Prognostic Value of a New Tool (the 3D/3D+) for Predicting 30-Day Mortality in Emergency Department Patients Aged 75 Years and Older.

The 3D/3D+ multidimensional geriatric assessment tool provides an optimal model of emergency care for patients aged 75 and over who attend the Emergency Department (ED). The baseline, or static, component (3D) stratifies the degree of frailty prior to the acute illness, while the current, or dynamic, component (3D+) assesses the multidimensional impact caused by the acute illness and helps to guide the choice of care facility for patients upon their discharge from the ED. The objective of this study was to evaluate the prognostic value of the 3D/3D+ to predict short- and long-term adverse outcomes in ED patients aged 75 years and older. Multivariable logistic regression models were used to identify the predictors of mortality 30 days after 3D/3D+ assessment. Two hundred and seventy-eight patients (59.7% women) with a median age of 86 years (interquartile range: 83-90) were analyzed. According to the baseline component (3D), 83.1% (95% CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) presented alterations in 60.1% (95% CI: 54.1-65.9). The choice of care facility at ED discharge indicated by the 3D/3D+ was considered appropriate in 96.4% (95% CI: 93.0-98.0). Thirty-day all-cause mortality was 19.4%. Delirium and functional decline were the dimensions on the 3D/3D+ that were independently associated with 30-day mortality. These two dimensions had an area under receiver operating characteristic of 0.80 (95% CI: 0.73-0.86) for predicting 30-day mortality. The 3D/3D+ tool enhances the provision of comprehensive care by ED professionals, guides them in the choice of patients' discharge destination, and has a prognostic validity that serves to establish future therapeutic objectives.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study.

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

Abordaje multidisciplinarde un paciente con una úlceraperianal asociada a pomadaantihemorroidal / Multidisciplinary approach to a patient with a perianal ulcer associated with hemorrhoidal ointment

Introducción: Hasta la fecha, la manifestación de una úlcera perianalprovocada por una pomada antihemorroidal no se ha descrito confrecuencia. Sin embargo, se ha objetivado un incremento de loscasos durante la pandemia de COVID-19. Caso clínico: Varónde 82 años independiente, que presentó una úlcera perianal de35,8 cm² sin ninguna patología ni enfermedad concomitante queexplicara su causa. La aplicación de criterios de exclusión exhaustivos,incluida una biopsia para rechazar el pioderma gangrenoso,identificó una pomada rectal hemorroidal como la causa de la úlcera.Plan de actuación: La herida curó tras aplicar una intervenciónmultidisciplinaria y una terapia con factores de crecimientoautólogos. Discusión y conclusiones: Este caso ha sido escasamentereportado en la literatura, aunque esta pomada hemorroidal secomercializa desde hace más de 40 años. Se recomienda evaluaciónmédica antes de la prescripción. (AU)

Introduction: Perianal ulcers resulting from the use of hemorrhoidalointments have been rarely reported to date. Nevertheless, therehas been a surge in the number of cases reported during theCOVID-19 pandemic. Case report: An independent 82-year-oldmale experienced a 35,80 cm² perianal ulcer, with no underlyingcondition or concomitant disease that could explain the cause ofthe ulcer. The application of thorough exclusion criteria, including abiopsy to rule out pyoderma gangrenosum, led to the identificationof a hemorrhoidal rectal ointment as the cause. Action plan: Theulcer healed completely when a multidisciplinary intervention and anautologous growth factors advanced therapy were applied. Discussionand conclusions: This case has been scarcely reported in the literature,although this hemorrhoidal ointment has been on the market for over40 years. Medical assessment before prescription and patients’ followup is recommended. (AU)

[3D/3D+ as a tool for rapid geriatric assessment and adequacy of the care resource at discharge from the Emergency Department]. / Las 3D/3D+ como herramienta de valoración geriátrica rápida y de adecuación del recurso asistencial al alta de los Servicios de Urgencias.

OBJECTIVE: Assess the 3D/3D+ rapid geriatric assessment tool for the early detection of frailty, its usefulness to identify the effects of the acute process on the functional, physical, cognitive and socioenvironmental dimensions, as well as the medications that may have triggered the patient's reason for visit. Finally, assess the usefulness of 3D/3D+ together with the clinical diagnosis to adequate care resource at discharge from the emergency department (ED). METHOD: Retrospective observational cohort study. Patients ≥75 years old, with clinical complexity visited at the ED were included. Basal frailty status was assessed using 3D (basal component), and the multidimensional impact of the acute process using 3D+ (current component). The main dependent variable was adequacy of the care resource at ED discharge. RESULTS: 278 patients were included, mean age 86 years (interquartile range: 83-90), 59.7% were women. According to the basal component (3D), 83.1% (95%CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) was altered in 60.1% (95%CI: 54.1-65.9). The adequacy of ED discharge was correct in 96.4% (95%CI: 93.0-98.0). One out of 4patients was admitted to a medicine ward. CONCLUSIONS: 3D/3D+ facilitates an optimal model of emergency care adapted to patients ≥ 75 years old treated in EDs. It stratifies the level of frailty (3D), detects the severity of patients' acute problems (3D+) and contributes to decision-making regarding the most appropriate care resource at ED discharge.

Las 3D/3D+ como herramienta de valoración geriátrica rápida y de adecuación del recurso asistencial al alta de los Servicios de Urgencias / 3D/3D+ as a tool for rapid geriatric assessment and adequacy of the care resource at discharge from the Emergency Department

Objetivo: Evaluar la herramienta de valoración geriátrica rápida 3D/3D+como cribado precoz de fragilidad; su utilidad para identificar la repercusión del proceso agudo en las dimensiones funcional, cognitiva, social y los posibles fármacos desencadenantes del motivo de consulta. Por último, la utilidad de las 3D/3D+junto al diagnóstico clínico para adecuar el recurso asistencial al alta del servicio de Urgencias hospitalario (SUH).Método: Estudio observacional de cohortes retrospectivo. Se incluyó a los pacientes de 75 o más años con complejidad clínica que fueron atendidos en el área médica del SUH. Se valoró el grado de fragilidad basal mediante las 3D (componente basal) y la repercusión multidimensional debida al proceso agudo mediante las 3D+(componente actual). La variable dependiente principal fue la adecuación del recurso asistencial al alta del SUH.Resultados: Se incluyó a 278 pacientes de edad media 86 años (rango intercuartil: 83-90) y 59,7% de mujeres. Según el componente basal (3D), el 83,1% (IC del 95%: 78,2-87,3) presentaba algún grado de fragilidad. El componente actual (3D+) estaba alterado en el 60,1% (IC del 95%: 54,1-65,9). La adecuación al alta del SUH fue correcta en un 96,4% (IC del 95%: 93,0-98,0). Uno de cada 4pacientes ingresó en hospitalización convencional.Conclusiones: Las 3D/3D+facilita un modelo óptimo de atención urgente adaptada a los pacientes de 75 o más años atendidos en los SUH. Estratifica el grado fragilidad (3D), detecta la gravedad debido al problema agudo por el que paciente consulta (3D+) y contribuye a la toma de decisiones sobre el recurso asistencial más apropiado al alta del SUH. (AU)

Objective: Assess the 3D/3D+ rapid geriatric assessment tool for the early detection of frailty, its usefulness to identify the effects of the acute process on the functional, physical, cognitive and socioenvironmental dimensions, as well as the medications that may have triggered the patient's reason for visit. Finally, assess the usefulness of 3D/3D+ together with the clinical diagnosis to adequate care resource at discharge from the emergency department (ED).Method: Retrospective observational cohort study. Patients ≥75 years old, with clinical complexity visited at the ED were included. Basal frailty status was assessed using 3D (basal component), and the multidimensional impact of the acute process using 3D+ (current component). The main dependent variable was adequacy of the care resource at ED discharge.Results: 278 patients were included, mean age 86 years (interquartile range: 83–90), 59.7% were women. According to the basal component (3D), 83.1% (95%CI: 78.2–87.3) presented some degree of frailty. The current component (3D+) was altered in 60.1% (95%CI: 54.1–65.9). The adequacy of ED discharge was correct in 96.4% (95%CI: 93.0–98.0). One out of 4patients was admitted to a medicine ward.Conclusions: 3D/3D+ facilitates an optimal model of emergency care adapted to patients ≥ 75 years old treated in EDs. It stratifies the level of frailty (3D), detects the severity of patients’ acute problems (3D+) and contributes to decision-making regarding the most appropriate care resource at ED discharge. (AU)

Improving individualized prescription in patients with multimorbidity through medication review.

BACKGROUND: Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study's main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index. METHODS: This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals. RESULTS: Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001). CONCLUSIONS: An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home.

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient's treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Assessment of frailty in elderly patients attending a multidisciplinary wound care centre: a cohort study.

BACKGROUND: The incidence of frailty and non-healing wounds increases with patients' age. Knowledge of the relationship between frailty and wound healing progress is greatly lacking. METHODS: The aim of this study is to characterize the degree of frailty in elderly patients attending a multidisciplinary wound care centres (MWCC). Additionally, we seek to assess the impact of frailty on the wound healing rate and wound healing time. An open cohort study was conducted on 51 consecutive patients aged > 70 years treated for wounds at an MWCC of an intermediate care hospital. The frailty score was determined according to the Frail-VIG index. Data were collected through patient questionnaires at the beginning of the study, and at 6 months or upon wound healing. Wounds were followed up every 2 weeks. To analyse the relationship between two variables was used the Chi-square test and Student's or the ANOVA model. The t-test for paired data was used to analyse the evolution of the frailty index during follow-up. RESULTS: A total of 51 consecutive patients were included (aged 81.1 ± 6.1 years). Frailty prevalence was 74.5% according to the Frail-VIG index (47.1% mildly frail, 19.6% moderately frail, and 7.8% severely frail). Wounds healed in 69.6% of cases at 6 months. The frailty index (FI) was higher in patients with non-healing wounds in comparison with patients with healing wounds (IF 0.31 ± 0.15 vs IF 0.24 ± 0.11, p = 0.043). A strong correlation between FI and wound healing results was observed in patients with non-venous ulcers (FI 0.37 ± 0.13 vs FI 0.27 ± 0.10, p = 0.015). However, no correlation was observed in patients with venous ulcers (FI 0.17 ± 0.09 vs FI 0.19 ± 0.09, p = 0.637). Wound healing rate is statically significantly higher in non-frail patients (8.9% wound reduction/day, P25-P75 3.34-18.3%/day;AQ6 p = 0.044) in comparison with frail patients (3.26% wound reduction/day, P25-P75 0.8-8.8%/day). CONCLUSION: Frailty is prevalent in elderly patients treated at an MWCC. Frailty degree is correlated with wound healing results and wound healing time.

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort.

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

Factors Associated with Medication Non-Adherence among Patients with Multimorbidity and Polypharmacy Admitted to an Intermediate Care Center.

Identifying determinants of medication non-adherence in patients with multimorbidity would provide a step forward in developing patient-centered strategies to optimize their care. Medication appropriateness has been proposed to play a major role in medication non-adherence, reinforcing the importance of interdisciplinary medication review. This study examines factors associated with medication non-adherence among older patients with multimorbidity and polypharmacy. A cross-sectional study of non-institutionalized patients aged ≥65 years with ≥2 chronic conditions and ≥5 long-term medications admitted to an intermediate care center was performed. Ninety-three patients were included (mean age 83.0 ± 6.1 years). The prevalence of non-adherence based on patients' multiple discretized proportion of days covered was 79.6% (n = 74). According to multivariable analyses, individuals with a suboptimal self-report adherence (by using the Spanish-version Adherence to Refills and Medications Scale) were more likely to be non-adherent to medications (OR = 8.99, 95% CI 2.80-28.84, p < 0.001). Having ≥3 potentially inappropriate prescribing (OR = 3.90, 95% CI 0.95-15.99, p = 0.059) was barely below the level of significance. These two factors seem to capture most of the non-adherence determinants identified in bivariate analyses, including medication burden, medication appropriateness and patients' experiences related to medication management. Thus, the relationship between patients' self-reported adherence and medication appropriateness provides a basis to implement targeted strategies to improve effective prescribing in patients with multimorbidity.

Association between anticholinergic burden and oropharyngeal dysphagia among hospitalized older adults.

BACKGROUND: Oropharyngeal dysphagia is an emerging age-related disorder that affects 23% of inpatients leading to malnutrition, dehydration, or aspiration pneumonia. Anticholinergic drugs can cause reduced peristalsis and dry mouth, both related to dysphagia. AIM: To determine the association between anticholinergic burden and oropharyngeal dysphagia in older inpatients. METHODS: Retrospective descriptive observational study. There are 239 patients. Dysphagia diagnosis based on routine volume-viscosity swallow test. Characteristics: age, functional loss (instrumental and basic activities), frailty (Frail-VIG-Index), geriatric syndromes, polypharmacy, and anticholinergic-cognitive-burden scale at admission. RESULTS: 25.5% of elderly patients diagnosed with dysphagia are more dependent and frailer than non-dysphagic patients. 83.6% scored ≥ 3 points on the ACB Scale [odds ratio: 4.46 (2.13-9.33)], which is statistically associated with dysphagia (p < 0.001). CONCLUSION: Patients with an ACB of ≥ 3 points at admission are more than four times as likely to develop oropharyngeal dysphagia. Evaluating anticholinergic burden routinely should be considered and, whenever possible, reduce it.

Medication regimen complexity on hospital admission in patients with advanced chronic conditions in need of palliative care.

OBJECTIVES: To evaluate characteristics of the medication complexity, risk factors associated with high medication complexity and their clinical consequences in patients with advanced chronic conditions. METHODS: A 10-month cross-sectional study was performed in an acute-hospital care Geriatric Unit. Patients with advanced chronic conditions were identified by the NECPAL test. Medication complexity was established using the Medication Regimen Complexity Index (MRCI) tool. Demographic, pharmacological and clinical patient data were collected with the objective of determining risk factors related to high medication complexity. Measured clinical outcomes were hospital length of stay, destination on hospital discharge, in-hospital mortality and 2-year survival. RESULTS: Two hundred and thirty-five patients (mean age 86.8, SD 5.37; 65.5% female) were recruited. MRCI's mean score was 38 points (SD 16.54, rank: 2.00-98.50), with 57.9% of patients with high medication complexity (MRCI >35 points).

Demencia avanzada y decisiones difíciles: una oportunidad para la planificación de decisiones anticipadas / Advanced dementia and critical decisions: an opportunity for advanced care planning

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Utilidad de los criterios STOPP-Pal: prácticas de valor encadenadas / Usefulness of STOPP-Pal criteria: linked value practices

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Armonización terapéutica: la necesaria alineación de los sistemas de salud con los resultados que importan a las personas / Therapeutic harmonization: the necessary alignment of the healthcare systems with the results that matters to the patients

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