A Community Program of Integrated Care for Frail Older Adults: +AGIL Barcelona.

OBJECTIVES: To assess the 3-month impact on physical function of a program for community-dwelling frail older adults, based on the integration of primary care, geriatric medicine, and community resources, implemented in "real life". DESIGN: Interventional cohort study. SETTING: Primary care in Barcelona, Spain. PARTICIPANTS: Individuals aged ≥80 years (n=134), presenting at least one sign of frailty (i.e., slow gait speed, weakness, memory complaints, involuntary weight loss, poor social support). INTERVENTION: After frailty screening by the primary care team, candidates were referred to a geriatric team (geriatrician + physical therapist), who performed a comprehensive geriatric assessment and designed a tailored multidisciplinary intervention in the community, including a) multi-modal physical activity (PA) sessions, b) promotion of adherence to a Mediterranean diet c) health education and d) medication review. MEASUREMENTS: Participants were assessed based on a comprehensive geriatric assessment including physical performance (Short Physical Performance Battery -SPPB- and gait speed), at baseline and at a three month follow-up. RESULTS: A total of 112 (83.6%) participants (mean age=80.8 years, 67.9% women) were included in this research. Despite being independent in daily life, participants' physical performance was impaired (SPPB=7.5, SD=2.1, gait speed=0.71, SD=0.20 m/sec). After three months, 90.2% of participants completed ≥7.5 physical activity sessions. The mean improvements were +1.47 (SD 1.64) points (p<0.001) for SPPB, +0.08 (SD 0.13) m/sec (p<0.001) for gait speed, -5.5 (SD 12.10) sec (p<0.001) for chair stand test, and 53% (p<0.001) improved their balance. Results remained substantially unchanged after stratifying the analyses according to the severity of frailty. CONCLUSIONS: Our results suggested that a "real-world" multidisciplinary intervention, integrating primary care, geriatric care, and community services may improve physical function, a marker of frailty, within 3 months. Further studies are needed to address the long-term impact and scalability of this implementation program.

The European Innovation Partnership on Active and Healthy Ageing Synergies: Protocol for a Prospective Observational Study to Measure the Impact of a Community-Based Program on Prevention and Mitigation of Frailty (ICP - PMF) in Community-Dwelling Older Adults.

Aim of this paper is to describe the protocol of the study "Impact of a Community-based Program on Prevention and Mitigation of Frailty in community-dwelling older adults" developed in the framework of the European Innovation Partnership on Active and Healthy Ageing. This proposal has been developed by the Partnership Action groups on frailty, fall prevention and polypharmacy in older. The proposal wants to assess the impact of community-based programs aimed to counteract three main outcomes related to frailty: hospitalization, institutionalization and death. Bringing together researchers from seven European countries, the proposal aims to achieve the critical mass and the geographical extension enough to provide information useful to all older European citizens. An observational study will be carried out to calculate the incidence of the different outcomes in relation to the various interventions that will be assessed; results will be compared with data coming from already established national, regional and local dataset using the observed/expected approach. The sample will be made up by at least 2000 citizens for each outcome. All the citizens will be assessed at the baseline with two multidimensional questionnaires: the RISC questionnaire and the Short Functional Geriatric Evaluation questionnaire. The outcomes will be assessed every six-twelve months.

Measuring the Effect of Carers on Patients' Risk of Adverse Healthcare Outcomes Using the Caregiver Network Score.

BACKGROUND: Although caregivers are important in the management of frail, community-dwelling older adults, the influence of different caregiver network types on the risk of adverse healthcare outcomes is unknown. OBJECTIVE: To examine the association between caregiver type and the caregiver network subtest of The Risk Instrument for Screening in the Community (RISC), a five point Likert scale scored from one ("can manage") to five ("absent/liability"). To measure the association between caregiver network scores and the one-year incidence of institutionalisation, hospitalisation and death. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: Community-dwelling adults, aged >65, attending health centres in Ireland, (n=779). PROCEDURE AND MEASUREMENTS: The caregiver network subtest of the RISC was scored by public health nurses. Caregivers were grouped dichotomously into low-risk (score of one) or high-risk (scores two-five). RESULTS: The majority of patients had a primary caregiver (582/779; 75%), most often their child (200/582; 34%). Caregiver network scores were highest, indicating greatest risk, when patients had no recognised primary caregiver and lowest when only a spouse or child was available. Despite this, patients with a caregiver were significantly more likely to be institutionalised than those where none was required or identified (11.5% versus 6.5%, p=0.047). The highest one-year incidence of adverse outcomes occurred when state provided care was the sole support; the lowest when private care was the sole support. Significantly more patients whose caregiver networks were scored high-risk required institutionalisation than low-risk networks; this association was strongest for perceived difficulty managing medical domain issues, odds ratio (OR) 3.87:(2.22-6.76). Only perceived difficulty managing ADL was significantly associated with death, OR 1.72:(1.06-2.79). There was no association between caregiver network scores and risk of hospitalisation. CONCLUSION: This study operationalizes a simple method to evaluate caregiver networks. Networks consisting of close family (spouse/children) and those reflecting greater socioeconomic privilege (private supports) were associated with lower incidence of adverse outcomes. Caregiver network scores better predicted institutionalisation than hospitalisation or death.

Assessment of enlarged perivascular spaces and their relation to target organ damage and mild cognitive impairment in patients with hypertension.

BACKGROUND AND PURPOSE: Enlarged perivascular spaces (EPVS) have been recently considered a feature of cerebral small vessel disease. They have been related to aging, hypertension and dementia but their relationship with hypertension related variables (i.e. target organ damage, treatment compliance) and mild cognitive impairment (MCI) is not fully elucidated. Our aims were to investigate the relation between basal ganglia (BG) and centrum semiovale (CSO) EPVS with vascular risk factors, hypertension related variables and MCI. METHODS: In all, 733 hypertensive individuals free of stroke and dementia from the Investigating Silent Strokes in Hypertensives, a magnetic resonance imaging Study (ISSYS) underwent brain magnetic resonance imaging and cognitive testing to diagnose MCI or normal cognitive aging. RESULTS: The numbers of participants presenting high grade (>10) EPVS at the BG and CSO were 23.3% and 40.0%, respectively. After controlling for vascular risk factors, high grade BG EPVS were associated with age (odds ratio 1.68; 95% confidence interval 1.37, 2.06), poor antihypertensive compliance (1.49; 1.03, 2.14) and the presence of microalbuminuria (1.95; 1.16, 3.28), whereas in the CSO only age (1.38; 1.18, 1.63) and male sex were associated with EPVS (1.73; 1. 24, 2.42). MCI was diagnosed in 9.3% of the participants and it was predicted by EPVS in the BG (1.87; 1.03, 3.39) but not in the CSO. This last association was greatly attenuated after correction for lacunes and white matter hyperintensities. CONCLUSIONS: Basal ganglia EPVS are associated with the presence of microalbuminuria and poor adherence to antihypertensive drugs. The BG EPVS relation with MCI is not independent of the presence of other cerebral small vessel disease markers.

Determinants of survival and hospitalization in older, heart failure patients receiving home healthcare.

INTRODUCTION: Since reported evidence is both scarce and controversial, the objective of this study is to determine the risk factors involved in the prognosis of older patients with heart failure (HF) receiving home healthcare from primary care professionals. METHODS: Retrospective cohort community study was carried out in 52 primary healthcare centers in Barcelona (Spain). A follow-up was performed between January 2009 and December 2012 with 7461 HF patients aged >64years. Information was obtained from primary care electronic medical records containing clinical data, functional and cognitive status, total mortality, and hospital admissions for cardiovascular events. RESULTS: Mortality and hospitalization during follow-up were higher in older, HF patients who received home healthcare than those who did not (HR 1.39, 95% CI 1.22-1.58 and 1.92 95% CI 1.72-2.14, respectively). The most relevant determinants for mortality were male gender (HR 1.40, 95%CI 1.10-1.79), previous hospital admission for HF (HR 1.29 95%CI 1.05-1.60), and severe dependence in activities for daily living (ADL) (HR 1.33, 95%CI 1.06-1.67). In contrast, severely dependent ADL patients were not more frequently hospitalized as a consequence of cardiovascular events (0.97, 95% CI 0.77-1.23). CONCLUSIONS: Due to their greater comorbidity and age, mortality and hospitalization in patients requiring home healthcare were higher than those who did not. Among the HF patients receiving home care, mortality and hospital admissions were higher in men, older patients, and in those previously hospitalized for HF. Severe dependence in ADL determined a higher mortality but was not related to increased hospital admission rates.

Cognitive assessment protocol design in the ISSYS (Investigating Silent Strokes in hYpertensives: a magnetic resonance imaging Study).

Hypertension and silent cerebrovascular lesions (SCL) detected by brain magnetic resonance imaging (MRI) are associated with an increased risk of cognitive decline. In a prospective observational study in 1000 hypertensive patients, aged 50-70 years, with no prior history of stroke or dementia, we will study the presence of mild cognitive impairment (MCI) and the relationship between SCL and cognition. All participants will be assessed by means of the Dementia Rating Scale-2 (DRS-2) and will undergo a brain MRI. In order to better characterize MCI and future dementia risk in our cohort, those patients that are suspected to be cognitively impaired according to the DRS-2 results will have a further neurological evaluation and complete neuropsychological testing. Follow-up for the entire cohort is planned to last for at least 3 years.

Evolution of self-rated health status in the elderly: cross-sectional vs. longitudinal estimates.

We assessed the perceived health status evolution among elderly subjects and examined the age-related differences in perceived health when comparing estimates obtained from cross-sectional and longitudinal approaches. Data come from a cohort of non-institutionalized individuals aged 65 years or older, living in Barcelona, Spain. One thousand three hundred fifteen (1315) elderly were successfully interviewed at baseline in 1986 and 754 (84.6% of the eligible) at the re-assessment (1993-1994). Estimates of change in perceived health status were calculated based on cross-sectional and longitudinal approaches. Cross-sectionally, no significant differences in the proportion of individuals with poor self-rated health were found (40.5 vs. 42.5%, P = 0.90). Among survivors, the proportion of individuals with poor health increased from 37.8% to 55.1% (P < 0.01), an 8.7-fold decline of perceived health when compared with the cross-sectional estimates. Comorbidity (aOR 2.1; 95%CI: 1.4-3.3) and no education (aOR 1.9; 95%CI: 1.1-3.2) were associated with a decline in health status after adjusting by baseline health status. We recommend the use of longitudinal studies to understand the evolution of perceived health in the elderly.

Comparison of performance-based and self-rated functional capacity in Spanish elderly.

Recent data have shown differences between Spain and the United States in the prevalence of reported disability among community elderly. Differences in reporting functional capacity by culture may contribute to these observed differences. The purpose of this study was to estimate the agreement between self-report of disability and performance-based measures for some basic mobility tasks in the community-dwelling elderly of a Mediterranean country. Interviews containing questions about difficulty for walking and rising from a chair, and performance-based measures (walking speed and chair stand tests) were carried out in 626 individuals aged 72 years and older in Barcelona, Spain. Kappa statistics were calculated, and logistic regression models were constructed to identify possible factors associated with under- and overreporting functional capacity. Moderate kappas (0.41-0.55) were found between self-report and performance-based measures. Patients who rated their health as "poor or very poor" were less likely to underreport disability (adjusted odds ratio (OR) = 0.2, 0.4) but more likely to overreport it (adjusted OR = 23.4, 9.9). No significant agreement differences by sex or informant source were found. These findings suggest that Spanish elderly self-report functional capacity accurately and that, contrary to previous results among US elderly, the direction of the observed disagreement is not systematic.

Unmet health care needs and mortality among Spanish elderly.

OBJECTIVES: This study estimates the prevalence of unmet health care needs among the elderly of Barcelona, Spain, and analyzes the association between unmet needs and mortality. METHODS: Home interviews were conducted with 1315 elderly in Barcelona. Individuals were classified as having a "health services need" if they reported being in fair, poor, or very poor health; suffering from two or more chronic conditions; or being dependent in at least one basic activity of daily living. Need was considered unmet if no visits to or from a physician in the previous 12 months were reported. Mortality was assessed from census data in August 1991. RESULTS: Between 10% and 25% of the elderly in need reported no use of health services. After a median of 60.3 months, those with unmet health care needs presented a higher risk of mortality, adjusted for several confounding factors: relative risk [RR] = 2.55 (95% confidence interval [CI] = 1.22, 5.32) for unmet activity of daily living dependency; RR = 1.80 (95% CI = 1.20, 2.70) for unmet comorbidity; and odds ratio = 1.10 (95% CI = 0.59, 2.05) for unmet poor self-rated health. CONCLUSION: Noninstitutionalized elderly individuals with unmet health care needs are at increased risk of dying.

[Self perception of health and complete evaluation of the elderly patient at a primary care center]. / Autopercepción de salud y evaluación integral del paciente anciano en un centro de atención primaria.

OBJECTIVES: 1) To make an integrated evaluation of the cognitive status, functional capacity, chronic disorders and social situation of the over-75 age group. 2) To find this group's self-perception of their health. DESIGN: A descriptive crossover study. SETTING: The Gòtic Health District in Barcelona. PARTICIPANTS: 316 people were included in the study. They were chosen by simple randomised sampling from the over-75s seen at the centre (n = 1,625). MEASUREMENTS AND MAIN RESULTS: To assess cognitive status, the Pfeiffer Short Portable Mental Status Questionnaire was used; for functional capacity, the Katz Index; and for chronic disorders, the medical records were reviewed. A questionnaire was used to find patients' social situation and assessed social relationships, social resources used and architectonic barriers. Self-perception of health status was evaluated using the Nottingham Health Profile. Prevalence of cognitive deterioration was 29.7%. 39.4% of patients were dependent in one or more basic activities of their daily life. 90.8% had a chronic disorder, the most frequent being AHT, arthrosis, obesity and dyslipemias. 28.3% lived alone and 26.7% used social services. CONCLUSIONS: We think this kind of assessment is useful in primary care. It would provide an integrated diagnosis (clinical, functional, medical and social) of elderly patients.

[Effect of various antiseptics on Chlamydia trachomatis]. / Action de différents antiseptiques sur Chlamydia trachomatis.

We compared the activity of different antiseptics (chlorhexidine, picloxidine dichlorhydrate, povidone-iodine, and noxythiolin) on Chlamydia trachomatis using two techniques. In the first, an antigenic preparation obtained from a Chlamydia trachomatis-infected cell culture was used. Different times of contact and different concentrations were studied. The antigen-antiseptic mixture was inoculated on healthy cell cultures and infected cells were counted 48 hours later. In the second technique, previously infected cells were incubated with antiseptics at different concentrations for 48 hours. Results are given as a percentage of infected cells. Chlorhexidine and picloxidine dichlorhydrate have a rapid action on Chlamydia trachomatis. Noxythiolin requires a longer period (2 hours) to be active. Povidone-iodine exhibits no activity on Chlamydia trachomatis.