A 2-Minute Cognitive Screener for Predicting 1-Year Functional Recovery and Survival in Older Adults After Hip Fracture Repair.

BACKGROUND: Implementing cognitive assessment in older people admitted to hospital with hip fracture-lying in bed, experiencing pain-is challenging. We investigated the value of a quick and easy-to-administer 10-point Cognitive Screener (10-CS) in predicting 1-year functional recovery and survival after hip surgery. METHODS: Prospective cohort study comprising 304 older patients (mean age = 80.3 ± 9.1 years; women = 72%) with hip fracture consecutively admitted to a specialized academic medical center that supports secondary hospitals in Sao Paulo Metropolitan Area, Brazil. The 10-CS, a 2-minute bedside tool including temporal orientation, verbal fluency, and three-word recall, classified patients as having normal cognition, possible cognitive impairment, or probable cognitive impairment on admission. Outcomes were time-to-recovery activities of daily living (ADLs; Katz index) and mobility (New Mobility Score), and survival during 1-year after hip surgery. Hazard models, considering death as a competing risk, were used to associate the 10-CS categories with outcomes after adjusting for sociodemographic and clinical measures. RESULTS: On admission, 144 (47%) patients had probable cognitive impairment. Compared to those cognitively normal, patients with probable cognitive impairment presented less postsurgical recovery of ADLs (77% vs 40%; adjusted sub-hazard ratio [HR] = 0.44; 95% confidence interval [CI] = 0.32-0.62) and mobility (50% vs 30%; adjusted sub-HR = 0.52; 95% CI = 0.34-0.79), and higher risk of death (15% vs 40%; adjusted HR = 2.08; 95% CI = 1.03-4.20) over 1-year follow-up. CONCLUSIONS: The 10-CS is a strong predictor of functional recovery and survival after hip fracture repair. Cognitive assessment using quick and easy-to-administer screening tools like 10-CS can help clinicians make better decisions and offer tailored care for older patients admitted with hip fracture.

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

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

ORTHOPEDIC SURGERY AMONG THE ELDERLY: CLINICAL CHARACTERISTICS.

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

Cirurgia ortopédica em idosos: aspectos clínicos / Orthopedic surgery among the elderly: clinical characteristics

A atenção a pacientes idosos submetidos à cirurgia ortopédica, particularmente os que necessitam de cirurgia de urgência, deve levar em conta a análise da capacidade física e de riscos específicos dos indivíduos idosos, na tentativa de reduzir riscos que, no entanto, permanecem elevados neste grupo. Apesar dos riscos, procedimentos desenvolvidos com prontidão têm efeito positivo na evolução destes pacientes. A atenção coordenada integrada por equipe clínica/geriátrica, ortopédica, anestésica, intensivistas e demais profissionais de saúde pode ser altamente benéfica neste grupo de pacientes.

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

Identification and treatment of osteoporosis among elderly patients with hip fractures.

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

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

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

Identification and treatment of osteoporosis among elderly patients with hip fractures

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

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

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

Delirium / Delirium

Delirium é uma apresentação comum de distúrbios agudos na população geriátrica. Tem sido associado a um pior prognóstico, aumento de permanência hospitalar e dos custos, bem como maiores taxas de morbidade e mortalidade entre os idosos. Os fatores predisponentes e precipitantes são hoje mais conhecidos e estão associados aos cuidados hospitalares.Estudos controlados demonstram que intervenções preventivas podem reduzir de 30% a 40% a incidência de delirium, essas intervenções estão essencialmente ligadas a melhor qualidade no cuidado hospitalar. Este artigo revisa recentes estudos sobre epidemiologia, diagnóstico, fisiopatologia, tratamento e prevenção do delirium na população idosa.

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

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

Princípios de oncogeriatria / Geriatric oncology: an introduction

Com o envelhecimento progressivo da populaçäo e por ser maior a incidência de câncer com o avançar da idade nos defrontaremos cada vez mais com pacientes idosos portadores de câncer para os quais será necessária uma abordagem clínica ampla e que enfoque tanto aspectos geriátricos como oncológicos. Este artigo visa revisar os princípios da avaliaçäo, tratamento, prevençäo e cuidados paliativos de pacientes idosos com câncer.

Interprofissionalidade / Interprofessional relation

A assistência à saúde do idoso vem evoluindo significativamente nas últimas décadas por vários motivos, incluindo o aumento de demanda pelas alterações demográficas, o maior conhecimento sobre o processo natural de envelhecimento e o acesso às técnicas diagnósticas e terapêuticas anteriormente reservadas aos jovens. Nada, porém, foi tão importante para este incremento qualitativo quanto a progressiva associação de conhecimentos, previamente restrita a cada profissão ou a cada especialidade profissional

Condicionamento físico em idoso: avaliaçäo pela eletrocardiografia de esforço / Physical conditioning in the aged: evaluation by stress electrocardiography

Foram estudados 26 pacientes com idades variando entre 65 e 75 anos (média 68,1 anos), sendo seis com coronariopatia em tratamento clínico, 11 com revascularizaçäo miocárdica e nove assintomáticos. Todos foram submetidos a um teste ergométrico inicial e a um programa de condicionamento físico. Os testes de avaliaçäo foram realizados aos três e/ou seis meses. As variáveis avaliadas foram: freqüência cardíaca, pressäo arterial, duplo produto, manifestaçöes clínicas, trabalho total, consumo máximo de oxigênio e resultados dos testes. Observou-se diminuiçäo do cansaço e dos sintomas durante os testes de controle, bem como elevaçäo do trabalho total e de consumo máximo de oxigênio aos três e, principalmente, aos seis meses de treinamento, com conseqüente melhora da capacidade aeróbica do grupo. Conclui-se que, na faixa etária estudada, o exercício induz evidente melhora das variáveis utilizadas na eletrocardiografia de esforço, sendo um método para avaliaçäo inicial, programaçäo e acompanhamento dos efeitos do condicionamento físico