Multimorbilidad, fragilidad y resultados en salud en población geriátrica

Antecedentes y objetivosLa multimorbilidad, definida como la presencia de dos o más enfermedades crónicas de forma simultánea en un individuo, y la fragilidad, es decir el estado de vulnerabilidad ante factores estresantes, tienen un gran impacto en la salud de los pacientes y en el uso de los recursos sanitarios. El objetivo general de esta tesis que se presenta es avanzar en el conocimiento de la epidemiología de la multimorbilidad en pacientes geriátricos y su impacto sobre los resultados en salud (interacción con la dependencia funcional, la mortalidad y la utilización de servicios sanitarios), basándonos en el análisis de grandes bases de datos clínico-administrativas de la población de Aragón. Las preguntas de investigación se responden en cuatro artículos publicados y vinculados a cada uno de los siguientes objetivos específicos: a) explorar la multimorbilidad en población geriátrica hospitalizada, b) caracterizar la población geriátrica centenaria de Aragón, c) definir las variables demográficas y clínicas que diferencian a los centenarios de los ancianos más jóvenes de Aragón y d) analizar la utilidad de la armonización de bases de datos en la caracterización de la población geriátrica con multimorbilidad y fragilidad en Europa.MetodologíaEl primer objetivo específico se abordó a través de análisis factorial exploratorio de los diagnósticos crónicos y síndromes geriátricos para la identificación de patrones de multimorbilidad, basado en correlaciones tetracóricas, debido a la naturaleza dicotómica (presencia/ausencia) de la variable diagnóstica. Análisis estratificado por grupos de edad y sexo.El segundo y tercer objetivos específicos se abordó mediante un estudio observacional retrospectivo en la Cohorte EpiChron (Aragón). Análisis de las características sociodemográficas, clínicas, consumo de fármacos y utilización de servicios sanitarios, utilizando información de historia clínica electrónica y bases de datos clínico-administrativas. Los resultados se han calculado como medias y/o frecuencias con intervalo de confianza del 95%. Para el análisis de diferencias por sexo, se ha utilizado el test de Kruskal-Wallis para comparar las medias y el test Chi-cuadrado de Pearson para comparar frecuencias. La significación estadística se ha establecido en pEl cuarto objetivo se abordó a través de un estudio descriptivo para valorar la capacidad de armonización de 4 bases de datos sobre salud en personas mayores.ConclusionesEl patrón de multimorbilidad dependencia inducida, compuesto exclusivamente por síndromes geriátricos, puede actuar como desencadenante del deterioro funcional, lo que subraya la importancia de la evaluación global de los pacientes geriátricos. La multimorbilidad parece ser la regla más que la excepción en esta población, que presenta principalmente un patrón cardiocerebrovascular. Abordar la atención médica en las personas mayores desde una perspectiva geriátrica integral es fundamental para preservar su salud y evitar los efectos negativos de la polifarmacia. El estado de salud aparentemente mejor en los centenarios que en nonagenarios y octogenarios, deja la puerta abierta para reconocer que esta población muere más como consecuencia de un mecanismo de envejecimiento biológico natural que por la presencia de enfermedades específicas. La identificación de factores potenciales para una longevidad excepcional requeriría más estudios longitudinales multidisciplinarios que deberían analizar simultáneamente información clínica, bioquímica y de estilo de vida.La aplicación de metodologías comunes de registro de información, facilita la armonización, la fusión de datos, la extrapolación a otros contextos y la posibilidad de trabajar de forma conjunta en múltiples campos de la geriatría. <br /

Paciente Crónico Complejo. Determinantes sociodemográficos, clínicos y de fragilidad

El envejecimiento poblacional y la elevada prevalencia de enfermedades crónicas han generado una serie de necesidades asistenciales que hoy son una realidad evidente. Un elevado porcentaje de los gastos de atención sanitaria se asocia con una pequeña proporción de la población con necesidades complejas en salud. Este hecho hace necesaria una adecuada identificación de estos pacientes, una valoración integral que nos haga prever, en la medida de lo posible, sus demandas y un modelo de continuidad asistencial que asegure el mejor cuidado de su salud. Los objetivos del estudio son: 1. Describir las características de la población atendida por la unidad de valoración sociosanitaria del sector Zaragoza II del HUMS. 2. Analizar la influencia de variables sociodemográficas, indicadores de fragilidad y variables clínicas, sobre el nivel de utilización de recursos, la supervivencia y la seguridad clínica y 3. Valorar la capacidad predictiva la herramienta de detección activa del paciente crónico complejo utilizada por la unidad de valoración sociossanitaria. El perfil de pacientes detectados en la UVSS-HUMS es el de una persona cercana a los 80 años, con riesgo social intermedio, casado, con buena situación previa funcional y cognitiva y en la que se produce un deterioro importante y brusco durante el proceso hospitalario, de los cuales más de un tercio fallece principalmente durante el primer mes tras el alta. El impacto conjunto de los determinantes sociales (i.e. riesgo social, vivir sólo o con persona de edad avanzada, y sobrecarga del cuidador) y clínicos (i.e. pluripatología, polimedicación, y situación funcional) sobre la utilización de servicios sanitarios y los resultados en salud puesto de manifiesto en este estudio, llama a la necesidad de integrar servicios sociales y sanitarios para responder a las demandas en salud de la población anciana frágil. La validez de la herramienta de detección activa del paciente crónico complejo utilizada por la UVSS-HUMS ha sido comprobada de forma empírica, mostrando una adecuada capacidad de discriminación de los pacientes más susceptibles de mejora ante intervenciones precoces basadas en una valoración integral geriátrica, y que tengan como objetivo la actuación preventiva y/o rehabilitadora

Do centenarians die healthier than younger elders? A comparative epidemiological study in Spain

This study aims to describe the clinical course, drug use, and health services use characteristics during the last year of life of elders who die being centenarians and to identify key aspects differentiating them from elders who die at an earlier age, with a particular focus on sex differences. We conducted an observational, population-based study in the EpiChron Cohort (Aragon, Spain). The population was stratified by sex and into three age sub-populations (80-89, 90-99, and >= 100 years), and their characteristics were described and compared. Multimorbidity was the rule in our elders, affecting up to 3 in 4 centenarians and 9 in 10 octogenarians and nonagenarians. Polypharmacy was also observed in half of the centenarian population and in most of the younger elders. Risk factors for cardiovascular disease (i.e., hypertension, dyslipidaemia, diabetes), cerebrovascular disease and dementia were amongst the most common chronic conditions in all age groups, whereas the gastroprotective drugs and antithrombotic agents were the most dispensed drugs. Centenarians presented in general lower morbidity and treatment burden and lower use of both primary and hospital healthcare services than octogenarians and nonagenarians, suggesting a better health status. Sex-differences in their clinical characteristics were more striking in octogenarians and tended to decrease with age

Health of Spanish centenarians: A cross-sectional study based on electronic health records

Background: With the number of centenarians increasing exponentially in Spain, a deeper knowledge of their socio-demographic, clinical, and healthcare use characteristics is important to better understand the health profile of the very elderly. Methods: We conducted a retrospective, cross-sectional observational study in the EpiChron Cohort (Aragon, Spain) aimed at analyzing the socio-demographic, clinical, drug use and healthcare use characteristics of 1680 centenarians during 2011-2015, using data from electronic health records and clinical-administrative databases. Results: Spanish centenarians (79.1% women) had 101.6 years on average. Approximately 80% of centenarians suffered from multimorbidity, with an average of 4.0 chronic conditions; 50% were exposed to polypharmacy, with an average of 4.8 medications; only 6% of centenarians were free of chronic diseases and only 7% were not on medication. Centenarians presented a cardio-cerebrovascular pattern in which hypertension, heart failure, cerebrovascular disease and dementia were the most frequent conditions. Primary care was the most frequently visited healthcare level (79% of them), followed by medical specialist consultations (23%), hospitalizations (13%), and emergency service use (9%). Conclusions: Multimorbidity is the rule rather than the exception in Spanish centenarians. Addressing medical care in the very elderly from a holistic geriatric view is critical in order to preserve their health, and avoid the negative effects of polypharmacy

Multimorbidity patterns in hospitalized older patients: Associations among chronic diseases and geriatric syndromes

Background/Objectives The clinical status of older individuals with multimorbidity can be further complicated by concomitant geriatric syndromes. This study explores multimorbidity patterns, encompassing both chronic diseases and geriatric syndromes, in geriatric patients attended in an acute hospital setting. Design Retrospective observational study. Setting Unit of Social and Clinical Assessment (UVSS), Miguel Servet University Hospital (HUMS), Zaragoza (Spain). Year, 2011. Participants A total of 924 hospitalized patients aged 65 years or older. Measurements Data on patients'' clinical, functional, cognitive and social statuses were gathered through comprehensive geriatric assessments. To identify diseases and/or geriatric syndromes that cluster into patterns, an exploratory factor analysis was applied, stratifying by sex. The factors can be interpreted as multimorbidity patterns, i.e., diseases non-randomly associated with each other within the study population. The resulting patterns were clinically assessed by several physicians. Results The mean age of the study population was 82.1 years (SD 7.2). Multimorbidity burden was lower in men under 80 years, but increased in those over 80. Immobility, urinary incontinence, hypertension, falls, dementia, cognitive decline, diabetes and arrhythmia were among the 10 most frequent health problems in both sexes, with prevalence rates above 20%. Four multimorbidity patterns were identified that were present in both sexes: Cardiovascular, Induced Dependency, Falls and Osteoarticular. The number of conditions comprising these patterns was similar in men and women. Conclusion The existence of specific multimorbidity patterns in geriatric patients, such as the Induced Dependency and Falls patterns, may facilitate the early detection of vulnerability to stressors, thus helping to avoid negative health outcomes such as functional disability

Baseline drug treatments as indicators of increased risk of COVID-19 mortality in Spain and Italy

This study aims to identify baseline medications that, as a proxy for the diseases they are dispensed for, are associated with increased risk of mortality in COVID-19 patients from two regions in Spain and Italy using real-world data. We conducted a cross-country, retrospective, observational study including 8570 individuals from both regions with confirmed SARS-CoV-2 infection between 4 March and 17 April 2020, and followed them for a minimum of 30 days to allow sufficient time for the studied event, in this case death, to occur. Baseline demographic variables and all drugs dispensed in community pharmacies three months prior to infection were extracted from the PRECOVID Study cohort (Aragon, Spain) and the Campania Region Database (Campania, Italy) and analyzed using logistic regression models. Results show that the presence at baseline of potassium-sparing agents, antipsychotics, vasodilators, high-ceiling diuretics, antithrombotic agents, vitamin B12, folic acid, and antiepileptics were systematically associated with mortality in COVID-19 patients from both countries. Treatments for chronic cardiovascular and metabolic diseases, systemic inflammation, and processes with increased risk of thrombosis as proxies for the conditions they are intended for can serve as timely indicators of an increased likelihood of mortality after the infection, and the assessment of pharmacological profiles can be an additional approach to the identification of at-risk individuals in clinical practice

Cohort Profile: The epidemiology of chronic diseases and multimorbidity. The EpiChron cohort study

Why was the cohort set up? Greater life expectancy in Europe over the past few decades has been translated into an increasing burden of chronic diseases that accumulate as the population ages, whereas acute infectious diseases have been progressively pushed into the background. The incidence of conditions such as hypertension, obesity and asthma has increased dramatically worldwide, and cancer, diabetes and respiratory and cardiovascular diseases are responsible for almost 70% of global deaths. Concurrently, the prevalence of multimorbidity (as of people affected by more than one chronic disorder) is also increasing and appears as the most common chronic condition at present. Multimorbidity affects almost 3 in 4 individuals aged 65 years and older, although it represents a problem not only for the elderly but also for adult and even young populations, at whom prevention strategies should aim. People affected by multimorbidity often experience fragmentation of care, greater and inadequate use of health services and polypharmacy, which in turn may increase the risk of low adherence and adverse drug reactions. All of this leads to individuals’ quality of life deterioration and higher risk of mortality. Besides, handling patients with multimorbidity represents a daily challenge for physicians and health systems..

Baseline chronic comorbidity and mortality in laboratory-confirmed COVID-19 cases: Results from the PRECOVID study in Spain

We aimed to analyze baseline socio-demographic and clinical factors associated with an increased likelihood of mortality in men and women with coronavirus disease (COVID-19). We conducted a retrospective cohort study (PRECOVID Study) on all 4412 individuals with laboratory-confirmed COVID-19 in Aragon, Spain, and followed them for at least 30 days from cohort entry. We described the socio-demographic and clinical characteristics of all patients of the cohort. Age-adjusted logistic regressions models were performed to analyze the likelihood of mortality based on demographic and clinical variables. All analyses were stratified by sex. Old age, specific diseases such as diabetes, acute myocardial infarction, or congestive heart failure, and dispensation of drugs like vasodilators, antipsychotics, and potassium-sparing agents were associated with an increased likelihood of mortality. Our findings suggest that specific comorbidities, mainly of cardiovascular nature, and medications at the time of infection could explain around one quarter of the mortality in COVID-19 disease, and that women and men probably share similar but not identical risk factors. Nonetheless, the great part of mortality seems to be explained by other patient-and/or health-system-related factors. More research is needed in this field to provide the necessary evidence for the development of early identification strategies for patients at higher risk of adverse outcomes

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe