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BACKGROUND The institutionalization of a patient with Alzheimer's disease or other dementia (ADOD) is the last resort for the latter's family and/or caregivers. We hypothesized that the degree of kinship between the patient and his/her caregiver would influence the likelihood of institutionalization. OBJECTIVE To assess the association between institutionalization of patients with ADOD and the degree of kinship with the family caregiver. METHODS A cross-sectional study of patients with ADOD aged 75 or over attending a memory center in France for the first time between 2011 and 2014, as recorded in the French National Alzheimer Database. Multivariable logistic regression was used to assess factors associated with institutionalization after adjustment for age, sex, the Mini-Mental State Examination score, educational level, and type of dementia. RESULTS A total of 52,874 patients were included. The primary caregiver was most often a child (54.8%) or the spouse (36.7%). Compared with the "spouse" reference category, all the other caregiver categories were associated with a significantly greater likelihood of institutionalization; the odds ratio [95% confidence interval] was 4.68 [3.67-5.92] when the carer was a grandchild, 5.48 [4.93-6.09] for a child, 4.93 [4.11-5.91] for a daughter-/son-in-law, 8.76 [7.15-10.70] for a sibling, and 8.93 [7.48-10.65] for a niece/nephew. CONCLUSION The likelihood of institutionalization of older patients with ADOD varied with the degree of kinship. Compared with the "spouse" reference category, the likelihood was higher for all other types of caregivers but was especially high when the caregiver was not a direct descendant of the patient.

Long-term care facility (LTCF) older residents display physiological alterations of cellular and humoral immunity that affect vaccine responses. Preliminary reports suggested a low early postvaccination antibody response against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The aim of this study was to focus on the specific T-cell response. We quantified S1-specific IgG, neutralizing antibody titers, total specific IFNγ-secreting T cells by ELISpot, and functionality of CD4+- and CD8+-specific T cells by flow cytometry, after two doses of the BNT162b2 vaccine in younger and older people, with and without previous COVID-19 infection (hereafter referred to as COVID-19-recovered and COVID-19-naive subjects, respectively). Frailty, nutritional, and immunosenescence parameters were collected at baseline in COVID-19-naive older people. We analyzed the immune response in 129 young adults (median age 44.0 years) and 105 older residents living in a LCTF (median age 86.5 years), 3 months after the first injection. Humoral and cellular memory responses were dramatically impaired in the COVID-19-naive older (n = 54) compared with the COVID-19-naive younger adults (n = 121). Notably, older participants’ neutralizing antibodies were 10 times lower than the younger’s antibody titers (p + and IFNγ+IL-2+TNFα+ cells among specific CD4+ T cells, and the frequency of specific CD8+ T cells were lower in COVID-19-naive older participants than in COVID-19-naive young adults (p p = 0.0018, respectively). However, COVID-19-recovered older participants (n = 51) had greater antibody and T-cell responses, including IFNγ+ and IFNγ+IL-2+TNFα+-specific CD4+ T cells (p +-specific CD8+ T cells (p + and CD8+ T cells, in addition to impaired antibody response, and that specific studies are warranted to assess the efficiency of SARS-CoV-2 mRNA-based vaccines, as in other immunocompromised subjects. Our study also shows that, despite their physiological alterations of immunity, vaccination is highly efficient in boosting the prior natural memory response in COVID-19-recovered older people.

ObjectiveDirect oral anticoagulants have been evaluated in the general population, but proper evidence for their safe use in the geriatric population is still missing. We compared the bleeding risk of a direct oral anticoagulant (rivaroxaban) and vitamin K antagonists (VKAs) among French geriatric patients with non-valvular atrial fibrillation (AF) aged ≥80 years.MethodsWe performed a sequential observational prospective cohort study, using data from 33 geriatric centres. The sample comprised 908 patients newly initiated on VKAs between September 2011 and September 2014 and 995 patients newly initiated on rivaroxaban between September 2014 and September 2017. Patients were followed up for up to 12 months. One-year risks of major, intracerebral, gastrointestinal bleedings, ischaemic stroke and all-cause mortality were compared between rivaroxaban-treated and VKA-treated patients with propensity score matching and Cox models.ResultsMajor bleeding risk was significantly lower in rivaroxaban-treated patients (7.4/100 patient-years) compared with VKA-treated patients (14.6/100 patient-years) after multivariate adjustment (HR 0.66; 95% CI 0.43 to 0.99) and in the propensity score–matched sample (HR 0.53; 95% CI 0.33 to 0.85). Intracerebral bleeding occurred less frequently in rivaroxaban-treated patients (1.3/100 patient-years) than in VKA-treated patients (4.0/100 patient-years), adjusted HR 0.59 (95% CI 0.24 to 1.44) and in the propensity score–matched sample HR 0.26 (95% CI 0.09 to 0.80). Major lower bleeding risk was largely driven by lower risk of intracerebral bleeding.ConclusionsOur study findings indicate that bleeding risk, largely driven by lower risk of intracerebral bleeding, is lower with rivaroxaban than with VKA in stroke prevention in patients ≥80 years old with non-valvular AF.

International audience; Background Music-based interventions appear to be efficient non-pharmacological approaches to improve emotional, social, and cognitive functioning of patients with neurodegenerative diseases such as Alzheimer's Disease (AD). Objectives Because the benefits seem to increase with patients motor involvement, we studied the ability to move in synchrony with musical rhythms and more specifically the impact of live performance compared to video recording of a musician on sensorimotor abilities in patients with cognitive impairments (AD, vascular and mixed dementia) and in patients with no evidence of cognitive impairments. Methods Sensorimotor synchronization (SMS) to a metronomic or a musical stimulus was assessed in patients when they were viewing a live musician or his pre-recorded video. Results Participants were better at synchronizing to a metronome than to music but this effect was modulated by the social context. While SMS to a metronome was better when facing a video than a live performance, there was no impact of the social context on SMS to music. Lastly, we found no group differences on SMS. Conclusion The decrease in synchronization ability to metronome in the live performance may be due to the social pressure associated with the presence of the musician. Such a pressure might be removed in pleasant and ecological social activities, like moving with music, explaining the lack of the social context effect on SMS to music. Remarkably, the group with cognitive impairments performed no worse than the group without cognitive impairments, which suggests relatively spared SMS abilities in these patients. By showing that it is possible to encourage a patient to synchronize with others, even in front of a video, the results of our study indicate that SMS can be used as a relevant predictor in clinical trials and open up promising therapeutic options for patients living in remote areas.

Purpose/introduction A Fracture Liaison Service (FLS) was set up at Lille University Hospital in 2016. The purpose of this study was to assess persistence with osteoporosis treatment in patients from the FLS over a period of 1 year, and to determine predictors of discontinuation. Methods The study population comprised adults of both genders, aged 50 or over, admitted to Lille University Hospital between January 2016 and January 2019 for a low-trauma fracture and managed in our FLS. Outcomes included (1) persistence rate at 1 year after treatment initiation, (2) persistence rate at 2 years after treatment initiation, (3) persistence rate at 1 and 2 years after treatment initiation according to type of treatment, (4) predictors of non-persistence, and (5) reasons for discontinuing treatment over 1 year after initiation. Persistence was determined using the Kaplan–Meier method. Results In all, 1224 patients (≥50 years old) with a recent history of low-trauma fracture (≤12 months) were identified. Of these, 380 patients – 79.2% female; mean (SD) age 76 (11) years – were seen at the FLS. In those 380 patients, 410 fractures were found and 360 of them (87.8%) were major fractures, breaking down as follows: vertebra (44%), hip (19%), proximal humerus (10%), and pelvis (8%). Osteoporosis treatment was prescribed for 367 (96.6%) patients and 275 of them began the prescribed treatment. The following anti-osteoporosis drugs were prescribed: zoledronic acid (n=150, 54.5%), teriparatide (n=63, 22.9%), and denosumab (n=39, 14.2%). Oral bisphosphonates were prescribed for a few patients (n=23, 8.4%). Persistence with osteoporosis medication (any class) was estimated at 84.1% (95% CI: 79.1% to 88.1%) at 12-month follow-up, and dropped to 70.3% (95% CI: 63.7% to 75.9%) at 24 months. When drug-specific analyses were performed using the Kaplan–Meier method, persistence rates at 12 and 24 months were found to be higher with denosumab than with any other treatment. Independent predictors of non-persistence at 12 months were ‘follow-up performed by a general practitioner (GP)’ – Odds Ratio (OR) for GP vs. FLS = 3.68; 95% CI, 1.52 to 8.90, p=0.004 – and ‘treatment with zoledronic acid’ – OR for zoledronic acid vs. denosumab = 3.39; 95% CI, 1.21 to 9.50, p=0.019; OR for zoledronic acid vs. teriparatide = 8.86; 95% CI, 1.15 to 68.10, p=0.035. Conclusions This study provides evidence of the success of our FLS in terms of long-term persistence with osteoporosis treatments. However, osteoporosis treatment initiation still needs to be improved.

Despite known adverse effects of anticholinergic (AC) medication, little work has been devoted to the impact of high anticholinergic burden on the rate of hospital readmission. The purpose of this study was to analyze prospectively the link between high AC burden and the rate of all-cause thirty-day hospital readmission in older people. This was a prospective non-interventional study conducted from January to August 2019 in one acute-care geriatric ward. All hospital stays of patients aged at least 75 years who were discharged to their home were included in the analysis. AC burden was determined from discharge prescriptions using the Anticholinergic Drug Scale (ADS) and the Anticholinergic Risk Scale (ARS), and defined as high if ≥3. The analysis concerned 350 hospital stays. Median patient age was 88 years (interquartile interval 84–91). In a multivariate analysis, the risk of hospital readmission within 30 days was not increased for patients with high AC burden (ADS≥3): odds ratio 1.16 [95% confidence interval 0.56–2.37], compared to a patient whose anticholinergic burden was not high. Unlike retrospective studies on this issue, the findings of our prospective analysis do not support a higher risk of hospital admission within 30 days for older people with high AC burden as assessed from their discharge prescriptions.

Drug-induced hyperkalemia is a frequent and severe complication in the hospital setting. Other risk factors may also induce hyperkalemia but the combination of drugs and precipitating factors has not been extensively studied. The aim was to identify drug-induced hyperkalemia events in hospitalized older patients and to describe their combinations with precipitating factors. Two experts independently analyzed retrospective data of patients aged 75 years or more. Experts identified 471 hyperkalemia events and concluded that 379 (80.5%) were induced by drugs. The cause was multifactorial (i.e., at least one drug with a precipitating factor) in 300 (79.2%) of the 379 drug-induced hyperkalemia. Most of the drug-induced hyperkalemia events were avoidable (79.9%)-mainly because of the multifactorial cause (e.g., dosage adaptation during acute kidney injury). Drug-induced hyperkalemia events are frequently combined with precipitating factors in hospitalized older patients and their prevention should focus on these combinations.

The traditional image of the African family that has long grant a place of choice to the elderly does match maybe any more the reality of today. The WHO report on violence and health 2002 and some studies carried out in other African countries suggest that elder abuse also exists in sub-Saharan Africa. To describe how the young Congolese adults consider their elderly and mistreatments that can result. A cross sectional study was realized between January and April, 2008 with 300 youth and adults aged 15 to 55 years (203 ≤ 25 years old), living in Brazzaville or in Pointe-Noire. The sample of 300 people was constituted according to the method of non-probability sampling. The data collection was made on the ground by state employees of the Ministry of Health, social affairs and family by means of a pre-established questionnaire containing open and closed questions. Youth and adults have contrasted and contradictory representations of the elderly. In 70% of the cases they said have good relationships with the elderly and qualified them as wise persons and as models but, conversely, more than 50% of them found them unwanted and disturbing. Witchcraft accusations are frequent with often serious consequences. Social transformations dispossess little by little the elderly people of their status and their prerogatives in Congo-Brazzaville. They come along with a change of look and behavior of the young adults towards them. Elder abuse in Congo-Brazzaville is an underestimated problem insufficiently denounced and fought.

La Presse Medicale - In Press.Proof corrected by the author Available online since jeudi 28 janvier 2016

International audience; BACKGROUND: Several studies have shown that the prescription of antiplatelet therapy (APT) is associated with an increased risk of oral anticoagulant (OAC) underuse in patients aged 75 years and over with atrial fibrillation (AF). An associated atheromatous disease may be the underlying reason for APT prescription. The objective of the study was to determine whether the association between underuse of OAC and APT prescription was explained by the presence of an atheromatous disease. METHODS AND RESULTS: We performed a retrospective, observational, single-centre study between 2009 and 2013 based on administrative data. Patients aged 75 years and over with non-valvular AF were identified in a database of 72,090 hospital stays. Prescriptions of anti-thrombotic medications and their association with the presence of atheromatous disease were evaluated by the mean of a logistic regression. A total of 2034 hospital stays were included (mean age 84.3 ± 5.2 years). The overall prevalence of known atheromatous disease was 25.9%. OAC underuse was observed in 58.5% of the stays. In multivariable analysis, the prescription of an APT was associated with an increased risk of OAC underuse [odds ratio (OR) 6.85; 95% confidence interval (CI) 5.50-8.58], independently of the presence of a concomitant known atheromatous disease (OR 0.78; 95% CI 0.60-1.01). Among the 692 stays with APT monotherapy (34.0%), 232 (33.5%) displayed an atheromatous disease. CONCLUSIONS: The underuse of OAC is associated with the prescription of APT in older patients with AF, regardless of the presence or absence of known atheromatous disease. Our results suggest that APT is often inappropriately prescribed instead of OAC.

Prescriptions of PIMs and anticholinergic drugs lead to adverse events and hospitalizations in the elderly. The objective of this study was to determine the prevalence of PIMs and prescriptions with a high anticholinergic effect in a French region. All prescriptions dispensed at community pharmacies in patients aged 75 and older between January 1 and March 31, 2012 were extracted from French Health Insurance information System - Nord-Pas-de-Calais Region for patients affiliated to the Social Security. Prescription of PIMs was defined according to the Laroche list. The anticholinergic score for each prescription was calculated using the Anticholinergic Drug Scale (ADS). 65.6% (n=207,979) of people aged over 75 years, living in the Nord-Pas-de-Calais Region were included, of which 4.5% (n=9284) living in nursing homes. Patients received an average of 8.3 drugs over the 3-month study period. In 32.6% (n=67,863) of patients, at least one PMI was prescribed. According to the ADS, 10.0% (n=20,978) of patients in the general population and 24.0% (n=2231) of patients living in nursing homes was exposed to a prescription with a high or very high anticholinergic score (ADS≥3). Hydroxyzine prescribed in 51.4% (n=10,792) of them ranked first among drugs most often reported. In conclusion, PMIs and anticholinergic drugs were commonly prescribed in elderly living in the Nord-Pas-de-Calais Region. Improving the quality of prescriptions in the elderly appears necessary.

Rationale, aims and objectives To assess the impact of an automated drug distribution system on medication errors (MEs). Methods Before-after observational study in a 40-bed short stay geriatric unit within a 1800 bed general hospital in Valenciennes, France. Researchers attended nurse medication administration rounds and compared administered to prescribed drugs, before and after the drug distribution system changed from a ward stock system (WSS) to a unit dose dispensing system (UDDS), integrating a unit dose dispensing robot and automated medication dispensing cabinet (AMDC). Results A total of 615 opportunities of errors (OEs) were observed among 148 patients treated during the WSS period, and 783 OEs were observed among 166 patients treated during the UDDS period. ME [medication administration error (MAE)] rates were calculated and compared between the two periods. Secondary measures included type of errors, seriousness of errors and risk reduction for the patients. The implementation of an automated drug dispensing system resulted in a 53% reduction in MAEs. All error types were reduced in the UDDS period compared with the WSS period (P

Objectif : Il s’agit d’une analyse du sommeil en fonction de la prise d’hypnotiques. Patients et methode : L’etude, prospective, observationnelle et multicentrique, a ete realisee en institution un jour donne. Les residents d’un âge ≥ 65 ans, ayant un Mini mental state (MMS) ≥ 15 et une coherence cotee A ou B (pour la grille Autonomie gerontologie groupes iso-ressources, ou AGGIR), sans aphasie ou pathologie aigue, ont ete inclus. Par definition, les plaintes de sommeil etaient exprimees par les residents et les troubles du sommeil etaient reperes par les soignants. Les aspects qualitatifs du sommeil tels que plainte versus trouble, difficulte d’endormissement et reveils nocturnes, de meme que les aspects quantitatifs (duree) ont ete analyses en fonction de la prise ou non d’hypnotiques. Resultats : Parmi les 635 residents inclus, 55,6 % prenaient des sedatifs. De plus, 28,2 % des residents presentaient des plaintes de sommeil et 11,4 % avaient des troubles du sommeil ( p < 0,001). Les residents sous hypnotiques, en comparaison aux residents sans hypnotiques, avaient davantage de plaintes de sommeil (31,2 % versus 24,8 % ; p < 0,05), de difficultes d’endormissement (38,6 % versus 26,5 % ; p < 0,001) et de reveils nocturnes (69,5 % versus 60,9 % ; p < 0,05). Il n’y avait aucune difference de duree de sommeil. Conclusion : Il semble exister une moins bonne qualite de sommeil chez les residents sous sedatifs.

Fear of falling may be as debilitating as the fall itself, leading to a restriction in activities and even a loss of autonomy.ObjectivesThe main objective was to evaluate the prevalence of the fear of falling among elderly fallers. The secondary objectives were to determine the factors associated with the fear of falling and evaluate the impact of this fear on the activity “getting out of the house”.Patients and methodProspective study conducted between 1995 and 2006 in which fallers and patients at high risk for falling were seen at baseline by the multidisciplinary falls consultation team (including a geriatrician, a neurologist and a physical medicine and rehabilitation physician) and then, again 6 month later, by the same geriatrician. The fear of falling was evaluated with a yes/no question: “are you afraid of falling?”.ResultsOut of 635 patients with a mean age of 80.6 years, 502 patients (78%) expressed a fear of falling. Patients with fear of falling were not older than those who did not report this fear, but the former were mostly women (P

In elderly individuals balance disorders and muscle weakness can lead to prescribing a walker. There are several different models. According to the very poor effort tolerance in this population, the energy cost necessary to operate walking technical aids should be taken into account when making a choice.ObjectiveCompare two types of walker in regards to energy cost produced during gait in weakened elderly individuals.MethodThirty subjects over the age of 65 (six men and 24 women, mean age 81.9 years) were admitted in geriatrics care. They all required a walker and performed the same 10-m course with a fixed walker, then with a model bearing front wheels. The walking speed (S) was computed, heart rate at rest (HRrest) and maximum heart rate (HRmax) were recorded during the test. The physiological cost index (PCI=HRmax−HRrest/S) was calculated. Finally a timed get-up-and-go (TGUG) test was performed with each of these technical aids.ResultsWith a rollator walker, HRmax was lower (P

Summary Background Elderly patients with an acute coronary syndrome (ACS) are less likely to be enrolled into randomized, controlled trials or receive guideline-recommended therapies, because of a higher burden of comorbidity, including functional decline. Aim To assess the prognostic value of functional decline in a prospective, observational cohort of elderly ACS patients. Methods ACS patients aged ≥ 70 years were enrolled. The ACS definition included ST- and non-ST-segment elevation myocardial infarction, and unstable angina pectoris. Clinical admission and laboratory data and echocardiographic variables were recorded. Functional decline was defined as needing assisted care in daily life. The study endpoint was all-cause mortality. Results Overall, 151 patients were enrolled (mean age 78 ± 5 years; 52% men). Twenty-eight (19%) patients had functional decline. No significant difference in therapeutic management was observed between patients with functional decline and those living independently. Twenty-seven (18%) patients died during follow-up (median 447 days). Functional decline correlated with poor outcome ( p = 0.008; hazard ratio [HR] 2.87 [1.31–6.25]). Other prognostic markers were diabetes, Killip class ≥ II, elevated E/Ea ratio, C-reactive protein, B-type natriuretic peptide, haemoglobin, glycaemia and no coronary angiography. By multivariable analysis, C-reactive protein > 13 mg/L correlated with poor outcome ( p = 0.007; HR 4.77 [1.52–14.96]). There was a trend towards correlation between functional decline and poor outcome ( p = 0.051; HR = 2.77 [0.99–7.72]). Conclusion Functional decline seems to portend poor prognosis in elderly ACS patients. Larger, community-based studies are needed to confirm these findings in a multivariable model.

To investigate whether home visits by a occupational therapist reduces the risk of falling and improves the autonomy of older patients hospitalized for falling.In this randomized, controlled trial set in a geriatric hospital, 60 patients (mean age, 83.5 yr) who were hospitalized for falling were recruited from the acute medicine department. A home visit from an occupational therapist and an ergotherapist assessed patients' homes for environmental hazards and recommended modifications. The outcomes measured were falls, autonomy, hospitalization for falling, institutionalization, and death.During the follow-up period, the rate of falls, hospitalization for falls, institutionalization, and death were not significantly different between the two groups. Both groups had a loss of dependence at 12 mo. This loss of dependence was significant in the control group but not in the intervention group.Home visits from occupational therapists during hospitalization of older patients at risk for falling can help to preserve the patient's autonomy.

Background: Postprandial hypotension (PPH) is increasingly recognized as a common cause of falls and syncopes in the elderly. The diagnosis of PPH is based on the measurement of meal-induced blood pressure (BP) changes. Although the problem of intraindividual reproducibility of PPH is of clinical importance, it has not been extensively studied. Objective: To assess the intraindividual reproducibility of PPH. Methods: 50 patients (42 women and 8 males, 83 ± 8 years) were included in the study. To evaluate PPH, we measured the BP before and every 15 min for 2 h after the start of a standardized mixed meal. The PPH was defined as a decrease in systolic BP of 20 mm Hg or more. Three sets of BP were obtained for each subject on 2 successive days: (1) between 08.00 and 10.00 h and (2) between 16.00 and 18.00 h on the 1st day and (3) between 08.00 and 10.00 h on the 2nd day. Results: 32 participants (64%) experienced PPH on at least one test. Among them, 19 (38%) had PPH on the first test, 16 (32%) had PPH on the second test, and 21 (42%) had PPH on the third test. The intraindividual reproducibility of PPH was good when the results of the two morning tests were compared together (kappa coefficient = 0.6), but was low when the morning test results were compared with the afternoon test results of the 1st day (kappa coefficient = 0.1). Conclusions: Because of the good reproducibility of postprandial BP changes, we conclude that the diagnosis of PPH may be based on a single standardized test. However, the test must be performed under circumstances (time of the meal, medications) similar to those in which the symptoms occurred.

In France, over 20% of hospitalizations of elderly people are a result of adverse drug events, of which 50% are considered preventable. Tools have been developed to detect inappropriate prescriptions. The Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) criteria are innovative and adapted to French prescriptions. This is one of the first French prospective studies to evaluate the impact of acute geriatric care on prescriptions at discharge in elderly patients using the STOPP/START criteria.The evaluation of prescriptions according to STOPP/START was carried out on admission and at discharge of patients in acute geriatric units at three hospitals in the Nord-Pas de Calais region, France. A total of 202 elderly hospitalized patients were included during the 4.5 months of the study (1.5 months per center).The mean number of drugs was seven on admission and at discharge. Over half of the prescriptions at admission contained at least one potentially inappropriate medication or one potential prescription omission. The prescriptions at discharge contained significantly fewer potentially inappropriate medications than prescriptions on admission (P 0.001). In contrast, there was no difference between prescriptions at discharge in terms of potential prescription omissions.Acute geriatric hospitalization in France improves prescriptions in terms of potentially inappropriate medication, but has no impact on potential prescription omissions. Further studies must be carried out to see if STOPP/START could be used as a tool in French prescription.

International audience; The objective of this systematic literature review is to discuss the latest French recommendation issued in 2012 that a fall within the past year should lead to bone mineral density (BMD) measurement using dual-energy X-ray absorptiometry (DXA). This recommendation rests on four facts. First, osteoporosis and fall risk are the two leading risk factors for nonvertebral fractures in postmenopausal women. Second, BMD measurement using DXA supplies significant information on the fracture risk independently from the fall risk. Thus, when a fall occurs, the fracture risk increases as BMD decreases. Third, osteoporosis drugs have been proven effective in preventing fractures only in populations with osteoporosis defined based on BMD criteria. Finally, the prevalence of osteoporosis is high in patients who fall and increases in the presence of markers for frailty (e.g., recurrent falls, sarcopenia [low muscle mass and strength], limited mobility, and weight loss), which are risk factors for both osteoporosis and falls. Nevertheless, life expectancy should be taken into account when assessing the appropriateness of DXA in fallers, as osteoporosis treatments require at least 12months to decrease the fracture risk. Another relevant factor is the availability of DXA, which may be limited due to geographic factors, patient dependency, or severe cognitive impairments, for instance. Studies are needed to better determine how the fall risk and frailty should be incorporated into the fracture risk evaluation based on BMD and the FRAX® tool.

Summary Background Ageing is a determining factor in skin cancer, but the incidence and prevalence of skin cancer in elderly patients are not known. Aim To determine the prevalence of skin cancers in elderly patients and to assess their associated geriatric syndromes. Methods Between January and April 2013, all consecutive incident patients hospitalized in the Acute Geriatric Unit of Lille University Hospital underwent a geriatric assessment and a systematic dermatological examination. A biopsy was taken whenever there was any lesion with suspicion of malignancy. Results In total, 204 patients (mean age 85.4 years) were included, and 16 cutaneous biopsies were taken from 15 patients. Histological examination confirmed skin cancer in 11 biopsies from 10 patients: 9 basal cell carcinomas, 1 squamous cell carcinoma (SCC) and 1 malignant lentigo. The prevalence of skin cancer was 4.9%. The geriatric assessment revealed severe geriatric syndromes in the 10 patients with skin cancer: severe dependence (8/10), possible cognitive impairment (10/10), and moderate or severe malnutrition (5/10). Conclusions The prevalence of skin cancer is high in frail elderly patients. The association of severe geriatric syndromes suggests that close collaboration between geriatricians and dermatologists is essential to optimize the treatment of skin carcinoma in elderly patients.

Puisieux F, Pollez B, Deplanque D, Di Pompeo C, Pardessus V, Thevenon A, Dewailly P: Successes and setbacks of the falls consultation: report on the first 150 patients. Am J Phys Med Rehabil 2001;80:909–915. We report the results of a Falls Consultation. Data concerning the first 150 patients are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home, and was reassessed by the same geriatrician 6 mo later. Of the 150 patients, 135 patients completed the initial evaluation. Most of them were frequent fallers. The population was very heterogeneous regarding the health status and the degree of disability. In most cases, falls were the result of several interacting factors. The most frequent recommendations from the staff were physical therapy, environmental changes, and medication changes. Over the following 6 mo, approximately one out of four patients had experienced new falls. However, the risk of falling was significantly reduced (5.3 ± 7.3 falls in 6 mo before vs. 0.8 ± 1.6 falls in 6 mo after the intervention). The Activities of Daily Living score was a predictor of recurrent falls, hospitalization, and institutionalization. Our results show that a multidisciplinary falls consultation can be efficient in reducing the risk of falls in nonselected elderly fallers but suggest that differential strategies are needed to manage adequately the more vigorous and the frail old person as well.

PURPOSE: Anticardiolipin antibodies may be associated with recurrent thromboembolic events in patients with myocardial infarction or stroke. We sought to determine the prevalence of anticardiolipin antibodies in patients with peripheral arterial disease and their association with subsequent thromboembolic events and mortality. METHODS: We ascertained anticardiolipin antibodies using a standardized enzyme-linked immunosorbent assay (immunoglobulin G [IgG] anticardiolipin ≥15 GPL units or IgM anticardiolipin ≥15 MPL units) in 232 patients with peripheral arterial disease and 100 control subjects. Patients were observed to determine overall and cardiovascular mortality, and incident thromboembolic events. RESULTS: IgG anticardiolipin antibodies were significantly more common in the patients with peripheral arterial disease (36 of 232 [16%]) than in the controls (7 of 100 [7%], P = 0.03). During a median follow-up of 3.5 years, 3 of the 232 patients were lost to follow-up and 56 (24%) died. Overall mortality was significantly greater in the IgG anticardiolipin–positive patients (16 of 35 [46%]) compared with those who were IgG anticardiolipin–negative (40 of 194 [21%], P = 0.0003), largely due to an increase in cardiovascular mortality among the IgG anticardiolipin–positive patients. In a multivariate proportional hazards analysis, IgG anticardiolipin antibodies were an independent risk factor for overall mortality (hazard ratio [HR] = 2.1, 95% confidence interval [CI]: 1.2 to 4.0) and cardiovascular mortality (HR = 4.4, 95% CI: 1.6 to 12). CONCLUSIONS: IgG anticardiolipin antibodies are common in patients with peripheral arterial disease and are associated with an increased risk of overall and cardiovascular mortality.

OBJECTIVES: To examine the influence of time of day and of meals on postural blood pressure (BP) changes in older adults. DESIGN: Prevalence study of BP changes in response to orthostasis. SETTING: A geriatric short-stay department PARTICIPANTS: A total of 126 inpatients (91 women and 35 men; mean age: 81.4 ± 7.9, range 61–95 years) were included in the study. MEASUREMENTS: Two sets of BP and heart rate measurements were obtained for each subject by one examiner using a standard mercury manometer: (1) in mid-morning (between 10:00 and 10:30 a.m.) and (2) within 30 to 60 minutes after lunch (between 1:00 and 1:30 p.m.). Orthostatic hypotension (OH) was defined as a systolic blood pressure (SBP) decline ≤ 20 mm Hg within 3 minutes after standing. RESULTS: Sixty-one participants (48%) experienced significant orthostatic BP decline on at least one reading. Among them, 46 (37%) had OH in the mid-morning, and 32 (25%) had OH after lunch (P = .05). Only 17 (13%) had OH on both readings (persistent OH). Forty-four patients (35%) had variable OH. Patients with persistent OH were more likely to exhibit symptoms of dizziness and had a lower body mass index and a higher mean basal supine SBP. There was a positive correlation between basal supine SBP and postural SBP decline. CONCLUSIONS: Because of the variability of postural BP changes, the diagnosis of OH should not be based on a single orthostatic BP measurement but requires repeated testing, at best under circumstances similar to those in which the symptoms occurred. The postprandial period is not particularly favorable to OH, suggesting that the ingestion of a meal does not worsen orthostatic BP changes in most aged patients. J Am Geriatr Soc 47:1332–1336,1999.

The purposes of this study were (1) to assess the prevalence of antiphospholipid (aPL) antibodies in patients with non-specific heart valve disease referred for valve replacement and (2) to determine whether the presence of aPL antibodies carries a risk for thrombotic events during a postoperative follow-up in a prospective cohort. The sera of 89 consecutive patients and 80 matched control subjects were tested for antibodies to cardiolipin (immunoglobulin G and immunoglobulin M) and for lupus anticoagulant. The prevalence of aPL antibodies was significantly higher in patients (19 [21%] of 89) than in control subjects (7 [9%] of 80) (p0.05). Patients were divided into two subgroups according to the presence (subgroup A) or the absence (subgroup B) of aPL antibodies. No significant difference in age or sex ratio was observed between the two subgroups. A history of arterial thrombosis was more frequent in subgroup A (8 [42%] of 19) than in subgroup B (8 [11%] of 70) (p0.01). No significant difference with respect to the occurrence of thrombotic events was observed during a median follow-up period of 8.7 months. Thus a high prevalence of aPL antibodies was found in patients referred for heart valve replacement compared with matched control subjects. No increased risk has been demonstrated in the patients with aPL antibodies.

Nursing home residents are very old, with multiple comorbidities and disabled for activities of daily living (ADLs). Therefore, they have a higher risk of accidents as falls or fractures or acute diseases as infections, which require hospitalization. Care's coordination and sharing of informations between hospitals and nursing homes are often insufficient even with agreements. Thus, discharge to nursing homes after hospitalization may be difficult for old patients because of incomplete oral or written transmissions.To examine both protocols and the quality of the return to the nursing homes after an hospitalization for old residents.A prospective multicenter study done by collecting data about consecutive returns into their nursing home after an hospitalization of more than 24 hours of nursing home residents aged 65 years and more.Twenty-eight nursing homes of the North of France were enrolled in the study. During the 3 months period of the study, 246 discharges after an hospitalization of 24 hours or more were registered. 225 residents (165 women and 60 men), mean age 85.0 ± 7.2, were concerned. Most of them were ADLs disabled, with a dementia for 47.1% of them. The average length of hospitalization was 11.6 days. At the end of hospitalization, the notification of return, which was made only in 82% of cases, was announced in average 1.3 days before the discharge. Unfortunately, in 32% of cases, the notification was made the day of the discharge. Residents went back home indifferently any day of the week but more often the Friday and less often the weekend. The day and the hour of the planned discharge were respected in 79.1% of cases. In most cases, nursing home caregivers have considered that the clinical status was stable or improved compared to the previous one. However in 28% of cases, a loss of autonomy was found. Medical doctors wrote a letter of discharge in 85.8% of cases. Nurses gave written transmissions only in 41.9% of cases.Many points concerning discharge from hospital, about old people living in nursing home, have to be improved: oral transmissions about patient's status, notification of the return, discharge's letter, nurse's transmissions and assessment of the loss of autonomy.

Objectives To assess the clinical significance of unsuspected rise in cardiac troponin I (cTnI) levels in elderly patients who have fallen. Design Monocentre prospective observational pilot study Participants Consecutive elderly patients (age >65 years) referred to the emergency department after being immobilised on the ground after a fall. Measurements Clinical, laboratory and Doppler echocardiography data were collected on admission to assess the cardiac correlates of increased cTnI. The survival endpoint was a composite of death or cardiovascular event. Results 60 patients were included in this study. Mean age was 81±8 years. Cardiac TnI was ≥0.05 ng/ml in at least one blood sample in 40 patients (67%). New diagnosis of cardiac disease was performed in 14 patients, 13 of them had cTnI ≥0.05 ng/ml. Transient apical ballooning was diagnosed in six patients. During a median follow-up of 92 (49–131) days death occurred in six patients, myocardial infarction in three, stroke in one and acute heart failure in five. Cardiac TnI ≥0.05 ng/ml was a predictor of these events (p=0.034). Conclusion An unsuspected rise in cTnI correlates with new diagnosis of cardiac disease and is a potential marker of stress induced cardiomyopathy in elderly patients who fall. Cardiac TnI might be a strong predictor of outcome in these patients.

International audience; Seizures are frequent in the elderly, but their diagnosis can be challenging. The objective of this work was to develop and validate an expert-based algorithm for the diagnosis of seizures in elderly people. A multidisciplinary group of neurologists and geriatricians developed a diagnostic algorithm using a combination of selected clinical, electroencephalographical and radiological criteria. The algorithm was validated by multicentre retrospective analysis of data of patients referred for specific symptoms and classified by the experts as epileptic patients or not. The algorithm was applied to all the patients, and the diagnosis provided by the algorithm was compared to the clinical diagnosis of the experts. Twenty-nine clinical, electroencephalographical and radiological criteria were selected for the algorithm. According to criteria combination, seizures were classified in four levels of diagnosis: certain, highly probable, possible or improbable. To validate the algorithm, the medical records of 269 elderly patients were analyzed (138 with epileptic seizures, 131 with non-epileptic manifestations). Patients were mainly referred for a transient focal deficit (40%), confusion (38%), unconsciousness (27%). The algorithm best classified certain and probable seizures versus possible and improbable seizures, with 86.2% sensitivity and 67.2% specificity. Using logistical regression, 2 simplified models were developed, the first with 13 criteria (Se 85.5%, Sp 90.1%), and the second with 7 criteria only (Se 84.8%, Sp 88.6%). In conclusion, the present study validated the use of a revised diagnostic algorithm to help diagnosis epileptic seizures in the elderly. A prospective study is planned to further validate this algorithm.

Although frail elderly people are particularly vulnerable to the adverse effects of alcohol, very little work on alcohol consumption patterns in older people living in nursing homes has been undertaken.To determine alcohol consumption patterns among the residents of 8 nursing homes of the Nord Pas-de-Calais in France, and the characteristics associated with heavy drinking (≥ 3 glasses of wine or equivalent/day).All residents were invited to participate in the study on condition that they satisfied the inclusion criteria (age ≥ 60 years, Mini Mental State of Folstein (MMSE)15, agreement) and the exclusion criteria (no oral communication, end of life). Two questionnaires were used, one for the residents and the other for the personnel nursing.Three hundred and sixty-eight residents [242 females (65.8%) and 126 males (34.2%); mean age, 80.5 ± 8.9 years] participated in the study. Among them, 98 (26.6%) reported no consumption of alcohol and 21 (5.7%) reported occasional consumption. The 249 (67.7%) others reported every-day consumption, principally in the restaurant at the time of the meals. Sixty-seven (18.2%), were heavy drinkers with an early-onset alcoholism for two out of three. Compared with the other residents participating in the study, the at-risk alcohol drinkers were younger and more likely to be a man.The study confirms that the prevalence of chronic at risk consumption is high in nursing homes. More efforts are needed to identify and improve management of alcohol disorders in this particular setting.

We developed a prescribing guideline containing recommendations for the initial empirical antibiotic therapy in community or nosocomial pneumonia. The aim of the present study was to examine the impact of this measure.The prescribing guideline was implemented in May 1999. We retrospectively reviewed the charts of all patients65 years with community-, or nursing home- or hospital-acquired pneumonia hospitalised in our department of acute geriatric care between May 1999 and November 2000. The criteria assessed were: consistence with the guideline, clinical effectiveness within 72 hours, adequation with the isolated germs and intra-hospital mortality.Data were collected on 112 patients (63 women et 49 men; mean age=80 +/- 8 Years). The pneumonia was community-acquired in 52 cases (46%), nursing home acquired in 25 cases (22%) and hospital-acquired in 35 cases (31%). Antibiotic prescription was consistent with the guideline in 64 cases (57%). When the antibiotic therapy was consistent, the patients were more likely to improve within 72 hours (45/64 versus 23/48; p=0.01). Despite a tendency, the number of antimicrobial treatments adapted to the isolated microorganisms was not significantly higher in the consistent group (22/36 adapted treatments versus 10/20). The intra-hospital mortality (25%) was similar in the two groups consistent and not consistent with the guideline. SARM was the most frequent multiresistant bacteria that was isolated.The use of a prescribing guideline might improve the efficiency of empirical probabilistic antibiotic therapies. The impact of the guideline use on overall antibiotic costs and microbiological flora remains to be determined.

Objectives. To evaluate spinal curvature changes over a 3-year period in postmenopausal women who had had an osteoporotic vertebral fracture within the last 3 months. Methods. Thoracic kyphosis and lumbar lordosis were measured using a curviscope at baseline and after 1, 3, 6, 12, and 36 months. Anteroposterior and lateral radiographs of the thoracolumbar spine were obtained after 1 and 3 years. Results. Sixty-one patients were included. At baseline, a significant increase in thoracic curvature was found in the subgroup with thoracic fractures as compared to the subgroups with thoracolumbar or lumbar fractures (64° ± 9°, 56° ± 10 , and 56° ± 13 , respectively; P

Although leuko-araiosis is a common finding on computed tomographic (CT) scans of the brain, its pathogenesis remains uncertain. To investigate the association between blood pressure (BP) disturbances and leuko-araiosis, we retrospectively reviewed CT scans and 24-hour ambulatory blood pressure monitorings of 79 elderly patients (57 women and 22 men; mean age: 83.3 ± 6.4 years). Of the 79 patients, 50 were demented (30 had Alzheimer’s disease and 18 vascular dementia) and 29 were not demented. The leuko-araiosis score (LA score) was determined by using Rezek’s scale. To evaluate short-term variation of BP, we determined (1) the variability of systolic and diastolic BPs (SBP, DBP; within-subject standard deviation of all readings over a 24-hour period), (2) the coefficient of variability (variability of BP/mean BP) and (3) the maximal variation of BP (difference between the maximum and minimum 24-hour BPs). Higher LA scores were associated with higher SBPs in 24-hour, diurnal and nocturnal periods, higher maximal variation of SBP, greater variability of SBP during 24-hour, diurnal and nocturnal periods and greater coefficient of variability of SBP during sleep. Our study suggests that elevations and short-term variations of SBP may contribute to the pathogenesis of white matter lesions in elderly persons.

BACKGROUND Postprandial hypotension (PPH) is increasingly recognized as a common cause of falls and syncope in elderly persons. Noninvasive ambulatory blood pressure monitoring (ABPM) has been recommended for detecting PPH. This study investigates postprandial blood pressure (BP) changes by means of ABPM in elderly patients experiencing falls or syncopes. METHODS Twenty-four-hour ABPM was performed in 156 inpatients (111 women, mean age 80.4 +/- 8.1 years). Among them, 45 had been admitted for falls and 75 for syncope; 36 with no history of falls or syncope served as controls. Postprandial change in systolic blood pressure (deltaSBP) was calculated by subtracting the mean SBP within the 2 hours following the meal from the mean SBP within the 2 hours preceding the meal. PPH was defined by a deltaSBP > or = 20 mm Hg. RESULTS For the entire group, mean SBP decreased after the three meals. On average, the decline in SBP was greater after breakfast than after lunch or dinner, and the number of patients experiencing PPH was greater after breakfast. Average maximal deltaSBP was significantly larger in the syncope group than in the other groups ( p < .05). Moreover, the number of patients experiencing PPH was significantly higher in the syncope/fall group than in the control group (23% vs 9%; p = .03). Compared with patients without PPH, patients with PPH were more likely to have a history of diabetes mellitus (p < .01) or to use more than three different drugs daily ( p = .04), and they showed greater daytime SBP variability (p < .0001). Furthermore, there was a strong positive correlation between preprandial SBP and deltaSBP after breakfast. CONCLUSIONS About one out of four elderly patients with falls or syncope experiences PPH, usually after breakfast. Postprandial decline in BP contributes to BP variability. deltaSBP and preprandial SBP are positively correlated.

STUDY DESIGN A prospective cross-sectional case-control study. OBJECTIVES To compare spinal curvatures in women with osteoporosis and control subjects with a new instrument, the curviscope. SUMMARY OF BACKGROUND DATA Few instruments are available for measuring spinal curvatures in the sagittal plane. Most of them have poor reproducibility, and they have been poorly investigated in osteoporosis. METHODS Ninety-eight postmenopausal women were evaluated. They were divided into two groups, according to their bone status: women with osteoporosis with at least one vertebral fracture (n = 51) and control subjects (n = 47). Women with osteoporosis were divided into two subgroups, according to the delay since the last vertebral fracture had occurred (i.e., more or less than 3 months). Quality of life was assessed by using a generic instrument, the Nottingham Health Profile, in patients with osteoporosis only. RESULTS Reproducibility of the curviscope was satisfactory. For kyphosis measurements, the coefficients of variation were 2.8% and 2.4% in control subjects and women with osteoporosis, respectively. Kyphosis values were significantly higher in women with osteoporosis than in age-matched control subjects (63 degrees +/- 13 degrees vs. 52 degrees +/- 11 degrees, respectively; P < 0.005). Nottingham Health Profile scores were significantly different (P < 0.05) in women with osteoporosis with a recently diagnosed vertebral fracture, compared with other women with osteoporosis in two aspects, physical mobility and energy. Kyphosis measurements were significantly correlated with age in the whole group (r = 0.26; P < 0.05). In the Nottingham Health Profile, physical mobility was significantly correlated with kyphosis (r = 0.35; P < 0.05). CONCLUSIONS The curviscope is a reliable tool, particularly useful in the assessment of osteoporosis. Moreover, kyphosis angles measured with the curviscope are markedly increased in women with osteoporosis, compared with control subjects. Finally, an increase of kyphosis angles is associated with decreased physical mobility.