Domingo Ruiz

Outcome Predictors of Pneumonia in Elderly Patients: Importance of Functional Assessment

Objectives: To evaluate the outcome of elderly patients with community‐acquired pneumonia (CAP) seen at an acute‐care hospital, analyzing the importance of CAP severity, functional status, comorbidity, and frailty.

Factors associated with hip fracture-related falls among patients with a history of recurrent falling

BACKGROUND People who have suffered falls are at greater risk of falling again. We study the characteristics of falls leading to hip fracture in people with a history of recurrent falls, comparing them with those of people with a history of sporadic falling. MATERIALS AND METHODS Analysis of the characteristics of a sample of 1225 patients consecutively admitted to six hospitals because of a hip fracture secondary to a fall (index fall) - index fall characteristics (location, time and the possible cause of the fall: intrinsic, extrinsic or combined risk factors) were also determined. Patients with a history of three or more falls (recurrent fallers) in the year prior to the index fall were identified as high-risk fallers; those with less than three falls were considered to be sporadic fallers. RESULTS The mean number of falls in the year prior to the index fall was 1.7+/-6.5; 227 patients (22%) had experienced three or more falls within that period. Most index falls (880, 71.8%) took place at the patients home, 232 (18.95%) in the street and 113 (9.2%) elsewhere; most (892, 72.9%) took place during daytime. Multiple stepwise logistic regression analysis showed that recurrent fallers were characterized by poorer baseline independence for activities of the daily living, a prior diagnosis of dementia, greater use of prescription drugs and a greater use of neuroleptics. For frequent fallers, the index fall was more often associated with an intrinsic factor than for sporadic fallers. CONCLUSIONS A significant percentage of patients experiencing a fall followed by hip fracture have a history of recurrent falling in the year prior to a fall-related hip fracture. Poorer functional and cognitive status, polypharmacy and the use of neuroleptics are more prevalent in this subgroup of patients, and intrinsic factors as a cause of the fall are more common in this group. Whether these circumstances associated with recurrent falling are responsible for this higher prevalence of intrinsic, non-accidental falls should be addressed prospectively in order to implement preventive strategies.

Predictive items of functional decline and 2-year mortality in nonagenarians—the NonaSantfeliu study

BACKGROUND Few studies have prospectively evaluated predictors of mortality or decline in functional capacity in nonagenarians. The aim of this study is to determine predictors of death or functional decline in basic activities of daily living in nonagenarians after 2 years of follow-up. METHODS One hundred and seventy-six nonagenarians were prospectively evaluated. Functional status was determined by the Lawton-Brody index (LI) and the Barthel Index (BI), and cognition by the Spanish version of the Mental State Examination. The Charlson score was used to measure co-morbidity. Nutritional status was evaluated by the short version of the Mini Nutritional Assessment questionnaire. RESULTS The sample comprised 135 women (76.3%) and 41 men. Mean age was 93 +/- 3.2 years. Mortality after 2 years was 36.3%. Forty-six (41%) of the 112 survivors presented BI losses >19%. One hundred and ten subjects (63%) presented the combined negative outcome item (death or functional decline). A multiple stepwise logistic regression analysis identified two variables associated with a fall of >19% on the BI or death: a low LI (odds ratio 0.785, 95% CI 0.656-0.940) and a low score at baseline on the Spanish version of the Mental State Examination (odds ratio 0.950, 95% CI 0.914-0.987). CONCLUSION Better cognitive status and higher capacity to perform instrumental activities of daily living (ADL) at baseline are the best predictors to identify which nonagenarians survived without major functional decline after a 2-year follow-up period.

Predictive items of one-year mortality in nonagenarians. The NonaSantfeliu Study

Background and aims: Few studies have prospectively evaluated predictors of mortality in nonagenarian cohorts. Our objective was to determine a set of predictors of all-cause mortality in a cohort of nonagenarians after one year of follow-up. Methods: 186 nonagenarians were evaluated prospectively, 137 of whom lived in their own homes (74%) and 49 (26%) were institutionalized. Functional status was determined by the Lawton-Brody (LI) and Barthel Index (BI), and cognition by the Spanish version of the Mini Mental State Examination (MEC). The Charlson score was used to measure global comorbidity. Nutritional status was evaluated by the short version of the Mini Nutritional Assessment questionnaire (short-MNA). Results: The sample was composed of 143 women (76.5%) and 43 men, with a mean age of 93.06 (3.1) years. The rate of mortality was 19.3%. There were no differences in mortality between men and women. Although the BI and LI were both related to 1-year mortality in bivariate, unadjusted analysis, their contribution was minimal in multivariate analyses. Age, heart failure and short-MNA remained associated with mortality in the multivariate analyses. Conclusions: This study supported the importance of age, heart failure and nutritional status in predicting 1-year mortality in nonagenarians.

Prevalencia de delirium en pacientes ingresados por procesos médicos

Fundamento y objetivo El delirium es un problema frecuente durante el ingreso hospitalario. Estudiamos la prevalencia de delirium en los pacientes ingresados en unidades de hospitalizacion de medicina interna general. Un segundo objetivo fue analizar si habia diferencias entre los pacientes con o sin delirium. Pacientes y metodo Estudio transversal de 165 pacientes ingresados por procesos medicos en 6 unidades de hospitalizacion de medicina interna general. Se cuantifico la capacidad funcional mediante el indice de Barthel (IB) y la comorbilidad mediante el indice de Charlson. Se utilizo el Confusional Assessment Method para el diagnostico de delirium en forma de corte transversal. Resultados Se ha evaluado a 101 mujeres (61,2%) y 64 varones, con una media (desviacion estandar) de edad de 80,3 (12) anos. La media del indice de Charlson fue de 2,6 (1,7). La media del IB previo al ingreso fue de 71,5 (27) y en el momento de la valoracion era de 40,3 (30). Presentaban delirium en el momento de la valoracion 42 (25,4%) pacientes. La regresion logistica mostro como variables independientes asociadas a tener delirium un peor IB en el momento de la valoracion y el diagnostico previo de demencia. Conclusiones Un alto porcentaje de los pacientes ingresados en unidades de hospitalizacion de medicina interna general presentan delirium. El deterioro cognitivo previo y una peor puntuacion en el IB en el momento de la valoracion tienen relacion con mayor riesgo de tener delirium.

Characteristics of fall-related hip fractures in community-dwelling elderly patients according to cognitive status

Background and aims: Falls are a major cause of morbidity and mortality in older people who have cognitive impairment. The present study compared the characteristics of community-dwelling patients, with and without previous diagnosis of dementia, hospitalized because of a hip fracture. Methods: 1024 consecutive patients >65 years (77.2% women, mean age 82.9 yrs) admitted for fall-related hip fracture to six Spanish hospitals during a 20-month period were included. Sociodemo-graphic data, geriatric assessment and characteristics (location, time and possible cause: intrinsic, extrinsic or combined risk factor) of falls leading to hip fracture were evaluated. Results: A total of 154 (15%) patients had a previous diagnosis of dementia. Analysis showed a greater number of previous falls before admission for hip fracture in demented patients. Moreover, in non-demented patients, we found both a predominance of falls during the day and of extrinsic factors. Conclusion: Some differences were observed, according to the cognitive status of elderly patients suffering a hip fracture due to a fall. A high percentage of dementia patients had suffered repeated falls prior to the fall-related hip fracture.

Circunstancias asociadas a las caídas responsables de fractura de fémur en pacientes ancianos. Diferencias por grupo de edad y género

Objetivo La mayoria de fracturas de femur acontecen tras una caida. El objetivo de este estudio es identificar las circunstancias asociadas a las caidas que provocan fractura de femur en una poblacion anciana. Pacientes y metodos Se estudiaron las caracteristicas de las caidas responsables de la fractura de femur en 410 pacientes ingresados de forma consecutiva en 6 centros durante el ano 2004. Se valoro el lugar, la hora y la posible causa de la caida, ya fuese causa intrinseca, extrinseca o combinada. Resultados Se incluyeron 316 (77%) mujeres y 94 varones con una edad media de 81,9 anos. La media del indice de Barthel previo fue de 77,5. El promedio de caidas durante los 12 meses previos fue de 1,9. En el 24% de los casos se documentaron caidas de repeticion (mas de dos caidas) previamente a la caida que provoco la fractura de femur. La caida acontecio en el domicilio en el 68% de los casos y en el 80% de los casos fue diurna (8-20 horas). En el 45% de los pacientes se considero que la caida tuvo una causa intrinseca, en el 33% extrinseca y en el 22% combinada. Conclusiones La mayoria de las caidas responsables de fractura de femur en el anciano son diurnas, en el domicilio y de causa intrinseca. Se debe intensificar la identificacion de los pacientes con riesgo elevado de caidas para establecer medidas de prevencion de los factores de riesgo evitables.

Prevalence of sarcopenia in patients attending outpatient geriatric clinics: the ELLI study

OBJECTIVES the aim of this study is to know the prevalence of sarcopenia in geriatric outpatient clinics using the EGWSOP (European Working Group on Sarcopenia in Older People) diagnostic criteria that include muscle mass, muscle strength and physical performance. METHODS subjects over 69 years old, able to walk without help and who attended five geriatric outpatient clinics were recruited. Body composition was assessed using bioimpedance analysis (BIA), grip strength using a JAMAR dynamometer and physical performance by the 4 m gait speed. Sarcopenia was diagnosed using the EGWSOP criteria (gait speed <0.8 m/s; grip strength <30 kg in men or <20 kg in women, and muscle mass index (MMI) <8.31 kg/m(2) in men or <6.68 kg/m(2) in women). RESULTS two hundred and ninety-eight subjects were included (median age 83.2 years, 63.1% women). 19.1% had sarcopenia (12.7% men, 22.9% women); 20.1% had low muscle mass; 68.8% had low gait speed and 81.2% low grip strength. Only 21.9% of the subjects with low grip strength and 19.5% of those with low gait speed had sarcopenia. No correlations between muscle mass and either muscle strength or gait speed were detected. CONCLUSIONS sarcopenia is present in one out of five subjects attending geriatric outpatient clinics.

Characteristics of falls producing hip fractures in nonagenarians

Objectives: To evaluate the characteristics associated with falls causing hip fracture in patients 90 years of age or older (nonagenarians). A second objective was to compare these characteristics with those present in younger patients (65–79 year-olds).Design: Prospective, observational study.Setting: Six hospitals in Barcelona (Spain) and its surrounding area.Participants: 105 nonagenarians diagnosed with hip fracture after a fall. Most patients were women (78; 74%), with a mean age of 92.2±2 years. All of them were living in the community, except for eight institutionalized patients. 221 patients aged 65 to 79 composed the younger patient’s comparison group.Measurements: Characteristics of falls causing hip fracture were analyzed: location, time and the risk factor for the fall, classified as intrinsic, extrinsic or combined.Results: The mean number of falls in the previous year was 1.5–22% of the patients reported having fallen two or more times. Falls usually happened while at home (70%) and during the day (64%). An intrinsic risk factor was considered the most likely cause in 37% of the cases, an extrinsic risk factor in 35%, and a combination in 28%. Multiple stepwise logistic regression analysis showed that nonagenarians were characterized by lower BI scores, more falls happening during night time, a higher use of, benzodiazepines and diuretics, and a lower use of non-benzodiazepinic hypnotics.Conclusions: Most falls causing hip fracture in nonagenarians happen during the day and at home. Falls in nonagenarians happening more frequently during nighttime, and these oldest subjects had lower BI scores, and a higher use of benzodiazepines and diuretics and less use of non-benzodiazepines hypnotics compared with the younger patients.

Assessing nutritional status in the elderly: evaluation of Chumlea´s equations for weight

BACKGROUND Weight is one of the most important parameters in assessing nutritional status. However, weight can be difficult to measure in elderly people who are unable to stand. Chumlea et al. created two equations to estimate weight in non-ambulatory patients using readily available body measurements. OBJECTIVE The aim of the study is to analyze the usefulness of Chumlea equations in assessing nutritional status of elderly hospitalized patients. METHODS We measured weight, height, arm and calf circumference, subscapular skinfold and knee height of 82 hospitalized elderly patients, all of whom were able to stand. Estimated weight (EW) was obtained by Chumlea equations. Body mass index (BMI) and Mini Nutritional Assessment test (MNA) were calculated using actual weight and EW. Bland-Altmann analysis and intraclass correlation coefficient (ICC) between real and estimated parameters were assessed. RESULTS We found a statistically significant ICC between actual weight and EW (r = 0.926), real BMI and estimated BMI (r = 0.910) and real MNA and estimated MNA (r = 0.982) (p < 0.001). Chumlea equations, however, underestimated weight: 54.05 (DS 11.88) vs 61.46 (DS 13.08); BMI: 22.30 (DS 4.61) vs 25.36 (DS 5.17) and MNA: 22.73 (DS 4.43) vs 23.30 (DS 4.33) (P<0.001). In spite of this underestimation, estimated MNA detected 100% of patients malnourished and 96% of those at risk of malnutrition. CONCLUSIONS Results obtained by Chumlea equations showed a good ICC with actual body weight and real BMI and MNA, but values were underestimated. These equations can be useful to detect undernourished hospitalized elderly patients.