myHealthHub for older adult inpatients to reduce loneliness, and improve patient engagement and mental health: protocol of a pilot randomized controlled trial

OBJECTIVES

Older Canadian adults make up 85% of hospital stays which are associated with increased loneliness, stress, anxiety, and/or depression. There is a need for novel approaches to reduce loneliness and mental health outcomes in older adult hospital inpatients to prevent further strain on an already overwhelmed healthcare system.

METHODS

This is a pilot randomized controlled trial (RCT) exploring the efficacy of a bedside multimodal interaction system, myHealthHub, on loneliness, quality of life (QOL), patient engagement, and other mental health outcomes compared to an active control group in older adult inpatients (n = 60) from baseline to 5-days. Qualitative analyses will be conducted through semi-structured interviews with older adults (n = 8-10) and hospital staff, nurses, and clinicians (n = 4-5) facilitating the service to evaluate patient engagement and experience with myHealthHub.

RESULTS

Not applicable.

CONCLUSION

This novel pilot clinical trial will obtain preliminary data on the efficacy of myHealthHub in reducing loneliness, QOL, patient engagement, and mental health outcomes in older adult inpatients. If successful, this could provide a potential means to improve patient experience in hospitals and reduce the burden and additional expense on the healthcare system.

Effects of virtual reality guided meditation in older adults: the protocol of a pilot randomized controlled trial

Background

Virtual reality (VR) based meditation has been shown to help increase relaxation and decrease anxiety and depression in younger adults. However, this has not been studied in Randomized Controlled Trials (RCT) in the older adult population. The aim of this RCT is to assess the feasibility and acceptability of a VR-guided meditation intervention for community-dwelling older adults and its effect on stress and mental health.

Methods

We will recruit 30 participants aged ≥ 60 years, whose perceived stress score (PSS) is > 14 (moderate stress), and randomize them 1:1 to the intervention or control waitlist group. The intervention will involve exposure to eight 15-min VR-guided meditation sessions distributed twice weekly for 4-weeks. Two modalities will be offered: in-home and at the hospital.

Data analysis

Baseline and post-intervention assessments will evaluate perceived stress, anxiety, depression, sleep quality, quality of life, and mindfulness skills. Analyses will employ mixed methods repeated ANOVA tests. Qualitative analyses through semi-structured interviews and participant observation will be used to assess participants' experiences. Study outcomes include: (A) feasibility and acceptability compared to a waitlist control (B) stress, using the Perceived Stress Scale (PSS); (C) anxiety, and depression, using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9); (D) insomnia, quality of life and mindfulness skills, using the Athens Insomnia Scale (AIS), Quality of Life Questionnaire (EQ-5D-5L) and Five Facets Mindfulness Questionnaire Short Forms (FFMQ-SF), respectively. We will also measure immersive tendencies, sickness and sense of presence using the Simulator Sickness Questionnaire (SSQ) and the Presence Questionnaire (PQ).

Discussion

Virtual reality-guided meditation could be an acceptable, feasible, safe, and cost-effective novel alternative health intervention for improving older adults' mental health.Clinical trial registration: NCT05315609 at https://clinicaltrials.gov.

Alzheimer's early detection in post-acute COVID-19 syndrome: a systematic review and expert consensus on preclinical assessments

Introduction

The risk of developing Alzheimer's disease (AD) in older adults increasingly is being discussed in the literature on Post-Acute COVID-19 Syndrome (PACS). Remote digital Assessments for Preclinical AD (RAPAs) are becoming more important in screening for early AD, and should always be available for PACS patients, especially for patients at risk of AD. This systematic review examines the potential for using RAPA to identify impairments in PACS patients, scrutinizes the supporting evidence, and describes the recommendations of experts regarding their use.

Methods

We conducted a thorough search using the PubMed and Embase databases. Systematic reviews (with or without meta-analysis), narrative reviews, and observational studies that assessed patients with PACS on specific RAPAs were included. The RAPAs that were identified looked for impairments in olfactory, eye-tracking, graphical, speech and language, central auditory, or spatial navigation abilities. The recommendations' final grades were determined by evaluating the strength of the evidence and by having a consensus discussion about the results of the Delphi rounds among an international Delphi consensus panel called IMPACT, sponsored by the French National Research Agency. The consensus panel included 11 international experts from France, Switzerland, and Canada.

Results

Based on the available evidence, olfaction is the most long-lasting impairment found in PACS patients. However, while olfaction is the most prevalent impairment, expert consensus statements recommend that AD olfactory screening should not be used on patients with a history of PACS at this point in time. Experts recommend that olfactory screenings can only be recommended once those under study have reported full recovery. This is particularly important for the deployment of the olfactory identification subdimension. The expert assessment that more long-term studies are needed after a period of full recovery, suggests that this consensus statement requires an update in a few years.

Conclusion

Based on available evidence, olfaction could be long-lasting in PACS patients. However, according to expert consensus statements, AD olfactory screening is not recommended for patients with a history of PACS until complete recovery has been confirmed in the literature, particularly for the identification sub-dimension. This consensus statement may require an update in a few years.

Isolating together during COVID-19: Results from the Telehealth Intervention Program for older adults

Background

A pressing challenge during the COVID-19 pandemic and beyond is to provide accessible and scalable mental health support to isolated older adults in the community. The Telehealth Intervention Program for Older Adults (TIP-OA) is a large-scale, volunteer-based, friendly telephone support program designed to address this unmet need.

Methods

A prospective cohort study of 112 TIP-OA participants aged ≥60 years old was conducted in Quebec, Canada (October 2020–June 2021). The intervention consisted of weekly friendly phone calls from trained volunteers. The primary outcome measures included changes in scores of stress, depression, anxiety, and fear surrounding COVID-19, assessed at baseline, 4 and 8-weeks. Additional subgroup analyses were performed with participants with higher baseline scores.

Results

The subgroup of participants with higher baseline depression scores (PHQ9 ≥10) had significant improvements in depression scores over the 8-week period measured [mean change score = −2.27 (±4.76), 95%CI (−3.719, −0.827), p = 0.003]. Similarly, participants with higher baseline anxiety scores (GAD7 ≥10) had an improvement over the same period, which, approached significance (p = 0.06). Moreover, despite peaks in the pandemic and related stressors, our study found no significant (p ≥ 0.09) increase in stress, depression, anxiety or fear of COVID-19 scores.

Discussion

This scalable, volunteer-based, friendly telephone intervention program was associated with decreased scores of depression and anxiety in older adults who reported higher scores at baseline (PHQ 9 ≥10 and GAD7 ≥10).

Implementing a Telehealth Support Tool for Community-Dwelling Older Adults During the COVID-19 Pandemic: A Qualitative Investigation of Provider Experiences

During the COVID-19 pandemic, policymakers had to quickly offer telehealth services to address older adults' needs. This study aimed to understand the experiences of providers who implemented a telephone-based telehealth tool named Socio-Geriatric Evaluation (ESOGER), which assessed health and social isolation risks in community-dwelling older adults in Quebec (Canada). This qualitative study used 20 semi-structured online/phone interviews with health and social service providers coming from publicly-funded healthcare facilities and community organizations. We included adopters and non-adopters of the telehealth tool. Interviews were audio-recorded and transcribed verbatim. We used reflexive thematic analysis to interpret the data. Three dimensions of providers' practice influenced the tool's implementation: service organization, working conditions, and interactions with older adults. Participants reported that the tool fostered continuity of care, provided guidance for their pandemic-related new tasks, and helped identify and support socially isolated older adults. Challenges to implementation included limited appropriateness of the telehealth tool for diverse services, feasibility barriers to adopting a new tool amid the health crisis, and acceptability challenges with some older adults. Despite relevance of the telehealth tool for providers, organizational, professional, and interactional barriers could hinder implementation success. Participatory approaches to telehealth may be promising avenues for future policies in this field.

Telemedicine and the rural dementia population: A systematic review

BACKGROUND

Telemedicine is a timely solution for the restrictions that COVID-19 social distancing places upon conventional modalities of healthcare provision. Geriatric populations affected by dementia require greater access to healthcare services, particularly in rural areas. As such, the aim of this systematic review is to examine the impact of telemedicine on health outcomes in elderly individuals with dementia living in rural areas.

METHODS

A systematic review was completed using Ovid Medline, Web of Science and ACM Digital Libraries. The keywords for the selection of articles were: (telemedicine OR Telehealth) AND (Rural) AND (Age* OR Eld*) AND (Dementia) and (Telemedicine) AND (Rural Health OR Rural Population OR Hospitals, Rural OR Rural Health Services) AND (Aged OR Aging) AND (Dementia OR Multi-Infarct Dementia OR Vascular Dementia OR Frontotemporal Dementia). Among the 94 articles identified, 79 (84.0 %) were screened, 58 (61.7 %) were assessed and 12 (12.8 %) were included.

RESULTS

The studies had diverse populations. Two were conducted in Australia, five in Canada, one in Korea, and four in the United States of America. The studies used a variety of cognitive tests and reported mixed results regarding the differences in patient performance when assessed in-person as compared to telemedicine consultation. Overall, both patients and physicians reported satisfaction with telemedicine; however, there were mixed results regarding the reliability of cognitive tests and the infrastructure required. Convenience, satisfaction, comfort and recommending telemedicine were reported to be high in the telemedicine group and physicians reported they would use telemedicine again.

CONCLUSION

The testing conditions and the accessibility of telemedicine yield inconclusive results as to whether telemedicine can improve the management of dementia in geriatric individuals.

Connecting During COVID-19: A Protocol of a Volunteer-Based Telehealth Program for Supporting Older Adults' Health

Introduction: Social-distancing due to COVID-19 has led to social isolation, stress, and mental health issues in older adults, while overwhelming healthcare systems worldwide. Telehealth involving phone calls by trained volunteers is understudied and may be a low-cost, scalable, and valuable preventive tool for mental health. In this context, from patient participatory volunteer initiatives, we have adapted and developed an innovative volunteer-based telehealth intervention program for older adults (TIP-OA). Methods and analysis: To evaluate TIP-OA, we are conducting a mixed-methods longitudinal observational study. Participants: TIP-OA clients are older adults (age ≥ 60) recruited in Montreal, Quebec. Intervention: TIP-OA volunteers make weekly friendly phone calls to seniors to check in, form connections, provide information about COVID-19, and connect clients to community resources as needed. Measurements: Perceived stress, fear surrounding COVID-19, depression, and anxiety will be assessed at baseline, and at 4- and 8-weeks. Semi-structured interviews and focus groups will be conducted to assess the experiences of clients, volunteers, and stakeholders. Results: As of October 15th, 2020, 150 volunteers have been trained to provide TIP-OA to 305 older clients. We will consecutively select 200 clients receiving TIP-OA for quantitative data collection, plus 16 volunteers and 8 clinicians for focus groups, and 15 volunteers, 10 stakeholders, and 25 clients for semi-structured interviews. Discussion: During COVID-19, healthcare professionals' decreased availability and increased needs related to geriatric mental health are expected. If successful and scalable, volunteer-based TIP-OA may help prevent and improve mental health concerns, improve community participation, and decrease healthcare utilization. Clinical Trial Registration: ClinicalTrials.gov NCT04523610; https://clinicaltrials.gov/ct2/show/NCT04523610?term=NCT04523610&draw=2&rank=1.

[Year in review : geriatrics]

In 2018, new recommendations about the prevention of falls and fractures emphasized the benefits from exercise and from multimodal prevention programs but did not endorse any more vitamin D supplementation for falls prevention. Results were contrasted for several studies testing exercise (negative) and cognitive training (mixed results) in the management of older patients suffering from neurocognitive disorders. The new direct oral anticoagulants are increasingly prescribed in older patients despite the paucity of data. New information has been released in 2018 from « real-world » data that seem reassuring about their risk/benefit ratio in old-old patients, provided a careful prescription. Finally, the Mediterranean diet is still gaining credit with a new study showing its benefits in preventing frailty in community-dwelling older persons.

[Cognitive remediation therapy for children: literature data and clinical application in a child and adolescent psychiatry department]

The hypothesis of cerebral plasticity in psychiatric disorders has encouraged clinicians to develop cognitive remediation therapy (CRT), a new therapeutic approach based on attention, memory, planning, and mental flexibility tasks. The first cognitive remediation programs were developed and validated for adults with schizophrenia and were shown to have a positive impact on executive functions as well as on quality of life. In children and adolescents, researchers emphasized the existence of executive dysfunction in neurodevelopmental disorders such as autistic spectrum disorder, attention deficit disorder, and eating disorders. For these disorders, neuropsychological studies suggest that memory, planning, attention and mental flexibility are impaired. Despite the paucity of studies on cognitive remediation (CR) in children, preliminary results have suggested, as in adults with schizophrenia, good compliance and optimization of executive functioning. Consequently, programs dedicated to young subjects were developed in English-speaking countries, and the Department of Child and Adolescent Psychiatry of Sainte Anne Hospital (Paris) developed a new CR program for children with attention deficit disorder, academic problems, or eating disorders. These programs complete the field of CRT proposed by Sainte Anne Hospital's Remediation and Psychosocial Rehabilitation Reference Center, initially designed for adults with schizophrenia. Our team used and adapted validated tools such as Delahunty and Wykes's CRT program (translated and validated in French by Amado and Franck) and Lindvall and Lask's CRT Resource Pack. One program was developed for an adolescent with anorexia nervosa and applied to the subject and her family, but the purpose of this paper is to present a CR approach for children with attention deficit disorder or academic disorder, a 6-month program based on paper-pencil tasks and board and card games. The team was trained in different kinds of cognitive remediation, and the program was applied by a clinical nurse with the supervision of a child and adolescent psychiatrist and the department's neuropsychologists. Paper-pencil tasks were adapted from the CRT program for adults; the card and board games used were geometric figures, illusions, Rush Hour(®), Set(®), Jungle Speed(®), Color Addict(®), etc. These games are available in stores and the program can be applied at home, which helps families set aside their preoccupations with their child's academic performance. Diagnostic and neuropsychological evaluations were done before the beginning of the therapy and repeated at the end of the 6-month program. This program does not ignore the metapsychological impact of the therapy, and work on self-esteem is also done. The presence of the therapist is necessary, which seems better than a computer program, which cannot encourage the young subject in the same personalized and empathetic way. We therefore conducted the first clinical feasibility trial of cognitive remediation in young subjects and present a clinical case of a 6-year-old boy with attention deficit disorder and academic disorder. The results of neuropsychological evaluations before and after therapy suggest improvement in executive functions and better self-esteem. Satisfaction for the boy and his family was high. Even if these results need to be replicated, cognitive remediation appears to be a new therapeutic tool, complementary to classical approaches used in childhood psychiatric disorders. The Department of Child and Adolescent Psychiatry will submit this program to a research program conducted by the National Health Department to study the impact of this approach in a controlled study.

Do not resuscitate orders and aging: impact of multimorbidity on the decision-making process

BACKGROUND

The "Do Not Resuscitate" orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients.

METHODS

A systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: "resuscitation orders" OR "do-not-resuscitate" combined with "aged, 80 and over" combined with "comorbidities" OR "chronic diseases".

RESULTS

Of the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19-1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07-1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08-3.20) for cancer, OR=1.07 (95% CI: 0.92-1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61-2.40) for stroke.

CONCLUSIONS

This systematic review and meta-analysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.

Physical training-related changes in gait variability while single and dual tasking in older adults: magnitude of gait variability at baseline matters

OBJECTIVES

Few studies have examined the effects of physical training programs on gait variability while single and dual tasking, and they reported mixed results. The aim of this study was to compare the stride time variability while single and dual tasking before and after a physical training program developed to improve gait stability in French community-dwelling older adults.

DESIGN

A prospective pre-post interventional cohort study.

SETTING

The community-dwelling area of "Pays de la Loire", France.

POPULATION

Forty-eight older adults (mean age ± standard deviation 72.2±8 years; 75% female).

METHODS

Physical training program consisted in 12 sessions scheduled to attend physical exercises 1 time a week with total time duration of 3 months. Coefficient of variation (CoV) of stride time under three walking conditions (i.e., walking alone, walking while backward counting, and while performing a verbal fluency task) was determined while steady-state walking using the SMTEC® footswitches system before and after the physical training program. Participants were separated into two groups based on being or not in the highest tertile (i.e., worst performance with cutpoint >4.4%) of the CoV of stride time while walking alone.

RESULTS

After physical training compared to before period, a significant decrease in CoV of stride time (i.e., better gait performance) while walking alone (2.8±2.8% versus 7±7.1%, P=0.001) but not while dual tasking (P=0.600 for counting backward and P=0.105 for verbal fluency task) was shown in participants who had highest (i.e., worst) gait variability at baseline. In addition, physical training modified the strategy of dual tasking in participants with highest gait variability at baseline compared to the other participants. Before training, a significant decrease in CoV of stride time (7±7.1% versus 4.9±4.6%, P=0.017) while counting backward was shown, but there was a significant increase after training (2.8±2.8% versus 5.4±5.8%, P=0.007).

CONCLUSIONS

Physical training reduced gait variability while walking alone in participants with gait instability, and influenced their strategy for dual tasking.

CLINICAL REHABILITATION IMPACT

Physical program training developed in the community to improve gait stability should included participants with high gait variability.

Effects on performance of ground wheat with or without insoluble fiber or whole wheat in sequential feeding for laying hens

Sequential feeding (SF) is an innovative system for laying hens consisting of nutrients separating energy, protein, and calcium supplies to fulfill nutrient requirements at the relevant time of day. In previous studies, hens received whole wheat in the morning and a balancer diet (rich in protein and calcium) in the afternoon. To improve SF utilization, the aim was to substitute whole wheat in the morning by an alternative energy supply: ground wheat and ground corn, with or without a proportion of whole wheat and insoluble fiber. The goal was to obtain the advantages observed in previous experiments with whole wheat [bigger gizzard, thinner hens, reduced feed conversion ratio (FCR)]. Four hundred thirty-two ISA Brown hens were housed in collective cages from 20 to 35 wk of age divided into 8 different treatments: a continuous control diet, a sequential diet with whole wheat in the morning, 3 wheat-based diets (ground wheat, ground wheat and 20% whole wheat, and ground wheat with 5% insoluble fiber) and 3 ground corn-based (ground corn, ground corn and 20% whole wheat, and ground corn with 5% insoluble fiber) provided in the morning. All sequential regimens received the same balancer diet rich in protein and calcium in the afternoon. Whole wheat SF gave the best results with an improved FCR compared with continuous control and all other SF diets. Wheat- and corn-based diets showed intermediate results between whole wheat SF and continuous feeding. Gizzard weight was higher and hens were lighter than with conventional continuous feeding, leading to an average FCR improvement of 3.2% compared with a continuous control. Thus, it is possible in SF diets to substitute, at least partially, whole wheat by ground wheat or ground corn with added insoluble fiber or some whole wheat, allowing more flexibility and economic optimization.

Je joue donc je pense : remédiation cognitive chez lesenfants au Centre Hospitalier Sainte-Anne

L’intérêt de la remédiation cognitive (RC) s’appuie sur l’observation de défaillances des fonctions exécutives dans de nombreux troubles psychiatriques. L’hypothèse est celle d’une restructuration cognitive du fait de la plasticité cérébrale et de la possibilité de remaniements cellulaires neurologiques stimulo-dépendants. Chez les enfants et les adolescents, des essais ont été réalisés chez des sujets cérébro-lésés et chez des sujets présentant un trouble déficit de l’attention/hyperactivité, un trouble du spectre autistique, un trouble des apprentissages ou une anorexie mentale [2–5]. Les programmes de remédiation cognitive s’appuient sur des tâches informatisées ou papier–crayon ou sur des jeux de société ciblant les déficits des fonctions exécutives. Le Centre Hospitalier Sainte-Anne a développé, depuis 2010, un centre psychiatrique de référence de remédiation cognitive et de réhabilitation psychosociale (C3RP) qui propose à des sujets adultes des programmes de Cognitive Remediation Therapy (CRT) [1]. En outre, depuis 2011, notre équipe réalise un travail clinique préliminaire de faisabilité en proposant à des enfants, en complément d’approches classiques appliquées en routine (rééducatives et/ou psychothérapiques), une prise en charge en RC. Nous utilisons des tâches « papier–crayon » de la CRT adaptées à l’enfant ainsi que des jeux de société issus des programmes anglo-saxons qui permettent à l’enfant d’utiliser différentes ressources cognitives. Notre but est d’améliorer les performances cognitives de ces enfants dans les domaines suivants : la flexibilité mentale, l’attention, la mémoire et la planification ainsi que l’estime de soi. Une évaluation neuropsychologique incluant un WISC-IV ; une figure de Rey et des sub-tests de la NEPSY mettent en avant des résultats prometteurs, illustrés par une vignette clinique portant sur un enfant qui a fait de nets progrès dans quatre dimensions sur cinq ciblées (Fig. 1). Ces résultats doivent être étendus à d’autres patients et sur d’autres centres pour envisager la généralisation de cette approche.

Fig. 1

Gait variability at fast-pace walking speed: a biomarker of mild cognitive impairment?

BACKGROUND

The interpretation of the increase in stride-to-stride variability of stride time (STV) regarding the evolution of cognitive deficits across the dementia spectrum is matter of debate.

OBJECTIVE

The aim of this study was to compare STV at usual and fast-pace walking speeds of MCI patients with that of cognitively healthy individuals (CHI) and Alzheimer's disease (AD) patients with mild dementia, while considering the effects of potential confounders.

METHODS

STV while walking at usual and fast-pace walking speeds was recorded with the GAITRite® system from 116 older adults (mean age 75.6±6.5 years; 55.2% female) divided into 3 groups according to their cognitive status (44 CHI, 39 MCI patients and 33 AD patients with mild dementia).

RESULTS

The full adjusted multiple linear regression models showed that high STV was associated with slow gait speed at usual-pace walking speed (P=0.002) and with the MCI status at fast-pace walking speed (P=0.015).

CONCLUSIONS

High STV at fast-pace walking speed was a specific gait disturbance of MCI patients in the sample of studied participants, and thus could be used in the future as a specific biomarker of MCI patients.

Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review

BACKGROUND

Screening of depressive symptoms is recommended in recurrent fallers. Compared to the 30-item and 15-item Geriatric Depression Scales (GDS), the 4-item GDS is easier to administer and quicker to perform. The association between abnormal 4-item GDS score and recurrent falls has not yet been examined. In addition, while depressive symptoms-related gait instability is well known, the association with recurrent falls has been few studied.

OBJECTIVE

1) To examine the association between abnormal 4-item GDS score and recurrent falls in community-dwelling older adults using original data from health examination centers (HEC) of French health insurance of Lyon, and 2) to perform a systematic review of studies that examined the association of depressive symptoms with recurrent falls among older adults.

METHODS

Firstly, based on a cross-sectional design, 2,594 community-dwellers (mean age 72.1±5.4years; 49.8% women) were recruited in HEC of Lyon, France. The 4-item GDS score (abnormal if score≥1) and recurrent falls (i.e., 2 or more falls in the past year) were used as main outcomes. Secondly, a systematic English and French Medline literature search was conducted on May 28, 2012 with no limit of date using the following Medical Subject Heading (MeSH) terms "Aged OR aged, 80 and over", "Accidental falls", "Depressive disorder" and "Reccurence". The search also included the reference lists of the retrieved articles.

RESULTS

A total of 19.0% (n=494) participants were recurrent fallers in the cross-sectional study. Abnormal 4-item GDS score was more prevalent among recurrent fallers compared to non-recurrent fallers (44.7% versus 25.0%, with P<0.001), and was significantly associated with recurrent falls (Odd ratio (OR)=1.82 with P<0.001 for full model; OR=1.86 with P<0.001 for stepwise backward model). In addition to the current study, the systematic review found only four other studies on this topic, three of them examining the association of depressive symptoms with recurrent falls using 30-item or 15-item GDS. All studies showed a significant association of depressive symptoms with recurrent falls.

CONCLUSIONS

The current cross-sectional study shows an association between abnormal 4-item GDS score and recurrent falls. This association of depressive symptoms with recurrent falls was confirmed by the systematic review. Based on these results, we suggest that recurrent falls risk assessment should involve a systematic screening of depressive symptoms using the 4-item GDS.

Who is at risk of long hospital stay among patients admitted to geriatric acute care unit? Results from a prospective cohort study

OBJECTIVE

(1) To confirm that vitamin D deficiency, defined as serum 25-hydroxyvitamin D (25OHD) concentration < 25 nmol/L, was associated with long length-of-stay (LOS) among older inpatients admitted to geriatric acute care unit; and (2) to examine which combination of risk factors of longer LOS including vitamin D deficiency best predicted longer LOS.

STUDY DESIGN AND SETTING

Based on a prospective cohort study with a 25-day follow-up on average, 531 consecutive older inpatients (mean age 85.0±7.2 years, 59.1% women) admitted to the geriatric acute care unit of Angers University Hospital, France, were included.

RESULTS

Linear regression models showed that male gender (P<0.025), delirium (P<0.015) and vitamin D deficiency (P<0.001) were independently associated with a longer LOS. The highest risk of a longer LOS was shown while combining vitamin D deficiency with male gender (Odds ratio (OR)=3.70 with P< 0.001). The risk increased significantly while delirium was associated with these two baseline characteristics (OR=4.76 with P=0.001). Kaplan-Meier distributions of discharge differed significantly between participants who had or not the combination of the 3 criteria (P<0.007).

CONCLUSIONS

Vitamin D deficiency, delirium and male gender were significant risk factors for a longer LOS in the studied sample of older inpatients.

Derivation and validation of a Short Form of the Mini-Mental State Examination for the screening of dementia in older adults with a memory complaint

BACKGROUND AND PURPOSE

To validate a Short Form of the Mini-Mental State Examination (SMMSE) as a screening test for dementia in older ambulatory individuals followed in a memory clinic for a memory complaint.

METHODS

A total of 202 cognitively healthy individuals, 100 individuals with a mild cognitive impairment and 304 demented individuals sent for a memory complaint by their primary care physician to a memory clinic were prospectively included in this cross-sectional study. They were randomized into derivation (n = 303) and validation (n = 303) groups. The SMMSE score was built from six memory items of MMSE, with a score ranging from 0 to 6 (i.e. best performance).

RESULTS

The receiver operating characteristic curve showed an area under the curve of 0.98 for the derivation group and 0.97 for the validation group without differences between curves (P = 0.254). The cut-off between the sensitivity and the specificity of the SMMSE score for clinically diagnosed dementia was ≤4. The performance of the SMMSE for the diagnosis of dementia was high in the derivation and validation groups: sensitivity at 93.1% and 93.8%, specificity at 93.8% and 90.5%, positive predictive value at 94.3% and 90.1%, negative predictive value at 92.5% and 94.0%, likelihood ratio of positive test at 14.9 and 9.8 and of negative test at 0.07 and 0.07, respectively.

CONCLUSIONS

The Short Form of the Mini-Mental State Examination was a good screening test for dementia in older individuals followed in a memory clinic for a memory complaint. The next step should be the confirmation of its discriminative value in older primary care patients.

Development of a short form of Mini-Mental State Examination for the screening of dementia in older adults with a memory complaint: a case control study

Background

Primary care physicians need a brief and accurate screening test of dementia. The objective of this study was to determine whether a short form of Mini-Mental State Examination (SMMSE) was as accurate as the Mini-Mental State Examination (MMSE) in screening dementia.

Methods

Based on case control design study, SMMSE and MMSE were assessed in 184 community-dwelling older adults (mean age 81.3 ± 6.5 years, 71.7% women) with memory complaint sent by their primary care physician to a memory clinic. Included participants were separated into two groups: cognitively healthy individuals and demented individuals.

Results

The trade-off between sensitivity and specificity of the SMMSE for clinically diagnosed dementia was 4. Based on the cut-off value ≤ 4 for SMMSE and a cut-off value ≤ 24 for MMSE, the sensitivity of both tests was similar (89.5% for SMMSE versus 90.0% for MMSE), whereas the specificity, the positive predictive values (PPV) and the negative predictive values (NPV) were higher for SMMSE compared to MMSE (85.4 versus 75.5% for specificity; 95.5% versus 92.8% for PPV; 70.0 versus 68.9 for NPV). The positive and negative Likehood Ratio (LR) of SMMSE were higher than those of MMSE (respectively, 6.1 versus 3.7; 8.1 versus 7.7). In addition, odds ratio (OR) for dementia was higher for the SMMSE compared to the MMSE (OR = 49.8 with 95% confident interval (CI) [18.0; 137.8] versus OR = 28.6 with 95% CI [11.6; 70.3]).

Conclusions

SMMSE seems to be an efficient short screening test for dementia among community-dwelling older adults with a memory complaint. Further research is needed to confirm its predictive values among unselected primary care older patients.

Analyse du profil socio-démographique et clinique de patients schizophrènes en fonction du traitement neuroleptique reçu

INTRODUCTION

Data concerning the characteristics of patients with schizophrenia and their treatment in day hospitals are scarce. Guidelines for clinical practice are, however, regularly published. Recommendations from the 1994 Consensus Conference underline the necessity of antipsychotic monotherapy in the long term treatment of schizophrenia. In the US the Schizophrenia Patient Outcome Research Team (PORT) published in 1999 treatment recommendations concerning the use of antipsychotics in the acute phase and in maintenance. For maintenance, the recommended dose should be between 300 and 600 mg/day (CPZ equivalents) (recommendation n 4).

AIM OF THE STUDY

The aim of this study is to establish the socio-demographic and clinical profile of patients according to the dose of antipsychotic medication prescribed. The study also examines the use of antipsychotic polypharmacy.

DESIGN

of the study. For this study, 116 patients treated in 12 different day hospital units were recruited. Inclusion criteria were: a DSM IV diagnosis of schizophrenia, being treated in a day hospital and having received antipsychotic medication for at last 2 months. Instruments were the MINI for a standardized diagnosis of schizophrenia, the CGI and the PANSS. Prescribed doses were transformed in chlorpromazine (CPZ) equivalents, in order to establish comparisons between patients.

RESULTS

The population sample was composed of 72 male (61.5%) and 44 female (38.5%) patients. The mean age was 36.4 years old. The mean education level was 11.3 years. A large majority (n=103, 88%) of patients was celibate, 65 patients (55.6%) lived on their own, the others lived with their family (45 patients, 38.5%) or with a spouse (7 patients, 6%). A large majority of patients (75.6%) received some form of state allowance. Only 1.7% were receiving a salary. The mean antipsychotic dose was 660 mg/day and 68% of patients were treated with an atypical antipsychotic (amisulpride, clozapine, olanzapine, risperidone). Thirty-two percent of patients were treated with doses between 600 and 1,000 mg/day and 24% with doses above 1,000 mg/day. When comparing patients according to the dose level they were receiving (<300 mg/day; 300 to 599 mg/day; and 600 to 999 mg/day;>1,000 mg/day), there was no significant difference between groups for socio-demographic variables. Patients treated with doses below 300 mg/day had a better psychosocial profile and were more often treated with loxapine, haloperidol and risperidone. Patients treated with doses above 1,000 mg/day were more often receiving clozapine. There was still a substantial number of patients treated with conventional antipsychotics in the above 1,000 mg/day range. Patients receiving an antipsychotic monotherapy were more often treated with clozapine or olanzapine and presented a higher rate of positive symptoms.

DISCUSSION

These results are discussed in comparison with present guidelines concerning the treatment of patients with schizophrenia.

[In vitro activity of pristinamycin against Streptococcus pneumoniae]

The activity of the pristinamycin was investigated using disk diffusion agar or ATB PNEUMO system and MIC determination using reference liquid medium method (NCCLS) on 749 S. pneumoniae strains isolated in Aquitaine in 1999. We have realized the killing curves against 10 isolates selected from erythromycin-susceptible and resistant S. pneumoniae strains. All the strains tested by ATB PNEUMO system were susceptible to pristinamycin, using disk diffusion agar, 6.8% of strains were intermediate or resistant. However the MIC's of pristinamycin determined by liquid dilution method against these strains were < 1 mg/L. These data suggest that the zone of inhibition around the disk was not correlated with MIC for erythromycin pneumococci and MIC testing must be performed. The results of killing curves showed a very good and rapid bactericidal activity of pristinamycin within two hours for concentration equal to 4 x MIC and four hours for 2 x MIC.

A truncated FGF receptor blocks neural induction by endogenous Xenopus inducers

We have examined the role of fibroblast growth factor (FGF) signalling in neural induction. The approach takes advantage of the fact that both noggin and the dominant negative mutant activin receptor (delta1XAR1) directly induce neural tissues in the absence of dorsal mesoderm. A truncated FGF receptor (XFD) is co-expressed with noggin or delta1XAR1 in both whole embryos and isolated animal caps. We demonstrate that inhibition of FGF signalling prevents neural induction by both factors. Furthermore, neural induction by organizers (the dorsal lip of blastopore and Hensen's node) is also blocked by inhibiting FGF signalling in ectoderm. It has been proposed that the specification of anterior neuroectoderm, including the cement gland, occurs in a sequential manner as gastrulation proceeds. We show that the specification of the most anterior neuroectoderm by noggin may occur before gastrulation and does not require FGF signalling, since both the cement gland marker XCG-1 and the anterior neural marker Otx-2 are normally expressed in ectodermal explants co-injected with noggin and XFD RNAs, but the cement gland cells are poorly differentiated. In contrast, the expression of both genes induced by CSKA.noggin, which is expressed after the mid-blastula transition, is strongly inhibited by the presence of XFD. Therefore the noggin-mediated neural induction that takes place at gastrula stages is abolished in the absence of FGF signalling. Since inhibition of FGF signalling blocks the neuralizing effect of different neural inducers that function through independent mechanisms, we propose that FGF receptor-related-signalling is required for the response to inducing signals of ectodermal cells from gastrula.

Nafadotride, a potent preferential dopamine D3 receptor antagonist, activates locomotion in rodents

Nafadotride (N[(n-butyl-2-pyrrolidinyl)methyl]-1-methoxy-4-cyano naphtalene-2-carboxamide) is a novel compound, which inhibits potently and stereoselectively [125I]iodosulpride binding at recombinant human dopamine D3 receptors. the levoisomer displays an apparent Ki value of 0.3 nM at the dopamine D3 receptor, but is 10 times less potent at the human recombinant dopamine D2 receptor. In comparison, the dextroisomer displays 20-fold less apparent affinity at the dopamine D3 receptor and reduced (2-fold) selectivity. l-Nafadotride displays iow, micromolar affinity at dopamine D1 and D4 receptors and negligible apparent affinity at various other receptors. In dopamine D3 receptor-transfected NG-108 15 cells, in which dopamine agonists increase mitogenesis, l-nafadotride has no intrinsic activity, but competitively antagonizes the quinpirole-induced mitogenetic response, monitored by [3H]thymidine incorporation with a pA2 of 9.6. In dopamine D2 receptor-transfected Chinese Hamster Ovary cells, l-nafadotride also behaves as a competitive antagonist of quinpirole-induced mitogenesis with an 11-fold lower potency. These studies establish nafadotride as a pure, extremely potent, competitive and preferential dopamine D3 receptor antagonist in vitro. l-Nafadotride displaces in vivo N-[3H]propylnorapomorphine accumulation at lower dosage and for longer periods in limbic structures, containing both dopamine D2 and D3 receptors than in the stratum, containing dopamine D2 receptor only. At low dosage (0.1-1 mg/kg), nafadotride, unlike haloperidol, a dopamine D2 receptor-preferring antagonist, increases spontaneous locomotion of habituated rats and climbing behavior of mice, at doses that do not modify striatal homovanillic acid levels. At high dosage (1-100 mg/kg), nafadotride, like haloperidol, produces catalepsy and antagonizes apomorphine-induced climbing.(ABSTRACT TRUNCATED AT 250 WORDS)

[Initiating thymoregulator treatment]

It is currently agreed that starting a lithium therapy is justified, as soon as the evolution of recurrent affective disorder is evident, by: the occurrence of an acute depressive episode during the four years preceding the current acute episode, that is to say 2 obvious acute episodes within 5 years which is enough to make highly probable a new acute short or medium dated episode; an acute manic episode caused by the high level of recurrence in bipolar patients and the frequent severe congruencies of an acute manic episode. The prophylactic efficacy of the lithium salts has been proved by several placebo-controlled studies: the result of these trials states that with placebo the recurrence level varies between 38% and 93%, whereas with lithium it is between 0% and 44%. The controlled trials in the sixties and seventies have made evident that about 1/3 of bipolar patients do not respond to lithium, the results varying according to the selection tests, the duration of the observation, the definition of the failure. We'll address three up to date questions. 1) Whereas the level of the lithium therapy is rather well established (0.6 to 1 mEq/l) and is of a great preventive efficacy with patients that are maintained in the high zone of the therapy scale, the present question is to know if it is necessary to split up the dose of lithium or to administer the daily dose in a single dose in the evening.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative analysis of the tissue distribution of three fibroblast growth factor receptor mRNAs during amphibian morphogenesis

We have used in situ hybridization to survey the expression pattern of three fibroblast growth factor receptor (FGFR) mRNAs (PFR-1, PFR-3 and PFR-4, which we previously identified as the amphibian Pleurodeles waltl homologs of human FGFR-1, FGFR-3 and FGFR-4, respectively) during morphogenesis. Previous work suggests that these FGFR mRNAs exhibit a distinct pattern of expression at early developmental stages. In the present study we have tested the functional activity of these receptors and shown that both FGF-1 (acidic FGF) and FGF-2 (basic FGF), but not FGF-7 (keratinocyte growth factor), can lead to their activation, suggesting that the three cDNAs encode functional receptors. Results from in situ hybridization indicate that various FGFRs are involved in various developmental events. Their involvement in these processes is both overlapping and distinct. During the differentiation of the central nervous system (CNS), PFR-1 and PFR-4 mRNAs show high levels of redundant expression, while the sites of expression of PFR-3 mRNA correlate with regions, such as the diencephalon and the rhombencephalon, undergoing important anatomic changes. The three FGFR mRNAs are distinctly expressed in the cranial ganglia, the pigmented epithelia of retina and the otic vesicles. Most significantly, we found that they are strongly expressed at cranial and branchial mesenchymal condensation sites. PFR-3 mRNA is expressed earlier in this process than PFR-1 and PFR-4 mRNAs. Furthermore PFR-3 mRNA is detected in the mesenchyme of the limb bud, while PFR-1 and PFR-4 mRNAs are found in the primordia of the skeletal elements. In addition, PFR-1 mRNA is expressed in axial mesenchyme and PFR-4 mRNA is detected in the melanophores, xanthophores and in the pronephros. These results suggest that various FGFRs may be involved in distinct developmental events including cell proliferation and differentiation. We also discuss the functional redundancy of the FGFR system during amphibian morphogenesis.

Expression of fibroblast growth factor receptor-2 splice variants is developmentally and tissue-specifically regulated in the amphibian embryo

There is increasing evidence that distinct fibroblast growth factor receptor (FGFR) genes are involved in embryonic development and that unique expression patterns of individual FGFRs correlate with tissue-specific functions. In addition, alternative splicing of mRNA transcripts from at least two of these genes (FGFR-1 and FGFR-2) can generate receptor variants with different ligand-binding specificity. By polymerase chain reaction methods and by screening a cDNA library, we have isolated five amphibian FGFR-2 splice variants which share a high degree of identity to their human counterparts. These mRNAs are developmentally regulated and are expressed in a tissue-specific manner. In particular, two alternative exons (termed IIIb and IIIc) in the second half of the third immunoglobulin-like loop are remarkably conserved and have a distinct pattern of regulation during development. Either aFGF or bFGF can activate IIIb- or IIIc-containing receptors. In contrast, KGF only activates IIIb-containing receptors. Exon IIIb-containing receptors are maternally derived mRNAs, whereas exon IIIc-containing receptors are zygotically expressed. Furthermore, their tissue distribution pattern was mutually exclusive. From the beginning of the neurula stage onward, IIIb transcripts are expressed in the epidermis, while IIIc transcripts are activated in the neuroectoderm by neural induction. At the late tail-bud stage, in situ hybridization revealed expression of IIIc mRNA in the telencephalon and the diencephalon, as well as in the head mesenchyme condensation sites originating from the proliferating neural crest cells. IIIb mRNA was detected in the epidermis and in the epithelium of the pharynx. Our data suggest that exon IIIb-containing receptors may play a role in the development of epithelial tissues, while exon IIIc-containing receptors may play a role during neural tissue formation.

Isolation and developmental expression of the amphibian homolog of the fibroblast growth factor receptor 3

Recent observations suggest that fibroblast growth factors (FGFs) and their receptors are involved in the control of embryogenesis. Several FGF receptor genes have been identified so far and their expression is differentially regulated. As part of a continuing effort to analyse the differential expression of FGF receptors and their potential role during amphibian development, we have isolated a Pleurodeles homolog of FGF receptor 3 (FGFR-3), which we designated PFR-3 because of its highest homology to human FGFR-3 (75% overall identity). PFR-3 is a maternally derived mRNA. While a low level of expression persists during the cleavage and gastrula stages, a significant increase in the mRNA was observed at the end of the gastrula stage. RNase protection analysis on dissected tissues showed that PFR-3 mRNA was mainly localized to the ectoderm at the early gastrula stage and then shifted to the embryonic neural tissues, whereas adult brain had decreased levels of PFR-3 mRNA expression. Consistent with the loss of FGF receptors during skeletal muscle terminal differentiation, PFR-3 as well as other FGF receptor mRNAs were undetectable in the adult skeletal muscle. However, highest levels of PFR-3 mRNA expression were found in the testis. In situ hybridization revealed strong expression in the germinal epithelium of the embryonic brain (especially the diencephalon and rhombencephalon) and neural tube, in the lens and the cranial ganglia. The epithelium of the developing gut, like the pharynx and esophagus, also prominently expressed PFR-3 mRNA. Other sites of expression were found in the liver and in the mesenchymal condensation sites of branchial arches.(ABSTRACT TRUNCATED AT 250 WORDS)

Protein synthesis controls cyclin stability in metaphase I-arrested oocytes of Patella vulgata

The metaphasic block of Patella vulgata oocytes depends on protein synthesis as an emetine treatment triggers metaphase/anaphase transition and leads to the sequential disappearance of cyclin A and B. Both cyclins are stable in metaphase-arrested oocytes which indicates that inhibition of protein synthesis activates cyclin proteolysis. The use of extracts prepared from metaphase-arrested oocytes and from emetine-treated oocytes fully confirms these in vivo findings. Considering previous observations about the regulation of protein synthesis throughout the cell cycle, we propose the involvement of a transient inhibition of translation in the activation of cyclin proteolysis and in exit from the M-phase arrest.