This review suggests that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects. Basing standards for quality of care and pay for performance on existing CPGs could lead to inappropriate judgment of the care provided to older individuals with complex comorbidities and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care. Developing measures of the quality of the care needed by older patients with complex comorbidities is critical to improving their care.

Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .

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Many people living with chronic conditions have multiple chronic conditions. Multimorbidity is defined here as the co-existence of two or more chronic conditions, where one is not necessarily more central than the others. Multimorbidity affects quality of life, ability to work and employability, disability and mortality. Currently, clinicians have limited guidance or evidence as to how to approach care decisions for such patients. Understanding how to best care and design the health system for patients with multimorbidity may lead to improvements in quality of life, utilization of healthcare, safety, morbidity and mortality. The objective of this paper is to review the implications of multimorbidity for the design of health system and to understand the research needs for this population. The consideration of people with multimorbidity is essential in the design and evaluation of health systems. Fundamentally, people with multimorbidity should receive a patient -and family-centered approach to care throughout the health system, and understanding how to deliver this type of care in effective and efficient ways is an enormous challenge, and opportunity, for clinicians, researchers, and policy makers today.

OBJECTIVES-To describe functional outcomes in the year following discharge for elders discharged from the hospital after an acute medical illness with a new or additional disability in Dr. Boyd conceptualized this paper, obtained funding, developed the design of the analysis with Drs. Covinsky and wrote this manuscript. Dr. Landefeld was responsible for collaborating in the following activities for this paper: study design and implementation, obtainment of funding, analysis and interpretation of data and critical revision of the manuscript for important intellectual content. Dr. Counsell was responsible for collaborating in the following activities for this paper: study design and implementation, obtainment of funding, analysis and interpretation of data and critical revision of the manuscript for important intellectual content. Dr. Palmer was a co-investigator responsible for collaborating in the following activities for this paper: design and implementation, interpretation of data, and critical revision of the manuscript for important intellectual content. Dr. Fortinsky was a co-investigator responsible for collaborating in the following activities for this paper: the analysis and interpretation of data and critical revision of the manuscript for important intellectual content. Dr. Kresevic was a co-investigator responsible for collaborating in the following activities for this paper: design and implementation, interpretation of data, and critical revision of the manuscript for important intellectual content. Dr. Covinsky was responsible for supervision of the entire project and manuscript, and collaborated on the design and implementation, analysis and interpretation of data, and undertook critical revision of this manuscript for important intellectual content. Sponsors' Role:The funding sources had no role in the design and conduct of the study, collection, management, analysis or interpretation of the data, the preparation, review or approval of the manuscript. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript their basic self-care activities of daily living(ADL)(compared to their preadmission baseline two weeks before admission), compared to elders discharged with baseline ADL function, and identify predictors of failure to recover to baseline function one year after discharge. DESIGN-Observational Study SETTING-Tertiary care hospital, Community teaching hospitalPARTICIPANTS-Older(≥70 years) patients non-electively admitted to general medical services (1993)(1994)(1995)(1996)(1997)(1998).MEASUREMENTS-Number of ADL disabilities 1,3,6,&12 months after discharge compared to pre-admission baseline. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each timepoint.RESULTS-By 12 months after discharge, among those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at their baseline function. Among those discharged with baseline fun...

In disabled older women, self-report of physician diagnosis of HF, PD, DM, cancer, stroke, and DD appears valid. In general, increasing comorbidity and age and decreasing cognition and education do not reduce validity for diseases where agreement was excellent overall.

Social isolation is an important and potentially modifiable risk that affects a significant proportion of the older adult population.

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