Specialized Care Resources for Diagnosis and Management of Patients Who Have Suffered Falls: Results of a National Survey in Geriatric Units.

INTRODUCTION: Clinical guidelines recommend comprehensive multifactorial assessment and intervention to prevent falls and fractures in older populations. METHODS: A descriptive study was conducted by the Falls Study Group of the Spanish Geriatric Medicine Society (SEMEG) to outline which types of healthcare-specific resources were assigned for fall assessment in Spanish geriatric departments. A self-reported seven-item questionnaire was delivered from February 2019 to February 2020. Where geriatric medicine departments were not available, we tried to contact geriatricians working in those areas. RESULTS: Information was obtained regarding 91 participant centers from 15 autonomous communities, 35.1% being from Catalonia and 20.8% from Madrid. A total of 21.6% reported a multidisciplinary falls unit, half of them in geriatric day hospitals. Half of them reported fall assessment as part of a general geriatric assessment in general geriatric outpatient clinics (49.5%) and, in 74.7% of cases, the assessment was based on functional tests. A total of 18.7% reported the use of biomechanical tools, such as posturography, gait-rides or accelerometers, for gait and balance analysis, and 5.5% used dual X-ray absorptiometry. A total of 34% reported research activity focused on falls or related areas. Regarding intervention strategies, 59% reported in-hospital exercise programs focused on gait and balance improvement and 79% were aware of community programs or the pathways to refer patients to these resources. CONCLUSIONS: This study provides a necessary starting point for a future deep analysis. Although this study was carried out in Spain, it highlights the need to improve public health in the field of fall prevention, as well as the need, when implementing public health measures, to verify that these measures are implemented homogeneously throughout the territory. Therefore, although this analysis was at the local level, it could be useful for other countries to reproduce the model.

Appropriateness of medication prescribing in nursing homes: A collaboration project between pharmacy and geriatric departments / Adecuación farmacoterapéutica en centros sociosanitarios: proyecto de coordinación entre servicio de farmacia y geriatría

Purpose: To evaluate the appropriateness of medication prescribing and to analyze interventions carried out in polymedicated elderly patients in nursing homes (NHs). Methods: Prospective study of potentially inappropriate medication prescribing in polymedicated older adults living in NHs, implemented via a collaborative project between NHs and the geriatric and pharmacy departments of a university hospital. The pharmacist reviewed patients’ active medical prescriptions and prepared an individualized report with proposals aimed at therapeutic optimization that was sent for evaluation to the geriatrician in charge of the NH. The drug-related problems (DRPs) were classified according to the Third Consensus of Granada and the potentially inappropriate prescriptions (PIPs) were identified by explicit criteria (STOPP/START, BEERS, LESS-CHRON), implicit criteria (MAI) and CheckTheMeds® software. It was measured the degree of acceptance of the interventions carried out, and the economic impact was calculated from the direct costs of the discontinued drugs. Results: Of the 210 patients reviewed by the pharmacy department, 105 patients from 10 NHs were analyzed. A total of 510 prescriptions with possible DRPs were identified (38.5% of all prescribed drugs). According to STOPP/START/BEERS or LESS-CHRON criteria, 41.2% were PIPs. The main DRPs identified were: unfavorable risk-benefit ratio, inappropriate dose/regimen, inappropriate treatment duration, probability of adverse events, medication not indicated, and duplicate therapy. Interventions were proposed for 81.5% of the DRPs detected, of which 73.3% were accepted. This resulted in a 23.1% reduction in the number of drugs prescribed per patient and an economic saving of €16,218 per 6-month period. (AU)

Objetivos: Adecuar la farmacoterapia y analizar las intervenciones realizadas en pacientes ancianos institucionalizados en centros sociosanitarios (CSS) con polifarmacia. Métodos: Estudio prospectivo de un programa de adecuación farmacoterapéutica en pacientes ancianos polimedicados de CSS mediante la puesta en marcha de un proyecto de coordinación de geriatría, farmacia hospitalaria y CSS desde el área de atención especializada. El farmacéutico realizó una revisión farmacoterapéutica de las prescripciones activas de los pacientes, elaborándose un informe individualizado con propuestas dirigidas a la optimización terapéutica. Los problemas relacionados con la medicación (PRM) encontrados se clasificaron según el Tercer Consenso de Granada, y las prescripciones potencialmente inapropiadas (PPI) se identificaron mediante criterios explícitos (STOPP/START, BEERS, criterios de deprescripción LESS-CHRON), criterios implícitos (MAI) y el programa informático CheckTheMeds®. Se midió el grado de aceptación de las intervenciones realizadas, y la repercusión económica se calculó a partir de los costes directos de los fármacos desprescritos.Resultados: De los 210 pacientes revisados por el servicio de farmacia se analizaron 105 pacientes evaluados por geriatría pertenecientes a 10 CSS. Se detectaron 510 prescripciones con posibles PRM (38,5% del total de fármacos prescritos). El 41,2% se correspondían a PPI según criterios STOPP/START/BEERS o LESS-CHRON. Los principales PRM identificados fueron: fármacos de beneficio/riesgo desfavorable, dosis o pauta no adecuada, duración no adecuada, mayor probabilidad de efectos adversos, medicamento no indicado y duplicidad. Se intervino en el 81,5% de los PRM detectados, con un grado de aceptación del 73,3% y una reducción del 23,1% en el número de medicamentos prescritos por paciente, con un ahorro económico de 16.218€/6 meses. (AU)

Appropriateness of medication prescribing in nursing homes: A collaboration project between pharmacy and geriatric departments.

PURPOSE: To evaluate the appropriateness of medication prescribing and to analyze interventions carried out in polymedicated elderly patients in nursing homes (NHs). METHODS: Prospective study of potentially inappropriate medication prescribing in polymedicated older adults living in NHs, implemented via a collaborative project between NHs and the geriatric and pharmacy departments of a university hospital. The pharmacist reviewed patients' active medical prescriptions and prepared an individualized report with proposals aimed at therapeutic optimization that was sent for evaluation to the geriatrician in charge of the NH. The drug-related problems (DRPs) were classified according to the Third Consensus of Granada and the potentially inappropriate prescriptions (PIPs) were identified by explicit criteria (STOPP/START, BEERS, LESS-CHRON), implicit criteria (MAI) and CheckTheMeds® software. It was measured the degree of acceptance of the interventions carried out, and the economic impact was calculated from the direct costs of the discontinued drugs. RESULTS: Of the 210 patients reviewed by the pharmacy department, 105 patients from 10 NHs were analyzed. A total of 510 prescriptions with possible DRPs were identified (38.5% of all prescribed drugs). According to STOPP/START/BEERS or LESS-CHRON criteria, 41.2% were PIPs. The main DRPs identified were: unfavorable risk-benefit ratio, inappropriate dose/regimen, inappropriate treatment duration, probability of adverse events, medication not indicated, and duplicate therapy. Interventions were proposed for 81.5% of the DRPs detected, of which 73.3% were accepted. This resulted in a 23.1% reduction in the number of drugs prescribed per patient and an economic saving of €16,218 per 6-month period. CONCLUSION: The appropriateness of medication prescribing in polymedicated older adults living in NHs by the pharmacist has made it possible to reduce DRPs and PIPs and to save costs thanks to the high degree of acceptance by geriatricians.

Effect of a multicomponent exercise program and cognitive stimulation (VIVIFRAIL-COGN) on falls in frail community older persons with high risk of falls: study protocol for a randomized multicenter control trial.

BACKGROUND: Falls represent important drivers of intrinsic capacity losses, functional limitations and reduced quality of life in the growing older adult's population, especially among those presenting with frailty. Despite exercise- and cognitive training-based interventions have shown effectiveness for reducing fall rates, evidence around their putative cumulative effects on falls and fall-related complications (such as fractures, reduced quality of life and functional limitations) in frail individuals remains scarce. The main aim of this study is to explore the effectiveness program combining an individualized exercise program and an executive function-based cognitive training (VIVIFRAIL-COGN) compared to usual care in the prevention of falls and fall-related outcomes over a 1-year follow-up. METHODS: This study is designed as a four-center randomized clinical trial with a 12-week intervention period and an additional 1-year follow-up. Three hundred twenty frail or pre-frail (≥ 1 criteria of the Frailty Phenotype) older adults (≥ 75 years) with high risk of falling (defined by fall history and gait performance) will be recruited in the Falls Units of the participating centers. They will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will participate in a home-based intervention combining the individualized Vivifrail multicomponent (aerobic, resistance, gait and balance and flexibility) exercise program and a personalized executive function-based cognitive training (VIVIFRAIL-COGN). The CG group will receive usual care delivered in the Falls Units, including the Otago Exercise Program. Primary outcome will be the incidence of falls (event rate/year) and will be ascertained by self-report during three visits (at baseline, and 6 and 12 weeks) and telephone-based contacts at 6, 9 and 12 months after randomization. Secondarily, effects on measures of physical and cognitive function, quality of life, nutritional, muscle quality and psychological status will be evaluated. DISCUSSION: This trial will provide new evidence about the effectiveness of an individualized multidomain intervention by studying the effect of additive effects of cognitive training and physical exercise to prevent falls in older frail persons with high risk of falling. Compared to usual care, the combined intervention is expected to show additive effects in the reduction of the incidence of falls and associated adverse outcomes. TRIAL REGISTRATION: NCT04911179 02/06/2021.

[An opportunity to identify and prevent frailty through falls intervention.] / Oportunidad para la detección y manejo precoz de la fragilidad a través del abordaje de las caídas.

Falls are one of the classic giant geriatric syndromes with a multifactorial etiopathogenesis and closely related to frailty, being this relationship bidirectional. The Consensus Document on the Prevention of Frailty and Falls approved by the Interterritorial Council of the National Health System in 2014 provides recommendations for the screening of frailty and falls in all older adults in order to develop a management plan in high risk older adults so to prevent disability. This review describes the intrinsic relationship between frailty and falls, falls assessment and screening instruments to use and detect frailty and finally gives evidence-based recommendations to reduce falls impact.

Las caídas son uno de los grandes síndromes geriátricos, con una etiopatogenia multifactorial y con una estrecha relación con la fragilidad, siendo esta relación bidireccional. El Documento de Consenso sobre Prevención de Fragilidad y Caídas aprobado por el Consejo Interterritorial del Sistema Nacional de Salud en 2014, propone un cribado universal de fragilidad y riesgo de caídas, con el objetivo de intervenir en aquellos ancianos de alto riesgo y por tanto prevenir discapacidad. Esta revisión evalúa la relación intrínseca entre caídas y fragilidad, describe las herramientas de valoración del paciente que presenta caídas, incidiendo en aquellos aspectos que detectan fragilidad y finalmente propone intervenciones que han demostrado reducir su impacto.

Results of an anaemia treatment protocol complementary to blood transfusion in elderly patients with hip fracture / Resultados de un protocolo de tratamiento de anaemia con terapias complementarias a transfusión en anciano con fractura de cadera

Background: Anaemia is a very common condition in elderly patients with hip fracture. The side effects of blood transfusions are well known, and further research on potential alternative therapies is needed. Objectives and design: A non-controlled descriptive study, conducted on 138 patients admitted for hip fracture, aimed at analysing the effects of an anaemia treatment protocol adjunctive to transfusion, based on the use of supra-physiological doses of intravenous iron and erythropoietin (IS/EPOS). The variables collected were, medical history, physical and cognitive status prior to fracture, as well as the need of blood products, medical complications during admission and their functional outcome at three and six months after the fracture were evaluated. Transfusion rates were compared with a historical control group when the only treatment for acute anaemia was transfusion (2011). Results: Almost half (63, 48%) of the patients received blood transfusion, with (91,70%) IS/EPOD. Intravenous iron did not reduce the percentage of transfused patients (56% vs. 44%), but it did reduce the number of blood units required (0.7 units less in IS/EPO group). Patients who required transfusion had a longer hospital stay, (1.7 days; 13.2 vs. 11.5; p<0.005). Patients who received IS had better functional recovery assessed with Barthel index and the Functional Ambulation Categories (FAC scale) at 3 and 6 months after the fracture. Patients with malnutrition or subtrochanteric fracture needed more tabletransfusions (p<0.005). Functional recovery at 3 and 6 months after fracture was better in patients who received intravenous iron. Neither blood transfusions nor intravenous iron were associated with infectious complications or increased mortality. The patient series of this study was compared with a group of patients with hip fracture and similar characteristics seen in 2011, before intravenous iron was available, revealing a 17% reduction in blood transfusion needs (p<0.005). Conclusion: The use of intravenous iron in elderly patients with hip fracture may help to reduce the number of blood units needed for the treatment of anaemia, although a causal relationship cannot be established due to not having a control group. Transfusions were associated with longer hospital stay in elderly patients with hip fracture

Introducción: El síndrome anémico es muy frecuente en el anciano ingresado por fractura de cadera. Los documentados efectos secundarios de la transfusión de hemoderivados hacen necesario investigar otras posibles alternativas terapéuticas. Material y métodos: Estudio descriptivo de 138 pacientes ingresados por fractura de cadera que evalúa el efecto de un protocolo de tratamiento de anemia perioperatoria complementario a transfusión, basado en el empleo de dosis suprafisiológicas de hierro intravenoso y eritropoyetina (FE/EPO). Se trata de un estudio descriptivo sin grupo control. Se evaluaron los antecedentes médicos de los pacientes, y su situación mental y física previas al ingreso, la necesidad de hemoderivados, las complicaciones en el ingreso y su evolución funcional en los 6 meses posteriores a la fractura. Los ratios de transfusión fueron comparados con los de una muestra histórica de similares características sin tratamiento con ferroterapia intravenosa (2011). Resultados: Recibieron transfusión el 48% de los pacientes (63) y ferroterapia parenteral con eritropoyetina (FE/EPO) el 70% (91). La administración de FE/EPO no disminuyó el porcentaje de pacientes hemotransfundidos (56 vs. 44%) de forma significativa, pero sí redujo el número de unidades de sangre requeridas (0,7 unidades menos en grupo de FE/EPO). Los pacientes que recibieron ferroterapia intravenosa tuvieron una estancia hospitalaria de 1,7 días inferior que los transfundidos (11,5 vs. 13,2; p<0,005). La administración de hierro parenteral se relacionó con tendencia a una mejor recuperación de capacidad de autocuidados y deambulación medidos mediante el índice de Barthel (IB) y la escala de deambulación de Holden (FAC) a los 3 y 6 meses de la fractura. La anemia y la malnutrición al ingreso, así como el tipo de fracturas subtrocantérea se relacionaron de forma independiente a mayor necesidad de transfusión (p<0,005). Ni las transfusiones ni el tratamiento con ferroterapia parenteral se asociaron a más complicaciones infecciosas ni a mayor mortalidad. Al comparar la muestra actual con un control histórico de pacientes con fractura de cadera sin disponibilidad de tratamiento con hierro intravenoso, se observa reducción actual del porcentaje de pacientes transfundidos en un 17% (p<0,005). Conclusión: El empleo de ferroterapia intravenosa en pacientes con fractura de cadera puede reducir el número de unidades de hemoderivados necesarias, sí bien no se puede establecerse una relación causal al no ser un estudio controlado. La transfusión se asocia con una prolongación de la estancia hospitalaria en el anciano ingresado por fractura de cadera

Results of an anaemia treatment protocol complementary to blood transfusion in elderly patients with hip fracture.

BACKGROUND: Anaemia is a very common condition in elderly patients with hip fracture. The side effects of blood transfusions are well known, and further research on potential alternative therapies is needed. OBJECTIVES AND DESIGN: A non-controlled descriptive study, conducted on 138 patients admitted for hip fracture, aimed at analysing the effects of an anaemia treatment protocol adjunctive to transfusion, based on the use of supra-physiological doses of intravenous iron and erythropoietin (IS/EPOS). The variables collected were, medical history, physical and cognitive status prior to fracture, as well as the need of blood products, medical complications during admission and their functional outcome at three and six months after the fracture were evaluated. Transfusion rates were compared with a historical control group when the only treatment for acute anaemia was transfusion (2011). RESULTS: Almost half (63, 48%) of the patients received blood transfusion, with (91,70%) IS/EPOD. Intravenous iron did not reduce the percentage of transfused patients (56% vs. 44%), but it did reduce the number of blood units required (0.7 units less in IS/EPO group). Patients who required transfusion had a longer hospital stay, (1.7 days; 13.2 vs. 11.5; p<0.005). Patients who received IS had better functional recovery assessed with Barthel index and the Functional Ambulation Categories (FAC scale) at 3 and 6 months after the fracture. Patients with malnutrition or subtrochanteric fracture needed more tabletransfusions (p<0.005). Functional recovery at 3 and 6 months after fracture was better in patients who received intravenous iron. Neither blood transfusions nor intravenous iron were associated with infectious complications or increased mortality. The patient series of this study was compared with a group of patients with hip fracture and similar characteristics seen in 2011, before intravenous iron was available, revealing a 17% reduction in blood transfusion needs (p<0.005). CONCLUSION: The use of intravenous iron in elderly patients with hip fracture may help to reduce the number of blood units needed for the treatment of anaemia, although a causal relationship cannot be established due to not having a control group. Transfusions were associated with longer hospital stay in elderly patients with hip fracture.