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Resume Objectifs Identifier les facteurs predictifs de mortalite a long terme a partir d’une cohorte de sujets âges de 75 ans ou plus, hospitalises via un service d’accueil des urgences (SAU). Methodes Les variables issues de l’evaluation geriatrique standardisee des patients de la cohorte multicentrique SAFES ont ete utilisees dans un modele de Cox pour predire la mortalite au cours des 3 ans de suivi. Resultats Cette cohorte etait constituee de 1 306 patients âges en moyenne de 85±6 ans. Au decours des 3 ans de suivi, 50 % des sujets etaient decedes. Apres ajustement sur le centre d’investigation, les variables sociodemographiques (âge, sexe, niveau d’education et lieu de vie) et le niveau de comorbidite, les variables influencant significativement la mortalite au cours des 36 mois etaient : un etat de denutrition severe (p Conclusion A l’aide d’echelles simples, couramment utilisees en geriatrie, une approche predictive de la mortalite a 3 ans est possible. Une correction de l’etat nutritionnel, une reconnaissance et une prise en charge des troubles cognitifs ainsi qu’une reeducation fonctionnelle doivent faire partie des priorites de soin.

Background: among elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors. Objective: to evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments. Design: prospective multi-centre study. Setting: nine French hospitals. Subjects: one thousand three hundred and sixmedical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort). Methods: using logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment. Results: data from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0–3.9), poor overall condition (OR = 2.01, 95% CI = 1.3–3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2–2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1–2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3–-0.8). Conclusions: markers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.

In France, there is evidence to suggest that 50% of elderly individuals are prescribed psychotropic medications. However, it is known that use of these agents increases the risk of falls, fractures and delirium in older people.To study the consumption of 'potentially inappropriate medication' (PIM) among patients agedor=75 years, paying particular attention to psychotropic drugs and the factors influencing the use of 'potentially inappropriate psychotropics' (PIPs).This was a cross-sectional analysis of a prospective multicentre cohort of 1306 hospitalized French patients agedor=75 years (the SAFEs [Sujet Agé Fragile: Evaluation et suivi (Frail Elderly Subjects: Evaluation and follow-up)] cohort). The present analysis involved the 1176 patients for whom there was information on the usual treatments being taken in the 2 weeks before hospitalization. The drugs were coded according to the Anatomical Therapeutic Chemical classification; the Beers list as updated in 2003 defined which medications were considered PIPs. Standardized geriatric assessment variables were recorded on inclusion in the study. Logistic regression analysis was performed to identify factors linked to use of psychotropics and PIPs.The mean number of drugs taken was 5.7+/-2.9 per patient. Twenty-eight percent of patients took at least one PIM. The number of patients who had taken at least one psychotropic drug in the 2 weeks before hospitalization (mean 1.6+/-0.9 psychotropics per patient) was 589 (50.1%). More than half of both the 510 patients with a depressive syndrome and the 543 patients affected by dementia were treated with psychotropics. Multivariate analysis showed that prescription of psychotropics was linked to the presence of a dementia syndrome (odds ratio [OR]=1.4; 95% CI 1.1, 1.9; p=0.03), the presence of a depressive syndrome (OR=1.7; 95% CI 1.3, 2.1; p0.001), living in an institution (OR=2.2; 95% CI 1.5, 3.4; p0.001), use of more than five drugs (OR=3.2; 95% CI 2.5, 4.2; p0.001) and Charlson's co-morbidity score1 (OR=0.6; 95% CI 0.5, 0.8; p=0.001). Nineteen percent of all psychotropics prescribed were PIPs. Of these PIPs, 66.5% were anxiolytics, 28.4% were antidepressants and 5.1% were antipsychotics. Use of PIPs in the multivariate analysis was associated only with consumption of more than five drugs (OR=1.7; 95% CI 1.1, 2.5; p=0.01).PIM use is common among hospitalized older adults in France. The most important determinant of risk of receiving a psychotropic medication or a PIP was the number of drugs being taken. The elderly, who have multiple co-morbidities, complex chronic conditions and are usually receiving polypharmacy, are at increased risk for adverse drug events. These adverse events are often linked to problems that could be preventable such as delirium, depression and falls. Regular review of prescriptions would help optimize prescription of psychotropics in the elderly. The Beers list is a good tool for evaluating PIMs but is too restrictive with respect to psychotropics; in the latter respect, the list could usefully be widened.

The objectives were to assess long-term adherence of the first HIV-1 patients receiving highly active antiretroviral therapy (HAART) in Senegal and to identify the main determinants of adherence. The first 180 patients enrolled in the Senegalese HAART initiative between August 1998 and April 2001 followed up for at least 30 days were eligible. Adherence was assessed monthly at each drug dispensation between November 1999 and November 2006 by a pharmacist using a pill count completed by a questionnaire. Adherence was expressed as the proportion of tablets taken to prescribed tablets. An adherence of 95% was considered to be good. A random-intercept logit model was fitted to identify the main determinants of adherence. Adherence data were available for 158 of 167 eligible patients. Twenty-nine patients died during the study period and 10 were lost to follow-up. Median treatment duration was 78 months accruing to 6657 person-months of observation. Overall mean adherence reached 91% [median: 100% interquartile range (IQR) 96-100%] and adherence exceeded 95% in 78% [95% CI 77-79%] of observations. After 4 years of treatment mean adherence stabilized around 90% and adherence >/= 95% stabilized around 70%. Treatment duration and protease inhibitor (PI)-based regimen (indinavir) had a negative effect on adherence but adherence tended to improve with time for patients receiving a PI. Patient-level variance was highly significant and accounted for a third of total variance. This work demonstrates that good long-term adherence can be achieved in the sub-Saharan context given close monitoring and adherence support measures confirms the worse adherence for indinavir and underlines the importance of patient heterogeneity. (authors)

Summary Objectives The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients. Methods 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 Âge 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). Results 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. Conclusion 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.

Objectives: To assess the long-term survival as well as the immunologic and virologic effectiveness adherence and drug resistance in HIV- infected patients receiving highly active antiretroviral therapy (HAART) in one of the oldest and best-documented African cohorts. Methods: A prospective observational cohort study included the first 176 HIV-1-infected adults followed in the Senegalese government-sponsored antiretroviral therapy initiative launched in August 1998. Patients were followed for a median of 30 months (interquartile range 21-36 months). HAART comprised 2 nucleoside reverse transcriptase inhibitors and either 1 protease inhibitor or 1 nonnucleoside reverse transcriptase inhibitor. Results: At baseline 92% of patients were antiretroviral naive and 82% had AIDS; the median CD4 count was 44 cells/mm(3) and median viral load was 202368 copies/mL. The survival probability was high (0.81 at 3 years; 95% CI 0.74-0.86) and was independently related to a baseline hemoglobin level

Objectives: Description and analysis of the Senegalese Antiretroviral Drug Access Initiative (ISAARV) the first governmental highly active antiretroviral therapy (HAART) treatment programme in Africa launched in 1998. Methods and results: ISAARV was initially an experimental project designed to evaluate the feasibility efficacy and acceptability of HAART in an African context. It was based on four principles: collective definition of the strategy with involvement of the health professionals who would be called on to execute the programme; matching to objectives to available means (gradual enrollment according to drug availability); monitoring by several research programmes; and ongoing adaptation of treatment and follow-up according to the latest international recommendations. Persons qualifying for antiretroviral (ARV) therapy are selected on the basis of immunological and clinical criteria regardless of economic and social considerations. A system of subsidies was created to favor access to ARV. Following the ARV price reductions that occurred in November 2000 100% subsidies were created for the poorest participants. Optimal adherence was ensured by monthly follow-up by pharmacists and support groups held by social workers and patient associations. The chosen supply and distribution system allowed drug dispensing to be strictly controlled. Conclusion: The ISAARV programme demonstrates that HAART can be successfully prescribed in Africa. This experience has served as the basis for the creation of a national treatment programme in Senegal planned to treat 7000 patients by 2006. (authors)

Objective To study the feasibility, effectiveness, adherence, toxicity and viral resistance in an African government HAART initiative. Methods A prospective observational cohort study started in Dakar in August 1998. Initial treatment consisted of two nucleoside reverse transcriptase inhibitors and one protease inhibitor. The patients attended monthly medical examinations. Plasma HIV-1 RNA and CD4 cell counts were determined at baseline and every 6 months. Intention-to-treat analyses were performed. Results Fifty-eight treatment-naive patients, mostly infected by HIV-1 strain CRF02-AG, were enrolled. Most were at an advanced stage of HIV disease (86.2% had AIDS). Adherence was good in 87.9% of patients and treatment was effective in most of them. Thus, HIV-1 RNA was undetectable in 79.6, 71.2, 51.4 and 59.3% of patients at months 1, 6, 12 and 18, respectively and the median viral load reduction was approximately 2.5 log10 copies/ml. The CD4 cell count rose by a median of 82, 147 and 180 x 106 cells/l at months 6, 12 and 18, respectively. At the same time points, the cumulative probability of remaining alive or free of new AIDS-defining events was 94.8, 85.0 and 82.3%. Most adverse effects (80.8%) were mild or moderate and only two cases of drug resistance occurred. Conclusion This study shows that HAART is feasible and well tolerated in African patients. Clinical and biological results were comparable to those seen in western cohorts, despite differences in the HIV-1 subtype distribution and an advanced disease stage when the treatment was initiated. Contrary to other recent studies in Africa, viral resistance rarely emerged.

Objectives: The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED). Design: Prospective multicentre cohort. Setting: Nine French university teaching hospitals. Participants: One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub-group analysis was performed on the 894 subjects with a caregiver. Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year. Results: Within one year after hospital admission, 210 (20.1%) subjects were institutionalised. For the overall study population, age >85 years (HR 1.6; 95%CI 1.1-2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1-2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1-2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4-2.6; p

Background The objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization. Methods A prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period. Results Crude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR = 1.83; 95% CI = 1.27–2.62) or a higher number of children (HR = 0.86; 95% CI = 0.78–0.96), balance problems (HR = 1.72; 95% CI = 1.19–2.47), malnutrition or risk thereof (HR = 1.93; 95% CI = 1.24–3.01), and dementia syndrome (HR = 1.88; 95% CI = 1.32–2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR = 1.92; 95% CI = 1.17–3.16), delirium (HR = 1.80; 95% CI = 1.24–2.62), and a high level of comorbidity (HR = 1.62; 95% CI = 1.09–2.40). Institutionalization (HR = 1.92; 95% CI = 1.37–2.71) and unplanned readmission (HR = 4.47; 95% CI = 3.16–2.71) within the follow-up period were also found as independent predictors. Conclusion The main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects’ prognosis favorably.

To access this article, please click on "Additional Links"., Adherence is one of the main predictors of antiretroviral treatment success. A governmental initiative was launched in 1998 for HIV-infected patients in Senegal to provide access to highly active antiretroviral therapy.

Objectives: The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management.Design: Prospective multicentre cohort.Setting: Nine French teaching hospitals.Participants: One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED).Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality.Results: Crude mortality rate after a six-week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1–3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5–16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2–33.1; p< .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 – 0.75; p< .001). The six-week mortality rate increased significantly (p< .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5–1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4–12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1–24.7) in the highest risk group.Conclusions: A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.

Background: The preservation of autonomy and the ability of elderly to carry out the basic activities of daily living, beyond the therapeutic care of any pathologies, appears as one of the main objectives of care during hospitalization. Objectives: To identify early clinical markers associated with the loss of independence in elderly people in short stay hospitals. Methods: Among the 1,306 subjects making up the prospective and multicenter SAFEs cohort study (Sujet Agé Fragile: Évolution et suivi—Frail elderly subjects, evaluation and follow-up), 619 medical inpatients, not disabled at baseline and hospitalized through an emergency department were considered. Data used in a multinomial logistic regression were obtained through a comprehensive geriatric assessment (CGA) conducted in the first week of hospitalization. Dependency levels were assessed at baseline, at inclusion and at 30days using Katz's ADL index. Baseline was defined as the dependence level before occurrence of the event motivating hospitalization. To limit the influence of rehabilitation on the level of dependence, only stays shorter than 30days were considered. Results: About 514 patients were eligible, 15 died and 90 were still hospitalized at end point (n=619). Two-thirds of subjects were women, with a mean age of 83. At day 30 162 patients (31%) were not disabled; 61 (12%) were moderately disabled and 291 severely disabled (57%). No socio-demographic variables seemed to influence the day 30 dependence level. Lack of autonomy (odds ratio (OR)=1.9, 95% confidence interval (CI)=1.2-3.6), walking difficulties (OR=2.7, 95% CI=1.3-5.6), fall risk (OR=2.1, 95% CI=1.3-6.8) and malnutrition risk (OR=2.2, 95% CI=1.5-7.6) were found in multifactorial analysis to be clinical markers for loss of independence. Conclusions: Beyond considerations on the designing of preventive policies targeting the populations at risk that have been identified here, the identification of functional factors (lack of autonomy, walking difficulties, risk of falling) suggests above all that consideration needs to be given to the organization per se of the French geriatric hospital care system, and in particular to the relevance of maintaining sector-type segregation between wards for care of acute care and those involved in rehabilitation

Objectives: To evaluate survival and investigate causes of death among HIV-1 infected adults receiving HAART in Senegal. Design: An observational prospective cohort. Methods: Mortality was assessed in the first patients enrolled between August 1998 and April 2002 in the Senegalese antiretroviral drug access initiative. First-line regimen combined two nucleoside reverse transcriptase inhibitors and either a non-nucleoside reverse transcriptase inhibitor or a protease inhibitor. The most likely causes of death were ascertained through medical records or post-mortem interviews (verbal autopsy). Results: Four hundred and four patients (54.7% women) were enrolled in the study and were followed for a median of 46 months (interquartile range: 32-57 months) after HAART initiation. At baseline, 5% were antiretroviral therapy (ART) non-naive, 39 and 55% were respectively at CDC stage B and C, median age, CD4 cell count and viral load were 37 years, 128 cells/mu l and 5.2 log cp/ml, respectively. Ninety-three patients died during follow-up and the overall incidence rate of death was 6.3/100 person-years [95% confidence interval (CI), 5.2-7.7]. During the first year after HAART initiation, 47 patients died and seven were lost to follow-up, yielding to a probability of dying of 11.7% (95% CI, 8.9-15.3%). The death rate, which was highest during the first year after HAART initiation, decreased with time yielding a cumulative probability of dying of 17.4% (95% Cl, 13.9-21.5%) and 24.6% (95% CI, 20.4-29.4%) at 2 and 5 years. Causes of death were ascertained in 76 deaths. Mycobacterial infections, neurotropic infections and septicaemia were the most frequent likely causes of death. Conclusions: This study underlines the early mortality pattern after HAART initiation and highlights the leading role of mycobacterial infections in the causes of death.

Access to programmes providing highly active antiretroviral therapy (HAART) is recent in Africa. In Senegal a national initiative was launched in 1998. The capacity of African patients to adhere to complex antiretroviral treatments (ARV) is largely unknown. We assessed adherence and identified the main reasons for treatment interruption in a prospective observational cohort of patients participating in an ARV access programme in Dakar Senegal. Adherence was estimated each month on the basis of the patients stated consumption and on the proportion of the prescribed dose returned unused to the dispensing pharmacy. A total of 158 patients were studied between November 1999 and October 2001. A cross-section analysis showed that the stated level of adherence was high: on average over the study period the patients said they had taken 91% of each monthly dose and that they had taken the full monthly dose during two-thirds of the months studied. Adherence tended to be better among patients who were required to make little or no contribution to the cost of their treatment through an appropriate pricing structure. Adherence was also better with efavirenz-containing regimens than with indinavir-containing regimens. These results show that adherence to HAART can be as high in Africa as that generally observed in industrialized countries and that the cost and type of drug regimen must be taken into account when designing ARV access programmes for poor communities. (authors)

Objectives The aim of this study was to identify factors predictive of nursing home admission (NHA) over a period of 1 year among elderly subjects with dementia. Methods The study population was drawn from the SAFES cohort that was formed within a national research program into the recruitment of emergency departments in 9 teaching hospitals. Subjects were to have been hospitalized in a medical ward in the same hospital as the emergency department to which they were initially admitted. Subjects who experienced NHA before emergency department admission were excluded. Those with a confirmed diagnosis of dementia were considered in the present analysis. NHA has been defined as the incident admission into either a nursing home or other long term care facility within the follow-up period. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 1-year NHA. Results The 425 subjects of the study were 86 ± 6 years old, and were mainly women (63%). NHA rate was 40% (n = 172). Four factors were identified to increase NHA risk: age 85 or older (hazard ratio [HR] = 1.5; 95% confidence interval [CI] = 1.1–2.1), inability to use the toilet (HR = 2.5; 95% CI = 1.5–4.2), balance disorders (HR = 1.5; 95% CI = 1.1–2.1), and living alone (HR = 1.5; 95% CI = 1.1–2.1). Three factors decreased this risk significantly: inability to transfer (HR = 0.5; 95% CI = 0.3–0.8), increased number of children (HR = 0.88; 95% CI = 0.96–0.99), and increased initial Mini-Mental State Examination score (HR = 0.97; 95% CI = 0.8–0.9). Conclusion NHA determinants in dementia are strongly linked to the patient’s own characteristics but also to his or her physical or social environment. Interventions should target both members of the dyad “patient-caregiver” because both are affected by the disease.