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Position of the Spanish Society of Internal Medicine" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "347" "paginaFinal" => "358" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "I. Vallejo Maroto, P. Cubo Romano, M.C. Mafé Nogueroles, M. Matesanz-Fernández, L.M. Pérez-Belmonte, I. Said Criado, R. Gómez-Huelgas, J. Díez Manglano" "autores" => array:9 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Vallejo Maroto" "email" => array:1 [ 0 => "ivmaroto@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Cubo Romano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.C." "apellidos" => "Mafé Nogueroles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Matesanz-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "L.M." "apellidos" => "Pérez-Belmonte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "I." "apellidos" => "Said Criado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "R." "apellidos" => "Gómez-Huelgas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 7 => array:3 [ "nombre" => "J." "apellidos" => "Díez Manglano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 8 => array:2 [ "colaborador" => "on behalf of the Focus Group on Aging of the Spanish Society of Internal Medicine and the Working Group on Polypathology and Advanced Age" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Unidad de Continuidad Asistencial de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad del Paciente Crónico Complejo, Servicio de Medicina Interna, Hospital Universitario Infanta Cristina, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital de Crónicos y Larga Estancia La Pedrera, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Lucus Augusti de Lugo, Lugo, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Álvaro Cunqueiro, Vigo, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Royo Villanova, Zaragoza, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones sobre la valoración integral y multidimensional del anciano hospitalizado. Posicionamiento de la Sociedad Española de Medicina Interna" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The progressive aging of the population along with improvement in social conditions and advances in healthcare have led to a marked increase in the number of patients with chronic diseases, frailty, and dependence. This entails a greater use of healthcare and social services resources.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Over the last 20 years, the mean age of patients admitted to internal medicine departments in our country has increased 19.3 years; in the period between 2007 and 2014, it increased three years.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> As a consequence, the profile of an elderly person that we as internists care for is an individual with a greater number of chronic diseases, a worse functional condition, and a more complex social situation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The hospitalization of elderly patients has been linked to greater mortality, disability, and institutionalization upon discharge.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The interaction among a patient’s comorbidities, frailty, and functional status predisposes him or her to poorer health outcomes and a greater need for public health and healthcare services. When hospitalized, elderly people undergo a deterioration in function, though on occasion it can be reversible.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A fundamental aim of the clinicians who care for hospitalized elderly people is for patients to regain the functional status they had prior to admission or to get as close to it as possible. Thus, it is necessary to know the individual’s baseline functional status at the time of admission and discharge. The proper evaluation and management of elderly patients in the hospital setting must include not only knowledge and treatment of medical problems but also the identification of other dimensions and contexts of the patient that may play a role in improving health outcomes. Therefore, a comprehensive, multidimensional assessment of elderly patients (CMAEP) and the development of an individualized treatment and follow-up plan are considered essential elements that must be incorporated into our habitual clinical practice.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The recommendations in this document are intended to serve as a guide for adapting healthcare practices in internal medicine departments to respond to this demographic shift and to the current epidemiological profile of hospitalized elderly people. With it, we hope to facilitate the identification of patients’ needs and vulnerabilities; contribute to developing individualized care plans; and increase teamwork so as to avoid functional and cognitive impairment in elderly people following hospitalization and, to the extent possible, improve health outcomes and their hospitalization experience.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Recommendations</span><p id="par0465" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><p id="par0035" class="elsevierStylePara elsevierViewall">Elderly people who have been hospitalized frequently present with early complications after discharge that are unrelated to the disease which led to the admission.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The use of hospital services exposes them to worse health outcomes, many of which are not directly related to the primary diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> These complications are also a consequence of hospital practices and medical treatment.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The loss of function due to elderly peoples’ lower physiological reserve, diminished ability to adapt to an unfamiliar setting, and, on occasion, cognitive impairment favors the onset of complications during hospitalization which lead to greater mortality and a higher risk of institutionalization upon discharge. In addition, patients perceive their hospitalization experience to be worse.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Conducting a CMAEP and planning an individualized intervention based on the deficiencies identified has been shown to prevent the progression of or even reverse frailty, reduce hospital readmissions, and increase the likelihood that an individual will be able to live at home 12 months following the discharge.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><elsevierMultimedia ident="tb0010"></elsevierMultimedia></p><p id="par0055" class="elsevierStylePara elsevierViewall">It is common for some of an elderly person’s functional capacities to be affected in a manner that is not very symptomatic or without explicit manifestations and for these problems to be undiagnosed; this makes him or her more vulnerable to external stressors.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Hospitalization may be a suitable time to make an early diagnosis of these situations of vulnerability. Cognitive impairment; subclinical emotional disorders; functional, nutritional, and social status; risk of incontinence, pressure sores, or falls; and pharmacological treatment are areas that must be assessed during the care of hospitalized elderly patients in internal medicine departments.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The instruments recommended for doing so are included in the Supplementary material.</p><p id="par0065" class="elsevierStylePara elsevierViewall">More than a diagnostic process in and of itself, the identification of these needs must facilitate the development of a coordinated, comprehensive plan for their treatment and follow-up with the aim of maintaining independence, improving disability, and restoring function in hospitalized elderly people.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The scientific literature recommends conducting a CMAEP on all elderly patients hospitalized for an acute illness.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The benefit of this intervention will be greater in frail or at-risk (pre-frail) elderly people. In patients with advanced chronic disease and/or a need for palliative care, its usefulness in monitoring functional decline and improvements in health will be more limited. In this group, the aims of symptoms relief and comfort should take precedence.<elsevierMultimedia ident="tb0015"></elsevierMultimedia></p><p id="par0080" class="elsevierStylePara elsevierViewall">Functional decline in the elderly and a decline in their ability to perform self-care can lead to a loss of independence and an increased need for institutionalization. A hospital admission is an opportunity to assess the ability of an elderly person to perform activities of daily living. Furthermore, it allows for developing an intervention that prevents the disability which tends to be associated with hospitalization.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Recording a patient’s functional status upon admission, upon discharge, and in relation to his or her baseline status is useful for guiding needs during the hospitalization and in the discharge planning process. On occasion, due to a patient’s circumstances or a clinician’s lack of time, an assessment can only be done during the hospitalization. In this case, the most recommendable course of action is to ask about the patient’s baseline condition prior to admission, as this would set the goal we must try to reach with our care.</p><p id="par0090" class="elsevierStylePara elsevierViewall">A decline in an elderly person’s baseline functional status can be a form of presentation of an underlying illness. It is important to include caregivers and family members in the interview and when creating the medical record. On the one hand, this serves to identify and get to know the caregiver and, on the other hand, to attempt to clarify some clinical problems.</p><p id="par0095" class="elsevierStylePara elsevierViewall">There are multiple instruments for assessing activities of daily living,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which are those oriented towards self-care. To evaluate them in an elderly person, we recommend using the Barthel Index.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It evaluates ten activities: feeding, bathing, dressing, grooming, bladder control, bowel control, toilet use, bed-chair transfer, walking, and going up/down stairs. It is scored from zero to 100 and the higher the score, the greater the patient’s autonomy. Although different cut-off points have been proposed for interpreting the results, one of the most used classificaitons establishes four degrees of dependence: total (<20 points), severe (from 21 to 60 points), moderate (from 61 to 90 points), and mild or independence (>90 points). The mean time required to administer the index is approximately five minutes.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Recently, some authors have suggested simplified versions of the Barthel Index—which are especially useful in polypathological patients—that evaluate only two or three activities (feeding and transfers, walking, or ability to go up and down stairs).<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In patients who are autonomous for basic activities, it is recommended to explore their capacity to carry out instrumental activities of daily living, which are those oriented towards interaction with the outside world. In order to evaluate these parameters, we propose using the Lawton-Brody Scale,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> which gathers information on different activities: using the telephone, shopping, preparing food, doing housework, laundry, using public transportation, managing medication, or handling financial matters. Each of them is assigned a numeric value: one (independent) or zero (dependent). The final score is the sum of all values and ranges from zero (maximum dependence) to eight (total independence). The mean time required to administer it is four minutes.</p><p id="par0110" class="elsevierStylePara elsevierViewall">At present, there are still differences in attitudes towards gender among the elderly in regard to domestic activities such as cooking, cleaning, and laundry. Therefore, males are considered dependent if they score less than five points.<elsevierMultimedia ident="tb0020"></elsevierMultimedia></p><p id="par0120" class="elsevierStylePara elsevierViewall">Cognitive impairment is frequent in hospitalized patients (25%–45%) without patients being aware of it. It is associated with greater mortality during the hospitalization.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–22</span></a> Therefore, it is essential to identify cognitive impairment in hospitalized elderly patients.</p><p id="par0125" class="elsevierStylePara elsevierViewall">We propose using Pfeiffer’s Short Portable Mental State Questionnaire.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a> It consists of ten questions and explores short- and long-term memory, orientation, information about day-to-day facts, and ability to calculate. Errors are counted and it is scored from 0 to 10. Four cognitive states are usually established: normal (0–2 points), mild cognitive impairment (3–4), moderate cognitive impairment (5–7), and severe cognitive impairment (8–10).</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is important to take education level into account: in patients with a low level of education (elementary school studies), one additional error is allowed per category, and in patients with a high level of education (university studies), one fewer error is allowed per category. It takes approximately three to five minutes to administer it. However, it is common for elderly patients, especially those with polypathology, to have problems maintaining attention during this time. Therefore, some authors have proposed brief versions that include just two or three questions.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In elderly patients with a Pfeiffer’s questionnaire score of more than two points, we recommend using Lobo’s <span class="elsevierStyleItalic">Mini-Examen Cognoscitivo</span> [Cognitive Mini-Test].<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,28</span></a> This test, which is widely used, takes approximately eight to ten minutes and evaluates various cognitive spheres: orientation, fixation, concentration, calculation, memory, language, and construction. It is scored from zero to 35. In people older than 65 years of age, a score of less than 24 points is considered to indicate cognitive impairment. When impairment is detected, it is recommended to classify it according to the Global Deterioration Scale and Functional Assessment Staging or the Reisberg scale,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> which stratify impairment into seven different stages. According to the cognitive and functional status observed, cognitive impairment is significant as of the fourth stage.<elsevierMultimedia ident="tb0025"></elsevierMultimedia></p><p id="par0145" class="elsevierStylePara elsevierViewall">Delirium, also called acute confusional state, is a cognition and consciousness disorder that has a rapid onset, fluctuating course, and exogenous origin. In Spain, it is listed as a diagnosis on 2.5% of discharge summaries of patients admitted to internal medicine departments,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> though a multicenter clinical study conducting in our setting found its prevalence to be 13%.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Delirium is more frequent in elderly patients, especially in institutionalized subjects and those with a worse functional status or those who present with risk factors such as dementia, malnutrition, hyponatremia, or use of urinary catheters.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31</span></a> Its onset is associated with worse health outcomes, increased length of hospital stay, greater risk of institutionalization, and greater mortality.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Various research studies have demonstrated the efficacy of delirium prevention strategies, the majority of which are nonpharmacological and multidisciplinary.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The most used instrument for detecting delirium is the Confusion Assessment Method.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> It is a scale that is easy to administer, takes less than five minutes, and can be conducted by nursing department professionals. Other instruments that have been shown to be useful and which can also be used by nursing department professionals include the 4AT<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> and the Nu-DESC.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a><elsevierMultimedia ident="tb0030"></elsevierMultimedia></p><p id="par0165" class="elsevierStylePara elsevierViewall">Depression is one of the most frequent and incapacitating syndromes among elderly people. In Spain, symptoms of depression are present in 29% of people older than 50 years of age and its prevalence increases with age up to 80 years of age.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> It is more frequent in women, those with a poor perception of their physical health, and those with disabilities. It is associated with other comorbidities such as Parkinson’s disease, Alzheimer’s disease, hip fracture, and rheumatic diseases.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Symptoms of depression are associated with worse quality of life and, in longitudinal studies, depression leads to greater long-term mortality.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37–39</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">To identify depression, we recommend a clinical interview and, if necessary, using Yesavage’s Geriatric Depression Scale, as it is a tool specifically developed for screening elderly patients.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The scale is an interview consisting of dichotomous responses that can be self-administered or administered by another person. There are various versions: a full version containing 30 items and other abbreviated versions containing 15, ten, five, four, and even one item.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> We suggest the version with four items for its ease-of-use and immediacy.<elsevierMultimedia ident="tb0035"></elsevierMultimedia></p><p id="par0180" class="elsevierStylePara elsevierViewall">Assessing the social situation allows for learning about the relationship between the elderly person and his/her surroundings. Aspects related to the home—whether the person is institutionalized or not—and family and social support are important issues when it comes to organizing a care plan, early planning for the hospital discharge, and guaranteeing continuity of care. Taking into account these variables, we can place the patient in the appropriate care level and organize the social resources they are going to require.</p><p id="par0185" class="elsevierStylePara elsevierViewall">We recommend that this assessment be done proactively and as early as possible. A joint approach between nursing department and social services professionals is necessary for the assessment.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Creating the medical record and the CMAEP itself can offer us clues about an elderly patient’s risk of social exclusion: for example, an absence of companions during hospitalization, living alone, being functionally dependent, not having a caregiver, having a mental illness, having toxic habits, or not having hot meals are all indicative of the patient’s status. In these situations, a more specific assessment must be conducted.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The Gijón social-familial assessment scale is useful for detecting social exclusion risk. It is administered by another person and evaluates five areas of social exclusion risk: family situation, housing, relationships and social contacts, support from the social network, and financial situation. The score ranges from zero to 20, with a greater score indicating a worse social situation. The patient is considered to be at risk of social exclusion if they score more than ten points.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Caring for a chronic patient and/or dependent person entails a burden for the caregiver. This burden has physical, mental, and financial consequences for the caregiver. The Zarit Burden Interview is useful for detecting and quantifying it.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43,44</span></a> This questionnaire explores four areas in which the main caregiver may experience negative repercussions: physical health, mental health, social activity, and financial resources. Though it was initially conceived of as an interview, use of the self-administered format has become widespread and today it is the most common version.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> It consists of 22 items. Each item is scored on a frequency scale that ranges from one (never) to five (almost always). The minimum score is 22 and the maximum score is 110. The following cut-off points have been established: 22–46 points indicates no overload, 47–55 points indicates mild overload, and 56–110 points indicates intense overload.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> One of the advantages of this instrument over others is that it helps predict the institutionalization of the older person receiving care.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In this regard, evaluating the capacity of the elderly patient, caregiver, and family to manage the disease and the need to implement lifestyle recommendations, self-care practices, follow-up appointments, and visits is also of interest. Some authors define this as the burden of treatment.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> It is advisable that each patient’s ability to manage their diseases is not overwhelmed by the burden of treatment, which could lead to a lack of adherence to our recommendations and worse health outcomes.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a><elsevierMultimedia ident="tb0040"></elsevierMultimedia></p><p id="par0215" class="elsevierStylePara elsevierViewall">Frailty is a status frequently associated with aging that is characterized by a decrease in the physiological reserve that leads to greater vulnerability when faced with adverse events. It is associated with a loss of resistance, increased risk of disability, and greater mortality and morbidity.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> It is a dynamic, reversible process.</p><p id="par0220" class="elsevierStylePara elsevierViewall">It is important to detect it during the hospitalization in order to delay its progression or even reverse it. To do so, we propose using the FRAIL questionnaire, which is a simple, validated tool.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49,50</span></a> It consists of five questions regarding fatigue, resistance, ambulation, illnesses, and loss of weight. The score ranges from zero to five. Patients are considered frail if their score is greater than or equal to three and pre-frail if their score is greater than or equal to one.</p><p id="par0225" class="elsevierStylePara elsevierViewall">As an alternative, we can use the easy-to-administer clinical frailty scale, which has clinical descriptors and pictograms, in order to stratify elderly people according to their degree of vulnerability.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Some authors consider all polypathological patients who cannot go up or down stairs to be frail and administer frailty scales only to those who can do so.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">In Spain, a multicenter study observed that 37% of hospitalized patients older than 70 years of age had malnutrition and that this prevalence was the same at discharge.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Malnutrition is more frequent among women; widowers or separated men; and people with comorbidity, functional dependence, and frailty. It is associated with prolonged hospital stays, greater mortality during hospitalization, greater institutionalization upon discharge, and higher healthcare costs.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53–55</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">It is important to carry out a malnutrition risk and nutritional status assessment early in hospitalized elderly patients. There are different tools to do so.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> We recommend the Mini Nutritional Assessment, which is simple, quick to administer, and does not require blood test parameters.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55,57</span></a> The CONUT index can be used as an alternative screening tool. It uses three blood test parameters (albumin, cholesterol, and total lymphocytes) and, though it does not diagnose malnutrition, it does detect a patient's risk of presenting with it.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">In addition, it is necessary to evaluate food intake throughout the hospitalization.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> If malnutrition or risk of presenting with it are detected, a nutritional intervention with a multidisciplinary approach must be considered. This could decrease the morbidity and mortality of the hospitalization, the mean length of stay, and healthcare costs.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Falls are frequent in hospitalized elderly people and have significant negative consequences in 12% of cases.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> We suggest identifying and recording patients’ prior history of falls, as it is one of the risk factors for falls during hospitalization. As a screening strategy, the three questions proposed by the Ministry of Health’s Consensus Document<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> may be useful: Has the patient had a fall that required medical attention in the past year? Has the patient had two or more falls in the last year? Does the patient have a gait disorder that is considered significant?</p><p id="par0250" class="elsevierStylePara elsevierViewall">Different tools are used to evaluate risk of falls.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> One of them is the Downton scale, which evaluates whether there have been previous falls, the patient’s medication, if the patient has a sensory deficit, the patient’s mental status, and walking. Patients with scores higher than two points are considered high risk.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> There are clinical practice guidelines that provide strategies and interventions for the prevention of falls during the hospitalization.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Pressure ulcers are frequent and affect 14% of patients hospitalized in internal medicine departments, especially older patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Up to 25% of ulcers occur during hospitalization and their presence are associated with greater mortality.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,66,67</span></a> It is advisable to evaluate ulcer risk upon admission. We recommend using the Norton scale,<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> which also has prognostic value, for doing so.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a><elsevierMultimedia ident="tb0045"></elsevierMultimedia></p><p id="par0265" class="elsevierStylePara elsevierViewall">During hospitalization, decision making must take into account the patient’s individual prognosis. Personalized diagnostic and therapeutic aims help avoid adopting a nihilistic, obstinate attitude.</p><p id="par0270" class="elsevierStylePara elsevierViewall">Estimating the prognosis of elderly patients is not easy. To do so, we can use indexes and tools to identify patients at high risk of death during the hospitalization<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> and to established their medium- and long-term prognosis.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">71–74</span></a> The Charlson Comorbidity Index, developed in 1987,<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> is the most commonly used tool. It estimates the probability of death within one year and takes 19 diseases into account. However, the weight placed on each of them, such as AIDS or peptic ulcers, is out-of-date in today’s context. Other indexes, such as the Walter Index<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> or the Pilotto Index,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> are valid options.</p><p id="par0275" class="elsevierStylePara elsevierViewall">A multicenter study in Spain developed a specific index for polypathological patients: the PROFUND index. It includes nine variables and incorporates clinical, demographic, blood test, psychological, functional, social, family, and healthcare dimensions. It stratifies risk of one-year and four-year mortality and has been externally validated.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">74–76</span></a> Given the high frequency of polypathology and multimorbidity in elderly people, we recommend using it to establish these patients’ prognosis. As an alternative, we can also use the CRONIGAL Index,<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> which was also developed in Spain and is applicable to complex polypathological and chronic patients.<elsevierMultimedia ident="tb0050"></elsevierMultimedia></p><p id="par0285" class="elsevierStylePara elsevierViewall">Chronic diseases are the leading cause of death worldwide. Elderly people often present with one or several advanced-stage chronic diseases. In these cases, the aim is to improve their quality of life through a palliative approach.</p><p id="par0290" class="elsevierStylePara elsevierViewall">In addition to the classic ‘surprise’ question: “Would you be surprised if this patient died in the next six months?” specific criteria such as those of the National Hospice Organization<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> or NECPAL scales can be used.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">The PALIAR Index, a tool to identify the probability of death in the next six months in patients with advanced-stage non-neoplasm chronic diseases, is also available.<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80,81</span></a> It consists of six items and is simple and fast to use.<elsevierMultimedia ident="tb0055"></elsevierMultimedia></p><p id="par0305" class="elsevierStylePara elsevierViewall">Promoting safe medication use is one of the aims of the National Health System’s Patient Safety Strategy.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> Polypharmacy is defined as the use of five or more drugs.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> According to the 2017 National Health Survey, 27.3% of elderly people 65 years of age or older in Spain are polymedicated.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">There is a direct relationship between the number of drugs prescribed and the prevalence of prescribing errors, drug interactions, and adverse effects. In addition, polypharmacy is associated with frailty, dependence, cognitive impairment, nutritional risk, risk of falls, and mortality.<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">85–87</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">In polymedicated elderly people, the prevalence of medication errors during the hospital stay is as high as 50% and is one of the main causes of morbidity. To decrease errors, we suggest carrying out a comprehensive review of pharmacological treatment that the patient took previously and comparing it to what is currently prescribed. This process is called a medication reconciliation.<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">88,89</span></a> It must be done at the time of hospital admission, during transfers between units, during transfers between hospitals, and at the time of discharge; that is, at all care transitions. We also recommend that it be done when planning the hospital discharge and recorded on the discharge summary in order to prevent errors and ensure any changes are made clear to the patient, caregiver, and primary care team. This strategy has been shown to improve hospital prescribing and decrease emergency room visits. However, its effects on the reduction of readmissions and mortality are still unknown.<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90,91</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">At the same time, carrying out a systematic review of medication with the patient and/or caregiver allows for evaluating treatment adherence. Adherence is an aspect of particular interest in the case of chronic diseases, in which treatment noncompliance can be as high as 50%.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> As a support and screening measure, we propose the Morisky-Green Test,<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> which consists of four simple questions.<elsevierMultimedia ident="tb0060"></elsevierMultimedia></p><p id="par0330" class="elsevierStylePara elsevierViewall">Changes in an elderly patient’s pharmacological treatment must be supported by evidence-based clinical indications as well as the patient’s functional, cognitive, and prognostic status, as these factors could affect the risk-benefit ratio of the drug.</p><p id="par0335" class="elsevierStylePara elsevierViewall">We believe that a prescription is inappropriate when the risk of suffering adverse events is greater than the clinical benefit. This could be because more medication than is clinically necessary is prescribed, necessary medications are not indicated, incorrect dosing or duration of treatment, duplicate drugs, or drugs being indicated that are considered inappropriate given the patient profile. There are different tools for facilitating appropriate prescribing and detecting inappropriate prescribing in elderly patients. The most used tools are the STOPP-START criteria,<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> Beers criteria,<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> and the PRISCUS list.<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">96</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Deprescribing consists of reviewing and evaluating the patient’s treatment plan with the aim of suspending, substituting, or reducing the dose of unnecessary medications or those with an unfavorable risk-benefit ratio.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a> No negative effects are associated with deprescribing. A systematic review found no deterioration in quality of life or greater mortality.<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> Deprescribing must always be agreed upon with the patient and the caregiver. It is also necessary to communicate it to the primary care team, observe the patient’s progress, and detect possible complications. The LESS CHRON criteria<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> is a tool for aiding deprescribing in polypathological patients. It is a list of drugs and situations in which suspension of medications can be considered and also includes variables that must be monitored as well as follow-up periods.</p><p id="par0345" class="elsevierStylePara elsevierViewall">It has been demonstrated that a review of treatment by a clinician working together with a pharmacist can improve prescription regimens.<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a> Taking advantage of a collaboration with the hospital pharmacist on the multidisciplinary team that cares for the elderly patient can provide added value and contribute to enhancing care safety strategies during admission and discharge from hospitalization.<elsevierMultimedia ident="tb0065"></elsevierMultimedia></p><p id="par0355" class="elsevierStylePara elsevierViewall">The CMAEP not only focuses on the patient’s clinical problem, but also on their vulnerabilities and needs. If the patient is managed well during the hospitalization, health outcomes can be improved and the cognitive and functional impairment associated with the hospitalization can be prevented. In addition, it allows for an early prediction of resources that will be needed during discharge planning and a better focus on transferring the patient to their setting and primary care team.</p><p id="par0360" class="elsevierStylePara elsevierViewall">The intervention plan must be agreed upon between the elderly patient, caregiver, and team of professionals who care for him or her together with the necessary support personnel in light of the CMAEP. On occasion, this includes gathering information and opinions from the primary care physician, primary care nurse, social workers, and the remaining stakeholders in the community who may be involved in the case. It can also be completed with other hospital specialists, who should know the value of the CMAEP; it must not be limited to a cross-consultation with a strictly clinical scope.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a><elsevierMultimedia ident="tb0070"></elsevierMultimedia></p><p id="par0370" class="elsevierStylePara elsevierViewall">Including a checklist after conducting the CMAEP can reduce variability and guarantee compliance with minimum quality standards in the care of elderly people during their hospitalization.<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102–104</span></a> With checklists, we can improve the safety of clinical care, continuity of care with primary care teams, and quality of our medical records (Appendix B).<elsevierMultimedia ident="tb0075"></elsevierMultimedia></p><p id="par0380" class="elsevierStylePara elsevierViewall">It is not necessary for the internist to have mastery of all technical aspects of the CMAEP. There are other professionals who can also evaluate aspects that are not strictly clinical. Primary care physicians, other specialists, nursing department professionals, physical therapists, occupational therapists, social workers, and pharmacists can contribute to the different aspects of the CMAEP.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> Together, all of these participants must work as a team and share information in order to produce a single evaluation.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">Another element that facilitates conducting the CMAEP is a shared digital platform with all the information on the results of the CMAEP.</p><p id="par0390" class="elsevierStylePara elsevierViewall">The CMAEP must not add another layer of bureaucracy to our regular clinical activity, although this will depend on the dynamics of the professionals who care for the elderly person.<elsevierMultimedia ident="tb0080"></elsevierMultimedia></p><p id="par0400" class="elsevierStylePara elsevierViewall">The discharge summaries of hospitalized elderly people must include the CMAEP in order to guarantee appropriate continuity of care between the hospital, primary care, and public health services. Given its potential benefits and for the sake of convenience, we suggest that the CMAEP be included within the electronic medical records of elderly patients.<elsevierMultimedia ident="tb0085"></elsevierMultimedia></p><p id="par0410" class="elsevierStylePara elsevierViewall">Elderly people’s capacities and needs change over time. Their assessment must be dynamic in order to adapt care to changes that arise. There is no consensus on how often or when the CMAEP must be redone. We propose updating it periodically—every six months, for example—as well as whenever a significant clinical change occurs in the elderly person.</p><p id="par0415" class="elsevierStylePara elsevierViewall">Ideally, both the CMAEP and the individualized intervention plan would be able to be spearheaded by the primary care team within the framework of strategies for continuity of care among different levels of care. The hospitalization of an elderly person may be a good time to review both the assessment and the plan, taking into account the patient’s new clinical condition and his or her views. It may also be a suitable moment to propose a joint review by the various professionals involved.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Final considerations</span><p id="par0420" class="elsevierStylePara elsevierViewall">Conducting a CMAEP must be included among internal medicine departments’ care strategies for chronicity and advanced age. Department chiefs and healthcare institution managers must facilitate this task by orienting our acute-care hospitals towards frailty; making resources available; and, along with specialists in more general fields (primary care, internal medicine, and geriatrics), driving the development of protocols to prevent the most common forms of iatrogenesis that hospitalization generates among elderly patients. Establishing clear policies on medication reconciliation (with the participation of other professionals such as pharmacists) and clinical safety can lead to greater quality of care in the hospitalization of these patients.</p><p id="par0425" class="elsevierStylePara elsevierViewall">The electronic medical record must facilitate multidisciplinary work by serving as a guide for the actions suggested in the individualized intervention plan. In this manner, professionals will be able to typify elderly peoples’ problems from different yet convergent perspectives and languages. It is this convergence which must be translated to the patient through appropriate actions which reverse, facilitate, or strengthen strategies oriented towards providing better health outcomes during hospitalization.</p><p id="par0430" class="elsevierStylePara elsevierViewall">In addition, training that facilitates improvements in internists’ skills in regard to these recommendations and facilitating greater teamwork with other healthcare professionals (nursing department professionals, physical therapists, dietitians, pharmacists, social workers, etc.) must be promoted. Training is necessary to avoid succumbing to the excuse of a lack of time, prevent a greater fragmentation of healthcare, and avert an increase in hospital bureaucracy.</p><p id="par0435" class="elsevierStylePara elsevierViewall">The internist’s global vision must promote shared care for the elderly. In this panorama, the CMAEP is the form of assessment with the greatest amount of evidence and which offers the most benefits. Conducting the CMAEP as a team and taking advantage of the results to coordinate with other professionals and care levels is a challenge that will yield improvements in the care of our patients and greater satisfaction in our daily practice.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0440" class="elsevierStylePara elsevierViewall">The creation of these recommendations has been the work of the Focus Group. We have not received any funding for their creation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0445" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1521549" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1379688" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1521550" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1379687" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Recommendations" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Final considerations" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-10" "fechaAceptado" => "2020-10-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1379688" "palabras" => array:4 [ 0 => "Internal medicine" 1 => "Hospitalization" 2 => "Elderly" 3 => "Comprehensive assessment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1379687" "palabras" => array:4 [ 0 => "Medicina interna" 1 => "Hospitalización" 2 => "Ancianos" 3 => "Valoración integral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This position paper describes the most relevant and essential aspects of a comprehensive, multidimensional assessment of hospitalized elderly people. The change in demographic patterns and the epidemiological profiles of diseases makes it necessary for internal medicine departments to adapt in order to take into account the vulnerabilities of the elderly in this context.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A comprehensive, multidimensional assessment and the multidisciplinary development of a care plan during hospitalization can have an impact in terms of preventing mortality, disability, and institutionalization at discharge. It is necessary for all internists to acquire skills to improve the hospitalization experience in the elderly and obtain better health outcomes in our patients. This document has been developed by the Focus Group on Aging and the Polypathological and Advanced Age Working Group and endorsed by the Spanish Society of Internal Medicine.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Este documento de posicionamiento describe los aspectos más relevantes e imprescindibles sobre la valoración integral y multidimensional del anciano hospitalizado. El cambio del patrón demográfico y del perfil epidemiológico de las enfermedades requieren una adaptación de los Servicios de Medicina Interna que tengan en cuenta las vulnerabilidades de las personas ancianas en este contexto.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Una valoración integral y multidimensional y la elaboración multidisciplinar de un plan de atención durante el ingreso pueden tener un impacto para evitar mortalidad, discapacidad e institucionalización al alta. Es necesario que todos los internistas adquiramos competencias para mejorar la experiencia de la hospitalización en la persona mayor y obtengamos mejores resultados en salud en nuestros pacientes. Este documento lo ha desarrollado el Grupo Focal de Envejecimiento y el Grupo de Trabajo de Pluripatología y Edad Avanzada, y está avalado por la Sociedad Española de Medicina Interna.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vallejo Maroto I, Cubo Romano P, Mafé Nogueroles MC, Matesanz-Fernández M, Pérez-Belmonte LM, Said Criado I, et al. Recomendaciones sobre la valoración integral y multidimensional del anciano hospitalizado. Posicionamiento de la Sociedad Española de Medicina Interna. Rev Clin Esp. 2021;221:347–358.</p>" ] 1 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The remaining members of the Focus Group on Aging of the Spanish Society of Internal Medicine and the Working Group on Polypathology and Advanced Age are listed in Appendix A.</p>" "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0450" class="elsevierStylePara elsevierViewall">R. Barba Martín, J. Carretero Gómez, P. Cubo Romano, J. Díez Manglano, F. Formiga, R. Gómez Huelgas, A. González Franco, A. López Soto, M.C. Mafé Nogueroles, M. Matesanz-Fernández, M. Ollero Baturone, L.M. Pérez-Belmonte, I. Said Criado, A. Pose Reino, I. Vallejo Maroto.</p>" "etiqueta" => "Appendix A" "titulo" => "Members of the Focus Group on Aging of the Spanish Society of Internal Medicine" "identificador" => "sec0030" ] 1 => array:4 [ "apendice" => "<p id="par0460" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix B" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:18 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 277776 ] ] 1 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0030" class="elsevierStylePara elsevierViewall">Recommendation 1. It is necessary to carry out a comprehensive, multidimensional assessment of elderly people hospitalized in internal medicine departments</p></span>" ] ] 2 => array:5 [ "identificador" => "tb0010" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0050" class="elsevierStylePara elsevierViewall">Recommendation 2. The comprehensive, multidimensional assessment must include a clinical assessment and an evaluation of the patient’s ability to perform activities of daily living, cognitive function, emotional state, medication, and social situation</p></span>" ] ] 3 => array:5 [ "identificador" => "tb0015" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0075" class="elsevierStylePara elsevierViewall">Recommendation 3. It is necessary to evaluate hospitalized elderly people’s ability to perform activities of daily living</p></span>" ] ] 4 => array:5 [ "identificador" => "tb0020" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0115" class="elsevierStylePara elsevierViewall">Recommendation 4. It is necessary to evaluate hospitalized elderly people’s cognitive status</p></span>" ] ] 5 => array:5 [ "identificador" => "tb0025" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0140" class="elsevierStylePara elsevierViewall">Recommendation 5. Delirium must be prevented and detected early in hospitalized elderly people</p></span>" ] ] 6 => array:5 [ "identificador" => "tb0030" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0160" class="elsevierStylePara elsevierViewall">Recommendation 6. Assessment of hospitalized elderly people’s emotional state and early detection of depression must be done using a screening tool or, when this is not possible, through a clinical interview</p></span>" ] ] 7 => array:5 [ "identificador" => "tb0035" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0175" class="elsevierStylePara elsevierViewall">Recommendation 7. During the hospitalization of elderly people, it is advisable to identify the main caregiver and risk of social exclusion</p></span>" ] ] 8 => array:5 [ "identificador" => "tb0040" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0210" class="elsevierStylePara elsevierViewall">Recommendation 8. In collaboration with nursing department professionals, it is necessary to assess the presence of other situations of risk such as frailty, malnutrition, risk of falls, and risk of pressure ulcers during the hospitalization of elderly people</p></span>" ] ] 9 => array:5 [ "identificador" => "tb0045" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0260" class="elsevierStylePara elsevierViewall">Recommendation 9. It is advisable to carry out a prognostic assessment of elderly hospitalized patients in order to, together with the patients and their families, adapt the aims and intensity of care, diagnostic tests, and treatment</p></span>" ] ] 10 => array:5 [ "identificador" => "tb0050" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0280" class="elsevierStylePara elsevierViewall">Recommendation 10. During the hospitalization, it is essential to identify elderly people with advanced chronic disease or those in palliative care in order to organize and plan care that takes into account their expectations, preferences, and values</p></span>" ] ] 11 => array:5 [ "identificador" => "tb0055" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0300" class="elsevierStylePara elsevierViewall">Recommendation 11. It is advisable to take advantage of the hospitalization to conduct a systematic review of the elderly person’s medication</p></span>" ] ] 12 => array:5 [ "identificador" => "tb0060" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0325" class="elsevierStylePara elsevierViewall">Recommendation 12. During the hospitalization of elderly people, the risks and benefits of prescribing a new drug or considering deprescribing a drug must be evaluated taking into account the results of the CMAEP</p></span>" ] ] 13 => array:5 [ "identificador" => "tb0065" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0350" class="elsevierStylePara elsevierViewall">Recommendation 13. The CMAEP must be accompanied by an individualized intervention plan for improving or resolving the problems identified</p></span>" ] ] 14 => array:5 [ "identificador" => "tb0070" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0365" class="elsevierStylePara elsevierViewall">Recommendation 14. It is recommendable to use checklists in order to improve the information obtained on the CMAEP during hospitalization</p></span>" ] ] 15 => array:5 [ "identificador" => "tb0075" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0375" class="elsevierStylePara elsevierViewall">Recommendation 15. The CMAEP can be done in a multidisciplinary manner with the participation of various professionals</p></span>" ] ] 16 => array:5 [ "identificador" => "tb0080" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0395" class="elsevierStylePara elsevierViewall">Recommendation 16. Following hospitalization, the results of the CMAEP must be recorded on the discharge summary</p></span>" ] ] 17 => array:5 [ "identificador" => "tb0085" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0405" class="elsevierStylePara elsevierViewall">Recommendation 17. 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