Nicolás Martínez Velilla

El ejercicio físico en el anciano frágil: una actualización

Frailty is a state of vulnerability that involves an increased risk of adverse events and disability in older adults. It is a condition with a complex etiology and pathophysiology. Skeletal muscle power decreases earlier than muscle strength with advancing age and is more strongly associated with functional capacity than muscle strength in frail elderly populations. Multicomponent exercise programs, and especially resistance exercise that includes muscle power training, are currently the most relevant interventions to slow down disability and other adverse outcomes, even in the oldest-old. Moreover, these programs are valuable interventions in other frailty domains, such as falls and cognitive decline. Physical exercise, in the frail elderly, should be prescribed with a progressive individualized plan and just like other medical treatments.

Delirium y delirium subsindrómico, prevalencia de un espectro de enfermedad

INTRODUCTION Subsyndromal delirium (SSD) is a developing concept of disease with a spectrum beyond the diagnostic dichotomy of delirium with standard criteria. MATERIAL AND METHODS To study the prevalence and significance of SSD we have conducted a cross-sectional prospective multicenter study of all patients admitted to three Geriatric Departments in tertiary hospitals. The SSD diagnostic criteria used were based on Marcantoniós criteria, and the DRS-R-98 scale was also used as a continuous variable of the degree of delirium. RESULTS We studied 85 patients, 56% women, Barthel 62 (SD: 32), age 87 (SD: 6), CIRS-G 24 (SD: 6.85). Three quarters (75.3%) of patients had at least one CAM positive item, and half of them with at least 13 points in the DRS-R-98 scale. The prevalence of delirium was 53% and 22.3% for SSD. The degree of delirium-DSS was associated with different geriatric syndromes, levels of malnutrition, and degree of functional and cognitive impairment, with a significant linear trend between groups. Patients without delirium have higher levels than those with subsyndromal delirium, and these in turn are higher than those without diagnosed delirium. There is also a tendency in the degree of delirium measured by the DRS-R-98. CONCLUSION Beyond the dichotomous concept of the presence or absence of delirium, this study suggests the probable continuity of cognitive processes and the possibility of more effective and earlier diagnostic and therapeutic measures.

Delirium subsindrómico en pacientes ancianos: revisión sistemática

In this systemic review, the articles published between 1990 and November 2012 on subsyndromal delirium (SSD), and specifically those with reference to geriatric patients, were analysed. In SSD, symptoms from the three nuclear domains of delirium (cognitive, circadian and higher order thinking) are simultaneously present, with mild to moderate severity. Although the search for these clinical characteristics is a useful guide, there are no universally accepted diagnostic criteria for SSD. Regardless of the criteria used for diagnosis, SSD is persistently associated with poor functional and cognitive outcome, longer hospital stay, institutionalisation, and increased mortality. Studies are needed on the physiopathology, treatment and prevention in the field of SSD, which is a particularly important clinical condition in geriatric patients.

Deterioro cognitivo y riesgo de caída en el anciano

Risk of fall is significantly increased in old people with cognitive decline due to specific associations between gait parameters and cognition. This association has recently been demonstrated, there being increasing evidence that cognitive domains such as attention, executive function and types of memory are critical for the correct regulation of gait. Gait disturbances can appear as early predictors of dementia in elderly patients. In the assessment of the fall risk, the use of dual tasks is novel, simple and relevant, especially in cognitive decline. Evidence for interventions in this population is limited, with vitamin D and physical exercise being the most encouraging, for decreasing the risk of fall in dementia.

Cognitive impairment and the risk of falling in the elderly

Risk of fall is significantly increased in old people with cognitive decline due to specific associations between gait parameters and cognition. This association has recently been demonstrated, there being increasing evidence that cognitive domains such as attention, executive function and types of memory are critical for the correct regulation of gait. Gait disturbances can appear as early predictors of dementia in elderly patients. In the assessment of the fall risk, the use of dual tasks is novel, simple and relevant, especially in cognitive decline. Evidence for interventions in this population is limited, with vitamin D and physical exercise being the most encouraging, for decreasing the risk of fall in dementia.

Carta al EditorSíndrome de fatiga por las guías de práctica clínicaClinical practice guidelines for fatigue syndrome

El deterioro cognitivo, la multimorbilidad, la polifarmacia y la omplejidad social y clínica son realidades incuestionables en el ía a día de aquellos que nos dedicamos a la prevención, el trataen las últimas 2 décadas5. Habiendo dicho esto, las guías de práctica clínica han demostrado reducciones en la variabilidad de oferta de cuidados médicos, ayudan en la toma de decisiones relacionadas con enfermedades aisladas, definen los estándares clínicos, ayudan a concentrar los esfuerzos para la mejora de servicios y facilitan la transición de resultados científicos a la vida clínica diaria. Los profesionales de la salud debemos saber ponderar la observancia de las recomendaciones recogidas en las guías de práctica clínica con las circunstancias personales, creencias, valores y preferencias de nuestros pacientes y sus cuidadores. Es nuestra responsabilidad asegurar el uso de medidas de resultados clínicos relevantes en el paciente anciano como la calidad de vida o la mejora de la capacidad funcional. Debemos avanzar hacia una sensata, progresiva y oportunista inclusión de ancianos frágiles y con multimorbilidad en los futuros ensayos clínicos. La implicación de los médicos, los propios pacientes y sus cuidadores debe ser la norma y no la excepción a la hora de diseñar, difundir y poner al día guías de práctica clínica dirigidas a mejorar el manejo de pacientes, no exclusivamente de enfermedades. Cabe esperar que entonces se reduzca el llamado «síndrome de fatiga por las guías de práctica clínica»; una debilitante condición caracterizada por irritabilidad y letargia ante la publicación de nuevas guías6.

Síndrome de fatiga por las guías de práctica clínica

El deterioro cognitivo, la multimorbilidad, la polifarmacia y la omplejidad social y clínica son realidades incuestionables en el ía a día de aquellos que nos dedicamos a la prevención, el trataen las últimas 2 décadas5. Habiendo dicho esto, las guías de práctica clínica han demostrado reducciones en la variabilidad de oferta de cuidados médicos, ayudan en la toma de decisiones relacionadas con enfermedades aisladas, definen los estándares clínicos, ayudan a concentrar los esfuerzos para la mejora de servicios y facilitan la transición de resultados científicos a la vida clínica diaria. Los profesionales de la salud debemos saber ponderar la observancia de las recomendaciones recogidas en las guías de práctica clínica con las circunstancias personales, creencias, valores y preferencias de nuestros pacientes y sus cuidadores. Es nuestra responsabilidad asegurar el uso de medidas de resultados clínicos relevantes en el paciente anciano como la calidad de vida o la mejora de la capacidad funcional. Debemos avanzar hacia una sensata, progresiva y oportunista inclusión de ancianos frágiles y con multimorbilidad en los futuros ensayos clínicos. La implicación de los médicos, los propios pacientes y sus cuidadores debe ser la norma y no la excepción a la hora de diseñar, difundir y poner al día guías de práctica clínica dirigidas a mejorar el manejo de pacientes, no exclusivamente de enfermedades. Cabe esperar que entonces se reduzca el llamado «síndrome de fatiga por las guías de práctica clínica»; una debilitante condición caracterizada por irritabilidad y letargia ante la publicación de nuevas guías6.

RevisiónDelirium subsindrómico en pacientes ancianos: revisión sistemáticaSubsyndromal delirium in elderly patients: A systematic review

In this systemic review, the articles published between 1990 and November 2012 on subsyndromal delirium (SSD), and specifically those with reference to geriatric patients, were analysed. In SSD, symptoms from the three nuclear domains of delirium (cognitive, circadian and higher order thinking) are simultaneously present, with mild to moderate severity. Although the search for these clinical characteristics is a useful guide, there are no universally accepted diagnostic criteria for SSD. Regardless of the criteria used for diagnosis, SSD is persistently associated with poor functional and cognitive outcome, longer hospital stay, institutionalisation, and increased mortality. Studies are needed on the physiopathology, treatment and prevention in the field of SSD, which is a particularly important clinical condition in geriatric patients.

Alteración de la marcha y disfagia secundaria a aneurisma basilar gigante en mujer nonagenaria

We describe the case of a 90-year-old woman with a giant fusiform cerebral aneurysm of the basilar artery who developed progressive ataxia and dysphagia. The interest of this case lies in the type, size, localization and clinical manifestations of the aneurysm. We analyze the case and review the main features of this entity.

O-17 Multicomponent exercise program effects on functional capacity and cognition in frail hospitalisedhospitalized patients

Background Frail older adults have reduced functional and physiological reserves, rendering them more vulnerable to the effects of hospitalisation, which frequently results in failure to recover from functional decline related to the hospitalisation and new disability.1 Alternative care models with an emphasis on multidisciplinary and continuing care units are currently being developed.2 Objective(s) To analyse the effects of a multicomponent exercise program on functional capacity and cognition in frail hospitalised patients. Methods Randomised clinical trial conducted in 193 patients admitted in a Geriatrics Acute Unit Hospitalised patients who met inclusion criteria (75 years and older, medical stable, frail or prefrail – SPPB (Short Physical Performance Battery) 4–9 –, previous ability to walk, able to communicate) were randomly assigned to the intervention or control group. The intervention consisted of a multicomponent exercise training program, composed of supervised progressive resistance exercise training at low-moderate intensities 30–60% RM (Repetition Maximum), balance-training, and walking for 5–7 consecutive days. During the training period, patients were trained in 20 min sessions twice a day (morning and evening). Evaluations of functional capacity (SPPB, Gait velocity, gait velocity under dual task conditions, Barthel index), strength and power assessments; maximal isometric force of handgrip, knee extension and hip flexion, 1RM -leg press, chest press and knee extension-, muscle power output at 50% 1RM in leg press exercise, and cognition; MMSE (Mini Mental State Examination), TMT-A (Trail Making Test A), Isaacs test were conducted at admission and previous to discharge in the control and intervention group. Results 193 completed pre/post evaluations (control group (CG) n = 83, intervention group (IG) n = 81). Drop-out was 15% due to different medical reasons (29 participants). In the IG, significant improvements were observed after the intervention in all strength and power assessments (hand grip, knee extension, hip flexion, 1RM – leg press, chest press – and muscle power output at 50%RM, p < 0.0001) and functional capacity parameters (SPPB, Gait velocity, gait velocity with dual task conditions p < 0.0001, and Barthel Index p < 0.05). Significant improvements were observed also in cognitive function (MMSE p < 0.0001, TMT-A p ≤ 0.001, Isaacs test p < 0.0001). In contrast, in the CG, no significant improvements after evaluations were detected in any of the strength, power, functional and cognitive parameters studied. Conclusions A multicomponent exercise program, with special emphasis in progressive resistance training, is an effective therapy to improve functional capacity and cognitive function in frail patients during hospitalizations. Individualised exercise training should be prescribed routinely in all frail - prefrail patients admitted to hospitals, as same as other medical treatment, in order to prevent functional impairment and cognitive decline. References Volpato S, Onder G, Cavalieri M, et al. Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalisationhospitalization. J Gen Intern Med 2007;22:668–674. Casas-Herrero A, Cadore EL, Zambom-Ferraresi F, et al. Functional capacity, muscle fat infiltration, power output, and cognitive impairment in institutionalised frail oldest old. Rejuvenation Res 2013;16:396–403.