La información del diagnóstico en la demencia

Dementia is a syndrome characterized by a progressive deterioration of cognitive functions, accompanied by psychiatric symptoms and behavioral disturbances that produce a progressive and irreversible disability. The way it should communicate the diagnosis of dementia is a key discussion point on which there is no unanimous agreement so far. The communicating of the diagnosis of dementia is a complex issue that affects not only, the patient but also to caregivers and health professionals who care and must conform to the ethical principles governing medical practice (autonomy, nonmaleficence, beneficence, and justice). Therefore, from the Dementia Working Group of the Catalan Geriatric Society (Grupo de Trabajo de Demencia de la Sociedad Catalana de Geriatría) arises the need to review the issue and propose a course of action for the disclosure of diagnosis.     

Evaluación breve del estado cognitivo de la demencia en estadios avanzados: resultados preliminares de la validación española del Severe Mini-Mental State Examination

Introduction

The cognitive assessment of patients with advanced dementia needs proper screening instruments that allow obtain information about the cognitive state and resources that these individuals still have. The present work conducts a Spanish validation study of the Severe Mini Mental State Examination (SMMSE).

Material and methods

Forty-seven patients with advanced dementia (Mini-Cognitive Examination [MEC]<11) were evaluated with the Reisberg's Global Deterioration Scale, MEC, SMMSE and Severe Cognitive Impairment Profile scales.

Results

All test items were discriminative. The test showed high internal ( α = 0.88), test-retest (0.64 to 1.00, P < .01) and between observers reliabilities (0.69-1.00, p < 0.01), both for scores total and for each item separately. Construct validity was tested through correlations between the instrument and MEC scores (r = 0.59, P < 0.01). Further information on the construct validity was obtained by dividing the sample into groups that scored above or below 5 points in the MEC and recalculating their correlations with SMMSE. The correlation between the scores in the SMMSE and MEC was significant in the MEC 0-5 group (r = 0.55, P < .05), but not in the MEC>5 group. Additionally, differences in scores were found in the SMMSE, but not in the MEC, between the three GDS groups (5, 6 and 7) (H = 11.1, P < .05).

Conclusions

The SMMSE is an instrument for the assessment of advanced cognitive impairment which prevents the floor effect through an extension of lower measurement range relative to that of the MEC.From our results, this rapid screening tool and easy to administer, can be considered valid and reliable.     

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.     

Actualización de la neumonía en el anciano

The incidence of pneumonia increases with age and contributes to morbidity and mortality in the elderly. In our setting, pneumonia is the sixth leading cause of death and the fourth most common diagnosis at discharge from acute hospitals. This article reviews current concepts in management of pneumonia in the elderly: healthcare-associated pneumonia, aspiration and oropharyngeal dysphagia, risk stratification, and indications of radiological, microbiological and biological markers. We present current evidence on antibiotic treatment (when to start, empirical coverage, duration, new drugs and combinations) and adjuvant treatment (steroids, early mobilization, oral hygiene, prevention and treatment of aspiration and cardiac complications). We emphasize preventive aspects and considerations regarding palliative treatment.     

La evaluación de la calidad de vida en personas con demencia

Quality of life (QoL) is one of the most important outcome variables in the study of the efficacy of interventions with people with dementia. However, its assessment is difficult 1) because it is a complex construct for which there is no unified theoretical or conceptual approach, and 2) because of the inherent difficulties in the cognitive impairments of the people under study. In this work different methods and instruments to this end are reviewed, and related findings are discussed. It is important to take into account the subjective view of the assessed person, as assessments done by proxies tend to underestimate QoL. In spite of the need for further development in this field, it is concluded that the instrument of choice is the QOL-AD, as it is change-sensitive, it correlates with health measurements, it is translated into several languages and it can be administered to people with low MMSE scores.     

Beneficios de la musicoterapia como tratamiento no farmacológico y de rehabilitación en la demencia moderada

An in-depth review is presented the possible benefits of music therapy in relation to the cognitive and/or behavioural level of elderly patients with dementia. We have carried out a systematic review of randomized controlled trials, case-control and pilot studies published from January 2000 to January 2012 using the Cochrane Database of Systematic Reviews, MEDLINE, Dialnet and CSIC. We focused on comparison of music therapy as non-pharmacological therapy, in patients over 65 years of age with moderate dementia, with regular therapeutic and occupational treatment. Ten articles were selected based on the inclusion criteria. The analysis of the results suggest that music Therapy influences the elderly people with dementia in a positive way by improving levels of behavioural and cognitive functioning and social participation.     

Instrumentos para medir la sobrecarga en el cuidador informal del paciente con demencia

The complexity of dementia caregiver burden concept has led to a significant number of assessment tests using various approaches. For this reason, a review of these measurementss could be useful for clinical or research purposes.     

Guía de consenso para el abordaje de la neumonía adquirida en la comunidad en el paciente anciano

The incidence of community-acquired pneumonia increases with age and is associated with an elevated morbidity and mortality due to the physiological changes associated with aging and a greater presence of chronic disease. Taking into account the importance of this disease from an epidemiological and prognostic point of view, and the enormous heterogeneity described in the clinical management of the elderly, we believe a specific consensus document regarding this patient profile is necessary. The purpose of the present work was to perform a review of the evidence related to the risk factors for the etiology, the clinical presentation, the management and the treatment of community-acquired pneumonia in elderly patients with the aim of producing a series of specific recommendations based on critical analysis of the literature. This document is the result of the collaboration of different specialists representing the Spanish Society of Emergency Medicine and Emergency Care (SEMES), the Spanish Society of Geriatrics and Gerontology (SEGG), the Spanish Society of Chemotherapy (SEQ), the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Respiratory Medicine and Thoracic Surgery (SEPAR), Spanish Society of Home Hospitalization (SEHAD) and the Spanish Society of Infectious Disease and Clinical Microbiology (SEIMC).     

Escalas de valoración del dolor en pacientes con demencia. Instrumentos de ayuda para el fisioterapeuta,el médico,el enfermero y el terapeuta ocupacional

The purpose of this study was to determine which scales are being used to evaluate pain in old people suffering from dementia.     

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.     

Relación entre el rendimiento en la prueba de estación unipodal y la velocidad del centro de presión en adultos mayores

Introduction

Frequent falls are one of the most important health problems in the elderly population. The unipedal stance test (UPST), asses postural stability and is used in fall risk measures. Despite this, there is little information about its relationship with posturographic parameters (PP) that characterizes postural stability. Center of pressure velocity (CoPV) is one of the best PP that describes postural stability. The aim of this study was to analyze the relation between UST score and CoPV in elderly population.

Materials and methods

A sample of 38 healthy elderly subjects where divided in two groups according to their UPST score, low performance (LP, n = 11) and high performance (HP, n = 27). The correlation between UPST score and COP mean velocity (CoPmV), recorded from a posturographic test, was analyzed between both groups.

Results

An inverse correlation between UPST score and CoPmV was found in both groups. However, this was higher in the LP group (r = −0.69, P = .02) compared to the HP (r = −0.39, P = .04).

Conclusions

Based on the results of this investigation, it may be concluded that the achievement on UPST has an inverse relationship with CoPmV, especially in subjects with low performance in the UPST.     

La participación de personas con demencia en las reuniones del plan de atención individualizada: impacto en el bienestar y la calidad del cuidado

Introduction

An individualised intervention plan (IIP) offers a new paradigm in the care of the elderly with dementia, with the aim of increasing their quality of life through personalisation, respect for their freedom, and their participation in the decisions that affect their lives.

Objective

To evaluate the impact of the residential home patient with dementia and their quality of care when they take part in the interdisciplinary meeting in which their care plan is decided.

Material and methods

A total of 52 elderly patients with dementia took part in the study. They were distributed into two groups, one experimental (37 residents) and another control (15 residents). The Dementia Care Mapping (DCM) tool was used to assess the well-being and quality of care of the residents. This tool was used twice, before and after the intervention.

Results

The well-being of the resident, evaluated using the DCM, was similar before and after the intervention in the experimental group. No differences were observed either on comparing the control and experimental groups. However, some indicators of carer behaviour were different before and after the intervention, and when the control and experimental group were compared.

Conclusion

The inclusion of elderly persons with dementia in their IIP meeting had a positive effect in the interaction of the staff with the residents, but not on the well-being of the resident.     

Planificación anticipada de decisiones en las enfermedades crónicas avanzadas

Introduction

Advanced care planning (ACP) helps in make decisions on the health problems of people who have lost the capacity for informed consent. It has proven particularly useful in addressing the end of life. The aim of this study was to determine the prevalence of ACP in patients with severe chronic diseases.

Material and methods

Review of medical records of patients with dementia, amyotrophic lateral sclerosis, Parkinson's disease, chronic obstructive pulmonary disease or interstitial lung disease, heart failure, chronic kidney disease on dialysis and cancer, all in advanced stages. We collected data on living wills or registered prior decisions by the physician according to clinical planned.

Results

A total of 135 patients were studied. There was a record of ACP in 22 patients (16.3%). In most of them it was planned not to start any vital treatment in the event of high risk of imminent death and lacking the ability to make decisions. Only two patients were had a legal living will.

Conclusion

The registration of ACP is relatively low, and this can affect decision-making in accordance with the personal values of patients when they do not have the capacity to exercise informed consent.     

Propuesta de una batería neuropsicológica para la exploración del síndrome de Capgras

Capgras syndrome is the most prevalent of the delusional misidentification syndromes. It appears in both psychiatric illness and organic brain damage. Cognitive and neuropsychiatric models (lateralization and disconnection) have been proposed to explain the syndrome. From a neuropsychological point of view Capgras syndrome seems to be due to damage of bifrontal and right limbic and temporal regions. Memory, feeling of familiarity, monitoring of self and reality would be altered. All of these cause a failure to adequately integrate the information about emotions and facial recognition. Relative preservation of the left frontal lobe may be necessary for the development of delusional response. There does not seem to be a differential pattern as regards the aetiology, but there is a common underlying neuropsychiatric mechanism. Based on theoretic models, and clinics features, we propose a neuropsychological battery to assess the Capgras syndrome, that should be sensitive to the main expected deficits.     

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.     

Impacto de la función tímica en el deterioro inmunológico asociado a la edad

Age-related biological deterioration also includes immune system deterioration and, in consequence, a rise in the incidence and prevalence of infections and cancers, as well as low responses to vaccination strategies. Out of all immune cell subsets, T-lymphocytes seem to be involved in most of the age-related defects. Since T-lymphocytes mature during their passage through the thymus, and the thymus shows an age-related process of atrophy, thymic regression has been proposed as the triggering event of this immune deterioration in elderly people. Historically, it has been accepted that the young thymus sets the T-lymphocyte repertoire during the childhood, whereupon atrophy begins until the elderly thymus is a non-functional evolutionary trace. However, a rising body of knowledge points toward the thymus functioning during adulthood. In the elderly, higher thymic function is associated with a younger immune system, while thymic function failure is associated with all-cause mortality. Therefore, any new strategy focused on the improvement of the elderly quality of life, especially those trying to influence the immune system, should take into account, together with peripheral homeostasis, thymus function as a key element in slowing down age-related decline.     

Prevención primaria del ictus en el anciano: evidencias actuales en el tratamiento de la hipertensión arterial

After age, arterial hypertension (AHT) is the most significant risk factor associated with stroke, and accounts for more than 25% of all strokes. The prevalence of AHT in the elderly in Spain is approximately 70%, which means that there are more than 5 million people over 65 years-old with hypertension in our country. There are currently numerous trials and meta-analyses that demonstrate that antihypertensive treatment clearly reduces the risk of stroke in elderly, and very elderly (≥80 years) subjects. However there are many areas of uncertainty such as, for example, when to start antihypertensive treatment, to what level should the blood pressure be lowered, or what is the best antihypertensive in the prevention of stroke in this population. In this article we present a review of the current evidence in the prevention of stroke in the elderly patient by means of treatment of the AHT.