[Spanish version of the STOPP/START 3 criteria: Advances in the detection of inappropriate prescribing medication in the older people]

The STOPP/START criteria are explicit physiologic systems-based criteria that summarize evidence on clinically relevant prescribing problems related to the use of potentially inappropriate medications (STOPP criteria) and potential prescribing omissions (START criteria). The two previous versions of the STOPP/START criteria were published in 2008 and 2015, and their Spanish versions in 2009 and 2015. Version3 of these criteria has just been published in 2023. The aim of this article is to present the Spanish translated version, and to review the use and impact that version2 of 2015 has had in our language. A translation from English to Spanish was performed by expert professionals with a high level of English of version3 of the STOPP/START criteria, which incorporates the evidence published from April 2014 to March 2022. In addition, a systematic review of publications that have used the Spanish translation of the previous version (version2 of 2015) of the STOPP/START criteria was performed. The new version, presented in this article, has 190 STOPP/START criteria (133 STOPP criteria and 57 START criteria), which is a 40% increase in the number of criteria compared to the previous version. The review found 37 studies (21 observational, 11 interventional and 5 other) that used the Spanish version instead of the international version. The Spanish version 3 of the STOPP/START criteria is an updated explicit list of potentially inappropriate medications and possible omissions in prescribing that aims to optimize medication and minimize adverse drug reactions during medication review in the elderly, particularly those with multimorbidity and polypharmacy. With this new version, the original criteria are intended to be more widely disseminated within the Spanish-speaking healthcare community. The Spanish version2 of the STOPP/START has been widely used, so we consider that the translation into Spanish has helped to improve pharmacotherapy in older patients with polypharmacy and multimorbidity in our linguistic environment.

Frailty and prognosis of older patients with chronic heart failure

INTRODUCTION AND OBJECTIVES

Heart failure (HF) is prevalent in advanced ages. Our objective was to assess the impact of frailty on 1-year mortality in older patients with ambulatory HF.

METHODS

Our data come from the FRAGIC study (Spanish acronym for "Study of the impact of frailty and other geriatric syndromes on the clinical management and prognosis of elderly outpatients with heart failure"), a multicenter prospective registry conducted in 16 Spanish hospitals including outpatients ≥ 75 years with HF followed up by cardiology services in Spain.

RESULTS

We included 499 patients with a mean age of 81.4±4.3 years, of whom 193 (38%) were women. A total of 268 (54%) had left ventricular ejection fraction <40%, and 84.6% was in NYHA II functional class. The FRAIL scale identified 244 (49%) pre-frail and 111 (22%) frail patients. Frail patients were significantly older, were more frequently female (both, P <.001), and had higher comorbidity according to the Charlson index (P=.017) and a higher prevalence of geriatric syndromes (P <.001). During a median follow-up of 371 [361-387] days, 58 patients (11.6%) died. On multivariate analysis (Cox regression model), frailty detected with the FRAIL scale was marginally associated with mortality (HR=2.35; 95%CI, 0.96-5.71; P=.059), while frailty identified by the visual mobility scale was an independent predictor of mortality (HR=2.26; 95%CI, 1.16-4.38; P=.015); this association was maintained after adjustment for confounding variables (HR=2.13; 95%CI, 1.08-4.20; P=.02).

CONCLUSIONS

In elderly outpatients with HF, frailty is independently associated with mortality at 1 year of follow-up. It is essential to identify frailty as part of the comprehensive approach to elderly patients with HF.

Stress cardiac magnetic resonance for mortality prediction and decision-making: registry of 2496 elderly patients with chronic coronary syndrome

INTRODUCTION AND OBJECTIVES

The management of elderly patients with chronic coronary syndrome (CCS) is challenging. We explored the prognostic value and usefulness for decision-making of ischemic burden determined by vasodilator stress cardiac magnetic resonance (CMR) imaging in elderly patients with known or suspected CCS.

METHODS

The study group comprised 2496 patients older than 70 years who underwent vasodilator stress CMR for known or suspected CCS. The ischemic burden (number of segments with stress-induced perfusion deficit) was calculated following the 17-segment model. Subsequently, we retrospectively analyzed its association with all-cause mortality and the effect of CMR-guided revascularization.

RESULTS

During a median follow-up of 4.58 years, there were 430 deaths (17.2%). A higher ischemic burden was an independent predictor of mortality (HR, 1.04; 95%CI, 1.01-1.07 for each additional ischemic segment; P=.006). This association was also found in patients older than 80 years and in women (P <.001). An interaction between revascularization and mortality was detected toward deleterious consequences at low ischemic burden and a protective effect in patients with extensive ischemia.

CONCLUSIONS

Vasodilator stress CMR is a valuable tool to stratify risk in elderly patients with CCS and might be helpful to guide decision-making in this scenario.

[Multidisciplinar revision of treatment in nursing home patients in COVID-19 context]

Objetivo

Durante la pandemia por COVID-19 se contó con un médico de apoyo a los centros sociosanitarios de nuestra Comunidad Autónoma, lo que permitió realizar una intervención multidisciplinar para revisar sistemáticamente la medicación prescrita a las personas institucionalizadas; el objetivo de este estudio es evaluar el impacto de esta intervención en la reducción del número de fármacos/paciente.

Métodos

Estudio multicéntrico prospectivo antes-después de una intervención en la que participan médicos y farmacéuticos de atención primaria en 4 centros sociosanitarios de menos de 50 residentes. Se realizó una revisión sistemática de la medicación a través de un algoritmo, donde se identificaron problemas relacionados con los medicamentos (PRM), los cuales fueron comunicados al médico por el farmacéutico de atención primaria a través de recomendaciones en la prescripción. Se midió el grado de aceptación por el médico de dichas recomendaciones.

Resultados

Se revisaron 121 pacientes con una edad media de 86,1 años (DE 7,2); el 87,6% eran mujeres. De estos, se pudo realizar la intervención en 98 pacientes que tomaban una media de 9,4 fármacos (DE 4,0), con una disminución estadísticamente significativa de -1,6 fármacos (IC95% -1,3 a -1,9) p< 0,001 después de la intervención. En estos, se detectaron 409 PRM, con una media de 4,2 PRM por paciente. Todos los PRM formaron parte de una recomendación, de las cuales fueron aceptadas 316 (77,3%). La mayoría de las recomendaciones fueron de prescripción o ajuste en la posología de un medicamento. Los psicofármacos, antihipertensivos y analgésicos fueron los grupos terapéuticos mayoritariamente implicados en los PRM detectados.

Conclusiones

Se ha observado una reducción estadísticamente significativa en el número medio de fármacos por paciente tras la intervención. Se han identificado PRM a través de la revisión sistemática de la medicación por el farmacéutico de atención primaria que han sido mayoritariamente aceptados por el médico.

[Predictive ability of baseline frailty and handgrip strength at admission on outcomes at discharge in a geriatric functional recovery unit]

OBJECTIVE

To evaluate the predictive capacity of different frailty scales, as well as the strength of the handgrip, and to determine their relationship with clinical favourable outcomes.

PATIENTS AND METHOD

Prospective study of patients admitted to the Geriatric Functional Recovery Unit (GFRU) of the Hospital Central Cruz Roja. The «FRAIL» scale, «Clinical Frailty Scale» (CFS) and «Fragil-VIG» index, and handgrip strength by hydraulic dynamometer were completed on admission. A functional gain was assumed as 20 or more points in the Barthel Index and return to home, as good outcomes at discharge. The discriminative capacity of favourable outcomes for each frailty scale and handgrip strength was analysed by means of ROC curves, calculating the C statistic (area under the curve = AUC).

RESULTS

The analysis included 74 patients (median age 82 years; 48.5% women), admitted for stroke recovery (65%), orthopaedic pathology (16%), and other causes (19%). The prevalence of frailty varied between 31% (FRAIL scale), 40% (CFS), and 57.5% («Fragil-VIG»). Median handgrip strength was 15 Kg in males (interquartile range 11-21), and 9 Kg in females (interquartile range 7-12). At discharge, 51.5% of patients had a functional gain of 20 or more points in Barthel index, and 63% returned to their previous home. The discriminating ability to achieve acceptable functional gain at discharge was good for CFS (AUC = 0.72; 95% CI; 0.60-0.84) and «Fragil-VIG» (AUC = 0.72; 95% CI;0.58-0.82), and handgrip strength was the only tool related to return home (AUC = 0.68; 95% CI;0.56-0.81).

CONCLUSION

To evaluate frailty on admission to a GFRU contributes to predicting favourable clinical outcomes, but the discriminating capacity of each scale is variable.

[Impact of antithrombotic treatment and geriatric syndromes in octogenarians with atrial fibrillation and ischaemic heart disease. Atrial Fibrillation and Ischemic Heart Disease in the Elderly]

BACKGROUND AND OBJECTIVES

The prevalence of atrial fibrillation (AF) and ischaemic heart disease (IHC) increases with age. They coexist in up to 20% of octogenarian patients, a situation that poses a therapeutic challenge. Trials that have addressed this scenario, which included a low percentage of octogenarians, showed that double therapy (single antiplatelet + anticoagulation) compared to triple therapy (double antiplatelet + anticoagulation) was associated with less bleeding events, especially with direct oral anticoagulants. These studies did not have sufficient power to detect differences in ischaemic events. On the other hand, prevalent characteristics in the elderly, such as geriatric syndromes, were not assessed in these studies, and are not usually evaluated in clinical practice. Accordingly, their prognostic impact remains unknown in this clinical context.

METHODS

Observational, prospective, and multicentre study that will include patients ≥ 80 years with AF and IHC in Spain. Baseline characteristics and geriatric syndromes will be assessed, as well as the choice of antithrombotic treatment. The primary endpoint is cardiovascular and overall mortality at one and three years follow-up.

RESULTS

This study will assess both characteristics and prognosis of octogenarian patients with AF and IHC in Spain, the factors involved in the choice of antithrombotic treatment, and the incidence of ischaemic and haemorrhagic events during the short- and long-term follow-up.

CONCLUSION

This study will contribute to improve the knowledge in terms of safety and efficacy of the different therapeutic options in older patients with AF and IHC, as well as their prognostic impact.

[Updated review of Clostridium difficile infection in elderly]

Clostridium difficile infection is the most common cause of health care-associated diarrhoea, and its incidence increases with age. Clinical challenges, risk of resistance to treatment, risk of recurrence, and treatment responses are different in elderly. The aim of this review is to discuss the updated epidemiology, pathophysiology, diagnosis, and therapeutic management of C. difficile infection in elderly with the available data.

[Impact of a centralised hospital admission system on the efficacy and efficiency of a geriatric functional recovery unit]

OBJECTIVE

To evaluate the influence of a change in the management of admissions on the activity and care outcomes of a Geriatric Functional Recovery Unit (GFRU).

MATERIAL AND METHODS

A retrospective observational study was conducted. Since 2000, the Hospital Central Cruz Roja GFRU has been collecting data grouped into periods of 4 years, except for the centralised admissions (September 2016-December 2018). The data collected on admission included the Red Cross Functional and Mental scales, the Barthel index, the main diagnosis of the functional decline (grouped into stroke, orthopaedic problem, and multifactorial immobility episodes), and comorbidity evaluated by the Charlson index. The following outcome variables were analysed: the overall and relative functional gain at discharge; length of hospital stay; the functional efficiency, discharges to nursing homes, and transfers to acute care units. An analysis was made of the relationship between the admissions from the centralised unit and the previous period (directly admission managed by GFRU), using multivariate analysis (linear regression for continuous outcome variables and logistic regression for the dichotomous ones), adjusted for admission variables.

RESULTS

Patients admitted from the centralised unit showed a greater overall and relative functional gain (difference between both means: 3.49 points, 95% CI; 1.65-5.33, and 12.41%, 95% CI; 0.74-24.08, respectively), longer stay (12.92 days, 95% CI; 11.54-14.30) and lower efficiency (-0.36, 95% CI; -0.16 to -0.57), higher risk of institutionalisation (OR 1.61, 95% CI; 1.19-2.16), and transfers to acute care units (OR 3.16, 95% CI; 2.24-4.47).

CONCLUSIONS

A centralised admissions system had an influence on the improvement of functional parameters in the patients, but with a longer length of hospital stay, and lower efficiency. Increases in institutionalisation at discharge and transfers to acute care units were also observed.

[Consensus document on overactive bladder in older patients]

Overactive nladder (OAB) is a clinical entity with a high prevalence in the population, having a high impact on quality of life, especially when it occurs with urge urinary incontinence. It is very important to highlight the low rate of consultation of this condition by the older population. This appears to depend on several factors (educational, cultural, professional), and thus leads to the low percentage of older patients who receive appropriate treatment and, on the other hand, a large percentage of older patients with a significant deterioration in their quality of life. Therefore, Scientific societies and Working Groups propose the early detection of OAB in their documents and clinical guidelines. Its etiology is not well known, but is influenced by cerebrovascular processes and other neurological problems, abnormalities of the detrusor muscle of bladder receptors, and obstructive and inflammatory processes of the lower urinary tract. Its diagnosis is clinical, and in the great majority of the cases it can be possible to establish its diagnosis and etiopathogenic orientation, without the need for complex diagnostic procedures. Currently, there are effective treatments for OAB, and we should decide the most appropriate for each elderly patient, based on their individual characteristics. Based on the main clinical practice guidelines, a progressive treatment is proposed, with the antimuscarinics being the most recommended drug treatment. Therefore, a group of very involved professionals in clinical practice for the elderly, and representing two scientific Societies (Spanish Society of Geriatrics and Gerontology [SEGG], and the Spanish Society of Primary Care Physicians [SEMERGEN]) developed this consensus document with the main objective of establishing practices and valid strategies, focused to simplify the management of this clinical entity in the elderly population, and especially to improve their quality of life. The recommendations presented in this consensus document are the result of a comprehensive review and critical discussion of articles, documents and clinical guidelines on OAB, both nationally and internationally. Are, where possible, levels of evidence and grades of recommendation are included.

[Review of functional impairment associated with acute illness in the elderly]

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.