Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study.

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

Improving individualized prescription in patients with multimorbidity through medication review.

BACKGROUND: Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study's main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index. METHODS: This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals. RESULTS: Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001). CONCLUSIONS: An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home.

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient's treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Assessment of frailty in elderly patients attending a multidisciplinary wound care centre: a cohort study.

BACKGROUND: The incidence of frailty and non-healing wounds increases with patients' age. Knowledge of the relationship between frailty and wound healing progress is greatly lacking. METHODS: The aim of this study is to characterize the degree of frailty in elderly patients attending a multidisciplinary wound care centres (MWCC). Additionally, we seek to assess the impact of frailty on the wound healing rate and wound healing time. An open cohort study was conducted on 51 consecutive patients aged > 70 years treated for wounds at an MWCC of an intermediate care hospital. The frailty score was determined according to the Frail-VIG index. Data were collected through patient questionnaires at the beginning of the study, and at 6 months or upon wound healing. Wounds were followed up every 2 weeks. To analyse the relationship between two variables was used the Chi-square test and Student's or the ANOVA model. The t-test for paired data was used to analyse the evolution of the frailty index during follow-up. RESULTS: A total of 51 consecutive patients were included (aged 81.1 ± 6.1 years). Frailty prevalence was 74.5% according to the Frail-VIG index (47.1% mildly frail, 19.6% moderately frail, and 7.8% severely frail). Wounds healed in 69.6% of cases at 6 months. The frailty index (FI) was higher in patients with non-healing wounds in comparison with patients with healing wounds (IF 0.31 ± 0.15 vs IF 0.24 ± 0.11, p = 0.043). A strong correlation between FI and wound healing results was observed in patients with non-venous ulcers (FI 0.37 ± 0.13 vs FI 0.27 ± 0.10, p = 0.015). However, no correlation was observed in patients with venous ulcers (FI 0.17 ± 0.09 vs FI 0.19 ± 0.09, p = 0.637). Wound healing rate is statically significantly higher in non-frail patients (8.9% wound reduction/day, P25-P75 3.34-18.3%/day;AQ6 p = 0.044) in comparison with frail patients (3.26% wound reduction/day, P25-P75 0.8-8.8%/day). CONCLUSION: Frailty is prevalent in elderly patients treated at an MWCC. Frailty degree is correlated with wound healing results and wound healing time.

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort.

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

Factors Associated with Medication Non-Adherence among Patients with Multimorbidity and Polypharmacy Admitted to an Intermediate Care Center.

Identifying determinants of medication non-adherence in patients with multimorbidity would provide a step forward in developing patient-centered strategies to optimize their care. Medication appropriateness has been proposed to play a major role in medication non-adherence, reinforcing the importance of interdisciplinary medication review. This study examines factors associated with medication non-adherence among older patients with multimorbidity and polypharmacy. A cross-sectional study of non-institutionalized patients aged ≥65 years with ≥2 chronic conditions and ≥5 long-term medications admitted to an intermediate care center was performed. Ninety-three patients were included (mean age 83.0 ± 6.1 years). The prevalence of non-adherence based on patients' multiple discretized proportion of days covered was 79.6% (n = 74). According to multivariable analyses, individuals with a suboptimal self-report adherence (by using the Spanish-version Adherence to Refills and Medications Scale) were more likely to be non-adherent to medications (OR = 8.99, 95% CI 2.80-28.84, p < 0.001). Having ≥3 potentially inappropriate prescribing (OR = 3.90, 95% CI 0.95-15.99, p = 0.059) was barely below the level of significance. These two factors seem to capture most of the non-adherence determinants identified in bivariate analyses, including medication burden, medication appropriateness and patients' experiences related to medication management. Thus, the relationship between patients' self-reported adherence and medication appropriateness provides a basis to implement targeted strategies to improve effective prescribing in patients with multimorbidity.

Pain management nursing practice assessment in older adults with dementia.

AIM: To assess pain management nursing practice in older adults with dementia through electronic health records (EHR). DESIGN: Retrospective study. METHODS: Data were collected from EHR related to pain management in older adults with dementia treated at the Acute Geriatrics Unit (AGU) of a university hospital in early 2018. RESULTS: EHR related to the pain of 111 patients were reviewed. Pain intensity was assessed at admission in 88% of patients and a median of 1.9 times per day of stay. A disproportionate number of the assessments (39%) occurred during the late shift. A median of 1 drug per day was administered. Pain was recorded in 28% of patients' care plans, and non-pharmacological interventions were recorded in 12%. In conclusion, exist variability in pain management nursing practice in older adults with dementia. Admission diagnosis correlated with the analgesic administration schedule, the number of drugs administered and the number of pain nursing annotations.

An mHealth Workplace-Based "Sit Less, Move More" Program: Impact on Employees' Sedentary and Physical Activity Patterns at Work and Away from Work.

BACKGROUND: Most workplace interventions that aim to reduce sedentary behaviour have 38 focused on employees' sedentary patterns at-work but less have focused on understanding the 39 impact beyond working time. The aim of this study was to evaluate the impact of a 13-week m-40 health workplace-based 'sit less, move more' intervention (Walk@WorkApp; W@W-App) on 41 physical activity (PA) and sitting in desk-based employees at-work and away from work. METHODS: Participants (n = 141) were assigned by hospital to an intervention group (IG; used the W@W-App; n = 90) or an active comparison group (A-CG; monitored occupational activity; n = 51). The W@W-App, installed on the participants´ own smartphones, provided real-time feedback for occupational sitting, standing, and stepping, and gave access to automated strategies to sit less and move more at work. Changes between groups were assessed for total sitting time, sedentary bouts and breaks, and light and moderate-to-vigorous PA (activPAL3TM; min/day) between the baseline and after program completion. RESULTS: Compared to the A-CG, employees that used the W@W-App program increased their number of daily breaks and the time spent on short sedentary bouts (<20 min, p = 0.047) during weekends. Changes in shortest sedentary bouts (5-10 min) during weekends were also statistically significant (p < 0.05). No changes in workday PA or sitting were observed. CONCLUSION: Desk-based employees seemed to transfer the W@W-App program knowledge outside of work. Evaluating the impact of workplace (mHealth-based or not) interventions at work but also away from work would provide a better understating of the impact of such interventions.

Intimate Partner Violence Among Patients Diagnosed With Severe Mental Disorder.

Intimate partner violence (IPV) has a remarkable impact on mental health and is common in people diagnosed with severe mental disorders (SMDs). Data of 102 outpatients were collected from clinical records and the Traumatic Life Events Questionnaire (TLEQ). Global estimation of lifetime IPV exposure was obtained by combining answers to selected TLEQ questions about physical, psychological, and sexual IPV. Overall, 24.5% of the participants reported at least one lifetime episode of IPV victimization. Female gender (odds ratio [OR] = 3.15, p = 0.016) and childhood trauma (OR = 4.7, p = 0.002) significantly increased the likelihood of IPV victimization. Conversely, posttraumatic stress disorder was not significantly increased in IPV victims. These findings are in line with current literature and suggest a remarkable and transdiagnostic prevalence of lifetime IPV victimization in SMD. Gender, childhood trauma, and SMD are relevant factors in IPV analysis and prevention. Diathesis of trauma, psychosocial vulnerability to revictimization and intersectional feminist theory help explain our results.

Profile and results of frail patient assessed by advanced practice nursing in an Emergency Department. / Perfil y resultados del paciente frágil valorado por la Enfermera de Práctica Avanzada en un servicio de urgencias.

OBJECTIVES: To describe the profile of patients evaluated by Nurse Care Management in an Emergency Department and identify the type of alternative healthcare resource assigned and report the results of clinical practice. MATERIAL AND METHODS: Prospective follow-up, on admission to the Emergency Department in an acute hospital and on discharge from the alternative healthcare resource, of patients assessed by Nurse Care Management, from July to December 2015. The patient characteristics, social environment and results of clinical practice were studied. RESULTS: 190 patients were included of whom 13 were readmitted (6.8%). 122 (59.8%) cases from the Emergency Department were referred to to intermediate care facilities, 71 (34.8%) cases for domiciliary care, 10 (4.9%) cases were referred to an acute care hospital and 1 (0.5%) died. Patients referred to intermediate care were more complex, presented geriatric syndromes as their reason for admission and diagnosed with dementia, while those referred to home care presented more respiratory and cardiovascular illnesses (p <0.05). The mean Barthel Index and polypharmacy before emergency admission were higher than at the time of discharge from the alternative healthcare resource (p <0.05). CONCLUSIONS: Patients presenting with advanced age, complexity, comorbidity, are referred to intermediate care facilities or domiciliary care, they are admitted to acute care hospitasl and are readmitted less than other patients. After being discharged from the alternative resource, they lose functional capacity and present less polypharmacy.

[Predicting Care and Repercussions for Caregivers of Surgical Patients at Home]. / Predicción de cuidados y repercusiones en los cuidadores en el domicilio de pacientes quirúrgicos.

Objectives: To analyze the correlation between the state of health, knowledge, and social support of surgical patients' caregivers at home, with the intensity of nursing care and its consequences. Methods: A longitudinal observational study with follow-up at admission, discharge and 10 days following discharge at home, held in the surgical hospitalization unit at the Vic University Hospital, (Barcelona). A non-randomized and consecutive sample of 317 informal caregivers of surgical patients with abdominal surgery was included in the study. The characteristics of caregivers were studied using the Nursing Outcomes Classification indicators. The intensity of nursing care, consequences and impact on patient quality of life was evaluated through the validated ICUB97-R questionnaire. Results: Most of the caregivers were women, with an average age of 52,9 ± 13,7years, with no previous experience as caregivers. The greatest intensity of care and impact was observed on caregivers who attended dependent and/or cancer diagnosed patients at home, dedicating the largest time to provide care (p < 0,005). Predictor variables for the occurrence of consequences during convalescence at home were emotional health satisfaction, routine activity disruption, fear, sleep pattern and being a dependent patient. Conclusions: Emotional health satisfaction, routine activity disruption, fear, sleep pattern and being a dependent patient before surgery are strong predictive variables for the occurrence of consequences on caregivers during convalescence at home. There is a significant negative correlation between punctuations in the ICUB97-R questionnaire and the Nursing Outcomes Classification indicators.

[Continuity of care from the acute care hospital: Results]. / La continuidad de cuidados desde el hospital de agudos: resultados.

OBJECTIVE: To describe the profile of patients treated by a Continuity of Care Manager in an acute-care center during the first six months of its activity, as well as the profile of patients treated and the resource allocation. METHOD: A prospective cross-sectional study was conducted on patients with complex care needs requiring continuity of care liaison, and who were attended by the Continuity of Care Nurse during the period from October 2013 to March 2014. Patient characteristics, their social environment and healthcare resource allocation were registered and analyzed. RESULTS: A total of 1,034 cases of demand that corresponded to 907 patients (women 55.0%; age 80.57±10.1; chronic 47.8%) were analyzed, of whom 12.2% were readmitted. In the multivariate model, it was observed that the variables associated with readmission were polypharmacy (OR: 1.86; CI: 1.2-2.9) and fall history prior to admission (OR: 0.586; CI: 0.36-2-88). CONCLUSIONS: Patients treated by a Continuity of Care Nurse are over 80 years, with comorbidities, geriatric syndromes, complex care, and of life needs, to whom an alternative solution to hospitalization is provided, thus preventing readmissions.

[Care and implications for caregivers of surgical patients at home]. / Cuidados e implicaciones en los cuidadores de pacientes quirúrgicos en el domicilio.

OBJECTIVE: To identify the care given by informal caregivers to patients who underwent abdominal surgery in the Consorci Hospitalari of Vic (Barcelona). To compare the responsibility burden for those caregivers in all the different stages of the surgical process. To determine the consequences of the care itself on the caregiver's health and to identify the factors that contribute to the need of providing care and the appearance of consequences for the caregivers in the home. METHODOLOGY: A longitudinal observational study with follow-up at admission, at discharge and 10 days, of 317 non-paid caregivers of patients who suffer underwent surgery. The characteristics of caregivers and surgical patients were studied. The validated questionnaire, ICUB97-R based on the model by Virginia Henderson, was used to measure the care provided by informal caregivers and its impact on patient quality of life. RESULTS: Most of the caregivers were women, with an average age of 52.9±13.7 years without any previous experience as caregivers. The greater intensity of care and impact was observed in the time when they arrived home after hospital discharge (p<0.05). The predictive variables of repercussions were being a dependent patient before the surgical intervention (ß=2.93, p=0.007), having a cancer diagnosis (ß=2.87, p<.001) and time dedicated to the care process (ß=0.07, p=0.018). CONCLUSIONS: Caregivers involved in the surgical process provide a great amount of care at home depending on the characteristics of patients they care for, and it affects their quality of life.

[Medication adherence and use of health services in patients with psychosis in the region of Osona (Catalonia, Spain)]. / Adherencia al tratamiento y utilización de servicios de salud pacientes con psicosis.

OBJECTIVE: To describe and analyze sociodemographic and clinical characteristics, medication adherence and use of health resources by country of birth of psychosis diagnosed patients treated with long-term antipsychotic injectable drugs in the region of Osona (Catalonia, Spain). METHOD: Descriptive observational study in psychosis diagnosed patients over 18 years old, receiving long-term antipsychotic injectable treatment and treated at a Mental Health Center for adults in Vic (Catalonia, Spain). RESULTS: 185 patients were included, of them: 163 (88.1%) were born in Spain and 22 (17.9%) abroad. The sample was gender homogeneous with differences in age, employment status, family situation and diagnosis (p < 0.05). Findings about medication adherence to long-term antipsychotic injectable ambulatory treatment reflected good compliance in both populations. 57.7% of Spain-born patients and 9.1% of abroad-born patients received the injectable treatment at Primary Care Center (p < 0.001). The rest of them received the treatment at Mental Health Center for adults. 22 patients (711.9%) were admitted at psychiatry hospitalization ward, 16 (9.8%) of them were born in Spain and 6 (27.3%) abroad (p = 0.012). CONCLUSIONS: All patients diagnosed with psychosis, either born or not in Spain, describe good adherence to long-term antipsychotic injectable treatment, with similar use of health resources from a quantitative point of view and some differences in the type of visits.

[Descriptive study of the results of nursing interventions applied to surgical patients]. / Pacientes quirúrgicos e intervenciones enfermeras estandarizadas. Estudio descriptivo sobre resultados.

OBJECTIVES: Knowing the evolution of health outcomes of surgical patients during their hospital stay, evaluating NOC outcome criteria at admission and discharge. MATERIAL AND METHODS: Prospective observational study conducted in the surgical hospital wards of the Hospital General de Vic, with patients who required surgical intervention of any specialty, of 18 or more years old and anesthetic risk levels I, II or III. The main outcome variables were indicators associates with each NOC of a standard of care based on the "patient type" concept. RESULTS: Four hundred and six patients participated. Of these, 69 (15%) were operated of the musculoskeletal system and 391 (85%) were operated on the digestive or urinary systems, male/ female genitalia, skin, integuments, and endocrine system. NOC scores high of all patients were maintained or improved, never worse and in all patients the number of falls and recurrent infections was constant, virtually no patient fell or became infected. CONCLUSIONS: The majority of surgical patients at the time of hospital discharge improves or maintain their conditions of admission and patients who never worse substantially.

Hypoglycemic events in intensive care patients: analysis by insulin administration method and sample type.

BACKGROUND: Intensive insulin treatment is associated with an increased risk of hypoglycemia, so strict glycemic monitoring is essential. The best type of sample for identifying hypoglycemia remains under debate. OBJECTIVES: To establish the number of hypoglycemic events in intensive care patients relative to insulin administration method and the method used to collect the blood sample. METHODS: Retrospective descriptive study lasting 6 months. Hypoglycemia was defined as a blood glucose level less than 80 mg/dL (mild: 50-79 mg/dL, severe: <50 mg/dL), measured with a bedside glucometer and blood from the arterial catheter or fingerstick, in critically ill patients who require insulin administered subcutaneously (with sliding scales) or via continuous intravenous perfusion (intense infusion protocol with a nurse-managed insulin therapy algorithm). RESULTS: Analysis of the 6636 samples from 144 critically ill patients revealed 188 mildly hypoglycemic samples (2.8%) and 3 severely hypoglycemic samples (0.04%). The prevalence of mild hypoglycemia was greater when insulin was administered intravenously (3.2%) rather than subcutaneously (2.3%; P = .04). Among patients receiving insulin intravenously, hypoglycemia was found more often in arterial (4.5%) than in capillary (2.8%) blood (P = .01). The prevalence of hypoglycemia in capillary blood samples did not differ significantly between subcutaneous (2.3%) and intravenous (2.8%) insulin therapies (P = .21). CONCLUSIONS: With a target blood glucose level of 110 to 140 mg/dL, few hypoglycemic events are detected in critically ill patients, regardless of whether insulin is administered intravenously or subcutaneously. Analysis of solely arterial samples may yield a higher prevalence of hypoglycemia than otherwise.