Preserving bone in cancers of the elderly: A necessity

The occurrence of bone fractures is frequent in the elderly population, and in cancer patients, especially with bone metastases. The growing incidence of cancer associated with an aging population implies important health challenges, including bone health. Decisions on cancer care in older adults have to take into account older adults' specificities. Screening tools as G8 or VES 13 and evaluating tools as comprehensive geriatric assessment (CGA) do not include bone-related items. Bone risk assessment is indicated according to identification of geriatric syndromes such as falls, history, and the oncology treatment plan. Some cancer treatments disrupt bone turnover and decrease bone mineral density. This is mainly caused by hypogonadism, induced by hormonal treatments and some chemotherapies. Treatments can also cause direct (i.e., chemotherapy, radiotherapy or glucocorticoids) or indirect toxicity through electrolyte disorders (i.e., some chemotherapies or tyrosine kinase inhibitors) on bone turnover. Bone risk prevention is multidisciplinary. Certain interventions proposed in the CGA aim to improve bone health and reduce the risk of falling. It is also based on the drug management of osteoporosis, and the prevention of complications from bone metastases. Management of fractures, related or not to bone metastases relates to the concept of orthogeriatrics. It is also based on the benefit-risk ratio of the operation, access to minimally invasive techniques, prehabilitation or rehabilitation, but also the prognosis related to cancer and geriatric syndromes. Bone health is essential in older cancer patient's care. Bone risk assessment should be part of CGA in routine use and specific decision-making tools should be developed. Bone event management must be integrated throughout the patient's care pathway and oncogeriatrics multidisciplinarity should include rheumatological expertise.

Risk Factors for Hospital Readmission and Death After Discharge of Older Adults from Acute Geriatric Units: Taking the Rank of Admission into Account

Objective

To analyze the impact of the number of hospital readmissions on the risks of further hospital readmission and death after adjustment for a range of risk factors.

Methods

We performed a multicentre prospective study of the DAMAGE cohort in the Hauts-de-France region of France. Patients aged 75 and over hospitalized initially in an acute geriatric unit (AGU) were included and followed up for 12 months. The risk of hospital readmission was analyzed using a Cox model, and its extension for recurrent events and the risk of death were analyzed using a Cox model for time-dependent variables.

Results

A total of 3081 patients were included (mean (SD) age: 86.4 (5.5)). In the multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital readmission rose progressively to 2.66 (1.44; 5.14), and the risk of death rose to 2.01 (1.23; 3.32) after five hospital admissions, relative to a patient with no hospital readmissions. The number of hospital readmissions during the follow-up period was the primary risk factor and the best predictor of the risk of hospital readmission and the risk of death.

Conclusion

Hospital readmission is the primary risk factor for further hospital readmissions and for death in older subjects discharged from an AGU.

Attitudes toward Alzheimer's disease: a qualitative study of the role played by social representation on a convenient sample of French general practitioners

BACKGROUND AND AIMS

It is commonly thought that Alzheimer's disease (AD) is under-diagnosed and that insufficient numbers of patients are receiving pharmacological treatment. These observations are often attributed to poor management of the disease by general practitioners (GPs) related to their lack of training in identifying cognitive decline. Our hypothesis is that there may be a relation between GPs' perceptions and their attitudes toward AD.

METHODS

We conducted a qualitative study, through semi-directive interviews focusing on their representations, of 25 GPs, masters in training courses, in Paris.

RESULTS

Analysis of interviews revealed five general trends. AD is seen by GPs as a "disease of autonomy", without specific medical treatment. Cognitive symptoms are less meaningful in GPs' view than the loss of autonomy. The main thing is to keep the patient at home. For GPs, the family is described as an essential partner in coping with the insufficiencies of available social programs. The use of specialists is less to confirm the diagnosis than to announce the "bad news". GPs declare scepticism as to the efficacy of AD medications, only granting them a certain "care" effect or a social role. The image of AD remains highly negative. The stigma of AD is seen as a barrier to its diagnosis.

CONCLUSIONS

This study is somewhat preliminary because of sample size. Nevertheless, the social representations of the disease influence GPs' attitudes toward making diagnoses in France. Priority seems to focus more on assisting GPs and families at the social level, rather than diagnosis or access to treatment.

[Cognitive impairment and chronic kidney disease: which links?]

Ageing of the population leads to an increase of cognitive disorders and chronic renal failure incidence. Compared to the general population, prevalence of cognitive impairment is more important in renal failure patients, especially in dialyzed patients. No direct link has been established between renal failure and cognitive impairment. The care of older and older patients and the high frequency of vascular risk factors, in particular hypertension and diabetes, partially explain the prevalence of vascular dementia and Alzheimer disease in this population. Other factors as the anemia, phosphocalcic metabolism disorders facilitate the cognitive impairment. The present work reviews the links existing between chronic renal failure and cognitive impairment.

Soluble receptor for advanced glycation end products: a new biomarker in diagnosis and prognosis of chronic inflammatory diseases

The formation of advanced glycation end products (AGEs) is a result of the non-enzymatic reaction between sugars and free amino groups of proteins. AGEs, through interacting with their specific receptor for AGEs (RAGE), result in activation of pro-inflammatory states and are involved in numerous pathologic situations. The soluble form of RAGE (sRAGE) is able to act as a decoy to avoid interaction of RAGE with its pro-inflammatory ligands (AGEs, HMGB1, S100 proteins). sRAGE levels have been found to be decreased in chronic inflammatory diseases including atherosclerosis, diabetes, renal failure and the aging process. The use of measuring circulating sRAGEs may prove to be a valuable vascular biomarker and in this review, we describe the implications of sRAGE in inflammation and propose that this molecule may represent a future therapeutic target in chronic inflammatory diseases.

Low-dose aspirin prevents age-related endothelial dysfunction in a mouse model of physiological aging

The age-related impairment of endothelium-dependent vasodilatation contributes to increased cardiovascular risk in the elderly. For primary and secondary prevention, aspirin can reduce the incidence of cardiovascular events in this patient population. The present work evaluated the effect of low-dose aspirin on age-related endothelial dysfunction in C57B/J6 aging mice and investigated its protective antioxidative effect. Age-related endothelial dysfunction was assessed by the response to acetylcholine of phenylephrine-induced precontracted aortic segments isolated from 12-, 36-, 60-, and 84-wk-old mice. The effect of low-dose aspirin was examined in mice presenting a decrease in endothelial-dependent relaxation (EDR). The effects of age and aspirin treatment on structural changes were determined in mouse aortic sections. The effect of aspirin on the oxidative stress markers malondialdehyde and 8-hydroxy-2'-deoxyguanosine (8-OhdG) was also quantified. Compared with that of 12-wk-old mice, the EDR was significantly reduced in 60- and 84-wk-old mice (P < 0.05); 68-wk-old mice treated with aspirin displayed a higher EDR compared with control mice of the same age (83.9 +/- 4 vs. 66.3 +/- 5%; P < 0.05). Aspirin treatment decreased 8-OHdG levels (P < 0.05), but no significant effect on intima/media thickness ratio was observed. The protective effect of aspirin was not observed when treatment was initiated in older mice (96 wk of age). It was found that low-dose aspirin is able to prevent age-related endothelial dysfunction in aging mice. However, the absence of this effect in the older age groups demonstrates that treatment should be initiated early on. The underlying mechanism may involve the protective effect of aspirin against oxidative stress.

Vieillissement: rôle et contrôle de la glycation

PURPOSE

Advanced glycation end-products (AGEs) accumulate in aging tissues and organs during rheumatoid arthritis and Alzheimer disease. These aging toxins are especially involved in cell alteration during diabetes mellitus (glycotoxin) and renal failure (uremic toxin). AGEs participate to the endothelial dysfunction leading to diabetic macro but also micro-angiopathy. AGEs binding to cell receptors are critical steps in the deleterious consequences of AGE excess. AGE-receptor activation altered cell and organ functions by a pro-inflammatory, pro-coagulant and pro-fibrosis factors cell response.

CURRENT KNOWLEDGE AND KEY POINTS

Non-enzymatic glycation and glycoxidation with glucose auto-oxidation represent the two main pathways resulting in AGE formation. No exclusive AGE classification is actually available. Pathophysiological mechanisms are described to explain AGE toxicity. AGEs bind to cell receptors inducing deleterious consequences such as endothelial dysfunction after endothelial RAGE activation. AGEs can also have deleterious effects through glycated protein accumulation or in situ protein glycation.

FUTURE PROSPECTS AND PROJECTS

Many in vitro or animal studies demonstrated that AGE deleterious effects can be prevented by glycation inhibitors, AGE cross-link breakers or AGE-RAGE interaction inhibition. New molecules are actually studied as new strategy to prevent or treat the deleterious effects of these aging toxins.

Multiple myeloma presenting with widespread osteosclerotic lesions

Sclerotic lesions are rare in malignant monoclonal gammopathies, although they are occasionally associated with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes). In most cases, osseous lesions in POEMS syndrome present as an isolated sclerotic deposit or a combination of both lytic and sclerotic lesions. Diffuse osteosclerosis is extremely rare and may lead to the diagnosis of multiple myeloma, classically known to present as lytic lesions in the skeleton, with or without diffuse osteoporosis. We report a 74-year-old woman with widespread and substantial osteosclerotic lesions, associated with IgA-lambda myeloma, and with no other criteria for POEMS syndrome, and who was rapidly diagnosed with compression of the spinal cord. Detailed knowledge of imaging features in myeloma emphasises the need to consider plasma cell neoplasm in the differential diagnosis of any pattern of bone sclerosis. Although exceptional, multiple myeloma must be borne in mind in the presence of diffuse bone sclerosis.