases, cancer, or human immunodeficiency virus infection, as well as for assessment of vaccine effectiveness in older adults. Currently, exercise and comprehensive geriatric interdisciplinary assessment and treatment are key interventions for frailty. As understanding of the biologic basis and complexity of frailty further improves, more effective and targeted interventional strategies and innovative geriatric-care models will likely be developed.

As the population ages, understanding the association between sleep patterns and physical frailty in older adults is crucial for formulating effective health interventions. This study aimed to explore the relationship among nap time, nighttime sleep duration, and physical frailty in older Chinese individuals; establish recommended sleep times; and provide a scientific and reasonable basis for the prevention and management of frailty in older adults. On the basis of the 2020 China Health and Retirement Longitudinal Study database, demographic information, health data, and lifestyle information of the research subjects were obtained. A total of 5,761 survey participants were included, and logistic regression and restricted cubic splines were used to explore the association between sleep duration and frailty. In our cross-sectional analysis, the duration of napping in older adults did not show a significant correlation with frailty. The optimal nighttime sleep interval for older adults was 7-8 h, and the maximum health benefit was achieved when nighttime sleep reached 7.5 h. Compared with older adults in China who slept 6-8 h at night, those with a sleep duration of <6 h (OR = 1.58, 95% CI: 1.36-1.82) were more likely to be frail. After adjusting for all covariates such as smoking, multimorbidity, self-rated health, social events, education level, and frequency of physical activity, we found no interaction between gender and age concerning sleep duration. The potential correlation between nighttime sleep duration and frailty in older adults is basically U-shaped. Older Chinese adults with a moderate nighttime sleep duration of 7-8 h exhibited the lowest likelihood of frailty than their counterparts. The duration of napping is not related to the likelihood of frailty in older people. Thus, the importance of sufficient nighttime sleep for the health of older adults must be emphasized.

IntroductionFrailty constitutes a risk for unplanned hospitalizations in older adults with cancer. This study examines whether comprehensive geriatric assessment (CGA) as an add-on to standard oncologic care can prevent unplanned hospitalizations in older adults with frailty and cancer who initiate curative oncological treatment. Materials and MethodsThis randomized controlled trial included older adults aged ≥70 with frailty (Geriatric 8 [G8] ≤14), and solid cancers who initiated curative oncological treatment. Participants were randomized 1:1 to either standard oncologic care (control) or standard oncologic care supplemented with CGA-guided interventions (intervention). Baseline characteristics were retrieved prior to randomization. The primary endpoint, the between-group rate ratio of unplanned hospitalizations within six months of treatment initiation, was analyzed using negative binominal regression. Analyses were performed using an intention-to-treat approach, followed by per-protocol analysis, including participants receiving CGA within 30 days of randomization, and preplanned subgroup analyses based on treatment modality and Geriatric 8 screening. Secondary endpoints included acute hospital contacts, treatment adherence, and toxicity. ResultsFrom November 1, 2020 to May 31, 2023, 173 participants were enrolled. Median age was 75 (interquartile range 72–79), 51.5% were female, 58% had a G8 score > 12, and 84% had Eastern Cooperative Oncology Group performance status 0–1. The most common cancer sites were lung (23%), upper gastrointestinal (15%), and breast (13%). The rate (per person-years) of unplanned hospitalization was 1.32 in the intervention group and 1.81 in the control group, with a between-group rate ratio of 0.74 (95% confidence interval [CI] 0.45–1.23, P = 0.25) favoring the intervention. The between-group rate ratio increased in the per-protocol analysis (0.64 [95% CI 0.37–1.10, P = 0.10]). Similarly, no significant between group differences were found in treatment adherence, rate of acute hospital contacts, or toxicity. DiscussionIn this study, CGA did not significantly reduce the rate of unplanned hospitalizations. Furthermore, no between-group differences were found in treatment adherence, toxicity lead hospitalizations, or treatment completion in older adults with cancer and frailty. However, per-protocol analysis suggests that increasing adherence to CGA may improve the outcome. Larger studies ensuring higher CGA adherence are warranted to confirm our findings.

There are no studies examining the prevalence of social frailty and associated factors in low- and middle-income countries. This study aimed to assess the prevalence of social frailty and identify the contributing factors among older adults in Türkiye. This cross-sectional study included 570 participants aged 65 and older, all outpatients at a geriatric clinic. Data for demographics and co-morbidities were collected. Anthropometric measurements and comprehensive geriatric assessments were conducted. Social frailty was assessed using the 5-item Social Frailty Index (SFI), and physical frailty was evaluated with the Fried Frailty Phenotype. Sarcopenia was diagnosed based on low handgrip strength and reduced calf circumference. Participants' mean age was 75.2 ± 6.3 years. Social frailty, depression, physical frailty and sarcopenia prevalence were 24%, 25%, 14% and 26%, respectively. Social frailty was reported to be statistically higher in women and those living alone, while significantly lower in married individuals. Depression, physical frailty and sarcopenia were more commonly observed in participants with social frailty (p < .01). Furthermore, participants with heart failure and Parkinson's disease were more socially vulnerable than those with other co-morbid conditions. Multivariate logistic regression analysis revealed that age, physical frailty and depressive mood significantly increased social frailty, whereas being married decreased it even after adjusting for potential confounding factors. Social frailty was more prevalent than physical frailty among Turkish older adults, reaching 24%. Advanced age, depression, physical frailty and being unmarried were strongly related factors to social frailty.

Exercise Testing and Training Strategies for Healthy and Frail Elderly

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail elderly person in order to develop a coordinated and integrated plan for treatment and long-term follow-up. CGA was significantly useful in reducing negative health outcomes such as mortality, functional decline, institutionalization or hospital readmission in different clinical settings and conditions. CGA has become the internationally established method to assess elderly people in clinical practice, because it is sensitive to the reliable detection of degrees of frailty. In several infectious diseases, there are risk factors related to functional disability, mobility limitation, cognitive impairment and concomitant geriatric syndromes. Therefore, there is a compelling need to incorporate CGA into the management approaches in older adults with infectious diseases and adopt CGA-based prognostic tools to facilitate clinical decision-making in older frail patients with infectious diseases. In this contest, the CGA-based multidimensional prognostic index (MPI), combining eight different domains of standard CGA (ADL, IADL, cognitive, nutrition, motility, comorbidity, polypharmacy, cohabitation status), showed very good accuracy in identifying older patients with community-acquired pneumonia (CAP) at different risk of mortality who need a different intensity of clinical interventions. Moreover, the addition of procalcitonin levels significantly improved the accuracy of MPI in predicting short-term mortality in older patients with CAP. These data suggest that the MPI may be poised to become a key parameter in infectious diseases and vaccination discussions.

The primary aim of the study was determining the validation of the modified 19-item Frailty Index (mFI-19), based on the standard procedure for creating a frailty index scoring in the accumulation deficit theory of Rockwood and comparing it with the gold standard comprehensive geriatric assessment (CGA) in old age patients with hip fracture. As a secondary aim, we compared prognostic accuracies of mFI-19 and CGA in predicting long-term mortality after surgery. A total of 364 older patients with hip fractures, each a candidate for surgery, were consecutively enrolled. All were subjected to CGA and mFI-19 at baseline and time to death (years from hip surgery) were collected prospectively. Mean patient age was 86.5 (SD: 5.65) years. The most common clinical phenotype (77%) was frail. Both CGA and mFI-19 performed similarly in predicting long-term mortality (Harrell's C-index: 0.66 and 0.68, respectively). The mFI-19 was validated, compared to the gold standard CGA, based on a systematic process for creating a frailty index in relation to the accumulation deficit. This is one of few prospective studies addressing long-term mortality in older adults with hip fractures, invoking a methodologically robust frailty screening assessment.

Background Recurrent hospitalisation is increasingly observed in older adults aged 65 or above and, is associated with increased risk of adverse outcomes including delayed recovery, increased morbidity, and mortality. We introduced Performa-based, Multi-Disciplinary Team (MDT) driven Comprehensive Geriatric Assessment (CGA) as a model of care of older patients admitted to an acute Irish hospital, and to see its impact in preventing acute re-hospitalisation after an acute admission. Methods CGA was performed, on inpatients aged 65 or older, admitted to a designated ward which had multidisciplinary team access, via a designed and prescribed Performa, by Advanced Nurse Practitioner and interventions suggested by it, were offered to those patients. The pilot continued for three months. Patients who underwent CGA, were monitored for re-admission at 3 months from the date of their discharge via hospital patient management system. Data was compiled and studied via Microsoft excel spread sheet. Results 28 patients were admitted to the designated ward who underwent the CGA during the time frame of the pilot. 26 (92.8%) patients did neither present to ED nor were admitted to hospital in the immediate 3 months post discharge from the hospital. CGA resulted in various multidisciplinary interventions/referrals on all patients which were studied as secondary aims. The major interventions were MDT referrals (physiotherapy 100%, occupational therapy 85.7%, Swallow Therapists 46.4% and dietetic referrals 32.1%) and deprescribing (50% of patients). Conclusion The pilot showed reduced acute re-hospitalisation rates in older patients undergoing CGA, and an attempt to adopt CGA as model of care in acute hospitals to prevent acute re-hospitalisation in such patients. In the model, CGA also offered multiple interventions including MDT referrals/interventions and deprescribing. Further powered research replicating similar results, is needed to explore and adopt such CGA based models of care in older inpatients in acute hospitals.