Mieke Deschodt

Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis

AbstractBackgroundComprehensive geriatric assessment for older patients admitted to dedicated wards has proven to be beneficial, but the impact of comprehensive geriatric assessment delivered by mobile inpatient geriatric consultation teams remains unclear. This review and meta-analysis aims to determine the impact of inpatient geriatric consultation teams on clinical outcomes of interest in older adults.MethodsAn electronic search of Medline, CINAHL, EMBASE, Web of Science and Invert for English, French and Dutch articles was performed from inception to June 2012. Three independent reviewers selected prospective cohort studies assessing functional status, readmission rate, mortality or length of stay in adults aged 60 years or older. Twelve studies evaluating 4,546 participants in six countries were identified. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies.ResultsThe individual studies show that an inpatient geriatric consultation team intervention has favorable effects on functional status, readmission and mortality rate. None of the studies found an effect on the length of the hospital stay. The meta-analysis found a beneficial effect of the intervention with regard to mortality rate at 6 months (relative risk 0.66; 95% confidence interval 0.52 to 0.85) and 8 months (relative risk 0.51; confidence interval 0.31 to 0.85) after hospital discharge.ConclusionsInpatient geriatric consultation team interventions have a significant impact on mortality rate at 6 and 8 months postdischarge, but have no significant impact on functional status, readmission or length of stay. The reason for the lack of effect on these latter outcomes may be due to insufficient statistical power or the insensitivity of the measuring method for, for example, functional status. The questions of to whom IGCT intervention should be targeted and what can be achieved remain unanswered and require further research. Trial registration: CRD42011001420 (http://www.crd.york.ac.uk/PROSPERO)

Preventing Delirium in Older Adults with Recent Hip Fracture Through Multidisciplinary Geriatric Consultation

To evaluate the effect of inpatient geriatric consultation teams (IGCTs), which have been introduced to improve the quality of care of older persons hospitalized on nongeriatric wards, on delirium and overall cognitive functioning in older adults with hip fracture.

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial

OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission.

The impact of frailty on postoperative outcomes in individuals aged 65 and over undergoing elective surgery for colorectal cancer: A systematic review

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 ≥65years. 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.

Prediction of functional decline in older hospitalized patients: a comparative multicenter study of three screening tools.

Background and aims: Older hospitalized patients are at risk of functional decline, which is associated with several negative outcomes. The aim of this study was to compare the predictive accuracy of the Identification of Seniors At Risk (ISAR), Variable Indicative for Placement risk (VIP) and the Flemish version of the Triage Risk Screening Tool (TRST) in predicting functional decline. Methods: A prospective cohort study with 30 days follow-up in geriatric, medical and surgical wards in 25 hospitals was conducted. 752 participants aged 75 years or older were eligible for inclusion. Baseline data were gathered within 72 hours of admission. Functional decline was defined as an increase of one point or more from the premorbid Katz score to the score 30 days post-discharge. Positive predictive value (PPV) and negative predictive value (NPV) were calculated on 2×2 tables as well as by Bayes’ theorem. Results: Functional decline at 30 days postdischarge was observed in 279 participants (39%). ISAR and Flemish TRST showed high sensitivity (88%–78%) and fair NPV (62%–67%), but low specificity (19%–30%) and low PPV (47%–48%) using the original cut-off of ≥2. The sensitivity of VIP with cut-off ≥2 was too low (62%), but could be optimized with cut-off ≥1, showing sensitivity, specificity, PPV and NPV of 88%, 21%, 48% and 68%, respectively. Accuracy varied between 40% and 61% for all instruments on all calculated cut-offs. Conclusions: All three instruments performed similarly well, showing good sensitivity and fair NPV, the two major characteristics for good screening tools. False positives could be filtered out according to the clinical expert opinion of a care team.

Camera-Based fall detection on real world data

Several new algorithms for camera-based fall detection have been proposed in the literature recently, with the aim to monitor older people at home so nurses or family members can be warned in case of a fall incident. However, these algorithms are evaluated almost exclusively on data captured in controlled environments, under optimal conditions (simple scenes, perfect illumination and setup of cameras), and with falls simulated by actors. In contrast, we collected a dataset based on real life data, recorded at the place of residence of four older persons over several months. We showed that this poses a significantly harder challenge than the datasets used earlier. The image quality is typically low. Falls are rare and vary a lot both in speed and nature. We investigated the variation in environment parameters and context during the fall incidents. We found that various complicating factors, such as moving furniture or the use of walking aids, are very common yet almost unaddressed in the literature. Under such circumstances and given the large variability of the data in combination with the limited number of examples available to train the system, we posit that simple yet robust methods incorporating, where available, domain knowledge (e.g. the fact that the background is static or that a fall usually involves a downward motion) seem to be most promising. Based on these observations, we propose a new fall detection system. It is based on background subtraction and simple measures extracted from the dominant foreground object such as aspect ratio, fall angle and head speed. We discuss the results obtained, with special emphasis on particular difficulties encountered under real world circumstances.

Camera Based Fall Detection Using Multiple Features Validated with Real Life Video

More than thirty percent of persons over 65 years fall at least once a year and are often not able to get up again unaided. The lack of timely aid can lead to severe complications such as dehydration, pressure ulcers and death. A camera based fall detection system can provide a solution. In this paper we compare four different fall features extracted from the dominant foreground object, as well as various combinations thereof. All tests are executed using real life data, which has been recorded at the home of 4 elderly, containing 24 falls. Experiments indicate that a fall detector based on a combination of aspect ratio, head speed and fall angle is preferred. The preliminary detector, which still has a substantial false alarm rate with a precision of 0.257(±0.073) and a promising recall of 0.896(±0.194), gives insights for further improvement as is discussed.

Effects of multi-domain interventions in (pre)frail elderly on frailty, functional, and cognitive status: a systematic review

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.

Validity of the interRAI Acute Care based on test content: A multi-center study

Background and aims: The MDS inter-RAI Acute Care is a comprehensive geriatric assessment tool for hospitalized older persons. The aim was to examine its validity based on test content by use in daily clinical practice. Methods: Clinical staff of multiple disciplines assessed 256 older persons (83.2±5.2 years; 60% female) in a cross-sectional multicenter study in nine acute hospitals. Test content was empirically tested by frequency distribution of clinical deficits, missing, and invalid data. Item relevance was quantified by the content validity index (CVI) and modified kappa statistics (κ*) based on assessors’ judgment. Results: Clinical deficits exceeded 30% in the majority of items (67%) across all assessment periods. Mean missing data for premorbid, admission, day-14 and discharge assessments were 9.7%, 5.3%, 29.3% and 13.7%, respectively. Invalid scores ranged from 3.9% to 26.7%. Of the 98 items, 82 had excellent CVI (≥0.78). Item relevance was excellent for 82 (κ*≥0.75), good for 9 (0.60≤κ*=0.74) and fair for 3 items (0.40=≤κ*<0.60). Item revision may optimize clinical relevance: removing 4 items with poor relevance would increase the overall CVI from 0.89 to 0.91, meeting the standard of excellent content validity (CVIaverage≥0.90). Conclusions: Although the frequency distribution provides evidence that item selection of the interRAI Acute Care is appropriate for the targeted population, its use in a clinical context reveals a substantial number of missing and invalid data. To improve validity, training should pay specific attention to items with low compliance and invalid records. Software applications should also be designed to improve data quality.

Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis

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.