Effects of influenza vaccination on mortality among frail, community-living elderly patients: an observational study

Effects of influenza vaccination on the risk of cardiovascular and respiratory diseases and all-cause mortality

BACKGROUND

Influenza vaccination is a simple strategy recommended for the prevention of influenza infection and its complications. This meta-analysis aimed to provide current supportive evidence for the breadth and validity of the observed protective effects of influenza vaccination on cardiovascular and respiratory adverse outcomes and all-cause mortality in older adults and in general adult population.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library to identify all published studies comparing influenza vaccination with placebo from the database inception to November 11, 2018. These included studies reporting the associations of influenza vaccination with the risk of aforementioned adverse outcomes.

RESULTS

The pooled adjusted relative risks among influenza-vaccinated people relative to unvaccinated people for the outcomes of interest were 0.74 (95 % confidence interval [CI] = 0.70-0.78) for cardiovascular diseases (63 studies), 0.82 (95 % CI = 0.75-0.91) for respiratory diseases (29 studies), and 0.57 (95 % CI = 0.51-0.63) for all-cause mortality (43 studies). We performed subgroup analysis of age, sex, and region/country and found that these protective effects were evident in the general adult population and particularly robust in older adults and in those with pre-existing specific diseases.

CONCLUSION

Influenza vaccine is associated with a significant risk reduction of cardiovascular and respiratory adverse outcomes as well as all-cause mortality. Such a preventative measure can benefit the general population as well as those in old age and with pre-existing specific diseases.

Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study

Background

Influenza and pneumococcal vaccines have been proved to be effective and safe in preventing and controlling infection among elderly, reducing morbidity and mortality. However, some evidences raised health concerns related to these vaccinations. This study aims to identify prevalence and outcomes related to influenza and pneumococcal vaccinations in a large European population of frail old people living in nursing homes (NHs).

Methods

We conducted a survival analysis of NH residents participating to the Services and Health for Elderly in Long-TERm project, a prospective cohort study collecting information on residents admitted to 57 NH in eight countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands and Israel). Clinical and demographical data were collected using the international resident assessement instrument for long-term care facilities. Incident mortality was recorded during 1-year follow-up. A shared-frailty Cox regression model was used to assess the impact of vaccination status on mortality.

Results

Mean age of 3510 participants was 84.6 years (SD = 7.7). In total, 81.7 and 27.0% received influenza and pneumococcal vaccination, respectively. Overall, 727 (20.7%) residents died during the follow-up period. After adjusting for potential confounders, which included age, sex, number of diseases, depression, cognitive and functional status, influenza (HR = 0.80; 95% CI 0.66-0.97) and the combination of influenza and pneumococcal vaccination (HR = 0.72; 95% CI 0.57-0.91), but not pneumococcal vaccination alone (HR = 0.52; 95% CI 0.25-1.06), were associated with a statistically significant reduction in mortality in respect of no vaccinations.

Conclusion

In a population of older adult living in NH influenza and the combination of influenza and pneumococcal vaccination were associated with a reduction in all-cause mortality respect to no vaccination.

Vaccines for preventing influenza in the elderly

BACKGROUND

The consequences of influenza in the elderly (those age 65 years or older) are complications, hospitalisations, and death. The primary goal of influenza vaccination in the elderly is to reduce the risk of death among people who are most vulnerable. This is an update of a review published in 2010. Future updates of this review will be made only when new trials or vaccines become available. Observational data included in previous versions of the review have been retained for historical reasons but have not been updated because of their lack of influence on the review conclusions.

OBJECTIVES

To assess the effects (efficacy, effectiveness, and harm) of vaccines against influenza in the elderly.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 11), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to 31 December 2016); Embase (1974 to 31 December 2016); Web of Science (1974 to 31 December 2016); CINAHL (1981 to 31 December 2016); LILACS (1982 to 31 December 2016); WHO International Clinical Trials Registry Platform (ICTRP; 1 July 2017); and ClinicalTrials.gov (1 July 2017).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs assessing efficacy against influenza (laboratory-confirmed cases) or effectiveness against influenza-like illness (ILI) or safety. We considered any influenza vaccine given independently, in any dose, preparation, or time schedule, compared with placebo or with no intervention. Previous versions of this review included 67 cohort and case-control studies. The searches for these trial designs are no longer updated.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed risk of bias and extracted data. We rated the certainty of evidence with GRADE for the key outcomes of influenza, ILI, complications (hospitalisation, pneumonia), and adverse events. We have presented aggregate control group risks to illustrate the effect in absolute terms. We used them as the basis for calculating the number needed to vaccinate to prevent one case of each event for influenza and ILI outcomes.

MAIN RESULTS

We identified eight RCTs (over 5000 participants), of which four assessed harms. The studies were conducted in community and residential care settings in Europe and the USA between 1965 and 2000. Risk of bias reduced our certainty in the findings for influenza and ILI, but not for other outcomes.Older adults receiving the influenza vaccine may experience less influenza over a single season compared with placebo, from 6% to 2.4% (risk ratio (RR) 0.42, 95% confidence interval (CI) 0.27 to 0.66; low-certainty evidence). We rated the evidence as low certainty due to uncertainty over how influenza was diagnosed. Older adults probably experience less ILI compared with those who do not receive a vaccination over the course of a single influenza season (3.5% versus 6%; RR 0.59, 95% CI 0.47 to 0.73; moderate-certainty evidence). These results indicate that 30 people would need to be vaccinated to prevent one person experiencing influenza, and 42 would need to be vaccinated to prevent one person having an ILI.The study providing data for mortality and pneumonia was underpowered to detect differences in these outcomes. There were 3 deaths from 522 participants in the vaccination arm and 1 death from 177 participants in the placebo arm, providing very low-certainty evidence for the effect on mortality (RR 1.02, 95% CI 0.11 to 9.72). No cases of pneumonia occurred in one study that reported this outcome (very low-certainty evidence). No data on hospitalisations were reported. Confidence intervaIs around the effect of vaccines on fever and nausea were wide, and we do not have enough information about these harms in older people (fever: 1.6% with placebo compared with 2.5% after vaccination (RR 1.57, 0.92 to 2.71; moderate-certainty evidence)); nausea (2.4% with placebo compared with 4.2% after vaccination (RR 1.75, 95% CI 0.74 to 4.12; low-certainty evidence)).

AUTHORS' CONCLUSIONS

Older adults receiving the influenza vaccine may have a lower risk of influenza (from 6% to 2.4%), and probably have a lower risk of ILI compared with those who do not receive a vaccination over the course of a single influenza season (from 6% to 3.5%). We are uncertain how big a difference these vaccines will make across different seasons. Very few deaths occurred, and no data on hospitalisation were reported. No cases of pneumonia occurred in one study that reported this outcome. We do not have enough information to assess harms relating to fever and nausea in this population.The evidence for a lower risk of influenza and ILI with vaccination is limited by biases in the design or conduct of the studies. Lack of detail regarding the methods used to confirm the diagnosis of influenza limits the applicability of this result. The available evidence relating to complications is of poor quality, insufficient, or old and provides no clear guidance for public health regarding the safety, efficacy, or effectiveness of influenza vaccines for people aged 65 years or older. Society should invest in research on a new generation of influenza vaccines for the elderly.

Vaccines for preventing influenza in the elderly

BACKGROUND

Vaccines have been the main global weapon to minimise the impact of influenza in the elderly for the last four decades and are recommended worldwide for individuals aged 65 years or older. The primary goal of influenza vaccination in the elderly is to reduce the risk of complications among persons who are most vulnerable.

OBJECTIVES

To assess the effectiveness of vaccines in preventing influenza, influenza-like illness (ILI), hospital admissions, complications and mortality in the elderly. To identify and appraise comparative studies evaluating the effects of influenza vaccines in the elderly. To document types and frequency of adverse effects associated with influenza vaccines in the elderly.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register (The Cochrane Library 2009, issue 4); MEDLINE (January 1966 to October Week 1 2009); EMBASE (1974 to October 2009) and Web of Science (1974 to October 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs, cohort and case-control studies assessing efficacy against influenza (laboratory-confirmed cases) or effectiveness against influenza-like illness (ILI) or safety. Any influenza vaccine given independently, in any dose, preparation or time schedule, compared with placebo or with no intervention was considered.

DATA COLLECTION AND ANALYSIS

We grouped reports first according to the setting of the study (community or long-term care facilities) and then by level of viral circulation and vaccine matching. We further stratified by co-administration of pneumococcal polysaccharide vaccine (PPV) and by different types of influenza vaccines. We analysed the following outcomes: influenza, influenza-like illness, hospital admissions, complications and deaths.

MAIN RESULTS

We included 75 studies. Overall we identified 100 data sets. We identified one RCT assessing efficacy and effectiveness. Although this seemed to show an effect against influenza symptoms it was underpowered to detect any effect on complications (1348 participants). The remainder of our evidence base included non-RCTs. Due to the general low quality of non-RCTs and the likely presence of biases, which make interpretation of these data difficult and any firm conclusions potentially misleading, we were unable to reach clear conclusions about the effects of the vaccines in the elderly.

AUTHORS' CONCLUSIONS

The available evidence is of poor quality and provides no guidance regarding the safety, efficacy or effectiveness of influenza vaccines for people aged 65 years or older. To resolve the uncertainty, an adequately powered publicly-funded randomised, placebo-controlled trial run over several seasons should be undertaken.

Overview of vaccination policies for the elderly in Western European countries

Age-related changes in the immune system are associated with increased susceptibility to infections, greater disease severity and poorer outcomes in the elderly compared with young adults. Both influenza and pneumonia are important causes of morbidity and mortality in the elderly, and herpes zoster also represents an important disease burden in this population. Vaccinations against influenza and Streptococcus pneumoniae (pneumococcus) have been shown to reduce the incidence of influenza and invasive pneumococcal disease, respectively, in the elderly. In addition, as is the case with diphtheria/tetanus and herpes zoster vaccines, they can help to reduce the associated burden of disease in vaccinated individuals. Despite the evidence of these benefits, there are considerable variations among the countries of Western Europe in their policies for vaccination in the elderly. Western European countries face the prospect of a population in which the proportion of elderly people is increasing, with a consequent increase in demand on the healthcare system. Acknowledgement of the benefits of vaccination in the elderly, together with comprehensive vaccination policies for this age group, could help to reduce some of these demands.

Case management, preventive strategies, and caregiver attitudes among older adults in home care: results of the ADHOC study

BACKGROUND

Among older adults, integration of health services in a continuum of care with case management programs was shown to reduce progression of functional decline, hospitalization, and institutionalization. We hypothesized that such an approach may also result in a higher rate of use of preventive strategies and lower caregiver distress.

METHODS

Data were from the baseline assessment of the AgeD in HOme Care project, a study enrolling subjects aged 65 years or older receiving home care in Europe. Preventive strategies considered were: (1) blood pressure measured in the last 2 years; (2) influenza vaccination in the last 2 years; (3) medication reviewed in the last 180 days.

RESULTS

Mean age of participants was 82.3 years and 2971 (74%) were women; 1539 (38%) received home care program based on case management. Overall, 1350 (88%) of 1539 participants in the case manager group and 2046 (83%) of 2468 of those in the no case manager group had blood pressure measured in the last 2 years (P < .001). After adjusting for potential confounders, this result was still statistically significant (OR 1.31, 95% CI: 1.08-1.59). Similarly, more participants in the case manager groups received influenza vaccination (1083/1539 [70%] versus 1293/2468 [52%], P < .001) and had medication reviewed (312/1539 [20%] versus 356/2468 [15%], P < .001) compared with those in the no case manager group and these associations were confirmed after adjusting for confounders (OR: vaccination 2.08, 95% CI: 1.81-2.39; medication review 1.69, 95% CI 1.42-2.01). Furthermore, the caregivers of subjects in case manager group were less likely to be unable to continue in caring activities (49/1320 [4%] versus 134/2129 [6%], P = .01) and less dissatisfied (28/1320 [2%] versus 83/1129 [4%], P < .001) compared with those in the no case manager group.

CONCLUSIONS

Home care services based on case management approach result in a higher rate of use of preventive strategies and lower burden for caregivers.

Pressure ulcer and mortality in frail elderly people living in community

Pressure ulcer is one of the most common, disruptive and often disabling conditions affecting frail older people. Purposes of the present study are to ascertain the prevalence of pressure ulcer and to explore the relationship between pressure ulcer and the risk of 1-year all-cause mortality in a large population of frail and very old people living in community. This was an observational cohort study. We analyzed data from the Italian Silver Network Home Care project that collected data on patients admitted to home care programs. A total of twelve home health agencies participated in such project evaluating the implementation of the minimum data set for home care (MDS-HC) instrument. A total of 3,103 patients were enrolled in the present study. The prevalence of patients with pressure ulcer was about 18%. During a follow-up of 12 months from the initial MDS-HC assessment, 160 subjects (29%) died in the pressure ulcer group compared to 368 subjects (14%) in the group of patient without pressure ulcer (p<0.001). After adjusting for age, gender and for all the significantly different variables between subjects with and without pressure ulcer at baseline, subjects with pressure ulcer were more likely to die compared to those without pressure ulcer (RR=1.92; 95% Cl 1.52-2.43).

Lack of correlation between nutritional status and seroprotection against influenza in a long term care facility

We conducted a prospective study in a long-term care facility. Virologic diagnosis was assessed using viral isolation, polymerase chain reaction and serology for all patients with a flu-like syndrome. Albumin, vitamins and trace elements were also measured.

RESULTS

The risk of influenza increased 6.5-fold in patients with an antibody titer of 40 during the influenza outbreak (P=0.04). Micronutrients and vitamins deficiencies were important. Patients with antibody titer >1:40 could still be infected by the virus without correlation with the nutritional status.

CONCLUSION

Humoral protection with a titer >1:40 might not be protective in the elderly. Nutritional deficiencies were too prevalent to detect any effect on the results.

In a prospective observational study, influenza vaccination prevented hospitalization among older home care patients

OBJECTIVE

The aim of the study is (1) to describe the prevalence of vaccination against influenza in older home care patients and (2) to investigate the protective effect of influenza vaccination for hospitalization events.

STUDY DESIGN AND SETTING

This is an observational study conducted in four large cohorts of elderly patients in home care during the 1998-1999, 1999-2000, 2000-2001, and 2001-2002 influenza seasons. We analyzed data from the Italian Silver Network Home Care project. A total of 2,201 patients were enrolled in the present study. The main outcome measures were prevalence of vaccination against influenza and the rate of hospitalization according to vaccination status and influenza season.

RESULTS

The rate of influenza vaccination was around 48% of the studied sample. During the follow-up including the peak of influenza and the total influenza season, 412 subjects (40%) were hospitalized among vaccinated compared to 610 subjects (59%) among not vaccinated (P<0.001). After adjusting for age, gender, location of home care program, and all the variables significantly different between vaccinated and not-vaccinated subjects, vaccinated subjects were less likely to be hospitalized compared to not-vaccinated subjects (OR, 0.73; 95% CI 0.60-0.90).

CONCLUSIONS

Vaccination against influenza has an important prognostic implication for frail geriatric patients living in the community.

Vaccines for preventing influenza in the elderly

BACKGROUND

Influenza vaccination of elderly individuals is recommended worldwide and has been targeted toward the elderly and those at serious risk of complications.

OBJECTIVES

Our aim was to review the evidence of efficacy, effectiveness and safety of influenza vaccines in individuals aged 65 years or older.

SEARCH STRATEGY

We searched the following databases on The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effectiveness (Issue 1, 2006); MEDLINE (January 1966 to March Week 3 2006); EMBASE (Dialog 1974 to 1979; SilverPlatter 1980 to December 2005); Biological Abstracts (SilverPlatter 1969 to December 2004); and Science Citation Index (Web of Science 1974 to December 2004).

SELECTION CRITERIA

We considered randomised, quasi-randomised, cohort and case-control studies assessing efficacy against influenza (laboratory-confirmed cases) or effectiveness against influenza-like illness (ILI) or safety. Any influenza vaccine given independently, in any dose, preparation or time schedule, compared with placebo or with no intervention was considered.

DATA COLLECTION AND ANALYSIS

We grouped reports first according to the setting of the study (community or long-term care facilities) and then by level of viral circulation and vaccine matching. We further stratified by co-administration of pneumococcal polysaccharide vaccine (PPV) and by different types of influenza vaccines. We analysed the following outcomes: influenza, influenza-like illness, hospital admissions, complications and deaths.

MAIN RESULTS

Sixty-four studies were included in the efficacy / effectiveness assessment, resulting in 96 data sets. In homes for elderly individuals (with good vaccine match and high viral circulation) the effectiveness of vaccines against ILI was 23% (6% to 36%) and non-significant against influenza (RR 1.04: 95% CI 0.43 to 2.51). We found no correlation between vaccine coverage and ILI attack rate. Well matched vaccines prevented pneumonia (VE 46%; 30% to 58%), hospital admission (VE 45%; 16% to 64%) and deaths from influenza or pneumonia (VE 42%, 17% to 59%). In elderly individuals living in the community, vaccines were not significantly effective against influenza (RR 0.19; 95% CI 0.02 to 2.01), ILI (RR 1.05: 95% CI 0.58 to 1.89), or pneumonia (RR 0.88; 95% CI 0.64 to 1.20). Well matched vaccines prevented hospital admission for influenza and pneumonia (VE 26%; 12% to 38%) and all-cause mortality (VE 42%; 24% to 55%). After adjustment for confounders, vaccine performance was improved for admissions to hospital for influenza or pneumonia (VE* 27%; 21% to 33%), respiratory diseases (VE* 22%; 15% to 28%) and cardiac disease (VE* 24%; 18% to 30%); and for all-cause mortality (VE* 47%; 39% to 54%). The public health safety profiles of the vaccines appear to be acceptable.

AUTHORS' CONCLUSIONS

In long-term care facilities, where vaccination is most effective against complications, the aims of the vaccination campaign are fulfilled, at least in part. However, according to reliable evidence the usefulness of vaccines in the community is modest. The apparent high effectiveness of the vaccines in preventing death from all causes may reflect a baseline imbalance in health status and other systematic differences in the two groups of participants.

Myelodysplasia: when to treat and how

Myelodysplastic syndrome (MDS) is a disorder of hematopoietic stem cells characterized by ineffective hematopoiesis. The result is pancytopenia leading to transfusion-dependent anemia, an increased risk of infection or bleeding, and a potential to progress to acute myeloid leukemia (AML). MDS is most prevalent among older individuals, many of whom also suffer from other medical conditions. MDS is classified according to World Health Organization criteria and the International Prognostic Scoring System. Supportive care remains the mainstay of therapy. Those with low-risk MDS can often be monitored for an extended period of time without specific therapy, whereas those with intermediate- or high-risk MDS benefit from treatment. Currently, only azacitidine is approved for the treatment of MDS. Several new agents are being tested, including inhibitors of angiogenesis (thalidomide, lenalidomide), farnesyl transferase inhibitors (lonafarnib, tipifarnib), and DNA methyltransferase inhibitors (azacitidine, decitabine). Lenalidomide appears particularly effective in patients with low-risk MDS with the deletion of chromosome 5q31. Allogeneic stem cell transplantation is an alternative for high-risk MDS. With advances in transplantation techniques, this treatment can be offered to an increasing number of patients. However, it is necessary to assess each patient's disease individually and to evaluate prognostic factors, other treatment options, and the appropriateness and timing of transplantation.

Cost-benefit analysis of influenza vaccination in a public healthcare unit

OBJECTIVE

Estimate the costs and benefits of influenza vaccination in a group of employees of an Italian District Health Authority, Unità Locale Socio Sanitaria (ULSS), to define a scheme of an economic evaluation to be used for other vaccination strategies.

DESIGN

In an observational study conducted from December 2002 to April 2003, 107 ULSS employees, voluntarily vaccinated, were compared with 107 nonvaccinated ULSS employees matched for age, sex, and job category. The outcome of cost-benefit analysis was evaluated by checking personnel department records about absences from work and their causes, including influenza. Costs and benefits of the influenza vaccination from the ULSS point of view were calculated.

RESULTS

The influenza vaccination strategy reduced absences from work by 23% and decreased the loss of working days by 30% and related cost. This difference is not significative. The ratio vaccination benefits/cost was euro4.2. The advantage of vaccination is confirmed by sensitivity analysis performed on the mean cost of a working day, which showed that the benefit-cost ratio ranged from euro4.5 to euro11.7.

CONCLUSIONS

The results suggest that the influenza vaccination strategy in our sample of people was cost-saving. The economic evaluation used in this study could also be used for other vaccination strategies and in other settings.

Functional status is a confounder of the association of influenza vaccine and risk of all cause mortality in seniors

BACKGROUND

Functional status limitations may be associated with both an increased risk of death and a decreased likelihood of influenza vaccination, and so may confound the association of influenza vaccination and risk of all cause mortality in seniors.

METHODS

We conducted a nested case-control study of persons >or=65 years of age that included 252 cases who died during an influenza season and 576 age-matched controls. We identified functional limitations by medical record review, and compared the effect of adjustment for those factors with that of adjustment for disease covariates defined by diagnosis codes, using methods reported by previous influenza vaccine effectiveness studies, on the association of influenza vaccination and risk of death.

RESULTS

Functional limitations, such as requiring assistance for bathing, were highly prevalent in cases, even in the subgroup defined as free of comorbidity by diagnosis code criteria, and were associated with a decreased likelihood of vaccination among controls. Adjustment for functional limitations resulted in an estimate of the relative risk of death in vaccinated persons compared with unvaccinated persons that was closer to the null [odds ratio (OR), 0.71; 95% confidence interval (95% CI), 0.47-1.06] than the unadjusted estimate (OR, 0.59; 95% CI, 0.41-0.83). In contrast, adjustment for diagnosis code covariates moved the estimate further from the null (OR, 0.45; 95% CI, 0.30-0.68).

CONCLUSIONS

Functional limitations appear to be important confounders of the association of vaccination and risk of death, while adjustment for diagnosis code covariates did not control for a healthy vaccinee bias. Further research is needed on methods to reduce the influence of bias in observational studies of influenza vaccine effectiveness.

Evidence of bias in estimates of influenza vaccine effectiveness in seniors

BACKGROUND

Numerous observational studies have reported that seniors who receive influenza vaccine are at substantially lower risk of death and hospitalization during the influenza season than unvaccinated seniors. These estimates could be influenced by differences in underlying health status between the vaccinated and unvaccinated groups. Since a protective effect of vaccination should be specific to influenza season, evaluation of non-influenza periods could indicate the possible contribution of bias to the estimates observed during influenza season.

METHODS

We evaluated a cohort of 72,527 persons 65 years of age and older followed during an 8 year period and assessed the risk of death from any cause, or hospitalization for pneumonia or influenza, in relation to influenza vaccination, in periods before, during, and after influenza seasons. Secondary models adjusted for covariates defined primarily by diagnosis codes assigned to medical encounters.

RESULTS

The relative risk of death for vaccinated persons compared with unvaccinated persons was 0.39 [95% confidence interval (95% CI), 0.33-0.47] before influenza season, 0.56 (0.52-0.61) during influenza season, and 0.74 (0.67-0.80) after influenza season. The relative risk of pneumonia hospitalization was 0.72 (0.59-0.89) before, 0.82 (0.75-0.89) during, and 0.95 (0.85-1.07) after influenza season. Adjustment for diagnosis code variables resulted in estimates that were further from the null, in all time periods.

CONCLUSIONS

The reductions in risk before influenza season indicate preferential receipt of vaccine by relatively healthy seniors. Adjustment for diagnosis code variables did not control for this bias. In this study, the magnitude of the bias demonstrated by the associations before the influenza season was sufficient to account entirely for the associations observed during influenza season.

Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG)

BACKGROUND

As more and more cancers occur in elderly people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters in the treatment of their patients.

METHODS

The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted.

RESULTS

Several biological and clinical correlates of aging have been identified. Their relative weight and clinical usefulness is still poorly defined. There is strong evidence that a CGA detects many problems missed by a regular assessment in general geriatric and in cancer patients. There is also strong evidence that a CGA improves function and reduces hospitalization in the elderly. There is heterogeneous evidence that it improves survival and that it is cost-effective. There is corroborative evidence from a few studies conducted in cancer patients. Screening tools exist and were successfully used in settings such as the emergency room, but globally were poorly tested. The article contains recommendations for the use of CGA in research and clinical care for older cancer patients.

CONCLUSIONS

A CGA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The task force cannot recommend any specific tool or approach above others at this point and general geriatric experience should be used.

The ilSIRENTE study: a prospective cohort study on persons aged 80 years and older living in a mountain community of Central Italy

BACKGROUND AND AIMS

"Invecchiamento e Longevità nel Sirente" (Aging and Longevity in the Sirente geographic area, ilSIRENTE) aims at investigating the socio-demographic, functional, clinical and biological characteristics of all subjects aged 80 years and older residing in a well-defined mountain area of Central Italy.

METHODS

Data are from the baseline evaluation of the ilSIRENTE prospective cohort study. A list of all persons living in the Sirente area was obtained from the Registry Offices of the 13 municipalities involved in the study. Data collection started in December 2003 and was completed in September 2004. Among the 429 residents older than 80 years eligible for the study, 364 accepted to participate (response rate 84%). Participants were assessed by trained staff who collected information on socio-demographic factors, clinical conditions, medication use, physical performance and muscle strength. All participants were also evaluated using the Minimum Data Set for Home Care (MDS-HC) form and a slightly modified version of the "Invecchiare in CHIANTI" study.

RESULTS

The mean age of participants was 85.6 +/- 4.8 years (range 80-102 years), with over 20% of participants aged 90 years or older. More than 65% of participants were women. Most participants (70%) were independent or required limited assistance in performing basic activities of daily living (ADL), whereas 30% of participants were independent in instrumental activities of daily living (IADL). Cognitive function (assessed by the Cognitive Performance Score) was normal in 80% of the sample. Higher degrees of disabilities (defined as the sum of dependencies in ADLs and IADLs) were associated with worse physical performance and lower muscle strength.

CONCLUSIONS

Data on the socio-demographic characteristics and health status of very old people living in the Sirente mountain community are discussed and compared with findings from other epidemiological studies.

Prevalence and predictors of influenza vaccination among frail, community-living elderly patients: an international observational study

The annual winter outbreak of influenza is one of the major cause of morbidity and mortality among frail elderly people. The aim of the present study was to identify prevalence and predictors of influenza vaccination in a large European population of frail and old people living in community. This was an observational study conducted in 11 European countries. We enrolled 3878 people 65 years and older already receiving home care services within the urban areas. All participants were assessed with the Minimum Data Set-Home Care (MDS-HC) instrument containing over 300 items, including socio-demographic, physical and cognitive characteristics of patients as well as medical diagnoses and medications received. A single question about the influenza vaccination status was used. The rate of influenza vaccination was around 59% of the studied sample. Significant geographical variations were evident in the prevalence of vaccination ranging from 31% of Prague (Czech Republic) to 88% of Rotterdam (The Netherlands). Overall, persons living alone were less likely to receive influenza vaccine as compared with those living with an informal caregiver (OR, 0.78; 95% CI 0.67-0.90). Similarly, cognitive impairment and presence of economic problems were associated with a lower likelihood of being vaccinated (OR: 0.69, 95% CI 0.59-0.80 and OR, 0.58; 95% CI 0.45-0.74, respectively). On the other hand, old age and comorbidity were associated with an higher probability of being vaccinated. In conclusion, more than 40% of subjects in this sample of home care patients in Europe did not receive influenza vaccination. Recommendations for influenza vaccination have not been adequately implemented.

Influenza Vaccination in the Elderly

Influenza causes substantial morbidity across the age spectrum. However, the elderly are especially vulnerable to the serious complications of influenza that might result in hospitalisation or death, and high rates of influenza-associated excess hospitalisation or death that exceed by several-fold the rates seen among most other age groups have consistently been observed in many countries and across many seasons. Thus, the elderly are included among the high priority groups for routine influenza vaccination by many national health authorities. Inactivated influenza virus vaccines are widely available across the globe and are safe and effective. Vaccination of elderly persons has been associated with significant reductions in hospitalisations for pneumonia and influenza as well as hospitalisations for other cardiopulmonary disorders and even cerebrovascular disease. Vaccination has also been associated with reductions in influenza-associated and all-cause mortality during influenza seasons. The benefits of vaccination extend not only to community-dwelling elderly but also to elderly who reside in nursing homes. Likewise, vaccination provides benefits to the very old and to elderly persons with underlying co-morbidities as well as to the healthy elderly. Despite the substantially increased risk for serious complications and impressive benefits from vaccination among the elderly, influenza vaccine utilisation remains below target rates for this group in nearly all countries. The need for improved prevention and control of influenza is recognised as a priority for the global community--both to reduce the morbidity and mortality associated with epidemic influenza and to prepare for the next pandemic. Enhancing vaccine delivery to elderly persons would represent important progress toward that goal.