[Comorbidity in the elderly: utility and validity of assessment tools]

[Proposing a workload indicator for hospital at home patients in Osakidetza - Basque Public Health Service]

INTRODUCTION AND OBJECTIVES

The Hospital at Home (HaH) setting currently lacks adequate workload indicators. This study suggests an indicator that can help in improving professional resources allocation.

MATERIALS AND METHODS

Prospective data was collected during May 2021 from patients treated in nine HaH units of Osakidetza-Basque Health Service (North of Spain). Direct care and travel times of healthcare staff was recorded. Data on inpatient days, number of visits, sociodemographic variables, health status, and patient pathologies, among others, were collected. The proposed indicator encompasses both the average visit time and the visit rates. It is called intensity and represents the average daily workload time per patient.

RESULTS

A total of n = 1,171 users were included in the analyses. Their mean age was 69.8 years, 45.5% were women and 25% lived more than 12 km away from the corresponding HaH unit. Workload variations were observed for nursing-only and medical-nursing teams, depending on the type of day and patient classification group. The average nursing-only teams workload time on working days was 10.82 min and on non-working days it was 14.78 min. The average workload time for medical-nursing teams, during the same days, was 20.40 min and 4.59 min, respectively. It was observed that certain patient types, like those in palliative care, represented a high workload for medical-nursing teams on working days.

CONCLUSIONS

The intensity indicator can help answering the question of how many patients can be assigned to a professional. It can also be used to adjust the staffing needs of the HaH units.

Non-metastatic castration-resistant prostate cancer: management recommendations

INTRODUCTION AND OBJECTIVE

Survival and quality of life (QoL) of patients with non-metastatic castration-resistant prostate cancer (nmCRPC) deteriorate significantly when they develop metastases. New generation antiandrogens (apalutamide, enzalutamide and darolutamide) can prolong metastasis-free survival (MFS) and overall survival (OS) in these patients, maintaining their QoL.

MATERIAL AND METHODS

After the performance of a systematic review of the literature, a scientific committee reached a consensus on simple and practical recommendations to consolidate and improve the management of patients with nmCRPC in urology consultations.

RESULTS

Recommendations are made on the frequency of PSA determination and imaging tests in patients with nmCRPC. The importance of co-morbidities in patients with nmCRPC is also highlighted, and recommendations are also made on functional and QoL assessment that can be carried out during urology consultations. The efficacy, safety, and effects on QoL of new generation antiandrogens are reviewed.

CONCLUSIONS

To evaluate treatment of patients with nmCRPC, it is necessary to consider co-morbidities and QoL, in addition to age. New generation antiandrogens are a safe and effective treatment option for patients with nmCRPC. The recommendations of this review can be helpful in optimizing the management of nmCRPC patients in urology consultations.

Effects of Sarcopenic Obesity and Its Confounders on Knee Range of Motion Outcome after Total Knee Replacement in Older Adults with Knee Osteoarthritis: A Retrospective Study

Sarcopenic obesity is closely associated with knee osteoarthritis (KOA) and has high risk of total knee replacement (TKR). In addition, poor nutrition status may lead to sarcopenia and physical frailty in KOA and is negatively associated with surgery outcome after TKR. This study investigated the effects of sarcopenic obesity and its confounding factors on recovery in range of motion (ROM) after total knee replacement (TKR) in older adults with KOA. A total of 587 older adults, aged ≥60 years, who had a diagnosis of KOA and underwent TKR, were enrolled in this retrospective cohort study. Sarcopenia and obesity were defined based on cutoff values of appendicular mass index and body mass index for Asian people. Based on the sarcopenia and obesity definitions, patients were classified into three body-composition groups before TKR: sarcopenic-obese, obese, and non-obese. All patients were asked to attend postoperative outpatient follow-up admissions. Knee flexion ROM was measured before and after surgery. A ROM cutoff of 125 degrees was used to identify poor recovery post-surgery. Kaplan-Meier curve analysis was performed to measure the probability of poor ROM recovery among study groups. Cox multivariate regression models were established to calculate the hazard ratios (HRs) of postoperative poor ROM recovery, using potential confounding factors including age, sex, comorbidity, risk of malnutrition, preoperative ROM, and outpatient follow-up duration as covariates. Analyses results showed that patients in the obese and sarcopenic-obese groups had a higher probability of poor ROM recovery compared to the non-obese group (all p < 0.001). Among all body-composition groups, the sarcopenic-obese group yielded the highest risk of postoperative physical difficulty (adjusted HR = 1.63, p = 0.03), independent to the potential confounding factors. Sarcopenic obesity is likely at the high risk of poor ROM outcome following TKR in older individuals with KOA.

Effects of Protein-Rich Nutritional Composition Supplementation on Sarcopenia Indices and Physical Activity during Resistance Exercise Training in Older Women with Knee Osteoarthritis

Older adults with knee osteoarthritis (KOA) are at high risk of sarcopenia. Protein-rich nutritional composition supplementation (PS) combined with resistance exercise training (RET) improves muscle gains and facilitates physical activity in older adults. However, whether PS augments the effects of RET on muscle mass and PA in patients with KOA remains unclear. Therefore, this study identified the effects of PS on sarcopenic indices and PA in older women with KOA subjected to an RET program. Eligible older women aged 60–85 years and diagnosed as having KOA were randomly assigned to either the experimental group (EG) or the control group (CG). Both groups performed RET twice a week for 12 weeks. The EG received additional PS during this period. Outcome measures included appendicular lean mass index, walking speed, physical activity, and scores on the Western Ontario and McMaster Universities Osteoarthritis Index—WOMAC). All measures were tested at baseline and after intervention. With participant characteristics and baseline scores as covariates, analysis of variance was performed to identify between-group differences in changes in all outcome measures after intervention. Statistical significance was defined as p < 0.05. Compared with the CG, the EG achieved greater changes in appendicular lean mass index (adjusted mean difference (aMD) = 0.19 kg/m², p < 0.01), physical activity (aMD = 30.0 MET-hour/week, p < 0.001), walking speed (aMD = 0.09 m/s, p < 0.05), and WOMAC global function (aMD = −8.21, p < 0.001) after intervention. In conclusion, PS exerted augmentative effects on sarcopenic indices, physical activity, and perceived global WOMAC score in older women with KOA through 12 weeks of RET.

Utilidad del índice de comorbilidad de Charlson en personas ancianas. Concordancia con otros índices de comorbilidad

Objetivo. El objetivo principal de nuestro estudio fue evaluar la utilidad actual del índice de comorbilidad de Charlson (CCI) para predecir la mortalidad en personas mayores y la concordancia entre varios índices. Diseño. Estudio observacional, cohorte concurrente. Emplazamiento. Servicio de Medicina Interna de un hospital terciario, pacientes ambulatorios de un centro de salud y residentes de cuatro hogares de ancianos. Participantes. 375 individuos ≥ 65 años, con supervivencia esperada ≥ 6 meses, sin deterioro cognitivo. Mediciones principales. Se realizaron tres índices: CCI, el índice geriátrico de comorbilidad (GIC) y el índice de Kaplan-Feinstein (KF). A los 12 meses, se registró mortalidad. Los datos se analizaron con IBM SPSS Statistics® versión 23.0. Resultados. Edad media: 81,4 años. El CCI mostró comorbilidad baja-media en el grupo ambulatorio de 65-75 años (43 [75,4%]); moderada-alta más común en hospitalizados (19 [61,3%]) y en hogares de ancianos (5 [62,5%]). Al año fallecieron 59 (16,1%) individuos: con CCI: 10 (6,4%) comorbilidad baja-media y 49 (23,3%) moderada-alta, odds ratio (OR) 3,63 (intervalo de confianza [IC] 95% 1,76-7,51); con KF: 27 (13,3%) baja-media y 32 (19,5%) moderada-alta, OR 1,38 (IC 95% 0,78-2,44), y con GIC: 45 (14,1%) baja-media y 14 (29,2%) moderada-alta, OR 2,47 (IC 95% 1,21-5,06). La concordancia entre CCI-KF fue: 65-75 años: K = 0,62, 76-85 años: K = 0,396, y ≥ 86 años: K = 0,255. La concordancia entre CCI-GIC: 65-75 años: K = 0,202, 76-85 años: K = 0,069, y ≥ 86 años: K = 0,118. Conclusión. El CCI es el mejor predictor de mortalidad después de 1 año de seguimiento. Concordancia considerable entre CCI y KF en los individuos de 65-75 años, en el resto de las franjas etarias la correlación con GIC fue insignificante. Palabras clave: comorbilidad, mortalidad, anciano frágil.

Impact of sarcopenia on rehabilitation outcomes after total knee replacement in older adults with knee osteoarthritis

Introduction:

Knee osteoarthritis (KOA) is associated with an increased risk of sarcopenia, and aging-related muscle deterioration continues after total knee replacement (TKR). Low skeletal muscle mass index may influence postoperative rehabilitation outcomes. Through this study, we aimed to investigate the impact of preoperative sarcopenia on clinical outcomes after postoperative rehabilitation in older Asian adults.

Methods:

A total of 190 older adults (39 men, 151 women) were enrolled from two previous trials and were classified as having no sarcopenia, class I sarcopenia, or class II sarcopenia according to definitions provided by the Asian Working Group for Sarcopenia (AWGS) and the European Working Group on Sarcopenia in Older People (EWGSOP). All patients were retrospectively analyzed before (T₀) and after (T₁) TKR rehabilitation and 10 months after surgery (T₂). The outcome measures included the timed up-and-go test (TUGT), gait speed (GS), timed chair rise (TCR), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical difficulty (WOMAC-PF). With patient characteristics and T₀ scores as covariates, an analysis of variance was performed to identify intergroup differences in changes of all outcome measures at T₁ and T₂.

Results:

According to the definitions of both the AWGS and EWGSOP, patients with class I and class II sarcopenia exhibited minor changes in TUGT, GS, TCR, and WOMAC-PF at T₁ and T₂ (all p < 0.05), compared with those without sarcopenia. For patients classified as having sarcopenia based on AWGS and EWGSOP definitions, no significant intergroup differences in WOMAC pain score was observed at T₁ or T₂ (all p > 0.05).

Conclusions:

Sarcopenia independently had negative impacts on the treatment effects of rehabilitation on physical mobility but not on pain outcome after TKR in older adults with KOA.

Intracranial Meningiomas in the Elderly: Clinical, Surgical and Economic Evaluation. A Multicentric Experience

Simple Summary

Meningiomas are the most common intracranial tumors. Given the increase in life expectancy and the widespread access and use of brain imaging, the incidence in the elderly population (≥65 years) is continuously increasing. The risk/benefit ratio of surgery in elderly patients with intracranial meningioma has not been clearly defined because of the lack of objective measurement tools. The aim of our work to understand the risk factors associated with postsurgical outcomes and how these risk factors affected postsurgical outcomes in elderly patients with intracranial meningioma.

Abstract

Meningioma is one of the most common intracranial tumors. It is benign and slow growing in the majority of cases. Given the increase in life expectancy and the number of radiological tests performed, the incidence in the elderly population (≥65 years) is continuously increasing. The surgical outcomes and prognostic factors in this age group are unclear. A retrospective analysis of all the patients treated for intracranial meningiomas in two different Italian institutions was performed. The clinical, radiological, surgical and follow-up data were retrospectively reviewed. Statistical analyses were performed to identify relationships between factors and outcomes. We also carried out an economic analysis. We analyzed 321 patients with intracranial meningioma. The mean age was 72.6 years (range, 65–90), with a female predominance (F/M, 1.41). Pre-operative deficits, cognitive impairment and seizures (p < 0.001) were associated with a worse post-operative Karnofsky performance scale (KPS) score (<80). A high pre-operative KPS score was associated with a good clinical and neurological outcome (p < 0.001). Being aged between 65 and 74 years, low surgical timing and Simpson removal grades of I and II were associated with a good outcome (p < 0.001). The length of hospitalization was significantly related to the outcome (p < 0.001). The complication rate was 14.3%. At 6-month follow-up, the mortality rate was 2.5%. The average cost was higher in patients with a pre-operative KPS score lower than 80. The outcome of intracranial-meningioma resection in elderly individuals is favorable when the pre-operative KPS score is >80. Treatment should be patient-specific, and additional factors should be considered. Patients with poor pre-operative clinical conditions might benefit from a combined strategy with partial resection and radiosurgery in order to reduce surgical timing and the complication rate.

Effects of Elastic Resistance Exercise on Postoperative Outcomes Linked to the ICF Core Sets for Osteoarthritis after Total Knee Replacement in Overweight and Obese Older Women with Sarcopenia Risk: A Randomized Controlled Trial

(1) Background: Knee osteoarthritis (KOA) and aging are associated with high sarcopenia risk; sarcopenia may further affect outcomes after total knee replacement (TKR). Elastic resistance exercise training (RET) limits muscle attenuation in older adults. We aimed to identify the effects of post-TKR elastic RET on lean mass (LM) and functional outcomes in overweight and obese older women with KOA by using the brief International Classification of Functioning, Disability and Health Core Set for osteoarthritis (Brief-ICF-OA). (2) Methods: Eligible women aged ≥60 years who had received unilateral primary TKR were randomly divided into an experimental group (EG), which received postoperative RET twice weekly for 12 weeks, and a control group (CG), which received standard care. The primary and secondary outcome measures were LM and physical capacity, respectively, and were linked to the Brief-ICF-OA. The assessment time points were 2 weeks prior to surgery (T₀) and postoperative at 1 month (T₁; before RET) and 4 months (T₂; upon completion of RET) of follow-up. An independent t test with an intention-to-treat analysis was conducted to determine the between-group differences in changes of outcome measures at T₁ and T₂ from T₀. (3) Results: Forty patients (age: 70.9 ± 7.3 years) were randomly assigned to the EG (n = 20) or CG (n = 20). At T₂, the EG exhibited significantly greater improvements in leg LM (mean difference (MD) = 0.86 kg, p = 0.004) and gait speed (MD = 0.26 m/s, p = 0.005) compared with the CG. Furthermore, the EG generally obtained significantly higher odds ratios than the CG for treatment success for most Brief-ICF-OA categories (all p < 0.001). Conclusions: Early intervention of elastic RET after TKR yielded positive postoperative outcomes based on the Brief-ICF-OA. The findings of this study may facilitate clinical decision-making regarding the optimal post-TKR rehabilitation strategy for older women with KOA.

Main Risk Factors Related to Activities of Daily Living in Non-Dialysis Patients with Chronic Kidney Disease Stage 3-5: A Case-Control Study

Introduction

Elderly people are at increased risk of falls, disability and death due to reduced functional reserve, decline in multiple systems functions, which affects their activities of daily living (ADL) and eventually develop into frailty. The ADL assessment is conducive to early detection to avoid further serious situations. Previous studies on patients’ activities of daily living with chronic kidney disease (CKD) are mainly focused on dialysis patients. Little information is available on non-dialysis patients.

Patients and Methods

A total of 303 elderly patients with CKD stage 3–5 who were admitted to our hospital were selected. ADL evaluation was performed on patients at admission, with Barthel index (BI) as the evaluation tool. They were divided into two groups based on BI (≥60 and <60). Demographic information, lifestyle and clinical profile were collected. The risk factors related to ADL were analyzed by univariate and multivariate models.

Results

The data of 303 patients enrolled in this study were analyzed. The average age of patients was 84.48± 7.14 years and 62.05% were male. There were 88 patients (29.04%) in BI <60 group and 215 patients (70.96%) in the BI ≥60 group. The average age of subjects in the two groups was 87.47 ± 5.85 years and 83.26± 7.28 years, respectively. On univariate analysis, ADL impairment was associated with many factors, such as age, body mass index, blood lipid, heart rate, smoking history, Charlson comorbidity index (CCI), hemoglobin, serum albumin, BNP, eGFR, etc. Multivariate logistic regression showed that age (OR 1.08, 95% CI 1.00–1.17, P=0.0390), Charlson comorbidity index (OR 4.75, 95% CI 1.17–19.30, P=0.0295), and serum albumin (OR 0.80, 95% CI 0.70–0.92, P=0.0012) were the independent risk factors of ADL impairment.

Conclusion

Decline of ADL in CKD patients was independently correlated with age, Charlson comorbidity index and serum albumin. ADL and its influential factors in the elderly CKD patients deserve further attention.

Asymptomatic aortic stenosis in a geriatric population. The role of frailty and comorbidity in mortality

INTRODUCTION AND OBJECTIVES

The prognosis of asymptomatic severe aortic stenosis (AS) has not been widely documented in elderly patients who are frequently frail and have comorbidities. We sought to analyze the factors that influence early mortality in geriatric patients with asymptomatic severe AS.

METHODS

This ambispective cohort study included 104 patients aged 70 years or older with asymptomatic severe AS. Epidemiological, geriatric, clinical and echocardiographic variables were collected and compared between frail and nonfrail patients. During follow-up, the time from diagnosis to mortality and the causes of death were recorded.

RESULTS

Overall, 59.6% of the patients were frail. During follow-up, 69.4% of the frail patients died, with a median time to mortality of 2.52 years (95%CI, 1.36-3.69). The overall 1-year survival rate in frail patients was 76%. On multivariate analysis, age (HR, 2.47; 95%CI, 1.00-6.12), a Charlson comorbidity index ≥ 5 (HR, 3.75; 95%CI, 1.47-9.52) and frailty (HR, 6.67; 95%CI, 1.43-9.52) were independently related to mortality. In total, 8.7% of the patients had a Charlson comorbidity index ≥ 5, and all these patients died during follow-up, with a median survival of 1.01 years (95%CI, 0.36-1.67). The area under the receiver operating characteristic curve of the Charlson index was 0.739 (95%CI, 0.646-0.832). In this population, values ≥ 5 showed high specificity (100%) but low sensitivity.

CONCLUSIONS

A high prevalence of frailty was present in geriatric patients with asymptomatic severe AS. Age, a Charlson index ≥ 5 and frailty were independent factors for mortality, conferring an unfavorable short-term prognosis.

Nutritional status and factors associated with non-institutionalized people over 75 years of age

OBJECTIVE

to determine the factors related to the risk of malnutrition in a non-institutionalized population over 75 years of age.

METHOD

a cross-sectional study was conducted using a questionnaire in a sample of 326 individuals over 75 years of age in Castellón (Spain), during 2015, and selected through intentional sampling.

RESULTS

Malnutrition prevalence was 2.8%. 26.9% of the individuals were at risk of malnutrition, whereas women presented a higher rate (31.5%). Women with a good overall health status showed a lower rate than men, 55% and 69%, respectively. Individuals that showed a lower risk of malnutrition are those with a positive perception than those who have a good overall health. Frail elderly people showed a higher risk of malnutrition (57.5%) compared to non-frail subjects (20.2%) p< 0.001.

CONCLUSION

Frail women, self-assessed health, overall health, and use of health care services (nursing consultation) were related to a higher risk of malnutrition.

Validation and Refinement of the Age, Comorbidities, and Albumin Index in Elderly Patients with Diffuse Large B-Cell Lymphoma: An Effective Tool for Comprehensive Geriatric Assessment

Diffuse large B‐cell lymphoma (DLBCL) is one of the most frequent types of malignant lymphoma in elderly people; thus, the management of elderly DLBCL patients is important. This study aimed to validate the ACA index in Chinese elderly DLBCL patients and to refine the ACA index to propose a more effective comprehensive geriatric assessment method that could serve as a guide for optimal personalized therapy for elderly DLBCL patients treated with R‐CHOP.

Background.

We aimed to validate and refine the Age, Comorbidities, and Albumin (ACA) index in elderly Chinese patients with diffuse large B‐cell lymphoma (DLBCL) and propose a more effective method for comprehensive geriatric assessment (CGA).

Materials and Methods.

Patients ≥65 years of age who had been diagnosed with de novo DLBCL in the Institute of Hematology, Beijing Hospital, were screened for eligibility (n = 99).

Results.

Based on the ACA index, 39, 31, 26, and 3 patients were categorized into the “excellent,” “good,” “moderate,” and “poor” groups, respectively. The 2‐year treatment‐related mortality rate was significantly higher and the survival rates poorer in the ACA “moderate to poor” group compared with those of the ACA “good” and “excellent” groups. Multivariable model analysis identified two independent predictors of overall survival: the instrumental activities of daily living (IADL) scale and the ACA index. IADL scores of 6 to 7 and the ACA “good” group were assigned 1 point; IADL scores ≤5 and the ACA “moderate to poor” group were assigned 2 points. Based on these data, we created a three‐category system (IADL ACA index [IACA index]): low risk, score 0; intermediate risk, score 1 to 2; and high risk, score 3 to 4. The IACA index could effectively discriminate the response rates, overall survival, and progression‐free survival rates in elderly patients with DLBCL.

Conclusion.

We observed that the ACA index could partially predict the clinical outcomes of elderly DLBCL patients in China. Based on this index, we proposed the IACA index as an effective tool for CGA in DLBCL.

Implications for Practice.

Diffuse large B‐cell lymphoma (DLBCL) is one of the most frequent types of malignant lymphoma in elderly people, and identifying patients suitable for curative therapy is critical in the improvement of clinical outcomes. Recently, some authors proposed the Age, Comorbidities, and Albumin (ACA) index. Combining the use of the instrumental activities of daily living (IADL) scale and the ACA index, this article describes the IADL ACA index (IACA index), which is an effective tool for comprehensive geriatric assessment in DLBCL.

Association of physical capacity with heart rate variability based on a short-duration measurement of resting pulse rate in older adults with obesity

BACKGROUND

Obesity can limit physical capacity and lower physical activity levels in elderly people. Low physical activity levels may be mediated by autonomic dysfunction with decreased heart rate variability (HRV). However, the relationship between autonomic dysfunction and low physical capability remains unclear. This cross-sectional study investigated the association of low physical capability with HRV in older adults with obesity.

MATERIALS AND METHODS

We recruited 231 old man and 210 old women with a mean (range) age of 65.5 (51-78) and 62.9 (52-76) years, respectively. Physical capability was measured using mobility tasks, including functional reach, single-leg stance (SLS), gait speed (GS), timed up and go, and timed chair rise (TCR), and the scores on these tasks were merged and transformed into a global physical capability score (GPCS). HRV was measured using a 7-min resting pulse-based technique, and the time- and frequency-domain indices of HRV were obtained including standard deviation of normal-to-normal intervals (SDNN), root mean square of successive differences at rest (rMSSD), and high-frequency (HF) power. All HRV indices were natural log (ln) transformed for analysis. Participants were divided into high, moderate, and low physical-capability groups according to their physical performance. Multivariate analysis of covariance was performed to test differences in HRV indices among physical-capability groups with participants' characteristics serving as covariates. A stepwise regression model was established to identify the determinants of HRV indices. We used hierarchical regression analysis to identify the association of the GPCS with HRV indices.

RESULTS

In both men and women, the low physical-capability group exhibited significantly increased heart rate (P <0.05) and decreased HRV in terms of a decreased ln[SDNN] (P <0.001), ln[rMSSD] (P <0.05) and ln[HF] (P <0.05), compared with the high physical-capability group. GS positively predicted ln[SDNN], whereas SLS, GS, and TCR were determinants of ln[HF], regardless of gender. The GPCS in older men and women independently accounted for 29.9% (P <0.001) and 23.7% (P <0.001), respectively, in variance in ln[SDNN].

CONCLUSIONS

A low physical-capability level is an independent determinant of decreased HRV in older adults with obesity.

Effects of Linearly Polarized Near-Infrared Irradiation Near the Stellate Ganglion Region on Pain and Heart Rate Variability in Patients with Neuropathic Pain

Background

Neuropathic pain associated with sympathetic overactivity can be effectively relieved by light irradiating the region near stellate ganglion (SGI), applied as an alternative to a conventional sympathetic blockade. The clinical effect of SGI on heart rate variability (HRV) and its association with pain outcomes require investigation.

Objective

This study attempted to identify the effects of SGI on pain outcomes and HRV indices and to determine the association between pain and HRV outcomes.

Design

A prospective double-blind, randomized study.

Setting

An outpatient pain medicine clinic.

Subjects and Methods

A total of 44 patients were enrolled and randomized into the experimental group ( n = 22) and control group ( n = 22). The experimental group received 12 sessions (twice weekly) of standard SGI, whereas the control group received the same protocol with sham irradiation. Pain and HRV were measured before and after each irradiation session. All outcome measures used in the first- and second-half treatment courses were analyzed.

Results

Pain and HRV outcome measures of the experimental group significantly improved after SGI when compared with the control group in both courses. Considering time and frequency domains, the changes in HRV in the second-half treatment course exceeded those in the first-half treatment course. Pain was significantly associated with postirradiated HRV indices ( P < 0.001).

Conclusions

Twelve sessions of SGI exerted time-dependent positive effects on pain and sympathovagal imbalance. HRV outcomes, including time and frequency domains, were an independent indicator of the clinical efficiency of SGI for treating pain in patients with neuropathic pain.

[Prognostic value of assessment tools on elderly patients with chronic advanced disease and end of life, admitted to an intermediate care centre]

OBJECTIVE

To apply 3advanced chronic disease evaluation tools in elderly patients admitted to an intermediate and long-term care centre, and evaluate its relationship with mortality.

METHODS

The NECPAL tool, PROFUND prognostic index, and Charlson comorbidity index were applied to 87 patients.

RESULTS

The NECPAL tool identified 31 patients (35.6%) in need of palliative care, and according to the PROFUND index, 45 (54.7%) had high/very high risk of mortality (≥7 points), and according to Charlson index, 31 (35.6%) had high comorbidity (≥4 points). Of the NECPAL positive patients, 80.5% had a PROFUND index score ≥7, and 48.3% a Charlson index ≥ 4. These percentages were 34.4% and 28.5% in negative NECPAL patients (P<.001 and P≤.06, respectively). Correlations between the 3tools: quantitative (Spearman) number of responses in NECPAL with PROFUND (r=.57; P<.001); with Charlson (r=.214; P<.047) and between PROFUND and Charlson (r=.157; P=.148). Qualitative (kappa) NECPAL (positive/negative) with PROFUND (cut-off 6/7) (0.40; P<.001), and Charlson (cut-off 3/4) (0.19; P=.080) and between PROFUND and Charlson (0.08; P=.399). Mortality prediction (area under the curve): NECPAL 3 months 0.81 (95% CI: 0.62-1.00); 6 months 0.71 (95% CI: 0.53-0.89) and 12 months 0.67 (95% CI: 0.52-0.82). PROFUND 3 months 0.71 (95% CI: 0.50-0.91); 6 months 0.73 (95% CI: 0.58-0.87), and 12 months 0.69 (95% CI: 0.57-0.81). Charlson 3 months 0.72 (95% CI: 0.52-0.91); 6 months 0.62 (95% CI: 0.45-0.80), and 12 months 0.64 (95% CI: 0.50-0.78).

CONCLUSIONS

The 3tools were significantly associated with high mortality. A low concordance was found between the results of the different tools.

Patient reported activities after reverse total shoulder arthroplasty in rotator cuff arthropathy patients

INTRODUCTION AND OBJECTIVE

Reverse total shoulder arthroplasty in rotator cuff arthropathy patients, improves anteversion and abduction, but not rotational, outcomes. The main aim of this study is to determine its repercussions on daily life activities in our patients.

MATERIAL AND METHODS

Between 2009 and 2011 we implanted 210 shoulder arthroplasties, 126 of them were reverse total shoulder arthroplasty in a rotator cuff arthropathy context. About 88% were women, with a mean age at time of surgery of 81 years, 95% were retired. The mean follow up was 53 months. The Constant scale, Visual Analogue Scale, Charlson Comorbidity Index, range of motion were measured for each patient and whether they could manage 40 daily life activities by means of a new questionnaire, classifying them according toshoulder functional demand.

RESULTS AND DISCUSSION

Mean normalized by sex and age Constant value was 81.2%. Mean Visual Analogue Scale and Charlson Index were 3.56 and 1.69 respectively. Improvement in anteversion and abduction, not in rotational range of motion. Limitation was found in low and high functional demand activities in 20% and 51% respectively, especially those which involved internal rotation.

CONCLUSION

Reverse total shoulder arthroplasty treatment for RCA in the elderly, achieves adequate pain management and good functional outcomes. Nevertheless, an important risk of DLA limitation must be accepted in those which involve internal rotation or shoulder high functional demand.

Effects of elastic resistance exercise on body composition and physical capacity in older women with sarcopenic obesity: A CONSORT-compliant prospective randomized controlled trial

BACKGROUND

Sarcopenia is associated with loss of muscle mass and an increased risk of physical disability in elderly people. However, the prevalence of sarcopenia has increased in obese elderly populations. The purpose of this study was to identify the clinical efficacy of elastic resistance exercise training (RET) in patients with sarcopenic obesity.

METHODS

This study was conducted at the rehabilitation center of a university-based teaching hospital and was designed as a prospective and randomized controlled trial with an intention-to-treat analysis. A total of 46 women aged 67.3 (5.2) years were randomly assigned to an experimental group (EG) and control group (CG). The EG underwent elastic RET for 12 weeks, and the CG received no RET intervention. All outcome measures were assessed at the baseline and posttest, including body composition measured using dual-energy X-ray absorptiometry, muscle quality (MQ) defined as a ratio of muscular strength to muscle mass, and physical capacity assessed using functional mobility tests. One-way analysis of covariance and Pearson correlation were used to compare outcomes between the 2 groups and to identify the relationship between changes in body composition and physical outcomes, respectively. A chi-square test was performed to identify differences in qualitative data between the 2 groups.

RESULTS

At the posttest, a significant between-group difference was observed in fat-free mass, MQ, and physical capacity (all P < .05); and a significant correlation was found between leg-lean-mass change and gait speed (r = 0.36; P < .05). After 12 weeks of elastic RET intervention, the EG had significantly fewer patients exhibiting sarcopenia (P < .05) and experiencing physical difficulty (P < .001) than the CG.

CONCLUSION

The present data suggest that elastic resistance exercise exerted benefits on the body composition, MQ, and physical function in patients with sarcopenic obesity. Regular exercise incorporating elastic RET should be used to attenuate muscle mass loss and prevent physical difficulty in obese older adults with sarcopenia on reconditioning therapy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-15006069.

CRONIGAL: Prognostic index for chronic patients after hospital admission

OBJECTIVE

We have followed patients admitted to a Polypathology and Advanced Age Unit for two years in order to identify the variables that best define the mortality prognosis at medium-term (1-2years) for chronic and polypathological patients requiring admission at an Internal Medicine Department.

METHODS

This is an observational, prospective study in clinical practice. Polypathological, chronic or multimorbidity patients were included. The classification of the Spanish Ministry for Health was used in order to classify patients as chronic or polypathological. The Charlson Index and Barthel Index were estimated and the Pfeiffer test was administered. The Spanish PROFUND Index was also used. Logistic regression models and Cox proportional hazard model were built in order to study the influence of prognostic factors on survival.

RESULTS

A total of 567 patients were included: 333 met polypathological (PPP) criteria and 234 chronic criteria (CC). Mean age was 84.8+7.3years. A total of 469 were followed up, most patients belonged to category E (282), 174 to category A and 118 to category C. The prognosis at one year of our patients can be estimated with 7 variables: age, neoplasia, delirium, Barthel, Pfeiffer, presence of atrial fibrillation, and creatinine. The area under the curve is 0.74.

CONCLUSION

The variables dementia, neoplasia, delirium at admission, Barthel Index under 60, or deceased spouse have mortality prognosis value at one or two years. An index with 7 variables applicable to chronic and polypathological patients after admission may serve as tool to better manage complex chronic patients and follow them up.

Institutional Registry of Elderly Patients With Hip Fracture in a Community-Based Tertiary Care Hospital in Argentina (RIAFC)

BACKGROUND

A clinical registry encompasses a selective set of rigorously collected and stored clinical data focused on a specific condition. Hip fracture is a common complication of osteoporosis in elderly patients. Hip fracture substantially increases the risk of death and major morbidity in the elderly patients. Limited data regarding hip fracture are available from Latin America and Argentina. The purpose of this project is to create an institutional registry of elderly patients with hip fracture in order to obtain data that reveal the impact of this disease in our environment, allowing us to evaluate different strategies of patient's care and clinical outcomes.

OBJECTIVE

To describe the implementation of an institutional registry of elderly patients with hip fracture in Argentina.

METHODS

In this article, we described the creation, implementation, and data management of a prospective registry of elderly patients with hip fracture. The registry contains information on baseline demographics, comorbidities, laboratory, and radiological data. Follow-up at 3 and 12 months postfracture is done by phone interview to assess physical function, readmissions, and morbi-mortality. Clinical Trials registry number NCT02279550.

CONCLUSION

In this project, we have created a hip fracture registry. We hope that this registry will provide valuable data that can lead us to new lines of research, addressed to answer questions raised in clinical practice.

Continuous passive motion and its effects on knee flexion after total knee arthroplasty in patients with knee osteoarthritis

PURPOSE

This study evaluated the effects of continuous passive motion (CPM) on accelerated flexion after total knee arthroplasty (TKA) and whether CPM application measures (i.e. initial angle and daily increment) are associated with functional outcomes.

METHODS

A retrospective investigation was conducted at the rehabilitation centre of a university-based teaching hospital. Patients who received CPM therapy immediately after TKA surgery were categorized into rapid-, normal-, and slow-progress groups according to their response to CPM during their acute inpatient stay. Knee pain, passive knee flexion, and knee function-measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-were assessed preoperatively at discharge and at 3- and 6-month outpatient follow-up visits.

RESULTS

A total of 354 patients were followed for 6 months after inpatient-stay discharge. The patients in the rapid-progress group (n = 119) exhibited significantly greater knee flexions than those in the slow-progress group did (n = 103) at the 3-month follow-up [mean difference (MD) = 10.3°, 95 % confidence interval (CI) 4.3°-16.3°, p < 0.001] and 6-month follow-up (MD = 10.9°, 95 % CI 6.3°-15.6°, p < 0.001). Significant WOMAC score differences between the rapid- and slow-progress groups were observed at the 3-month follow-up (MD = 7.2, 95 % CI 5.4-9.1, p < 0.001) and 6-month follow-up (MD = 16.1, 95 % CI 13.4-18.7, p < 0.001). CPM initial angles and rapid progress significantly predicted short- and long-term outcomes in knee flexion and WOMAC scores (p < 0.001).

CONCLUSION

When CPM is used, early application with initial high flexion and rapid progress benefits knee function up to 6 months after TKA.

LEVEL OF EVIDENCE

II.

Effect of body mass index on knee function outcomes following continuous passive motion in patients with osteoarthritis after total knee replacement: a retrospective study

OBJECTIVE

Obesity may influence postoperative rehabilitation outcomes after total knee replacement (TKR). The aim of this study was to evaluate the effects of body mass index (BMI) on the progression of inpatient rehabilitation using continuous passive motion (CPM) and its treatment outcomes.

PARTICIPANTS AND SETTING

A retrospective study was conducted in a rehabilitation centre. In total, 354 patients undergoing primary TKR were enrolled through medical chart review.

INTERVENTION

All patients commenced the CPM programme immediately after surgery and continued until hospital discharge.

MAIN OUTCOME MEASURES

Knee flexion, pain score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function score.

DESIGN

Patients were divided into five BMI groups: normal weight (n=59), overweight (n=95), Class I obesity (n=90), Class II obesity (n=82) and Class III obesity (n=28). All outcome measures were recorded at admission; daily during the inpatient stay; at discharge; and at 1-, 3- and 6-month follow-up assessments.

RESULTS

During CPM exercises, obese patients had a smaller initial flexion angle (P<0.001) and a smaller daily increment in the CPM motion arc (P<0.001) compared with patients of normal weight. Severe obesity was associated with poor knee flexion [adjusted odds ratio (aOR) 11.9, 95% confidence interval (CI) 3.49 to 40.94, P<0.001] and WOMAC physical function score (aOR 5.09, 95% CI 1.62 to 16.03, P=0.005) at 6-month follow-up.

CONCLUSIONS

Obesity had a negative effect on progress during the CPM protocol, which commenced immediately after surgery and continued until discharge. Obesity was also associated with poorer self-reported function at 6-month follow-up.

Asthma, COPD and comorbidities in elderly people

Co-morbidities are a significant problem in the elderly population but are rarely presented and analyzed for interdependencies among the various coexisting chronic diseases.

OBJECTIVE

The aim of this study was to present a profile of comorbidities in elderly patients with and without asthma and COPD.

METHODS

Respondents were recruited at 20 sites in Poland. Stratified random sampling from patient databases resulted in 15,973 patients older than 60 years of age. A retrospective analysis of medical history and ICD-10 codes was performed. In addition, patients underwent a spirometry test with a bronchial reversibility test and were administered questionnaires on the prevalence of chronic diseases by doctors.

RESULTS

The study population consisted of 1023 asthmatic patients, 1084 patients with COPD and 1076 control subjects without any signs of bronchoconstriction and with correct spirometry. Patients with asthma exhibited a similar distribution of cardiovascular and metabolic co-morbidities as the control group. However, asthmatic patients had a higher prevalence of arterial hypertension and depression with an odds ratio (OR) = 1.48 (95% CI: 1.38-1.62) and OR = 1.52 (95% CI: 1.44-1.68), respectively. Coronary disease (OR = 2.12; 95% CI: 1.97-2.33), cor pulmonale (OR = 3.1; 95% CI: 2.87-3.22) and heart failure (OR = 2.71; 95% CI: 2.64-3.11) were predominantly observed in patients with COPD. Patients with severe asthma exhibited a greater predisposition to cardiovascular and neuropsychiatric diseases.

CONCLUSION

Asthma coexisted frequently with arterial hypertension and depression in elderly patients. Patients with COPD have a more exaggerated profile of coexisting diseases, specifically cardiovascular problems.

[Nutritional status assessment in Geriatrics: Consensus declaration by the Spanish Society of Geriatrics and Gerontology NutritionWork Group]

Ongoing population ageing is one of the factors influencing the increase in the prevalence of undernutrition, as elderly people are a vulnerable group due to their biological, psychological and social characteristics. Despite its high prevalence, undernutrition is underdiagnosed in the geriatric sphere. For this reason, the aim of this consensus document is to devise a protocol for geriatric nutritional assessment. A multidisciplinary team has been set up within the Spanish Society of Geriatrics and Gerontology (in Spanish Sociedad Española de Geriatría y Gerontología [SEGG]) in order to address undernutrition and risk of undernutrition so that they can be diagnosed and treated in an effective manner. The MNA-SF is a practical tool amongst the many validated methods for nutritional screening. Following suspicion of undernutrition, or after establishing the presence of undernutrition, a full assessment will include a detailed nutritional history of the patient. The compilation of clinical-nutritional and dietetic histories is intended to help in identifying the possible risk factors at the root of a patient's undernutrition. Following this, an anthropometric assessment, combined with laboratory data, will describe the patient's physical and metabolic changes associated to undernutrition. Currently, the tendency is for further nutritional assessment through the use of non-invasive techniques to study body composition in association with functional status. The latter is an indirect index for nutritional status, which is very interesting from a geriatrician's point of view. To conclude, correct nutritional screening is the fundamental basis for an early undernutrition diagnosis and to assess the need for nutritional treatment. In order to achieve this, it is fundamental to foster research in the field of nutritional geriatrics, in order to expand our knowledge base and to increasingly practice evidence-based geriatrics.

Association of the clinical frailty scale with hospital outcomes

BACKGROUND

The clinical frailty scale (CFS) was validated as a predictor of adverse outcomes in community-dwelling older people. In our hospital, the use of the CFS in emergency admissions of people aged ≥ 75 years was introduced under the Commissioning for Quality and Innovation payment framework.

AIM

We retrospectively studied the association of the CFS with patient characteristics and outcomes.

DESIGN

Retrospective observational study in a large tertiary university National Health Service hospital in UK.

METHODS

The CFS was correlated with transfer to specialist Geriatric ward, length of stay (LOS), in-patient mortality and 30-day readmission rate.

RESULTS

Between 1st August 2013 and 31st July 2014, there were 11 271 emergency admission episodes of people aged ≥ 75 years (all specialties), corresponding to 7532 unique patients (first admissions); of those, 5764 had the CFS measured by the admitting team (81% of them within 72 hr of admission). After adjustment for age, gender, Charlson comorbidity index and history of dementia and/or current cognitive concern, the CFS was an independent predictor of in-patient mortality [odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.48 to 1.74, P < 0.001], transfer to Geriatric ward (OR = 1.33, 95% CI: 1.24 to 1.42, P < 0.001) and LOS ≥ 10 days (OR = 1.19, 95% CI: 1.14 to 1.23, P < 0.001). The CFS was not a multivariate predictor of 30-day readmission.

CONCLUSIONS

The CFS may help predict in-patient mortality and target specialist geriatric resources within the hospital. Usual hospital metrics such as mortality and LOS should take into account measurable patient complexity.

[The Norton Scale as predictor of health-related quality of life in institutionalized elderly]

OBJECTIVE

A low Norton Scale (NS) score predicts pressure ulcer risk and several adverse outcomes in the elderly. On the other hand, health-related quality of life (HRQOL) is an indicator with clinical and predictive utilities. The aim was to assess the relationship between NS and HRQOL, in a gender analysis.

METHOD

Fifty-one women and 39 men, institutionalized and aged≥65 years, were evaluated through personal interview and medical records. The NS, HRQOL -with EuroQol-5D-, age, body mass index, falls, use of psychoactive drugs, cognitive function and Charlson, Barthel and Tinetti indexes, were assessed. Two regression models were developed, with EuroQol-5D as dependent variable.

RESULTS

The NS showed the same score in both sexes, with a median (interquartile range) value of 19 (2). Women presented a worse HRQOL, with an EuroQol-5D=0.78, whereas it was 0.87 in men (P=.02). The NS score was correlated with HRQOL in women (r=0.57; P<.001) but not in men (r=0.15; P=.36). After adjusting for confounders, the NS showed a β value of 0.54 (P=.02) in women and β=0.35 (P=.14) in men.

CONCLUSIONS

The NS has shown to be the strongest factor on HRQOL in women, regardless of age, comorbidity and the rest of covariates. Conversely, the relationship was weaker and non-significant in men.

Comorbidity burden assessment in older people admitted to a Portuguese University Hospital

PURPOSE

To determine the most valuable comorbidity index to apply in a clinical context and its prospective association with 1-year mortality and 3-month readmission. The authors also intend to gauge the evolution of older patients' admission profile over 13 years, in the same clinical setting.

SUBJECTS/MATERIALS AND METHODS

The authors analyzed data from 100 consecutive patients admitted in 2012. The Charlson Comorbidity Index (CCI), the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and the Medication-Based Disease Burden Index (MDBI) were used to evaluate comorbidity. Length of stay, number of diagnoses and of medications, readmission and mortality were assessed. A p value <0.05 was considered significant.

RESULTS

Mean age was 80.6 years, mean length of stay was 8.8 days, and mean number of diagnosis per patient was 7.9. Mean values of score were of 3.6 for the CCI, 11.3 for the CIRS-G and 0.552 for the MDBI. Three-month readmission and 1-year mortality rates related to higher CCI and CIRS-G scores. No association was found between MDBI and the outcomes evaluated. One-year mortality reached 24 % and 3-month readmission was of 43 %. Comparing the two samples, mean age increased in 2.1 years and the number of diagnosis by 2.2. Length of stay decreased 2 days.

DISCUSSION AND CONCLUSION

CCI was easier to use but the CIRS-G was better at evaluating comorbidity. MDBI did not seem to be a trustworthy tool. Despite an older population with high comorbidity, length of stay decreased over 13 years. However, readmission was high. Introduction of geriatric care standards is required to improve health outcomes for older patients.

The impact of common co-morbidities (as measured using the Charlson index) on hip fracture risk in elderly men: a population-based cohort study

We used a large population-based health care database to determine the impact of common co-morbidities on hip fracture risk amongst elderly men. We demonstrated that diabetes, chronic obstructive pulmonary disease, renal failure, HIV infection, dementia, and cerebrovascular disease are independent predictors of hip fracture, as is a Charlson score of ≥ 3.

INTRODUCTION

Risk factors for hip fractures in men are still unclear. We aimed to identify common co-morbidities (amongst those in the Charlson index) that confer an increased risk of hip fracture amongst elderly men.

METHODS

We conducted a population-based cohort study using data from the SIDIAP (Q) database. SIDIAP(Q) contains primary care and hospital inpatient records of a representative 30% of the population of Catalonia, Spain (>2 million people). All men aged ≥ 65 years registered on 1 January 2007 were followed up until 31 December 2009. Both exposure (co-morbidities in the Charlson index) and outcome (incident hip fractures) were ascertained using ICD codes. Poisson regression models were fitted to estimate the effect of (1) each individual co-morbidity and (2) the composite Charlson index score, on hip fracture risk, after adjustment for age, body mass index, smoking, alcohol drinking, and use of oral glucocorticoids.

RESULTS

We observed 186,171 men for a median (inter-quartile range) of 2.99 (2.37-2.99) years. In this time, 1,718 (0.92%) participants had a hip fracture. The following co-morbidities were independently associated with hip fractures: diabetes mellitus, chronic obstructive pulmonary disease (COPD), renal failure, HIV infection, dementia, and cerebrovascular disease. A Charlson score of ≥ 3 conferred an increased hip fracture risk.

CONCLUSION

Common co-morbidities including diabetes, COPD, cerebrovascular disease, renal failure, and HIV infection are independently associated with an increased risk of hip fracture in elderly men. A Charlson score of 3 or more is associated with a 50% higher risk of hip fracture in this population.

[Chronic disease, mortality and disability in an elderly Spanish population: the FRADEA study]

INTRODUCTION

The objective of this study was to analyse the relationships between the major chronic diseases and multiple morbidity, with mortality, incident disability in basic activities of daily living, and loss of mobility in the elderly.

MATERIAL AND METHODS

A total of 943 participants were selected from the FRADEA Study, using available baseline data of chronic diseases, and at the follow-up visit of mortality, incident disability, and loss of mobility. The analysis was made of the unadjusted and adjusted association between the number of chronic diseases, the number of 14 pre-selected diseases, and the presence of two or more chronic diseases (multiple morbidity) with adverse health events recorded.

RESULTS

Participants with a higher number of diseases (OR 1.11; 95% CI: 1.02-1.22), and 14 pre-selected diseases (OR 1.19; 95% CI: 1.03-1.38) had a higher adjusted mortality risk, but not a higher incident disease or mobility loss risk. Subjects with multiple morbidity had a higher non-significant mortality risk (HR 1.45; 95% CI: 0.87-2.43), than those without multiple morbidity. Disability-free mean time in participants with and without multiple morbidity was 846±34 and 731±17 days, respectively (Log-rank χ(2) 7.45. P=.006), and with our without mobility loss was 818±32 and 696±13 days, respectively (Log rank χ(2) 10.99. P=.001).

CONCLUSIONS

Multiple morbidity was not associated with mortality, incident disability in ADL, or mobility loss in adults older than 70 years, although if mortality is taken into account, the number of chronic diseases is linear.

Patterns of comorbidity and multimorbidity in the oldest old: the Octabaix study

BACKGROUND

Multimorbidity is associated with higher mortality, increased disability, a decline in functional status and a lower quality of life. The objective of the study is to explore patterns of multimorbidity in an elderly population.

METHODS

328 community inhabitants aged 85 years were included. Socio-demographic variables and data from the global geriatric assessment were evaluated. Information on the presence of sixteen common chronic conditions was collected: hypertension, diabetes mellitus, dyslipidemia, ischemic cardiomyopathy, heart failure, stroke, chronic obstructive pulmonary disease, (COPD), atrial fibrillation, peripheral arterial disease, Parkinson's disease, cancer, dementia, anemia, chronic kidney disease (CKD), visual impairment and deafness. Hierarchical cluster analysis was performed.

RESULTS

The rate of multimorbidity (>1 disease) was 95.1%. Men had a higher percentage of COPD and malignancy. Four main clusters were identified. The highest value of the bivariate correlation matrix was that between heart failure and visual impairment. These two diseases were included in a cluster with atrial fibrillation, CKD, heart failure, stroke, high blood pressure and diabetes mellitus.

CONCLUSIONS

The large majority of oldest old subjects had multimorbidity. The results confirm the non-random co-occurrence of certain diseases in this age group.

Differences in the therapeutic approach to colorectal cancer in young and elderly patients

PURPOSE

To analyze differences in the therapeutic approach to and tumor-related mortality of young and elderly colorectal cancer (CRC) patients.

PATIENTS AND METHODS

This was a descriptive study of a retrospective cohort, based on administrative databases, of all patients with CRC diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, type of treatment received, survival time, and cause of death. We compared differences between a young group (YG) (age <75 years) and an older group (OG) (age ≥75 years) and assessed the variables associated with receiving different therapeutic options (multivariate analysis) and with survival time (Cox proportional hazards models).

RESULTS

The study included 503 patients (YG, 320; OG, 183), with mean ages of 63.1 years in the YG and 81.8 years in the OG. No differences were observed between the groups in degree of differentiation, extension, tumor stage, or comorbidity. After adjustment for gender, comorbidity, and tumor localization and extension, YG patients were more likely than OG patients to receive surgery, radiotherapy, and chemotherapy and less likely to receive palliative care. After a median follow-up of 36.5 months, YG patients had a longer tumor-specific survival time than OG patients (36.41 months vs 26.05 months). After further adjustment, the YG had a lower tumor-specific mortality risk (hazard ratio, 0.66) than the OG.

CONCLUSION

In comparison with younger patients, elderly CRC patients are undertreated, mainly because of their age and not because of their tumor type or comorbidity. Elderly patients have a significantly shorter tumor-specific survival time, partially because of this undertreatment.

[The interrater reliability of four common comorbidity indexes used in elderly patients]

OBJECTIVE

To report on the interrater reliability of four common comorbidity indexes used in the hospitalised elderly: Charlson Index (CI), Geriatric Cumulative Illness Rating Scale (CIRS-G), Index of Co-existent Disease (CoD) and Kaplan-Feinstein Index (KFI).

METHOD

Four trained observers, independently reviewed the same 40 medical charts of hospitalised geriatric patients. Scores for the four indexes were calculated, along with the intraclass correlations coefficient (ICC) (quantitative index: CI and CIRS-G) and Kappa coefficient (qualitative index: CoD and KFI). The agreement <0.4 was considered deficient, 0-4-0.75 acceptable and >0.75 excellent.

RESULTS

A total of 40 patients (29 women) of 85.93 (±5.35) years were analysed. Intraclass correlations coefficient: CI: 0.78 (95% CI: 0.67-0.86); CIRS-G (score): 0.66 (95% CI: 0.53-0.78). Kappa coefficient: KFI: 0.51 to 0.76; CoD: 0.44-0.66. The application time was lower for the Charlson index (median of 39seconds [30-45]) and the KFI (42seconds [35-52]) and higher for CIRS-G (score) (128seconds [110-160]) and CoD (102seconds [80-124]).

CONCLUSIONS

Of the four comorbidity indexes used in a hospitalised elderly population, the CI, and CIRS-G (score), are those that have better interrater reliability. The Charlson index and KFI show a lower application time than the CIRS-G (score).

[Comparison of three methods for measuring multiple morbidity according to the use of health resources in primary healthcare]

OBJECTIVE

To compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC).

DESIGN

Retrospective study using computerized medical records.

SETTING

Thirteen PHC teams in Catalonia (Spain).

PARTICIPANTS

Assigned patients requiring care in 2008.

MAIN MEASUREMENTS

The socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs.

STATISTICAL ANALYSIS

3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R(2)), p< .05.

RESULTS

The study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R(2)=50.4%, the ChI an R(2)=29.2% and BUR an R(2)=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results.

CONCLUSIONS

The CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix.

[Use of a proxy to the Charlson index to study the short and long-term comorbidity and mortality in the elderly]

OBJECTIVES

To design a proxy to the Charlson comorbidity index (PrCCI) for use in studies with pre-existing data sources and to analyse its influence on mortality risk in elderly people.

DESIGN

Longitudinal study.

SETTING

Population base, From "Aging in Leganes" cohort.

PARTICIPANTS

All individuals with complete information (n=978, aged 65 years old and older) were included in the construction of the proxy (PrCCI).

MEASUREMENTS

A proxy (PrCCI) was created based on the original Charlson Comorbidity Index (CCI) and the available pre-existing data from the "Aging in Leganes" study. The relationship between PrCCI and mortality was assessed using a Survival analysis. Cox proportional Hazard Models were adjusted for possible confusion factors.

RESULTS

The PrCCI varied from 0 to 11 points (median=2 points, RI25-75=1-3). It was higher in women than in men until 79 years old, but no differences were found for both men and women from 80 years old. Individuals who scored four and more points in the new index had a higher mortality risk after 5 and 15 years of follow up, even after controlling for sociodemographic, health behaviours and health status related covariables (HR: 3.69, 95% CI: 1.52-8.96 and 2.14, 95% CI: 1.42-3.21, respectively).

CONCLUSION

The proxy to the Charlson comorbidity index is easy and useful to measure comorbidity in studies in population from 65 to 75 years old, which use pre-existing data bases and data available in the primary care setting. The association between PrCCI and mortality shows that it is useful as comorbidity index.