World guidelines for falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES: to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS: a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS: all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS: the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

New horizons in falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries. METHODS: a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient's perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together. CONCLUSION: in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.

Prevalence in vulnerable population of liver fibrosis identified by transient elastography.

BACKGROUND: Transient elastography (TE) is a useful tool for the assessment of hepatic fibrosis as an alternative to liver biopsy, but it has not been validated as a screening procedure in apparently healthy people. AIM: To determine the prevalence of advanced liver fibrosis diagnosed by TE in a socioeconomically challenged rural population. MATERIAL AND METHODS: We enrolled 299 participants aged over 18 years old from a vulnerable population in Mexico who responded to an open invitation. All participants had their history recorded and underwent a general clinical examination and a liver stiffness measurement, performed by a single operator according to international standards. RESULTS: Overall, 7.35% participants were found to be at high risk for cirrhosis. Three variables correlated with a risk for a TE measure ≥ 9 kPa and significant fibrosis: history of alcohol intake [7.95 vs. 92.04%, odds ratio (OR) 4.47, 95% confidence interval (CI) 1.45-13.78, P = 0.0167], body mass index (BMI) ≥ 30 kg/m2 (30.87 vs. 69.12%, OR 4.25, 95%CI 1.04-6.10, P = 0.049), and history of diabetes mellitus (14.87 vs. 85.12%, OR 2.76, 95%CI 1.002-7.63, P = 0.0419). In the multivariate analyses BMI ≥ 30 kg/m2 was the only significant risk factor for advanced liver fibrosis or cirrhosis (OR 2.54, 95%CI 1.02-6.3, P = 0.0460). CONCLUSION: TE could be useful as a screening process to identify advanced liver fibrosis in the general and apparently healthy population.

Recurrent pancreatic pseudocyst diagnosed 9 years after initial surgical drainage.

CONTEXT: A pancreatic pseudocyst is defined as a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue which is not lined by epithelium. Acute pseudocysts occur in acute pancreatitis but can be found after an acute exacerbation of chronic pancreatitis. Chronic pancreatic pseudocysts are typically found in chronic pancreatitis but may develop after an occurrence of acute pancreatitis as well. Most acute fluid collections and pseudocysts will show spontaneous resolution while the remaining may persist with or without symptoms, or progress to produce complications. Treatment is indicated for persistent, symptomatic pseudocysts and, in the case of complications. There is no clear consensus regarding the optimal clinical or radiologic follow-up after treatment. Detection of late recurrence is not common, and the possibility of a cystic neoplasm must be ruled out. CASE REPORT: We report the case of a 67-year-old female patient who was referred to our institution as the result of a pancreatic pseudocyst. The patient had presented a pancreatic pseudocyst 9 years earlier which had been surgically treated by a cystogastrostomy. No additional acute pancreatic episodes occurred. The diagnostic and treatment approach of this unusual late recurrent pancreatic pseudocyst is herein described. CONCLUSION: The unusual late presentation of a recurrent pancreatic pseudocyst requires clinical, laboratory and radiological evaluation. In the present case, the clinical background, amylase fluid levels and tomographic findings were highly suggestive of a pancreatic pseudocyst.

[The importance of updating criteria of altered fasting glucose levels in Mexico]. / Importancia de la actualización en México del criterio de glucosa en ayuno alterada.

OBJECTIVE: To evaluate the impact of applying the 2003-ADA-proposed lower normality value of fasting glucose (FG) on impaired fasting glucose (IFG), prevalence and the agreement between diagnostic categories from ADA-2003 FG values and WHO two hours oral glucose tolerance test (OGTT) current criteria in a Mexican population with suspected diabetes. METHODS: A retrospective cross sectional study was undertaken. We analyzed fasting and 2 hours post load glucose values of 2062 patients and compared diagnostic categories on the basis of different criteria. RESULTS: Considering fasting values, prevalence of IFG changed from 17.7 % to 41.3 % when applying ADA-1997 or ADA-2003 criteria, respectively. Furthermore, based on their OGTT values (WHO-1999), 63 % the 852 IFG patients identified by ADA-2003 criteria were reclassified as having diabetes (26.1 %) or IGT (36.9 %). A heavy kappa test showed a moderate diagonal agreement of 0.43260 (CI 95 % = 0.43214-0.43305) between diagnostic categories from ADA-2003 with FG and OGTT values and WHO current criteria. CONCLUSIONS: The lower ADA-2003 criteria for IFG identifies a higher ratio of patients with IGT or DM.

Sarcopenia y su relevancia en la práctica clínica / Sarcopenia and its relevance in clinical practice

La sarcopenia se define como una combinación de baja fuerza y masa muscular con alteración funcional del músculo, que afecta a poblaciones de diferentes edades por diversos motivos. La prevalencia global en adultos mayores se ha estimado en 10% (IC 95%: 8-12%) en hombres y 10% (IC 95%: 8-13%) en mujeres. Recientemente ha cobrado importancia su detección en enfermedades reumáticas, particularmente las inflamatorias. En esta revisión narrativa hemos considerado: a) recomendaciones para el diagnóstico de la sarcopenia; b) herramientas útiles para la práctica clínica y la investigación; c) su relación con las enfermedades reumáticas. Según el último Consenso Europeo de Sarcopenia la búsqueda debe comenzar cuando el paciente reporta síntomas y/o signos (debilidad, lentitud al caminar, desgaste muscular, pérdida de masa muscular, etc.). Para los adultos mayores se recomienda el cuestionario SARC-F como herramienta de tamizaje. Varias pruebas establecen los puntos de corte que deben utilizarse para diagnosticar la baja fuerza muscular, la disminución en la masa muscular y la alteración en el rendimiento físico. La relevancia de diagnosticar precozmente la sarcopenia se basa en el impacto clínico, económico y social que tiene, incluyendo la funcionalidad y calidad de vida de las personas, muy importante en aquellas con enfermedades reumatológicas.

Sarcopenia is defined as a combination of low muscle strength and mass with muscle function impairment that affects the population at different age ranges for different reasons. The global prevalence at the elderly was estimated at 10% (95% CI: 8-12%) in men and 10% (95% CI: 8-13%) in women. In recent years, the detection of sarcopenia in rheumatic diseases has become relevant. The aim of this revision was to develop a review regarding: a) recommendations for the diagnosis of sarcopenia; b) most useful tools for detection in clinical practice and research; c) relationship with some rheumatic diseases. According to the latest European Sarcopenia Consensus, in clinical practice, the search must start when the patient reports symptoms and signs (weakness, slow walking, muscle wasting, disease that leads to muscle loss, etc.). For the elderly population the SARC-F test is recommended as a screening tool. Several tests have established cut-off points to be used to diagnose low muscle strength, decrease in muscle mass or physical performance impairment. The relevance of early diagnosis of sarcopenia is based on the clinical, economic, social impact and also on functionality and quality of life in people, particularly in those with rheumatic diseases.

Relación entre fibromialgia y sarcopenia: el papel del abordaje nutricional / Fibromyalgia and sarcopenia relation: the role of nutritional approach

Introducción: la fibromialgia (FM) es un síndrome caracterizado por la presencia de dolor musculoesquelético crónico y generalizado, de origen no articular, que puede llegar a ser invalidante y afectar la esfera biológica, psicológica y social del paciente. Estado del arte: no se han publicado recomendaciones nutricionales específicas para las personas con FM y también existe un vago conocimiento acerca de los parámetros relacionados con la evaluación de la composición corporal (masa musculoesquelética, masa grasa, agua corporal, etc.) y la alteración en la fuerza muscular (p. ej., dinapenia, por dinamometría de mano, flexión de la rodilla, entre otras), así como la evaluación en términos de sarcopenia. Discusión: pocos estudios publicados hasta el momento describen en profundidad la composición corporal de las personas con FM. La mayoría se centran casi exclusivamente en la descripción del peso y el índice de masa corporal (IMC), por lo que existe poco conocimiento acerca de otros parámetros de relevancia, como por ejemplo aquellos relacionados con masa y fuerza muscular o masa grasa. La alimentación se menciona en varias publicaciones, pero no existen guías o pautas específicas de recomendaciones nutricionales para esta población. Algunos pacientes adoptan diversas dietas, estrategias o planes alimentarios sin ningún tipo de orientación de los profesionales de la salud, e incluso a veces, siguiendo fuentes de información no fiables, poniendo en riesgo su salud. Las publicaciones científicas no evalúan la asociación o el impacto del estado nutricional y la inadecuada alimentación en la calidad de vida. Conclusiones: en las personas con FM, conocer el estado nutricional, más allá del peso, determinando la composición corporal y la prevalencia de dinapenia o sarcopenia o ambas permitiría realizar un abordaje nutricional más adecuado. Este conocimiento podría ser coadyuvante en la terapéutica, logrando una mejoría en su desempeño físico y una mejor calidad de vida. (AU)

Introduction: fibromyalgia (FM) is a syndrome charcaterized by the presence of chronic, and generalized musculoskeletal pain, not articular in origin, which can become disabling and affect the biological, psychological, and social sphere of the patient. State of the art: no specific nutritional recommendations have been published for people with FM and there is also a vague knowledge regarding parameters related to body composition assessment (skeletal muscle mass, body fat mass, water, etc.) and loss of muscle strength (for example, dynapenia, by handgrip, knee flexion, among others), as well as assessment in terms of sarcopenia. Discussion: there are few studies published so far that completely describe the body composition in people with FM. Most of them focus almost exclusively on weight and body mass index (BMI), so there is a lack of knowledge about other descriptive parameters, such as those related to muscle mass and strength or fat mass. Diet is mentioned in several publications, but there are no specific guidelines for nutritional recommendations for this population. Some patients follow several diets, strategies or eating plans without health care professionals' guidance, and sometimes even following unreliable sources of information, putting themselves at risk. Scientific publications do not evaluate the association or impact of nutritional status and inadequate nutrition on quality of life in FM. Conclusions: in people with FM, knowledge of the nutritional status, beyond weight, determining body composition and the prevalence of dynapenia and/or sarcopenia would allow a more accurate nutritional approach. This knowledge could be helpful for the treatment, achieving an improvement in their physical performance and a better quality of life. (AU)

The HUGE formula (hematocrit, urea, gender) for screening for chronic kidney disease in elderly patients: a study of diagnostic accuracy.

Chronically reduced glomerular filtration rate (GFR) in old people does not always mean that they suffer from chronic kidney disease (CKD) since their GFR can just be reduced by aging. The HUGE equation has been recently described and validated in Spain for screening CKD without taking into account the patient's GFR value. This equation is based on patient's hematocrit, plasma urea levels and gender. The present study documented that the HUGE equation had and acceptable performance for screening CKD in elderly Argentine patients.

How to differentiate renal senescence from chronic kidney disease in clinical practice.

Renal aging is frequently confused with chronic nephropathy in clinical practice, since there are some similarities between them, particularly regarding reduced glomerular filtration rate (GFR). However, there are many differences between these two entities which can help any practitioner to distinguish between them, such as: GFR deterioration rate, hematocrit, renal handling of urea, creatinine and some electrolytes, tubular acidification, urinalysis, and renal imaging. Differentiation between renal aging and chronic renal disease is crucial in order to avoid unnecessary medicalization of what is a physiological change associated with the healthy aging process, and the potential harmful consequences of such overdiagnosis. A recently described equation (HUGE), as well as an adequate nephrological evaluation and follow up can help physicians to distinguish both entities.

Glomerular filtration rate equations: a comprehensive review.

Since evaluation of glomerular filtration rate (GFR) is very important in daily medical care, and reliable methods for measuring GFR are too complicated, there has been along decades an enormous effort for developing accurate GFR equations. In the present review article, we performed a comprehensive analysis of the mainly described GFR equations, and we concluded that although MDRD, CKD-EPI, DRA and Gregori-Macías equations are valid to monitor renal function as well as to stage and follow up renal patients, the clinical nephrological evaluation still remains the best alternative for diagnosing renal health and disease.

Healthy Aging in the Americas

[EXTRACT]. In just the past 50 years, life expectancy has increased by more than 20 years. This significant increase in longevity is due in part to advances in medicine, public health interventions, biotechnology, and social and economic development that have made it possible for people to live longer than at any other time in history.

Envejecimiento saludable en la Región de las Américas

Tan solo en los últimos 50 años, la esperanza de vida ha aumentado en más de 20 años. Este aumento significativo de la longevidad se debe en parte a los avances de la medicina, las intervenciones de salud pública, la biotecnología y el desarrollo social y económico, que han permitido a las personas vivir más que en cualquier otro momento de la historia. En América Latina y el Caribe, la proporción de personas de 60 o más años de edad aumentará incluso en 18% durante el próximo decenio y para el 2050 se ubicará entre 25% y 30% de la población. Esta transición ocurrirá en 35 años, que es tan solo la mitad del tiempo que requirió en Estados Unidos y Canadá.

Frailty phenotype and chronic kidney disease: a review of the literature.

Frailty is a construct originally coined by gerontologists to describe cumulative declines across multiple physiological systems that occur with aging and lead individuals to a state of diminished physiological reserve and increased vulnerability to stressors. Fried et al. provided a standardized definition for frailty, and they created the concept of frailty phenotype which incorporates disturbances across interrelated domains (shrinking, weakness, poor endurance and energy, slowness, and low physical activity level) to indentify old people who are at risk of disability, falls, institutionalization, hospitalization, and premature death. Some authors consider the presence of lean mass reduction (sarcopenia) as part of the frailty phenotype. The frailty status has been documented in 7 % of elderly population and 14 % of not requiring dialysis CKD adult patients. Sarcopenia increases progressively along with loss of renal function in CKD patients and is high in dialysis population. It has been documented that prevalence of frailty in hemodialysis adult patients is around 42 % (35 % in young and 50 % in elderly), having a 2.60-fold higher risk of mortality and 1.43-fold higher number of hospitalization, independent of age, comorbidity, and disability. The Clinical Frailty Scale is the simplest and clinically useful and validated tool for doing a frailty phenotype, while the diagnosis of sarcopenia is based on muscle mass assessment by body imaging techniques, bioimpedance analysis, and muscle strength evaluated with a handheld dynamometer. Frailty treatment can be based on different strategies, such as exercise, nutritional interventions, drugs, vitamins, and antioxidant agents. Finally, palliative care is a very important alternative for very frail and sick patients. In conclusion, since the diagnosis and treatment of frailty and sarcopenia is crucial in geriatrics and all CKD patients, it would be very important to incorporate these evaluations in pre-dialysis, peritoneal dialysis, hemodialysis, and kidney transplant patients in order to detect and consequently treat the frailty phenotype in these groups.

Therapeutic alternatives and palliative care for advanced renal disease in the very elderly: a review of the literature.

The overall number of very elderly patients (>79 years of age) requiring renal replacement therapy is rising in the Western societies, with a choice for managing advanced chronic renal disease among hemodialysis, peritoneal dialysis, kidney transplant, conservative, or palliative care. The selection of the most adequate alternatives should be tailored to meet individual needs, considering variables such as patient's choice, clinical status, and social context, analyzed from a geriatric perspective, aiming not only to prolong patient's life expectancy, but also to improve the patient's quality of life. Frailty and sarcopenia are highly prevalent comorbidities found in very elderly population, particularly in the end-stage chronic renal disease population. Both comorbidities have a strong negative impact on health general status, and specific treatment should be provided in conjunction with the selected management for renal replacement, except when a palliative care has been implemented. Moreover, the detected degree of frailty in a renal patient can have an important influence on the decision about which modality of renal replacement treatment will be selected. All these alternatives and considerations are discussed in the present review article.

Are currently GFR estimating equations and standard Kt/V value adequate for advanced chronic kidney disease (CKD) frail elderly patients?

Chronic kidney disease (CKD) elderly patients have a reduced glomerular filtration rate (GFR) due to the combination of ageing and chronic nephropathy damage. This situation is very important to be taken into account in order to prescribe an adequate medication and dialysis dose in this aged group. Besides, cognitive and urinary incontinence problems make difficult to obtain an adequate 24-h urine collection in order to evaluate creatinine clearance in this group. Thus, a reliable GFR estimating equation would be very useful for assisting elderly CKD patients. Additionally, Kt/V is the main parameter currently used for dosing dialysis in stage V CKD young and elderly patients. However, frailty and sarcopenia are prevalent disorders usually suffered by old people, who also present many physiological changes that could make GFR estimating equations and standard Kt/V value to become unreliable in this particular group. In conclusion, based on all these facts, it seems crucial for clinical geriatric nephrology to carefully evaluate how reliable current GFR estimating equations are, as well as which would be an adequate Kt/V value in CKD frail elderly patients.

Renin-angiotensin-aldosterone system and the aging kidney.

Human senescence induces changes in the renin-angiotensin-aldosterone system (RAAS) which consists of a substantial decrease in its plasma activity. Consequently, the distal tubule´s capability of handling sodium and potassium is significantly reduced in the elderly, while distal tubule acidification is slightly delayed but preserved in this age group. Several studies in animal models support the hypothesis that senile renal structural changes could be induced by the local production of angiotensin II, and also that enalapril significantly decreases senile mesangial expansion, glomerulosclerosis and peritubular and medullar interstitial sclerosis. The same applies to several highly prevalent diseases in the elderly, such as hypertension, obesity, cardiac insufficiency, chronic nephropathy and dementia. In conclusion, the relationship between the RAAS and senescence is complex, since not only does aging cause many changes on this hormonal system, but also RAAS overactivity seems to be one of the main inducing mechanisms for normal senescence, and for many prevalent diseases in the elderly.

Total hip arthroplasty for hip fractures: 5-year follow-up of functional outcomes in the oldest independent old and very old patients.

INTRODUCTION: This study aimed to determine the dislocation and reoperation rate, functional outcomes, and the survival rate of the unique subset of very old but lucid and independent patients with hip fractures following a total hip arthroplasty (THA) and geriatric team-coordinated perioperative care. METHOD: Between 2000 and 2006, previously independent ambulatory patients ≥80 years old presenting with an intracapsular hip fracture were given THAs under the care of an integrated orthopedic surgery-geriatric service. Their fracture-related complications, ambulation, mental status, and survival were followed for 5 to 11 years postinjury. RESULTS: Five years postinjury, 57 (61.3%) patients of the original study group were living. In all, 3 (3.2%) patients had postoperative hip dislocations (and 2 patients had dislocation twice) and 2 reoperations were needed within the first postoperative month. There were no hip dislocations or reoperations after the first year. Radiographs obtained on 88% of the surviving patients at 5 years postoperatively showed that all remained unchanged from their immediate postoperative images. Nearly half of the patients were still able to ambulate as they did preoperatively and their mixed-model equation was statistically unchanged. CONCLUSION: This study of patients >80 years old with previously good functional status demonstrates that with appropriate surgical (best prosthesis, good operating technique, and regional anesthesia) and geriatric (pre- and postoperative assessments, close follow-up, medication adjustments, and fall-prevention instruction) care, they have few hip dislocations and reoperations, survive postfracture at least as long as their noninjured contemporaries, and continue to function and ambulate as they did prior to their injury.

Zenker's Diverticulum: Diagnostic Approach and Surgical Management.

Zenker's diverticulum (ZD), also known as cricopharyngeal, pharyngoesophageal or hypopharyngeal diverticulum, is a rare condition characterized by an acquired outpouching of the mucosal and submucosal layers originating from the pharyngoesophageal junction. This false and pulsion diverticulum occurs dorsally at the pharyngoesophageal wall between the inferior pharyngeal constrictor and the cricopharyngeus muscle. The pathophysiology of ZD involves altered compliance of the cricopharyngeus muscle and raised intrabolus pressure. Decreased compliance of the upper esophageal sphincter and failure to open completely for effective bolus clearance both lead to an increase in the hypopharyngeal pressure gradient. Different open surgical techniques and transoral endoscopic approaches have been described for the management of ZD, although there is no consensus about the best option. We report the case of a 61-year-old patient with a 7-year history of dysphagia and odynophagia for solid food, which after 2 months progressed to dysphagia for liquids and after 4 months to regurgitation 2-6 h after meals. The patient experienced a 12-kg weight loss. Diagnosis was established by esophagogram, which showed a diverticulum through the posterior pharyngeal wall, suggestive of a ZD. Esophagogastroduodenoscopy showed a pouch with erythematous mucosa. Under general anesthesia, diverticulectomy and myotomy were performed. After an uneventful recovery and adequate oral intake, the patient remains free of symptoms at 4 months of follow-up.