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[Frailty as potential indicator of perioperative risk for older patients].
Derwall, M, Coburn, M
Der Anaesthesist. 2020;(3):151-158
Abstract
BACKGROUND Physical, cognitive and social frailty is increasingly being recognized as a prognostic factor in the perioperative treatment of older patients; however, the concept of frailty has not been introduced into clinical routine in anesthesia. OBJECTIVES Definition of terms, presentation of tools for determining the degree of frailty and measures to improve the clinical outcome of patients at risk. Proposal of a pragmatic approach for the detection and treatment of high-risk patients in everyday clinical practice. MATERIAL AND METHODS Evaluation of current reviews and original publications. Discussion and modification of established frailty assessment tools in context of the needs in perioperative medicine. RESULTS The degree of frailty is associated with the postoperative outcome. Depending on the definition used, the term frailty refers to a degraded resilience in the physical, mental or social domain. Although there is still no universal definition of frailty, it is clear that frailty is directly correlated with survival and postoperative morbidity. Classical perioperative risk markers such as age or ASA classification do not reach such high predictive value. For the perioperative screening and evaluation of frail patients, an adapted version of the MAGIC assessment in combination with two signal questions is recommended. The extent of frailty in a patient can be improved by a sufficient diet, by physiotherapeutic exercises and by providing cognitive aids; however, scientific proof that preoperative improvement of the frailty status subsequently improves postoperative results is available for only a few specific clinical conditions. CONCLUSION In contrast to commonly used perioperative risk classifications, frailty is a sensitive marker for the patient's biological age. Therefore, it appears more suitable for estimating the perioperative risk than chronological age or other conventional tools, such as the ASA classification and is therefore a prerequisite for patient centered treatment pathways.
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Trans-specific Geriatric Health Assessment (TGHA): An inclusive clinical guideline for the geriatric transgender patient in a primary care setting.
Gamble, RM, Taylor, SS, Huggins, AD, Ehrenfeld, JM
Maturitas. 2020;:70-75
Abstract
There is a growing concern in the field of geriatric medicine that transgender health is often overlooked and under-reported. Not only does this impact the health and safety of the aging transgender community, but it also often influences the ability of physicians to provide high-quality evidence-based care. This article reviews the current knowledge base for geriatric transgender health and aims to organize evidence-based clinical recommendations for the primary care provider. Our proposed guideline, the Trans-specific Geriatric Health Assessment (TGHA), highlights areas of current clinical practice that do not address the geriatric transgender experience and modifies them to include trans-specific clinical recommendations found in the literature. The TGHA emphasizes topics such as cognitive function, vision and hearing, gait and stability, nutrition, sleep, functional/social status, urogenital health, psychiatric health, hormone replacement therapy, cancer screening, disease prevention and advanced care planning. Our review also addresses the limitations of certain clinical topics and where there is significant need for supportive research.
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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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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.