Planificación del alta desde urgencias para reducir eventos adversos a 30 días en pacientes mayores frágiles con insuficiencia cardiaca aguda: diseño y justificación del ensayo clínico DEED FRAIL-AHF / Planning to reduce 30-day adverse events after discharge of frail elderly patients with acute heart failure: design and rationale for the DEED FRAIL-AHF trial

Objetivos: Demostrar la eficacia de una intervención integral en la transición de cuidados (Plan de Alta Guiado Multinivel, PAGM) para disminuir eventos adversos a 30 días en ancianos frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde servicios de urgencias (SU) y validar los resultados de dicha intervención en condiciones reales. Método: Se seleccionarán pacientes mayores de 70 años frágiles con diagnóstico principal de ICA dados del alta a su domicilio desde SU. La intervención consistirá en aplicar un PAGM: 1) lista de verificación sobre recomendaciones clínicas y activación de recursos; 2) programación de visita precoz; 3) transmisión de información a atención primaria; 4) hoja de instrucciones al paciente por escrito. Fase 1: ensayo clínico con asignación al azar por conglomerados emparejado. Se asignará de forma aleatoria 10 SU (N = 480) al grupo de intervención y 10 SU (N = 480) al grupo de control. Se compararán los resultados entre grupo de intervención y control. Fase 2: estudio cuasi-experimental. Se realizará la intervención en los 20 SU (N = 300). Se comparará los resultados entre la fase 1 y 2 del grupo de intervención y entre la fase 1 y 2 del grupo de control. La variable principal de resultado es compuesta (revisita a urgencias u hospitalización por ICA o mortalidad de origen cardiovascular) a los 30 días del alta. Conclusiones: El estudio valorará la eficacia y factibilidad de una intervención integral en la transición de cuidados para reducir resultados adversos a 30 días en ancianos frágiles con ICA dados de alta desde los SU

Objectives: To demonstrate the efficacy of a system for comprehensive care transfer (Multilevel Guided Discharge Plan [MGDP]) for frail older patients diagnosed with acute heart failure (AHF) and to validate the results of MGDP implementation under real clinical conditions. The MGDP seeks to reduce the number of adverse outcomes within 30 days of emergency department (ED) discharge. Method: We will enroll frail patients over the age of 70 years discharged home from the ED with a main diagnosis of AHF. The MGDP includes the following components: 1) a checklist of clinical recommendations and resource activations, 2) scheduling of an early follow-up visit, 3) transfer of information to the primary care doctor, and 4) written instructions for the patient. Phase 1 of the study will be a matched-pair cluster-randomized controlled trial. Ten EDs will be randomly assigned to the intervention group and 10 to the control group. Each group will enroll 480 patients, and the outcomes will be compared between groups. Phase 2 will be a quasi-experimental study of the intervention in 300 new patients enrolled by the same 20 EDs. The outcomes will be compared to those for each Phase-1 group. The main endpoint at 30 days will be a composite of 2 outcomes: revisits to an ED and/for hospitalization for AHF or cardiovascular death. Conclusions: The study will assess the efficacy and feasibility of comprehensive MGDP transfer of care for frail older AHF patients discharged home

Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association.

Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.

[Chronic ischaemic heart disease in the elderly]. / Cardiopatía isquémica crónica en el anciano.

It is the aim of this manuscript to take into account the peculiarities and specific characteristics of elderly patients with chronic ischaemic heart disease from a multidisciplinary perspective, with the participation of the Spanish Society of Cardiology (sections of Geriatric Cardiology and Ischaemic Heart Disease/Acute Cardiovascular Care), the Spanish Society of Internal Medicine, the Spanish Society of Primary Care Physicians and the Spanish Society of Geriatrics and Gerontology. This consensus document shows that in order to adequately address these elderly patients a comprehensive assessment is needed, which includes comorbidity, frailty, functional status, polypharmacy and drug interactions. We conclude that in most patients medical treatment is the best option and that this treatment must take into account the above factors and the biological changes associated with aging.

Guidelines on the management of implantable cardioverter defibrillators at the end of life.

This article is a joint document of the Spanish Society of Geriatrics and Gerontology, the Spanish Society of Palliative Care and the Section of Geriatric Cardiology of the Spanish Society of Cardiology. Its aim is to address the huge gap that exists in Spain with regard to the management of implantable cardioverter defibrillators (ICDs) in the final stages of life. It is increasingly common to find patients carrying these devices that are in the terminal stage of an advanced disease. This occurs in patients with advanced heart disease and subsequent heart failure refractory to treatment but also in a patient with an ICD who develops cancer disease, organ failure or other neurodegenerative diseases with poor short-term prognosis. The vast majority of these patients are over 65, so the paper focuses particularly on the elderly who are in this situation, but the decision-making process is similar in younger patients with ICDs who are in the final phase of their life.

[Guidelines on the management of implantable cardioverter defibrillators at the end of life]. / Guía sobre el manejo de desfibriladores automáticos implantables al final de la vida.

This article is a joint document of the Spanish Society of Geriatrics and Gerontology, the Spanish Society of Palliative Care and the Section of Geriatric Cardiology of the Spanish Society of Cardiology. Its aim is to address the huge gap that exists in Spain with regard to the management of implantable cardioverter defibrillators (ICDs) in the final stages of life. It is increasingly common to find patients carrying these devices that are in the terminal stage of an advanced disease. This occurs in patients with advanced heart disease and subsequent heart failure refractory to treatment but also in a patient with an ICD who develops cancer disease, organ failure or other neurodegenerative diseases with poor short-term prognosis. The vast majority of these patients are over 65, so the paper focuses particularly on the elderly who are in this situation, but the decision-making process is similar in younger patients with ICDs who are in the final phase of their life.

[Delirium prevention and treatment in elderly hip fracture]. / Prevención y tratamiento del delírium en ancianos con fractura de cadera.

The fracture of the proximal femur or hip fracture in the elderly usually happens after a fall and carries a high morbidity and mortality. One of the most common complications during hospitalization for hip fracture is the onset of delirium or acute confusional state that in elderly patients has a negative impact on the hospital stay, and prognosis, worsening functional ability, cognitive status and mortality. Also the development of delirium during hospitalization increases health care costs. Strategies to prevent and treat delirium during hospitalization for hip fracture have been less studied. In this context, this paper aims to conduct a review of the literature on strategies that exist in the prevention and treatment of delirium in elderly patients with hip fracture.

Unusual duodenal presentation of leishmaniasis.

This case report describes an atypical case of duodenal leishmaniasis in an elderly patient not infected with human immunodeficiency virus. Investigation of this 84 year old woman with a constitutional syndrome and dysphagia revealed anaemia of chronic disorder, a high erythrocyte sedimentation rate, and polyclonal hypergammaglobulinaemia. Abdominal ultrasonography revealed thickening of the stomach wall, which was seen to be inflamed during gastroscopy. Duodenal histology revealed numerous leishmania amastigotes within macrophages. This was confirmed by bone marrow biopsy and leishmania serology. This case report stresses the importance of atypical symptoms and the unusual location of visceral leishmaniasis, not only in immunodepressed patients, but also in elderly immunocompetent patients.

Linfadenopatías generalizadas y síndrome constitucional en una anciana de 94 años / Generalised lymphadenopathies and constitutional syndrome in a 94-year-old woman

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[Epidemiology of hip fractures in the elderly in Spain]. / Epidemiología de la fractura de cadera en ancianos en España.

BACKGROUND: Ninety percent of hip fractures (HF) occur in people older than 64 years. We describe the epidemiological data (age, sex, date of admission and discharge and mortality) of elderly with hip fracture in the different regions of Spain. METHOD: Data obtained from the Minimum Data Set of the Ministry of Health were used to analyse hip fracture incidence (Identified by codes 820.0 through 820.9 of the International Classification of Diseases) from 1996 through 1999. Demographic data of Spanish population were obtained from the National Institute of Statistics. HF rates were calculated using crude and age-and-sex adjusted density of incidence. Factors associated with in-hospital mortality were assessed by multivariate analyses. RESULTS: 89% (130.414) of 146.383 HF cases studied were in elderly patients with a mean age of 82 years old, being 78% females. The results showed a great variability through the different regions. Length of hospital stay was 16 days, and in-hospital mortality was 5%. Global HF rate was 517 cases per 100.000 elderly per year (270 cases/100.000 elderly males and 695/100.000 elderly females). In-hospital mortality was higher in males than females (8.1% vs 4.2%, respectively), increases progressively with age and it is higher during winter months. Factors associated with mortality were old age, male gender, fractured in winter, and living in Regions others than Mediterranean and Canary Islands. CONCLUSIONS: Hip fracture is a condition that occurs more commonly in elderly people. It is more frequent in females and shows a great variation in incidence, mortality and length of hospital stay through different Spanish regions.

Epidemiología de la fractura de cadera en ancianos en España / Epidemiology of hip fracture in elderly in Spain

Fundamento: El 90 por ciento de las fracturas de cadera (FC) ocurren en mayores de 64 años. Pretendemos describir las características epidemiológicas de los ancianos con FC en lo que respecta a edad, sexo, época de ingreso, estancia hospitalaria y mortalidad en las distintas Comunidades Autónomas (CCAA) de España. Método: Se analizan datos de incidencia de FC (Código 820.0 al 820.9 de la Clasificación Internacional de Enfermedades) entre los años 1996 y 1999, obtenidos del registro nacional del Conjunto Mínimo Básico de Datos del Ministerio de Sanidad. Los datos de la población se obtienen del Instituto Nacional de Estadística. Las tasas de FC se calculan mediante densidad de incidencia bruta y ajustada. Se analizan los factores que influyen en la mortalidad hospitalaria mediante análisis multivariante. Resultados: De las 146.383 FC estudiadas 130.414 (89 por ciento) corresponden a mayores de 64 años, con una edad media de 82 años (78 por ciento mujeres). Existe una gran variabilidad en los resultados entre las CCAA. La estancia media hospitalaria es de 16 días y la mortalidad hospitalaria del 5 por ciento. La incidencia global de FC es de 517 casos por 100.000 ancianos y año (270 casos/100.000 varones y 695/100.000 mujeres). La mortalidad hospitalaria es el doble en varones que en mujeres (8,1 por ciento y 4,2 por ciento respectivamente), aumenta exponencialmente con la edad, y es mayor en invierno. Los más ancianos, varones, que se fracturan en invierno y que no habitan en las Comunidades del Mediterráneo y Canarias tienen más probabilidades de fallecer en el hospital tras una FC. Conclusiones: La FC es una patología afecta preferentemente a los ancianos, más frecuentemente en mujeres y con una gran variación en la incidencia, mortalidad y estancia hospitalaria entre las distintas CCAA (AU)

Functional integrity of the CD28 co-stimulatory pathway in T lymphocytes from elderly subjects.

INTRODUCTION: the antigen CD28, expressed in most T cells, has co-stimulatory properties and plays a pivotal role in clonal T cell anergy mechanisms. METHODS: we have compared proliferative T cell responses after anti-CD3 or in phorbol myristate acetate activation with concomitant CD28 signal in peripheral blood mononuclear cells from healthy donors aged over 65 [elderly donors; ED] and young healthy donors (YD); mean age 30+/-2.7 years). RESULTS: no proliferative responses were observed in ED and YD with anti-CD28 monoclonal antibody alone. These responses both were defective in ED, particularly after anti-CD3 monoclonal antibody stimulus (7604 compared with 12,438 c.p.m. in YD, P=0.001) and were corrected when anti-CD28 monoclonal antibody was added to the culture (17,216 vs 18,536, not significant). Functional integrity of the CD28 co-stimulatory pathway was demonstrated by analysis of CD25 expression, interleukin-2 secretion and interleukin-2 gene expression on T cells from ED and YD. Age-associated phenotypic T cell changes were not crucial for an adequate CD28 response. CONCLUSION: these experiments demonstrate the integrity of the CD28 pathway in elderly people, and suggest that ageing does not affect different T cell activation pathways equally.

Early lymphocyte activation in elderly humans: impaired T and T-dependent B cell responses.

Immunosenescence is characterized by an increase in autoantibody production. Because both T and B cell stimulation are key events for producing antibodies, we investigated early T and B cell activation by means of CD23 and CD40L (two very early activation antigens). PBMC from elderly humans (EH) were studied following culture with either medium, anti-CD3mAb, rIL-4, or PMA + ionomycin. CD23 expression on elderly B cells after anti-CD3 challenge of PBMC, a reflect of T-dependent B cell activation, was clearly defective. Conversely, CD23 expression on EH B cells following activation with soluble factors as rIL-4 was preserved. CD40L expression was also impaired in EH T cells following anti-CD3 challenge. However, activation by means of PMA and/or ionomycin was preserved both in T cells (CD40L expression) and in B cells (CD23 expression). These results indicate that a defective T-dependent B cell activation related to defective T cell activation located between surface membrane and PKC/ionomycin function is an intrinsic characteristic of immunosenescence. We have not found intrinsic B-cell defects, and we conclude that the characteristically impaired early B cell activation in EH is mostly due to T cell defects.

Early T-cell activation in elderly humans.

This study characterizes the early steps of T lymphocyte activation in elderly subjects. The expression of CD69, the earliest inducible antigen which appears with T lymphocyte activation, was assessed in T cells cultured with medium, anti-CD3 or PMA. The proliferative responses of T cells stimulated through CD69 and CD3 pathways were also studied. Donors included 31 healthy elderly [age mean (SD) 80(8) years] and 33 healthy young [age 30(5) years] subjects. In elderly people, the expression of CD69 was lower in T cells cultured with medium [3.4% (1.65-5.9; 25-75 percentiles) vs. 10% (6-18), p < 0.0003] and anti-CD3 activated [28.1% (16.5-53.8) vs. 79.5% (73-89), p < 0.0002] T cells. With PMA at 10 ng/ml, CD69 expression was higher in both groups of T cells, though still lower in the aged [84.5% (70.9-94.9) vs. 99% (65.7-100), p = 0.051]. CD69 T cells expression was equal in both groups with 2 ng/ml of PMA, but the co-stimulatory responses to CD69 under these conditions and in the presence of anti-CD3 were lower in the aged (16914 vs. 28904 cpm, p < 0.02) and (6944 vs. 14370 cpm, p < 0.02) respectively. Aged T cells failed to express CD25 at the same levels of young T cells when stimulated with CD69. These results suggests an age-associated defect in the very early steps of T lymphocyte activation that might influence later stages of lymphocyte function. An alteration in the transmission of the activation signal from the cell surface to protein kinase C may play a primary role in this defect.

Influence of sex on the short-term outcome of elderly patients with a first acute myocardial infarction.

BACKGROUND: Sex seems to affect the course of acute myocardial infarction (AMI) in the general population. Although the epidemiological importance of female sex among patients with AMI is more important from the sixth decade of life, little is known about the impact of sex on the outcome of AMI in the elderly. METHODS AND RESULTS: To determine the differences between sexes in the outcome of AMI in the elderly, we compared the clinical history and evolution of 204 consecutive patients (99 men, 105 women) > or = 75 years of age admitted with a first AMI. Women had a higher prevalence (P < .01) of hypertension (60% versus 32%) and diabetes (41% versus 18%), whereas men were more frequently smokers (41% versus 4%, P < .0001); these factors were associated with higher rates of congestive heart failure. Women showed lower ejection fractions and higher rates of congestive heart failure (odds ratio [OR], 2.32; 95% CI, 1.32 to 4.12) and shock (OR, 2.78; 95% CI, 1.29 to 6.40). Mortality rate was higher in women (40% versus 23%, P = .01; OR, 2.29; 95% CI, 1.26 to 4.26); however, sex was excluded as an independent predictor of in-hospital mortality in every regression model tested (OR, 0.75; 95% CI, 0.25 to 2.21). CONCLUSIONS: After a first AMI, elderly women experience a more complicated hospital course than men. The increase in mortality risk seems to be related to the impact of cardiovascular risk factors on left ventricular function more than to sex itself.