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Sarcopenia is currently understood as an organ insufficiency. However, the distinction of acute and chronic sarcopenia as different categories, which makes sense in this conceptual framework, is still evolving. The first set of modern definitions of sarcopenia only considered chronic sarcopenia. However, research showed that function in acute care settings differs from the loss that evolves slowly over months or years, and this fact is starting to permeate modern definitions. The updated version of the EWGSOP sarcopenia identifies acute and chronic sarcopenia as subcategories. Different studies have reported rates of incident sarcopenia in hospitalized older patients around 15% to 20%, which adds to the prevalent sarcopenia present on admission. Diagnosing sarcopenia in acute settings carries specific challenges related to the patients, the acute condition and limitations in the use of diagnostic tests for muscle mass, muscle strength and physical performance. Prevention and management of acute sarcopenia rely on exercise during admission, but the quality of evidence is still low. Nutrition intervention and drugs may have a role, but more research is needed.

Background The infection by SARS-CoV-2 (COVID-19) has been especially serious in older patients. The aim of this study is to describe baseline and clinical characteristics, hospital referrals, 60-day mortality, factors associated with hospital referrals and mortality in older patients living in nursing homes (NH) with suspected COVID-19. Methods A retrospective observational study was performed during March and April 2020 of institutionalized patients assessed by a liaison geriatric hospital-based team. Were collected all older patients living in 31 nursing homes of a public hospital catchment area assessed by a liaison geriatric team due to the suspicion of COVID-19 during the first wave, when the hospital system was collapsed. Sociodemographic variables, comprehensive geriatric assessment, clinical characteristics, treatment received including care setting, and 60-days mortality were recorded from electronic medical records. A logistic regression analysis was performed to analyze the factors associated with mortality. Results 419 patients were included in the study (median age 89 years old, 71.6 % women, 63.7 % with moderate-severe dependence, and 43.8 % with advanced dementia). 31.1 % were referred to the emergency department in the first assessment, with a higher rate of hospital referral in those with better functional and mental status. COVID-19 atypical symptoms like functional decline, delirium, or eating disorders were frequent. 36.9% had died in the 60 days following the first call. According to multivariate logistic regression age (p 0.010), Barthel index Conclusions and implications 31% of the nursing home patients assessed by a liaison geriatric hospital-based team for COVID-19 were referred to the hospital, being more frequently referred those with a better functional and cognitive situation. The 60-days mortality rate due to COVID-19 was 36.8% and was associated with older age, functional dependence, the presence of tachypnea and fever, and the use of ceftriaxone. Geriatric comprehensive assessment and coordination between NH and the hospital geriatric department teams were crucial.

Background & aims: The literature regarding enteral nutrition and mortality in older frail people is limited and still conflicting. Moreover, the potential role of comprehensive geriatric assessment is poorly explored. We therefore aimed to investigate whether the Multidimensional Prognostic Index (MPI), an established tool that assesses measures of frailty and predicts mortality, may help physicians in identifying patients in whom ETF (enteral tube feeding) is effective in terms of reduced mortality. Methods: Observational, longitudinal, multicenter study with one year of follow-up. Data regarding ETF were recorded through medical records. A standardized comprehensive geriatric assessment was used to calculate the MPI. Participants were divided in low (MPI-1), moderate (MPI-2) or severe (MPI-3) risk of mortality. Data regarding mortality were recorded through administrative information. Results: 1064 patients were included, with 79 (13 in MPI 1–2 and 66 in MPI-3 class) receiving ETF. In multivariable analysis, patients receiving ETF experienced a higher risk of death (odds ratio, OR = 2.00; 95% confidence intervals, CI: 1.19–3.38). However, after stratifying for their MPI at admission, mortality was higher in MPI-3 class patients (OR = 2.03; 95%CI: 1.09–3.76), but not in MPI 1–2 class patients (OR = 1.51; 95%CI: 0.44–5.25). The use of propensity score confirmed these findings. Conclusions: ETF is associated with a higher risk of death. However, this is limited to more frail patients, suggesting the importance of the MPI in the prognostic evaluation of ETF. © 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism

Oropharyngeal dysphagia (OD) is associated with adverse outcomes that require a multidisciplinary approach with different strategies. Our aim was to assess the adherence of older patients to dysphagia management recommendations during hospitalization, after a specific nurse guided dysphagia education intervention and to identify short term complications of OD and their relationship with short-term adherence. We carried out a prospective observational study in an acute and an orthogeriatric unit of a university hospital over ten months with a one-month follow-up. Four hundred and forty-seven patients (mean age 92 years, 70.7% women) were diagnosed with dysphagia using Volume-Viscosity Swallow Test (V-VST). Compensatory measures and individualized recommendations were explained in detail by trained nurse. Therapeutic adherence was directly observed during hospital admission, after an education intervention, and self-reported after one-month. We also recorded the following reported complications at one month, including respiratory infection, use of antibiotics, weight loss, transfers to the emergency department, or hospitalization). Postural measures and liquid volume were advised to all patients, followed by modified texture food (95.5%), fluid thickeners (32.7%), and delivery method (12.5%). The in-hospital compliance rate with all recommendations was 37.1% and one-month after hospital discharge was 76.4%. Both compliance rates were interrelated and were lower in patients with dementia, malnutrition, and safety signs. Higher compliance rates were observed for sitting feeding and food texture, and an increase in adherence after discharge in the liquid volume and use of thickeners. Multivariate logistic regression analysis showed that adherence to recommendations during the month after discharge was associated with lower short-term mortality and complications (i.e., respiratory infection, use of antibiotics, weight loss, transfers to the emergency department, or hospitalization). One-third of our participants followed recommendations during hospitalization and three-quarters one month after admission, with higher compliance for posture and food texture. Compliance should be routinely assessed and fostered in older patients with dysphagia.

COVID-19 pandemic is relentlessly spreading worldwide since it was described in Wuhan in december 2019. A high incidence in health care workers has been described in Spain. The number or articles discussing this condition is exponentially growing, but few published cases report on what physicians have faced in their daily work. It is key that health care providers learn how to convey the severity that COVID-19 can reach, in order to raise awareness on the importance of prevention.

Immunosuppression (IS) and autoimmune disease (AD) are prevalent in patients with severe coronavirus disease 2019 (COVID-19), but their impact on its clinical course is unknown. We investigated relationships between IS, AD, and outcomes in patients hospitalized with COVID-19. Data on consecutive admissions for COVID-19 were extracted retrospectively from medical records. Patients were assigned to one of four cohorts, according to whether or not they had an AD (AD and NAD) or were immunosuppressed (IS and NIS). The primary endpoint was development of severe acute respiratory distress syndrome (ARDS); secondary endpoints included death, and a composite of mechanical ventilation (MV) or death. A total of 789 patients were included: 569 (72.1%) male, 76 (9.6%) with an AD, and 63 (8.0%) with IS. Relative to the NIS-NAD cohort, patients in the IS-AD cohort had a significantly reduced risk of severe ARDS (adjusted hazard ratio [aHR] 0.42; 95% confidence interval [CI] 0.23–0.80; p = 0.008). No significant relationships between IS or AD status and either death or the composite of MV and death were identified, although a trend towards higher mortality was identified in the IS-NAD cohort (aHR vs NIS-NAD 1.71; 95% CI 0.94–3.12; p = 0.081). Patients in this cohort also had higher median serum levels of interleukin-6 compared with IS-AD patients (98.2 vs 21.6 pg/mL; p = 0.0328) and NIS-NAD patients (29.1 pg/mL; p = 0.0057). In conclusion, among patients hospitalized with COVID-19, those receiving immunosuppressive treatment for an AD may have a reduced risk of developing severe ARDS. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-020-00927-y.

Despite the increasing evidence of the benefit of corticosteroids for the treatment of moderate-severe coronavirus disease 2019 (COVID-19) patients, no data are available about the potential role of high doses of steroids for these patients. We evaluated the mortality, the risk of need for mechanical ventilation (MV), or death and the risk of developing a severe acute respiratory distress syndrome (ARDS) between high (HD) and standard doses (SD) among patients with a severe COVID-19. All consecutive confirmed COVID-19 patients admitted to a single center were selected, including those treated with steroids and an ARDS. Patients were allocated to the HD (≥ 250 mg/day of methylprednisolone) of corticosteroids or the SD (≤ 1.5 mg/kg/day of methylprednisolone) at discretion of treating physician. Five hundred seventy-three patients were included: 428 (74.7%) men, with a median (IQR) age of 64 (54–73) years. In the HD group, a worse baseline respiratory situation was observed and male gender, older age, and comorbidities were significantly more common. After adjusting by baseline characteristics, HDs were associated with a higher mortality than SD (adjusted OR 2.46, 95% CI 1.59–3.81, p

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that has spread rapidly worldwide. The role of immunosuppression among COVID-19 patients has not been elucidated and management may be challenging. OBJECTIVE: To assess differences in severe outcomes of hospitalized patients with COVID-19 according to immune system state. DESIGN: Retrospective single-center observational study with confirmed COVID-19 patients admitted to Hospital Universitario Ramón y Cajal from March 18, 2020 to April 04, 2020. The final date of follow-up was April 09, 2020.PARTICIPANTS: Confirmed COVID-19 patients. MAIN MEASURES: The primary endpoint was development of moderate-severe acute respiratory distress syndrome (ARDS). Time to moderate-severe ARDS, the need for mechanical or non-invasive ventilation (MV/NIV), death, and a composite of death or MV/NIV were secondary endpoints. KEY RESULTS: Of 138 patients included, 27 (19.6%) were immunosuppressed (IS), with 95 (68.8%) male patients and a median (Q1, Q3) age of 68 (54–78) years. Among the baseline characteristics, no relevant or significant differences were observed between IS and non-immunosuppressed (non-IS) patients, detecting a non-severe immunosupression among IS. A significantly lower proportion of IS patients (22.2% [95%CI, 9.8–43.0%]) compared to non-IS patients (49.5% [95%CI, 40.2–58.9%]) developed moderate-severe ARDS, in both unadjusted (OR 0.29 [95%CI, 0.11–0.76], p=0.014) and adjusted (aOR 0.16 [95%CI, 0.05–0.55], p=0.004) analyses. After stratifying by pathologies, only IS autoimmune diseases remained significant (aOR 0.12 [95%CI, 0.03–0.57], p=0.007). Non-significant trends toward a longer time to moderate or severe ARDS, a lower need for MV/NIV, and a lower risk of death or MV/NIV were detected in IS. CONCLUSIONS: In our cohort of COVID-19 patients, non-severe immunosuppression was associated with a lower risk of moderate-severe ARDS, especially among AD. This suggests a potential protective effect from a hypothesized host hyper-inflammatory response and warrants reconsideration of management of IS patients.

The role of immunosuppression among coronavirus disease 2019 (COVID-19) patients has not been elucidated and management may be challenging. This observational study included confirmed COVID-19 patients. The primary endpoint was the development of moderate-severe acute respiratory distress syndrome (ARDS). Time to moderate-severe ARDS, the need for mechanical or noninvasive ventilation (MV/NIV), death, and a composite of death or MV/NIV were secondary endpoints. Of 138 patients included, 27 (19.6%) were immunosuppressed (IS) and 95 (68.8%) were male, with a median (IQR) age of 68 (54-78) years. A significantly lower proportion of IS patients (25.9%) compared to non-IS patients (52.3%) developed moderate-severe ARDS, in both unadjusted (0.32; 95% CI, 0.13-0.83; p = .017) and adjusted (aOR, 0.25; 95% CI, 0.08-0.80; p = .019) analyses. After stratifying by pathologies, only IS patients with autoimmune diseases remained significant (aOR 0.25; 95% CI, 0.07-0.98; p = .046). Nonsignificant trends toward a longer time to moderate or severe ARDS, a lower need for MV/NIV, and a lower risk of death or MV/NIV were detected among IS. In our cohort of COVID-19 patients, nonsevere immunosuppression was associated with a lower risk of moderate-severe ARDS, especially among AD. This suggests a potential protective effect from a hypothesized hyper-inflammatory response.

INTRODUCTIONDespite the increasing evidence of the benefit of corticosteroids for the treatment of moderate-severe Coronavirus disease 2019 (COVID-19) patients, no data are available about the potential role of high doses of steroids for these patients.METHODSAll consecutive confirmed COVID-19 patients admitted to a single center were selected, including those treated with steroids and an acute respiratory distress syndrome (ARDS). Patients were allocated to the high doses (HD, ≥250mg/day of methylprednisolone) of corticosteroids or the standard doses (SD, ≤1.5mg/kg/day of methylprednisolone) at discretion of treating physician. The primary endpoint was the mortality between both cohorts and secondary endpoints were the risk of need for mechanical ventilation (MV) or death and the risk of developing a severe ARDS.RESULTS573 patients were included: 428 (74.7%) men, with a median (IQR) age of 64 (54–73) years. In HD cohort, a worse baseline respiratory situation was observed and male sex, older age and comorbidities were significantly more common. After adjusting by baseline characteristics, HD were associated with a higher mortality than SD (adjusted-OR 2.46, 95% CI 1.58 – 3.83, pCONCLUSIONOur real-world experience advises against exceeding 1-1.5mg/kg/day of corticosteroids for severe COVID-19 with an ARDS, especially in older subjects. This reinforces the rationale of modulating rather than suppressing immune responses in these patients.SUMMARYIn patients with severe COVID-19, high doses of corticosteroids are associated with a higher mortality and risk of need for mechanical ventilation or death compared to standard doses. This deleterious effect is mainly observed in the elderly.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that has spread rapidly worldwide. The role of immunosuppression among COVID-19 patients has not been elucidated and management may be challenging.OBJECTIVE: To assess differences in severe outcomes of hospitalized patients with COVID-19 according to immune system state.DESIGN: Retrospective single-center observational study with confirmed COVID-19 patients admitted to Hospital Universitario Ramón y Cajal from March 18, 2020 to April 04, 2020. The final date of follow-up was April 09, 2020.PARTICIPANTS: Confirmed COVID-19 patients.MAIN MEASURES: The primary endpoint was development of moderate-severe acute respiratory distress syndrome (ARDS). Time to moderate-severe ARDS, the need for mechanical or non-invasive ventilation (MV/NIV), death, and a composite of death or MV/NIV were secondary endpoints.KEY RESULTS: Of 138 patients included, 29 (21%) were immunocompromised (IC), with 95 (68.8%) male patients and a median (IQR) age of 68 (54 – 78) years. Among the baseline characteristics, no relevant or significant differences were observed between IC and non-immunocompromised (non-IC) patients. A significantly lower proportion of IC patients (24.1% [95% CI, 11.4 – 44.0%]) compared to non-IC patients (49.5% [95% CI, 40.1 – 59.0%]) developed moderate-severe ARDS, in both unadjusted (OR 0.32 [95% CI, 0.13 – 0.82], p=0.018) and adjusted (aOR 0.16 [95% CI, 0.05 – 0.52], p=0.003) analyses. A positive non-significant trend toward a longer time to moderate or severe ARDS, a lower need for MV/NIV, and a lower risk of death or MV/NIV were detected in IC. A trend toward a shorter- hospitalization in IC was observed.CONCLUSIONS: In our cohort of COVID-19 patients, immunosuppression was associated with a lower risk of moderate-severe ARDS. This suggests a potential protective effect from a hypothesized host hyper-inflammatory response and warrants reconsideration of drug discontinuation in IC patients.

Objectives Oropharyngeal dysphagia is a geriatric syndrome that is usually underdiagnosed in older patients. The aim of this study was to determine the prevalence and identify the main risk factors of dysphagia in the oldest old patients admitted to an acute geriatric unit. Design Observational prospective study. Setting and Participants Older patients admitted to an acute geriatric unit of a university hospital. Measures 329 patients (mean age 93.5 years, range 81-106) were assessed for oropharyngeal dysphagia within 48 hours of hospital admission using the Volume-Viscosity Swallow Test. Demographic characteristics, geriatric assessment, geriatric syndromes, comorbidities, drug treatment, and complications were examined to determine their association with the presence of dysphagia. Results Oropharyngeal dysphagia was present in 271 (82.4%) of the participants. Multivariate logistic regression showed that malnutrition [odds ratio (OR) 3.62, 95% confidence interval (CI) 1.01-12.93; P = .048], admission for respiratory infection (OR 2.89, 95% CI 1.40-5.94; P = .004), delirium (OR 2.89, 95% CI 1.40-5.94; P = .004), severe dependency (OR 3.23, 95% CI 1.23-8.87; P = .017), and age (OR 1.11, 95% CI 1.01-1.21; P = .03) were significantly associated with dysphagia. The use of a calcium antagonist at the time of admission was associated with a reduced risk of dysphagia (OR 0.39, 95% CI 0.16-0.92; P = .03). Conclusions and Implications The prevalence of oropharyngeal dysphagia is high in the oldest old patients admitted to an acute geriatric unit when assessed with an objective diagnostic method. Our findings suggest that objective swallowing assessment should be routinely performed on admission in order to start early interventions to avoid complications of dysphagia in this complex population.

Background Multi-morbidity and polypharmacy increase the risk of non-trivial adverse drug reactions (ADRs) in older people during hospitalization. Despite this, there are no established interventions for hospital-acquired ADR prevention. Methods We undertook a pragmatic, multi-national, parallel arm prospective randomized open-label, blinded endpoint (PROBE) controlled trial enrolling patients at six European medical centres. We randomized 1,537 older medical and surgical patients with multi-morbidity and polypharmacy on admission in a 1:1 ratio to SENATOR software-guided medication optimization plus standard care (intervention, n = 772, mean number of daily medications = 9.34) or standard care alone (control, n = 765, mean number of daily medications = 9.23) using block randomization stratified by site and admission type. Attending clinicians in the intervention arm received SENATOR-generated advice at a single time point with recommendations they could choose to adopt or not. The primary endpoint was occurrence of probable or certain ADRs within 14 days of randomization. Secondary endpoints were primary endpoint derivatives; tertiary endpoints included all-cause mortality, re-hospitalization, composite healthcare utilization and health-related quality of life. Results For the primary endpoint, there was no difference between the intervention and control groups (24.5 vs. 24.8%; OR 0.98; 95% CI 0.77–1.24; P = 0.88). Similarly, with secondary and tertiary endpoints, there were no significant differences. Among attending clinicians in the intervention group, implementation of SENATOR software-generated medication advice points was poor (~15%). Conclusions In this trial, uptake of software-generated medication advice to minimize ADRs was poor and did not reduce ADR incidence during index hospitalization.

Resumen Objetivo Describir las indicaciones de colocacion de gastrostomia percutanea (GP) en pacientes mayores en un hospital universitario, las caracteristicas de los pacientes en los que se realiza, sus complicaciones a largo y corto plazo y la mortalidad asociada. Metodos Estudio descriptivo y retrospectivo de todos los pacientes mayores de 75 anos a los que se les coloco una GP en un periodo de 3 anos en la Unidad de Radiologia Vascular Intervencionista. Se estudio la indicacion del procedimiento en cada caso, revisando posteriormente en la historia clinica electronica la aparicion de complicaciones y la mortalidad durante un periodo de seguimiento de 36 meses. Resultados Pacientes: n = 74, con una edad media de 84 ± 6,1 anos, 57% mujeres. El 40% vivia en una residencia. El 80% sufria deterioro cognitivo. La principal indicacion para la colocacion de la GP fue la disfagia en la demencia avanzada (56,8%), seguida de tumores de la cavidad orofaringea (12,2%), enfermedad de Parkinson (10,8%) e ictus (9,6%). Se coloco la gastrostomia con caracter irreversible en el 90,5% de los casos. La complicacion mas frecuente fue la broncoaspiracion (32,4%). La mortalidad global fue de 59,5% con una mediana de seguimiento de 18 meses. Conclusiones La presencia de disfagia en la demencia avanzada fue la principal indicacion de realizacion de gastrostomias en mayores de 75 anos. Esta intervencion no solo no evito la aparicion de broncoaspiraciones, sino que estas representaron su complicacion mas frecuente. La mortalidad a medio plazo de los pacientes en quienes se coloca una gastrostomia es elevada.

ObjectivesThe Sarcopenia Quality of Life (SarQoL) questionnaire, a sarcopenia-specific patient-reported outcome measure, evaluates quality of life with 55 items. It produces 7 domain scores and 1 overall quality of life score, all between 0 and 100 points. This study aims to contribute to the interpretation of the SarQoL scores by calculating the standard error of measurement (SEM) and smallest detectable change (SDC) in a sample of subjects from 9 studies.MethodsSubjects from 9 studies (conducted in Belgium, Brazil, Czech Republic, England, Greece, Lithuania, Poland and Spain) were included. The SEM, a measure of the error in the scores that is not due to true changes, was calculated by dividing the standard deviation of the difference between test and retest scores (SDdiff) by √2. The SDC, defined as change beyond measurement error, was calculated by multiplying SDdiff by 1.96. Bland-Altman plots were assessed for the presence of systematic errors.ResultsA total of 278 sarcopenic subjects, aged 77.67 ± 7.64 years and 61.5% women, were included. The SEM for the overall SarQoL score ranged from 0.18 to 4.20 points for the individual studies, and was 2.65 points when all subjects were analyzed together. The SDC for the overall score ranged from 0.49 to 11.65 points for the individual studies, and was 7.35 points for all subjects. The Bland-Altman plots revealed no systematic errors in the questionnaire.ConclusionThis study shows that, for individual subjects, a change in overall quality of life of at least 7.35 points (on a scale from 0 to 100) would have to be observed to confirm that a true change, beyond measurement error, has occurred. It also demonstrated that the SarQoL questionnaire is a precise instrument, with the observed scores within less than 3 points of the theoretical "true score".

Resumen Objetivo Evaluar los cambios producidos en la practica de la sedacion paliativa en la agonia en pacientes mayores hospitalizados antes y despues de la implantacion de un protocolo hospitalario de sedacion paliativa. Material y metodos Estudio retrospectivo descriptivo tipo antes-despues de pacientes mayores de 65 anos que fueron tratados con midazolam y fallecieron durante la hospitalizacion en un hospital terciario en 2 trimestres, uno previo y otro posterior a la implantacion del protocolo. Se excluyo a aquellos en quienes la indicacion de midazolam no fue la sedacion paliativa y los ingresados en cuidados intensivos. Se registraron las caracteristicas de los pacientes y su servicio de ingreso, el consentimiento, la limitacion del esfuerzo terapeutico y el proceso de sedacion (sintoma refractario, dosis, evaluacion y otros medicamentos). Se analizaron las asociaciones empleando la prueba de la chi al cuadrado y la t de Student. Resultados Se incluyo a 143 pacientes sin diferencias relevantes entre ambos grupos en cuanto a caracteristicas demograficas ni sintomatologia. Se registro la indicacion de no reanimacion cardiopulmonar en aproximadamente el 70% de cada grupo y el consentimiento para la sedacion en el 91% antes y el 84% despues del protocolo. Las dosis de induccion y de mantenimiento de midazolam se adecuaban a las recomendaciones en el 1,31% de los pacientes antes y el 10,4% despues del protocolo (p = 0,02) y las dosis de rescate en el 1,31 y el 11,9%, respectivamente (p = 0,01). La dosis de midazolam utilizada en pacientes en quienes se uso el protocolo fue significativamente menor que cuando no se empleo (9,86 mg vs. 18,67 mg, p Conclusiones El uso de midazolam en la sedacion paliativa en la agonia mejoro ligeramente tras la instauracion de un protocolo hospitalario de sedacion paliativa. El porcentaje de sedaciones adecuadas y el proceso general apenas mejoro con el protocolo. Es necesario continuar el proceso de formacion y reevaluar la efectividad de estas medidas en el futuro.

Rationale, aims and objectives The aim of this study is to adapt and assess the interrater reliability of a potential future risk matrix for medication errors in medication administration recording (ME-MAR). Methods The study was carried out in a teaching hospital. It was conducted in two phases. In the first phase, a consensus method was used in order to adapt the potential future risk matrix published by the National Patient Safety and Otero et al. to the ME-MAR. The consensus method consisted in a nominal group formed by four pharmacists. In the second phase, a multidisciplinary group of experts in patient safety assessed the reliability of the adapted matrix. Five raters evaluated 100 ME-MAR. Its reliability was evaluated using the kappa statistic. Results In the first phase, two meetings were necessary until consensus was reached to adapt the potential future risk matrix to the ME-MAR. For this purpose, the two following categories were defined: likelihood of ME-MAR's recurrence and most likely consequences of ME-MAR. The definition of each grade of likelihood of recurrence was based on the incidence of ME-MAR from an unpublished study carried out in our hospital. In order to determine the most likely consequences of ME-MAR, a two-dimensional matrix was designed, with severity per type of ME-MAR on one axis and the class of medication on the other. In the second phase, the reliability of the matrix was tested. The overall interrater agreement for the five raters was substantial at 0.68 (Confidence interval 95% 0.60–0.76). Conclusion The adapted matrix of potential future risk to ME-MAR is reliable and can serve as a guide for future studies.

Background the STOPP-START criteria were developed to detect potentially inappropriate prescribing (PIP) in older people. The reasons why multidisciplinary geriatric teams decide not to follow STOPP-START criteria have not been studied. Objective to analyse compliance with the recommendations of the STOPP-START criteria in older inpatients. Design ambispective, non-randomised study. SUBJECTS SETTING: three hundred and eighty-eight consecutive patients aged 80 years or over admitted to the acute geriatric medicine unit of a University hospital. Methods STOPP-START criteria were systematically used by a pharmacist to assess pre-admission treatments, and the multidisciplinary geriatric team decided what drugs were recommended after discharge. Two researches independently assessed how many STOPP-START recommendations were accepted by the team, and if they were not accepted, why. Results two hundred and eighty-four PIPs were identified (0.8 per subject) according to STOPP criteria. Two hundred and forty-seven of these prescriptions (87.0%) were discontinued at discharge. STOPP recommendations were not accepted in 37 cases, mostly because the team considered other therapeutic priorities (lorazepam, n = 12; risperidone, n = 5; other, n = 18). Three hundred and ninety-seven PIPs were identified according to START criteria (1.1 per subject). START recommendations were not followed at discharge in 264 cases (66.5%). The most frequent reasons were as follows: severe disability (n = 90), the use of other effective treatments for the condition (n = 38) and high risk of severe adverse effects (n = 32). Not following START criteria was significantly associated with dependency for basic activities of daily living (ADLs) (odds ratio, OR: 0.66 for compliance with a recommendation; 0.49-0.89), dependency for instrumental ADLs (OR: 0.64; 0.48-0.85) or inability to walk (OR: 0.72; 0.54-0.98). Conclusions potentially inappropriate drugs are usually discontinued, but many older hospitalised patients do not receive potentially recommended medications. More research on the reasons and consequences of this fact is needed.

Objective: To assess the extent of exclusion of older individuals from ongoing clinical trials regarding type 2 diabetes mellitus. Design: Cohort study. Setting: World Health Organization Clinical Trials Registry Platform. Participants: Using the Participation of the Elderly in Clinical Trials methodology, data from ongoing clinical trials on type 2 diabetes mellitus were extracted from the platform on July 31, 2011. Measurements: Proportion of trials excluding individuals using an arbitrary upper age limit or other exclusion criteria that might indirectly cause limited recruitment of older individuals. Exclusion criteria were classified as justified or poorly justified. Results: Of 440 trials investigating treatments for type 2 diabetes mellitus, 289 (65.7%) excluded individuals using an arbitrary upper age limit. Such exclusion was significantly more common in trials with calculated sample sizes of less than 100 subjects (73.6% vs 59.5%; P = .002). Exclusion for comorbidity was present in 338 trials (76.8%); this exclusion was poorly justified in 236 trials (53.6%). Exclusion for polypharmacy (29.5% of trials), cognitive impairment (18.4%), short life expectancy (8.9%), and other poorly justified exclusion criteria that could limit the inclusion of older individuals was also present. Only six trials (1.4%) were designed specifically to study older adults. Conclusion: Despite the recommendations of international regulatory agencies, exclusion of older individuals from ongoing trials regarding type 2 diabetes mellitus is frequent�higher than reported for other age-related diseases. This exclusion limits the value of the evidence that clinicians use when treating old, frail, complex patients with diabetes mellitus.

To describe the indications of insertion of a percutaneous gastrostomy (PG) in older patients in a university hospital, as well as patient characteristics, short and long term complications, and mortality.Retrospective descriptive study of all patients over 75 years who had a PG inserted during a three year period by the Interventional Radiology Department. The indication of the procedure was reviewed, and the incidence of complications and mortality during a 36 months follow-up period were assessed through electronic medical records.The study included 74 patients, with a mean age of 84±6.1 years, and 57% were female. Furthermore, 40% lived in nursing homes and 80% had cognitive impairment. The main indications for PG insertion were dysphagia in severe dementia (56.8%), tumours of the oropharyngeal cavity (12.2%), Parkinson's disease (10.8%), and stroke (9.6%). PG was permanent in 90.5% of cases. The most common complication was aspiration pneumonia (32.4%). Overall mortality was 59.5% after a median follow-up of 18 months.Dysphagia in severe dementia was the main indication for PG in patients over 75 years. This intervention did not prevent aspiration pneumonia, which was the most common complication. Mortality in patients who have a PG was high.

Older people are a heterogeneous group of patients, often with multiple comorbidities for which they are prescribed a large number of drugs, leading to an increased risk of adverse drug reactions (ADR) and drug interactions. This risk is compounded by physiological age-related changes in physiology, changes in drug pharmacokinetics and pharmacodynamics, as well as by disease-related, functional and social issues. Inappropriate prescription of drugs is common in the older individuals and contributes to the increased risk of ADR. Several tools have been developed to detect potentially inappropriate prescription, the most frequently used in Spain being Beers' criteria. However, the value of these criteria is limited, especially as they were developed in a different healthcare system. In this article, the Spanish version of a new tool to detect potentially inappropriate prescriptions-STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right i.e. appropriate, indicated Treatment) criteria-is presented. The creation, development, reliability, and use of these criteria in routine practice is described and discussed. These criteria have shown better sensitivity than Beers' criteria in detecting prescription problems and have the added value of being able to detect not only inappropriate prescription of some drugs, but also the omission of well indicated drugs. The STOPP/START criteria could become a useful screening tool to improve prescription in older people.

Introduccion el ingreso hospitalario por enfermedad aguda supone para determinados ancianos de riesgo una perdida de autonomia no siempre relacionada con la enfermedad causante de dicha hospitalizacion. La importancia de este problema en nuestro medio sanitario, y si existen diferencias segun el servicio en que se produzca el ingreso, no se conocen suficientemente. Objetivo estudiar la incidencia de deterioro funcional, factores asociados y diferencias entre los servicios de medicina interna y geriatria, en ancianos hospitalizados por enfermedad aguda. Material y metodos estudio prospectivo de cohortes. Analizamos las caracteristicas sociodemograficas, la comorbilidad motivo de ingreso y gravedad, el uso de varias practicas hospitalarias, la tasa de mortalidad y de perdida funcional durante el ingreso. Se definio deterioro funcional como la perdida de autonomia para al menos una de las actividades basicas de la vida diaria, con respecto a la situacion previa al ingreso. La influencia del servicio se analizo mediante un modelo de regresion logistica multiple. Resultados estudiamos a 379 pacientes (140 en el servicio de geriatria [SG] y 239 en medicina interna [MI]). Los pacientes ingresados en SG eran mayores (87 frente a 81,5 anos; p 48 h, el uso de psicofarmacos y sujeciones o de medicacion nocturna se asociaron a deterioro funcional. En el analisis multivariable, el ingreso en MI se asocio a mayor riesgo de deterioro funcional. Conclusiones el deterioro funcional durante la hospitalizacion es frecuente en los pacientes fragiles. Determinados factores asociados con la practica clinica y, por tanto, modificables se asocian a ese deterioro. El ingreso de estos pacientes en el SG conlleva menor perdida de autonomia que su ingreso en MI.

Background Pressure ulcers (PUs) are frequent in older patients, and the healing process is usually challenging, therefore, prevention should be the first strategic line in PU management. Nonpharmacologic interventions may play a role in the prevention of PUs in older people, but most systematic reviews (SRs) have not addressed this specific population using convincing outcome measures. Objective To summarize and critically appraise the evidence from SRs of the primary studies on nonpharmacologic interventions to prevent PUs in older patients. Design SR and meta-analysis of comparative studies. Data sources PubMed, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL (from inception to October 2013) were searched. A new search for updates in the Cochrane Database was launched in July 2014. Eligibility criteria for selecting studies SRs that included at least 1 comparative study evaluating any nonpharmacologic intervention to prevent PUs in older patients, in any healthcare setting, were selected. Any primary study with experimental design was then identified and included. Data extraction From each primary study, quality assessment was undertaken as specified by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation working group. Interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis, using the incidence of new pressure ulcers as the main outcome measure. Results One hundred ten SRs with 65 primary studies satisfied the inclusion criteria. The most frequent interventions explored in these trials were support surfaces (41 studies), repositioning (8), and nutrition interventions (5). High quality of evidence was not found for any intervention, mainly because of a high risk of bias and imprecision. There is moderate quality evidence to support the use of alternating pressure support mattresses over usual hospital mattresses in medical and surgical inpatients, low quality evidence to support constant low pressure devices and Australian medical sheepskin over usual mattresses, and very low quality evidence to support nutrition interventions in hospital settings. No recommendations on hydration, repositioning, standardized risk assessment, or multicomponent interventions can be done. Conclusions In older patients at high risk to suffer PUs, high-technology and low- technology support surfaces can significantly reduce the incidence of PUs. Nutrition intervention may also have a role in preventing PUs in hospital settings. More evidence is needed to support other recommendations, which is specially lacking for repositioning.

The aim of this study is to adapt and assess the interrater reliability of a potential future risk matrix for medication errors in medication administration recording (ME-MAR).The study was carried out in a teaching hospital. It was conducted in two phases. In the first phase, a consensus method was used in order to adapt the potential future risk matrix published by the National Patient Safety and Otero et al. to the ME-MAR. The consensus method consisted in a nominal group formed by four pharmacists. In the second phase, a multidisciplinary group of experts in patient safety assessed the reliability of the adapted matrix. Five raters evaluated 100 ME-MAR. Its reliability was evaluated using the kappa statistic.In the first phase, two meetings were necessary until consensus was reached to adapt the potential future risk matrix to the ME-MAR. For this purpose, the two following categories were defined: likelihood of ME-MAR's recurrence and most likely consequences of ME-MAR. The definition of each grade of likelihood of recurrence was based on the incidence of ME-MAR from an unpublished study carried out in our hospital. In order to determine the most likely consequences of ME-MAR, a two-dimensional matrix was designed, with severity per type of ME-MAR on one axis and the class of medication on the other. In the second phase, the reliability of the matrix was tested. The overall interrater agreement for the five raters was substantial at 0.68 (Confidence interval 95% 0.60-0.76).The adapted matrix of potential future risk to ME-MAR is reliable and can serve as a guide for future studies.

To measure changes in the practice of palliative sedation during agony in hospitalised elderly patients before and after the implementation of a palliative sedation protocol.A retrospective before-after study was performed in hospitalised patients over 65 years old who received midazolam during hospital admission and died in the hospital in two 3-month periods, before and after the implementation of the protocol. Non-sedative uses of midazolam and patients in intensive care were excluded. Patient and admission characteristics, the consent process, withdrawal of life-sustaining treatments, and the sedation process (refractory symptom treated, drug doses, assessment and use of other drugs) were recorded. Association was analysed using the Chi(2) and Student t tests.A total of 143 patients were included, with no significant differences between groups in demographic characteristics or symptoms. Do not resuscitate (DNR) orders were recorded in approximately 70% of the subjects of each group, and informed consent for sedation was recorded in 91% before vs. 84% after the protocol. Induction and maintenance doses of midazolam followed protocol recommendations in 1.3% before vs 10.4% after the protocol was implemented (P=.02) and adequate rescue doses were used in 1.3% vs 11.9% respectively (P=.01). Midazolam doses were significantly lower (9.86mg vs 18.67mg, P.001) when the protocol was used than when it was not used. Ramsay sedation score was used in 8% vs. 12% and the Palliative Care Team was involved in 35.5% and 16.4% of the cases (P=.008) before and after the protocol, respectively.Use of midazolam slightly improved after the implementation of a hospital protocol on palliative sedation. The percentage of adequate sedations and the general process of sedation were mostly unchanged by the protocol. More education and further assessment is needed to gauge the effect of these measures in the future.

Background Pressure ulcers (PUs) are more frequent in older patients, and the healing process is usually challenging. Nonpharmacologic interventions may play a role in the treatment of older people with PUs, but most systematic reviews (SRs) have not addressed this specific population using convincing outcome measures. Objective To summarize and critically appraise the evidence from SRs of the primary studies on nonpharmacologic interventions to treat PUs in older patients. Design SR and meta-analysis of comparative studies. Methods PubMed, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL (from inception to October 2013) were searched. A new search for updates in the Cochrane Database was launched in July 2014. SRs that included at least 1 comparative study evaluating any nonpharmacologic intervention to treat PUs in older patients, in any health care setting, were included. Any primary study with experimental design was then identified and included. From each primary study, quality assessment was undertaken as specified by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation working group. Interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis, using complete ulcer healing as the outcome measure. Results One hundred ten SRs with 45 primary studies satisfied the inclusion criteria. The most frequent interventions explored in these trials were support surfaces (13 studies), nutrition (8), and electrotherapy (6). High or moderate quality of evidence was found in none of the interventions, mainly because of the very serious risk of bias of most studies and imprecision in the treatment effect. Evidence grade is very low or insufficient to support the use of any support surface, nutrition intervention, multicomponent interventions, repositioning or other adjunctive therapy (ultrasound, negative pressure, laser, electromagnetic, light, shock wave, hydrotherapy, radiofrequency, or vibration therapy) to increase the rates of PU healing in older patients. Electrotherapy showed some beneficial effect in the treatment of PUs, although the quality of evidence is low. Conclusions In older patients with PUs, evidence to use any nonpharmacologic therapy to increase the rates of wound healing is inconclusive, except for low quality evidence that supports the use of electrotherapy. This situation is especially alarming for interventions that are usually standard clinical practice (repositioning, support surfaces). Although there is some evidence in younger populations and other types of ulcers, studies in older populations with PUs using sound methodology are needed.

Potentially inappropriate prescribing is common in older people presenting to hospital with acute illness in Ireland. The aim of this study was to determine if this phenomenon is unique to Ireland or whether it is a more widespread problem in hospitals across Europe.Prospective data were collected from 900 consecutive older patients admitted to six university teaching hospitals (150 patients per centre) in Geneva (Switzerland), Madrid (Spain), Oostende (Belgium), Perugia (Italy), Prague (Czech Republic) and Cork (Ireland). Age, gender, comorbidity, cognitive status, prescription medicines taken before admission and baseline haematological, biochemical and electrocardiographic data were recorded. STOPP and Beers' criteria were applied to detect potentially inappropriate medicines (PIMs). START criteria were applied to detect potentially inappropriate prescribing omissions (PPOs).The overall PIM prevalence rate was 51.3% using STOPP criteria, varying from 34.7% in Prague to 77.3% in Geneva, and 30.4% using Beer's criteria, varying from 22.7% in Prague to 43.3% in Geneva. Using START criteria, the overall PPO prevalence rate was 59.4%, ranging from 51.3% in Cork to 72.7% in Perugia. Polypharmacy predicted the presence of PIMs using STOPP criteria [with 10 medications: odds ratio (OR) 7.22, 95% confidence interval (CI) 4.30-12.12, p 0.001] and Beers' criteria (with 10 medications: OR 4.87, 95% CI 3.00-7.90, p 0.001). Increasing co-morbidity (Charlson Index ≥2) and age ≥85 years significantly predicted PPOs.Potentially inappropriate drug prescribing and the omission of beneficial drugs are highly prevalent in acutely ill hospitalized older people in six European centres.

O 013 Sensor-based home activity monitoring of geriatric fracture patients in rehabilitation –The GAL NATARS study M. Marscholleka,b,c,d,e,f,g,h,i, M. Apela,b,c,d,e,f,g,h,i, P. Bentea,b,c,d,e,f,g,h,i, L. Dasenbrocka,b,c,d,e,f,g,h,i, K. Elbersa,b,c,d,e,f,g,h,i, R. Hauxa,b,c,d,e,f,g,h,i, A. Heina,b,c,d,e,f,g,h,i, G. Kolba,b,c,d,e,f,g,h,i, H. Kunemunda,b,c,d,e,f,g,h,i, C. Lammel-Polchaua,b,c,d,e,f,g,h,i, M. Meisa,b,c,d,e,f,g,h,i, H. Meyer zu Schwabedissena,b,c,d,e,f,g,h,i, H. Remmersa,b,c,d,e,f,g,h,i, E.E. Steena,b,c,d,e,f,g,h,i, J. Wanga,b,c,d,e,f,g,h,i, K.H. Wolf a,b,c,d,e,f,g,h,i, J. Bauera,b,c,d,e,f,g,h,i a Hannover Medical School, Hannover, Germany b Klinikum Oldenburg, Oldenburg. Germany c Std. Klinikum Braunschweig, Braunschweig, Germany d St. Bonifatius Hospital Lingen, Lingen, Germany e TU Braunschweig, Braunschweig, Germany f OFFIS, Oldenburg, Germany g Universitat Vechta, Vechta, Germany h Horzentrum Oldenburg, Oldenburg, Germany i Universitat Osnabruck, Osnabruck, Germany