José Juan García-González

A frailty index to predict the mortality risk in a population of senior mexican adults

BackgroundFrailty in the elderly can be regarded as nonspecific vulnerability to adverse health outcomes, caused by multiple factors. The aim was to analyze the relationships between the frailty index, age and mortality in a two year follow up study of Mexican elderly.MethodsA frailty index was developed using 34 variables. To obtain the index, the mean of the total score for each individual was obtained. Survival analyses techniques were used to examine the risk ratios for the different levels of the frailty index. Kaplan-Meier estimates were obtained, adjusted for age and gender. Cox proportional hazards models were also built to obtain hazard ratio estimates.ResultsA total of 4082 participants was analyzed. Participants had an average age of 73 years and 52.5% were women. On average, participants were followed-up for 710 days (standard deviation = 111 days) and 279 of them died. Mortality increased with the frailty index level, especially in those with levels between .21 to .65, reaching approximately 17% and 21%, respectively. Cox proportional hazards models showed that participants with frailty index levels associated to increased mortality (.21 and higher) represent 24.0% of those aged 65-69 years and 47.6% of those 85 and older.ConclusionThe frailty index shows the properties found in the other studies, it allows stratifying older Mexican into several groups different by the degree of the risk of mortality, and therefore the frailty index can be used in assessing health of elderly.

The Mini-mental State Examination revisited: ceiling and floor effects after score adjustment for educational level in an aging Mexican population.

BACKGROUND The Mini-mental State Examination (MMSE) is the most widely used cognitive test, both in clinical settings and in epidemiological studies. However, correcting its score for education may create ceiling effects when used for poorly educated people and floor effects for those with higher education. METHODS MMSE and a recent cognitive test, the seven minute screen (7MS), were serially administered to a community sample of Mexican elderly. 7MS test scores were equated to MMSE scores. MMSE-equated 7MS differences indicated ceiling or floor effects. An ordinal logistic regression model was fitted to identify predictors of such effects. RESULTS Poorly educated persons were more prevalent on the side of MMSE ceiling effects. Concentration (serial-sevens), orientation and memory were the three MMSE subscales showing the strongest relationship to MMSE ceiling effects in the multivariate model. CONCLUSION Even when MMSE scores are corrected for educational level they still have ceiling and floor effects. These effects should be considered when interpreting data from longitudinal studies of cognitive decline. When an education-adjusted MMSE test is used to screen for cognitive impairment, additional testing may be required to rule out the possibility of mild cognitive impairment.

Handgrip Strength Predicts Functional Decline at Discharge in Hospitalized Male Elderly: A Hospital Cohort Study

Functional decline after hospitalization is a common adverse outcome in elderly. An easy to use, reproducible and accurate tool to identify those at risk would aid focusing interventions in those at higher risk. Handgrip strength has been shown to predict adverse outcomes in other settings. The aim of this study was to determine if handgrip strength measured upon admission to an acute care facility would predict functional decline (either incident or worsening of preexisting) at discharge among older Mexican, stratified by gender. In addition, cutoff points as a function of specificity would be determined. A cohort study was conducted in two hospitals in Mexico City. The primary endpoint was functional decline on discharge, defined as a 30-point reduction in the Barthel Index score from that of the baseline score. Handgrip strength along with other variables was measured at initial assessment, including: instrumental activities of daily living, cognition, depressive symptoms, delirium, hospitalization length and quality of life. All analyses were stratified by gender. Logistic regression to test independent association between handgrip strength and functional decline was performed, along with estimation of handgrip strength test values (specificity, sensitivity, area under the curve, etc.). A total of 223 patients admitted to an acute care facility between 2007 and 2009 were recruited. A total of 55 patients (24.7%) had functional decline, 23.46% in male and 25.6% in women. Multivariate analysis showed that only males with low handgrip strength had an increased risk of functional decline at discharge (OR 0.88, 95% CI 0.79–0.98, p = 0.01), with a specificity of 91.3% and a cutoff point of 20.65 kg for handgrip strength. Females had not a significant association between handgrip strength and functional decline. Measurement of handgrip strength on admission to acute care facilities may identify male elderly patients at risk of having functional decline, and intervene consequently.

Usefulness of two instruments in assessing depression among elderly Mexicans in population studies and for primary care

OBJECTIVE To determine the psychometric qualities of the CES-DR and GDS scales in the elderly and compare them to clinical psychiatric diagnoses. MATERIAL AND METHODS The first phase consisted of home interviews for determining the psychometric qualities of the GDS and CES-DR scales. In the second phase, psychiatrists conducted diagnostic interviews. The sample consisted of 534 participants older than 60 years of age insured by the Mexican Institute of Social Security. RESULTS First phase: Cronbachs alpha for the GDS was 0.87 and 0.86 for CES-DR. The GDS factorial analysis found eight factors that could explain 53.5% of the total variance and nine factors that explained 57.9% in the CES-DR. Second phase: Compared to the psychiatric diagnoses, CES-DR reported a sensitivity of 82% and a specificity of 49.2%; GDS reported 53.8% sensitivity and 78.9% specificity. CONCLUSIONS CES-DR and GDS scales have high reliability and adequate validity but the CES-DR reports higher sensitivity.

The hospital appropriateness evaluation protocol in elderly patients: a technique to evaluate admission and hospital stay

BACKGROUND Aging of the population represents one of the main challenges for health systems because of the increase in the demand for hospital services. To be able to count on tools that allow an objective evaluation of hospital-resource use becomes indispensable for health systems. OBJECTIVE To evaluate the reliability and validity of the Appropriateness Evaluation Protocol (AEP) regarding the appropriateness of admissions and hospital stays in elderly patients. In a scenario of scarce resources, to have a valid instrument will make it possible to evaluate the process of care in our growing elderly population in a standardized way. METHODS We carried out a retrospective study of 144 randomly chosen elderly patients admitted to the hospital with 394 even-numbered hospital-stay days. For the reliability analysis between the pair of nurses with the AEP and the pair of specialists, the details of the hospital admissions and the stay days were obtained from the clinical files. Criteria validity was conducted by pairs of physicians, including two internists, two general surgeons and two geriatricians. Only the agreements were compared with agreements of the AEP-trained nurses. Disagreements were excluded from the final analysis. RESULTS Inter-rater (inter-reviewer) agreement of hospital admissions and days spent by the patient presented a kappa coefficient of >0.70, while these admissions and hospital-stay days was >0.70. Sensitivity and positive predictor value to detect inappropriate admissions were not calculated because no agreement existed on inappropriate admissions. Specificity and negative predictive value to detect appropriate admission was >94.0% and >98.0%. Sensitivity and positive predictor value to detect inappropriate hospital-stay days was >44.0% and >10.0%, while specificity and negative predictor value for detecting appropriate hospital-stay days was >79.0% and >88.0%. CONCLUSIONS AEPs high-reliability and moderate-validity results with regard to clinical judgement positions it as a useful instrument for appropriate hospitalization screening in elderly patients.

Impacto de un programa de atención domiciliaria al enfermo crónico en ancianos: calidad de vida y reingresos hospitalarios

OBJETIVO: Evaluar el impacto del programa Atencion Domiciliaria al Enfermo Cronico (ADEC) comparado con la atencion habitual (AH) a ancianos con dependencia funcional, derechohabientes del Instituto Mexicano del Seguro Social (IMSS). MATERIAL Y METODOS: Cohorte prospectiva a tres meses a partir del egreso hospitalario en dos hospitales de la Ciudad de Mexico. Se ingresaron 130 ancianos con dependencia funcional, 70 insertados al programa ADEC y 60 con atencion habitual. Se midio impacto en reingresos hospitalarios y calidad de vida a partir de la escala Perfil de Impacto de la Enfermedad (SIP, por sus siglas en ingles). RESULTADOS: La edad promedio de los ancianos fue de 74 anos (61/103) y 60% fueron mujeres. El principal diagnostico fue enfermedad vascular cerebral (EVC) (30.77%). El grupo de ADEC mejoro la calidad de vida en la dimension psicosocial [46.26 (±13.85) comparado con 29.45 (±16.48) vs. 47.03 (±16.47) a 42.36 (±16.35) p 0.05). CONCLUSIONES: El programa mejoro la dimension psicosocial de calidad de vida.

Economic burden to primary informal caregivers of hospitalized older adults in Mexico: a cohort study

BackgroundThe burden of out of pocket spending for the Mexican population is high compared to other countries. Even patients insured by social security institutions have to face the cost of health goods, services or nonmedical expenses related to their illness. Primary caregivers, in addition, experience losses in productivity by taking up responsibilities in care giving activities. This situation represents a mayor economic burden in an acute care setting for elderly population. There is evidence that specialized geriatric services could represent lower overall costs in these circumstances and could help reduce these burdens.The aim of this study was to investigate economic burden differences in caregivers of elderly patients comparing two acute care services (Geriatric and Internal Medicine). Specifically, economic costs associated with hospitalization of older adults in these two settings by evaluating health care related out of pocket expenditures (OOPE), non-medical OOPE and indirect costs.MethodsA comparative analysis of direct and indirect costs in hospitalised elderly patients (60-year or older) and their primary informal caregivers in two health care settings, using a prospective cohort was performed. Economic burden was measured by out of pocket expenses and indirect costs (productivity lost) due to care giving activities. The analysis included a two-part model, the first one allowing the estimation of the probability of observing any health care related and non-medical OOPE; and the second one, the positive observations or expenditures.ResultsA total of 210 subjects were followed during their hospital stay. Of the total number of subjects 95% reported at least one non-medical OOPE, being daily transportation the most common expense. Regarding medical OOPE, medicines were the most common expense, and the mean numbers of days without income were 4.12 days. Both OOPE and indirect costs were significantly different between type of services, with less overall economic burden to the caregivers of elderly hospitalized in the geriatric unit. The final model showed that type of service and satisfaction had the largest coefficients (-0.68 and 0.662 respectively, p<0.001).ConclusionsThis study allowed us to identify associated factors of economic burden in elderly hospitalized in acute care units. It opens as well, an issue that should not be overlooked in framing public policies regarding elderly health care.

Drug-drug interactions at hospital admission in geriatric patients in a single facility: a retrospective study.

BACKGROUND Individuals older than 60 years of age have multiple simultaneous diseases, for which the average number of medications is greater than five, leading up to 3% possibility of having an adverse reaction event. OBJECTIVE To detect potential drug-drug interactions (PDDIs) and report the average hospital stay for severity potential PPIs, in adults 60 years of age and older in an Internal Medicine Service. METHODS This was a retrospective analysis with a review of the clinical records of patients 60 years of age and older. The length of stay, number and type of prescribed daily medications, PDDIs, and number of admission diagnoses for each patient, were reviewed. RESULTS This study included 342 patients with an average and standard deviation of 6 ± 3.0 medications per day. The PDDI levels were 27 (7.9%) severe, 94 (27.5%) moderate, and 61 (17.8%) had both types of interactions. Severe interactions, presented a hospital stay of 10 days, and moderate interaction a 13-day stay. CONCLUSION The most common interactions and their average length of stay may be utilized for quality evaluation of the medication process of such a major patient population as that of the older adult in the hospital setting.