Validation of self-reported adherence in chronic patients visiting pharmacies and factors associated with the overestimation and underestimation of good adherence.

BACKGROUND: Studies validating indirect methods to identify nonadherence in chronic patients who visit pharmacies are lacking. The aim of this study was to validate self-reported adherence and assess the variables associated with both overestimation and underestimation of good adherence when using this method. MATERIALS AND METHODS: An observational, cross-sectional study was undertaken to validate self-reported adherence in 132 community pharmacies throughout Spain in 6237 chronic patients. The Morisky-Green test was used as the validation method and through a 2 × 2 table, the validity indicators, predictive values, and likelihood ratios were calculated. To assess the variables associated with both overestimation and underestimation of good adherence, multivariate logistic regression analysis and calculation of the area under the ROC curve were used to evaluate discriminatory capacity. RESULTS: Sensitivity was 27.8% (95% CI: 26.2-29.4) and specificity was 93.9% (95% CI: 93.1-94.7). Discrepancy analysis obtained a significant overestimation of good adherence (p < 0.001). The factors associated with overestimating good adherence were performing a mnemonic trick (p < 0.001), not self-medicating (p < 0.001), a high level of physical activity (p < 0.001), and an older age (p = 0.014). Factors associated with underestimation were self-medication (p < 0.001), desiring more information (p < 0.001), smoking (p = 0.014), not engaging in physical activity in the low (p = 0.006) or high (p < 0.001) categories, having a younger mean age (p = 0.007), and taking two to three (p = 0.029) or four or more (p < 0.001) chronic treatments. CONCLUSION: Self-reported adherence has good specificity but poor sensitivity. The associated profiles of the discrepancies were obtained to identify both good and poor adherence.

The situation of infection in the elderly in Spain: a multidisciplinary opinion document.

Infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. It is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. In an attempt to give the widest possible focus to this issue, the Health Sciences Foundation has convened experts from different areas to produce this position paper on Infection in the Elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. The format is that of discussion of a series of pre-formulated questions that were discussed by all those present. We begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. We also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. In this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed.

Nutritional problems in nursing homes with special reference to Spain.

In this review, after some short conceptual and demographical introductory remarks, I will focus my attention on four topics: a) The question of nutritional assessment of the elderly living in a nursing-home; b) Main nutritional disorders; c) Nursing-homes nutritional studies in Spain; and d) Guidelines and protocols.

Dementia and Nutrition. Intervention study in institutionalized patients with Alzheimer disease.

OBJECTIVES: To know nutritional status of a group of institutionalized patients with moderate Alzheimer's Disease (AD), and to ascertain the effects of an intervention with nutritional supplements on morbidity and mortality after one year follow-up. PATIENTS AND METHODS: 99 patients (mean age: 86.5 years), 80 women, with a diagnosis of AD according with NINCDS/ADRDA criteria, were recruited from 8 nursing-homes. 25 were included in an intervention group and received a nutritional supplements along 12 months. Evolution was evaluated according to the Functional Assessment Staging Test (FAST). Patients with FAST levels 5-6 were included. General clinical variables as well as variables reflecting cognitive state and nutritional status: anthropometric, biochemical data and Mini Nutritional Assessment (MNA) were analysed. Statistical analysis was carry out with the SPSS 10.0 package. RESULTS: Mean time since diagnosis was 49 months, with a 20.2 months duration of institutionalization. Mean value of MNA was 20.1 3.5. 16.5% of patients had a BMI equal o lower than 21. After one year the intervention group showed higher levels of albumin (P=05), pre-albumin (P=05), iron (P=01), zinc (P=05), and beta-carotene (P=05) than the control group. The same response in BMI (P=05), MNA (P=05), and triceps skinfold (P=01). Mortality was lower (16% vs. 22.7%), without statistical significance, in the intervention group, as it was the number of infectious events (47% vs. 66% P=05), and the days in bed (7.5 2.1 vs. 17.3 5.6 P=05). CONCLUSION: Nutritional supplements applied to a group of patients with AD living in nursing-homes can reduce morbidity and mortality after one year follow-up.

[Infective endocarditis in the aged]. / Endocarditis infecciosa en el anciano.

This paper reviews the current questions and the new aspects related to Infective Endocarditis in elderly patients. Four points are emphasized: a) epidemiological changes during the last decades, b) clinical features and diagnostic challenges of infective endocarditis in the elderly, c) mortality and prognosis, and d) preventive and therapeutic measures that must be taken into account.

[Arterial hypertension in the elderly. The outstanding aspects]. / Hipertensión arterial en el anciano. Aspectos destacables.

Arterial hypertension (AHT) is one of the principal health problems facing the community today. Because the prevalence of AHT among the elderly is high and management of the condition is problematic, concern is increasing as the population ages. This article provides the following: a) a short summary of epidemiological data, the most important being the criteria used to define the disease, which has a prevalence of around 50% in patients over 65 years of age (and higher among women); b) a discussion of the role of AHT as a risk factor in the elderly; c) a review of the most important findings and conclusions from studies carried out among the elderly, and d) some final considerations toward the eventual formulation of treatment guidelines.

[Primary double neoplasias (author's transl)]. / Neoplasias primitivas dobles.

Data of 22 patients with primary double tumors are reviewed, collected from a total of 39.000 clinical protocols of which 1.168 were malignant. All were histologically verified. Criteria were those established by Warren & Gates i.e. a) each tumor must present clear signs of malignancy, b) each tumor must be different from the other, c) all possibility that one tumor may be a metastasis of the other must be excluded. Twelve of the cases were male and 10 female, representing 1.88% of the total with malignancies. In 6 cases both tumors appeared simultaneously, while the time interval was between 1 and 43 years in the remaining 16. Hematologic neoplasias are predominant with 12/44, followed by digestive and urogenital ones with 8/44 in each sub-group. Association between double tumors is assessed and causal factors which may influence or favor the appearance of two or more neoplasias are discussed.

Intravenous magnesium load test in elderly patients with protein-energy malnutrition.

Forty-two elderly patients were subjected to a nutritional assessment and an intravenous magnesium load (0.5 mmol/kg). After 48 h, patients with protein-calorie malnutrition (PCM) showed magnesium retentions (MgR) above 20 per cent, thus indicating magnesium deficit, and greater (P < 0.001) than those from well-nourished patients. The discriminating cross-point for undernourished patients was at 28 per cent with 95 per cent sensibility and specificity. There were significant correlations between MgR and most nutritional parameters. An increase of the RMg constitutes a PCM indicator which may be useful to quantify it.

[Cerebrovascular accidents and atrial fibrillation in the elderly patient]. / Accidente cerebrovascular y fibrilación auricular en el paciente anciano.

BACKGROUND: Cerebrovascular disease is the third cause of death in much of the occidental countries. Nowadays atrial fibrillation (AF) is well recognized as an independent and important risk factor for stroke in elderly people. Our aim is to know the frequency of AF in the patients who were admitted to a hospital for an ischemic stroke, the clinical risk factors associated to brain embolism and the prevention of cardiogenic brain embolism. METHODS: 164 patients older than 65 years were admitted to the hospital during 5 months, those who were suspected of stroke were studied prospectively. Only the patients who had a cerebral infarction demonstrated by computed tomography of brain with a neurological alteration of at least 3 days were included in the study. RESULTS: Fifty eight patients (27 men) met the ischemic stroke criteria. 22 of them had AF (9 men). Three of them had no other clinical risk factors associated and 19 had: hypertension in 10 cases, 8 had previous stroke and 1 had a episode of congestive heart failure 3 months before being admitted in the hospital. At the moment of admission only 4 patients were treated with aspirin and none with warfarin. CONCLUSIONS: a) 38% of elderly patients with stroke have AF. b) The association with other clinical factors that increase the risk of brain embolism is high (86%). c) The percentage of patients having a preventing treatment for cardiogenic embolism is very low.

[Significance of emergency care in the elderly patient]. / Importancia de la asistencia urgente en el paciente anciano.

OBJECTIVES: To analyse the statistical and characteristics of the attendance to the elderly patient at the Emergency Department of a General Hospital. METHODS: Retrospective study of patients > or = 65 years assisted at the Emergency Department of the Hospital Clínico San Carlos (Madrid), during 1998, taking into consideration different parameters as age, sex, time of year, referred pathology and final destination; results were compared with data relating to the population under 65. RESULTS: Over 28.4% of the 129,586 subjects that attended the Emergency Department were elderly people. Those ones aged between 65-74 years demanded assistance more frequently, being women's requests higher, particularly among the eldest patients. Assistance requests were higher in winter time, being the most common reason for consultation medical and surgical general troubles (76.4%), followed by trauma emergencies (12.35%). Hospital admission's percentage of elderly people was three times higher than the non-elderly ones, needing more admissions men than women (29 vs 22.7%). CONCLUSIONS: The high statistical of urgent attendance to the elderly patient compared with younger people as well as the higher number of admissions due to this assistance, seem to make necessary the implantation of Geriatric Evaluation Units at the hospital's Emergency Departments.

[The results of a program of preoperative hospital assessment of geriatric patients]. / Resultados de un programa de evaluación preoperatoria hospitalaria en pacientes geriátricos.

In order to illustrate the possibilities that offers the specialized geriatric evaluation during the preoperative period of elderly patients in a general hospital, the results obtained throughout two years are presented and compared, according to preestablished design, in 551 urological patients (U) (age: 75.4 years) and 597 traumatological patients (T) (age: 79 years), all of them over 65 years old. The more frequent interventions were hip fractures (88% of T), prostatic adenoma and vesical urothelioma (42 and 27% of U). Only in 10% of T and 18% of U, we did not observed related problems. The most frequent of these were cardiovascular, neuropsychiatric and respiratory problems, especially in group T. Some kind of recommendations were given in 88% of T and 80% of U. The average period in taking care of these inter-consultations was 1.3 days and the number of perioperative visits was 2.4. In 42% of T and 74% of U, we did not observe psychical discapacities. The average surgical risk measured by the ASA was grade III or IV in 22% of T and 12% of U, similar figures than the ones of the cardiac risk (Goldman). We believe that this type of specialized evaluation is more comprehensive and renders important benefits both for the elderly patients and for the surgeon, when compared with the traditional system of preoperative evaluation.

[Geriatrics seen from the primary care perspective]. / La geriatría vista desde la atención primaria.

PURPOSE: To know the Primary Care Physicians opinion related to their own praxis, background, and needs for a specific medical support in geriatric medicine. METHODS: A closed mailed questionnaire, with 22 items. Descriptive analysis of the results. PEOPLE SAMPLE: 559 answers. 77% men. Age: main group (44%) between 35 and 39 years old. 80% of the sample worked in health centers as primary care physicians. RESULTS: a) Praxis: 50% of the physicians attend more than 20 elderly patients every day. 38% of them have specific aged oriented protocols. 74% of them take age into account when decide the appropriate doses of drugs. b) Geriatric background: None at the undergraduate period: 96%. Some sort of postgraduate formation: 42%. Are able to identify at less a geriatric book: 34%. A score of 4.5 (over 10) was the result of their own assessment about their level of geriatric knowledge. 95% of the answers miss a better formation in geriatrics, and 93% of them think that this formation would change their clinical approach to the elderly patient. c) Needs of specialized geriatric support: It would be helpful to them according to a 84% of the answers. It could be as a "Geriatric Inhospital Service" in the opinion of a 44% of the cases (this question had a 18% of abstentions); and with geriatricians working as extrahospitalary consultants according to the answers of the 79% (6% of abstentions). CONCLUSIONS: Primary care physicians have: 1. Many elderly patients, with an acceptable level of attention to them. 2. A poor geriatric formation and awareness of their needs. 3. Need of a specialized support in their daily work.

[Immobility syndrome in patients being care for in a home care unit]. / Síndrome de inmovilidad en pacientes atendidos en una unidad de ayuda a domicilio.

OBJECTIVES: to asses in a group of elderly patients included in a Home Care Unit, the level of immobility, the functional status based on the Katz's index and the Red Cross scale, and their medical, psychological and social consequences. METHODS: assessment of elderly patients visited during three consecutive months, through and standardized protocol with 14 items related with the previous aspects. RESULTS: 114 elderly patients (71% females) were visited during this time. The mean age was 82.4 years. 71 patients (65.7%) had immobility, with a mean age of 83.4 years and females predominance. Based on the level of immobility, 24 patients were in bed and 44 patients were able to be in bed-armchair. 74% of the patients were severely disabled on the activities daily living (Katz G); 85% of the patients had a severe physical disability (Red Cross scale 4-5), whereas a lower percentage (36%) had severe mental disability (Red Cross scale 4-5). Neurological disorders were the most frequent etiology of immobility (72%), with only one cause in 27 patients, two causes in 20 patients and more than three causes in 24 patients. Medical consequences were the most frequent, mainly urinary and chest infections, pressure sores and constipation. CONCLUSIONS: Immobility's syndrome represents a common medical problem in the geriatric care, related specially with the neurological and osteo-articular disorders, conditioning a high mobility.

[Preoperative geriatric assessment in major surgery in the aged]. / Valoración preoperatoria geriátrica en la cirugía mayor del anciano.

The objective of this study is to investigate if a comprehensive geriatric assessment is useful for predicting morbimortality, functional impairment and the risk for institutionalization for elderly patients after major surgery. A prospective study was carried out at a tertiary hospital, between April and June 1993, including those elderly surgical inpatients for whom a preoperative assessment of the Geriatric Department was demanded. Beside traditional parameters of surgical risk (ASA clas, Goldman index, respiratory and nutritional risk), other medical, functional and social parameters were evaluated. A perioperative follow-up was made and a new functional evaluation one month after discharge. 49.5% of the patients presented perioperative complications and the mortality rate was 10%. 11% needed residential accommodation after discharge. Traditional surgical risks as well as previous functional capacity were predictors of perioperative morbimortality. But only previous functional capacity and nutritional status predict institutionalization. No predictors of functional impairment were found, with the exception of perioperative complications.

[Treatment with propantheline for urinary incontinence caused by bladder instability in the elderly]. / Tratamiento con propantelina de la incontinencia urinaria por inestabilidad vesical en pacientes ancianos.

We conducted a clinical study of a group of aged patients with established urinary incontinence due to vesical instability, in order to assess clinical response to propantheline. Mixed forms of vesical instability were excluded (associated to stress or lower urinary tract obstruction). All patients received propantheline orally at a dosage of 15 mg/6 hours. Modifications in the urinary symptomatology and the impact on functional capacity were analyzed at 3, 6 and 12 months of treatment. We observed a positive response in 63.4% of patients (36.6% curative and 26.8% improvement). Such response was observed during the first three months of treatment and persisted during the twelve months of clinical follow-up. Adverse effects were uncommon and well-tolerated by patients, being mouth dryness the most frequent symptom.

[The effectiveness of geriatric interconsultation in elderly patients admitted to traumatology]. / La eficacia de la interconsulta geriátrica en pacientes ancianos ingresados en traumatología.

OBJECTIVE: To determine the effect of inpatient geriatric consultation in elderly orthopedic patients. DESIGN: Before-after intervention trial. SETTING: Tertiary care university hospital in Madrid (Spain). PATIENTS: All patients older than 64 years admitted to the orthopedic department during one year before (481 patients) and six months after (283 patients) the establishment of geriatric consultation. INTERVENTION: A geriatric consultation team (attending physician and fellow) evaluated, and actively treated when appropriate, most of the patients; follow-up ensued when need until clinical stability or death. MAIN OUTCOME MEASURES: In-hospital mortality, length of hospital stay and transfers to other departments. RESULTS: There was no difference in sex (percent males 23% vs 24%), age (79.2 vs 79.1 years), or length of stay (27.7 vs 26.3 days). Lower in-hospital mortality (9.36% vs 4.95%, p = 0.017) and more transfers to other departments (4.99% vs 12.37%, p = 0.0007) occurred in the study group. CONCLUSIONS: This model of geriatric consultation achieved a lower mortality in orthopedic elderly patients. Length of stay did not change, but there was a higher rate of transfers to other departments. Further controlled studies are needed.

[Mesenteric panniculitis in an 87-year-old female patient]. / Paniculitis mesentérica en una paciente de 87 años.

We report a case of atypical presentation of mesenteric panniculitis in a 87 year old woman. The mesenteric panniculitis disease and the cases published are revised. Delirium as atypical disease presentations and especially dementia, are briefly analyzed.

Progression of Alzheimer disease in Europe: data from the European ICTUS study.

The clinical progression of Alzheimer disease (AD) was studied in European subjects under treatment with AChE inhibitors (AChE-I) in relation to geographical location over a 2-years period. One thousand three hundred and six subjects from 11 European countries were clustered into 3 regions (North, South, West) and investigated with biannual follow-up over 2 years. Primary outcomes were cognitive, functional and behavioral measures. Caregiver burden, hospital admission and admission to nursing home were also recorded. Participant cognitive function declined non-linearly over time (MMSE: -1.5 pts/first year, -2.5 pts/second year; ADAScog: + 3.5 pts/first year, + 4.8 pts/second year), while the progression of behavioral disturbances (NPI scale) was linear. Neither scale showed regional differences, and progression of the disease was similar across Europe despite different health care systems. Functional decline (ADL, IADL) tended to progress more rapidly in Southern Europe (p=0.09), while progression of caregiver burden (Zarit Burden Interview) was most rapid in Northern Europe (5.6 pts/y, p=0.04). Incidences of hospital admission (10.44, 95%CI: 8.13-12.75, p < 0.001) and admission to nursing home (2.97, 95%CI: 1.83-4.11, p < 0.001) were lowest in Southern Europe. In general cognitive and functional decline was slower than in former cohorts. European geographical location reflecting differences in culture and in health care system does not impact on the progression of AD but does influence the management of AD subjects and caregiver burden.