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

OBJECTIVES

To examine the survival rates of subjects aged 95 or over after a follow-up period of 3 years, and to determine predictive factors for mortality risk.

DESIGN

A prospective cohort study.

SETTING

A community-based study.

PARTICIPANTS

Forty-eight subjects aged 95 or over.

MEASUREMENTS

Sociodemographic data, Barthel Index, Lawton-Brody Index, Spanish version of the Mini-Mental State Examination, short version of the Mini Nutritional Assessment, comorbidity (Charlson Index), and prevalent chronic diseases were evaluated. Patients who died were compared with the rest.

RESULTS

Thirty-six deaths (75%) were recorded during follow-up. The Cox multivariate analysis showed that lower Barthel Index scores and a history of heart failure were independently associated with long-term mortality.

CONCLUSIONS

In subjects aged 95 or over, poor functional status and history of heart failure were the two independent risk factors for 3-year mortality.

[Occupational dermatoses. Cross-cultural adaptation of the Nordic Occupational Skin Questionnaire (NOSQ-2002) from English to Spanish and Catalan]

BACKGROUND

Eczema of the hands and urticaria are very common occupational dermatoses. The Nordic Occupational Skin Questionnaire (NOSQ-2002), developed in English, is an essential tool for the study of occupational skin diseases. The short version of the questionnaire is useful for screening and the long version is used to study risk factors. OBJECTIVE. The aim of this study was to culturally adapt the long version of the NOSQ to Spanish and Catalan and to ensure comprehension, semantic validity, and equivalence with the original.

METHODS

The principles of the International Society for Pharmacoeconomics and Outcomes Research for good research practices were applied. A 4-phase method was used, with direct, revised translation, back translation, and cognitive interviews.

RESULTS

After direct translation, a first version was issued by the Spanish Working Group. This version was evaluated in cognitive interviews. Modifications were made to 39 questions (68 %) in the Spanish version and 27 questions (47 %) in the Catalan version. Changes included addition of examples to improve understanding, reformulation of instructions, change to use of a direct question format, and addition of certain definitions. The back translation was evaluated by the original authors, leading to a further 7 changes in the Spanish version and 2 in the Catalan version. The third consensus version underwent a second round of cognitive interviews, after which the definitive version in each language was issued. CONCLUSION. Spanish and Catalan versions of the NOSQ-2002 questionnaire are available at www.ami.dk/NOSQ and www.arbejdsmiljoforskning.dk.

Characteristics of falls producing hip fractures in nonagenarians

OBJECTIVES

To evaluate the characteristics associated with falls causing hip fracture in patients 90 years of age or older (nonagenarians). A second objective was to compare these characteristics with those present in younger patients (65-79 year-olds).

DESIGN

Prospective, observational study.

SETTING

Six hospitals in Barcelona (Spain) and its surrounding area.

PARTICIPANTS

105 nonagenarians diagnosed with hip fracture after a fall. Most patients were women (78; 74%), with a mean age of 92.2+/-2 years. All of them were living in the community, except for eight institutionalized patients. 221 patients aged 65 to 79 composed the younger patient's comparison group.

MEASUREMENTS

Characteristics of falls causing hip fracture were analyzed: location, time and the risk factor for the fall, classified as intrinsic, extrinsic or combined.

RESULTS

The mean number of falls in the previous year was 1.5 - 22% of the patients reported having fallen two or more times. Falls usually happened while at home (70%) and during the day (64%). An intrinsic risk factor was considered the most likely cause in 37% of the cases, an extrinsic risk factor in 35%, and a combination in 28%. Multiple stepwise logistic regression analysis showed that nonagenarians were characterized by lower BI scores, more falls happening during night time, a higher use of, benzodiazepines and diuretics, and a lower use of non-benzodiazepinic hypnotics.

CONCLUSIONS

Most falls causing hip fracture in nonagenarians happen during the day and at home. Falls in nonagenarians happening more frequently during nighttime, and these oldest subjects had lower BI scores, and a higher use of benzodiazepines and diuretics and less use of non-benzodiazepines hypnotics compared with the younger patients.

Falls in nonagenarians living in their own homes: the Nonasantfeliu study

OBJECTIVES

To evaluate the prevalence of falls and their circumstances in non-institutionalized people older than 89 years and living in an urban community.

DESIGN

Cross-sectional cohort study.

SETTING

Community-based study.

PARTICIPANTS

137 nonagenarians living at home.

MEASUREMENTS

We evaluated sociodemographic data, capacity to perform basic activities according to the Barthel Index (BI) and instrumental activities on the Lawton-Brody Index (LI), cognition with the Spanish version of the Mini-Mental State Examination (MEC), near visual acuity by the Snellen test, and auditory acuity with the whisper test.

RESULTS

Ninety-nine women (72%) and 38 men with an average age of 93.07 years (0.7) were included. 48.1% of them had suffered a fall during the last year, and in 20% of cases this had happened on more than one occasion. In 5.7% of cases, falls led to fractures. Factors associated with falls were a lower LI and a greater number of prescribed drugs. In the multivariate analysis the only factor related to falls was the number of drugs taken (p>0.001, odds ratio 0.785, 95% confidence interval 0.676-0.912).

CONCLUSIONS

Measures to prevent falls among nonagenarians should be intensified due to their high frequency. In this age group the increase in the percentage of falls is mainly related to the higher number of drugs taken.

Diferencias entre nonagenarios según su lugar de residencia. Estudio NonaSantfeliu

OBJECTIVE

By means of a cross-sectional study, describe the differential characteristics between a group of inhabitants of a same municipality over 89 years of age who are permanently institutionalized and those of the same age who continue to live in the community, trying to identify a profile of nonagenarians with high risk of living in a nursing home.

MATERIAL AND METHODS

One hundred and eighty six nonagenarians were studied: 137 (74%) were living in their home and 49 (26%) in a nursing home. Sociodemographic data, ability to perform basic daily activities with Barthel Index (BI) or instrumental activities with Lawton and Brody Index (LI), cognition with the Spanish version of the Mini-Mental State Examination (MEC) and comorbidity (Charlson Index) were evaluated. Cardiovascular risk factors and other prevalent diseases were also studied.

RESULTS

A total of 143 women (76.5%) and 43 men with a mean age of 93.06 years were studied. A predominance of women, single persons, worse IL, and greater consumption of drugs was observed in the bivariate analysis in the nonagenarians living in residences and widowers than in those living in the community. The multivariate analysis showed that the features of being single and having a lower IL were independent factors of living in a nursing home.

CONCLUSIONS

The main difference between nonagenargian patients who live in the community and those in residences is that the latter are mainly single and have a low score on a scale that quantities instrumental activities of the daily life.

A prospective evaluation of the cost of psoriasis in Spain (EPIDERMA project: phase II)

OBJECTIVE

To estimate the direct and indirect costs related to psoriasis in Spain.

METHODS

We performed a 12-month, multicentre, prospective longitudinal and observational study. Overall expense of care was assessed as the sum of direct and indirect costs.

RESULTS

A total of 797 patients with varying demographics and different degrees of severity of psoriasis were included in the study. The mean total cost of psoriasis, including direct and indirect items, was 1,079 euro per patient and year. The major sources of expenditure were prescription drugs (46.6%), followed by medical activities (34.5%). Mean costs in patients with moderate and severe psoriasis were approximately 1.5 and 2.5 times higher than in those with mild psoriasis, respectively.

CONCLUSIONS

In Spain, psoriasis is associated with substantial costs both to the National Health System and to the patients.

El lugar de fallecimiento de las personas ancianas en Cataluña

STUDY OBJECTIVE

To describe the place of death of the elderly and to analyze the factors associated with death occurring in an acute care hospital.

DESIGN

Cross-sectional interview of a randomized sample of individuals aged 65 or over who died during the year 1998. Three to four months after the death of the elderly subject, the main caregiver was interviewed about the socio-demographic characteristics, chronic conditions, functional and cognitive status, and use of health services in the months previous to the death, as well as the place where death occurred and their preferences on this site.

SETTING

Six areas of Catalonia, Spain, differing in the level of health and end of life social services.

PARTICIPANTS

584 caregivers (78.6% response rate).

MAIN RESULTS

Mean age of the deceased elderly was 81.4 (+/- 8) and half of them were females. 52% (95% CI: 47.5-55.7) had died in acute care hospitals. 35% of the caregivers of those dying at an acute hospital reported that they would have preferred another place for death. After adjustment, variables associated with dying in acute care hospitals were: living in an area with lower availability of social and health services for the end of life (OR: 2.8; 95% CI: 1.4-5.5) and suffering from chronic obstructive pulmonary disease (OR: 1.7; 95% CI: 1.1-2.5).

CONCLUSIONS

Acute hospitals are the predominant place of death in Catalonia, Spain. The place of death seems to be more closely influenced by the availability of end-of-life care services. There is a clear preference for dying at an alternative place to acute hospitals.

[Elastosis perforans serpiginosa in a patient with pseudoxanthoma elasticum]

A 34-year-old female previously diagnosed of pseudoxanthoma elasticum developed an annular plaque with serpiginous borders of 42 by 30 mm in diameter on the inner left arm. A similar lesion later appeared on the inner right arm. Histopathological examination of a papule showed short, fragmented, granular, basophilic and calcified elastic fibers in the mid-reticular dermis. The epidermis showed hyperplasia surrounding degenerated and normal elastic fibers. Transepidermal elimination channels of these elastic fibers were also observed. These findings were consistent with the diagnosis of elastosis perforans serpiginosa. Abundant multinucleated giant cells were observed surrounding the area of epidermal hyperplasia and in the reticular dermis. The patient was treated with tazarotene, and the plaques disappeared in 9 months.

[Interobserver concordance in functional assessment by Barthel Index]

BACKGROUND

The aim of this study is to analyze interobserver "reproductiveness" between clinical nurses in gerontology and residents in family medicine in their first contact with the Barthel Index (BI).

MATERIALS AND METHODS

One hundred patients were assessed. BI at two weeks before admission was scored by a patient or carer interview. Eighteen patients were excluded because interviews were not completed.

RESULTS

Mean BI of 82 patient included, assessed by nurses was 87.3 and by residents 88.2. In 40 patients some differences in the mean values of BI were observed. When analyzing the overall BI score the agreement was high (r=0.793) but interobserver agreement was low (kappa<0.4) in some fields such as eating, dressing and transfers and medium in others (kappa from 0.40 to 0.75).

CONCLUSIONS

Low reproductiviness interobserver in some patients of the BI when clinical nurses in gerontology and residents in family medicine are compared suggest that they need specific training in functional capacity evaluation in order to improve the BI use.

Síndrome confusional agudo en pacientes ancianos ingresados por patología médica

INTRODUCTION

Delirium or acute confusional syndrome (ACS) is a frequent problem during hospitalization of elderly patients. We study the appearance of delirium and its characteristics in patients admitted to an internal medicine service.

METHODS

Prospective study of 148 patients over 64 years admitted due to medical condition (non-surgical) in the internal medicine service of the University Hospital of Bellvitge. Functionality was quantified with the Barthel index (BI) and comorbidity with the Charlson index (CI). The Confusional Assessment Method was used for the diagnosis of the ACS.

RESULTS

Seventy-seven (77) (52%) of the 148 patients were women, with a mean age of 78.5 years. The CI was 2.2. Mean of previous BI was 81.7. Mortality during admission was 8% (12 patients). A total of 42.5% of the patients (63) had ACS (30% prevalent). It was hyperactive in 68%, hypoactive in 16% and mixed in 16%. In 38% of the patients, the ACS had morning predominance and 62% it appeared after the evening. Advanced age was the only significant differences between patients with or without ACS (p < 0.001). There were no significant differences in the ACS percentage between patients who survived or who died (p = 0.36).

CONCLUSIONS

Frequency of appearance of the confusional picture is high in patients admitted to acute hospitals, it being more frequent in the elderly. Measures to prevent the confusional picture in elderly patients who are hospitalized should be increased.

End-of-life preferences in elderly patients admitted for heart failure

BACKGROUND

Heart failure is increasing in prevalence and incidence, with considerable mortality among the elderly.

AIM

To determine preferences concerning cardiopulmonary-resuscitation (CPR) and end-of-life care in elderly patients hospitalized for heart failure.

DESIGN

Prospective interview-based survey.

METHODS

Patients >64 years old admitted for acute heart failure were interviewed to address their preferences regarding end-of-life care and cardio-pulmonary resuscitation (CPR) when facing the last stages of their disease.

RESULTS

We interviewed 80 patients (mean age 79 years; 58% women). Thirty-two (40%) expressed a wish not to have CPR. Only two had previously discussed their CPR preferences with their physicians. When recovery from the illness was considered unlikely, 40 (50%) participants preferred to receive treatment at home, 32 (40%) preferred in-hospital management, and 8 (10%) were unsure. Thirty-three patients (41%) expressed a desire for spiritual support, 38 (48%) said not and the remaining 9 (11%) were indifferent.

DISCUSSION

Advance planning of end-of-life procedures and doctor-patient communication regarding these items remains poor and must be improved.