BACKGROUND:Social isolation is increasingly prevalent among older adults and is associated with adverse health outcomes, yet its impact in surgical populations remains poorly defined. Lack of systematic measurement during surgical care has limited large-scale investigation of social isolation and its associations with postoperative outcomes. METHODS:We conducted a prospective validation study of adults ≥ 65 years old admitted to inpatient surgical services at an academic medical center to evaluate the accuracy of a semi-automated, rule-based natural language processing (NLP) algorithm for identifying social isolation from routine electronic health record (EHR) clinical notes from index hospitalizations. NLP performance was validated against a 6-item Social Isolation Index administered in-person during hospitalization. The primary outcome was sensitivity of the NLP algorithm for identifying social isolation. RESULTS:Among 249 enrolled patients (median age, 74 years; 55% female), 55 (22.1%) were classified as socially isolated by the patient-reported reference standard, and the NLP algorithm identified social isolation in 47 patients (18.9%). Sensitivity was 0.84 (95% CI, 0.71-0.92); specificity was 0.99 (95% CI, 0.97-1.00); positive predictive value was 0.98 (95% CI, 0.89-1.00); negative predictive value was 0.96 (95% CI, 0.92-0.98); accuracy was 0.96 (95% CI, 0.93-0.98); F1 score was 0.90 (95% CI, 0.84-0.96). CONCLUSIONS:In this prospective validation study of older surgical patients, a semi-automated, rule-based NLP algorithm demonstrated strong performance in identifying social isolation using routine EHR documentation. With further automation and external validation, EHR-based identification of social isolation could complement embedded screening tools in perioperative care strategies.

OBJECTIVE:Identify consensus-based policy and practice recommendations and develop research priorities to enhance surgical decision-making in the context of dementia. SUMMARY BACKGROUND DATA:People Living with Dementia (PLWD) and their families and healthcare providers face clinical, ethical, and psychosocial challenges when making surgical decisions. METHODS:We conducted a modified Delphi panel August-December 2024, consisting of interviews, surveys, and virtual discussions. Panel members rated potential recommendations on importance and feasibility for practice and policy recommendations, and priority for research recommendations. RESULTS:23 stakeholders, including surgeons, other clinicians, researchers, policy experts, PLWD and care partners participated on the panel. Policy and practice recommendations (n=28) and research recommendations (n=21) covered the following domains: 1) Obtaining information about cognitive impairment, physical function, capacity to consent, and general goals of care for patients with surgical conditions; 2) Advancing resources to support surgical decision-making in the context of dementia; 3) Enhancing care collaboration and team-based care for patients with surgical conditions in the context of dementia; 4) Using policy to enhance surgical decision-making for patients living with dementia; 5) Increasing surgical clinician knowledge and understanding of the dementia context. Of 28 policy and practice recommendations rated by the panel, 25 achieved consensus for high importance but uncertain feasibility, 2 reached consensus for both high importance and feasibility, and 1 remained uncertain on both importance and feasibility. All 21 research recommendations reached consensus for high priority. CONCLUSIONS:This study provides direction to inform surgical practice, policy development, and future research to support surgical decision-making for PLWD, families, and clinicians.

Introduction Patients undergoing colorectal surgery with fecal ostomy experience biopsychosocial challenges during recovery. We aimed (1) to describe clinician's perceived challenges with biopsychosocial recovery after ostomy surgery and (2) to examine current solutions to address patient psychosocial challenges while recovering. Methods We conducted qualitative focus groups evaluating clinician perspectives using a semistructured interview guide. Colorectal surgeons, gastrointestinal psychologists, colorectal surgery nurse practitioners, and ostomy nurses were included. Results Five interview sessions were performed including focus groups and individual interviews. Clinicians were 73% female, all White, and with varied experience (2-40 y in practice). All participants reported ostomy-related emotional distress occurs after surgery and impacts patient recovery and adaptation. Participants reported distress was mitigated when the ostomy relieved functional symptoms and in patients with time to cope with needing an ostomy due to chronic diseases. Patients with permanent ostomies were felt to adapt faster. Emotional distress increased dependence on caregivers, prolonged hospital stays, and delayed adaptation to daily life. Ostomy nurses reported they spent significant time addressing patient distress in clinical encounters. Participants reported a lack of training, time, and resources to help manage patients’ emotional distress. Conclusions Clinicians treating colorectal surgery patients with ostomy frequently note clinically significant emotional distress. This distress hinders patients’ ability to adapt to life with an ostomy. An ostomy specific distress management intervention is needed to improve biopsychosocial outcomes during surgical recovery and adaptation.

Importance Clinicians, people living with dementia (PLWD), and their caregivers face clinical, ethical, and psychosocial challenges when making surgical decisions. Objective To explore clinician experiences with surgical decision-making when a patient has dementia. Design, Setting, and Participants This qualitative study uses case studies compiled from interviews, surveys, and resource review across 12 sites and 178 clinicians. Interviews were conducted between November 2021 and May 2023, while analysis of interview data and associated survey data continued until December 2024. Exposure One interview. Main Outcomes and Measures The primary outcome was themes describing clinician experiences with surgical decision-making when a patient has dementia. Results Among 178 participants (64 surgeons, 100 other clinicians, and 14 hospital leaders), mean (SD) age was 47 (10.9) years, and 92 participants (51.7%) were female. Three main themes were identified. The first theme found that challenges with clinician identification of dementia and assessment of capacity in the surgical setting were barriers to optimal surgical decision-making. Furthermore, inconsistent documentation of cognitive impairment in electronic health records (EHR) and/or lack of EHR interoperability across health systems made it difficult to rely on medical records to identify dementia in a patient’s history. Theme 2 identified that caregivers and nonsurgical clinicians were key contributors to surgical decision-making, but misaligned expectations, caregiver burden, and limited preparation complicated the process. Given the lack of EHR documentation for PLWD, clinicians needed to rely on caregivers to provide a sufficient picture of patients’ cognitive and physical functioning, as well as their goals and values that were relevant to the surgical decision. The third theme found that clinician appraisal of the relevance of dementia to surgical outcomes variably shaped the surgical decision-making process with PLWD and their caregivers. Clinicians commonly perceived that dementia negatively impacts surgical outcomes and recovery among PLWD, yet participants rarely referenced evidence, such as published data or care guidelines, supporting these views. Conclusions and Relevance Results of this qualitative study suggest that clinicians face challenges to surgical decision-making for PLWD, including limited documentation or resources to support identification of dementia, variable caregiver involvement, and constrained access to dementia care specialists who can support the decision-making process. Addressing these challenges may include improving communication pathways with longitudinal clinicians, EHR documentation for older adults, routine and meaningful inclusion of caregivers, and access to nonsurgical clinicians who can support surgical decision-making.

BACKGROUND:Patients undergoing fecal ostomy surgery often struggle to adapt to life, particularly when the surgery is performed for colorectal cancer. Maladaptation to life with an ostomy is associated with psychosocial challenges that affect daily quality of life (QoL). The aim of this systematic review was to identify interventions that address the self-care education and psychosocial needs of patients with colorectal cancer living with an ostomy and to examine their efficacy and effectiveness. METHODS:A systematic search was conducted in Ovid MEDLINE, American Psychological Association PsycInfo, Cochrane Clinical Trials, Cumulative Index to Nursing and Allied Health Literature, Embase, and Web of Science on September 10, 2025. Randomized controlled trials, prospective cohort studies, case studies, and retrospective studies of tested interventions used before or after ostomy surgery with a specific focus on patients with colorectal cancer were included. Patient-reported outcomes, including QoL, were summarized. RESULTS:A total of 14 of the 21 included studies reported a positive outcome in QoL for the intervention group. The remaining studies reported mixed results or did not use validated QoL measures. Several studies used additional resources, such as trained nurses. No study reported harm associated with the intervention. CONCLUSION:Interventions designed to improve QoL in patients with colorectal cancer after ostomy surgery showed promising improvements in patient-centered outcomes; however, these interventions are resource-intensive. Most studies reported improved QoL or no harm. Future work is needed to understand the scalability of these interventions to better support this patient population.

BACKGROUND:Despite professional guidelines encouraging integration, palliative care (PC) remains underutilized among surgical patients. OBJECTIVES:We sought to characterize contextual factors influencing PC integration in surgical practice from the patient perspective. METHODS:We used a combination of ethnographic observations and semistructured interviews with seriously ill older adults to explore perceptions of and behaviors related to PC among patients undergoing surgery. RESULTS:Across 207 observations and 19 interviews, we identified that patients were either unaware of PC or equated it with end-of-life care, believing that pursuing PC would mean forgoing surgery or efforts at recovery. Patients were nevertheless observed elevating concerns related to PC domains, including social or psychological burdens, during visits with surgeons. When presented with a comprehensive definition of PC, some patients were receptive to increased integration with surgery, whereas others preferred that their surgeons contribute only technical expertise. CONCLUSIONS:Our results offer new perspectives on established findings, including that patients equate PC with hospice and end-of-life treatments. Although patients in our study endorsed these same attitudes, they also exhibited interest in discussing broad domains of PC with their surgeons, highlighting further opportunities for integration.

CONTEXT:After hip fracture, older adults experience burdensome treatments and high mortality; they may therefore benefit from palliative care (PC). Best practices for PC integration during inpatient hip fracture care remain understudied. OBJECTIVES:To determine frequency of inpatient PC process documentation for seriously ill older adults with hip fracture and explore clinicians' perspectives on observed documentation patterns. METHODS:We used an explanatory sequential mixed-methods design. In a cohort of seriously ill adults ≥66 years old admitted for hip fracture from 2016 to 2019 at an academic health system, natural language processing was used to measure documentation of inpatient PC processes: healthcare proxy designations, code status limitations, goals of care conversations (GOCC), hospice discussions, and specialty PC. We then conducted semi-structured interviews (n = 10) with clinicians, exploring perspectives on documentation rates. Transcripts were coded thematically using a mixed deductive-inductive approach. RESULTS:Among 1433 hip fracture admissions, GOCC, hospice discussions, and specialty PC were documented in <25% each. Clinicians viewed these rates as reflective of under-documentation and under-delivery. Workflow barriers included lack of standardized processes and diffusion of responsibility across interdisciplinary teams. Emphasis on efficient perioperative optimization and minimizing prolonged hospitalizations competed with perceived time for delivery of GOCC and specialty PC. Clinicians described a rescue-oriented surgical culture in which the palliative value of surgical repair for hip fracture paradoxically limited surgeons' view on their role in GOCC. CONCLUSION:PC process documentation during hip fracture admissions was low. Limited standardization, role uncertainty, and cultural factors limited PC documentation and delivery, highlighting opportunities to strengthen PC integration in surgical care.

Objective: To explore surgical clinicians’ understanding of and activities related to palliative care (PC) in major elective surgery among seriously ill older adults. Summary Background Data: Despite professional standards and guidelines, PC remains infrequently utilized among seriously ill older adults undergoing major elective surgery. Methods: We conducted observations of clinic encounters and interviews with clinicians at seven clinical sites within a single regional health system. Using deductive analysis, we characterized patterns of PC delivery for seriously ill older surgical patients during clinic visits and identified opportunities to support PC integration in surgery. Results: Across 207 patient encounters and 15 clinician interviews (20% medical oncology and PC, 13% surgical oncology, urology, and orthopedics, and 7% in rehabilitative medicine) we found that clinicians in multiple surgical disciplines provided care aligned with PC, despite many surgeons endorsing a belief that PC and surgery were in conflict. Observations further revealed that surgeons redirected conversation to biomedical problems over psychosocial issues even when patients raised subjects like spiritual or psychosocial distress. Opportunities to help alleviate tension between PC and surgery include reframing of the “fixer” identity to include non-surgical approaches and underscoring the overlap between the aims of surgery and PC. Conclusions: Our findings suggest opportunities to align surgical practice and PC to more comprehensively address needs of seriously ill older surgical patients.

Older adults have higher rates of ostomy permanency and complications during recovery after surgery. Surgical teams are not trained to address the psychosocial needs that often arise in the aging population recovering from ostomy surgery. This study aims to refine and establish the acceptability and usability of the Geriatric Assessment Strategy for Ostomy Management and Adaptation (GA-Stoma), an intervention aimed at identifying existing individual patient support and reducing distress and anxiety among older adults recovering from ostomy surgery. We describe the proposed study design, methodology, and training protocol. We will conduct an open pilot (n=12 patients and n=4 clinicians) of assessments to first identify the level of distress and types of support patients require. Next, patients will be guided to complete web-based videos that address frequent challenges faced by older adults recovering from ostomy surgery, considering practical management, emotional and adaptation concerns. Qualitative one-to-one semi structured interviews will be conducted with patient and clinician participants to explore the acceptability and usability of the program and refine the intervention and study procedures. This study has been approved by the Mass General Brigham Institutional Review Board. Study funding was obtained, and recruitment is planned for the spring 2026. Through this study, we will refine the intervention and study procedures to improve intervention acceptability and usability. These improvements will allow us to establish the usability and acceptability of the intervention before efficacy testing to ultimately determine the ability of this intervention to improve biopsychosocial outcomes after fecal ostomy surgery among older adults. NCT07424586

BACKGROUND:A growing number of emergency general surgery (EGS) admissions comprise of adults age 65 years and older, who are more likely to experience missed or delayed diagnoses, and subsequently worse postoperative outcomes. We aimed to ascertain the perspectives of clinicians on the diagnostic challenges unique to older adults with EGS conditions and strategies to improve feedback. METHODS:In this qualitative study, semi-structured focus groups were conducted with frontline clinicians with experience in providing high volume care to older adult EGS patients to explore diagnostic challenges, tools, and feedback strategies. Questions focused on clinical gaps and approaches, tools, and the mechanisms in place to provide feedback on patient diagnosis and assessment. Focus groups were transcribed and qualitatively analyzed using an inductive approach. RESULTS:Twenty-two clinicians participated in one of six focus groups. Clinicians reported three key diagnostic challenges: nontextbook presentations, comorbidities, and older-age specific complications. Nondiagnostic factors remained high priorities including functional health status, patient preferences, family involvement, and health related social needs. Practical tools addressing these gaps included the use of multidisciplinary expertise, surgical risk calculators, cognitive assessments, functional health assessments, and protocols guiding goals of care discussions. Participants shared barriers and facilitators for implementation of these tools. CONCLUSION:Frontline clinicians identified several high priority considerations unique in EGS for older adults. To address these, context-specific tools and strategies were detailed and inform ongoing work to incorporate feedback and solutions into frontline settings. Future work in quality improvement should incorporate these high priority areas into existing quality improvement frameworks.

Older adults with hip fracture face a sudden decline in health, yet most never receive palliative care. This study used ethnography to examine how palliative care is woven into surgical care, revealing strengths in primary palliative care integration as well as unmet needs such as psychosocial and caregiving challenges.

BACKGROUND:Education and support for ostomy are instrumental in surgical recovery and adaptation. This study aimed to evaluate (i) the challenges faced by fecal ostomy patients with colorectal cancer and (ii) the resources necessary for recovery. METHODS:This study recruited patients 21 to 90 days after scheduled fecal ostomy surgery for locally advanced or metastatic colorectal cancer from a single tertiary academic center. This study conducted 1:1 semistructured interviews until thematic saturation using hybrid deductive-inductive coding. RESULTS:This study interviewed 20 patients (80% male; mean age of 59.7 years). Several major themes emerged, including challenges in (i) practical ostomy management, (ii) emotional distress, (iii) adaptation to daily life, and (iv) provider relationships. The participants faced ostomy care challenges owing to peristomal skin issues, leaks, and difficulty ordering supplies. Many participants noted significant distress or anxiety related to embarrassment caused by leaks, odors, or noise. This distress led participants to fear going out in public, embarrassment from the ostomy, and anxiety about their daily activities (eg, returning to work and relationships). When adapting to life with an ostomy, several participants noted that anxiety affected their ability to care for the ostomy and resume their daily activities, leading to social isolation. Patients reported challenges with provider relationships and a lack of anticipatory guidance from the surgical team preoperatively, including insufficient education on practical management, ordering of ostomy supplies, ensuring adequate hydration, and maintaining proper nutrition. CONCLUSION:Patients with colorectal cancer who require fecal ostomy face several challenges related to ostomy. Interventions that address practical management, navigating distress, adaptation, and provider education are needed to provide tailored education and support.

BACKGROUND:Seriously ill older surgical patients with preoperative palliative care needs, such as those with pain, depression, functional dependence, and care partner needs, may benefit from palliative care, but their prevalence, characteristics, and outcomes have not been described. STUDY DESIGN:We used data from the Health and Retirement Survey linked to Medicare claims and included older adults (age 66 years or older) with and without serious illness who underwent major elective surgery between 2007 and 2019. Exposures included serious illness and pain, depression, functional dependence, and care partner needs before operation. Outcomes were 1-year healthcare usage and cost (ie total hospital days, hospital readmission, emergency department visits, and Medicare cost). RESULTS:Among 2,499 older adults undergoing major elective surgery, 63% were seriously ill, and 79% reported pain, depression, functional dependence, or care partner needs. Seriously ill older adults with preoperative palliative care needs experienced a higher rate of total hospital days (incidence rate ratio [IRR] 2.0, 95% CI 1.5 to 2.6), hospital readmission (IRR 2.0, 95% CI 1.6 to 2.4) and emergency department visits (IRR 1.9, 95% CI 1.6 to 2.3). Adjusted 1-year healthcare cost was significantly higher among seriously ill older adults with these palliative care needs compared with those without serious illness (mean [SE] cost $38,187 [2,291] vs $20,129 [1,742]). CONCLUSIONS:Seriously ill older adults undergoing major elective surgery had a high prevalence of palliative care needs, which were associated with increased healthcare usage and cost. These findings highlight the imperative to identify and intervene in older surgical patients who may benefit from palliative care.

OBJECTIVE:Understand challenges faced by older adults who undergo elective major surgery. BACKGROUND:Preparation for and recovery from elective major surgery is often described from clinician perspectives, limiting insights into older patients' experiences. METHODS:We conducted a qualitative study with adults age 65+ years, 30-90 days post colectomy, using interviews and surveys at a Northeastern U.S. tertiary surgical clinic. Guided by a modified Framework method, we arranged data into domains, themes and subthemes. We categorized patient-identified challenges using the Geriatric 5 Ms framework as deductive themes. Then, we identified additional themes and subthemes inductively. RESULTS:From November 2022 to August 2023, twenty patients completed the study. Themes of personal patient challenges included: the mind (i.e., coping with uncertainty, anxiety/frustration, and underappreciated cognitive challenges), mobility (i.e., physical limitations and challenges completing activities of daily living), medications (i.e., understanding medication frequency and side effects), multi-complexity (i.e., surgical recovery in the context of multi-morbidity), and what matters most (i.e., matters related to self, care-partners, and recovery expectations). Themes of process characteristics included challenges discussing the decision for surgery, understanding expectations for surgical recovery, and obtaining anticipatory guidance. Patients with fecal ostomy described heightened emotional challenges and social support needs. CONCLUSIONS:Modifiable challenges older adult patients perceive after elective major surgery often stemmed from perioperative anxiety, uncertainty, inadequate communication and insufficient social support. These findings can guide clinicians in optimizing surgical care and inform future research developing interventions aimed at addressing emotional stressors and enhancing communication between patients and surgical teams.

INTRODUCTION:Little is known about the association between age and fecal ostomy surgery trends over time. We aim to 1) determine the rate of fecal ostomy operations over time and 2) compare rates of colostomy formation between patients older and younger than 65 y. MATERIALS AND METHODS:Retrospective multi-institutional cohort study of patients ≥18 y who underwent colorectal resection between 2003 and 2014 using the Nationwide Inpatient Sample database. Patients were identified using International Classification of Diseases, 9th edition Procedural Codes. A difference-in-difference analysis was performed to evaluate the differences in colostomy formation between age groups. RESULTS:Out of 819,441 adult patients who underwent major colorectal resection, 136,840 (16.6%) required ostomy formation. Median age was 63 y (interquartile range 51-74), 50% were female. Overall, 82,606 (10.0%) patients underwent a colostomy formation and 54,234 (6.6%) an ileostomy formation. Rates of colostomy formation decreased (13.2%-7.1% in <65 and 14.0%-7.2% in ≥65). Incidence of ileostomy formation increased for both age groups (6.1%-9.9% in <65 and 3.8%-6.3% in ≥65). The difference-in-difference analysis showed that the decline in colostomy formation was less pronounced among the older adult cohort (odds ratio 0.49, 95% confidence interval 0.47-0.50) than those <65 (odds ratio 0.42, 95% confidence interval 0.41-0.44). CONCLUSIONS:Incidence of colostomy formation decreased in both groups over the study period. In contrast, the decline in colostomy formation was slower among older adults. This highlights a significant change in surgical trends across the United States with increasing rates of ileostomy use. Appropriate resource allocation and support are vital to the recovery of this growing surgical patient population.

BACKGROUND Falls are a leading cause of morbidity and mortality among older adults in the United States. Current fall prevention interventions rely on provider referral or enrollment during inpatient admissions and require engagement and independence of the patient. Community emergency medical services (CEMS) are a unique opportunity to rapidly identify older adults at risk for falls and provide proactive fall prevention interventions in the home. We describe the demographics and treatment characteristics of the older adult population most likely to benefit from these interventions. MATERIALS AND METHODS We linked 2019 Healthcare Cost and Utilization Project Massachusetts State Emergency Department (ED) and State Inpatient Databases with American Hospital Association survey data to query ED encounters and inpatient admissions for adults age ≥55 with ED encounters for fall-related injury between July 1, 2019 and December 31, 2019. Univariable descriptive statistics assessed participant characteristics and bivariable tests of significance compared diagnoses, disposition, and hospital characteristics between older adults with and without an EMS encounter in the six months prior to the presenting fall. RESULTS Of 66,027 older adults who presented with a fall to a Massachusetts ED in July-December 2019, 7,942 (11%) had a prior encounter with EMS in the preceding six months, most of which included an injury diagnosis (99%). Compared to older adults without previous EMS encounters, those with previous EMS encounters were more often in poorer health (17% vs. 10% with multiple or complex comorbidities, p<0.001) and of lower socioeconomic status (12% vs. 8% in lowest neighborhood income quartile, p<0.001; 10% vs. 6% enrolled in Medicaid, p<0.001) compared to those without a prior EMS encounter. CONCLUSIONS A significant proportion of older adults presenting to the ED with fall related injury have encounters with EMS in the preceding months. These participants are predisposed to poorer health and economic outcomes worsened by their fall and thus demonstrate a population that would benefit from CEMS fall prevention programs.

Despite efforts to increase the clinician-scientist pipeline, fewer physicians or surgeons are pursuing scientific careers, particularly in aging, threatening future advances in care. One critical challenge for early-stage physician/surgeon scientists is the demanding and inflexible nature of medical training, particularly residency training that offers few opportunities for sustained research engagement. The National Institutes of Health’s Stimulating Access to Research in Residency (StARR) R38 initiative represents a recent effort to directly integrate intensive, 1-2 year-long research experiences into residency. We present early insights from all StARR programs funded by the National Institute on Aging--the University of California San Francisco, Duke University, Brigham and Women’s Hospital, and Massachusetts General Hospital--which have collectively engaged 27 physicians/surgeons-in-training in basic, clinical, or translational aging science since 2021. Of the 15 NIA StARR graduates who have already completed residency, including 5 from traditionally underrepresented backgrounds, all have so far continued in academic training or careers, and 9 remain engaged in aging science. Mixed-methods evaluation data from graduating scholars demonstrate StARR’s meaningful impact on career trajectories and research commitment. However, program implementation has revealed key educational challenges: establishing effective interdisciplinary mentorship teams; balancing rigorous methodological training with productivity pressures; identifying sustainable funding pathways; and defining aging research focus across diverse specialties. These findings inform broader efforts to restructure medical education for research integration; while StARR’s early success suggests that systematic, extended research training during residency can effectively cultivate physician-scientists in aging, programmatic innovations are needed to address identified training barriers and ensure scalability across institutions.