¿Qué opinan los socios de la Sociedad Española de Geriatría y Gerontología sobre las guías de práctica clínica en geriatría? / What do the members of the Spanish Society of Geriatrics and Gerontology think about clinical practice guidelines in geriatrics?

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Las guías de práctica clínica en geriatría: ¿son realmente útiles? / Clinical practice guidelines in geriatrics: are they really useful?

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Functional status and mortality at month and year in nonagenarians hospitalized due to acute medical illness.

OBJECTIVES: To analyze risk factors associated with short and long-term mortality in nonagenarians hospitalized due to acute medical conditions. DESIGN, SETTING, AND PARTICIPANTS: Prospective study of all patients aged 90 years or older admitted in a geriatric unit during 2009 due to medical acute illness. Baseline variables were collected at admission (sex, cause of admission, Charlson index, serum albumin, functional, and mental status), functional loss at admission (as the difference between Barthel index(BI) 2 weeks before admission and BI at admission), and functional loss at discharge(as the difference between BI 2 weeks before admission and BI at discharge). The association of these variables with mortality at 1 month and 1 year after admission was analyzed by multivariate Cox regression analysis. RESULTS: Out of all patients admitted, 434 (33%) were 90 years old or older and 76.3% were female. Mortality at 1 month and 1 year after admission was 19% and 57%, respectively. In the month mortality multivariate analysis, being older (HR, 1.11; 95% CI=1.02 to 1.20), a previous Barthel index less than 40 points (HR, 5.87; 95% CI=1.16 to 29.67), and functional loss at admission (HR; 1.13; 95% CI=1.03 to 1.25) were independent risk factors. When patients that died 1 month after admission were excluded, the presence of hypoalbuminemia <3g/dl (HR, 2.70; 95% CI=1.69 to 4.32) and functional loss at discharge (HR-1.08, 95% CI=1.03 to 1.14) were the factors associated with 1 year mortality. CONCLUSIONS: In nonagenarians, functional impairment is the most important risk factor associated with short and long-term mortality after hospitalization due to acute medical illness.

Eficiencia de las unidades geriátricas de agudos: metaanálisis de estudios controlados / Efficiency of acute geriatric units: a meta-analysis of controlled studies

Objetivo. Tras objetivar la eficacia en la reducción de la incidencia de deterioro funcional y mayor probabilidad de volver al domicilio previo entre los pacientes ancianos hospitalizados por patología médica aguda atendidos en unidades geriátricas de agudos (UGA) frente a las unidades de cuidados convencionales nos proponemos evaluar la eficiencia de dicha atención. Material y métodos. Revisión sistemática y metaanálisis de estudios controlados (aleatorizados, no aleatorizados y casos-control) que compararon la atención en UGA con la atención en unidades convencionales de hospitalización en pacientes de 65 y más años con patología médica aguda. Se excluyeron estudios sobre bases de datos administrativas, los que evaluaban la atención sobre una sola patología y los que valoraban unidades con cuidados en fase aguda y subaguda. Se realizó una revisión bibliográfica de artículos publicados hasta el 31 de agosto de 2008 en Medline, Embase, Biblioteca Cochrane y listado de referencias de revisiones sistemáticas y artículos revisados. La selección de los estudios y extracción de datos sobre estancia y costes de atención hospitalaria se realizó por dos investigadores de forma independiente. Resultados. Se incluyeron 11 estudios, de los que 5 fueron aleatorizados, 4 no aleatorizados y 2 estudios caso-control disponiendo de datos de estancia para todos ellos y de costes hospitalarios en 7 (4 ensayos clínicos, 2 estudios no aleatorizados y 1 caso-control). El análisis global de todos los estudios mostró que, en comparación con los ancianos hospitalizados en unidades convencionales, los que lo hicieron en las UGA tuvieron una reducción estadísticamente significativa de la estancia hospitalaria (diferencia de medias de – 1,01 días; IC del 95%, –1,66 a –0,36) y de los costes hospitalarios de atención (diferencia de medias de –330 dólares; IC del 95%, –540 a –120). Conclusiones. La atención en UGA es más eficiente que la proporcionada en unidades convencionales ya que, además de conseguir una reducción de la incidencia de deterioro funcional al alta y aumentar la probabilidad de volver al domicilio previo, lo hacen con una reducción de la estancia media hospitalaria y los costes hospitalarios de la atención(AU)

Objective. After analysing the effectiveness in the reduction in the incidence of functional impairment and a higher probability of returning home between elderly patients hospitalised due to an acute medical illness cared for in acute geriatric units (AGU) compared to conventional care units, we propose to assess the efficiency of this care. Material and methods. A systematic review and meta-analysis was made of controlled studies (randomised, no randomised and case-control) that compared care in UGA with care in conventional hospital units of patients of 65years and over with an acute medical illness. Studies on administrative data bases, those that evaluated care of a single disease, and those that assessed units with care in the acute and sub-acute phase were excluded. A literature review was performed on articles published up to 31st of August 2008 in Medline, Embase, Cochrane Library, and references of systematic reviews and reviewed articles. The selection of the studies and the extraction of data on the hospital stay and care costs was made independently by two different researchers. Results. A total of 11 studies were included, of which 5 were randomised, 4 were non-randomised, and 2 case control, all of them providing data on hospital stay, with 7 of them providing data on hospital costs (4 clinical trials, 2 non-randomised and 1 case-control). The overall analysis of all the studies showed that those admitted to UGA had a statistically significant reduction in hospital length of stay compared to the elderly hospitalised in conventional units (mean difference –1.01days; 95% CI, –1.66 to –0.36) and hospital care costs (mean difference of –330 US dollars; 95% CI, –540 to –120). Conclusions. Care in AGU is more efficient than that provided in conventional units, since, as well as achieving a reduction in the incidence of functional impairment at discharge and increasing the probability of returning home, they reduce mean hospital stay and the hospital care costs(AU)

[Efficiency of acute geriatric units: a meta-analysis of controlled studies]. / Eficiencia de las unidades geriátricas de agudos: metaanálisis de estudios controlados.

OBJECTIVE: After analysing the effectiveness in the reduction in the incidence of functional impairment and a higher probability of returning home between elderly patients hospitalised due to an acute medical illness cared for in acute geriatric units (AGU) compared to conventional care units, we propose to assess the efficiency of this care. MATERIAL AND METHODS: A systematic review and meta-analysis was made of controlled studies (randomised, no randomised and case-control) that compared care in UGA with care in conventional hospital units of patients of 65 years and over with an acute medical illness. Studies on administrative data bases, those that evaluated care of a single disease, and those that assessed units with care in the acute and sub-acute phase were excluded. A literature review was performed on articles published up to 31st of August 2008 in Medline, Embase, Cochrane Library, and references of systematic reviews and reviewed articles. The selection of the studies and the extraction of data on the hospital stay and care costs was made independently by two different researchers. RESULTS: A total of 11 studies were included, of which 5 were randomised, 4 were non-randomised, and 2 case control, all of them providing data on hospital stay, with 7 of them providing data on hospital costs (4 clinical trials, 2 non-randomised and 1 case-control). The overall analysis of all the studies showed that those admitted to UGA had a statistically significant reduction in hospital length of stay compared to the elderly hospitalised in conventional units (mean difference -1.01 days; 95% CI, -1.66 to -0.36) and hospital care costs (mean difference of -330 US dollars; 95% CI, -540 to -120). CONCLUSIONS: Care in AGU is more efficient than that provided in conventional units, since, as well as achieving a reduction in the incidence of functional impairment at discharge and increasing the probability of returning home, they reduce mean hospital stay and the hospital care costs.

Recovery of functional impairment after acute illness and mortality: one-year follow-up study.

BACKGROUND: Functional status in older people is a dynamic situation, which makes it necessary to evaluate functional capacity at different times to determinate their prognostic value. OBJECTIVE: To examine the association between functional status (baseline and change after acute illness) and mortality and functional changes at 1 year. METHODS: Hospital-based prospective longitudinal cohort study of all patients over 65 years old, admitted for multidisciplinary treatment of functional impairment after acute illness in a medium-stay unit (post-acute geriatric unit) of a teaching hospital ascribed to the Spanish National Health Service from Spain during 15 consecutive months. Functional status (Barthel Index, BI) was assessed prior to the acute illness, at admission in a post-acute unit, at discharge and 1 year later. At admission, other variables were collected: sociodemographic, main diagnostic for hospitalization (stroke, orthopedic process, or deconditioning), serum albumin, comorbidity (Charlson Index), cognitive status (Pfeiffer s Short Portable Mental Status Questionnaire). In order to analyze mortality 1 year after discharge, a Cox regression analysis was performed. RESULTS: Three hundred and sixty-nine patients constituted the study population, mean age was 80.74 years (SD 7.4), 66.6% were female and 1 year after discharge mortality was 20%. In the multivariate analysis, variables associated with a higher 1-year mortality were age (HR 1.06; 95% CI = 1.00-1.07) male gender (HR 2.11; 95% CI = 1.26-3.55), worse prior functional status (HR 0.98; 95% CI = 0.96-0.99), and higher functional loss in BI at admission (HR 1.02; 95% CI = 1.00-1.04). On the other hand, a greater functional gain in BI at discharge was associated with a lower 1-year mortality (HR 0.98; 95% CI = 0.96-0.99). CONCLUSIONS: The main functional gain obtained after treatment in a multidisciplinary post-acute geriatric unit is independently associated with a reduction in long-term mortality. In addition to baseline functional status and after acute illness, the subsequent potential recovery is very important to predict poor long-term outcomes.

Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis.

OBJECTIVE: To assess the effectiveness of acute geriatric units compared with conventional care units in adults aged 65 or more admitted to hospital for acute medical disorders. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, and the Cochrane Library up to 31 August 2008, and references from published literature. Review methods Randomised trials, non-randomised trials, and case-control studies were included. Exclusions were studies based on administrative databases, those that assessed care for a single disorder, those that evaluated acute and subacute care units, and those in which patients were admitted to the acute geriatric unit after three or more days of being admitted to hospital. Two investigators independently selected the studies and extracted the data. RESULTS: 11 studies were included of which five were randomised trials, four non-randomised trials, and two case-control studies. The randomised trials showed that compared with older people admitted to conventional care units those admitted to acute geriatric units had a lower risk of functional decline at discharge (combined odds ratio 0.82, 95% confidence interval 0.68 to 0.99) and were more likely to live at home after discharge (1.30, 1.11 to 1.52), with no differences in case fatality (0.83, 0.60 to 1.14). The global analysis of all studies, including non-randomised trials, showed similar results. CONCLUSIONS: Care of people aged 65 or more with acute medical disorders in acute geriatric units produces a functional benefit compared with conventional hospital care, and increases the likelihood of living at home after discharge.

Reduction of functional deterioration during hospitalization in an acute geriatric unit.

The purpose of this study was to compare the incidence of functional deterioration of elderly patients hospitalized in acute care geriatric units compared to that in a conventional care unit. We performed a prospective controlled study over 9 months of patients above 65 years old with acute medical pathology. Upon discharge, we compared the degree of functional deterioration using the Katz index compared to the basal level before admission of both groups. Of the 143 patients studied, 68 were admitted to the geriatric care unit and 75 to the conventional care unit. In the geriatric unit, the incidence of functional deterioration occurred in 13 patients (19.1%), while in the conventional care unit it occurred in 30 (40%) (p=0.01). In a multivariate analysis of logistical regression, the odds ratio of developing functional deterioration at discharge in the conventional care unit, compared to the geriatric unit was 4.24 (95% CI: 1.50-11.99). The length of stay was shorter in the geriatric unit (7.5 vs. 9.92, p=0.03). We conclude that the elderly patients admitted to a geriatric care unit showed less functional deterioration on discharge compared with those kept in another care unit of a conventional type.

[Functional gain and length of hospital stay at a medium-stay geriatric care unit at the Central Red Cross Hospital in Madrid, Spain]. / Ganancia funcional y estancia hospitalaria en la unidad geriatrica de media estancia del Hospital Central de Cruz Roja de Madrid.

BACKGROUND: The medium-stay or convalescent care geriatric units were defined by the Spanish National Health Institute in 1996 as being the level of geriatric hospital care aimed at recovering those functions, activities or sequelae having undergone changes as a result of different prior processes. This study is aimed at evaluating the characteristics of patients related to functional gain and stay in medium-stay geriatric units. METHODS: A study was made of all those patients admitted throughout the May 2000-December 2001 period. The weekly and overall functional gain was evaluated using the Barthel Index (BI), the hospital stay and the effectiveness (BI at discharge-BI at admission/during stay) having been evaluated. An improvement in the weekly gain of BI>5 points was set at the effectiveness threshold. RESULTS: A total of 459 patients averaging age 80.56 (+/-7.45) admitted for functional recovery from sequelae of ictus (48.4%), orthopedic disorders (26.3%) and immobility due to other ailments (23.5%) were evaluated. The total functional gain was 29.71 (+/-16.75) Barthel Index points, entailing an average stay of 24.93 (+/-12.94) days and a 1.44 (+/-1.02) effectiveness. The weekly functional gain was above the threshold set during the first three weeks, independently of the age and disorder for which admitted. In the multivariate regression analysis, the age, admission due to ictus, functional impairment prior to admission, cognitive impairment at admission, comorbility and delay in admission were related to a lesser functional gain. Admission due to ictus and a better functional condition prior to admission and better cognitive condition at admission were related to a longer stay. CONCLUSIONS: Hospital stays in medium-stay geriatric units is adequate, at least during the first three weeks. A comparison of the results among units should be adjusted by age, the disorder for which admitted, comorbility and functional and cognitive condition of the patients.