Estudio controlado sobre la eficacia de una valoración e intervención integral en pacientes ancianos ingresados en una unidad de convalecencia geriátrica

La valoración geriátrica integral es un proceso diagnóstico multidimensional e interdisciplinar que detecta necesidades y capacidades funcionales, cognitivas y sociales de ancianos, así como problemas médicos para establecer planes de intervención y seguimiento individualizados. Aunque se realiza en muchos entornos asistenciales, las unidades de convalecencia ofrecen intervenciones geriátricas intensas y prolongadas en el tiempo que generan efectos positivos en la salud de los ancianos. Objetivo:Evaluar la eficacia de un programa de valoración e intervención geriátrica en ancianos en fase postaguda de una enfermedad, que ingresaron en una unidad de convalecencia(grupo intervención), comparándola con un grupo similar dado de alta a domicilio(grupo control). Método:Se preseleccionaron 375 hospitalizados mayores de 65 años que cumplían alguna condición: imposibilidad de levantarse de la silla/cama, imposibilidad de andar y/o alteración del estado mental. Se les realizó seguimiento y al alta se valoraron criterios de inclusión y exclusión, para seleccionar 149 pacientes elegibles.De ellos, 63(42,29%), fueron rechazados (no fueron randomizados por no disponer de cuidador), quedando 86(57,71%) a los que se asignó aleatoriamente destino al alta: convalecencia geriátrica (grupo intervención) o domicilio (grupo control).Tras el resultado de la randomización, se pidió al paciente consentimiento para ser incluido en el grupo asignado (doble consentimiento aleatorizado Zelen). En caso de negativa, se adjudicó el destino alternativo. Ambos grupos se analizaron posteriormente mediante la técnica de"intención de tratamiento"(IT) y también según el destino real(DR) al que se incorporaron. Nueve pacientes fueron excluidos tras randomización, quedando 77. Se realizó seguimiento de ambos grupos a los 3 y 6 meses tras el alta, recogiéndose las siguientes variables: supervivencia, capacidad funcional, función cognitiva, comorbilidad, lugar de residencia, necesitar cuidador, número caídas, consumo fármacos, número reingresos hospitalarios y calidad de vida (Perfil Salud Nottingham). Resultados:Al comparar ambas cohortes al inicio del estudio, no se hallaron diferencias significativas en ambos análisis (IT y DR). A los tres meses quedaron 54 pacientes (15 fallecidos y 8 perdidos). A los seis meses 34 (3 fallecidos y 17 perdidos) Tanto las pérdidas como los fallecimientos se distribuyeron de forma similar en ambos grupos de estudio y análisis. A los tres meses en el análisis IT no se hallaron diferencias significativas en las variables estudiadas, salvo un menor número de reingresos y caídas en grupo intervención (no significación estadística en IT (p=0,55) pero sí en análisis DR (p=0.004)). En IT hubo mejor percepción de calidad de vida (dimensiones social (p=0.049) y emocional (P=0.018) en el grupo intervención. El tamaño del efecto (relevancia clínica del cambio) fue mediano (0.69) y grande (0.92) respectivamente. A los seis meses en el análisis IT se observan más reingresos hospitalarios y mayor uso de fisioterapia domiciliaria y tendencia a requerir cuidador (grupo control) sin alcanzar significación estadística. En el grupo intervención y análisis IT, hubo tendencia a mejor percepción de calidad de vida sin significación estadística pero con relevancia clínica (índices tamaño del efecto>80 en energía, dolor y puntuación total, y>50 en social y movilidad). La puntuación NHP mostró tendencia a mejoría en ambos grupos y análisis, alcanzando significación en DR en dimensiones energía (p=0.09) y total (p=0.020). Conclusiones:A los tres y seis meses, la intervención geriátrica en convalecencia proporcionó mejor percepción de calidad de vida en algunas dimensiones y tendencia a menor número de reingresos/caídas. Hubo también reducción en el número de fármacos presentes a los tres meses (sólo significativo en análisis DR). No se observaron diferencias significativas respecto a mejoría de capacidad funcional, función cognitiva y supervivencia, o necesidad de recursos de atención domiciliaria entre ambos grupos de estudio

Three measures of physical rehabilitation effectiveness in elderly patients : a prospective, longitudinal, comparative analysis

Rehabilitation success is measured by instruments that assess performance of activities of daily living. Guidelines on the use and choice of these instruments are lacking. The present study aimed to analyse prognostic indicators of physical rehabilitation effectiveness in elderly patients according to three rehabilitation impact indices. Prospective, longitudinal study in a post-acute care unit. The study included rehabilitation-eligible deconditioned elderly in-patients prospectively admitted to post-acute care (n = 685, aged 83.2 ± 8.3 years, mean length of stay 15 ± 9.2 days). Data Collection: Premorbid health status variables (PHSV): age, sex, comorbidity (Charlson index), medical history (heart failure, pulmonary disease, cerebrovascular disease, dementia), previous living situation and pre-admission functional status (premorbid Lawton and Barthel indices). Admission health status variables (AHSV): main diagnoses, referral source, physical (Barthel-adm) and cognitive function (Pfeiffer test), undernutrition and dysphagia. Outcome Measures: Absolute functional gain (AFG, admission-to-discharge Barthel change), relative functional gain (RFG, achieved percentage of potential gain) and rehabilitation efficiency index (REI, AFG over length of stay). Univariate analysis considered these parameters, along with PHSV and AHSV. Multivariate logistic regression analysis was performed for AFG ≥20, RFG ≥35 % and REI ≥ 0.50. Greater AFG was associated with 14 variables, 8 PHSV (57.1 %) and 6 AHSV (42.8 %); greater RFG with 9 variables, 3 PHSV (33.3 %) and 6 AHSV (66.6 %); and REI with 9 variables, 4 PHSV (44.4 %) and 5 AHSV (55.5 %). Mean AFG value was 34.5 ± 15.8 in patients who achieved complete recovery (RFG 100 %, n = 189, 27.5 %) and 35.3 ± 15.0 (p = 0.593) in the remaining patients (n = 311, 45.4 %). In multivariate analysis, only Barthel-adm was related to all three rehabilitation impact indices. Both premorbid and acute-process variables have a greater impact on AFG and REI, compared to RFG. Although AFG gives information about the degree of reduction in dependence, it does not provide clinical information about post-rehabilitation functional status (mean AFG values did not differ between patients with and without complete recovery). A future implication for evaluating rehabilitation effectiveness in elderly patients is to recommend RFG corrected by premorbid Barthel score, which is less affected by previous health conditions, as the optimum method to assess the degree to which maximum potential improvement was achieved

Estudio controlado sobre la eficacia de una valoración e intervención integral en pacientes ancianos ingresados en una unidad de convalecencia geriátrica

La valoración geriátrica integral es un proceso diagnóstico multidimensional e interdisciplinar que detecta necesidades y capacidades funcionales, cognitivas y sociales de ancianos, así como problemas médicos para establecer planes de intervención y seguimiento individualizados. Aunque se realiza en muchos entornos asistenciales, las unidades de convalecencia ofrecen intervenciones geriátricas intensas y prolongadas en el tiempo que generan efectos positivos en la salud de los ancianos. Objetivo:Evaluar la eficacia de un programa de valoración e intervención geriátrica en ancianos en fase postaguda de una enfermedad, que ingresaron en una unidad de convalecencia(grupo intervención), comparándola con un grupo similar dado de alta a domicilio(grupo control). Método:Se preseleccionaron 375 hospitalizados mayores de 65 años que cumplían alguna condición: imposibilidad de levantarse de la silla/cama, imposibilidad de andar y/o alteración del estado mental. Se les realizó seguimiento y al alta se valoraron criterios de inclusión y exclusión, para seleccionar 149 pacientes elegibles.De ellos, 63(42,29%), fueron rechazados (no fueron randomizados por no disponer de cuidador), quedando 86(57,71%) a los que se asignó aleatoriamente destino al alta: convalecencia geriátrica (grupo intervención) o domicilio (grupo control).Tras el resultado de la randomización, se pidió al paciente consentimiento para ser incluido en el grupo asignado (doble consentimiento aleatorizado Zelen). En caso de negativa, se adjudicó el destino alternativo. Ambos grupos se analizaron posteriormente mediante la técnica de“intención de tratamiento”(IT) y también según el destino real(DR) al que se incorporaron. Nueve pacientes fueron excluidos tras randomización, quedando 77. Se realizó seguimiento de ambos grupos a los 3 y 6 meses tras el alta, recogiéndose las siguientes variables: supervivencia, capacidad funcional, función cognitiva, comorbilidad, lugar de residencia, necesitar cuidador, número caídas, consumo fármacos, número reingresos hospitalarios y calidad de vida (Perfil Salud Nottingham). Resultados:Al comparar ambas cohortes al inicio del estudio, no se hallaron diferencias significativas en ambos análisis (IT y DR). A los tres meses quedaron 54 pacientes (15 fallecidos y 8 perdidos). A los seis meses 34 (3 fallecidos y 17 perdidos) Tanto las pérdidas como los fallecimientos se distribuyeron de forma similar en ambos grupos de estudio y análisis. A los tres meses en el análisis IT no se hallaron diferencias significativas en las variables estudiadas, salvo un menor número de reingresos y caídas en grupo intervención (no significación estadística en IT (p=0,55) pero sí en análisis DR (p=0.004)). En IT hubo mejor percepción de calidad de vida (dimensiones social (p=0.049) y emocional (P=0.018) en el grupo intervención. El tamaño del efecto (relevancia clínica del cambio) fue mediano (0.69) y grande (0.92) respectivamente. A los seis meses en el análisis IT se observan más reingresos hospitalarios y mayor uso de fisioterapia domiciliaria y tendencia a requerir cuidador (grupo control) sin alcanzar significación estadística. En el grupo intervención y análisis IT, hubo tendencia a mejor percepción de calidad de vida sin significación estadística pero con relevancia clínica (índices tamaño del efecto>80 en energía, dolor y puntuación total, y>50 en social y movilidad). La puntuación NHP mostró tendencia a mejoría en ambos grupos y análisis, alcanzando significación en DR en dimensiones energía (p=0.09) y total (p=0.020). Conclusiones:A los tres y seis meses, la intervención geriátrica en convalecencia proporcionó mejor percepción de calidad de vida en algunas dimensiones y tendencia a menor número de reingresos/caídas. Hubo también reducción en el número de fármacos presentes a los tres meses (sólo significativo en análisis DR). No se observaron diferencias significativas respecto a mejoría de capacidad funcional, función cognitiva y supervivencia, o necesidad de recursos de atención domiciliaria entre ambos grupos de estudio.The comprehensive geriatric assessment is a multidimensional and interdisciplinary diagnostic process to detect needs and functional, cognitive and social skills and medical problems to establish contingency plans and individualized monitoring. Though it done in many care settings, convalescence units offer intense and prolonged nursing interventions while generating positive effects on the health of the elderly. Objective: To evaluate the effectiveness of a program of geriatric assessment and intervention in elderly post-acute phase of an illness, who were admitted to a convalescence unit (intervention group), compared with a similar group discharged home (control group). Method: 375 hospitalized over 65 years old who meet certain condition were pre-selected. These conditions were: inability to rise from the chair/bed, unable to walk and/or altered mental status. They were followed up and at the moment of discharge inclusion and exclusion criteria were assessed, to select 149 patients. 63(42.29%) were rejected (were not randomized due to lack of caregiver), leaving 86 (57, 71%) who were randomly assigned discharge destination: geriatric convalescence unit (intervention group) or home (control group) .After the result of randomization, the patient consent to be included in the assigned group (Zelen randomized double consent was requested ). If not, he was awarded the alternative destination. Both groups were further analyzed using the technique of "intention to treat" (IT) as well as the true destination (DR) to which they were incorporated. Nine patients were excluded after randomization, leaving 77. Both groups were followed for 3 and 6 months after discharge, collecting the following variables: survival, functional capacity, cognitive function, comorbidity, place of residence, need caregiver, number falls, drug consumption, number readmissions and quality of life (Nottingham Health Profile). Results: When comparing both groups at baseline, no significant differences in both analyzes (IT and DR) were found. After three months, 54 patients (15 deaths and 8 lost) were. At six months, 34 (3 deaths and 17 missing) were. Losses and deaths were distributed similarly in both groups of study and analysis. After three months in the IT analysis, no significant differences in the studied variables were found, except fewer readmissions and falls in the intervention group (no statistical significance in IT (p = 0.55) but DR analysis (p = 0.004)). In IT there were better perception of quality of life (social (p = 0.049) and emotional (P = 0.018) dimensions in the intervention group. The effect size (clinical relevance of change) was medium (0.69) and large (0.92) respectively. After six months, the IT analysis showed more readmissions and greater use of home physiotherapy and trend seen to require caregiver (control group) but it was not statistically significant. In the intervention group analysis IT showed a tendency to better perception of quality life. It was not statistically significant but clinically relevant (effect size index> 80 in energy, pain and total score, and> 50 in social and mobility). The NHP score showed a tendency to improvement in both groups and analysis, reaching significance in DR dimensional energy (p = 0.09) and total (p = 0.020). Conclusions: For the three and six months, geriatric convalescence intervention provided better perception of quality of life in some dimensions and tendency to fewer readmissions / falls. There was also reduction in the number of drugs present at three months (only significant in the analysis DR). No significant differences were observed for improvement in functional capacity, cognitive function and survival, or need for home care resources between the two study group

Three measures of physical rehabilitation effectiveness in elderly patients: a prospective, longitudinal, comparative analysis.

BACKGROUND: Rehabilitation success is measured by instruments that assess performance of activities of daily living. Guidelines on the use and choice of these instruments are lacking. The present study aimed to analyse prognostic indicators of physical rehabilitation effectiveness in elderly patients according to three rehabilitation impact indices. METHODS: Prospective, longitudinal study in a post-acute care unit. The study included rehabilitation-eligible deconditioned elderly in-patients prospectively admitted to post-acute care (n = 685, aged 83.2 ± 8.3 years, mean length of stay 15 ± 9.2 days). DATA COLLECTION: Premorbid health status variables (PHSV): age, sex, comorbidity (Charlson index), medical history (heart failure, pulmonary disease, cerebrovascular disease, dementia), previous living situation and pre-admission functional status (premorbid Lawton and Barthel indices). Admission health status variables (AHSV): main diagnoses, referral source, physical (Barthel-adm) and cognitive function (Pfeiffer test), undernutrition and dysphagia. OUTCOME MEASURES: Absolute functional gain (AFG, admission-to-discharge Barthel change), relative functional gain (RFG, achieved percentage of potential gain) and rehabilitation efficiency index (REI, AFG over length of stay). Univariate analysis considered these parameters, along with PHSV and AHSV. Multivariate logistic regression analysis was performed for AFG ≥20, RFG ≥35 % and REI ≥ 0.50. RESULTS: Greater AFG was associated with 14 variables, 8 PHSV (57.1 %) and 6 AHSV (42.8 %); greater RFG with 9 variables, 3 PHSV (33.3 %) and 6 AHSV (66.6 %); and REI with 9 variables, 4 PHSV (44.4 %) and 5 AHSV (55.5 %). Mean AFG value was 34.5 ± 15.8 in patients who achieved complete recovery (RFG 100 %, n = 189, 27.5 %) and 35.3 ± 15.0 (p = 0.593) in the remaining patients (n = 311, 45.4 %). In multivariate analysis, only Barthel-adm was related to all three rehabilitation impact indices. CONCLUSIONS: Both premorbid and acute-process variables have a greater impact on AFG and REI, compared to RFG. Although AFG gives information about the degree of reduction in dependence, it does not provide clinical information about post-rehabilitation functional status (mean AFG values did not differ between patients with and without complete recovery). A future implication for evaluating rehabilitation effectiveness in elderly patients is to recommend RFG corrected by premorbid Barthel score, which is less affected by previous health conditions, as the optimum method to assess the degree to which maximum potential improvement was achieved

Serum albumin is a strong predictor of sepsis outcome in elderly patients

The incidence of sepsis is disproportionately higher in elderly adults, and age is an independent predictor of mortality. Retrospective analysis was conducted among patients admitted to the emergency department in a tertiary teaching hospital from January 2016 to June 2017. To study the prognosis determinants of sepsis among elderly patients attended in the emergency room of a tertiary care hospital. As secondary objectives, we aimed to describe the causes of sepsis, the general outcome, and the general characteristics of these patients. Two hundred thirty-five episodes data of patients admitted throughout the 15-month study period who were diagnosed with sepsis, severe sepsis or septic shock, were included. Throughout the study cohort, 51 patients (21.7%) fulfilled the criteria of severe sepsis or septic shock. All-cause mortality was 11 patients (4.7%) on day 14 and 27 (11.5%) on day 30. Prognosis factors associated with 30-day mortality were the following: albumin level < 2.6 g/dl (first quartile of the overall population), odds ratio (OR 3.26, 95% CI 12-9.41; p = 0.029), Charlson comorbidity index (OR 1.23, 95% CI 1.04-1.45; p = 0.012), C-reactive protein on admission (OR 1.04, 95% CI 0.99-1.08; p = 0.062), and non-adequacy of the initial antimicrobial therapy (OR 3.3, 95% CI 1.06-10.4; p = 0.039). Among elderly patients with sepsis, strong predictors of mortality such as albumin could be considered as part of prognosis and future potential interventions. Adequacy of antimicrobial therapy at admission must be one of the objectives in the treatment of sepsis, also in the elderly, since it is an independent predictor of mortality

Valoración del estado nutricional en una unidad de convalecencia: evaluación inicial y seguimiento

Fundamentos: Evaluar el estado nutricional de pacientes ingresados en una unidad de convalecencia mediante elMNA y analizar los factores que influyen en su mejoría. Métodos: A todos los pacientes se les realizó una valoración del estado nutricional según el MNA. Se efectuó un programa de intervención sobre el estado nutricional sistematizado en 4 etapas. Resultados: Se realizó el MNA a 118 pacientes, con el resultado de 9 pacientes (7,6%) correctamente nutridos,55 (46,6%) con riesgo de desnutrición y 54 (45,7%)desnutridos. Al 87% de los pacientes desnutridos se les realizó un MNA de control al mes; el 82,98% mejoraron respecto al previo (13,6±2,3 vs 16,5±2,9; p<0,001).En 24 pacientes, esta mejoría supuso el paso a la categoría superior de rango de puntuación del MNA. El número de pacientes que habían mejorado ¡Ý 20 puntos en el índice de Barthel era significativamente superior en el grupo que había cambiado de categoría de MNA(p<0.005). El índice de masa corporal y la albúmina en los que habían mejorado el MNA era significativamente superior (24,2±5,8 vs 19,3±9,4; p<0,05) (3,85±0,46vs 3,25±0,37; p<0,05). Conclusiones: Existe una alta prevalencia de desnutrición al ingreso. La mejoría del MNA estuvo relacionada significativamente con una mejoría en la capacidad funcional, el IMC y la albúmina

Quality of Life in Older Patients after a Heart Failure Hospitalization : Results from the SENECOR Study

Information about health-related quality of life (HRQoL) in heart failure (HF) in older adults is scarce. We aimed to describe the HRQoL of the SENECOR study cohort, a single-center, randomized trial comparing the effects of multidisciplinary intervention by a geriatrician and a cardiologist (intervention group) to that of a cardiologist alone (control group) in older patients with a recent HF hospitalization. HRQoL was assessed by the short version of the disease-specific Kansas Cardiomyopathy Questionnaire (KCCQ-12) in 141 patients at baseline and was impaired (KCCQ-12 < 75) in almost half of the cohort. Women comprised 50% of the population, the mean age was 82.2 years, and two-thirds of patients had preserved ejection fraction. Comorbidities were highly prevalent. Patients with impaired HRQoL had a worse NYHA functional class, a lower NT-proBNP, a lower Barthel index, and a higher Clinical Frailty Scale. One-year all-cause mortality was 22.7%, significantly lower in the group with good-to-excellent HRQoL (14.5% vs. 30.6%; hazard ratio 0.28; 95% confidence interval 0.10-0.78; p = 0.014). In the group with better HRQoL, all-cause hospitalization was lower, and there was a trend towards lower HF hospitalization. The KCCQ-12 questionnaire can provide inexpensive prognostic information even in older patients with HF. (Funded by grant Primitivo de la Vega, Fundación MAPFRE. ClinicalTrials number, NCT03555318)

Malnutrition according to ESPEN definition predicts long-term mortality in general older population: Findings from the EPIDOS study-Toulouse cohort

International audienceBACKGROUND:The European Society of Clinical Nutrition and Metabolism (ESPEN) has developed a consensus definition of malnutrition. This study aimed to determine the prevalence of malnutrition according to the ESPEN definition in otherwise healthy community-dwelling older women and to explore its value for predicting long-term mortality in this population.METHODS:This prospective population-based cohort study included 181 women (age ≥75 years) from a subsample of the EPIDémiologie de l'OStéoporose (EPIDOS) study participants from Toulouse. Inclusion criteria were the availability of the data on variables required to apply the ESPEN definition and survival after 7 years of follow-up. Primary outcome was mortality at 12-year follow-up; main covariates were malnutrition assessment according to the ESPEN consensus and its components (unintentional weight loss, BMI, and FFMI). Body composition was assessed by dual-energy X-ray absorptiometry at baseline and at 7-year follow-up. Kaplan-Meier survival curves and adjusted Cox regressions were performed. Analysis was adjusted for age, hypertension, diabetes mellitus, and coronary heart disease as potential confounders.RESULTS:Complete data were available for 179 of the 181 women in the EPIDOS-Toulouse cohort (83.1 ± 2.2 years) and 13 (7.3%) fulfilled the ESPEN definition for malnutrition at 7-year follow-up. Malnutrition was associated with increased risk of mortality (adjusted HR = 4.4 [95%CI: 1.7-11.3]). Among the ESPEN components, only BMI was associated with increased mortality (adjusted HR=0.6 [95%CI: 0.4-0.9]).CONCLUSIONS:Although malnutrition prevalence according to the ESPEN definition was relatively low (7.3%) in this sample of otherwise healthy community-dwelling older French women, malnutrition was associated with 4.4-fold higher mortality risk at 12-year follow-up

Additional file 1: of Three measures of physical rehabilitation effectiveness in elderly patients: a prospective, longitudinal, comparative analysis

STROBE Statement—Checklist of items that should be included in reports of cohort studies

Randomized controlled trial comparing a multidisciplinary intervention by a geriatrician and a cardiologist to usual care after a heart failure hospitalization in older patients: The SENECOR study

Background: The prognosis of older patients after a heart failure (HF) hospitalization is poor. Methods: In this randomized trial, we consecutively assigned 150 patients 75 years old or older with a recent heart failure hospitalization to follow-up by a cardiologist (control) or follow-up by a cardiologist and a geriatrician (intervention). The primary outcome was all-cause hospitalization at a one-year follow-up. Results: All-cause hospitalization occurred in 47 of 75 patients (62.7%) in the intervention group and in 58 of 75 patients (77.3%) in the control group (hazard ratio, 0.67; 95% confidence interval, 0.46 to 0.99; p = 0.046). The number of patients with at least one HF hospitalization was similar in both groups (34.7% in the intervention group vs. 40% in the control group, p = 0.5). There were a total of 236 hospitalizations during the study period. The main reasons for hospitalization were heart failure (38.1%) and infection (14.8%). Mortality was 24.7%. Heart failure was the leading cause of mortality (54.1% of all deaths), without differences between groups. Conclusions: A follow-up by a cardiologist and geriatrician in older patients after an HF hospitalization was superior to a cardiologist's follow-up in reducing all-cause hospitalization in older patients. (Funded by Beca Primitivo de la Vega, Fundación MAPFRE. Clinicaltrials: gov number, NCT03555318)