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Model d'atenció integral; Valoració multidimensional; Diagnòstic Modelo de atención integral; Valoración multidimensional; Diagnóstico Comprehensive care model; Multidimensional valuation; Diagnosis Actualment no existeix a Catalunya un consens sobre quin hauria de ser el mínim comú denominador d’escales i eines d’elecció per a la valoració de les diferents dimensions de les persones grans amb multimorbiditat, fragilitat, cronicitat complexa o avançada. Aquest escenari fa evident la necessitat de disposar d’escales i eines consensuades i compartides que facilitin l’aproximació multidimensional a aquestes persones de forma objectiva i pragmàtica, amb l’objectiu d'ajudar els professionals en aquest procés d’individualització de l’atenció. És per aquest motiu que, impulsat per la Direcció General de Planificació i Recerca en Salut i per l’oficina eSalut, s’ha promogut i desenvolupat aquest consens i es vol assegurar que la proposta pugui ser suportada en l’entorn digital.

Introduction: Home Care Services (HCS) for care-dependent individuals enable their independent lives at home. We aimed to characterize users and evaluate the impact of social HCS for dependent individuals. Methods: Retrospective study including all social HCS recipients for individuals with the official recognition of dependency from Catalonia using 2018–2019 data from the Autonomy and Dependency Care System and the Catalan Health Surveillance System. Variables were social and healthcare services utilization and expenditure. HCS recipients were compared to non-recipients. Changes in services utilization and expenditure before and after HCS were estimated. Results: The 48,885 individuals who received HCS in 2019 were mostly >84 years, women, and had moderate dependency. Recipients’ prevalence was higher among low-/very-low-income individuals. HCS users had a higher morbidity burden than non-recipients with increased healthcare service utilization and associated expenditures. After HCS initiation, Telecare, day center, and most healthcare services utilization increased. Social and healthcare service-associated expenditures increased from a mean of 535 to 867 €/individual/month after HCS initiation, mostly due to HCS. Conclusions: Social HCS dependency recipients were overall very old, with moderate dependency, low-income, high morbidity, and intensive use of healthcare services. HCS is associated with increased social service-associated expenditures and modestly decreased healthcare-associated expenditures.

El índice de fragilidad Frágil-VIG y la escala de Braden son instrumentos validados para la valoración de la fragilidad y el riesgo de desarrollar lesiones relacionadas con la dependencia (LRD) respectivamente. El índice Frágil-VIG es un instrumento multidimensional que permite una evaluación rápida y eficaz del grado de fragilidad en el contexto de la práctica clínica. Objetivo: Investigar la validez convergente y discriminativa del índice Frágil-VIG respecto a la escala de Braden. Métodos Estudio transversal en dos centros de Atención Primaria de Salud de Barcelona (APS). Participaron en el estudio todas las personas incluidas en el programa de atención domiciliaria durante el año 2018, sin criterios de exclusión. Enfermeras de APS administraron el índice Frágil-VIG y la escala de Braden mediante evaluaciones personales en el domicilio de cada participante durante la atención habitual. Las relaciones entre ambos instrumentos se examinaron mediante el coeficiente de correlación de Pearson. Resultados Se incluyeron cuatrocientos doce participantes. La puntuación del índice Frágil-VIG correlacionó negativamente con la escala de Braden (r=-0,597; P

Resumen Introduccion La fragilidad puede ser detectada con distintas herramientas y en multiples entornos. Entre los diferentes sistemas de cribado, la velocidad de marcha (VM) y el Timed Up-and- Go (TUG) se postulan como sistemas sencillos y facilmente aplicables. Existen pocos datos sobre su aplicabilidad en pacientes hospitalizados en centros de atencion intermedia. Material y metodos Estudio descriptivo para determinar la aplicabilidad de la VM y el TUG como herramientas de cribado de fragilidad en un hospital de atencion intermedia, asi como una estimacion de la prevalencia de fragilidad al alta mediante estas pruebas de ejecucion funcional. Se consideraron fragiles los pacientes con una VM 12 s. Se incluyeron todos pacientes atendidos por la unidad de rehabilitacion del centro a lo largo del ano 2015. Resultados Novecientos nueve fueron los pacientes incluidos (edad media de 80,12 anos). De estos, solo 205 (22,6%) estaban en condiciones de realizar la VM y TUG en el momento del alta; de estas 205 personas, el 89,8% (VM) y el 92,2% (TUG) presentaban criterios de fragilidad, no habiendo diferencias estadisticamente significativas entre ambas herramientas (p = 0,25). Conclusiones La utilizacion de la VM y el TUG para el cribado de fragilidad tiene una aplicabilidad limitada en el entorno de atencion intermedia. A pesar de ello, los resultados obtenidos indican una alta prevalencia de fragilidad en este entorno. Seran necesarios mas estudios para corroborar estos datos.

The World Health Organization has developed the Integrated Care of Older People (ICOPE) strategy, a program based on the measurement of intrinsic capacity (IC) as "the composite of all physical and mental attributes on which an individual can draw". Multicomponent interventions appear to be the most effective approach to enhance IC and to prevent frailty and disability since adapted physical activity is the preventive intervention that has shown the most evidence in the treatment of frailty and risk of falls. Our paper describes the development of a multi-domain group-based intervention addressed to older people living in the community, aimed at improving and/or maintaining intrinsic capacity by means of promoting physical activity, healthy nutrition, and psychological wellbeing in older people. The process of intervention development is described following the Guidance for reporting intervention development studies in health research (GUIDED). The result of this study is the AMICOPE intervention (Aptitude Multi-domain group-based intervention to improve and/or maintain IC in Older PEople) built upon the ICOPE framework and described following the Template for Intervention Description and Replication (TIDieR) guidelines. The intervention consists of 12 face-to-face sessions held weekly for 2.5 h over three months and facilitated by a pair of health and social care professionals. This study represents the first stage of the UK Medical Research Council framework for developing and evaluating a complex intervention. The next step should be carrying out a feasibility study for the AMICOPE intervention and, at a later stage, assessing the effectiveness in a randomized controlled trial.

Frailty and hip fracture are closely related and are associated with high risk of functional decline and mortality. The objective of this study is to analyze whether the Frail-VIG index [IF-VIG] (fragility index validated in the geriatric population) maintains its predictive capacity for mortality in old patients with hip fracture.Observational, cohort, longitudinal and ambispective study on patients admitted to an acute geriatric unit with a hip fracture. Patients were classified according to their degree of frailty into three groups by the IF-VIG: no frailty/initial frailty (≤0.35), moderate frailty (0.36-0.50) and advanced frailty (0.50). The follow-up period was 24months. The three groups were compared using survival curves and ROC curves were analyzed to assess the prognostic capacity of IF-VIG.A total of 103 patients were included; 73.8% were women, with a mean age of 87years. There were no differences between groups in relation to the type of fracture, the kind of surgery, the waiting time until surgery and the mobilization time. Overall, in-hospital mortality was 7.76%, significantly higher in the advanced frailty group (23.3%). We also found significant differences in mortality at 24months of follow-up according to the IF-VIG. The under the ROC curve area at 3, 6, 12 and 24months was 0.90 (0.83-0.97), 0.90 (0.82-0.97), 0.91 (0.86-0.97) and 0.88 (0.81-0.94), respectively.The IF-VIG appears to be a good tool in predicting mortality in old patients with hip fracture.

The Frail-VIG index and the Braden scale are validated instruments for assessing frailty and the risk of developing dependency-related skin lesions respectively. The Frail-VIG index is a multidimensional instrument that allows rapid and efficient assessment of the degree of frailty in the context of clinical practice.Our aim was to investigate the convergent and discriminative validity of the Frail-VIG index with regard to Braden scale value.We carried out a cross-sectional study in 2 primary health care centres of the Catalan Institute of Health, Barcelona (Spain). Participants in the study were all people included under a home care programme during the year 2018. No exclusion criteria were applied. We used the Frail-VIG index to measure frailty and the Braden scale to measure the risk of developing pressure ulcers. Trained nurses administered both instruments during face-to-face assessments in a participant's home during usual care. The relationships between both instruments were examined using Pearson's correlation coefficient.Four hundred and twelve participants were included. Frail-VIG score and Braden scale value were negatively correlated (r=-0.597; P.0001). Non-frail people had a lower risk of developing dependency-related skin lesions than moderate to severe frail people. The Braden scale value declined significantly as the Frail-VIG index score increased.Frail-VIG index demonstrated a convergent validity with the Braden scale. Its discriminative validity was optimal, as their scores showed an excellent capacity to differentiate between people with a higher and lower risk of developing. These findings provide additional pieces of evidence for construct validity of the Frail-VIG index.

Background In 2018, the European Working Group on Sarcopenia in Older People (EWGSOP2) updated the original definition of sarcopenia, establishing new criteria to be used globally. Early diagnosis of sarcopenia in nursing home residents and the identification of contributing factors would target interventions to reduce the incidence of malnutrition, social isolation, functional decline, hospitalization and mortality. Aim Verify the prevalence and the degree of severity of sarcopenia according to the new EWSGOP2 criteria and to analyse its associated factors in residents living in nursing homes in Central Catalonia (Spain). Design A cross-sectional multicenter study was conducted in 4 nursing homes. SARC-F test was applied as the initial screening, muscle strength was measured by a dynamometer, skeletal muscle mass by bioimpedance analysis and physical performance by Gait Speed. Four categories were used: total probable sarcopenia, probable sarcopenia, confirmed sarcopenia and severe sarcopenia. Results Among the total sample of 104 nursing home residents (mean age 84.6, ± 7.8; median 86, IQR 110), 84.6% were women and 85 (81.7%) (95% confidence interval [CI] 73.0-88.0) had total probable sarcopenia, 63 (60.5%) had probable sarcopenia, 19 (18.3%) had confirmed sarcopenia and 7 (6.7%) had severe sarcopenia. In the bivariate analysis, obesity was negatively associated and total time in sedentary behavior positively associated with all sarcopenia categories. In addition, malnutrition and urinary continence were positively associated with total and probable sarcopenia. Urinary incontinence was a positive associated factor of total and probable sarcopenia. In the multivariate analysis, obesity represented a negative associated factor: OR = 0.13 (0.03 - 0.57), p = 0.007 and OR = 0.14 (0.03 - 0.60), p = 0.008 with total and probable sarcopenia, respectively, adjusted by urinary incontinence status. For confirmed sarcopenia, obesity also represented a negative associated factor OR = 0.06 (0.01 - 0.99), p = 0.049 and the total time in sedentary behavior a positive associated factor OR = 1.10 (1.00- 1.20), p = 0.040. Conclusions According the EWGSOP2 criteria, high prevalence of sarcopenia was found in institutionalized older people, ranging from 6.7 to 81.7% depending on the category. Malnutrition, urinary incontinence and total time in sedentary behavior were associated with sarcopenia, whilst obesity represented a protective factor in this population.

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index, therapeutical complexity and anticholinergic and sedative burden, and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women, mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home, the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p &lt, 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

The World Health Organization has developed the Integrated Care of Older People (ICOPE) strategy, a program based on the measurement of intrinsic capacity (IC) as 'the composite of all physical and mental attributes on which an individual can draw'. Multicomponent interventions appear to be the most effective approach to enhance IC and to prevent frailty and disability since adapted physical activity is the preventive intervention that has shown the most evidence in the treatment of frailty and risk of falls. Our paper describes the development of a multi-domain group-based intervention addressed to older people living in the community, aimed at improving and/or maintaining intrinsic capacity by means of promoting physical activity, healthy nutrition, and psychological wellbeing in older people. The process of intervention development is described following the Guidance for reporting intervention development studies in health research (GUIDED). The result of this study is the AMICOPE intervention (Aptitude Multi-domain group-based intervention to improve and/or maintain IC in Older PEople) built upon the ICOPE framework and described following the Template for Intervention Description and Replication (TIDieR) guidelines. The intervention consists of 12 face-to-face sessions held weekly for 2.5 h over three months and facilitated by a pair of health and social care professionals. This study represents the first stage of the UK Medical Research Council framework for developing and evaluating a complex intervention. The next step should be carrying out a feasibility study for the AMICOPE intervention and, at a later stage, assessing the effectiveness in a randomized controlled trial. This research was funded by the program POCTEFA (European Union) in the context of the APTITUDE project, reference EFA232/16. Nicolás Martínez-Velilla received funding from La Caixa Foundation (ID 100010434), under agreement LCF/PR/PR15/51100006.

Myasthenia gravis (MG), amyotrophic lateral sclerosis and Guillain-Barre syndrome (GBS) have been classically considered as exceptional or unusual diseases in people with a geriatric profile. Over the past 25 years, several population-based studies have been conducted in the Osona area (Barcelona), which, for the first time, has led to describing the high global incidences in the elderly, especially those over 80 years-old. The results suggest the possibility of underdiagnosis of these neuromuscular diseases in the elderly, a fact that could be especially relevant in the case of MG and GBS, since they are 2potentially reversible entities with high mortality in the event of underdiagnosis and absence of treatment.

ObjectivesTo assess the degree of frailty in older people with different advanced diseases and its relationship with end-of-life illness trajectories and survival.MethodsProspective, observational study, including all patients admitted to the Acute Geriatric Unit of the University Hospital of Vic (Spain) during 12 consecutive months (2014–2015), followed for up to 2 years. Participants were identified as end-of-life people (EOLp) using the NECPAL (NECesidades PALiativas, palliative care needs) tool and were classified according to their dominant illness trajectory. The Frail-VIG index (Valoración Integral Geriátrica, Comprehensive Geriatric Assessment) was used to quantify frailty degree, to calculate the relationship between frailty and mortality (Receiver Operating Characteristic (ROC) curves), and to assess the combined effect of frailty degree and illness trajectories on survival (Cox proportional hazards model). Survival curves were plotted using the Kaplan-Meier estimator with participants classified into four groups (ie, no frailty, mild frailty, moderate frailty and advanced frailty) and were compared using the log-rank test.ResultsOf the 590 persons with a mean (SD) age of 86.4 (5.6) years recruited, 260 (44.1%) were identified as EOLp, distributed into cancer (n=31, 11.9%), organ failure (n=79, 30.4%), dementia (n=86, 33.1%) and multimorbidity (n=64, 24.6%) trajectories. All 260 EOLp had some degree of frailty, mostly advanced frailty (n=184, 70.8%), regardless of the illness trajectory, and 220 (84.6%) died within 2 years. The area under the ROC curve (95% CI) after 2 years of follow-up for EOLp was 0.87 (0.84 to 0.92) with different patterns of survival decline in the different end-of-life trajectories (pConclusionsAll older people towards the end-of-life in this study were frail, mostly with advanced frailty. The degree of frailty is related to survival across the different illness trajectories despite the differing survival patterns among trajectories. Frailty indexes may be useful to assess end-of-life older people, regardless of their trajectory.

The World Health Organization has developed the Integrated Care of Older People (ICOPE) strategy, a program based on the measurement of intrinsic capacity (IC) as “the composite of all physical and mental attributes on which an individual can draw”. Multicomponent interventions appear to be the more effective approach to enhance IC and to prevent frailty and dependence, being adapted physical activity is the preventive intervention that has shown more evidence in the treatment of frailty and risk of falls. The present study aims to describe the development of a multi-domain group-based intervention addressed to frail older people living in the community aimed to improve and/or maintain intrinsic capacity by means of promoting physical activity, healthy nutrition, and psychological wellbeing in frail older people. We used the GUIDED checklist to describe the development process of AMICOPE (Aptitude Multi-domain group-based intervention to improve and/or maintain IC in frail Older PEople). The intervention was built upon the ICOPE framework and it is described with Template for Intervention Description and Replication (TIDieR) guidelines and it includes dietary advice, cognitive stimulation strategies, medication review, goal setting, and activities to strengthen social support and manage depressive symptoms, as well as strength, balance and flexibility exercise using the Vivifrail program. The study represents the first stage of the UK Medical Research Council framework for developing and evaluating a complex intervention. The next step should be carrying out a feasibility study for the AMICOPE intervention, and in a later stage, assessing the effectiveness in a randomized controlled trial.

Frailty; Psychometrics; Feasibility Fragilitat; Psicometria; Viabilitat Fragilidad; Psicometría; Viabilidad The study aimed to assess the reliability of the scores, evidence of validity, and feasibility of the Frail-VIG index. A validation study mixing hospitalized and community-dwelling older people was designed. Intraclass correlation coefficient (ICC) was used to assess the inter-rater agreement and the reliability. The construct validity of the Frail-VIG index with respect to the Frailty Phenotype (FP) was evaluated by calculating the area under the receiver operating characteristic curve (AUC-ROC). Convergent validity with the Clinical Frailty Scale (CFS) was assessed using Pearson’s correlation coefficients. The feasibility was evaluated by calculating the average time required to administer the Frail-VIG index and the percentage of unanswered responses. A sample of 527 older people (mean age of 81.61, 56.2% female) was included. The inter-rater agreement and test–retest reliability were very strong: 0.941 (95% CI, 0.890 to 0.969) and 0.976 (95% CI, 0.958 to 0.986), respectively. Results indicated adequate convergent validity of the Frail-VIG index with respect to the FP, AUC-ROC 0.704 (95% CI, 0.622 to 0.786), and a moderate to strong positive correlation between the Frail-VIG index and CFS (r = 0.635, 95% CI, 0.54 to 0.71). The Frail-VIG index administration required an average of 5.01 min, with only 0.34% of unanswered responses. The Frail-VIG index is a reliable, feasible, and valid instrument to assess the degree of frailty in hospitalized and community-dwelling older people.

Background The number of days spent at home in the last six months of life has been proposed as a comprehensive indicator of high-value patient-centered care; however, information regarding the determinants of this outcome is scarce, particularly among the general population. We investigated the determinants of spending time at home within the six months preceding death. Methods Population-based, retrospective analysis of administrative databases of the Catalan government. The analysis included adult (≥18 years) individuals who died in Catalonia (North-east Spain) in 2017 and met the McNamara criteria for palliative care. The primary outcome was the number of days spent at home within the last 180 days of life. Other variables included the cause of death, demographic characteristics, and socioeconomic status, stratified as very low, low, mid, and high level. Results The analysis included 40,137 individuals (19,510 women; 20,627 men), who spent a median of 140 days (IQR 16–171) at home within the six months preceding death (women 140 [16–171]; men 150 [100–171]). Female gender was an independent factor of staying fewer days at home (OR 0.80 [95% CI 0.77–0.82]; ppppp Conclusions Our results suggest that end-of-life care is associated with gender and socioeconomic inequalities; women and individuals with lower socioeconomic status spend less time at home within the last 180 days of life.

This chapter elaborates on the Chronic Care Program in Catalonia. Implementation of a successful chronic and integrate public policy requires perseverance, time, having a humble attitude and continuing learning efforts. Based on the authors experience, they highlight the key lessons learned from the journey of integrated care in Catalonia.

[spa] Objetivo: Consensuar una herramienta de valoración multidimensional/geriátrica rápida (VMGR), como sistema compartido y universal de valoración multidimensional de personas con multimorbilidad, fragilidad, complejidad o situación avanzada, para todos los profesionales del sistema de salud y social de Catalun ̃a. Disen ̃o: Consenso de profesionales en tres fases, combinando sesiones presenciales con trabajo telemático. Emplazamiento: Catalun ̃a. Participantes: Se constituyó un grupo de 27 profesionales de carácter interdisciplinario repre- sentativo de los distintos ámbitos de atención. Método: Se han combinado las metodologías de Design thinking para el consenso inicial de características de la herramienta de VMGR (fase 1), con la metodología Lean Start-Up para el disen ̃o de la nueva herramienta de VMGR (fase 2), que finalmente se testeó en un grupo de pacientes (fase 3). Resultados: En la fase 1 se consensuó que la herramienta de VMGR ideal debía permitir una valoración ad hoc de las personas, ser rápida y ágil (tiempo < 10 minutos), identificar las dimen- siones alteradas mediante preguntas trigger y facilitar el diagnóstico de situación (idealmente cuantificado). En la fase 2 se elaboró el prototipo de una nueva herramienta de VMGR de 15 + dos preguntas (VIG-Express), finalmente testeada en 35 personas en la fase 3. Conclusiones: En los resultados preliminares, la herramienta VIG-Express parece facilitar una valoración multidimensional sencilla y rápida y la personalización de las intervenciones, así como una mirada única y un relato compartido entre los profesionales de los distintos ámbitos de atención. Serán necesarios más estudios para corroborar estos hallazgos. [spa] Objective: To reach a consensus on an rapid multidimensional/geriatric assessment (RMGA) tool for all health and social professionals of Catalonia as a shared and universal system to assess patients with multimorbidities, frailty, complexity or advanced conditions. Design: Three-phase consensus of professionals, combining in-person sessions with telematics. Location: Catalonia. Participants: A group of 27 interdisciplinary professionals from different care settings. Method: The Design Thinking methodology for an initial consensus on the characteristics of the RMGA tool (Phase 1) has been combined with the Lean Startup methodology to create a new RMGA tool (Phase 2), and then tested in a group of patients (Phase 3). Results: In Phase 1, a consensus was reached that the perfect RMGA tool should allow for an ad hoc assessment of patients, be fast and flexible (

Background The Frail-VIG frailty index has been developed recently. It is an instrument with a multidimensional approach and a pragmatic purpose that allows rapid and efficient assessment of the degree of frailty in the context of clinical practice. Our aim was to investigate the convergent and discriminative validity of the Frail-VIG frailty index with regard to EQ-5D-3L value. Methods We carried out a cross-sectional study in two Primary Health Care (PHC) centres of the Catalan Institute of Health (Institut Català de la Salut), Barcelona (Spain) from February 2017 to January 2019. Participants in the study were all people included under a home care programme during the study period. No exclusion criteria were applied. We used the EQ-5D-3L to measure Health-Related Quality of Life (HRQoL) and the Frail-VIG index to measure frailty. Trained PHC nurses administered both instruments during face-to-face assessments in a participant’s home during usual care. The relationships between both instruments were examined using Pearson’s correlation coefficient and multiple linear regression analyses. Results Four hundred and twelve participants were included in this study. Frail-VIG score and EQ-5D-3L value were negatively correlated (r = − 0.510; P Conclusions Frail-VIG index demonstrated a convergent validity with the EQ-5D-3L value. Its discriminative validity was optimal, as their scores showed an excellent capacity to differentiate between people with better and worse HRQoL. These findings provide additional pieces of evidence for construct validity of the Frail-VIG index.

ObjectiveTo develop and validate a prognostic model to assess mortality risk at 24 months in patients with advanced chronic conditions.MethodsRetrospective design based on a previous population cohort study with 789 adults who were identified with the surprise question and NECPAL tool from primary and intermediate care centres, nursing homes and one acute hospital of Spain. A Cox regression model was used to derive a mortality predictive model based on patients’ age and six previously selected NECPAL prognostic factors (palliative care need identified by healthcare professionals, functional decline, nutritional decline, multimorbidity, use of resources, disease-specific criteria of severity/progression). Patients were split into derivation/validation cohorts, and four steps were followed: descriptive analysis, predictors’ assessment, model estimation and model assessment.ResultsAll predictive variables were independently associated with increased risk of mortality at 24 months. Performance model including age was good; discrimination power by area under the curve (AUC) was 0.72/0.67 in the derivation/validation cohorts, and correlation between expected and observed (E/O) mortality ratio was 0.74/0.70. The model showed similar performance across settings (AUC 0.65–0.74, E/O 1.00–1.01), the best performance in oncological patients (AUC 0.78, E/O 0.76) and the worst in dementia patients (AUC 0.58, E/O 0.85). Based on the number of factors affected, three prognostic stages with significant differences and a median survival of 38, 17.2 and 3.6 months (pConclusionThe NECPAL prognostic tool is accurate and eventually useful at the clinical practice. Stratification in risk groups may enable early intervention and enhance policy-making and service planning.

Background Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age.Methods Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA, Grupos de Morbilidad Ajustada)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system.Results This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in median age (83 vs. 87 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (pConclusions There is a growing gap between the clinical and demographic characteristics of age-matched IOP and non-IOP, which overlaps with a higher mortality rate of IOP. The profile of resources utilization of IOP compared with non-IOP strongly suggests a deficiency of preventive actions and stresses the need to rethink the care model for IOP from a social and health care perspective.

espanolLa pandemia de COVID-19 ha sido especialmente agresiva en el ambito residencial, entorno donde la mortalidad supone mas del 50 % del total de las muertes por esta enfermedad. Pero las repercusiones (fisicas y emocionales) que esta crisis ha condicionado, tanto en los residentes como en sus familias y en los profesionales, van mucho mas alla de estos datos. En primer lugar, y mediante la revision de la (escasa) bibliografia existente, de los (escasos) datos disponibles en nuestro pais y de la (intensa) experiencia vivida por parte de alguno de estos profesionales, en el presente articulo revisamos el impacto de la pandemia en este ambito. En segundo lugar, se describen algunas propuestas desarrolladas con el objetivo de aportar respuesta a esta crisis, desde la perspectiva de los cuidados paliativos. Finalmente, y partiendo de las evidencias publicadas y de la propia experiencia, los autores formulan una serie de recomendaciones especificas y pragmaticas sobre la atencion paliativa en el ambito residencial, a corto, medio y largo plazo. EnglishThe COVID-19 pandemic has been very aggressive in nursing homes, where mortality accounts for more than 50% of all deaths from this disease. But the physical and emotional repercussions go far beyond these data, both for residents and their families, and for professionals. Firstly, we review the impact of the pandemic in nursing homes based on a review of the existing literature, the data available in Spain, and the experience lived by some of these professionals. Secondly, some proposals developed by organizations with the objective of providing a response to this crisis from the palliative care perspective are described. Finally, and based on the published evidence and their own experience, the authors provide a series of specific and pragmatic recommendations on palliative care in nursing homes for the short, medium and long term.

ObjectiveTo develop a proposal for a 2-year mortality prognostic approach for patients with advanced chronic conditions based on the palliative care need (PCN) items of theNECesidades PALiativas(NECPAL) CCOMS-ICO V.3.1 2017 tool.MethodsA phase 1 study using three components based on the NECPAL items: (1) a rapid review of systematic reviews (SRs) on prognostic factors of mortality in patients with advanced chronic diseases and PCNs; (2) a clinician and statistician experts' consensus based on the Delphi technique on the selection of mortality prognostic factors; and (3) a panel meeting to discuss the findings of components (1) and (2).ResultsTwenty SRs were included in a rapid review, and 50% were considered of moderate quality. Despite methodological issues, nutritional and functional decline, severe and refractory dyspnoea, multimorbidity, use of resources and specific disease indicators were found to be potentially prognostic variables for mortality across four clinical groups and end-of-life (EoL) trajectories: cancer, dementia and neurologic diseases, chronic organ failure and frailty. Experts’ consensus added ‘needs’ identified by health professionals. However, clinicians were less able to discriminate which NECPAL items were more reliable for a ‘general’ model. A retrospective cohort study was designed to evaluate this proposal in phase 2.ConclusionsWe identified several parameters with prognostic value and linked them to the tool’s utility to timely identify PCNs of patients with advanced chronic conditions in all settings of care. Initial results show this is a clinical and feasible tool, that will help with clinical pragmatic decision-making and to define services.

Palliative care must be early applied to all types of advanced chronic and life limited prognosis patients, present in all health and social services. Patients' early identification and registry allows introducing palliative care gradually concomitant with other measures. Patients undergo a systematic and integrated care process, meant to improve their life quality, which includes multidimensional assessment of their needs, recognition of their values and preferences for advance care planning purposes, treatments review, family care, and case management. Leaded by the National Department of Health, a program for the early identification of these patients has been implemented in Catalonia (Spain). Although the overall benefits expected, the program has raised some ethical issues. In order to address these challenges, diverse institutions, including bioethics and ethics committees, have elaborated a proposal for the program's advantages. This paper describes the process of evaluation, elaboration of recommendations, and actions done in Catalonia.

The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process.

Potentially inappropriate medications (PIMs) are common in palliative care patients, but no specific tools have been used to determine these PIMs. To evaluate the prevalence of PIMs according to specific tool ‘STOPP-Frail’, related factors with its existence and clinical consequences. This is a post hoc analysis from a 10-month prospective cross-sectional study. Upon hospital admission in an acute geriatric unit (AGU), demographic and pharmacological data were collected to determine related associated factors. The main outcome was prevalence and type of PIMs (by STOPP-Frail criteria). Measured clinical outcomes were adverse drug events, length of stay, location upon discharge, in-hospital mortality and 1-year survival. Two hundred thirty-five patients (mean age 86.80; 65.50% women) were recruited. Overall, 67.2% of patients had ≥ 1 criterion (mainly ‘drugs without clinical indication’ due to alimentary tract and metabolism drugs). Related factors associated with PIMs according to STOPP-Frail criteria were moderate polypharmacy (OR 7.16 CI 95% 2.27–22.52) and excessive polypharmacy (OR 7.30 CI 95% 2.34–22.73), but not advanced age (OR 0.26 CI 95% 0.12–0.53) or previous hospitalisations (OR 0.61 CI 95% 0.48–0.79). There were no differences in clinical outcomes. PIMs according to STOPP-Frail are often used in palliative care patients. PIMs were associated with polypharmacy, but no related morbidity or mortality effects have been observed.

Objectives To evaluate characteristics of the medication complexity, risk factors associated with high medication complexity and their clinical consequences in patients with advanced chronic conditions. Methods A 10-month cross-sectional study was performed in an acute-hospital care Geriatric Unit. Patients with advanced chronic conditions were identified by the NECPAL test. Medication complexity was established using the Medication Regimen Complexity Index (MRCI) tool. Demographic, pharmacological and clinical patient data were collected with the objective of determining risk factors related to high medication complexity. Measured clinical outcomes were hospital length of stay, destination on hospital discharge, in-hospital mortality and 2-year survival. Results Two hundred and thirty-five patients (mean age 86.8, SD 5.37; 65.5% female) were recruited. MRCI’s mean score was 38 points (SD 16.54, rank: 2.00–98.50), with 57.9% of patients with high medication complexity (MRCI >35 points).

Patients with multiple disorders and on multiple medication are often associated with clinical complexity, defined as a situation of uncertainty conditioned by difficulties in establishing a situational diagnosis and decision-making. The patient-centred care approach in this population group seems to be one of the best therapeutic options. In this context, the preparation of an individualised therapeutic plan is the most relevant practical element, where the pharmacological plan maintains an important role. There has recently been a significant increase in knowledge in the area of adequacy of prescription and adherence. In this context, we must find a model must be found that incorporates this knowledge into clinical practice by the professionals. Person-centred prescription is a medication review model that includes different strategies in a single intervention. It is performed by a multidisciplinary team, and allows them to adapt the pharmacological plan of patients with clinical complexity.