Estudio transversal multicéntrico sobre la prevalencia de delirium en unidades de ortogeriatría: protocolo de «Estudio DELFRA 24» / Multicenter cross-sectional study on the prevalence of delirium in orthogeriatric units: «DELFRA 24 study» protocol

Introducción El delirium es la complicación perioperatoria más frecuente en el adulto mayor con fractura de cadera (FC) conllevando un impacto catastrófico en su recuperación funcional y su estado cognitivo. Actualmente se desconoce la prevalencia real de este síndrome ya que no está protocolizada su detección y abordaje en la práctica clínica habitual. Métodos Se realizará un estudio observacional multicéntrico de tipo transversal a nivel nacional en el que participarán distintas unidades de ortogeriatría de España. Se evaluará la prevalencia de delirium con la escala 4AT, así como las características de este y su relación con otros síndromes geriátricos, variables sociodemográficas, características de la cirugía y parámetros analíticos. Resultados La recogida de datos se llevará a cabo el próximo día mundial del delirium (miércoles 13 de marzo de 2024), por lo que los resultados se esperan durante el segundo o tercer trimestre del año 2024. Conclusiones Conocer la prevalencia real y las características del delirium en mayores con FC podría contribuir a sensibilizar en la detección sistemática, la prevención y el abordaje protocolizado del delirium en servicios quirúrgicos, disminuyendo el impacto de sus consecuencias. (AU)

Introduction Delirium is the most common perioperative complication in older adults with hip fracture (HF), leading to a catastrophic impact on their functional recovery and cognitive status. Currently, the true prevalence of this syndrome is unknown as its detection and management are not standardized in clinical practice. Methods A multicenter observational cross-sectional study will be conducted nationwide, involving different orthogeriatric units in Spain. The prevalence of delirium will be assessed using the 4AT scale, along with its characteristics and its relationship with other geriatric syndromes, sociodemographic variables, surgical characteristics, and laboratory parameters. Results Data collection is scheduled to take place on World Delirium Day (Wednesday, March 13, 2024), and therefore, the results are expected during the second or third quarter of 2024. Conclusions Understanding the real prevalence and characteristics of delirium in older adults with HF could contribute to the development of strategies for its detection and management, reducing the impact of its consequences. (AU)

Estudio transversal multicéntrico sobre la prevalencia de delirium en unidades de ortogeriatría: protocolo de «Estudio DELFRA 24» / Multicenter cross-sectional study on the prevalence of delirium in orthogeriatric units: «DELFRA 24 study» protocol

Introducción El delirium es la complicación perioperatoria más frecuente en el adulto mayor con fractura de cadera (FC) conllevando un impacto catastrófico en su recuperación funcional y su estado cognitivo. Actualmente se desconoce la prevalencia real de este síndrome ya que no está protocolizada su detección y abordaje en la práctica clínica habitual. Métodos Se realizará un estudio observacional multicéntrico de tipo transversal a nivel nacional en el que participarán distintas unidades de ortogeriatría de España. Se evaluará la prevalencia de delirium con la escala 4AT, así como las características de este y su relación con otros síndromes geriátricos, variables sociodemográficas, características de la cirugía y parámetros analíticos. Resultados La recogida de datos se llevará a cabo el próximo día mundial del delirium (miércoles 13 de marzo de 2024), por lo que los resultados se esperan durante el segundo o tercer trimestre del año 2024. Conclusiones Conocer la prevalencia real y las características del delirium en mayores con FC podría contribuir a sensibilizar en la detección sistemática, la prevención y el abordaje protocolizado del delirium en servicios quirúrgicos, disminuyendo el impacto de sus consecuencias. (AU)

Introduction Delirium is the most common perioperative complication in older adults with hip fracture (HF), leading to a catastrophic impact on their functional recovery and cognitive status. Currently, the true prevalence of this syndrome is unknown as its detection and management are not standardized in clinical practice. Methods A multicenter observational cross-sectional study will be conducted nationwide, involving different orthogeriatric units in Spain. The prevalence of delirium will be assessed using the 4AT scale, along with its characteristics and its relationship with other geriatric syndromes, sociodemographic variables, surgical characteristics, and laboratory parameters. Results Data collection is scheduled to take place on World Delirium Day (Wednesday, March 13, 2024), and therefore, the results are expected during the second or third quarter of 2024. Conclusions Understanding the real prevalence and characteristics of delirium in older adults with HF could contribute to the development of strategies for its detection and management, reducing the impact of its consequences. (AU)

[Multicenter cross-sectional study on the prevalence of delirium in orthogeriatric units: «DELFRA 24 study¼ protocol]. / Estudio transversal multicéntrico sobre la prevalencia de delirium en unidades de ortogeriatría: protocolo de «Estudio DELFRA 24¼.

INTRODUCTION: Delirium is the most common perioperative complication in older adults with hip fracture (HF), leading to a catastrophic impact on their functional recovery and cognitive status. Currently, the true prevalence of this syndrome is unknown as its detection and management are not standardized in clinical practice. METHODS: A multicenter observational cross-sectional study will be conducted nationwide, involving different orthogeriatric units in Spain. The prevalence of delirium will be assessed using the 4AT scale, along with its characteristics and its relationship with other geriatric syndromes, sociodemographic variables, surgical characteristics, and laboratory parameters. RESULTS: Data collection is scheduled to take place on World Delirium Day (Wednesday, March 13, 2024), and therefore, the results are expected during the second or third quarter of 2024. CONCLUSIONS: Understanding the real prevalence and characteristics of delirium in older adults with HF could contribute to the development of strategies for its detection and management, reducing the impact of its consequences.

Geriatric syndromes and functions in older adults with COVID-19 hospitalized in sub-acute care: a multicenter study.

OBJECTIVE: Alternatives to conventional acute hospitalizations have been particularly useful during the COVID-19 pandemic. However, little is known on the management and outcomes of COVID-19 in older patient admitted to non-acute settings. The main aim of this study was to determine the effect of geriatrics syndromes on functional outcomes in older COVID-19 patients cared in sub-acute units. METHODS: Prospective multicenter observational cohort study of patients aged 65 years and older with COVID-19, admitted to sub-acute units in Italy and Spain. Multivariable logistic regression models were used to test the association between geriatric syndromes and other clinical variables, and the functional status at discharge, defined by a Barthel Index > = 80. RESULTS: A total of 158 patients were included in the study with a median age of 82 [Interquartile Range 81, 83]; of these 102 (65%) patients had a Barthel Index ≥ 80 at discharge. In the main multivariable logistic regression model a higher severity of frailty-measured with the Clinical Frailty Scale-(OR 0.30; CI 0.18-0.47), and the presence of delirium (OR 0.04; CI 0.00-0.35) at admission were associated with lower odds of a higher functional status at discharge. Other variables associated with lower functional status were female gender (OR 0.36; CI 0.13-0.96), and a higher number of comorbidities (OR 0.48; CI 0.26-0.82). CONCLUSION: The study reports a relatively high prevalence of functional recovery for older COVID-19 patients admitted to sub-acute units. Additionally, it underlines the importance of targeting geriatrics syndromes, in particular frailty and delirium, for their possible effects on functional recovery.

Two European Examples of Acute Geriatric Units Located Outside of a General Hospital for Older Adults With Exacerbated Chronic Conditions.

OBJECTIVE: Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs. DESIGN: Exploratory cohort study. SETTING AND PARTICIPANTS: Subacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics. MEASURES: We compared setting, characteristics, and outcomes between patients admitted to the 2 units. RESULTS: Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH). CONCLUSIONS AND IMPLICATIONS: These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.

Visual and Hearing Impairment Are Associated With Delirium in Hospitalized Patients: Results of a Multisite Prevalence Study.

OBJECTIVE: Sensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium. DESIGN: Cross-sectional study nested in the 2017 "Delirium Day" project. SETTING AND PARTICIPANTS: Patients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy. METHODS: Delirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters). RESULTS: A total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2-2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1-1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6-1.2, P = .36; OR 1.1; CI 0.8-1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6-1.2, P = .27; OR 1.1, CI 0.8-1.4, P = .63). CONCLUSIONS AND IMPLICATIONS: Our findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.

IMAGINE study protocol of a clinical trial: a multi-center, investigator-blinded, randomized, 36-month, parallel-group to compare the effectiveness of motivational interview in rehabilitation of older stroke survivors.

BACKGROUND: Rehabilitation pathways are crucial to reduce stroke-related disability. Motivational Interviewing (MI), as a person-centered complex intervention, aimed to empower and motivate, and could be a resource to improve rehabilitation outcomes for older stroke survivors. The IMAGINE project aims to assess the impact of MI, as a complement to standard geriatric rehabilitation, on functional improvement at 30 days after admission, compared to standard geriatric rehabilitation alone, in persons admitted to geriatric rehabilitation after a stroke. Secondary objectives include assessing the impact of MI on physical activity and performance, self-efficacy, safety, cost-utility, participants' experiences and functional status at 3 months. METHODS: We will conduct a multicenter randomized clinical trial in three geriatric rehabilitation hospitals in Spain. Older adults after mild-moderate stroke without previous severe cognitive impairment or disability will be randomized into the control or intervention group (136 per group, total N = 272). The intervention group will receive 4 sessions of MI by trained nurses, including the design of a personalized rehabilitation plan agreed between stroke survivors and nurses based on stroke survivors´ goals, needs, preferences and capabilities. Main outcome will be the Functional Independence Measure (FIM). In-hospital physical activity will be measured through accelerometers and secondary outcomes using validated scales. The study includes a process evaluation and cost-utility analysis. DISCUSSION: Final results are expected by end of 2020. This study will provide relevant information on the implementation of MI as a rehabilitation reinforcement tool in older stroke survivors. A potential reduction in post-stroke disability and dependence would increase person's health-related quality of life and well-being and reduce health and social care costs. IMAGINE has the potential to inform practice and policymakers on how to move forward towards shared decision-making and shared responsibilities in the vulnerable population of older stroke survivors. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03434938 , registered on January 2018.

Diagnóstico del delirium en pacientes con demencia, un gran reto / Diagnosing delirium in patients with dementia, a great challenge

El delirium, a pesar de su alta incidencia, graves consecuencias y potencial reversibilidad, sigue siendo un síndrome infradiagnosticado. En pacientes con demencia, el profesional sanitario puede encontrar dificultades para diferenciar si el paciente presenta alteraciones cognitivas y trastornos conductuales propios de la demencia o, por el contrario, se encuentra ante un cuadro de delirium superpuesto a la demencia (DSD). Ante esta dificultad, se han propuesto en los últimos años distintas herramientas para mejorar el diagnóstico de DSD. Estas herramientas intentan ser fáciles y rápidas de aplicar, y a pesar de centrarse en la evaluación de aspectos cognitivos como la atención o el nivel de consciencia, algunas de ellas han incorporado la valoración de otros aspectos más novedosos, como la capacidad de responder a estímulos externos (estado de alerta o activación) o el grado de movilidad

Delirium, despite its high incidence, serious consequences and potential reversibility, remains an underdiagnosed syndrome. In patients with dementia, the healthcare professional may find significant difficulties in differentiating whether the patient presents cognitive alterations and behavioural disorders characteristic of dementia or, on the contrary, is faced with a delirium superimposed on dementia (DSD). In view of this difficulty, many tools have been proposed in recent years to improve the diagnosis of DSD in these highly complex patients. The aim of these tools is to be easy and quick to apply, and although focusing on assessing cognitive aspects such as attention or level of consciousness, some of them have also incorporated the assessment of other more novel aspects, such as the ability to respond to external stimuli (Arousal) or the degree of mobility

Diagnosing delirium in patients with dementia, a great challenge. / Diagnóstico del delirium en pacientes con demencia, un gran reto.

Delirium, despite its high incidence, serious consequences and potential reversibility, remains an underdiagnosed syndrome. In patients with dementia, the healthcare professional may find significant difficulties in differentiating whether the patient presents cognitive alterations and behavioural disorders characteristic of dementia or, on the contrary, is faced with a delirium superimposed on dementia (DSD). In view of this difficulty, many tools have been proposed in recent years to improve the diagnosis of DSD in these highly complex patients. The aim of these tools is to be easy and quick to apply, and although focusing on assessing cognitive aspects such as attention or level of consciousness, some of them have also incorporated the assessment of other more novel aspects, such as the ability to respond to external stimuli (Arousal) or the degree of mobility.

Impairments in balance and mobility identify delirium in patients with comorbid dementia.

ABSTRACTDiagnosing delirium superimposed on dementia (DSD) remains challenging because of a lack of specific tools, though motor dysfunction in delirium has been relatively under-explored. This study aimed to use dysfunction in balance and mobility (with the Hierarchical Assessment of Balance And Mobility: HABAM) to identify DSD. This is a cross-sectional multicenter study, recruiting consecutive patients ≥70 years admitted to five acute or rehabilitation hospitals in Ireland, Italy, Portugal, and Switzerland. Delirium was diagnosed using DSM-5 criteria; dementia was determined by the Mini-Mental State Examination and the Questionnaire of Cognitive Decline in the Elderly. HABAM score was recorded at admission. Out of 114 patients (mean age ± SD = 82 ± 7; 54% female), dementia alone was present in 24.6% (n = 28), delirium alone in 18.4% (n = 21) and DSD in 27.2% (n = 31). Patients with DSD had a mean HABAM score 7 points greater than those with dementia alone (19.8 ± 8.7 vs 12.5 ± 9.5; p < 0.001); 70% of participants with DSD were correctly identified using the HABAM at a cut off of 22 (sensitivity 61%, specificity 79%, AUC = 0.76). Individuals with delirium have worse motor function than those without delirium, even in the context of comorbid dementia. Measuring motor function using the HABAM in older people at admission may help to diagnose DSD.

Delirium Subtypes and Associated Characteristics in Older Patients With Exacerbation of Chronic Conditions.

OBJECTIVE: The prevalence and prognosis of delirium motor subtypes are not yet well established. We analyzed the prevalence of motor subtypes of delirium, as well as their risk factors and outcomes, among older vulnerable patients admitted for short-term management of exacerbated chronic conditions. METHODS: Cohort study of patients aged 65 and older who developed delirium while admitted to a subacute care unit for 12 months (N = 352). Confusion Assessment Method was used to determine the presence of delirium and the Delirium Motor Subtype Scale was used to define the motor subtype. Outcomes included discharge destination, mortality, readmission, and functional trajectories. RESULTS: Out of 352 patients with delirium (mean age= 87.4, 73.6% with dementia), hyperactive delirium was the most prevalent subtype (40.6%), followed by mixed (31%), hypoactive (25.9%), and nonmotor (2.6%). In multivariate models, worse preadmission functional status (odds ratio [OR] [95% confidence interval {CI}] = 0.97 [0.96-0.98]) and higher comorbidity (OR [95% CI] = 1.3 [1.04-1.51]) were associated with an increased risk of hypoactive delirium. In multivariate models adjusted for different variables, including disability, hypoactive delirium was associated with mortality compared with hyperactive delirium (OR [95% CI] = 4.7 [1.6-14]) and mixed delirium (OR [95% CI] = 2.0 [1.02-3.9]) and with worse functional recovery (Beta[95% CI] = -0.2 [-12.0-(-0.4)]). CONCLUSION: Delirium motor subtypes were associated with different patient characteristics and outcomes. Hypoactive delirium seems to affect more vulnerable patients and to be associated with worse outcomes. More research on the different delirium subtypes could help develop better preventive and management strategies.

Integrated primary and geriatric care for frail older adults in the community: Implementation of a complex intervention into real life.

BACKGROUND: Frailty is highly prevalent in older persons and associated with negative health-related events and costs. Despite successful clinical trials, translation of evidence into implementation of dedicated programs has been scarce. This is probably due to funding limitations and lack of generalizability of rigid schemes adopted in controlled studies. We propose a guidance to implement complex interventions against frailty in the community, and describe the design and early findings of the +AGIL Barcelona program. METHODS: A guidance "decalogue" resulted from an experts' panel prioritization of recommendations by international independent bodies. On this basis, we reorganized existing primary care, geriatrics and community-based resources to implement our program, which includes a screening, a multi-component intervention modulated on the comprehensive geriatric assessment and integrated follow-up plus continuity through community-based resources. The pre-post impact of the program on physical function, as well as on clinical endpoints, person-center outcomes and costs will be assessed. RESULTS: Integrated care, multi-component, person-centered strategies to empower the final users in a flexible and adaptable way should be promoted after raising awareness and potentially convey long term investments. In 22 months, 185 participants (mean age ±â€¯SD = 81.6 ±â€¯5.7 years, 72% women) joined the program. Although independent in the activities of daily living, participants showed clear indicators of frailty (Short Physical Performance Battery = 7.1 ±â€¯2.5; gait speed = 0.69 ±â€¯0.2 m/s). CONCLUSIONS: +AGIL Barcelona may represent a unique model to manage frailty in older community-dwellers, translating evidence into pragmatic clinical practice. Further research will clarify the effects of this intervention.

Risk Factors and Outcomes of Delirium in Older Patients Admitted to Postacute Care with and without Dementia.

BACKGROUND: Delirium research is poorly studied in postacute care, a growing setting due to aging populations, as well as in dementia, a critical risk factor for delirium and particularly prevalent in postacute care. We investigated risk factors for delirium and its outcomes in older adults with and without dementia admitted to a subacute care unit (SCU) after exacerbated chronic conditions. METHODS: This is a prospective cohort study including patients ≥65 years old admitted to an SCU for 12 months. We collected demographics, comprehensive geriatric assessments, and presence of dementia and delirium at admission. Outcomes included discharge to previous living situation, mortality, and functional evolution. Due to the high prevalence of dementia, a subgroup analysis was performed to investigate specific risk factors for delirium and related outcomes. RESULTS: Of 909 patients (mean age [±SD] 85.8 ± 6.7; 60% women, 47.5% with dementia), 352 (38.7%) developed delirium. The main risk factor for delirium was dementia (HR [95% CI] 5.2 [3.5-7.7]); age, functional status, and urinary tract infections were also independently associated with delirium. In dementia patients, only age (HR [95% CI] 1.0 [1.004-1.1]) and being male (HR [95% CI] 1.7 [1.04-2.6]) were associated with delirium. Delirium was associated with greater mortality (10.8 vs. 3.9%; p < 0.001) and greater functional decline in the entire sample (-12.3 vs. -6.4 Barthel index points; p < 0.001). In the dementia subgroup, patients with delirium experienced greater functional loss (p = 0.013) and less functional recovery (p = 0.025). CONCLUSIONS: In older patients admitted to postacute care, dementia is the main risk factor for delirium, and delirium carries worse clinical and functional outcomes. In patients with dementia, delirium is also relevant, since it entails a functional loss at admission and lower functional recovery.

Perfil y evolución de pacientes crónicos complejos en una unidad de subagudos / Profile and evolution of chronic complex patients in a subacute unit

Objetivo: Para mejorar el manejo de pacientes pluripatológicos, en Cataluña se ha promovido la identificación como paciente crónico complejo (PCC) o con enfermedad crónica avanzada (MACA). Ante descompensaciones se promueve el ingreso de estos pacientes en unidades de subagudos (SG) ubicadas en hospitales de atención intermedia y especializadas en geriatría, como alternativa al hospital de agudos. Queremos evaluar los resultados del ingreso de PCC/MACA en SG. Diseño: Estudio cuantitativo descriptivo-comparativo, transversal. Emplazamiento: Unidad de subagudos de un hospital de atención intermedia. Participantes: Pacientes ingresados consecutivamente en SG durante 6 meses. Mediciones principales: Comparamos características basales (datos demográficos, clínicos y de valoración geriátrica integral), resultados al alta y a 30días post-alta entre pacientes identificados como PCC/MACA vs otros pacientes. Resultados: De 244 pacientes (promedio edad ± DE = 85,6 ± 7,5; 65,6% mujeres), 91 (37,3%) eran PCC/MACA (PCC = 79,1%, MACA = 20,9%). Estos, comparado con los no identificados, presentaban mayor comorbilidad (Charlson = 3,2 ± 1,8 vs 2,0; p = 0,001) y polifarmacia (9,5 ± 3,7 fármacos vs 8,1 ± 3,8, p = 0,009). Al alta, el retorno al domicilio habitual y la mortalidad fueron comparables. PCC/MACA tuvieron mayor mortalidad sumando los 30 días post-alta (15,4% vs 8%; p = 0,010); en un análisis multivariable, la identificación PCC/MACA (p = 0,006) y demencia (p = 0,004) se asociaba a mayor mortalidad. A pesar de que PCC/MACA reingresaban más a 30días (18,7% vs 10,5%; p = 0,014), en el análisis multivariable las únicas variables asociadas independientemente a reingresos fueron sexo masculino, polifarmacia e insuficiencia cardiaca. Conclusiones: A pesar de mayor comorbilidad y polifarmacia, los resultados de PCC/MACA al alta de SG fueron comparables con los otros pacientes, aunque experimentaron más reingresos a 30días, posiblemente por su comorbilidad y polimedicación (AU)

Objective: To improve the management of geriatric pluripathologic patients in Catalonia, the identification of chronic complex patient (PCC) or patients with advanced chronic disease (MACA) has been promoted. Patients with exacerbated chronic diseases are promoted to be admitted in subacute units (SG) located in intermediate hospitals and specialized in geriatric care, as an alternative to acute hospital. The results of the care process in patients identified as PCC/MACA in SG have not been evaluated. Design: Descriptive-comparative, cross-sectional, and quantitative study. Location: SG located in intermediate care hospital. Participants: Consecutive patients admitted in the SG during 6 months. Main measurements: We compared baseline characteristics (demographic, clinical and geriatric assessment data), results at discharge and 30days post-discharge between PCC/MACA patients versus other patients. Results: Of 244 patients (mean age ± SD = 85,6 ± 7,5; 65.6%women), 91 (37,3%) were PCC/MACA (PCC=79,1%, MACA = 20,9%). These, compared with unidentified patients, had greater comorbidity (Charlson index = 3,2 ± 1,8 vs 2,0; p = 0,001) and polypharmacy (9,5 ± 3,7 drugs vs 8,1 ± 3,8; p = 0,009). At discharge, the return to usual residence and mortality were comparable. PCC/MACA had higher mortality adding the mortality at 30 day post-discharge (15,4% vs 8%; p = 0,010). In a multi-variable analysis, PCC/MACA identification (p = 0,006), as well as a history of dementia (p = 0,004), was associated with mortality. Although PCC/MACA patients had higher readmission rate at 30 day (18,7% vs 10,5%; p = 0,014), in the multivariable analyses, only male, polypharmacy, and heart failure were independently associated to readmission. Conclusions: Despite having more comorbidity and polypharmacy, the outcomes of patients identified as PCC/MACA at discharge of SG, were comparable with other patients, although they experienced more readmissions within 30 days, possibly due to comorbidity and polypharmacy (AU)

[Profile and evolution of chronic complex patients in a subacute unit]. / Perfil y evolución de pacientes crónicos complejos en una unidad de subagudos.

OBJECTIVE: To improve the management of geriatric pluripathologic patients in Catalonia, the identification of chronic complex patient (PCC) or patients with advanced chronic disease (MACA) has been promoted. Patients with exacerbated chronic diseases are promoted to be admitted in subacute units (SG) located in intermediate hospitals and specialized in geriatric care, as an alternative to acute hospital. The results of the care process in patients identified as PCC/MACA in SG have not been evaluated. DESIGN: Descriptive-comparative, cross-sectional, and quantitative study. LOCATION: SG located in intermediate care hospital. PARTICIPANTS: Consecutive patients admitted in the SG during 6months. MAIN MEASUREMENTS: We compared baseline characteristics (demographic, clinical and geriatric assessment data), results at discharge and 30days post-discharge between PCC/MACA patients versus other patients. RESULTS: Of 244 patients (mean age±SD=85,6±7,5; 65.6%women), 91 (37,3%) were PCC/MACA (PCC=79,1%, MACA=20,9%). These, compared with unidentified patients, had greater comorbidity (Charlson index=3,2±1,8 vs 2,0; p=0,001) and polypharmacy (9,5±3,7 drugs vs 8,1±3,8; p=0,009). At discharge, the return to usual residence and mortality were comparable. PCC/MACA had higher mortality adding the mortality at 30day post-discharge (15,4% vs 8%; p=0,010). In a multi-variable analysis, PCC/MACA identification (p=0,006), as well as a history of dementia (p=0,004), was associated with mortality. Although PCC/MACA patients had higher readmission rate at 30day (18,7% vs 10,5%; p=0,014), in the multivariable analyses, only male, polypharmacy, and heart failure were independently associated to readmission. CONCLUSIONS: Despite having more comorbidity and polypharmacy, the outcomes of patients identified as PCC/MACA at discharge of SG, were comparable with other patients, although they experienced more readmissions within 30days, possibly due to comorbidity and polypharmacy.

Estudio de aplicabilidad de la entrevista motivacional para potenciar la rehabilitación en pacientes geriátricos ingresados en una unidad de convalecencia / Feasibility study of motivational interviewing to improve rehabilitation in an Intermediate Care Hospital

Objetivo: La rehabilitación de las personas mayores es una intervención compleja, en la cual intervienen múltiples componentes (clínica, cognitiva, anímica etc.). Nuestro estudio pretende comprobar si la entrevista motivacional (EM) (basada en una atención centrada en la persona), con adaptaciones, es aplicable en pacientes con fractura de fémur o ictus que realizan rehabilitación en una unidad de convalecencia. Metodología: Se realizan entrevistas motivacionales a 20 pacientes > 65 años (10 con fractura de fémur y 10 con ictus). Un geriatra formado en EM realiza dos entrevistas a cada paciente, una inicial en < 72 horas del ingreso y otra de seguimiento la semana siguiente. Para que los pacientes recuerden los ejercicios acordados, se entregan trípticos adaptados. Resultados: Todos los pacientes aceptaron y valoraron satisfactoriamente las dos entrevistas. La segunda entrevista mostraba mejor aceptación si realizada antes del 6è día, porqué se recordaba mejor al profesional y los objetivos acordados. La demanda de esta intervención fue alta (4-5 pacientes/semana). El mejor momento per realizar la entrevista es por la tarde, evitando interferir en el funcionamiento de la planta. La EM en pacientes con deterioro cognitivo leu presenta mayor dificultad, y en 3 ocasiones se incorporó a la entrevista al cuidador principal, con muy buena respuesta. La motivación de los pacientes para realizar rehabilitación fue alta (poca ambivalencia), por ello durante las entrevistas no se trabajó tanto la ambivalencia, sino en empoderar a los pacientes y ayudarlos a encontrar herramientas para aumentar las probabilidades de éxito. Conclusiones: La EM es una herramienta fácilmente aplicable dentro del entorno socio sanitario, realizando algunas adaptaciones. La motivación de los pacientes es alta y la EM se centra sobre todo en empoderar al paciente. Este estudio abre la puerta a evaluar, en un futuro, si la intervención es efectiva en este ámbito

Objective: Our main objective was to test the feasibility of adding a patient centered motivational intervention to the usual rehabilitation in an Intermediate Care (IC) Hospital for patients admitted after a hip fracture or stroke. Methods: 20 patients>65 years (10 hip fracture;10 stroke) participated in the study, receiving two motivational interviewing sessions by a trained geriatrician, the first within the 72 hours after admission, the second one week later. All patients were given leaflets informing about different rehabilitation exercises to perform besides formal physical therapy provided in the hospital, among which they could choose those they felt more suitable. Data collected included socio-demographics, comorbidity, and clinical, cognitive and functional status. Results: The motivational intervention was accepted by all patients and all felt it to be appropriate. Opportunities for this intervention were high,4-5 patients per week, best time for the interventions was in the afternoons, which avoided interferences with hospital activities. In patients with mild cognitive impairment the intervention was harder, and in 3 occasions the primary caregiver was invited to participate, with high acceptance and enthusiasm. Patients at baseline were already highly motivated to do rehabilitation, and ambivalence was not big. Therefore most of the interviews focussed on empowering patients and helping them to identify and set their own goals during rehabilitation. Conclusions: Adding specific motivational interventions to usual rehabilitation treatment in older patients admitted after a hip fracture or stroke, is feasible and acceptable in our IC Hospital. Since patients are quite prone to rehabilitation, interviews tend to focus on empowerment. Further, rigorous research is needed

Geriatric Screening Tools to Select Older Adults Susceptible for Direct Transfer From the Emergency Department to Subacute Intermediate-Care Hospitalization.

OBJECTIVES: Early transfer to intermediate-care hospitals, low-tech but with geriatric expertise, represents an alternative to conventional acute hospitalization for selected older adults visiting emergency departments (EDs). We evaluated if simple screening tools predict discharge destination in patients included in this pathway. DESIGN, SETTING, AND PARTICIPANTS: Cohort study, including patients transferred from ED to the intermediate-care hospital Parc Sanitari Pere Virgili, Barcelona, during 14 months (2012-2013) for exacerbated chronic diseases. MEASUREMENTS: At admission, we collected demographics, comprehensive geriatric assessment, and 3 screening tools (Identification of Seniors at Risk [ISAR], SilverCode, and Walter indicator). OUTCOME: Discharge destination different from usual living situation (combined death and transfer to acute hospitals or long-term nursing care) versus return to previous situation (home or nursing home). RESULTS: Of 265 patients (mean age ± SD = 85.3 ± 7.5, 69% women, 58% with acute respiratory infections, 38% with dementia), 80.8% returned to previous living situation after 14.1 ± 6.5 days (mean ± SD). In multivariable Cox proportional hazard models, ISAR >3 points (hazard ratio [HR] 2.06, 95% confidence interval [95% CI] 1.16-3.66) and >1 pressure ulcers (HR 2.09, 95% CI 1.11-3.93), but also continuous ISAR, and, in subanalyses, Walter indicator, increased the risk of negative outcomes. Using ROC curves, ISAR showed the best prediction among other variables, although predictive value was poor (AUC = 0.62 (0.53-0.71) for ISAR >3 and AUC = 0.65 (0.57-0.74) for continuous ISAR). ISAR and SilverCode showed fair prediction of acute hospital readmissions. CONCLUSIONS: Among geriatric screening tools, ISAR was independently associated with discharge destination in older adults transferred from ED to intermediate care. Predictive validity was poor. Further research on selection of candidates for alternatives to conventional hospitalization is needed.