Maria do Carmo Sitta

Prognostic factors for mortality among patients above the 6th decade undergoing non-cardiac surgery: cares - clinical assessment and research in elderly surgical patients

PURPOSE To ascertain perioperative morbimortality and identify prognostic factors for mortality among patients ≥55 years who undergo non-cardiac surgery. METHODS A retrospective cohort of 403 patients relating to perioperative morbidity-mortality. Data were collected from a standardized protocol on gender, age, comorbidities, medications used, smoking, alcohol abuse, chronic use of benzodiazepine, nutritional status, presence of anemia, activities of daily living, American Society of Anesthesiology classification, Detsky’s modified cardiac risk index - American College of Physicians, renal function evaluation, pulmonary risk according to the Torrington scale, risk of thromboembolic events, presence of malignant disease and complementary examinations. RESULTS The mean age of the subjects was 70.8 ± 8.1 years. The “very old” (≥80 years) represented 14%. The mortality rate was 8.2%, and the complication rate was 15.8%. Multiple logistic regression showed that a history of coronary heart disease (OR: 3.75; p=0.02) and/or valvular heart disease (OR: 31.79; p=0.006) were predictors of mortality. The American Society of Anesthesiology classification was shown to be the best scale to mark risk (OR: 3.01; p=0.016). Nutritional status was a protective factor, in which serum albumin increases of 1 mg/dl decreased risk by 63%. DISCUSSION The results indicate that serum albumin, coronary heart disease, valvular heart disease and the American Society of Anesthesiology classification could be prognostic predictors for aged patients in a perioperative setting. In this sample, provided that pulmonary, cardiac and thromboembolic risks were properly controlled, they did not constitute risk factors for mortality. Furthermore, continuous effort to learn more about the preoperative assessment of elderly patients could yield intervention possibilities and minimize morbimortality.

Age, invasive ventilatory support and outcomes in elderly patients admitted to intensive care units

BACKGROUND although advancing age is associated with worse outcomes on mechanically ventilated elderly patients admitted to intensive care units (ICU), this relation has not been extensively investigated on patients not requiring invasive ventilatory support. OBJECTIVE to determine the relationship between age and in-hospital mortality of elderly patients, admitted to ICU, requiring and not requiring invasive ventilatory support. DESIGN prospective observational cohort study conducted over a period of 11 months. SETTING medical-surgical ICU at a Brazilian university hospital. SUBJECTS a total of 840 patients aged 55 years and older were admitted to ICU. METHODS in-hospital death rates for patients requiring and not requiring invasive ventilatory support were compared across three successive age intervals (55-64; 65-74 and 75 or more years), adjusting for severity of illness using the Acute Physiologic Score. RESULTS age was strongly correlated with mortality among the invasively ventilated subgroup of patients and the multivariate adjusted odds ratios increased progressively with every age increment (OR = 1.60, 95% CI = 1.01-2.54 for 65-74 years old and OR = 2.68, 95% CI = 1.58-4.56 for > or =75 years). For the patients not submitted to invasive ventilatory support, age was not independently associated with in-hospital mortality (OR = 2.28, 95% CI = 0.99-5.25 for 65-74 years old and OR = 1.95, 95% CI = 0.82-4.62 for > or =75 years old). CONCLUSIONS the combination of age and invasive mechanical ventilation is strongly associated with in-hospital mortality. Age should not be considered as a factor related to in-hospital mortality of elderly patients not requiring invasive ventilatory support in ICU.

Identification and treatment of osteoporosis among elderly patients with hip fractures

OBJECTIVE: To evaluate the profile of osteoporosis treatment among patients hospitalized due to hip fractures at a tertiary-level university hospital. To compare the impact of hospitalization on approaches toward treating bone mass losses. METHOD: The medical records of 123 hip fracture patients aged 60 years and over at the Institute of Orthopedics, Hospital das Clínicas, University of São Paulo School of Medicine, between 2004 and 2006 were reviewed and analyzed with respect to approaches towards investigating osteoporosis and treatments before and after fracture. RESULTS: The patients’ mean age was 78 ± 8.3 years, and the majority were women (71.54%). The patients had a mean of 2.72 comorbidities and used 3.26 medications on average. Among these patients, 12.3% reported a previous diagnosis of osteoporosis, and 5.83% were on medication for this. The mean waiting time for surgery was 6.3 ± 7.54 days, and seven patients (5.7%) died during the hospitalization. There were no investigations using bone densitometry, no changes in osteoporosis therapy between admission and discharge (p = 0.375), and no reports of referrals for the patient to have access to treatment. CONCLUSIONS: Investigations and treatments of osteoporosis and strategies for preventing new fractures were not implemented during the hospitalization of these elderly patients with hip fractures, even though this is the most feared complication of osteoporosis. These data need to be disseminated so that professionals dealing with elderly patients are attentive to the need for primary and secondary prevention of osteoporosis because of the impact of fractures on these patients’ quality of life, independence, morbidities, and mortality.

Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study

BACKGROUND although the importance of identifying hip fracture patients with high risk for delirium has been well established, considerable controversy exists over the choice of the screening tool. The most commonly used cognitive screeners take an excessive amount of time and include drawing tasks that can be troublesome for individuals with hip fracture who are invariably lying in bed. OBJECTIVE to evaluate the properties of the 10-point Cognitive Screener (10-CS), a 2-min bedside tool, for predicting delirium in older adults with hip fracture. DESIGN prospective cohort study. SETTING a tertiary referral hospital in São Paulo, Brazil. SUBJECTS non-delirious older adults with hip fracture (n = 147). METHODS the 10-CS was administered as a baseline predictor. The test is composed of three-item temporal orientation (date, month, year), category fluency (animals in 1 min) and three-word recall. Incident delirium has been diagnosed according to the Confusion Assessment Method (CAM) that was administered daily from admission to discharge. RESULTS during hospitalisation, 61 (41.5%) patients developed delirium. The 10-CS presented excellent accuracy for predicting delirium, with an area under ROC curve of 0.83 (95% CI 0.76-0.89). After adjusting for demographic and clinical variables, participants with probable cognitive impairment (score ≤ 5) were more likely to develop delirium (HR = 7.48; 95% CI 2.2-25.4) compared with participants with a normal score. Lower scores on the 10-CS were also independently associated with a longer length of stay. CONCLUSIONS the 10-CS is an easy-to-use bedside tool with adequate properties to stratify the risk of delirium in older adults with hip fracture.

Association between plasma testosterone level and bone mineral density in healthy elderly men.

the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study design and conceptualization: Nilsson, Nyberg, Adolfsson, Bergdahl, Bergdahl. Statistical analyses: Hansson, S€ orman. Interpretation of results and reviewing the manuscript: all authors. Drafting and revising manuscript: Hansson, S€ orman. All authors approved the final manuscript. Sponsor’s Role: None.

Osteomalacia and vitamin D deficiency in the elderly

INTRODUCTION Osteomalacia is one of the most common osteometabolic diseases among the elderly and may be associated with osteoporosis. It is typically caused by lack of vitamin D and is characterized by mineralization deficiency of the osteoid matrix in the cortical and trabecular bone, resulting in accumulation of osteoid tissue. Vitamin D deficiency is a pathogenic factor of osteoporosis that can be modified. The elderly are at particularly high risk for developing osteomalacia, which is frequently misdiagnosed. […] Osteomalacia and [...]

Bone Mineral Density and High-Performance Aerobic Activity in Older Adults Experience in Brazil

Population aging has exhibited a significant increase in the last decades. For instance, in Brazil, recent projections by the IBGE 1 (Instituto Brasileiro de Geografia e Estatistica/Brazilian Institute of Geography and Statistics) forecast a threefold increase of the elderly population by 2050 from the current 10.8% to 29.7% of the country’s total population, corresponding to almost 65 million people. The life expectancy at birth of the overall population increased to 73 years in the last decade (1999-2009), ranging from 73.9 to 77 years among females and 66.3 to 69 years among males. Such aging of the Brazilian population will pose increasing challenges to the national public health system, SUS (Sistema Unico de Saude/Unified Health System), as older adults exhibit a larger number of chronic diseases, which contribute to loss of function‐ ality and decline of the quality of life.

ORTHOPEDIC SURGERY AMONG THE ELDERLY: CLINICAL CHARACTERISTICS

Care for elderly patients undergoing orthopedic surgery, particularly for those requiring emergency surgery, needs to take into account an analysis of physical capacity and risks specific to elderly individuals, in an attempt to reduce the risks. Nevertheless, these remain high in this group. Despite the risks, procedures developed promptly have a positive effect on these patients’ evolution. Coordinated care, composed of teams of specialists within clinical medicine, geriatrics, orthopedics, anesthesiology and critical care, along with other healthcare professionals, may be highly beneficial for this group of patients.