[Prognostic factors of functional recovery in very elderly stroke patients. A one-year follow-up study]. / Factores pronósticos de recuperación funcional en pacientes muy ancianos con ictus. Estudio de seguimiento al año.

INTRODUCTION: Although an advanced age is a factor associated to a poorer functional prognosis following a stroke, the capacity for recovery can be determined by other intercurrent clinical, functional and mental factors. AIM: To evaluate the factors that determine the functional prognosis on discharge of very elderly patients who were admitted to hospital for their functional recovery after suffering a stroke. PATIENTS AND METHODS: We conducted a longitudinal observational study of 168 patients over 65 years of age, who were hospitalised consecutively over a 15-month period. On admission, data concerning a number of clinical, neurological, functional and mental variables were collected. On being discharged from hospital their functional situation (Barthel index) and institutionalisation were evaluated. RESULTS: The 48 patients aged 85 and above presented a lower degree of overall and relative functional recovery on discharge from hospital. Nevertheless, 52% had gained more than 20 points on the Barthel index on being discharged with respect to their score when they were admitted; on discharge 44% had recovered over 50% of the functional loss they had suffered following the stroke. On including the other basal variables in a logistic regression analysis, a very advanced age was associated in an independent manner to a greater risk of being institutionalised, but not to a poorer functional prognosis at discharge. Severe functional impairment on admission and post-stroke depression were the factors that were independently associated to moderate-severe disability on admission; in addition, the more severe the neurological consequences were, the lower the level of functional recovery was. CONCLUSIONS: The capacity for functional recovery in very elderly stroke patients is mainly determined by the degree of functional and neurological repercussion. The functional prognosis should be individualised according to these factors, regardless of the age.

[Unilateral apraxia of eyelid closure in ischemic stroke: role of the right hemisphere in the emotional gesture communication]. / Apraxia unilateral del cierre palpebral tras un ictus isquémico: el papel del hemisferio derecho en la comunicacion gestual mocional.

INTRODUCTION: Apraxia of eyelid closure (AEC) is an infrequent disorder that is characterised by the inability to close the eyelids on command, although spontaneous blinking and reflex shutting of the eyes is preserved. Very few cases of unilateral AEC have been reported and no long-term follow-ups have been carried out. We report the case of a patient with unilateral AEC that was followed up over a 3-year period and also discuss the role played by the right hemisphere in this disorder. CASE REPORT" We examined the case of a 67-year-old right-handed male who was admitted because of a parietotemporal infarction with extension into the subcortex. A few days after the stroke the patient reported the inability to close his left eye on command, although he was still able to blink spontaneously and the blink and visual threat reflexes were preserved. This deficiency was associated to a dense hemiparesis on the left side and notable aprosodia affecting language. At 3 years' follow-up the AEC had not improved significantly. CONCLUSIONS: There are data to suggest that the right hemisphere is related to emotional perception and expressiveness, as well as the regulation of language prosody. Likewise, symbolic anthropology stresses the importance of winking as a gesture involved in non-verbal communication. These data suggest that AEC may be a consequence of a dysfunction of the role played by the right hemisphere in emotional expressiveness through gestures. The association with language aprosodia could support this hypothesis.

[Evaluation of the diagnostic value of a Spanish adaptation of the Buschke Memory Impairment Screen in the detection of dementia and cognitive impairment]. / Evaluacion de la utilidad diagnostica de una adaptacion espanola del Memory Impairment Screen de Buschke para detectar demencia y deterioro cognitivo.

INTRODUCTION: Screening tests for dementia are a fundamental tool in specialist consultation and primary care. The instruments currently used are time-consuming and the diagnostic performance they offer is rather poor. The original version of the Buschke Memory Impairment Screen (MIS) is a quick simple test with high discriminatory power. AIMS: Our aim was to validate a Spanish version of the MIS in specialist consultation. PATIENTS AND METHODS: We conducted a prospective study in 91 subjects aged over 60 who visited the outpatient department for cognitive evaluation. All the patients received a similar diagnostic evaluation and the MIS was administered as a blind test. This Spanish version of the MIS was produced by means of a cross-cultural adaptation. RESULTS: The area below the ROC curve for dementia on the MIS was 0.92, with a similar result for cognitive deterioration (CD). A cut-off score of 4 or less offered a sensitivity rate of 91.9% (CI 95%: 83.4-96.4%) and a specificity level of 81.0% (CI 95%; 70.3-88.6%) for the detection of CD. Likewise, a cut-off score of 3 or below presented a sensitivity rate of 96.1% (CI 95%: 85.7-99.3%) and a degree of specificity of 72.6% (CI 95%: 63.2-80.3%) for the detection of dementia. Interobserver and test-retest reliability (0.85 and 0.81, respectively) were adequate. CONCLUSIONS: This version of the Buschke MIS offers a high level of discriminatory power both for dementia and for CD, as well as an adequate degree of inter and intraobserver reliability within the context of a specialist consultation. Because it is quick (less than 4 minutes) and simple to administer, MIS represents a reasonable alternative to other screening methods.

[Variables associated with functional recovery and post-discharge institutionalization of elderly cared in an average stay geriatric unit]. / Variables asociadas a la recuperación funcional y la institucionalización al alta en ancianos ingresados en una unidad geriátrica de media estancia.

BASIS: To describe the evolution and results of the rehabilitation of elderly disabled cared in an average stay geriatric unit, and to define the factors associated with functional improvement and post-discharge institutionalization. PATIENTS AND METHOD: Observational longitudinal study in 459 patients with functional disability consecutively hospitalized between May 2000 and December 2001. Basal variables collected included the clinical, functional, mental, and sociodemographic manifestations previous to the admission. The favorable functional response (defined as a functional gain during the admission of > or = 20 points in the Barthel index) and the post-discharge institutionalization were regarded the main result variables. RESULTS: The average age of patients was 80.56 (SD: +/- 7.45) years, 64.9% were women and 81% came from acute hospital units; the main cause of disability was stroke (48.5%) followed by orthopedic pathology (26.2%) and immobility for different causes (23.5%). 72.5% of patients get functional improvement and 16.4% were institutionalized after the discharge. The main independent risk factors for poor functional response found in the multivariate analysis were a scoring in Pfeiffer's cognitive test of 5-7 points (OR: 0.42; 95% CI: 0,22-0.78) and > or = 8 (OR: 0.29; 95% CI: 0.12-0.71), and a scoring in Barthel's index < 60 prior to the deterioration (OR: 0.36; 95% CI: 0.14-0.93). Independent risk factors for institutionalization after the discharge were age (OR: 1.06; 95% CI: 1.01-1.12), and a scoring in the Gijon's sociofamiliar scale > or = 9 (OR: 6.83; 95% CI: 1.91-24.47). A functional disability after the discharge in the Barthel's index < 40 also was independently associated to post-discharge institutionalization (OR: 3,07; 95% CI: 1.04-10.06). CONCLUSIONS: Most of elderly with recent disability benefit functionally from care in specific hospital geriatric units. Moderate or severe cognitive deterioration after hospitalization is associated to lower recovery probability. Very advanced age, higher social precariousness and severe disability after discharge are associated with higher risk of institutionalization.

[Outcome at year after rehabilitation of proximal femur fracture in older than 84 years]. / Resultados al año de la rehabilitación tras fractura de fémur proximal en mayores de 84 años.

OBJECTIVE: To evaluate rehabilitation outcomes at discharge and at year patients older 85 years admitted to functional treatment after hip fracture. METHOD: A prospective study of inpatients admitted after hip fracture to medium-stay geriatric unit between May 2000 and September 2002. Baseline, clinical variables (location of fracture, serum albumin and Charlson comorbidity index), functional status assessed by Barthel Index, mobility by Physical Red Cross Scale and cognitive status by Pfeiffer questionnaire. Functional status, mobility, institutionalization and death was evaluated at discharge and by phone interview at years after discharge. RESULTS: 116 patients were studied (42% with 85 years and older, 85% women). After multivariable logistic analysis, age older than 84 years did not appear as a factor related to functional dependence or institutionalization at discharge or one year after. Indeed, oldest old age was not related with death or institutionalization and mobility dependence one year after. In the other hand, the presence of cognitive impairment at admission and functional impairment before hip fracture were independently variable associated to the presence of poor outcome at discharge and one year after. CONCLUSIONS: Oldest old age does not appear as a independent risk factor of poor outcomes after rehabilitation of hip fracture when other related clinical, functional and mental factors are considered.

Resultados al año de la rehabilitación tras fractura de fémur proximal en mayores de 84 años / Outcomes after a year of rehabilitation of proximal femur fracture in older than 84 years

Objetivo: Valorar los resultados de la rehabilitación en pacientes de 85 y más años con fractura de cadera y su persistencia al año, en relación con ancianos más jóvenes. Método: Estudio prospectivo de todos los pacientes ingresados con fractura de cadera para recuperación funcional en una unidad geriátrica de media estancia entre mayo de 2000 y septiembre de 2002. Se recogieron variables clínicas (tipo de fractura, albúmina sérica e índice de comorbilidad de Charlson), situación funcional (Índice de Barthel), capacidad de deambulación (escala física de Cruz Roja) y la situación cognitiva (test de Pfeiffer). La situación funcional, deambulación e institucionalización fueron las variables de resultado al alta. El seguimiento se realizó telefónicamente recogiendo al año la incidencia de muerte, institucionalización, situación funcional y capacidad de deambulación. Resultados: Se estudiaron 116 pacientes (42 por ciento 85 años; 85 por ciento mujeres). Tras el análisis logístico multivariante la edad 85 no fue un factor asociado a dependencia funcional o institucionalización al alta. Tampoco se asoció al riesgo de muerte o institucionalización ni de deambulación dependiente al año del alta. Por contra, la presencia de deterioro cognitivo al ingreso y de deterioro funcional previo a la fractura se asociaron de forma independiente a la presencia de estos pobres resultados al alta y al año. Conclusiones: La edad muy avanzada no aparece como un factor de riesgo independiente de pobres resultados tras la rehabilitación de fractura de cadera cuando se consideran otros factores clínicos, funcionales y mentales asociados (AU)

[The community activity of a hospital geriatrics service: a practical example of coordination between primary and specialized care]. / Actividad comunitaria de un servicio de geriatría hospitalario: un ejemplo práctico de coordinación entre atención primaria y especializada.

OBJECTIVES: To describe the management of the geriatric hospital home assessment team to support at primary care in the need of health of geriatric patients. DESIGN: Prospective observational study. SETTING: 5-North health district from Madrid. PARTICIPANTS AND METHODS: All patients evaluated at home and the coordination activities between primary care and hospital geriatric service, developed by the geriatric assessment team between january 1997 at december 1999. Inquiry to primary care physicians about the usefulness of geriatric hospital home assessment team. MAIN RESULTS: 524 patients was assisted at home by the geriatric assessment team to request primary care (58.4% at all patients attended), 83.24 +/- 7.21 years old (68.1% females), with pluripathology (4.02 +/- 1.86 diagnostics) and polypharmacy (4.95 +/- 2.8), moderate-severe functional disability (Barthel Index < 60 at 65% and Red Cross functional disability > 2 at 74.4%) and frequently cognitive impairment (41.2% with Pfeiffer > 5). The main reasons of primary care to consult was functional impairment (28.4%), medical process assessment (16.2%), geriatric assessment (13.2%), skin ulcers (13.2%) and behavioral disorders (10.8%). 865 telephone call and 178 meeting in health center of primary care for consultation or medical management or for coordinating medical management was attended. 62% of primary care physician inquired to answer back. The belief of 100% answers was about de usefulness of the geriatric assessment team activity, mainly because their specialization on geriatric care (76.7%) and their responsibility of the hospital resources (65.1%). CONCLUSIONS: The activity of geriatric hospital home assessment team is useful as support of primary care on assessment and management geriatric patients in the community and coordinate hospital and primary care to resolve health problems in this population.

Actividad comunitaria de un servicio de geriatría hospitalario: un ejemplo práctico de coordinación entre atención primaria y especializada / community care of the hospital geriatric service: practice of the coordination between primary care and the specialist

Objetivo.Describir la actividad asistencial y de coordinación de un equipo especializado hospitalario (equipo de Asistencia Geriátrica Domiciliaria, AGD) en el apoyo a atención primaria de salud (APS) para la atención de pacientes geriátricos. Diseño.Estudio observacional prospectivo. Emplazamiento.Área de Salud 5-Norte de Madrid (distritos de Tetuán y Fuencarral). Pacientes y métodos. Evaluación de todos lospacientes atendidos en su domicilio a petición de APS, así como de las actividades de coordinación entre servicio de geriatría y APS realizadas por el equipo de AGD desde el 1 de enero de 1997 hasta el 31 de diciembre de 1999. Valoración de los médicos de APS sobre la actividad del equipo de AGD mediante encuesta anónima. Resultados principales.Se atendieron en domicilio un total de 524 pacientes a petición de APS (un 58,4 por ciento del total de pacientes nuevos atendidos en ese período de tiempo por el equipo de AGD), con una edad media de 83,24 ñ 7,21 años, 68,1 por ciento mujeres, 4,02 ñ 1,86 diagnósticos, 4,95 ñ 2,8 fármacos, alto grado de incapacidad funcional (74,4 por ciento con una puntuación > 2 en la escala de incapacidad física de Cruz Roja y 65 por ciento con un índice de Barthel 5 en el test de Pfeiffer). Los motivos más frecuentes de consulta fueron deterioro funcional (28,4 por ciento), control clínico (16,2 por ciento), valoración geriátrica (13,4 por ciento), úlceras cutáneas (13,2 por ciento) y trastornos del comportamiento (10,8 por ciento). De forma paralela se atendieron 865 consultas clínicas telefónicas y se realizaron 178 reuniones en centros de salud. Un 62 por ciento de los médicos respondió a la encuesta. El 100 por ciento consideró útil la actividad del equipo de AGD, destacando como características más determinantes su especialización en los cuidados geriátricos (76,7 por ciento) y la disponibilidad de recursos hospitalarios (65,1 por ciento). Conclusiones.La actividad de un equipo geriátrico especializado de ubicación hospitalaria tiene un ámbito de actuación establecido en la comunidad como apoyo a la APS. Esta actividad viene definida, por una parte, por la necesidad de apoyo a la APS en la asistencia domiciliaria a pacientes geriátricos con elevada complejidad clínica e incapacidad y, por otro lado, por su labor de coordinación entre APS y hospital y de consultor de la APS para la resolución de problemas de atención que presentan los pacientes geriátricos en la comunidad, independientemente de su grado de incapacidad (AU)

[Emergency hospital admission in medical services: causes, justification, social factors, and their differences in function of age]. / Ingreso hospitalario urgente en servicios médicos: causas, justificación, factores sociales y sus diferencias en función de la edad.

BACKGROUND: Increasing attention has been given to the care to elderly patients in emergency departments (ED). Moreover, few data are available about final phase of the process, that is hospital admission from ED. This study was conducted to establish appropriateness, reasons and social factors related to hospital admission in medical services from ED and their age-related differences. METHODS: The Appropriateness Evaluation Protocol scale (AEP) was applied prospectively to 515 patients 15 years and older admitted to medical services through an ED. Patients who did not meet any AEP criteria were evaluated for other medical or social factors as conditions for their admission. RESULTS: The sample was composed by 303 elders (65 years and older, mean age = 77 +/- 6 years) and 212 adults (15-64 years old, mean age = 45 +/- 14). 271 elderly patients (89.4%) and 173 adults (81.6%) meet AEP criteria (p = 0.01). Hospitalary admission for diagnostic procedures is more frequent in younger than in older group (14.2% versus 6.9%, p = 0.01). No differences are detected in hospital admissions based upon strictly social factors: 7 (2.3%) in elderly group and 7 (3.3%) in younger one (p = 0.05). CONCLUSIONS: Urgent hospital admissions in medical services are justified more frequently in elderly patients. These patients are admitted for diagnostic procedures less frequently than younger group. No age-dependent difference in strictly social admissions is detected.