Juan Ignacio González-Montalvo

Optimización del tratamiento médico en pacientes geriátricos con fractura de cadera. Influencia del equipo consultor geriátrico

Resumen Introduccion evaluar la influencia de un equipo consultor geriatrico (ECG) en la prescripcion de farmacos a ancianos con fractura de cadera en fase aguda. Material y metodos estudio prospectivo, controlado, que compara dos grupos: los pacientes tratados por el ECG y los no tratados por este equipo. Se determinan las diferencias en ingesta de farmacos antes y despues del proceso. Todas las diferencias se han considerado estadisticamente significativas cuando p Resultados se estudio a 449 pacientes, edad media de 83,0 anos (83% mujeres). Los pacientes tratados por el ECG tomaban mas medicamentos antes del ingreso, durante este y en el momento del alta (todas las diferencias con p Conclusiones los pacientes seguidos en la unidad de geriatria tomaron mas farmacos antes del ingreso y durante este, pero tambien se detectaron mas diagnosticos. La prescripcion del ECG tiende a optimizar el tratamiento ya que la administracion de farmacos se dirige a problemas frecuentes en estos pacientes (anemia, desnutricion, osteoporosis, estrenimiento), que en el grupo control son insuficientemente detectados y tratados. Estas diferencias podrian explicar, en parte, la mejor evolucion que presentan los pacientes con fractura de femur seguidos por los ECG.

Evaluacion de los pacientes con miedo a caidas. El metodo empleado modifica los resultados? Una revision sistematica

OBJECTIVE To analyse if the use of different methods to assess fear of falling (FF), changes the risk factors for developing it, and the consequences arising from this. DESIGN Systematic review. DATA SOURCES Electronic data bases, MEDLINE, EMBZ, EMBASE, CINAHL and PBMA. Key words <<fear, fall and aged+65 years>>, <<fear of falling>>, <<post-fall syndrome>>, <<self-efficacy, fall and aged+65 years>>. PERIOD 1966-March 2008. SELECTING THE STUDIES: Inclusion/exclusion criteria: original observational studies, clearly identifying the method employed to measure FF and which mention risk factors and/or the consequences arising from this fear. A total of 327 summaries were initially identified, from which 24 articles were selected. DATA COLLECTION The abstracts and articles were selected by the first author. If there were doubts, the opinion of the second signatory was considered. The method for detecting FF, the risk factors and/or the consequences were collected and analysed. RESULTS There is a large variety of FF assessment methods, which can be grouped into three types: a) they question directly if it exists; b) they question on the limitation of activity due to this fear, and c) they use scales that detect and quantify the fear. The main risk factors: changes in gait, previous falls, failing sight, health problems, female sex and lack of social support. Main consequences: balance problems, depression, increased risk of falls and less social activity. CONCLUSIONS The risk factors and consequences of FF are similar in the different studies, particularly those that employ direct questions. The study population, the objective and the time available have an effect on the choice of method for assessing FF.

Baseline and pre-operative 1-year mortality risk factors in a cohort of 509 hip fracture patients consecutively admitted to a co-managed orthogeriatric unit (FONDA Cohort)

INTRODUCTION The aim of this study was to determine the patient characteristics that predict 1-year mortality after a hip fracture (HF). METHODS All patients admitted consecutively with fragility HF during 1 year in a co-managed orthogeriatric unit of a university hospital (FONDA cohort) were assesed. Baseline and admission demographic, clinical, functional, analytical and body-composition variables were collected in the first 72 h after admission. A protocol designed to minimize the consequences of the HF was applied. One year after the fracture patients or their carers were contacted by telephone to ascertain their vital status. RESULTS A total of 509 patients with a mean age of 85.6 years were included. One-year mortality was 23.2%. The final multivariate model included 8 independent mortality risk factors: age >85 years, baseline functional impairment in basic activities of daily living, low body mass index, cognitive impairment, heart disease, low hand-grip strength, anaemia at admission, and secondary hyperparathyroidism associated with vitamin D deficiency. The association of several of these factors greatly increased mortality risk, with an OR (95% confidence interval [CI]) of 5.372 (3.227-8.806) in patients with 4 to 5 factors, and an OR (95% CI) of 11.097 (6.432-19.144) in those with 6 or more factors. CONCLUSIONS In addition to previously known factors (such as age, impairment in basic activities of daily living, cognitive impairment, malnutrition and anaemia at admission), other factors, such as muscle strength and hyperparathyroidism associated with vitamin D deficiency, are associated with greater 1-year mortality after a HF.

Consumo de medicamentos en mayores de 65 años en Oporto (Portugal) y riesgo de prescripción de medicamentos potencialmente inapropiados

OBJECTIVE To determine medication consumption in the older people from a central area of Oporto; determine the prevalence of prescription of Potentially Inappropriate Medication and to analyse the polypharmacy and other important connected factors. DESIGN, SETTING AND PATIENTS Cross-sectional study with a sample of 747 patients older than 64 years, who were attended in a Primary care health centre: USF Rainha D. Amélia, Oporto, Portugal. MAIN OUTCOME MEASURES identification of all medication prescribed from electronic registers. Polypharmacy was considered more than 5 medication prescribed and Potential Inappropriate Medication was identified by Beers criteria 2012. The socio-demographic factors, diagnosis and health care services use were registered too. Logistic regression analysis was used to determine the association between co-variables. RESULTS There were 89.2% (95%CI: 87.6-92.0) of the studied population with at least one prescription. The polypharmacy was present at 59.2% (95%CI: 55.7-62.7) of people. The Potential Inappropriate Medication was present in 37.0% (95%CI: 33.5-40.5) of the cases. The Potential Inappropriate Medication was related with increasing age [OR=1.02 (95%CI: 1.00-1.05)], polypharmacy [OR=4.45 (95%CI: 3.12-6.36)], and be diagnosed with depression/anxiety [OR=2.18 (95%CI: 1.36-3.51)] and/or arthrosis [OR=1.64 (95%CI: 1.11-2.42)]. CONCLUSION The rate of medication prescription, polypharmacy and the prescription of Potentially Inappropriate Medication are very high in Portuguese population studied. The polypharmacy is the most important factor related with this potential inappropriate medication. The physician need to have carefully with prescription of the anxiolytic and anti-inflammatory pain drugs.

ACTUALIZACIÓN BIBLIOGRÁFICAFractura de cadera en el paciente mayorHip fracture in the elderly

La fractura de cadera es un problema de salud, cuya incidencia aumenta a partir de los 60 años siguiendo un patrón exponencial hasta la edad de 84 años. Su importancia viene dada no solo por su elevada frecuencia, sino también por la mortalidad asociada (reducción de un 25% de la esperanza de vida), su morbilidad (presentan 4,2 veces más inmovilidad y 2,6 veces más dependencia funcional que los ancianos sin fractura de cadera) y su alto coste económico y social. En la actualidad, a los objetivos clásicos de la cirugı́a de la fractura de cadera (reducción de la fractura, prevención de la necrosis avascular y disminución de la mortalidad) se añaden otros objetivos más ambiciosos como son el retorno del paciente al nivel de salud prefractura y a su nivel funcional lo más pronto posible, y el retorno al medio ambiente y al entorno social en que se encontraba el paciente antes del episodio.

Fractura de cadera en el paciente mayor

La fractura de cadera es un problema de salud, cuya incidencia aumenta a partir de los 60 años siguiendo un patrón exponencial hasta la edad de 84 años. Su importancia viene dada no solo por su elevada frecuencia, sino también por la mortalidad asociada (reducción de un 25% de la esperanza de vida), su morbilidad (presentan 4,2 veces más inmovilidad y 2,6 veces más dependencia funcional que los ancianos sin fractura de cadera) y su alto coste económico y social. En la actualidad, a los objetivos clásicos de la cirugı́a de la fractura de cadera (reducción de la fractura, prevención de la necrosis avascular y disminución de la mortalidad) se añaden otros objetivos más ambiciosos como son el retorno del paciente al nivel de salud prefractura y a su nivel funcional lo más pronto posible, y el retorno al medio ambiente y al entorno social en que se encontraba el paciente antes del episodio.

Eficiencia de las unidades geriátricas de agudos en los hospitales españoles

OBJECTIVES To review published data from Spanish hospitals in which comparisons had been made between the mean length of stay in patients admitted to acute geriatric units (AGU) and those admitted to other departments using the diagnosis-related groups (DRG) classification system and to describe our own experience. MATERIAL AND METHODS The Spanish reports collected in a previous systematic review were reviewed. The case mix of our hospital was added by analyzing episodes in patients older than 74 years old discharged during a 24-month period and included in the most frequent DRGs. The length of stay in patients admitted to the AGU was compared with that in the remaining medical departments in the hospital and with the standard average stay in the corresponding autonomous region. RESULTS Data were obtained from five Spanish general hospitals. The comparison revealed that the mean length of stay in the AGU was 8-19% shorter than that of similar patients in the other medical departments of the same hospitals. In one hospital, the reduction in the mean length of stay was 21% in patients older than 80 years. In three of the four hospitals where comparisons with the standard were performed, the mean length of stay in the AGU was lower for most of the DRGs, showing reductions of 7-9%. CONCLUSIONS These results allow us to conclude that, based on the commonly used patient classification and coding system, Spanish AGUs are more efficient than the remaining medical services in the acute hospitalization of elderly patients in our setting.

Prevalence of malnutrition in a cohort of 509 patients with acute hip fracture: the importance of a comprehensive assessment

Backgrounds/objectives:Malnutrition is very common in acute hip fracture (HF) patients. Studies differ widely in their findings, with reported prevalences between 31 and 88% mainly because of small sample sizes and the use of different criteria. The aim of this study was to learn the prevalence of malnutrition in a large cohort of HF patients in an comprehensive way that includes the frequency of protein–energy malnutrition, vitamin D deficiency and sarcopenia.Subjects/methods:A 1-year consecutive sample of patients admitted with fragility HF in a 1300-bed public University Hospital, who were assessed within the first 72 h of admission. Clinical, functional, cognitive and laboratory variables were included. Energy malnutrition (body mass index (BMI) <22 kg/m2), protein malnutrition (serum total protein <6.5 g/dl or albumin <3.5 g/dl), vitamin D deficiency (serum 25-OH-vitamin D <30 ng/dl) and sarcopenia (low muscle mass plus low grip strength) were considered.Results:Five hundred nine HF patients were included. The mean age was 85.6±6.9 years and 79.2% were women. Ninety-nine (20.1%) patients had a BMI <22 kg/m2. Four hundred nine patients (81.2%) had protein malnutrition. Eighty-seven (17.1%) patients had both energy and protein malnutrition. Serum vitamin D was <30 ng/ml in 466 (93%) patients. The prevalence of sarcopenia was 17.1%.Conclusions:Protein malnutrition and vitamin D deficiency are the rule in acute HF patients. Energy malnutrition and sarcopenia are also common. A nutritional assessment in these patients should include these aspects together.

Demora del tratamiento quirúrgico de la fractura de cadera: un suma y sigue de problemas

en el que es-tudian la mortalidad y costes asociados a la demora del tratamiento quirurgico por fractura de cadera (FC). Tras analizar una muestra de 1.856 intervenciones con una estancia preoperatoria de 2,7 dias y una postoperatoria de 9,7 dias y un coste me-dio por ingreso de 12.552 euros, encuen-tran que la demora quirurgica muestra una clara influencia en el coste del proceso. Hecho que no debe pasar desapercibido en estos tiempos en que es necesario mo-dificar las practicas que se demuestren su-peradas por otras menos costosas. En Espana la mediana de tiempo entre el ingreso y la intervencion se situa alre-dedor de los 3 dias y hasta el 25% de los pacientes son intervenidos despues del sexto dia

Spanish National Hip Fracture Registry (SNHFR): a description of its objectives, methodology and implementation.

OBJECTIVE To ascertain the current situation and clinical variability of the provision of care for Hip Fracture (HF) in Spain and the factors related to it by using a National Registry (NHFR) with high patient numbers and territorial representation NHFR, and to compare results on a national and international level and propose standards and criteria to improve healthcare quality. DESIGN Continuous registry for at least three years of a representative sample of patients admitted to Spanish hospitals due to HF using the Minimum Common Dataset - international Fragility Fracture Network (FFN) MCD, adapted for Spanish. STUDY SCOPE AND SUBJECTS: all patients over the age of 74 years who are hospitalized with a diagnosis of a fragility HF at the participating hospitals distributed throughout the Spanish territory. Initially 48 hospitals are included, and we expect to incorporate the highest number of sites possible. RESULTS It is expected to ascertain the current situation of provision of care for HF in Spain. Each hospital will be offered information regarding their results and their situation compared to the rest. The results from national hospitals will be compared to others included in the registry and to hospitals abroad, which use the same database. Variability will be studied, care standards will be established, and objectives will be proposed for the continuous improvement of the care process of this condition.