La unidad de ortogeriatría de agudos. Evaluación de su efecto en el curso clínico de los pacientes con fractura de cadera y estimación de su impacto económico

Objective

To study the effects of the management of hip fracture patients in an acute orthogeriatric unit shared between the departments of Orthopedic Surgery and Geriatrics compared with the usual hospital care, and to analyse financial differences in both systems of care.

Method

Prospective quasy-experimental randomized intervention study in 506 patients admited to a terciary hospital with an osteoporotic hip fracture. The usual model of care was the admission to the orthopedic ward with a request to Geriatrics (RC) and the study model consisted of the admission to an orthogeriatric unit (OGU) for the shared co-management between orthopaedic surgeons and geriatricians. This model included the appointment of one spokesperson from each department, the specialist geriatric nurse management, early geriatric assessment, shared daily clinical care, weekly joint ward round and coordinated planning of the surgery schedule, the start of the ambulation and the time and setting of patient discharge.

Results

Two hundred fifty five consecutive patients admitted to the OGU and 251 patients managed simultaneusly by the RC model were included. Except for a mean age slightly lower in the OGU group, there were no differences neither in the baseline patients characteristics nor in the surgical rates between the two groups. Among the OGU patients group it was more frequent to receive rehabilitation in the acute setting, to be able to walk at discharge and to be referred to a geriatric rehabilitation unit (all with P<.05). The OGU patients received geriatric assessment and were operated on earlier than the RC patients (P<.001). The length of stay in the acute ward was 34% shorter in the OGU patients (mean 12.48±5 vs 18.9±8.6 days, P<.001) (median 12 [9-14] vs 17 [13-23] days, P<.001). The whole hospital length of stay, including the days spent in the geriatric rehabilitation units, was 11% shorter in the OGU patients (mean 21.16 ±14.7 vs 23.9 ±13.8 days, P<0.05) (median 14 [10-31] vs 20 [14-30] days, P<.001). The OGU saved 1,207 € to 1,633 € per patient when estimated by the costs for process model, and 3,741 € when estimated by the costs for stay model.

Conclusions

The OGU is a hospital setting that provides an improvement in the patients functional outcome and a reduction in the hospital length of stay. Therefore it saves health care resources. These findings show the OGU as an advisable setting for the acute care of hip fracture patients.     

Efectos del entrenamiento en estrategias de regulación emocional en el bienestar de cuidadores de enfermos de Alzheimer

Introduction

The present research shows the results of a psychoeducational intervention programme centered on the regulation of the emotion among Alzheimer patients’ caregivers.

Materials and methods

52 informal caregivers of Alzheimer's patients participated. These caregivers were distributed into two groups: the experimental group (n = 20) and the control group (n = 32). All the participants were evaluated before and after the intervention programme through the application of different measurement tools measuring variables related to the care giving process; stressors, modulation variables and care giving consequences.

Results

In the inter group contrast, the experimental group, when compared with the control condition, obtained higher scores in positive affect, subjective well-being, regulation of emotions, and satisfaction with caregiving. However, the experimental group recorded lower values in perceived stress and negative affect. With reference to the intragroup contrast, the experimental group showed a significant decrease in dysfunctional thoughts and emotional attention. The control group registered higher levels of psychosocial support and lower satisfaction with caregiving.

Conclusions

The training programme, that we both developed and conducted, has contributed to a greater feeling of emotional well-being amongst the its participant caregivers, who now take more adequate care of their emotions and suffer fewer dysfunctional thoughts in relation to caregiving. In future studies, the stability of the results presented in this investigation should be established due to the progressive character of the skills learned during the programme, and the changing needs associated with the caregiving process.     

Evaluación de un programa de intervención en residencias geriátricas para reducir la frecuentación hospitalaria

Objectives

This study describes the outcomes of an intervention program in Nursing Homes and their effects on emergency room attendance, hospital admissions, and pharmaceutical expenditure.

Material and methods

This involved non-randomised community intervention in Nursing Homes with a control group. The program was implemented gradually from 2007 to 2009 in 10 Nursing Homes (857 beds) which participated voluntarily. The control group consisted of 14 Nursing homes (1,200 beds), which refused to participate or were not assigned to our Primary Care centres. Intervention consisted of comprehensive geriatric assessment and follow-up visits by trained personnel, review and adjustment of drug treatment, case management and staff training.

Results

In the Nursing Homes where the program was carried out, emergency room attendance decreased from 1165‰ (95%CI 1100-1240]) in 2006 to 674‰ (95%CI 620-730) in 2009, while in the control group it increased from 1071 (95%CI 1020-1130) to 1246‰ (95%CI 1190-1310). The hospital admissions also decreased from 48.4% (95%CI 45-52) in 2006 to 32.1% (95%CI 29-35) in 2009, while in the control group increased from 43.5% (95%CI 41-46) to 55.8% (95%CI 53-59). There was also a 9% reduction in pharmacy cost compared with an increase of 11.9% in the control group.

Conclusions

The intervention has proved effective at reducing hospital admissions and emergency room attendance in institutionalised patients, thereby streamlining pharmacy costs.     

Fiabilidad interobservador de los 4 índices de comorbilidad más utilizados en pacientes ancianos

Objective

To report on the interrater reliability of four common comorbidity indexes used in the hospitalised elderly: Charlson Index (CI), Geriatric Cumulative Illness Rating Scale (CIRS-G), Index of Co-existent Disease (CoD) and Kaplan-Feinstein Index (KFI).

Method

Four trained observers, independently reviewed the same 40 medical charts of hospitalised geriatric patients. Scores for the four indexes were calculated, along with the intraclass correlations coefficient (ICC) (quantitative index: CI and CIRS-G) and Kappa coefficient (qualitative index: CoD and KFI). The agreement <0.4 was considered deficient, 0-4-0.75 acceptable and >0.75 excellent.

Results

A total of 40 patients (29 women) of 85.93 (±5.35) years were analysed. Intraclass correlations coefficient: CI: 0.78 (95% CI: 0.67-0.86); CIRS-G (score): 0.66 (95% CI: 0.53-0.78). Kappa coefficient: KFI: 0.51 to 0.76; CoD: 0.44-0.66. The application time was lower for the Charlson index (median of 39 seconds [30-45]) and the KFI (42 seconds [35-52]) and higher for CIRS-G (score) (128 seconds [110-160]) and CoD (102 seconds [80-124]).

Conclusions

Of the four comorbidity indexes used in a hospitalised elderly population, the CI, and CIRS-G (score), are those that have better interrater reliability. The Charlson index and KFI show a lower application time than the CIRS-G (score).     

Disnea y psicopatología en el paciente anciano con enfermedad pulmonar obstructiva crónica

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease with dyspnoea perception as a main symptom. In severe stages, dyspnoea can constitute a risk factor for depression, anxiety and somatization disorders.

Objective

The objective was to evaluate the presence of these psychopathologies based on dyspnoea and severity stages in patients with COPD.

Materials and methods

Patients (n=51) were evaluated by means of the Hospital Anxiety and Depression Scale, the dyspnoea scale (MRC), the General Health Questionnaire (GHQ-28) and spirometric criteria.

Results

The increase in dyspnoea level and disease severity lead to a progressive worsening of anxiety, depressive and somatic symptoms with clinical relevance (P<0.05). There was a significant correlation between those parameters (P<0.05).

Conclusions

The early detection and treatment of these psychopathologies associated with dyspnoea and progression of the disease must be taken into account in this complex pathology.     

Localization of nerve growth factor (NGF) receptors in the mitochondrial compartment: Characterization and putative role

Background

The neurotrophin NGF receptors trkA and p75NTR are expressed in the central and peripheral nervous system as well as in non-neuronal tissues; originally described to localize to the plasma membrane, recent studies have suggested other intracellular localizations for both NGF receptors.

Scope of review

In order to determine whether NGF receptors localize to the mitochondrial compartment mitochondria isolated from human kidney, rat tissues and a human podocyte as cell line before and after differentiation were used.

Major conclusions

Our results demonstrate that NGF receptors are localized in the mitochondrial compartment of undifferentiated human podocytes and in all tissues analyzed including rat central nervous system. In mitochondria p75NTR, but not trkA, co-immunoprecipitates with the adenine nucleotide translocator (ANT) and the phosphodiesterase 4 isoform A5 (PDE4A5). Moreover, NGF, via trkA, protects isolated mitochondria of rat brain cortex from mitochondrial permeability transition induced by Ca²⁺.

General significance

Although NGF receptors have been described as mainly citoplasmatic so far, we proved evidence of their expression at the mitochondrial level and their interaction with specific proteins. Our results demonstrating the expression of NGF receptors in the mitochondria provide new insights into the role of NGF at subcellular level, in different areas of the organism, including CNS.     

El Instrumento de Fragilidad para Atención Primaria de la Encuesta de Salud, Envejecimiento y Jubilación en Europa (SHARE-FI): resultados de la muestra española

Background

Frailty is a syndrome with important epidemiological and clinical implications in older adults. One of the most accepted definitions of frailty is that of Fried and Walston, who operationalised it according to five well defined criteria. However, their criteria are not readily applicable in primary care, where practitioners need tools to identify patients who require priority access to more specialised resources. With that objective in mind, our research group published the Frailty Instrument of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI). The present paper reports the results of the Spanish sample.

Methods

In the wave 1 of SHARE (2004), the Spanish sample was composed of 1,279 women and 933 men, all living in the community (mean age: 65.6 years). For each sex, a latent class analysis was used to summarise the five (adapted) frailty criteria into three incremental frailty classes. We tested the association of the frailty classes against a biopsychosocial range of wave 1 variables; the predictive validity of the frailty classes was tested using mortality data from the second wave of SHARE (2006-2007), which were available for 846 women and 660 men.

Results

The frailty classes had the expected cross-sectional associations. The age-adjusted Odds ratio for mortality (with 95% confidence interval) associated with the frail class was 3.2 (1.0-10.2) for women and 8.3 (3.1-22.1) for men.

Discussion

SHARE-FI is a valid and freely accessible instrument, which is intended to facilitate the adoption of the frailty paradigm in primary care.     

Implantación de una Unidad de Ortogeriatría de Agudos en un hospital de segundo nivel

Background

Patients with hip fracture (HF), due to their characteristics, require a specific support. The Acute Orthogeriatric Unit (OGU) has been shown to be one of the most beneficial.

Objective

To evaluate the main variables of HF patients treated at an OGU and compare them with the previous referral model (RC).

Material and methods

A prospective observational study with retrospective control was conducted on 169 patients, split into two groups. In the RC group, patients were admitted to conventional trauma ward. In the OGU group, an early geriatric assessment was performed, and patients were simultaneously attended daily by the orthopaedic surgeon, nurse and geriatrician, and the surgery times, work load, discharge and destination, were planned in a weekly meeting with the rest of professionals.

Results

A total of 71 patients were included in the RC group and 96 in the OGU group. The preoperative characteristics were similar, except for a slightly higher comorbidity in the OGU group. The OGU patients were operated on earlier (3.82±2.08 vs 4.61±2.5 days; P<.32), and overall hospital stay was reduced by 28% (11.84±4.04 vs 16.46±8.4 days; P<.001). The functional efficiency (Barthel Index at discharge-Barthel Index at admission/overall stay - stay before surgery) was higher in the OGU group (1.56±0.7 vs 2.61±1.1; P<.05). There were no differences in functional status, mortality or discharge location.

Conclusions

The OGU is a level of care that provides effective medical care in HF patients in general hospitals.     

Prevalencia y principales características de la incontinencia urinaria en la población anciana institucionalizada de Madrid

Introduction

Urinary incontinence (UI) has been poorly studied in Spanish nursing homes. The objective is to determine the prevalence and related factors of UI in institutionalized older people in Madrid, Spain.

Methods

A probabilistic sample of 754 subjects 65 years of age and older living in public and private institutions in Madrid was randomly selected through stratified cluster sampling. Residents, caregivers and physicians were interviewed. UI was defined as any leakage in the previous 14 days. We asked about the frequency (occasional, nocturnal, frequent and total), quantity (drops or small quantities, very much), and types (urge, stress, due to cognitive impairment, and due to walking difficulty). To determine the factors associated with UI, we built logistic regression models that adjusted for age, sex, functional dependency (Barthel index) and cognitive status (Pfeiffer's test).

Results

The prevalence of UI was 53.6%. Of all residents 35.8% had frequent or total UI. Among those incontinent 60.1% had a very large quantity of urine loss and the most common presentation was mixed (54.1%). The most frequent type in the population was urgent UI (26.8%) followed by UI due to walking difficulty (21.4%). UI was associated (odds ratios [95% CI]) with moderate (3.51 [1.56-7.89]) and severe functional disability (44.71 [10.99-181.94]), faecal incontinence (4.97 [2.04-12.16]), stroke (4.59 [1.06-19.87]), physical restraints (4.03 [1.02-17.87]), and falls (2.10 [1.16-3.81]). The mean (95% CI) number of pads used per person per day was 3.0 (2.4-3.6).

Conclusions

The prevalence of UI was somewhat higher than that of other comparable populations. Mixed forms, including functional types, were common.     

Évaluation de méthodes automatiques de segmentation des volumes tumoraux en tomographie par émission de positons par comparaison avec des contours manuels réalisés par un groupe d’experts

Objective

Set up a framework for evaluating automatic segmentation methods of tumour volumes on PET images.

Patient and methods

This study was performed with PET images of 18 patients with non-Hodgkin's lymphoma. One target lesion per patient was pointed out. Each lesion was then three times manually delineated by five experts. Four automatic methods (the application of a threshold of 42% of the maximum SUV, the MIP-based method, the Daisne et al. method and the Nestle et al. method) were evaluated by comparison with the set of manual delineations.

Results

From the manual delineations, we have concluded to a moderate intra-operator variability and to a reduced interoperator reproducibility. From statistical tests performed on various quantitative criteria, there was no significant difference between the MIP-based method, the Daisne et al. method and the Nestle et al. one. The application of a threshold of 42% of the maximum SUV appears to be less efficient.

Conclusion

This work proposes a comparison and an evaluation protocol for segmentation methods. The generated data set will be distributed online for the community to simplify the evaluation of any new method of segmentation.     

Hospital costs associated with delirium in older medical patients

Introduction

Delirium is a common and serious complication in older patients, associated with increased, potentially preventable, morbidity and mortality. The aim of this study was to evaluate the associated costs of delirium during hospitalization in a university affiliated hospital in Chile.

Materials and methods

Prospective cohort study of consecutive patients 65 years and older, admitted to a medical ward. A psychogeriatric team assessed patients during the first and every 48 h until discharge using the Confusion Assessment Method (CAM-S), length of hospital stay, pharmacy and total hospitalization costs were analyzed. Statistical analysis was performed using bivariate and multivariate analysis according to delirium diagnosis.

Results

Data from 454 patients was analyzed, 160 of them in a delirium cohort (35.2%) and 294 in a non-delirium cohort (64.8%). The delirium cohort had a longer hospital stay (DATA) and higher mortality (7.0% versus 1.7%). The median of total costs of delirium during hospital stay was 38.7% higher than the non-delirium cohort (P < .001). Total costs were significantly higher in the delirium cohort after adjustment of covariables (P = .01).

Conclusions

This study confirms that delirium is associated with significantly greater costs. Considering that effective delirium prevention is possible, the knowledge of associated costs can help health care providers to justify prevention strategies and finally give better care for older patients.     

Calidad de vida y sobrecarga de los cuidadores de pacientes con daño cerebral adquirido

Introduction

The health impact of acquired brain injury (ABI) is not only apparent in the patient, but also in the loss of health related quality of life (HRQol) of their carers. The objectives of this study were to measure the loss of HRQol as well as the burden of the carers of patients with ABI.

Material and methods

A retrospective study was conducted with 76 carers of patients with ABI. A questionnaire was used to collect information on the sociodemographic aspects, carer burden (Zarit Scale) and the HRQol (EuroQol Questionnaire) of the carers. A multiple linear regression model was constructed to analyse the effect of the different variables.

Results

The carers were predominantly women over 50 years, retired or dedicated to domestic tasks and who cared for their husband or one of their parents. One third showed a high risk of claudication. The mean HRQol obtained with the EuroQol went from a similar score to that of the general population (0.9) in the group without burden, to 0.67 in the group with risk of claudication. The regression models explained the burden better than the loss in quality of life.

Conclusions

Carers of patients with brain injury suffer a significant loss in HRQol compared to the general population. The deterioration arises from the mental dimensions and depends on the level of burden.     

Resultados de la endarterectomía carotídea en pacientes ancianos

Introduction

Forty-five per cent of stoke patients have a surgically accessible stenosis. The objective of our study is to describe the response to carotid endarterectomy (EA) in patients of advanced age compared to younger ones.

Material and method

Retrospective evaluation of the clinical history of all patients who underwent an endarterectomy in a tertiary hospital between January 1995 and December 2006. The patients were grouped into those 75 years or older and those less than this age. The incidence of peri-operative complications in the first month after surgery, and the long-term mortality was evaluated using a survival analysis.

Results

Data were collected on 147 EA in 134 patients of 75 years or more, and on 201 EA in 177 patients less than 75 years-old. The incidence of peri-operative complications was similar in both groups, with a mortality of 2% in the older age group and a stroke incidence of 2.6% (half transient ischaemic accidents). The older patients had a mean follow-up of 4.1 years, with a survival of 86% at one year and 54% at 5 years and with the main cause of death being heart disease.

Conclusions

Carotid EA is a safe and effective technique for the treatment of extracranial carotid stenosis in the elderly, having the same peri-operative morbidity and mortality as younger ones. Age must not affect our therapeutic attitude, although an exhaustive cardiology study must be made in the elderly prior to the operation.     

Utilización del servicio de urgencia de un hospital universitario por los adultos mayores en Santiago de Chile

Introduction

An increase in visits to Emergency Departments by older adults has been reported, but there are no data available on this in countries in the early phases of demographic and epidemiological transition. This paper describes the characteristics of people over 60 years-old (AM) who visited the Emergency Department of the Hospital Clínico Universitario de la Pontificia Universidad Católica, Chile (SU-PUC), compared to those less than 60 years-old (AJ).

Material and methods

Demographic data and reasons for admission and re-admission were collected retrospectively from the SU-PUC monthly statistics report. Obstetrics, paediatrics and «scheduled admissions» were excluded. The frequencies were compared using Chi-squared (significance: P < .05).

Results

A total of 37,660 visits to the SU-PUC were recorded (81% AJ; 19% AM; with 8% being older than 75 years). No statistical differences were found in the visit time (70% daytime), or by season between the groups.A total of 7,414 (19.6%) of those who visited were hospitalised, with differences being detected between groups (AM: 48.9% vs 12.9% AJ; P < .001), particularly in those over 75 years (59%). The primary cause of admission was cardiopulmonary in AM (22%) and gastrointestinal in AJ (31%). Re-admissions were 10% in AM and 6% in AJ (P < .001).

Conclusion

The use of SU by AM and some characteristics of their care process (hospitalisation) are similar to those found in countries in more advanced phases of demographic transition.     

Eficiencia de las unidades de agudos de geriatría frente al resto de servicios hospitalarios. Análisis de la casuística de 5 años ajustada por GRD

Introduction

Hospital occupancy rate by older patients is high, and it will be even higher in the future. Their hospital stay is usually longer, making it important for hospitals to develop structures with the best efficiency possible.

Phosphorylation of the arginine/serine repeats of lamin B receptor by SRPK1—Insights from molecular dynamics simulations

Background

Arginine/serine (RS) repeats are found in several proteins in metazoans with a wide variety of functions, many of which are regulated by SR protein kinase 1 (SRPK1)-mediated phosphorylation. Lamin B receptor (LBR) is such a protein implicated in chromatin anchorage to the nuclear envelope.

Methods

Molecular dynamics simulations were used to investigate the conformation of two LBR peptides containing four (human-) and five (turkey-orthologue) consecutive RS dipeptides, in their unphosphorylated and phosphorylated forms and of a conserved peptide, in isolation and in complex with SRPK1. GST pull-down assays were employed to study LBR interactions.

Results

Unphosphorylated RS repeats adopt short, transient helical conformations, whereas serine phosphorylation induces Arginine-claw-like structures. The SRSRSRSPGR peptide, overlapping with the LBR RS repeats, docks into the known, acidic docking groove of SRPK1, in an extended conformation. Phosphorylation by SRPK1 is necessary for the association of LBR with histone H3.

Conclusions

The C-terminal region of the LBR RS domain constitutes a recognition platform for SRPK1, which uses the same recognition mechanism for LBR as for substrates with long RS domains. This docking may promote unfolding of the RS repeats destined to be phosphorylated. Phosphorylation induces Arginine-claw-like conformations, irrespective of the RS-repeat length, that may facilitate interactions with basic partners.

General significance

Our results shed light on the conformational preferences of an important class of repeats before and after their phosphorylation and support the idea that even short RS domains may be constituents of recognition platforms for SRPK1, thus adding to knowledge towards a full understanding of their phosphorylation mechanism.     

Efectividad de una intervención educativa sobre hipertensión arterial dirigida a pacientes hipertensos de edad avanzada

Introduction

Hypertension is the most prevalent cardiovascular risk factor among people over the age 60. The aim of this study is to assess the effectiveness of an educational intervention tool, and its reliability.

Material and methods

Experimental study, prospective, randomised, parallel-group in a sample of 120 patients, 62 in the intervention group and 58 in the control group. The intervention group received a written and oral educational program on hypertension and cardiovascular risk; the control group did not receive any intervention.

Results

At the end of the intervention there was an increase in the percentage of correct responses, with statistically significant differences compared to the control group, as regards knowledge of hypertension, risk factors associated with the risks of having high blood pressure and control medication.

Conclusion

The implementation of an educational intervention on hypertension and cardiovascular risk associated with the same care activity is capable of increasing the level of knowledge by elderly hypertensive patients admitted to hospital.     

Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

Objective

To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002-2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.

Method

A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.

Results

The intervention, as modelled, reached 9685 children aged 5-9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).

Conclusion

Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.