Valor pronóstico a corto plazo de la proteína C reactiva en ancianos con insuficiencia cardíaca aguda / The short-term prognostic value of C-reactive protein in elderly patients with acute heart failure

Introducción y objetivos: la proteína C reactiva (PCR) plasmática ha sido evaluada como marcador pronóstico en insuficiencia cardíaca aguda (ICA). Sin embargo, no está confirmado que posea validez pronóstica cuando la población de ICA analizada está constituida por pacientes de edad avanzada. Métodos: analizamos los valores plasmáticos de PCR en todos los pacientes ingresados en servicios de medicina interna por ICA de cualquier tipo. Evaluamos la asociación existente entre dichos valores, las características clínicas basales de los pacientes y las tasas de mortalidad y reingreso por cualquier causa a los 3 meses del alta. Para las comparaciones se estratificó a los pacientes en terciles de valor de PCR bajo, medio y alto (< 2,24mg/l, 2,25-11,8mg/l y>11,8mg/l, respectivamente). Resultados: se incluyó a 1.443 pacientes, con una mediana de edad de 80 años (rango intercuartílico 73-85); de ellos, 680 (47%) eran hombres, con una carga de comorbilidad moderada; el 60,1% presentaba fracción de eyección del ventrículo izquierdo preservada (> 50%). El análisis multivariante confirmó la existencia de una asociación independiente entre valores elevados de PCR al ingreso y la presencia de infección respiratoria, presión sistólica baja y función renal alterada. Tres meses después del ingreso índice, un total de 142 pacientes (9,8%) habían fallecido y 268 (18,6%) habían reingresado o habían muerto. Los valores de la PCR en el momento del ingreso no se correlacionaron con la tasa de mortalidad por cualquier causa a los 3 meses (p=0,79), ni con la tasa a los 3 meses de reingreso por cualquier causa (p=0,96) o con la combinación de ambos acontecimientos (p=0,96). Sin embargo, los valores altos de la PCR se asociaron a estancias hospitalarias más prolongadas (p<0,001). Conclusión: nuestro estudio no confirma la existencia de una asociación entre los valores de PCR plasmáticos presentes en el ingreso en los ancianos con ICA con un mayor riesgo de mortalidad o reingreso a los 3 meses

Introduction and objectives: plasma c-reactive protein (crp) has been tested as a prognostic marker in acute heart failure (ahf). Whether its measurement really provides significant prognostic information when applied to elderly patients with ahf episodes remains unclear. Methods: we measured the plasma crp values of patients admitted because of any type of ahf to internal medicine services. We evaluated the association of these values with the patients' baseline clinical characteristics and their 3-month posdischarge all-cause mortality or readmission rates. For comparison purposes, we divided the sample in tertiles of low, medium and high crp values (<2,24mg/l, 2,25-11,8mg/l and>11,8mg/l). Results: we included 1443 patients with a median age of 80 years (interquartile range 73-85); 680 (47%) were men, with a moderate comorbid burden. 60.1% had preserved left ventricular ejection fraction (> 50%). Multivariate analysis confirmed an independent association between higher crp values and the presence of respiratory infection, lower systolic blood pressure and deteriorated renal function upon admission. Three months after the index admission, a total of 142 patients (9.8%) had died, and 268 (18.6%) had either been readmitted or died. admission crp values did not correlate with 3-month all-cause mortality (P=0.79), 3-month all-cause readmission (P=0.96) or the combination of both events (P=0.96). However, higher crp values were associated with a longer length of stay (P<0.001). Conclusion: our study does not confirm an association between admission plasma crp values in elderly ahf patients and subsequent higher 3-month mortality or readmission risks

The short-term prognostic value of C-reactive protein in elderly patients with acute heart failure. / Valor pronóstico a corto plazo de la proteína C reactiva en ancianos con insuficiencia cardíaca aguda.

INTRODUCTION AND OBJECTIVES: Plasma c-reactive protein (crp) has been tested as a prognostic marker in acute heart failure (ahf). Whether its measurement really provides significant prognostic information when applied to elderly patients with ahf episodes remains unclear. METHODS: We measured the plasma crp values of patients admitted because of any type of ahf to internal medicine services. We evaluated the association of these values with the patients' baseline clinical characteristics and their 3-month posdischarge all-cause mortality or readmission rates. For comparison purposes, we divided the sample in tertiles of low, medium and high crp values (<2,24mg/l, 2,25-11,8mg/l and>11,8mg/l). RESULTS: We included 1443 patients with a median age of 80 years (interquartile range 73-85); 680 (47%) were men, with a moderate comorbid burden. 60.1% had preserved left ventricular ejection fraction (> 50%). Multivariate analysis confirmed an independent association between higher crp values and the presence of respiratory infection, lower systolic blood pressure and deteriorated renal function upon admission. Three months after the index admission, a total of 142 patients (9.8%) had died, and 268 (18.6%) had either been readmitted or died. admission crp values did not correlate with 3-month all-cause mortality (P=0.79), 3-month all-cause readmission (P=0.96) or the combination of both events (P=0.96). However, higher crp values were associated with a longer length of stay (P<0.001). CONCLUSION: Our study does not confirm an association between admission plasma crp values in elderly ahf patients and subsequent higher 3-month mortality or readmission risks.

Es básico realizar una valoración e intervención geriátricas en el paciente anciano hospitalizado / A geriatric assessment followed by geriatric intervention is essential for elderly hospitalized patients

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Nonagenarios en Medicina Interna: otra epidemia del siglo XXI / Nonagenarians in Internal Medicine: another 21st century epidemic

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Riesgo de mortalidad en pacientes con diabetes mellitus tipo 2 hospitalizados por insuficiencia cardiaca aguda / Mortality in type 2 diabetes patients admitted because of acute heart failure

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Inappropriate prescribing in elderly people with diabetes admitted to hospital.

AIMS: To assess inappropriate prescribing in older people with diabetes mellitus during the month prior to a hospitalization, using tools on potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) and comparing inappropriate prescribing in patients with without diabetes. METHODS: In an observational, prospective multicentric study, we assessed inappropriate prescribing in 672 patients aged 75 years and older during hospital admission. The Beers, Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria and Assessing Care of Vulnerable Elders (ACOVE-3) medicine quality indicators were used. We analysed demographic and clinical factors associated with inappropriate prescribing. RESULTS: Of 672 patients, 249 (mean age 82.4 years, 62.9% female) had a diagnosis of diabetes mellitus. The mean number of prescribing drugs per patient with diabetes was 12.6 (4.5) vs. 9.4 (4.3) in patients without diabetes (P < 0.001). Of those patients with diabetes, 74.2% used 10 or more medications; 54.5% of patients with diabetes had at least one Beers-listed PIM, 68.1% had at least one STOPP-listed PIM, 64.6% had at least one START-listed PPO and 62.8% had at least one ACOVE-3-listed PPO. Except for the Beers criteria, these prevalences were significantly higher in patients with diabetes than in those without. After excluding diabetes-related items from these tools, only STOPP-listed PIMs remained significantly higher among patients with diabetes (P = 0.04). CONCLUSIONS: Polypharmacy is common among older patients with diabetes mellitus. Inappropriate prescribing is higher in older patients with diabetes, even when diabetes-related treatment is excluded from the inappropriate prescribing evaluation.

Serum high-density lipoprotein cholesterol levels correlate well with functional but not with cognitive status in 85-year-old subjects.

OBJECTIVES: We evaluate the association between high-density lipoprotein cholesterol (HDL-C) levels and physical and cognitive performance indicators in 85-year-old subjects. DESIGN: Prospective cohort study. SETTING: A community-based study. PARTICIPANTS: 321 subjects enrolled in the Octabaix Study. METHODS: Functional status was determined using the Lawton-Brody Index (LI) and the Barthel Index (BI). Cognition was assessed using the modified Spanish version of the Mini-Mental State Examination (MEC). We also measured risks related to nutrition and falls, as well as comorbidity and chronic drug prescription. HDL-C serum concentrations <40 mg/dl for men and <46 mg/dl for women were used as cut-off values to discriminate between normal and low HDL-C concentrations. RESULTS: The sample consisted of 197 women (61%) and 124 men. Mean HDL-C levels were 56.5 ± 15 mg/dl, with gender differences being found (59.3 ± 15 mg/dl in women vs. 52.1 ± 13 mg/dl in men; p<0.0001). Sixty-one subjects (19%) had low HDL-C values. HDL-C levels correlated with BI (r=0.11, p=0.04) and LI (r=0.17, p=0.002) scores, but not with MEC scores (r=0.08, p=0.13). Poor BI and LI scores, lower MEC scores, a risk of falls and malnutrition, and polypharmacy were all associated with lower HDL-C values in the bivariate analysis. Multiple logistic regression analysis showed only a significant association between normal HDL-C serum values and better BI scores (p<0.001, OR 1.02, 95% CI 1.01-1.04). CONCLUSIONS: Individuals with higher levels of HDL-C had better functional and cognitive status, but after multivariate analysis this relationship only remained significant for functional status.

[Heart failure in the elderly patient]. / La insuficiencia cardíaca en el paciente anciano.

Heart failure is a highly prevalent clinical syndrome, especially among those between 70 to 90 years of age. In the elderly patient, as opposed to that occurring in younger patients, the causal and facilitating mechanisms of the syndrome and its decompensations are generally varied and simultaneous, the clinical presentation is less specific, the diagnostic tools are less accurate and less effective or more difficult to apply. These limitations predispose to more episodes of decompensation and hospital admission, a higher risk of physical disability and poor symptom control, and worse short- or middle- term survival prognosis. Unfortunately, the amount and quality of scientific evidence related to the management of heart failure in this elderly population is smaller than that available for younger adults, which serves as the base for the elaboration of clinical practice guidelines. This review deals with the differential features of heart failure in the geriatric population.

La insuficiencia cardíaca en el paciente anciano / Heart failure in the elderly cardiac failure patient

La insuficiencia cardíaca es un síndrome clínico muy prevalente, cuya incidencia aumenta especialmente entre la séptima y la octava décadas de la vida. En el paciente anciano, a diferencia de lo que ocurre en el paciente joven, los mecanismos causales y facilitadores del síndrome y sus descompensaciones suelen ser variados y simultáneos, la clínica es más inespecífica, las herramientas diagnósticas menos precisas y los tratamientos menos efectivos o más difíciles de aplicar. Estas limitaciones predisponen a mayor incidencia de descompensaciones e ingresos hospitalarios, mayor riesgo de discapacidad física y mal control sintomático, y a un pronóstico vital comprometido a corto o medio plazo. Lamentablemente, el grado de “evidencia” científica relacionada con el diagnóstico y tratamiento de la insuficiencia cardíaca en los ancianos es más escaso y de peor calidad del que se dispone para la población adulta, que sirve de base para la elaboración de las guías de práctica clínica. En esta revisión se abordan los aspectos diferenciales de la insuficiencia cardíaca en la población geriátrica(AU)

Heart failure is a highly prevalent clinical syndrome, especially among those between 70 to 90 years of age. In the elderly patient, as opposed to that occurring in younger patients, the causal and facilitating mechanisms of the syndrome and its decompensations are generally varied and simultaneous, the clinical presentation is less specific, the diagnostic tools are less accurate and less effective or more difficult to apply. These limitations predispose to more episodes of decompensation and hospital admission, a higher risk of physical disability and poor symptom control, and worse short- or middle- term survival prognosis. Unfortunately, the amount and quality of scientific evidence related to the management of heart failure in this elderly population is smaller than that available for younger adults, which serves as the base for the elaboration of clinical practice guidelines. This review deals with the differential features of heart failure in the geriatric population(AU)

Predictors of 3-year mortality in subjects over 95 years of age. The NonaSantfeliu study.

OBJECTIVES: To examine the survival rates of subjects aged 95 or over after a follow-up period of 3 years, and to determine predictive factors for mortality risk. DESIGN: A prospective cohort study. SETTING: A community-based study. PARTICIPANTS: Forty-eight subjects aged 95 or over. MEASUREMENTS: Sociodemographic data, Barthel Index, Lawton-Brody Index, Spanish version of the Mini-Mental State Examination, short version of the Mini Nutritional Assessment, comorbidity (Charlson Index), and prevalent chronic diseases were evaluated. Patients who died were compared with the rest. RESULTS: Thirty-six deaths (75%) were recorded during follow-up. The Cox multivariate analysis showed that lower Barthel Index scores and a history of heart failure were independently associated with long-term mortality. CONCLUSIONS: In subjects aged 95 or over, poor functional status and history of heart failure were the two independent risk factors for 3-year mortality.

[Mortality-associated factors in nonagenarian. The Nona-Santfeliu Study. Two years of follow-up]. / Factores asociados a mortalidad en nonagenarios. Estudio NonaSantfeliu. Seguimiento a los dos años.

OBJECTIVES: Few studies have prospectively evaluated predictors of mortality in the very elderly. This study has aimed to determine which factors could predict death in nonagenarians after two years of follow-up. PATIENTS AND METHOD: 176 nonagenarians were evaluated prospectively, 137 (74%) of whom lived in their own home and 49 (26%) of whom were institutionalized. Sociodemographic data were collected. Functional status was determined by the Lawton-Brody and the Barthel index, and cognition by the Spanish version of the Mental State Examination (MEC). The Charlson index was used to measure overall co-morbidity. RESULTS: The sample consisted of 135 women (76.3%) and 41 men. Mean age was 93 +/- 3.2 years. Mean Barthel index was 60.8 +/- 30, Lawton index 2.1 +/- 2.2 and MEC 21 +/- 11. The mean of Charlson index was 1.4 +/- 1.7. Six-four patients had died after two years of follow-up (36.3%). Charlson index (oR 1.370, 95% Ci 1.113-1.686, p < 0.003), Lawton index (OR 0.750, 95% CI 0.586-0.960, p < 0.02) and MEC (OR 0.964, 95% CI 0.932-0.997, p < 0.003) were variables independently associated with death after 24 months of follow-up. CONCLUSION: Higher comorbidity, incapacity to perform instrumental ADL at baseline and poor cognitive status are predictors of mortality after 2 years of follow-up in nonagenarians.

Factores asociados a mortalidad en nonagenarios. Estudio NonaSantfeliu. Seguimiento a los dos años / Mortality-associated factors in nonagenarian. The Nona-Santfeliu Study. Two years of follow-up

Objetivos. Pocos estudios han evaluado los factores predictores de mortalidad en las personas muy ancianas. El objetivo del presente estudio fue evaluar qué factores podían predecir la muerte en pacientes nonagenarios después de dos años de seguimiento. Pacientes y método. Se evaluaron 176 nonagenarios, de los que el 73% vivían en su domicilio y el resto en residencia. Se recogieron datos sociodemográficos, la capacidad para realizar actividades básicas con el índice de Barthel (IB) y para instrumentales con el índice de Lawton (IL). Se valoró la cognición con el miniexamen cognitivo de Lobo (MEC) y la comorbilidad con el índice de Charlson. Resultados. Se trataba de 135 mujeres (76,3%) y 41 varones, con una edad media de 93 ± 3 años. La media del IB fue 60,8 ± 30, la del IL 2,1 ± 2,2, la del MEC 21 ± 11 y la del índice de Charlson 1,4 ± 1,7. Sesenta y cuatro pacientes habían fallecido a los dos años de seguimiento (36,3%). El índice de Charlson (OR: 1,370; IC 95%: 1,113-1,686; p < 0,003), IL (OR: 0,750; IC 95%: 0,586-0,960; p < 0,02) y MEC (OR: 0,964; IC 95%: 0,932-0,997; p < 0,003), resultaron factores independientes de mortalidad a los 2 años de seguimiento. Conclusiones. Una mayor comorbilidad, la incapacidad para realizar actividades instrumentales y la disfunción cognitiva son predictores de mortalidad después de 2 años de seguimiento en las personas mayores de 89 años (AU)

Objectives. Few studies have prospectively evaluated predictors of mortality in the very elderly. This study has aimed to determine which factors could predict death in nonagenarians after two years of follow-up. Patients and method. 176 nonagenarians were evaluated prospectively, 137 (74%) of whom lived in their own home and 49 (26%) of whom were institutionalized. Sociodemographic data were collected. Functional status was determined by the Lawton-Brody and the Barthel index, and cognition by the Spanish version of the Mental State Examination (MEC). The Charlson index was used to measure overall co-morbidity. Results. The sample consisted of 135 women (76.3%) and 41 men. Mean age was 93 ± 3.2 years. Mean Barthel index was 60.8 ± 30, Lawton index 2.1 ± 2.2 and MEC 21 ± 11. The mean of Charlson index was 1.4 ± 1.7. Six-four patients had died after two years of follow-up (36.3%). Charlson index (oR 1.370, 95% Ci 1.113-1.686, p < 0.003), Lawton index (OR 0.750, 95% CI 0.586-0.960, p < 0.02) and MEC (OR 0.964, 95% CI 0.932-0.997, p < 0.003) were variables independently associated with death after 24 months of follow-up. Conclusion. Higher comorbidity, incapacity to perform instrumental ADL at baseline and poor cognitive status are predictors of mortality after 2 years of follow-up in nonagenarians (AU)

Characteristics of falls producing hip fractures in nonagenarians.

OBJECTIVES: To evaluate the characteristics associated with falls causing hip fracture in patients 90 years of age or older (nonagenarians). A second objective was to compare these characteristics with those present in younger patients (65-79 year-olds). DESIGN: Prospective, observational study. SETTING: Six hospitals in Barcelona (Spain) and its surrounding area. PARTICIPANTS: 105 nonagenarians diagnosed with hip fracture after a fall. Most patients were women (78; 74%), with a mean age of 92.2+/-2 years. All of them were living in the community, except for eight institutionalized patients. 221 patients aged 65 to 79 composed the younger patient's comparison group. MEASUREMENTS: Characteristics of falls causing hip fracture were analyzed: location, time and the risk factor for the fall, classified as intrinsic, extrinsic or combined. RESULTS: The mean number of falls in the previous year was 1.5 - 22% of the patients reported having fallen two or more times. Falls usually happened while at home (70%) and during the day (64%). An intrinsic risk factor was considered the most likely cause in 37% of the cases, an extrinsic risk factor in 35%, and a combination in 28%. Multiple stepwise logistic regression analysis showed that nonagenarians were characterized by lower BI scores, more falls happening during night time, a higher use of, benzodiazepines and diuretics, and a lower use of non-benzodiazepinic hypnotics. CONCLUSIONS: Most falls causing hip fracture in nonagenarians happen during the day and at home. Falls in nonagenarians happening more frequently during nighttime, and these oldest subjects had lower BI scores, and a higher use of benzodiazepines and diuretics and less use of non-benzodiazepines hypnotics compared with the younger patients.

[Circumstances associated to falls resulting in hip fracture in community-dwelling subjects older than 94 years old]. / Circunstancias asociadas a las caídas responsables de fractura de fémur en pacientes mayores de 94 años no institucionalizados.

OBJECTIVE: To evaluate the circumstances associated with falls resulting in hip fracture in the 95 years of age or older community-dwelling patients. MATERIAL AND METHODS: A prospective, observational study, was conducted in 6 hospitals in the Barcelona area on the characteristics associated with falls resulting in hip fracture in 30 patients aged > 94 years old. Location, time and the risk factor for the fall (classified as intrinsic, extrinsic or combined) were evaluated. RESULTS: Mean number of falls in the previous year was 1.6, 5 (16.7%) of the patients reporting having fallen two or more times. Falls usually occurred while at home, a high percentage (46.7%) of which occurred during the night. When the differences were evaluated by sex, there was a high percentage of uncorrected auditory loss in men and high number of chronic drugs and psychotropic drugs in women. CONCLUSIONS: Most falls causing hip fracture in community-dwelling very elderly subjects occur at home. Nearly half of the falls occur during the night.

[Characteristics of falls producing hip fracture in an elderly population. Differences according to age and gender]. / Circunstancias asociadas a las caídas responsables de fractura de fémur en pacientes ancianos. Diferencias por grupo de edad y género.

BACKGROUND: The majority of hip fractures are produced because of a fall. We examined the characteristics associated with falls causing hip fracture in elderly patients. MATERIAL AND METHODS: Characteristics of falls owing to hip fracture were analyzed in 410 consecutive patients admitted in 6 hospitals during the 2004. We evaluated the location, time and the possible cause of fall: intrinsic risk factor, extrinsic or combined. RESULTS: We evaluated 316 women (77%) and 94 men, mean age 81.9 years. Previous to the hip fracture, the mean BI was 77.5. The mean value of falls during the last year was 1.9. Previously to the fall that caused hip fracture, we found that 24% of the patients had fallen repeatedly (more than two falls). Usually falls were at home (68%) and during daytime (80%). In 45% of patients an intrinsic risk factor was considered the most likely cause, in 33% an extrinsic risk factor and in 22% a combination. CONCLUSIONS: The majority of falls owing to hip fracture in elderly people happen in daytime, at home and due to intrinsic risk factors. Efforts to identify elderly people at risk of fall should be stressed in order to establish preventive measures.