Clinic Case
Delirium as a geriatric syndrome in the initial presentation of Takotsubo syndrome
Delirium como un síndrome geriátrico en la presentación inicial del síndrome de Takotsubo
Jesus Lopez Gomeza,
, Elisa Garcia Terceroa, Juan Antonio Avellana Zaragozaa, Angel Belenguer Vareaa, Daniela Villalón Rubioa, Rodrigo Trigo Suareza, Cristina Cunha-Pérezb, Francisco José Tarazona-Santabalbinaa,c,d
Corresponding author
a Geriatric Medicine Department, Hospital Universitario de la Ribera, Alzira, Spain
b School of Doctorate, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
c Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
d Medical School, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
Read
33
Timeswas read the article
7
Total PDF
26
Total HTML
Share statistics
array:23 [ "pii" => "S0211139X24000167" "issn" => "0211139X" "doi" => "10.1016/j.regg.2024.101482" "estado" => "S300" "fechaPublicacion" => "2024-05-01" "aid" => "101482" "copyright" => "SEGG" "copyrightAnyo" => "2024" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Geriatr Gerontol. 2024;59:" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S0211139X24000143" "issn" => "0211139X" "doi" => "10.1016/j.regg.2024.101480" "estado" => "S300" "fechaPublicacion" => "2024-05-01" "aid" => "101480" "copyright" => "SEGG" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Rev Esp Geriatr Gerontol. 2024;59:" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:9 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al editor</span>" "titulo" => "<span class="elsevierStyleItalic">Millennials</span> y generación Z: intentando retener el talento de los nuevos geriatras. Un reto compartido... y competido" "tienePdf" => "es" "tieneTextoCompleto" => "es" "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Millennials and gen Z: trying to retain new geriatricians’ talent. When coopetition is the key" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniel Rosselló-Jiménez, Sami Loutfi, Mireia Llonch-Masriera" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Daniel" "apellidos" => "Rosselló-Jiménez" ] 1 => array:2 [ "nombre" => "Sami" "apellidos" => "Loutfi" ] 2 => array:2 [ "nombre" => "Mireia" "apellidos" => "Llonch-Masriera" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211139X24000143?idApp=UINPBA00004N" "url" => "/0211139X/0000005900000003/v2_202409170520/S0211139X24000143/v2_202409170520/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0211139X23001865" "issn" => "0211139X" "doi" => "10.1016/j.regg.2023.101465" "estado" => "S300" "fechaPublicacion" => "2024-05-01" "aid" => "101465" "copyright" => "SEGG" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Geriatr Gerontol. 2024;59:" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Hematoma intramuscular espontáneo en vasto anterior del cuádriceps en una paciente mayor: a propósito de un caso" "tienePdf" => "es" "tieneTextoCompleto" => "es" "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Spontaneous intramuscular hematoma in the anterior compartment of the quadriceps in an older patient: About a case" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1032 "Ancho" => 3475 "Tamanyo" => 199097 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pruebas complementarias de imagen de miembros inferiores. A)<span class="elsevierStyleHsp" style=""></span>Tomografía axial computarizada de miembros inferiores que muestra el hematoma en vasto anterior izquierdo (flecha blanca). B)<span class="elsevierStyleHsp" style=""></span>Ecografía clínica del cuádriceps izquierdo con hematoma (línea punteada), comparado con C)<span class="elsevierStyleHsp" style=""></span>ecografía clínica del cuádriceps derecho íntegro (línea punteada).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cecilia D. Palacios-Revilla, Raquel Ramírez-Martín, Concepción Murillo Gayo, Juan I. González-Montalvo" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Cecilia D." "apellidos" => "Palacios-Revilla" ] 1 => array:2 [ "nombre" => "Raquel" "apellidos" => "Ramírez-Martín" ] 2 => array:2 [ "nombre" => "Concepción" "apellidos" => "Murillo Gayo" ] 3 => array:2 [ "nombre" => "Juan I." "apellidos" => "González-Montalvo" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211139X23001865?idApp=UINPBA00004N" "url" => "/0211139X/0000005900000003/v2_202409170520/S0211139X23001865/v2_202409170520/es/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinic Case</span>" "titulo" => "Delirium as a geriatric syndrome in the initial presentation of Takotsubo syndrome" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jesus Lopez Gomez, Elisa Garcia Tercero, Juan Antonio Avellana Zaragoza, Angel Belenguer Varea, Daniela Villalón Rubio, Rodrigo Trigo Suarez, Cristina Cunha-Pérez, Francisco José Tarazona-Santabalbina" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Jesus" "apellidos" => "Lopez Gomez" "email" => array:1 [ 0 => "jblg93@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Elisa" "apellidos" => "Garcia Tercero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Juan Antonio" "apellidos" => "Avellana Zaragoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Angel" "apellidos" => "Belenguer Varea" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Daniela" "apellidos" => "Villalón Rubio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Rodrigo" "apellidos" => "Trigo Suarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Cristina" "apellidos" => "Cunha-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "Francisco José" "apellidos" => "Tarazona-Santabalbina" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Geriatric Medicine Department, Hospital Universitario de la Ribera, Alzira, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "School of Doctorate, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Medical School, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Delirium como un síndrome geriátrico en la presentación inicial del síndrome de Takotsubo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 719 "Ancho" => 2007 "Tamanyo" => 204169 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electrocardiographic assessment of the patient conducted in the A&E.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical case presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present a clinical case involving an 88-year-old woman with a medical history marked by depression and knee osteoarthritis, devoid of known cardiovascular risk factors, and undergoing treatment with sertraline and paracetamol. A functional assessment revealed complete self-sufficiency in basic activities of daily living, indicated by a Lawton index score of 3, necessitating external assistance for household chores. Subjective complaints of memory issues, marked by frequent forgetfulness and occasional erratic behaviour, suggest the presence of previously undetected mild cognitive impairment. In terms of the clinical progression, the patient exhibited symptoms 24<span class="elsevierStyleHsp" style=""></span>h before admission typified by aggressiveness and agitation. These behaviours escalated as she exhibited resistance to verbal commands from both relatives and attending clinicians, coupled with fluctuating attention. Relatives reported similar, albeit less intense, symptoms over the past four weeks, primarily occurring at night and subsiding spontaneously. The morning preceding admission, the patient was discovered on the floor of her residence. However, it remained unclear whether she had fallen or chosen to lie down. She presented temporal–spatial disorientation, incoherent speech, prompting evaluation by the primary care physician, who subsequently referred her to the hospital Accident and Emergency Department (A&E).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Upon arrival at the A&E, the patient presented haemodynamic stability, registering a blood pressure of 140/90 millimetres of mercury. She remained afebrile, exhibited normal resting respiration, appeared composed, yet demonstrated disorientation concerning time and space. Despite this, she responded to verbal commands without alterations in attention or a propensity towards agitation. Notably, she displayed symptoms of delirium, as indicated by the 4AT scale assessment. Cardiopulmonary auscultation revealed no significant abnormalities, except for wet crackles apparent in both lung bases. Abdominal examination yielded no pertinent findings, with an absence of peripheral oedema or indications of deep vein thrombosis. Furthermore, aside from the manifestations of delirium, no associated neurological focalities were observed. An electrocardiographic assessment unveiled a 2<span class="elsevierStyleHsp" style=""></span>mm ST-segment elevation in the anterior aspect (v2–v4) (see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The administration of nitrates in conjunction with dual antiplatelet therapy followed. A cranial CT scan highlighted indications of chronic hypoperfusion coupled with cortical atrophy. Laboratory analysis indicated an initial troponin T elevation of 18,500<span class="elsevierStyleHsp" style=""></span>ng/ml, subsequently escalating to 22,550<span class="elsevierStyleHsp" style=""></span>ng/ml 3<span class="elsevierStyleHsp" style=""></span>h later. The case was deliberated upon by the Emergency Department in consultation with the Intensive Care Unit (ICU), which determined against ICU admission, opting instead to admit the patient to the Geriatric Acute Medical Unit following confirmation of her clinical stability.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Throughout her hospitalization, the patient remained free of chest pain, displaying a gradual improvement in behavioural symptoms. The comprehensive etiological investigation culminated in a haemodynamic catheterization procedure, ruling out a coronary lesion as the instigator of the clinical presentation (<a class="elsevierStyleCrossRef" href="#sec0025">S1, supplementary archive</a>). However, evidence of possible anteroseptal hypokinesia emerged from the procedure. Transthoracic echocardiography corroborated the presence of anteroseptal hypokinesia alongside basal hyperkinesia, resulting in a reduced left ventricular ejection fraction (LVEF) of 30%. The patient exhibited positive clinical progress during her hospital stay. Clopidogrel was discontinued, and pharmacological adjustments were made to address heart failure with a reduced ejection fraction. Following clinical stabilization and a decline in serum troponin T levels, she was discharged from the hospital. Subsequent outpatient assessment at the geriatric clinic revealed no recurrent similar episodes. Mild cognitive impairment of likely vascular origin was noted, devoid of associated behavioural or psychological symptoms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">In the depicted clinical scenario, the sequence of events and the exclusion of secondary organic etiologies (including myocarditis, pheochromocytoma, and thyrotoxicosis) associated with Takotsubo syndrome prompt the consideration of hyperactive delirium as the primary organic cause. This hypothesis is likely due to the concomitant adrenergic stimulation in a patient exhibiting a probable cognitive impairment characterized by a vascular profile previously unreported, concomitant with a reduced left ventricular ejection fraction a condition not previously documented, potentially contributing to cerebral hypoperfusion<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The classic presentation of Takotsubo syndrome commonly involves chest pain, sometimes accompanied by dyspnoea, following an acute stressful event.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> However, it's noteworthy that delirium has not previously been identified or documented as a triggering factor for this cardiac condition.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It holds true that the geriatric demographic often exhibits atypical or divergent symptoms compared to the typical manifestations of various pathological conditions. Moreover, the pathophysiological mechanisms linked to delirium, particularly the activation of the sympathoadrenergic axis, may potentially serve as an inducer or causative factor in such scenarios<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4–6</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical atypicality observed within this age cohort predominantly stems from the cumulative effects of ageing, which gradually diminish the functional reserves across various organs and tissues, consequently altering their responsiveness. Delirium, as a clinical manifestation, often signifies serious underlying pathologies or emerges as a part of their progression. It can occasionally be linked to the therapeutic regimen administered to the patient, particularly in cases involving inappropriate prescriptions, exacerbating cognitive disorders already present<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a>.</p></span><span id="sec1025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1025">Conflict of interests</span><p id="par1055" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span><span id="sec1125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1125">Ethical considerations</span><p id="par1155" class="elsevierStylePara elsevierViewall">The authors declare that they have obtained the patient's consent for the publication of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case presentation" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec1025" "titulo" => "Conflict of interests" ] 3 => array:2 [ "identificador" => "sec1125" "titulo" => "Ethical considerations" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0050" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0025" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 719 "Ancho" => 2007 "Tamanyo" => 204169 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electrocardiographic assessment of the patient conducted in the A&E.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 1785941 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Kurisu" 1 => "H. Sato" 2 => "T. Kawagoe" 3 => "M. Ishihara" 4 => "Y. Shimatani" 5 => "K. Nishioka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/mhj.2002.120403" "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "2002" "volumen" => "143" "paginaInicial" => "448" "paginaFinal" => "455" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11868050" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Takotsubo syndrome: state-of-the-art review by an expert panel – part 1" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Dias" 1 => "I.J. Núñez-Gil" 2 => "F. Santoro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.carrev.2019.03.021" "Revista" => array:6 [ "tituloSerie" => "Cardiovasc Revasc Med" "fecha" => "2019" "volumen" => "20" "paginaInicial" => "70" "paginaFinal" => "79" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31307928" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characterization of Tako-tsubo Cardiomyopathy in Spain: Results from the RETAKO National Registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I.J. Núñez Gil" 1 => "M. Andrés" 2 => "M. Almendro Delia" 3 => "A. Sionis" 4 => "A. Martín" 5 => "T. Bastante" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Cardiol." "fecha" => "2015" "volumen" => "68" "paginaInicial" => "505" "paginaFinal" => "512" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Application of multiple omics to understand postoperative delirium pathophysiology in humans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.M. Vasunilashorn" 1 => "S.T. Dillon" 2 => "E.R. Marcantonio" 3 => "T.A. Libermann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000533789" "Revista" => array:6 [ "tituloSerie" => "Gerontology" "fecha" => "2023" "volumen" => "69" "paginaInicial" => "1369" "paginaFinal" => "1384" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/37722373" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delirium in older persons" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.S. Oh" 1 => "T.G. Fong" 2 => "T.T. Hshieh" 3 => "S.K. Inouye" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2017.12067" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2017" "volumen" => "318" "paginaInicial" => "1161" "paginaFinal" => "1174" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28973626" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic accuracy of the Spanish version of the 4AT scale (4AT-ES) for delirium screening in older in patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. Delgado-Parada" 1 => "D. Morillo-Cuadrado" 2 => "J. Saiz-Ruiz" 3 => "A. Cebollada-Gracia" 4 => "J. Ayuso-Mateos" 5 => "A.J. Cruz-Jentoft" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Psychiatr." "fecha" => "2022" "volumen" => "26" "paginaInicial" => "182" "paginaFinal" => "190" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Initial clinical presentation of Takotsubo cardiomyopathy with-a focus on electrocardiographic changes: a literature review of cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.F. Sanchez-Jimenez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4330/wjc.V5.i7.228" "Revista" => array:6 [ "tituloSerie" => "World J Cardiol" "fecha" => "2013" "volumen" => "5" "paginaInicial" => "228" "paginaFinal" => "241" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23888192" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the diagnosis of Takotsubo (blister) cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Kawai" 1 => "A. Kitabatake" 2 => "Tomoike H:" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1253/circj.71.990" "Revista" => array:6 [ "tituloSerie" => "Circ J" "fecha" => "2007" "volumen" => "71" "paginaInicial" => "990" "paginaFinal" => "992" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17527002" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/0211139X/0000005900000003/v2_202409170520/S0211139X24000167/v2_202409170520/en/main.assets" "Apartado" => array:4 [ "identificador" => "88235" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Caso Clínico" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/0211139X/0000005900000003/v2_202409170520/S0211139X24000167/v2_202409170520/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211139X24000167?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 1 | 1 | 2 |
| 2024 September | 7 | 0 | 7 |
| 2024 July | 1 | 0 | 1 |
| 2024 June | 2 | 2 | 4 |
| 2024 May | 10 | 1 | 11 |
| 2024 April | 1 | 0 | 1 |
| 2024 March | 1 | 0 | 1 |
| 2024 February | 3 | 3 | 6 |
