Relaciones de la fragilidad y el agotamiento con el estado de salud en pacientes con EPOC

espanolResumen de la Tesis Doctoral titulada: Relaciones de la Fragilidad y el Agotamiento con el Estado de Salud en Pacientes con EPOC. Antecedentes: La Enfermedad Pulmonar Obstructiva Cronica (EPOC) produce un declive gradual en el estado de salud de las personas que la padecen, el cual se intensifica con cada exacerbacion aguda. La fragilidad es un predictor de deterioro funcional y hospitalizacion en poblaciones de ancianos. Sin embargo, su relacion con el estado de salud de los pacientes con EPOC ha sido poco explorada. Se ha explorado basicamente con el modelo de fragilidad fisica de Fried (que utiliza cinco caracteristicas), evidenciando que esa fragilidad es un determinante del estado de salud, medido con el CAT (COPD Assessment Test), y que una de sus caracteristicas (andar) predice la readmision hospitalaria por exacerbacion. Objetivos: Determinar: 1) si la fragilidad fisica y sus caracteristicas individuales tienen un impacto diferencial sobre la puntuacion CAT; 2) la probabilidad de transicion entre estados de agotamiento y no agotamiento durante 2 anos, y los predictores de la aparicion de episodios de agotamiento; 3) si la fragilidad (medida con un modelo multidimensional) es un factor de riesgo para la readmision hospitalaria por exacerbacion aguda de EPOC; y 4) si su adicion a un modelo predictivo mejora la precision para discriminar pacientes con riesgo de readmision. Metodos: Se realizaron dos estudios exploratorios usando diferentes poblaciones, modelos de fragilidad y medidas del estado de salud. Estudio 1: estudio longitudinal que incluyo a 137 pacientes con EPOC estable. Los datos se recogieron en tres momentos (inicio, al ano y a los 2 anos). La fragilidad se midio utilizando el modelo fenotipo Fried (perdida de peso involuntaria, baja actividad fisica, agotamiento, velocidad de marcha lenta y baja fuerza de agarre). Para el primer objetivo se utilizaron modelos de regresion. Para el segundo, se calculo el porcentaje de transiciones y se aplicaron modelos generales de estimacion. Estudio 2: estudio prospectivo que incluyo a 103 pacientes hospitalizados con exacerbaciones de su EPOC y seguidos durante 90 dias despues de su alta. Los datos se recogieron en dos momentos (durante hospitalizacion y a los 90 dias del alta revisando las historias para determinar la readmision hospitalaria). La fragilidad multidimensional se midio con la Reported Edmonton Frail Scale. Para el tercer objetivo se usaron modelos de regresion. Para el ultimo objetivo se compararon areas bajo diferentes curvas de caracteristica operativa del receptor. Resultados: Estudio 1: El 73,7% de los pacientes eran pre-fragiles y 8,7% fragiles fisicos. De las cinco caracteristicas de fragilidad, la fuerza de agarre, la actividad fisica y el agotamiento fueron las mas afectadas (60,6%, 27,0% y 19,7%, respectivamente). Solo el agotamiento fue determinante independiente de la puntuacion CAT (?=5,12, p = 0,001) una vez ajustado por otros determinantes (disnea, exacerbaciones y ansiedad). Se identifico que 10,3% de las 204 transiciones anuales que iniciaron sin agotamiento lo presentaron al siguiente. Los predictores de su aparicion fueron: puntuacion CAT (odds ratio [OR] = 1,10; IC 95%:1,01-1,21), depresion (OR = 6,89; IC 95%:1.00-47.41) y sexo femenino (OR = 6.88, IC 95%: 1.83-25.73). Estudio 2: La fragilidad severa fue un factor de riesgo para la readmision (OR = 5,19; IC 95%: 1,26-21,50). Edad, numero de hospitalizaciones previas y duracion de la estancia tambien fueron relevantes. La fragilidad mejoro la precision predictiva de la readmision. Conclusiones: De las caracteristicas individuales de fragilidad del modelo de Fried, solo agotamiento es determinante del CAT. El agotamiento tiene un patron evolutivo dinamico. Las mujeres, y pacientes con sintomas depresivos y CAT alto tienen mayor predisposicion a sufrir nuevos episodios de agotamiento. Pacientes con fragilidad multidimensional severa presentan mayor probabilidad de readmision que los no fragiles. La adicion de la fragilidad a un modelo predictivo de readmision hospitalaria mejora su precision. EnglishAbstract of the Doctoral Thesis entitled: Relationships of Frailty and Exhaustion with the State of Health in Patients with COPD. Background: Chronic Obstructive Pulmonary Disease (COPD) produces a gradual decline in the health status of people who suffer from it, which intensifies with each acute exacerbation. Frailty is a predictor of functional deterioration and hospitalization in elderly populations. However, its relationship with the health status of patients with COPD has been little explored. It has been explored basically with the Fried physical frailty model (which uses five characteristics), showing, first, that this frailty is a determinant of health status, measured with the CAT (COPD Assessment Test), and, second, that one of its characteristics (walking) predicts hospital readmission due to exacerbation. Aims: To determine: 1) whether physical frailty and its individual characteristics have a differential impact on the CAT score; 2) the probability of transition between states of exhaustion and non-exhaustion during 2 years, and the predictors of the appearance of episodes of exhaustion; 3) if frailty (measured with a multidimensional model) is a risk factor for hospital readmission due to acute exacerbation of COPD; and 4) if its addition to a predictive model improves the accuracy to discriminate patients with risk of readmission. Methods: Two exploratory studies were carried out using different populations, fragility models and measures of health status. Study 1: longitudinal study that included 137 patients with stable COPD. The data was collected in three moments (beginning, after one year and after 2 years). Frailty was measured using the Fried phenotype model (involuntary weight loss, low physical activity, exhaustion, slow walking speed and low grip strength). For the first aim, regression models were used. For the second, the percentage of transitions was calculated and general estimation models were applied. Study 2: a prospective study that included 103 patients hospitalized with exacerbations of their COPD and followed up for 90 days after discharge. The data was collected in two moments (during hospitalization and 90 days after discharge, reviewing the histories to determine hospital readmission). Multidimensional frailty was measured with the Reported Edmonton Frail Scale. For the third aim, regression models were used. For the last aim, areas were compared under different receiver operating characteristic curves. Results: Study 1: 73.7% of patients were pre-frail and 8.7% frail physical. Of the five characteristics of fragility, grip strength, physical activity and exhaustion were the most affected (60.6%, 27.0% and 19.7%, respectively). Only exhaustion was conclusive independent of the CAT score (? = 5.12, p = 0.001) once adjusted for other determinants (dyspnea, exacerbations and anxiety). It was identified that 10.3% of the 204 annual transitions that began without exhaustion presented it the next year. The predictors of its occurrence were: CAT score (odds ratio [OR] = 1.10, 95% CI: 1.01-1.21), depression (OR = 6.89, 95% CI: 1.00-47.41) and female sex (OR = 6.88, 95% CI: 1.83-25.73). Study 2: Severe frailty was a risk factor for readmission (OR = 5.19, 95% CI: 1.26-21.50). Age, number of previous hospitalizations and length of stay were also relevant. Frailty improved the predictive accuracy of readmission. Conclusions: Of the individual frailty characteristics of the Fried model, only exhaustion is determinant of CAT. Exhaustion has a dynamic evolutionary pattern. Women, and patients with depressive symptoms and high CAT are more predisposed to suffer new episodes of exhaustion. Patients with severe multidimensional frailty have a higher probability of readmission than non-frail patients. The addition of frailty to a predictive model of hospital readmission improves its accuracy.

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