Aspectos cognitivos y legales en personas mayores: "Sano Juicio"

In Chile, 7.1% of people aged over 60 years have some type of cognitive disorder. The frequency of the latter increases to 13% in people between 75-79 years and 36.2% in people over 85 years. The concept of mild cognitive impairment (MCI) and dementia have evolved over time. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) uses the term minor and major neurocognitive disorder, replacing the DCL and dementia respectively. Major cognitive disorder impairs functional performance while minor disorders does not. There is an arbitrary discrimination against the elderly. A form of discrimination is the request made by some notaries of a medical certification of the cognitive function for older people willing to carry out a legal procedure. This request has the sole effect of pre-establishing evidence in favor of the notary and not protecting the testator or the vulnerable person. Assessing the ability of older people to care for themselves and their possessions has important implications for them and their families, since there is a serious risk of prejudice when someone is declared as disabled. Thus, considering the epidemiology of cognitive disorders in our country we propose a series of legal and medical discussion points aimed to protect autonomy and to protect individuals and their possessions when they have difficulties to control their decisions.

Consumo de alcohol en el adulto mayor chileno que viaja / Alcohol consumption among traveling Chilean older people

Background: Problems associated with alcohol consumption are prevalent in Chile, but little is known about the situation in the elderly. Aim: To perform a screening to detect alcohol-related problems and risks in the Chilean older people who travel. Material and Methods: The Alcohol Use Disorders Identification Test (AUDIT) questionnaire was answered by 1,076 travelers aged 60 to 93 years (66% females), who participated in trips organized by the Chilean National Tourism Service (SERNATUR). Results: Seventy six percent of respondents acknowledged to have ingested an alcoholic drink during the last month. The average AUDIT score was of 2.2 ± 2.6. Only 3.7% of the sample had a score equal or higher than eight, considered as risky use. Within this last group, 60% had symptoms of alcohol dependence. A higher alcohol consumption was associated with male gender (p < 0.01), being younger than 75 years of age (p < 0.01), having a medium-low economic income (p < 0.01) and having a higher education level (p = 0.03). There was no significant association with the respondents´ occupation. Conclusions: In this sample of Chilean traveling older people, there was a high prevalence of alcohol consumption, and nearly 4% of respondents had alcohol related problems.

Toma de Decisiones en pacientes con demencia avanzada / Making decisions in advance dementia

El envejecimiento poblacional ha permitido que sea cada vez más frecuente encontrarse con pacientes que tiene enfermedades cuya probabilidad de presentación aumenta con la edad. Este es el caso de las demencias, que en las etapas más avanzadas presentan variadas complicaciones que requieren tomar decisiones que implican dilemas éticos, recursos y consideraciones clínicas complejas. Existen hoy en día estudios que han permitido conocer mejor el curso de la demencia avanzada y establecer pronósticos según los distintos estadios de la patología los cuales se ven determinados por la situación funcional del paciente. Por otra parte es imperativo conocer la efectividad de las intervenciones evitando las acciones fútiles o aquellas que impliquen riesgos o molestias que superan los beneficios. El objetivo de este artículo es entregar herramientas que sean útiles para los clínicos que atendemos personas mayores en diversos ámbitos tanto médicos como quirúrgicos para aunar las voluntades anticipadas si las hay, los valores y deseos de las familias y los conocimientos médicos existentes para entregar la mejor decisión a un paciente portador de demencia avanzada.

Population ageing has allowed it to be increasingly frequent to encounter patients having diseases whose presentation probability increases with age. This is the case of dementia which in the more advanced stages presents varied complications requiring decisions that involve ethical dilemmas, resources and complex clinical considerations. Today there are studies that have helped better understand the course of advanced dementia and establish prognosis according to the different stages of the disease, which are determined by the patient's functional status. On the other hand it is imperative to know the effectiveness of interventions while avoiding ineffective actions or those involving hazards or inconveniences that outweigh the benefits. This article aims to provide tools that are useful for those of us that as clinicians assist senior patients in both medical and surgical fields, help to bring together wills, if there are, values and wishes of families and existing medical knowledge, in order to deliver the best decision for a patient with advanced dementia.

Evaluación de 1497 adultos mayores institucionalizados, usando el sistema de clasificación de pacientes RUG T-18 / Assessment of 1497 Chilean nursing home residents, using the Resource Utilization Group method, RUG T-18

Background: There is little information about Chilean elderly residents of long term care facilities, regarding their characteristics and need for resources. Aim: To describe main characteristics and resource utilization of residents of one of the largest nursing homes in Chile, Fundación Las Rosas de Ayuda Fraterna. Material and Methods: In a cross sectional and descriptive study, all residents were evaluated using the RUG T-18 method, that assess activities of daily living and the complexity of their clinical situation. Results: We assessed 1497 subjects 60 years old and over (73 percent women), with an age range of 60-106 years. Thirty six percent had urinary incontinence, 19 percent required assistance for feeding, and 38 percent needed help for walking or moving. Fifty seven percent were in the lowest category of complexity, ½Institutionalization¼. Very few residents were in the most demanding categories, no one classified as ½Rehabilitation¼, and only 0.7 percent were in ½Special Care¼. Conclusions: This study is an important start point to learn more about elderly subjects living in nursing homes in Chile (Rev Méd Chile 2004; 132: 701-6).

Impacto biomÚdico de los viajes en adultos mayores chilenos / Biomedical impact of traveling for Chilean elderly

Background: In Chile there is a program named "Vacations for Elderly during Low Season". Aim: To characterize participants of this program and to measure the impact of traveling in their health and wellbeing. Material and methods: Two anonymous and voluntary questionnaires were applied to 4200 participants, before and after a ten days vacation package. Results: Before traveling, questionnaires were answered by 802 subjects, and after traveling by 4057 (69 percent women, 22 percent older than 75 years old, 15.8 percent living alone). The presence and maintaining of good health were most appreciated at this age and 59 percent classified their health as good or excellent. Twenty five percent referred sensory problems (seeing or hearing), 12 percent reported urinary incontinence and 21 percent presented falls in the last three months; depression screening (GDS-5) was positive in 16 percent. Chronic disease prevalence was similar to the general Chilean elderly population. After traveling they reported significant improvements in the items sociability, wellbeing, mood, appetite, insomnia and ostheoarthritic pain. Conclusions: Elderly who traveled were mainly women, who thought that maintaining good health is the most precious value. After traveling they improved significantly different aspects of wellbeing. Promotion of this kind of recreation programs is an important tool for integration and enhancement of quality of life in elderly subjects in our country (Rev MÚd Chile 2004; 132: 573-8).

Estudio comparativo de mujeres mayores de noventa años y ancianas menores institucionalizadas / A comparative study of institutionalized nonagenarian and younger elderly women

Background: The number of nonagenarians is rapidly growing in Chile. This age group is mainly female, with higher frailty markers and in higher risk of being placed at nursing homes. Aim: To describe features of nonagenarian women and compare them with a group of women between 60-89 years, both living in nursing homes, in terms of disability and resource use at the institution. Subjects and methods: A total of 230 nonagenarian women and 460 women, aged 60-89 years, were evaluated in the nursing home Fundación Las Rosas de Ayuda Fraterna (only for poor elderly) in Santiago, Chile. The assessment instruments were the Geriatric Assessment instrument FEGAUC, functional and mental evaluation scales of Spanish Red Cross and the Resource Utilization System, RUG T18, an independent diagnostic classification system that allows the determination of resource use in terms of cost and personnel needs. Results: Nonagenarian women had significantly (p <0.05) more disability (falls, urinary incontinence, memory problems and mobility difficulties), and were classified in RUG categories of higher resource utilization and dependency than younger women. Nevertheless, nonagenarians were a very heterogeneous group, almost half of them were able of moving by themselves or required little assistance and had minimal memory problems. Conclusions: Nonagenarian women assessed in this institution are an heterogeneous group, some with minimal disability and other more frail and dependent than the younger elderly women, being classified in higher categories of resource utilization RUG T18 (Rev Méd Chile 2004; 132: 33-9).

Exceso de mineralocorticoides en hipertensos esenciales: enfoque clínico diagnóstico / Evidences for mineralocorticoid excess in essential hypertension: clinic and diagnosis viewpoint

Background: Primary hyperaldosteronism is more frequent among subjects with essential hypertension than previously thought. The prevalence, according to local and international evidence could fluctuate between 9 and 10 percent. Aim: To investigate if subjects with essential hypertension have different aldosterone and renin plasma levels than normotensive subjects. Patients and methods: One hundred twenty five subjects with essential hypertension, not receiving medications for at least two weeks prior to the study and 168 age and sex matched normotensive controls were studied. Blood was drawn between 9 and 10 AM during a sodium free diet to determine plasma aldosterone, plasma renin activity and potassium. Results: Plasma aldosterone was higher in hypertensive subjects than controls (11.6 ñ 7.6 and 9.9 ñ 5.1 ng/dl respectively; p=0.04). Plasma renin activity was lower in hypertensives than controls (1.42 ñ 1.28 and 1.88 ñ 1.39 ng/ml/h respectively; p<0.001). Thus, plasma aldosterone/plasma renin activity ratio was higher in hypertensives (13.8 ñ 13.5 and 8.3 ñ 7.8; p<0.001). A pathological ratio was defined as over 25, corresponding to the mean plus two standard deviations of the control group. Primary hyperaldosteronism was found in 5/125 hypertensives (4 percent) and 1/168 normotensive subject (0.6 percent). None had hypokalemia. Conclusions: Subjects with essential hypertension have higher plasma aldosterone and lower plasma renin activity than normal controls. A plasma aldosterone/plasma renin activity over 25 was defined as abnormal