Valor pronóstico del diagnóstico principal en ancianos ingresados en una unidad geriátrica de agudos al alta y al año / Prognostic value of the primary diagnosis in elderly patients admitted to an acute geriatric unit at discharge and one year later

Objetivo. Analizar la asociación entre el diagnóstico principal que motiva el ingreso hospitalario en una unidad geriátrica de agudos (UGA) y el riesgo de mortalidad intrahospitalaria y al año del alta. Material y métodos. Estudio longitudinal de los pacientes que ingresaron en la UGA del Hospital Central de la Cruz Roja de Madrid durante 2009. El diagnóstico de ingreso se agrupó por grupos relacionados por el diagnóstico (GRD). La fecha de fallecimiento fue recogida del informe médico y del Índice Nacional de Defunciones del Ministerio de Sanidad. Como variable resultado se analizó la asociación entre diagnósticos al ingreso y deterioro funcional al alta (medido como una pérdida de 10 o más puntos entre el Índice de Barthel al alta respecto al previo al ingreso), mortalidad durante el ingreso, a los 3 meses y al año del alta. El análisis se ajustó por edad, sexo, comorbilidad, situación funcional y cognitiva, y niveles de albúmina sérica. Resultados. Se estudiaron 1.147 pacientes, con una edad media de 86,7 años (DE: ± 6,7), 66% eran mujeres. Fallecieron durante el ingreso un 10,1% y presentaron deterioro funcional al alta el 36,6%. La mortalidad postalta fue del 25,5% a los 3 meses y el 42,2% al año. La frecuencia de los principales diagnósticos al ingreso (entre paréntesis su mortalidad intrahospitalaria y al año) fueron insuficiencia cardiaca 21,4% (8,1 y 37,4%), neumonía no aspirativa 13,3% (12,3 y 46,4%) y neumonía aspirativa 4,7% (27,5 y 71%), bronconeumopatías 13,3% (6,6 y 38,2%), infección urinaria 10,2% (5,1 y 42,7%) e ictus (excluyendo AIT) 9,9% (13,3 y 46,9%). En el análisis multivariante solo el ingreso por neumonía aspirativa se asociaba de forma independiente con mayor riesgo de mortalidad intrahospitalaria (odds ratio-2,23; IC95% = 1,13-44,42) y el ingreso por ictus a la presencia de deterioro funcional al alta (odds ratio-6,01; IC95% = 3,42-10,57). Ningún diagnóstico se asoció de manera independiente con aumento del riesgo de muerte a los 3 meses y al año. Conclusiones. El ingreso por neumonía aspirativa conlleva un mayor riesgo de muerte en ancianos hospitalizados por patología médica aguda. Tras el alta, el riesgo aumentado de muerte debe ser atribuido a otros factores diferentes al diagnóstico (AU)

Objective. To analyse the relationship between the primary diagnosis on admission to an Acute Geriatric Unit (AGU) and the risk of hospital mortality and one year after discharge. Material and methods. A longitudinal study was conducted on patients admitted to the Central Hospital AGU Red Cross in Madrid in 2009. The admission diagnosis was grouped by Diagnosis Related Groups (DRGs). The date of death was collected from the medical charts and the National Death Index Ministry of Health report. The main outcome of study was the association between diagnoses on admission and functional impairment at discharge (measured as a loss of 10 or more points between the Barthel Index at discharge and that on admission), mortality during hospitalization, at 3 months and one year after discharge. The multivariate analysis was adjusted for age, sex, comorbidity, functional and cognitive status, and serum albumin. Results. The study included1147 patients, with a mean age of 86.7 years (SD ± 6.7), and 66% were women. During admission, 10.1% of patients died and 36.6% had functional impairment at discharge. After discharge, 25.5% died at 3 months, and 42.2% at one year. The distribution of the primary diagnoses at admission (between parentheses hospital mortality and at year) were heart failure, 21.4% (8.1% and 37.4%), pneumonia,13.3% (12.3% and 46.4%), and aspiration pneumonia, 4.7% (27.5%, y 71%), respiratory diseases,13.3% (6.6% and 38.2%), urinary infection,10.2% (5.1% and 42.7%), and stroke (excluding AIT), 9.9% (13.3% and 46.9%). In the multivariate analysis, only admissions due to aspiration pneumonia were independently associated with increased risk of hospital mortality (odds ratio, 2.23; 95% CI = 1.13 to 44.42), and stroke with increased risk of functional impairment at discharge (odds ratio, 6.01; 95% CI = 3.42-10.57). No diagnosis was independently associated with increased risk of death at 3 months and at year. Conclusions. Admission from aspiration pneumonia carries an increased risk of death in elderly patients hospitalised for acute medical conditions. After discharge, the risk of death must be attributed to factors other than the admission diagnosis (AU)

[Prognostic value of the primary diagnosis in elderly patients admitted to an acute geriatric unit at discharge and one year later]. / Valor pronóstico del diagnóstico principal en ancianos ingresados en una unidad geriátrica de agudos al alta y al año.

OBJECTIVE: To analyse the relationship between the primary diagnosis on admission to an Acute Geriatric Unit (AGU) and the risk of hospital mortality and one year after discharge MATERIAL AND METHODS: A longitudinal study was conducted on patients admitted to the Central Hospital AGU Red Cross in Madrid in 2009. The admission diagnosis was grouped by Diagnosis Related Groups (DRGs). The date of death was collected from the medical charts and the National Death Index Ministry of Health report. The main outcome of study was the association between diagnoses on admission and functional impairment at discharge (measured as a loss of 10 or more points between the Barthel Index at discharge and that on admission), mortality during hospitalization, at 3 months and one year after discharge. The multivariate analysis was adjusted for age, sex, comorbidity, functional and cognitive status, and serum albumin. RESULTS: The study included1147 patients, with a mean age of 86.7 years (SD±6.7), and 66% were women. During admission, 10.1% of patients died and 36.6% had functional impairment at discharge. After discharge, 25.5% died at 3 months, and 42.2% at one year. The distribution of the primary diagnoses at admission (between parentheses hospital mortality and at year) were heart failure, 21.4% (8.1% and 37.4%), pneumonia,13.3% (12.3% and 46.4%), and aspiration pneumonia, 4.7% (27.5%, y 71%), respiratory diseases,13.3% (6.6% and 38.2%), urinary infection,10.2% (5.1% and 42.7%), and stroke (excluding AIT), 9.9% (13.3% and 46.9%). In the multivariate analysis, only admissions due to aspiration pneumonia were independently associated with increased risk of hospital mortality (odds ratio, 2.23; 95% CI=1.13 to 44.42), and stroke with increased risk of functional impairment at discharge (odds ratio, 6.01; 95% CI=3.42-10.57). No diagnosis was independently associated with increased risk of death at 3 months and at year CONCLUSIONS: Admission from aspiration pneumonia carries an increased risk of death in elderly patients hospitalised for acute medical conditions. After discharge, the risk of death must be attributed to factors other than the admission diagnosis.

¿Qué pacientes se benefician más de la atención geriátrica hospitalaria en opinión de los especialistas en Geriatría? / Which patients benefit the most from hospital geriatric care in the opinion of the geriatricians?

Objetivo. Conocer en la práctica cuál o cuáles son los criterios considerados por los geriatras hospitalarios como los más idóneos para seleccionar a los pacientes que más se pueden beneficiar de la atención geriátrica hospitalaria. Material y métodos. Se elaboró una encuesta en la que se presentaron diversos criterios socio-demográficos, clínicos, funcionales y mentales incluidos en las definiciones de paciente geriátrico y anciano frágil. La encuesta se envió a todos los especialistas en Geriatría de los diferentes hospitales del Servicio Madrileño de Salud. Se les pidió que respondieran a cada criterio indicando si lo consideraban muy prioritario, prioritario, poco prioritario o nada prioritario. Las respuestas se agruparon según el tipo de hospital (con docencia MIR, sin docencia MIR y hospitales de apoyo de media y larga estancia). Resultados. Se recibieron un total de 83 encuestas (70% de la población a estudio): 42 de hospitales con docencia MIR de Geriatría (74% de las posibles), 20 de aquellos con urgencias externas, pero sin docencia MIR (56% de las posibles) y 21 de hospitales de media y larga estancia (84% de las posibles). Todos los criterios propuestos fueron considerados individualmente como prioritarios o muy prioritarios por más del 50% de los encuestados. La edad de 85 y más años, el ingreso por fractura de cadera, la presencia de deterioro funcional o cognitivo agudo, la fragilidad y el deterioro inexplicado del estado de salud fueron considerados de manera individual como criterios muy prioritarios para la selección de población diana por más del 85% de los encuestados. Conclusiones. Determinados criterios como la edad muy avanzada o la presencia de procesos geriátricos específicos como fractura de cadera o deterioro funcional o cognitivo agudo, son identificados por los geriatras como útiles para seleccionar a los pacientes hospitalizados subsidiarios de recibir atención geriátrica especializada(AU)

Objective. To assess the most appropriate criteria considered by geriatricians to select patients who might benefit the most from geriatric hospital care. Material and methods. We carried out a survey that consisted of various socio-demographic, clinical, functional and mental criteria included in the definition of the geriatric and frail elderly patient. The survey was sent to all specialists in geriatrics in the different hospitals of the Madrid Health Service. They were asked to answer to each criterion indicating whether they considered it as high priority, priority, low priority or no priority. The responses were clustered by type of hospital: acute hospitals with or without a post-graduate geriatric program for medical residents, and medium and long stay hospitals. Results. A total of 83 questionnaires were completed (70% of the study population): 42 teaching hospitals a post-graduate geriatric program (74% of possible), 20 of those with an emergency department but without a post-graduate geriatric program (56% of possible), and 21 medium and long stay hospitals (84% of potential). All proposed criteria were considered individually as priority or high-priority by more than 50% of respondents. An age 85 years and over, admission for hip fracture, the presence of severe cognitive or functional impairment, frailty, and unexplained deterioration of health status, were considered individually as criteria for selecting high-priority target population by more than 85% of respondents. Conclusions. Certain criteria, such as advanced age, or the presence of geriatrics-specific conditions, such as hip fracture or severe functional or cognitive impairment, are identified by geriatricians as useful to select patients to receive geriatric specialist hospital care(AU)

[Which patients benefit the most from hospital geriatric care in the opinion of the geriatricians?]. / ¿Qué pacientes se benefician más de la atención geriátrica hospitalaria en opinión de los especialistas en Geriatría?

OBJECTIVE: To assess the most appropriate criteria considered by geriatricians to select patients who might benefit the most from geriatric hospital care. MATERIAL AND METHODS: We carried out a survey that consisted of various socio-demographic, clinical, functional and mental criteria included in the definition of the geriatric and frail elderly patient. The survey was sent to all specialists in geriatrics in the different hospitals of the Madrid Health Service. They were asked to answer to each criterion indicating whether they considered it as high priority, priority, low priority or no priority. The responses were clustered by type of hospital: acute hospitals with or without a post-graduate geriatric program for medical residents, and medium and long stay hospitals. RESULTS: A total of 83 questionnaires were completed (70% of the study population): 42 teaching hospitals a post-graduate geriatric program (74% of possible), 20 of those with an emergency department but without a post-graduate geriatric program (56% of possible), and 21 medium and long stay hospitals (84% of potential). All proposed criteria were considered individually as priority or high-priority by more than 50% of respondents. An age 85 years and over, admission for hip fracture, the presence of severe cognitive or functional impairment, frailty, and unexplained deterioration of health status, were considered individually as criteria for selecting high-priority target population by more than 85% of respondents. CONCLUSIONS: Certain criteria, such as advanced age, or the presence of geriatrics-specific conditions, such as hip fracture or severe functional or cognitive impairment, are identified by geriatricians as useful to select patients to receive geriatric specialist hospital care.

Métodos de evaluación de la función renal en el paciente anciano: fiabilidad e implicaciones clínicas / Renal function evaluation methods in the elderly: Reliability and clinical implications

La enfermedad renal crónica (ERC) se encuentra presente en la tercera parte de la población española mayor de 65 años. Su detección e intervención de forma precoz aportarían un efecto beneficioso sobre la supervivencia, contribuyendo en la reducción de la morbimortalidad cardiovascular asociada y en la disminución del riesgo de yatrogenia farmacológica. La determinación del filtrado glomerular ha sido considerada tradicionalmente como el mejor parámetro de evaluación de la función renal, cuya valoración no debe basarse únicamente en los resultados de concentración sérica o aclaramiento de creatinina. La aplicación de ecuaciones predictivas resulta útil en el diagnóstico, la clasificación y el control ambulatorio de pacientes con ERC. En la mayoría de los estudios realizados sobre población anciana, la fórmula MDRD-4 (Modification of Diet in Renal Disease) obtiene una precisión y una exactitud más razonable que Cockcroft-Gault (CG), considerándola como el nomograma de elección en este sector poblacional. Las situaciones clínicas en las que se precise una rápida estimación de función renal o ajustes farmacológicos aproximados permiten el uso de la ecuación de CG, siempre recordando sus limitaciones (AU)

Chronic renal disease (CRD) is found in a third of the Spanish population aged more than 65 years old. Detection and early treatment would increase survival and help to reduce associated cardiovascular morbidity and mortality as well as the risk of pharmacological iatrogeny. Determination of the glomerular filtration rate has traditionally been considered the best parameter for renal function evaluation, which should not be based exclusively on serum creatinine concentration or creatinine clearance. The application of predictive equations is useful in the diagnosis, classification and outpatient management of patients with CRD. Most studies performed in the elderly have found that the Modification of Diet in Renal Disease (MDRD-4) has greater precision and accuracy than the Cockcroft-Gault formula, and is considered the nomogram of choice in this age group. The Cockcroft-Gault formula can be used when rapid estimation of renal function or drug adjustments are required, so long as the limitations of this method are taken into account (AU)

Métodos de evaluación de la función renal en el paciente anciano: fiabilidad e implicaciones clínicas / Renal function evaluation methods in the elderly: Reliability and clinical implications

La enfermedad renal crónica (ERC) se encuentra presente en la tercera parte de la población española mayor de 65 años. Su detección e intervención de forma precoz aportarían un efecto beneficioso sobre la supervivencia, contribuyendo en la reducción de la morbimortalidad cardiovascular asociada y en la disminución del riesgo de yatrogenia farmacológica. La determinación del filtrado glomerular ha sido considerada tradicionalmente como el mejor parámetro de evaluación de la función renal, cuya valoración no debe basarse únicamente en los resultados de concentración sérica o aclaramiento de creatinina. La aplicación de ecuaciones predictivas resulta útil en el diagnóstico, la clasificación y el control ambulatorio de pacientes con ERC. En la mayoría de los estudios realizados sobre población anciana, la fórmula MDRD-4 (Modification of Diet in Renal Disease) obtiene una precisión y una exactitud más razonable que Cockcroft-Gault (CG), considerándola como el nomograma de elección en este sector poblacional. Las situaciones clínicas en las que se precise una rápida estimación de función renal o ajustes farmacológicos aproximados permiten el uso de la ecuación de CG, siempre recordando sus limitaciones(AU)

Chronic renal disease (CRD) is found in a third of the Spanish population aged more than 65 years old. Detection and early treatment would increase survival and help to reduce associated cardiovascular morbidity and mortality as well as the risk of pharmacological iatrogeny. Determination of the glomerular filtration rate has traditionally been considered the best parameter for renal function evaluation, which should not be based exclusively on serum creatinine concentration or creatinine clearance. The application of predictive equations is useful in the diagnosis, classification and outpatient management of patients with CRD. Most studies performed in the elderly have found that the Modification of Diet in Renal Disease (MDRD-4) has greater precision and accuracy than the Cockcroft-Gault formula, and is considered the nomogram of choice in this age group. The Cockcroft-Gault formula can be used when rapid estimation of renal function or drug adjustments are required, so long as the limitations of this method are taken into account(AU)

[Renal function evaluation methods in the elderly: reliability and clinical implications]. / Métodos de evaluación de la función renal en el paciente anciano: fiabilidad e implicaciones clínicas.

Chronic renal disease (CRD) is found in a third of the Spanish population aged more than 65 years old. Detection and early treatment would increase survival and help to reduce associated cardiovascular morbidity and mortality as well as the risk of pharmacological iatrogeny. Determination of the glomerular filtration rate has traditionally been considered the best parameter for renal function evaluation, which should not be based exclusively on serum creatinine concentration or creatinine clearance. The application of predictive equations is useful in the diagnosis, classification and outpatient management of patients with CRD. Most studies performed in the elderly have found that the Modification of Diet in Renal Disease (MDRD-4) has greater precision and accuracy than the Cockcroft-Gault formula, and is considered the nomogram of choice in this age group. The Cockcroft-Gault formula can be used when rapid estimation of renal function or drug adjustments are required, so long as the limitations of this method are taken into account.

Resultados asistenciales de las unidades geriátricas de agudos. Revisión sistemática / Measuring results in acute care for the elderly units. A systematic review

Fundamento: revisar de manera sistemática la información existente en la literatura científica sobre los resultados asistenciales de las unidades geriátricas de agudos (UGA) hospitalarias. Material y método: la estrategia de búsqueda incluyó la consulta en bases bibliográficas (MEDLINE, EMBASE, Dialnet y Cochrane Central Register of Controlled Trials), la revisión de los sumarios de 5 revistas de geriatría y la búsqueda retrospectiva de citas en los artículos existentes. Resultados: se encontraron 41 publicaciones con datos sobre resultados asistenciales de las UGA. De ellas, 21 cumplieron los criterios de inclusión. Éstas aportaron datos de 18 experiencias en 19 hospitales. Todos los trabajos, excepto uno, encontraron una reducción de la estancia media en las UGA respecto a la hospitalización en otros servicios. La reducción fue del 30 al 54% en los trabajos que analizaron muestras históricas, superior al 10% en la mayoría de los estudios de bases de datos hospitalarias y del 17 al 46% (p < 0,01) en los estudios de casos y controles. De los 5 estudios aleatorizados con grupo control, 2 mostraron reducciones significativas de la estancia media (del 19 y el 24%, p < 0,01); otros 2, tendencias en el mismo sentido (del 3 y el 12%, respectivamente), y, 1 incremento de la estancia (32%). Estos estudios encontraron tendencias a la reducción de costes, a menor institucionalización y a mejoría funcional en los pacientes de las UGA. Conclusiones: los estudios existentes muestran una reducción de las estancias de los ancianos hospitalizados por enfermedad aguda en unidades geriátricas respecto a la hospitalización convencional en otros servicios médicos. Esto supone un ahorro de recursos sin merma en la calidad asistencial. Debe plantearse la puesta en marcha de UGA en los hospitales donde no existan todavía

Background: the aim of this study was to perform a systematic review of the scientific information related to the results of in-hospital acute care for the elderly (ACE) units. Material and method: the search strategy included consultation of different bibliographic databases (MEDLINE, EMBASE, Dialnet and the Cochrane Central Register of Controlled Trials), review of the contents pages of five geriatric journals, and a retrospective search of the references in published articles. Results: forty-one articles with information on the results of ACE units were identified. Of these, only 21 met the inclusion criteria. These 21 articles provided data on 18 experiences in 19 hospitals. All the studies except one found a reduction in the mean length of stay in ACE units compared with conventional hospitalization. This reduction ranged from 30% to 54% in studies with historical samples, was more than 10% in hospital database studies, and ranged from 17% to 46% (P<.01) in case-control studies. Of 5 randomized controlled studies, 2 reported significant reductions in length of stay (19% and 24%, P<.01), another two studies reported trends in the same direction (3% and 12%) and 1 study found an increase in length of stay (32%) in the ACE unit. These studies reported tendencies towards reduced costs, lower institutionalization and functional improvement in patients admitted to ACE units. Conclusions: the studies performed to date show reductions in length of stay in elderly patients admitted to ACE units for acute illness compared with conventional hospitalization, leading to resource savings without decreasing the quality of care. The establishment of ACE units should be considered in hospitals without these units