Caídas en el paciente neurogeriátrico. Réplica / Falls in patients with neurogeriatric disorders. Reply

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[Characteristics of falls of neurological cause in the elderly]. / Caracteristicas de las caídas de causa neurológica en ancianos.

INTRODUCTION: Falls are a cause of disability and death in geriatric population. Third part of the elderly suffer at least one fall per year. Neurological illness are a very important risk factor in developing falls. AIM: To establish the differences between neurological and not neurological patients with recurrent falls. PATIENTS AND METHODS: We select 113 patients over 65 years-old with two or more falls in the last six months, collecting demographic and medical data, as well as a functional, mental and social evaluation, gait and balance tests and posturography. Complementary examinations were done to clarify the diagnosis in each case. RESULTS: Average age was 78 years-old. We define a group A, patients in which the main cause of falls is a neurological disease and group B with a non-neurological cause. Group A shows more number of falls (p < 0.053), worse functional (p < 0.002) and mental (p < 0.001) situation and more comorbility (p = 0.05), as well as worse scores in gait tests. CONCLUSIONS: Neurological illness are a very important risk factor in falls due to the disturbances in gait and balance that they produce. Dementia, parkinsonism and cerebrovascular diseases are frequently found in elderly patients with recurrent falls. Patients with falls due to neurological illness tend to fall oftener and have worse mental and functional situation. Evaluating neurological risk factors in geriatric patients with recurrent falls is essential to establish appropriate prevention strategies.

Características de las caídas de causa neurológica en ancianos / Characteristics of valls of neurological cause in the elderly

Las caídas son causa de discapacidad y muerte en la población geriátrica. Un tercio de los ancianossufre al menos una caída al año. Las patologías neurológicas son un importante factor de riesgo en la producción de caídas. Objetivo. Establecer las diferencias entre ancianos con caídas de repetición en función de que padezcan o no alguna patologíaneurológica. Pacientes y métodos. Se seleccionaron 113 pacientes mayores de 65 años con dos o más caídas en los últimos seis meses y se recogieron variables demográficas y médicas, valoración funcional, mental, social, de la marcha y el equilibrio, y posturografía. Se realizaron las pruebas complementarias en cada caso para aclarar el diagnóstico. Resultados.La edad media fue de 78 años. Se definió un grupo A, pacientes en los que la causa fundamental de la caída era neurológica, y un grupo B, con causa no neurológica. El grupo A presentó mayor número de caídas (p = 0,053), peor situación funcional (p = 0,002) y mental (p < 0,001) y mayor morbilidad (p = 0,05), así como peor puntuación en los test de valoración de lamarcha. Conclusiones. Las enfermedades neurológicas constituyen un importante factor de riesgo en la producción de caídas por las alteraciones de la marcha y el equilibrio que producen. Las demencias, los síndromes parkinsonianos y la enfermedadcerebrovascular se encuentran con frecuencia entre la población de ancianos con caídas de repetición. Los pacientes con caídas de causa neurológica presentan más caídas y peor situación funcional y mental. Identificar factores de riesgo neurológico en ancianos con caídas resulta fundamental para establecer estrategias de prevención adecuadas (AU)

Falls are a cause of disability and death in geriatric population. Third part of the elderly suffer at leastone fall per year. Neurological illness are a very important risk factor in developing falls. Aim. To establish the differences between neurological and not neurological patients with recurrent falls. Patients and methods. We select 113 patients over 65years-old with two or more falls in the last six months, collecting demographic and medical data, as well as a functional, mental and social evaluation, gait and balance tests and posturography. Complementary examinations were done to clarifythe diagnosis in each case. Results. Average age was 78 years-old. We define a group A, patients in which the main cause of falls is a neurological disease and group B with a non-neurological cause. Group A shows more number of falls (p < 0.053), worse functional (p < 0.002) and mental (p < 0.001) situation and more comorbility (p = 0.05), as well as worse scores in gaittests. Conclusions. Neurological illness are a very important risk factor in falls due to the disturbances in gait and balance that they produce. Dementia, parkinsonism and cerebrovascular diseases are frequently found in elderly patients with recurrent falls. Patients with falls due to neurological illness tend to fall oftener and have worse mental and functional situation. Evaluating neurological risk factors in geriatric patients with recurrent falls is essential to establish appropriate prevention strategies (AU)

Utilidad de la estación unipodal en la valoración del riesgo de caídas / Utility of one-leg balance in evaluation of the risk of falls

Objetivo: comparar los resultados obtenidos en la estación unipodal con el análisis del equilibrio estático mediante posturografía. Métodos: 59 sujetos mayores de 64 años. Se evaluó la estación unipodal y el Modified Clinical Test for the Sensory Interaction on Balance mediante el posturógrafo Balance Master (Neurocom®). Grupo A: sujetos que no realizaron la estación unipodal, y grupo B: los que sí pudieron realizarla. Resultados: grupo A: 37,2% (22). Grupo B: 62,6% (37). Sobre una superficie dura y con los ojos abiertos, el centro de gravedad del grupo A se desplazó 0,4 grados/s (0,28-0,6) y el del grupo B 0,2 grados/s (0,1-0,3) (p = 0,01). Sobre una superficie firme y con los ojos cerrados, el centro de gravedad del grupo A se desplazó 0,5 grados/s (0,3-0,8) y el del grupo B 0,3 grados/s (0,1-0,4) (p = 0,002). Sobre una superficie almohadillada y con los ojos abiertos, el centro de gravedad del grupo A se desplazó 1,1 grados/s (0,90-1,60) y el del grupo B 0,9 grados/s (0,73-1,3) (p = 0,045). Sobre una superficie almohadillada y con los ojos cerrados, el centro de gravedad del grupo A se desplazó 6 grados/ s (4-6) y el del grupo B 2,3 grados/s (1,63-3,08) (p < 0,001). Conclusiones: los sujetos de edad avanzada capaces de mantener la estación unipodal durante al menos 5 s muestran un menor desplazamiento de su centro de gravedad que los que no lo consiguen. Los resultados se mantienen cuando se suprimen las aferencias visual y propioceptiva (AU)

Aims: to compare posturographic test with One-Leg Balance test in the elderly. Methods: we studied 59 healthy men and women living in the community who were at least 65 years of age. All of them were evaluated with One–Leg Balance (defined as the ability to stand on one leg unsupported for 5 seconds) and Modifies Clinical Test for the Sensory Interaction on Balance by the Balance Master (Neurocom®). We distributed the patients in two groups. Group A included those who couldn’t perform one-leg balance and group B those who could perform it. Results: 62.6% of subjects could perform one-leg balance and 37.2% could not perform it. On a firm surface with opened eyes, the A group made a variation of 0.4 deg/s (0.28-0.6) in the gravity center position and the B group 0,2 deg/s (0.1-0.3) (p = 0.010). On a firm surface with closed eyes, the A group made a variation of 0.5 deg/s (0.3-0.8) and the B group 0.3 deg/s (0.1- 0.4) (p = 0.002). On a foam surface with open eyes, the A group made a variation of their gravity center position of 1.10 deg/s (0.90-1.60) and the B group 0.9 deg/s (0.73-1.30) (p = 0.045). On a foam surface with closed eyes the A group made a variation of their gravity center position of 6 deg/s (4-6) and the B group 2.3 deg/s (1.63-3.08) (p < 0.001). Conclusions: elderly patients who can perform one-leg balance, make less variations of their gravity centre. The results are the same when visual and propioceptive afferences are suppressed (AU)

Evaluación del riesgo de caídas. Protocolos de valoración clínica / Evaluating the risk of falls. Clinical evaluation protocols

Las caídas son una de las principales causas de lesiones, de incapacidad e incluso de muerte en los pacientes ancianos. En todo paciente que se cae, se deben valorar las consecuencias, los factores de riesgo de las caídas y el riesgo de presentar nuevas caídas. La valoración de los factores de riesgo de caídas debe incluir los siguientes aspectos: anamnesis rigurosa, valoración geriátrica exhaustiva, exploración física general, exploración de los órganos de los sentidos, exploración del equilibrio y la marcha, evaluación del entorno y realización de determinadas exploraciones complementarias (posturografía). Los protocolos de evaluación permiten identificar el mayor número de factores de riesgo. Numerosos tests clínicos (Tinetti, timed and go) permiten valorar el riesgo de nuevas caídas y de presentar consecuencias severas. La creación de unidades de caídas como equipos multidisciplinarios destinados de forma específica a la valoración de anciano con caídas de repetición y a la prevención de caídas es muy importante (AU)

Falls are one of the main causes of lesions, disability and even death in elderly patients. In all patients who fall, the repercussions and risk factors for falls and their recurrence should be evaluated. Evaluation of risk factors for falls should include the following: thorough medical history, exhaustive geriatric evaluation, general physical examination, examination of sense organs, balance and gait, evaluation of the environment, and complementary examinations (posturography). Evaluation protocols allow a greater number of risk factors to be identified. Numerous clinical tests (Tinetti, timed and go) allow the risk of new falls and of severe consequences to be assessed. The creation of falls units with multidisciplinary teams specifically designated to evaluate the elderly with recurrent falls and the prevention of falls is highly important (AU)

[Basal immunological parameters in a group of retirees]. / Parámetros inmunológicos basales en un grupo de viejos-jóvenes.

OBJECTIVES: a) establish the major immunological parameters for clinical use in a group of retirees; b) correlate its levels in relation to gender; c) assess the influence of some specific factors (substance abuse, diseases) on the analyzed parameters. MATERIAL AND METHODS: study period: 1990-1999; sample: 249; 102 men (M); 147 women (W). Median age: 67.03 (4.2) years. Analyzed immunological variables: total leukocytes, lymphocytes B, immunoglobulins (IgG, IgA and IgM), rheumatoid factor, lymphocytes subpopulations (CD4, CD8, ratio), natural killer, complement (C3 and C4) and delayed hypersensitivity tests. TECHNIQUES: flow cytometry (EPICS-Profile II) and Multitest IMC. STATISTICAL ANALYSIS: SPSS version 10.0.Results. Gender influence: leukocytes: M: 6,699.4 (1,615.0); W: 6,105.9 (1,470.5); p < 0,003; lymphocytes B (%): M: 9.4 (5.0); W: 11.3 (4.1); p < 0,003; IgG: M: 1,155.7 (320.0); W: 1,116.1 (257.8); p = 0,28, IgM: M: 112.7 (69.3); W: 136.8 (85.6); p < 0,01; IgA: M: 276.1 (114); W: 254.0 (122); p = 0,15; rheumatoid factor: M: 18.5 (6.6); W: 20.9 (18.8); p = 0,020; CD4 (%): M: 42.2 (9.7); W: 47.3 (9,1); p < 0.001; CD8 (%): M: 30.3 (10,8); W: 25.0 (10.2); p < 0,001; scores: M: 13.2 (7.4); 11m: 10.0 (7.2); p < 0,005. Influence of the substance abuse: smokers; lymphocytes B (%): 8.8 (3.4); No: 10.9 (4.7); p < 0.008; CD8 (%): smokers: 31.8 (13.2); No: 26.2 (9.9); p < 0.003; CD4/CD8 ratio: smokers: 1.6 (0.9); No: 2.0 (1.3); p < 0,05; scores: smokers: 14.3 (6.8); No: 10.8 (7.5); p < 0.02; alcoholism: lymphocytes B (%): 8.7 (2.5). No: 10.8 (4.7); p < 0.001; alcoholism: store: 16.9 (6.7); No: 10.7 (7.3); p < 0,001. Influence of the diseases: diabetes: CD4 (%): 49.4 (12.0); diabetics versus healthy: p = 0,05; CD4/CD8 ratio: 2.6 (2.5); diabetics versus healthy: p = 0,04; EPOC: CD8 (%): 32.9 (16,3); COPD versus healthy: p = 0,07; neoplasias NK (%): 17.1 (21.4); neoplasias versus healthy: p < 0,01. CONCLUSIONS. a) there are differences according to the gender in the parameters of normalcy of some variables; b) smoking and alcoholism alter the immunological test analyzed, and c) some chronic diseases influence the subpopulations of lymphocytes and the cutaneous test of delayed hypersensitivity.

Parámetros inmunológicos basales en un grupode viejos-jóvenes / Basal inmunological parameters in a group of retirees

Objetivos. a) valorar los principales parámetros inmunológicos de uso clínico en un grupo de jubilados; b) correlacionar sus niveles en función del género, y c) valorar la influencia sobre los parámetros analizados de determinados factores (hábitos tóxicos, enfermedades).Material y métodos. Período de estudio: 1990-1999; muestra: 249; 102 hombres (H); 147 mujeres (M). Edad media: 67,03 ñ 4,2 años. Variables inmunológicas analizadas: leucocitos totales, linfocitos B, inmunoglobulinas (IgG, A y M), factor reumatoide, subpoblaciones de linfocitos (CD4, CD8, ratio), natural killer (NK), complemento (C3 y C4) y pruebas de hipersensibilidad retardada. Técnicas: citometría de flujo (EPICS-Profile II) y Multitest IMC. Análisis estadístico: SPSS versión 10.0.Resultados. Influencia del género: leucocitos: H: 6.699,4 (1.615,0); M: 6.105,9 (1.470,5); p< 0,003; linfocitos B ( por ciento); H: 9,4 (5,0); M: 11,3 (4,1); p < 0,003; IgG; H: 1.155,7; (320,0) M: 1.116,1 (257,8); p = 0,28; IgM; H: 112,7 (69,3); M: 136,8 (85,6); p < 0,01; IgA; H: 276,1 (114); M: 254,0 (122); p = 0,15; factor reumatoide: H: 18,5 (6,6); M: 20,9 (18,8); p = 0,20; CD4 ( por ciento); H: 42,2 (9,7); M: 47,3 (9,1); p < 0,001; CD8 ( por ciento); H: 30,3 (10,8); M: 25,0 (10,2); p < 0,001; score; H: 13,2 (7,4); M: 10,0 (7,2); p < 0,005. Influencia de los hábitos tóxicos: fumadores: linfocitos B ( por ciento): 8,8 (3,4); No: 10,9 (4,7); p < 0,008; CD8 ( por ciento); fumadores: 31,8 (13,2); No: 26,2 (9,9); p < 0,003; cociente CD4/CD8: fumadores: 1,6 (0,9); No: 2,0 (1,3); p < 0,05; score: fumadores: 14,3 (6,8); No: 10,8 (7,5); p < 0,02; hábito enólico, linfocitos B ( por ciento): 8,7 (2,5); No: 10,8 (4,7); p < 0,001; hábito enólico, score: 16,9 (6,7); No: 10,7 (7,3); p < 0,001. Influencia de las enfermedades: diabetes; CD4 ( por ciento): 49,4 (12,0); diabéticos frente a sanos: p = 0,05; cociente CD4/CD8: 2,6 (2,5); diabéticos frente a sanos: p = 0,04; enfermedad pulmonar obstructiva crónica (EPOC): CD8 ( por ciento), 32,9 (16,3); EPOC frente a sanos: p = 0,07; neoplasias: NK ( por ciento): 17,1 (21,4); neoplasias frente a sanos: p < 0,01. Conclusiones. a) existen diferencias en función del género en los parámetros de normalidad de algunas variables; b) el tabaquismo y el hábito enólico alteran las pruebas inmunológicas analizadas, y c) determinadas enfermedades crónicas influyen en las subpoblaciones de linfocitos y en las pruebas cutáneas de hipersensibilidad retardada (AU)

Epidemiología del tabaquismo en las personas mayores en España / Epidemiology of tobacco use in Spanish old people

La prevalencia global del tabaquismo ha disminuido en los últimos 10 años, aunque según los datos de la ENSE 97 fuma el 35,7% de la población de 16 y más años y tan sólo el 49,2% no ha fumado nunca. Un análisis por grupos de edad indica que los jóvenes y adultos no mayores han tenido prevalencias de tabaquismo superiores a la población mayor, fenómeno que puede significar tasas de incidencia y prevalencia de enfermedades cardiovasculares más altas en un futuro próximo al hacerse progresivamente mayores esas nuevas generaciones. Si estudiamos la prevalencia de tabaquismo en los mayores según las últimas ENSE, la proporción de personas mayores que no han sido ni son fumadores ha ido en aumento. Si nos fijamos en los mayores de 75 años, el descenso en fumadores activos se detiene en 1995, ya que la ENSE 97 muestra un ligero repunte. A esta edad la prevalencia del tabaquismo es la más baja, especialmente por el incremento de aquellos que han abandonado este hábito. Las diferencias igualmente son llamativas en función del sexo, según el estudio ECEHA, 1996, un 28% de los varones mayores no han fumado nunca, frente al 86% de las mujeres (AU)

The global prevalence of the consumption of tobacco has decreased in the last 10 years, although the 35,7% of 16 or more years old smokes and the 49,2% has never smoked (as the ENSE 97 explains). An analysis by groups of age indicates that young and medium people have prevalence of tobacco over the older one. That means incidence and prevalence taxes of cardiovascular illness higher in the nest future, when this people become older. If we study the prevalence of the consumption of tobacco in elderly in Spain, as the last ENSE, the proportion of elderly people that have never smoked is increasing. If we thing about elderly over 75 years old, the decreasing of active smokers stops in 1995 because the ENSE 97 shows a little increasing. In this age the prevalence of the consumption of tobacco is the less one, specially because of the increasing of those that leave the habit of smoking (AU)

[Mesenteric panniculitis in an 87-year-old female patient]. / Paniculitis mesentérica en una paciente de 87 años.

We report a case of atypical presentation of mesenteric panniculitis in a 87 year old woman. The mesenteric panniculitis disease and the cases published are revised. Delirium as atypical disease presentations and especially dementia, are briefly analyzed.

[Immobility syndrome in patients being care for in a home care unit]. / Síndrome de inmovilidad en pacientes atendidos en una unidad de ayuda a domicilio.

OBJECTIVES: to asses in a group of elderly patients included in a Home Care Unit, the level of immobility, the functional status based on the Katz's index and the Red Cross scale, and their medical, psychological and social consequences. METHODS: assessment of elderly patients visited during three consecutive months, through and standardized protocol with 14 items related with the previous aspects. RESULTS: 114 elderly patients (71% females) were visited during this time. The mean age was 82.4 years. 71 patients (65.7%) had immobility, with a mean age of 83.4 years and females predominance. Based on the level of immobility, 24 patients were in bed and 44 patients were able to be in bed-armchair. 74% of the patients were severely disabled on the activities daily living (Katz G); 85% of the patients had a severe physical disability (Red Cross scale 4-5), whereas a lower percentage (36%) had severe mental disability (Red Cross scale 4-5). Neurological disorders were the most frequent etiology of immobility (72%), with only one cause in 27 patients, two causes in 20 patients and more than three causes in 24 patients. Medical consequences were the most frequent, mainly urinary and chest infections, pressure sores and constipation. CONCLUSIONS: Immobility's syndrome represents a common medical problem in the geriatric care, related specially with the neurological and osteo-articular disorders, conditioning a high mobility.

[Geriatrics seen from the primary care perspective]. / La geriatría vista desde la atención primaria.

PURPOSE: To know the Primary Care Physicians opinion related to their own praxis, background, and needs for a specific medical support in geriatric medicine. METHODS: A closed mailed questionnaire, with 22 items. Descriptive analysis of the results. PEOPLE SAMPLE: 559 answers. 77% men. Age: main group (44%) between 35 and 39 years old. 80% of the sample worked in health centers as primary care physicians. RESULTS: a) Praxis: 50% of the physicians attend more than 20 elderly patients every day. 38% of them have specific aged oriented protocols. 74% of them take age into account when decide the appropriate doses of drugs. b) Geriatric background: None at the undergraduate period: 96%. Some sort of postgraduate formation: 42%. Are able to identify at less a geriatric book: 34%. A score of 4.5 (over 10) was the result of their own assessment about their level of geriatric knowledge. 95% of the answers miss a better formation in geriatrics, and 93% of them think that this formation would change their clinical approach to the elderly patient. c) Needs of specialized geriatric support: It would be helpful to them according to a 84% of the answers. It could be as a "Geriatric Inhospital Service" in the opinion of a 44% of the cases (this question had a 18% of abstentions); and with geriatricians working as extrahospitalary consultants according to the answers of the 79% (6% of abstentions). CONCLUSIONS: Primary care physicians have: 1. Many elderly patients, with an acceptable level of attention to them. 2. A poor geriatric formation and awareness of their needs. 3. Need of a specialized support in their daily work.

[The effectiveness of geriatric interconsultation in elderly patients admitted to traumatology]. / La eficacia de la interconsulta geriátrica en pacientes ancianos ingresados en traumatología.

OBJECTIVE: To determine the effect of inpatient geriatric consultation in elderly orthopedic patients. DESIGN: Before-after intervention trial. SETTING: Tertiary care university hospital in Madrid (Spain). PATIENTS: All patients older than 64 years admitted to the orthopedic department during one year before (481 patients) and six months after (283 patients) the establishment of geriatric consultation. INTERVENTION: A geriatric consultation team (attending physician and fellow) evaluated, and actively treated when appropriate, most of the patients; follow-up ensued when need until clinical stability or death. MAIN OUTCOME MEASURES: In-hospital mortality, length of hospital stay and transfers to other departments. RESULTS: There was no difference in sex (percent males 23% vs 24%), age (79.2 vs 79.1 years), or length of stay (27.7 vs 26.3 days). Lower in-hospital mortality (9.36% vs 4.95%, p = 0.017) and more transfers to other departments (4.99% vs 12.37%, p = 0.0007) occurred in the study group. CONCLUSIONS: This model of geriatric consultation achieved a lower mortality in orthopedic elderly patients. Length of stay did not change, but there was a higher rate of transfers to other departments. Further controlled studies are needed.

[The results of a program of preoperative hospital assessment of geriatric patients]. / Resultados de un programa de evaluación preoperatoria hospitalaria en pacientes geriátricos.

In order to illustrate the possibilities that offers the specialized geriatric evaluation during the preoperative period of elderly patients in a general hospital, the results obtained throughout two years are presented and compared, according to preestablished design, in 551 urological patients (U) (age: 75.4 years) and 597 traumatological patients (T) (age: 79 years), all of them over 65 years old. The more frequent interventions were hip fractures (88% of T), prostatic adenoma and vesical urothelioma (42 and 27% of U). Only in 10% of T and 18% of U, we did not observed related problems. The most frequent of these were cardiovascular, neuropsychiatric and respiratory problems, especially in group T. Some kind of recommendations were given in 88% of T and 80% of U. The average period in taking care of these inter-consultations was 1.3 days and the number of perioperative visits was 2.4. In 42% of T and 74% of U, we did not observe psychical discapacities. The average surgical risk measured by the ASA was grade III or IV in 22% of T and 12% of U, similar figures than the ones of the cardiac risk (Goldman). We believe that this type of specialized evaluation is more comprehensive and renders important benefits both for the elderly patients and for the surgeon, when compared with the traditional system of preoperative evaluation.