Editorial
A geriatric assessment followed by geriatric intervention is essential for elderly hospitalized patients
Es básico realizar una valoración e intervención geriátricas en el paciente anciano hospitalizado
Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Formiga, D. Chivite" "autores" => array:2 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Formiga" "email" => array:1 [ 0 => "fformiga@bellvitgehospital.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">?</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Chivite" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "?" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Es básico realizar una valoración e intervención geriátricas en el paciente anciano hospitalizado" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The aging of the population has led to a growing group of elderly patients with multiple simultaneous diseases, functional and cognitive limitations and a risk of psychophysical decline due to multiple triggers, which generates a significant and growing rate of hospitalizations.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Hospitalizing an elderly individual can lead to negative effects on their state of health, a loss of functional capacity and a reduced quality of life. Hospitalization can also result in the patient being unable to return home and to transfers to convalescence or long-stay centers, regardless of the reason for the hospitalization.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> The various proposed solutions for alleviating this phenomenon include a search for alternatives to conventional hospitalization, such as short-stay units (SSUs), which were created to provide a hospital care modality that helps shorten the hospitalization time to the essential minimum. These units have proven useful in reducing the impact of conventional hospitalization on elderly patients.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To learn more about the appropriateness of using these devices, we need articles such as the one by Fernández Alonso et al.,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> published in this issue of <span class="elsevierStyleSmallCaps">Revista Clínica Española</span>. The authors analyzed the effect of a multidimensional intervention on the short-term progress of a cohort of frail elderly patients, after hospitalization in an SSU. The study included patients 75 years of age or older (identified as “frail” based on a score =2 on the Identification of Seniors at Risk [ISAR] scale<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a>), comparing the postdischarge progress of 2 cohorts: a preintervention control group (81 patients treated in 2013) and an intervention group (137 patients treated in 2016). The intervention was started by scheduling a medical appointment soon after the discharge and detecting and changing potentially inappropriate prescriptions. This type of intervention should be practiced systematically for any elderly hospitalized patient. We can therefore assume that this intervention was performed to some measure in the control cohort within standard clinical practice. The study also performed (when deemed necessary) a nutritional intervention (interconsultation with a specialist and prescribing energy-protein supplements as indicated), functional intervention (appointment with rehabilitation or occupational therapist in case of potentially reversible acute functional impairment), cognitive intervention (appointment with the specialist and the start of psychoactive drugs, if appropriate) and social intervention (by the social worker, providing information and managing new social resources, if necessary). Finally, primary care was contacted at discharge to ensure continuity of care.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In our opinion as internists dedicated to geriatric care, this set of measures should be systematic and is essential for proper clinical practice when caring for elderly patients, who should be treated holistically and not just as a collection of isolated “diseases”.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> enhances the importance of not stopping at the Comprehensive Geriatric Assessment (CGA) but rather applying the corresponding intervention. The multivariate analysis showed that a multidimensional intervention acts as a protective factor for the future onset of adverse events (death/readmission for any cause/severe functional impairment) during the 30 days after discharge (adjusted relative risk, 0.40; 95% confidence interval 0.23–0.68; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001). This benefit was achieved despite the possible differences between the control and intervention groups, which characterize a quasi-experimental study. The study could not rule out “contamination” in which the control group could have undergone undocumented geriatric intervention.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Beyond its design, the study had a number of significant limitations, which were recognized by the authors, such as its single-center nature and the fact that the care plan was established at the physician's discretion, according to the affected domains of the abbreviated CGA, but without establishing certain predetermined objective criteria for generating the intervention. Compliance after the intervention could not be ensured, the intervention was not differentiated according to the predominant disease, and the follow-up was not face-to-face.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It would have been interesting to determine the progress of the group that was excluded from the intervention, because it probably included patients who, because of the CGA, were indicated measures that could have improved the health results of the control group.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The most beneficial approach for treating elderly patients and the one with the highest level of evidence is the CGA, which is based on a clinical, functional, cognitive, social and nutritional assessment (domains all measured in the aforementioned study) and leads to the design of a treatment plan and follow-up.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> There are, however, a number of constraints, such as the time needed to perform the CGA (15<span class="elsevierStyleHsp" style=""></span>min for its abbreviated version, according to the authors) and the potential difficulty that a short hospitalization can represent for correctly assessing all of its components.</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is important that healthcare teams treating elderly patients have the geriatric training (and sensitivity) to systematically incorporate (in a multidisciplinary and interdisciplinary manner) the CGA data into the medical records, as is performed with the cardiovascular antecedents and surgical interventions. If the CGA is available at the hospital admission, interventions can be performed.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> We agree with the authors that it is better to have the information related to function, cognition, nutritional risk and social risk during hospitalization than after discharge. This information would probably be useful for all hospitalized patients older than 75 years and even for nonagenarians,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> not just for those selected by a screening scale such as ISAR.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is also advisable, through expert consensus, to systematize the scales and procedures for applying the various items of the CGA, to standardize the expected results of a possible intervention and make it as efficient as possible.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> The evaluated study used widely disseminated scales, although it is worth examining how frailty was assessed. There are 2 methods for assessing frailty. The first method considers frailty to be a phenotype characterized by objective deficits in physical function that precede dependence but are, <span class="elsevierStyleItalic">a priori</span>, independent of comorbidity.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> The second method considers frailty as the consequence of the accumulated deficits composed of diseases, disability, clinical symptoms and laboratory data.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> The authors’ use of an ISAR score =2 is in keeping with the second approach. The ISAR scale evaluates the need for assistance for daily life activities and more assistance after the acute process, as well as the sensory deficit, cognitive impairment, hospitalization in the past 6 months and consumption of 3 or more drugs. A very easy-to-apply alternative is the FRAIL questionnaire,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> which evaluates fatigue, resistance, ambulation, comorbidities and weight loss through 5 simple questions. The questionnaire is of considerable usefulness for an initial approach to frailty in hospitalized patients.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, the comprehensive health assessment of elderly hospitalized patients is essential, not only by determining the disease that motives the hospitalization but also through an assessment that includes, at least, the basic aspects of the CGA: comorbidity, polypharmacy, function, cognition, nutrition and social risk. Prevention, early detection and treatment of geriatric syndromes (delirium, insomnia, falls, etc.) should also be added during hospitalization, as well as incorporating daily frailty assessments for elderly patients.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a> The results of the study by Fernández Alonso et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> reinforce the idea (shared by the editors) that not understanding the elderly patient in their entirety is a major clinical mistake.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "?" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Formiga F, Chivite D. Es básico realizar una valoración e intervención geriátricas en el paciente anciano hospitalizado. Rev Clin Esp. 2018;218:187–189.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The THIRD transition: the clinical evolution oriented to the contemporary older patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Rodriguez-Mañas" 1 => "F. Rodriguez-Artalejo" 2 => "A.J. 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| Year/Month | Html | Total | |
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| 2023 March | 7 | 4 | 11 |
| 2020 September | 0 | 1 | 1 |
| 2018 May | 0 | 2 | 2 |
| 2018 April | 0 | 1 | 1 |
