Abelardo Montero

Utility of Geriatric Assessment to Predict Mortality in the Oldest Old: The Octabaix Study 3-Year Follow-Up

OBJECTIVE Few studies have prospectively evaluated the utility of geriatric assessment tools as predictors of mortality in the oldest population. We investigated predictors of death in an oldest-old cohort after 3 years of follow-up. METHODS The Octabaix study is a prospective, community-based study with a follow-up period of 3 years involving 328 subjects aged 85 at baseline. Data were collected on functional and cognitive status, co-morbidity, nutritional and falls risk, quality of life, social risk, and long-term drug prescription. Vital status for the total cohort was evaluated after 3 years of follow-up. RESULTS Mortality after 3 years was 17.3%. Patients who did not survive had significantly poorer baseline functional status for basic and instrumental activities of daily living (Barthel and Lawton Index), higher co-morbidity (Charlson), higher nutritional risk (Mini Nutritional Assessment), higher risk of falls (Tinetti Gait Scale), poor quality of life (visual analog scale of the Quality of Life Test), and higher number of chronic drugs prescribed. Cox regression analysis identified the Lawton Index (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.73-0.89) and the number of chronic drugs prescribed (HR 1.09, 95% CI 1.01-1.18) as independent predictors of mortality at 3 years. CONCLUSIONS Among the variables studied, the ability to perform instrumental activities of daily living and using few drugs on a chronic basis at baseline are the best predictors of which oldest-old community-dwelling subjects survive after a 3-year follow-up period.

Clinical relevance of Acinetobacter baumannii ventilator-associated pneumonia.

despite a relatively simple atomic structure, acts selectively by blocking the N-methyl-D-aspartate receptor. Because N-methyl-D-aspartate receptor antagonists are known to possess neuroprotective properties, a first study in rats was performed to investigate possible neuroprotection. During cardiopulmonary bypass surgery, neuroprotection of xenon was confirmed. The protective effect of xenon in animals is seen in subanaesthetic concentrations. In an unpublished study by our group, when cardiopulmonary resuscitation was performed in pigs, xenon reduced damage to the central nervous system (T. Marx, unpublished data). The use of xenon therefore is proposed in procedures where potential central nervous impairment is expected, including cardiac bypass surgery, cerebral trauma, and stroke (8). Prolonged ICU stay due to neuronal damage after cardiac bypass surgery alone is regarded to cost

Evidence of functional declining and global comorbidity measured at baseline proved to be the strongest predictors for long-term death in elderly community residents aged 85 years: a 5-year follow-up evaluation, the OCTABAIX study

2– 4 billion in the United States annually (9). The cost/benefit relationship, which in the view of other authors limits xenon’s use in anesthesia (4), therefore must be considered. Cost reduction by minimizing cerebral damage and reducing the length of ICU stay must been taken into consideration. Xenon’s use during ICU therapy can be expected in the near future, if further studies confirm the results of the animal experiments. Regarding this, the work of Dr. Bedi et al. (10), published in this issue of Critical Care Medicine, is overdue concerning the future of xenon. The application for ICU sedation was found to be feasible when using a closed ventilator system. The authors explain that in addition to the well-known properties like rapid recovery and hemodynamic stability, in closed-system anesthesia the requirements for the substance are reduced dramatically when all tissues are saturated. The inhaled concentrations used for sedation are below the concentration of xenon used in anesthesia (approximately 70%) (10). It is an important milestone for xenon’s future to demonstrate how xenon could be administered during ICU therapy. I regret that the authors did not measure the real xenon usage to give a rough estimation of the expected costs. Regarding closed-system ventilation during ICU therapy, some further studies have to be kept in mind regarding the accumulation of volatile compounds in breathing systems. High concentrations of possibly toxic compounds must be avoided. Under physiologic conditions, human breath contains 100 gaseous and volatile substances (11). This composition of human exhaled breath could be changed totally under conditions of severe organ failure. During conditions like sepsis or multiple organ failure, this might be a problem whose importance could not be assessed until now (12). Thomas Marx, MD Department of Cardiac Anaesthesia University of Ulm Ulm, Germany

Characteristics of falls producing hip fracture in patients on oral anticoagulants

Objective To investigate the predictive value of functional impairment, chronic conditions, and laboratory biomarkers of aging for predicting 5-year mortality in the elderly aged 85 years. Methods Predictive value for mortality of different geriatric assessments carried out during the OCTABAIX study was evaluated after 5 years of follow-up in 328 subjects aged 85 years. Measurements included assessment of functional status comorbidity, along with laboratory tests on vitamin D, cholesterol, CD4/CD8 ratio, hemoglobin, and serum thyrotropin. Results Overall, the mortality rate after 5 years of follow-up was 42.07%. Bivariate analysis showed that patients who survived were predominantly female (P=0.02), and they showed a significantly better baseline functional status for both basic (P<0.001) and instrumental (P<0.001) activities of daily living (Barthel and Lawton index), better cognitive performance (Spanish version of the Mini-Mental State Examination) (P<0.001), lower comorbidity conditions (Charlson) (P<0.001), lower nutritional risk (Mini Nutritional Assessment) (P<0.001), lower risk of falls (Tinetti gait scale) (P<0.001), less percentage of heart failure (P=0.03) and chronic obstructive pulmonary disease (P=0.03), and took less chronic prescription drugs (P=0.002) than nonsurvivors. Multivariate Cox regression analysis identified a decreased score in the Lawton index (hazard ratio 0.86, 95% confidence interval: 0.78–0.91) and higher comorbidity conditions (hazard ratio 1.20, 95% confidence interval: 1.08–1.33) as independent predictors of mortality at 5 years in the studied population. Conclusion The ability to perform instrumental activities of daily living and the global comorbidity assessed at baseline were the predictors of death, identified in our 85-year-old community-dwelling subjects after 5 years of follow-up.

Association between diabetes and mortality in elderly patients admitted for a first episode of acute heart failure

Objective: To analyze the demographic and clinical characteristics of patients on chronic anticoagulant therapy (CAT) admitted because of a hip fracture secondary to a fall, and to compare with patients not receiving CAT. Methods: A prospective, observational study realized in six hospitals in the Barcelona area. Demographic and clinical characteristics of patients were collected. The index fall characteristics – cause, height, location, and time of occurrence – were evaluated. Results: Of the 1225 patients included, 99 (8%) patients were on CAT. When we compare with the rest logistic regression analysis showed that patients receiving CAT were more likely to be male (odds ratio 3.7), not institutionalized (odds ratio 3.5), to take more number of drugs (odds ratio 1.3), to have dementia (odds ratio 2.1) and stroke (odds ratio 1.7). Results revealed a higher prevalence of combined factors as the cause of the index fall in the group of patients on anticoagulants. Conclusions: Characteristics of falls were very similar when comparing the group of patients receiving CAT with those who did not. A prior history of falls should lead physicians to take actions for preventing falls causing hip fracture, in all patients and particularly in these on CAT.

Emergence and Rapid Spread of Carbapenem Resistance during a Large and Sustained Hospital Outbreak of Multiresistant Acinetobacter baumannii

To examine whether the presence of a prior diagnosis of diabetes mellitus (DM) influences mortality risk in elderly patients experiencing a first episode of heart failure (HF) hospitalization.