Olga Herminia Torres

Background: There are very few studies on walking recovery, its predictors and impact on survival in oldest-old patients after a hip fracture. Methods: This study is a retrospective review which included all patients older than 95 years admitted with a fragility hip fracture between December 2009 and September 2015 in a tertiary university hospital in Barcelona. Walking ability was assessed using the Functional Ambulation Classification (FAC) prior to admission and 6 months after discharge. The objective of our study is to assess walking recovery and its predictors in oldest-old patients at 6 months after discharge, and to determine whether there was a relationship with short and long-term survival. Results: One hundred and fifty-two patients were included in the study. Prior to the fracture, 78.3% of patients could walk independently, 36.8% after the fracture. A higher previous FAC score (p < 0.001, OR 3.658), absence of delirium during admission (p = 0.010, OR 3.45), and being able to carry out full weight-bearing (p = 0.026, OR 12.705) were associated with better walking recovery. The area under the ROC curve was 0.819 (p < 0.001). Mean survival after discharge was 2.24 years (SD 1.185). Patients with a post-fracture FAC ≥ 3 showed better survival. Conclusions: Predictors of walking recovery in patients with exceptional longevity were a higher previous FAC score, being able to carry out full weight-bearing, and absence of delirium. Patients able to walk unaided within six months of discharge showed better survival. These findings highlight the importance of functional outcomes when assessing prognosis in the oldest-old.

(1) Background: Knowledge about the behavior of antibiotics in critically ill patients has been increasing in recent years. Some studies have concluded that a high percentage may be outside the therapeutic range. The most likely cause of this is the pharmacokinetic variability of critically ill patients, but it is not clear which factors have the greatest impact. The aim of this systematic review is to identify risk factors among critically ill patients that may exhibit significant pharmacokinetic alterations, compromising treatment efficacy and safety. (2) Methods: The search included the PubMed, Web of Science, and Embase databases. (3) Results: We identified 246 observational studies and ten clinical trials. The most studied risk factors in the literature were renal function, weight, age, sex, and renal replacement therapy. Risk factors with the greatest impact included renal function, weight, renal replacement therapy, age, protein or albumin levels, and APACHE or SAPS scores. (4) Conclusions: The review allows us to identify which critically ill patients are at a higher risk of not reaching therapeutic targets and helps us to recognize the extensive number of risk factors that have been studied, guiding their inclusion in future studies. It is essential to continue researching, especially in real clinical practice and with clinical outcomes.

Background and aims: Community-acquired pneumonia (CAP) is a major threat to older adults, but mid-term implications are poorly described. The aim was to analyze functional decline, institutionalization, malnutrition, and risk factors after hospital admission for CAP. Methods: This prospective observational study included patients over 65 years discharged after CAP between May 2019 and July 2021. We performed a comprehensive geriatric assessment and a general nutritional assessment 30–60 days after CAP. This included the MNA and blood test with trace elements and vitamins. The main outcomes were functional decline, institutionalization, and malnutrition. Multivariate logistic regression was used for the analyses. Results: In total, 144 patients of 77.15 ± 7.91 years, 55.6% male, and 9% previously institutionalized were analyzed. At hospital admission, the Charlson Comorbidity Index (CCI) was 1.5 ± 1.6, the Pneumonia Severity Index was 98.1 ± 25.9, and the previous Barthel Index (BI) was 93.06 ± 17.13. Hospital stay was 9.72 ± 7.88 days. After 44.6 ± 14.4 days, 48.6% patients showed functional decline and 19.4% were institutionalized. Age (OR 1.17; CI 95% 1.09–1.26), previous institutionalization (29.1; 3.7–224.7), BI (1.09; 1.05–1.14), CCI (1.5; 1.1–2.1), and length of stay (1.1, 1.02–1.18) were independently associated with functional decline. The only predictors of new institutionalization were previous BI (0.96; 0.93–0.99) and length of stay (1.06; 1.00–1.13). The MNA indicated malnutrition in 28% of the community-dwelling patients and 67.9% of those institutionalized, with risk of malnutrition being 45.7% and 9.5%, respectively, after an average of 44.6 days of CAP diagnosis. The predictors of malnutrition were previous institutionalization (10.62; 2.20–51.21), BI (0.95; 0.92–0.98), and length of stay (1.12; 1.04–1.20). Micronutrient deficiencies were mainly zinc (61.8%), vitamin D (54.5%), and vitamin C (45.1%). An MNA score < 17 points or hypoalbuminemia showed good specificity to identify these deficiencies. Conclusions: After CAP admission, functional decline, institutionalization, and malnutrition rates were high. Longer hospital stay was a common risk factor for all outcomes. The presence of hypoalbuminemia or an MNA < 17 in older patients should prompt suspicion of deficiencies in micronutrients, such as vitamin D, C, and zinc.

This study tested the hypothesis that a more senescent immune system would predict a worse outcome in older patients hospitalized for community-acquired pneumonia (CAP). CAP has long been responsible for high rates of mortality and readmissions among older people. Although immunosenescence is a key factor in the increased susceptibility to infections, there are no related biomarkers currently available in clinical practice. In this context, the aim of this prospective study was to identify immunosenescence-related biomarkers to predict outcomes in patients older than 65 years hospitalized for CAP. We evaluated 97 patients admitted to our hospital for CAP in 2019 and 2020. All patients were followed for 1 year. Our findings showed that elevated levels of early differentiated CD28+ CD27+ T cells at admission were associated with better short (2 months) and long-term (1 year) outcomes in terms of mortality and readmissions. Early differentiated CD28+ CD27+ CD4+ T cell counts were even better long-term predictors. In conclusion, early differentiated CD28+ CD27+ T cells could be useful biomarkers to identify high-risk older patients with CAP, helping clinicians with risk stratification and follow-up.

Summary The leading causes of mortality in our study were pneumonia, diseases of the circulatory system, and dementias. In patients with hip fractures, the emphasis should be placed not only on measures to prevent falls and osteoporosis, but also on preventing functional decline and pneumonia. Purpose To describe the specific causes of death in patients who died up to 2 years after sustaining a hip fracture, how many of those deaths were directly related to the hip fracture, and the risk factors for mortality. Methods A retrospective review of the clinical data of all patients admitted with hip fractures between December 2009 and September 2015. Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems (ICD10) Results In the first 2 years after hip fracture, 911 patients (32.7%) died. The leading causes of mortality were pneumonia 177 (19.4%), diseases of the circulatory system 146 (16%), and dementias 126 (13.9%). Thirty patients (3.2%) died from causes directly related to hip fracture or surgery. Mortality risk factors with a higher relative risk were advanced age, male sex, higher comorbidity, delirium, and medical complications during admission. Conclusions Pneumonia and circulatory system diseases were the commonest causes of death in our study. In patients with hip fractures, emphasis should be placed on preventing functional decline and pneumonia. In a few patients, death was directly related to the hip fracture, although decompensation of chronic illness as a result of hip fracture and fracture-related functional decline may have been indirect causes. Patients with worse conditions at admission had the highest risk of mortality.

Objectives. To analyze factors related to drug-resistant pathogens (DRPs) in community-onset pneumonia (COP) and whether previously suggested criteria are useful in our emergency-department. Methods. Prospective 1-year study of adults coming to the emergency department for COP. We assessed the usefulness of criteria used in health-care associated pneumonia (HCAP), as well the Shorr index, the Barthel index, and clinical suspicion of resistant pathogens. Data were analyzed by multiple logistic regression and the area under the receiver operating characteristic curve (AUC). Results. We included 139 patients with a mean (SD) age of 75.9 (15.3) years; 63.3% were men. Forty-nine COP patients (35.2%) were at risk for DRP-caused pneumonia according to HCAP criteria; 43 (30.9%) according to the Shorr index, and 56 (40.3%) according to the Aliberti index. A score of less than 60 derived from the Barthel index was recorded for 25 patients (18%). Clinical suspicion of a DRP was recorded for 11 (7.9%). A DRP was isolated in 5 patients (3.6%) (3, Pseudomonas aeruginosa; 2, methicillin-resistant Staphylococcus aureus). Multiple logistic regression analysis identified 2 predictors of DRP-caused COP: hospital admission within the last 90 days (odds ratio [OR], 8.92; 95% CI, 1.92-41.45) and initial arterial blood oxygen saturation (OR, 0.85; 95% CI, 0.74-0.98). The AUC was 0.91 (95% CI, 0.85-0.98). The model identified 22 patients (16.8%) at risk for DRP-caused pneumonia. The positive and negative predictive values were 20% and 99.1%, respectively, for the model 90 day period (vs 8.7% and 98.9%, respectively, for criteria used in HCAP). Conclusions. Hospitalization within the 90 day period before a COP emergency and arterial blood oxygen saturation were good predictors of DRP in our setting. Criteria of DRP in HCAP, on the other hand, had lower ability to identify patients at risk in COP.

Purpose The purpose of this study is to describe the characteristics of older patients treated with psychotropic medicines and the associated factors and to assess their inappropriate use. Methods An observational, prospective study was carried out in 672 elderly patients admitted to seven hospitals for a year. A comparison of sociodemographic characteristics, geriatric variables, multimorbidity and the number of prescribed medicines taken in the preceding month before hospitalization between patients treated with psychotropics and those not treated was performed. To assess factors associated with psychotropics, multivariate logistic regression analyses were performed. Inappropriate use was assessed using the Beers and the STOPP criteria. Results A total of 57.5 % patients (median [Q1–Q3] age 81.7 [78.2–86.1], 65.7 % female) were treated with psychotropics (44.2 % anxiolytics, 22.6 % antidepressants and 10.8 % antipsychotics). Independent factors associated with the use of psychotropics were female gender (OR = 2.3; CI 95 %,1.6–3.5), some degree of disability on admission (slight [OR = 2.2; 1.2–4.2], moderate [OR = 3.2, 1.6–6.6], severe [OR = 3.4; 1.4–8] and very severe [OR = 5.1; 2.0–12.8]) and polypharmacy (5–9 medicines [OR = 3.0; 1.3–6.9] and ≥10 medicines [OR = 6.0; 2.7–13.6]). The associated factors varied depending on the different types of psychotropics. In patients treated with psychotropics, the percentage of those with at least one Beers (61.6 %) or at least one STOPP (71.4 %) criteria was significantly higher in comparison with those not treated with psychotropics (30.7 and 47.7 %, respectively, p < 0.001). Conclusions Psychotropics are widely used in the elderly population and often their use is inappropriate. Female gender, a poor functional status and polypharmacy, are the characteristics linked to their use. Interventional strategies should be focused on patients with these characteristics.