Joan Espaulella

Identifying patients with chronic conditions in need of palliative care in the general population: development of the NECPAL tool and preliminary prevalence rates in Catalonia.

Palliative care (PC) has focused on patients with cancer within specialist services. However, around 75% of the population in middle-income and high-income countries die of one or more chronic advanced diseases. Early identification of such patients in need of PC becomes crucial. In this feature article we describe the initial steps of the NECPAL (Necesidades Paliativas [Palliative Needs]) Programme. The focus is on development of the NECPAL tool to identify patients in need of PC; preliminary results of the NECPAL prevalence study, which assessed prevalence of advanced chronically ill patients within the population and all socio-health settings of Osona; and initial implementation of the NECPAL Programme in the region. As first measures of the Programme, we present the NECPAL tool. The main differences from the British reference tools on which NECPAL is based are highlighted. The preliminary results of the prevalence study show that 1.45% of the total population and 7.71% of the population aged over 65 are ‘surprise question’ positive, while 1.33% and 7.00%, respectively, are NECPAL positive, and surprise question positive with at least one additional positive parameter. More than 50% suffer from geriatric pluri-pathology conditions or dementia. The pilot phase of the Programme consists of developing sectorised policies to improve PC in three districts of Catalonia. The first steps to design and implement a Programme to improve PC for patients with chronic conditions with a public health and population-based approach are to identify these patients and to assess their prevalence in the healthcare system.

Lower limb function and 10-year survival in population aged 75 years and older

BACKGROUND Scientific societies recommend assessing lower limb function in usual clinical practice. The Short Physical Performance Battery (SPPB) is one of the most validated tools to assess this, but its capacity to predict long-term mortality in very old population attending primary care has not been studied. OBJECTIVE To assess the ability of the SPPB to predict 10-year survival in individuals aged 75 and over. METHODS Prospective cohort study with a 10-year follow-up. A representative sample of people aged 75 years or older without severe dependence (Barthel Index > 20) treated at a Spanish primary care centre (n = 315). Baseline evaluation included geriatric assessment with most well-known death predictors. The three SPPB subtasks (standing balance, walking speed and chair stand tests) were administered. Kaplan-Meier curves and Cox proportional hazard models were calculated for all-cause mortality. RESULTS Mean age was 81.9 years (60.6% female). Ten-year survival of elders with SPPB score <7 and ≥7 was 0.23 and 0.37 (P < 0.001), respectively. This difference remained statistically significant in the Cox model adjusted by age, gender, number of drugs prescribed, cognitive status, body mass index and visual sharpness (adjusted hazard ratio = 1.37; 95% confidence interval: 1.01-1.86). Also, walking speed and chair stand subtasks were both individual-independent predictors of 10-year survival. CONCLUSIONS Our findings indicate that SPPB is an independent predictor of long-term survival. The chair stand subtask could be a predictor as useful as the full performance battery, becoming a good alternative for primary care where the burden of performing all three subtasks could be excessive.

Factores asociados al estado funcional en personas de 75 o más años de edad no dependientes

OBJECTIVES To identify the factors associated with functional status in a population aged ≥ 75 years without severe dependence. METHODS A cross-sectional study of a random sample (n = 315) of elderly persons in a primary care setting (El Remei Primary Care Center, Vic, Barcelona, Spain) was carried out. Functional status was evaluated by three physical performance tests: the Guralnik chair stand test of lower limb function, Lawton-Brodys index of instrumental activities of daily living (IADL), and the Barthel index of basic activities of daily living (BADL). A backward multiple linear regression model was used to analyze the association of sociodemographic and clinical variables with functional status. RESULTS The mean age was 81.9 years and 60.6% were female. Around 50% of elderly patients without total dependence showed disability for IADL and a third showed lower limb functional limitation. The variables associated with lower limb functional status were marital status, body mass index, number of drugs, and vision and hearing impairment (R(2) = 0.208). The variables associated with IADL were age, cognitive impairment, vision and hearing impairment, and lower limb functional limitation (R(2) = 0.434). The variables associated with the Barthel index were age, sex, poor self-perceived health, and lower limb functional limitation (R(2) = 0.389). CONCLUSIONS The risk factors associated with functional status in our population ≥ 75 years of age without severe dependence were the number of drugs and sensory impairment.

Aceptabilidad y cumplimiento en el uso de los protectores de cadera en ancianos con demencia ingresados en una unidad de psicogeriatría

OBJECTIVE To detect the percentage of patients with dementia admitted to a psychogeriatric department, who have a high risk of falls, and to evaluate acceptance and compliance with hip protectors during their stay in hospital and 2 weeks and 3 months after discharge. MATERIAL AND METHODS We performed a hospital-based prospective cohort study. Risk of falling was evaluated on the basis of immediate bipedal standing instability or abnormal semi-tandem posture, a get-up-and-go test time of more than 20 seconds, or clinical judgement. Compliance during hospital stay was evaluated through nursing records and compliance outside hospital by telephone interviews at 15 days and 3 months after discharge. RESULTS A total of 115 patients consecutively admitted to the psychogeriatric department of the Santa Creu Hospital in Vic were assessed. Sixty patients (52.2%) were excluded from the study, the main reason being dependence on another person for walking. Of the 55 patients included, 44 (80.0%) had a high risk of falls and were candidates for hip protectors. In-hospital compliance was 80.5% (95% CI: 65.1-91.2). The most common cause of non-compliance was removal of the hip protector by the patient. Compliance after discharge was 64.5% (95% CI: 45.4-80.8) at 2 weeks and 57.1% (95% CI: 28.9-82.4) at 3 months. CONCLUSIONS A high risk of falling was found in a large percentage of patients with dementia who were not dependent on others for walking. Compliance was not a problem in the use of hip protectors in a high-risk population in the hospital-admission setting but was weaker in the community setting.Objetivo detectar el porcentaje de pacientes con demencia ingresados en una unidad de psicogeriatria con elevado riesgo de caidas y valorar el grado de aceptacion y cumplimiento del uso de los protectores de cadera durante el ingreso, a los 15 dias y a los 3 meses del alta. Material y metodos estudio de cohortes prospectivo de base hospitalaria. Para la valoracion del riesgo de caidas se utilizo la inestabilidad a la bipedestacion inmediata o semitandem alterado, o un Get-up-and-Go superior a 20 s o a juicio clinico como resultado de la evaluacion geriatrica. El cumplimiento intrahospitalario se baso en los registros de enfermeria y el cumplimiento extrahospitalario mediante entrevista telefonica a los 15 y 3 meses del alta. Resultados se evaluo a 115 pacientes admitidos consecutivamente en la Unidad de Psicogeriatria del Hospital de la Santa Creu de Vic. Se excluyo a 60 pacientes (52,2%); el motivo principal fue la dependencia para la marcha. De los 55 pacientes incluidos, 44 (80,0%) presentaban elevado riesgo de caidas y fueron candidatos a protectores de cadera. El cumplimiento intrahospitalario fue del 80,5% (intervalo de confianza [IC] del 95%, 65,1-91,2); la causa mas frecuente de no cumplimiento fue la retirada de los protectores por parte del paciente. A los 15 dias del alta, el cumplimiento extrahospitalario fue del 64,5% (IC del 95%, 45,4-80,8) y a los 3 meses del 57,1% (IC del 95%, 28,9-82,4). Conclusiones un elevado porcentaje de pacientes dementes no dependientes para la marcha presentaban un alto riesgo de caidas. En el ambito de hospitalizacion, el cumplimiento no es un problema para la utilizacion de protectores de cadera en poblacion de alto riesgo, y es discutible en el entorno comunitario.