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Tailoring Assessments and Prescription in Cardiac Rehabilitation for Older Adults: The Relevance of Geriatric Domains.
Fiatarone Singh, MA
Clinics in geriatric medicine. 2019;(4):423-443
Abstract
Older adults have distinctive health challenges that are relevant to the prevention and treatment of cardiovascular diseases and are potentially modifiable by cardiac rehabilitation. Cardiac rehabilitation in older adults provides opportunity to assess sarcopenia, obesity, osteoporosis, frailty, falls risk, arthritis, cognition, special senses, self-efficacy, depression, social support, polypharmacy, and nutritional adequacy. Therefore, broadening standard assessments to include these domains can help detect modifiable vulnerabilities and inform therapeutic priorities.
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Peri-operative optimisation of elderly and frail patients: a narrative review.
Chan, SP, Ip, KY, Irwin, MG
Anaesthesia. 2019;:80-89
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Abstract
With increasing life expectancy and technological advancement, provision of anaesthesia for elderly patients has become a significant part of the overall case-load. These patients are unique, not only because they are older with more propensity for comorbidity but a decline in physiological reserve and cognitive function invariably accompanies ageing; this can substantially impact peri-operative outcome and quality of recovery. Furthermore, it is not only morbidity and mortality that matters; quality of life is also especially relevant in this vulnerable population. Comprehensive geriatric assessment is a patient-centred and multidisciplinary approach to peri-operative care. The assessment of frailty has a central role in the pre-operative evaluation of the elderly. Other essential domains include optimisation of nutritional status, assessment of baseline cognitive function and proper approach to patient counselling and the decision-making process. Anaesthetists should be proactive in multidisciplinary care to achieve better outcomes; they are integral to the process.
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Relevance to assess and preserve muscle strength in aging field.
Buckinx, F, Aubertin-Leheudre, M
Progress in neuro-psychopharmacology & biological psychiatry. 2019;:109663
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According to the revised European consensus on sarcopenia, muscle strength is the primary parameter of sarcopenia and is associated with adverse outcomes or physical limitation. This literature review aims to clarify how and why to measure and preserve muscle strength in older population. Overall, the relationship between muscle strength and physical function is impacted by level of muscle mass, the degree of obesity (BMI), age and physical activity. Therefore, these factors are to be considered in the evaluation of muscle strength. It is necessary to have objective, reliable and sensitive tools to assess muscle strength, in different populations to detect and quantify weakness, to adapt physical exercises to patients' capacity and to evaluate the effects of treatment. Handgrip strength measurement might be reasonable for clinical practice while the measurement of knee flexors/extensors strength with both 1RM and dynamometers is increasingly important yet restricted by the requirement of special equipment. Physical activity and nutrition are two important behavioral factors to maintain muscle strength. Combined exercise and nutrition interventions improved muscle strength to a more prominent degree than exercise or nutrition alone.
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Geriatric Nutritional Risk Index as a predictor for mortality: a meta-analysis of observational studies.
Hao, X, Li, D, Zhang, N
Nutrition research (New York, N.Y.). 2019;:8-20
Abstract
The Geriatric Nutritional Risk Index (GNRI) is a valuable simplified tool to predict mortality. However, the results of previous studies are inconsistent and controversial. To summarize the evidence regarding the association of GNRI levels with the risk of all-cause and cardiovascular (CV) mortality, we conducted this meta-analysis. Relevant studies were identified through a systematic electronic literature search. We estimated combined hazard ratios (HRs) to assess the association between GNRI and the risk of mortality by using a meta-analysis method. The Cochrane Q test and the inconsistency statistic were used to assess the between-study heterogeneity. Subgroup analysis and sensitivity analysis were performed. Twenty-six observational studies involving 17 097 participants were identified in this meta-analysis. With the highest category used as the reference group, the lowest-category GNRI was significantly associated with an increased risk of all-cause (HR: 1.32, 95% confidence interval: 1.22-1.43) and CV (HR = 2.10, 95% confidence interval: 1.72-2.57) mortality. Subgroup analyses based on the participant ethnicity, age, and the duration of the follow-up period did not substantially change the main results. In summary, a lower GNRI is associated with an elevated risk of both all-cause and CV mortality. Given the significant heterogeneity among the included studies, further investigations with larger sample sizes are required to confirm the value of the GNRI in predicting mortality and to explore the combined effects of malnutrition and mortality.
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Cardiac Rehabilitation in Older Adults with Heart Failure: Fitting a Square Peg in a Round Hole.
Flint, KM, Pastva, AM, Reeves, GR
Clinics in geriatric medicine. 2019;(4):517-526
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Cardiac rehabilitation (CR) is a structured exercise and lifestyle program that improves mortality and quality of life in patients with heart failure (HF) with reduced ejection fraction. However, significant gaps remain in optimizing CR for older adults with HF. This review summarizes the state of the science and specific knowledge gaps regarding older adults with HF. The authors discuss the importance of geriatric complexities in the design and implementation of CR, summarize promising future research in this area, and provide a clinical framework for current CR clinicians to follow when considering the specific needs of older adults with HF.
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Peripheral Arterial Disease: Supervised Exercise Therapy Through Cardiac Rehabilitation.
Thomas, SG, Marzolini, S, Lin, E, Nguyen, CH, Oh, P
Clinics in geriatric medicine. 2019;(4):527-537
Abstract
Peripheral arterial disease (PAD) is frequently underdiagnosed and undertreated. This review identifies specific subgroups within older adults more likely to develop PAD, and describes methods to diagnose PAD and provide evidence in support of systematic referral to cardiac rehabilitation programs to enhance successful comprehensive management. Clear evidence and guidelines support the routine use of supervised exercise therapy to improve function, reduce risk of cardiovascular morbidity and mortality, and enhance the success of endovascular interventions.
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Malnutrition Screening and Assessment in Hospitalised Older People: a Review.
Dent, E, Hoogendijk, EO, Visvanathan, R, Wright, ORL
The journal of nutrition, health & aging. 2019;(5):431-441
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Malnutrition (undernutrition) remains one of the most serious health problems for older people worldwide. Many factors contribute to malnutrition in older people, including: loss of appetite, polypharmacy, dementia, frailty, poor dentition, swallowing difficulties, social isolation, and poverty. Malnutrition is common in the hospital setting, yet often remains undetected by medical staff. The objective of this review is to compare the validity and reliability of Nutritional Screening Tools (NSTs) for older adults in the hospital setting. We also provide an overview of the various nutritional screening and assessment tools used to identify malnutrition in hospitalised older adults. These include: Subjective Global Assessment (SGA), the Mini Nutritional Assessment (MNA), MNA-short form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Simplified Nutritional Appetite Questionnaire (SNAQ), Geriatric Nutrition Risk Index (GNRI) and anthropometric measurements. The prevalence and outcomes of malnutrition in hospitalised older adults are also addressed.
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The Role of the Comprehensive Geriatric Assessment in the Evaluation of the Older Cancer Patient.
Blanquicett, C, Cohen, JB, Flowers, C, Johnson, T
Oncology (Williston Park, N.Y.). 2019;(11)
Abstract
Geriatric assessments have now been recommended as part of the standard evaluation of an older adult considering cancer therapy. While the need for a more in-depth performance status evaluation of an older person with cancer was identified over 20 years ago, completion of a comprehensive geriatric assessment (CGA) is time-consuming and not frequently performed as part of the standard assessment of older cancer patients. Evidence suggests that incorporating such an evaluation could be useful for potentially determining the patient's chemotherapy tolerability or treatment completion, toxicity, and survival, as age alone has been shown to poorly predict treatment failure, and performance status assessments commonly used in oncology practice may lack predictability. This review describes the increasing role of the CGA and geriatric assessment screening tools as well as their pertinent domains across various settings in the evaluation of the older adult with cancer who is considering cancer treatment.
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Preoperative Management of the Geriatric Patient: Frailty and Cognitive Impairment Assessment.
Dalton, A, Zafirova, Z
Anesthesiology clinics. 2018;(4):599-614
Abstract
As the population ages, more geriatric patients will be presenting for surgical procedures. Preoperative evaluation seeks to assess patients for geriatric syndromes: frailty, sarcopenia, functional dependence, and malnutrition. Age-related changes in physiology increase risk for central nervous system, cardiovascular, pulmonary, renal, hepatic, and endocrine morbidity and mortality. Identification of various comorbidities allows for preoperative optimization and for opportunities for intervention including nutritional supplementation and prehabilitation, which may improve postoperative outcomes.
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Preoperative Assessment in Older Adults: A Comprehensive Approach.
Kumar, C, Salzman, B, Colburn, JL
American family physician. 2018;(4):214-220
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Abstract
Surgical outcomes are significantly influenced by patients' overall health, function, and life expectancy. A comprehensive geriatric preoperative assessment of older adults requires expanding beyond an organ-based or disease-based assessment. At a preoperative visit, it is important to establish the patient's goals and preferences, and to determine whether the risks and benefits of surgery match these goals and preferences. These discussions should cover the possibility of resuscitation and ventilator support, prolonged rehabilitation, and loss of independence. The assessment should include evaluation of medical comorbidities, cognitive function, decision-making capacity, functional status, fall risk, frailty, nutritional status, and potentially inappropriate medication use. Problems identified in any of these key areas are associated with an increased risk of postoperative complications, institutionalization, functional decline, and, in some cases, mortality. If a patient elects to proceed with surgery, the risks should be communicated to surgical teams to allow for inpatient interventions that lower the risk of postoperative complications and functional decline, such as early mobilization and limiting medications that can cause delirium. Alcohol abuse and smoking are associated with increased rates of postoperative complications, and physicians should discuss cessation with patients before surgery. Physicians should also assess patients' social support systems because they are a critical component of discharge planning in this population and have been shown to predict 30-day postoperative morbidity.