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

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

Genistein effect on cognition in prodromal Alzheimer's disease patients : the GENIAL clinical trial

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 effective 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 defined polyphenol that acts by multimodal specific mechanisms. Our group previously showed that genistein supplementation is effective to treat the double transgenic (APP/PS1) AD animal model

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

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

Spanish National Hip Fracture Registry (RNFC) : First-year results and comparison with other registries and prospective multi-centric studies from Spain

Fundamentos: El Registro Nacional de Fracturas de Cadera (RNFC) es un registro español multicéntrico, prospectivo y continuo, que comenzó en 2017. El objetivo de este artículo fue presentar los datos del primer informe anual y compararlos con los registros autonómicos y los estudios multicéntricos realizados recientemente en España. Métodos: Se incluyeron las personas de 75 años o más atendidas con el diagnóstico de fractura de cadera por fragilidad en alguno de los hospitales participantes en el RNFC, entre enero y octubre de 2017. En el análisis estadístico se utilizó la media y desviación estándar o mediana y rangos intercuartílicos para las variables numéricas y los porcentajes para las variables categóricas. Se realizó un análisis descriptivo global de la casuística y se comparó con los datos disponibles de los estudios previos mencionados. Resultados: Se registraron 7.208 personas de 54 hospitales, con una edad media de 86,7 años (DE 5,6). El 75,4% fueron mujeres y el 36,4% presentaron deterioro cognitivo previo. La demora quirúrgica media fue de 75,7 horas (DE 63,6) y la estancia media fue de 10,9 días (DE 6,7). De las personas que vivían en un domicilio antes de la fractura (75,4%), menos de la mitad (37,0%) volvieron a él tras el alta hospitalaria. Al mes, había fallecido el 7,1%. La comparación con los otros estudios mostró algunas diferencias importantes, sobre todo en la ubicación previa, en el porcentaje de pacientes institucionalizados de novo (7,7-29,4%) y en el porcentaje con tratamiento antiosteoporótico al alta (14,5-36,7%). Conclusiones: El RNFC es la mayor base de datos prospectiva que aporta datos sobre el perfil de los pacientes hospitalizados por fractura de cadera en España. La comparación con otros estudios recientes muestra algunas diferencias importantes.OBJECTIVE: The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi- centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain. METHODS: We included persons 75 years or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies. RESULTS: The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%). CONCLUSIONS: The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differences

Registro Nacional de Fracturas de Cadera (RNFC): Resultados del primer año y comparación con otros registros y estudios multicéntricos españoles

Background: The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi- centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain. Methods: We included persons 75 years of age or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies. Results: The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%). Conclusions: The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differencesFundamentos: El Registro Nacional de Fracturas de Cadera (RNFC) es un registro español multicéntrico, prospectivo y continuo, que comenzó en 2017. El objetivo de este artículo fue presentar los datos del primer informe anual y compararlos con los registros autonómicos y los estudios multicéntricos realizados recientemente en España. Métodos: Se incluyeron las personas de 75 años o más atendidas con el diagnóstico de fractura de cadera por fragilidad en alguno de los hospitales participantes en el RNFC, entre enero y octubre de 2017. En el análisis estadístico se utilizó la media y desviación estándar o mediana y rangos intercuartílicos para las variables numéricas y los porcentajes para las variables categóricas. Se realizó un análisis descriptivo global de la casuística y se comparó con los datos disponibles de los estudios previos mencionados. Resultados: Se registraron 7.208 personas de 54 hospitales, con una edad media de 86,7 años (DE 5,6). El 75,4% fueron mujeres y el 36,4% presentaron deterioro cognitivo previo. La demora quirúrgica media fue de 75,7 horas (DE 63,6) y la estancia media fue de 10,9 días (DE 6,7). De las personas que vivían en un domicilio antes de la fractura (75,4%), menos de la mitad (37,0%) volvieron a él tras el alta hospitalaria. Al mes, había fallecido el 7,1%. La comparación con los otros estudios mostró algunas diferencias importantes, sobre todo en la ubicación previa, en el porcentaje de pacientes institucionalizados de novo (7,7-29,4%) y en el porcentaje con tratamiento antiosteoporótico al alta (14,5-36,7%). Conclusiones: El RNFC es la mayor base de datos prospectiva que aporta datos sobre el perfil de los pacientes hospitalizados por fractura de cadera en España. La comparación con otros estudios recientes muestra algunas diferencias importantesThe RNFC has been financed through donations by AMGEN SA, UCB Pharma, Abbott Laboratories and FAES Farma, as well as a Research Grant from the Fundación Mutua Madrileña (AP169672018)

Relación entre parámetros funcionales respiratorios y clínicos en una cohorte prospectiva de ancianos frágiles comunitarios

The population over 65 years represents 15% of the current population. Epidemiological estimates increase this percentage to 30% by 2050. An important part of this age stratum meets diagnostic frailty criteria, a situation that can have direct impact on respiratory function. The main objective of this study is analyze the lung capacity of a group of frail elderly residents in Sollana and Carcaixent. An observational, descriptive, analytical, cross-sectional study with a random sample of subjects, aged 75 or more, with the presence of 3 or higher on five of the criteria by Fried. A sample of 99 patients (55,6% women, n = 55), mean age 79,3 years, 86,9% non-smoking, 6,1% COPD, 21,1% IC and 90,9% sarcopenia was analyzed. Spirometric parameters found below the normal range were FEV2575 (76,11%), FEV25 (48,68%), FEV50 (65,55%), PEF (51,33%), and PEM in women and men (63,69 cmH2O y 96,52 cmH2O, respectively). Furthermore, significant differences in the CVI and FVC were found by sex and presence of sarcopenia, and in FEV1 in terms of smoking or not. Similarly, significance in FEV1/FVC, FEV2575, FEV50 and FEV75 was obtained, with influence of gender and smoking, as well as influence of sarcopenia on respiratory pressures. Therefore, we can say that male gender and the presence of sarcopenia were the two most influential factors on respiratory parameters in a population of frail comunity-dwelling elderly.La población mayor de 65 años representa el 15% de la población actual. Las previsiones epidemiológicas incrementan este porcentaje al 30% para el año 2050. Una parte importante de este estrato de edad cumple criterios diagnósticos de fragilidad, situación que puede tener repercusión directa sobre su función respiratoria. El objetivo principal de este estudio es analizar la capacidad pulmonar de un grupo de ancianos frágiles residentes en Sollana y Carcaixent. Se realizó un estudio observacional, descriptivo, analítico, transversal, con un muestreo aleatorio de sujetos de 75 años o más, con presencia de 3 o más sobre 5 de los criterios según Fried. Se analizó una muestra de 99 pacientes (55,6% mujeres, n = 55), con una media de edad de 79,3 años, 86,9% no fumadores, 6,1% EPOC, 21,1% IC y 90,9% sarcopenia. Los parámetros espirométricos hallados por debajo del rango de normalidad fueron FEV2575 (76,11%), FEV25 (48,68%), FEV50 (65,55%), PEF (51,33%) y PEM en mujeres y hombres (63,69 cmH2O y 96,52 cmH2O, respectivamente). Asimismo, se hallaron diferencias significativas en la CVI y FVC según el sexo y la presencia de sarcopenia, y en FEV1 en función de la presencia de hábito tabáquico. Igualmente, se obtuvo significación en FEV1/FVC, FEV2575, FEV50 y FEV75, con influencia del sexo y hábito tabáquico, así como de la sarcopenia sobre ambas presiones respiratorias. Por tanto, se puede afirmar que el sexo masculino y la presencia de sarcopenia fueron los dos factores con mayor influencia sobre los parámetros respiratorios en una población de ancianos frágiles comunitarios