[Old age and the new ICD-11: Position of the Latin American Academy of Medicine for Older PersonsA velhice e a nova CID-11: posição da Academia Latino-americana de Medicina do Idoso]. / La vejez y la nueva CIE-11: posición de la Academia Latinoamericana de Medicina del Adulto Mayor.

Since 1948, the World Health Organization has been publishing the International Statistical Classification of Diseases and Related Health Problems (ICD), a coded system of causes of disease and death with an in-depth revision every 10-15 years. In its latest revision, the ICD-11 uses nomenclature characterizing old age as "initial and final geriatric periods," implying the medicalization of this stage of life, which has created confusion and sparked controversy. This article discusses the new nomenclature proposed, given the current knowledge about old age and the aging process and its most accepted definition. The ICD not only classifies diseases but periods of life and "health-related problems," and old age per se is not a health-related problem for many people at this stage of life. It is therefore essential to change or provide a more nuanced definition of the term "old age" in the ICD-11, so it is not perceived as a symptom, sign, or anomalous clinical outcome, and to introduce nomenclature that more accurately reflects pathological aging. Two terms that are enjoying growing experimental and bibliographic support are "fragility" and "loss of intrinsic capacity," which offer greater precision when defining the condition of a person who is not experiencing healthy aging.

Desde 1948, a Organização Mundial da Saúde publica um sistema codificado de causas de doença e morte sob o nome de Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde (CID), com revisões profundas a cada 10-15 anos. Sua última versão, a CID-11, utiliza determinada terminologia para caracterizar a velhice como "períodos geriátricos iniciais e finais", o que implica uma medicalização dessa fase da vida que tem gerado confusão e polêmica. Este artigo discute a nova terminologia proposta à luz dos conhecimentos atuais sobre a velhice e o processo de envelhecimento, e sua definição mais aceita. A CID não classifica apenas as doenças, mas também períodos da vida e "problemas de saúde", sendo que a velhice por si só não representa um problema de saúde para muitos que se encontram nesta fase da vida. A partir dessa perspectiva, é imprescindível alterar ou qualificar o verbete "velhice" da CID-11 para que não seja percebido como sintoma, sinal ou resultado clínico anormal, e em seu lugar introduzir termos que melhor reflitam o estado de envelhecimento patológico. Entre os termos que têm crescente suporte experimental e bibliográfico estão "fragilidade" e "perda de capacidade intrínseca", que proporcionam uma precisão muito maior na definição da condição de quem não goza de um envelhecimento saudável.

Logros académicos en Geriatría y Gerontología en Costa Rica / Academic achievements in Geriatrics and Gerontology in Costa Rica

Resumen El análisis panorámico de la información demográfica en Costa Rica y Latinoamérica evidencia el impacto que tiene y tendrá la demanda de servicios especializados en Geriatría y Gerontología, en los diferentes niveles de atención en un sistema nacional de salud y la comunidad. Esto involucra un enfoque multidisciplinario, interdisciplinario y transdisciplinario, por la complejidad inherente a las situaciones. El desarrollo histórico de la geriatría internacional y nacional, junto con los invaluables aportes académicos mediante diferentes modalidades de enseñanza: educación médica continua, grado y postgrado, con la participación activa del Hospital Nacional de Geriatría y Gerontología de la Caja Costarricense de Seguro Social y de la Facultad de Medicina de la Universidad de Costa Rica, colocan al país en una posición aventajada en esta área de formación de recurso humano; los logros académicos obtenidos en los últimos 28 años permiten un escenario más optimista para las personas adultas mayores en el país.

Abstract The panoramic analysis of demographic information in Costa Rica and Latin America, demonstrates the impact it has and will have the demand for specialized services in Geriatrics and Gerontology at different levels of care in the national health system and the community; which involves a multidisciplinary, interdisciplinary and transdisciplinary approach due to the complexity of the situations. The historical development of international and national geriatrics, and the invaluable academic contributions in the different teaching modalities: Continuing, Undergraduate and Postgraduate Medical Education, with the active participation of the National Hospital of Geriatrics and Gerontology of the Costa Rican Social Security SYSTEM and of The Faculty of Medicine of the University of Costa Rica, places Costa Rica in an advantageous position in this area of human resource training, the academic achievements obtained in the last 28 years allow us to see a more optimistic outlook for older adults in the country.

Clinical, functional, mental and social profile of the Nicoya Peninsula centenarians, Costa Rica, 2017.

BACKGROUND: In Latin America, knowledge about the demography and health status of adults aged 100 years and over is scarce. Insufficient studies of the elderly population in Costa Rica exist despite having a "Blue Zone" (geographical area with a high concentration of centenarians) in the Peninsula of Nicoya, with a high percentage of centenarians in the districts of Santa Cruz, Nicoya, Hojancha, Nandayure and Carrillo. AIMS: To describe the clinical, functional, mental and social profile of centenarians residing in the Blue Zone of the Peninsula of Nicoya, Costa Rica. METHODS: This is a cross-sectional study using a population base of 43 community-dwelling centenarians. A comprehensive geriatric assessment was performed, including sociodemographic information, health status, electrocardiogram and laboratory tests. RESULTS: The mean age of centenarians was 101.93 years, of whom 18 (42%) were men and 25 (58%) women. Two (4.6%) resided in nursing homes. Women had worse results than men in the evaluation of dependence on basic and instrumental activities of daily living, and the short physical performance battery performance test. A high prevalence of low Vitamin D levels (87.3%), atrial fibrillation (9.3%) and visual impairment (46.5%) was found. CONCLUSIONS: This is the first study describing the medical, functional, mental and social profile of centenarians in the Peninsula of Nicoya (Blue Zone) in Costa Rica. This population has a high prevalence of malnutrition and hypertension with dependence on the basic activities of daily living, and a low prevalence for diabetes, depression, ischemic heart disease, chronic obstructive pulmonary disease, and polypharmacy.

Adverse outcomes of frailty in the older population of Costa Rica / Eventos adversos de la Fragilidad en la población adulta mayor de Costa Rica

Resumen Objetivo: Entre los años del 2000 y 2050 el número de habitantes mayores de 60 años de edad en Costa Rica se duplicarán. Un número considerable de ellos llegarán a ser frágiles. Estudios han demostrado la relación entre la condición de fragilidad y pobres desenlaces. El objetivo del presente trabajo fue identificar los eventos adversos asociados a la fragilidad en la población adulta mayor de Costa Rica. Métodos: Para realizar el análisis, se emplea la totalidad de los casos disponibles en la base de datos del estudio de CRELES en el 2005, que pertenecen a la cohorte que da seguimiento en el periodo 2005-2009. En el año de partida de esta cohorte, se cuenta con un total de 2827 pacientes. El fenotipo de la fragilidad fue construido basado en el modelo fenotípico. Se realizó un análisis longitudinal, y se examinó los años iniciales y finales de esta cohorte. Los desenlaces analizados fueron la mortalidad, los ingresos hospitalarios, el deterioro funcional, las caídas y la autopercepción de la salud en el año 2009. Se utilizó una técnica de regresión logística multinomial, utilizando variables de desenlaces como variables dependientes. La condición de fragilidad se utilizó como variable independiente. Como resultado, se obtuvo una odds ratio para la incidencia de cada categoría de desenlaces con un 95% de confianza. Resultados: La condición de fragilidad se asoció con mayor deterioro funcional, aumento en los ingresos hospitalarios y empeoramiento en la autopercepción de la salud. Conclusión: La fragilidad se relacionó con pobres desenlaces en la población costarricense. La identificación de esta condición proporciona una oportunidad para una intervención temprana.

Abstract Objective: Between 2000 and 2050 the number of inhabitants aged 60 years or older in the World and in Costa Rica will double. A considerable number of them will become frail. Studies have shown the relationship between the frailty condition and poor outcomes. The aim of this study was to identify the adverse outcomes of frailty in the older Costa Rican population. Methods: To carry out the analysis, all the available cases of the CRELES study database in 2005 which belong to the cohort that follows in the period 2005-2009 were used. In the year of the initial cohort there was a total of 2827 patients. A frailty phenotype was constructed based on the phenotypic model. A longitudinal analysis was conducted, and it examined the initial and final years of this cohort. The outcome variables analysed were mortality, hospital admittances, functional deterioration, falls, and self-perception of worsening health in the year 2009. A multinomial logistic regression technique was used, using outcome variables as dependent variables. The frailty condition was used as an independent variable. As a result, there was an odds ratio obtained for the incidence of each outcome category with 95% confidence. Results: Frailty was associated with functional declines, hospital admittances, and worsening of the self-perception. Conclusion: Frailty was related to adverse outcomes in Costa Rica. Identifying this provides an opportunity for an early intervention.

Comparative analysis of aging policy reforms in Argentina, Chile, Costa Rica, and Mexico.

This investigation uses case studies and comparative analysis to review and analyze aging policy in Argentina, Chile, Costa Rica, and Mexico and uncovers similarities and relevant trends in the substance of historical and current aging policy across countries. Initial charity-based approaches to poverty and illness have been gradually replaced by a rights-based approach considering broader notions of well-being, and recent reforms emphasize the need for national, intersectoral, evidence-based policy. The results of this study have implications for understanding aging policy in Latin America from a welfare regime and policy makers' perspective, identifying priorities for intervention and informing policy reforms in developing countries worldwide.

Volunteer provision of long-term care for older people in Thailand and Costa Rica.

PROBLEM: Demand for long-term care services for older people is increasing rapidly in low- and middle-income countries. Countries need to establish national long-term care systems that are sustainable and equitable. APPROACH: The Governments of Costa Rica and Thailand have implemented broadly comparable interventions to deploy volunteers in long-term home care. Both countries trained older volunteers from local communities to make home visits to impoverished and vulnerable older people and to facilitate access to health services and other social services. LOCAL SETTING: Costa Rica and Thailand are upper-middle-income countries with strong traditions of community-based health services that they are now extending into long-term care for older people. RELEVANT CHANGES: Between 2003 and 2013 Thailand's programme trained over 51 000 volunteers, reaching almost 800 000 older people. Between 2010 and 2016 Costa Rica established 50 community care networks, serving around 10 000 people and involving over 5000 volunteers. Despite some evidence of benefits to the physical and mental health of older people and greater uptake of other services, a large burden of unmet care needs and signs of a growth of unregulated private services still exist. LESSONS LEARNT: There is scope for low- and middle-income countries to develop large-scale networks of community-based long-term care volunteers. The capacity of volunteers to enhance the quality of life of clients is affected by the local availability of care services. Volunteer care networks should be complemented by other initiatives, including training about health in later life for volunteers, and investment in community long-term care services.

Is Geriatric Medicine Possible in a Middle-Income Country? The Case of Costa Rica.

This article outlines the current and future-projected demographic data, organization, networks for the care of older people, and perspectives in Costa Rica in relation to the challenges resulting from exponential growth of the older adult population, most notably those aged 80 and older. It includes consideration of the Norms of Integrated Care of the Older Adult of Costa Rica's national social security system and contributions from other public and private institutions. It also makes note of commentaries on the need for ever-increasing efforts to manage the care of Costa Rica's burgeoning older adult population.

Características clínicas de los casos de demencia diagnosticados en la Clínica de Memoria del Hospital Nacional de Geriatría y Gerontología / Clinical aspects of dementia cases diagnosed at the Memory Clinic of the National Geriatric and Gerontology Hospital

Antecedentes: la demencia es una entidad clínica cada vez más prevalente en nuestro medio, cuya incidencia aumenta con la edad. El objetivo del presente estudio es identificar los principales tipos de demencia atendidos en una unidad de trastornos de memoria. Métodos: registro consecutivo y estandarizado de pacientes diagnosticados con demencia en la Unidad de Trastornos de Memoria y Conducta, del Hospital Nacional de Geriatría y Gerontología. Resultados: se evaluó 1659 casos, de los cuales el 65,8% reunió criterios de demencia. El 42,9% correspondió a enfermedad de Alzheimer, el 28,5% a demencia secundaria a patología vascular, el 17,1% a formas mixtas, y el 11,5% a tipos varios. La edad media fue de 79,6 + 6,7 años, y el 66,2% fueron mujeres. La escolaridad promedio fue 4,95 + 4,09 años; el 41,7% estaba casado; el 47,3% tenía un hijo como cuidador; el tiempo promedio entre la aparición de los síntomas y el diagnóstico clínico fue de 3,18 + 2,6 años. La puntuación media del test Minimental fue de 18,35 + 5,9 puntos; en el test de dibujo del reloj fue de 3,4 + 2,5, y el Clinical Dementia Rating fue de 1,7 + 0,7; el 45,2% de los casos correspondió a CDR de 1. El 24% de los casos tenía antecedente familiar de demencia, y el 95,7% presentaba uno o más factores de riesgo cardiovascular, siendo la HTA el más frecuente, en un 70,2%. El 27,1% de los casos fue demencias leves; el 31,9%, moderadas; el 39,3% moderadas-severas, y el 1,7%, severas. El 90% de los casos presentó uno o más trastornos neuroconductuales. Conclusiones: la determinación de los principales tipos de demencia en la población adulta mayor y sus principales características, ha permitido registrar gran cantidad de información que se desconocía y que será de útil para la gestión y planificación de estrategias de atención en salud pública.

Background: Dementia is an increasingly prevalent clinical entity in the medical field, whose incidence increases with age. The purpose of this study is to identify the main types of dementia treated in a memory-disorders unit. Methodology: A consecutive and standardized register of patients diagnosed with dementia at the Memory Disorders Unit of the National Geriatrics and Gerontology Hospital. Results: 1659 cases were evaluated, 65.8% met criteria for dementia. 42.9% of the cases were Alzheimer’s disease, 28.5% secondary vascular dementia pathology, mixed forms represented 17.1% and 11.5% were diverse types. The mean age was 79.6 + 6.7 years and 66.2% were women. Average schooling was 4.95+ 4.09 years, 41.7% were married, 47.3% had a child as a caregiver, the average time between onset of symptoms and the clinical diagnosis was 3.18 + 2.6 years. The mean Minimental test score was 18.35 + 5.9 points, in the clock drawing test it was 3.4 + 2.5 and the Clinical Dementia Rating was 1.7 + 0.7; 45.2% of cases were CDR 1. 24% of cases had a family history of dementia and 95.7% had one or more cardiovascular risk factors, with AHT being the most common in 70.2%. 27.1% of dementia cases were mild, 31.9% moderate, 39.3% moderatesevere and 1.7% were severe. 90% of patients had one or more neurobehavioral disorders. Conclusions: The determination of the main types of dementia in the elderly population and their main features has allowed the registry of abundant information that was unknown and that will be useful for the management and strategic planning of public health care.

El envejecimiento en Costa Rica: una perspectiva actual y futura / The ageing process in Costa Rica: a current and future perspective

El artículo es descriptivo sobre el envejecimiento en su definición, alcances demográficos, organizativos, red de cuido y perspectivas de la realidad actual y futura en la que está inmersa Costa Rica, como un fenómeno poblacional explosivo, dadas sus altas esperanzas de vida, especialmente en el grupo poblacional de 80 y más. Se analiza el estado actual de la Red de Atención Integral a la Persona Adulta Mayor dentro de la Seguridad Social, así como acciones por realizar de parte de las diferentes instancias públicas y privadas, tomando muy en cuenta su integralidad. Finalmente, se reflexiona sobre las necesidades inminentes que planteará una población envejecida, y las estrategias para enfrentarlas adecuadamente.

This article describes the ageing process, as well as its definition, demographic data and organization; the elderly care network and the current and future perspectives of its reality in Costa Rica. This is part of a population phenomenon characterized by high life-expectancy of the population group 80 years and older. The article makes an analysis of the Integral Care Network for the Elderly (Red de Atención Integral a la Persona Adulta Mayor), sponsored by the social security system; and suggests actions that must be carried out by other relevant public and private institutions, also taking into account the integrality among them. Finally, the article presents some thoughts about the imminent needs of an increasingly ageing population and suggestions on how to deal with it.

Memory clinic experience under a social security health system in Costa Rica.

Dementia and mild cognitive impairment (MCI) are an increasingly prevalent clinical entity in our field, showing an increasing incidence with age. OBJECTIVE: The purpose of this study was to identify the main types of dementia and MCI treated in a memory disorders unit in Costa Rica. METHODS: A consecutive and standardized register of patients diagnosed with dementia and MCI at the memory disorders unit of the National Geriatrics and Gerontology Hospital (NGGH) was analyzed. RESULTS: Dementia was diagnosed in 63.5% of the 3572 cases, whereas 10.6% met criteria for MCI. The most frequent type of dementia was Alzheimer's disease (47.1%), followed by vascular pathology (28.9%), mixed forms (17.2%) and other types (6.8%). In MCI, 69.5% were of amnestic multiple domain type and 14.3% were non-amnestic multiple domain, while 41.3% were of vascular and 35.8% of neurodegenerative etiology. Mean age was 79.6±6.7 years and 64.7% were women in dementia cases whereas mean age was 76.4±6.9 years and 62.1% were women in MCI. Mean years of schooling was 4.95±4.09 years and 6.87±4.71, while mean time between onset of symptoms and clinical diagnosis was 3.2±2.6 years and 2.67±2.69 years, in dementia and MCI, respectively. CONCLUSION: The determination of the main types of dementia and MCI in Costa Rica and their main features has allowed the registration of comprehensive, hitherto unavailable information that will be useful for the management and strategic planning of public health care.

Demência e transtorno cognitivo leve (CCL) é uma entidade clínica cada vez mais prevalente, mostrando uma incidência crescente com a idade. OBJETIVO: O objetivo deste estudo foi o de identificar os principais tipos de demência e CCL tratados em uma unidade de transtornos da memória de Costa Rica. MÉTODOS: Um registo consecutivo e padronizado de pacientes com diagnóstico de demência e CCL na unidade de transtorno de memória do Hospital Geral de Geriatria e Gerontologia. RESULTADOS: Demência foi diagnosticada em 63,5% dos 3.572 casos, enquanto 10,6% tiveram diagnóstico de CCL. O tipo mais frequente de demência foi a doença de Alzheimer (47,1%), seguido de doença vascular (28,9%), formas mistas (17,2%) e outros tipos (6,8%). No CCL, 69,5% eram de tipo amnéstico de múltiplos domínios e 14,3% eram não-amnéstcios de múltiplos domínios, enquanto 41,3% eram de etiologia vascular e 35,8% de etiologia neurodegenerativa. A média de idade foi de 79,6±6,7 anos e 64,7% eram mulheres em casos de demência ao passo que a média de idade foi de 76,4±6,9 anos e 62,1% eram mulheres nos casos de CCL. A média de anos de estudo foi de 4,95±4,09 anos e 6,87±4,71, o tempo entre o início dos sintomas eo diagnóstico clínico médio foi de 3,2±2,6 anos e 2,67±2,69 anos em demência e CCL, respectivamente. CONCLUSÃO: A determinação dos principais tipos de demência e CCL na Costa Rica e as suas principais características permitiu o registro de informação abundante que era desconhecida e que será útil para a gestão e planejamento estratégico da saúde pública.

Fibrilación atrial en los adultos mayores: [revisión] / Atrial fibrillation in the elderly: [review]

La fibrilación atrial es la taquiarritmia más prevalente en los adultos mayores. La frecuencia de dicha arritmia aumenta con la edad, presentándose en un 1.5 por ciento de los 50 a 59 años a 10 por ciento de los 80 a 89 años. La fibrilación atrial no valvular incrementa el riesgo de sufrir un evento cerebrovascular isquémico cardioembólico en 5 veces y causa el 15 por ciento de todos los accidentes cerebrovasculares isquémicos en Estados Unidos de América. El manejo de la fibrilación atrial se enfoca, principalmente, en la prevención de los fenómenos tromboembólicos y en el control de la frecuencia y ritmo cardiaco. La anticoagulación, cuando está indicada, ha demostrado ser la principal herramienta en la prevención de dichos eventos. Sin embargo, aunque las complicaciones hemorrágicas son más frecuentes, en esta población, y aumentan con la edad, sobrepasa por mucho, el beneficio al riesgo. El control de la frecuencia cardiaca ha demostrado ser igual o mejor que el control del ritmo en cuanto a prevención de eventos cerebrovasculares y mortalidad en estos pacientes. La edad cronológica por sí sola, no es contraindicación algun para ofrecer una terapia óptima. Debe tomarse en cuenta el estado funcional, cognitivo y social, así como aspectos fisiológicos del envejecimiento con respecto a la prescripción de medicamentos. Cuando, a pesar del tratamiento adecuado, la sintomatología persiste, las estrategias invasivas han demostrado ser beneficiosas, pero faltan estudios que involucren a individuos mayores.

Atrial fibrillation is the most prevalent arrhythmia in the elderly. Its frequency increases with age, being 1.5% from 50 to 59 years old and 10% from 80 to 89 years old. Non valvular atrial fibrillation increases 5 fold the risk of suffering an stroke and causes 15% of strokes in the USA. Atrial fibrillation management focuses in the prevention of thromboembolic phenomena andheart rate and rhythm control. Anticoagulation, when indicated, has demonstrated to be the main tool in the prevention of these events.Nevertheless, although bleeding complications are more frequent in this population and increase with age, anticoagulation benefits are greater than the risks. Heart rate control is better than rhythm control regarding cerebrovascular accidents and mortality. Age by itself is not acontraindication to offer optimal therapy. Functional, mental and social status, must be taken into account as well as physiological aspects of aging when it comes to prescribing medications. If symptoms persist in spite of adequate treatment, invasive strategies have demonstrated to beof benefit, however studies in elderly population are lacking.

La atención de los ancianos: un desafio para los anos noventa / Elderly care: a challenge to the years ninety

El libro presenta, con un enfoque integrado y actualizado, diversos temas relacionados con la salud y bienestar del anciano. Va dirigido a todos los responsables de la atención directa de este grupo y de tomar decisiones que sirvan de base para la adopcion de políticas pertinentes. Como dice el prologo: "El rapido envejecimiento de la poblacion en los países en desarrollo, la identificacion de necesidades especificas en la poblacion anciana, ciertas circunstancias desestabilizadoras de la vida actual y futura (migracion a las ciudades, desempleo y subdesempleo, fallas en los sistemas de seguridad social, reduccion del tamano de las familias, entre otras) y las limitaciones en el crecimiento económico constituyen poderosas razones para que los gobiernos y las organizaciónes nacionales e internacionales, gubernamentales y no gubernamentales, relacionadas con el bienestar y la salud de las sociedades, se interesen y trabajen entusiasta y coordinadamente en favor de las personas de edad avanzada". La obra consta de 52 articulos, divididos en seis secciones, que cubren las siguientes áreas: el envejecimiento, la vision integral de los ancianos, principales aspectos de salud de los ancianos, bases para la atención de los ancianos, promocion del bienestar de los ancianos y perspectivas

Unidad de posgrado de geriatría y gerontología / Graduate unit on geriatrics and gerontology

Dentro de los acelerados cambios demográficos para la población anciano se encuentra Costa Rica con esperanza de vida al nacer progresivamente elevada. Razones suficientes para preparar toda la infraestructura necesaria de una manera inmediata y progresiva, con el objeto de darle la asistencia geronto-geriátrica oportuna a esta creciente población de 60 años y más. Es por esto que se ha diseñado el presente programa de docencia, cuya finalidad es capacitar de la manera más completa posible, a los futuros médicos geriatras y gerontólogos que necesita Costa Rica. Para el diseño del presente programa se revisaron los mejores programas de docencia de países Europeos y de Norte América, así como toda la experiencia acumulada por el equipo de profesionales que participaron