482Direct oral anticoagulant rivaroxaban in very old and frail patients: A one-year prospective follow-up of a large-scale cohort (SAFIR-AC)

Background/Introduction

Age is one of the strongest predictors/risk factors for ischemic stroke in subjects with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) have been shown to be effective in the prevention of this condition; however, clinical evidence on bleeding risk with this therapeutic strategy in very old and frail geriatric patients is poor.

Purpose

To assess bleeding risk in French geriatric patients aged ≥80 years and diagnosed with AF newly treated with rivaroxaban.

Methods

Subjects, presenting to one of 33 geriatric centers, with non-valvular AF and recent initiation of a treatment with rivaroxaban were enrolled in the study and followed-up every 3 months for 12 months. Clinical and routine laboratory data and evaluation scores, such as HAS-BLED, HEMORR2HAGES, ATRIA, and CHA2DS2-VASc, as well as comprehensive geriatric evaluation were reported. Major bleeding, as defined in ROCKET AF study, was reported at each visit, and this primary outcome was adjudicated by an independent committee. Results of this cohort were compared with findings from a similar cohort treated with vitamin K antagonists (VKAs) from the same centers (n=924).

Results

A total of 1045 subjects were enrolled in the study of whom 995 (95%) had a one-year follow-up (analyzed population). The mean (standard deviation (SD)) age was 86.0 (4.3) years, with the majority of patients being female (61%), 23% aged 90 years or older, and 48% having an estimated glomerular filtration rate (eGFR) <50 mL/min. The main comorbidities were hypertension in 77% of subjects, malnutrition 49%, anemia 43%, dementia 39%, heart failure 36%, and falls 27%. The mean (SD) score for CHA2DS2-VASc was 4.8 (1.4), HAS-BLED 2.4 (0.9), Mini-Mental State Examination (MMSE) 21.5 (6.9), Activities of Daily Living (ADL) 4.4 (1.9), and Charlson Comorbidity Index 6.7 (2.0). The one-year rate of major bleeding events was 6.4% of which 0.8% were fatal and 1.1% intracranial hemorrhages (ICH), whereas the one-year rate of ischemic stroke was 1.4% and all-cause mortality 17.9%. Computed with VKA cohort findings and adjusted for age, gender, eGFR and Charlson score, this would result in a hazard ratio of 0.54 (95% confidence interval [CI], 0.38 to 0.78) for major bleeding, 0.36 (0.17 to 0.76) for ICH, 0.62 (0.29 to 1.33) for ischemic stroke, and 0.82 (0.65 to 1.02) for all-cause mortality, in favor of rivaroxaban.

Conclusions

This is the first large-scale prospective study in geriatric population in AF subjects treated with DOAC (rivaroxaban) Major bleeding risk appeared higher in very old than younger population, however major bleeding and ICH rates were significantly lower with rivaroxaban than with VKAs when used in the same geriatric population. This study indicates that Rivaroxaban can be used in very old and frail patients for the treatment of non-valvular AF.

Acknowledgement/Funding

Unrestricted grant from Bayer

Association between dementia and reduced walking ability and 30-day mortality in patients with extended-spectrum beta-lactamase-producing Escherichia coli bacteremia

Previous studies have shown controversial results of factors associated with short-term mortality in patients with extended-spectrum beta-lactamase (ESBL)-producing E. coli bacteremia and no research has investigated the impact of the geriatric assessment criteria on short-term mortality. Our objective was to determine whether dementia and walking ability are associated with 30-day mortality in patients with ESBL-producing E. coli bacteremia. All blood bottle cultures, analyzed from January 2008 to April 2015, in the Bacteriology Department of a 2,600-bed, university-affiliated center, Nantes, France, were retrospectively extracted. Factors associated with short-term mortality in patients with ESBL-producing E. coli bacteremia: 140 patients with an ESBL-producing E. coli bloodstream infection were included; 22 (15.7%) patients died within 30 days following the first positive blood bottle culture of ESBL-producing E.coli. In multivariate analysis, a reduced ability to walk (OR = 0.30; p = 0.021), presence of dementia (OR = 54.51; p = 0.040), a high Sepsis-related Organ Failure Assessment (SOFA) score (OR = 1.69; p < 0.001), presence of neutropenia (OR = 12.94; p = 0.049), and presence of a urinary tract infection (OR = 0.07; p = 0.036), were associated with 30-day mortality. Our findings provide new data showing an independent association between 30-day mortality with dementia and reduced walking ability, in patients with ESBL-producing E. coli bacteremia. These criteria should be considered in the therapeutic management of patients with ESBL-producing E. coli bacteremia.

Relationship between achieved personalized glycaemic targets and monitoring of clinical events in elderly diabetic patients

AIM

Recent guidelines for the management of type 2 diabetes (T2DM) in the elderly recommend adjusting the therapeutic target (HbA_1c) according to the patient's health. Our study aimed to explore the association between achieving the recommended personalized HbA_1c target and the occurrence of major clinical events under real-life conditions.

METHODS

The T2DM S.AGES cohort was a prospective multicentre study into which 213 general practitioners recruited 983 non-institutionalized T2DM patients aged>65 years. The recommended personalized HbA_1c targets were<7%, <8% and <9% for healthy, ill and very ill patients, respectively. Major clinical events (death from any cause, major vascular events and/or hospitalization) were recorded during the 3-year follow-up. Mixed-effects logistic regression models were used for the analyses.

RESULTS

Of the 747 patients analyzed at baseline, 551 (76.8%) were at their recommended personalized HbA_1c target. During follow-up, 391 patients (52.3%) experienced a major clinical event. Of the patients who did not achieve their personalized HbA_1c target (compared with those who did), the risk (OR) of a major clinical event was 0.95 (95% CI: 0.69-1.31; P=0.76). The risk of death, major vascular event and hospitalization were 0.88 (95% CI: 0.40-1.94; P=0.75), 1.14 (95% CI: 0.7-1.83; P=0.59) and 0.84 (95% CI: 0.60-1.18; P=0.32), respectively.

CONCLUSION

Over a 3-year follow-up period, our results showed no difference in risk of a major clinical event among patients, regardless of whether or not they achieved their personalized recommended HbA_1c target. These results need to be confirmed before implementing a more permissive strategy for treating T2DM in elderly patients.

Predictors of Health-Related Quality of Life Decline after Transcatheter Aortic Valve Replacement in Older Patients with Severe Aortic Stenosis

BACKGROUND

Transcatheter aortic-valve implantation (TAVI) has been shown to improve survival and quality of life in patients with severe aortic stenosis. However, one-third of patients have poor outcome as death, functional decline or quality of life (QoL) decline. The aim of this study was to determine cardiac and geriatric predictors of physical and mental QoL decline 6 months after a TAVI procedure in patients aged 75 and older.

METHODS

Between January 2013 and June 2014, we did a prospective and multicenter study including patients ≥ 75 years old referred for TAVI. The primary outcome was the measure of QoL, assessed by the Short Form 36 survey (SF-36), before and 6 months after the intervention. Association between QoL decline and baseline characteristics including cardiac and geriatric factors was analysed by logistic regression models.

RESULTS

Mean age of the 150 patients studied was 83.7 years old and 56% were men. The primary end point, mean SF-36 physical summary score, significantly improved between baseline and 6-month (33.6 vs. 36.4, p=0.003) whereas mental component score significantly decreased (48.2 vs. 36.4, p-value<0.001). However, patients with presence of depressive symptoms before the intervention had mental QoL improvement at six months (OR 0.04 [0.01-0.19], p-value<0.001) and no significant geriatric predictors were associated with physical QoL decline.

CONCLUSION

The mental QoL significantly decreased and patients with preoperative depressive symptoms had mental QoL improvement at six months. Researches are needed to confirm that mental QoL of patients with depressive symptoms can be improved by TAVI.

Analysing Time to Event Data in Dementia Prevention Trials: The Example of the GuidAge Study of EGb761

Time-to-event analysis is frequently used in medical research to investigate potential disease-modifying treatments in neurodegenerative diseases. Potential treatment effects are generally evaluated using the logrank test, which has optimal power and sensitivity when the treatment effect (hazard ratio) is constant over time. However, there is generally no prior information as to how the hazard ratio for the event of interest actually evolves. In these cases, the logrank test is not necessarily the most appropriate to use. When the hazard ratio is expected to decrease or increase over time, alternative statistical tests such as the Fleming-Harrington test, provide a better sensitivity. An example of this comes from a large, five-year randomised, placebo-controlled prevention trial (GuidAge) in 2854 community-based subjects making spontaneous memory complaints to their family physicians, which evaluated whether treatment with EGb761 can modify the risk of developing AD. The primary outcome measure was the time to conversion from memory complaint to Alzheimer's type dementia. Although there was no significant difference in the hazard function of conversion between the two treatment groups according to the preplanned logrank test, a significant treatment-by-time interaction for the incidence of AD was observed in a protocol-specified subgroup analysis, suggesting that the hazard ratio is not constant over time. For this reason, additional post hoc analyses were performed using the Fleming-Harrington test to evaluate whether there was a signal of a late effect of EGb761. Applying the Fleming-Harrington test, the hazard function for conversion to dementia in the placebo group was significantly different from that in the EGb761 treatment group (p = 0.0054), suggesting a late effect of EGb761. Since this was a post hoc analysis, no definitive conclusions can be drawn as to the effectiveness of the treatment. This post hoc analysis illustrates the interest of performing another randomised clinical trial of EGb761 explicitly testing the hypothesis of a late treatment effect, as well as of using of better adapted statistical approaches for long term preventive trials when it is expected that prevention cannot have an immediate effect but rather a delayed effect that increases over time.

Determinants in treatment decision-making in older patients with symptomatic severe aortic stenosis

BACKGROUND

Three treatment options are available for patients with aortic stenosis: surgical aortic valve replacement (SAVR), transcatheter aortic valve implantation (TAVI) and medical treatment (MT). However, little is known about how Heart Team treatment decisions are made under routine conditions. The aim of this study was to identify the cardiac and geriatric components associated with treatment decision-making in older patients with symptomatic severe aortic stenosis.

METHODS

Between 2011 and 2013, 337 consecutive patients ≥75 years old referred for pre-operative evaluation in Nantes University Hospital had a comprehensive cardiac and geriatric assessment. In this observational retrospective study, relationships between treatment decision-making and cardiac or geriatric components were evaluated through multivariable models.

RESULTS

Surgical aortic valve replacement was proposed to 108 patients, TAVI to 131 and medical treatment to 98 patients. Mean age was 83±4 years and 51% were women. Geriatric components associated with treatment decision-making between SAVR vs. TAVI were age (p<0.001, OR=0.790), comorbidity score (p=0.027, OR=0.86), functional status (p<0.001, OR=1.46), and gait speed (p<0.001, OR=0.23). Cardiac components associated with decision-making between SAVR vs. TAVI were history of previous cardiac surgery (p<0.001, OR=0.09), left ventricular ejection fraction <50% (p<0.001, OR=0.14), coronary artery disease requiring revascularization (p=0.019, OR=0.4). Between TAVI vs. medical treatment, only history of previous cardiac surgery and presence of another severe valve disease were significant.

CONCLUSION

Comorbidities, functional status and physical performance, were significantly associated with the consensual treatment decision-making, independently of cardiac components in older patients with symptomatic severe aortic stenosis.

Frailty and nutrition: searching for evidence

Frailty is a geriatric syndrome that predicts disability, morbidity and mortality in the elderly. Poor nutritional status is one of the main risk factors for frailty. Macronutrients and micronutrients deficiencies are associated with frailty. Recent studies suggest that improving nutritional status for macronutrients and micronutrients may reduce the risk of frailty. Specific diets such as the Mediterranean diet rich in anti-oxidants, is currently investigated in the prevention of frailty. The aim of this paper is to summarize the current body of knowledge on the relations between nutrition and frailty, and provide recommendations for future nutritional research on the field of frailty.

Therapeutic management in ambulatory elderly patients with atrial fibrillation: the S.AGES cohort

Few epidemiologic studies have specifically focused on very old community dwelling population with atrial fibrillation (AF). The objectives of the AF-S.AGES cohort were to describe real-life therapeutic management of non-institutionalized elderly patients with AF according to age groups, i.e., 65-79 and ≥ 80 and to determine the main factors associated with anticoagulant treatment in both groups.

METHODS

Observational study (N=1072) aged ≥ 65 years old, recruited by general practitioners. Characteristics of the sample were first evaluated in the overall sample and according to age (< 80 or ≥ 80 years) and to use of anticoagulant treatment at inclusion. Logistic models were used to analyze the determinants of anticoagulant prescription among age groups.

RESULTS

Mean age was 78.0 (SD=6.5) years and 42% were ≥ 80 years. Nineteen percent had paroxysmal AF, 15% persistent, 56% permanent and 10% unknown type, 77% were treated with vitamin K antagonists (VKA), 17% with antiplatelet therapy with no differences between age groups. Rate-control drugs were more frequently used than rhythm-control drugs (55% vs. 37%, p < 0.001). VKA use was associated with permanent AF, younger age and cancer in patients ≥ 80 years old and with permanent AF and preserved functional autonomy in patients < 80 years old. Hemorrhagic scores were independently associated with non-use of VKA whereas thromboembolic scores were not associated with VKA use.

CONCLUSIONS

In this elderly AF outpatient population, use of anticoagulant therapy was higher even after 80 years than in previous studies suggesting that recent international guidelines are better implemented in the elderly population.

[Regional and peripheral arterial stiffness measured by pOpmetre® in patients with Cvx risk factor, link with carotid plaques]

PURPOSE

Aortic stiffness is a functional and structural consequence of ageing and arteriosclerosis. Regional arterial stiffness can be easily evaluated using pOpmetre(®) (Axelife SAS, France). This new technique assesses the pulse wave transit time (TT) between the finger (TTf) and the toe (TTt). Based on height chart, regional pulse wave velocity (PWV) between the toe and the finger can be estimated (PWVtf). pOpscore(®) index is also calculated as the ratio between PWVtoe and PWVfinger and can be considered as a peripheral vascular stiffness index. The aim of the study was to evaluate the relationship between pOpmetre(®) indices and the presence of carotid plaques in a population with cardiovascular risk factors.

METHODS

In 77 consecutive patients recruited for a vascular screening for atherosclerosis (46 men aged 54 ± 2 years; 31 women aged 49 ± 3 years; ns), the difference between TTt and TTf (called Dt-f), the regional pulse wave velocity between the toe and the finger (PWVtf = constant × height/Dt-fm/s) and pOpscore(®) were measured by pOpmetre(®). Presence of carotid plaques was assessed using ultrasound imaging. The local aortic stiffness (AoStiff) was evaluated by the Physioflow(®) system.

RESULTS

No difference was found between patients with or without carotid plaques (n=25 versus 52) for Ankle-Brachial Pressure Index (ABPI: 1.15 ± 0.04 versus 1.12 ± 0.03), nor for diastolic or systolic blood pressure (87 ± 3 versus 82 ± 2; 137 ± 3 versus 132 ± 2 mmHg). The first group was older than the second (59 ± 2 versus 49 ± 2 years, P<0.002) with a larger intimae media thickness (0.69 ± 0.02 versus 0.63 ± 0.01 mm, P<0.004), a higher AoStiff (10.4 ± 0.7 versus 8.2 ± 0.5m/s, P<0.02), and PWVtf (14.3 ± 1.0 versus 10.7 ± 0.7 m/s, P<0.004) and a shorter Dt-f (57.9 ± 5.1 versus 73.5 ± 3.5 ms, P<0.01). PWVtf (r(2)=0.49, P<0.0001) and Dt-f (r(2)=0.54, P<0.0001) correlated with age. A significant difference in pOpscore(®) index was observed between both groups (1.51 ± 0.3 versus 1.41 ± 0.2, P<0.006).

CONCLUSION

Our results show a significant arterial stiffness indices measured by pOpmetre(®) in patients with and without carotid plaques.

Vitamin D supplementation in older adults: searching for specific guidelines in nursing homes

BACKGROUND

The prevalence of vitamin D insufficiency is very high in the nursing home (NH) population. Paradoxically, vitamin D insufficiency is rarely treated despite of strong clinical evidence and recommendations for supplementation. This review aims at reporting the current knowledge of vitamin D supplementation in NH and proposing recommendations adapted to the specificities of this institutional setting.

DESIGN

Current literature on vitamin D supplementation for NH residents was narratively presented and discussed by the French Group of Geriatrics and Nutrition.

RESULT

Vitamin D supplementation is a safe and well-tolerated treatment. Most residents in NH have vitamin D insufficiency, and would benefit from vitamin D supplement. However, only few residents are actually treated. Current specific and personalized protocols for vitamin D supplementation may not be practical for use in NH settings (e.g., assessment of serum vitamin D concentrations before and after supplementation). Therefore, our group proposes a model of intervention based on the systematic supplementation of vitamin D (1,000 IU/day) since the patient's admission to the NH and throughout his/her stay without the need of a preliminary evaluation of the baseline levels. Calcium should be prescribed only in case of poor dietary calcium intake.

CONCLUSION

A population-based rather than individual-based approach may probably improve the management of vitamin D insufficiency in the older population living in NH, without increasing the risks of adverse health problems. The clinical relevance and cost effectiveness of this proposal should be assessed under NH real-world conditions to establish its feasibility.

Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Société Française de Gériatrie et de Gérontologie) Workshop--Athens January 20-21, 2012

Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate.

OBJECTIVES

The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons.

PARTICIPANTS

Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG).

RESULTS

Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice.

CONCLUSION

Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

Treatment-limiting decisions, comorbidities, and mortality in the emergency departments: a cross-sectional elderly population-based study

BACKGROUND

Older adults experience a higher risk of death in the emergency departments (EDs), in part, as a result of their comorbidities. A treatment-limiting decision is often reported for older adults who die in the EDs. The Charlson Comorbidity Index (CCI) is a validated method for the scoring of comorbidities. Whether an association between the CCI and treatment-limiting decisions exists remains unknown.

OBJECTIVE

To determine whether the CCI was associated with the treatment-limiting decisions made for older patients who die in the EDs.

METHODS

A total of 2,095 patients ≥65 years old who died in the EDs in France and Belgium were prospectively included between 2004 and 2005. The recorded data included: 1) the CCI score; 2) patient age; 3) gender; 4) living in senior housing facilities; 5) hospitalizations occurring in the previous year; 6) presence of functional limitations (according to the Knaus classification); 7) chronic diseases; and 8) presence of organ failure(s). A treatment-limiting decision was defined as a predetermined choice not to implement therapies that would otherwise be required to sustain life.

RESULTS

A treatment-limiting decision was identified in 993 (47%) patients. Fully-adjusted logistic regression model showed that a CCI ≥ 5 (OR=25.56 with P=0.037), age ≥85years (OR=20.33 with P<0.001), living in an institution (OR=0.15 with P=0.017), hematologic (OR=6.92 with P=0.020) and respiratory disease (OR=0.17 with P=0.046), and neurologic causes (OR=0.20 with P=0.010) of organ failure were significantly associated with treatment-limiting decisions.

CONCLUSION

An elevated CCI score (≥5) was associated with a treatment-limiting decision in elderly patients evaluated in the EDs. Further research is needed to corroborate this finding.

[A new index to evaluate arterial ageing independently of arterial blood pressure: pOpscore(®)]

AIM

Pulse wave velocity does not correlate to age in the upper limb but in the aorta and lower limb. We studied the link between ageing and pulse wave transit time (PWtt) indexes at the toe and finger.

PATIENTS AND METHODS

Measurements were performed in 300 patients in occupational medicine and primary care after 5minutes supine rest using the device studied (pOpmètre(®), Axelife SAS, France). It measures transit time between R-ECG and finger or toe pulse signal (ttf or ttt respectively). We define as follows three indexes: difference between transit times: Dtf=ttt-ttf; pulse wave velocity PWVft=k*subjects height/Dtf (m/s); and the pOpscore(®) as the ratio of toe PWV/fingerPWV.

RESULTS

Of the 300 tested patients, 147 were analysed using univariate correlation: age (P<10(-4)), SBP (P<10(-4)), DBP (P<0.02) and BMI (P<0.04) correlated to Dtf, PWVtf and pOpscore(®). Using stepwise regression analysis with Age, BMI, SBP, DBP, MBP: Dtf was dependent with age (P<10(-4)) and SBP (P<0.01); PWVtf with age (P<0.0001), SBP (P<0.01) and DBP (P<0.05); pOpscore(®) was dependent only to age (P<10(-4)).

CONCLUSION

In this study, in contrast with the other vascular indexes studied dependent to age and blood pressure, pOpscore(®) was dependent only to ageing. pOpmètre(®) is a promising technique for routine determination of arterial stiffness and pOpscore(®) appears to be appropriate to study the structural vascular ageing in outpatient.

IAGG workshop: health promotion program on prevention of late onset dementia

IAGG, WHO, and SFGG organized a international workshop on Health promotion programs on prevention of late on-set dementia. Thirty world specialists coming from Europe, North America, Asia, South America, Africa and Australia, shared their experience on methods and results of large epidemiological interventions to reduce incidents of dementia or delay its on-set. Chaired by Laura FRATIGLIONI, an expert in Epidemiological studies on dementia issues, the workshop gave opportunity for discussions and controversies about the state-of-the-art. Based on different national and international trials (ADAPT, MAPT, FINGER, GUDIAGE, GEM etc) the questions remained opened for different aspects of methodology, the choice of domain or multi domain intervention, the choice and the definition of the target populations, the best age of candidates, the issues related to the discrepancy between late effects, and interventions' duration. We are please to publish in the Journal, the presentations presented to this workshop. These publications will complete previously task force published in the journal in the last two years on methodological issues for Alzheimer's trials including end point, biomarkers, and the experience of past therapeutic trials.

Diagnosis of Alzheimer's disease patients with rapid cognitive decline in clinical practice: interest of the Deco questionnaire

BACKGROUND

Patients with Alzheimer's disease (AD) who deteriorate rapidly are likely to have a poorer prognosis. There is a clear need for a clinical assessment tool to detect such a decline in newly diagnosed patients.

OBJECTIVE

To identify the predictive factors of rapid cognitive decline (RCD) in a cohort of patients with mild to moderate AD ; and to validate a self-questionnaire for caregivers as a diagnostic tool for rapid decline.

DESIGN AND ANALYSIS

An open-label, observational, 12-month, multicenter, French study. Physicians were asked to record data of three eligible rivastigmine naïve (or on rivastigmine for < 1 year) AD patients. Risk factors of RCD and the detection power of the Détérioration Cognitive Observée scale (Deco), a 19 item self-questionnaire for caregivers, were assessed at endpoint using regression analyses.

RESULTS

Out of the 361 patients enrolled in the study, 91 (25.2%) were excluded due to loss of follow-up. Among subjects using cholinesterase inhibitors or memantine, 161 (59.6%) experienced a stabilization (29.2%) or an improvement (30.4%) in global functioning as measured by the CGI-C. Sixty of the remaining 204 patients retained for analysis (29.6%, CI 95% [23.4; 35.8]) lost three or more points on the MMSE score between the inclusion and one of the follow-up visit. In the multivariate logistic regression analysis, institutionalization, higher level of education and the loss of 3 points or more on the MMSE were found to be significant predictors of a rapid cognitive loss in this population. The threshold which maximizes the predictive values of the Deco score as a diagnostic tool of rapid cognitive decline was significantly different according to the age of the patient (below or over 75 years old). A score below 16 for patients < 75 years old and below 14 for patients ≥ 75 years old consistently predicted a RCD within the next year.

CONCLUSION

The Deco test appears to be a simple tool to alert the physician to the possibility of an aggressive course of the disease which warrants particular management.

How to manage recurrent falls in clinical practice: guidelines of the French Society of Geriatrics and Gerontology

BACKGROUND

Health care professionals need a simple and pragmatic clinical approach for the management of recurrent fallers in clinical routine.

OBJECTIVE

To develop clinical practice recommendations with the aim to assist health care professionals, especially in primary care in the management of recurrent falls.

METHODS

A systematic English and French review was conducted using Medline, Embase, Pascal and Cochrane literature. Search included systematic reviews, meta-analyses, controlled trials, cohort studies, case-control studies and transversal studies published until July 31, 2008. The following Medical Subject Heading (MeSH) terms were used: "aged OR aged, 80 and over", "frail elderly", "Accidental Fall", "Mental Recall", and "Recurrent falls". The guidelines were elaborated according the Haute Autorite de Sante methods by a multidisciplinary working group comprising experts and practitioners.

RESULTS

A fall is an event that results in a person coming to rest inadvertently on the ground or floor or other lower level and should be considered as a recurrent event as soon as a subject reported at least two falls in a 12-month period. Recurrent falls impose a prompt and appropriate management with the first aim to systematically evaluate the severity of falls. The evaluation of fall severity should be based on a standardized questionnaire and physical examination. It is recommended not to perform cerebral imaging in the absence of specific indication based on the clinical examination and to reevaluate the subject within a week after the fall. Prior to any intervention and after an evaluation of signs of severity, it is recommended to systematically assess the risk factors for falls. This evaluation should be based on the use of validated and standardized tests. The education of recurrent fallers and their care givers is required in order to implement appropriate intervention. In the event of a gait and/or balance disorders, it is recommended to prescribe physiotherapy. A regular physical activity should be performed with low to moderate intensity exercise. It is recommended to perform rehabilitation exercises with a professional, between therapy sessions and after each session, in order to extend rehabilitation benefits to the daily life.

CONCLUSION

The clinical guidelines focused on management (i.e., diagnosis, assessment and treatment) of recurrent falls in clinical routine. They provide answers to the following clinical questions: 1) How to define recurrent falls? 2) How to identify severe falls? 3) How to assess recurrent falls? and 4) How to treat recurrent falls?

Central auditory processing in aging: the dichotic listening paradigm

OBJECTIVE

Aging is associated with cognitive changing. Central auditory processing dysfunction may explain some understanding difficulties in elderly. It may be evaluated with the dichotic listening (DL) test, a widely-used experimental paradigm for studying inter-hemispheric interactions and attentional processes. This study examines central auditory language processing with a dichotic listening task in right-handed old subjects according to their age.

DESIGN

Cross sectional-study.

SETTING

memory clinic and geriatric unit.

PARTICIPANTS

Adult group (Ad) consisted in 26 subjects (21 women and 5 men) aged 50-69 years and an old adults group (Old-Ad) consisted in 20 subjects (19 women and 1 man) aged 70 to 89 years.

MEASUREMENTS

DL consisted in a free-recall word task and a digit forced-attention task (forced-right: FR and forced-left: FL) in order to study central auditory language processing. In addition, we used neuropsychological tests to study executive functions and cognitive control, sustained by the prefrontal cortex.

RESULTS

In the free recall condition, we confirmed the classic right ear advantage (REA) in both groups, particularly in older subjects. In the forced condition, we observed an ear advantage with a change in ear asymmetry as a consequence of instruction: REA in FR and a left-ear advantage (LEA) in FL. We compared contaminations by the contra-lateral inattentive ear: reports of the left ear (LE) in the FR condition and reports of the right ear (RE) in the FL condition. Contaminations by the RE in the FL condition were more pronounced in Old-Ad suggesting difficulties in competition between the natural tendency for the RE and the instruction. In the Old-Ad group, the correlation between the RE score in FL and TMT B-A/A suggests an impairment in mental flexibility.

CONCLUSION

DL may be helpful to study central auditory dysfunction in aging. Our results suggest difficulties in attentional control and executive functions. Central auditory dysfunction should be evaluated in elderly because it potentially contributes to difficulty of hearing in noisy environment with consequences in the rehabilitation of presbyacousic subjects. More studies are needed to investigate the predictive value of DL as a marker of cognitive decline, particularly executive functions.

Vitamin D-related changes in physical performance: a systematic review

OBJECTIVE

The objective of this study was to systematically review all the published articles examining the effects of low serum vitamin D concentration and vitamin D supplementation on muscle, balance and gait performance among people aged 65 and older.

METHODS

An English and French Medline search ranging from January 2004 to November 2008 indexed under the Medical Subject Heading (MeSH) terms "aged OR aged, 80 and over" AND "Vitamin D OR Vitamin D Deficiency" combined with the terms "Gait" OR "Gait Apraxia" OR "Gait Disorders, Neurologic" OR "Walking" OR "Mobility Limitation" OR "Polyneuropathy" OR "Proprioception" OR "Ataxia" OR "Accidental Falls" was performed.

RESULTS

Of the 102 selected studies, 16 met the selection criteria and were included in the final analysis. There were 8 observational studies and 8 interventional studies. The number of participants ranged from 24 to 33067. A majority of studies examined community-dwelling older women. Five observational studies showed a significant positive association, whereas three studies did not. Four of the 5 studies and two of the 3 studies which tested the vitamin D supplementation effect, respectively on balance and gait, showed no significant effect. Four studies showed a significant effect on muscle strength, while this effect was not observed in three others studies. In addition, there was no significant association between vitamin D supplementation and an improvement of the sit-to-stand test results in 50% of the studies.

CONCLUSIONS

The findings show that the association between vitamin D and physical performance remains controversial. Observational studies and clinical trials yielded divergent results, which highlights the complex and to date still poorly understood association between serum vitamin D concentration or vitamin D supplementation and physical performance.

Key priorities in managing glucose control in older people with diabetes

Older people with diabetes represent a major and increasing proportion of our elderly population and their care requires better organisation. Targets for risk factor control and pathways of care must be adjusted to the subject's general health status. It is thus advisable to screen for frailty. We have carried out a detailed literature review of the studies published on diabetes in older people since 1990. Studies were considered if they included groups or subgroups of diabetic patients > 65 years old. This review discusses the elaboration of general targets for care, the approach to risk factor control, the screening and the specific prevention or management of complications, the integration of geriatric concepts in diabetes care and the specificity of education with respect to frailty status.

Is there an association between serum 25-hydroxyvitamin D concentration and muscle strength among older women? Results from baseline assessment of the EPIDOS study

OBJECTIVE

To examine whether low serum 25-hydroxyvitamin D (25OHD) concentration were associated with low muscle strength while taking into account the effects of potential confounders among a cohort of community-dwelling women aged 75 years and older.

DESIGN

Cross-sectional study corresponding to the baseline assessment of the EPIDOS study.

SETTING

Five French cities including Amiens, Lyon, Montpellier, Paris and Toulouse.

PARTICIPANTS

Randomized sample of 440 women included in the EPIDOS study.

MEASUREMENT

Maximal isometric voluntary contraction strength of the lower limb and hand with computerized dynamometers, serum 25OHD and parathyroid hormone concentration. Age at baseline evaluation, number of chronic diseases, body mass index (BMI), use of calcium drug, practice of a regular physical activity, serum calcium concentration and clearance of creatinine were used as covariables. Subjects were separated into 3 groups based on serum 25 OHD levels with the following cut-off values: < 15 ng/ml, 15-30 ng/ml and > 30 ng/ml.

RESULTS

More than 90% of women had a serum 25OHD insufficiency (i.e. < 30 ng/ml) and 40.2% had a related secondary hyperparathyroidism. The mean value of muscle strength was not different among the 3 groups of women (174.9 +/- 53.2 for serum 25OHD < 15 ng/ml versus 175.9 +/- 52.6 for serum 25OHD 15-30 ng/ml versus 173.4 +/- 53.1 for serum 25OHD > 30 ng/ml with P=0.946 for quadriceps, and 56.1 +/- 13.2 for serum 25OHD < 15 ng/ml versus 57.1 +/- 13.5 for serum 25OHD 15-30 ng/ml versus 61.1 +/- 12.7 for serum 25OHD > 30 ng/ml with P= 0.064 for handgrip). There was no significant association between serum 25OHD concentration and quadriceps strength (crude beta = 0.03 with P = 0.891 and adjusted beta = -0.04 with P = 0.837). Univariate linear regression showed a significant association between serum 25OHD concentration and handgrip strength (crude beta = 0.16 with P = 0.049) but not while using an adjusted model (adjusted beta = 0.13 with P = 0.106).

CONCLUSIONS

The findings of this study do not support the hypothesis of a relationship between low serum 25OHD concentration and low muscle strength. Further research is needed to corroborate and explain this finding.

[Microalbuminuria and urinary albumin excretion: French guidelines]

Measurement of urinary albumin excretion (UAE) may be done on a morning urinary sample or on a 24 hour-urine sample. Values defining microalbuminuria are: - 24-hour urine sample: 30-300 mg/24 hours - Morning urine sample: 20-200 mg/mL or 30-300 mg/g creatinine or 2.5-25 mg/mmol creatinine (men) or 3.5-35 mg/mol (women). - Timed urine sample: 20-200 mug/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been shown in humans. In diabetic subjects, microalbuminuria is a marker of increased risk of cardiovascular (CV) and renal morbidity and mortality in type 1 and type 2 diabetic subjects. The increase in UAE during follow-up is also a marker of CV and renal risk in type 1 and type 2 diabetic subjects; its decrease during follow-up is associated with lower risks. In non-diabetic subjects, microalbuminuria is a marker of increased risk for diabetes mellitus, deterioration of the renal function, CV morbidity and all-cause mortality. It is a marker of increased risk for the development of hypertension in normotensive subjects, and is associated with unfavorable outcome in patients with cancer and lymphoma. Persistence or elevation of UAE overtime is associated with deleterious outcome in some hypertensive subjects. Measurement of UAE may be recommended in hypertensive subjects with 1 or 2 CV risk factors in whom CV risk remains difficult to assess, and in those with refractory hypertension: microalbuminuria indicates a high CV risk and must lead to strict control of arterial pressure. Studies focused on microalbuminuria in non-diabetic, non-hypertensive subjects are limited; most of them suggest that microalbuminuria predicts CV complications and deleterious outcome as it is in diabetic or hypertensive subjects. Subjects with a history of CV or cerebrovascular disease have an even greater CV risk if microalbuminuria is present than if it is not; however, in all cases, therapeutic intervention must be aggressive regardless of whether microalbuminuria is present or not. It is not recommended to measure UAE in non-diabetic non-hypertensive subjects in the absence of history of renal disease. Monitoring of renal function (UAE, serum creatinine and estimation of GFR) is annually recommended in all subjects with microalbuminuria.

MANAGEMENT

in patients with microalbuminuria, weight reduction, sodium restriction (< 6 g/day), smoking cessation, strict glucose control in diabetic subjects, strict arterial pressure control are necessary; in diabetic subjects: use of maximal doses of ACEI or ARB are recommended; ACEI/ARB and thiazides have synergistic actions on arterial pressure and reduction of UAE; in non-diabetic subjects, any of the five classes of anti-hypertensive medications (ACEI, ARB, thiazides, calcium channel blockers or beta-blockers) can be used.

A practical approach to estimate resting energy expenditure in frail elderly people

OBJECTIVES

Some prediction equations of resting energy expenditure (REE) are available and can be used in clinical wards to determine energy requirements of patients. The aim of the present study was to assess the accuracy of those equations in sick elderly patients, using the Bland and Altman methods with our database of 187 REE measurements.

DESIGN

The 3 equations tested were Harris and Benedict equation of 1919, WHO/FAO/UNU equation of 1985 and Fredrix et al. equation of 1990. In addition, three models developed from the present data were tested.

RESULTS

The present study shows that the Fredrix et al equation gave an accurate prediction of REE without significant bias along the whole range of REE. It also shows that under-weight sick elderly patients (BMI

CONCLUSION

A simple formula using a factor multiplying body weight, i.e. 22 kcal/kg/d in under-weight and 19 kcal/kg/d in normal weight sick elderly was accurate to predicting REE and bias was not influenced by the level of REE. This model included half of the group in the range of +/- 10% of the difference between predicted REE and measured REE, but the confidence interval of the bias was +/- 400 kcal/d. Conversely, the Harris and Benedict and WHO formulae did accurately predict REE.

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Key Words Collapse

MESH Headings

• Aged
• Aged, 80 and over
• Aging/metabolism
• Basal Metabolism/physiology
• Calorimetry, Indirect
• Energy Metabolism/physiology
• Female
• Frail Elderly
• Geriatric Assessment/methods
• Humans
• Male
• Mathematics
• Nutritional Status
• Predictive Value of Tests
• Reproducibility of Results
• Sensitivity and Specificity

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Grants Collapse

Affiliation(s)

C Gaillard Pôle de médecine interne et maladies métaboliques, Angers, France
E Alix
A Salle
G Berrut
P Ritz

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Prevalence of sarcopenia in the French senior population

INTRODUCTION

A muscle mass normalized for height2 (MMI) or for body weight (SMI) below 2SD under the mean for a young population defines sarcopenia. This study aimed at setting the cutoffs and the prevalence of sarcopenia in the French elderly population. Another objective was to compare the results obtained with SMI and MMI.

METHODS

Muscle mass was assessed by bioelectrical impedance analysis in 782 healthy adults (< 40 years) to determine skeletal mass index (SMI, muscle mass*100/weight) and muscle mass index (MMI, muscle mass/height2). Prevalence was estimated in 888 middle aged (40-59 years) and 218 seniors (60-78 years). All were healthy people.

RESULTS

For women mean-2SD were 6.2 kg/m2 (MMI) and 26.6% (SMI); for men limits were 8.6 kg/m2 (MMI) and 34.4% (SMI). In middle aged persons a small number of them were identified as sarcopenic. In healthy seniors, 2.8% of women and 3.6% of men were sarcopenic (MMI). The prevalence was 23.6% in women and 12.5% in men with SMI. MMI and SMI identified different sarcopenic populations, leaner subjects for MMI while fatter subjects for SMI.

CONCLUSION

Cutoff values for the French population were defined. Prevalence of sarcopenia was different from that in the US population.

Nutritional risk score is not sensitive enough to predict weight loss in diseased elderly subjects

OBJECTIVES

malnutrition is highly prevalent in diseased elderly people, especially in hospital departments, and weight loss also occurs during hospital stays. Among the tools proposed to define malnutrition and to screen persons at risk of malnutrition, the nutritional risk score (NRS) has been suggested as a simple tool.

DESIGN AND PARTICIPANTS

the aim of the present study was to test the validity of the NRS to predict weight changes 3 months after discharge. NRS and visual analogue scales for hunger, early satiety, thirst, fatigue and pain were performed in 106 patients aged 65 yrs and over, 67 treated for cancer, without overt malnutrition.

RESULTS

forty six patients lost more than 1 kg. None of the parameters tested was correlated with weight changes, except NRS which was weakly correlated (r=-0.22, P=0.037). However a 0 score at NRS was associated with weight changes ranging -9 to +5 kg. Furthermore, the 11 patients with a high NRS score and weight loss were in a clinical situation that made it very likely that they would lose weight. In conclusion, NRS is not a valid score to predict weight change.

Microalbuminuria and urinary albumin excretion: French clinical practice guidelines

Urinary albumin excretion (UAE) may be assayed on a morning urinary sample or a 24 h-urine sample. Values defining microalbuminuria are: 1) 24-h urine sample: 30-300 mg/24 h; 2) morning urine sample: 20-200 mg/ml or 30-300 mg/g creatinine or 2.5-25 mg/mmol creatinine (men) or 3.5-35 mg/mmol (women); 3) timed urine sample: 20-200 mug/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been obtained in humans.

IN DIABETIC SUBJECTS

Microalbuminuria is a marker of increased risk of cardiovascular (CV) and renal morbidity and mortality in type 1 and type 2 diabetic subjects. The increase in UAE during follow-up is associated with greater CV and renal risks in type 1 and type 2 diabetic subjects; its decrease during follow-up is associated with lower risks. IN NON-DIABETIC SUBJECTS: Microalbuminuria is a marker of increased risk for diabetes mellitus, deterioration of renal function, CV morbidity and all-cause mortality. It is a marker of increased risk for the development of hypertension in normotensive subjects, and is associated with unfavorable outcome in patients with cancer and lymphoma. Persistence of elevated UAE during follow-up is associated with poor outcome in some hypertensive subjects. Measurement of UAE may be recommended in hypertensive medium-risk subjects with 1 or 2 CV risk factors in whom CV risk remains difficult to assess, and in those with refractory hypertension: microalbuminuria indicates a high CV risk and must lead to strict control of arterial pressure. Studies focused on microalbuminuria in non-diabetic non-hypertensive subjects are limited; most of them suggest that microalbuminuria predicts CV complications and deleterious outcome. Subjects with a history of CV or cerebrovascular disease have an even greater CV risk if microalbuminuria is present than if it is not; however, in all cases, therapeutic intervention must be aggressive regardless of whether microalbuminuria is present or not. It is not recommended to measure UAE in non-diabetic non-hypertensive subjects in the absence of history of renal disease. Monitoring of renal function (UAE, serum creatinine and estimation of GFR) is recommended annually in all subjects with microalbuminuria.

MANAGEMENT

In patients with microalbuminuria, weight reduction, sodium restriction (<6 g per day), smoking cessation, strict glucose control in diabetic subjects, strict arterial pressure control are necessary; in diabetic subjects: use of maximal doses of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are recommended; ACEI/ARB and thiazides have synergistic actions on arterial pressure and reduction of UAE; in non-diabetic subjects, any of the five classes of anti-hypertensive medications (ACEI, ARB, thiazides, calcium channel blockers or beta-blockers) can be used.

[Hypercalcaemia and malignant lymphoma. One case report]

Hypercalcaemia occurs in less than 15% of lymphomas but is associated with a poor prognosis. A patient known to have a testicular lymphoma was admitted because of asthenia and weight loss. Hypercalcemia and high serum level of calcitriol were found. A high-grade lymphoma attesting a Richter's syndrome was diagnosed. Palliative treatment consisting in corticosteroids and pamidronate was instituted. Hypercalcaemia in lymphoma has a poor prognosis and is often attributed to an acquired uncontrolled vitamin D 1-alpha-hydroxylase activity by the macrophages close to the lymphomatous cells. Influences of TNFalpha, interleukine 6 and PTHrp are also reported.

Étude de la planification de l’action au moyen du test du plan du zoo dans la maladie d’Alzheimer

INTRODUCTION

Executive dysfunction is regularly reported in patients with Alzheimer's disease. Nevertheless few studies have focused on planning ability in this neurodegenerative disease.

OBJECTIVES

This study aimed to investigate the formulation and the execution of plans in Alzheimer's disease using an ecological planning subtask derived from the Behavioural Assessment of the Dysexecutive Syndrome test battery, the "Zoo Map Test". There are two trials. The first trial consists of a "high demand" version of the subtask in which the subjects must plan in advance the order in which they will visit designated locations in a zoo (formulation level). In the second, or "low demand" version, the subject is simply required to follow a concrete externally imposed strategy to reach the locations to visit (execution level). The test was given to 16 patients with Alzheimer's disease and 13 normal elderly subjects.

RESULTS

The two way ANOVAs mainly showed more difficulties in patients with Alzheimer's disease than in healthy elderly in both conditions. The difference between formulation and execution was greater in patients with Alzheimer's disease than in healthy elderly. Planning impairments mainly correlated with behavioural changes (in particular motivational changes) observed by patient's relatives.

CONCLUSION

These results suggest that patients with Alzheimer's disease have some problems to mentally develop logical strategies and to execute complex predetermined plans, which are partially related to behavioural changes.

Energy requirements in frail elderly people: A review of the literature

This review collates studies of healthy, sick, underweight (BMI < or = 21 kg/m2) and very elderly people (> or = 90 yr), in whom resting energy expenditure (REE) was measured using indirect calorimetry. We have observed the following: (1) REE, when adjusted for differences in both body weight and fat-free mass (FFM), is similar in healthy and in sick elderly people being 20 and 28 kcal/kg of FFM per day, respectively, (2) their nutritional status influences their energy requirements given that weight-adjusted REE increases in line with a decrease in BMI, (3) total energy expenditure is lower in sick elderly people given that their physical activity level, i.e. the ratio of total energy expenditure to REE, is reduced during disease averaging at 1.36, (4) energy intake (EI) being only 1.23 x REE is insufficient to cover energy requirements in sick elderly patients, whereas the EI of healthy elderly people appears sufficient to cover requirements, and finally, (5) gender ceases to be a determinant of REE in people aged 60 yr or over, with the Harris & Benedict equation capable of accurately predicting mean REE in this population, whether healthy or sick.

IANA (International Academy on Nutrition and Aging) Expert Group: weight loss and Alzheimer's disease

Weight loss, together with psychological and behavioural symptoms and problems of mobility, is one of the principal manifestations of Alzheimer's disease (AD). Weight loss may be associated with protein and energy malnutrition leading to severe complications (alteration of the immune system, muscular atrophy, loss of independence). Various explanations have been proposed such as atrophy of the mesial temporal cortex, biological disturbances, or feeding behaviours; however, none has been proven. Prevention of weight loss in AD is a major issue. It requires regular follow-up and must be an integral part of the care plan. The aim of this article is to review the present state of scientific knowledge on weight loss associated with AD. We will consider four points: the natural history of weight loss, its known etiological factors, its consequences and the various management options.

RETRACTED: Estimation of height from knee-heel length in middle age Caucasian adults

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