Effects of Exercise Intervention for the Management of Delirium in Hospitalized Older Adults: A Randomized Clinical Trial.

OBJECTIVE: Delirium is a serious neuropsychiatric syndrome frequently occurring in hospitalized older adults, for which pharmacological treatments have shown limited effectiveness. Multicomponent physical exercise programs have demonstrated functional benefits; however, the impact of exercise on the course of delirium remains unexplored. The aim of this study was to investigate the effect of an individualized, multicomponent exercise intervention on the evolution of delirium and patient outcomes. DESIGN: A single-center, single-blind randomized controlled trial. SETTING AND PARTICIPANTS: Medical inpatients with delirium in an acute geriatric unit of a tertiary public hospital. METHODS: Thirty-six patients (mean age 87 years) were recruited and randomized into 2 groups. The control group received usual care and the intervention group received individualized physical exercise (1 daily session) for 3 consecutive days. Primary endpoints were the duration and severity of delirium (4-AT, Memorial Delirium Assessment Scale) and change in functional status [Barthel Index, Short Physical Performance Battery, Hierarchical Assessment of Balance and Mobility (HABAM), and handgrip strength]. Secondary endpoints included length of stay, falls, and health outcomes at 1- and 3-month follow-up. RESULTS: The intervention group showed more functional improvement at discharge (HABAM, P = .015) and follow-up (Barthel, P = .041; Lawton P = .027). Less cognitive decline was observed at 1 and 3 months (Informant Questionnaire on Cognitive Decline in the Elderly, P = .017). Exercise seemed to reduce delirium duration by 1 day and contribute to delirium resolution at discharge, although findings did not reach statistical significance. No exercise-related adverse events occurred. CONCLUSION AND IMPLICATIONS: Findings suggest that individualized exercise in acutely hospitalized older patients with delirium is safe, may improve delirium course and help preserve post-hospitalization function and cognition.

The Impact of Geriatric Conditions in Elderly Patients with Coronary Heart Disease: A State-of-the-Art Review.

The growing geriatric population presenting with coronary artery disease poses a primary challenge for healthcare services. This is a highly heterogeneous population, often underrepresented in studies and clinical trials, with distinctive characteristics that render them particularly vulnerable to standard management/approaches. In this review, we aim to summarize the available evidence on the treatment of acute coronary syndrome in the elderly. Additionally, we contextualize frailty, comorbidity, sarcopenia, and cognitive impairment, common in these patients, within the realm of coronary artery disease, proposing strategies for each case that may assist in therapeutic approaches.

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)

Association of postoperative delirium with serum and cerebrospinal fluid proteomic profiles: a prospective cohort study in older hip fracture patients.

Postoperative delirium (POD) is a common neuropsychiatric complication in geriatric inpatients after hip fracture surgery and its occurrence is associated with poor outcomes. The purpose of this study was to investigate the relationship between preoperative biomarkers in serum and cerebrospinal fluid (CSF) and the development of POD in older hip fracture patients, exploring the possibility of integrating objective methods into future predictive models of delirium. Sixty hip fracture patients were recruited. Blood and CSF samples were collected at the time of spinal anesthesia when none of the subjects had delirium. Patients were assessed daily using the 4AT scale, and based on these results, they were divided into POD and non-POD groups. The Olink® platform was used to analyze 45 cytokines. Twenty-one patients (35%) developed POD. In the subsample of 30 patients on whom proteomic analyses were performed, a proteomic profile was associated with the incidence of POD. Chemokine (C-X-C motif) ligand 9 (CXCL9) had the strongest correlation between serum and CSF samples in patients with POD (rho = 0.663; p < 0.05). Although several cytokines in serum and CSF were associated with POD after hip fracture surgery in older adults, there was a significant association with lower preoperative levels of CXCL9 in CSF and serum. Despite the small sample size, this study provides preliminary evidence of the potential role of molecular biomarkers in POD, which may provide a basis for the development of new delirium predictive models.

[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.

Effect of immunology biomarkers associated with hip fracture and fracture risk in older adults.

Osteoporosis is a skeletal disease that can increase the risk of fractures, leading to adverse health and socioeconomic consequences. However, current clinical methods have limitations in accurately estimating fracture risk, particularly in older adults. Thus, new technologies are necessary to improve the accuracy of fracture risk estimation. In this observational study, we aimed to explore the association between serum cytokines and hip fracture status in older adults, and their associations with fracture risk using the FRAX reference tool. We investigated the use of a proximity extension assay (PEA) with Olink. We compared the characteristics of the population, functional status and detailed body composition (determined using densitometry) between groups. We enrolled 40 participants, including 20 with hip fracture and 20 without fracture, and studied 46 cytokines in their serum. After conducting a score plot and two unpaired t-tests using the Benjamini-Hochberg method, we found that Interleukin 6 (IL-6), Lymphotoxin-alpha (LT-α), Fms-related tyrosine kinase 3 ligand (FLT3LG), Colony stimulating factor 1 (CSF1), and Chemokine (C-C motif) ligand 7 (CCL7) were significantly different between fracture and non-fracture patients (p < 0.05). IL-6 had a moderate correlation with FRAX (R2 = 0.409, p < 0.001), while CSF1 and CCL7 had weak correlations with FRAX. LT-α and FLT3LG exhibited a negative correlation with the risk of fracture. Our results suggest that targeted proteomic tools have the capability to identify differentially regulated proteins and may serve as potential markers for estimating fracture risk. However, longitudinal studies will be necessary to validate these results and determine the temporal patterns of changes in cytokine profiles.

Biomarkers of delirium risk in older adults: a systematic review and meta-analysis.

Delirium is a neuropsychiatric syndrome associated with increased morbidity and mortality in older patients. The aim of this study was to review predictive biomarkers of delirium in older patients to gain insights into the pathophysiology of this syndrome and provide guidance for future studies. Two authors independently and systematically searched MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases up to August 2021. A total of 32 studies were included. Only 6 studies were eligible for the meta-analysis, pooled results showed a significant increase in some serum biomarkers (C-reactive protein [CRP], tumour necrosis factor alpha [TNF-α] and interleukin-6 [IL-6]) among patients with delirium (odds ratio = 1.88, 95% CI 1.01 to 1.637; I2 = 76.75%). Although current evidence does not favour the use of any particular biomarker, serum CRP, TNF-α, and IL-6 were the most consistent biomarkers of delirium in older patients.

Effect of a Multicomponent Intervention with Tele-Rehabilitation and the Vivifrail© Exercise Programme on Functional Capacity after Hip Fracture: Study Protocol for the ActiveFLS Randomized Controlled Trial.

INTRODUCTION: Hip fractures are the most common fracture leading to hospitalization and are associated with high costs, mortality rates and functional decline. Although several guidelines exist for preventing new fractures and promoting functional recovery, they tend to focus on osteoporosis treatment and do not take into account the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. Moreover, most health systems are fragmented and are incapable of providing appropriate management for frail and vulnerable individuals who are at risk of experiencing fragility fractures. Multicomponent interventions and physical exercise using tele-rehabilitation could play a role in the management of hip fracture recovery. However, the effectiveness of exercise prescription and its combination with a comprehensive geriatric assessment (CGA) is still unclear. METHODS: This randomized clinical trial will be conducted at the Hospital Universitario de Navarra (Pamplona, Spain). A total of 174 older adults who have suffered a hip fracture and fulfil the criteria for inclusion will be randomly allocated to either the intervention group or the control group. The intervention group will receive a multicomponent intervention consisting of individualized home-based exercise using the @ctive hip app for three months, followed by nine months of exercise using Vivifrail. Additionally, the intervention group will receive nutrition intervention, osteoporosis treatment, polypharmacy adjustment and evaluation of patient mood, cognitive impairment and fear of falling. The control group will receive standard outpatient care according to local guidelines. This research aims to evaluate the impact of the intervention on primary outcome measures, which include changes in functional status during the study period based on the Short Physical Performance Battery. DISCUSSION: The findings of this study will offer valuable insights into the efficacy of a comprehensive approach that considers the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. This study's findings will contribute to the creation of more effective strategies tailored to the requirements of these at-risk groups.

Effectiveness of a multicomponent exercise training program for the management of delirium in hospitalized older adults using near-infrared spectroscopy as a biomarker of brain perfusion: Study protocol for a randomized controlled trial.

Delirium is an important cause of morbidity and mortality in older adults admitted to hospital. Multicomponent interventions targeting delirium risk factors, including physical exercise and mobilization, have been shown to reduce delirium incidence by 30-40% in acute care settings. However, little is known about its role in the evolution of delirium, once established. This study is a randomized clinical trial conducted in the Acute Geriatric Unit of Hospital Universitario de Navarra (Pamplona, Spain). Hospitalized patients with delirium who meet the inclusion criteria will be randomly assigned to the intervention or the control group. The intervention will consist of a multicomponent exercise training program, which will be composed of supervised progressive resistance and strength exercise over 3 consecutive days. Functional Near-Infrared Spectroscopy (NIRS) will be used for assessing cerebral and muscle tissue blood flow. The objective is to assess the effectiveness of this intervention in modifying the following primary outcomes: duration and severity of delirium and functional status. This study will contribute to determine the effectiveness of physical exercise in the management of delirium. It will be the first study to evaluate the impact of a multicomponent intervention based on physical exercise in the evolution of delirium. Clinical trial registration: ClinicalTrials.gov. identifier: NCT05442892 (date of registration June 26, 2022).

A Feasibility Study for Implementation "Health Arcade": A Study Protocol for Prototype of Multidomain Intervention Based on Gamification Technologies in Acutely Hospitalized Older Patients.

The aim of this article is to present the research protocol for a study that will evaluate the feasibility of implementation of Health Arcade prototype multidomain intervention based on physical and cognitive training using gamification technologies at improving care for older people hospitalized with an acute illness. A total of 40 older people will be recruited in a tertiary public hospital at Pamplona, Spain. The intervention duration will be four to nine consecutive days. Additionally, the patients will receive encouragement for maintaining active during hospital stay and for reducing sedentary time. Primary implementation-related outcomes will be the adherence to treatment (i.e., number of games and days completed during the intervention period), reaction or response time, and number of success and failures in each game per day. Secondary implementation-related outcomes will be self-perceived grade of difficulty, satisfaction, enjoyment per game and session, and self-perceived difficulties in handling the prototype hardware. Other health-related outcomes will also be assessed such as functional capacity in activities of daily living, mood status, quality of life, handgrip strength, physical activity levels, and mobility. The current study will provide additional evidence to support the implementation of multidomain interventions designed to target older persons with an acute illness based on friendly technology. The proposed intervention will increase accessibility of in-clinical geriatrics services, improve function, promote recovery of the health, and reduce economic costs.

Trastorno obsesivo-compulsivo (TOC) de inicio tardío: A propósito de un caso / Late onset obsessive-compulsive disorder (OCD): A case report

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Síndrome de leucoencefalopatía posterior reversible en un paciente con enfermedad de Parkinson y sintomatología inicial psiquiátrica: una presentación clínica compleja / Posterior reversible leukoencephalopathy syndrome in a patient with Parkinson’s disease and initial psychiatric symptoms: a complex clinical presentation

Introducción. La relevancia del fármaco inmunosupresor tacrolimús en la prevención del rechazo y la enfermedad de injerto contra huésped en pacientes trasplantados es indiscutible. Sin embargo, con frecuencia, el tacrolimús presenta efectos neurotóxicos, incluyendo cuadros graves, como el síndrome de leucoencefalopatía posterior reversible. Caso clínico. Varón de 75 años, con antecedentes de trasplante renal hace cinco años, en tratamiento con tacrolimús y micofenolato, y de enfermedad de Parkinson avanzada, en tratamiento con varios agonistas dopaminérgicos. Acudió a urgencias por un cuadro de una semana de evolución consistente en alucinaciones visuales, delirios, ánimo expansivo, confusión y cefalea. La exploración psicogeriátrica por focos mostró como primera opción diagnóstica una psicosis secundaria a agonistas dopaminérgicos, sin excluir otras causas yatrógenas a pesar de encontrarse el tacrolimús en el rango terapéutico (8,3 ng/mL). Se realizaron una tomografía computarizada craneal, que no mostró hallazgos significativos, y una resonancia magnética, en la que se visualizó un edema parietooccipital bilateral, hallazgo compatible con un síndrome de leucoencefalopatía posterior reversible. Durante el ingreso se sustituyó el tacrolimús por everolimús y se ajustó la medicación dopaminérgica, con lo que se produjo de forma rápida una remisión completa del cuadro. Conclusiones. El diagnóstico de síndrome de leucoencefalopatía posterior reversible debe considerarse en los pacientes con antecedentes de trasplante de órgano en tratamiento con fármacos inmunosupresores que presentan un cuadro de instauración aguda con síntomas neurológicos o psiquiátricos

Introduction. The relevance of the immunosuppressive drug tacrolimus in the prevention of rejection and graft-versushost disease in transplanted patients is beyond all doubt. However, tacrolimus often has neurotoxic effects, including severe conditions such as posterior reversible leukoencephalopathy syndrome. Case report. A 75-year-old male who had undergone a kidney transplantation five years earlier, for which he was receiving treatment with tacrolimus and mycophenolate. He also had advanced Parkinson’s disease, treated with several dopamine agonists. The patient visited the emergency department after a week-long history of visual hallucinations, delirium, expansive mood, confusion and headache. The focal psychogeriatric examination revealed psychosis secondary to dopaminergic agonists as the first diagnostic option, without excluding other possible iatrogenic causes despite the tacrolimus being within the therapeutic range (8.3 ng/mL). Both cranial computed tomography, which did not show any significant findings, and a magnetic resonance scan, in which a bilateral parietooccipital oedema was observed, were performed, this latter finding being compatible with posterior reversible leukoencephalopathy syndrome. While the patient was in hospital, tacrolimus was replaced by everolimus, and the dopaminergic medication was adjusted, resulting in a swift and full remission of the clinical signs and symptoms. Conclusions. The diagnosis of posterior reversible leukoencephalopathy syndrome should be considered in patients with a history of organ transplantation treated with immunosuppressive drugs who have an acute onset condition with neurological or psychiatric symptoms

Catatonía de origen multifactorial: a propósito de un caso / Catatonia of multifactorial origin: A case report

La catatonia es un síndrome neuropsiquiátrico conformado por síntomas en la esfera psicomotora, conductual, cognitiva, afectiva y disautonómica. Frecuentemente, pasa desapercibido o es confundido con otros trastornos, lo que conduce a su infradiagnóstico. A pesar de su etiología múltiple y de la frecuente superposición de causas en un mismo paciente, de manera errónea se suele asumir un origen psiquiátrico. Se presenta el caso de un varón de 54 años con antecedentes de trastorno bipolar tipo 1 con alta sospecha de catatonía, en el que se identificaron múltiples condiciones médicas subyacentes además de una descompensación afectiva. El tratamiento precoz sintomático con altas dosis de lorazepam y la corrección de las múltiples causas médicas resultó clave para la resolución completa del cuadro en una semana

Catatonia is a neuropsychiatric syndrome consisting of symptoms in the psychomotor, behavioral, cognitive, affective and disautonomic area. It often goes unnoticed or is confused with other disorders, which leads to its underdiagnosis. Despite its multiple etiology and the frequent overlapping of causes in the same patient, a psychiatric origin is usually assumed in the wrong way. We present the case of a 54-year-old male with a history of bipolar disorder type 1 with a probable catatonia, in which multiple underlying medical conditions were identified in addition to an affective decompensation. Early symptomatic treatment with high doses of lorazepam and the correction of the multiple medical causes was the key to the complete resolution of the condition in a week

Colesteatoma congénito gigante en paciente octogenario / Giant congenital cholesteatoma in an octogenarian patient

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