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.

Una propuesta destinada a complementar el cuestionario Font-Roja de satisfacción laboral

INTRODUCTION

Several studies have shown the need to include the physical work environment among the dimensions included in job satisfaction evaluation. However, this dimension was not included in the Font-Roja questionnaire. The present study introduces two items exploring this dimension and adheres to the hypothesis that physical work environment has a significant impact on job satisfaction evaluation.

METHOD

A total of 227 geriatric workers participated in this study. The participants completed the Font-Roja job satisfaction questionnaire with 2 additional items exploring the physical work environment. Factor analysis and principal components analysis with rotation varimax were used to determine the diverse components of job satisfaction. To determine the coherence of the scales and the consistency of the added items, Cronbach's a was used. These methods were applied to both questionnaires, the classical 24-item questionnaire and the extended 26-item questionnaire.

RESULTS

The classical Font-Roja questionnaire was composed of 8 factors, explaining 60.02% of the variance. The extended questionnaire was structured into 9 factors, explaining 61.81% of the variance. The new factor was composed of both added items. The internal consistency of the Font-Roja classical scale was alpha = 0.773 and that of the extended scale was alpha = 0.791.

DISCUSSION

The extended scale is superior to the classical scale. The results obtained seem to support the hypothesis that, for analysis of job satisfaction, the instruments used should contain items on the physical work environment.

The Effectiveness and Cost-Effectiveness of Respite for Caregivers of Frail Older People

The proportion of frail elderly people in the industrialized world is increasing. Respite care is a potentially important way of maintaining the quality of life for these people and their caregivers. The objective of this systematic review was to determine the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their caregivers. To identify relevant studies, 37 databases were searched, and reference checking and citation searches were undertaken. Well-controlled effectiveness studies were eligible for inclusion, with uncontrolled studies admissible only in the absence of higher-quality evidence. Studies assessed the effect of community-based respite on caregivers of frail elderly people relative to usual care or to another support intervention. Eligible economic evaluations also addressed costs. Where appropriate, data were synthesized using standard meta-analytic techniques. Ten randomized, controlled trials, seven quasi-experimental studies and five uncontrolled studies were included in the review. For all types of respite, the effects upon caregivers were generally small, with better-controlled studies finding modest benefits only for certain subgroups, although many studies reported high levels of caregiver satisfaction. No reliable evidence was found that respite care delays entry to residential care or adversely affects frail older people. The economic evaluations all assessed day care, which tended to be associated with similar or higher costs than usual care. Given the increasing numbers of frail elderly people and the lack of up-to-date, good-quality evidence for all types of respite care, better-quality evidence is urgently needed to inform current policy and practice.

Síntomas depresivos en personas mayores. Prevalencia y factores asociados

OBJECTIVES

To estimate the prevalence of depressive symptoms in people older than 64 and to analyze their association with sociodemographic factors, frailty markers, and disabling diseases.

METHODS

A survey-based, cross-sectional descriptive study was carried out. The sample was composed of 417 elderly people living in Guadalajara (Spain), selected on the basis of health cards. Depressive symptoms were assessed using Yesavage's test (cut-off: 6 or more items). The questionnaire contained sociodemographic and clinical items and evaluation scales for cognitive impairment, disability, and social risk. The frailty markers studied were age over 80 years old, female sex, cognitive impairment, disability, polypharmacy, comorbidity, and social risk.

RESULTS

The prevalence of depressive symptoms was 19.7% (95% CI, 15.9-23.4) and clinical depression was diagnosed in 5% (95% CI, 2.3-7.7). Depressive symptoms were more frequent in elderly individuals living in rural environments than in those living in urban areas (p < 0.05). These symptoms increased with age (p linear trend < 0.001) and were associated with social risk (p < 0.001), comorbidity (p < 0.001), cognitive impairment (p < 0.01), and disability (p < 0.05). When a multivariate statistical analysis was applied using logistic regression models, only comorbidity (odds ratio [OR] = 2.38; 95% CI, 1.35-4.20) and social risk (OR = 2.69; 95% CI, 1.50-4.83) were significantly associated.

CONCLUSIONS

The prevalence of depressive symptoms is very high in the elderly, four times higher than a diagnosis of clinical depression. Social risk and comorbidity are strongly associated with depressive symptoms.

Dying in hospital of terminal heart failure or severe dementia: the circumstances associated with death and the opinions of caregivers

BACKGROUND

Improving the care provided to elderly patients affected by end-stage chronic diseases dying in acute hospitals is a health priority. We evaluated the circumstances related to death in end-stage non-cancer patients dying in two acute care hospitals, and their caregiver's opinions about the death.

METHODS

Some 102 patients, over 64 years of age, with end-stage dementia (37%) or congestive heart failure (64%), were included in the study. Caregiver's opinions on the circumstances of death were obtained using a questionnaire. In addition, we collected data regarding written instructions on several items, including do not resuscitate (DNR) orders, decisions about care in terms of the level or intensity of interventions, information provided to relatives about the prognosis, total withdrawal of normal drug therapy, and provision of palliative care.

RESULTS

Caregivers stated that the clinical information was accurate in 67.6% of cases, and the control of symptoms was good in 55%. However, the perception of pain persisted in 14% and uncontrolled dyspnoea in 45%. The end-of-life care was assessed as: excellent 30.5%, good 36%, fairly good 25.5%, bad 6%, and very bad 2%. DNR orders were specified in 89% of patients, decisions concerning the intensity of care in 64%, and 80% of relatives were aware of the prognosis. Drug therapy was withdrawn in 64% of cases, and terminal palliative care was initiated in 79.5%.

CONCLUSION

Our results suggest that some aspects of the palliative care provided to elderly patients with end-stage chronic diseases, admitted to acute care hospitals, could be improved. Such aspects include the clinical information provided and the successful control of specific symptoms.

Os sentidos e destinos do cuidar na preparação dos cuidadores de idosos

Neste trabalho apresentamos alguns pressupostos teóricos que informam a preparação de cuidadores de idosos, proposta por dois cursos realizados na cidade do Rio de Janeiro. Utilizamos uma metodologia qualitativa adotando como instrumentos de coleta de dados a observação participante e gravação das aulas, entrevistas com os coordenadores e, como fontes documentais, os programas, apostilas e referências bibliográficas. Os dados, ordenados em categorias descritivas, foram analisados à luz da literatura. Concluímos com uma reflexão acerca dos pressupostos que têm referenciado a preparação dos cuidadores de idosos e suas conseqüências para o cuidar, inclusive o debate entre estes e a enfermagem. Destacamos: a oposição entre cuidados invisíveis, cuidados visíveis e cuidados técnicos; a naturalização do cuidar como um valor em detrimento de um aprendizado técnico; e as concepções de cuidado social e cuidado com a saúde. Consideramos que tanto a ênfase no cuidado social, ao afastar a figura médica da doença, quanto a ênfase no cuidado à saúde, que tem a doença como mote reflexivo, ao desconsiderarem a importância do cuidado técnico, podem, com isso, não levar em consideração a complexidade dos aspectos subjetivos e físicos ligados à existência concreta do enfermo idoso.

Relationship of serum leptin concentration with age, gender, and biomedical parameters in healthy, non-obese subjects

It is known that the circulating levels of leptin, the adipocyte hormone implicated in the control of energy balance, are correlated with fat body mass (FBM), although the influences of other physiological conditions are not fully understood. We investigated the relationships of serum leptin concentration with age, gender, and 36 hormone-metabolic parameters in a sample of a well defined healthy population (n=246; age range 20-93 years), and in subgroups of lean individuals according to their body mass index (BMI), within similar age range and gender distribution. Only insulin secretion (positively) and testosteronemia (negatively, in males) show direct correlations. The other relationships are not significant but throughout collaborating variables, such as serum lipids, especially through FBM, lean body mass (LBM) through insulin secretion, and gender through FBM. In males, LBM correlates with insulin secretions, s-IGF-1 and with s-testosterone. The relationship between insulin secretion and LBM persists up to advanced age. From the present study it may be concluded that the positive relationship of leptin with insulin secretion and the negative one with testosterone, indicate direct implications of leptin in insulin signaling, as well as in male sexual development. Finally, the fact that the amount of secreted insulin depends on LBM and the latter on testosterone and IGF-1, indicates the importance of muscle mass in the control of insulin secretion.

[Analysis of the Educational Program for Self-Care in the Elderly (PECA) for improving the quality of life of the elderly]

OBJECTIVE

To determine the efficacy over 12 months of the educational programme on self-care of the elderly (PECA), which covers quality of life, nutritional status, and perceived social support of people over 65 living in their own homes.

DESIGN

Pre-test/post-test experimental study with control group.

SETTING

Urban population in the Manso Health District (Example, Barcelona), Spain.

PARTICIPANTS

Persons over 65 living in their own homes, healthy or with chronic illnesses characteristic of their age, who had a normal score in the Pfeiffer test. A total of 70 subjects (35 per group) were selected and 5 of the control group left the study.

INTERVENTION

Programme on self-care of the elderly, including education on physical activity, nutrition, and social support.

MEASUREMENTS

Dependent variables were quality of life, measured by the Nottingham Health Profile; nutritional status, measured by the Mini-Nutritional Assessment (MNA); and social support, measured by the Duke-Unk Functional Social Support Scale.

RESULTS

The study sample had an average age of 70.9 (SD, 3.1); 88.2% had self-perception of good health; and 21% lived alone. We only found statistically significant differences between pre- and post-intervention observations in nutritional status (P=.001).

CONCLUSION

Despite a statistically significant difference in the variable of nutritional status, the difference was not "clinically" relevant. The ineffectiveness of the intervention is due to our starting from a very homogeneous sample, which had good health status and well-established social networks.

El suicidio en la España de hoy

Spain presents one of the lowest suicide rates (8.7 per 100,000) but, as well as Ireland, it has also experienced one of the highest rate increases both within Europe and within the world. In our country, it can be observed an increase in the suicide rates from 1975 to 1994, being this increase greater in men than in women. It can also be noted that there was a stabilisation in the following years. Social factors, specially those which have to deal with gender roles and changes in these roles, are the most common explanations. Another possible explanation for the observed increase in mortality due to suicide among young men could be the AIDS epidemic and intravenous drug addiction, that was observed in Spain during the eighties and nineties. Furthermore, we are witnessing an epidemic related to violence against children and women. Literature strongly suggests that child abuse (psychological and sexual) is associated with increased suicide risk in adolescent or adult life. Women experience violence from their intimate partners and have a greater risk of suffering from chronic pain, diverse somatisations, greater substance use like drugs and alcohol, depression and suicide attempt. The association between work precariousness and suicide seems to be due to economic and social and family support factors, which can lead to greater vulnerability to mental health problems. These factors are of great relevance, since Spain presents one of the highest unemployment and temporary employment rates in the European Union. It seems reasonable that, due to the individualism that characterises the contemporary society, its demands and the new role of women in the work market that cause, among others, a greater difficulty in combining work and family life, are factors that could explain the lack of decrease in suicide rates.

Inmunomediación o hiperviscosidad en la hipoacusia neurosensorial rápidamente progresiva. Una aproximación terapéutica

INTRODUCTION

To evaluate the therapeutic response and the rheologic and immunological characteristics in subjects bearing of rapidly progressive sensorineural hearing loss (RPSHL).

PATIENTS AND METHODS

A comparative prospective study on three groups of damaged ears treated with piracetam (n=29), corticosteroids (n=32) and plabcebo (n=25). Hearing loss and recovery level, whole blood filterability (WBF) and a Western-blot (WB) to anticochlear antibodies were evaluated.

RESULTS

Recovery average was 20,8 +/- 55,9% in the first group, with progressive of deafness in the rest (p<0,01). WB did not show differences among groups. The higher WBF at the end of therapy was detected on group 1 (20,36 +/- 2,54 Vs 18,42 +/- 3,42 microl/seg on group 3; p<0,05). Moreover, it impaired only on those treated with piracetam, with statistically significative differences over the other two groups.

CONCLUSIONS

We detected alterations on WBF in patients with RPSHL that justify the use of rheoactive measures as a pathophysiological therapy.

[Nutritional assessment of the fragile elderly in primary care]

OBJECTIVE

To determine in primary care the nutritional status of elderly people at risk of malnutrition and to evaluate their evolution after an intervention.

DESIGN

Descriptive, with follow-up.

SETTING

Urban health centre.

SUBJECTS

Patients over 65, with criteria as fragile elderly or incapacitated and registered on a doctor's list (N=131). Nutritional risk factors were identified in the consultation or at home in 46 of those included in the study (March-September 2003).

MEASUREMENTS

Age, sex. Factors in risk of malnutrition: loss of weight, acute or chronic illness associated with malnutrition, social factors. Anthropometric indices: Body Mass Index (BMI), tricipital fold (TF) and percentage, brachial perimeter (BP), calf perimeter (CP), arm muscular circumference (AMC), and percentage. Analytic indices: lymphocytes, transferrin, albumin. Malnutrition: when at least 2 of the above parameters were disturbed. Type: calories, protein, mixed. Degree: light, moderate, or severe.

INTERVENTION

special diets and/or nutritional supplements. Parameters were re-assessed at 6 months (t test, paired samples).

RESULTS

Average age of 83, with 63% women. Nutritional risk factors: loss of weight 41%, acute illness 39%, chronic illness 10.5%, cognitive deterioration 4%, social risk 2%. 80.4% suffered malnutrition (32.5% calories, 46% mixed, 21.5% protein; 27% light, 56.7% moderate, 16.3% severe). Mean values on anthropometric parameters: BMI 21, TF 11.3 mm (TF% 72%), BP 22 cm, AMC 19.4 (%AMC 90%), CP 28 cm (%CP 87%). Mean analytic values were: transferrin 243, albumin 3.7, lymphocytes 1600. Nutritional supplements were indicated in 11 cases. 32 cases were re-evaluated later and no significant improvement was found for any parameter (=.05).

CONCLUSIONS

Malnutrition is common in the elderly with risk factors (loss of weight and acute illness), with calorie or mixed malnutrition the most common kinds. There was no improvement in anthropometric parameters at 6 months follow-up.

Prevalencia y factores de riesgo de sospecha de maltrato en población anciana

BACKGROUND AND OBJECTIVE

We determined the prevalence and associated risk factors in the suspicion of elder abuse in the old population.

PATIENTS AND METHOD

We included a total of 209 patients > or = 72 years of age without cognitive deterioration (score in test of Pfeiffer (3/4) 4 points). The questionnaire of suspicion of elder abuse used was one recommended by the Canadian Task Force and the American Medical Association; it consists of 9 questions and the presence of a positive answer is considered as indicative of suspicion of abuse.

RESULTS

The prevalence of suspicion of elder abuse was 52.6% (at least one positive answer to the questionnaire). 8.6% affirmatively responded to 2 questions and 2% to 3. Female gender, widowhood, deficiency of studies, living alone or in institutions and having exerted a remunerated work were the associated variables in the bivariant analysis with regard to the suspicion of abuse. In the model of logistic regression, there was a significant association with the civil status and the coexistence of the familiar nucleus, with a greater risk of elder abuse in unmarried and/or widowers (p < 0.001) and in those living alone (p < 0.0001).

CONCLUSIONS

There is a high prevalence of suspicion of elder abuse in the old population.

Diseño y validación de un cuestionario para la detección de depresión mayor en pacientes ancianos

BACKGROUND AND OBJECTIVE

The aim of this study was to design and validate a scale to detect major depressive disorders in elderly individuals in primary care (Detection of Depression in the Elderly Scale [DDES]).

METHODS

We performed an observational and cross-sectional study for the validation of a scale, administered by means of a personal interview, in 259 patients aged 65 years old or older. Available instruments were reviewed and the questions were designed. Subsequently, a first pilot study was performed. In a second pilot study the reproducibility of the instrument was analyzed. The gold standard was the result of a standardized psychiatric interview performed by psychiatrists (DSM-IV criteria and SCAN interviews).

RESULTS

The intraclass correlation coefficients corresponding to the test-retest and inter-rater reliability were 0.858 (95% confidence interval [CI], 0.634-0.946) and 0.908 (95% CI, 0.726-0.969) respectively. Two hundred sixteen subjects underwent an assessment, in which primary care and psychiatric evaluations were blinded. Major depression was diagnosed in 81 patients (37.5%; 95% CI, 31.1-44.4). The internal consistency of the DDES was good (Cronbach's alpha = 0.79). Exploratory factorial analysis revealed an 8-component structure (55.8% of explained variance). A cutoff score of 15 or more for the DDES showed sensitivity of 90.1% (95% CI, 80.95-95.33), specificity of 74.8% (95% CI, 66.48-81.71) and a likelihood ratio (+) of 3.58 (95% CI, 2.65-4.83).

CONCLUSIONS

The DDES is a clinically useful instrument for the detection of major depression in elderly patients in primary care.

Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality

OBJECTIVES

To evaluate and identify factors determining survival in elderly patients with advanced dementia.

METHODS

A prospective, follow-up, observational analysis in a cohort of 67 community-based patients aged 65 years or older with dementia defined by DSM-IV and stage 7A or above on the FAST scale. Data were recorded on socio-demographic variables, FAST, Katz index, language, swallowing ability, diet, nutritional status (from anthropometric and laboratory data), associated diseases and medical complications during the previous 12 months. Survival was analyzed by the Kaplan-Meier method. Prognostic factors for survival were identified by the Cox proportional hazards regression model.

RESULTS

The median follow-up was 832 days. The mean age was 82.2+/-6.7 years and 92.5% were women. A comorbid condition was present in 71.6%, most frequently hypertension (22.4%). A clinical event had occurred in 52 (77.6%) patients during the previous year (pneumonia, urinary infection, stroke, pressure sore, dehydration, sepsis or others). A total of 25 (37.3%) patients died. The mean survival was 676 days (95% confidence interval, 600-752 days). Cox proportional hazards model showed that independent prognostic factors for mortality were having pneumonia within the previous year (RR:3.7; p=0.001), a permanent nasogastric tube (RR:3.5; p=0.003) and serum albumin values below 3.5 g/dL (RR:2.9; p=0.028).

CONCLUSIONS

In patients with advanced dementia, hypoalbuminemia and pneumonia are strongly and positively associated with mortality. Artificial nutrition via a nasogastric tube reduces survival in these patients.

[Falls in the elderly: knowing to act]

OBJECTIVE

To study the prevalence of falls and to analyze the associated factors in non institutionalized population aged 65 or older in Catalonia.

MATERIAL AND METHODS

Data were collected from the 2002 Health Survey of Catalonia. Information on self reported falls according age, sex, educational level, social class, suffering chronic diseases and disabilities in people aged 65 or older (542 men and 665 women) was analyzed. Multivariate logistic analysis was applied.

MEASUREMENTS AND MAIN RESULTS

17.9% of the population aged 65 or older reported falls during the last twelve months. The frequency increases with ageing. To be women, to have university studies, having three or more chronic diseases and two disabilities is associated to a high risk of falling. Comparing 1994 and 2002 Health Surveys of Catalonia, the proportion of elderly people who reported falls has significantly increased.

CONCLUSIONS

Although it is necessary to advance on the knowledge of the risk factors and interventions addressed to prevent and reduce the occurrence of falls in the elderly people, a multifactorial and intersectorial approach seems the most adequate.

[Dying in the hospital from an end-stage non-oncologic disease: a decision making analysis]

BACKGROUND AND OBJECTIVE

The aim of the study was to evaluate palliative decision-making in non- oncological patients who died in an acute care hospital.

PATIENTS AND METHOD

293 patients > 64 years old were analyzed. These patients suffered from dementia (46%), end-stage congestive heart failure (31%) and end-stage chronic obstructive pulmonary disease (23%). We evaluated written information about: do not resuscitate (DNR) orders, graduation of therapeutic decisions, information provided to relatives about prognosis, total withdrawal of other drug therapy and provision of terminal care.

RESULTS

DNR orders were specified in 37% of cases, graduation of therapeutic decisions in 18% and knowledge of the prognosis by relatives in 57%. Drug withdrawal was carried out in 56% and palliative care in 65% patients.

CONCLUSIONS

Identification and provision of palliative care, in an acute care hospital, of elderly patients at their last admission prior to death because of non-oncological end-stage diseases must be improved.

[Streptococcus pneumoniae transmission in a nursing home: analysis of an epidemic outbreak]

BACKGROUND AND OBJECTIVE

On the basis of an outbreak of pneumococcal pneumonia in a nursing home, we analyze causes and patterns of transmission and discuss preventive interventions carried out on the target population.

PATIENTS AND METHOD

A retrospective cohort study was designed on 232 residents to identify risk factors associated with the outbreak. A descriptive study of those nasopharyngeal carriers of pneumococcus among nursing home workers was also carried out.

RESULTS

Twenty cases of pneumococcal pneumonia were detected with 4 deaths; 13 cases were confirmed. Cases occurred on a close temporal aggregation form but they were quite disseminated spatially. Among the factors investigated, an older age was the only factor significantly associated (p = 0.02) with the risk of disease. In 4 workers, strains of Streptococcus pneumoniae were isolated from nasopharyngeal swabs; two of them corresponded to the serotype 3, as it was the strain isolated from the blood of a nursing home case. The number of new cases decreased dramatically after vaccination and/or chemoprophylaxis.

CONCLUSIONS

Vaccination and chemoprophylaxis administered to nursing home residents seemed effective measures to halt the spread of this outbreak. Detection of the S. pneumoniae antigen by immunochromatographic tests in urine samples is a valuable tool for detecting an outbreak.

[Experience with the management of subtalar dislocation]

In 10 and 3 years resp., material of two surgical departments - with great material - 10 cases of luxation - without fracture - occurred in the subtaler joint have been treated. All 10 patients suffered covered, subtaler dislocations. After conservative treatment all 10 patients recovered and are back at work.