Evolución clínica y funcional de los pacientes que ingresan en residencias tras una fractura de cadera. Implementación de un programa de intervención multinivel

Background and objectiveThe aim of this study was to determine the clinical and functional outcomes of patients discharged to nursing homes after a hip fracture.MethodsThe study included all patients admitted to a group of nursing homes after a hip fracture in 2016. A geriatric assessment protocol was applied, and patients were treated with a specific protocol for 90 days. They were assessed for nutritional status (Mini-Nutritional Assessment and Body Mass Index), pain (Visual Analogue Scale, and the PAINAD Scale), the presence of pressure ulcers, blood test (D vitamin, haemoglobin, proteins), and functional status (Barthel index and Functional Assessment Categories).ResultsOut of a total of 175 patients, 116 (75%) met the inclusion criteria. The mean age was 84.9 years old (±6.7 SD), and 91 (78.4%) were women. At admission, 73.8% of 65 residents had anaemia, 76.7% hypovitaminosis D, 88% malnutrition or «at risk of malnutrition», and 15.3% had pressure ulcers. After 90 days, the moderate-severe functional status (Barthel index < 60) was reduced from 90.4 to 39.6%, dependence due to gait from 97.3 to 36.1%, and moderate-severe pain from 88.9 to 14.4%. Most of the pressure ulcers healed (94.4%).ConclusionsPatients admitted to nursing homes after a hip fracture had poor clinical and functional status. This study shows that after 90 days from admission these patients had positive outcomes in terms of functionality, gait, pain control, and pressure ulcers healing.     

Rehabilitación geriátrica multidisciplinar en el paciente con fractura de cadera y demencia

Hip fracture and dementia rates increase with age, and both groups of patients suffer increased morbidity and mortality and functional impairment. The management of these patients is a challenge for the orthogeriatric and rehabilitation team process, as despite the evidence on the benefit, the results analysed are still worse than in patients without cognitive impairment. For this reason, and due to the limitation in health resources, many of them have problems in accessibility to them, or are limited to a less intense rehabilitation. There are insufficient studies on the best rehabilitation interventions in this group of patients, but it is suggested: 1) to use a multidisciplinary rehabilitation model adapted to the patient with dementia, and 2) to redefine results of the rehabilitation of these patients not only in terms of functional improvement, without highlighting other concepts, such as quality of life, decrease in complications or improved social support.     

Seudoaneurisma diferido de arteria femoral profunda tras intervención quirúrgica de fractura de cadera. A propósito de un caso

The diagnosis of pseudoaneurysm of the deep femoral artery as a late complication after orthopaedic surgery is uncommon.The causes of the injury of the artery may be due to the intervention technique itself (mainly the orthopaedic materials or the use of clips), and less frequently by fragments displaced by the trochanter.A case of pseudoaneurysm of the deep femoral artery by a less displaced trochanter fragment is presented in this article, showing how the different professionals interacted, and with the intervention of specialists in angioradiology to resolve it.     

Evaluación de las complicaciones clínicas de los pacientes con fractura de cadera y sus factores asociados en una Unidad de Agudos de Ortogeriatría

Introduction

The incidence of clinical complications in hip fracture (HF) patients is high and variable due to their heterogeneous nature. The aim of the study was to assess the clinical complications and their associated factors in HF patients admitted to the Orthopaedic Geriatric Unit of a 283 bed University Hospital. An average of 200 HF patients is attended yearly.

Planificación anticipada de los cuidados y del uso de recursos hospitalarios en pacientes con COVID-19 en un programa de atención integrada para adultos mayores frágiles en residencias

ObjectivesTo estimate the magnitude and importance of a process of stratification and advance care planning and the use of health resources, among patients in an integrated health care program for frail elderls in nursing homes,that were referred to the hospital with COVID-19.Material and methodsProspective cohort study of patients > 64 years old with COVID-19 infection, in a health care program in nursing homes (from 3/15/2020 to 9/15/2020). The identification of patients with palliative needs, the performing and visible registration in electronic health records of the advance care planning and the use of intensive care were assessed.ResultsWe included 374 COVID-19 patients. 88% were women, the median age was 88 years old. The 79% were patients with palliative needs, of which 68% had the advance care planning (P<.001) registered in the electronic health record. Only 1% of patients with palliative needs and severity criteria were admitted to the intensive care unit. Overall mortality was 25%. Of those who died, 74% had severity criteria (P<.001) and 90% had palliative needs (P<.001).ConclusionsCarrying out a care process based on identification of patients with palliative needs and advance care planning and a central and visible registration of advance care planning in health records, could improve the quality and safety of care and optimize the use of intensive care health resources at all times and especially in public health emergencies.     

Impacto de la hospitalización en pacientes centenarios ingresados por enfermedad aguda. Descripción de una serie de 165 casos y comparación con la literatura

IntroductionThe number of centenarians is increasing with the aging of the Spanish population. This age group might present different clinical features from younger groups. This study was carried out to determine the impact hospital admission on centenarians with an acute disease.Materials and methodsA retrospective observational study was conducted that included patients ≥100 years-old admitted from 1995 to 2016 to a third level university hospital and attended by the Geriatrics department in the acute ward, the Orthogeriatric ward, and by request. An analysis was made using the clinical-administrative databases containing information about the demographics, clinical, functional and cognitive features, length of hospital length, as well as discharge destination.ResultsThe study included 165 patients with a mean age of 101.6 ± 1.7 (range 100-109) years, of whom 140 (85%) were female. The mean hospital stay was 10.3 ± 7.4 days. Respiratory infections (41%) were the most common cause of admission to the Acute Geriatric Unit (AGU). The overall in-hospital mortality was 16%, but mortality in AGU reached up to 31%. There was an increase on moderate-severe functional disability (51% to 96%), and on the inability to walk independently (52% to 99%) from baseline to admission. There was a reduction in people living in their own home from 71% prior to admission to 29% at hospital discharge.ConclusionsCentenarians who required hospital admission showed a high rate of mortality, a significant deterioration in their functional capacity, and a decrease in their chances of going back to their own home at discharge.     

Resultados de la ventilación mecánica no invasiva en pacientes no candidatos a intubación en un hospital de subagudos. Estudio de seguimiento a un año

Elderly patients with multiple morbidity and do not intubate (DNI) orders frequently present with acute respiratory failure. There are data supporting the effectiveness of non-invasive ventilation (NIV) in this context. Our chronic disease hospital developed an integrated care clinical pathway for the use of NIV in acute respiratory failure in the emergency room and wards in 2010. The aim of this study was to assess the outcome of NIV in patients with acute respiratory failure who had a DNI order in a sub-acute care hospital.MethodsObservational, one year-follow up study. The main variables were in-hospital mortality and one year mortality. Other variables recorded were: demographics, clinical data, functional data, performance of daily life activities, dementia, arterial blood gases and re-admissions.ResultsThe study included a total of 102 patients, of which 22% were in institutions. The mean age 81 ± 7.47% males, with a Charlson index 3.7 ± 1, and Barthel index 54 ± 31. The overall mortality during the admission was 33% (34 patients). Among those patients ventilated outside the protocol indication, the mortality was significantly greater, at 71% (P > .05). Overall one-year survival rate was 46%. This survival rate was statistically higher in patients with obesity hypoventilation syndrome and a Barthel > 50.ConclusionsNIV is a useful technique in a hospital for chronic patients in an elderly population with a therapeutic ceiling. Despite their disease severity and comorbidity, acceptable survival rates are achieved. A correct case selection is needed. Obesity hypoventilation syndrome and those with Barthel index > 50 have a better prognosis.     

Enfermedad cardiovascular tras infección por SARS-CoV-2 en pacientes ancianos. Resultados del seguimiento anual de una cohorte de supervivientes

IntroductionAlthough the effects of SARS-CoV-2 infection on the cardiovascular system is well known in the acute phase, the cardiovascular impact of the elderly population surviving COVID-19 respiratory infection after 1 year of follow-up has not been sufficiently studied.MethodsObservational registry of 240 elderly patients (75 years or older), consecutively admitted for COVID-19 respiratory infection and survivors of the same, between March 1 and April 30, 2020, at the Hospital General Universitario de Ciudad Real. The incidence of major cardiovascular events [MACE] (cardiovascular death [CD], acute coronary syndrome [ACS], cerebrovascular disease [CVD], venous thromboembolic disease [VTE] and heart failure [HF]) was prospectively analysed.ResultsThe mean age was 83.75 ± 5.75 years. After a mean follow-up of 352.2 ± 70.4 days, 13.8% of patients died and 9.6% had MACE, the most frequent being heart failure, with no differences in severity or overall course of acute illness. In the multivariate Cox regression model, the risk of developing MACE was higher in patients with chronic obstructive pulmonary disease and (HR 4.29; 95%CI 1.62-11.39; P = .003) and loop diuretic (HR 2.99; 95%CI 1.27-7.07; P = .01).ConclusionsIn elderly COVID-19 survivors, the incidence of MACE after one year of follow-up is high, the main manifestation being heart failure.     

Resultado de la actualización de la vía clínica de la fractura de cadera del anciano en un hospital universitario de Madrid

Background and objectivesOrthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge.Material and methodA retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48 hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year.ResultsMedian age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48 hours (27,7% vs 36,8% p = 0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p < 0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p < 0.001), greater number of discharges in 15 days (78,2% vs 91,5% p < 0.001), lower delirium (54,1% vs 43,5% p = 0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year.ConclusionsUpdating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.     

Formación de cuidadores en un programa de estimulación cognitiva: efectos diferenciales según el tipo de cuidador

Background and objectivesThe ageing population and the increasing dependency associated with it, makes the caregiver a highly relevant figure nowadays. The present study analyzes the socio-demographic differences between family and professional caregivers and their satisfaction and implication in a training program for caregivers.MethodsThe sample consisted of 59 caregivers of older people (37 were family caregivers and 22 professional caregivers) which received and implemented a caregivers training program in their daily care functions. These caregivers were trained in communication skills and cognitive stimulation strategies so they could use them in their daily care activities with the older adults under their care during a period of 3 months. All the participants were assessed with a socio-demographic questionnaire, 2 questionnaires to analyze their satisfaction with their work and the training received and one questionnaire to analyze their ability to detect and react to memory and behavior problems in the older adults they attended.ResultsThe results showed socio-demographic differences, improvements in satisfaction in family caregivers and a greater commitment in their daily work after the treatment in both groups although these effects could be due to different reasons.ConclusionsThe research shows the benefits of carrying out training programs for caregivers as they significantly increase the quality and satisfaction with caregiving. The study also displays the need to adjust such programs taking into account that the socio-demographic characteristics and training needs are different depending on whether de caregiver is a family member or a professional.     

Diabetes mellitus y riesgo de fractura de cadera. Revisión sistemática

Background and objectivesIt has been reported that the risk of fracture is increased in patients with diabetes mellitus (DM). The aim of this study was to investigate the possible relationship between DM and hip fracture, as well as any associated risk factors, by means of a systemic review of the literature.MethodsPubMed and SCOPUS databases were used to search for relevant studies published from January 2001 to August 2018. Retrospective and prospective cohort studies were selected in which the estimated risk of hip fracture was demonstrated by comparing groups of diabetic patients with non-diabetics. A search was also made for risk factors independent from the association between DM and hip fracture.ResultsA total of 27 articles that fulfilled the inclusion criteria were included. A clear association was observed in diabetic patients (women and men) compared to non-diabetics patients. Among the risk factors, the most important ones were the fact that diabetes was type 1, probably associated with greater risk to a longer duration of DM, and being a female.ConclusionsThere is an increased risk of hip fracture in patients diagnosed with DM. This association is more significant in diabetes type 1 and women.     

Evaluación del grado de consecución de objetivos de control metabólico en pacientes con diabetes mellitus tipo 2

ObjectiveTo evaluate the extent to which metabolic targets in type 2 diabetes (DM-2) are achieved in the Endocrinology and Clinical Nutrition Unit of the Hospital Puerta del Mar in Cadiz (Spain) from 2005 to 2008.MethodThe database included in the computer application HP-Doctor used for all patients attended in our unit (admissions, consultations and peripheral centers) was analyzed. All patients with a principal or secondary diagnosis of DM-2 were included. Clinical characteristics, chronic complications, drug treatment and the percentage of patients who achieved annual mean targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDLc) were analyzed.ResultsFrom 2005 to 2008, the number of DM-2 patients with computerized records increased by 108.7%. In 2008, 1,177 patients were evaluated. A total of 10.8% were active smokers, 53% had hypertension, and 51.2% and 12.6% presented with retinopathy and cardiovascular disease, respectively. During the study period, the percentage of patients with a mean HbA1c <7% was similar (2005: 31.7% 2008: 30.4%), those with LDLc <100 mg/dl increased from 19.2% to 25.6% and only 9.2% of patients achieved both targets, HbA1c <7% and LDLc <100 mg/dl.ConclusionsIn 2008, only 30% of DM-2 patients achieved a mean HbA1c < 7% and only 25% had LDLc < 100 mg/dl. Metabolic control in DM-2 patients should be improved.