RMG 21 07 1

The Journal of Latin American
Geriatric
Medicine
Volume 7 – Number 1 – 2021
Published Quarterly – ISSN: 2462-2958 / eISSN: 2462-4616 – www.conameger.org
ORIGINAL ARTICLES
Correlation of the SARC-F questionnaire with muscle mass
in Colombian elderly with osteosarcopenia 1
Miguel Cadena-Sanabria, Joaquín Vergara-Sánchez, Ma. Paula Castrillón,
Johanna M. Quintero-Cure, Andrés Roa, Cristian C. Llano-Ceballos,
Mónica Romero-Marín, and Gustavo A. Parra-Zuluaga
Relationship of functionality before hip fracture with mortality
in older adults 8
Aileve A. Quiñones-Salgado, Juan M. Shiguetomi-Medina,
Marco V. González-Rubio, Oscar O. Ortega-Berlanga and
Gonzalo R. González-González
Deficiencia de vitamina B12 y fragilidad en adultos mayores
del centro de México 13
Marisol Silva-Vera, Ma. de Jesús Jiménez-González, Raúl F. Guerrero-Castañeda,
Alejandra A. Silva-Moreno y Jorge A. Morales-Treviño
Mexican hip fracture audit (ReMexFC): 2019 annual report 20
Juan C. Viveros-García, Aldyn Anguiano-Medina, Enrique Arechiga-Muñoz,
José O. Duarte-Flores, Eliud Robles-Almaguer, Marco A. Ramos-Rojas,
Leonor E. Zapata-Altamirano, José F. Torres-Naranjo, Roberto E. López-Cervantes,
and Lizbeht S. Baldenebro-Lugo
Validation of the frontal assessment battery in Mexican
older adults with cognitive impairment 29
Alberto J. Mimenza-Alvarado, J. Octavio Duarte-Flores, Lidia A. Gutiérrez-Gutiérrez,
Ma. José Suing-Ortega, and Sara G. Aguilar-Navarro
COLEGIO NACIONAL
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The Journal of Latin American
Geriatric
Medicine
Volume 7 – Number 1 – 2021
Published Quarterly – ISSN: 2462-2958 / eISSN: 2462-4616 – www.conameger.org
Revista disponible íntegramente en versión electrónica en www.conameger.org
Editor en Jefe Comité Editorial

Sara Gloria Aguilar Navarro Ulises Pérez Zepeda
Instituto Nacional de Ciencias Médicas y Nutrición Instituto Nacional de Geriatría. Ciudad de México
Salvador Zubirán (INCMNSZ). Ciudad de México Juan Cuadros Moreno
Instituto Mexicano del Seguro Social. Ciudad de México
Coeditores Clemente Zúñiga Gil
Hospital Ángeles Tijuana, B.C.
J. Alberto Avila Funes
Instituto Nacional de Ciencias Médicas y Nutrición Ma. del Consuelo Velázquez Alva
Salvador Zubirán (INCMNSZ). Ciudad de México UAM Xochimilco. Ciudad de México
Ivonne Becerra Laparra Julio Díaz Ramos
Antiguo Hospital Civil Fray Antonio Alcalde. Guadalajara, Jal.
Fundación Médica Sur. Ciudad de México
Alejandro Acuña Arellano
Jorge Luis Torres Gutiérrez Hospital General Regional No. 251 IMSS. Metepec, Edomex,
Hospital Regional ISSSTE. León, Gto. México
Fundación Médica Sur. Ciudad de México
Mónica Tapia Hernández Comité Editorial Internacional
Hospital Ángeles Lomas, Ciudad de México, México
Martha Eugenia Valdivia Proa Mikel Izquierdo Redín (España)
ISSSTE Monterrey, Nuevo León, México José Ricardo Jáuregui (Argentina)
Shapira Moises (Argentina)
Consejo Editorial
Carlos Alberto Cano Gutiérrez (Colombia)
Luis Miguel Gutiérrez Robledo José Fernando Gómez (Colombia)
Instituto Nacional de Geriatría.
Ciudad de México Gabriela Villalobos Rojas (Costa Rica)
Carmen García Peña Óscar Monge Navarro (Costa Rica)
Instituto Nacional de Geriatría. José Francisco Parodi García (Perú)
Ciudad de México
Carlos Sandoval Cáceres (Perú)
Carlos D´hyver de las Deses Aldo Sgaravatti (Uruguay)
Universidad Nacional Autónoma de México.
Ciudad de México
David Leal Mora
Antiguo Hospital Civil Fray Antonio Alcalde.
Guadalajara, Jal.
Jorge Reyes Guerrero†
Instituto Nacional de Ciencias Médicas y Nutrición
Salvador Zubirán (INCMNSZ). Ciudad de México
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www.conameger.org J Lat Am Geriat Med. 2021;7(1):1-7
THE JOURNAL OF LATIN AMERICAN GERIATRIC MEDICINE ORIGINAL ARTICLE
Correlation of the SARC-F questionnaire with muscle

mass in Colombian elderly with osteosarcopenia
Miguel Cadena-Sanabria1,2,3, Joaquín Vergara-Sánchez1, Ma. Paula Castrillón2,
Johanna M. Quintero-Cure4, Andrés Roa2, Cristian C. Llano-Ceballos5, Mónica Romero-Marín3*, and
Gustavo A. Parra-Zuluaga2
1
Department of Geriatrics, Clínica FOSCAL, Floridablanca; 2Geriatrics Investigative Group, Universidad Autónoma de Bucaramanga; 3GERMINA
Investigative Group, Universidad Industrial de Santander, Bucaramanga; 4Scanography, Clínica FOSCAL Internacional, Floridablanca; 5Clinical
Geriatrics, GESENCRO IPS, Palmira. Colombia
Abstract
Aim: The aim of the study was to determine the association between low muscle mass evaluated by Dual-energy X-ray absorptiometry
(DXA) and the SARC-F questionnaire. Methods: This was a cross-sectional study of patients over 60 years sent to bone densitometry
between April and November 2018. The SARC-F questionnaire and body assessment measures were applied using DXA. The presence
of low muscle mass was determined using the European criteria EWGSOP2 and osteoporosis according to the WHO. Results: Fifty-two
patients were included, with a mean age of 74.27 years (SD ± 7.04), 88.4% were women, and mean body mass index 21.89 (SD ± 3.36).
About 28.85% had a SARC-F > 4. The mean skeletal muscle mass index was 6.54 kg/m2 (SD ± 0.92). About 32.69% of the patients had
low muscle mass according to the EWGSOP2 criteria. The prevalence of osteosarcopenia was 7.69% (Osteopenia/osteoporosis plus
sarcopenia with SARC-F > 4 and low muscle mass). Conclusions: The ability of the SARC F instrument to discriminate low muscle mass
was not found in this cohort of Colombian older adults. The prevalence of osteoporosis and sarcopenia presented a distribution similar
to that described in the literature. It is necessary to carry out research in Colombia aimed at defining the muscle mass reference values.
Key words: Aged. Dual-energy X-ray absorptiometry. Geriatric medicine. Osteoporosis. SARC-F. Sarcopenia.
Correlación del cuestionario SARC-F con la masa muscular en adultos mayores

colombianos con osteosarcopenia
Resumen
Objetivo: Determinar la relación entre una masa muscular baja evaluada por DXA en una población cribada para osteo-
porosis y el cuestionario SARC-F. Métodos: Estudio de corte transversal en individuos mayores de 60 años enviados a densi-
tometría ósea entre abril y noviembre de 2018. Se aplicó el cuestionario SARC-F y medidas de evaluación corporal con DXA. La
masa muscular baja se determinó a través de los criterios europeos EWGSOP2 y la osteoporosis según los parámetros de la OMS.
Resultados: Se incluyó a 52 pacientes, con edad promedio de 74.27 años (DE ± 7.04) y 88.4% correspondió a mujeres, con IMC
promedio de 21.89 (DE ± 3.36). El 28.85% presentó un SARC-F ≥ 4. El promedio del índice de masa muscular esquelética (IMME)
fue de 6.54 kg/m2 (DE ≥ 0.92). El 32.69% del total de la muestra tenía una masa muscular baja según los criterios EWGSOP2. La
prevalencia de osteosarcopenia fue del 7.69% (osteopenia/osteoporosis más sarcopenia [SARC-F > 4] y masa muscular baja).
Conclusión: No se encontró capacidad del instrumento SARC-F para diferenciar la masa muscular baja en esta cohorte de adul-
tos mayores colombianos. La prevalencia de osteoporosis y sarcopenia mostró una distribución similar a la descrita en las pub-
licaciones médicas. Son necesarias más investigaciones en Colombia para definir los valores de referencia de la masa muscular.
Palabras clave: Anciano. DXA. Geriatría. Osteoporosis. SARC-F. Sarcopenia.
Correspondence to:
*Mónica Romero-Marín
Clínica FOSCAL Internacional
Calle 157 # 23 – 99
Floridablanca, Santander, Colombia
E-mail: moniromma@hotmail.com
2462-4616/© 2021 Colegio Nacional de Medicina Geriátrica, A.C. Published by Permanyer. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1
J Lat Am Geriatric Med. 2021;7(1)
INTRODUCTION of five items considering cardinal findings or conse-

quences of sarcopenia. It has been validated through
Osteosarcopenia (OS) is a geriatric syndrome char-
different cohorts, demonstrating internal consistency,
acterized by the coexistence of bone mineral loss
and adequate reproducibility. People with scores of
(defined as T Score < −1 according to WHO criteria) and
4 or higher are more likely to have a deficit in daily
sarcopenia1. The sum of these conditions increases the
life activities, lower performance in execution-based
probability of adverse outcomes in elderly patients in measures, lower scores in short performance physical
terms of functional performance and vital prognosis. battery (SPPB), and an increased risk of hospitaliza-
Patients with hip fractures with OS have been found tion and mortality according to Baltimore’s longitu-
to have 1.8 times more risk of mortality in the 1st year2. dinal study (odds ratio 3.0 Confidence interval 95%
The prevalence of OS reported in different studies is 1.57-5.73)11. Regarding the correlation of SARC-F
between 5 and 37%, being more common in women specifically with muscle mass, it has been proven
and patients over 65 years old3. Huo et al.4 described poor association with appendicular mass evaluated
a higher prevalence of sarcopenia in people with by Bioimpedanciometry (r 0.34)12. The sensitivity of
osteoporosis, compared with those with osteopenia SARC F has been reported between 14 and 21% with
(62.7% vs. 47.4%) in Penrith, Australia. To date, there high specificity, above 90%, which makes it an impor-
are no data on the incidence or prevalence of OS in tant questionnaire to discriminate probable cases of
Colombia. Sarcopenia that would require a full assessment13.
Much of the studies published so far in international Due to the great variability of cutoff points and the
literature, define sarcopenia considering the low mus- absence of studies that estimate the applicability of
cle mass as the main diagnostic criteria, also, they base the SARC-F questionnaire and its correlation with the
the cutoff points on those established by the 2010 objective muscle mass assessment estimated by DXA,
European consensus5: a appendicular muscle mass this study was conducted. The main objective is to
index < 5.5 kg/m2 in women and 7.26 kg/m2 in men, determine the association between low muscle mass
by Dual Advanced X-ray Energy (DXA). The cutoff point determined by DXA and the score obtained in the
is based in Baumgartner’s study6, where low muscle SARC-F questionnaire in a population of Colombian
mass was established as a value of 2 standard devia- older adults with suspected osteoporosis. The sec-
tions (SD) below the mean of a young reference group. ondary objective is to know the prevalence of OS in
On the other side, reference values proposed by the this population.
2018 European consensus7 for the appendicular mus-
cle mass index are based on an Australian population8.
In Colombia, DXA appendicular mass measurement METHODS
is not widely available, and for this reason, finding a A cross-sectional observational study was designed,
screening tool that allows the clinician better decision- with a sample of patients attending bone densitom-
making at the patient’s bedside can improve both etry for osteoporosis screening or monitoring dur-
diagnostic suspicion and use of the health resource. ing 2018, at International FOSCAL Clinic Escanografía
Comparatively, in the Latin American context, there is S.A. Center (Scanography Public Limited Company).
available data in Chile and Mexico. The data found in A non-probabilistic sampling of consecutive cases
the southern country for the cutoff points of the skel- of all subjects who met the inclusion criteria was
etal muscle mass index obtained by DXA were 5.77 kg/ performed.
m2 in women and 7.19 kg/m2 in men. This data were The inclusion criteria were having 60 years or more
retrieved from a geriatric population (over 60 years and signing informed consent. Patients with severe
old) without values estimated from a group of younger dementia, Barthel Index < 60 points, active cancer
people9. The values obtained in Mexico reported cut- except for skin, recent use in the past 3 months of ste-
off points of the DXA appendicular skeletal muscle roids (equivalent to 10 mg daily of prednisolone), and
mass index in a population of young patients, by locat- amputation of some limbs were excluded from the
ing two SD below average10. Globally, the most used study. Body composition determination was made
cutoff points for OS are 6 kg/m2 in women and 7 kg/m2 using GE Healthcare’s Lunar Prodigy Advance dual-
in men, proposed by the European consensus in 2018. energy absorption (DXA) equipment using enCORE
On the other hand, SARC-F is a questionnaire devel- 13.2 software. Osteoporosis was defined according to
oped to identify people at risk of sarcopenia. It consists the WHO criteria through the T score value. A t value
2
M. Cadena-Sanabria, et al.: SARC-F and DXA muscle mass correlation
≤ to −2.5 was classified as osteoporosis and a T value physical activity at least 3 times/week. The most com-
between −1 and −2.4 as osteopenia. mon comorbidity was osteoarthrosis, followed by
The day of the test validated to the Mexican Spanish Diabetes mellitus and chronic obstructive pulmonary
SARC F questionnaire13 was applied by a team of doc- disease. The mean body mass index (BMI) was 21.89.
tors previously trained by a specialist in Geriatrics. All participants had a sufficient functional capacity in
Appendicular muscle mass was determined with the Activities of Daily Living. Concerning bone mineral
Relative Musculoskeletal Index (weight in Kg/size density, 53.85% had density in osteoporosis range
in m2) based on the Baumgartner equation, which according to the WHO criteria. About 16.67% of the
was automatically calculated by the equipment. To population had evidence of morphometric vertebral
determinate the presence of low muscle mass, the fracture.
reference values of the second European consensus
(values <7 kg/m2 in men, <6 kg/m2 in women)7 were
SARC-F and muscle mass
considered. The presence of Sarcopenia was defined
by the summation of a score in SARC F of 4 or more Applying the SARC – F questionnaire, 28.8% of people
associated with low muscle mass. Variables of physical had 4 or more points. Body composition assessment
performance from the EWGSOP2 Sarcopenia Criteria through the relative Appendicular Muscle Mass Index
such as gait speed, short physical performance bat- had a mean of 6.53 kg/m2. According to EWGSOP2
tery, and timed-up-and-go test were not measured. criteria, 32.69% of participants had low muscle mass,
On the other hand, patients who had a bone mineral and the prevalence of Sarcopenia and OS was 9.62%
density with a T score value of < −1 and sarcopenia and 7.69%, respectively. However, this prevalence var-
were classified as OS. All participants signed written ies in the scenario of different cutoff points published
informed consent. The study received the endorse- in Latin America (Table 2). In subjects listed as osteo-
ment from the ETHICS Committee CEI FOSCAL accord- sarcopenic, the mean Appendicular Muscle Mass was
ing to Act No. 30 of 2017. 5.23 kg/m2 (SD ± 0.97) versus 6.65 kg/m2 (SD ± 0.83)
in patients without OS (p = 0.0024). Concerning the
correlation between the SARC-F questionnaire with
Statistical analysis
muscle mass, there are no statistically significant dif-
Descriptive analysis was performed with the cen- ferences between the SARC F Value and the preva-
tral trend and dispersion measurements (mean and lence of low muscle mass (Table 3), or between the
SD or median and interquartile ranges), depending SARC F Value and mean Appendicular Muscle Mass
on the normality distribution of quantitative vari- Index (Table 4). Therefore, in our region, we found
ables. Qualitative variables were expressed with abso- inappropriate discrimination of the SARC-F question-
lute and relative frequencies. Subsequently, group naire for DXA Estimated Muscle mass.
comparison analysis was performed using t-test or
Wilcoxon statistical tests for quantitative variables
DISCUSSION
based on the distribution of the variables; Chi-square
statistical tests or Fisher’s exact test was used for qual- Our findings demonstrate there is no associa-
itative variables, depending on the amount of data for tion between the SARC F questionnaire and values
each category. of appendicular muscle mass index, lacking in the
proper discrimination of patients that, with positive
screening, does not have OS.
RESULTS
Bahat et al., on a Turkish validation study of SAR-F,
The study included 52 patients. The general char- described the poor capacity of discrimination of the
acteristics are summarized in table 1. About 88.46% questionnaire for the detection of low muscle mass,
of the participants were women. The most common according to EWGSOP2 Criteria, with a sensitiv-
indication of DMO was osteoporosis screening. About ity of 20% and a specificity of 81%. This sensitivity
25.49% of participants had a previous fracture; how- was lower compared with the one for grip strength,
ever, only 17.3% of them knew they had osteopo- reported in 33.7% by the National Institutes of
rosis and were under treatment. It should be noted Health, the Up and Go Test, reported in 58.3%, and
that < 2% of people knew the term Sarcopenia. On the SPPB reported in 55.2%14. However, SARC-F was
the other hand, only 21.15% of subjects performed an excellent tool for excluding the altered muscle
3
Table 1. Patient characteristics Table 1. Patient characteristics (continued)

VSARC F > 4, n (%)
Characteristic Total (n = 52)
Characteristic Total (n = 52)
Low muscle mass EWGSOP2, 17 (32.69)
Age, mean (SD), y 74.27 (± 7.04) n (%)
Women, n (%) 46 (88.46) Men 13 (28.26)
Urban, n (%) 47 (90.38)
Women 4 (66.67)
Weight mean (SD), kg 68.29 (10.21)
Bone Mineral Density, g/cm2
Height mean (SD), m 1.56 (0.06)
Hip, median (IQR) 0.74
BMI mean (SD) 21.89 (3.36)
Lumbar spine, mean (SD) (0.69-0.88)
Previous fracture, n (%) 13 (25.49)
Radus 33%, mean (SD) 0.95 (0.17)
Forearm 4 (7.69)
Osteopenia (T score < −1.0-−2.4), 0.68 (0.127)
Hip 3 (5.77) n (%)
Vertebral 2 (3.85) Osteoporosis (T score < −2.5), n 22 (42.31)
Knee and foot 2 (3.85) (%)
Hand 1 (1.92) Morphometric vertebral fracture, 28 (53.85)
n (%)
Other 1 (1.92)
Treatment for osteoporosis with 9 (17.3) No 40 (83.33)
previous fracture, n (%) 1 vertebra 6 (12.5)
Densitometry’s indication, n (%) 2 or more vertebrae 2 (4.17)
Osteoporosis screening 39 (75)
Osteoporosis monitorization 4 (7.69)
Previous fracture 3 (5.77)
Unknown 5 (9.62)
Physical activity 3 or more times 11 (21.15)
per week, n (%) Table 2. Prevalence of Sarcopenia and
Comorbidities, n (%) Osteosarcopenia in the cohort, according to
different criteria of low muscle mass
Osteoarthrosis 16 (30.77)
Diabetes mellitus 11 (21.57) Criteria of low Sarcopeniaa Osteosarcopeniab
muscle mass
Chronic obstructive pulmonary 7 (13.46)
disease EWGSOP2 9.62% 7.69%
Chronic use of steroids 7 (13.46) Mexico10 1.92% 1.92%
Heart failure 6 (11.76) Colombia (BIA)11 17.31% 15.38%
Chronic kidney disease 5 (9.62) a
Sarcopenia: SARC F > 4 AND low muscle mass.
b
Osteosarcopenia: Sarcopenia AND BMD < −1.0 in T
Cancer 4 (7.69) score.
Rheumatoid arthritis 3 (5.77)
Stroke 1 (1.92)
Charlson Comorbidity index ≥ 3, 5 (10.2)
n (%)
Comprehensive geriatric function in Sarcopenia. In this study, the assessment
assessment, median (IQR) of the muscle mass was made with bioimpedanci-
Barthel Index 100 (95-100) ometry and not with DXA15. Besides, Nguyen et al.
Lawton’s Instrumental Activities of 7 (6-8) documented in the SARC-F Vietnam Validation Study,
Daily Living Scale
with 764 participants from a geriatric hospital (mean
Mini Mental State Examination 25 (24-27)
age of 71.5 ± 8.9 years), a discriminatory capacity of
(MMSE)
0.72 for Sarcopenia criteria (EWGSOP2). They evalu-
Mini Nutritional Assessment 8 (7-10)
Short Form (MNA-SF) ated appendicular muscle mass with DXA. The mean
VSARC F > 4, n (%) 15 (28.85) appendicular muscle mass index was 4.7 kg/m2, and
the BMI was 21.7 kg/m2. 64.9% of patients with sar-
(Continues) copenia had SARC-F of 4 or more, while 31.8% of
4
and discriminatory capacity (AUC) to 0.92. However,

Table 3. Correlation of SARC F questionnaire with
in this publication, the calf perimeter cutoff was
muscle mass according to different criteria of low
muscle mass 33 cm for women and 34 cm for men17. Our study
did not check whether the calf perimeter association
Criteria of All SARC F p value
Low Muscle patients Questionnaire improved SARC-F sarcopenia discrimination capac-
Mass (n = 52) ity, although it may be useful to improve the tool
<4 ≥4
(n = 37) (n = 15) performance.
EWGSOP2a, 17 12 5 0.95 The prevalence of OS in our study (7.69%) is simi-
n (%) (32.69) (32.4) (33.3) lar to the one published by Rubek – Nielsen et al.3,
Mexicob, 2 1 1 0.501 reflecting the need for optimizing diagnostic cri-
n (%) (3.85) (2.7) (6.6) teria in each region of the world. Furthermore, the
Colombia 31 22 9 0.97 frequency of osteopenia and osteoporosis in this
(BIA)c, n (%) (59.62) (59.4) (60)
study is like that described by Szlejf et al. in Mexico
a
EWGSOP2 (European Working Group on Sarcopenia in City18, where they reported a prevalence of 77.8% of
Older People 2 Consensus): Women < 6 kg/m2, Men
< 7 kg/m2.
these conditions, and a 33.7% of sarcopenia.14 While
b
Mexico: Women < 4.72 kg/m2, Men < 5.86 kg/m2. Hologic equipment was used for DXA, it does not
c
Manizales, Colombia (Bioimpedanciometry): Women present much variability with the methods used in
< 6.42 kg/m2, Men < 8.39 kg/m2.
our research for DMO evaluation. Unfortunately, the
cutoff points taken for muscle mass assessment were
those of the US National Institute of Health, which
are not equivalent with sarcopenia data obtained
Table 4. Mean muscle mass, according to SARC F
in this study, a situation widely described in other
Questionnaire papers as a relevant limitation for comparing differ-
Muscle All SARC F p value ent values of this condition19.
mass patients Questionnaire In Colombia, available muscle composition data
(n = 52) were found in Manizales and Bogota, but these were
<4 ≥4
(n = 37) (n = 15) not performed with DXA. The research group of the
All 6.54 6.606 6.38 (1.09) 0.4301 University of Caldas reported muscle body composi-
patients, (0.92) (0.85) tion data by the bioimpedance method with values
mean (SD) corresponding to 6.42 kg/m2 in women and 8.39 kg/m2
Women, 6.47 6.51 6.4 (1.12) 0.7102 in men, based on the cutoff point of 2 SD below the
mean (SD) (0.93) (0.85)
average of young patients20. It should be noted that
the calculation of body composition performed by
bioimpedance requires a conversion equation that is
patients without sarcopenia had these values on the calibrated regarding the lean mass value measured
questionnaire16. with DXA in a specific population7. Researchers of the
Because of this, SARC F is a tool easily used by SABE Colombia group of the Javeriana University in
the clinician for the screening of patients with sus- Bogota have defined Sarcopenia taking into account
the grip strength (cutoff point of 30 kg for men and
pected sarcopenia, given its high specificity for the
20 kg for women), the walking speed (in the lowest
detection of the compromised muscle function.
quintile between the 2nd and 5th group), and the calf
However, this measure cannot be fully assumed as a
perimeter (< 31 cm), showing a prevalence of 11.5%
specific surrogate of the composition of the muscle
in the population studied, with the first EWGSOP cri-
fiber, considering the multiple factors that influence teria21. This study lacks ideal body composition mea-
its generation, development, maintenance, and surements and did not concomitantly evaluate bone
function. mineral density and therefore does not allow the
Studies conducted in Brazil and China with older estimation of OS. The new EWGSOP2 criteria, when
adults demonstrate better sensitivity of SARC-F com- strictly applied, should also be considered to decrease
bined with an indirect measure of muscle mass such the prevalence of sarcopenia, compared with the first
as calf circumference, increasing sensitivity to 60.7%, ones22.
5
Due to the diagnostic modalities for the determina- FUNDING

tion of body composition, the different cutoff points,
This research has not received any specific grant
its heterogeneity, and the interindividual variability of
from agencies of the public, commercial, or non-profit
the population, we consider that the sum of these fac-
sectors.
tors makes it hard to find a correlation between the
SARC-F questionnaire and the body composition in
this group of patients. ETHICAL DISCLOSURES
This one is the first study that evaluates both
Protection of people and animals. The authors
muscle and bone body composition in older adults
declare that no experiments were performed on
in Colombia, from a reference center in the forma-
humans or animals for this research.
tion of radiologists and primary care physicians,
Confidentiality of the data. The authors declare
with great experience in densitometric diagnosis.
that they have followed the protocols of their work
The main limitations of the study are the sample
center on the publication of patient data.
size, and the absence of longitudinal follow-up to
Right to privacy and informed consent. The
evaluate the prediction of OS with fractures and
authors have obtained the informed consent of the
functional impairment. Besides, our definition of OS
patients and/or subjects referred to in the article. This
lacks information about physical performance mea-
document is in the possession of the corresponding
sures included in the European consensus. However, author.
this way reveals low potency and muscle efficiency
as self-reporting. This information, in addition to
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osteoporosis in older people: a systematic review and meta-analysis.
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a limited ability of the instrument to discriminate 5. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F,
this muscle alteration. The prevalence of osteoporo- et al. Sarcopenia: European consensus on definition and diagnosis. Age
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Ross RR, et al. Epidemiology of sarcopenia among the elderly in New
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that explores the prevalence of OS in Colombia esti- 7. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al.
Sarcopenia: revised European consensus on definition and diagnosis.
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8. Gould H, Brennan SL, Kotowicz MA, Nicholson GC, Pasco JA. Total
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ing reference values of muscle mass for Colombia in 9. Lera L, Ángel B, Sánchez H, Picrin Y, Hormazabal MJ, Quiero A, et al.
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10. Alemán-Mateo H, Valenzuela RE. Erratum: skeletal muscle mass indi-
ACKNOWLEDGMENTS ces in healthy young Mexican adults aged 20-40 years: implications
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The authors would like to thank the study par- 11. Ferrucci L. The Baltimore longitudinal study of aging (BLSA): a 50-year-
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Universidad Autónoma de Bucaramanga for their 12. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F:
a symptom score to predict persons with sarcopenia at risk for poor
assistance with data collection. This work was sup- functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7:28-36.
13. Ida S, Kaneko R, Murata K. SARC-F for screening of sarcopenia among
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14. Parra-Rodríguez L, Szlejf C, García-González AI, Malmstrom TK, Cruz-
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of the Spanish-language version of the SARC-F to assess sarcopenia
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The authors have no conflicts of interest. 2016;17:1142-6.
6
15. Bahat G, Yilmaz O, Kiliç C, Oren MM, Karan MA. Performance of SARC-F 19. Mayhew AJ, Raina P. Sarcopenia: new definitions, same limitations. Age
in regard to sarcopenia definitions, muscle mass and functional mea- Ageing. 2019;48:613-4.
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16. Nguyen TN, Khuong LQ, Nguyen T, Hoai T, Hospital NG, Van Minh H. corte provisionales para el diagnóstico de sarcopenia en ancianos de
Reliability and validity of SARC-F questionnaire to assess sarcopenia Caldas, Colombia. Biomedica. 2018;38:521-6.
among Vietnamese geriatric patients. Clin Interv Aging. 2020;15:879-86. 21. Samper-Ternent R, Reyes-Ortiz C, Ottenbacher KJ, Cano CA. Frailty and
17. Yang M, Hu X, Xie L, Zhang L, Zhou J, Lin J, et al. Screening sarcopenia sarcopenia in Bogotá: results from the SABE Bogotá study. Aging Clin
in community-dwelling older adults: SARC-F vs SARC-F combined with Exp Res. 2017;29:265-72.
calf circumference (SARC-CalF). J Am Med Dir Assoc. 2018;19:277.e1-8. 22. Reiss J, Iglseder B, Alzner R, Mayr-Pirker B, Pirich C, Kässmann H, et al.
18. Szlejf C, Parra-Rodríguez L, Rosas-Carrasco O. Osteosarcopenic obesity: Consequences of applying the new EWGSOP2 guideline instead of the
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dle-aged and older women. J Am Med Dir Assoc. 2017;18:733.e1-5. Age Ageing. 2019;48:713-8.
7
Relationship of functionality before hip fracture with

mortality in older adults
Aileve A. Quiñones-Salgado1, Juan M. Shiguetomi-Medina2, Marco V. González-Rubio1,
Oscar O. Ortega-Berlanga1, and Gonzalo R. González-González1*
1
Department of Geriatrics, Hospital Central “Dr. Ignacio Morones Prieto;” 2Faculty of Medicine, Universidad Autónoma de San Luis Potosí. San
Luis Potosí, Mexico
Abstract
Background: Functionality before hip fracture (HF) is considered a predictor of mortality. At the end of the post-fracture
1st year, 60% do not regain ambulation, and immobility is a predictor of complications and mortality. Objective: The objec-
tive of the study was to analyze the relationship of pre-HF functionality with immediate, early, and late post-operative mortality.
Material and methods: Retrospective cohort study in old adults in a concentration hospital. Immediate (before 1-month post-frac-
ture), early (2-12 months post-fracture), and late (after 1 year post-fracture) mortality were defined; functionality was assessed by
Barthel scale: dependent or independent. Cox regression was used to determine survival trend. Results: Seventy-five patients were
included (66% women), 37 patients were between 80 and 89 years of age, and 12 subjects were categorized as dependent. In the imme-
diate mortality group (n = 18), the risk of death was similar between dependents and independents; in early mortality (n = 19) depen-
dents had a risk of dying (Relative Risk [RR] 0.18), and in late mortality (n = 39) the risk persisted higher in dependent patients (RR 0.14)
than in independents. Conclusion: Dependence is a risk factor for early and late mortality, but not relevant for immediate mortality.
Key words: Functionality. Pre-fracture. Mortality. Hip fracture.
Relación de la funcionalidad anterior a la fractura de cadera con mortalidad en

adultos mayores
Resumen
Antecedentes: La funcionalidad anterior a la fractura de cadera (FC) se considera predictor de mortalidad. Al término del primer
año posterior a la fractura, el 60% no recupera la deambulación y la inmovilidad es un factor predictor de complicaciones y
mortalidad. Objetivo: Analizar la relación de la funcionalidad antes de la FC con mortalidad inmediata, temprana y tardía
posquirúrgica. Material y métodos: Estudio de cohorte retrospectivo realizado en adultos mayores en un hospital de concen-
tración. Se definieron: mortalidad inmediata (antes del primer mes posterior a la fractura), temprana (2° a 12° meses posteriores
a la fractura) y tardía (>1 año después de la fractura); se valoró la funcionalidad mediante la escala de Barthel: dependiente o
independiente. Se empleó regresión de Cox para determinar la tendencia de supervivencia. Resultados: Se incluyó a 75 pacien-
tes (66% mujeres), 37 se encontraban entre 80 y 89 años y 12 se categorizaron como dependientes. En el grupo de mortalidad
inmediata (n = 18), el riesgo de muerte fue similar entre dependientes e independientes; en el de mortalidad temprana (n = 19),
los dependientes tenían un riesgo de morir (RR, 0.18) y en el de mortalidad tardía (n = 38), el riesgo persistió mayor en los paci-
entes dependientes (RR, 0.14) que en los independientes. Conclusión: La dependencia es un factor de riesgo para mortalidad
temprana y tardía, pero no relevante para la mortalidad inmediata.
Palabras clave: Funcionalidad anterior a la fractura. Mortalidad. Fractura de cadera. Adulto mayor.
Correspondence to:
*Gonzalo R. González-González
Geriatrics Department
Hospital Central “Dr. Ignacio Morones Prieto”
Av. Venustiano Carranza w/n, University area
C.P. 78290, San Luis Potosí, SLP., Mexico
E-mail: geriatriaslp@hotmail.com
8
A.A. Quiñones-Salgado, et al.: Hip fracture with mortality in older adults
INTRODUCTION in increased mortality, to carry out measures such as

expediting surgical intervention and rehabilitation
The increase in the older adult population has
therapy in those patients with greater vulnerability,
generated a higher incidence of osteoporosis1,2, an
that is, with greater dependence before HF.
important health problem due to its social and health
The aim of this study is to analyze the relationship
impact, high cost, and high disability3. Worldwide,
of functionality before HF with immediate, early, and
more than 200 million people are reported to have late post-surgical mortality.
osteoporosis, of which 8.9% will present a fracture4-6.
Hip fracture (HF) due to fragility stands out for its
multifactorial origin and its bio-psycho-social affec- MATERIALS AND METHODS
tion, due to complications such as cognitive impair- Analytical observational retrospective study which
ment, functional impairment, immobility, sarcopenia, included 389 patients with HF, and were admitted to
and depression, among others; generating an impact the Central Hospital “Dr. Ignacio Morones Prieto” in
on quality of life and increasing disability in the the city of San Luis Potosi, Mexico from the period of
elderly3,7,8. June 2014 to July 2019. We selected 75 patients who
In Mexico, at the end of the 20th century, an aver- met the following inclusion criteria: age older than
age of 100 HF/day was reported, affecting the female 60 years, with fragility HF, undergoing surgical fixa-
gender 4 times more, with a risk of between 8.5% and tion or hemiarthroplasty, with functional assessment
18% of HF during their lifetime9,10. In 2005, an inci- by Barthel scale on admission, who died within the
dence of 169 women and 98 men with HF per 100,000 period of interest, and registered in the state base of
population-years was reported11. death certificates.
Patients with HF show an increase in mortality when Surviving patients, patients with incomplete infor-
compared to non-fractured patients of the same age mation, and patients with pathological fractures, bilat-
and gender12,13. Mortality is observed between 6% and eral fractures, history of HF, periprosthetic fracture, or
10% in the 1st year, 30% after the 1st year post-fracture, with non-surgical management were excluded from
and 40% 2 years after the event14,15. The male gender the study.
has a higher mortality risk (HR 1.64 [95% Confidence The Barthel Scale score, months of discharge-func-
Interval, 1.3-2.06])16,17. tion (defined as time from date of surgical event to
In the field of Geriatrics, a “functionally healthy” date of death), age, gender, and cause of death were
older adult is defined as one capable of facing a pro- studied.
cess of change, with an adequate level of functional The study was approved by the Ethics Committee
adaptation and personal satisfaction1,2. Therefore, a (24-CEU-001-20160427) and the Research Committee
dependent elderly person will have a lower capacity (Reg. 17CI24028093) of the central hospital Dr. Ignacio
to adapt to HF and with this, a higher risk of complica- Morones Prieto, with permission to access patient
tions and death. records.
It is reported that 40% of patients with HF will
recover their ambulation 1-year post-fracture, 60%
will use a walking aid, and 33% will not recover their
Determination of mortality and
independence18-20. However, no mention is made of
functionality
the degree of functionality of these patients before The sample was divided into three groups: patients
their injury. with immediate mortality, was defined as the event
It is assumed that independent patients with pre- occurring within the 1st month after HF surgery,
served ambulation will have a greater chance of patients with early mortality, when it occurred within
recovering gait and avoiding the complications asso- the 2nd and 12th months, and patients with late mor-
ciated with immobility. tality when it occurred after 1 year after the surgical
In a study carried out in a Japanese population21, event.
it was identified that a low Barthel index before the The degree of functionality of the patient during
fracture generated a greater risk of poor recovery and admission was determined by means of the Barthel
higher mortality. scale, that patient with a score < 60 points was defined
Therefore, it is necessary to know whether in our as a dependent patient, and that patient with a score
environment, pre-fracture functionality plays a role ≥ 60 points as an independent patient.
9
Table 1. Demographic characteristics of study population

Characteristics Immediate mortality Early mortality Late mortality
(n = 18) (%) (n = 19) (%) (n = 39) (%)
Female 11 (61) 16 (84) 24 (61)
Condition “Dependence” 4 (22) 3 (15) 5 (12)
Age
60-69 0 0 3 (7)
70-79 2 (11) 9 (47) 13 (33)
80-89 10 (55) 8 (42) 19 (48)
90-100 6 (33) 2 (10) 4 (10)
Death’s diagnosis
Pneumonia 6 (33) 7 (36) 11 (28)
Cardiac insufficiency 2 (11) 4 (21) 2 (5)
Sepsis 2 (11) 3 (15) 3 (7)
Renal illness 0 1 (5) 2 (5)
Thromboembolic 3 (16) 0 0
Myocardial Infarction 5 (27) 4 17 (43)
Others 0 0 4 (10)
Statistical analysis 24%), four patients were categorized as dependent, in

the early death group (no. 19, 25%) three patients were
Sequential non-probabilistic sampling was done.
dependent, and in the late mortality group (no. 38, 52%),
A sample size was calculated for the state of San
with five dependent patients (Table 1). The proportion of
Luis Potosí, considering 308,000 old adults (State risks is protective for the group of independent patients
Government, 2016)22, and a reported maximum over dependents. A trend of the same risk of dying
prevalence of HF of 1.1% (2009)23; margin of error 5%, among dependents and independents was observed
with a confidence of 95%. The required sample was during the 1st post-operative month. In the early mor-
17 patients. However, since the causes are multifacto- tality group, an increased risk of dying with Relative Risk
rial, more patients were included in a period of time (RR) 0.18 (0.065-0.539 p = 0.001, CI 95%) was observed
in accordance with Hanke and Wichern24 you want in dependent patient compared to independents; simi-
to recommend that this type of sample should be at larly, in late mortality, the group of dependents had an
least 50 individuals. No randomization method was increased risk of death (RR 0.14 [0.064-0.336 p < 0.001 CI
applied. Through Cox regression, the risk of mortal- 95%]) compared to independent patients (Table 2). In
ity was determined by comparing dependent versus relation to death diagnoses, in the immediate mortal-
independent patients over time. ity group the most common causes were: Pneumonia
(33%) e Acute Myocardial Infarction (27%). In the early
RESULTS mortality group, pneumonia was the most common
cause of death at 36%, followed by heart failure with
Of the 75 patients studied, 50 subjects (66.67%) were 21%. And in the late mortality group, that is, after the
female. Age ranged from 60 to 100 years, most subjects 1st year after 100, acute myocardial infarction was the
were between 80 and 89 years of age (n = 37, 49.3%), first cause (43%), followed by pneumonia (28%).
12 subjects (16%) categorized as previously dependent.
They were divided into the three groups, according to
DISCUSSION
their respective date of death: immediate, early, and
late post-fracture mortality, and related to their state In this study, the sample studied has characteristics
of functionality. In the immediate death group (No. 18, to other studies in terms of age, gender, and causes
10
A.A. Quiñones-Salgado, et al.: Hip fracture with mortality in older adults
Table 2. Relative risk (with 95% CI) of mortality in relation with de functionality before the hip fracture
Dependent patients Total patients Relative risk CI 95% p value
(RR)
Immediate mortality 4 18 0.34 0.1150-1.037 0.05
Early mortality 3 19 0.18 0.0652-0.5393 0.001
Late mortality 5 38 0.14 0.0643-0.3363 < 0.001
120% patients. Unlike the results obtained in the ishidou21

study, where the low Barthel index was a significant
100% determinant of mortality risk after adjusting to age
and gender. Within the 2nd-12th months of post-frac-
80%
ture, defined as early mortality, independence was
60%
observed to be a protective factor in maintaining sur-
vival in this period. In our knowledge, there are no
>12
40% studies evaluating these same criteria, although it is
reported that within the 1st year post-fractura there is
20%
a mortality of 20-24%31,32; however, the level of func-
tionality of the samples is unknown. In early and late
0%
0 2 4 6 8 10 12 14 16 mortality groups, the trend remains that pre-FC inde-
Independence Dependence
pendence is a protective factor of mortality. Similar to
Figure 1. Mortality by functionality over time. the Haentjens study et al.29, it was observed that the
risk of mortality decreased substantially over time,
especially in those functional patients. However, in
our study, we find ourselves as limiting: sample size
of death3,6,7,11. There is evidence of an increased risk of
and inequality in the proportion in number between
falling in independent patients with preserved wan-
dependents and independents. A larger sample will
dering, during their mobilization outside or inside the
be required to obtain conclusive data.
home25. For this reason, our work obtained sample
5 times more independent patients than dependent
patients. A higher incidence of the female gender CONCLUSION
was observed, being the most physiologically vulner- Our study found that independence, with a Barthel
able to this pathology26,27. The most common age was index > 60 points, is a protective factor for post-frac-
80-89 years, as reported by studies in the American ture mortality when compared to dependent patients.
population28. Of the total sample of 76 patients in this However, this protection was not evident within the
study, 18 older adults (23%) were observed to have 1st month.
died within the 1st month of post-fracture, subse-
quently there was a distribution of 19 patients (25%)
throughout the 2nd-12th months; and finally, 51% of AKNOWLEDGMENTS
the sample died after the post-show year (Fig. 1). In honor and in memory of Dr. Francisco Javier López
Similar results were obtained in a recent meta-analy- Esqueda (1959-2019), a pillar in the formation and
sis where the magnitude and duration of excess post- consolidation of the specialty of Mexican Geriatrics.
fracture mortality were explored in the first 3 months,
and remained high for the 1st year, gradually descend-
ing to even 10 years29,30. In the immediate mortal-
FUNDING
ity group (< 1 year), dependency was not observed This research has not received any specific grant
to contribute as a risk factor for mortality, because from agencies in the public, commercial, or non-profit
it was similar among independent and dependent sectors.
11
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hours admission and quality of hip fracture care: a nationwide cohort
study of performance measures and 30-day mortality. Int J Qual Health
All authors declare that they have no conflicts of Care. 2016;28:324-31.
14. Sobaranes FS, González PA, Moreno CY. Funcionalidad en adultos may-
interest. ores y su calidad de vida. Rev Esp Med Quir. 2009;14:161-75.
15. Negrete-Corona J, Alvarado-Soriano JC, Reyes-Santiago LA. Fractura de
cadera como factor de riesgo en la mortalidad en pacientes mayores de
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16. Koh GC, Tai BC, Ang LW, Heng D, Yuan JM, Koh WP. All-cause and cause-
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Protection of human and animal subjects. The Osteop Int. 2013;24:1981-9.
17. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mor-
authors declare that no experiments were performed tality of hip fractures in the United States. JAMA. 2009;302:1573-9.
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of functional recovery one year following hospital discharge for hip
Confidentiality of data. The authors declare that fracture: a prospective study. J Gerontol. 1990;45:M101-7.
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The aftermath of hip fracture: discharge placement, functional status
Right to privacy and informed consent. The change, and mortality. Am J Epidemiol. 2009;170:1290-9.
21. Ishiduo Y, Koriyama C, Kakoi H, Setoguchi T, Nagano S, Hirotsu M,
authors declare that no patient data appear in this et al. Predictive factors of mortality and deterioration in performance of
article. activities of daily living after hip fracture surgery in Kagoshima, Japan.
Geriatr Gerontol Int. 2017;17:391-401.
22. Diagnóstico del Envejecimiento Demográfico en el Estado de
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12
THE JOURNAL OF LATIN AMERICAN GERIATRIC MEDICINE ARTÍCULO ORIGINAL
Deficiencia de vitamina B12 y fragilidad en adultos

mayores del centro de México
Marisol Silva-Vera1*, Ma. de Jesús Jiménez-González1, Raúl F. Guerrero-Castañeda1,
Alejandra A. Silva-Moreno1 y Jorge A. Morales-Treviño2
División de Ciencias de la Salud e Ingenierías, Universidad de Guanajuato, Campus Celaya-Salvatierra; 2Servicio de Medicina Interna, Hospital
1
General Regional No. 58, Instituto Mexicano del Seguro Social. León, Guanajuato, México
Resumen
Introducción: La fragilidad se relaciona con caídas, fracturas, limitación de las actividades de la vida diaria y aumento de
la hospitalización en adultos mayores. El objetivo de este estudio fue investigar el nexo entre la fragilidad y la vitamina B12.
Metodología: Se realizó un estudio de corte transversal y de relación; se incluyó a 240 adultos mayores de 60 a 70 años, de
ambos géneros, que acudieron a la consulta. Se consideraron criterios de exclusión enfermedades neurológicas y pacientes que
no completaron las pruebas. Todos los pacientes se evaluaron con los criterios de Fried para fragilidad. La deficiencia de vitamina
B12 se definió como una cifra <400 pg/ml. Se utilizó la prueba t de Student, la prueba U de Mann-Whitney y la prueba no para-
métrica Kruskal-Wallis. Resultados: A los pacientes se les estratificó por grupos. El 86.6% de los participantes presentaba por lo
menos alguna enfermedad crónico-degenerativa. Los valores de vitamina B12 decrecieron respecto de la fragilidad. Se mostró
una relación significativa entre las cifras de vitamina B12, la debilidad y la baja actividad física. Conclusión: La disminución de
vitamina B12 es un posible factor de riesgo para experimentar fragilidad en el adulto mayor.
Palabras clave: Fragilidad. Vitamina B12. Adulto mayor. Micronutrientes.
Vitamin B12 deficiency and frailty in older adults from central Mexico
Abstract
Background: Frailty is associated with recurrent falls, fractures, limitation of activities of daily living, and increased hospitaliza-
tion in older adults. The aim of this study was to investigate the association between frailty and vitamin B12, which has been
shown to be related to numerous geriatric syndromes. Methodology: A cross-sectional and association study was carried out;
including 240 adults aged 60 to 70 years, of both genders, who wandered to the outpatient clinic and without cognitive altera-
tions. Neurological diseases and patients who did not complete the tests were considered exclusion criteria. All patients were
evaluated with the Fried criteria for frailty. Vitamin B12 deficiency was defined as a serum level less than 400 pg/ml. Student’s t test,
the Mann-Whitney U test and the non-parametric Kruskal-Wallis test were used. Results: The patients were stratified in a fragile,
prefragile and robust group. 86.6% of the patients had at least some chronic degenerative disease. Vitamin B12 levels decreased
as severity increased with respect to frailty. A significant association between vitamin B12 levels, weakness and low physical activ-
ity was shown. Conclusion: The decrease in vitamin B12 is a possible risk factor for frailty in the elderly.
Key words: Frailty. Vitamin B12. Elderly. Micronutrients.
Correspondencia:
*Marisol Silva-Vera
Universidad de Guanajuato
Barros Sierra No. 201
Ejido Santa María del Refugio
Celaya, Guanajuato, México
E-mail: msilva@ugto.mx
2462-4616/© 2021 Colegio Nacional de Medicina Geriátrica, A.C. Publicado por Permanyer. Este es un artículo open access bajo la licencia CC BY-NC-ND
13
INTRODUCCIÓN la absorción de la vitamina B12, ya que el ácido clorhí-

drico y la pepsina son esenciales para su liberación de
La fragilidad es un síndrome de causa múltiple y se
las proteínas alimentarias7.
caracteriza por una disminución de la fuerza, resis-
Además, cierta evidencia muestra que la deficien-
tencia y función fisiológica reducida que acentúa
cia de vitamina B12 se relaciona con varias enferme-
la vulnerabilidad de un individuo para desarrollar
dades crónicas, como el accidente cerebrovascular8,
dependencia o muerte1. En todo el mundo, la preva- deterioro cognitivo9, osteoporosis10, desacondiciona-
lencia de fragilidad entre la población geriátrica es miento físico11, neuropatías, alteraciones de la marcha
hasta de un 48%2. La fragilidad se vincula con caídas, y equilibrio, caídas recurrentes, depresión, hipoten-
fracturas, restricción de actividades de la vida diaria, sión ortostática, valores elevados de homocisteína, y
disminución de la movilidad, pérdida de la función aumento del riesgo cardiovascular12; otros investiga-
cognitiva, aumento de la frecuencia de hospitaliza- dores refieren que ciertas conductas como el alcoho-
ción e institucionalización en residencias, además de lismo crónico, o una mala absorción debido a la dieta
mortalidad3. Por lo tanto, la identificación de los facto- o una operación13, consumo de largo plazo de inhi-
res que causan fragilidad son aspectos muy importan- bidores de la bomba de protones y antagonistas de
tes de investigar. los receptores de histamina H214, así como consumo
El mal estado nutricional se reconoce como un fac- de metformina15, han incrementado la prevalencia de
tor de riesgo para muchas afecciones relacionadas deficiencia de vitamina B12 en poblaciones de edad
con la edad y, en fecha más reciente, ha surgido el avanzada.
papel de la deficiencia de la vitamina B12 en el desa- Otros investigadores demostraron que los pacien-
rrollo de varias enfermedades crónicas. tes con sarcopenia tienen cifras más bajas de vitamina
La vitamina B12 o cobalamina es una vitamina hidro- B12 circulante en comparación con los controles, lo
soluble que contiene cobalto que no puede sintetizar que sugiere que la deficiencia de vitamina B12 podría
el cuerpo humano y, por lo tanto, debe extraerse de afectar la función del músculo esquelético16.
los alimentos o sintetizarse a partir de la microbiota Sin embargo, la correlación entre la deficiencia de
intestinal4. micronutrientes y la fragilidad no es clara. La inci-
La vitamina B12 en la dieta se une por lo regular a las dencia de deficiencia de vitamina B12 aumenta con
proteínas en los alimentos y requiere para su libera- la edad17 y muy pocos estudios se han realizado para
ción los ácidos gástricos y la pepsina en el estómago. revisar si la deficiencia de vitamina B12, tiene algún
Una vez que la vitamina B12 se libera, se une a la hap- efecto directo sobre el desarrollo de la fragilidad18. El
tocorrina salival (HC) que protege a la vitamina del objetivo de este estudio fue investigar el nexo entre
ambiente ácido del estómago mientras se desplaza los valores de vitamina B12 y la fragilidad cuantificados
hacia el intestino delgado. En el intestino delgado, la con los criterios de Fried en los adultos mayores.
vitamina B12 se une al factor intrínseco (IF) producido
por las células parietales gástricas. En el íleon, el com-
plejo IF‐vitamina B12 se une al receptor cubam, lo que MATERIAL Y MÉTODOS
facilita la endocitosis en el lisosoma. En este último, Se condujo un estudio de corte transversal y de rela-
el IF se degrada y la vitamina B12 se libera al citosol ción en adultos mayores de 60 a 70 años, de ambos
y luego se moviliza al torrente sanguíneo. La mayor géneros, que acudieron a la consulta externa del IMSS
parte de la vitamina B12 (80%) está unida al HC, en 4 de enero del 2018 a diciembre del 2019, con su par-
tanto que el resto lo hace a la transcobalamina5. ticipación libre y voluntaria, previa firma de consen-
Los adultos mayores están en riesgo de mostrar una timiento informado. Los resultados se le entregaron
deficiencia de vitamina B12 debido a una prevalencia con recomendaciones o con referencia a un médico
elevada de atrofia gástrica, que a su vez perjudica la especialista, según correspondiera.
liberación de la vitamina B12 de las proteínas de los Se realizó un muestreo no probabilístico, con la par-
alimentos para su absorción, una inflamación crónica ticipación de 240 pacientes. Los criterios de inclusión
del estómago que afecta hasta un 30% de los adultos fueron: edad de 65 a 70 años, no poseer alteraciones
mayores de 60 años6. cognitivas y ser capaz de deambular. Se consideraron
La gastritis atrófica se caracteriza por una atrofia de criterios de exclusión enfermedades neurológicas que
la mucosa que conduce a una secreción reducida de imposibilitaran efectuar las evaluaciones y pacien-
ácido gástrico y, por lo tanto, a una disminución de tes que no completaran todas las pruebas. El poder
14
M. Silva-Vera, et al.: Deficiencia de vitamina B12 y fragilidad
estadístico calculado para las relaciones entre los ter- La actividad física se evaluó con el tiempo autoin-
ciles de vitamina B12 en suero fue del 82%. formado medido en horas, dedicado diariamente a
Los participantes se entrevistaron sobre las varia- actividades ligeras, moderadas y vigorosas. Las kilo-
bles sociodemográficas, neurocognitivas, psicoso- calorías gastadas por semana se calculan mediante
ciales y biológicas; se tomaron muestras de sangre un algoritmo estandarizado. Esta variable está estra-
periférica, previo ayuno de 8 h, para medir los valores tificada por género. Los hombres con 383 kilocalorías
de concentración sérica de vitamina B12 y ácido fólico, gastadas por actividad física por semana son frágiles,
además de glucosa, urea, creatinina y albúmina. mientras que las mujeres se consideraron frágiles si
Las muestras se procesaron antes de cuatro horas consumían 270 kilocalorías por semana.
desde el momento de la punción venosa, antes de lo Los pacientes con tres o más componentes se agru-
cual se mantuvieron en refrigeración a 4ºC. Las cifras paron en el grupo frágil; con la presencia de uno o
séricas de vitamina B12 se determinaron mediante dos componentes se agruparon como prefrágiles y
inmunoanálisis competitivo por quimioluminiscencia cuando el paciente no tenía ninguno de los compo-
directa (ADVIA Centaur®). A los adultos mayores se les nentes se agrupó como robusto.
clasificó de acuerdo con los criterios de Fried para la Además, los pacientes se dividieron en dos grupos:
fragilidad y se clasificaron en tres grupos: robustos valor de vitamina B12 por encima y por debajo de
(n = 80), prefrágiles (n = 80) y frágiles (n = 80). 200 pg/ml. Luego se compararon los grupos en térmi-
El estado de fragilidad física de Fried se evaluó de nos de los criterios de Fried.
acuerdo con los cinco componentes del síndrome Se excluyó a los pacientes con diagnóstico reciente
propuestos y se validaron en el Estudio de Salud de cáncer, insuficiencia cardíaca, insuficiencia renal,
Cardiovascular19. insuficiencia hepática e insuficiencia respiratoria
La pérdida de peso involuntaria o no intencional se aguda y pacientes que recibieron vitamina B12 o com-
definió como un índice de masa corporal <18.5 kg/m2 plementos de folato antes de tomar la muestra de
o pérdida de peso no intencional >4.5 kg en los últi- vitamina B12 en sangre.
mos seis meses. Asimismo, todos los pacientes se evaluaron para las
La lentitud se clasificó en concordancia con los funciones cognitivas y se excluyó a los individuos con
valores del quintil más bajo (estratificados por sexo un miniexamen del estado mental <23 (clasificado
y altura) en el promedio de dos mediciones de la como deterioro cognitivo).
prueba de velocidad de marcha rápida de 4.6 m. El estudio se inició después de recibir la aprobación
Tiempo de caminata, estratificado por género y del comité de ética del IMSS HGZ No. 4. Los participan-
altura. Hombres: límite de tiempo para caminar tes fueron informados de los procedimientos, benefi-
4.6 m como criterio de fragilidad: altura ≤ 173 cm ≥ cios y riesgos potenciales de los estudios a efectuar,
7 s; altura ≥ 173 cm ≥ 6 s. Mujeres: altura ≤ 159 cm ≥ en consonancia con la Declaración de Helsinki sobre
7 s; altura ≥ 159 cm ≥ 6 s. investigación en seres humanos. Se realizó solo con
La debilidad se midió por la extensión dominante los adultos mayores que decidieron participar tras
de la rodilla. Los participantes en el quintil más bajo obtener su consentimiento informado por escrito,
de un valor promedio ajustado por género e índice concedido libremente.
de masa corporal de tres estudios se definieron como
débiles. La fuerza de extensión de rodilla se estratificó
ANÁLISIS ESTADÍSTICO
por sexo y cuartiles de índice de masa corporal.
El agotamiento se determinó por medio de dos Para lograr un grado de confianza del 95% y un mar-
preguntas de la Center for Epidemiologic Studies gen de error del 5% se requirió un tamaño de muestra
Depression Scale. Se preguntó a los participantes si de 240 pacientes. Los datos se analizaron con SPSS
en la última semana sentían que todo lo que hacían para Windows, versión 25.0 (SPSS, Inc., Chicago, IL,
era un esfuerzo y no tenían ganas de hacer nada. EE.UU.). Para la estadística descriptiva, las variables
Los participantes podían responder: 0 = nunca o medibles se evaluaron con la prueba de bondad de
casi nunca (menos de un día); 1 = a veces (1-2 días); ajuste de Kolmogorov-Smirnov para determinar la
2 = con frecuencia (3-4 días); 3 = siempre o casi siem- normalidad de la distribución.
pre (5-7 días). Los participantes que contestaron con Las variables con distribución normal se expresaron
frecuencia o siempre en alguna de las dos preguntas como media y desviación estándar y las variables que
se clasificaron como frágiles para este criterio. no siguieron una distribución normal se presentaron
15
como mediana. Cuando se consideraron dos grupos,

Tabla 1. Características demográficas de los
se revisó la diferencia entre las medias con la prueba t
pacientes
de Student, en tanto que la importancia de la diferen-
cia entre medianas se analizó al aplicar la prueba U de Variable Robusto Prefrágil Frágil p
(n = 80) (n = 80) (n = 80)
Mann-Whitney.
Cuando se consideraron más de dos grupos, la Edad (años) 65.9 ± 65.7 ± 63.6 ± 0.190
4.8 5.3 4.6
diferencia entre las medias se evaluó con el análisis
Género 0.149
paramétrico de la prueba de varianza, en tanto que Masculino (%) 33 27 35
la importancia entre los valores medios se investigó Femenino (%) 47 53 45
a través de la prueba no paramétrica de Kruskal- Escolaridad (%) 13/44/23 17/41/22 27/35/18 0.440
Wallis. Una p <0.05 se consideró estadísticamente 0-5/6-11/≥11
años
significativa.
Estado civil
Para la comparación de más de dos grupos se utilizó
Acompañado (%) 39 52 72 0.197
ANOVA unidireccional, seguido de la prueba de com- Solo (%) 41 28 8
paración múltiple de Bonferroni. Los datos se expresan como media ± desviación
estándar. Mediana y frecuencia. *p <0.05.
RESULTADOS
Se estudió a un total de 240 adultos mayores. La
edad promedio de los participantes fue de 68.9 años
(60-70 años); el 60.4% de la muestra correspondió a Tabla 2. Comparación de los criterios de Fried
mujeres. El 23% de los pacientes tenía hasta cinco entre los pacientes
años de escolaridad primaria. El 4% no sabía leer o Componentes Robusto Prefrágil Frágil p
escribir. El 76% pertenecía a un estrato socioeconó- de fragilidad (n = 80) (n = 80) (n = 80)
mico medio o bajo. La fragilidad se observó con más IMC (kg/m2) 26.4 ± 24.0 ± 21.8 ± 0.180
frecuencia en los pacientes que vivían acompañados 2.60 3.05 1.70
o con su pareja (Tabla 1). Respecto del estado nutri- Lentitud/ 4.6 ± 6.04 ± 9.91 ± 0.001
cional, la media de IMC fue de 27.0 kg/m2 ± 4.0 DE, con velocidad de 0.26 1.23 1.29
marcha (m/s)
límites inferior y superior de 16.4 y 37.9 kg/m2, respec-
Debilidad/ 16.31 ± 13.84 ± 5.71 ± 0.001
tivamente. Un 27% de los pacientes estudiados tuvo fuerza de 5.01 4.53 3.94
obesidad de grado I (Tabla 2). extensión de
Para determinar la fragilidad, los pacientes se eva- rodilla (kg)
luaron mediante los criterios de Fried. La Tabla 2 Agotamiento 1.65 ± 1.93 ± 2.65 ± 0.001
muestra las diferencias significativas entre los grupos. (%) 0.80 0.47 0.12
Como se muestra en la Tabla 3, cuando se comparó Actividad 1,391.0 ± 655.4 ± 257 ± 0.001
física (kcal) 985.5 363.8 125
a los grupos prefrágil y frágil con un grupo control, se
Los datos se expresan como media ± desviación
observó que la hipertensión arterial sistémica, la insu- estándar. *p <0.05.
ficiencia venosa periférica, la osteoporosis, la diabetes
mellitus de tipo II, la enfermedad pulmonar obstruc-
tiva crónica y la sarcopenia se presentaban con mayor
frecuencia en estos grupos (p <0.05). El 86.6% de los
pacientes geriátricos tenía por lo menos alguna enfer-
DISCUSIÓN
medad crónico-degenerativa. En este estudio se buscó la correlación entre la cifra
Los valores de vitamina B12 se redujeron de acuerdo sérica de vitamina B12 y la fragilidad en pacientes
con el incremento de la gravedad respecto de la fra- geriátricos y se determinó que el valor de vitamina
gilidad (p <0.001); por su parte, los valores de ácido B12 podría vincularse con la fragilidad en este tipo de
fólico y vitamina D no mostraron diferencias significa- pacientes.
tivas entre los grupos (Tabla 4). La prevalencia de la deficiencia de vitamina B12
La Tabla 5 muestra la relación entre los valores de vita- entre los pacientes geriátricos que se evaluaron fue
mina B12 y la debilidad medida con la fuerza de exten- del 66.6%, en comparación con otros estudios que
sión de la rodilla y la baja actividad física (p <0.001). alcanzaron el 40%20.
16
Tabla 3. Porcentaje de comorbilidades Tabla 5. Relación entre los valores de vitamina B12
y fragilidad
Variable Robusto Prefrágil Frágil p
(n = 80) (n = 80) (n = 80) Componentes Vitamina Vitamina B12
Hipertensión 46.2 68.6 69.3 0.001 de fragilidad B12 ≥400 (pg/ml) ≤400 (pg/ml)
Insuficiencia 2.2 4.5 10.2 0.048 Pérdida de 8.1 (6.7-9.7) 9.5 (7.6-11.9)
venosa peso (kg/m2)
periférica Lentitud/ 20.7 (18.0-23.6) 21.2 (18.1-24.5)
Osteoporosis 14.3 16.1 33.0 0.002 velocidad de
marcha (m/s)
Diabetes 15.4 31.4 29.5 0.001
mellitus Debilidad/ 14.2 (11.8-16.9) 28.0 (23.9-32.6)*
fuerza de
Hiperlipidemia 23.1 26.3 21.6 0.684 extensión de
Enfermedad 2.2 9.6 11.4 0.049 rodilla (kg)
pulmonar Agotamiento 32.5 (26.6-38.3) 30.9 (25.5-36.9)
obstructiva (%)
crónica
Baja actividad 20.3 (17.7-23.3) 26.6 (23.4-30.0)*
Enfermedad 8.8 16.7 18.2 0.149 física
coronaria
Los datos se expresan como porcentajes (%). *p <0.05.
Insuficiencia 3.3 4.5 9.1 0.182 Prueba de ji cuadrada; ajustado por edad y género.
cardíaca
Enfermedad 4.4 5.8 10.2 0.249
cerebrovascular
Sarcopenia 0.0 30.8 40.9 0.001
Los datos se expresan como porcentajes (%). para el estado nutricional22 y pueden aumentar las
*p <0.05. necesidades de vitaminas23. La anorexia y la disfagia
con una ingestión dietética deficiente pueden com-
prometer aún más el estado de las vitaminas. El con-
sumo prolongado de medicamentos, como inhibido-
res de la bomba de protones, los bloqueadores H2, la
Tabla 4. Concentraciones séricas de parámetros metformina, entre otros, pueden interferir o reducir
del laboratorio la absorción y el metabolismo de la vitamina B1224.
Variable Robusto Prefrágil Frágil p
Estos resultados mostraron que al menos el 86.6%
(n = 80) (n = 80) (n = 80) de los pacientes presentaba alguna enfermedad
Glucosa (mg/dl) 102.76 107.24 105.37 0.936 crónico-degenerativa.
Albúmina (g/dl) 4.27 4.20 4.04 0.182 En este protocolo, el nivel de educación de los
Vitamina B12 458.28 202.07 102.4 0.001 pacientes frágiles y prefrágiles fue más bajo que el del
(pg/ml) grupo control. En el Reino Unido se evaluó la fragili-
Ácido fólico (ng/dl) 8.86 8.68 8.11 0.389 dad de los gemelos y se determinó que incluso entre
Vitamina D (ng/dl) 27.96 25.90 22.44 0.086 ellos un nivel educativo más bajo incrementaba la
Los datos se expresan como media ± desviación predisposición a la fragilidad25.
estándar. *p <0.05. La predisposición a la fragilidad puede relacionarse
con la influencia del nivel educativo en los malos
hábitos26, ingresos más bajos, menor cuidado perso-
nal y deficiencia cognitiva agravada. De acuerdo con
los hallazgos de las publicaciones médicas, se detectó
A diferencia de otras investigaciones21, estos resul-
un mayor número de comorbilidades entre los indivi-
tados no revelaron que la prevalencia de la deficien-
duos frágiles y prefrágiles. La incidencia de hiperten-
cia de vitamina B12 aumentara con la edad entre los sión, diabetes mellitus, enfermedad pulmonar obs-
pacientes. Es probable que esto se deba al hecho de tructiva crónica, osteoporosis y sarcopenia fue mayor
que los pacientes se encontraban en el intervalo de en los individuos frágiles y prefrágiles27.
edad de 65 a 70 años. Es muy importante reconocer los factores de
Sin embargo, las múltiples comorbilidades y riesgo que desencadenan el desarrollo de la fragili-
el estado de enfermedad crónica son perjudiciales dad, ya que podrían dar lugar a un mayor número de
17
complicaciones. Se ha pensado que la relación entre RESPONSABILIDADES ÉTICAS

la deficiencia de vitamina B12 que se observa con fre-
Protección de personas y animales. Los autores
cuencia en la población anciana, y que se vincula con
declaran que para esta investigación no se han reali-
síndromes geriátricos, como deficiencia cognitiva,
zado experimentos en seres humanos ni en animales.
trastornos del equilibrio y la marcha, caídas frecuen-
Confidencialidad de los datos. Los autores decla-
tes, depresión e hipotensión ortostática, se correla-
ran que han seguido los protocolos de su centro de
ciona con la fragilidad28.
trabajo sobre la publicación de datos de pacientes.
Sin embargo, la comparación de la deficiencia de
Derecho a la privacidad y consentimiento infor-
vitamina B12 con los subparámetros de los criterios de
mado. Los autores han obtenido el consentimiento
Fried mostró diferencias entre los grupos. En la biblio- informado de los pacientes o sujetos referidos en el
grafía se han hallado muy pocos estudios que investi- artículo. Este documento obra en poder del autor de
guen la relación entre la cifra de vitamina B12 y la fragi- correspondencia.
lidad. En un estudio conducido en 2010 se demostró
la correlación entre diferentes variaciones genéticas
que afectan el mecanismo de transporte de la vita- BIBLIOGRAFÍA
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19
Mexican hip fracture audit (ReMexFC): 2019 annual report

Juan C. Viveros-García1*, Aldyn Anguiano-Medina2, Enrique Arechiga-Muñoz3, José O. Duarte-Flores4,
Eliud Robles-Almaguer5, Marco A. Ramos-Rojas6, Leonor E. Zapata-Altamirano7, José F. Torres-Naranjo8,
Roberto E. López-Cervantes9, and Lizbeht S. Baldenebro-Lugo10
1
Internal Medicine and Orthogeriatrics, Hospital Regional ISSSTE, León, Guanajuato; 2Department of Geriatrics, Hospital de Alta Especialidad
ISSSTE, Morelia, Michoacán; 3Department of Geriatrics, Hospital General de Zacatecas, Zacatecas; 4Geriatrics Department, Hospital General
de Zona No 83, Instituto Mexicano del Seguro Social, Morelia, Michoacán; 5Department of Geriatrics, Hospital Regional PEMEX, Reynosa,
Tamaulipas; 6Department of Geriatrics, Hospital General de Zona No 1, Instituto Mexicano del Seguro Social, Colima; 7Department of
Geriatrics, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City; 8Management, Centro de Investigación Ósea y de la Composición
Corporal, Guadalajara; 9Orthopedic Surgery, Hospital San Francisco de Asís, Guadalajara; 10Clinical Research Department, Hospital Regional
ISSSTE León, Guanajuato. Mexico
Abstract
Background: Hip fracture (HF) is associated with negative outcomes, functional decline, and high costs. HF audits helped improv-
ing compliance in key performance indicators (KPI) and achieving better health-care outcomes. Objective: The aim of the audit
is to know socio-demographic characteristics of HF in Mexico, the compliance to KPI and outcomes. Methodology: Prospective
multicentric, observational, and descriptive study in seven public hospitals in Mexico. We included patients 60 years and older with
fragility HF. We measured socio-demographic characteristics, pre fracture gait and functional status, in-hospital KPI and outcomes
after 30 days. The authors used descriptive statistics for de analysis. Results: We included 220 patients, mean age was 81 years, 75%
were women. The most frequent fracture was transtrochanteric. Mean surgical delay was of 144 h. After 30 post-discharge, 18% had
an independent gait, mean mortality was 11.4%. Conclusions: Our compliance to KPI is low, and our health-care outcomes could be
improved. A national audit will help to know our current status in HF care and built policies to improve quality of care and outcomes.
Key words: Hip fracture. Audit. Fragility fractures. Orthogeriatrics.
Registro Mexicano de Fractura de Cadera (ReMexFC): informe anual 2019
Resumen
Introducción: La fractura de cadera causa múltiples efectos negativos en la salud, tiene altos costos y provoca dependencia con
frecuencia. Los registros de fractura de cadera han promovido el apego a indicadores de calidad y mejorado los resultados asis-
tenciales. Objetivo: Conocer las características sociodemográficas de la fractura de cadera en México, apego a indicadores de
calidad y resultados asistenciales. Metodología: Estudio prospectivo, multicéntrico, observacional y descriptivo en siete hospi-
tales públicos de México. Se incluyó a mayores de 60 años con fractura de cadera por fragilidad. Se midieron las variables prefrac-
tura, al ingreso, apego a indicadores de calidad en fase aguda, al alta y resultados asistenciales a los 30 días. Se usó estadística
descriptiva. Resultados: Se incluyó a 220 pacientes y la edad media fue de 81 años. El 75% correspondió a mujeres. La fractura
mas frecuente fue la transtrocantérica con 54%. La demora quirúrgica fue de 144 horas. A los 30 días, el 18% caminaba independi-
entemente y la mortalidad fue de 11.4%. Conclusiones: Se observa una baja adherencia a los indicadores de calidad. Un registro
nacional ayudará a conocer el estado actual de la asistencia de fractura de cadera y generar políticas para la atención y mejorar
los resultados. Existen muchos puntos de oportunidad para mejorar la atención.
Palabras clave: Fractura de cadera. Registro. Fractura por fragilidad. Ortogeriatría.
Correspondence to:
*Juan C. Viveros-García
Pradera, 1101
Col. Aztecas
León, Guanajuato, Mexico
E-mail: drviveros.geriatria@gmail.com
20
J.C. Viveros García, et al.: Mexican hip fracture audit 2019
INTRODUCTION of the Mexican Institute of Social Security (IMSS)

were the General Hospital of Zone 1, IMSS, Colima
In the past decades, we faced an increase in the
and the General Hospital of Zone 83 IMSS, Morelia.
number of elders; consequently, the number of
From the Institute of Social Security and Services
chronic non-communicable diseases such as osteo-
for State Workers (ISSSTE), the Regional Hospital of
porosis is increasing1. Fragility fractures are the most León and the High Specialty Hospital of Morelia were
important complication of osteoporosis2 and hip frac- included in the study. The National Health Minister,
ture (HF) is the most serious because its high mortal- the participating hospitals were the General Hospital
ity, costs, and functional decline3-5. of Zacatecas, and the General Hospital of Mexico
HF has a in hospital mortality between 2% to “Dr. Eduardo Liceaga,” finally, from the Petróleos
8% and 25% to 35% after the 1st year6-8. In the Latin Mexicanos (PEMEX) healthcare system, the Reynosa
American region, a study in Chile reported in-hos- Regional Hospital. All of them received authorization
pital mortality of 3%9 and of 27% in the 1st year in from their respective ethics and research committees.
Colombia10. In Mexico, the pilot phase of the Mexican The study included patients 60 years or older with
HF audit (ReMexFC) reported an in-hospital mortality diagnosis of fragility HF, defined as those who suf-
of 7.4% and 14% after 30 days11. Other negative con- fered a low-energy trauma or a fall from their own
sequences of HF a decline in quality of life12 as well as standing position. All information was captured by
very high costs13. the senior investigator of each hospital and sent to
The HF audits began in the United Kingdom with the a digital platform, without including any personal
National HF Database (NHFD), this registry managed information. Only the data manager had access to the
to capture more than 60,000 HFs4. These registries cloud in which the data were stored during the study.
improve mortality, surgical delay, early mobilization Each hospital received an identification letter from
and increased the involvement of geriatricians14-19. “A” to “G” to guarantee the anonymity of the center
The ReMexFC started in 2018, its objectives and meth- when the results were published, and only the main
odology were recently earlier20 followed by the pilot researcher from each hospital and the data manager
phase11. were aware of the identity of each letter. After the
individual descriptive analysis of hospitals, feedback
Objectives was sent regarding their performance.
We measured the variables suggested by the
The main objective of ReMexFC is to know the Fragility Fracture Network21 (FFN) in their minimum
socio-demographic characteristics of HF in Mexican in common dataset (MCD)22. These included demo-
older adults with HF, as well as compliance to key per- graphical and pre-fracture characteristics, in-hospital
formance indicators (KPI) and health-care outcomes. KPI, outcomes at discharge and after a 30-day follow-
The secondary objectives of ReMexFC are to up period (Table 1). The gait was assessed by the
acknowledge individual compliance from the partici- Functional Ambulatory Category23, mental state at
pating hospitals to be able to generate health policies admission with the Pfeiffer scale24, surgical risk through
and quality improvement projects in HF care, with the American Society of Anesthesiology (ASA) scale25.
follow-up throughout the next years. To measure functional status we used Barthell scale26
and finally the Confussion Assessment Method (CAM)
was used for the diagnosis of delirium27.
METHODS
ReMexFC is a national project with the participation
of multiple hospitals in different states of Mexico. It
began with its pilot phase in 2018. This paper corre- Descriptive statistics were used for the analysis of
sponds to the results of 2019. Each hospital has an the variables. In the case of qualitative, frequencies
investigator responsible for capturing data and send- and percentages are reported. In the case of quantita-
ing information all HFs patients admitted to their tive variables, means ± standard deviations or medi-
hospital. ans with interquartile range are reported, depending
We conducted a multicenter, prospective, longitudi- on the variable in the normality tests (Kolmogorov–
nal, and observational study in seven public hospitals Smirnov or Shapiro). The SPSS statistical package from
of different health systems in Mexico. The hospitals IBM (Inc., Chicago, IL, version 24) was used.
21
Table 1. Minimum common database or MCD
In-hospital phase
Patient´s General Information Pre-Fracture Characteristics
Gender Place of residence
Age MobilityΨ
Gait aids
City and State Mental statusα
Hospital Surgical riskβ
Private or public hospital Side of the fracture
Type of fracture
Osteoporosis treatment∑
In-Hospital Functional satutsχ
Date and time of arrival to emergency room Discharge
Date and time of admission to traumatology
ward Destination after discharge
Sore ulcers before admission Date of discharge
Deliriumπ Hospital length of stay
Date and time of surgery Osteoporosis treatment
Orthopedic implant used in surgery In-hospital mortality
Surgical delay in hours 30-day follow-up
Use of femoral blocking Readmission
Anesthesia modality used
Specialist Surgical reintervention
Weight bearing the day after surgery Mortality
Gait and need for aids
Osteoporosis treatment∑
Functional status
Ψ Functional Ambulatory Category (FAC): FAC 0= Unable to walk FAC 1= Requires great help from one person.
FAC 2 = Requires little help from one person. FAC 3 = walks independently in interiors but needs supervision.
FAC 4 = Walks independently in interiors without supervision. FAC 5= Walks in interiors and exteriors independently.
α Pfeiffer’s scale.
β American Society of Anesthesiology (ASA).
∑ calcium, vitamin D and antiresorptive or anabolic drugs.
χ Barthel index.
π Confusion assessment method.
half of them were evaluated during their stay by a

RESULTS
geriatrician. In the post-operative period, 26.8% sat
Between January and December 2019, a total of out of bed and 15.3% started partial weight bearing
220 patients with hip fragility fracture were admit- as tolerated during hospitalization. Length of stay was
ted in all of the hospitals. The socio-demographic 8 days (interquartile range 6-12), and after discharge
and baseline prefracture characteristics are presented only 4.1% entered long-term care.
in table 2. The mean age was 81 years, most of the The most frequently used device was the dynamic
patients lived at home and had an independent gait. hip screw system (DHS) with 44% of cases, followed
More than half of the patients had a high surgical by partial prostheses with 35.1%. The intracapsular
risk and 58% and at admission were had disorienta- patients received prostheses or hemiprostheses in
tion or with cognitive dysfunction. The most frequent 64.9% of the cases. In the case of transtrochanteric,
fracture was transtrochanteric and only 10% received 50.4% of the cases received a DHS system and 2.4%
treatment for osteoporosis before the fracture. a centromedullary nail (CCM). Finally, the subtrochan-
Regarding the KPI and health-care outcomes are teric 61.5% were treated with the DHS system and
shown in table 3. The median surgical delay was 144 h 7.6% with CCM.
(interquartile range 96-214) and only 4.5% of patients The health-care outcomes are shown in table 4. The
had surgery in the first 48 h after admission. Almost most frequent causes of the surgical delay were the
22
Table 2. Pre-fracture characteristics, type of fracture, surgical risk, and mental status at admission
General A B C D E F G
(n = 220) (n = 43) (n = 51) (n = 23) (n = 18) (n = 16) (n = 45) (n = 24)
Age 81(74.2- 78.3(72- 79.2 ± 8.0 82.5 ± 8.4 83 ± 8.5 81 ± 10.2 81.8 ± 6.2 82.2 ± 9.1
87) 86)
Female gender 165 (75) 34 (79.1) 29 (56.9) 15 (62.2) 14 (77.8) 11 (68.8) 41 (91.1) 21 (87.5)
Functional status∆ 85 81.4 90 (77.5-98)88 (78-98)75 (38.7-90)80 (41.2-95)90 (67.5-100)71.8 ± 20.7
(65-97) (70-100)
Residence
Own home 214 43 (100) 51 (100) 21 (93.3) 17 (94.4) 15 (93.8) 44 (97.8) 23 (95.8)
(93.3)
Long-term care 6 (2.7) - - 2 (8.7) 1 (5.6) 1 (6.3) 1 (2.2) 1 (4.2)
Independent gaitΦ 184 43 (100) 47 (92.3) 13 (47.7) 12 (66.7) 12 (75.1) 43 (96.6) 14 (58.4)
(83.6)
Mental status∇ 128 14 (32.6) 27 (52.9) 8 (34.8) 14 (77.8) 7 (43.3) 34 (75.6) 24 (100)
(58.2)
High surgical riskϑ 141 33 (76.8) 28 (54.9) 17 (73.9) 6 (33.3) 11 (68.8) 28 (62.2) 18 (75)
(64.1)
Type of fracture
Intracapsular non 45 (20.5) 8 (18.6) 3 (5.9) 6 (26.1) 5 (27.8) 5 (31.3) 2 (4.4) 16 (66.7)
displaced
Intracapsular 15 (6.8) 3 (7.0) 2 (3.9) 1 (4.3) 1 (5.6) 1 (6.3) 5 (11.1) 2 (8.3)
displaced
Transtrochanteric 124 26 (60.5) 34 (66.7) 14 (60.9) 9 (50) 3 (18.8) 36 (80) 2 (8.3)
(56.4)
Subtrochanteric 28 (12.7) 6 (14) 10 (19.6) 2 (8.7) 2 (11.1) 2 (12.5) 2 (4.4) 4 (16.7)
Results reported as mean ± standard deviation or median (interquartile range). Categorical variables are reported in N (%).
ϑ
American Society of Anesthesiology (ASA) III-IV.
Φ
Functional ambulatory Category (FAC) 3-5.
∆
Barthel index.
∇ Pfeiffer test > 3 mistakes.
lack of available theater and the lack of surgical mate- A and E only 6.7% and 5.3% did so. Regarding func-
rial. Only 11% of the cases with a delay of more than tionality, the median Barthel index was 35 points
48 h were due to the patient’s own conditions such as (interquartile range 15-55). About 25.5% continue to
anticoagulation or clinical instability. The main com- receive treatment for osteoporosis. The hospital that
plications were delirium in 31.3% and sore ulcers in had the best compliance to osteoprotective treatment
25.5%. In-hospital mortality was 3.7%. was “A” with 80%, while “C” only 6.3%. The readmission
Mean surgical delay from each hospital is shown rate was 7.6% of and 4.8% required reintervention.
in figure 1, three hospitals showed a surgical delay
below mean (Hospital A, E, and G), but none of them
DISCUSSION
achieved 48 h or less. Hospital E had the lower length
of stay followed by hospitals A and G. In-hospital The mean age in ReMexFC 2018 report was 7811, and
complications were very heterogeneous. Delirium in this 2019 report was of 81 years; however, it must
occurred in 23.2% in hospital B, against 7.3% in hos- be considered that three hospitals were added with
pital E. Sore ulcers range from 1.3% in hospital E to mean age > 80 years. In European registries, Ireland
31.6% in hospitals A and B. has an average age of 81 years17, 86 years in Spain,
After 30 days (Table 5), 75 patients were lost to 85 years in Italy, and 81 in England16. In Latin America,
follow-up, and 19 (11.6%) died, leaving 145 cases for there are no published national registries. Some stud-
analysis. Of these, 40.7% of the patients were not yet ies in the region have found average ages of 81 years
walking. The hospital with the highest number of in Colombia, Cuba, and Chile10,28,29 and in the case of
patients who walked independently was B, while in Ecuador of 80 years30.
23
Table 3. In-hospital health-care outcomes and key performance indicators
(n = 220) (n = 43) (n = 51) (n = 23) (n = 18) (n = 16) (n = 45) (n = 24)
Surgical delay 144 128 168 301.7 ± 157.1206 ± 123105 (90-113)163 (135-237) 98
(h) (96-214) (88-164) (114-251) (88-163)
Surgery in the 10 (4.5) 5 (11.6) 1 (2) - - 2 (12.5) 1 (2.2) 1 (4.2)
first 48 h
Type of surgery
Total 16 (7.2) 2 (4.7) 4 (7.8) - 1 (5.5) 1 (6.2) 6 (13.3) 2 (8.4)
prostheses
hemiprostheses79 (35.9) 18 (41.8) 17 (33.3) 5 (21.7) 8 (44.4) 8 (50.0 18 (40.2) 5 (20.8)
DHSϑ 97 (44.1) 19 (44.1) 23 (45.1) 14 (60.9) 6 (33.3) 7 (43.8) 11 (24.4) 17 (70.8)
Centromedular 5 (2.2) 2 (4.6) - - - - 3 (6.6) -
nail
Anesthesia
technique
Regional 168 40 (93) 47 (92.2) 12 (57.1) 15 (93.8) 16 (100) 14 (36.8) 24 (100)
(76.4)
General 8 (3.9) 1 (2.3) 1 (2) - 1 (6.2) - 5 (13.2) -
Femoral 3 (1.36) - 1 (2) - - - 2 (4.4) -
blockage
Evaluated by 99 (45.4) 38 (88.4) 7 (13.7) 9 (39.1) - 9 (56.3) 14 (31.1) 22 (91.7)
geriatrician
Sat the day after 59 (26.8) 23 (53.5) 15 (29.4) 2 (8.7) - 1 (6.3) 6 (14.6) 12 (50)
surgery
Weight bearing 32 (15.3) - 8 (15.7) 3 (13.0) - 5 (31.3) 4 (9.8) 12 (50)
as tolerated the
day after surgery
Osteoporosis 57 (26.9) 23 (53.5) 1 (2.2) 2 (8.7) - 6 (37.5) 10 (22.2) 15 (62.5)
treatment at
discharge
Length of stay 8 (6-12) 7(6-9) 9.9 14.5 ± 6.6 9.1 ± 4.9 5.7 ± 1.7 9 (7-12) 7.3 ± 1.8
(7.3-13.8)
Destination after
discharge
Home 196 35 (81.4) 45 (88.2) 20 (87.0) 17 (100) 15 (93.8) 41 (91.1) 23 (95.8
(89.1)
Long-term care 9 (4.1) - 1 (1.9) 3 (13) - 1 (6.3) 3 (6.7) 1 (4.2)
Continuous variables are reported as mean ± standard deviation or median (interquartile range). Categorical variables are
reported in N (%).
ϑ DHS=Dynamic hip screw.
The median surgical delay is 144 h, and only 4.5% The HIP ATTACK study34 suggests that the surgical
of patients underwent surgery in the first 48 h of stay. delay is justified in cases where the patient’s clinical
This is one of the most relevant issues in HF care, status is unstable.
because of its implications in the health-care out- Our surgical delay contrasts with other countries,
comes, mortality, and costs. Furthermore, it is a modi- for example, in Scotland 72% of patients undergo
fiable factor in the patient pathway. International surgery in the first 36 h34, 70% in Ireland17, and 40%
standards suggest that surgery should be performed in Spain16. A review of HF work in Mexico from 2000
in the first 36 to 48 h31-33. The main cause of delay was to 2018 did not found any paper focused in surgical
administrative situations unrelated to the clinical con- delay, which suggests that it is a point of opportunity
dition of the patient. in our country35. Our audit found that 25% of patients
24
Table 4. Main causes of surgical delay, in-hospital mortality and morbidity
(n = 220) (n = 43) (n = 51) (n = 23) (n = 18) (n = 16) (n = 45) (n = 24)
Cause for surgical delayθ
No theater available 121 (57.9) 29 (67.4) 26 (51.0) 4 (17.4) 2 (11.5) 13 (81.3) 28 (71.8) 19 (79.2)
No surgical material 47 (22.5) 5 (11.6) 18 (35.8) 9 (39.1) 13 (76.5) - 2 (5.1) -
available
anticoagulation 7 (3.3) - - 4 (17.4) - - - 3 (12.5)
Unstable clinical status 16 (7.7) 4 (9.3) 3 (5.9) 3 (13) 1 (5.6) - 4 (8.9) 1 (4.2)
Complications
Delirium 67 (31.3) 16 (37.2) 16 (31.4) 7 (30.4) 4 (25) 5 (31.3) 14 (31.3 5 (20.8)
Sore ulcers 56 (25.5) 18 (41.9) 18 (35.3) 2 (8.7) 1 (11.2) 1 (6.3) 14 (31.1) 2 (8.3)
Mortality 8 (3.7) 1 (2.3) 5 (9.8) - 1 (5.6) - 1 (2.2) -
Pre-surgery 5 (2.3) - 3 (5.9) - 1 (5.6) - 1 (2.2) -
Post-surgery 3 (1.4) 1 (2.3) 2 (3.9) - - - - -
θ
191 patients included in this analysis (5 died before surgery, 10 non-surgical patients, and 14 with no delay).
Categorical variables are reported in n (%).
Figure 1. Comparative surgical delay A: length of stay B: and main complications. The dotted line corresponds to
the 48-h standard for surgical delay. The dashed lines correspond to the overall median.
25
Table 5. Healthcare outcomes after 30 days of follow-up
(n = 145) (n = 15) (n = 43) (n = 16) (n = 11) (n = 19) (n = 31) (n = 10)
Barthel index 35(15-55) 26.7 ±16 42 ± 27.6 35 (30- 48) 37.7 ± 20 26.8 ± 25.1 40.3 ± 30.2 33.5 ± 18.6
Gait
Not able to walk 59 (40.7) 13 (86.7) 20 (46.5) 12 (75) 8 (72.7) 12 (63.2) 12 (38.7) 9 (90)
Independent gaitλ 18 (12.4) 1 (6.7) 8 (18.6) - - - 9 (29) -
Osteoporosis 37 (25.5) 12 (80) 7 (16.3) 1 (6.3) - 8 (42.1) 5 (16.1) 4 (40)
treatment
Residence
Home 136 (93.8) 15 (100) 43 (100) 13.8 (81.3) 11 (100) 16 (84.2) 28 (90.3) 10 (100)
Long-term care 9 (6.2) - - 3 (18.8) - 3 (15.8) 3 (9.7) -
Readmission 11 (7.6) - 1 (2.3) 1 (6.3) - 4 (21.1) 4 (12.9) 1 (10)
Mortality 19 (11.6) 1 (0.6) 7(4.3) 2 (1.2) 1 (0.6) 3 (1.8) 4 (2.4) 1 (0.6)
Continuous variables are reported as mean ± standard deviation or median (interquartile range). Categoric variables are
reported in N (%).
λ FAC 3-5.
developed sore ulcers. This contrasts with the 2% of Regarding mortality, in the acute phase it is rela-
the German audit, or 4% in Spain16. tively low, 3.7%, with a range of 2.2% to 9.8%. Spain,
Another important topic is the device used. The Scotland, Germany, and the United Kingdom oscil-
British guidelines for clinical excellence or NICE31 for late between 4 and 5% mortality in the in-hospital
its acronym in English suggest sticking to certain phase16, however at 30 days it increased to 11.6%.
types of devices based on the type of fracture. This contrasts with Spain reporting 7%36 and Australia
In the ReMexFC, the most frequently used device 5%37. This disparity may be due to multiple causes;
was the DHS with 44%, followed by partial prosthesis however, we consider that the main reason is compli-
with 35.1%. Of the intracapsular patients, 54.3% had ance to KPI such as surgical delay, early mobilization,
a hemiprosthesis and 10.5% a total prosthesis. About and weight bearing.
50.4% of the transtrochanteric fractures received Finally, osteoporosis treatment at discharge has
DHS system. Europe has given much more weight to been one of the most important points in the second-
devices such as centromedullary nails in subtrochan- ary prevention model, considering the imminent risk
teric fractures; England reported in the NHFD 91.6% of fracture in the 1st weeks after a fragility fracture. In
used a centromedullary nail for this type of fracture4. the ReMexFC, 26.9% of the patients received treat-
In the ReMexFC, this device was only used in 2.4% of ment for osteoporosis at discharge, and it remains
all fractures, corresponding to 17.8% of subtrochan- almost without change at 30 days. In England in the
teric ones. This may be explained by the budgets of NHFD they have a 50% adherence to discharge4, but it
public hospitals that does not include in most of our drops to 34% at 30 days. There are hospitals in Mexico
health-care systems centromedullar nails because of that did not provide treatment, which is a point of
the high costs compared with DHS. enormous opportunity of improvement.
Early movilizacion and rehabilitation are also asso- The main weaknesses of the registry is that we do not
ciated with HF outcomes. We reported that 15% of have yet representation at the national level, in addi-
patients started weight bearing as tolerated the day tion to the fact that the participating hospitals have a
after surgery, and 30 days after discharge 40% were no relatively low number of cases, we have < 1% of the
able to walk yet. This contrasts with the FONDA cohort estimated HFs annually in Mexico38. In Mexico there are
at the Hospital Universitario de la Paz, Madrid, where very few orthogeriatric units in the country, so that the
almost half of their patients started weight bearing clinical contribution of geriatrics to HF care is not avail-
ambulation during the acute phase of the HF, and who able nationwide. Efforts should be made to increase
at 3 months 3 out of 4 have independent gait8. the centers in the country with orthogeriatric wards.
26
The main strengths of the study are that as far as REFERENCES

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28
Validation of the frontal assessment battery in Mexican

older adults with cognitive impairment
Alberto J. Mimenza-Alvarado1,2, J. Octavio Duarte-Flores1, Lidia A. Gutiérrez-Gutiérrez3,
Ma. José Suing-Ortega1, and Sara G. Aguilar-Navarro1,2*
1
Geriatric Medicine and Neurological Geriatrics Fellowship; 2Department of Geriatric Medicine; 3Department of Neurology and Psiquiatric.
Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
Abstract
Background: Cognitive impairment (CI) can produce frontal dysfunction. Frontal Assessment Battery (FAB) is a brief cog-
nitive and behavioral battery. Objectives: The objective of the study was to validate the FAB in Mexican older adults with CI.
Methods: This was a observational, cross-sectional, and comparative study. It included 90 participants: Dementia (n = 30), Mild
CI (MCI) (n = 30), and Cognitively Healthy (n = 30). The neuropsychological battery included Neuropsi, MoCA-E, and FAB. The cate-
gorical variables were reported in proportions and percentages, and the continuous in mean and standard deviation. ANOVA was
used for continuous variables and Chi-square for categorical variables. Pearson’s Correlation Coefficient (CC) was calculated. Yield
was established by Receiver Operating Characteristic and Area Under the Curve (AUC) calculation. Results: The mean age was
76.2 ± 7.2 years, 63.3% women (n = 57). Cronbach’s alpha coefficient was 0.71. FAB obtained positive and strong CC for Neuropsi
(r = 0.617, p < 0.05) and total MoCA-E (r = 0.795, p < 0.05). The dementia AUC was 0.80 (95% CI, 0.70-0.89; p < 0.001) with a cutoff
point of ≤ 14 (sensitivity 73% and specificity 70%). The AUC of MCI was 0.74 (95% CI, 0.61-0.86; p = 0.001) with a cutoff point of ≤
16 (sensitivity 83.3% and specificity 63.3%). Conclusions: FAB is a valid tool in Mexican older adults with CI.
Key words: Frontal assessment. Cognitive impairment. Frontal assessment battery. Frontal dysfunction.
Validación de la batería de evaluación frontal en adultos mayores mexicanos con

deterioro cognitivo
Resumen
Antecedentes: El deterioro cognitivo (DC) puede producir disfunción frontal. La batería de evaluación frontal (FAB, Frontal
Assessment Battery) es una batería cognitiva breve y conductual. Objetivos: Validar la FAB en adultos mayores mexicanos con DC.
Métodos: Estudio observacional, transversal y comparativo. Incluyó a 90 participantes: demencia (n = 30), deterioro cognitivo leve
(DCL) (n = 30) y cognitivamente saludable (n = 30). La batería neuropsicológica incluyó Neuropsi, MoCA-E y FAB. Las variables cat-
egóricas se informaron en proporciones y porcentajes, y las continuas en media y desviación estándar. ANOVA para las variables con-
tinuas y χ2 para las categóricas. Se calculó el coeficiente de correlación de Pearson (CCP). Resultados: La edad media fue de 76.2 ±
7.2 años, con 63.3% de mujeres (n = 57). El coeficiente alfa de Cronbach fue de 0.71. La FAB obtuvo CCP positiva y fuerte para Neuropsi
(r = 0.617, p < 0.05) y MoCA-E total (r = 0.795, p < 0.05). La AUC de demencia fue 0.80 (IC95%, 0.70-0.89; p < 0.001) con punto de corte
de ≤14 (sensibilidad, 73%; especificidad, 70%). La AUC de DCL fue de 0.74 (IC 95%, 0.61-0.86; p = 0.001) con punto de corte de ≤16
(sensibilidad, 83.3%; especificidad, 63.3%). Conclusiones: La FAB es una herramienta válida en adultos mayores mexicanos con DC.
Palabras clave: Evaluación frontal. Deterioro cognitivo. Batería de evaluación frontal. Disfunción frontal.
Correspondence to:
*Sara G. Aguilar-Navarro
Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”
Vasco de Quiroga, 15
Col. Belisario Domínguez Section XVI, Del. Tlalpan
C.P. 14080, Mexico City, Mexico
E-mail: sgan30@hotmail.com
29
INTRODUCTION Participants
As a consequence of population aging, cognitive Men and women older than 65 years were included
impairment (CI) represents a public health problem. in the study. The selection of the participants was
In 2015, it affected more than 47 million people in non-probabilistic and for convenience. Three groups
the world, and it is estimated that by 2030 it will were established: dementia group, MCI group, and
affect 75 million, a figure that will triple by 2050. In Cognitively Healthy (CH) group. The diagnosis of
Mexico, 3.5 million people with CI could be reached, dementia was determined by the criteria of DSM-
which will undoubtedly have an impact on the 519 and/or NINCDS-ADRDA20. The criteria of Petersen
health system1. The World Health Organization and et al.14 is used for the diagnosis of MCI. The CH group
the Alzheimer’s Association International recom- was established through a standardized clinical and
mend increasing basic and clinical research that neuropsychological evaluation that ruled out a cogni-
allows early detection of CI2. Dementia is character- tive alteration according to education and gender21.
ized by a progressive loss of cognition that impacts Those with uncontrolled or untreated depressive
the individual’s performance3, while Mild CI (MCI) symptoms were excluded from the study, defined
represents a prodromal stage that can potentially with a score > 5 by the 15-item version of Geriatric
progress to dementia4. Depression Scale22, delirium, visual or hearing impair-
CI can affect various brain regions, including the ment, illiterate, history of neurological or psychiatric
frontal lobes; their function is to maintain cognitive, disease, severe rheumatoid arthritis, motor sequelae
behavioral, and motor functions. The prefrontal area of cerebrovascular disease, uncontrolled hyperten-
involves connections with other cortical and subcor- sion, untreated thyroid disease, glycosylated hemo-
tical areas5, so the damage to these networks affects globin ≥ 9%, history of severe hypoglycemia, pres-
behavior and executive function6. CI can produce ence of heart failure severe, or recent traumatic brain
executive dysfunction to varying degrees, establish- injury.
ing cognitive patterns for its approach7,8. There are
various tests to assess frontal function, however, they Measurements
are extensive tests and require prior training, limiting
their application9,10. All participants were evaluated by a specialist in
Dubois et al. designed a specific test, called Frontal geriatrics and/or neurology, considering the clinical
Assessment Battery (FAB), with the aim of evaluating criteria of the expert as the gold standard, later all
the cognitive and behavioral function of the fron- participants were subjected to a neuropsychological
tal lobe11. This test has been used in various clinical evaluation. In addition, a clinical history and compre-
situations, such as Frontotemporal Dementia (FTD)12, hensive geriatric evaluation were carried out, from
Alzheimer’s Disease (AD)13, and Vascular Dementia, which socio-demographic data and functional status
among others14. Socio-cultural factors can modify the were obtained through scales that measure: Basic
Activities of Daily Living23 and Instrumented Activities
performance of this test, so validations are necessary
of Daily Living (IADL)24. The neuropsychological evalu-
in each country15-18. Brief tests, such as the FAB, could
ation included two tests: the Brief Neuropsychological
help evaluate patients with frontal dysfunction.
test in Spanish (Neuropsi), standardized in the
The objective of our study was to determine the
Mexican population by age, sex, and education21,
validity of FAB in Mexican older adults with CI, as well
and the MoCA-E test25,26. Both tests were compared
as to know the cutoff points of the test.
against the FAB11.
METHODS
FAB
Study design
The FAB is a brief cognitive and behavioral battery
This was a observational, cross-sectional, and com- that can be used at the bedside, useful to assess fron-
parative study carried out in a Memory Clinic of a ter- tal lobe functions, and consists of six subtests that
tiary hospital in Mexico City. The study was approved explore conceptualization, mental flexibility, motor
by the Institutional Ethics Committee. All participants programming, sensitivity to interference, inhibitory
signed an informed consent. control, and environmental autonomy. Each subtest
30
A.J. Mimenza-Alvarado, et al.: Frontal assessment battery and cognitive impairment
Table 1. Clinical and socio-demographic characteristics of the participants
Total (n = 90) CH (n = 30) MCI (n = 30) Dementia (n = 30) p

Age (years) A,C
76.2 ± 7.2 72.8 ± 6.5 77.9 ± 6.3 78.1 ± 7.6 0.005
Female n (%) 57 (63.3) 25 (83.3) 17 (56.7) 15 (50) 0.018
Education (years) 13.2 ± 5.0 14.0 ± 4.0 12.0 ± 5.6 13.6 ± 5.3 0.293
BADL (Katz) 5.7 ± 0.5 5.7 ± 0.4 5.7 ± 0.7 5.8 ± 0.3 0.427
IADL (Lawton and Brody)B,C 6.2 ± 2.3 7.5 ± 1.0 7.0 ± 1.5 4.2 ± 2.5 <0.001
NeuropsiA,B,C 93.0 ± 20.7 110.4 ± 7.7 91.6 ± 20.3 77.1 ± 16.3 <0.001
MoCA-EA,B,C 22.0 ± 5.6 26.1 ± 2.0 22.9 ± 3.7 16.9 ± 5.8 <0.001
FABA,B,C 13.8 ± 3.9 16.7 ± 1.5 14.0 ± 3.0 10.8 ± 4.2 <0.001
Data are Media ± Standard Deviation. CH: cognitively healthy; MCI: mild cognitive impairment; BADL: basic activities of daily
living; IADL: Instrumented activities of daily life; MoCA-E: montreal cognitive assessment; FAB: frontal assessment battery.
Data are analyzed with ANOVA for continuous variables and Chi-square for categorical variables, a Post-hoc analysis with
Turkey test is performed. ACH versus MCI, p < 0.05; BMCI versus Dementia, p < 0.05; CCH versus Dementia, p < 0.05.
has a value from 0 to 3, so the maximum score is 18, group (p < 0.05) and dementia group (p < 0.05), respec-
with the lowest one indicating greater frontal dys- tively. The group with dementia had a lower score in
function11 (Annex 1 in Spanish). To determine the IADL compared to the CH (p < 0.05) and MCI group
convergent correlation, the subtests that specifically (p < 0.05), as well as a worse performance in Neuropsi,
evaluate frontal lobe functions of each of the instru- MoCA-E, and FAB compared to the rest of the groups
ments were selected. (p < 0.001), while the MCI group had a better perfor-
mance than the dementia group, but worse perfor-
mance compared to the CS group (p < 0.001). Table 1
shows the clinical and socio-demographic character-
The categorical variables were reported in propor- istics of the groups. Cronbach’s Alpha Coefficient was
tions and percentages, and the continuous variables 0.71 for the FAB. The characteristics of frontal function
in mean and standard deviation. The analysis of tests performance by groups are presented in table 2.
and subtests was performed with a Z score. ANOVA Regarding the correlation, it is observed that
was used to compare means, and for categorical Chi- the FAB obtained a high CC for Neuropsi (r = 0.617,
square. A post hoc analysis with Tukey’s test is per- p < 0.05) and MoCA-E (r = 0.795, p < 0.05), while the
formed. For internal consistency, Cronbach’s Alpha mental flexibility subtests (r = 0.422, p < 0.05), motor
was calculated. Construct validity was determined by programming (r = 0.437, p < 0.05), and sensitivity to
the original author11. Pearson’s Correlation Coefficient interference (r = 0.357, p < 0.05) obtained a moder-
(CC) was calculated for concurrent validity. The per- ate correlation, unlike the conceptualization subtests
formance was established by means of the Receiver (r = 0.228, p < 0.05), inhibitory control (r = 0.262,
Operating Characteristic (ROC), the calculation of p < 0.05), and environmental autonomy (r = 0.278,
Area Under the Curve (AUC) was performed to estab- p < 0.05) where the correlation was weak (Table 3).
lish cutoff point, as well as sensitivity and specificity. The ROC curve for FAB in relation to the dementia
p < 0.05 was considered statistically significant. The group showed an AUC of 0.800 (95% CI, 0.70-0.89;
SPSS statistical package (SPSS, Inc., Chicago IL, ver- p < 0.001), with a cutoff point of ≤14, sensitivity of
sion 20.0 for Windows) was used. 73% (95% CI, 0.89-0.57), and specificity of 70% (95%
CI, 0.81-0.58), PPV of 55%, NPV of 84%. The ROC curve
for FAB in relation to the MCI group showed an AUC of
RESULTS
0.742 (95% CI, 0.61-0.86; p = 0.001), with a cutoff point
The validation process was carried out on 90 partici- of ≤ 16, sensitivity of 83.3% (95% CI, 0.96-0.69), and
pants. The mean age was 76.2 ± 7.2 years, 63% women specificity of 63.3% (95% CI, 0.71-0.35), PPV of 64%,
(n = 57), and the mean education was 13.2 ± 5.0 years. and NPV of 76%. Figure 1 shows the ROC curves of the
The CH group was significantly younger than the MCI FAB in CI.
31
Table 2. Performance of the frontal function
Subtest CH (n = 30) MCI (n = 30) Dementia (n= 30) p

Neuropsi Similarities A,C
0.54 ± 0.38 −0.15 ± 1.10 −0.39 ± 1.09 < 0.001
Phonological verbal fluencyC 0.33 ± 0.65 0.09 ± 1.27 −0.42 ± 0.83 0.010
MF, change hand positionA,B,C 0.70 ± 0.65 0.14 ± 0.83 −0.84 ± 0.82 < 0.001
MF, opposite reactionsA,B,C 0.57 ± 0.25 0.01 ± 0.86 −0.58 ± 1.24 < 0.001
MF, alternating movementsC 0.41 ± 0.56 −0.03 ± 0.93 −0.38 ± 1.24 0.007
TotalA,B,C 0.83 ± 0.37 −0.07 ± 0.98 −0.76 ± 0.78 < 0.001
MoCA-E Trail Making Test Part BA,C 0.64 ± 0.69 −0.08 ± 1.01 −0.55 ± 0.89 < 0.001
TotalA,B,C 0.73 ± 0.35 0.16 ± 0.66 −0.89 ± 1.04 <0.001
FAB Conceptualization 0.18 ± 0.53 −0.17 ± 0.91 −0.01 ± 1.37 0.374
Mental flexibilityA,C 0.47 ± 0.45 −0.23 ± 1.17 −0.23 ± 1.06 0.006
Motor programmingB,C 0.48 ± 0.58 0.28 ± 0.78 −0.76 ± 1.08 < 0.001
Sensitivity to interferenceB,C 0.54 ± 0.39 0.12 ± 0.89 −0.66 ± 1.15 <0.001
Inhibitory controlA,B,C 0.71 ± 0.67 −0.04 ± 0.94 −0.67 ± 0.84 < 0.001
Environmental autonomy 0.19 ± 0.31 0.19 ± 0.31 −0.38 ± 1.62 0.032
TotalA,B,C 0.72 ± 0.38 0.04 ± 0.77 −0.76 ± 1.07 < 0.001
CH: cognitively healthy; MCI: mild cognitive impairment; MF: motor functions; MoCA-E: montreal cognitive assessment;
FAB: frontal assessment battery. The data are analyzed with ANOVA, and a Post-hoc analysis with Tuckey’s test is
performed. ACH versus MCI, p < 0.05; BMCI versus Dementia, p < 0.05; CCH versus Dementia, p < 0.05. Group means are
expressed in Z scores.
A Dementia B MCL
1.0
1.0
FAB
MoCA-E FAB
Neuropsi MoCA-E
0.8 Reference 0.8 Neuropsi
Reference
0.6 0.6
Sensibility
Sensitivity
0.4 0.4
0.2 0.2
0.0
0.0 0.0 0.2 0.4 0.6 0.8 1.0
0.0 0.2 0.4 0.6 0.8 1.0
Specificity
Specificity
Figure 1. Receiver operating characteristic curve performance of FAB with CI. A: Dementia, FAB AUC 0.800 (95%
IC, 0.70-0.89; p < 0.001), MoCA AUC 0.708 (95% IC, 0.59-0.82; p < 0.001); Neuropsi AUC 0.827 (95% IC, 0.74-0.01;
p < 0.001). B: MCI, FAB 0.742 (95% IC, 0.61-0.86; p = 0.001); MoCA 0.683 (95% IC, 0.54-0.82; p = 0.015; Neuropsi
AUC 0.738 (95% CI, 0.60-0.86; p = 0.002). MCI: mild cognitive impairment; FAB: Frontal assessment battery.
DISCUSSION and MCI, similar to that published by Iavarone et al.16,

Wong et al.27, and Dubois et al.11.
The results of our study show that the FAB has a A strong correlation was observed between the
moderate internal consistency, and that it is a valid FAB and the global assessment tests, MoCA-E, and
test in Mexican older adults with CI, both for dementia Neuropsi. A study by Abrahámová et al. demonstrated
32
similar findings between MoCA-E and FAB28. The cor-

relation between MoCA-E and FAB can be explained
0.795*
0.617*
Total
as a consequence of the psychometric ability of
MoCA-E to evaluate executive function from specific
Environmental tests such as working memory, abstract reasoning,
autonomy
planning, inhibition, attention, and mental flexibility8.
0.278*
Comparing the FAB, MoCA-E, and Neuropsi sub-
tests, the domains of conceptualization, inhibitory
control, and environmental autonomy demonstrated
a weak correlation, while mental flexibility, motor
Inhibitory
control
0.262*
programming, and sensitivity to interference demon-
strated a moderate correlation. For all the above, an
adequate convergent validity was observed between
the FAB, MoCA-E, and Neuropsi. Our findings could
Sensitivity to
interference
be explained because most of the executive function

0.357*
tasks in these tests activate neural networks promi-

FAB: frontal assessment battery; VF: verbal fluency; MF: motor functions; MoCA-E: montreal cognitive assessment; *, p < 0.05. nently distributed in the prefrontal cortex8.
Regarding the different types of CI, FAB allowed
to discriminate between MCI and dementia in the
programming
subtests of motor programming, sensitivity to inter-

0.437*
Motor
ference, and inhibitory control. The decrease in

scores on the motor programming subtests could be
explained as a consequence of the fact that individu-
als with poor motor function are associated with a
higher risk of dementia29. On the other hand, those
Mental flexibility
FAB
with self-behavior deficits and lesions in the ventral

0.422*
frontal regions could be unable to inhibit inappro-

priate responses and show greater frontal dysfunc-
tion11. Therefore, the FAB could discriminate between
subtypes of CI when the subtests are qualitatively
analyzed30,31.
Conceptualization
Our findings suggest that FAB has good diagnos-

tic precision for dementia, with an AUC of 0.800 (95%
0.228*
CI, 0.70-0.89, p < 0.001), with a cutoff point of ≤ 14,

sensitivity of 73%, and specificity of 70%. The cutoff
point found is similar to that reported by Custodio
et al. who propose a cutoff point ≤ 14.5, although
with a sensitivity of 97.7%, and specificity of 81.1% in
Trail Making Test Part B
Table 3. Pearson’s correlation coefficient
the Peruvian population32. Chong et al. also showed

MF, opposite reactions
Phonological verbal
a cutoff point similar to ours, but in the Chinese

Specific subtests
MF, change hand
population, with a sensitivity of 91% and specificity

MF, alternating
of 70.3%33. In the case of MCI, FAB demonstrated an

movements
Similarities
adequate AUC, with a cutoff point of ≤ 16, a sensi-

position
fluency
tivity of 83.3%, and a specificity of 63.3%. It is pos-

Total
Total
sible that FAB is useful for detecting MCI, although

it is convenient to complement it with another test,
this as a result of its low specificity. Bezdicek et al.
demonstrated a cutoff point of ≤ 16 to discriminate
Neuropsi
MoCA-E
patients with MCI from those of CH (sensitivity 84.4%

and specificity 81.2%)34. Hurtado et al. reported a
cutoff point of ≤ 12.5, with a sensitivity of 74.1%
33
and specificity of 72.2%30. Chong et al. improved CONFLICTS OF INTEREST

diagnostic accuracy when combining MMSE and FAB
The authors declare that they have no conflict of
to identify MCI in a Chinese population (sensitivity
interest.
91.3% and specificity 77%)33.
ETHICAL DISCLOSURES
Strengths and limitations
Protection of human and animal subjects. The
The main strength of our study is based on the fact
authors declare that the procedures followed were
that it is the first study to validate FAB in Mexican
in accordance with the regulations of the relevant
older adults with CI. Likewise, it also provides infor-
clinical research ethics committee and with those of
mation regarding the performance of the test for
the Code of Ethics of the World Medical Association
its application in the clinical field. Another relevant
(Declaration of Helsinki).
aspect is that participants with MCI and dementia
Confidentiality of data. The authors declare that
were included. On the other hand, the main limitation they have followed the protocols of their work center
of our study is that it was not possible to differentiate on the publication of patient data.
between the subtypes of dementia, in addition the Right to privacy and informed consent. The
test-retest validity was not performed, and the aver- authors have obtained the written informed consent
age level of education could limit the external validity of the patients or subjects mentioned in the article.
of the study. The corresponding author is in possession of this
document.
CONCLUSIONS
The findings of our study show that the FAB is a use- REFERENCES
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form statistical analysis. All authors interpreted the 14. Rodríguez del Álamo A, Catalán Alonso MJ, Carrasco Marín L. FAB: apli-
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35
Annex 1. The Frontal Assessment Battery (FAB)
Subprueba 1. Conceptualización (semejanzas). “¿En qué se parece… un plátano y una naranja?” … ¿una mesa y una
silla?” … ¿una rosa, un tulipán y una margarita?”. En caso de un fallo total (por ejemplo: “no son iguales”) o fallo parcial
(por ejemplo: “ambos tienen cáscara”), ayude al sujeto diciendo: “tanto un plátano como una naranja son…” pero puntúe
0 para el ítem, no ayude al sujeto con los siguientes dos ítems. Cuente como correctas únicamente las respuestas categóricas
(frutas, muebles, flores).
3 correctas 3 puntos
1 correcta 1 punto
Subprueba 2. Flexibilidad mental (fluidez verbal). “Diga tantas palabras como pueda que comiencen con la letra F,
cualquier palabra, excepto nombres propios y derivados”. Si el sujeto no responde en los primeros 5 segundos diga “por
ejemplo, frío”. Si el sujeto hace una pausa de 10 segundos, estimúlelo diciendo “cualquier palabra que comience con la
letra F”. El tiempo permitido es de 60 segundos. Puntúe únicamente las palabras correctas, no tome en cuenta las
repeticiones o palabras derivadas.
Más de 9 palabras 3 puntos
6 a 9 palabras 2 puntos
3 a 5 palabras 1 punto
Menos de 3 palabras 0 puntos
Subprueba 3. Programación motora (series motrices). “Fíjese bien en lo que hago…” [examinador con su mano izquierda
realiza 3 series puño-canto-palma]. “Con su mano derecha haga las mismas series, primero conmigo y luego usted solo”
[3 repeticiones más junto al paciente] “Ahora, hágalo usted solo”.
3 correctas El paciente lleva a cabo 6 series consecutivas por sí solo
2 correctas El paciente lleva a cabo al menos 3 series consecutivas solo
1 correcta El paciente falla solo, pero hace las 3 series con el examinador
0 correctas El paciente no puede llevar a cabo al menos 3 series consecutivas
Subprueba 4. Sensibilidad a la interferencia (instrucciones conflictivas). “Toque 2 veces cuando yo toque una vez” [para
asegurarse que el sujeto ha entendido las instrucciones, se realiza una serie de 3 ensayos 1-1-1]. “Toque una vez cuando yo
toque 2 veces” [para asegurarse de que el sujeto ha entendido las instrucciones, se realiza una serie de 3 ensayos 2-2-2]. [El
examinador entonces lleva a cabo la siguiente serie 1-1-2-1-2-2-2-1-1-2].
Sin errores 3 puntos
1-2 errores 2 puntos
≥ 2 errores 1 punto
Golpea como el examinador ≥ 4 veces consecutivas 0 puntos
Subprueba 5. Control inhibitorio (Go-No Go). “Toque una vez cuando yo toque una vez” [para asegurarse de que el
sujeto ha entendido las instrucciones, se realiza una serie de 3 ensayos 1-1-1]. “No toque cuando yo toque 2 veces” [para
asegurarse de que el sujeto ha entendido las instrucciones, se realiza una serie de 3 ensayos 2-2-2]. [El examinador entonces
lleva a cabo la siguiente serie 1-1-2-1-2-2-2-1-1-2].
Sin errores 3 puntos
1-2 errores 2 puntos
≥ 2 errores 1 punto
Golpea como el examinador ≥ 4 veces consecutivas 0 puntos
Subprueba 6. Autonomía ambiental (conducta de prensión). [Examinador está sentado frente al paciente y coloca las
manos del mismo palmas arriba sobre sus rodillas. Sin hablar o ver al paciente, el investigador acerca sus manos a las del
paciente y toca sus palmas, para ver si el sujeto las toma espontáneamente. Si el paciente las toma, el examinador intenta de
nuevo después de pedirle] “Ahora, no tome mis manos”.
El paciente no toma las manos del examinador 3 puntos
El paciente duda y pregunta qué debe hacer 2 puntos
El paciente toma las manos sin dudar 1 punto
Toma las manos a pesar de pedirle explícitamente que no lo haga 0 puntos
Puntuación total ________

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The Journal of Latin American

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© 2021 Permanyer México

Edición impresa en México

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half of them were evaluated during their stay by a

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Table 5. Healthcare outcomes after 30 days of follow-up

The main strengths of the study are that as far as REFERENCES

THE JOURNAL OF LATIN AMERICAN GERIATRIC MEDICINE ORIGINAL ARTICLE

Validation of the frontal assessment battery in Mexican

Validación de la batería de evaluación frontal en adultos mayores mexicanos con

Table 1. Clinical and socio-demographic characteristics of the participants

Total (n = 90) CH (n = 30) MCI (n = 30) Dementia (n = 30) p

Table 2. Performance of the frontal function

Subtest CH (n = 30) MCI (n = 30) Dementia (n= 30) p

DISCUSSION and MCI, similar to that published by Iavarone et al.16,

similar findings between MoCA-E and FAB28. The cor-

be explained because most of the executive function

tasks in these tests activate neural networks promi-

subtests of motor programming, sensitivity to inter-

ference, and inhibitory control. The decrease in

with self-behavior deficits and lesions in the ventral

frontal regions could be unable to inhibit inappro-

Our findings suggest that FAB has good diagnos-

CI, 0.70-0.89, p < 0.001), with a cutoff point of ≤ 14,

the Peruvian population32. Chong et al. also showed

a cutoff point similar to ours, but in the Chinese

MF, change hand

population, with a sensitivity of 91% and specificity

of 70.3%33. In the case of MCI, FAB demonstrated an

adequate AUC, with a cutoff point of ≤ 16, a sensi-

tivity of 83.3%, and a specificity of 63.3%. It is pos-

sible that FAB is useful for detecting MCI, although