Cable fixation and early total hip arthroplasty in the treatment of acetabular fractures in elderly patients.

Eighteen patients with acetabular fractures, with a mean age of 76 years, were treated with cable fixation and acute total hip arthroplasty. Nine were T-shaped fractures, 4 associated transverse and posterior wall, 2 transverse, 2 posterior column and posterior wall, and 1 anterior and posterior hemitransverse fractures. One patient experienced 3 episodes of hip dislocation within 10 months after surgery. All the others had a good outcome at a mean follow-up time of 36 months. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This option provides good primary fixation, stabilizes complex acetabular fractures in elderly patients, and permits early postoperative mobilization.

Carboplatin and weekly paclitaxel doublet chemotherapy compared with monotherapy in elderly patients with advanced non-small-cell lung cancer: IFCT-0501 randomised, phase 3 trial.

BACKGROUND: Platinum-based doublet chemotherapy is recommended to treat advanced non-small-cell lung cancer (NSCLC) in fit, non-elderly adults, but monotherapy is recommended for patients older than 70 years. We compared a carboplatin and paclitaxel doublet chemotherapy regimen with monotherapy in elderly patients with advanced NSCLC. METHODS: In this multicentre, open-label, phase 3, randomised trial we recruited patients aged 70-89 years with locally advanced or metastatic NSCLC and WHO performance status scores of 0-2. Patients received either four cycles (3 weeks on treatment, 1 week off treatment) of carboplatin (on day 1) plus paclitaxel (on days 1, 8, and 15) or five cycles (2 weeks on treatment, 1 week off treatment) of vinorelbine or gemcitabine monotherapy. Randomisation was done centrally with the minimisation method. The primary endpoint was overall survival, and analysis was done by intention to treat. This trial is registered, number NCT00298415. FINDINGS: 451 patients were enrolled. 226 were randomly assigned monotherapy and 225 doublet chemotherapy. Median age was 77 years and median follow-up was 30.3 months (range 8.6-45.2). Median overall survival was 10.3 months for doublet chemotherapy and 6.2 months for monotherapy (hazard ratio 0.64, 95% CI 0.52-0.78; p<0.0001); 1-year survival was 44.5% (95% CI 37.9-50.9) and 25.4% (19.9-31.3), respectively. Toxic effects were more frequent in the doublet chemotherapy group than in the monotherapy group (most frequent, decreased neutrophil count (108 [48.4%] vs 28 [12.4%]; asthenia 23 [10.3%] vs 13 [5.8%]). INTERPRETATION: Despite increased toxic effects, platinum-based doublet chemotherapy was associated with survival benefits compared with vinorelbine or gemcitabine monotherapy in elderly patients with NSCLC. We feel that the current treatment paradigm for these patients should be reconsidered. FUNDING: Intergroupe Francophone de Cancérologie Thoracique, Institut National du Cancer.

Effectiveness of a drug dosing service provided by community pharmacists in polymedicated elderly patients with renal impairment a comparative study

Background: Drug dosing errors are common in renal-impaired patients. Appropriate dosing adjustment and drug selection is important to ensure patients" safety and to avoid adverse drug effects and poor outcomes. There are few studies on this issue in community pharmacies. The aims of this study were, firstly, to determine the prevalence of dosing inadequacy as a consequence of renal impairment in patients over 65 taking 3 or more drug products who were being attended in community pharmacies and, secondly, to evaluate the effectiveness of the community pharmacist"s intervention in improving dosing inadequacy in these patients when compared with usual care. Methods: The study was carried out in 40 Spanish community pharmacies. The study had two phases: the first, with an observational, multicentre, cross sectional design, served to determine the dosing inadequacy, the drug-related problems per patient and to obtain the control group. The second phase, with a controlled study with historical control group, was the intervention phase. When dosing adjustments were needed, the pharmacists made recommendations to the physicians. A comparison was made between the control and the intervention group regarding the prevalence of drug dosing inadequacy and the mean number of drug-related problems per patient. Results: The mean of the prevalence of drug dosing inadequacy was 17.5% [95% CI 14.6-21.5] in phase 1 and 15.5% [95% CI 14.5-16.6] in phase 2. The mean number of drug-related problems per patient was 0.7 [95% CI 0.5-0.8] in phase 1 and 0.50 [95% CI 0.4-0.6] in phase 2. The difference in the prevalence of dosing inadequacy between the control and intervention group before the pharmacists" intervention was 0.73% [95% CI (−6.0) - 7.5] and after the pharmacists" intervention it was 13.5% [95% CI 8.0 - 19.5] (p < 0.001) while the difference in the mean of drug-related problems per patient before the pharmacists" intervention was 0.05 [95% CI( -0.2) - 0.3] and following the intervention it was 0.5 [95% CI 0.3 - 0.7] (p < 0.001). Conclusion: A drug dosing adjustment service for elderly patients with renal impairment in community pharmacies can increase the proportion of adequate drug dosing, and improve the drug-related problems per patient. Collaborative practice with physicians can improve these results.

Effectiveness of a drug dosing service provided by community pharmacists in polymedicated elderly patients with renal impairment a comparative study

Background: Drug dosing errors are common in renal-impaired patients. Appropriate dosing adjustment and drug selection is important to ensure patients" safety and to avoid adverse drug effects and poor outcomes. There are few studies on this issue in community pharmacies. The aims of this study were, firstly, to determine the prevalence of dosing inadequacy as a consequence of renal impairment in patients over 65 taking 3 or more drug products who were being attended in community pharmacies and, secondly, to evaluate the effectiveness of the community pharmacist"s intervention in improving dosing inadequacy in these patients when compared with usual care. Methods: The study was carried out in 40 Spanish community pharmacies. The study had two phases: the first, with an observational, multicentre, cross sectional design, served to determine the dosing inadequacy, the drug-related problems per patient and to obtain the control group. The second phase, with a controlled study with historical control group, was the intervention phase. When dosing adjustments were needed, the pharmacists made recommendations to the physicians. A comparison was made between the control and the intervention group regarding the prevalence of drug dosing inadequacy and the mean number of drug-related problems per patient. Results: The mean of the prevalence of drug dosing inadequacy was 17.5% [95% CI 14.6-21.5] in phase 1 and 15.5% [95% CI 14.5-16.6] in phase 2. The mean number of drug-related problems per patient was 0.7 [95% CI 0.5-0.8] in phase 1 and 0.50 [95% CI 0.4-0.6] in phase 2. The difference in the prevalence of dosing inadequacy between the control and intervention group before the pharmacists" intervention was 0.73% [95% CI (−6.0) - 7.5] and after the pharmacists" intervention it was 13.5% [95% CI 8.0 - 19.5] (p < 0.001) while the difference in the mean of drug-related problems per patient before the pharmacists" intervention was 0.05 [95% CI( -0.2) - 0.3] and following the intervention it was 0.5 [95% CI 0.3 - 0.7] (p < 0.001). Conclusion: A drug dosing adjustment service for elderly patients with renal impairment in community pharmacies can increase the proportion of adequate drug dosing, and improve the drug-related problems per patient. Collaborative practice with physicians can improve these results.

Falls efficacy predicts functional status on month after discharge in elderly patients undergoing post-accute rehabilitation

Objective: To investigate the relationship between falls efficacy at admission and functional status reported one month after discharge from post-acute rehabilitation in a cohort of elderly patients. Methods: Participants were elderly patients admitted to postacute rehabilitation in an academic geriatric facility. Data on demographics and affective status were collected upon admission; functional status and gait speed were measured at admission and at discharge; self-reported functional status and history of falls since discharge were collected one month after discharge (follow-up). Falls efficacy was measured using the Fall Efficacy Scale, that assesses confidence in performing 12 activities of daily living without falling (range 0 to 100, higher score indicating higher confidence). Patients were classified using the median FES score at baseline (95) as cut-off to divide the population into "confident" and "fearful" groups. Results: Participants' (N=180, mean age 81.3±7.1 years, 75.6% women) mean FES score was 92.3±8.7 at baseline (range 60-100). Basic ADL score averaged 3.5±1.6 at baseline, 4.7±1.3 at discharge, and 5.5±0.7 at follow-up (self-reported). Baseline FES score was positively correlated with basic ADL at follow-up (rho=0.35, p<.001). At follow-up, 58.7% of the patients were fully independent in basic ADL, this proportion being significantly higher in confident than fearful patients (70.7% vs 42.4%, p<.001). Compared to confident patients, those fearful had significantly lower odds (OR 0.3, 95%CI 0.2-0.6, p<.001) to report full independence at follow-up. This relationship remained (adjOR = 0.4, 95%CI 0.2-0.8, p=.01) after controlling for demographics, baseline gait speed, depressive symptoms, functional status at discharge, and history of falls since discharge. Conclusion: In this cohort of older rehab patients, poor falls efficacy at admission was associated with lower function reported one month after discharge even after controlling for initial mobility performance and functional status at discharge. Further studies should determine whether interventions aiming at falls efficacy improvement will also result in improved function in fearful subjects undergoing rehabilitation.

Glioblastoma in elderly patients: health-related quality of life (hrqol) in a randomized trial comparing 6-weeks of tadiotherapy (rt) vs hypofractionated rt over 2 weeks vs temozolomide chemotherapy (tmz)

BACKGROUND: Despite advances in treatment, survival of patients with GBM over 60 years is still often less than 1 year. In the perspective of a short expected survival, the quality of the remaining life and the effects of therapy on health-related quality of life (HRQoL) should be given special emphasis when recommending treatment for the individual patients. Several studies have focused on survival of the elderly, but few data are available on HRQoL for different treatments. In a randomized trial, we compared survival and HRQoL for 3 treatment options, 6 weeks of RT, vs hypofractionated RT, or chemotherapy with TMZ. MATERIALS AND METHODS: Newly diagnosed GBM patients, age ≥60 years with PS 0-2, were randomized to either standard RT (60 Gy in 2-Gy fractions over 6 weeks), hypofractionated RT (34 Gy in 3.4-Gy fractions over 2 weeks), or 6 cycles of chemotherapy with TMZ (200 mg/m2 day 1-5 every 28 days). QoL was determined by the EORTC QLQ 30 questionnaire and the Brain Cancer Module at inclusion, before start of therapy, at 6 weeks, 3 months, and 6 months after start of treatment. Patients were followed until death. The primary study endpoint was overall survival (OS) and secondary objectives were HRQoL, neurologic symptom control, and safety. RESULTS: A total of 342 patients were included and 292 patients were randomized between the 3 treatment options and 50 patients between hypofractionated RT and TMZ. Median age was 70 years (range 60-92) with 58% being male. Performance status was 0-1 for 75% of patients and 73% had undergone surgical resection. CONCLUSION: The results from the HRQoL analysis of this trial will be presented together with survival data at the upcoming EANO meeting.

Prospective comparison of clinical prognostic scores in elderly patients with pulmonary embolism.

Background: The Geneva Prognostic Score (GPS), the Pulmonary Embolism Severity Index (PESI), and its simplified version (sPESI) are well known clinical prognostic scores for pulmonary embolism (PE).Objectives: To compare the prognostic performance of these scores in elderly patients with PE. Patients/Methods: In a multicenter Swiss cohort of elderly patients with venous thromboembolism, we prospectively studied 449 patients aged ≥65 years with symptomatic PE. The outcome was 30-day overall mortality. We dichotomized patients as low- vs. higher-risk in all three scores using the following thresholds: GPS scores ≤2 vs. >2, PESI risk classes I-II vs. III-V, and sPESI scores 0 vs. ≥1. We compared 30-day mortality in low- vs. higher-risk patients and the areas under the receiver operating characteristic curve (ROC). Results: Overall, 3.8% of patients (17/449) died within 30 days. The GPS classified a greater proportion of patients as low risk (92% [413/449]) than the PESI (36.3% [163/449]) and the sPESI (39.6% [178/449]) (P<0.001 for each comparison). Low-risk patients based on the sPESI had a mortality of 0% (95% confidence interval [CI] 0-2.1%) compared to 0.6% (95% CI 0-3.4%) for low-risk patients based on the PESI and 3.4% (95% CI 1.9-5.6%) for low-risk patients based on the GPS. The areas under the ROC curves were 0.77 (95%CI 0.72-0.81), 0.76 (95% CI 0.72-0.80), and 0.71 (95% CI 0.66-0.75), respectively (P=0.47). Conclusions: In this cohort of elderly patients with PE, the GPS identified a higher proportion of patients as low-risk but the PESI and sPESI were more accurate in predicting mortality.

Screening fo osteoporosis in elderly patients admitted to post-acute rehabilitation.

Background: Screening for osteoporosis is important in older patients admitted to post-acute rehabilitation. However, DXA measurement is sometimes difficult to perform because of difficulties in positioning the patient and artefacts (osteoarthritis, prosthesis). The objectives were to determine the prevalence of unknown clinical osteoporosis in rehab patients and to determine new strategies for identifying clinical osteoporosis in this population. Method: Over a 9-months period, patients consecutively admitted to post-acute rehabilitation were included in th stdy. Patients with osteoporosis diagnosis, and those with terminal illness or severe physical limitations were excluded. Patients underwent Bone Mineral Density (BMD) by DXA and Vertebral Fracture Assessment (VFA). Clinical osteoporosis was defined as BMD ≤-2.5 SD at any site (lumbar spine, femoral neck, total hip or distal radius), ≥1 vertebral fracture, ≥1 hip fracture, or another fragility fracture and BMD ≤-2 SD. Results: Overall, 102 (17.0%) of the 600 patients admitted to rehab refused to participate in the study or were unable to consent. Among the 498 remaining patients, 99 (19.9%) were excluded because of already known diagnosis of osteoporosis, 101 (20.3%) were excluded because of terminal illness, severe physical limitations, and 45 (9.0%) because of inability to perform DXA during the stay (death, hospital transfer). Overall, 253 patients were assessed with DXA and VFA (166 women, mean age 83±7 years, mean BMI 27±6 kg/m2, and 87 men, mean age 82±6 yrs, mean BMI 27±5 kg/m2). Of these, 70% had history of fall during the last 6 months and 9.1% had hip fracture history. Prevalence of osteoporotic vertebral fracture was 36% in women and 32% in men. Overall, 152 (60.1%) patients had clinical osteoporosis (women: 67%; men: 46%) according to above criteria. Hip fracture history and vertebral fracture assessment identified correctly 105 (69.1%) of these 152 patients. Conclusion: A high prevalence of osteoporosis was observed in this population of rehab patients. Osteoporosis status should be systematically assessed in these patients at high fall risk, at least with careful history of hip fracture and an assessment for vertebral fractures with spine X-ray.

Du delirium au syndrome démentiel: prise en charge médicamenteuse dans les EMS fribourgeois [Management of elderly patients with delirium or dementia in Swiss nursing homes].

Management of elderly patients with delirium or dementia in Swiss nursing homes Dementia and delirium are among the most frequent medical conditions in older nursing home residents. Their management require a coordinated interdisciplinary approach, including for drug prescription. Using a systematic literature review of published meta-analyses and guidelines, prescription algorithms were developed adressing the pharmacological management of cognitive symptoms of dementia and delirium in older nursing home residents in the canton of Fribourg.

Validity of the FACIT-Sp to assess spiritual well-being in elderly patients

Among instruments measuring spiritual well-being, the Functional Assessment of Chronic Illness Therapy-Spiritual well-being (FACIT-Sp-12) is the most widely used instrument in research. It has been validated in patients suffering from cancer or HIV/AIDS, but has rarely been used in elderly patients. The objectives of this study were to determine the psychometric properties and suitability of the FACIT-Spto assess spiritual well-being in hospitalized elderly patients. This cross-sectional study uses a mixed method approach. Subjects were patients (N = 208), aged 65 years and older, consecutively admitted in post-acute rehabilitation. Psychometric properties of the FACITSp were investigated. The internal structure of the FACIT-Sp (factor structure and internal consistency) was assessed. Convergent validity of the FACIT-Sp was assessed using the Spiritual Distress Assessment Tool (SDAT), the question "Are you at peace?" and the Geriatric Depression Scale (GDS). Predictive validity was assessed using length of stay (LOS) and discharge destination. Understanding and interpretation of FACIT-Sp items were consecutively assessed in a sub-sample of 135 patients. Results show that FACIT-Sp scores ranged from 7 to 46 (mean 29.6 ± 7.8); 23.1% of the patients had high spiritual well-being. Cronbach's α was g ood ( 0.85). Item-to-total correlations were all significant (0.34 to 0.73). Principal component analyses performed with 2 or 3 factors were only moderately consistent with previous work. FACIT-Sp correlated with SDAT, "Are you at peace?" and GDS (Rho = −0.45, P < 0.001; 0.51, P < 0.001 and −0.38, P < 0.001). No association was found with LOS or discharge destination. Spontaneous comments about one or more FACIT-Sp items were made by 97/135 (71.9%). Specifically, items that address purpose and meaning in life were frequently found difficult to answer. Analyses suggest that the FACIT-Sp may underestimate spiritual well-being in older patients. In conclusion, despite having acceptable psychometric properties, the FACIT-Sp presents limitations for measurement of spiritual well-being in hospitalized elderly patients.

Traumatisme isolé du thorax chez la personne âgée [Isolated chest trauma in elderly patients].

In elderly patients, a blunt trauma of the chest is associated with a significant risk of complications and mortality. The number of ribs fractures (≥ 4), the presence of bilateral rib fractures, of a pulmonary contusion, of existent comorbidities or acute extra-thoracic traumatic lesions, and lastly the severity of thoracic pain, are indeed important risk factors of complications and mortality. Their presence may require hospitalization of the patient. When complications do occur, they are represented by alveolar hypoventilation, pulmonary atelectasia and broncho-pulmonary infections. When hospitalization is required, it may allow for the specific treatment of thoracic pain, including locoregional anesthesia techniques.

Pro and con arguments in using alternative dialysis regimens in the frail and elderly patients.

In the last decade, an increasing number of patients over 75 years of age are starting renal replacement therapy. Frailty is highly prevalent in elderly patients with end-stage renal disease (ESRD) in the context of the increased prevalence of some ESRD-associated conditions: protein-energy wasting, inflammation, anaemia, acidosis or hormonal disturbances. There are currently no hard data to support guidance on the optimal duration of dialysis for frail/elderly ESRD patients. The current debate is not about starting dialysis or managing conservatory frail ESRD patients, but whether a more intensive regimen once dialysis is initiated (for whatever reasons and circumstances) would improve patients' outcome. The most important issue is that all studies performed with extended/alternative dialysis regimens do not specifically address this particular type of patients and therefore all the inferences are derived from the general ESRD population. Care planning should be responsive to end-of-life needs whatever the treatment modality. Care in this setting should focus on symptom control and quality of life rather than life extension. We conclude that, similar to the general dialysed population, extensive application of more intensive dialysis schedules is not based on solid evidence. However, after a thorough clinical evaluation, a limited period of a trial of intensive dialysis could be prescribed in more problematic patients.

Association between smoking and recurrence of venous thromboembolism and bleeding in elderly patients with past acute venous thromboembolism.

BACKGROUND: While the association between smoking and arterial cardiovascular events has been well established, the association between smoking and venous thromboembolism (VTE) remains controversial. OBJECTIVES: To assess the association between smoking and the risk of recurrent VTE and bleeding in patients who have experienced acute VTE. PATIENTS/METHODS: This study is part of a prospective Swiss multicenter cohort that included patients aged ≥65years with acute VTE. Three groups were defined according to smoking status: never, former and current smokers. The primary outcome was the time to a first symptomatic, objectively confirmed VTE recurrence. Secondary outcomes were the time to a first major and clinically relevant non-major bleeding. Associations between smoking status and outcomes were analysed using proportional hazard models for the subdistribution of a competing risk of death. RESULTS: Among 988 analysed patients, 509 (52%) had never smoked, 403 (41%) were former smokers, and 76 (8%) current smokers. After a median follow-up of 29.6months, we observed a VTE recurrence rate of 4.9 (95% confidence interval [CI] 3.7-6.4) per 100 patient-years for never smokers, 6.6 (95% CI 5.1-8.6) for former smokers, and 5.2 (95% CI 2.6-10.5) for current smokers. Compared to never smokers, we found no association between current smoking and VTE recurrence (adjusted sub-hazard ratio [SHR] 1.05, 95% CI 0.49-2.28), major bleeding (adjusted SHR 0.59, 95% CI 0.25-1.39), and clinically relevant non-major bleeding (adjusted SHR 1.21, 95% CI 0.73-2.02). CONCLUSIONS: In this multicentre prospective cohort study, we found no association between smoking status and VTE recurrence or bleeding in elderly patients with VTE.