Retos futuros de la Ortogeriatría

El paciente geriátrico que ingresa en el hospital con diagnóstico de fractura de cadera, presenta unos retos quirúrgicos, anestésicos, rehabilitadores y de manejo clínico que precisa de una atención perioperatoria específica, especializada, interdisciplinar y coordinada. Con este objetivo, a finales de los años cincuenta del siglo XX se articularon las primeras unidades específicas atendidas por geriatras y traumatólogos. El Hospital Universitario de la Ribera dispone de un modelo de atención ortogeriátrica que, de forma protocolizada, atiende a los pacientes geriátricos con diagnóstico de fractura de cadera, tratando de aportar una atención integral y precoz, enfatizando la premura en la valoración geriátrica, la intervención quirúrgica y en el inicio precoz del tratamiento rehabilitador. Los datos publicados describen una mortalidad intrahospitalaria del 4,7%, una estancia media de 8,9 (SD 4,26) días y una estancia prequirúrgica de 2,4 (SD 1,9) días. Los reingresos se cifraron en un 2,3%. Al alta deambulaba el 64% de los pacientes, cifra que se incrementó al 77,4% al mes y al 80,2% a los 6 meses. Recuperar la capacidad de deambular se relacionó con la situación funcional previa, el estado cognitivo y la edad y, la supervivencia con el estado funcional, la insuficiencia cardiaca, el estado cognitivo, la edad y ser varón. Comparados los datos de estancia media con la media de los publicados por el Ministerio de Sanidad para el mismo proceso, se estimó un ahorro de más de 480.000 euros al añoThe geriatric patient who entered the hospital with a diagnosis of hip fracture presents a surgical, anesthetics, clinical management and rehabilitation challenges that requires a specific, specialized, interdisciplinary and coordinated perioperative care. To this end, in the late fifties of the twentieth century the first specific units served by geriatricians and orthopedic surgeons were articulated. Hospital Universitario de la Ribera has a model orthogeriatric attention, that in a protocolized way, serves geriatric patients diagnosed with hip fracture, trying to provide a comprehensive and early care, emphasizing the urgency in the geriatric assessment, intervention surgical and early initiation of rehabilitation treatment. Published data describes the hospital mortality of 4.7%, an average stay of 8.9 (SD 4.26) days and a preoperative stay of 2.4 (SD 1.9) days. Readmissions amounted to 2.3%. High wandered to 64% of patients, a figure that increased to 77.4% the month and 80.2% at 6 months. Regain the ability to roam was associated with prior functional status, cognitive status and age and survival with functional status, heart failure, cognitive status, age and being male. Data compared with the average length of stay of those published by the Spanish Ministry of Health for the same process, a savings of more than 480,00

Orthogeriatric management: Improvements in outcomes during hospital admission due to hip fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms “hip fracture”, “geriatric assessment”, “second hip fracture”, “surgery”, “perioperative management” and “orthogeriatric care”, in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery

Relationship between the risk of falling and prescribed medication in community-dwelling elderly subjects.

Abstract Introduction: The risk of falling increases with age. A third of the population over 65 has one or more falls per year. Objetive: to know the relationship between drug prescription and falls in the elderly. Materials and Methods: a study was carried out through a community intervention in individuals ≥ 70 years of age. Results: The sample was composed of 249 participants, 160 women (64%), with a mean age of 74.47 years (SD 5.33). During the 12 months prior to the study, the mean of falls per person was 0.5 (SD 0.94), the mean of the risk factors was 2.73 (SD 1.4) and the mean of the medication prescribed was 4.2 (SD 3.0). The percentage of the reduction of falls after the study was 12%. The amount of medication prescribed correlated with the incidence of falls before and after the study, r=0.193, p=0.002 y r2=0.170, p=0.009, respectively. Prior to the study, the individuals who were prescribed beta-blockers and antidepressants, had a fall incidence of 0.74 (SD 1.14) and 1.22 (SD 1.09), respectively, however after the intervention there was no relationship between drug prescription and falls. Conclusions: the fall prevention community program was effective since it prevented the negative effects of medication on falls. An interdisciplinary community intervention reduces the global incidence of falls and the incidence of falls related to some specific medication

Risk Factors for Mortality in Nursing Home Residents: An Observational Study

Purpose: Identifying mortality risk factors in people living in nursing homes could help healthcare professionals to individualize or develop specific plans for predicting future care demands and plan end-of-life care in this population. This study aims to identify mortality risk factors in elderly nursing home (NH) residents, based on variables adapted to this environment, routinely collected and easily accessible to their healthcare professionals. Methods: A prospective, longitudinal, observational study of NH residents aged 65 years and older was carried out collecting sociodemographic, functional and cognitive status, nutritional variables, comorbidities, and other health variables. These variables were analyzed as mortality risk factors by Cox proportional hazard models. Results: A total of 531 residents (75.3% female; average age 86.7 years (SD: 6.6)) were included: 25.6% had total dependence, 53.4% had moderate to severe cognitive impairment, 84.5% were malnourished or at risk of malnutrition, and 79.9% were polymedicated. Risk of mortality (hazard ratio, HR) increased in totally dependent residents (HR = 1.52; p = 0.02) and in those with moderate or severe cognitive impairment ((HR = 1.59; p = 0.031) and (HR = 1.93; p = 0.002), respectively). Male gender (HR = 1.88; p < 0.001), age 80 years (HR = 1.73; p = 0.034), hypertension (HR = 1.53; p = 0.012), atrial fibrillation/arrhythmia (HR = 1.43; p = 0.048), and previous record of pneumonia (HR = 1.65; p = 0.029) were also found to be mortality drivers. Conclusion: Age and male gender (due to the higher prevalence of associated comorbidity in these two variables), certain comorbidities (hypertension, atrial fibrillation/arrhythmia, and pneumonia), higher functional and cognitive impairment, and frequency of medical emergency service care increased the risk of mortality in our study. Given their importance and their easy identification by healthcare professionals in nursing homes, these clinical variables should be used for planning care in institutionalized older adults.Grupo Ballesol (Valencia, Spain) provided financial support for conducting the research and publishing the article. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscriptEnfermerí

Early interdisciplinary hospital intervention for elderly patients with hip fractures – functional outcome and mortality

OBJECTIVES: Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: This observational, retrospective study was performed in an orthogeriatric care unit on patients aged >70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7 + 6.4 years. RESULTS: On admission to the unit, the average Barthel score of these patients was 77.2 + 27.8 points, and the average Charlson index score was 2.14 + 2.05. The mean length of stay was 8.9 + 4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay. CONCLUSIONS: Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery

A Community Program of Integrated Care for Frail Older Adults : +AGIL Barcelona

Objectives: To assess the 3-month impact on physical function of a program for community-dwelling frail older adults, based on the integration of primary care, geriatric medicine, and community resources, implemented in \u201creal life\u201d. Design: Interventional cohort study. Setting: Primary care in Barcelona, Spain. Participants: Individuals aged 6580 years (n=134), presenting at least one sign of frailty (i.e., slow gait speed, weakness, memory complaints, involuntary weight loss, poor social support). Intervention: After frailty screening by the primary care team, candidates were referred to a geriatric team (geriatrician + physical therapist), who performed a comprehensive geriatric assessment and designed a tailored multidisciplinary intervention in the community, including a) multi-modal physical activity (PA) sessions, b) promotion of adherence to a Mediterranean diet c) health education and d) medication review. Measurements: Participants were assessed based on a comprehensive geriatric assessment including physical performance (Short Physical Performance Battery -SPPB- and gait speed), at baseline and at a three month follow-up. Results: A total of 112 (83.6%) participants (mean age=80.8 years, 67.9% women) were included in this research. Despite being independent in daily life, participants\u2019 physical performance was impaired (SPPB=7.5, SD=2.1, gait speed=0.71, SD=0.20 m/sec). After three months, 90.2% of participants completed 657.5 physical activity sessions. The mean improvements were +1.47 (SD 1.64) points (p&lt;0.001) for SPPB, +0.08 (SD 0.13) m/sec (p&lt;0.001) for gait speed, 125.5 (SD 12.10) sec (p&lt;0.001) for chair stand test, and 53% (p&lt;0.001) improved their balance. Results remained substantially unchanged after stratifying the analyses according to the severity of frailty. Conclusions: Our results suggested that a \u201creal-world\u201d multidisciplinary intervention, integrating primary care, geriatric care, and community services may improve physical function, a marker of frailty, within 3 months. Further studies are needed to address the long-term impact and scalability of this implementation program

A Community Program of Integrated Care for Frail Older Adults: +AGIL Barcelona

Objectives: To assess the 3-month impact on physical function of a program for community-dwelling frail older adults, based on the integration of primary care, geriatric medicine, and community resources, implemented in 'real life'. Design: Interventional cohort study. Setting: Primary care in Barcelona, Spain. Participants: Individuals aged ≥80 years (n=134), presenting at least one sign of frailty (i.e., slow gait speed, weakness, memory complaints, involuntary weight loss, poor social support). Intervention: After frailty screening by the primary care team, candidates were referred to a geriatric team (geriatrician + physical therapist), who performed a comprehensive geriatric assessment and designed a tailored multidisciplinary intervention in the community, including a) multi-modal physical activity (PA) sessions, b) promotion of adherence to a Mediterranean diet c) health education and d) medication review. Measurements: Participants were assessed based on a comprehensive geriatric assessment including physical performance (Short Physical Performance Battery -SPPB- and gait speed), at baseline and at a three month follow-up. Results: A total of 112 (83.6%) participants (mean age=80.8 years, 67.9% women) were included in this research. Despite being independent in daily life, participants' physical performance was impaired (SPPB=7.5, SD=2.1, gait speed=0.71, SD=0.20 m/sec). After three months, 90.2% of participants completed ≥7.5 physical activity sessions. The mean improvements were +1.47 (SD 1.64) points (p<0.001) for SPPB, +0.08 (SD 0.13) m/sec (p<0.001) for gait speed, -5.5 (SD 12.10) sec (p<0.001) for chair stand test, and 53% (p<0.001) improved their balance. Results remained substantially unchanged after stratifying the analyses according to the severity of frailty. Conclusions: Our results suggested that a 'real-world' multidisciplinary intervention, integrating primary care, geriatric care, and community services may improve physical function, a marker of frailty, within 3 months. Further studies are needed to address the long-term impact and scalability of this implementation program

Direct Oral Anticoagulants versus Warfarin in Octogenarians with Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis

Direct oral anticoagulants (DOACs) have been demonstrated to be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). This meta-analysis aims to assess the effect of DOACS vs. VKA in patients ≥ 80 and AF. Primary endpoints were stroke or systemic embolism and all-cause death. Secondary endpoints included major bleeding, intracranial bleeding, and gastrointestinal bleeding. A random-effects model was selected due to significant heterogeneity. A total of 147,067 patients from 16 studies were included, 71,913 (48.90%) treated with DOACs and 75,154 with VKA (51.10%). The stroke rate was significantly lower in DOACs group compared with warfarin group (Relative risk (RR): 0.72; 95% confidence interval (CI): 0.63-0.82; p < 0.001). All-cause mortality was significantly lower in DOACs group compared with warfarin group (RR: 0.82; 95% CI: 0.70-0.96; p = 0.012). Compared to warfarin, DOACs were not associated with reductions in major bleeding (RR: 0.85, 95% CI 0.69-1.04; p = 0.108) or gastrointestinal bleeding risk (RR: 1.08, 95% CI 0.76-1.53; p = 0.678) but a 43% reduction of intracranial bleeding (RR: 0.47, IC 95% 0.36-0.60; p < 0.001) was observed. Our meta-analysis demonstrates that DOACs are effective and safe with statistical superiority when compared with warfarin in octogenarians with AF

Validation of score in mna scale like nutritional risk factor in institutionalized geriatric patients with moderate and severe cognitive impairment

Introducción: La valoración geriátrica integral incluye el examen del apartado nutricional debido a la alta prevalencia de desnutrición en este tipo de pacientes; especialmente en los pacientes con deterioro cognitivo asociado. Las escalas de cribado del estado nutricional presentan preguntas de autopercepción subjetiva de difícil respuesta en pacientes mayores con demencia. Objetivo: Estudiar la especificidad, el valor predictivo positivo y la sensibilidad de la escala MNA para la detección de malnutrición en pacientes diagnosticados de enfermedad de Alzheimer con deterioro cognitivo avanzado. Material y métodos: Se diseñó un estudio descriptivo poblacional con una muestra de 52 pacientes mayores de 70 años, institucionalizados, con enfermedad de Alzheimer grado moderado y severo. Se estudió la sensibilidad, especificidad y valor predictivo positivo de la escala MNA respecto a los parámetros de malnutrición del American Institute of Nutrition (AIN). Resultados: Los valores de sensibilidad, especificidad y valor predictivo positivo son 60%, 94,7% y 93,8% respectivamente. Existe una correlación significativa (p < 0,001) ente la puntuación obtenida en la escala MNA y la escala de riesgo de caídas Tinneti (r = 0,577), de función Barthel (r = 0,742), de valoración cognitiva MEC (r = 0,651) y los niveles de creatinina (r = 0,402). Más del 50% de la muestra presentó al menos un parámetro de malnutrición AIN alterado. Conclusiones: La escala MNA presenta una menor sensibilidad y especificidad en estos pacientes. El diseño de una escala de valoración nutricional sin valoraciones subjetivas y sólo con parámetros objetivos podría mejorar la eficacia de la misma en ancianos institucionalizados con deterioro cognitivo moderado y severo.Introduction: comprehensive geriatric assessment includes examination of the nutritional status given the high prevalence of hyponutrition in this kind of patients, particularly in patients with associated cognitive impairment. Scales for screening the nutritional status include questions on self-perception difficult to answer by demented elder patients. Objective: To study the specificity, the positive predictive value, and the sensitivity of the MNA scale to detect malnutrition in patients diagnosed with Alzheimer’s disease with advanced cognitive impairment. Material and methods: a population-based descriptive study with a sample of 52 patients older than 70 years, institutionalized, and with moderate-severe Alzheimer’s disease was designed. The sensitivity, specificity, and positive predictive value of MNA scale were studied regarding the parameters on malnutrition of the American Institute of Nutrition (AIN). Results: the sensitivity, specificity, and positive predictive values were 60%, 94.7%, and 93.8%, respectively. There was a significant correlation (p < 0.001) between the score obtained with the MNA Scale and the Tinneti’s Risk of Fall Scale (r = 0.577), the Barthel’s function (r = 0.742), the MCT cognitive assessment (r = 0.651), and creatinine levels (r = 0.402). More than 50% of the sample presented at least one malnutrition parameter altered. Conclusions: the MNA Scale presents lower sensitivity and specificity in these patients. Designing a nutritional assessment scale without subjective evaluations and only with objective parameters might improve its efficiency in institutionalized elderly patients with moderate-severe cognitive impairment.Nutrición humana y dietétic

Genistein effect on cognition in prodromal Alzheimer's disease patients. The GENIAL clinical trial

Background: Delaying the transition from minimal cognitive impairment to Alzheimer’s dementia is a major concern in Alzheimer’s disease (AD) therapeutics. Pathological signs of AD occur years before the onset of clinical dementia. Thus, long-term therapeutic approaches, with safe, minimally invasive, and yet efective substances are recommended. There is a need to develop new drugs to delay Alzheimer’s dementia. We have taken a nutritional supplement approach with genistein, a chemically defned polyphenol that acts by multimodal specifc mechanisms. Our group previously showed that genistein supplementation is efective to treat the double transgenic (APP/PS1) AD animal model. Methods: In this double-blind, placebo-controlled, bicentric clinical trial, we evaluated the efect of daily oral supplementation with 120 mg of genistein for 12 months on 24 prodromal Alzheimer’s disease patients. The amyloidbeta deposition was analyzed using 18F-futemetamol uptake. We used a battery of validated neurocognitive tests: Mini-Mental State Exam (MMSE), Memory Alteration Test (M@T), Clock Drawing Test, Complutense Verbal Learning Test (TAVEC), Barcelona Test-Revised (TBR), and Rey Complex Figure Test. Results: We report that genistein treatment results in a signifcant improvement in two of the tests used (dichotomized direct TAVEC, p=0.031; dichotomized delayed Centil REY copy p=0.002 and a tendency to improve in all the rest of them. The amyloid-beta deposition analysis showed that genistein-treated patients did not increase their uptake in the anterior cingulate gyrus after treatment (p=0.878), while placebo-treated did increase it (p=0.036). We did not observe signifcant changes in other brain areas studied. Conclusions: This study shows that genistein may have a role in therapeutics to delay the onset of Alzheimer’s dementia in patients with prodromal Alzheimer’s disease. These encouraging results indicate that this should be followed up by a new study with more patients to further validate the conclusion that arises from this study.This work was supported by the following grants: CB16/10/00435 (CIBERFES) from Instituto de Salud Carlos III, (PID2019-110906RB-I00/ AEI/10.13039/501100011033) and RED2018-102576-T from the Spanish Ministry of Innovation and Science, PROMETEO/2019/097 from “Consellería de Innovación, Universidades, Ciencia y Sociedad Digital de la Generalitat Valen ciana” and EU Funded H2020- DIABFRAIL-LATAM (Ref: 825546), European Joint Programming Initiative “A Healthy Diet for a Healthy Life” (JPI HDHL) and of the ERA-NET Cofund ERA-HDHL (GA N° 696295 of the EU Horizon 2020 Research and Innovation Programme) and Fundación Ramón Areces y Fundación Soria Melguizo. to J.V. and Grant PID2020-113839RB-I00 funded by MCIN/ AEI/10.13039/501100011033, PCIN-2017-117 of the Ministry of Economy and Competitiveness, and the EU Joint Programming Initiative ‘A Healthy Diet for a Healthy Life’ (JPI HDHL INTIMIC-085) to CB. We also acknowledge funding from the Spanish Ministry of Science, Innovation, and Universities (RTI2018099200-B-I00), the Generalitat of Catalonia, Agency for management of University and Research Grants (2017SGR696) and the Department of Health (SLT002/16/00250) to RP. Part of the equipment employed in this work has been funded by Generalitat Valenciana and co-fnanced with ERDF funds (OP ERDF of Comunitat Valenciana 2014-2020). M.J. is a “Serra Hunter” Fellow