Esther M.M. van de Glind

Pre-arrest predictors of survival after resuscitation from out-of-hospital cardiac arrest in the elderly a systematic review

BackgroundTo enable older people to make decisions about the appropriateness of cardiopulmonary resuscitation (CPR), information is needed about the predictive value of pre-arrest factors such as comorbidity, functional and cognitive status on survival and quality of life of survivors. We systematically reviewed the literature to identify pre-arrest predictors for survival, quality of life and functional outcomes after out-of-hospital (OHC) CPR in the elderly.MethodsWe searched MEDLINE (through May 2011) and included studies that described adults aged 70 years and over needing CPR after OHC cardiac arrest. Prognostic factors associated with survival to discharge and quality of life of survivors were extracted. Two authors independently appraised the quality of each of the included studies. When possible a meta-analysis of odd’s ratios was performed.ResultsTwenty-three studies were included (n = 44,582). There was substantial clinical and statistical heterogeneity and reporting was often inadequate. The pooled survival to discharge in patients >70 years was 4.1% (95% CI 3.0-5.6%). Several studies showed that increasing age was significantly associated with worse survival, but the predictive value of comorbidity was investigated in only one study. In another study, nursing home residency was independently associated with decreased chances of survival. Only a few small studies showed that age is negatively associated with a good quality of life of survivors. We were unable to perform a meta-analysis of possible predictors due to a wide variety in reporting and statistical methods.ConclusionsAlthough older patients have a lower chance of survival after CPR in univariate analysis (i.e. 4.1%), older age alone does not seem to be a good criterion for denying patients CPR. Evidence for the predictive value of comorbidities and for the predictive value of age on quality of life of survivors is scarce. Future studies should use uniform methods for reporting data and pre-arrest factors to increase the available evidence about pre arrest factors on the chance of survival. Furthermore, patient-specific outcomes such as quality of life and post-arrest cognitive function should be investigated too.

Comorbidity and favorable neurologic outcome after out-of-hospital cardiac arrest in patients of 70 years and older.

INTRODUCTION Advanced age is reported to be associated with lower survival after out-of-hospital cardiac arrest (OHCA). We aimed to establish survival rate and neurological outcome at hospital discharge after OHCA in older patients and evaluated whether pre-OHCA comorbidity was associated with favorable neurologic outcome. METHODS From a prospective registry of all cardiopulmonary resuscitation (CPR) attempts after OHCA, we established survival in 1332 patients aged ≥ 70 years in whom resuscitation with non-traumatic etiology was attempted in 2009-2011. Pre-OHCA factors (age, gender, residing in long-term care institution, Charlson Comorbidity Index [CCI] score) and resuscitation parameters (initial rhythm, bystander witnessed, bystander CPR and time to defibrillator connection) with survival at hospital discharge with favorable neurologic outcome were regressed in the 851 patients of whom CCI was known. RESULTS We found a 12% survival to discharge rate in patients aged ≥ 70 years (70-79 years: 16%; ≥ 80 years: 8%, p=0.001). Among surviving patients, 90% survived with favorable neurologic outcome. In a model with only pre-OHCA factors age was significantly associated with outcome (age OR 0.94, 95%CI 0.91-0.98), p = 0.003). High CCI score (≥ 4) was not statistically significant when associated with survival (7% vs. 12%, OR 0.53, 95%CI (0.25-1.13), p = 0.10). When adjusted for resuscitation parameters, OR for high CCI was 0.71 (95% CI 0.28-1.80, p = 0.47), also none of the other pre-OHCA factors remained statistically significant. CONCLUSION In the Netherlands, the survival rate in older patients was 12%; the great majority survived with favorable neurologic outcome. Resuscitation-related factors and not comorbidity determine outcome after OHCA in older patients.

The chance of survival and the functional outcome after in-hospital cardiopulmonary resuscitation in older people: a systematic review

BACKGROUND physicians are frequently confronted with the question whether cardiopulmonary resuscitation (CPR) is a medically appropriate treatment for older people. For physicians, patients and relatives, it is important to know the chance of survival and the functional outcome after CPR in order to make an informed decision. METHODS a systematic search was performed in MEDLINE, Embase and Cochrane up to November 2012. Studies that were included described the chance of survival, the social status and functional outcome after in-hospital CPR in older people aged 70 years and above. RESULTS we identified 11,377 publications of which 29 were included in this review; 38.6% of the patients who were 70 years and older had a return of spontaneous circulation. More than half of the patients who initially survived resuscitation died in the hospital before hospital discharge. The pooled survival to discharge after in-hospital CPR was 18.7% for patients between 70 and 79 years old, 15.4% for patients between 80 and 89 years old and 11.6% for patients of 90 years and older. Data on social and functional outcome after surviving CPR were scarce and contradictory. CONCLUSIONS the chance of survival to hospital discharge for in-hospital CPR in older people is low to moderate (11.6-18.7%) and decreases with age. However, evidence about functional or social outcomes after surviving CPR is scarce. Prospective studies are needed to address this issue and to identify pre-arrest factors that can predict survival in the older people in order to define subgroups that could benefit from CPR.

Search filters to identify geriatric medicine in Medline

Objectives To create user-friendly search filters with high sensitivity, specificity, and precision to identify articles on geriatric medicine in Medline. Design A diagnostic test assessment framework was used. A reference set of 2255 articles was created by hand-searching 22 biomedical journals in Medline, and each article was labeled as ‘relevant’, ‘not relevant’, or ‘possibly relevant’ for geriatric medicine. From the relevant articles, search terms were identified to compile different search strategies. The articles retrieved by the various search strategies were compared with articles from the reference set as the index test to create the search filters. Measures Sensitivity, specificity, precision, accuracy, and number-needed-to-read (NNR) were calculated by comparing the results retrieved by the different search strategies with the reference set. Results The most sensitive search filter had a sensitivity of 94.8%, a specificity of 88.7%, a precision of 73.0%, and an accuracy of 90.2%. It had an NNR of 1.37. The most specific search filter had a specificity of 96.6%, a sensitivity of 69.1%, a precision of 86.6%, and an accuracy of 89.9%. It had an NNR of 1.15. Conclusion These geriatric search filters simplify searching for relevant literature and therefore contribute to better evidence-based practice. The filters are useful to both the clinician who wants to find a quick answer to a clinical question and the researcher who wants to find as many relevant articles as possible without retrieving too many irrelevant articles.

Underrepresentation of patients with pre-existing cognitive impairment in pharmaceutical trials on prophylactic or therapeutic treatments for delirium: A systematic review

OBJECTIVE Representation of hospitalized patients with pre-existing cognitive impairment in pharmaceutical delirium trials is important because these patients are at high risk for developing delirium. The aim of this systematic review is to investigate whether patients with cognitive impairment were included in studies on pharmacological prophylaxis or treatment of delirium and to explore the motivations for their exclusion (if they were excluded). STUDY DESIGN This study was a systematic review. A MEDLINE search was performed for publications dated from 1 January 1985 to 15 November 2012. Randomized and non-randomized controlled trials that investigated medication to prevent or treat delirium were included. The number of patients with cognitive impairment was counted, and if they were excluded, motivations were noted. RESULTS The search yielded 4293 hits, ultimately resulting in 31 studies that met the inclusion criteria. Of these, five studies explicitly mentioned the percentage of patients with cognitive impairment that were included. These patients comprised a total of 8% (n = 279 patients) of the 3476 patients included in all 31 studies. Ten studies might have included cognitively impaired patients but did not mention the exact percentage, and sixteen studies excluded all patients with cognitive impairment. The motivations for exclusion varied, but most were related to the influence of dementia on delirium. CONCLUSION The exclusion of patients with pre-existing cognitive impairment hampers the generalizability of the results of these trials and leaves clinicians with limited evidence about the pharmacological treatment of this group of vulnerable patients who have an increased risk of side effects.

Reviews of individual patient data (IPD) are useful for geriatrics: an overview of available IPD reviews.

To determine how many individual patient data (IPD) reviews that included older people were available in MEDLINE and whether the effectiveness of treatments differed between older and younger individuals.

Barriers to and Facilitators of Participation of Older Adults in a Placebo-Controlled Randomized Clinical Trial

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For which clinical rules do doctors want decision support, and why?: A survey of Dutch general practitioners

Despite the promise of decision support for improving care, alerts are often overridden or ignored. We evaluated Dutch general practitioners’ intention to accept decision support in a proposed implementation based on clinical rules regarding care for elderly patients, and their reasons for wanting or not wanting support. We developed a survey based on literature and structured interviews and distributed it to all doctors who would receive support in the proposed implementation (n = 43), of which 65 percent responded. The survey consisted of six questions for each of 20 clinical rules. Despite concerns about interruption, doctors tended to choose more interruptive forms of support. Doctors wanted support when they felt the rule represented minimal care, perceived a need to improve care, and felt responsible for the action and that they might forget to perform the action; doctors declined support due to feeling that it was unnecessary and due to concerns about interruption.

Acetaminophen for self-reported sleep problems in an elderly population (ASLEEP): a randomized double-blind placebo-controlled trial.

association remained significant in cohort studies, cross-section studies, and case-control studies. Our meta-analysis has several strengths. First, a significant association was evaluated from our prospective cohort studies (RR=1.22, 95% CI 1.01–1.46, n=6), strongly identifying the effect of tooth loss on dementia risk. Second, the large number of participants included in this meta-analysis reduced the sampling error to a great extent and allowed a much greater possibility of reaching a reasonable conclusion. Other limitations should be considered. The time of the occurrence of tooth loss and the length of the edentulous period cannot be determined exactly; this may lead to the bias of incomparability of results to some extent. In conclusion, our meta-analysis indicates that tooth loss might be positively associated with the increased risk of dementia among older people.