Partnering with cattle ranchers for forest landscape restoration.

Transforming Latin America's extensive grazing systems is critical for forest landscape restoration (FLR) but conservation initiatives rarely make efforts to include cattle ranchers. Engaging ranchers requires understanding their perceptions about how improved management and conservation practices fit into their overall production strategy. To assess ranchers' motivations and limitations for adopting conservation-friendly practices, I surveyed 191 ranchers and extension agents participating in a silvopastoral project in Colombia. I found that ranchers are integrating multiple practices they perceive as complementary for achieving their goals: practices aimed at improving productivity are motivated by utilitarian values, while practices targeting environmental degradation and climate change are driven by stewardship and identity values. Input costs and labor shortages currently limit the expansion of conservation-friendly practices, but in-kind support and small cash payments could potentially alleviate these barriers. Silvopastoral ranchers can be instrumental partners in FLR provided that initiatives are designed with their perspectives in mind.

Nutritional Status and Functional Outcomes in Older Adults Admitted to Geriatric Rehabilitations: The SAFARI Study.

Objective: Evidence about the role of nutritional status (NS) on functional outcomes (FO) after rehabilitation in older adults is scarce. Our aim was to analyze the association between NS and FO in older adults admitted to geriatric rehabilitation units. Methods: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) multicenter study enrolled patients aged ≥65 years admitted to geriatric rehabilitation units in Italy and Spain. FO were absolute and relative functional gain (AFG-RFG) in Barthel Index (BI) at 1 and 3 months after admission. The association between NS (Mini Nutritional Assessment-Short Form) and FO was explored using linear regression and mixed models, adjusted for potential confounders. Analyses were then stratified for diagnosis at admission. Results: We included 415 patients (mean age 81.4 years [SD: 7.7]; 67% female; 9.4% malnourished [MN], 42.7% at risk of malnutrition [RM], and 48% well nourished [WN]). Admission diagnoses were hip fracture (39.5%), elective orthopedic surgery (EOS) (29.5%), and stroke (31%). In an adjusted linear mixed model, MN and RM participants had lower BI compared to WN (MN: ß: -8.47, p = 0.023; RM: ß: -5.22, p = 0.031), and differences between groups remained stable over time. After stratification for admission diagnosis, only MN patients admitted after EOS had worse FO, both at 30 days (AFG: ß adjusted: -13.54, p < 0.001; RFG: ß: -32, p < 0.001) and 3 months (AFG: ß adjusted: -17.79, p < 0.001; RFG: ß: -26.77, p = 0.002). Conclusions: In our sample, poor NS is associated with worse BI in older adults admitted to geriatric rehabilitation units; in patients undergoing EOS, MN is associated with worse FO. Our results documented for the first time the importance of assessing nutritional status before EOS.

Delirium Subtypes and Associated Characteristics in Older Patients With Exacerbation of Chronic Conditions.

OBJECTIVE: The prevalence and prognosis of delirium motor subtypes are not yet well established. We analyzed the prevalence of motor subtypes of delirium, as well as their risk factors and outcomes, among older vulnerable patients admitted for short-term management of exacerbated chronic conditions. METHODS: Cohort study of patients aged 65 and older who developed delirium while admitted to a subacute care unit for 12 months (N = 352). Confusion Assessment Method was used to determine the presence of delirium and the Delirium Motor Subtype Scale was used to define the motor subtype. Outcomes included discharge destination, mortality, readmission, and functional trajectories. RESULTS: Out of 352 patients with delirium (mean age= 87.4, 73.6% with dementia), hyperactive delirium was the most prevalent subtype (40.6%), followed by mixed (31%), hypoactive (25.9%), and nonmotor (2.6%). In multivariate models, worse preadmission functional status (odds ratio [OR] [95% confidence interval {CI}] = 0.97 [0.96-0.98]) and higher comorbidity (OR [95% CI] = 1.3 [1.04-1.51]) were associated with an increased risk of hypoactive delirium. In multivariate models adjusted for different variables, including disability, hypoactive delirium was associated with mortality compared with hyperactive delirium (OR [95% CI] = 4.7 [1.6-14]) and mixed delirium (OR [95% CI] = 2.0 [1.02-3.9]) and with worse functional recovery (Beta[95% CI] = -0.2 [-12.0-(-0.4)]). CONCLUSION: Delirium motor subtypes were associated with different patient characteristics and outcomes. Hypoactive delirium seems to affect more vulnerable patients and to be associated with worse outcomes. More research on the different delirium subtypes could help develop better preventive and management strategies.

¿Mides la velocidad de la marcha en tu práctica diaria? Una revisión / Do you measure gait speed in your daily clinical practice? A review

La velocidad de la marcha (VM) a paso habitual es una medida fácil, rápida, económica, fiable e informativa. Con un cronómetro, como los que actualmente se encuentran en todos los móviles, dos marcas en el suelo y una mínima estandarización, un profesional sanitario obtiene una medida más objetiva y rápida respecto a muchas de las escalas habituales de valoración de las actividades de la vida diaria, por ejemplo. La VM es uno de los pilares del fenotipo de fragilidad y está fuertemente relacionada con la sarcopenia. Es un potente marcador de caídas, discapacidad incidente y de muerte, útil sobre todo como cribado en el ámbito comunitario o de atención primaria. Paralelamente, en los últimos años empieza a tener evidencia también en el pronóstico de procesos médicos agudos o en el paciente posquirúrgico, y se está estudiando la utilidad de esta herramienta en los pacientes con demencia, a la luz de su relación con las alteraciones cognitivas. La VM cumple los requerimientos fundamentales para una buena herramienta de cribado. Sin embargo, no se utiliza en la práctica clínica. ¿Por qué? Esta revisión, que no pretende ser sistemática ni exhaustiva, tiene diferentes objetivos: 1)revisar la relación entre VM y fragilidad; 2)revisar las principales técnicas de mediciön; 3)aportar evidencia en diferentes perfiles clínicos (personas mayores aparentemente sanas, con deterioro cognitivo, con cáncer, con otras patologías o problemas de salud) y en diferentes ámbitos (comunitario, hospitalización, rehabilitación), y 4)reflexionar de manera crítica sobre por qué todavía no se utiliza de manera rutinaria y qué faltaría para potenciar esta utilización (AU)

Gait speed (GS), measured at usual pace, is an easy, quick, reliable, non-expensive and informative measurement. With a standard chronometer, like those that currently found in mobile phones, and with two marks on the floor, trained health professionals obtain a more objective and quick measurement compared with many geriatric scales used in daily practice. GS is one of the pillars of the frailty phenotype, and is closely related to sarcopenia. It is a powerful marker of falls incidence, disability and death, mostly useful in the screening of older adults that live in the community. In recent years, the evidence is reinforcing the usefulness of GS in acute care and post-surgical patients. Its use in patients with cognitive impairment is suggested, due to the strong link between cognitive and physical function. Although GS meets the criteria for a good geriatric screening tool, it is not much used in clinical practice. Why? This review has different aims: (I) disentangling the relationship between GS and frailty; (II) reviewing the protocols to measure GS and the reference values; (III) reviewing the evidence in different clinical groups (older adults with frailty, with cognitive impairment, with cancer or other pathologies), and in different settings (community, acute care, rehabilitation), and (IV) speculating about the reasons for its poor use in clinical practice and about the gaps to be filled (AU)

[Do you measure gait speed in your daily clinical practice? A review]. / ¿Mides la velocidad de la marcha en tu práctica diaria? Una revisión.

Gait speed (GS), measured at usual pace, is an easy, quick, reliable, non-expensive and informative measurement. With a standard chronometer, like those that currently found in mobile phones, and with two marks on the floor, trained health professionals obtain a more objective and quick measurement compared with many geriatric scales used in daily practice. GS is one of the pillars of the frailty phenotype, and is closely related to sarcopenia. It is a powerful marker of falls incidence, disability and death, mostly useful in the screening of older adults that live in the community. In recent years, the evidence is reinforcing the usefulness of GS in acute care and post-surgical patients. Its use in patients with cognitive impairment is suggested, due to the strong link between cognitive and physical function. Although GS meets the criteria for a good geriatric screening tool, it is not much used in clinical practice. Why? This review has different aims: (i)disentangling the relationship between GS and frailty; (ii)reviewing the protocols to measure GS and the reference values; (iii)reviewing the evidence in different clinical groups (older adults with frailty, with cognitive impairment, with cancer or other pathologies), and in different settings (community, acute care, rehabilitation), and (iv)speculating about the reasons for its poor use in clinical practice and about the gaps to be filled.

Estudio de aplicabilidad de la entrevista motivacional para potenciar la rehabilitación en pacientes geriátricos ingresados en una unidad de convalecencia / Feasibility study of motivational interviewing to improve rehabilitation in an Intermediate Care Hospital

Objetivo: La rehabilitación de las personas mayores es una intervención compleja, en la cual intervienen múltiples componentes (clínica, cognitiva, anímica etc.). Nuestro estudio pretende comprobar si la entrevista motivacional (EM) (basada en una atención centrada en la persona), con adaptaciones, es aplicable en pacientes con fractura de fémur o ictus que realizan rehabilitación en una unidad de convalecencia. Metodología: Se realizan entrevistas motivacionales a 20 pacientes > 65 años (10 con fractura de fémur y 10 con ictus). Un geriatra formado en EM realiza dos entrevistas a cada paciente, una inicial en < 72 horas del ingreso y otra de seguimiento la semana siguiente. Para que los pacientes recuerden los ejercicios acordados, se entregan trípticos adaptados. Resultados: Todos los pacientes aceptaron y valoraron satisfactoriamente las dos entrevistas. La segunda entrevista mostraba mejor aceptación si realizada antes del 6è día, porqué se recordaba mejor al profesional y los objetivos acordados. La demanda de esta intervención fue alta (4-5 pacientes/semana). El mejor momento per realizar la entrevista es por la tarde, evitando interferir en el funcionamiento de la planta. La EM en pacientes con deterioro cognitivo leu presenta mayor dificultad, y en 3 ocasiones se incorporó a la entrevista al cuidador principal, con muy buena respuesta. La motivación de los pacientes para realizar rehabilitación fue alta (poca ambivalencia), por ello durante las entrevistas no se trabajó tanto la ambivalencia, sino en empoderar a los pacientes y ayudarlos a encontrar herramientas para aumentar las probabilidades de éxito. Conclusiones: La EM es una herramienta fácilmente aplicable dentro del entorno socio sanitario, realizando algunas adaptaciones. La motivación de los pacientes es alta y la EM se centra sobre todo en empoderar al paciente. Este estudio abre la puerta a evaluar, en un futuro, si la intervención es efectiva en este ámbito

Objective: Our main objective was to test the feasibility of adding a patient centered motivational intervention to the usual rehabilitation in an Intermediate Care (IC) Hospital for patients admitted after a hip fracture or stroke. Methods: 20 patients>65 years (10 hip fracture;10 stroke) participated in the study, receiving two motivational interviewing sessions by a trained geriatrician, the first within the 72 hours after admission, the second one week later. All patients were given leaflets informing about different rehabilitation exercises to perform besides formal physical therapy provided in the hospital, among which they could choose those they felt more suitable. Data collected included socio-demographics, comorbidity, and clinical, cognitive and functional status. Results: The motivational intervention was accepted by all patients and all felt it to be appropriate. Opportunities for this intervention were high,4-5 patients per week, best time for the interventions was in the afternoons, which avoided interferences with hospital activities. In patients with mild cognitive impairment the intervention was harder, and in 3 occasions the primary caregiver was invited to participate, with high acceptance and enthusiasm. Patients at baseline were already highly motivated to do rehabilitation, and ambivalence was not big. Therefore most of the interviews focussed on empowering patients and helping them to identify and set their own goals during rehabilitation. Conclusions: Adding specific motivational interventions to usual rehabilitation treatment in older patients admitted after a hip fracture or stroke, is feasible and acceptable in our IC Hospital. Since patients are quite prone to rehabilitation, interviews tend to focus on empowerment. Further, rigorous research is needed

Valoración geriátrica y factores pronósticos de mortalidad en pacientes muy ancianos con neumonía extrahospitalaria / Geriatric Assessment and Prognostic Factors of Mortality in Very Elderly Patients With Community-Acquired Pneumonia

Introducción: Analizar la relación de parámetros Obtenidos en la valoración geriátrica con la mortalidad en ancianos con neumonía extrahospitalaria (NEH) en una unidad de geriatría de agudos (UGA). Método: Un total de 456 pacientes (≥ 75 años). Variables: edad, sexo, procedencia, antecedentes, nivel de conciencia, frecuencia cardíaca y respiratoria, presión arterial, datos de laboratorio, derrame pleural, afectación multilobar, capacidad funcional (independencia para actividades de la vida diaria) previa al ingreso (índice de Lawton [IL], índice de Barthel previo [IBp]) y en el momento del ingreso (IBi), función cognitiva (test de Pfeiffer [TP]), comorbilidad (índice de Charlson [ICh]) y nutrición (proteínas totales, albúmina). Resultados: Los 110 pacientes que fallecieron durante el ingreso (24,2%) tuvieron mayor edad (86,6 ± 6,4 vs 85,1 ± 6,4; p < 0,04), mayor comorbilidad (ICh 2,35 ± 1,61 vs 2,08 ± 1,38; p < 0,083), menor capacidad funcional (IL: 0,49 ± 1,15 vs 1,45 ± 2,32; p < 0,001; IBp: 34,6 ± 32,9 vs 54,0 ± 34,1; p < 0,001; IBi: 5,79 ± 12,5 vs 20,5 ± 22,9; p < 0,001), mayor porcentaje de pérdida funcional al ingreso (85,9 ± 23,2 vs 66,4 ± 28,6; p < 0,0001), mayor deterioro cognitivo (TP: 7,20 ± 3,73 vs 5,10 ± 3,69; p < 0,001) y mayor desnutrición (albúmina 2,67 ± 0,54 vs 2,99 ± 0,49; p < 0,001). Hubo también mayor mortalidad con alteración de conciencia (49,2%; p < 0,01), taquipnea (33,3%; p < 0,01), taquicardia (44,4%; p < 0,002), urea elevada (31,8; p < 0,001), anemia (44,7%; p < 0,02), derrame pleural (42,9%; p < 0,002) y afectación multilobar (43,2%; p < 0,001). En el análisis multivariado resultaron significativos: edad ≥ 90 años (OR: 3,11 [IC 95%: 1,31-7,36]), alteración de conciencia (3,19 [1,66-6,15]), hematocrito < 30% (2,87 [1,19-6,94]), derrame pleural (3,77 [1,69-8,39]) y afectación multilobar (2,76 [1,48-5,16]). El sexo femenino y la capacidad funcional más conservada previa (IL ≥ 5) y en el momento del ingreso (IBi ≥ 40) fueron protectores de mortalidad (0,40 [0,22-0,70]; 0,09 [0,01-0,81] y 0,11 [0,02-0,51]). Conclusiones: Los parámetros de valoración geriátrica y las variables clínicas habituales estuvieron relacionados con la mortalidad

Introduction: To assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit.MethodsFour hundred fifty-six patients (≥ 75 years). Variables: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin). Results: A hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6 ± 6.4 vs 85.1 ± 6.4, P < 0.04), had more comorbidity (ChI 2.35 ± 1.61 vs 2.08 ± 1.38; P < 0.083), worse functional impairment [(LI: 0.49 ± 1.15 vs 1.45 ± 2.32, P < 0.001) (BIp: 34.6 ± 32.9 vs 54.0 ± 34.1, P < 0.001) (BIa: 5.79 ± 12.5 vs 20.5 ± 22.9, P V< 0.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4 ± 28.6; P < 0.0001), worse cognitive impairment (PT: 7.20 ± 3.73 vs 5.10 ± 3.69, P < 0.001) and malnutrition (albumin 2.67 ± 0.54 vs 2.99 ± 0.49, P < 0.001). Mortality was higher with impaired consciousness [49.2% (P < 0.01)], tachypnea [33.3% (P < 0.01)], tachycardia [44.4% (P < 0.002), high urea levels [31.8 (P < 0.001)], anemia [44.7% (P < 0.02)], pleural effusion [42.9% (P < 0.002)], and multilobar infiltrates [43.2% (P < 0.001)]. In the multivariate analysis, variables associated with mortality were: age ≥ 90 years [OR: 3.11 (95% CI: 1.31-7.36)], impaired consciousness [3.19 (1.66-6.15)], hematocrit < 30% [2.87 (1.19-6.94)], pleural effusion [3.77 (1.69-8.39)] and multilobar infiltrates [2.76 (1.48-5.16)]. Female sex and a preserved functional status prior (LI ≥ 5) and during admission (BIa ≥ M40) were protective of mortality [0.40 (0.22-0.70), 0.09 (0.01-0.81) and 0.11 (0.02-0.51)]. Conclusions: Geriatric assessment parameters and routine clinical variables were associated with mortality

Geriatric assessment and prognostic factors of mortality in very elderly patients with community-acquired pneumonia.

INTRODUCTION: To assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit. METHODS: Four hundred fifty-six patients (≥75years). VARIABLES: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin). RESULTS: A hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6±6.4 vs 85.1±6.4, P<.04), had more comorbidity (ChI 2.35±1.61 vs 2.08±1.38; P<.083), worse functional impairment [(LI: 0.49±1.15 vs 1.45±2.32, P<.001) (BIp: 34.6±32.9 vs 54.0±34.1, P<.001) (BIa: 5.79±12.5 vs 20.5±22.9, P<.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4±28.6; P<.0001), worse cognitive impairment (PT: 7.20±3.73 vs 5.10±3.69, P<.001) and malnutrition (albumin 2.67±0.54 vs 2.99±0.49, P<.001). Mortality was higher with impaired consciousness [49.2% (P<.01)], tachypnea [33.3% (P<.01)], tachycardia [44.4% (P<.002), high urea levels [31.8 (P<.001)], anemia [44.7% (P<.02)], pleural effusion [42.9% (P<.002)], and multilobar infiltrates [43.2% (P<.001)]. In the multivariate analysis, variables associated with mortality were: age ≥90years [OR: 3.11 (95%CI: 1.31 to 7.36)], impaired consciousness [3.19 (1.66 to 6.15)], hematocrit <30% [2.87 (1.19 to 6.94)], pleural effusion [3.77 (1.69 to 8.39)] and multilobar infiltrates [2.76 (1.48 to 5.16)]. Female sex and a preserved functional status prior (LI≥5) and during admission (BIa≥40) were protective of mortality [0.40 (0.22 to 0.70), 0.09 (0.01 to 0.81) and 0.11 (0.02 to 0.51)]. CONCLUSIONS: Geriatric assessment parameters and routine clinical variables were associated with mortality.