José Manuel Ribera Casado

Guías de práctica clínica de la Sociedad Española de Cardiología en la valoración del riesgo quirúrgico del paciente cardiópata sometido a cirugía no cardíaca

Todo paciente que va a someterse a una intervencion quirurgica requiere una evaluacion cardiovascular que establezca su riesgo quirurgico. Por otro lado, una importante proporcion de las muertes ocurridas durante la cirugia se deben a complicaciones cardiovasculares, muchas de las cuales se podrian evitar valorando correctamente el riesgo cardiologico de la intervencion. La cirugia y la anestesia someten al paciente a situaciones de estres durante el periodo perioperatorio, que obligan a que se establezca la capacidad del enfermo de responder a esas demandas, desaconsejando la cirugia si se considera que el riesgo es inasumible. Cada vez aumenta mas la proporcion de casos de cirugia mayor en pacientes de mas de 65 anos, con el consiguiente incremento de la comorbilidad cardiovascular, especialmente por el riesgo de infarto de miocardio, angina inestable e insuficiencia cardiaca perioperatoria. Seguidamente se establecen unas recomendaciones para la valoracion cardiovascular del paciente cardiologico que va a someterse a una intervencion quirurgica no cardiaca.

Valor pronóstico de la valoración funcional al ingreso en una unidad de corta estancia de Urgencias

INTRODUCTION To determine the prognostic value of functional impairment on the final destination of elders admitted for acute medical illness to an emergency short-stay unit (ESSU). MATERIAL AND METHODS We performed a prospective analysis of patients aged more than 65 years old admitted to the ESSU of Hospital Clínico San Carlos in Madrid in April 2008. A protocol was designed that included epidemiologic variables (age and gender), clinical variables (reason for admission, comorbidity measured by the Charlson Index [CI]) and functional variables (previous, admission and functional decline [FD] measured with the Barthel [BI] and Lawton Indexes [LI]). The prognostic value of FD on the decision to admit patients was analyzed through ROC curves and the cut points that maximized sensitivity and specificity were determined. RESULTS Sixty patients were included with a mean age of 80.7 (SD 8.2) years and 71.7% were women. The reasons for admission were acute infections in 31.7%, heart failure in 23.3%, syncope in 15.0%, intestinal obstruction in 11.7%, gastrointestinal bleeding in 10.0%, and arrhythmias in 8.3%. The mean CI was 2.27 (1.45). Functional assessment was as follows: mean previous BI score: 79.25 (SD 25) and at admission: 62.92 (SD 28.19). Mean previous LI score: 4.85 (SD 2.45) and at admission: 2.98 (SD 2.42).): BI-FD: 20% (1.25-38.23), LI-FD 37.5% (16.7-70.2%). FD was found in 100% of the patients. The mean length of stay was 1.70 (SD 0.62) days. Discharge destination was home discharge in 46.7% and hospitalization unit in 53.3%. Multivariate analysis according to discharge destination (home vs hospitalization) provided the following results : BI-FI > or = 16% (OR=7.99 [1.1-60.5], p=0.037), LI-FI > or =35% (OR=19.6 [0.04-0.52], p <0.0001). CONCLUSIONS Patients with significant FD in the emergency room should not be admitted to an ESSU since significant FD is a prognostic factor for transfer to a conventional ward.

Análisis de mortalidad tras el ingreso en una unidad de agudos de geriatría: influencia de la dependencia funcional*

Objetivo: analizar la influencia de diversos factores clinicos y funcionales en la tasa de mortalidad anual tras ingreso en unidad de agudos de geriatria (UGA). Material y metodos: pacientes ingresados durante 6 meses en la UGA. Se excluyeron los ingresos inadecuados o trasladados a otro servicio en el primer dia. Para la valoracion clinica, funcional y psiquica basal se utilizaron los indices de Katz y de Barthel, la escala de la Cruz Roja fisica y la presencia de demencia. Los datos al ingreso: mortalidad, complicaciones, impacto funcional del ingreso. En el seguimiento al ano se analizaron los datos de mortalidad cruda y comorbilidad (indice de Charlson [ICh]). Se analizo la influencia de los datos basales y del ingreso en la supervivencia. El analisis estadistico se realizo mediante la comparacion de medias y proporciones mediante las pruebas de la ?2, de la t de Student y ANOVA de un factor. El estudio de supervivencia se realizo mediante curvas de Kaplan-Meier y regresion de Cox, con un intervalo de confianza del 95%. Se utilizo el programa SPSS 11.0 para el procesamiento estadistico de los datos. Resultados: se analizo a 336 pacientes, con una edad media ± desviacion estandar de 85,6 ± 6,9 anos; el 59,2% eran mujeres. El grupo relacionado de diagnostico principal fue de 541. Datos basales: demencia moderada o grave, 39,3%; dependencia en mas de 3 actividades basicas, 45,4%; movilidad restringida, 48,2%, e incontinencia funcional, 29,9%. Datos del ingreso: impacto funcional, 19,5%, e infeccion nosocomial, 47,6%. La mortalidad intrahospitalaria fue del 22,9%. Durante el seguimiento hubo un 5,1% de perdidas. Al ano fallecieron 107 pacientes mas (total 184; 54,8%). La mitad de los fallecimientos se produjo en los primeros 59 dias contados desde el dia del ingreso. Mediana de supervivencia, 275 dias. Comorbilidad ICh > 2 (47,6%). Las causas de defuncion fueron: en el 37,5% de los casos, respiratoria, y en el 31,0% de los pacientes, circulatoria. Los factores relacionados con la mortalidad fueron: sexo varon (p = 0,029), demencia (p = 0,002), perdida funcional (p < 0,001), infeccion respiratoria nosocomial (p = 0,026), cuadro confusional (p < 0,001) y comorbilidad (p = 0,015); no se encontro asociacion con la edad u otros factores clinicos. En el modelo de regresion de Cox, unicamente ser varon (p = 0,021) y la perdida funcional asociada al ingreso (p < 0,001) se asociaron a mortalidad en el seguimiento. Conclusiones: se observo una elevada mortalidad durante los primeros dos meses desde el ingreso hospitalario, sobre todo por afeccion respiratoria y circulatoria. Aunque el sexo se asocia con la mortalidad en el seguimiento, esta depende en mayor medida de la situacion funcional. Se hace necesario establecer estrategias preventivas o de intervencion en determinados grupos de ancianos de riesgo en los que es previsible una elevada mortalidad.

Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients (HF-Geriatrics).

BackgroundDisease management programmes (DMPs) have been shown to reduce hospital readmissions and mortality in adults with heart failure (HF), but their effectiveness in elderly patients or in those with major comorbidity is unknown. The Multicenter Randomised Trial of a Heart Failure Management Programme among Geriatric Patients (HF-Geriatrics) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity.Methods/DesignClinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain. Each patient should meet at least one of the following comorbidty criteria: Charlson index ≥ 3, dependence in ≥ 2 activities of daily living, treatment with ≥ 5 drugs, active treatment for ≥ 3 diseases, recent emergency hospitalization, severe visual or hearing loss, cognitive impairment, Parkinsons disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), anaemia, or constitutional syndrome. Half of the patients will be randomly assigned to a 1-year DMP led by a case manager and the other half to usual care. The DMP consists of an educational programme for patients and caregivers on the management of HF, COPD (knowledge of the disease, smoking cessation, immunizations, use of inhaled medication, recognition of exacerbations), diabetes (knowledge of the disease, symptoms of hyperglycaemia and hypoglycaemia, self-adjustment of insulin, foot care) and depression (knowledge of the disease, diagnosis and treatment). It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance. The main outcome variables are quality of life, hospital readmissions, and overall mortality during a 12-month follow-up.DiscussionThe physiological changes, lower life expectancy, comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF. The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty, and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients.Trial registration(ClinicalTrials.gov number, NCT01076465).

Age Discrimination, Eppur Si Muove (Yet It Moves)†

nine other medications. The promethazine led to multiple side effects, followed by medications to treat those side effects. She was ultimately hospitalized in a catatonic state and bed-bound for 4 months, and it took a year’s worth of recovery before she could interact with her family again. Mrs. Smith’s age is important because the American Geriatrics Society (AGS) recommends against using promethazine in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Despite promethazine’s effectiveness in its study populations, it should have been avoided in her case. As a medical student, hearing this story terrified me because I would have chosen the same treatment for Mrs. Smith What her doctor and I failed to consider are the effects that the prescribed medication would have on an 83-year-old vs the younger individuals in which its efficacy and safety were tested. After completing my preclinical curriculum, I realized I was not taught how to care for older adults. Our education exposes us to a wide breadth of subjects and fields, but our lectures and rotations lack a dedicated exposure to geriatrics. According to the Census Bureau, the United States had more than 40 million elderly persons in 2010 and will have 70 million by 2029. Despite this increase in the size of this population and its healthcare needs, the number of geriatricians in the country is inadequate and dwindling. According to the AGS, there was a 33% decline in medical school graduates pursuing advanced training in geriatric medicine between 2005 and 2010. Although we cannot reverse this trend and build a sufficient geriatric physician workforce overnight, we can better prepare current medical students for the practice of geriatric medicine that they will assume, regardless of their field. To see firsthand the approach to care in elderly adults and what we as medical students must do to practice it competently, I requested to work 1 month on a geriatrics unit during my internal medicine subspecialty rotation. The approach to care I witnessed was different from what I had seen on other services, even when I had been caring for older adults, and it changed how I will care for elderly adults in the future. One practice I observed is deprescribing, or stopping a current medication. Deprescribing is necessary to combat polypharmacy, which is prevalent, and sometimes dangerous, in elderly adults. More than 36% of people aged 75 to 85 are taking five or more prescribed medications, and almost 100,000 adults aged 65 and older are hospitalized for adverse drug events each year. Although polypharmacy is risky, deprescribing can be dangerous. Appropriate medications extend and improve the quality of life as well. Choosing which ones to discontinue can amount to playing Russian roulette. To address this, Dr. Joshua Uy, a geriatrician on my rotation, taught a tactic he called “the partnership with patients.” The partnership uses close follow-up to obtain feedback on the effects of deprescribing, as opposed to adherence to an evidence-based algorithm that I have learned on other rotations. This collaborative relationship allows the doctor and the patient to balance risks and benefits and make shared decisions to treat or not in time-limited trials. Combining their knowledge of geriatric-specific guidelines such as the Beers criteria with the partnership strategy allowed Dr. Uy and his colleagues to personalize medical care to each person. Despite the importance of deprescribing and other skills that geriatricians need and interactions that they have with greater frequency, such as palliative care and the dying experience, only approximately 10% of my classmates will complete a geriatrics rotation during medical school. Although most medical students will not become geriatricians, the majority will care for older adults, and it is essential that we learn to do so responsibly. The task falls on medical schools and us as students. Our curriculums should better emphasize geriatric medicine in our preclinical years and should provide more opportunities on a geriatric service in our clinical years. As students, we must take the initiative to pursue clerkships, subinternships, and electives in geriatric medicine. As Dr. William Osler once said, “The good physician treats the disease; the great physician treats the patient who has the disease.” If those words ring true today, then the future of American medicine must learn to treat the 83-year-old Mrs. Smith and not just her nausea.

Geriatría y cuidados paliativos: algunas reflexiones

This article attempts to provide a framework for reflection on the relationships between 2 close specialties, such as geriatrics and palliative care. In medicine today, with the progressive ageing of the population, 80% of deaths occur at a very advanced age, and a high percentage of these are potentially likely to receive palliative care in their final stages. The reflections offered in this presentation are made from a perspective of someone who has always worked in the geriatrics field. Throughout this article, some the common points in the historic evolution of both specialities are made and discussed. The inter-relationships and common ground in other fields may be, their form of understanding medical care, clinical objectives, doctrinal bases, the work methodology, or the overlapping of some elements of training. Several aspects of where they differ on these same points are also discussed. It is concluded with a call for collaboration between the specialists of both fields, as well as in the need to demand that the health administrations introduce larger palliative teams in all hospitals in the country.

Cirugía cardiaca y edad avanzada

La cirugia cardiaca sigue teniendo un papel fundamental en el arsenal terapeutico de muchas cardiopatias. Ello es asi a pesar de los avances espectaculares que determinados farmacos o distintas formas de cardiologia intervencionista han experimentado durante los ultimos anos. Sin embargo, contemplada desde el paciente anoso, esta modalidad terapeutica constituye uno de los campos donde, durante decadas, se ha venido aplicando la discriminacion por edad; el ageism de la literatura de habla inglesa. La edad ha sido, y en gran parte lo sigue siendo, un caballo de batalla a la hora de sentar indicaciones y contraindicaciones en los diferentes protocolos objeto de discusion. En ese contexto, tres son las principales preguntas a las que habria que dar respuesta. La primera, definir de que indicaciones estamos hablando y si estas son las mismas que las establecidas para los sujetos mas jovenes. La segunda, determinar el riesgo quirurgico en cuanto a mortalidad y morbilidad, entendiendo que las comparaciones no deben hacerse tanto en funcion de la edad (viejos frente a menos viejos) cuanto en relacion con lo que serian otras opciones alternativas a la cirugia en cada caso concreto, con independencia de la edad del paciente. La ultima cuestion buscara definir e identificar cuales son los factores de riesgo que pueden determinar un peor pronostico y, sobre esa base, establecer estrategias que reduzcan este riesgo. La respuesta al primero de estos puntos es facil. En el viejo, como en el joven, existen dos grandes campos de actuacion quirurgica: la coronaria y la valvular. La patologia coronaria esta muy vinculada a los cambios asociados al proceso de envejecer y, en la medida en que se van conociendo y se controlan cada vez mejor sus factores de riesgo, la edad en la que se manifiesta se ha ido retrasando hasta convertirse en una patologia tipicamente geriatrica. Por lo que respecta a las enfermedades valvulares, reducida a un caracter residual la Cirugia cardiaca y edad avanzada

Avances en cardiología geriátrica

El continuo envejecimiento de la poblacion es una autentica realidad. La media de personas de mas de 65 anos en la Union Europea alcanzara el 29,9% en 2050, casi el doble del 16,4% que hay en la actualidad. Aproximadamente, un tercio de personas en esta edad tiene enfermedad cardiovascular clinica. Los medicos responsables del paciente cardiopata anciano deben estar familiarizados con las diferentes manifestaciones clinicas, pronosticas y de manejo de las enfermedades cardiovasculares en la senectud. Asi, la necesidad de continuar la educacion medica en cardiologia geriatrica es evidente en si, y ese es uno de los cometidos de la seccion de cardiologia geriatrica. Este numero extraordinario de la revista es una magnifica oportunidad para actualizar aspectos importantes de la cardiologia geriatrica, como el envejecimiento cardiovascular, la insuficiencia cardiaca y la fibrilacion auricular.

Microbiota intestinal y envejecimiento: ¿un nuevo camino de intervención?

Intestinal microbiota (IM) has continued to be the subject in all types of studies and publications. More is known on its different components and functions, as well as the changes that take place in IM through the life cycle, and the role of the factors involved in these changes. The aim of this review is to update the relationship between IM and aging. The presentation in 4 sections: (i)main factors of the human ageing process, underlining those related with gut changes; (ii)conceptual meaning of words like microbiota and other related terms; (iii)to comment on the most current findings as regards the changes in IM that occur in the ageing process, whether arising from the physiology or from disease situations, or other factors (environment, diet, drugs, etc.), and the health-consequences of these changes, and (iv)possibilities of different active positive interventions, with emphasis on diet measures.

¿Se discrimina a los mayores en función de su edad? Visión del profesional

INTRODUCTION It is generally believed that legislation is an essential resource in the prevention of discriminatory behaviour against older people. This study first examines the Spanish legislation for potential age discrimination and then uses the C-EVE-D questionnaire to ask professionals in social work and health care settings the extent to what certain ageist behaviours described in the questionnaire are observed in practice. METHODS The field study was carried out with professionals in geriatrics and gerontology, who are members of Spanish Society for Geriatrics and Gerontology (SEGG). The EVE discrimination questionnaire consists of 28 items which investigate the existence of age discrimination in medical and social care contexts. RESULTS A total of 174 people (63% women; mean age: 45.6 years) took part in the study, with a mean professional experience of 17.2 years. Doctors made up 59% of the sample, psychologists 19%, with the rest coming from other professions. The first 20 discrimination items of the EVE-D questionnaire were significantly positively reported by more than 60% of the sample. CONCLUSIONS Although Spanish legislation, from the constitution down to the rules that govern social and health care settings, clearly prohibits any kind of discrimination with regard to age, our results show that Spanish professionals most closely involved in the care of older people perceive both direct and indirect age discrimination. Furthermore, evidence was found of prejudice in the treatment of older people as a phenomenon in day-to-day health and social services care, both when analysing medical cases and, to a greater extent, cases of a more general nature and/or relating to co-existence.