Michèle Monette

Are frailty markers useful for predicting treatment toxicity and mortality in older newly diagnosed cancer patients? Results from a prospective pilot study

INTRODUCTION The concept of frailty may be useful to characterize vulnerability. The aim of this pilot study was to explore the association between frailty/functional status and treatment toxicity at 3 months and mortality at 6 months. METHODS Patients aged ≥65 years referred to the Jewish General Hospital, Montreal, with a new cancer diagnosis. Seven frailty markers and 4 functional status measures were examined. Logistic regression was used to examine the association between frailty/functional status and toxicity, and Cox models for time to death. RESULTS 112 participated, median age 74.1, 31 had toxicity and 15 died. At baseline, 88% had ≥1 frailty marker. Low grip strength predicted toxicity (OR 8.47, 95%CI: 1.3-53.6), ECOG performance status and ADL disability predicted time to death. CONCLUSION The majority had ≥1 frailty marker. Low grip strength predicted toxicity, none of the functional measures did. Further researcher investigating the usefulness of frailty markers is needed.

The Psychosocial Impact of Assistive Devices Scale (PIADS): Translation and preliminary psychometric evaluation of a Canadian-French version

This article reports on the Canadian–French translation of the Psychosocial Impact of Assistive Devices Scale (PIADS), a 26-item questionnaire that measures the quality of life (QoL) impacts of using assistive technologies from the person with disabilitys point of view. Following standard procedures, the study included forward and backward translations, committee reviewing, pre-testing with bilingual lay people, and psychometric evaluation of the translated questionnaire with subjects with mobility impairment (n = 83) and visual impairment (n = 37). The use of translators translating in their mother tongue and the participation of one author of the questionnaire contributed to the quality of the translation. We found that words that had equivalence in English and French did not necessarily cover the same areas of meaning. The subscales (n = 3) and total scale of the French PIADS achieved good test–retest stability (ICC of 0.77–0.90) and internal consistency (0.75–0.94). Concurrent validity with the source PIADS also produced acceptable coefficients (0.77–0.83). At the item level, non-significant t test (p > 0.10) results supported the premise that the scores were not different across languages, except for two items. The results are robust enough to recommend the use of the Canadian–French questionnaire for the investigation of the QoL impacts of assistive technologies for persons with disability.

Clinical experience of cancer specialists and geriatricians involved in cancer care of older patients: A qualitative study

INTRODUCTION Cancer is an important health problem in older persons. The aim of this study was to explore how cancer specialists and geriatricians manage the treatment of older patients with cancer. METHODS Interviews using semi-structured open-ended questions. SAMPLE physicians working in oncology and geriatric medicine at McGill affiliated hospitals. ANALYSIS Grounded-theory approach. RESULTS 24 cancer specialists and 17 geriatricians participated. There was considerable variability with regard to assessment, treatment plan, and follow-up care and little collaboration between both specialists. The cancer specialists have more older cancer patients in their practice and collaborate with geriatricians mostly to deal with complications of cancer treatment. However, both groups of specialists expressed a desire to collaborate more and had similar research priorities. CONCLUSIONS There was considerable variability in the management of older patients with cancer. Care for older patients with cancer might be improved by more collaboration between cancer specialists and geriatricians.

Difficulties in decision making regarding chemotherapy for older cancer patients: A census of cancer physicians

INTRODUCTION The management of older cancer patients is often suboptimal. This study aims to understand the management of older cancer patients who may receive chemotherapy. METHODS A questionnaire was mailed in 2006-2007 to 181 medical oncologists and hematologists practicing in the Province of Quebec, Canada. Physicians, involved in treatment decisions regarding chemotherapy in cancer patients aged 70 years and older, were eligible. RESULTS The response rate was 45.7%. Treatment toxicity (24.4%), comorbidities (20.5%), and lack of social support (10.9%) were reported as challenges when caring for older cancer patients. Comorbidities and functional status were reported as principal factors when making treatment decisions regarding chemotherapy; 77.5% of respondents expressed interest in collaborating with geriatricians. CONCLUSIONS The concerns of respondents about comorbidities, functional status, and social support, along with their interest to collaborate with geriatricians, support the need for a partnership between these two disciplines.

Identification of Quality of Care Deficiencies in Elderly Surgical Patients by Measuring Adherence to Process-Based Quality Indicators

BACKGROUND The ability to measure surgical quality of care is important and can lead to improvements in patient safety. As such, processes should be carried out in an identical fashion for all patients, regardless of how vulnerable or complex they are. Our objectives were to assess quality of surgical care delivered to elderly patients and to determine the association between patient characteristics and quality of care. STUDY DESIGN This is a retrospective pilot cohort study, conducted in a single university-affiliated hospital. Using the institutions National Surgical Quality Improvement Program (NSQIP) database (2009 to 2010), 143 consecutive patients 65 years or older, undergoing elective major abdominal surgery, were selected. Adherence to 15 process-based quality indicators (QIs) was measured, and a pass rate was calculated for each individual QI. The association between patient characteristics (age, sex, Charlson Comorbidity Index, functional status, wound class) and patient quality score was assessed using multiple linear regression. RESULTS Quality indicators with the lowest pass rates included postoperative delirium screening (0%), level of care documentation (0.7%), cognition and functional assessment at discharge (4.9%), oral intake documentation (12.6%), and pressure ulcer risk assessment (35.0%). The mean patient quality score was 46.8% ± 10.7% (range 16.7% to 75.0%). No association was found between patient characteristics and patient quality score. CONCLUSIONS Quality of care delivered to elderly patients undergoing major surgery at our institution was generally poor and independent of patient characteristics. Although quality appears to be uniform across different patients, these results provide targets for quality improvement initiatives.

A long-term care center interdisciplinary education program for antipsychotic use in dementia: program update five years later.

BACKGROUND While antipsychotic (AP) medications are frequently used in long-term care, current evidence suggests that the risks may offset the benefits, necessitating periodic reassessment of their use. The aims of this present study were: (1) to assess rates of AP use five years after our first intervention to determine the long-term impact; and (2) to implement an updated AP reduction educational intervention program at the same center five years later in order to determine whether AP use could be further reduced. METHODS Participants were residents with dementia receiving AP medication. The educational program component included separate lectures on pharmacologic and non-pharmacologic treatment of behavioral and psychological symptoms of dementia (BPSD). Completion of the Nursing Home Behavior Problems Scale (NHBPS), physician interviews concerning AP treatment plans for subjects with dementia, and AP administration and dose assessment occurred both at baseline and again between four to five months after the educational program. RESULTS Of 308 long-term residents with dementia, 53 (17.2%) were receiving regular APs, primarily for agitation, aggressivity, other behavioral problems and psychosis. Of these, six died and one was transferred, leaving 46 participants. At five months, ten (21.7%) residents were no longer receiving APs and seven (15.2%) were on a lower dose; thus, 17 (37.0%) were either discontinued or on a lower dose. There was no worsening of NHBPS scores. CONCLUSION Despite the low prevalence (17.2%) of AP users at the beginning of the current study compared to that observed five years prior (30.5%), it is still possible to further decrease the proportion of users.

Association of resident and room characteristics with antipsychotic use in long-term care facilities (LTCF).

Inappropriate and widespread prescribing of antipsychotics in LTCF is of concern. This study aimed to explore the association of resident and room characteristics with antipsychotic use in this setting. This is cross-sectional secondary analysis of the baseline data of 280 residents ≥ 65 years old, from a prospective, observational, LTCF multi-site (n=7) cohort study on delirium. Demographic data included age, sex and length of stay. Resident characteristics assessed were presence of dementia, disruptive behavior, delirium and use of restraints. Room characteristics assessed were single room, clock/calendar, and telephone. Separate logistic regression models were used to explore the association of resident and room characteristics with antipsychotic use, adjusting for demographic variables. Mean age was 84.9 ± 7.0 years (± S.D.) with 56% female. The mean prevalence of antipsychotics use was 31.1% (range: 25.6-50.0%). The regression model of resident characteristics revealed a significant association between disruptive behavior (OR=1.18, 95% CI=1.12-1.25) and antipsychotic use. The model of room characteristics revealed a significant association between absence of a clock or calendar (OR=1.93, 95% CI=1.04-3.56) and absence of a telephone (OR=2.79, 95% CI=1.48-5.25). Our results suggest that behavior problems are associated with a higher likelihood of antipsychotic use. Absence of a clock/calendar and of a telephone was related to antipsychotic use. Further research is needed to confirm these findings.