Características clínicas y pronóstico de la lesión medular traumática en pacientes mayores de 75 años

ObjectiveTo analyze the incidence and characteristics of traumatic spinal cord injury (SCI) in geriatric population of Galicia (Spain), hospital management and functional prognosis.MethodsComparative retrospective study. Patients admitted with acute traumatic SCI during the time period between January 2010 and December 2016 were included. Two groups established: The elderly over and under 75 years of age, with the latter acting as a control group.ResultsThree hundred seventy-nine patients were studied (27.2% ≥75 years). The main etiology in the >75 years group were falls: 80.6%. There were 65.7% who presented incomplete spinal cord injuries with mean motor index (MI) of 44.9/100. Upon discharge, 90.8% were dependent. Hospital mortality was 34.9%. Those >75 years suffered from more cervical injuries (74.8 vs. 51.2%; p<0.001), longer delay in diagnosis (31.1 vs. 9.2%; p<0.001) and higher hospital mortality (34.9 vs. 3.2%; p<0.001). Fewer surgical interventions were performed, with a longer delay. Percentages for admission into ICU, mechanical ventilation and performing a tracheostomy proved to be similar. There were no significant differences found in the evolution according to the ASIA scale or the MI.Conclusions1) The frequency of traumatic SCI in the elderly in Galicia is high; 2) Neurological evolution is similar to younger patients but the level of dependence is higher; 3) The level of care provided is similar in both groups, except for the surgical indication, and 4) Hospital mortality is high.     

Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis

ObjectiveMultiple treatment options for acetabular fractures in geriatric patients exist. However, no large-scale studies have reported the outcomes of acute total hip arthroplasty (THA) in this patient population. We systematically evaluated all available evidence to characterize clinical outcomes, complications, and revisions of acute THA for acetabular fractures in geriatric patients.MethodsMeta-analysis of 21 studies of 430 acetabular fractures with mean follow-up of 44 months (range, 17−97 months). Two independent researchers searched and evaluated the databases of Ovid, Embase, and United States National Library of Medicine using a Boolean search string up to December 2019. Population demographics and complications, including presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE), were recorded and analyzed.ResultsWeighted mean Harris Hip Score was 83.3 points, and 20% of the patients had reported complications. The most common complication was HO, with a rate of 19.5%. Brooker grade III and IV HO rates were lower at 6.8%. Hip dislocation occurred at a rate of 6.1%, 4.1% of patients developed VTE, deep infection occurred in 3.8%, and neurological complications occurred in 1.9%. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the time to each revision was described in only a few studies. The revision rate was 4.3%.ConclusionsAcute THA is a viable option for treatment of acetabular fracture and can result in acceptable clinical outcomes and survivorship rates in older patients but with an associated complication rate of approximately 20%. Considering the limited treatment options, THA might be a viable alternative for appropriately selected patients.     

Developing a Brief Neuropsychological Battery for Early Diagnosis of Cognitive Impairment

ObjectivesEarly diagnosis of cognitive impairment is increasingly emphasized in the literature to facilitate timely preventive interventions. Although bedside cognitive tests such as the Montreal Cognitive Assessment (MoCA) are widely used for such early diagnostic purposes, they may not have comparable performance to a full neuropsychological battery (FNB) in diagnosing early cognitive impairment. This study investigated whether a small subset of neuropsychological tests can be added on to MoCA to match its performance to that of the FNB in discriminating mild cognitive impairment and dementia (MCI/dementia) from normal cognition.DesignCross-sectional diagnostic study.SettingAlzheimer's Disease Centers across the United States.ParticipantsOlder participants (≥50 years) who completed MoCA and the FNB (N = 9187).MeasuresThe study sample was split into two: the derivation sample (n = 1837) was used to develop a brief neuropsychological battery that best discriminated MCI/dementia (using the best-subset approach with 10-fold cross-validation); while the validation sample (n = 7350) verified its actual performance in discriminating MCI/dementia.ResultsA 3-item neuropsychological battery was identified, comprising MoCA, Benson Complex Figure Recall, and Craft Story 21 Delayed Recall. It had excellent performance in discriminating MCI/dementia from normal cognition (area under the receiver operating characteristic curve [AUROC] 90.0%, 95% confidence interval [CI] 89.2%-90.7%), which was comparable to that of the FNB (AUROC 88.4%, 95% CI 87.6%-89.2%). By contrast, MoCA alone had significantly worse AUROC (86.9%, 95% CI 86.0%-87.7%) than that of the FNB.Conclusions/ImplicationsUsing rigorous methods, this study developed a brief neuropsychological battery that maintained the brevity of a bedside cognitive test, while rivaling the diagnostic performance of an FNB in early cognitive impairment. This brief battery offers a viable alternative when the FNB is needed but cannot be feasibly administered in nonspecialty clinics. It can have a wider health systems effect of improving patients’ access to accurate diagnosis in early cognitive impairment and facilitating timely interventions to delay the progression of cognitive impairment.     

Predictors of mortality in an aging community-based cohort in Korea

Background: Multiple factors related to specific dimensions of health – general, physical and mental – contribute to mortality in the elderly, but their relative contributions to mortality risk is not well‐known. The objectives of this prospective population‐based cohort study were to measure mortality rates and to identify predictors of mortality in community‐dwelling men and women aged 65 years or older in Korea by examining self assessments of general health, objective medical burden, and measurement of cognition, mood and function. Methods: A total of 1245 elderly (529 men; 716 women) were followed up longitudinally for 3.5 years. Fixed predictor variables observed at baseline examined in Cox proportional hazards models were age, sex, education, chronic medical illnesses, self‐rated health, basic activities of daily living, depression measured by the Geriatric Depression Scale, and cognition measured by the Mini‐Mental State Examination. Results: Mortality rates were similar to those of the 2001 Korean population. Older age, male sex, poor self‐rated health and presence of cerebrovascular disease were significant predictors of mortality. Presence of ischemic heart disease and cerebrovascular disease at baseline predicted mortality in men, but not in women. Depression predicted mortality only when chronic medical illnesses were excluded from the model. Conclusions: Subjective self‐rated health and objective medical burden are strong independent predictors of mortality in this elderly community population, in addition to age and sex.     

上海市社区医生对老年抑郁症态度和知识的问卷调查

目的了解社区医生对老年期抑郁症的态度及其相关知识掌握情况。方法应用自行编制的态度和知识问卷对157名社区医生进行调查,共收到有效问卷122份,应答率77.7%。根据是否接受过抑郁症相关知识的培训,122名社区医生被分成培训组和非培训组,应用老年抑郁症态度和知识问卷,对这两组医生进行有关态度和知识掌握程度的比较。结果除了培训组在治疗抑郁症的自信心、更少将没有自杀风险的患者转诊给精神科医生明显好于非培训组外(P<0.05,P<0.01),两组医生对老年期抑郁症的态度没有差别。培训组医生对抑郁症相关知识的掌握情况,均明显好于非培训组医生(P<0.01)。但两组社区医生对老年期抑郁症的病因、临床表现以及治疗的认识或态度等方面均存在一定的局限性。结论接受过培训的社区医生对老年期抑郁症的态度的某些方面及其相关知识的掌握情况较非培训组医生好,但两组医生在对老年期抑郁症态度及知识的掌握程度方面仍存在很多不足。因此需要进一步加强对社区医生进行有关老年抑郁症相关知识的培训。     

Effectiveness of Comanagement Model: Geriatric Medicine and Vascular Surgery

ObjectivesOlder surgical patients frequently develop postoperative complications due to their frailty and multiple comorbidities. Geriatric medicine consultation helps to optimize risk factors and improve outcomes in patients with hip fracture. This study aimed to evaluate patient outcomes before and after comanagement model implementation between geriatric medicine (Geriatric Surgical Service) and vascular surgery services.DesignThis was a case-control study involving emergency vascular surgical patients who were comanaged by vascular surgery, geriatric medicine, and geriatric nursing services.Settings and ParticipantsThis study was conducted in a tertiary hospital in Singapore from 2015 to 2018 with acute vascular surgical patients aged older than 65 years.MethodsA retrospective cohort of 135 patients from 2013 to 2014 (control group) who fulfilled the criteria for the comanagement model was compared with a prospective cohort of 348 patients who were comanaged by a geriatric surgical service from 2015 to 2018, and a further subgroup analysis of patients between 2015 and 2016 (n = 150) (early intervention group) and between 2017 and 2018 (n = 198) (late intervention group) was performed.ResultsComanaged patients had a significantly shorter length of hospital stay (11.6 vs 20.8 days, P = .001), reduced nosocomial infections (3% vs 12% for urinary tract infection, P = .003) and decreased 30-day readmission rates (22% vs 34%, P = .011). A trend of a decreased incidence of fluid overload was noted in patients comanaged with the geriatric surgical service (3% vs 7%, P = .073). Subgroup analysis showed progressive reductions in the length of stay (15.4 vs 11.6 days, P = .001), 30-day readmission rate (35% vs 22%, P = .01), and nosocomial urinary tract infection (8% vs 3%, P = .003) between the early intervention group and the late intervention group. Although they were not statistically significant, reductions were also observed in the delirium rate (13% vs 11%) and other postoperative medical complications in the early intervention group and the late intervention group.Conclusion and ImplicationsDespite having increasing comorbidities, older vascular surgical inpatients had a significantly shorter length of stay, reduced nosocomial infections, and decreased 30-day readmission rates through a comanagement model with vascular surgery and geriatric medicine services. Improvements in outcomes were observed over time as the model of care evolved. Geriatric medicine intervention in the perioperative period improves the outcomes of older acute vascular surgical patients.