To describe and compare geriatricians’ roles in geriatric oncology and onco-surgical care across Europe. Geriatric oncology practices varied widely across 34 countries: 19

In a Norwegian national cross-sectional survey, we assessed the burden of selected late effects (LEs) by a 95-item questionnaire in tumor-free Hodgkin lymphoma survivors (HLSs) diagnosed at age ≥60 years. Responses were compared to age- and sex-matched controls. A total of 290 older HLSs diagnosed 2000-2021 received the questionnaire, 193 (67%) were included. Median age at survey was 76 years (range 63-92) and median time since diagnosis 7 years (2-23). Compared to controls, HLSs reported significantly higher rates of heart failure (10% vs. 6%), atrial fibrillation (19% vs. 14%), memory problems (48% vs. 37%), other cognitive difficulties (34% vs. 17%) and chronic fatigue (29% vs. 13%). HLSs scored lower on physical and mental health-related quality of life (HRQoL) and more often reported needing help with basic (P-ADL) and instrumental activities of daily living (I-ADL). However, differences were small, only for fatigue and dependence in I-ADL did the difference reach moderate statistical effect size.

To explore the experiences of older adults living with frailty who received an intervention initiated in acute geriatric units that extended beyond end-of-life decisions and included participation of next of kin. The initiation of ACP may foster trust and confidence in the physician–patient relationship, increase involvement through illness education, and give room for patients’ emotional and existential responses to illness. Participation of next of kin may also amplify patient benefit by supporting continuation of conversations after discharge, strengthening trust, and helping prevent later conflicts between relatives and clinicians when patients can no longer participate. Introducing ACP earlier, during the acute admission of home-dwelling older persons living with frailty, when prognosis is still uncertain and relatives are involved, can improve the quality of communication and decision-making about serious illness by safeguarding information and involvement preferences, providing illness education, and incorporating existential concerns into conversations and decision-making about care. Advance care planning (ACP) enables individuals to elicit values and preferences regarding medical treatment and care, and to record and review them before loss of capacity. In Norway as in most European countries, ACP is rarely performed. This is worrisome given the benefits of ACP, and the lack of research and understanding of the patient’s perspective, particularly in contexts where ACP is new. This paper is the first to explore how the initiation of ACP is experienced by older persons living at home with frailty who are encountering ACP for the first time, using a concept of ACP that extends beyond end-of-life decision-making. This qualitative study is part of a cluster-randomized controlled trial in which home-dwelling patients admitted to acute geriatric units were invited to participate in the initiation of ACP with their next of kin. We interviewed ten of these patients about their experiences and conducted a reflexive thematic analysis. The patients reported that the initiation of ACP fostered trust and confidence, promoted emancipation and insight, enabled them to remain at home longer, opened up space for emotional and existential issues as precursors to decision-making, and promoted a more direct and honest connection with the physician. The initiation of ACP can be integrated into routine geriatric care and may provide important benefits for patients by filling gaps and adding new dimensions to usual care. ACP is an underused tool in communication and decisions concerning severe illness that more patients could benefit from. ClinicalTrials.gov Identifier NTCT05681585. Registered 03.01.23.

This study aimed to assess how intrinsic capacity, functional ability, and frailty are integrated into European undergraduate medical curricula, and to develop an educational tool to address identified gaps. Intrinsic capacity is significantly underrepresented in curricula compared to frailty and functional ability, with limited teaching and minimal inclusion in learning outcomes. An interactive PDF teaching tool showed promise in improving the understanding and teaching of intrinsic capacity across Europe. Embedding intrinsic capacity into medical education is vital to align with WHO priorities on healthy ageing, and innovative tools like interactive PDFs can help bridge current educational gaps. This study aimed to evaluate how intrinsic capacity, functional ability, and frailty are integrated into European undergraduate medical curricula and to develop an educational tool to address identified gaps. A two-phase approach was adopted. Phase 1 involved an exploratory survey of 19 universities across 10 European countries to assess whether these concepts were included in curricula, how they were taught, and the allocated teaching hours. Phase 2 focused on creating and disseminating an interactive PDF for teachers and students. The tool was pilot-tested and translated into multiple languages, followed by a feedback survey. Frailty appeared in learning outcomes in 89

BACKGROUND:Co-design methods, which create innovation tailored to the end-user needs and setting, are increasingly used to improve research uptake and impact. Peer review and methodologists have emphasised the need for early, meaningful, and continuous involvement of stakeholders, and the transparent and detailed reporting of co-design methods. The implementation of both complex interventions (such as an integrated care pathway), and technology, into healthcare is difficult and has high failure rates. Designing, implementing, and adapting interventions to ensure they work in the local context requires in-depth understanding of multiple end-users' needs, processes, and contexts. Achieving this requires early, meaningful, and continuous engagement between multiple end-users. This study aimed to contribute to co-design research by reporting the: 1) process used to develop and test Participatory Rapid Appraisal and Focus Groups methods to co-design integrated care. 2) details of how the method was applied in the GERONTE project. 3) core steps involved in this co-design method (to facilitate use and/ or adaptation of the method). AIM:The study aimed to develop, test, and evaluate a co-design method that: I. enabled early, continuous, and meaningful engagement of multiple end-users in different locations and across different design iterations. II. enabled timely feedback and checking between the end-users and design team. III. optimised end-users participation by being flexible in the time, duration, and method of data collection and feedback. MATERIALS AND METHODS:The Participatory Rapid Appraisal and Focus Group to co-design integrated care method was developed in four stages. The first stage involved defining the project's co-design needs and reviewing the co-design literature to identify how to meet these. GERONTE aimed to co-design, evaluate, and prepare for EU-wide deployment, an integrated technology-supported care pathway for older adults with cancer and other morbidities. Focus Groups and Participatory Rapid Appraisal, in combination, were chosen as an empirically-based and practical approach. Focus Groups (FG) provided a participatory-based way to collect data in order to identify and agree multiple stakeholders' needs and collective priorities. Participatory Rapid Appraisal (PRA) provided a timely way; to gain participant feedback on the data collected; and, to ensure accuracy in the data sent to the pathway and technology design teams. The second stage involved applying the method in the GERONTE Project (using meetings between the project team, technologists, and older adults to develop a co-design protocol for the project). The third stage involved the use, refinement, evaluation, and reporting of the co-design method. The fourth stage, evaluation of the method, is ongoing. RESULTS AND DISCUSSION:This study resulted in the development of a structured approach to using Participatory Rapid Appraisal and Focus Groups in combination to co-design technology-supported integrated care. This method is proposed as an evidenced-based, practical, user-friendly way to co-design (or adapt an existing design) an integrated technology-supported care pathway. This co-design method involves three cycles of design. Each cycle involves multidisciplinary FG to collect semi-structured data followed by rapid analysis and feedback of the FG data to the participants to design or refine the intervention.

Background: In recognition of the value and impact of holistic and patient-centred care, clinicians, patients, and healthcare organisations have advocated for practical changes to help integrate existing services. Technology is needed to enable the scale and speed of data organisation and sharing and communication needed to integrate clinical services and sites. Implementing complex or technology-supported interventions is difficult, and has high failure rates, as it requires changes to a number of embedded and interrelated processes, roles, and policies. Implementation Science (IS), which draws from a multidisciplinary base and has established theories, models, and frameworks (TMF) is increasingly used to improve research translation and efficiency. While there has been a widely reported rapid increase in the number of new TMF, including frameworks specific to either complex or technology-supported interventions, there is no single framework specific to the implementation of complex and technology-supported interventions (which are increasingly used). This paper describes the structured way that Realist Research, the Consolidated Framework for Implementation Science (CFIR), and the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework were combined, applied, and tested to plan, implement, and evaluate a complex technology-supported intervention to integrate existing services. Aim: The FIT in Integrated Care study aimed, as part of a multi-site Randomised Controlled Trial, to build on existing IS to co-design, test, and evaluate a structured, practical, and comprehensive way to plan, implement, and evaluate the implementation of a complex technology-supported intervention that integrates existing services. Methods: The FIT in Integrated Care was co-designed in three stages. The first stage defined the function that the new framework needed to fulfil and identified suitable IS theory and practice to inform its structure and content. The second stage involved developing the new framework (structure, content) and applying it to the GERONTE* intervention. Realist research, the CFIR, and the NASSS framework were chosen and combined because of their relevance (to IS and to complex and technology-supported interventions), evidence base, combined comprehensiveness, and compatibility. The new fr↔amework was refined based on end-user feedback. The third stage, which is ongoing, involves the broader and longer-term testing, evaluation, and reporting on the framework’s functionality and user-friendliness in implementing a complex technology-supported intervention to integrate existing care services. Results: The FIT in Integrated Care study resulted in the combination and application of existing IS theory and practice, into an evidenced-based, structured, practical, user-friendly multi-stakeholder framework to plan, implement, and evaluate the implementation of a complex technology-supported intervention that integrates existing services. This new framework focuses research and analysis on the ‘context, mechanism of action, and outcomes’ to enable understanding of ‘how, in what context and for who’ the intervention works (so as to support wider adoption and/ or adaptation). Conclusion: Combining Realist research, the CFIR, and NASSS framework provides an evidence-based, robust, user-friendly way to plan, implement, and evaluate a complex technology-supported intervention that integrates existing healthcare services.

The introduction of evidence-based patient-centred care (EBPCC) into the cancer treatment pathway requires older adults with cancer and their support networks to actively participate in the decision-making process. EBPCC is a combination of evidence-based practice (EBP) and patient-centred care (PCC). EBPCC is a healthcare approach that focuses on the needs and preferences of the patient. However, the increasingly complex nature of cancer treatment options, the heterogeneity of older adults, and the probability of comorbidities can make it a complicated and difficult task for older adults with cancer to process these options, evaluate the information presented, and determine their preferred treatment pathway. EBPCC can effectively facilitate shared decision-making in the clinic for older adults with cancer but may not fulfil the healthcare expectations of all older adults. Older adult patients newly diagnosed with cancer may expect a more holistic approach to their care, with emphasis on 'what matters most for the patient?' In this paper, we consider EBPCC and its effectiveness in building active collaboration between clinicians and older adults with cancer. We examine EBPCC from both clinician and patient perspectives and reflect on the extent that heterogeneity, comorbidities, and generational characteristics influence these perspectives. We then evaluate the cancer clinical pathway for its preparedness to meet the future needs of this heterogenous population.

Background and aims: The Norwegian Registry for Primary Health Care (NRPHC) is a mandatory register for all publicly funded primary healthcare services in Norway, including long-term care (LTC) services. The registry holds information on diagnoses for recipients of LTC services, but little is known regarding data quality and completeness. Methods: The study population consisted of all LTC recipients in Norway in 2023 ( N =393,446). We investigated the proportion registered with any diagnosis in NRPHC LTC data. We compared diagnoses reported by LTC providers with diagnoses reported by general practitioners and by specialist health services. Additionally, we investigated the distribution of diagnoses by type of LTC provided. Diagnoses presumed common among recipients of LTC were investigated (diabetes, cardiovascular diseases, chronic obstructive lung diseases, cancer, mental disorders/substance use disorders, dementia, intellectual disability and hip fracture). Results: Diagnoses were reported by LTC providers for 51.4% of LTC recipients. Diagnoses were more often reported for users with more complex services (long-term institutional stay: 85.5%; assistive technology: 30.5%). Including data from general practitioners and specialist health services increased prevalence estimates compared with using NRPHC LTC data alone (dementia: 14.2% vs 8.2%; chronic obstructive lung diseases: 12.7% vs. 4.1%). Based on all available data, the prevalence of reported dementia among recipients of long-term institutional stay was 58.7%. The prevalence of reported substance use disorders among recipients of home-based services was 13.4%. Conclusions: Data on diagnoses reported by LTC providers to the NRPHC are insufficient and should be supplemented with data from other sources.

Background and objective Whether radical prostate cancer treatment affects long-term physical performance and physical activity in older men is not known. We aimed to compare physical performance and self-reported physical activity between relapse-free older prostate cancer survivors and population-based controls. Methods A single-centre, cross-sectional study including 109 men aged >= 70 yr receiving robotic-assisted radical prostatectomy (61.5%) or external beam radiotherapy (38.5%) between 2014 and 2018 was conducted. Population-based matched (age, gender, and education) controls (n = 327) were drawn from the Tr & oslash;ndelag Health Study. The primary (the Short Physical Performance Battery [SPPB] summary score) and secondary (gait speed, grip strength, one-legged balance, and the self-reported Physical Activity Index) outcomes were compared between survivors and controls by adjusted linear mixed models. Key findings and limitations The SPPB score, gait speed, and Physical Activity Index did not differ between survivors (mean age 78.3 yr, mean time since treatment 52.9 mo) and controls (mean age 78.2 yr). Survivors had slightly poorer grip strength (regression coefficient [RC] -5.81, p < 0.001, 95% confidence interval [CI] -7.46; -4.17) and one-legged balance (RC -4.36, p < 0.001, 95% CI -6.72; -2.00; adjusted models), but the clinical significance is uncertain. Small sample size and potential selection of the fittest survivors are limitations that may reduce the generalisability of our findings. Conclusions and clinical implications 3 to 8 yr after radical prostate cancer treatment, older men's overall physical performance and physical activity level were comparable with those of matched controls. This suggests that the treatment had little impact on functional status. Patient summary In this study, we investigated physical function in older men several years after they had undergone curatively intended treatment for prostate cancer in comparison with men in a general population of the same age and education. We found that physical function was similar, except slightly poorer grip strength and balance on one leg in men treated for prostate cancer. We conclude that the overall physical function was comparable with that of the general population and believe that this indicates that prostate cancer treatment was well tolerated despite older age. (c) 2024 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons. org/licenses/by/4.0/).

Background Population ageing and strained public resources challenge the future provision of health and care services. We assess the uptake of formal health-related care services (FCS), either home health care (HHC) or short- or long-term institutional care (IC), before and after an acute hospital admission in a full-population sample of older persons. Methods Multinominal logistic population average regression models were applied to Norwegian registry data on older persons (aged 75+) in 2021 ( N = 68,803) at hospital discharge following admission for select diagnoses ( N = 94,748) to examine how functional status (for FCS users) and comorbidities (for non-FCS users), acute hospital admissions and sociodemographic characteristics are associated with HHC and IC uptake within 4 weeks and at 6 months post-discharge. Results Altogether, 53% of the sample were already recipients of FCS at the time of the acute event, 43% in HHC and 10% in IC. Overall, the shares increased to 33% for IC and decreased to 29% for HHC 4 weeks post-discharge. At 6 months, the respective shares were 14 and 35%. Among HHC recipients at hospital admission, 44% transitioned to IC within 4 weeks. At 6 months, the share had declined to 21%. Multivariate models showed that transitions into and within FCS were associated with older age, female sex, comorbidities/functional status and living alone. Trauma, cerebrovascular and geriatric conditions were substantially associated with subsequent FCS uptake, and especially IC. Short-term IC transitions were more common among HHC-users than non-HHC-users. In terms of moderating factors, larger differences were observed by living situation as opposed to sex and functional status/comorbidity. Conclusions Irrespective of prior FCS uptake, acute hospital admissions are associated with subsequent FCS uptake, especially for trauma, cerebrovascular and geriatric conditions. Minor variations across sociodemographic characteristics suggest need-based, equitable service provision. The mode (HHC vs IC) and temporality of FCS uptake warrants further research to identify policy measures that may improve care trajectories to ensure sustainable, safe, and high-quality care and rehabilitation following acute hospitalizations of older individuals. Clinical practice and future research should include hospital frailty measures to improve predictions of future FCS needs, particularly for persons unknown to the FCS system pre-hospitalization.

The incidence and age of patients with anal cancer is increasing. With the changing demographics, there is an increasing need to develop harmonised treatment approaches for patients not fit for standard-of-care chemoradiotherapy (CRT). This paper reviews the literature on the treatment of non-metastatic anal cancer in older or frail patients. We then describe assessment and management of frailty in patients with anal cancer. We present results from an international survey of anal cancer clinicians (n = 45) to provide a snapshot of self-reported current practice of patients who are unsuitable for standard CRT. The results highlight the heterogeneous practice in this area, due to the lack of clinical trials focusing on older and frailer patients. Potential modification strategies are proposed for older, comorbid, unfit, and frail patients in the management of anal cancer based on the literature and the survey results of current practice. For patients unfit for CRT, this may involve modified chemotherapy or radiotherapy doses, and for patients with severe frailty, palliative radiotherapy regimens. Finally, we describe challenges, limitations, and considerations for future research in this area.

[This corrects the article DOI: 10.1016/j.euros.2024.11.005.].

Immune checkpoint inhibitors (ICIs) have substantially advanced the treatment landscape for a wide variety of malignancies. Older adults represent a large and rapidly growing demographic, among whom ICIs are widely prescribed. Management of ICI-associated toxicity among older adults, particularly in the presence of frailty and comorbidity, poses unique challenges. In this Policy Review, developed by the International Society of Geriatric Oncology (SIOG), we offer an evidence-based framework for health-care providers, caregivers, and policy makers for treating older adults with ICIs, focusing on unique considerations for this population that are not adequately addressed by existing guidelines, and expanding them to encompass geriatric oncology principles.

Background Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions. Methods This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient’s preferences for information and involvement and the clinician’s perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis. Discussion The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science. Trial registration ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.

Objectives Due to prognostic uncertainty and limited decision-making capacity, the choice to perform transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS) and comorbid dementia is challenging. This study explores older adults' perspectives on complex decision-making preceding TAVI in the hypothetical setting of comorbid dementia.Design Qualitative study entailing semistructured interviews. Analysis was by systematic text condensation. The interview guide addressed their attitudes regarding treatment dilemmas before TAVI in patients living with dementia.Setting Patients were recruited from the TAVI outpatient clinic at a university hospital performing TAVI.Participants A purposive sample of 10 older adults (5 women) with AS and without dementia (range 77-94 years), where 8/10 had undergone TAVI were included.Results Three main challenges were identified: (1) Risk assessment. Participants found it hard to compare the burden of aortic stenosis vs dementia. They acknowledged the dilemma of implanting a new heart valve to achieve symptom relief while risking severe dementia in the future due to prolonged life span. (2) Autonomous capacity. A profound uncertainty was described regarding who should participate in decision-making if the person was incapacitated due to dementia. (3) Customised information. Participants advocated for thorough information describing facts and uncertainty, aiming to protect and support the person living with dementia.Conclusion Older adults with severe aortic stenosis find it hard relating to dilemmas arising from providing TAVI in patients living with dementia. There is a need for tailor-made information to support autonomy and decision-making under uncertainty.