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The growing needs related to the loss of autonomy of elderly people should be the opportunity to imagine alternatives to nursing homes. In this context, our study aimed to assess the effect of a reinforced home care model on the evolution of frailty in elderly people whose health conditions could have justified entering a nursing home.A retrospective observational study focusing on the evolution of the SEGA score and other variables reflecting the frailty of people over 75 years old according to classic home care, institutionalization, or reinforced home care.The average SEGA scores of the Ehpad-@-Dom (reinforced home care) and SAD (classic home care) groups are significantly better than that of the Ehpad group after 6 months (T6: Ehpad-@-Dom vs Ehpad, p =0.01 and SAD vs Ehpad, p=0.039) and 12 months (T12: Ehpad-@-Dom vs Ehpad, p=0.021).“Reinforced home care” seems to be an alternative to the classic nursing home model.Face aux besoins liés à la perte d’autonomie des personnes âgées vieillissantes, des alternatives à l’institutionnalisation doivent être imaginées. Dans ce contexte, notre étude visait à évaluer l’effet d’un modèle de maintien à domicile renforcé sur l’évolution de la fragilité de personnes âgées dont l’état de santé aurait pu justifier une institutionnalisation.Étude observationnelle rétrospective s’intéressant à l’évolution du score SEGA et d’autres variables reflétant la fragilité de personnes âgées de plus de 75 ans en fonction d’un maintien à domicile classique, une institutionnalisation, ou un maintien à domicile renforcé.Les score SEGA moyens des groupes Ehpad-@-Dom (maintien à domicile renforcé) et SAD (maintien à domicile classique) sont significativement meilleurs que celui du groupe Ehpad après 6 mois (T6 : Ehpad-@-Dom vs Ehpad, p = 0,01 et SAD vs Ehpad, p = 0,039) et 12 mois (T12 : Ehpad-@-Dom vs Ehpad, p = 0,021).Le « maintien à domicile renforcé » semble être une alternative à l’entrée classique en Ehpad.

Discharge from hospital is a key moment in the care of patients over 75 years of age. The organisation of the transition from hospital to home by home help and care management networks can be effective. Our aim was to evaluate impact of a case management program on 30 days rehospitalisation rates. Retrospective study of the multicentre cohort type carried out on patients monitored by the MAIA of Aube between 2018 and 2020. The risk of re-hospitalisation was significantly lower at 30 days among MAIA patients (1.6% vs. 19.5%; p < 0.0001), as well as at 90 days (4.8 % vs. 35.8 %; p < 0.0001). On the other hand, lengths of stay were longer in this group (20.9 vs. 11 days; p = 0.005) and the patients consulted the emergency department more often (40.8 % vs. 17.1 %; p < 0.0001). We could not conclude on mortality and falls. A positive impact of the Aube MAIA scheme on early and late readmission to hospital was shown.

The aim of this study was to describe the predictive role of the modified SEGA fragility score on nursing home admission, rehospitalization, falls and mortality.We performed a prospective, single-center cohort study in patients leaving geriatric hospitalization between July 2016 and February 2017, with follow-up at 6 months. Patients 65 years of age and over, returning home, were included. The primary outcome measure was admission to an institution at 6 months. We realized a Cox model to explore the predictive character of the variables.Thirty-three patients (18.4%), mean age 80.9 years (± 6.5), were not very fragile. At 6 months, 13.5% of the fragile or very fragile patients and 1.2% of the patients who were not very fragile had entered the institution (p = 0.169). Fragility status was statistically significantly associated with rehospitalization at 3 months (p = 0.026) and single or multiple drop at 6 months) month (p = 0.003).The SEGAm grid would predict the occurrence of derogatory events and improve return home.

The SEGA instrument has demonstrated good performance in screening for frailty. However, its predictive ability in elderly patients presenting with acute coronary syndrome have never been evaluated. We aimed to study the prognostic value at one year of the frailty level assessed by the SEGA instrument, in a population of patients aged 80 years old or more hospitalised for acute coronary syndrome. All consecutive patients aged 80 years or older hospitalised for myocardial infarction type 1 between November 2016 and October 2017 were included. All underwent standardised geriatric assessment including estimation of frailty by the SEGA instrument. The primary outcome was the time to death from any cause. In all 64 patients were included for a mean age of 85.3±4 years. Using the SEGA instrument, 24% patients were classified "frail" and 44% "very frail"; 18 (28%) deaths were observed during follow-up. When adjusted for patient age, body mass index and arterial hypertension, survival status was not significantly related with frailty status (HR=1.1, 95% CI=0.4-3.1, p=0.8).

Entertiens Jacques Cartier, QUEBEC, CANADA, 16-/10/2017 - 17/10/2017; BACKGROUND: Because cognitive processes decline in the earliest stages of Alzheimer's disease, the driving abilities are often affected. The naturalistic driving approach is relevant to study the driving habits and behaviors in normal or critical situations in a familiar environment of participants. OBJECTIVE: This pilot study analyzed in-car video recordings of naturalistic driving in patients with early-stage Alzheimer's disease and in healthy controls, with a special focus on tactical self-regulation behavior. METHODS: Twenty patients with early-stage Alzheimer's disease (Diagnosis and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] criteria), and 21 healthy older adults were included in the study. Data collection equipment was installed in their personal vehicles. Two expert psychologists assessed driving performance using a specially designed Naturalistic Driving Assessment Scale (NaDAS), paying particular attention to tactical self-regulation behavior, and they recorded all critical safety events. RESULTS: Poorer driving performance was observed among Alzheimer's disease drivers: their tactical self-regulation behavior was of lower quality. AD patients had also twice as many critical events as healthy drivers and three times more 'unaware' critical events. CONCLUSION: This pilot study using a naturalistic approach to accurately show that Alzheimer's disease drivers have poorer tactical self-regulation behavior than healthy older drivers. Future deployment of assistance systems in vehicles should specifically target tactical self-regulation components.

Tuteur methodologique D. Jolly. Tuteur thematique R. Mahmoudi. Etat de la question La fragilite du sujet âge est associee a la survenue d’evenement de sante negatif. L’objectif de cette etude etait de comparer les capacites predictives de deux echelles de fragilite (phenotype de Fried et la grille SEGAm : « Short Emergency Geriatric Assessment modified ») en termes d’hospitalisations et de perte d’independance a un an dans une population âgee ambulatoire. Materiel et methodes Etude prospective multicentrique, realisee chez des sujets âges de 70 ans et plus. Des variables cliniques et celles de l’evaluation geriatriques standardisee ont ete recueillies. Une regression logistique binaire univariee et multivariee a ete realisee avec comme variables d’interet l’hospitalisation et la perte d’independance a un an. Resultats Le risque d’hospitalisation a un an n’etait pas lie au statut de fragilite evalue par le phenotype de Fried et la grille SEGAm. Concernant la perte d’independance, selon le phenotype de Fried il existait une augmentation du risque chez les pre-fragiles et fragiles (respectivement OR : 2,29 IC 95 % [1,05–5,00] ; OR : 9,33 IC 95 % [2,07–42,05]) qui n’etait plus significative apres ajustement (respectivement OR ajuste : 1,11 IC 95 % [0,49–2,47] ; OR ajuste : 2,66 IC 95 % [0,67–10,46]). Selon SEGAm, les sujets fragiles et tres fragiles etaient significativement plus a risque de perte d’independance (OR : 2,91 IC 95 % [1,21–6,98] ; OR ajuste : 3,27 [1,40–7,60]). Conclusion La capacite predictive des echelles de fragilite du sujet âge depend des evenements d’interet. La grille SEGAm peut etre utilisee dans une strategie de prevention dans une population âgee ambulatoire.

RFMASA, LYON, FRANCE, 08-/06/2016 - 10/06/2016; La question de l'aptitude à la conduite des conducteurs présentant une maladie d'Alzheimer débutante est au coeur des préoccupations des praticiens et des familles. S'il est bien admis que l'activité doit cesser quand la maladie est avancée, certains conducteurs peuvent conduire en sécurité en phase débutante car les déficits attentionnels et exécutifs restent modérés. Il importe cependant de pouvoir identifier les signaux qui témoignent d'une conduite dégradée nécessitant une réduction voire un arrêt de la conduite. Deux techniques d'observation sont souvent employées pour évaluer la performance de conduite : le simulateur de conduite et le véhicule instrumenté équipé de caméras permettant une évaluation d'une heure environ par un expert. Une approche plus récemment utilisée consiste à placer un dispositif d'enregistrement vidéo directement dans le véhicule personnel du participant pendant un mois environ. Cette approche, dite naturelle (naturalistic driving) fait l'objet de la présente étude. Elle permet d'étudier l'activité de conduite « au plus près » c'est-à-dire dans des conditions réelles et familières des participants (parcours quotidiens). Ainsi l'activité de conduite de 20 patients et 21 contrôles a été analysée sur une période d'un mois. Les patients ont été recrutés dans trois centres hospitaliers (Reims, Paris et Strasbourg). Les enregistrements ont été codés à l'aide d'un outil spécialement conçu pour cette étude : le Naturalistic Driving Assessment Scale (NaDAS). Les événements critiques (accidents, presqu'accidents, incidents) ont également été comptabilisés. Les difficultés les plus significatives chez les patients ont été observées aux niveaux du maintien sur la voie, du contrôle de la vitesse, du traitement des informations visuelles et des manoeuvres de tourne-à-gauche. Les patients comptabilisaient également un plus grand nombre d'événements critiques. Ils ne déclaraient cependant pas plus de difficultés que les contrôles et ne déclaraient pas avoir changé leurs habitudes de conduite par rapport à avant (40 ans). L'approche en naturalistic driving est prometteuse car elle permet une analyse approfondie de l'activité des conducteurs.

A study was carried out in the Marne department with the aim of describing the comorbidities and the treatments of a representative sample of the population living in nursing homes. It reveals the most frequent pathologies and the most commonly prescribed classes of therapies thereby aiding the assessment of the care costs of elderly people and the anticipation of their needs.

Contexte : Les demences sont des maladies chroniques et evolutives, pour lesquelles aucun traitement curatif n’est disponible. L’evaluation de la qualite de vie du patient constitue donc un element important de sa prise en charge. Objectif : Il s’agit de realiser une synthese de la litterature afin de repertorier les instruments de qualite de vie specifiques des demences, et d’identifier les facteurs associes a la qualite de vie. Methodes : Ont ete recensees des etudes referencees PubMed, publiees entre novembre 1996 et decembre 2010, s’interessant au developpement ou a la validation d’outils de qualite de vie specifiques aux demences, ou ayant inclus un de ces outils dans l’evaluation d’interventions therapeutiques. Resultats : Neuf instruments de qualite de vie ont ete repertories. Le lieu de vie et le niveau d’education ne semblent pas avoir d’influence. Âge et sexe montrent des resultats discordants. Un lien, bien que de faible amplitude, semble exister avec l’etat cognitif. Les facteurs le plus frequemment associes a une moindre qualite de vie sont les troubles du comportement, la dependance, et le fardeau de l’aidant. La qualite de vie sous traitements pharmacologiques est mal evaluee, tandis que les interventions de therapie occupationnelle et de stimulation cognitive semblent avoir un effet positif modere.

Population aging and the increasing prevalence of Alzheimer's disease and related disorders raise the question about the existence of legal tools to protect and maintain patient autonomy. Against this background, it is essential that physicians are aware of the different legal options that allow them to help patients in need. Justice protection (sauvegarde de justice), guardianship (curatelle) and trusteeship (tutelle) are useful tools, but they leave no room for anticipation. While these emergency tools have to be constantly adapted to the condition of the protected adult, they are still imposed. Thus the emergence of a new tool, the future power of attorney (mandat de protection future), asserts the right to foresight, and allows the patient to regain a central position in their future management.

Even though the efforts in research have detailed further the physiopathology and the dynamics of the frailty process an operational definition of frailty is still far from being unequivocal. Studies carried out from the SAFEs cohort study allowed a pragmatic approach in the identification of the at-risk groups for the lost of independency during the hospital stay and factors influencing their future at short-, mid- and long-term. Based upon these results, we propose to discuss the relevance of the current operational indicators of frailty in order to show that clinical markers or indicators are insufficient to differentiate the frailty process from normal ageing. Finally we give rise to the imperative necessity to detect frailty at a preclinical stage with the help of biological and more particularly inflammatory markers.

The ageing of the french population confronts our society with enormous challenges of which the adaptation and the organization of health and psychosocial cares to aged people. The SAFEs cohort analysis has led to better identify older inpatients that presented adverse outcomes during their hospitalization or after their hospital discharge. From the main results, a feature discussion concerning care models adaptation is proposed. This feature discussion highlights: the importance to rehabilitate functional disorders as soon as possible from the admission in the hospital environment; the negative impact playing by a fragmented and sometimes "over"-specialized hospital care system; the importance of the coordination in cares within and between hospital- and community-care models; the necessity for health care professionals to be better trained to geriatric medicine specificities. Therefore, with the double objective of both optimizing the use of the financial resources and to implement adapted and good quality cares, it is necessary to elaborate a real and concrete health policy specifically dedicated to co-morbid and disabled old adults. Such health policy will have to target the care networks as a whole and lead to specific and adequate financing assistances.

The ageing of the french population confronts our society with enormous challenges of which the adaptation and the organization of health and psychosocial cares to aged people. The SAFEs cohort analysis has led to better identify older inpatients that presented adverse outcomes during their hospitalization or after their hospital discharge. From the main results, a feature discussion concerning care models adaptation is proposed. This feature discussion highlights: the importance to rehabilitate functional disorders as soon as possible from the admission in the hospital environment; the negative impact playing by a fragmented and sometimes "over"-specialized hospital care system; the importance of the coordination in cares within and between hospital- and community-care models; the necessity for health care professionals to be better trained to geriatric medicine specificities. Therefore, with the double objective of both optimizing the use of the financial resources and to implement adapted and good quality cares, it is necessary to elaborate a real and concrete health policy specifically dedicated to co-morbid and disabled old adults. Such health policy will have to target the care networks as a whole and lead to specific and adequate financing assistances.

To identify the factors predictive of long-term mortality among a cohort of subjects aged 75 years or older hospitalized from the emergency department.Variables from the standardized geriatric assessment of members of the multicenter SAFES cohort were applied to a Cox model to predict mortality over a 3-year follow-up.This cohort comprised 1306 patients with a mean age of 85+/-6 years. Half the patients died during the 3 years of follow-up. After adjustment for center, social and demographic variables (age, sex, educational level, and community or institutional residence) and level of comorbidity, the variables that significantly influenced mortality over the next 36 months were: severe malnutrition (p0.03), dementia (p0.001) and/or confusion (p0.001), walking problems (p=0.001) and recent hospitalization (p0.001). No significant association was found between depression and mortality (p=0.40).A predictive approach to mortality at 3 years is possible with simple scales widely used in geriatrics. Correction of malnutrition, recognition and management of cognitive disorders, and functional rehabilitation must be included in the priorities of care.

The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients.This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Agé Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG).The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A "risk of malnutrition" (OR=14.07) and "mood disorders" (OR=2,5) were both early markers for prolonged hospitalization. Although not statistically significant, "walking difficulties" (OR=2.72) and "cognitive impairment" (OR=5.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katz's Activities of Daily Living Index or its course during hospitalization.Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

General principles of medical ethics are discussed in the context of care for patients with severe dementia.

Many factors can lead to edema. Hypoalbuminemia and the inability of the renal distal tubule to excrete salt are a common cause of edema, that can be due to a defect of albumin synthesis or malnutrition, kidney disease, protein-losing enteropathy, or increased protein catabolism. Hypoalbuminemia is frequent amongst elderly people. Its prevalence ranges from 4% to 50% depending on whether they live at home or in hospice. In normal circumstances, albumin has a double function to maintain oncotic pressure and to transport endogenous or exogenous substances. Lack of albumin is thus responsible for numerous pathological states. In this article, we report two clinical observations in patients aged over 65, suffering from generalized, highly invalidating edema, with low albumin states due to malnutrition. A rapid long-term recovery was observed after administrating albumin, and produced a far better quality of life for the patients. The clinical results obtained following this specific indication warrant further research work to verify their scientific validity on a larger scale.