Francesc Orfila

Evolution of self-rated health status in the elderly: Cross-sectional vs. longitudinal estimates

We assessed the perceived health status evolution among elderly subjects and examined the age-related differences in perceived health when comparing estimates obtained from cross-sectional and longitudinal approaches. Data come from a cohort of non-institutionalized individuals aged 65 years or older, living in Barcelona, Spain. One thousand three hundred fifteen (1315) elderly were successfully interviewed at baseline in 1986 and 754 (84.6% of the eligible) at the re-assessment (1993-1994). Estimates of change in perceived health status were calculated based on cross-sectional and longitudinal approaches. Cross-sectionally, no significant differences in the proportion of individuals with poor self-rated health were found (40.5 vs. 42.5%, P = 0.90). Among survivors, the proportion of individuals with poor health increased from 37.8% to 55.1% (P < 0.01), an 8.7-fold decline of perceived health when compared with the cross-sectional estimates. Comorbidity (aOR 2.1; 95%CI: 1.4-3.3) and no education (aOR 1.9; 95%CI: 1.1-3.2) were associated with a decline in health status after adjusting by baseline health status. We recommend the use of longitudinal studies to understand the evolution of perceived health in the elderly.

Risk prediction in the community: A systematic review of case-finding instruments that predict adverse healthcare outcomes in community-dwelling older adults

Few case-finding instruments are available to community healthcare professionals. This review aims to identify short, valid instruments that detect older community-dwellers risk of four adverse outcomes: hospitalisation, functional-decline, institutionalisation and death. Data sources included PubMed and the Cochrane library. Data on outcome measures, patient and instrument characteristics, and trial quality (using the Quality In Prognosis Studies [QUIPS] tool), were double-extracted for derivation-validation studies in community-dwelling older adults (>50 years). Forty-six publications, representing 23 unique instruments, were included. Only five were externally validated. Mean patient age range was 64.2-84.6 years. Most instruments n=18, (78%) were derived in North America from secondary analysis of survey data. The majority n=12, (52%), measured more than one outcome with hospitalisation and the Probability of Repeated Admission score the most studied outcome and instrument respectively. All instruments incorporated multiple predictors. Activities of daily living n=16, (70%), was included most often. Accuracy varied according to instruments and outcomes; area under the curve of 0.60-0.73 for hospitalisation, 0.63-0.78 for functional decline, 0.70-0.74 for institutionalisation and 0.56-0.82 for death. The QUIPS tool showed that 5/23 instruments had low potential for bias across all domains. This review highlights the present need to develop short, reliable, valid instruments to case-find older adults at risk in the community.

Prevalence and Associated Factors of Silent Brain Infarcts in a Mediterranean Cohort of Hypertensives

Silent brain infarcts (SBIs) are detected by neuroimaging in approximately 20% of elderly patients in population-based studies. Limited evidence is available for hypertensives at low cardiovascular risk countries. Investigating Silent Strokes in Hypertensives: a Magnetic Resonance Imaging Study (ISSYS) is aimed to assess the prevalence and risk factors of SBIs in a hypertensive Mediterranean population. This is a cohort study in randomly selected hypertensives, aged 50 to 70 years old, and free of clinical stroke and dementia. On baseline, all participants underwent a brain magnetic resonance imaging to assess prevalence and location of silent infarcts, and data on vascular risk factors, comorbidities, and the presence of subclinical cardiorenal damage (left ventricular hypertrophy and microalbuminuria) were collected. Multivariate analyses were performed to determine SBIs associated factors. A total of 976 patients (49.4% men, mean age 64 years) were enrolled, and 163 SBIs were detected in 99 participants (prevalence 10.1%; 95% CI, 8.4%–12.2%), most of them (64.4%) located in the basal ganglia and subcortical white matter. After adjustment, besides age and sex, microalbuminuria and increasing total cardiovascular risk (assessed by the Framingham-calibrated for Spanish population risk function) were independently associated with SBIs. Male sex increased the odds of having SBIs in 2.5 as compared with females. Our results highlight the importance of considering both global risk assessment and sex differences in hypertension and may be useful to design future preventive interventions of stroke and dementia.

Effectiveness of a primary care based multifactorial intervention to improve frailty parameters in the elderly: a randomised clinical trial: rationale and study design

BackgroundFrailty is a highly prevalent condition in old age leading to vulnerability and greater risk of adverse health outcomes and disability. Detecting and tackling frailty at an early stage can prevent disability. The purpose of this study is to evaluate the effectiveness of a multifactorial intervention program to modify frailty parameters, muscle strength, and physical and cognitive performance in people aged 65 years or more. It also assesses changes from baseline in falls, hospitalizations, nutritional risk, disability, institutionalization, and home-care.Methods/designThe current study is a randomised single-blind, parallel-group clinical trial, with a one and a half year follow-up, conducted in eight Primary Health Care Centres located in the city of Barcelona. Inclusion criteria are to be aged 65 years or older with positive frailty screening, timed get-up-and-go test between 10 to 30 seconds, and Cognition Mini-Exam (MEC-35) of Lobo greater than or equal to 18. A total of 352 patients have been equally divided into two groups: intervention and control. Sample size calculated to detect a 0.5 unit difference in the Short Physical Performance Battery (Common SD: 1.42, 20% lost to follow-up). In the intervention group three different actions on frailty dimensions: rehabilitative therapy plus intake of hyperproteic nutritional shakes, memory workshop, and medication review are applied to sets of 16 patients. Participants in both intervention and control groups receive recommendations on nutrition, healthy lifestyles, and home risks.Evaluations are blinded and conducted at 0, 3, and 18 months. Intention to treat analyses will be performed. Multivariate analysis will be carried out to assess time changes of dependent variables.DiscussionIt is expected that this study will provide evidence of the effectiveness of a multidisciplinary intervention on delaying the progression from frailty to disability in the elderly. It will help improve the individual’s quality of life and also reduce the rates of falls, hospital admissions, and institutionalizations, thus making the health care system more efficient. This preventive intervention can be adapted to diverse settings and be routinely included in Primary Care Centres as a Preventive Health Programme.Trial registrationClinicalTrials.gov PRS: NCT01969526. Date of registration: 10/21/2013.

Assessment of enlarged perivascular spaces and their relation to target organ damage and mild cognitive impairment in patients with hypertension

Enlarged perivascular spaces (EPVS) have been recently considered a feature of cerebral small vessel disease. They have been related to aging, hypertension and dementia but their relationship with hypertension related variables (i.e. target organ damage, treatment compliance) and mild cognitive impairment (MCI) is not fully elucidated. Our aims were to investigate the relation between basal ganglia (BG) and centrum semiovale (CSO) EPVS with vascular risk factors, hypertension related variables and MCI.

Cognitive assessment protocol design in the ISSYS (Investigating Silent Strokes in hYpertensives: A magnetic resonance imaging Study) ☆

Hypertension and silent cerebrovascular lesions (SCL) detected by brain magnetic resonance imaging (MRI) are associated with an increased risk of cognitive decline. In a prospective observational study in 1000 hypertensive patients, aged 50-70 years, with no prior history of stroke or dementia, we will study the presence of mild cognitive impairment (MCI) and the relationship between SCL and cognition. All participants will be assessed by means of the Dementia Rating Scale-2 (DRS-2) and will undergo a brain MRI. In order to better characterize MCI and future dementia risk in our cohort, those patients that are suspected to be cognitively impaired according to the DRS-2 results will have a further neurological evaluation and complete neuropsychological testing. Follow-up for the entire cohort is planned to last for at least 3 years.

Effects of a Primary Care-Based Multifactorial Intervention on Physical and Cognitive Function in Frail, Elderly Individuals: A Randomized Controlled Trial

Abstract Background Detecting and managing frailty at early stages can prevent disability and other adverse outcomes. The study aim was to evaluate whether a multifactorial intervention program could modify physical and cognitive frailty parameters in elderly individuals. Methods We conducted a multicenter, randomized, single-blind, parallel-group trial in community-living prefrail/frail elderly individuals in Barcelona. A total of 352 patients, aged ≥65 years old with positive frailty screening, was randomized into two groups to receive a 12-week multidisciplinary intervention or usual care, with concealed allocation. The intervention consisted of: exercise training, intake of hyperproteic nutritional shakes, memory training, and medication review. Main outcome assessments with multivariate analysis were conducted at 3 and 18 months. Results A total of 347 participants (98.6%) completed the study, mean age 77.3 years, 89 prefrail subjects (25.3%), and 75.3% female (n = 265). Eighteen-month assessments were performed in 76% of the sample. After 3 and 18 months, adjusted means difference between-groups showed significant improvements for the intervention group in all comparisons: Short Physical Performance Battery score improved 1.58 and 1.36 points (p < .001), handgrip strength 2.84 and 2.49 kg (p < .001), functional reach 4.3 and 4.52 cm (p < .001), and number of prescriptions decreased 1.39 and 1.09 (p < .001), respectively. Neurocognitive battery also showed significant improvements across all dimensions at 3 and 18 months. Conclusions A physical, nutritional, neurocognitive, and pharmacological multifaceted intervention was effective in reversing frailty measures both at short-term and 18 months. Lasting benefits of a multi-intervention program among frail elderly individuals encourage its prioritization.

Dementia Rating Scale-2 normative data for middle-and older-aged Castilian speaking Spaniards

Abstract Objectives: The Dementia Rating Scale-2 (DRS-2) is frequently used as a dementia screening tool in clinical and research settings in Spain. The present study describes DRS-2 Total and subscale scores in community-dwelling Spaniards, aged 50–71, and provides normative data for its use in Castilian Spanish-speaking individuals. Methods: The sample consisted of 798 individuals who participated in an observational study on essential hypertension. Mean age was 62.8 years (SD = 5.4), mean education was 8.6 years (SD = 3.4) with 47.9% females. Almost all of them were receiving blood pressure-lowering drugs (93%) and most of them had fairly well-managed blood pressure control (M systolic/diastolic blood pressure = 142.3/77.0 ± 16.0/9.2 mm Hg). We applied a previously described method of data normalization from the Mayo’s Older Americans Normative Studies to obtain the Castilian Spanish DRS-2 norms. Results: Worse performance on Total and subscale scores was associated with older age (p < .05) and fewer years of education (p < .001). Women obtained lower raw Total scores than men (131.68 ± 7.2 vs. 133.10 ± 6.90, p < .005), but had fewer years of education (7.96 ± 3.33 vs. 9.17 ± 3.45, p < .001). This gender difference disappeared after correcting for age and years of education. Total and subscale scores are presented adjusted by age, and normative data are shown for Total scores adjusted by age and years of education. Conclusions: These norms are useful for studying cognitive status and cognitive decline in research and clinical settings in Castilian Spanish-speaking populations.

Determinants of survival and hospitalization in older, heart failure patients receiving home healthcare

INTRODUCTION Since reported evidence is both scarce and controversial, the objective of this study is to determine the risk factors involved in the prognosis of older patients with heart failure (HF) receiving home healthcare from primary care professionals. METHODS Retrospective cohort community study was carried out in 52 primary healthcare centers in Barcelona (Spain). A follow-up was performed between January 2009 and December 2012 with 7461 HF patients aged >64years. Information was obtained from primary care electronic medical records containing clinical data, functional and cognitive status, total mortality, and hospital admissions for cardiovascular events. RESULTS Mortality and hospitalization during follow-up were higher in older, HF patients who received home healthcare than those who did not (HR 1.39, 95% CI 1.22-1.58 and 1.92 95% CI 1.72-2.14, respectively). The most relevant determinants for mortality were male gender (HR 1.40, 95%CI 1.10-1.79), previous hospital admission for HF (HR 1.29 95%CI 1.05-1.60), and severe dependence in activities for daily living (ADL) (HR 1.33, 95%CI 1.06-1.67). In contrast, severely dependent ADL patients were not more frequently hospitalized as a consequence of cardiovascular events (0.97, 95% CI 0.77-1.23). CONCLUSIONS Due to their greater comorbidity and age, mortality and hospitalization in patients requiring home healthcare were higher than those who did not. Among the HF patients receiving home care, mortality and hospital admissions were higher in men, older patients, and in those previously hospitalized for HF. Severe dependence in ADL determined a higher mortality but was not related to increased hospital admission rates.

The Community Assessment of Risk and Treatment Strategies (CARTS): An Integrated Care Pathway to Manage Frailty and Functional Decline in Community Dwelling Older Adults

The Community Assessment of Risk & Treatment Strategies (CARTS) is an evolving integrated care pathway for community-dwelling older adults, designed to screen for and prevent frailty through the use of innovative, novel targeted risk screening instruments, comprehensive geriatric assessment, tailored interventions and integrated patient-centred multi-disciplinary monitoring. This multimodal service aims to positively affect risk and frailty transitions, to reduce adverse healthcare outcomes and achieve the European Innovation Partnerships on Active and Healthy Ageing’s (EIP-AHA) goal of improved healthy life years. The CARTS programme builds on the activities and deliverables defined within Action Plan A3 of the EIP-AHA ‘Prevention and early diagnosis of frailty, both physical and cognitive, in older people’, aiming to use information and communications technology (ICT) to facilitate its implementation in clinical practice. The CARTS instruments have been piloted in Ireland as well as in Portugal, Spain and Australia. An update on the research conducted to date and future plans are presented.