Timing of Hospice Referral and Families' Perceptions of Services: Are Earlier Hospice Referrals Better?

OBJECTIVES: To determine whether families of patients who enroll in hospice near the end of life believe that they receive less benefit from hospice services than families of patients who enroll earlier. DESIGN: Semistructured interviews at the time of hospice enrollment and 1 month after the patient's death. SETTING: This study was conducted at the Hospice of Lancaster County, Lancaster, PA, over a 12-month period spanning 2003-2004. PARTICIPANTS: First-time hospice admissions. MEASUREMENTS: Interviews assessed the anticipated helpfulness of six hospice services (enrollment interviews) and the actual helpfulness of the same services (follow-up interviews). RESULTS: Length of stay in hospice was associated with families' reports of the number of services provided (Spearman rho=0.34, P<.001), and with the mean helpfulness ratings for the services that were provided (Spearman rho=0.34, P<.001), although even with short lengths of stay, most families reported that they received the services that they anticipated and that those services were helpful. CONCLUSION: These results indicate that families feel they receive greater benefits from longer lengths of stay in hospice. Future efforts to define an "optimal" length of stay in hospice should consider patients' and families' perceptions of the benefits that hospice offers.     

Is Endoscopic Retrograde Cholangiopancreatography Safe in Patients 90 Years of Age and Older?

Background/Aims

This case-control study evaluated the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in patients 90 years of age and older.

Methods

From January 2005 to August 2011, 5,070 cases of ERCP were performed at our institution. Of these, 43 cases involved patients 90 years of age and older (mean age, 91.7±1.9 years). A control group of 129 cases (mean age, 65.7±14.8 years) was matched by the patient sex, sphincterotomy, and presence of choledocholithiasis using a propensity score. The patients’ medical records were retrospectively reviewed for comorbidity, periampullary diverticulum, urgent procedure, conscious sedation, technical success, procedure duration, ERCP-related complication, and death.

Results

Between the case and control groups, there was no significant difference with regard to comorbidity, periampullary diverticulum, and urgent procedure. Conscious sedation was performed significantly less in the patient group versus the control group (28 [65%] vs 119 [92%], respectively; p=0.000). There was no significant difference in the technical success, procedure duration, or ERCP-related complications. In both groups, there was no major bleeding or perforation related to ERCP. Post-ERCP pancreatitis occurred significantly less in the patient group compared to the control group (0 vs 13 [10%], respectively; p=0.004). One death occurred from respiratory arrest in the case group.

Conclusions

ERCP can be performed safely and successfully in patients aged 90 years and older without any significant increase in complications.     

How Do Patients Aged 85 and Older Fare with Abdominal Surgery?

OBJECTIVES: To review the outcomes of patients aged 85 and older after abdominal surgery in terms of mortality, morbidity, and change in residential status and to analyze factors predicting such outcomes.
DESIGN: Retrospective clinical cohort study.
SETTING: A tertiary regional hospital in Victoria, Australia.
PARTICIPANTS: One hundred seventy-nine patients aged 85 and older who had abdominal surgery between 1998 and 2008.
MEASUREMENTS: Mortality, complications (morbidity), and change in residential status.
RESULTS: The patient sample had a mean age of 88.6, a mortality rate of 17.3%, and a morbidity rate of 62.8%. Approximately two-thirds (64%) of all abdominal surgeries were emergency surgeries. Factors predicting mortality included American Society of Anesthesiologists (ASA) score and premorbid residential status. Risk factors predicting severity of complications were ASA score and emergency surgery. Significant factors contributing to change in residential status were ASA score and severity of complications. Age, sex, and number of comorbidities were not significant factors.
CONCLUSION: Patients aged 85 and older experienced mortality rates of 17.3% after abdominal surgery. ASA score and premorbid residential status appear to be more important than age in determining risk for abdominal surgery in older persons.     

Are Survival Rates Different for Young and Older Patients With Rectal Cancer?

PURPOSE Although it is generally believed that young patients with rectal cancer have worse survival rates, no comprehensive analysis has been reported. This study uses a national-level, population-based cancer registry to compare rectal cancer outcomes between young vs. older populations.METHODS All patients with rectal carcinoma in the Surveillance, Epidemiology, and End Results cancer database from 1991 to 1999 were evaluated. Young (range, 20–40 years; n = 466) and older groups (range, 60–80 years; n = 11,312) were compared for patient and tumor characteristics, treatment patterns, and five-year overall and stage-specific survival. Cox multivariate regression analysis was performed to identify predictors of survival.RESULTS Mean ages for the groups were 34.1 and 70 years. The young group was comprised of more black and Hispanic patients compared with the older group (P < 0.001). Young patients were more likely to present with late-stage disease (young vs. older: Stage III, 27 vs. 20 percent respectively, P < 0.001; Stage IV, 17.4 vs. 13.6 percent respectively, P < 0.02). The younger group also had worse grade tumors (poorly differentiated 24.3 vs. 14 percent respectively, P < 0.001). Although the majority of both groups received surgery (85 percent for each), significantly more young patients received radiation (P < 0.001). Importantly, overall and stage-specific, five-year survival rates were similar for both groups (P = not significant).CONCLUSIONS Although previous studies have found young rectal cancer patients to have poorer survival compared with older patients, this population-based study shows that young rectal cancer patients seem to have equivalent overall and stage-specific survival.Supported in part by The American Society of Colon and Rectal Surgeons Limited Project Grant.Presented at the meeting of the Association for Academic Surgery, Sacramento, California, November 13 to 15, 2003.     

Older Patients with Colon Cancer: Is Adjuvant Chemotherapy Safe and Effective?

PURPOSE: To investigate the efficacy and toxicity of fluorouracil‐based adjuvant chemotherapy in patients aged 70 years and older with resected Stage II or III colon cancer who are at high risk for recurrence. BACKGROUND: Colorectal cancer accounts for 15% of all cancers in men and women and, after lung cancer, is the second‐leading cause of cancer overall and the first in women aged 75 and older. 1 Older patients with cancer do not receive what is considered to be standard chemotherapy and are treated less often than younger patients regardless of the disease site or stage at diagnosis. 2 , 3 Adjuvant chemotherapy for colon cancer reduces the risk of death significantly, compared with surgery alone. 4 , 5 Currently, fluorouracil plus leucovorin for 6 to 8 months is standard adjuvant treatment for node‐positive Stage III colon cancer. 6 , 7 The benefits of fluorouracil‐based therapy for Stage II colon cancer are unclear. For all patients with colon carcinoma in the National Cancer Data Base, the use of surgery plus chemotherapy declined with age; 40% of patients younger than 50 received both treatments, compared with 20% of patients aged 70 to 79. There is now accumulating evidence suggesting that selected older patients can receive the same benefit as their younger counterparts, without a significant increase in toxic effects. A careful appraisal of the treatment of older patients with adjuvant chemotherapy for colon cancer is presented. DATA SOURCES: All reported studies (except three trials that have not yet completed follow‐up and one trial unavailable because of computer malfunction) comparing postoperative fluorouracil plus leucovorin or fluorouracil plus levamisole with surgery alone were identified using a Medline search, a search of bibliographies, and discussion with the leaders of each identified trial. STUDY SELECTION CRITERIA: Seven studies that met the following criteria were included in this pooled analysis: inclusion of patients aged 70 and older; type of chemotherapy used was fluorouracil plus leucovorin or fluorouracil plus levamisole, treatment started between 21 and 56 days after surgery, and patients with Stage II or III adenocarcinoma of the colon who underwent curative resection were enrolled. In all seven trials, patients with Stage II or III colon cancer were randomly assigned to chemotherapy or no treatment after surgery. Five studies tested fluorouracil in doses ranging from 370 to 425 mg/m² of body surface area and leucovorin in doses ranging from 20 to 200 mg/m² daily for 5 days, repeated every 4 to 5 weeks. The duration of treatment in the trials of fluorouracil plus leucovorin was six cycles in four of the trials and 12 cycles in the fifth. In the other two trials, fluorouracil was administered by rapid intravenous injection at a dose of 450 mg/m² on 5 consecutive days. On day 28, weekly injections of the same dose were given to the patient. Throughout treatment, levamisole was administered orally at a dose of 50 mg three times daily from Day 1 through 3 and repeated every 2 weeks. The duration of treatment in both trials of fluorouracil plus levamisole was 1 year. Adverse events were graded according to National Cancer Institute Common Toxicity Criteria or the World Health Organization Toxicity Scale. In all trials, patients were examined and toxicity data were documented at least monthly. DATA EXTRACTION: The outcome and toxic effects recorded for each patient were obtained from all seven trials. The primary endpoints were overall survival (defined as time from study entry to death) and time to recurrence (defined as the time from study entry to first confirmed relapse). Data on overall survival and time to recurrence were analyzed up to 8 years from the date of randomization. The primary statistical goal of the analysis was to test for an age‐by‐treatment interaction. The results were presented using 10‐year age groups. Multivariate models were used to adjust for baseline performance status and stage. Relationships between rates of adverse events and age were analyzed using Pearson statistics. Hazard ratios (HRs), with accompanying 95% confidence intervals (CIs), were reported for comparisons of patients who received chemotherapy and those who did not. RESULTS: Of 3,347 patients from seven randomized trials, 86 (2.5%) were deemed ineligible and were excluded from the pooled analysis. Of the rest, 43% had Stage II and 57% Stage III disease. A Death without the recurrence of cancer: The probability of death without recurrence of cancer was strongly associated with age. The oldest patients had a higher probability of dying without evidence of recurrence (13%) than the youngest patients (2%). In addition, 32% of deaths of the oldest patients but only 5% of deaths of the youngest patients were due to causes other than the cancer. Approximately 30% of the patients in each group died with recurrence of cancer over the 8‐year follow‐up period. B Effect of chemotherapy: Adjuvant chemotherapy had a significant positive effect on overall survival and time to tumor recurrence (P < .001 for each). The 5‐year overall survival was 71% for those who received adjuvant therapy, compared with 64% for those untreated ( HR for death from any cause = 0.76; 95% CI = 0.68–0.85). The 5‐year recurrence‐free rate was 69% in treated patients, compared with 58% in untreated patients (HR for recurrence = 0.68; 95% CI = 0.60–0.76). No significant interaction was observed between age and efficacy of treatment. The P‐values for the test of interaction in which age was divided into four categories were 0.61 for overall survival and 0.33 for the time to tumor recurrence. The overall survival and freedom from recurrence was similar in the adjuvant treatment and no adjuvant treatment groups according to age group for the first 5 years of follow‐up. After 5 years, patients aged 70 and older had decreased overall survival because of death from other causes. C Adverse events according to age group: Although it was not a randomized comparison, patients treated with fluorouracil plus levamisole had significantly more leukopenia and nausea or vomiting (P = .001 and P = .05, respectively), whereas those treated with fluorouracil plus leucovorin had significantly more stomatitis and diarrhea (P = .001 for both comparisons). Therefore, separate analysis of toxicity according to age for the two treatment regimens was performed. Age was not significantly related to the rate of Grade 3 or higher nausea or vomiting, stomatitis, or diarrhea in patients treated with fluorouracil plus leucovorin or fluorouracil plus levamisole. Leukopenia was significant in patients with levamisole and fluorouracil treatment (31% of subject ≥70 vs 17% of subject <70, P < .001) and borderline significantly higher in patients with fluorouracil and leucovorin treatment (8% of subjects ≥70 vs 4% of subjects <70, P = .05). CONCLUSION: This analysis supports the benefit of adjuvant chemotherapy in patients with resected Stage II and III colon cancer. There is no evidence that the susceptibility of colon cancer to chemotherapy differs in younger and older patients. In this analysis, older patients did not have higher rates of nausea, vomiting, stomatitis, or diarrhea than younger patients. Leukopenia was significantly higher in older patients who received fluorouracil and levamisole and was borderline significantly higher in those who received fluorouracil and leucovorin. No reductions in the dose of fluorouracil are recommended for patients with altered renal or hepatic function, because this may decrease the efficacy. 7 The patients enrolled in these trials may not be representative of all older patients with colon cancer.     

Dysphagia and Advancing Age: Are Manometric Abnormalities More Common in Older Patients?

The universal process of aging may result in physiologic deterioration. Dysphagia may be more common in older patients. The effect of aging on esophageal manometry is not well established. The aim of this study was to determine if esophageal motility studies and associated symptoms in older patients with dysphagia differ significantly from younger patients. Patients who were 65 years of age or older (N = 53) were compared with patients who were 18–45 years of age (N = 53). Presenting symptoms, manometric findings, and diagnoses were compared between the two groups. In the older group, there were 29 women (55%), in the younger group there were 35 women (66%). The mean age of the older group was 75 ± 7 years, the mean age in the younger group was 34 ± 7 years. All patients reported dysphagia to solids. No significant differences were found in the reporting of associated symptoms. There were no significant differences in average lower esophageal sphincter (LES) resting pressure, residual LES pressure, LES relaxation, or peristalsis between groups. Older patients were as likely to have a normal study as younger patients (18% vs 23%, P = NS) and were also as likely to have the diagnosis of achalasia (32% vs 34%, P = NS). In conclusion, older and younger patients referred for manometric study of dysphagia have similar manometric findings. Esophageal manometry can be helpful in determining abnormalities in motility in both older and younger patients.     

The Accuracy of Clinician Perceptions of “Usual” Blood Pressure Control

BACKGROUND The term “clinical inertia” is used to describe the failure to manage a chronic condition aggressively enough to bring it under control. The underlying mechanisms for clinical inertia remain poorly understood. OBJECTIVE To describe one potential mechanism for clinical inertia, seen through the lens of clinician responses to a computerized hypertension reminder. DESIGN Cohort study. PARTICIPANTS A total of 509 hypertensive patients from 2 primary care clinics in urban Veterans Health Administration (VA) Medical Centers. All patients had elevated blood pressure (BP) values that triggered a computerized reminder. Given a set of possible responses to the reminder, clinicians asserted at least once for each patient that medication adjustments were unnecessary because the BP was “usually well controlled”. MEASUREMENTS Using recent BP values from the electronic medical record, we assessed the accuracy of this assertion. RESULTS In most instances (57%), recent BP values were not well controlled, with the systolic BP (56%) much more likely to be elevated than the diastolic BP (13%). Eighteen percent of recent systolic BP values were 160 mmHg or greater. CONCLUSIONS When clinicians asserted that the BP was “usually well controlled”, objective evidence frequently suggested otherwise. This observation provides insight into one potential mechanism underlying clinical inertia.     

Natural Orifice Translumenal Endoscopic Surgery (NOTES): Patients�� Perceptions and Attitudes

Background

Natural orifice translumenal endoscopic surgery (NOTES) has generated a surge of enthusiasm among researchers by virtue of its challenge to the dogma and potential benefits. However, no data is available in the medical literature about NOTES' acceptance by patients in Asia. The aim of the study is to survey patients?? perceptions and attitudes towards NOTES.

Methods

It is a questionnaire-based multi-center study on inpatient subjects with various gastrointestinal disorders from 14 hospitals in 12 cities of China. Procedural details with the benefits and risks of NOTES, laparoscopic surgery, and conventional surgery were explained to all registered candidates. They were required to choose and cite reasons for adopting one of the above three surgical techniques as the preferred mode of treatment. The reasons for selection of the surgical treatment were: safety, efficacy, cost, postoperative pain, abdominal wounds, and scarring.

Results

There were 1,797 cases, including 976 (54.3%) males and 821 females (45.7%). Based on their comprehension of the procedure, 802 (44.6%) patients opted for NOTES, 757 (42.1%) for laparoscopic surgery, and 238 (13.2%) for conventional surgery. NOTES was mainly selected by the young and educated persons, especially females and by those with past exposure to laparoscopy or conventional surgery. The choice of treatment was significantly correlated with age (P = 0.0021), education (P = 0.0209), past medical history (laparoscopy, P = 0.0134; open surgery, P < 0.0001), and department of admission (P = 0.0173). The preference for NOTES was based on safety (37.3%), cost (17.6%), elimination of postoperative scars (16.1%), abdominal wounds (16.0%), and efficacy (13.1%).

Conclusions

The vast majority of patients prefer mini-invasive surgery to conventional surgery. The potential recipients of NOTES are educated and younger age groups. However, a few consider NOTES as a safe and effective intervention at present.     

How Can Optimization of Medical Treatment Avoid Unnecessary Implantable Cardioverter-Defibrillator Implantations in Patients With Idiopathic Dilated Cardiomyopathy Presenting With “SCD-HeFT Criteria?”

To assess the proportion and long-term outcomes of patients with idiopathic dilated cardiomyopathy and potential indications for implantable cardioverter-defibrillator before and after optimization of medical treatment, 503 consecutive patients with idiopathic dilated cardiomyopathy were evaluated from 1988 to 2006. A total of 245 patients (49%) satisfied the "Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) criteria," defined as a left ventricular ejection fraction of ≤0.35 and New York Heart Association (NYHA) class II-III on registration. Among these, 162 (group A) were re-evaluated 5.4 ± 2 months later with concurrent β-blockers and angiotensin-converting enzyme inhibitor use. Of the 162 patients, 50 (31%) still had "SCD-HeFT criteria" (group A1), 109 (67%) had an improved left ventricular ejection fraction and/or New York Heart Association class (group A2), and 3 (2%) were in NYHA class IV. Of the 227 patients without baseline "SCD-HeFT criteria" (left ventricular ejection fraction >0.35 or NYHA class I), 125 were evaluated after 5.5 ± 2 months. Of these 227 patients, 13 (10%) developed "SCD-HeFT criteria" (group B1), 111 (89%) remained without "SCD-HeFT criteria" (group B2), and 1 (1%) had worsened to NYHA class IV. The 10-year mortality/heart transplantation and sudden death/sustained ventricular arrhythmia rate was 57% and 37% in group A1, 23% and 20% in group A2 (p <0.001 for mortality/heart transplantation and p = 0.014 for sudden death/sustained ventricular arrhythmia vs group A1), 45% and 41% in group B1 (p = NS vs group A1), 16% and 14% in group B2 (p = NS vs group A2), respectively. In conclusion, two thirds of patients with idiopathic dilated cardiomyopathy and "SCD-HeFT criteria" at presentation did not maintain implantable cardioverter-defibrillator indications 3 to 9 months later with optimal medical therapy. Their long-term outcome was excellent, similar to that observed for patients who had never met the "SCD-HeFT criteria."     

Cardiovascular Risks of Probenecid Versus Allopurinol in Older Patients With Gout

Background

Patients with gout are at an increased risk of cardiovascular (CV) disease including myocardial infarction (MI), stroke, and heart failure (HF).

Does the St. Mark’s Incontinence Score Reflect Patients’ Perceptions? A Review of 390 Patients

Purpose The St. Mark’s incontinence score is widely used to evaluate the severity of fecal incontinence. It is unknown to what extent such scores relate to patients’ perceptions about their condition. The primary goal of this study was to assess this correlation. Secondary goals were to evaluate the relationship between different types of incontinence, age, gender, and the continence score and to assess the sensitivity of St. Mark’s incontinence score to a change in patients’ perception and outcome evaluation after treatment. Methods Patients’ subjective perception of bowel control (using a 0–10 scale) and St. Mark’s incontinence score for 390 patients were reviewed. Change in the score was documented for 131 patients who underwent biofeedback treatment and compared with patients’ outcome evaluation. Results There was a moderate correlation between patients’ perception of bowel control and the St. Mark’s incontinence score (r = −0.55; P < 0.001). The correlation was maintained, regardless of type of incontinence (r = −0.48 to −0.55), age (≤60 years: r = −0.54; >60 years: r = −0.58; P < 0.001) or gender (male: r = −0.48; female: r = −0.53; P < 0.001) of patients. St. Mark’s incontinence score was sensitive to a change in patients’ subjective evaluation after the treatment. Conclusions The St. Mark’s incontinence score correlates moderately well with patients’ subjective perception and is reliable regardless of the type of incontinence, patients’ age, or gender. It is suitable for the severity assessment of fecal incontinence and the evaluation of a treatment outcome. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. Reprints are not available     

Lipid-Lowering Therapy in Patients 75 Years and Older: Clinical Priority or Superfluous Therapy?

The incidence and prevalence of cardiovascular (CV)-related morbidity and mortality significantly increase with age. In the elderly, hypercholesterolemia with elevated total and low-density-lipoprotein cholesterol is a significant predictor of incident and recurrent CV disease. Multiple lines of evidence have established the benefit of statin therapy to lower cholesterol levels and reduce the risk of CV events as well as prevent progression of subclinical atherosclerotic disease. Elderly patients, particularly those older than 75 years, have not been well represented in randomized clinical trials evaluating lipid lowering therapy. The limited available data from clinical trials do support the benefit of statin therapy in the elderly population. Based upon these data, cholesterol treatment guidelines endorse statin therapy as the primary treatment of hypercholesterolemia in elderly patients, though caution is recommended given the greater number of co-morbid conditions and concern for poly-pharmacy common in the elderly. Additional research is needed to better establish the benefit of statin therapy in the elderly within the context of reducing CV risk, minimizing side effects, and improving overall quality of life.     

“Set it and Forget it”: Women’s Perceptions and Opinions of Long-Acting Topical Vaginal Gels

Women’s initial understandings and anticipated acceptability of long-acting vaginal gels as potential anti-HIV microbicides was investigated by exploring the perceptibility variables associated with prototype formulations. Four focus groups with 29 women, aged 18–45, were conducted to consider gel prototypes with varied physicochemical and rheological properties. Participants responded favorably to the concept of long-acting vaginal gels as microbicides. Distinctions in understandings and stated needs regarding product dosing, characteristics, and effectiveness offer valuable insights into product design. Long-acting vaginal gels capable of protecting against HIV/STIs will be a viable option among potential users, with dosing frequency being an important factor in willingness to use.     

Long-term Prognosis of Patients Older Than Ninety Years After Permanent Pacemaker Implantation: Does the Procedure Save the Patients?

Background

The implantation of a permanent pacemaker (PPM) is life-saving for patients with life-threatening bradycardia. However, the effectiveness and prognosis of PPM implantations for extremely old patients (≥ 90 years old) have not been investigated.

Methods

From 2001-2012, a total of 108 patients older than 90 years were identified from 2630 consecutive patients receiving PPM implantations in our hospital as the study group. For each study patient, 4 age-, sex-, and comorbidity-matched subjects who did not have the diagnoses of bradyarrhythmias indicated for PPM implantations were selected from the “Taiwan National Health Research Database” to constitute the control group (n = 432). The study end point was all-cause mortality.

Results

The median age of the study population was 91 (interquartile range, 90-93) years. Among the PPM group, 45 patients died during the follow-up with an annual mortality rate of 18.7%. The risk of mortality did not differ significantly between the study and control groups with a hazard ratio of 1.020 (95% confidence interval, 0.724-1.437; P = 0.912) after the adjustment for age and sex. Procedure-related complications occurred in 7.4% of the patients receiving PPM implants, and pocket hematoma was the most common. The preimplantation history of heart failure and cerebrovascular accident, rather than age, were significant predictors of mortality among PPM recipients.

Conclusions

Nonagenarians with severe bradyarrhythmias could retain the same life expectancies as those without bradyarrhythmias through PPM implantations. Extremely old age (≥90 years) should not be a barrier for PPM implants when indications are present.