Impact of a geriatric intervention based on the Comprehensive Geriatrics Assessment on avoidable admissions in older patients at risk evaluated in the Emergency Department.

OBJECTIVE: To know the impact of a geriatric intervention based on the Comprehensive Geriatric Assessment (CGA) on avoidable admissions in older patients at risk evaluated in the Emergency Department. METHOD: Prospective observational unicenter study. We included patients, from October 1, 2018 to January 31, 2020, over 75 years who were attended at the Emergency Department with a Triage Risk Screening Tool (TRST) score≥2. All patients were evaluated by a geriatrician through the CGA. The reasons for going to the Emergency room were collected and also the main intervention carried out by Geriatrics, whether admission or discharge was indicated and whether the admission was avoidable. We did a cost analysis calculating this by (bed/day×average stay×number of admissions avoided). RESULTS: We included 260 patients, 66% were women and the mean age was 86 years. 73.5% patients had polypharmacy, the mean Charlson index was 2.5 (5.6). 63.3% were independent for walking and 20.8% independent for basic activities of daily living. 59% had cognitive impairment. 91.5% lived at home. The most frequent reason for visiting the Emergency room was decline of general state in 22% and the most frequent intervention carried out by Geriatrics was assistance in the decision making process in 35.4% followed by referral to a preferential outpatient geriatric care circuit in 32.7%. Other interventions carried out by Geriatrics was assistance in clarifying diagnosis (4.2%), assistance in pharmacological adjustment (8.5%), referral to a standard geriatric care pathway (13.1%), telephone follow-up (4.2%) and/or coordination with Social Services for care planning (11.2%). Including all patients, 29.2% required hospital admission and 70.8% were discharged. 40% admissions were avoided, which meant more than 540 thousand euros saved. CONCLUSIONS: A standardized CGA coordinated by Geriatrics in older patients at risk of suffering adverse events in the Emergency room reduces admissions and costs, so it should therefore be established as a recommendation of good clinical practice.

Characterization of data-driven geriatric syndrome clusters in older people with HIV: a Mexican multicenter cross-sectional study.

Background: As living with HIV has been proposed as a condition that may accelerate aging, the main objective of this work was to estimate the prevalence of geriatric syndromes (GS) among older Mexicans with HIV dwelling in the community. Secondly, to evaluate whether the accumulation of GS could be associated with an adverse HIV-related clinical profile, independent of chronological age. Methods: Multicenter, cross-sectional study including 501 community-dwelling people aged ≥50 years with HIV. The overall prevalence of nine selected GS and their cumulative number were estimated. An Age-Independent Cumulative Geriatric Syndromes scale (AICGSs) was constructed, and correlations between the AICGSs and HIV-related parameters assessed. Finally, k-mean clustering analyses were performed to test the secondary objective. Findings: Median age 56 (IQR: 53-61) years, 81.6% of men. Polypharmacy (74.8%), sensorial deficit (71.2%), cognitive impairment (53.6%), physical disability (41.9%), pre-frailty (27.9%), and falls (29.7%), were the more prevalent GS. A significant negative correlation was found between the AICGSs and normalized values of CD4+ nadir cell counts (r = -0.126; 95%: CI: -0.223 to -0.026, p < 0.05). Similarly, a significant inverse adjusted association between the CD4+ nadir cells and the AICGSs was observed on linear regression analysis (ß -0.058; 95%: CI: -0.109 to -0.007, p = 0.03). Cluster analysis identified three differentiated groups varying by age, metabolic comorbidities, AICGSs, and HIV-related parameters. Interpretation: An elevated prevalence of GS was observed in the studied population. Moreover, the accumulation of GS was associated with adverse HIV-related profiles, independent of age. Thus, early detection and management of GS are crucial to promote healthier aging trajectories in people with HIV. Funding: This work was funded in part by the National Center for the Prevention and Control of HIV/AIDS in Mexico (CENSIDA)-National Ministry of Health.

CD4/CD8 Ratio During Human Immunodeficiency Virus Treatment: Time for Routine Monitoring?

In the last decade, studies in persons with HIV (PWH) on antiretroviral therapy (ART) have shed light on the significance of persistently high CD8 counts and low CD4/CD8 ratios. A low CD4/CD8 ratio reflects increased immune activation and is associated with an increased risk of severe non-AIDS events. As a result, many clinicians now believe that the CD4/CD8 ratio can help in HIV monitoring, and many researchers now report it as an efficacy marker in interventional studies. However, the topic is more complex. Recent studies have not yielded unanimous conclusions on the ability of the CD4/CD8 ratio to predict adverse outcomes, and only some clinical guidelines recommend monitoring it. Knowledge gaps remain on the best cutoff points, associated clinical events, effects of treatments, and how the CD4/CD8 ratio could improve decision making in the clinic. Here, we critically review the literature, identify knowledge gaps, and discuss the role of the CD4/CD8 ratio as a marker for HIV monitoring.

Estudio exploratorio prospectivo de los factores asociados a eventos adversos en salud en personas mayores que viven con VIH / An exploratory prospective study of the factors associated with adverse health outcomes in older adults living with HIV

Introducción Gracias al tratamiento antirretroviral en Occidente, la infección por el virus de la inmunodeficiencia humana (VIH) se ha convertido en una enfermedad crónica. Hoy, el 50% de las personas que viven con VIH son mayores de 50 años y en torno al 20% de los nuevos casos de esta infección se dan en ese mismo grupo etario. Este trabajo tiene por objeto el analizar los factores clínicos y sociodemográficos asociados a eventos adversos en salud (caídas, visitas a urgencias, ingresos hospitalarios y muerte) en una cohorte de personas mayores de 55 años con infección por VIH. Métodos Estudio exploratorio prospectivo con cuatro años de seguimiento. Se incluyeron personas con infección por VIH seguidas en las consultas de enfermedades infecciosas de dos hospitales de Madrid. Se recogieron datos sociodemográficos y variables clínicas. Se evaluó la situación funcional, mental y social de los participantes. Se revisaron en las historias clínicas de los pacientes número de caídas, visitas a los servicios de urgencias, ingresos hospitalarios y muertes producidas durante el periodo estudiado. Resultados Se incluyeron 117 pacientes con una edad media de 61,4 (desviación estándar 6,6) años y una mediana de seguimiento de 47 meses (35 a 50). De estos sujetos, el 25% tenía síntomas depresivos y el 10% tenía algún grado de deterioro cognitivo en la visita inicial. Las frecuencias de eventos adversos en salud registradas fueron: caídas del 7,7%, visitas a urgencias del 53%, ingresos hospitalarios del 33,3% y muertes del 2,6%. Los síntomas de depresión se asociaron con caídas y visitas a urgencias en el análisis bivariado. Los factores asociados a ingreso hospitalario fueron haber adquirido la infección por consumo de drogas por vía parenteral, ser frágil y ser menor de 65 años. Se realizó análisis multivariado para el resultado de ingresos hospitalarios con las variables que mostraron p < 0,05 en el análisis bivariado y ninguna de ellas alcanzó significación estadística. Conclusiones Los síntomas de depresión y el deterioro cognitivo se presentan con una alta frecuencia en estos pacientes, por lo que debería realizarse tamizaje de ambos de forma sistemática en este grupo poblacional. Son necesarios estudios con más pacientes y mayor tiempo de seguimiento que permitan identificar los factores de riesgo asociados a eventos adversos en las personas mayores que viven con VIH.

Introducción Gracias al tratamiento antirretroviral en Occidente, la infección por el virus de la inmunodeficiencia humana (VIH) se ha convertido en una enfermedad crónica. Hoy, el 50% de las personas que viven con VIH son mayores de 50 años y en torno al 20% de los nuevos casos de esta infección se dan en ese mismo grupo etario. Este trabajo tiene por objeto el analizar los factores clínicos y sociodemográficos asociados a eventos adversos en salud (caídas, visitas a urgencias, ingresos hospitalarios y muerte) en una cohorte de personas mayores de 55 años con infección por VIH. Métodos Estudio exploratorio prospectivo con cuatro años de seguimiento. Se incluyeron personas con infección por VIH seguidas en las consultas de enfermedades infecciosas de dos hospitales de Madrid. Se recogieron datos sociodemográficos y variables clínicas. Se evaluó la situación funcional, mental y social de los participantes. Se revisaron en las historias clínicas de los pacientes número de caídas, visitas a los servicios de urgencias, ingresos hospitalarios y muertes producidas durante el periodo estudiado. Resultados Se incluyeron 117 pacientes con una edad media de 61,4 (desviación estándar 6,6) años y una mediana de seguimiento de 47 meses (35 a 50). De estos sujetos, el 25% tenía síntomas depresivos y el 10% tenía algún grado de deterioro cognitivo en la visita inicial. Las frecuencias de eventos adversos en salud registradas fueron: caídas del 7,7%, visitas a urgencias del 53%, ingresos hospitalarios del 33,3% y muertes del 2,6%. Los síntomas de depresión se asociaron con caídas y visitas a urgencias en el análisis bivariado. Los factores asociados a ingreso hospitalario fueron haber adquirido la infección por consumo de drogas por vía parenteral, ser frágil y ser menor de 65 años. Se realizó análisis multivariado para el resultado de ingresos hospitalarios con las variables que mostraron p < 0,05 en el análisis bivariado y ninguna de ellas alcanzó significación estadística. Conclusiones Los síntomas de depresión y el deterioro cognitivo se presentan con una alta frecuencia en estos pacientes, por lo que debería realizarse tamizaje de ambos de forma sistemática en este grupo poblacional. Son necesarios estudios con más pacientes y mayor tiempo de seguimiento que permitan identificar los factores de riesgo asociados a eventos adversos en las personas mayores que viven con VIH.

Effects of frailty, geriatric syndromes, and comorbidity on mortality and quality of life in older adults with HIV.

BACKGROUND: To understand the effects of frailty, geriatric syndromes, and comorbidity on quality of life and mortality in older adults with HIV (OAWH). METHODS: Cross-sectional study of the FUNCFRAIL multicenter cohort. The setting was outpatient HIV-Clinic. OAWH, 50 year or over were included. We recorded sociodemographic data, HIV infection-related data, comorbidity, frailty, geriatric syndromes (depression, cognitive impairment, falls and malnutrition), quality of life (QOL) and the estimated risk of all-cause 5-year mortality by VACS Index. Association of frailty with geriatric syndromes and comorbidity was evaluated using the Cochran-Mantel-Haenszel test. RESULTS: Seven hundred ninety six patients were included. 24.7% were women, mean age was 58.2 (6.3). 14.7% were 65 or over. 517 (65%) patients had ≥3 comorbidities, ≥ 1 geriatric syndrome and/or frailty. There were significant differences in the estimated risk of mortality [(frailty 10.8%) vs. (≥ 3 comorbidities 8.2%) vs. (≥ 1 geriatric syndrome 8.2%) vs. (nothing 6.2%); p = 0.01] and in the prevalence of fair or poor QOL [(frailty 71.7%) vs. (≥ 3 comorbidities 52%) vs. (≥ 1 geriatric syndrome 58.4%) vs. (nothing 51%); p = 0.01]. Cognitive impairment was significantly associated to mortality (8.7% vs. 6.2%; p = 0.02) and depression to poor QOL [76.5% vs. 50%; p = 0.01]. CONCLUSIONS: Frailty, geriatric syndromes, and comorbidity had negative effects on mortality and QOL, but frailty had the greatest negative effect out of the three factors. Our results should be a wake-up call to standardize the screening for frailty and geriatric syndromes in OAWH in the clinical practice. TRIAL REGISTRATION: NCT03558438.

Different profiles among older adults with HIV according to their chronological age and the year of HIV diagnosis: The FUNCFRAIL cohort study (GeSIDA 9817).

BACKGROUND: People in their fifties with HIV are considered older adults, but they appear not to be a homogeneous group. OBJECTIVE: To evaluate the differences among older adults with HIV according to their chronological age and the year of HIV diagnosis. METHODS: Cross-sectional study of the FUNCFRAIL cohort. Patients 50 or over with HIV were included and were stratified by both chronological age and the year of HIV diagnosis: before 1996 (long-term HIV survivors [LTHS]) and after 1996. We recorded sociodemographic data, HIV-related factors, comorbidities, frailty, physical function, other geriatric syndromes, and quality of life (QOL). RESULTS: We evaluated 801 patients. Of these, 24.7% were women, 47.0% were LTHS, and 14.7% were 65 or over. Of the 65 or over patients, 73% were diagnosed after 1996. Higher rates of comorbidities among LTHS were found, being the more prevalent: COPD, history of cancer, osteoarthritis, depression, and other psychiatric disorders while the more prevalent among the 65 or over patients were: hypertension, diabetes, dyslipidemia, cancer, and osteoarthritis. LTHS showed a significantly worse QOL. There were no differences by the year of HIV diagnosis regarding frailty and functional impairment (SPPB <10) but they were more than twice as prevalent in the 65 or over patients compared to the other chronological age groups. CONCLUSIONS: A LTHS and a 65 or over person are both "older adults with HIV," but their characteristics and requirements differ markedly. It is mandatory to design specific approaches focused on the real needs of the different profiles.

Deprescribing of non-antiretroviral therapy in HIV-infected patients.

PURPOSE: In recent decades, the life expectancy of HIV-infected patients has increased considerably, to the extent that the disease can now be considered chronic. In this context of progressive aging, HIV-infected persons have a greater prevalence of comorbid conditions. Consequently, they usually take more non-antiretroviral drugs, and their drug therapy are more complex. This supposes a greater risk of drug interactions, of hospitalization, falls, and death. In the last years, deprescribing has gained attention as a means to rationalize medication use. METHODS: Review of the different therapeutic approach that includes optimization of polypharmacy and control and reduction of potentially inappropriate prescription. RESULTS: There are several protocols for systematizing the deprescribing process. The most widely used tool is the Medication Regimen Complexity Index, an index validated in HIV-infected persons. Anticholinergic medications are the agents that have been most associated with major adverse effects so, various scales have been employed to measure it. Other tools should be employed to detect and prevent the use of potentially inappropriate drugs. Prioritization of candidates should be based, among others, on drugs that should always be avoided and drugs with no justified indication. CONCLUSIONS: The deprescribing process shared by professionals and patients definitively would improve management of treatment in this population. Because polypharmacy in HIV-infected patients show that a considerable percentage of patients could be candidates for deprescribing, we must understand the importance of deprescribing and that HIV-infected persons should be a priority group. This process would be highly feasible and effective in HIV-infected persons.

Beyond orthogeriatric co-management model: benefits of implementing a process management system for hip fracture.

Hip fracture is a major health care problem worldwide. Business process management systems (PMSs) have made significant contributions in health care environments to improve patient care standards. The effectiveness of PMS applied to hip fracture in older adults in the acute phase has been demonstrated. INTRODUCTION: Fragility fracture is a major health care problem worldwide. Business PMSs have made significant contributions in health care environments to improve patient care standards. It is a new way of management that defines a homogeneous application procedure involving eliminating steps that add no value and developing explicit supervision criteria, in addition to identifying the appropriate managers. PURPOSE: The aim of our trial was to assess the effectiveness of the PMS applied to hip fracture versus the orthogeriatric co-management model in the acute phase. METHODS: All consecutive patients aged ≥ 65 who were admitted to Hospital Universitario Infanta Leonor between January 1, 2009, and December 31, 2016, for acute hip fracture surgery were included. We compared the effectiveness indicators in the acute phase between the preprocess period (orthogeriatric co-management) and the process period. RESULTS: One thousand two hundred twenty-two patients were included (76.6% women). Mean age (SD) was 83.9 (6.4) years. Effectiveness management indicators are the following: length of hospital stay, time to admission to the ward from the emergency department, preoperative stay, surgery in < 48 h, and the operating room availability which were all improved in the process period with statistical significance. Effectiveness clinical indicators are the following: the numbers of patients with operated limb loading approved after surgery, discharged to home, and with osteoporosis treatment postfracture at the time of discharge which were statistically significantly higher in the process period, and the number of patients who suffered from delirium was statistically significantly lower in the process period. The number of in-hospital deaths was lower during the process period without statistical significance. CONCLUSION: Our results demonstrated the effectiveness of the PMS applied to hip fracture in older adults compared with an orthogeriatric co-management model in the acute phase, based on both management indicators and clinical indicators.