Risks, indications and technical aspects of colonoscopy in elderly or frail patients. Position paper of the Societat Catalana de Digestologia, the Societat Catalana de Geriatria i Gerontologia and the Societat Catalana de Medicina de Familia i Comunitaria. / Riesgos, indicaciones y aspectos técnicos de la colonoscopia en pacientes de edad avanzada o con fragilidad. Documento de posicionamiento de la Societat Catalana de Digestologia, la Societat Catalana de Geriatria i Gerontologia i la Societat Catalana de Medicina de Familia i Comunitaria.

Colonoscopy (CS) is an invasive diagnostic and therapeutic technique, allowing the study of the colon. It is a safe and well tolerated procedure. However, CS is associated with an increased risk of adverse events, insufficient preparation and incomplete examinations in the elderly or frail patient (PEA/F). The objective of this position paper was to develop a set of recommendations on risk assessment, indications and special care required for CS in the PEA/F. It was drafted by a group of experts appointed by the SCD, SCGiG and CAMFiC that agreed on eight statements and recommendations, between them to recommend against performing CS in patients with advanced frailty, to indicate CS only if the benefits clearly outweigh the risks in moderate frailty and to avoid repeating CS in patients with a previous normal procedure. We also recommended against performing screening CS in patients with moderate or advanced frailty.

Hip fractures in the oldest old. Comparative study of centenarians and nonagenarians and mortality risk factors.

INTRODUCTION: Centenarians and nonagenarians constitute a rapidly growing age group in Western countries and they are expected to be admitted to hospital with hip fractures. The aim of this study was to compare outcomes of centenarian and nonagenarian patients following a hip fracture and to identify risk factors related to in-hospital and post-discharge mortality in both groups. PATIENTS AND METHODS: A prospective evaluation of centenarian patients and nonagenarian controls admitted to a tertiary university hospital in Barcelona with hip fractures over a period of 5 years and 9 months. Baseline characteristics and outcomes in both patient groups were compared. Variables associated with in-hospital, 30-day, 3-month and 1-year mortality were also analyzed. RESULTS: Thirty-three centenarians and 82 nonagenarians were included. The most relevant statistically significant differences found were: Barthel index at admission (61.90 vs. 75.22), number of drugs before admission (4.21vs 5.55), in-hospital complication rates (97 vs. 78%), readmissions at 3 months and 1 year (0 vs 11.7% and 3.4 vs. 19.5% respectively) and mortality at 3 months and 1 year (41.4 vs. 20.8% and 62.1 vs. 29.9%, respectively). Mean number of complications, rapid atrial fibrillation, mean age, and urinary tract infection were risk factors associated with mortality. CONCLUSIONS: Centenarian patients had similar in-hospital outcomes to nonagenarians, but experienced more complications and twice the 3-month and 1-year mortality rate. The mean number of complications was the risk factor most consistently related to in-hospital and post-discharge mortality. These findings emphasize the need to improve care in very old patients to prevent complications.

Mitigar consecuencias del calentamiento global y efecto invernadero: reflexiones para la formación en salud / To mitigate effects of global warming and greenhouse effect: reflections for training in health / Mitigar os efeitos do aquecimento global e do efeito estufa: reflexões para a formação em saúde

Objetivo: Reflexionar sobre el conocimiento comunitario frente a las medidas que adoptan ante los efectos del calentamiento global, asumiendo el rol de la responsabilidad social como institución formadora en salud. Material y Método: Investigación cualitativa etnográfica; el número de participantes fue intencional, 20 familias participantes (una por barrio), toda vez cumplieran los criterios de suficiencia y profundidad en el análisis inductivo de información, obtenida con entrevista a profundidad y guía de observación no participante, soportados con referentes conceptuales de la relación sociedad y salud, bioética ambiental y teorías de educación ambiental. Resultados: Se develaron categorías relacionados a estilos de vida que adoptan, no pertinentes para el cuidado preventivo y la respuesta social institucional para la gestión de estrategias pertinentes, correspondiendo a una adopción inminente no pertinente de modos de vida saludables y medidas protectoras específicas. Conclusión: Incluir esta temática en contenidos curriculares de Enfermería y proponer un trabajo incluyente interdisciplinar e intersectorial para el trabajo comunitario con la búsqueda de nuevos modos de cuidados, entornos naturales saludables y manejo bioético requerido.

Objective: To reflect on community knowledge before measures adopted to global warming effects, assuming the social responsibility role as a health training institution. Method and Material: Qualitative ethnographic research, with intentional number of participants, 20 participating families (1 per neighborhood), provided they fulfilled the sufficiency and depth criteria in the information inductive analysis which was obtained through in-depth interviews and non-participant observation guide, supported by conceptual referents of the society and health, environmental bioethics, and environmental education theories relationships. Results: categories related to lifestyles they adopt were unveiled which are not relevant to preventive care,and the social institutional response for pertinent management, corresponding to an irrelevant imminent adoption of healthy lifestyles and specific protective measures. Conclusion: Including this issue in the Nursing Program curriculum content and proposing an inclusive interdisciplinary and cross-sectoral work for community work by finding new care ways, healthy natural environments and bioethical management required.

Objetivo: Refletir sobre o conhecimento da comunidade contra as medidas que tomem para os efeitos do aquecimento global, assumindo o papel de responsabilidade social na instituição de formação em saúde. Métodos: Pesquisa etnográfica qualitativa, o número de participantes foi intencional, 20 famílias participantes (uma por trimestre), uma vez que preenchiam os critérios de suficiência e profundidade de análise indutiva das informações obtidas entrevistas em profundidade e guia de observação participante custeadas com referenciais conceituais relações da sociedade e da saúde e bioética ambientais teorias da educação ambiental. Resultados: Foram reveladas categorias relacionadas ao estilo de vida incoerente adotar cuidados preventivos e de resposta social institucional para estratégias de gestão relevantes correspondentes a uma adoção iminente irrelevante de estilos de vida saudáveis e medidas de proteção específicas. Conclusão: Incluir esta questão no conteúdo curricular de enfermagem e propor um trabalho interdisciplinar e intersetorial, inclusive para o trabalho comunitário em encontrar novas maneiras de cuidar e ambientes naturais saudáveis e manipulação de bioética necessário.

Assessing nutritional status in the elderly evaluation of Chumlea equations for weight.

BACKGROUND: Weight is one of the most important parameters in assessing nutritional status. However, weight can be difficult to measure in elderly people who are unable to stand. Chumlea et al. created two equations to estimate weight in non-ambulatory patients using readily available body measurements. OBJECTIVE: The aim of the study is to analyze the usefulness of Chumlea equations in assessing nutritional status of elderly hospitalized patients. METHODS: We measured weight, height, arm and calf circumference, subscapular skinfold and knee height of 82 hospitalized elderly patients, all of whom were able to stand. Estimated weight (EW) was obtained by Chumlea equations. Body mass index (BMI) and Mini Nutritional Assessment test (MNA) were calculated using actual weight and EW. Bland-Altmann analysis and intraclass correlation coefficient (ICC) between real and estimated parameters were assessed. RESULTS: We found a statistically significant ICC between actual weight and EW (r = 0.926), real BMI and estimated BMI (r = 0.910) and real MNA and estimated MNA (r = 0.982) (p < 0.001). Chumlea equations, however, underestimated weight: 54.05 (DS 11.88) vs 61.46 (DS 13.08); BMI: 22.30 (DS 4.61) vs 25.36 (DS 5.17) and MNA: 22.73 (DS 4.43) vs 23.30 (DS 4.33) (P<0.001). In spite of this underestimation, estimated MNA detected 100% of patients malnourished and 96% of those at risk of malnutrition. CONCLUSIONS: Results obtained by Chumlea equations showed a good ICC with actual body weight and real BMI and MNA, but values were underestimated. These equations can be useful to detect undernourished hospitalized elderly patients.

[Influence of patients' age in the probabilistic models of mortality on admission in general internal medicine wards]. / Influencia de la edad en los índices probabilísticos de mortalidad al ingreso en salas convencionales de Medicina Interna.

BACKGROUND AND OBJECTIVE: The predictive models of in-hospital mortality in the departments of Internal Medicine have not reached a generalized use. Our hypothesis is that the very elderly patients interfere in the models currently in use. PATIENTS AND METHOD: In this observational, prospective cohort study, 1,500 patients admitted consecutively in the department of Internal Medicine were analysed. A logistic regression analysis based on the REMS model was used for the whole series and after segmenting it according to if the age of patients was 85 years or less, or more than 85 years. RESULTS: The global in-hospital mortality of the patients was 12%. Although the REMS model predicted a global mortality of 11.9%, sensitivity and specificity for an individual prediction were not satisfactory because the AUC was only 0.704. When the sample was split according to the age of patients, the model gained precision for the group ≤ 85 years (AUC 0.799), whereas it lost sensitivity and specificity for the group of patients > 85 years (AUC 0.66). CONCLUSIONS: Age of patients interferes in the general models of prediction of mortality in departments of Internal Medicine. There may be important variables in advanced age not taken into account in the predictive models nowadays available. We think that specific predictive models of in-hospital mortality in Internal Medicine should be designed for patients of advanced age.

[Age of patients admitted to Internal Medicine departments in Spain: a twenty years perspective]. / La edad de los pacientes atendidos en los servicios de medicina interna en España: una perspectiva de 20 años.

BACKGROUND AND OBJECTIVE: To analyze the age of patients admitted to Spanish General Internal Medicine (IM) departments over the past 20 years with the hypothesis that patients' age has increased significantly. PATIENTS AND METHODS: On one hand, we analyzed the age of patients admitted in the department of the authors. Secondly we analyzed data provided by the Ministry of Health. Finally we compared a number of different articles from the late eighties with a recent series. RESULTS: Mean age of patients in our department has increased in 19.3 years in 20 years. According to CMBD, the patients ≥ 75 years increased 4.4% from 2005 to 2009. When comparing the historical and recent series, the average age of the patients increased 8.3 years. CONCLUSIONS: All three sources confirm the hypothesis that patients admitted to IM are significantly older than some years ago, and that this increase in age is greater than the expected by aging of the general population.

Effect of prophylactic treatment with low-molecular-weight heparin bemiparin sodium on serum potassium levels: a prospective observational study.

Hyperkalaemia is a serious adverse effect of unfractionated heparin, but the effect of low-molecular-weight heparins (LMWHs) on potassium levels is not clear. Previous studies have shown a disparity of results depending on the dose and type of LMWH used. To analyse potassium level variations in medical and surgical inpatients receiving the LMWH bemiparin sodium at prophylactic doses and assess the consequent effective risk of hyperkalaemia in a real-life setting. This was a prospective observational study conducted over a 9-month period in a university teaching hospital. Patients consecutively admitted to internal medicine wards for general medical conditions (n = 145) or to traumatology wards for hip fractures (n = 98) and who received prophylactic bemiparin sodium were enrolled in the study. The intervention consisted of daily dosages of bemiparin sodium (Hibor) 3500 IU (56%) or 2500 IU (44%) for a minimum of 5 days. The mean age of participants was 80.5 years, with 91.8% being aged > or =65 years. Eighty-six percent of patients had co-morbidities and 79.4% were taking medication affecting potassium homeostasis. The main outcome measures were variations in serum potassium levels observed within 4-8 days of starting bemiparin sodium and the presence of hyperkalaemia (serum potassium >5.1 mmol/L) while on bemiparin sodium treatment. After patients had received bemiparin sodium for a median 6-day period, the mean (+/-SD) serum potassium level increased from 4.1 +/- 0.5 to 4.3 +/- 0.5 mmol/L (p < 0.001). Hyperkalaemia >5.1 mmol/L developed in ten patients (4.1%), but serum potassium levels >5.5 mmol/L related to bemiparin sodium were present in only two (0.8%). Laboratory tests between the fourth and eighth days identified all but one case of hyperkalaemia. Patients were not symptomatic and discontinuation of bemiparin sodium treatment was not required. There were no statistically significant differences in potassium disturbances between older (aged > or =65 years) and younger (aged <65 years) patients. The maximum serum potassium level showed a significant inverse correlation with bodyweight (R = -0.731; p = 0.016) and creatinine clearance (R = -0.640; p = 0.046), and a positive correlation with the individual variation in serum potassium levels (R = 0.692; p = 0.027) and with serum potassium levels after 4-8 days on bemiparin sodium treatment (R = 0.741; p = 0.014). Baseline potassium level (odds ratio [OR] 26.5, 95% CI 4.7, 150.3; p < 0.001) and treatment with ACE inhibitors (OR 10.5, 95% CI 1.9, 57.8; p = 0.007) were the only predictors of hyperkalaemia at admission (c-statistic 0.88, 95% CI 0.78, 0.99). For patients not receiving ACE inhibitors, a baseline serum potassium >4.6 mmol/L was considered the cut-off value for predicting hyperkalaemia (sensitivity 90% and specificity 70%). Serum potassium levels in in-hospital traumatology and medical patients increased significantly with bemiparin sodium prophylaxis but the incidence of relevant hyperkalaemia was low. Patients taking bemiparin sodium who are treated with ACE inhibitors or who have a baseline potassium level >4.6 mmol/L should be monitored for serum potassium levels between days 4 and 8 of hospital admission.

Ability of physiological parameters versus clinical categories to predict mortality on admission to an internal medicine ward.

BACKGROUND: The prediction of mortality in internal medicine departments may help in taking diagnostic and therapeutic decisions. We analyzed the usefulness of two mortality prediction models, one physiological and the other mainly clinical, and determined whether one approach is better than the other to predict mortality at admission. METHODS: This is a prospective observational cohort study in patients admitted to an acute internal medicine ward in a tertiary care, urban, university teaching hospital in Spain. Five hundred consecutive patients either electively admitted or coming from the emergency department from May to December 2008 were analyzed. Medical history, physical examination and routine clinical laboratory tests were performed on admission. At discharge, diagnosis and dead or survived status was recorded. Logistic regression analyses were used to test variables that emerged as independent predictors of mortality. The area under the curve was used to determine which model best predicted mortality. RESULTS: Mortality in the ward was 13.0%. Age, chronic respiratory failure, creatinine, mean arterial pressure, respiratory rate and Glasgow coma scale independently predicted mortality. ROC curves showed that the physiological model was superior to the clinical model, but differences were not statistically significant. The predictive capacity improved when the two models were combined but the improvement was not significant. CONCLUSIONS: Both models are satisfactory predictors of in-hospital mortality for management purposes but neither proved to be a useful tool for individual predictions. Complementary approaches need to be considered.

El sentido cultural del cuidado en casa del enfermo / The meaning of cultural carefully in house of the sick

Esta investigación tiene un diseño cualitativo descriptivo, transversal para comprender las diferencias existentes en los conocimientos, actitudes y prácticas influidas por la percepción o sentido cultural de cuidar del cuidador primario, como elemento básico para caracterizar elementos culturales presentes en el ambiente de cuidado al enfermo o discapacitado que está en casa a través de la indagación profunda de la percepción y sentimientos que tiene tanto el cuidador primario como el ser cuidado en casa. Se realizó con los usuarios inscritos del Programa de Promoción y Prevención de la indagación profunda de la percepción y sentimientos Universidad Popular del Cesar (IPS-UPC) de los enfermos crónicos y discapacitados a nivel comunitario del grupo extramural de la comuna cinco y del Hospital Eduardo Arredondo Daza de la ciudad de Valledupar, Colombia. El valor de realizar este proyecto, está en desocultar los múltiples significados que en la realidad vivida por los seres cuidadores primarios y en los seres cuidados; son esas distintas formas de percibir la existencia, influido por el conocimiento de lo ancestral, los sentimientos y la sabiduría de la cultura que cada uno posee para expresarse en las múltiples formas que el cuidado lo acontece y lo requiere para dar el sentido cultural característico y diferenciado que se percibe en el modo de cuidar y la satisfacción de quien lo recibe y lo ofrece. Este aspecto fue valioso para la comunidad académica del programa de enfermería, porque ubicó epistémicamente la transculturalidad del cuidado como una mirada y forma de enseñar transdisciplinariamente, enseñando y ofreciendo el cuidado desde la cultura, sentimientos y pensamientos del ser cuidado para el mantenimiento de la vida y la salud, en la que estudiantes de enfermeria desde sus primeras experiencias formativas deben incursionar en la intervención holística que se requiere en el cuidado de la salud y de la vida

This investigation has a descriptive qualitative design, traverse to understand the existent differences in the knowledge, attitudes and practices influenced by the perception or cultural sense of taking care of the primary caretaker, as basic element to characterize elements cultural present in the atmosphere of care to the sick person or discapacitado that this at home through the deep inquiry of the perception and feelings that he/she has so much the primary caretaker as being taken care at home. It was made with the entered users of the Program of Promotion and Prevention of the IPS-UPC of the chronic sick persons and discapacitados at community level of the group extramural of the commune five and of the Hospital Eduardo Arredondo Daza of the city of Valledupar, Colombia. The value to carry out this project is in desocultar the multiple meanings that in the reality lived by the beings primary caretakers and in the taken care beings they are those different forms of perceiving the existence, influenced by the knowledge of the ancestral thing, the feelings and the wisdom of the culture that each one possesses to be expressed in the multiple forms that the care happens him and it requires it to give the characteristic and differentiated cultural sense that it is perceived in the way of taking care and the satisfaction of who receives it and he/she offers it. This aspect was valuable for the academic community of the infirmary program, because it located epistemicamente the transculturalidad of the care as a look and form of teaching transdisciplinariamente, teaching and offering the care from the culture, feelings and thoughts of being taken care for the maintenance of the life and the health, in which infirmary students from their first formative experiences should intrude in the look holìstica that is required in the care of the health and of the life.

Short- and long-term outcomes of older patients in intermediate care units.

OBJECTIVE: To evaluate short- and long-term outcomes of elderly patients (>or=65 years) treated at an intermediate care unit (IMCU) and to identify outcome predictors. DESIGN AND SETTING: Prospective observational study in the IMCU of a university teaching hospital. PARTICIPANTS: We studied 412 patients over 8 months, classified into three groups: under 65years (control group, n=158), 65-80 (n=186), and >80 (n=68). MEASUREMENTS: At admission: APACHE II, TISS-28 first day, Charlson Index, diagnosis, and prior Barthel Index. OUTCOME MEASURES: in-hospital mortality, length of stay, discharge destination, and 2-year mortality and readmissions. Data analysis included multivariate logistic regression and receiver operating characteristics area under the curve (ROC AUC). RESULTS: No statistically significant differences between groups were observed in hospital mortality (14.1%), discharge to a long-term facility (2.7%), or 2-year readmissions (1.2+/-2.1). However, hospital stay was longer in patients aged 65-80years (14 vs.10 days) and 2-year mortality was higher in those 65 or over (34% vs.10.6%). In the overall series in-hospital mortality was predicted by APACHE II, first-day TISS-28, and diagnosis (ROC AUC 0.81), and 2-year mortality by Charlson Index and age (ROC AUC 0.77). In the elderly patients 2-year mortality was predicted by Charlson and Barthel indices (ROC AUC 0.70). CONCLUSIONS: Illness severity and therapeutic intervention at admission to IMCU were predictors of short-term mortality, whereas the strongest predictor of long-term mortality was comorbidity. Our results suggest that comprehensive assessment of elderly patients at admission to IMCUs may improve outcome prediction.