Patterns of multimorbidity in primary care electronic health records: A systematic review.

Background: Multimorbidity, the coexistence of multiple chronic conditions in an individual, is a complex phenomenon that is highly prevalent in primary care settings, particularly in older individuals. This systematic review summarises the current evidence on multimorbidity patterns identified in primary care electronic health record (EHR) data. Methods: Three databases were searched from inception to April 2022 to identify studies that derived original multimorbidity patterns from primary care EHR data. The quality of the included studies was assessed using a modified version of the Newcastle-Ottawa Quality Assessment Scale. Results: Sixteen studies were included in this systematic review, none of which was of low quality. Most studies were conducted in Spain, and only one study was conducted outside of Europe. The prevalence of multimorbidity (i.e. two or more conditions) ranged from 14.0% to 93.9%. The most common stratification variable in disease clustering models was sex, followed by age and calendar year. Despite significant heterogeneity in clustering methods and disease classification tools, consistent patterns of multimorbidity emerged. Mental health and cardiovascular patterns were identified in all studies, often in combination with diseases of other organ systems (e.g. neurological, endocrine). Discussion: These findings emphasise the frequent coexistence of physical and mental health conditions in primary care, and provide useful information for the development of targeted preventive and management strategies. Future research should explore mechanisms underlying multimorbidity patterns, prioritise methodological harmonisation to facilitate the comparability of findings, and promote the use of EHR data globally to enhance our understanding of multimorbidity in more diverse populations.

Mobile applications to prescribe physical exercise in frail older adults: review of the available tools in app stores.

INTRODUCTION: Different remote interventions, such as applications (apps), have been used to continue promoting healthy ageing and preventing disability during the COVID-19 pandemic. The growing trend of apps in health is exponential and may facilitate scaling up physical activity prescription. Numerous tools are available, but little is known regarding their appropriateness, validation and recommendation, especially for frail older adults. METHODS: In-house, we developed an application that makes both the Apple app Store and the Google Play Store searchable using topic-related keywords and facilitates the extraction of basic app-information of the search results. The study was aimed at apps available to an English-speaking market. The resulting apps were filtered using various inclusion and exclusion criteria. The resultant apps underwent a more in-depth characterisation and searches for scientific publications on each app website and PubMed. RESULTS: From an initial search result of >2,800 apps, 459 met the initial inclusion criteria. After a more in-depth review of their features, 39 apps remained for possible app in older frail patients. After testing them, 22 apps were excluded. Seventeen apps fit the inclusion and exclusion criteria and were deemed appropriate after peer review. Of these, only one app, Vivifrail, had any type of publication/published evidence. CONCLUSION: Apps can be valuable tool in prescribing exercise for frail older adults living in the community. However, few apps seem useful on a large scale, and there is limited evidence to support their effectiveness. It is important to invest in adapting Information and Communication Technologies to this population group.

Sustained improvement of intrinsic capacity in community-dwelling older adults: The +AGIL Barcelona multidomain program.

BACKGROUND: Different programs promote healthy ageing through the optimization of intrinsic capacity. However, a major challenge is to assess their sustained effects over time. +AGIL Barcelona, a consolidated multidomain program, aims to optimize older adults' intrinsic capacity through a coordinated approach among primary care, geriatrics and community resources, in agreement with the integrated care for older people (ICOPE) guidelines. We aimed to evaluate the +AGIL Barcelona longitudinal effect on older adults' physical performance. METHODS: All +AGIL Barcelona consecutive participants since 2016 were enrolled. After a comprehensive geriatric assessment, a tailored, multidisciplinary intervention aligned with the ICOPE guidelines is offered. It includes a 10-week boost multicomponent exercise program, nutritional and sleep-hygiene counselling, revision and optimization of pharmacological treatments and screening for cognitive impairment, depression and loneliness. Changes in physical performance after 3 and 6 months were assessed using mixed models including baseline frailty degree, time and all potential significant confounders. RESULTS: We included 194 participants in the analysis (mean age = 81.6 [standard deviation = 5.8], 68% women). An independent, clinically and statistically significant improvement in physical performance (Short Physical Performance Battery [SPPB] test, combining gait speed, strength and balance) was found at 3 months (SPPB mean change: 1.4; 95% CI: 1.1-1.6) and 6 months (SPPB mean change: 1.1; 95% CI 0.8-1.5). Equivalent results were observed for all the SPPB sub-tests. CONCLUSIONS: A coordinated, multidisciplinary and integrated program can benefit older adults' intrinsic capacity. The participants' empowerment and the connection with the available community resources are critical points for a successful intervention.

Experience, facilitators, and barriers to the implementation of a multicomponent programme in older people living in the community, +AGIL Barcelona: A qualitative study.

Introduction: The +AGIL Barcelona programme is a multicomponent care intervention for frail older adults (FOAs) living in the community. To improve the programme, it is essential to investigate the experience of all participants. Our objective was to explore the perspective of FOA and professionals about the barriers, facilitators, and improvement elements of the development of the +AGIL Barcelona programme. Qualitative descriptive approach. Were included FOA and professionals who participated in the +AGIL Barcelona programme. Methods: Three focus groups and four interviews were conducted. These were analyzed following the qualitative method of content analysis. The criteria of scientific rigor of credibility, dependence, and transferability were ensured throughout the study. Results: Three themes and seven sub-themes were developed: facilitators (positive experience and perceived benefits), barriers (self-perceived health status, digital divide, and continuity of the programme at home), and improvements elements (programme continuity and adaptation of technology). All the participants felt satisfied, highlighting aspects such as interpersonal relationships and social contact, face-to-face sessions guided by a physiotherapist, and the functional improvement achieved. Some of the difficulties were the self-perception of frailty, the need for technological support, and continuing the exercise programme at home. Conclusion: The FOA who participated in the +AGIL Barcelona programme perceived direct benefits for their health and physical condition due to the development of self-confidence by being able to perform physical exercise despite their baseline condition, and the professionals experienced an improvement in the quality of care due to work in a multidisciplinary team.

Effects on Sleep Quality of Physical Exercise Programs in Older Adults: A Systematic Review and Meta-Analysis.

BACKGROUND: Given the beneficial effects of exercise in different populations and the close relationship between healthy ageing and sleep quality, our objective was to determine if physical exercise delivered through a structured program improves sleep quality in older adults. METHODS: Embase, PubMed/MEDLINE, Web of Science, and Cochrane Register of Clinical Trials (CENTRAL) were searched to 15 January 2023. Studies that applied physical exercise programs in older adults were reviewed. Two independent reviewers analysed the studies, extracted the data, and assessed the quality of evidence. RESULTS: Of the 2599 reports returned by the initial search, 13 articles reporting on 2612 patients were included in the data synthesis. The articles used interventions based on yoga (n = 5), multicomponent exercise (n = 3), walking (n = 2), cycling (n = 1), pilates (n = 1), elastic bands (n = 1), and healthy beat acupunch (n = 1). In the intervention group, we found significant improvement in Pittsburgh sleep quality index of -2.49 points (95% CI -3.84 to -1.14) in comparison to the control group (p = 0.0003) and sleep efficiency measured with objective instruments (MD 1.18%, 95% CI 0.86 to 1.50%, p < 0.0001). CONCLUSION: Our results found that physical exercise programs in older adults improve sleep quality and efficiency measured with objective instruments.

Comprehensive Geriatric Hospital at Home: Adaptation to Referral and Case-Mix Changes During the COVID-19 Pandemic.

OBJECTIVES: To describe the evolution of a Hospital at Home (HAH) based on comprehensive geriatric assessment (CGA), including its adaptability to changing case-mixes and pathways during the COVID-19 pandemic. DESIGN: Observational study of consecutive admissions to a combined step-up (admissions from home) and step-down (hospital discharge) HAH during 3 periods: prepandemic (2018‒February 2020) vs pandemic (March‒December 2020, and January‒December 2021). SETTING AND PARTICIPANTS: Participants were all consecutive patients admitted to a CGA-based HAH, located in Barcelona, Spain. Referrals followed acute events or exacerbation of chronic conditions, by either primary care (step-up) or after post-acute discharge (step-down). METHODS: HAH intervention based on CGA and incorporated geriatric rehabilitation. Patient case-mix, functional evolution (Barthel index), and mortality were compared across periods and between pathways. RESULTS: HAH capacity expanded 3 fold from 15 to 45 virtual beds and altogether managed 688 consecutive patients [mean age (SD) = 82.5 (9.6) years; 59% women]. Pandemic case-mix was slightly older (mean age = 83.5 vs 82 years, P = .012) than prepandemic, with greater mobility impairment. Across periods, step-up increased (26.1%, 40.9%, 48.2%, P < .01) because of medical events, skin ulcers, and post-acute stroke, whereas step-down decreased; multivariable models showed no differences in functional improvement or mortality. When comparing pathways, step-up featured older patients with higher comorbidity, worse functional status, and lower absolute functional gain than step-down (5.6 vs 13 points of Barthel index, P < .01), remaining statistically significant after adjusting for covariates (P = .003); no differences in mortality were observed. CONCLUSIONS AND IMPLICATIONS: A multipurpose, step-down and step-up CGA HAH expanded its activity and adapted to changing case-mixes and pathways throughout COVID-19 pandemic waves. Although further quantitative and qualitative studies are needed to assess the impact of this model, our results suggest that harnessing the adaptability of HAH may help advance a paradigm shift toward more person-centered, cost-effective models of clinical care aimed at older adults.

Effectiveness of home-based exercise delivered by digital health in older adults: a systematic review and meta-analysis.

BACKGROUND: regular physical exercise is essential to maintain or improve functional capacity in older adults. Multimorbidity, functional limitation, social barriers and currently, coronavirus disease of 2019, among others, have increased the need for home-based exercise (HBE) programmes and digital health interventions (DHI). Our objective was to evaluate the effectiveness of HBE programs delivered by DHI on physical function, health-related quality of life (HRQoL) improvement and falls reduction in older adults. DESIGN: systematic review and meta-analysis. PARTICIPANTS: community-dwelling older adults over 65 years. INTERVENTION: exercises at home through DHI. OUTCOMES MEASURES: physical function, HRQoL and falls. RESULTS: twenty-six studies have met the inclusion criteria, including 5,133 participants (range age 69.5 ± 4.0-83.0 ± 6.7). The HBE programmes delivered with DHI improve muscular strength (five times sit-to-stand test, -0.56 s, 95% confidence interval, CI -1.00 to -0.11; P = 0.01), functional capacity (Barthel index, 5.01 points, 95% CI 0.24-9.79; P = 0.04) and HRQoL (SMD 0.18; 95% CI 0.05-0.30; P = 0.004); and reduce events of falls (odds ratio, OR 0.77, 95% CI 0.64-0.93; P = 0.008). In addition, in the subgroup analysis, older adults with diseases improve mobility (SMD -0.23; 95% CI -0.45 to -0.01; P = 0.04), and balance (SMD 0.28; 95% CI 0.09-0.48; P = 0.004). CONCLUSION: the HBE programmes carried out by DHI improve physical function in terms of lower extremity strength and functional capacity. It also significantly reduces the number of falls and improves the HRQoL. In addition, in analysis of only older adults with diseases, it also improves the balance and mobility.

Comment on Blancafort Alias et al. A Multi-Domain Group-Based Intervention to Promote Physical Activity, Healthy Nutrition, and Psychological Wellbeing in Older People with Losses in Intrinsic Capacity: AMICOPE Development Study. Int. J. Environ. Res. Public Health 2021, 18, 5979.

We read with interest the article by Blancafort et al. [...].

Sleep disturbances and the speed of multimorbidity development in old age: results from a longitudinal population-based study.

BACKGROUND: Sleep disturbances are prevalent among older adults and are associated with various individual diseases. The aim of this study was to investigate whether sleep disturbances are associated with the speed of multimorbidity development among older adults. METHODS: Data were gathered from the Swedish National study of Aging and Care in Kungsholmen (SNAC-K), an ongoing population-based study of subjects aged 60+ (N = 3363). The study included a subsample (n = 1189) without multimorbidity at baseline (< 2 chronic diseases). Baseline sleep disturbances were derived from the Comprehensive Psychiatric Rating Scale and categorized as none, mild, and moderate-severe. The number of chronic conditions throughout the 9-year follow-up was obtained from clinical examinations. Linear mixed models were used to study the association between sleep disturbances and the speed of chronic disease accumulation, adjusting for sex, age, education, physical activity, smoking, alcohol consumption, depression, pain, and psychotropic drug use. We repeated the analyses including only cardiovascular, neuropsychiatric, or musculoskeletal diseases as the outcome. RESULTS: Moderate-severe sleep disturbances were associated with a higher speed of chronic disease accumulation (ß/year = 0.142, p = 0.008), regardless of potential confounders. Significant positive associations were also found between moderate-severe sleep disturbances and neuropsychiatric (ß/year = 0.041, p = 0.016) and musculoskeletal (ß/year = 0.038, p = 0.025) disease accumulation, but not with cardiovascular diseases. Results remained stable when participants with baseline dementia, cognitive impairment, or depression were excluded. CONCLUSION: The finding that sleep disturbances are associated with faster chronic disease accumulation points towards the importance of early detection and treatment of sleep disturbances as a possible strategy to reduce chronic multimorbidity among older adults.

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.

Exercise-Based Interventions to Enhance Long-Term Sustainability of Physical Activity in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

Exercise is a form of physical activity (PA). PA is an important marker of health and quality of life in older adults. The purpose of this study was to conduct a systematic review of the literature to assess the effect of exercise-based interventions on an at least six-month follow up PA measure, and to describe the specific strategies implemented during the intervention to strengthen the sustainability of PA in community-dwelling 65+ year-old adults. We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42017070892) of randomized clinical trials (RCT). We searched three electronic databases during January 2018 to identify RCT assessing any type of exercise-based intervention. Studies had to report a pre-, post-, and at least 6-month post-intervention follow-up. To be included, at least one PA outcome had to be assessed. The effect of exercise-based interventions was assessed compared to active (e.g., a low-intensity type of exercise, such as stretching or toning activities) and non-active (e.g., usual care) control interventions at several time points. Secondary analyses were conducted, restricted to studies that reported specific strategies to enhance the sustainability of PA. The intervention effect was measured on self-reported and objective measures of time spent in PA, by means of standardized mean differences. Standardized mean differences of PA level were pooled. Pooled estimates of effect were computed with the DerSimonian-Laird method, applying a random effects model. The risk of bias was also assessed. We included 12 studies, comparing 18 exercise intervention groups to four active and nine non-active control groups. Nine studies reported specific strategies to enhance the long-term sustainability of PA. The strategies were mostly related to the self-efficacy, self-control, and behavior capability principles based on the social cognitive theory. Exercise interventions compared to active control showed inconclusive and heterogeneous results. When compared to non-active control, exercise interventions improved PA time at the six-months follow up (standardized mean difference (SMD) 0.30; 95%CI 0.15 to 0.44; four studies; 724 participants; I2 0%), but not at the one- or two-years follow-ups. No data were available on the mid- and long-term effect of adding strategies to enhance the sustainability of PA. Exercise interventions have small clinical benefits on PA levels in community-dwelling older adults, with a decline in the observed improvement after six months of the intervention cessation.

Nutritional Status and Functional Outcomes in Older Adults Admitted to Geriatric Rehabilitations: The SAFARI Study.

Objective: Evidence about the role of nutritional status (NS) on functional outcomes (FO) after rehabilitation in older adults is scarce. Our aim was to analyze the association between NS and FO in older adults admitted to geriatric rehabilitation units. Methods: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) multicenter study enrolled patients aged ≥65 years admitted to geriatric rehabilitation units in Italy and Spain. FO were absolute and relative functional gain (AFG-RFG) in Barthel Index (BI) at 1 and 3 months after admission. The association between NS (Mini Nutritional Assessment-Short Form) and FO was explored using linear regression and mixed models, adjusted for potential confounders. Analyses were then stratified for diagnosis at admission. Results: We included 415 patients (mean age 81.4 years [SD: 7.7]; 67% female; 9.4% malnourished [MN], 42.7% at risk of malnutrition [RM], and 48% well nourished [WN]). Admission diagnoses were hip fracture (39.5%), elective orthopedic surgery (EOS) (29.5%), and stroke (31%). In an adjusted linear mixed model, MN and RM participants had lower BI compared to WN (MN: ß: -8.47, p = 0.023; RM: ß: -5.22, p = 0.031), and differences between groups remained stable over time. After stratification for admission diagnosis, only MN patients admitted after EOS had worse FO, both at 30 days (AFG: ß adjusted: -13.54, p < 0.001; RFG: ß: -32, p < 0.001) and 3 months (AFG: ß adjusted: -17.79, p < 0.001; RFG: ß: -26.77, p = 0.002). Conclusions: In our sample, poor NS is associated with worse BI in older adults admitted to geriatric rehabilitation units; in patients undergoing EOS, MN is associated with worse FO. Our results documented for the first time the importance of assessing nutritional status before EOS.

Functional Near-Infrared Spectroscopy to Study Cerebral Hemodynamics in Older Adults During Cognitive and Motor Tasks: A Review.

The integrity of the frontal areas of the brain, specifically the prefrontal cortex, are critical to preserve cognition and mobility in late life. Prefrontal cortex regions are involved in executive functions and gait control and have been related to the performance of dual-tasks. Dual-task performance assessment may help identify older adults at risk of negative health outcomes. As an alternative to neuroimaging techniques that do not allow assessment during actual motion, functional Near-Infrared Spectroscopy (fNIRS) is a non-invasive technique that can assess neural activation through the measurement of cortical oxygenated and deoxygenated hemoglobin levels, while the person is performing a motor task in a natural environment as well as during cognitive tasks. The aim of this review was to describe the use of fNIRS to study frontal lobe hemodynamics during cognitive, motor and dual-tasks in older adults. From the 46 included publications, 20 studies used only cognitive tasks, three studies used motor tasks and 23 used dual-tasks. Our findings suggest that fNIRS detects changes in frontal activation in older adults (cognitively healthy and mild cognitive impairment), especially while performing cognitive and dual-tasks. In both the comparison between older and younger adults, and in people with different neurological conditions, compared to healthier controls, the prefrontal cortex seems to experience a higher activation, which could be interpreted in the context of proposed neural inefficiency and limited capacity models. Further research is needed to establish standardized fNIRS protocols, study the cerebral hemodynamic in different neurological and systemic conditions that might influence cortical activation and explore its role in predicting incident health outcomes such as dementia.

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.

Change in cognitive performance is associated with functional recovery during post-acute stroke rehabilitation: a multi-centric study from intermediate care geriatric rehabilitation units of Catalonia.

Recovery after a stroke is determined by a broad range of neurological, functional and psychosocial factors. Evidence regarding these factors is not well established, in particular influence of cognition changes during rehabilitation. We aimed to investigate whether selective characteristics, including cognitive performance and its change over time, modulate functional recovery with home discharge in stroke survivors admitted to post-acute rehabilitation units. We undertook a multicenter cohort study, including all patients discharged from acute wards to any geriatric rehabilitation unit in Catalonia-Spain during 2008. Patients were assessed for demographics, clinical and functional variables using Conjunt Mínim Bàsic de Dades dels Recursos Sociosanitaris (CMBD-RSS), which adapts the Minimum Data Set tool used in America's nursing homes. Baseline-to-discharge change in cognition was calculated on repeated assessments using the Cognitive Performance Scale (CPS, range 0-6, best-worst cognition). The multivariable effect of these factors was analyzed in relation to the outcome. 879 post-stroke patients were included (mean age 77.48 ± 10.18 years, 52.6% women). A worse initial CPS [OR (95% CI) = 0.851 (0.774-0.935)] and prevalent fecal incontinence [OR (95% CI) = 0.560 (0.454-0.691)] reduced the likelihood of returning home with functional improvement; whereas improvement of CPS, baseline to discharge, [OR (95% CI) = 1.348 (1.144-1.588)], more rehabilitation days within the first 2 weeks [OR (95% CI) = 1.011 (1.006-1.015)] and a longer hospital stay [OR (95% CI) = 1.011 (1.006-1.015)] were associated with the outcome. In our sample, different clinical characteristics, including cognitive function and its improvement over time, are associated with functional improvement in stroke patients undergoing rehabilitation. Our results might provide information to further studies aimed at exploring the influence of cognition changes during rehabilitation.

Valoración geriátrica y factores pronósticos de mortalidad en pacientes muy ancianos con neumonía extrahospitalaria / Geriatric Assessment and Prognostic Factors of Mortality in Very Elderly Patients With Community-Acquired Pneumonia

Introducción: Analizar la relación de parámetros Obtenidos en la valoración geriátrica con la mortalidad en ancianos con neumonía extrahospitalaria (NEH) en una unidad de geriatría de agudos (UGA). Método: Un total de 456 pacientes (≥ 75 años). Variables: edad, sexo, procedencia, antecedentes, nivel de conciencia, frecuencia cardíaca y respiratoria, presión arterial, datos de laboratorio, derrame pleural, afectación multilobar, capacidad funcional (independencia para actividades de la vida diaria) previa al ingreso (índice de Lawton [IL], índice de Barthel previo [IBp]) y en el momento del ingreso (IBi), función cognitiva (test de Pfeiffer [TP]), comorbilidad (índice de Charlson [ICh]) y nutrición (proteínas totales, albúmina). Resultados: Los 110 pacientes que fallecieron durante el ingreso (24,2%) tuvieron mayor edad (86,6 ± 6,4 vs 85,1 ± 6,4; p < 0,04), mayor comorbilidad (ICh 2,35 ± 1,61 vs 2,08 ± 1,38; p < 0,083), menor capacidad funcional (IL: 0,49 ± 1,15 vs 1,45 ± 2,32; p < 0,001; IBp: 34,6 ± 32,9 vs 54,0 ± 34,1; p < 0,001; IBi: 5,79 ± 12,5 vs 20,5 ± 22,9; p < 0,001), mayor porcentaje de pérdida funcional al ingreso (85,9 ± 23,2 vs 66,4 ± 28,6; p < 0,0001), mayor deterioro cognitivo (TP: 7,20 ± 3,73 vs 5,10 ± 3,69; p < 0,001) y mayor desnutrición (albúmina 2,67 ± 0,54 vs 2,99 ± 0,49; p < 0,001). Hubo también mayor mortalidad con alteración de conciencia (49,2%; p < 0,01), taquipnea (33,3%; p < 0,01), taquicardia (44,4%; p < 0,002), urea elevada (31,8; p < 0,001), anemia (44,7%; p < 0,02), derrame pleural (42,9%; p < 0,002) y afectación multilobar (43,2%; p < 0,001). En el análisis multivariado resultaron significativos: edad ≥ 90 años (OR: 3,11 [IC 95%: 1,31-7,36]), alteración de conciencia (3,19 [1,66-6,15]), hematocrito < 30% (2,87 [1,19-6,94]), derrame pleural (3,77 [1,69-8,39]) y afectación multilobar (2,76 [1,48-5,16]). El sexo femenino y la capacidad funcional más conservada previa (IL ≥ 5) y en el momento del ingreso (IBi ≥ 40) fueron protectores de mortalidad (0,40 [0,22-0,70]; 0,09 [0,01-0,81] y 0,11 [0,02-0,51]). Conclusiones: Los parámetros de valoración geriátrica y las variables clínicas habituales estuvieron relacionados con la mortalidad

Introduction: To assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit.MethodsFour hundred fifty-six patients (≥ 75 years). Variables: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin). Results: A hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6 ± 6.4 vs 85.1 ± 6.4, P < 0.04), had more comorbidity (ChI 2.35 ± 1.61 vs 2.08 ± 1.38; P < 0.083), worse functional impairment [(LI: 0.49 ± 1.15 vs 1.45 ± 2.32, P < 0.001) (BIp: 34.6 ± 32.9 vs 54.0 ± 34.1, P < 0.001) (BIa: 5.79 ± 12.5 vs 20.5 ± 22.9, P V< 0.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4 ± 28.6; P < 0.0001), worse cognitive impairment (PT: 7.20 ± 3.73 vs 5.10 ± 3.69, P < 0.001) and malnutrition (albumin 2.67 ± 0.54 vs 2.99 ± 0.49, P < 0.001). Mortality was higher with impaired consciousness [49.2% (P < 0.01)], tachypnea [33.3% (P < 0.01)], tachycardia [44.4% (P < 0.002), high urea levels [31.8 (P < 0.001)], anemia [44.7% (P < 0.02)], pleural effusion [42.9% (P < 0.002)], and multilobar infiltrates [43.2% (P < 0.001)]. In the multivariate analysis, variables associated with mortality were: age ≥ 90 years [OR: 3.11 (95% CI: 1.31-7.36)], impaired consciousness [3.19 (1.66-6.15)], hematocrit < 30% [2.87 (1.19-6.94)], pleural effusion [3.77 (1.69-8.39)] and multilobar infiltrates [2.76 (1.48-5.16)]. Female sex and a preserved functional status prior (LI ≥ 5) and during admission (BIa ≥ M40) were protective of mortality [0.40 (0.22-0.70), 0.09 (0.01-0.81) and 0.11 (0.02-0.51)]. Conclusions: Geriatric assessment parameters and routine clinical variables were associated with mortality

Geriatric assessment and prognostic factors of mortality in very elderly patients with community-acquired pneumonia.

INTRODUCTION: To assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit. METHODS: Four hundred fifty-six patients (≥75years). VARIABLES: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin). RESULTS: A hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6±6.4 vs 85.1±6.4, P<.04), had more comorbidity (ChI 2.35±1.61 vs 2.08±1.38; P<.083), worse functional impairment [(LI: 0.49±1.15 vs 1.45±2.32, P<.001) (BIp: 34.6±32.9 vs 54.0±34.1, P<.001) (BIa: 5.79±12.5 vs 20.5±22.9, P<.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4±28.6; P<.0001), worse cognitive impairment (PT: 7.20±3.73 vs 5.10±3.69, P<.001) and malnutrition (albumin 2.67±0.54 vs 2.99±0.49, P<.001). Mortality was higher with impaired consciousness [49.2% (P<.01)], tachypnea [33.3% (P<.01)], tachycardia [44.4% (P<.002), high urea levels [31.8 (P<.001)], anemia [44.7% (P<.02)], pleural effusion [42.9% (P<.002)], and multilobar infiltrates [43.2% (P<.001)]. In the multivariate analysis, variables associated with mortality were: age ≥90years [OR: 3.11 (95%CI: 1.31 to 7.36)], impaired consciousness [3.19 (1.66 to 6.15)], hematocrit <30% [2.87 (1.19 to 6.94)], pleural effusion [3.77 (1.69 to 8.39)] and multilobar infiltrates [2.76 (1.48 to 5.16)]. Female sex and a preserved functional status prior (LI≥5) and during admission (BIa≥40) were protective of mortality [0.40 (0.22 to 0.70), 0.09 (0.01 to 0.81) and 0.11 (0.02 to 0.51)]. CONCLUSIONS: Geriatric assessment parameters and routine clinical variables were associated with mortality.

The use of subcutaneous scopolamine as a palliative treatment in Parkinson's disease.

Parkinson's disease (PD) is a degenerative, chronic and irreversible condition. Palliative medicine may play an important role in the care of patients with PD to maintain the quality of life. Scopolamine is a non-competitive antagonist at muscarinic acetylcholine receptors, which was used many years ago in the treatment for PD. To the best of our knowledge, there are no previously reported cases of the use of scopolamine for symptom relief at the end of life in patients with PD. The case reported here shows that treatment with a subcutaneous scopolamine was a useful alternative in a terminal cancer patient with severe tremors unable to take oral PD medication.