Síndrome coronario agudo en nonagenarios: evolución clínica y validación de las principales escalas de riesgo

Introduction

Several risk scores regarding the probability of death/complications in the acute setting and during the follow-up of patients admitted with acute coronary syndromes (ACS) have been published, such as the GRACE, TIMI and ZWOLLE risk score. Our objective was to assess the prognosis of nonagenarians admitted to a coronary care unit with an ACS, as well as the usefulness of each of these scores.

Material and methods

A retrospective analysis was performed on nonagenarians with an ACS admitted between 2003 and 2011. Vital status was determined at 14, 30 days, and 6 months after the ACS, and later during the follow-up. The risk scores were evaluated by area under the curve ROC (AUC).

Results

A total of 45 patients with an ACS, 26 (57.8%) with ST-segment elevation and 19 (42.2%) with non-ST elevation. The GRACE- AUC for in-hospital mortality was excellent, 0.91, (95% CI: 0.82-1; P<.001), and for the combined event (in-hospital mortality and re-infarction) was 0.83 (95% CI: 0.66-1.0; P<.01). However, the GRACE-AUC at 6 months for mortality was 0.34 (95% CI: 0.09-0.58; P=.45), and for the combined event it was 0.51 (95% CI: 0.26-0.77; P=.95). The TIMI-AUC and ZWOLLE-AUC did not reach statistical significance.

Conclusions

It is useful calculate the GRACE risk score in order to estimate risk and survival in the acute phase of ACS in nonagenarians. This can help appropriate in making invasive or conservative treatment decisions.     

Análisis de las defunciones de pacientes con demencia ingresados en una unidad de psicogeriatría

Aim

To determine the characteristics of patients with dementia who died in a psychogeriatric unit, and to describe the conditions that led to their death.

Material and methods

Observational study of patients who died in the Psychogeriatric unit of Hospital de la Santa Creu de Vic during a three and a half year period.

Results

Of the 554 patients admitted during the study period, we recorded a mortality of 14.6% (81 patients). The analysis of those who died showed that 67.9% were women, with a mean age of 85.8 years, with the most frequent cause being Alzheimer type dementia (37%) and being in an advanced stage (CDR3, GDS 6-7) in 72.8% of cases. On admission the following characteristics were recorded: Mini Mental State Examination (MMSE) 9.5, Barthel Index (BI) prior to entry 50.1, BI on admission 17.4, and Neuropsychiatric Inventory (NPI) 31.4. A therapeutic limitation treatment was determined for 84% of patients on admission. From the analysis of the conditions that lead to death it was noted that: In 74.1% of the patients the death was a direct result of a triggering event (the most frequent being respiratory infection), in 17.3% the death occurred by a gradual decline, with no clear precipitating factor, and in 8.6% of patients palliative sedation was required due to poorly controlled symptoms.

Conclusions

Intercurrent problems were the most common factors related to the death of the patients. Most patients died in the stages prior to the established criteria for terminal dementia. In some cases patients may experience disorder behavior as a refractory symptom.     

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.     

Implicaciones de los síntomas depresivos en los ancianos hospitalizados por afección médica

Introduction

Depressive symptoms in hospitalized patients are very common, and they have been related to higher mortality. The aim of the study was to estimate the prevalence of depressive symptoms in hospitalized elderly patients and its relationship to various diseases, as well as their functional and mental status and mortality.

Material and methods

A total of 115 patients over 64 years of age were prospectively studied. The validated Spanish version of the Geriatric Depression Scale of Yesavage (15-item version) was used. Patients were considered to have depressive symptoms if ≥6 points were obtained. The demographic characteristics, the Charlson comorbidity index, the diagnosis at admission, the functional status assessed by the Barthel and Lawton-Brodie index, the mental capacity assessed by the Pfeiffer questionnaire, the length of the hospital stay, and hospital mortality were recorded.

Results

Out of the 115 patients studied, with a mean age of 70.5 years, 71 (61.7%) were female. Depressive symptoms were observed in 46 patients (40%, 95% CI: 34.8-43.9). Patients who died showed a significantly higher score on the Yesavage scale (P=.04). The multivariate analysis showed a significantly independent association between depressive symptoms and functional capacity (P=.026), mental status (P=.021), renal failure (P=.001), liver disease (P=.018), and osteoarthritis (P=.017), but losing the previously seen significant association with diabetes (P=.43).

Conclusions

The prevalence of depressive symptoms in hospitalized elderly patients is high, and is associated with the diagnoses of renal failure, liver disease and osteoarthritis, with a higher comorbidity and especially with a poorer functional capacity.     

Under-use of adjuvant chemotherapy in women aged ≥70 years diagnosed with breast cancer in a university hospital

Introduction

Patient age often limits the therapeutic efforts of the oncologist. The aim of this study was to determine whether chemotherapy is used less frequently in elderly women aged 65-69 years diagnosed with breast cancer, compared to younger women.

Methods

A retrospective study was performed including women greater than 65 years old who had localised breast cancer and were treated at a University Hospital. Patients were classified into two groups, 65-69 years old and ≥ 70 years old. The differences in patient characteristics, tumour characteristics, chemotherapy treatment and chemotherapy-associated toxicity were analysed in both groups.

Results

A total of 164 women, with an average age of 73.7 years, were included in this study. There were no significant differences in the characteristics of the patients or their tumours. However, 75% of women <70 years old were treated with chemotherapy compared to just 34% of the older women (P<.001). The resulting levels of toxicity were similar between age groups.

Conclusions

Women ≥ 70 years old were treated with chemotherapy less frequently, even though the features and tumour characteristics of the women, as well as the toxicity of the treatment, were similar to that in younger women.     

Adaptación y validación de la versión española de la escala de evaluación de dolor en personas con demencia avanzada: PAINAD-Sp

Introduction

Pain in elderly people is considered a major concern in nursing home facilities affecting between 49% and 83% of the residents. Progression of Alzheimer's Disease causes more communication difficulties in patients with advanced dementia and therefore more problems to understand even the most simple pain evaluation scales. Identification and implementation of appropriate pain management strategies depends on an adequate pain assessment.

Material and methods

The main objective of the study was to validate the Spanish version of the PAINAD Scale (PAINAD-Sp) and to assess its applicability in Spanish Geriatric Nursing Homes. The 20 patients diagnosed with severe dementia from a Geriatric Centre in Spain were observed by five observers with different professional profiles for 5 minutes to each participant, and PAINAD-Sp Scale was administered simultaneously to a Visual Analogical Scale-VAS. Three different observational conditions were established: resting condition, during presumably pleasant activity and during presumable painful activity.

Results

Cronbach's alpha ranged between 0.467 and 0.827 (average 0.692), and rose if Breathing item was deleted. Inter-rater reliability ranged between 0.587 and 0.956. Correlation between PAINAD-Sp Scale total measures and VAS was statistically significant (P<.05) in all measures and ranged from 0.517 to 0.868.

Conclusions

Findings in the study showed that the scale is useful to measure pain in non communicative patients suffering from dementia. The scale maintains good levels of reliability for different healthcare professionals even when they have little training.     

Serum insulin-like growth factor levels do not predict functional recovery after hospitalization in nonagenarian patients

AIM: To analyze the insulin-like growth factor 1 (IGF-1) serum levels in nonagenarian patients and to investigate the predictive capacity of this measure to assess the functional recovery of this population following hospitalization. METHODS: We performed a prospective study in 60 consecutive nonagenarian patients admitted for medical or surgical diseases. We assessed IGF-1 serum levels and nutritional status. The functional status was assessed using the Barthel index. Thirty-four patients were reinvestigated 3 months after discharge from hospital. RESULTS: The mean levels of IGF-1 were lower in nonagenarians than in younger patients. No relationship was found between IGF-1 levels and nutritional status. The decline in Barthel index values 3 months after discharge from hospital did not correlate with serum levels of IGF-1 on admission. CONCLUSION: IGF-1 serum levels in nonagenarian patients do not predict functional recovery after hospitalization.     

Prevención de las úlceras de talón en un hospital de media estancia. Estudio comparativo de vendaje clásico almohadillado respecto a las taloneras hidrocelulares de poliuretano

Introduction

The aim of the study is to determine the incidence of heel pressure ulcers (UPPT) and to compare the two systems for UPPT prevention: classic padded bandage and polyurethane heel.

Material and methods

Prospective intervention study in a medium-long hospital stay of all people admitted that had no UPPT but had a risk of UPPT according to the Braden Scale or clinical judgment. The patients were randomized to prevention with classic padded bandage or polyurethane heel. The outcome variable was the incidence of UPPT for each study group, which was recorded every 15 days or when there were clinical changes.

Results

Of the 940 patients evaluated, 409 with a mean age of 80.5 years and 59.1% women,were included in the study. Of these, 78% had Barthel score ≤30; 28.6% dementia; delirium 37.6%; 27.6% diabetes; and 19.6% other UPP. The overall incidence was 2.9% UPPT; 2.49% in the classic padded bandage and 3.37% in the polyurethane heel group (p=0.82).

Conclusions

No statistically significant differences were observed between the group with the classical dressing and the group with the polyurethane heel dressing. The use of multiple measures to prevent UPPT achieved a low incidence of these.     

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.     

Descripción de los resultados y costes de una intervención preventiva a nivel respiratorio en el anciano institucionalizado: ensayo controlado aleatorizado

Introduction

The institutionalized elderly with functional impairment show a greater decline in respiratory muscle (RM) function. The aims of the study are to evaluate outcomes and costs of RM training using Pranayama in institutionalized elderly people with functional impairment.

Material and methods

A randomized controlled trial was conducted on institutionalized elderly people with walking limitation (n = 54). The intervention consisted of 6 weeks of Pranayama RM training (5 times/week). The outcomes were measured at 4 time points, and were related to RM function: the maximum respiratory pressures and the maximum voluntary ventilation. Perceived satisfaction in the experimental group (EG) was assessed by means of an ad hoc questionnaire. Direct and indirect costs were estimated from the social perspective.

Results

The GE showed a significant improvement related with strength (maximum respiratory pressures) and endurance (maximum voluntary ventilation) of RM. Moreover, 92% of the EG reported a high satisfaction. The total social costs, direct and indirect, amounted to €21,678.

Conclusions

This evaluation reveals that RM function improvement is significant, that intervention is well tolerated and appreciated by patients, and the intervention costs are moderate.     

Experiencia con el uso del registrador implantable de eventos en una serie de personas mayores con caídas y sospecha de síncopes de origen arrítmico

Objective

To review our experience on using an implantable loop recorder (ILR) in patients with recurrent falls, when an arrhythmogenic cause is suspected.

Material and methods

This is a retrospective, observational study of patients with repetitive unexplained falls, suspected syncope, or electrocardiographic abnormalities. All of them had been evaluated by a cardiologist, who decided to implant a loop recorder (ILR) for an accurate diagnosis.

Results

A total of 13 patients received an ILR. The average falls rate for the sample was 3.3. The mean age was 78 years, and 46% were female, with a mean follow-up period of 24 months. During this time, three patients did not suffer from a new fall. An arrhythmogenic diagnosis was obtained in 5 patients: bradycardia was identified in 4 cases, and tachycardia in one of them. The symptoms did not coincide with a documented arrhythmia in the rest of the patients.

Conclusion

ILR is a helpful tool to establish an arrhythmogenic cause of unexplained and recurrent falls, in this selected sample of older adults.     

New-onset atrial fibrillation and prognosis in nonagenarians after acute myocardial infarction

Background

The influence of new-onset atrial fibrillation (AF) on the long-term prognosis of nonagenarians who survive acute myocardial infarction (AMI) has not been demonstrated.

Objective

Our aim was to study the association between new-onset AF and long-term prognosis of nonagenarians who survive AMI.

Methods

From a total of 96 patients aged ≥89 years admitted during a 5-year period, 64 (67 %) were discharged alive and are the focus of this study.

Results

Mean age was 91.0 ± 2.0 years, and 39 patients (61 %) were women. During admission, 9 patients (14 %) presented new-onset AF, 51 (80 %) did not present AF, and 4 (6 %) had chronic AF. During follow-up (mean 2.3 ± 2.6 years; 6.6 ± 3.6 years in survivors), 58 patients (91 %) died, including the 9 patients with new-onset AF. Cumulative survival at 6, 12, 18, 24, and 30 months was 68.3 %, 57.2 %, 49.2 %, 47.6 %, and 31.8 %, respectively. The only two independent predictors of mortality in the multivariate analysis were age (hazard ratio [HR] 1.14; 95 % confidence interval [CI] 1.01–1.28; p = 0.04) and new-onset AF (HR 2.3; 95 % CI 1.1–4.8; p = 0.02).

Conclusion

New-onset AF is a marker of poor prognosis in nonagenarians who survive AMI.     

Natural Killer Cell Immunoglobulin-like Receptor (KIR) genotypes in Follicular Lymphoma patients: Results of a pilot study

Aims

The Natural Killer Cell Immunoglobulin-like Receptor (KIR) genotype profiling in Follicular Lymphoma has not been reported before in the literature.

Materials and methods

DNA extracted from 20 Follicular Lymphoma patients and 62 healthy controls was analyzed for KIR genotyping using a polymerase chain reaction/sequence specific primers technique (PCR/SSP) for the presence of 16 KIR gene and pseudogene loci.

Results

The AA, AB, and BB genotype frequencies were, respectively, 20%, 60% and 20% with an A:B ratio of 1:1. KIR 2DL4, KIR 3DL2, KIR 3DL3, and KIR 3DP1*003 were presented in all individuals. No significant difference between patients and controls was detected.

Conclusion

KIR genotyping profile does not seem to be associated with Follicular Lymphoma. The results presented in this pilot research represent the first international report about this important clinical entity.     

Levels of 25-hydroxyvitamin D in familial longevity: the Leiden Longevity Study

Background:

Low levels of 25(OH) vitamin D are associated with various age-related diseases and mortality, but causality has not been determined. We investigated vitamin D levels in the offspring of nonagenarians who had at least one nonagenarian sibling; these offspring have a lower prevalence of age-related diseases and a higher propensity to reach old age compared with their partners.

Methods:

We assessed anthropometric characteristics, 25(OH) vitamin D levels, parathyroid hormone levels, dietary vitamin D intake and single nucleotide polymorphisms (SNPs) associated with vitamin D levels. We included offspring (n = 1038) of nonagenarians who had at least one nonagenarian sibling, and the offsprings’ partners (n = 461; controls) from the Leiden Longevity Study. We included age, sex, body mass index, month during which blood sampling was performed, dietary and supplemental vitamin D intake, and creatinine levels as possible confounding factors.

Results:

The offspring had significantly lower levels of vitamin D (64.3 nmol/L) compared with controls (68.4 nmol/L; p = 0.002), independent of possible confounding factors. There was no difference in the levels of parathyroid hormone between groups. Compared with controls, the offspring had a lower frequency of a genetic variant in the CYP2R1 gene (rs2060793) (p = 0.04). The difference in vitamin D levels between offspring and controls persisted over the 2 most prevalent genotypes of this SNP.

Interpretation:

Compared with controls, the offspring of nonagenarians who had at least one nonagenarian sibling had a reduced frequency of a common variant in the CYP2R1 gene, which predisposes people to high vitamin D levels; they also had lower levels of vitamin D that persisted over the 2 most prevalent genotypes. These results cast doubt on the causal nature of previously reported associations between low levels of vitamin D and age-related diseases and mortality.Vitamin D plays a critical role in bone formation,¹ immune cell differentiation, and in the inhibition of proliferation and angiogenesis in cancer.² Low serum levels of 25-hydroxyvitamin D3 (25[OH] vitamin D) are associated with increased mortality, cardiovascular disease, diabetes mellitus, cancer, multiple sclerosis, allergy, asthma, infection, depression, mental illness and musculoskeletal pain.^3–6 However, because of design limitations, previous studies have not been able to infer causality.⁷ A meta-analysis that included 51 studies and more than 30 000 individuals in each treatment group showed no reduction in all-cause or cardiovascular mortality with vitamin D supplementation,⁸ suggesting that low serum levels of vitamin D are a consequence rather than a cause of disease.Vitamin D status is routinely assessed by measurement of serum concentration of the prohormone 25(OH) vitamin D, which is the most stable and abundant metabolite of vitamin D in circulation. In the current study, we investigated the association between serum levels of 25(OH) vitamin D and familial longevity. We assessed vitamin D levels in the offspring of nonagenarian siblings whom we have previously shown to have a lower prevalence of cardiovascular diseases and lower mortality compared to age- and environmental-matched controls.^9,10 We also assessed whether genetic variation in 3 genes¹¹ was associated with 25(OH) vitamin D levels among the offspring of nonagenarians who had at least 1 nonagenarian sibling, and their partners.