Asociación entre comorbilidad, proceso asistencial y complicaciones en pacientes con EPOC

Introducción: La enfermedad pulmonar obstructiva crónica (EPOC) se considera una ambulatory care sensitive condition (ACSC), es decir, una enfermedad para la que una atención primaria (AP) efectiva disminuiría el riesgo de hospitalización. La presencia de comorbilidades en pacientes con EPOC influye en su estado de salud y en la aparición de complicaciones en los pacientes, lo cual podría repercutir en la frecuentación hospitalaria de los mismos. Objetivo: Analizar la influencia de la comorbilidad y los indicadores del proceso asistencial de AP en el manejo de la EPOC, así como en la aparición de complicaciones que deriven en un ingreso hospitalario urgente y/o una visita a urgencias. Principales medidas de resultado: Visitas a urgencias e ingresos urgentes por exacerbaciones de la EPOC. Pacientes y método: Estudio observacional, analítico, longitudinal de una cohorte prospectiva y de base poblacional sobre 17.756 individuos con diagnóstico de EPOC en 2010. Se partió de una base datos de carácter poblacional integrada con datos procedentes de la historia clínica electrónica de AP de Aragón (OMI-AP), la base de datos de altas hospitalarias (CMBD), el sistema de información de urgencias (PCH) y la base de datos de usuarios (BDU). Se construyeron modelos de regresión logística para estudiar la asociación entre comorbilidad, indicadores del proceso asistencial y las variables resultado, ajustando por edad, sexo y nivel de severidad de la EPOC. Resultados: La prevalencia de la EPOC en Aragón fue del 1.6%, siendo del 1.3% en individuos entre 45-64 y 5.3% en ancianos mayores de 64 años. El 75.1% de los pacientes con EPOC fueron hombres y la edad media fue de 71 años. El 93.3% de la población con EPOC presentó al menos una comorbilidad, y el número medio de comorbilidades en la población fue de 3.6. La frecuencia de comorbilidad fue mayor en mujeres y en individuos mayores de 64 años. Las comorbilidades más frecuentes fueron dislipemias, hipertensión arterial, diabetes mellitus, varices, obesidad y depresión. El riesgo de visitas a urgencias e ingresos urgentes se incrementó un 5% por cada comorbilidad adicional. Ser mujer, el hecho de haber solicitado un hemograma y la consulta sobre consumo de tabaco resultaron ser factores protectores. Sin embargo, la solicitud de una espirometría por parte del médico resultarón ser factores de riesgo en la población de estudio. Conclusión: La comorbilidad constituye un factor esencial a considerar en el estudio de la calidad asistencial de los servicios de AP debido a su influencia en el manejo de la EPOC y en la frecuentación hospitalaria derivada de las complicaciones de la misma

Disease or function? What matters most for self-rated health in older people depends on age

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The Weldability of Duplex Stainless-Steel in Structural Components to Withstand Corrosive Marine Environments

There is still a considerable gap in the definition of the weldability of Duplex Stainless Steel (DSS). A lack of clarity that is explained by the standard specification of the maximum content of equivalent carbon that defines a “weldable” steel coupled with the fact that the alloying elements of DSS exceed this defined limit of weldability. In this paper, welding quality in an inert environment and in presence of chlorides is analyzed with the aim of defining optimum welding conditions of 2001, 2304, and 2205 DSS. The same procedure is followed for a hybrid weld between DSS 2205 and a low carbon mild steel, S275JR. As main output, this study defined the optimal welding conditions with tungsten inert gas without filler for each type of DSS weld that showed excellent anti-corrosion performance, with the exception of the DSS 2205-S275JR weld where widespread corrosion was observed. Additionally, this study established a relationship between the thermal input during welding and the content of alloying elements in defect-free joints. Furthermore, it demonstrated that an increase in ferrite content did not lead to a worse corrosion resistance, as expected after passivation.This research was funded by ACERINOX EUROPA through Center for the Development of Industrial Technology (CDTI) within the frame of IISIS project, grant number IPT-20111023

Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study

Abstract Background The burden of medications near the end of life has recently come under scrutiny, because several studies suggested that people with life-limiting illness receive potentially futile treatments. Methods We identified 511,843 older adults (>65 years) who died in Sweden between 2007 and 2013 and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. Decedents' characteristics at time of death were assessed through record linkage with the National Patient Register, the Social Services Register, and the Swedish Education Register. Results Over the course of the final year before death, the proportion of individuals exposed to ≥10 different drugs rose from 30.3% to 47.2% ( P Conclusion Polypharmacy increases throughout the last year of life of older adults, fueled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit. Clinical guidelines are needed to support physicians in their decision to continue or discontinue medications near the end of life

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

Anxiety, Depression and Quality of Life in Older Adults: Trajectories of Influence across Age.

This study focuses on the influence of anxiety and depression on individual trajectories of quality of life in old age through a longitudinal approach. A representative sample of adults aged 50+ living in Portugal and participating in wave 4 (W4) and wave 6 (W6) of the Survey of Health, Ageing and Retirement in Europe (SHARE) project was considered. Participants, 1765 at baseline (W4) and 1201 at follow up (W6), were asked about their quality of life (CASP-12) and emotional status (Euro-D scale; five items from the Beck Anxiety Inventory). Linear Mixed Effects models were performed to identify factors associated with changes in quality of life across age. Increasing age was found to have a significant negative effect on quality of life. Lower education and higher levels of depression and anxiety at baseline were also associated with worse quality of life; 42.1% of the variation of CASP-12 across age was explained by fixed and random effects, being depression followed by anxiety as the factors that presented with the highest relative importance. Both depression and anxiety play an important role in quality of life in older adults and must be acknowledged as important intervention domains to foster healthy and active aging.This paper uses data from SHARE waves 4 and 6 (DOI: 10.6103/SHARE.w4.710, DOI: 10.6103/SHARE.w6.710). The SHARE data collection has been funded by the European Commission through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005-028857, SHARELIFE: CIT4-CT-2006-028812), FP7 (SHARE-PREP: GA N°211909, SHARE-LEAP: GA N°227822, SHARE M4: GA N°261982) and Horizon 2020 (SHARE-DEV3: GA N°676536, SERISS: GA N°654221) and by DG Employment, Social Affairs & Inclusion. Additional funding from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, the U.S. National Institute on Aging (U01_AG09740-13S2, P01_AG005842, P01_AG08291, P30_AG12815, R21_AG025169, Y1-AG-4553-01, IAG_BSR06-11, OGHA_04-064, HHSN271201300071C) and from various national funding sources is gratefully acknowledged (see www.share-project.org). This work is part of the QASP research project and has been funded by the Institute of Health Carlos III, Intramural Strategical Action in Health AESI 2018, Ref: PI18CIII/00046.S

Cholinesterase inhibitors and non-steroidal anti-inflammatory drugs and the risk of peptic ulcers:A self-controlled study

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in adults aged 65 years and older. Their gastrointestinal adverse event risk might be further reinforced when using concomitant cholinesterase inhibitors (ChEIs). We aimed to investigate the association between NSAIDs and ChEI use and the risk of peptic ulcers in adults aged 65 years and older. Methods: Register-based self-controlled case series study including adults ≥65 years with a new prescription of ChEIs and NSAIDs, diagnosed with incident peptic ulcer in Sweden, 2007–2020. We identified persons from the Total Population Register individually linked to several nationwide registers. We estimated the incidence rate ratio (IRR) of peptic ulcer with a conditional Poisson regression model for four mutually exclusive risk periods: use of ChEIs, NSAIDs, and the combination of ChEIs and NSAIDs, compared with the non-treatment in the same individual. Risk periods were identified based on the prescribed daily dose, extracted via a text-parsing algorithm, and a 30-day grace period. Results: Of 70,060 individuals initiating both ChEIs and NSAIDs, we identified 1500 persons with peptic ulcer (median age at peptic ulcer 80 years), of whom 58% were females. Compared with the non-treatment periods, the risk of peptic ulcer substantially increased for the combination of ChEIs and NSAIDs (IRR: 9.0, [6.8–11.8]), more than for NSAIDs alone (5.2, [4.4–6.0]). No increased risks were found for the use of ChEIs alone (1.0, [0.9–1.2]). Discussion: We found that the risk of peptic ulcer associated with the concomitant use of NSAIDs and ChEIs was over and beyond the risk associated with NSAIDs alone. Our results underscore the importance of carefully considering the risk of peptic ulcers when co-prescribing NSAIDs and ChEIs to adults aged 65 years and older.</p

Association Between Speed of Multimorbidity Accumulation in Old Age and Life Experiences: A Cohort Study

Abstract Rapidly accumulating multiple chronic conditions (multimorbidity) during aging are associated with many adverse outcomes. We explored the association between 4 experiences throughout life—childhood socioeconomic circumstances, early-adulthood education, midlife occupational stress, and late-life social network—and the speed of chronic disease accumulation. We followed 2,589 individuals aged ≥60 years from the Swedish National Study on Aging and Care in Kungsholmen for 9 years (2001–2013). Information on life experiences was collected from detailed life-history interviews. Speed of disease accumulation was operationalized as the change in the count of chronic conditions obtained from clinical examinations, medical histories, laboratory data, drug use, and register linkages over 9 years. Linear mixed models were used to analyze the data. Speed of disease accumulation was lower in individuals with more than elementary education (for secondary, β × time = −0.065, 95% CI: −0.126, −0.004; for university, β × time = −0.118, 95% CI: −0.185, −0.050); for active occupations compared with high-strain jobs (β × time = −0.078, 95% CI: −0.138, −0.017); and for richer social networks (for moderate tertile, β × time = −0.102, 95% CI: −0.149, −0.055; for highest tertile, β × time = −0.135, 95% CI: −0.182, −0.088). The association between childhood circumstances and speed of disease accumulation was attenuated by later-life experiences. Diverse experiences throughout life might decelerate chronic disease accumulation during aging

patterns of multimorbidity in a population based cohort of older people sociodemographic lifestyle clinical and functional differences

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Multimorbidity Patterns and 6-Year Risk of Institutionalization in Older Persons: The Role of Social Formal and Informal Care

Abstract Objectives The aim was to evaluate patterns of multimorbidity that increase the risk of institutionalization in older persons, also exploring the potential buffering effect of formal and informal care. Design Prospective cohort study. Setting and Participants The population-based Swedish National study on Aging and Care in Kungsholmen, Stockholm, Sweden. Measures In total, 2571 community-dwelling older adults were grouped at baseline according to their underlying multimorbidity patterns, using a fuzzy c-means cluster algorithm, and followed up for 6 years to test the association between multimorbidity patterns and institutionalization. Results Six patterns of multimorbidity were identified: psychiatric diseases; cardiovascular diseases, anemia, and dementia; metabolic and sleep disorders; sensory impairments and cancer; musculoskeletal, respiratory, and gastrointestinal diseases; and an unspecific pattern including diseases of which none were overrepresented. In total, 110 (4.3%) participants were institutionalized during the follow-up, ranging from 1.7% in the metabolic and sleep disorders pattern to 8.4% in the cardiovascular diseases, anemia, and dementia pattern. Compared with the unspecific pattern, only the cardiovascular diseases, anemia, dementia pattern was significantly associated with institutionalization [relative risk ratio (RRR) = 2.23; 95% confidence interval (CI) 1.07‒4.65)], after adjusting for demographic characteristics and disability status at baseline. In stratified analyses, those not receiving formal care in the psychiatric diseases pattern (RRR 3.34; 95% CI 1.20‒9.32) and those not receiving formal or informal care in the 'cardiovascular diseases, anemia, dementia' pattern (RRR 2.99; 95% CI 1.20‒7.46; RRR 2.79; 95% CI 1.16‒6.71, respectively) had increased risks of institutionalization. Conclusions and Implications Older persons suffering from specific multimorbidity patterns have a higher risk of institutionalization, especially if they lack formal or informal care. Interventions aimed at preventing the clustering of diseases could reduce the associated burden on residential long-term care. Formal and informal care provision may be effective strategies in reducing the risk of institutionalization