Francesc Formiga

Tratamiento de la diabetes tipo 2 en el paciente anciano

Treatment of type 2 diabetes in the elderly represents a major challenge both in terms of clinical management and public health. Aging is causing a marked increase in the pandemic of diabetes in elderly people. However, scientific evidence to support the most appropriate treatment for diabetes in the elderly is scarce. Given the heterogeneity of the elderly population, which includes subjects with very different functional and cognitive capacities, co-morbidities, and life expectancy, it is critical to make a comprehensive assessment from a biopsychosocial perspective, to address the vascular risk factors integrally, and to establish individually tailored targets for glycemic control. In frail elderly or individuals with a short life expectancy, it may be reasonable to maintain HbA1c between 7.6%-8.5%. The therapeutic strategy for elderly patients with type 2 diabetes should be individualized and agreed with the patient and their caregivers, according to the objective. Improving quality of life, assuring patient safety and avoiding the adverse effects of antidiabetic treatment should be prioritized. Given the increased susceptibility of the elderly to severe hypoglycemia and its consequences, antidiabetic therapies that minimize the risk of hypoglycemic events should be selected.

Mild presentation of systemic lupus erythematosus in elderly patients assessed by SLEDAI

Objective: Systemic lupus erythematosus (SLE) predominantly affects young patients. SLE starting in later life has a clinical presentation different than in younger patients. We have used the SLE Disease Activity Index (SLEDAI) to explore the relationship between age of onset and disease activity. Methods: We selected all patients controlled in our hospital at the moment of clinical diagnosis of SLE (100 patients; 85 females and 15 males). They were classified in two groups: those with early onset (<50 y) and those with late onset (>50 y) based on their age at the moment of clinical diagnosis of SLE. Results: In 12 patients the onset of SLE was > 50 y (10 females and two males; mean age 59 y). The early onset patients had significantly higher SLEDAI values at the presentation and during the first year of disease with respect to elderly patients. Antibodies to DNA and hypocomplementemia were detected more often in younger patients. Conclusion: Our results confirm using SLEDAI, that the lupus of the elderly patients is a distinct clinical subgroup with a milder course of disease.

Patterns of comorbidity and multimorbidity in the oldest old: the Octabaix study.

BACKGROUND Multimorbidity is associated with higher mortality, increased disability, a decline in functional status and a lower quality of life. The objective of the study is to explore patterns of multimorbidity in an elderly population. METHODS 328 community inhabitants aged 85 years were included. Socio-demographic variables and data from the global geriatric assessment were evaluated. Information on the presence of sixteen common chronic conditions was collected: hypertension, diabetes mellitus, dyslipidemia, ischemic cardiomyopathy, heart failure, stroke, chronic obstructive pulmonary disease, (COPD), atrial fibrillation, peripheral arterial disease, Parkinsons disease, cancer, dementia, anemia, chronic kidney disease (CKD), visual impairment and deafness. Hierarchical cluster analysis was performed. RESULTS The rate of multimorbidity (>1 disease) was 95.1%. Men had a higher percentage of COPD and malignancy. Four main clusters were identified. The highest value of the bivariate correlation matrix was that between heart failure and visual impairment. These two diseases were included in a cluster with atrial fibrillation, CKD, heart failure, stroke, high blood pressure and diabetes mellitus. CONCLUSIONS The large majority of oldest old subjects had multimorbidity. The results confirm the non-random co-occurrence of certain diseases in this age group.

Mortality and Morbidity in Nonagenarian Patients following Hip Fracture Surgery

Background: The number of people living more than 90 years is increasing, and this population shows a high incidence of hip fractures. Objective: To study prospectively the mortality and morbidity following hip fracture surgery in nonagenarian patients. Methods and Subjects: 106 nonagenarian patients were admitted for femoral neck fracture and treated surgically in the traumatology and geriatric departments of two university hospitals. All patients received comprehensive geriatric assessment. 75 patients were followed up after a 3-month control period. Mortality and functional status were assessed using the Barthel index (BI) and mobility, dependency on walking aids, residential status, and degree of residual pain were the items assessed for morbidity. Results: In-hospital mortality was 10%; the 3-month accumulate mortality was 20%. The mean BI of the 75 patients who survived was 53 showing a persistent decrease compared with their BI previous to the hip fracture (79; p < 0.003). The decline in BI after 3 months persisted in 91% of patients. Before injury, 11% patients were housebound, while 45% were housebound 3 months later. 54% were independent before the fracture occurred, and only 16% 3 months later. Only 12% of patients who survived were unable to return to their pre-admission dwelling. Conclusions: Findings of low perioperative mortality and acceptable morbidity support the view that surgery followed by rehabilitation is indicated in selected nonagenarian patients.

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.

Association of antiphospholipid antibodies with retinalvascular disease in systemic lupus erythematosus

OBJECTIVES To study the prevalence and characteristics of retinal vascular disease in patients with systemic lupus erythematosus (SLE) and to analyze their relationship with antiphospholipid antibodies (aPL) and other serological markers. PATIENTS AND METHODS Eighty-two consecutive patients (77 women and 5 men; mean age, 36 years) were studied. All patients fulfilled the 1982 revised criteria of the American College of Rheumatology for the classification of SLE. Ophthalmologic examination included assessment of best corrected visual acuity, tonometry, slit-lamp biomicroscopy, and fundus examination. Serologic studies included determination of anticardiolipin antibodies (aCL) (ELISA), lupus anticoagulant (LA) (coagulation tests), antinuclear antibodies (indirect immunofluorescence), anti-DNA (Farrs test), and anti-ENA antibodies (counterimmunoelectrophoresis). RESULTS Retinal vascular disease was detected in 13 (15%) of 82 SLE patients. The retinal lesions consisted of retinal vascular occlusions in six patients (five arterial and one venous), cotton-wool spots in three, optic disc edema in three, retinal hemorrhages in three, and ischemic optic neuropathy in one. Antiphospholipid antibodies were detected in 10 (77%) of these 13 patients: nine had aCL and two had the LA. When compared with patients without retinal vascular disease, patients with retinopathy had a higher prevalence of aPL (77% v. 29%, P = .005). CONCLUSIONS Retinal vascular disease is frequent in patients with SLE. The presence of aPL is associated with a higher prevalence of retinal abnormalities in SLE patients.

Lipid and lipoprotein levels in premenopausal systemic lupus erythematosus patients.

The purpose of this study was to assess the prevalence of dyslipoproteinemia and to analyze the clinical variables that are associated with it in a sample of premenopausal systemic lupus erythematosus (SLE) patients. We studied 53 premenopausal (34.5 y) SLE outpatients and 45 controls. Clinical variables studied included patient age, weight, height, body mass index (BMI), age at disease onset, disease duration, clinical activity of SLE, renal involvement and drug therapy. Total cholesterol (TC), high-and low-density lipoprotein cholesterol (HDL-C and LDL-C), and triglycerides were measured using standard enzymatic techniques. Apolipoproteins (apo) A-I and B were determined by radial immunodiffusion. Twenty-nine patients (55%) and 14 controls (30%) had dyslipoproteinemia. An increase in TC, triglycerides, HDL3-C, apo A-I and apo B, and a decrease in HDL2-C and HDL-C/TC index was found in SLE patients in comparison with controls. TC (P ‘ 0.007), apo B (P ‘ 0.02), LDL-C (P ‘ 0.03) and triglycerides (P ‘ 0.0001) were significantly correlated with proteinuria. Patients on prednisone therapy had higher triglycerides levels (P ‘ 0.03) than untreated patients. TC (P ‘ 0.01), LDL-C (P ‘ 0.006) and triglycerides (P ‘ 0.04) were also correlated with the dose of prednisone. Dyslipoproteinemia is a common feature in adult SLE premenopausal patients which is characterized by an increase in TC, triglycerides and apo B, and an abnormal distribution of HDL subclasses. Corticosteroid therapy and proteinuria are the best predictors of dyslipoproteinemia in these patients.

Valoración de la capacidad funcional después de un ingreso hospitalario en pacientes nonagenarios

Fundamento Despues de un ingreso hospita-lario puede existir una perdida en la capaci-dad funcional, posiblemente mas importan-te en las personas mas ancianas. Pacientes y metodo Se estudio de manera prospectiva a 125 pacientes nonagenarios ingresados en los hospitales de Bellvitge y Clinic de Barcelona, y se realizo un control a los 3 meses. Resultados Veinticuatro pacientes (19%) fa-llecieron durante el ingreso. En los 101 res-tantes la media del indice de Barthel (IB) previo fue de 75, al ingreso 33 (p Conclusiones En los pacientes nonagenarios despues de una hospitalizacion se produce una alteracion funcional que persiste a los 3 meses del alta.

Morir en el hospital por enfermedad terminal no oncológica: análisis de la toma de decisiones

Dado el progresivo envejecimiento de la poblacion, ha aumentado el porcentaje de ancianos afectados de enfermedades cronicas en fase terminal, que acaban falleciendo en un hospital de agudos 1 . Por tanto, es basico que en dichos hospitales se otorgue al paciente terminal el derecho a morir con dignidad, pudiendo elegir y gestionar su propia vida, sus condiciones y su final 2 . En trabajos previos nuestro grupo ha detectado una baja implantacion de medidas paliativas en pacientes que fallecian por insuficiencia cardiaca congestiva (ICC) 3 terminal o en pacientes con demencia en fase terminal 4

Evaluación funcional y cognitiva en una población urbana de mayores de 89 años: Estudio NonaSantFeliu

Resumen Introduccion el aumento de la expectativa de vida debe ser a expensas de conseguir un aumento en la vida activa o libre de incapacidad. Evaluamos la capacidad funcional y cognitiva de los habitantes > 89 anos de una poblacion urbana (estudio Nona- SantFeliu) y comprobamos si existen diferencias segun el sexo. Material y metodos estudio poblacional, longitudinal y observacional. Al comienzo del estudio (primer corte transversal) se presentan los datos de todos los > 89 anos de una ciudad: datos sociodemograficos, actividades basicas mediante el indice de Barthel (IB), actividades instrumentales mediante el indice de Lawton (IL), capacidad cognitiva con miniexamen cognoscitivo de Lobo (MEC) y comorbilidad (indice de Charlson). Resultados de 186 nonagenarios entrevistados, 143 (76,5%) eran mujeres; la edad media ± desviacion estandar era de 93,1 ± 3,1 anos, y 149 (80,2%) eran viudos/as. El 26% estaba institucionalizado. El valor medio del IB fue de 60,8 ± 30,0: el 56% era independientes o con dependencia leve; IL medio, 2,1 ± 2,8. En el MEC obtuvieron una media de 21,0 ± 11,0 puntos, y en el 56% fue superior a 23. La media del indice Charlson era de 1,4 ± 1,7. No existen diferencias significativas por sexos. Conclusiones a pesar de su avanzada edad, la mayoria de nonagenarios tienen un leve deterioro funcional y cognitivo, con baja comorbilidad. No se detectaron diferencias significativas segun el sexo. Futuros estudios deben ayudarnos en la deteccion de personas nonagenarias con gran riesgo de deterioro en poco tiempo, para iniciar intervenciones que retrasen la aparicion de una mayor discapacidad.