Elisabet Sánchez

An Intervention Integrated into Daily Clinical Practice Reduces the Incidence of Delirium During Hospitalization in Elderly Patients

OBJECTIVES: To analyze the effectiveness of a multicomponent intervention integrated into daily practice for the prevention of in‐hospital delirium in elderly patients.

Prevalence of geriatric syndromes and impact on clinical and functional outcomes in older patients with acute cardiac diseases

Objective To assess the prevalence of major geriatric syndromes (MGSs)―frailty, cognitive impairment, severe dependence and depression―and their influence on outcomes in unselected patients with acute cardiac diseases. Design Observational prospective study with 12-month clinical and functional follow-up. Setting Clinical cardiology unit of a university hospital in Madrid, Spain. Patients Consecutive patients ≥75 years old urgently admitted to the cardiology unit. Intervention Systematic comprehensive geriatric assessment. Main outcome measures 12-month rates of mortality, readmission, functional decline and need for new social help. Results Among the 211 patients studied, 127 (60.2%) presented at least one MGS on admission: 86 frailty (40.8%), 67 cognitive impairment (31.8%), 31 severe dependency (14.7%) and 9 depression (4.3%). Patients with MGSs were slightly older (82±5 vs 81±4 years, p=0.02) but did not show greater disease severity or comorbidity. The presence of MGSs was associated with a higher incidence of functional decline during hospitalisation (35.7% vs 8.6%, p=0.002) and higher 12-month age-, comorbidity- and diagnosis-adjusted risks of readmission (OR, 2.1.92; 95% CI 0.98 to 3.7), functional decline (OR, 2.86; 95% CI 1.41 to 5.79) and need for new social help (OR, 3.10; 95% CI 1.45 to 6.60). MGSs were also associated with a higher 12-month mortality rate, which was only obvious in patients hospitalised for heart failure but not for other reasons. Conclusions A majority of older patients hospitalised for acute cardiac conditions in a cardiology department show at least one MGS on admission. MGSs are associated with poorer inhospital and postdischarge functional and clinical outcomes, particularly in patients with heart failure.

Prevalence and prognostic impact of frailty and its components in non‐dependent elderly patients with heart failure

The aim of this study was to evaluate the prevalence, clinical features, and the independent impact of frailty—a geriatric syndrome characterized by the decline of physiological systems—and its components, on prognosis after heart failure (HF) hospitalization.

El anciano con cardiopatía terminal

El objetivo de este documento del Grupo de Estudio «El anciano con cardiopatia terminal», de la Seccion de Cardiologia Geriatrica de la Sociedad Espanola de Cardiologia, es aportar un punto de vista experto que permita un mejor conocimiento de la situacion y una mejora en el manejo y la toma de decisiones en los ultimos dias de vida del paciente de edad avanzada que sufre una cardiopatia. Los cardiopatas ancianos constituyen un grupo heterogeneo y es necesaria una valoracion exhaustiva, especialmente de los factores que condicionan el pronostico (cardiopatia, comorbilidad, situacion funcional y datos de fragilidad) antes de tomar decisiones, sobre todo aquellas que conlleven limitacion del esfuerzo terapeutico como las ordenes de no reanimar o la desactivacion de desfibriladores automaticos implantables. Los ancianos con cardiopatias terminales tienen derecho a disponer de una serie de cuidados y atenciones, entre ellos no sufrir inutilmente, respeto a su libertad de conciencia, conocer su situacion, opinar sobre posibles intervenciones y recibir asistencia psicoespiritual. Los cuidados paliativos deben dirigirse al control de los sintomas tras el diagnostico de la enfermedad incurable y no iniciarse unicamente en la fase de agonia. Estos cuidados estan poco desarrollados en las cardiopatias y deben de tenerse presentes en los ancianos con insuficiencia cardiaca avanzada. Su objetivo es conseguir el maximo bienestar para el paciente desde un punto de vista integral, mejorar su calidad de vida antes del fallecimiento y evitar el empleo de tratamientos agresivos que consumen recursos sin resultados.

FRAIL‐HF, a Study to Evaluate the Clinical Complexity of Heart Failure in Nondependent Older Patients: Rationale, Methods and Baseline Characteristics

The clinical scenario of heart failure (HF) in older hospitalized patients is complex and influenced by acute and chronic comorbidities, coexistent geriatric syndromes, the patients ability for self‐care after discharge, and degree of social support. The impact of all these factors on clinical outcomes or disability evolution is not sufficiently known. FRAIL‐HF is a prospective observational cohort study designed to evaluate clinical outcomes (mortality and readmission), functional evolution, quality of life, and use of social resources at 1, 3, 6, and 12 months after admission in nondependent elderly patients hospitalized for HF. Clinical features, medical treatment, self‐care ability, and health literacy were prospectively evaluated and a comprehensive geriatric assessment with special focus on frailty was systematically performed in hospital to assess interactions and relationships with postdischarge outcomes. Between May 2009 and May 2011, 450 consecutive patients with a mean age of 80 ± 6 years were enrolled. Comorbidity was high (mean Charlson index, 3.4 ± 2.9). Despite being nondependent, 118 (26%) had minor disability for basic activities of daily living, only 76 (16.2%) had no difficulty in walking 400 meters, and 340 (75.5%) were living alone or with another elderly person. In addition, 316 patients (70.2%) fulfilled frailty criteria. Even nondependent older patients hospitalized for HF show a high prevalence of clinical and nonclinical factors that may influence prognosis and are usually not considered in routine clinical practice. The results of FRAIL‐HF will provide important information about the relationship between these factors and different postdischarge clinical, functional, and quality‐of‐life outcomes.

Centenarians and their hearts: A prospective registry with comprehensive geriatric assessment, electrocardiogram, echocardiography, and follow-up.

BACKGROUND Data on the cardiac characteristics of centenarians are scarce. Our aim was to describe electrocardiogram (ECG) and echocardiography in a cohort of centenarians and to correlate them with clinical data. METHODS We used prospective multicenter registry of 118 centenarians (28 men) with a mean age of 101.5±1.7 years. Electrocardiogram was performed in 103 subjects (87.3%) and echocardiography in 100 (84.7%). All subjects underwent a follow-up for at least 6 months. RESULTS Centenarians with abnormal ECG were less frequently females (72% vs 93%), had higher rates of previous consumption of tobacco (14% vs 0) and alcohol (24% vs 12%), and scored lower in the perception of health status (6.8±2.0 vs 8.3±6.8). Centenarians with significant abnormalities in echocardiography were less frequently able to walk 6 m (33% vs 54%). Atrial fibrillation/flutter was found in 27 subjects (26%). Mean left ventricular (LV) ejection fraction was 60.0±10.5%. Moderate or severe aortic valve stenosis was found in 16%, mitral valve regurgitation in 15%, and aortic valve regurgitation in 13%. Diastolic dysfunction was assessed in 79 subjects and was present in 55 (69.6%). Katz index and LV dilation were independently associated with the ability to walk 6 m. Age, Charlson and Katz indexes, and the presence of significant abnormalities in echocardiography were associated with mortality. CONCLUSIONS Centenarians have frequent ECG alterations and abnormalities in echocardiography. More than one fifth has atrial fibrillation, and most have diastolic dysfunction. Left ventricular dilation was associated with the ability to walk 6 m. Significant abnormalities in echocardiography were associated with mortality.

Incidence and impact of delirium on clinical and functional outcomes in older patients hospitalized for acute cardiac diseases

BACKGROUND Delirium is one of the most frequent complications of hospitalization in elderly patients. Its influence on prognosis in patients admitted for acute cardiac diseases is not well known. The objective of this study is to assess the incidence of delirium and its impact on clinical and functional outcomes in older patients hospitalized for acute cardiac diseases. METHODS We prospectively analyzed 203 patients aged 75years or older admitted to a cardiology unit. Delirium was diagnosed with the Confusion Assessment Method. Logistic regression analysis was used to assess independent predictors of in-hospital delirium and to examine the independent risk of mortality, readmission, functional decline, and need for new help at discharge, at 1month and 12months associated with the development of delirium, after adjusting for age, comorbidity, and initial diagnosis. RESULTS The incidence of delirium was 17.2%. Patients with delirium were older (83±5 vs 81±5years, P=.016) and showed a higher prevalence of major geriatric syndromes (82.9% vs 54.5%, P=.002). Aggressive ventilation modes, urinary catheters, prolonged fluid therapy, night treatments, longer immobilization, and physical restrain were associated with the incidence of delirium. Patients with delirium presented longer stays (8.9±6.2 vs 6.5±4.0days, P=.016) and a greater adjusted risk of functional decline at discharge (odds ratio 2.94, 95% CI 1.10-7.86, P=.032) and of 12-month mortality (odds ratio 4.20, 95% CI 1.81-9.74, P=.001). CONCLUSION Delirium is a common preventable complication in older patients with acute cardiac diseases. It is associated with poorer in-hospital functional and clinical outcomes, and increased postdischarge mortality.

Application of ultrasound for muscle assessment in sarcopenia: towards standardized measurements

PurposeMeasurement of muscle mass is paramount in the screening and diagnosis of sarcopenia. Besides muscle quantity however, also quality assessment is important. Ultrasonography (US) has the advantage over dual-energy X-ray absorptiometry (DEXA) and bio-impedance analysis (BIA) to give both quantitative and qualitative information on muscle. However, before its use in clinical practice, several methodological aspects still need to be addressed. Both standardization in measurement techniques and the availability of reference values are currently lacking. This review aims to provide an evidence-based standardization of assessing appendicular muscle with the use of US.MethodsA systematic review was performed for ultrasonography to assess muscle in older people. Pubmed, SCOPUS and Web of Sciences were searched. All articles regarding the use of US in assessing appendicular muscle were used. Description of US-specific parameters and localization of the measurement were retrieved.ResultsThrough this process, five items of muscle assessment were identified in the evaluated articles: thickness, cross-sectional area, echogenicity, fascicle length and pennation angle. Different techniques for measurement and location of measurement used were noted, as also the different muscles in which this was evaluated. Then, a translation for a clinical setting in a standardized way was proposed.ConclusionsThe results of this review provide thus an evidence base for an ultrasound protocol in the assessment of skeletal muscle. This standardization of measurements is the first step in creating conditions to further test the applicability of US for use on a large scale as a routine assessment and follow-up tool for appendicular muscle.

RESPONSE LETTER TO DR. INOUYE ET AL.

no or minimal effectiveness for delirium. In summary, given the substantial methodological limitations of the Vidán study, the conclusions are erroneous and misleading. Their intervention is not effective in prevention of delirium. The take-home message from this article is that watering down the proven HELP intervention strategy is inefficient and ineffective. In this era of relentless cost-cutting and quick fixes, this study provides yet another example to bolster the well-known truth, stated by George Washington Carver . . . ‘‘There is no shortcut to achievement.’’