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Sociedad Española de Cardiología. Proyecto de Registro Clínico de la Sección de Cardiología Clínica 2013 4.388 JCR (2016) Q1, 8/49 Geriatrics and Gerontology UEM

To describe the indications of insertion of a percutaneous gastrostomy (PG) in older patients in a university hospital, as well as patient characteristics, short and long term complications, and mortality.Retrospective descriptive study of all patients over 75 years who had a PG inserted during a three year period by the Interventional Radiology Department. The indication of the procedure was reviewed, and the incidence of complications and mortality during a 36 months follow-up period were assessed through electronic medical records.The study included 74 patients, with a mean age of 84±6.1 years, and 57% were female. Furthermore, 40% lived in nursing homes and 80% had cognitive impairment. The main indications for PG insertion were dysphagia in severe dementia (56.8%), tumours of the oropharyngeal cavity (12.2%), Parkinson's disease (10.8%), and stroke (9.6%). PG was permanent in 90.5% of cases. The most common complication was aspiration pneumonia (32.4%). Overall mortality was 59.5% after a median follow-up of 18 months.Dysphagia in severe dementia was the main indication for PG in patients over 75 years. This intervention did not prevent aspiration pneumonia, which was the most common complication. Mortality in patients who have a PG was high.

Background Pressure ulcers (PUs) are frequent in older patients, and the healing process is usually challenging, therefore, prevention should be the first strategic line in PU management. Nonpharmacologic interventions may play a role in the prevention of PUs in older people, but most systematic reviews (SRs) have not addressed this specific population using convincing outcome measures. Objective To summarize and critically appraise the evidence from SRs of the primary studies on nonpharmacologic interventions to prevent PUs in older patients. Design SR and meta-analysis of comparative studies. Data sources PubMed, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL (from inception to October 2013) were searched. A new search for updates in the Cochrane Database was launched in July 2014. Eligibility criteria for selecting studies SRs that included at least 1 comparative study evaluating any nonpharmacologic intervention to prevent PUs in older patients, in any healthcare setting, were selected. Any primary study with experimental design was then identified and included. Data extraction From each primary study, quality assessment was undertaken as specified by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation working group. Interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis, using the incidence of new pressure ulcers as the main outcome measure. Results One hundred ten SRs with 65 primary studies satisfied the inclusion criteria. The most frequent interventions explored in these trials were support surfaces (41 studies), repositioning (8), and nutrition interventions (5). High quality of evidence was not found for any intervention, mainly because of a high risk of bias and imprecision. There is moderate quality evidence to support the use of alternating pressure support mattresses over usual hospital mattresses in medical and surgical inpatients, low quality evidence to support constant low pressure devices and Australian medical sheepskin over usual mattresses, and very low quality evidence to support nutrition interventions in hospital settings. No recommendations on hydration, repositioning, standardized risk assessment, or multicomponent interventions can be done. Conclusions In older patients at high risk to suffer PUs, high-technology and low- technology support surfaces can significantly reduce the incidence of PUs. Nutrition intervention may also have a role in preventing PUs in hospital settings. More evidence is needed to support other recommendations, which is specially lacking for repositioning.

This article first reports the spontaneous course of frailty conditions, and then focuses on randomized, controlled frailty interventions (such as physical exercise, nutrition, combined exercise plus nutrition, and multifactorial interventions) or metaanalysis in community-dwelling older adults or volunteers published in 2012, 2013, and 2014. The main take-home messages that emerge from recent literature are summarized.

Summary Background The reported prevalence of sarcopenia ranges widely depending on its definition criterion. European Working Group on Sarcopenia in Older People (EWGSOP) developed a practical clinical definition and consensus diagnostic criteria. This definition recommends using normative data of the study population rather than other reference populations. Objective We aimed to define the reference cut-off values for muscle mass, muscle strength and calf circumference in Turkey in order to improve general applicability of EWGSOP criteria. Material and methods Healthy young adults between 18 and 39 years of age with no known chronic disease or chronic drug usage were included in our study to serve as reference population for assessing muscle mass. Community-dwelling older outpatients were prospectively recruited from the geriatrics outpatient clinics of a university hospital for assessing hand grip strength and calf circumference. Body composition was assessed by bioimpedance analysis. Muscle strength was assessed measuring hand grip strength with a Jamar hand dynamometer. The cut-off thresholds for muscle mass were defined as the mean-2SD of the values of the young reference study population; for grip strength were calculated from ROC analyses using cut-off values that predicted gait speed Results The young reference group included a total of 301 participants (187 male, 114 female; mean age: 26.5 ± 4.6 years). The cut-off thresholds for skeletal muscle mass indexes were 9.2 kg/m 2 and 7.4 kg/m 2 in males and females, respectively. The older community dwelling group included 406 subjects (123 male, 283 female, mean age: 76.6 ± 6.7 years). The cut-off thresholds for hand grip strength were 32 kg and 22 kg for males and females. The cut-off threshold for calf circumference was 33 cm for both males and females. Conclusions The cut-off thresholds for muscle mass, grip strength and calf circumference were somewhat higher but comparable with other reference populations. Further worldwide studies from different nations and countries are needed to obtain better reference values.

Scope First- and second-generation antipsychotics (FGAs and SGAs, respectively), both inhibit cholesterol biosynthesis and impair the intracellular cholesterol trafficking, leading to lipid accumulation in the late endosome/lysosome compartment. In this study we examined if curcumin, a plant polyphenol that stimulates exosome release, can alleviate antipsychotic-induced intracellular lipid accumulation. Methods HepG2 hepatocarcinoma cells were treated with antipsychotics or placebo and DiI-labelled LDL for 18 h and then exposed to curcumin for the last 2 h. Cells and media were collected separately and used for biochemical analyses, electron microscopy and immunocytochemistry. Exosomes were isolated from the incubation medium by ultracentrifugation. Results Curcumin treatment reduced the number of heterolysosomes and shifted their subcellular localization to the periphery, as revealed by electron microscopy, and stimulated the release of lysosomal β-hexosaminidase and exosome markers flotillin-2 and CD63 into the media. The presence of DiI in exosomes released by cells preloaded with DiI-LDL demonstrated the endolysosomal origin of the microvesicles. Furthermore, curcumin increased the secretion of cholesterol as well as LDL-derived DiI and [3H]-cholesterol, in association with a decrease of intracellular lipids. Thus, the disruption of lipid trafficking induced by FGAs or SGAs can be relieved by curcumin treatment. This polyphenol, however, did not mitigate the reduction of cholesterol esterification induced by antipsychotics. Conclusion Curcumin stimulates exosome release to remove cholesterol (and presumably other lipids) accumulated within the endolysosomal compartment, thereby normalizing intracellular lipid homeostasis. This action may help minimize the adverse metabolic effects of antipsychotic treatment, which should now be evaluated in clinical trials.

Objective Studies have found that the atypical antipsychotic drug, risperidone, reduces non-cognitive symptoms, such as aggression, agitation, and psychosis, in patients with Alzheimer's disease. This study assessed whether these effects extend to patients with vascular or mixed-type dementia. Methods In this multicentre, open-label, prospective study, 75 elderly patients with vascular or mixed-type dementia and concomitant behavioural and psychological symptoms were treated with risperidone for up to 6 months. Results Risperidone decreased the frequency and severity of overall behavioural and psychological symptoms, as determined by the Neuropsychiatric Inventory, to a mean total score of 7.2±0.7 at end-point compared with 21.0±1.5 at baseline (P

Los medicos tenemos el privilegio y la obligacion de acompanar, cuidar y aliviar el sufrimiento de muchas personas que se encuentran en las ultimas etapas de sus vidas. Este privilegio, que ha sido consustancial a la actividad medica a lo largo de muchos siglos, cuando la capacidad tecnica de la medicina se encontraba aun muy limitada, se esta redefiniendo en las ultimas decadas, a medida que los avances economicos, la higiene y la ciencia medica permiten que la mayor parte de los recien nacidos hoy en muchos paises puedan aspirar a alcanzar edades muy avanzadas. Es paradojico, no obstante, que los avances medicos apenas nos permitan curar enfermedades. La lista de dolencias agudas y cronicas cuya curacion mejora con los avances medicos se limita en general a las infecciones, algunos canceres muy agresivos y unas pocas enfermedades mas. La cirugia si permite curar en algunas ocasiones, pero muchas veces lo consigue a expensas de importantes secuelas en los organos afectados o mediante la extirpacion de todo o parte de los mismos. Por supuesto, las ciencias medicas evitan hoy dia que muchos pacientes mueran de un infarto o una complicacion diabetica, a expensas de mantener una enfermedad arteriosclerotica o metabolica cronica que les acompane el resto de sus dias. Uno de los exitos de la Oncologia actual es alargar el tiempo de supervivencia en pacientes no curables, convirtiendo algunos canceres en enfermedades cronicas. No es extrano que las personas mayores hayan sido percibidas desde hace mucho tiempo como un cajon en el que se acumulan todas las enfermedades cronicas adquiridas a lo largo de la vida.

There is much ambiguity regarding the term “nursing home” in the international literature. The definition of a nursing home and the type of assistance provided in a nursing home is quite varied by country. The International Association of Gerontology and Geriatrics and AMDA foundation developed a survey to assist with an international consensus on the definition of “nursing home.” Sin financiación 6.616 JCR (2015) Q1, 2/49 Geriatrics & Gerontology UEM

Background Data on the cardiac characteristics of centenarians are scarce. Our aim was to describe electrocardiogram (ECG) and echocardiography in a cohort of centenarians and to correlate them with clinical data. Methods We used prospective multicenter registry of 118 centenarians (28 men) with a mean age of 101.5 ± 1.7 years. Electrocardiogram was performed in 103 subjects (87.3%) and echocardiography in 100 (84.7%). All subjects underwent a follow-up for at least 6 months. Results Centenarians with abnormal ECG were less frequently females (72% vs 93%), had higher rates of previous consumption of tobacco (14% vs 0) and alcohol (24% vs 12%), and scored lower in the perception of health status (6.8 ± 2.0 vs 8.3 ± 6.8). Centenarians with significant abnormalities in echocardiography were less frequently able to walk 6 m (33% vs 54%). Atrial fibrillation/flutter was found in 27 subjects (26%). Mean left ventricular (LV) ejection fraction was 60.0 ± 10.5%. Moderate or severe aortic valve stenosis was found in 16%, mitral valve regurgitation in 15%, and aortic valve regurgitation in 13%. Diastolic dysfunction was assessed in 79 subjects and was present in 55 (69.6%). Katz index and LV dilation were independently associated with the ability to walk 6 m. Age, Charlson and Katz indexes, and the presence of significant abnormalities in echocardiography were associated with mortality. Conclusions Centenarians have frequent ECG alterations and abnormalities in echocardiography. More than one fifth has atrial fibrillation, and most have diastolic dysfunction. Left ventricular dilation was associated with the ability to walk 6 m. Significant abnormalities in echocardiography were associated with mortality. 4.332 JCR (2015) Q1, 26/124 Cardiac & cardiovascular systems UEM

the aim of this study is to know the prevalence of sarcopenia in geriatric outpatient clinics using the EGWSOP (European Working Group on Sarcopenia in Older People) diagnostic criteria that include muscle mass, muscle strength and physical performance.subjects over 69 years old, able to walk without help and who attended five geriatric outpatient clinics were recruited. Body composition was assessed using bioimpedance analysis (BIA), grip strength using a JAMAR dynamometer and physical performance by the 4 m gait speed. Sarcopenia was diagnosed using the EGWSOP criteria (gait speed0.8 m/s; grip strength30 kg in men or20 kg in women, and muscle mass index (MMI)8.31 kg/m(2) in men or6.68 kg/m(2) in women).two hundred and ninety-eight subjects were included (median age 83.2 years, 63.1% women). 19.1% had sarcopenia (12.7% men, 22.9% women); 20.1% had low muscle mass; 68.8% had low gait speed and 81.2% low grip strength. Only 21.9% of the subjects with low grip strength and 19.5% of those with low gait speed had sarcopenia. No correlations between muscle mass and either muscle strength or gait speed were detected.sarcopenia is present in one out of five subjects attending geriatric outpatient clinics.

Background Pressure ulcers (PUs) are more frequent in older patients, and the healing process is usually challenging. Nonpharmacologic interventions may play a role in the treatment of older people with PUs, but most systematic reviews (SRs) have not addressed this specific population using convincing outcome measures. Objective To summarize and critically appraise the evidence from SRs of the primary studies on nonpharmacologic interventions to treat PUs in older patients. Design SR and meta-analysis of comparative studies. Methods PubMed, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL (from inception to October 2013) were searched. A new search for updates in the Cochrane Database was launched in July 2014. SRs that included at least 1 comparative study evaluating any nonpharmacologic intervention to treat PUs in older patients, in any health care setting, were included. Any primary study with experimental design was then identified and included. From each primary study, quality assessment was undertaken as specified by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation working group. Interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis, using complete ulcer healing as the outcome measure. Results One hundred ten SRs with 45 primary studies satisfied the inclusion criteria. The most frequent interventions explored in these trials were support surfaces (13 studies), nutrition (8), and electrotherapy (6). High or moderate quality of evidence was found in none of the interventions, mainly because of the very serious risk of bias of most studies and imprecision in the treatment effect. Evidence grade is very low or insufficient to support the use of any support surface, nutrition intervention, multicomponent interventions, repositioning or other adjunctive therapy (ultrasound, negative pressure, laser, electromagnetic, light, shock wave, hydrotherapy, radiofrequency, or vibration therapy) to increase the rates of PU healing in older patients. Electrotherapy showed some beneficial effect in the treatment of PUs, although the quality of evidence is low. Conclusions In older patients with PUs, evidence to use any nonpharmacologic therapy to increase the rates of wound healing is inconclusive, except for low quality evidence that supports the use of electrotherapy. This situation is especially alarming for interventions that are usually standard clinical practice (repositioning, support surfaces). Although there is some evidence in younger populations and other types of ulcers, studies in older populations with PUs using sound methodology are needed.

International audience; The aging process is associated with gradual and progressive loss of muscle mass along with lowered strength and physical endurance. This condition, sarcopenia, has been widely observed with aging in sedentary adults. Regular aerobic and resistance exercise programs have been shown to counteract most aspects of sarcopenia. In addition, good nutrition, especially adequate protein and energy intake, can help limit and treat age-related declines in muscle mass, strength, and functional abilities. Protein nutrition in combination with exercise is considered optimal for maintaining muscle function. With the goal of providing recommendations for health care professionals to help older adults sustain muscle strength and function into older age, the European Society for Clinical Nutrition and Metabolism (ESPEN) hosted a Workshop on Protein Requirements in the Elderly, held in Dubrovnik on November 24 and 25, 2013. Based on the evidence presented and discussed, the following recommendations are made (a) for healthy older people, the diet should provide at least 1.0-1.2 g protein/kg body weight/day, (b) for older people who are malnourished or at risk of malnutrition because they have acute or chronic illness, the diet should provide 1.2-1.5 g protein/kg body weight/day, with even higher intake for individuals with severe illness or injury, and (c) daily physical activity or exercise (resistance training, aerobic exercise) should be undertaken by all older people, for as long as possible. (C) 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Comprehensive Geriatric Assessment (CGA) is the main measurement tool used by Geriatricians. A 2000 survey demonstrated great variability in the tools used for CGA among Spanish Geriatric Departments. A new survey to detect 13-year trends in the use of CGA tools in our country is presented.Descriptive study using a structured questionnaire on the use of CGA tools in different levels of care sent to the Heads of 39 Spanish Geriatric Departments or Services (27 with postgraduate teaching in Geriatrics) during the first three months of 2013.The response rate was 97.4%. It was found that 78.4% (29 centers) used different tools depending on the level of care. Barthel and Lawton index were the most used functional assessment tools in all Departments and across all geriatric levels, although gait speed and Tinetti scale were frequently used in Day Hospital and Outpatient clinics. The Mini Mental State Exam and its Spanish version Mini Examen Cognoscitivo were the most used mental scales (97.4%), followed by tools for assessing depression-behavior (86.8%) and severity of cognitive impairment tools (84.2%). CGA tools were used in 43.2% of the emergency departments of the hospitals surveyed, being the most frequent. More than two-thirds (69.4%) of the Departments reported that their affiliated Primary Care centers used CGA tools, with the Barthel and Lawton again being indexes the most used. Most of the responding Departments considered that the main domains of CGA are functional, mental and social status. Nutrition, comorbidity, falls and pressure ulcers are other important domains.There is still a great variability in the CGA tools being used in Spanish Geriatric Departments, although there is a trend towards a greater use of Barthel index, greater adaptation of tools to each level of care, and increasing assessment of new domains like frailty, nutrition or comorbidity.

International audience; Objective: to examine the clinical evidence reporting the prevalence of sarcopenia and the effect of nutrition and exercise interventions from studies using the consensus definition of sarcopenia proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). Methods: PubMed and Dialog databases were searched (January 2000–October 2013) using pre-defined search terms. Prevalence studies and intervention studies investigating muscle mass plus strength or function outcome measures using the EWGSOP definition of sarcopenia, in well-defined populations of adults aged ≥50 years were selected. Results: prevalence of sarcopenia was, with regional and age-related variations, 1–29% in community-dwelling populations, 14–33% in long-term care populations and 10% in the only acute hospital-care population examined. Moderate quality evidence suggests that exercise interventions improve muscle strength and physical performance. The results of nutrition interventions are equivocal due to the low number of studies and heterogeneous study design. Essential amino acid (EAA) supplements, including ∼2.5 g of leucine, and β-hydroxy β-methylbutyric acid (HMB) supplements, show some effects in improving muscle mass and function parameters. Protein supplements have not shown consistent benefits on muscle mass and function. Conclusion: prevalence of sarcopenia is substantial in most geriatric settings. Well-designed, standardised studies evaluating exercise or nutrition interventions are needed before treatment guidelines can be developed. Physicians should screen for sarcopenia in both community and geriatric settings, with diagnosis based on muscle mass and function. Supervised resistance exercise is recommended for individuals with sarcopenia. EAA (with leucine) and HMB may improve muscle outcomes.

Introduction: Older adults with advanced cognitive impairment have a limited life expectancy and the use of multiple drugs is of questionable benefit in this population. The aim of the present study was to assess if, in a sample of nursing home (NH) residents with advanced cognitive impairment, the effect of polypharmacy on mortality differs depending on estimated life expectancy. Methods: Data were from the Services and Health for Elderly in Long TERm care (SHELTER) project, a study collectinginformationonresidentsadmittedto57NHsin8Europeancountries.Polypharmacywasdefined as the concomitant use of 10 or more drugs. Limited life expectancy was estimated based on an Advanced Dementia Prognostic Tool (ADEPT) score of 13.5 or more. A Cognitive Performance Scale score of 5 or more was used to define advanced cognitive impairment. Participants were followed for 1 year. Results: Mean age of 822 residents with advanced cognitive impairment entering the study was 84.6 (SD 8.0) years, and 630 (86.6%) were women. Overall, 123 participants (15.0%) had an ADEPT score of 13.5 or more (indicating limited life expectancy) and 114 (13.9%) were on polypharmacy. Relative to residents with ADEPT score less than 13.5, those with ADEPT score of 13.5 or higher had a lower use of benzodiazepines, antidementia drugs, and statins but a higher use of beta-blockers, digoxin, and antibiotics. Polypharmacy was associated with increased mortality among residents with ADEPT score of 13.5 or more (adjusted hazard ratio [HR] 2.19, 95% confidence interval [CI]: 1.15e4.17), but not among those with ADEPT score less than 13.5 (adjusted HR 1.10, 95% CI: 0.71e1.71). Discussion: Polypharmacy is associated with increased mortality in NH residents with advanced cognitive impairment at the end of life. Conclusion: These findings underline the need to assess life expectancy in older adults to improve the prescribing process and to simplify drug regimens.

Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate.The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons.Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG).Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice.Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

Background and aims: sarcopenia has been indicated as a reliable marker of frailty and poor prognosis among the oldest individuals. We evaluated the impact of sarcopenia on the risk of all-cause death in a population of frail older persons living in community. Methods: we analysed data from the Aging and Longevity Study, a prospective cohort study that collected data on all subjects aged 80 years and older residing in the Sirente geographic area (n= 364). The present analysis was conducted among those subjects who were between 80 and 85 years of age at the time of the baseline assessment (n= 197). The main outcome measure was all-cause mortality over 7-year follow-up. According to the European Working Group on Sarcopenia in Older People (EWGSOP) criteria, the diagnosis of sarcopenia required the documentation of low muscle mass and the documentation of either low muscle strength or low physical performance. Cox proportional regression models were used to estimate crude and adjusted hazard ratios and 95% confidence intervals of death by the presence of sarcopenia. Results: using the EWGSOP-suggested criteria, 43 subjects with sarcopenia (21.8%) were identified. During the 7-year follow-up, 29 (67.4%) participants died among subjects with sarcopenia compared with 63 subjects (41.2%) without sarcopenia (P< 0.001). After adjusting for potential confounders including age, gender, education, activities of daily living (ADL) impairment, body mass index, hypertension, congestive heart failure, chronic obstructive pulmonary disease, number of diseases, TNF-α, participants with sarcopenia had a higher risk of death for all causes compared with non-sarcopenic subjects (HR: 2.32, 95% CI: 1.01–5.43). Conclusions: our results obtained from a representative sample of very old and frail subjects show that sarcopenia is associated with mortality, independently of age and other clinical and functional variables.

Older people reaching end-of-life status are particularly at risk of adverse effects of drug therapy. Polypharmacy, declining organ function, co-morbidity, malnutrition, cachexia and changes in body composition all sum up to increase the risk of many drug-related problems in individuals who receive end-of-life care. End of life is defined by a limited lifespan or advanced disability. Optimal prescribing for end-of-life patients with multimorbidity, especially in those dying from non-cancer conditions, remains mostly unexplored, despite the increasing recognition that the management goals for patients with chronic diseases should be redefined in the setting of reduced life expectancy. Most drugs used for symptom palliation in end-of-life care of older patients are used without solid evidence of their benefits and risks in this particularly frail population. Appropriate dosing or optimal administration routes are in most cases unknown. Avoiding or discontinuing drugs that aim to prolong life or prevent disability is usually common sense in end-of-life care, particularly when the time needed to obtain the expected benefits from the drug is longer than the life expectancy of a particular individual. However, discontinuation of drugs is not standard practice, and prescriptions are usually not adapted to changes in the course of advanced diseases. Careful consideration of remaining life expectancy, time until benefit, goals of care and treatment targets for each drug seems to be a sensible framework for decision making. In this article, some key issues on drug therapy at the end of life are discussed, including principles of decision making about drug treatments, specific aspects of drug therapy in some common geriatric conditions (heart failure and dementia), treatment of acute concurrent problems such as infections, evidence to guide the choice and use of drugs to treat symptoms in palliative care, and avoidance of some long-term therapies in end-of-life care. Solid evidence is lacking to guide optimal pharmacotherapy in most end-of-life settings, especially in non-cancer diseases and very old patients. Some open questions for research are suggested.

To assess the most appropriate criteria considered by geriatricians to select patients who might benefit the most from geriatric hospital care.We carried out a survey that consisted of various socio-demographic, clinical, functional and mental criteria included in the definition of the geriatric and frail elderly patient. The survey was sent to all specialists in geriatrics in the different hospitals of the Madrid Health Service. They were asked to answer to each criterion indicating whether they considered it as high priority, priority, low priority or no priority. The responses were clustered by type of hospital: acute hospitals with or without a post-graduate geriatric program for medical residents, and medium and long stay hospitals.A total of 83 questionnaires were completed (70% of the study population): 42 teaching hospitals a post-graduate geriatric program (74% of possible), 20 of those with an emergency department but without a post-graduate geriatric program (56% of possible), and 21 medium and long stay hospitals (84% of potential). All proposed criteria were considered individually as priority or high-priority by more than 50% of respondents. An age 85 years and over, admission for hip fracture, the presence of severe cognitive or functional impairment, frailty, and unexplained deterioration of health status, were considered individually as criteria for selecting high-priority target population by more than 85% of respondents.Certain criteria, such as advanced age, or the presence of geriatrics-specific conditions, such as hip fracture or severe functional or cognitive impairment, are identified by geriatricians as useful to select patients to receive geriatric specialist hospital care.

Proper nutrition is an essential part of successful aging and may delay the onset of diseases. Nutrition-related problems in older subjects have been long-time ignored; good nutritional status is an essential component of health and a relevant part of therapeutic plans of most chronic diseases. Moreover, food and nutrition are a relevant aspect of most cultures and are strongly linked with individual lifestyles. Research has proved that nutritional intervention can improve outcomes in many clinical scenarios. This is especially true for older individuals with different acute and chronic conditions and diseases, or with malnutrition. Nutritional intervention can provide sufficient energy, protein and micronutrients, maintain or improve nutritional status, reduce morbidity and increase survival. Evidence is still lacking on the impact of nutritional intervention on physical and mental function, and on quality of life, very relevant outcomes for older individuals. Nutritional screening and assessment should become part of health care of both healthy and sick older people. Nutritional counseling and intervention should be embedded in a general care plan that takes into account all aspects of an aging person. Nutritional programs that aim for high compliance should be individualized, and would have to consider every aspect of old age: beliefs, attitudes, preferences, expectations, and aspirations.

Potentially inappropriate prescribing is common in older people presenting to hospital with acute illness in Ireland. The aim of this study was to determine if this phenomenon is unique to Ireland or whether it is a more widespread problem in hospitals across Europe.Prospective data were collected from 900 consecutive older patients admitted to six university teaching hospitals (150 patients per centre) in Geneva (Switzerland), Madrid (Spain), Oostende (Belgium), Perugia (Italy), Prague (Czech Republic) and Cork (Ireland). Age, gender, comorbidity, cognitive status, prescription medicines taken before admission and baseline haematological, biochemical and electrocardiographic data were recorded. STOPP and Beers' criteria were applied to detect potentially inappropriate medicines (PIMs). START criteria were applied to detect potentially inappropriate prescribing omissions (PPOs).The overall PIM prevalence rate was 51.3% using STOPP criteria, varying from 34.7% in Prague to 77.3% in Geneva, and 30.4% using Beer's criteria, varying from 22.7% in Prague to 43.3% in Geneva. Using START criteria, the overall PPO prevalence rate was 59.4%, ranging from 51.3% in Cork to 72.7% in Perugia. Polypharmacy predicted the presence of PIMs using STOPP criteria [with 10 medications: odds ratio (OR) 7.22, 95% confidence interval (CI) 4.30-12.12, p 0.001] and Beers' criteria (with 10 medications: OR 4.87, 95% CI 3.00-7.90, p 0.001). Increasing co-morbidity (Charlson Index ≥2) and age ≥85 years significantly predicted PPOs.Potentially inappropriate drug prescribing and the omission of beneficial drugs are highly prevalent in acutely ill hospitalized older people in six European centres.

Background Apathy is an important and distressing behavioural symptom in Alzheimer's disease and in various neuropsychiatric disorders. Recently, diagnostic criteria for apathy have been proposed. Objectives In groups of patients suffering from different neuropsychiatric diseases, (i) to estimate the prevalence of patients meeting the proposed diagnostic criteria; (ii) to estimate the concurrent validity of the criteria with the neuropsychiatric inventory (NPI) apathy item; (iii) to identify the most frequently met criteria or sub-criteria in each specific neuropsychiatric disease and (iv) to estimate the inter-observer reliability of the diagnostic criteria for apathy. Methods This cross-sectional, multicentric, observational study was performed on 306 patients. Each of the participating centres had to check the presence of apathy according to the diagnostic criteria for apathy in consecutive patients belonging to the following diagnoses list: Alzheimer disease (AD), mixed dementia, mild cognitive impairment (MCI), Parkinson's disease (PD), Schizophrenia (DSM-IV) and major depressive episode. In addition to the clinical interview, the assessment included the Mini Mental Score Examination (MMSE) and the NPI. At the end of the visit, clinicians were required to check the diagnostic criteria for apathy. Results Using the diagnostic criteria for apathy, the frequency of apathy was of 53% in the whole population, 55% in AD, 70% in mixed dementia, 43% in MCI, 27% in PD, 53% in schizophrenia and 94% in major depressive episode. In AD, mixed dementia, MCI and PD, the NPI apathy score was significantly higher for patient fulfilling the apathy criteria. Goal-directed cognitive activity (criteria B2-Cognition) was the most frequently observed domain followed by goal-directed behaviour (criteria B1—Behaviour) and emotion (criteria B3), respectively. Inter-rater reliability was high for the overall diagnostic (κ coefficient = 0.93; p = 0.0001) and for each criteria. Conclusion This study is the first one to test the diagnostic criteria for apathy in clinical practice. Results make the diagnostic criteria useful for clinical practice and research. Copyright © 2010 John Wiley & Sons, Ltd.

Sarcopenia is a common and prominent geriatric syndrome, of major interest for daily clinical practice of professionals working with older people. The number of affected individuals and its relation with disability, frailty, many chronic diseases, lifestyle and adverse outcomes are extremely relevant for geriatric care. Moreover, biological changes that lead to the loss of muscle mass and strength are intrinsically related to the mechanisms of aging. It is not therefore surprising that research in this field is growing exponentially in recent years, and sarcopenia has been placed in recent years in the forefront of research in geriatric medicine and gerontology. The Spanish Society of Geriatrics and Gerontology has recently created an Observatory of Sarcopenia, which aims to promote educational and research activities in this field. The first activity of the Observatory has been to offer the Spanish speaking scientific community a review of the current status of sarcopenia, that may allow unifying concepts and fostering interest in this promising field of geriatrics.

Background Inappropriate prescriptions are common in older people admitted to nursing homes. Commonly used instruments to detect potential inappropriate prescriptions have limitations that have precluded wide use, and new instruments are needed. Objective The goal of this study was to determine the value of the S creening T ool of O lder P erson’s potentially inappropriate P rescriptions/ S creening T ool to A lert doctors to the R ight, ie appropriate, indicated T reatment (STOPP-START) criteria and the Australian criteria to detect potentially inappropriate drug prescriptions in older people on admission to nursing home care. Methods Cross-sectional study of 100 consecutive patients (mean age 84.7 ± 7.5 years, 80% women) admitted to 6 assisted living nursing homes, with systematic review of prescriptions used at the time of nursing home admission using the STOPP-START and the Australian criteria looking for potentially inappropriate drug treatments. Results Using the STOPP criteria, 79% of the subjects showed at least one potentially inappropriate prescription. Omissions of potentially appropriate drugs were found by the START criteria in 74% of them. The Australian criteria detected at least one potential problem in 95% of the sample. The number of subjects with 2 or more problems detected was highest using the Australian criteria (72%). The most frequent potentially inappropriately used drugs detected were proton-pump inhibitors, benzodiazepines, antipsychotic drugs, and anticholinergic drugs; many cases of duplicate medications and drug interactions were also detected. Underuse of statins and aspirin in patients with high cardiovascular risk, and of calcium and vitamin D in osteoporosis was also frequent. Conclusions A high number of potentially inappropriate drug prescriptions can be detected at the time of admission to nursing home care by the use of systematic instruments. Both STOPP-START criteria and the Australian criteria performed well in this setting. The impact of this detection on health outcomes and costs should be assessed before they can be widely recommended.

PURPOSE OF REVIEW: Highly prevalent in the population older than 65 years and leading to poor outcomes (functional decline and its related consequences), sarcopenia does not benefit yet either of a clear understanding of its pathophysiology or of precise clinical or biological markers allowing its identification. RECENT FINDINGS: The new scientific definition of 'geriatric syndromes' challenges the authors to review the current sarcopenia literature, allowing them to affirm that sarcopenia cannot be considered as an age-related disease but as a true 'geriatric syndrome'. More than 50% of the population older than 80 years suffer from this medical condition, which is linked to multiple causations: the ageing process itself, genetic susceptibility, certain life habits, changes in living conditions and a number of chronic diseases. Moreover, sarcopenia favours poor outcomes such as mobility disorders, disability, poor quality of life and death. SUMMARY: Considering sarcopenia as a geriatric syndrome allows us to request its recognition and assess its multiple risk factors, to implement a clinical and public health approach to the management of sarcopenic patients and population at risk and to disentangle the links among sarcopenia, frailty, disability and mortality.

The physiopathology of delirium has still not been characterized in depth, although this entity can be defined as a functional brain disorder provoked by one or multiple organic causes that display a common clinical syndrome. Certain specific brain regions that are involved in delirium have been identified, such as the prefrontal cortex, the thalamus and the basal ganglia, especially in the nondominant hemisphere. Functional changes occur in a large number of neurotransmitters: the most frequent and best characterized are a reduction of cholinergic function and an increase in dopaminergic and gabaergic function, although alterations in almost all neurotransmitter systems (serotoninergic, noradrenergic, glutaminergic, histaminergic) have been found. Inflammation also seems to play an important role, at least in some types of delirium. Delirium in the elderly typically has a multifactorial etiology, with several simultaneous or sequential causes. Numerous risk factors have been described, both predisposing individuals to delirium and triggering this syndrome. Knowledge of these factors and their interactions is of great clinical importance and consequently etiologic diagnosis should be based on a multifactorial model.

Older people are a heterogeneous group of patients, often with multiple comorbidities for which they are prescribed a large number of drugs, leading to an increased risk of adverse drug reactions (ADR) and drug interactions. This risk is compounded by physiological age-related changes in physiology, changes in drug pharmacokinetics and pharmacodynamics, as well as by disease-related, functional and social issues. Inappropriate prescription of drugs is common in the older individuals and contributes to the increased risk of ADR. Several tools have been developed to detect potentially inappropriate prescription, the most frequently used in Spain being Beers' criteria. However, the value of these criteria is limited, especially as they were developed in a different healthcare system. In this article, the Spanish version of a new tool to detect potentially inappropriate prescriptions-STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right i.e. appropriate, indicated Treatment) criteria-is presented. The creation, development, reliability, and use of these criteria in routine practice is described and discussed. These criteria have shown better sensitivity than Beers' criteria in detecting prescription problems and have the added value of being able to detect not only inappropriate prescription of some drugs, but also the omission of well indicated drugs. The STOPP/START criteria could become a useful screening tool to improve prescription in older people.

BACKGROUND. In September 2008, under the French Presidency of the European Union and with the support of the Polish Minister of Health, a European Summit on Age-Related Disease was organised inWroclaw (Poland). At this meeting, European politicians, gerontologists and geriatricians gathered to discuss a common approach to future challenges related to age-related disease. Politicians and decision-makers from the European Union and Ministers of Health and their deputies from many European countries raised the problems and difficulties to be tackled in a growing population with a high burden of disease, and asked scientists to write a consensus document with recommendations for future actions and decisions. Scientists and clinicians worked in parallel in three different groups, on health promotion and preventive actions, basic research in age-related disease, and clinical aspects of disease in older people. Beforehand, the format of the paper with recommendations was discussed, and it was finally agreed that, for a better understanding by decision- makers, it would be divided in two different columns: one with facts that were considered settled and agreed by most experts (under the heading We know), and a second with recommendations related to each fact (We recommend). No limit on the number of topics to be discussed was settled. After careful and detailed discussion in each group, which in most cases included the exact wording of each statement, chairpersons presented the results in a plenary session, and new input from all participants was received, until each of the statements and recommendations were accepted by a large majority. Areas with no consensus were excluded from the document. Immediately after the Summit, the chairpersons sent the document both to the main authors and to a list of experts (see footnote) who had made presentations at the summit and agreed to review and critically comment on the final document, which is presented below. As regards the scientific aspects of the planning of the Summit, several organisations, under the leadership of the EUGMS, were asked both to review the program and to suggest names of speakers and participants. After the Summit, the Boards of these organizations (European Union Geriatric Medicine Society (EUGMS), International Association of Gerontology and Geriatrics-European Region (IAGGER), European Association of Geriatric Psychiatry (EAGP), International Society of Gerontechnology (ISG) and International Society for the Study of the Aging Male (ISSAM) agreed to consider the document as an official paper, and help with its dissemination. The name Silver Paper was used, recalling the grey or silvery hair of our older citizens, as an easy reference. It has been sent officially to several bodies of the European Union and to Health Ministers of most European countries; and will be published in other languages in local journals. Its declared intention is to foster changes in policies which may, in the future, reduce the burden of disease in old age.

At the European summit on age-related disease (Wroclaw, September 11-13, 2008), held under the French Presidency of the European Union experts from the different gerontology disciplines proposed a program of research and development that has been endorsed by the European Union Geriatric Medicine Society, the International Association of Geriatrics and Gerontology – European Region, the European Association of Geriatric Psychiatry, the International Society for Gerontechnology, and the International Society for the Study of the Aging Male. The program includes basic research, health promotion and preventive action, and clinical care.