The importance of evaluating fragility and dependence

Marco Martínez, J.; Plaza Canteli, S.

doi:10.1016/j.rceng.2019.05.004

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Marco Martínez, S. Plaza Canteli" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Marco Martínez" "email" => array:1 [ 0 => "javiermarco.z@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Plaza Canteli" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección Medicina Perioperatoria, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Paliativos, Hospital Severo Ochoa, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La importancia de evaluar la fragilidad y la dependencia" ] ] "textoCompleto" => "In recent years, we have witnessed the advent and establishment of polypathological patients in the practice of internal medicine. The inversion of the population pyramid, medical advances and social progress form the three pillars of this new patient profile, which expends a considerable portion of our time and healthcare resources, with still much more to come.This expanding group typically shares the traits of frailty and high dependence, an increasingly common situation in internal medicine. These patients are elderly, often live alone, and many times require assistance for their daily activities. Their needs grow the older they get, as their loneliness deepens and as their polypathology progresses.There is therefore a growing need to go beyond the clinical assessment and physical examination performed in daily practice and that is taught to internal medicine students. These patients’ frailty and thus their degree of dependence should form part of the clinical assessment, given the percentage of polypathological patients treated in internal medicine.The study by Bernabeu-Wittel et al. published in this issue of the journal highlights this problem. As mentioned by the authors, most polypathological patients have varying degrees of dependence, which can be severe in more than 30% of cases.<a class="elsevierStyleCrossRefs" href="#bib0045">1,2</a> A healthcare intervention cannot be conducted, either individually or as a whole, for these patients without first conducting a frailty assessment. The Barthel index (BI) is the most commonly used tool for this assessment, but employing the index lengthens the time clinicians spend with patients in the initial clinical assessment. The authors propose simplifying the previous screening using an abbreviated BI that facilitates and shortens the initial assessment. To this end, the authors designed a cross-sectional multicenter study that included more than 1600 patients (most from hospitals with some outpatient representation and home hospitalization). After performing a complete BI, the authors identified those items with better positive and negative predictive values for obtaining a BI≥90 points. The item with the highest negative predictive value was the ability to feed and groom oneself. The items with the highest positive predictive value were the ability to walk and go up and down stairs. The authors proposed an algorithm for applying this simplified BI whose first question is, “Can the patient go up and down stairs?” If the patient is able to do so, the BI is >90, and a full BI needs to be performed. If the patient is unable to do so, the next question is, “Can the patient feed themselves?” If they can, the BI is between 60 and 89, indicating the patient has moderate dependence and that a full BI needs to be performed. If they unable to do so, the BI is <60, indicating the patient has severe dependence.The authors recognize that the lack of validation of the study's results with an independent patient cohort is one of the study's weaknesses. There is also a disproportion between the number of hospitalized patients and outpatients in the sample. The study's strengths are the participation of 37 hospital centers distributed throughout Spain and the considerable number of patients.In our opinion, this is an original study in its approach, which achieves useful results if they can be validated. Of course, the authors are aiming in the right direction. One has to look no further than the study's first table, which shows the characteristics of this consecutively recruited patient cohort. Here are just some of the data: the number of comorbidities per patient was 4.5, 70% had high blood pressure, 35% had atrial fibrillation, the mean Charlson index was 4, 47% had a New York Heart Association classification of III-IV, and 31% had a BI<60.This is the setting in which we work, a scenario that could worsen. Including information regarding frailty and dependence in the assessment of our patients in a global and practical manner appears to be essential. On the other hand, we increasingly need to work fast and in a variety of settings. In our opinion, the study by Bernabeu-Wittel et al. is heading in that direction: an abbreviated and fast BI.At this time, 46% of discharges from internal medicine departments are of patients 80 years or older, and attendance in internal medicine departments increases as the population age group that requires the most treatment increases. The latest RECALMIN report<a class="elsevierStyleCrossRef" href="#bib0055">3</a> recommends having specific information on the healthcare needs of patients older than 80 years admitted to internal medicine departments. It is precisely these groups<a class="elsevierStyleCrossRef" href="#bib0060">4</a> that have specific requirements and for which the same hospitalization process can increase the patient's frailty and vulnerability and result in readmissions.<a class="elsevierStyleCrossRefs" href="#bib0065">5,6</a>The latest RECALMIN survey showed that only 54% of the departments stated having implemented a systematic care program for complex chronic patients, which covered only 31% of the Spanish population. There is therefore a noticeable gap between the recommendations of the standards document for multiple-disease units<a class="elsevierStyleCrossRef" href="#bib0075">7</a> and the strategy for approaching chronicity in the Spanish national health system.<a class="elsevierStyleCrossRef" href="#bib0080">8</a>There is still much to do. It is essential that we give frailty and dependence the place they deserve and include them definitively in our medical records, assessments and documents. A major step would be to progress toward their quick and reliable assessment." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Marco Martínez J, Plaza Canteli S. La importancia de evaluar la fragilidad y la dependencia. Rev Clin Esp. 2019;219:449–450." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional decline over one-year follow up in a multicenter cohort of polypathological patients: a new approach to functional prognostication" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Bernabeu-Wittel" 1 => "M. Ollero-Baturone" 2 => "A. Ruiz-Cantero" 3 => "L. Moreno-Gaviño" 4 => "B. Barón-Franco" 5 => "A. 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Vol. 219. Issue 8.

Pages 449-450 (November 2019)

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