Approach to the elderly patient with vertebral fracture due to bone fragility. / Abordaje del adulto mayor con fractura vertebral por fragilidad ósea.

Osteoporosis is a metabolic and systemic disease characterized by alterations at the level of bone tissue with loss of bone mineral density, changes in microarchitecture, mineralization and remodeling that determine greater bone fragility and risk of fracture. Falls in the elderly are a risk factor closely related to fragility fractures and numerous studies demonstrate this relationship. Vertebral fractures are a major cause of morbidity and mortality. The epidemiology differs from osteoporotic fractures at other skeletal sites, as only one-third are clinically recognized. In the elderly, the approach to osteoporotic vertebral fracture involves comprehensive evaluation of the patient, since it is both a cause and a consequence of multiple geriatric syndromes. This fracture, in its acute phase and subsequently, can lead to destabilization of other organs and systems of the elderly, medical complications at different levels, functional deterioration, dependence, and even the need for institutionalization. Therefore, it is important to carry out a multiple assessment of patients with vertebral fractures, addressing not only the history and risk factors of osteoporosis, but also those factors that lead to falls, as well as a comprehensive geriatric assessment and the complications closely associated with it. In this chapter we address each of these aspects that are necessary in the individual and multidimensional approach to the elderly patient with vertebral fracture due to bone fragility.

Factores predictivos del riesgo de fractura de cadera osteoporótica en octogenarios / Predictive factors of osteoporotic hip fracture in octogenarians

Objetivo Este estudio tiene como objetivo identificar los factores de riesgo asociados con las fracturas de cadera osteoporóticas en octogenarios y busca perfeccionar las estrategias de prevención primaria para estas fracturas. Material y métodos Realizamos un estudio de casos y controles en el que participaron personas de 79 años o más con fracturas de cadera, comparándolas con controles de la misma edad y sexo sin antecedentes de fracturas de cadera. Se recogieron factores epidemiológicos, clínicos, antropométricos y analíticos. Se evaluó la presencia de osteoporosis mediante densitometría ósea. Definimos la sarcopenia según los criterios del Grupo de Trabajo Europeo sobre Sarcopenia en Personas Mayores (EWGSOP2). Resultados Se analizaron 95 pacientes por grupo, con una edad media de 82 años, de los cuales 74% eran mujeres. El análisis multivariado incluyó factores estadísticamente significativos encontrados en el análisis univariado (p<0,05). Estos factores incluyeron el índice de Barthel, la evaluación nutricional mediante la herramienta CONUT, el ácido fólico, la deficiencia de vitamina D, la presencia de fracturas previas, la pérdida de agudeza visual, la circunferencia bicipital, la sarcopenia y la osteoporosis (densitometría en el cuello del fémur). El estado nutricional (OR: 0,08 [0,01-0,61]), los niveles de ácido fólico (OR 0,32 [0,1-1]) y la pérdida de agudeza visual (OR 33,16 [2,91-377,87]) fueron los factores de riesgo independientes asociados con fractura de cadera. Conclusiones La evaluación del estado nutricional en pacientes de edad avanzada, junto con una evaluación geriátrica integral, representan herramientas fácilmente reproducibles y rentables. Estas herramientas pueden ayudar eficazmente a identificar a las personas con riesgo de sufrir fracturas de cadera, contribuyendo así a medidas preventivas más específicas y eficientes. (AU)

Objective This study aims to identify the risk factors associated with osteoporotic hip fractures in octogenarians and seeks to refine primary prevention strategies for these fractures. Material and methods We conducted a case–control study involving individuals aged 79 years and older with hip fractures, comparing them to age- and sex-matched controls without a history of hip fractures. We collected epidemiological, clinical, anthropometric, and analytical factors. We evaluated the presence of osteoporosis using bone densitometry. We defined sarcopenia according the European Working Group on Sarcopenia in Older People criteria (EWGSOP2). Results Ninety-five patients per group were analyzed, with a mean age of 82 years, of which 74% were women. The multivariate analysis included statistically significant factors found in the univariate analysis (P<.05). These factors included the Barthel Index, nutritional assessment using the CONUT tool, folic acid, vitamin D deficiency, presence of previous fractures, loss of visual acuity, bicipital circumference, sarcopenia, and osteoporosis (densitometry in the neck of the femur). The nutritional state (OR: 0.08 [0.01–0.61]), the folic acid levels (OR 0.32 [0.1–1]), and a loss of visual acuity (OR 33.16 [2.91–377.87]) were the independent risk factors associated with hip fracture. Conclusions The assessment of nutritional status in elderly patients, coupled with a comprehensive geriatric assessment, represents easily reproducible and cost-effective tools. These tools can effectively aid in identifying individuals at risk of hip fractures, thereby contributing to more targeted and efficient preventive measures. (AU)

Factores predictivos del riesgo de fractura de cadera osteoporótica en octogenarios / Predictive factors of osteoporotic hip fracture in octogenarians

Objetivo Este estudio tiene como objetivo identificar los factores de riesgo asociados con las fracturas de cadera osteoporóticas en octogenarios y busca perfeccionar las estrategias de prevención primaria para estas fracturas. Material y métodos Realizamos un estudio de casos y controles en el que participaron personas de 79 años o más con fracturas de cadera, comparándolas con controles de la misma edad y sexo sin antecedentes de fracturas de cadera. Se recogieron factores epidemiológicos, clínicos, antropométricos y analíticos. Se evaluó la presencia de osteoporosis mediante densitometría ósea. Definimos la sarcopenia según los criterios del Grupo de Trabajo Europeo sobre Sarcopenia en Personas Mayores (EWGSOP2). Resultados Se analizaron 95 pacientes por grupo, con una edad media de 82 años, de los cuales 74% eran mujeres. El análisis multivariado incluyó factores estadísticamente significativos encontrados en el análisis univariado (p<0,05). Estos factores incluyeron el índice de Barthel, la evaluación nutricional mediante la herramienta CONUT, el ácido fólico, la deficiencia de vitamina D, la presencia de fracturas previas, la pérdida de agudeza visual, la circunferencia bicipital, la sarcopenia y la osteoporosis (densitometría en el cuello del fémur). El estado nutricional (OR: 0,08 [0,01-0,61]), los niveles de ácido fólico (OR 0,32 [0,1-1]) y la pérdida de agudeza visual (OR 33,16 [2,91-377,87]) fueron los factores de riesgo independientes asociados con fractura de cadera. Conclusiones La evaluación del estado nutricional en pacientes de edad avanzada, junto con una evaluación geriátrica integral, representan herramientas fácilmente reproducibles y rentables. Estas herramientas pueden ayudar eficazmente a identificar a las personas con riesgo de sufrir fracturas de cadera, contribuyendo así a medidas preventivas más específicas y eficientes. (AU)

Objective This study aims to identify the risk factors associated with osteoporotic hip fractures in octogenarians and seeks to refine primary prevention strategies for these fractures. Material and methods We conducted a case–control study involving individuals aged 79 years and older with hip fractures, comparing them to age- and sex-matched controls without a history of hip fractures. We collected epidemiological, clinical, anthropometric, and analytical factors. We evaluated the presence of osteoporosis using bone densitometry. We defined sarcopenia according the European Working Group on Sarcopenia in Older People criteria (EWGSOP2). Results Ninety-five patients per group were analyzed, with a mean age of 82 years, of which 74% were women. The multivariate analysis included statistically significant factors found in the univariate analysis (P<.05). These factors included the Barthel Index, nutritional assessment using the CONUT tool, folic acid, vitamin D deficiency, presence of previous fractures, loss of visual acuity, bicipital circumference, sarcopenia, and osteoporosis (densitometry in the neck of the femur). The nutritional state (OR: 0.08 [0.01–0.61]), the folic acid levels (OR 0.32 [0.1–1]), and a loss of visual acuity (OR 33.16 [2.91–377.87]) were the independent risk factors associated with hip fracture. Conclusions The assessment of nutritional status in elderly patients, coupled with a comprehensive geriatric assessment, represents easily reproducible and cost-effective tools. These tools can effectively aid in identifying individuals at risk of hip fractures, thereby contributing to more targeted and efficient preventive measures. (AU)

Predictive factors of osteoporotic hip fracture in octogenarians.

OBJECTIVE: This study aims to identify the risk factors associated with osteoporotic hip fractures in octogenarians and seeks to refine primary prevention strategies for these fractures. MATERIAL AND METHODS: We conducted a case-control study involving individuals aged 79 years and older with hip fractures, comparing them to age- and sex-matched controls without a history of hip fractures. We collected epidemiological, clinical, anthropometric, and analytical factors. We evaluated the presence of osteoporosis using bone densitometry. We defined sarcopenia according the European Working Group on Sarcopenia in Older People criteria (EWGSOP2). RESULTS: Ninety-five patients per group were analyzed, with a mean age of 82 years, of which 74% were women. The multivariate analysis included statistically significant factors found in the univariate analysis (p < 0.05). These factors included the Barthel Index, nutritional assessment using the CONUT tool, folic acid, vitamin D deficiency, presence of previous fractures, loss of visual acuity, bicipital circumference, sarcopenia, and osteoporosis (densitometry in the neck of the femur). The Nutritional state (OR: 0.08 [0.01-0.61]), the folic acid levels (OR 0.32 [0.1-1]), and a loss of visual acuity (OR 33.16 [2.91-377.87]) were the independent risk factors associated with hip fracture. CONCLUSIONS: The assessment of nutritional status in elderly patients, coupled with a comprehensive geriatric assessment, represents easily reproducible and cost-effective tools. These tools can effectively aid in identifying individuals at risk of hip fractures, thereby contributing to more targeted and efficient preventive measures.

Developing new hospital-at-home models based on Comprehensive Geriatric Assessment: Implementation recommendations by the Working Group on Hospital-at-Home and Community Geriatrics of the Catalan Society of Geriatrics and Gerontology / Desarrollo de nuevos modelos de hospitalización a domicilio basados en la valoración geriátrica integral: recomendaciones del grupo de trabajo de Hospitalización a domicilio y geriatría comunitaria de la Sociedad Catalana de Geriatría y Gerontología para su implementación

Last decade, the Government of Catalonia have urged an integrated care strategy for planning the care model to older populations living with frailty, multimorbidity and advanced illnesses. Based on international evidence that was reviewed by a group of experts from the Catalan Society of Gerontology and Geriatrics, we summarised some recommendation to adapt hospital-at-home care to older populations in our system. We defined Comprehensive Geriatric Assessment (CGA) hospital-at-home (HaH) as a specialised home hospitalisation service formed by interdisciplinary teams, characterised by using the clinical methodology of CGA, and by adapting geriatric units’ protocols for the provision of person-centred care at home. Main benefits of CGA-HaH in these populations are: response to heath crises according to individualised care plans based on the situational diagnosis carried out by Primary Care teams; provision of a comprehensive health and social approach tailored to the complexity of cases and situations; and adaptation of multipurpose hospitalisation, by working on different person-centred care, aspects, such as caregivers support on care provision, focusing on function or home adaptation. (AU)

En la última década el gobierno de Cataluña ha diseñado un plan estratégico de atención integrada para planificar la atención del subgrupo de pacientes mayores con fragilidad, multimorbilidad y enfermedad avanzada, con la intención de mejorar la salud y el manejo clínico. Guiándonos en la evidencia internacional, revisada por un grupo de expertos de la Societat Catalana de Geriatria i Gerontologia, revisamos recomendaciones para adaptar los modelos a la población mayor de nuestro sistema. Así, definimos la hospitalización a domicilio geriátrica o basada en la valoración geriátrica integral (VGI) como una hospitalización a domicilio especializada basada en equipos interdisciplinares que utilizan la VGI como instrumento de trabajo de manera similar a las unidades de hospitalización geriátricas. Estas intervenciones ofrecen beneficios en responder a crisis de salud dando continuidad al diagnóstico situacional y a los planes individualizados planteados por los equipos de atención primaria, en realizar una valoración integral de la complejidad en todos sus aspectos, y en ofrecer una hospitalización integral centrada en la persona, trabajando aspectos como el apoyo a los cuidadores en la atención, la recuperación funcional y la adaptación del domicilio. (AU)

Developing new hospital-at-home models based on Comprehensive Geriatric Assessment: Implementation recommendations by the Working Group on Hospital-at-Home and Community Geriatrics of the Catalan Society of Geriatrics and Gerontology.

Last decade, the Government of Catalonia have urged an integrated care strategy for planning the care model to older populations living with frailty, multimorbidity and advanced illnesses. Based on international evidence that was reviewed by a group of experts from the Catalan Society of Gerontology and Geriatrics, we summarised some recommendation to adapt hospital-at-home care to older populations in our system. We defined Comprehensive Geriatric Assessment (CGA) hospital-at-home (HaH) as a specialised home hospitalisation service formed by interdisciplinary teams, characterised by using the clinical methodology of CGA, and by adapting geriatric units' protocols for the provision of person-centred care at home. Main benefits of CGA-HaH in these populations are: response to heath crises according to individualised care plans based on the situational diagnosis carried out by Primary Care teams; provision of a comprehensive health and social approach tailored to the complexity of cases and situations; and adaptation of multipurpose hospitalisation, by working on different person-centred care, aspects, such as caregivers support on care provision, focusing on function or home adaptation.

Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era - A Portuguese study.

OBJECTIVES: Identifying frequent users' (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age. METHODS: A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed. RESULTS: CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users. CONCLUSIONS: This study showed that 97.1% of patients had needs that would justify an interventional care plan. This intervention should be extended to primary care and nursing homes. While not providing a robust model, our study has indicated nutritional problems, polypharmacy, and an elevated Charlson index as the features with more weight in frequent users' admissions.

Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era – A Portuguese study / Valoración geriátrica integral de pacientes mayores y factores asociados de frecuentación en servicios de urgencias en la era pre-COVID-19 – Un estudio portugués

Objectives: Identifying frequent users’ (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age. Methods: A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed. Results: CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users. (AU)

Objetivos: Identificar factores asociados con usuarios frecuentadores (≥ 3 ingresos/año) en un departamento de urgencias (DU), mediante valoración geriátrica integral (VGI) y describir las características de los pacientes mayores de 65 años que acuden a urgencias.Métodos: El estudio transversal se realizó entre agosto del 2017 y junio del 2018 en un DU de Lisboa, Portugal. Se realizó una VGI además de la historia clínica. Se crearon scores clínicos, funcionales, mentales, sociales, basándose en el protocolo de cuestionario del grupo de geriatría de la Sociedad Portuguesa de Medicina Interna y se desarrolló un modelo estadístico para identificar los factores asociados con la alta frecuentación.Resultados: Se realizó una VGI a 426 usuarios mayores de un DU. La edad media fue de 79,3 años, siendo 53,8% mujeres con un 84,7% de multimorbilidad, 51,2% de dependencia de las actividades básicas (Katz), 75,6% instrumentales (Lawton < 5 en mujeres, < 3 hombres y 40% de dependencia de la marcha (Holden). El 52% tenían síntomas depresivos (Yesavage), 65,7% tenían deterioro cognitivo (MMSE < 24), 63% estaban desnutridos/en riesgo de desnutrición (MNA < 23,5). El 33,1% estaba en riesgo social (Gijón, APGAR familiar). La polifarmacia con el uso de un promedio de 6,5 medicamentos al día. Los scores sociales, clínicos, funcionales y mentales fueron adversos en el 48,6, 79,6, 54,9 y 83,1%, respectivamente. Hubo 2,7 admisiones/año y el 39,9% eran usuarios frecuentes de DU (≥ 3/año). Un modelo de regresión logística fue débil, pero mostró que los pacientes con polifarmacia, índice de comorbilidad de Charlson elevado y un estado nutricional adverso presentaban mayor riesgo de ser usuarios frecuentes. (AU)

Descripción y aplicación clínica de las escalas de valoración geriátrica integral: una revisión sistemática rápida de revisiones / Description and clinical application of comprehensive geriatric assessment scales: a rapid systematic review of reviews

Objetivo Realizar una descripción de las principales escalas utilizadas en la valoración geriátrica integral mediante un análisis narrativo detallando su aplicación clínica en relación con sus ventajas y desventajas en función de sus propiedades psicométricas (valoración mental) y los sesgos en su aplicación. Las escalas seleccionadas fueron: índice de Barthel, índice de Katz, escala de Lawton y Brody, mini-examen del estado mental, test del reloj, escala de depresión geriátrica y la escala de recursos sociales. Métodos Se realizó una revisión sistemática rápida de revisiones en MEDLINE (PubMed) hasta enero de 2021, informando de los hallazgos mediante PRISMA, 2020. Para construir la estrategia de búsqueda reproducible se empleó el lenguaje MeSH, palabras clave y los operadores booleanos AND y OR. Resultados Se seleccionaron 31 que cumplieron los criterios de elegibilidad; 18 revisiones sistemáticas, 12 revisiones de la literatura y una revisión de alcance. Se encontraron múltiples versiones para algunas de las escalas y se constataron sesgos en su interpretación. Se recomienda la administración de cuestionarios cortos y fáciles de aplicar y se aconseja que los puntos de corte se definan según la educación formal. Conclusión Las escalas de valoración geriátrica integral son instrumentos baratos, eficaces y útiles para detectar problemas y potencialidad en las personas mayores. Deben ser de fácil aplicación, no extensas, válidas para múltiples culturas y distintos niveles de educación formal y aplicables a diferentes grados de discapacidad. Es recomendable que los profesionales sanitarios se entrenen en su uso para evitar sesgos en la interpretación de los resultados (AU)

Objective This work aims to describe the main scales used in comprehensive geriatric assessment through a narrative analysis detailing their clinical application in relation to their advantages and disadvantages in terms of their psychometric properties (mental assessment) and biases in their application. The scales selected were: Barthel Index, Katz Index, Lawton and Brody Scale, Mini-Mental State Examination, Clock Test, Geriatric Depression Scale, and the Social Resources Scale. Methods We conducted a rapid systematic review of reviews in MEDLINE (PubMed) up to January 2021, reporting findings using PRISMA, 2020. MeSH language, keywords, and the Boolean operators AND and OR were used to construct the reproducible search strategy. Results Thirty-one works were selected that met the eligibility criteria: 18 systematic reviews, 12 literature reviews, and one scoping review. Multiple versions were found for some of the scales and biases in their interpretation were observed. Short, easy-to-administer questionnaires are recommended and cut-off points should be defined by formal education. Conclusion Comprehensive geriatric assessment scales are inexpensive, effective, and useful instruments for identifying problems and potential problems in the elderly. They should be easy to apply, not extensive, valid for multiple cultures and different levels of formal education, and applicable to individuals with different degrees of disability. It is recommended that health professionals be instructed in their use to avoid biases in the interpretation of the results (AU)

Description and clinical application of comprehensive geriatric assessment scales: A rapid systematic review of reviews.

OBJECTIVE: This work aims to describe the main scales used in comprehensive geriatric assessment through a narrative analysis detailing their clinical application in relation to their advantages and disadvantages in terms of their psychometric properties (mental assessment) and biases in their application. The scales selected were: Barthel Index, Katz Index, Lawton and Brody Scale, Mini-Mental State Examination, Clock Test, Geriatric Depression Scale, and the Social Resources Scale. METHODS: We conducted a rapid systematic review of reviews in MEDLINE (PubMed) up to January 2021, reporting findings using PRISMA, 2020. MeSH language, keywords, and the Boolean operators AND and OR were used to construct the reproducible search strategy. RESULTS: Thirty-one works were selected that met the eligibility criteria: 18 systematic reviews, 12 literature reviews, and one scoping review. Multiple versions were found for some of the scales and biases in their interpretation were observed. Short, easy-to-administer questionnaires are recommended and cut-off points should be defined by formal education. CONCLUSION: Comprehensive geriatric assessment scales are inexpensive, effective, and useful instruments for identifying problems and potential problems in the elderly. They should be easy to apply, not extensive, valid for multiple cultures and different levels of formal education, and applicable to individuals with different degrees of disability. It is recommended that health professionals be instructed in their use to avoid biases in the interpretation of the results.

Multimorbilidad y síndromes geriátricos. Su efecto sobre la mortalidad en adultos mayores con sepsis / Multimorbidity and geriatric syndromes. Their effect on mortality in older adults with sepsis

Resumen Introducción: la sepsis se diagnostica en más de 60% de los adultos mayores (AM) en el mundo. Estos AM con frecuencia presentan multimorbilidad y alguno de los síndromes geriátricos, llevando a discapacidad física, cognitiva y psicosocial, lo cual produce altos costos para los sistemas de salud, resultando en un problema grave de salud pública. Objetivo: identificar el impacto de la multimorbilidad y los síndromes geriátricos en la morta lidad de AM hospitalizados por sepsis en una unidad geriátrica de agudos a 30 días de su ingreso. Material y métodos: estudio observacional, analítico de casos y controles anidado en una cohorte. Resultados: se analizaron 238 pacientes con edad media de 83.15±7.12 años, 52.1% fueron mujeres y el 99% tenían al menos una comorbilidad, la mortalidad a 30 días fue 34%. La infección urinaria fue la causa principal de hospitalización (42.9%), obteniendo un aislamiento microbio-lógico en 43.3% de los casos, siendo la Escherichia coli el agente causal más frecuente (46.6%). La regresión logística múltiple mostró que la enfermedad renal crónica (OR 2.1 IC 95% 1.1-4.8; p=0.037), el delirium (OR 3.1 IC 95% 1.6-5.8; p=0.001) y la discapacidad (índice de Barthel <60; OR 3.4 IC 95% 1.5-7.5; p=0.002) se asociaron de manera significativa con la mortalidad a 30 días desde el ingreso a la unidad geriátrica de agudos en paciente con sepsis. Conclusión: en los AM hospitalizados por sepsis, la multimorbilidad, la enfermedad re nal crónica y los síndromes geriátricos representados por delirium y discapacidad fueron los predictores de mortalidad a 30 días. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2125).

Abstract Introduction: sepsis is diagnosed in more than 60% of older adults (OAs) worldwide. These OAs often have multimorbidity and one of the geriatric syndromes, leading to physical, cognitive and psychosocial disability with consequently high healthcare costs, resulting in a serious public health problem. Objective: to determine the impact of multimorbidity and geriatric syndromes on the 30-day mortality rate of OAs hospitalized for sepsis in an acute geriatric unit Materials and methods: an observational, analytical, nested case-control study. Results: 238 patients with a mean age of 83.15±7.12 were analyzed; 52.1% were women and 99% had at least one comorbidity; the 30-day mortality was 34%. Urinary tract infection was the main cause of hospitalization (42.9%), with microbiological isolation achieved in 43.3% of cases and Escherichia coli being the most common causal agent (46.6%). Multiple logistic regression showed that chronic kidney disease (OR 2.1 95% CI 1.1-4.8; p=0.037), delirium (OR 3.1 95% CI 1.6-5.8; p=0.001) and disability (Barthel index <60; OR 3.4 95% CI 1.5-7.5; p=0.002) were significantly related to 30-day mortality in patients with sepsis admitted to an acute geriatric unit. Conclusion: in OAs hospitalized for sepsis, multimorbidity, chronic kidney disease and geriatric syndromes (represented by delirium and disability) were the predictors of 30-day mortality. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2125).

Encefalitis autoinmune por pembrolizumab en anciano con carcinoma no microcítico avanzado de pulmón. Caso clínico / Pembrolizumab-associated autoimmune encephalitis in an elderly patient with advanced non-small cell lung cancer. A clinical case

Los objetivos terapéuticos en el paciente geriátricoson la mejora de su calidad de vida y de su capacidadfuncional frente al mero incremento de su supervivencia. En patología neoplásica, la decisión de iniciar tratamiento curativo, especialmente inmunoterapia, deberealizarse tras una completa valoración de los riesgospotenciales. El paciente geriátrico es más susceptiblea desarrollar reacciones adversas y de mayor gravedadque el paciente más joven.Se presenta el caso de un anciano octogenario concarcinoma no microcítico pulmonar que desarrolló toxicidad neurológica tras tratamiento con pembrolizumab. Se realiza un diagnóstico diferencial de encefalitisy una revisión de los casos de encefalitis autoinmunepor pembrolizumab para mejorar nuestro conocimiento de esta infrecuente toxicidad. El trabajo interdisciplinar y la valoración geriátrica integral son elementosesenciales para prevenir el deterioro funcional del anciano.(AU)

Therapeutic objectives for the geriatric patient areimprovement of quality of life and functional capacityrather than a mere increase in survival. In neoplasticdisease, the decision to initiate administration of curative therapies, especially immunotherapy, shouldbe taken only after any potential risks have been takeninto account. Geriatric patients are more susceptibleto developing more serious adverse reactions than theyounger population.We report the case of an octogenarian patient withnon-small cell lung cancer who developed neurologictoxicity following pembrolizumab therapy. We carryout a differential diagnosis of encephalitis and providea literature review of pembrolizumab-associated au-toimmune encephalitis cases in order to improve ourknowledge of this unusual toxicity. An interdisciplinaryapproach and comprehensive geriatric assessment areessential components to prevent functional decline inthe elderly.(AU)

Factores asociados a caídas en el servicio ambulatorio de geriatría de un hospital universitario en Bogotá (Colombia) / Factors Associated with Falls in the Outpatient Geriatric Service of a University Hospital in Bogotá, Colombia / Fatores associados a quedas no serviço ambulatorial de geriatria de um hospital universitário em Bogotá, Colômbia

Resumen Introducción: las caídas en el adulto mayor influyen de manera negativa en su estado funcional y el riesgo de caídas se eleva progresivamente con la edad, por lo que es importante objetivar todos los factores de riesgo de cada paciente. El objetivo fue describir la prevalencia y los factores asociados con caídas en los pacientes del servicio ambulatorio de geriatría del Hospital Universitario San Ignacio en Bogotá (Colombia). Materiales y métodos: se realizó un estudio descriptivo con pacientes valorados en la consulta externa de geriatría del Hospital Universitario San Ignacio desde enero de 2017 hasta diciembre de 2018. Resultados: se incluyeron 233 pacientes, en quienes se documentó una prevalencia de caídas del 44.5 %. En el análisis bivariado, las variables con asociación estadísticamente significativa fueron: la presencia de trastorno neurocognitivo mayor (TNCM) (OR: 2.31; IC 95 %: 1.28-4.18; p: 0.005), el miedo a caer (OR: 2.27; IC 95 %: 1.24-4.18; p: 0.008), un grado de dependencia moderado a total (OR: 1.93; IC 95 %: 1.11-3.35; p: 0.019) y un mal estado nutricional (OR: 1.18; IC 95 %: 1.099-3.18; p: 0.02). No obstante, en el análisis multivariado, las variables que mantuvieron la asociación fueron el TNCM (OR: 2.09; IC 95 %: 1.14-3.86; p: 0.001) y el miedo a caer (OR: 2.27; IC 95 %: 1.19-4.32; p: 0.001). Conclusión: las variables asociadas con caídas en nuestra población se relacionan con lo descrito en la literatura mundial; son necesarias intervenciones para corregir estos factores y evitar caídas, así como diseñar más estudios para detectar otros factores asociados.

Abstract Introduction: Falls in the elderly have a negative impact on functional status and the risk of falls increases progressively with age, so it is important to objectify all the risk factors of each patient. Our objective was to describe the prevalence and factors associated with falls in patients from the geriatric outpatient service of the San Ignacio University Hospital in Bogotá, Colombia. Materials and methods: A descriptive study was carried out with patients assessed in the geriatric outpatient clinic of the San Ignacio University Hospital from January 2017 to December 2018. Results: 233 patients were included, documenting a prevalence of falls of 44.5%. In the bivariate analysis, the variables with a statistically significant association were: the presence of major neurocognitive disorder (MNCD) (OR: 2.31; 95 %> CI: 1.284.18; p: 0.005), fear of falling (OR: 2.27; 95 %> CI: 1.24-4.18; p: 0.008), a moderate to total degree of dependence (OR: 1.93; 95 %> ci 1.11-3.35; p: 0.019) and a poor nutritional status (OR: 1.18; 95 °/o CI: 1.099-3.18; p: 0.02). However, in the multivariate analysis, the variables that maintained the association were MNCD (OR: 2.09; 95 %> CI: 1.14-3.86; p: 0.001) and fear of falling (OR: 2.27; 95 %> CI: 1.19-4.32; p: 0.001). Discussion: The variables associated with falls in our population are related to what is described in the world literature; Interventions are necessary to correct these factors and avoid falls in our population, as well as to design more studies to detect other associated factors.

Resumo Introdução: as quedas em idosos impactam negativamente o estado funcional e o risco de quedas aumentam progressivamente com a idade, por isso é importante objetivar todos os fatores de risco de cada paciente. Nosso objetivo foi descrever a prevalência e os fatores associados às quedas em pacientes do ambulatório de geriatria do Hospital Universitário San Ignacio em Bogotá, Colômbia. Materiais e métodos: foi realizado um estudo descritivo com pacientes avaliados no ambulatório de geriatria do Hospital Universitário San Ignacio no período de janeiro de 2017 a dezembro de 2018. Resultados: foram incluídos 233 pacientes, documentando uma prevalência de quedas de 44,5%. Na análise bivariada, as variáveis com associação estatisticamente significativa foram: presença de trastorno neurocognitivo maior (TNCM) (OR: 2.31; IC 95%: 1,28-4,18; p: 0,005), medo de cair (OR: 2,27; IC 95%: 1,24-4,18; p: 0,008), grau de dependência moderado a total (OR: 1,93; IC 95%: 1,11-3,35; p: 0,019) e estado nutricional ruim (OR: 1,18; IC 95%: 1,099-3,18; p: 0,02); porém, na análise multivariada, as variáveis que mantiveram a associação foram TNCM (OR: 2,09; IC 95%: 1,14-3,86; p: 0,001) e medo de cair (OR: 2,27; IC 95%: 1,19-4,32; p: 0,001). Conclusão: as variáveis associadas às quedas em nossa população estão relacionadas ao que é descrito na literatura mundial; são necessárias intervenções para corrigir esses fatores e evitar quedas em nossa população, bem como desenhar mais estudos para detectar outros fatores associados.

Evaluación geriátrica guiada por G8 en la decisión del tratamiento de adultos mayores con cáncer: un estudio piloto / Geriatric evaluation guided by G8 in the decision to treat older adults with cancer: a pilot study / Avaliação geriátrica guiada pelo G8 na decisão de tratar idosos com câncer: um estudo piloto

Introducción: El cáncer es una enfermedad asociada al envejecimiento y tiene una alta prevalencia en los adultos mayores. La valoración geriátrica integral (VGI) mejora los cuidados de los adultos mayores (AM) con cáncer. En contextos sanitarios con recursos limitados, no todos los AM podrán ser evaluados por un geriatra. Un modelo en 2 pasos, incluyendo el test G8, en la consulta habitual del oncólogo, permite seleccionar aquellos pacientes que se beneficiarán de una VGI. Esta puede aportar en la toma de decisiones del tratamiento oncológico específico. Objetivo: Evaluar el beneficio del test G8 y la VGI en ≥ 70 años con cáncer candidatos a recibir quimioterapia. Material y Métodos: Estudio observacional, descriptivo, de corte transversal, de una muestra no probabilística de pacientes ≥ de 70 años con diagnóstico de cáncer y candidatos a recibir quimioterapia. Se aplicó el G8 por el oncólogo y se completó la VGI en los que presentaron alteración en algunas de las áreas evaluadas. Resultados: Se analizaron 32 pacientes. Se realizó G8 a todos, en 21 de ellos se completó la VGI. En estos, en reunión multidisciplinaria con oncólogo y geriatra se discutió el tratamiento. En el 38% de los pacientes se cambió la conducta oncológica tras contar con la valoración geriátrica integral. Conclusión: Creemos que la incorporación del G8 en la práctica clínica del oncólogo aporta una herramienta de cribado útil para identificar los pacientes ≥70 años que se benefician de una VGI previa al inicio de tratamiento oncoespecífico, optimizando de esta manera los recursos.

Introduction: Cancer is a disease associated with aging and has a high prevalence in older adults. Comprehensive geriatric assessment (CGA) improves the care of older adults (OA)with cancer. In healthcare settings with limited resources, not all OA may be evaluated by a geriatrician. A 2-step model, including the G8 test, in the usual oncologist consultation, allows selecting those patients who will benefit from CGA. This can contribute to decision-making regarding specific cancer treatment. Objective: To evaluate the benefit of the incorporation of the G8 test and CGA in the ≥ 70 years with cancer candidates for chemotherapy. Material and Methods: Observational, descriptive, cross-sectional study of a non-probability sample of patients ≥ 70 years of age with a diagnosis of cancer and candidates for chemotherapy. The G8 was applied by the oncologist and the CGA was completed in those who presented alteration in some of the evaluated areas. Results: 32 patients were analyzed. G8 was performed in all, in 21 of them the CGA was completed. In these, the treatment was discussed in a multidisciplinary meeting with an oncologist and a geriatrician. Oncological behavior was changed in 38% of patients after having a comprehensive geriatric evaluation. Conclusion: We believe that the incorporation of the G8 test in the clinical practice of the oncologist provides a useful screening tool to identify patients ≥70 years who benefit from CGA prior to the start of oncospecific treatment, thus optimizing resources.

Introdução: O câncer é uma doença associada ao envelhecimento e tem alta prevalência em idosos. A avaliação geriátrica ampla (AGA) melhora o atendimento a idosos com câncer. Em ambientes de saúde com recursos limitados, nem todos eles podem ser avaliadas por um geriatra. Um modelo de duas etapas, incluindo o teste G8, na consulta oncológica usual, permite selecionar os pacientes que serão beneficiados pela AGA. Isso pode contribuir para a tomada de decisões em relação ao tratamento específico do câncer. Objetivo: Avaliar o benefício da incorporação do teste G8 e AGA nos ≥ 70 anos com câncer, candidatos à quimioterapia. Material e Métodos: Estudo observacional, descritivo e transversal de uma amostra não probabilística de pacientes com idade ≥ 70 anos com diagnóstico de câncer e candidatos à quimioterapia. O G8 foi aplicado pelo oncologista e a AGA foi realizada naqueles que apresentaram alteração em algumas das áreas avaliadas. Resultados: 32 pacientes foram analisados. O G8 foi realizado em todos, em 21 deles a AGA foi aplicada. Nesses, o tratamento foi discutido em reunião multidisciplinar com oncologista e geriatra. O tratamento oncológico foi alterado em 38% dos pacientes após uma avaliação geriátrica amplia. Conclusão: Acreditamos que a incorporação do teste G8 na prática clínica do oncologista fornece uma ferramenta de triagem útil para identificar pacientes com idade ≥70 anos que se beneficiam da AGA antes do início do tratamento oncoespecífico, otimizando recursos.

[Geriatric interventions in the older with cancer based on comprehensive geriatric assessment. Optimization areas: what the geriatrician can contribute to the multidisciplinar team]. / Intervenciones geriátricas en el mayor con cáncer basadas en la valoración geriátrica integral. Áreas de optimización: lo que el geriatra puede aportar al equipo multidisciplinar.

INTRODUCTION: The ageing of the world population, the early detection of some types of tumours, and the increasing survival rates demand/claim a change of model in the specific care of older cancer patient. According to recent data, it is estimated that there will be 29.5 million patients with cancer in 2040, more than 50% of them over 65 years. Most cancer-related deaths and survivorships also belong to this group of age. In this context, the multidisciplinary management of these processes and the development of oncogeriatric oncology become more relevant, both in the decision-making process and in the planning of interventions that affect oncological treatment outcomes and patients' survival, autonomy and quality of life. The evaluation by a geriatrician identifies vulnerability areas using the comprehensive geriatric assessment (CGA) as the key tool, leading us to detect problems that are unidentified by the Eastern Cooperative Oncology Group Performance Status (ECOG) or the Karnofsky index (IK) and bringing us valuable information, essential in the decision-making process. I To conclude, the evaluation by a geriatrician allows to identify impairments, classify the elderly, uncover vulnerability and intervene on it, and predict treatment-related toxicity and mortality, taking part on the decision making process. The CGA offers the possibility to apply a tailored treatment according to the characteristics of each patient. Investigation is necessary in order to get specific evidence to adapt care models working in a multidisciplinary way. Therefore, the collaboration between the different specialists that are involved in the care of cancer elderly patient is essential.

INTRODUCCIÓN: El envejecimiento de la población mundial, la detección cada vez más precoz de algunos cánceres y las mayores tasas de supervivencia reclaman un cambio de paradigma en la atención específica al paciente mayor con cáncer. Según datos recientes, se estima que habrá 29,5 millones de pacientes con cáncer para 2040, más del 50% mayores de 65 años. La mayoría de las muertes por cáncer y de los supervivientes también pertenecen a este grupo etario. En este contexto aparece, y adquiere cada vez mayor relevancia, el manejo multidisciplinar de estos procesos y el desarrollo de la oncogeriatría, tanto en el momento de participar en la toma de decisiones como en el de planificar intervenciones en determinados aspectos que influyen en los resultados del tratamiento oncoespecífico, en la supervivencia, en la autonomía y en la calidad de vida de los pacientes. La evaluación por un geriatra identifica áreas de vulnerabilidad usando como herramienta clave la valoración geriátrica integral (VGI), que permite detectar problemas que no identifican ni la Eastern Cooperative Oncology Group Performance Status (ECOG) ni el índice de Karnofsky (IK) y proporciona información muy valiosa, indispensable en la toma de decisiones. En conclusión, la valoración por un geriatra permite: descubrir déficits, clasificar a los mayores, identificar vulnerabilidad e intervenir sobre ella, predecir toxicidad al tratamiento oncoespecífico y mortalidad y participar en la toma de decisiones. Por tanto, la VGI contribuye a diseñar un tratamiento adaptado a las características de cada paciente. Es necesario seguir investigando para obtener evidencia científica específica y adaptar los modelos asistenciales para trabajar de forma multidisciplinar, siendo imprescindible la colaboración entre los distintos especialistas implicados en la atención al paciente mayor con cáncer.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]. / Geriatría transversal. Un reto asistencial para el siglo xxi.

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

[Impact of frailty and other geriatric syndromes on the clinical management and prognosis of elderly ambulatory patients with heart failure. A prospective and multicentre study]. / Impacto de la FRAgilidad y otros síndromes Geriátricos en el manejo clínico y pronóstico del paciente anciano ambulatorio con Insuficiencia Cardiaca (FRAGIC). Estudio prospectivo y multicéntrico.

BACKGROUND AND OBJECTIVES: Heart failure (HF) is a chronic disease that is often associated with ageing. There are predictive models based on variables that associate it with a poor prognosis, although those do not include common conditions in the elderly, such as frailty or comorbidity. The aim of this study is to determine the clinical and epidemiological characteristics of a cohort of elderly outpatients with HF followed-up by cardiologists. This will include a study of the prevalence of frailty and other geriatric syndromes, as well as their impact on the prognosis, and to evaluate whether these may improve predictive ability of such predictive models. MATERIAL AND METHODS: Observational, prospective, and multicentre study that will include 400 patients ≥75years old with chronic HF followed-up in Spanish tertiary hospitals by cardiology specialists in HF. Patients will undergo a comprehensive geriatric assessment, and prediction of events will be performed based on MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) and Barcelona-Bio HF calculator scores. The primary endpoint is cardiovascular and overall mortality at 1 and 3years follow-up. RESULTS: This study will assess both the characteristics and prognosis of elderly patients with HF followed-up by cardiologists in Spain and the applicability in the elderly population of scores used in the general population with chronic HF. CONCLUSION: This is the first prospective study that will systematically assess frailty and other geriatric syndromes in the elderly outpatient with HF in Spain and followed-up by cardiologists, thus contributing to improve knowledge about both its prevalence and impact on our patients.

[Integral approach to the older patient with cancer]. / El abordaje integral del paciente oncológico de edad avanzada.

INTRODUCTION: The world population, as well as the number of elderly people, grow exponentially. Elderly individuals are at a higher risk of developing an oncological disease, especially because they are subject to a longer period of exposure to carcinogens, and a worse capacity for regeneration of their deoxyribonucleic acid (DNA) (1). Cancer in elderly individuals represents 80% of the annual deaths secondary to this pathology (2). The older patient with cancer presents many differences with respect to the rest of elderly individuals. On the one hand, functional limitation and geriatric syndromes are more prevalent (3), as well as the presence of frailty (4). In addition, they habitually have a worse perception of their health status (4). For all these reasons, the attention to oncological older patients must be specialized and, in their evaluation, the use of a fundamental tool is required, the Comprehensive Geriatric Assessment (CGA). As its name indicates, its application requires collaboration between different specialties (5,6). This multidisciplinary work will improve the baseline situation of the patient, in those cases in which it is possible, and will facilitate the subsequent therapeutic management (7). Finally, the existence of concrete organizational models, such as the Oncogeriatrics Units, or the Cancer Consultations in the Elderly, can facilitate and favor this integral approach (5). In this article a review of all these concepts is carried out.

INTRODUCCIÓN: La población mundial, así como el número de personas de edad avanzada, crecen exponencialmente. Los individuos ancianos tienen más riesgo de desarrollar una enfermedad oncológica debido, sobre todo, a que están sometidos a un periodo de exposición a carcinógenos más prolongado y por una peor capacidad de regeneración de su ácido desoxirribonucleico (ADN) (1). El cáncer en individuos de edad avanzada representa el 80% de los fallecimientos anuales secundarios a esta patología (2). El anciano oncológico presenta una serie de diferencias con respecto al resto de individuos de edad avanzada. Por un lado, son más prevalentes la limitación funcional y los síndromes geriátricos (3), así como la presencia de fragilidad (4); además, habitualmente tienen una peor percepción de su estado de salud (4). Por todos estos motivos, la atención al anciano oncológico debe ser especializada, y en su evaluación se requiere el uso de una herramienta fundamental, la valoración geriátrica integral (VGI), que, como su nombre indica, para su aplicación requiere de la colaboración entre distintas especialidades (5,6). Este trabajo multidisciplinar permitirá mejorar la situación basal del paciente en aquellos casos en los que sea posible y facilitará que el manejo terapéutico posterior sea idóneo (7). Por último, la existencia de modelos organizativos concretos, tales como las unidades de oncogeriatría o las consultas de cáncer en el anciano, pueden facilitar y favorecer dicho abordaje integral (5). En este artículo se lleva a cabo una revisión de todos estos conceptos.

[Elderly patients in the Emergency Department. Is it the best scenario to make complex decisions?] / El paciente anciano en Urgencias. ¿Es el mejor escenario para la toma de decisiones complejas?

Clinical evaluation of elderly patients must include a comprehensive geriatric assessment. This is vital when deciding if a patient with a demonstrated critical disease should receive an active treatment, defined as the set of measures to treat an acute disease. The clinical outcomes are presented of four elderly patients who were admitted from the Emergency Department and whose severe acute diseases were treated with Comfort Measures Only. During their admission in the Geriatrics Acute Unit, and due to a reported clinical improvement, an active treatment was provided. All patients were discharge from the hospital after a favourable clinical course.

[What is the role of the comprehensive geriatric assessment in Geriatric Oncology?] / ¿Cuál es el papel de la valoración geriátrica integral en Oncogeriatría?

The growing increase in world population and generalised aging have been accompanied by an increase in the prevalence of cancer in the elderly. Aging is associated with certain physiological changes, some of which are enhanced by the neoplasm itself. Along with this, the elderly oncology patient usually has more problems than the rest of the elderly, and has a multitude of deficits. These characteristics require a special handling of the older patient with cancer, by using the main tool used in Geriatrics, the comprehensive geriatric assessment. This article analyses the importance of the comprehensive geriatric assessment in this population group, paying special attention to its ability to predict the toxicity of chemotherapy and the survival of the elderly oncology, as well as its ability to classify these patients into groups that help in the decision making process.