[Primary care detection of the elderly at risk: recommendation]

[Analysis of the effect of a program of cognitive stimulation in elderly people with normal aging in primary care: Randomized clinical trial]

OBJECTIVE

To provide evidence of the effectiveness of a community health intervention, that includes a cognitive stimulation program, to prevent the deterioration of cognitive abilities in our population of elderly people with normal cognition that are living in the community.

DESIGN

Randomized clinical trial (CONSORT group norms) LOCATION: San José Norte-Centro Health Center and La Caridad Foundation (Zaragoza, Spain).

PARTICIPANTS

201 people aged 65 or older, with a MEC score of at least 28 points, which were randomized between the Intervention group (101) and the Control group (100).

INTERVENTION

The intervention was applied in 10 sessions of 45minutes, one per week. It used materials designed by one of the authors, which addressed the following areas: memory, orientation, language, praxis, gnosis, calculation, perception, logical reasoning, attention-concentration and programming.

MAIN MEASUREMENTS

The main outcome variables were MEC, Set-Test, Barthel and Lawton-Brody.

RESULTS

Increases of the main result variables over their baseline level were analized. For MEC variable, the Intervention group obtained, on average, 1.58 points more than the Control group in the evaluation performed immediately after the intervention. After 6months, the improvement was 1.51 points and after a year, it was of 2.04 points. All these differences were statistically significant. For Set-Test, Barthel and Lawton-Brody variables, no statistically significant differences were observed between Intervention group and Control group.

CONCLUSIONS

Cognitive stimulation with our program is effective to maintain or improve cognitive performance, measured with the variable MEC, our population of elderly people with normal cognition that are living in the community. There is no evidence that this improvement is transferred to the activities of daily life measured with Barthel and Lawton-Brody variables.

Prevalence of frailty and factors associated with frailty in the elderly population of Lleida, Spain: the FRALLE survey

The aim of this study was to assess the prevalence of frailty and to identify factors associated with frailty in older people living in the community through a cross-sectional study of community-dwelling persons age 75 and older. A total of 640 individuals were interviewed using the FRALLE survey between 2009 and 2010. This survey measures frailty through the five Fried criteria, and through questions on sociodemographics, health habits, health status, social relations and data on health-related quality of life. The mean age of the participants was 81.3 ± 5.0; 39.7% were men. The prevalence of frailty was 9.6% (95% confidence interval (CI): 7.6-11.5) and that of pre-frailty was 47% (95% CI: 42.7-51.2). After the logistic regression, age (over 85 years) (odds ratio (OR): 3.61; 95% CI: 1.65-7.91; p<0.001), depressive symptoms (OR: 3.13; 95% CI: 1.37-7.13; p=0.0006), comorbidity (OR: 5.20; 95% CI: 1.78-15.16; p=0.0002), cognitive impairment (OR: 3.22; 95% CI: 1.48-7.02; p=0.0003), poor social ties (OR: 0.57; 95% CI: 0.43-0.77; p<0.001) and poor physical health (OR: 0.98; 95% CI: 0.97-0.98; p<0.001) were significantly associated with frailty. There is great variability in the prevalence of frailty depending on the study considered. The lack of homogeneity in the measurement of the five criteria, the age of participants and the degree of dependence could explain the differences observed. Here, the factors associated with frailty were age, comorbidity, cognitive impairment and depressive symptoms, while the diversity of social interaction and health-related physical function were protective factors.

[Reliability of the VIDA questionnaire for assessing instrumental activities of daily living (iADL) in the elderly]

OBJECTIVE

To analyse the inter- and intra-examiner reliability of the VIDA questionnaire, and their concordance with the "timed get up and go" test in people aged ≥75 years.

DESIGN

Descriptive study of a diagnostic test.

LOCATION

Primary Health Care. SUBJECTS-INTERVENTION: Application of 71 pairs of VIDA questionnaire, by one (38) or two professionals (33), in people aged ≥75 years with no significant sensory or physical-psychic impairment. Stratified sample based on ADL (Barthel index) to obtain a variety of responses that would ensure a range of scores of the questionnaire.

MAIN MEASUREMENTS

Overall score of VIDA questionnaire, "get up and go" test (functional), Pfeiffer questionnaire (cognitive), and risk factors of frailty (comorbidity, falls, recent hospitalisation, sensory disturbance, social impairment, polypharmacy).

RESULTS

Mean age 81.3 years±4.8, with a 65.5% moderate-severe change in Barthel index. The mean score of the questionnaire was 31.3±7.9, with a rank of 11 to 38 (maximum). There were no differences according to gender (P=0.78). Inter-examiner reliability (n 33): Intraclass Correlation Coefficient (ICC) 0.94, 95% Confidence Interval (CI) 0.88-0.97, P<0.0001. Intra-examiner reliability (n 38): ICC 0.96, CI 0.93-0.98, P<0.0001. Correlation coefficient (rho of Spearman) with the "get up and go" test (n 67) 0.61 (moderate), P<0.0001. Lower score if there are ≥ 2 frailty factors (P=0.015).

CONCLUSIONS

VIDA questionnaire is a very reliable tool, with no gender bias. It demonstrates an association with other functionality measures and with frailty factors in the elderly.

[Frailty criteria in the elderly: a pilot study]

OBJECTIVE

To measure the frailty of people 75 years or over and who live in their own homes based on Fried's criteria and modified by Ávila-Funes.

DESIGN

Pilot study of cross-sectional design. SITE: Primary Health Care Centres (7) in the city of Lleida.

PARTICIPANTS

A probabilistic sample was selected for every stratum. The total sample was 323 individuals.

PRIMARY MEASUREMENTS

Socio-demographic characteristics, measurement of the five frailty criteria (involuntary lose of weight, low energy or exhaustion, slow mobility, muscle weakness, low physical activity), and geriatric assessment scales (Charlson Index, Pfeiffer's Test, Katz Index, Lawton and Brody Index, MNA Test and CES-D scale).

RESULTS

The prevalence of frailty was 8.5%. Factors associated with frailty were, female sex and low monthly income. It was observed that if the frailty increases, there is deterioration of cognitive status, activities of daily living and nutritional status. There is also higher morbidity. Frailty criteria scores showed a significant correlation with geriatric assessment scales scores.

CONCLUSIONS

The prevalence of frailty in elderly people is similar to those in other studies that have used the same criteria. The measurement of frailty criteria in this study demonstrates a better ability for transcription of results. A frailty study using specific markers enhances prevention and improvement of new intervention programs.

[Prevalence of frailty in an elderly Spanish urban population. Relationship with comorbidity and disability]

AIM

To estimate prevalence of frailty, by Fried criteria, in a Spanish urban old population, and to analyse relationship with comorbidity and disability.

POPULATION

Aged ≥ 65 living in Peñagrande area (Fuencarral district in Madrid, Spain).

DESIGN

Cross-sectional study. Baseline evaluation of "Cohort of Peñagrande" established in 814 person.

MEASUREMENTS

Frailty was defined by the presence of ≥ 3 of the following criteria: unintentional weight loss, weakness (grip strength), exhaustion, low walking speed, and low physical activity. Age, gender, marital status, educational level, global income at home, comorbidity and disability were measured. A descriptive bivariate and multivariate analysis was performed and ponderated by age and gender in study population. Association was estimated by Odds Ratio and confidence intervals (OR, IC 95%).

RESULTS

73,3% participated (N=814), 48,6% were men and the median age was 76 [71-83]. The estimated prevalence of frailty in the study population was 10,3% (IC95%: 8,2-12,5): 8,1% male and 11,9% female (p=0.084). Frailty was associated with aged ≥ 85 (OR=3,61; IC95%: 1,26-10,29), low educational level (OR=1,71; IC95%: 1,01-2,90), comorbidity (OR=1,27; IC95%:1,03-1,56 by each process) and disability (OR=15,61; IC95%: 8,88-27,45).

CONCLUSIONS

Prevalence of frailty in an elderly spanish population is similar to international studies. In our environment first beneficiary population for frailty detection is constituted by people aged ≥ 85, and those with comorbidity and low educational level.

[The frail elderly. Detection and management in Primary Care]

In this article the current state in the detection and management directives of the frail elderly from Primary Care are reviewed. These include the recommendations of the 2009 Preventive Activities Program and Health Promotion of the Spanish Society of Family and Community Medicine (PAPPS-semFYC) and define future lines worthy of review. The lack of defined limits between frailty and good functionality, and with disability and dependency, makes it difficult to diagnose. The two currently most widely methods for detecting the frail elderly are: screening based on risk factors with a sound prediction of suffering adverse events and functional loss (advanced age, hospitalisation, falls, changes in movement and balance, muscle weakness and little exercise, comorbidity, adverse social conditions, multiple medications, etc.) or based on the loss of incipient functionality or early loss if there is still no ostensible degree of incapacity or dependence, and with the possibilities of reversing or modifying it with suitable interventions. Other detection methods, although less used or in the experimental phase include, detection of a phenotype (geriatric syndrome) according to clinical criteria established by Fried, or by biological markers (pre-clinical stage).

[Randomized clinical trial on the efficacy of global geriatric assessment in primary care]

OBJECTIVE

the family doctor is in a unique position to prevent complications in the elderly population. The aim of this study was to evaluate the efficacy of a multifactorial intervention in reducing morbidity and mortality after a global geriatric assessment (GGA) was performed.

MATERIAL AND METHODS

a randomized clinical trial with a control group was carried out in elderly patients aged more than 75 years old visited in the primary care setting over a 18-month period. An individualized intervention was applied to all patients in the intervention group (IG) identified as frail by the GGA. A group session was offered to the remaining patients in the IG.

RESULTS

there were 620 participants: 49.7% were randomized to the IG and 50.3% to the control group (CG). Follow-up was completed by 430 (69.4%) participants. At the end of the study, the CG showed a significantly greater risk of depression (Yesavage) than the IG (P=.048). During the follow-up, 13% of the IG and 5% of the CG changed their initial status of frailty to one of non-frailty, while 11% of the IG and 22% of the CG were newly diagnosed as frail (P< .001). The total number of events (nursing home admission, home visits, deaths) was 15% in the IG and 17% in the CG (P=.64).

CONCLUSIONS

the intervention proved to be effective in containing the number of patients newly diagnosed as frail and in increasing the number of participants who reversed their status from frail to non-frail during the follow-up. GGA is effective if used in conjunction with an intervention.

[Preventing dependency in the elderly.]

INTRODUCTION

dependency, i.e. the need to depend on another person to perform activities of daily living, is the main concern and cause of suffering and poor quality of life in the elderly. The prevalence of dependency increases with age and is related to the presence of prior disease and fragility. Dependency is associated with increased morbidity, mortality and institutionalization, as well as with greater health and social resource utilization, all of which increases health costs.

OBJECTIVE

to create a consensus document on the main health recommendations for the prevention of dependency in the elderly, based on the scientific evidence available to date, with the collaboration of scientific societies and public health administrations (the Spanish Ministry of Health, Autonomous Communities and Cities).

METHODS

a) a preliminary consensus document was drafted by an expert group composed of representatives of various scientific societies and health administrations. This document was based on a review of the recommendations and guidelines published by the main organizations involved in health promotion and the prevention of disease, functional deterioration and dependency in the elderly; b) the consensus document was reviewed by the remaining experts assigned by the scientific societies and central and autonomous administrations; c) the final document was approved after a session in which the text was discussed and reviewed by all the experts participating in the working group (including the academic committee); d) the document was presented and discussed in the First National Conference on Prevention and Health Promotion in Clinical Practice in Spain. All participating experts signed a conflicts of interest statement.

RESULTS

the document provides recommendations, with their grades of evidence, grouped in the following three categories: a) health promotion and disease prevention, with specific preventive activities for the elderly, including prevention of geriatric syndromes; b) prevention of functional deterioration, with clinical recommendations that can be applied in primary and specialized care; c) prevention of iatrogeny (drug prescription, inappropriate use of diagnostic and therapeutic modalities and healthcare). These recommendations were tailored to the characteristics of the older person (OP), categorized in five groups: healthy OP, OP with chronic disease, fragile or at risk OP, dependent OP, and OP at the end of life.

CONCLUSION

these recommendations should be implemented by public health administrations to improve strategies for the prevention of dependency in the elderly in the XXI century.