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As hospitals' visiting times are extended, patients' families and friends are granted an ever more important place. The nursing team of an acute geriatrics unit open 24/7 examined the place and the role of patients' families and friends and their involvement in care.

As is the case with all medical and surgical departments, the proportion of elderly patients in intensive care departments is gradually increasing.At Ambroise Pare hospital, in Boulogne-Billancourt, a natural collaboration has been set up between intensive care staff and geriatricians to adapt the care provided and to limit situations of unreasonable therapeutic obstinacy, notably thanks to a standardised gathering of information.

The elderly represent a large percentage of patients seen in departments of vascular surgery. Delirium is a frequent perioperative complication in this population and contributes to increased morbidity and mortality. Prevention of problems associated with mental confusion rests in identifying comorbidities, their severity, and the risk factors associated with delirium syndrome. The aging of our population implies management of increasing numbers of older patients who often have concomitant pathologies and, consequently, polypharmacy. Optimization of their management rests on collaboration between surgeons, anesthetists, and geriatrists.

A study carried out in two hospitals in the Paris region shows that the patients surveyed find the health care surrogate system interesting but also that there is widespread lack of awareness of the subject. The system appears to correspond to patients' expectations with the majority of patients nominating a family member.

Many healthcare professionals prejudge the capacity of a patient suffering from Alzheimer's disease to designate a health care surrogate. Consequently they deprive themselves of a person with whom they can discuss the patient's care while also depriving the patient of support and assistance.While the task of the health care surrogate is made more difficult as a result of cognitive disorders, their role can only be beneficial in a balanced relationship.

The theme of the surrogate is not established in the practice of general practitioners yet. Their long-term relation with patients places them in a favorable position to approach this topic. The surrogate could improve the quality of patient's care. Some factors limiting the surrogate's designation are indicators of the current deficiencies of the surrogate's device.

A procedure for the systematic nomination of a health care surrogate was put in place following a multi-disciplinary approach within an acute care geriatric unit at Ambroise-Paré hospital in Boulogne-Billancourt. Its originality lies in the way the whole team, on the initiative of a doctor, prepared the procedure, implemented it and assessed it. A review.

Purpose Elderly patients form a heterogeneous population. Evaluation of geriatric factors may help evaluate a patient's health status to better adapt treatment. Patients and Methods Elderly patients with previously untreated metastatic colorectal cancer (mCRC) were randomly assigned to receive fluorouracil (FU) -based chemotherapy either alone or in combination with irinotecan (IRI) in the Fédération Francophone de Cancérologie Digestive (FFCD) 2001-02 study. Sites participating in the geriatric substudy completed geriatric screening tools to perform prognostic factor analyses for treatment safety during the first 4 months after treatment initiation. Results The geriatric score was calculated in 123 patients (44%). Median age was 80 years (range, 75 to 91 years). The Charlson comorbidity index was ≤ 1 in 75%, Mini-Mental State Examination (MMSE) score was ≤ 27/30 in 31%, and Instrumental Activities of Daily Living (IADL) showed impairment in 34% of the patients. Seventy-one patients (58%) had grade 3 to 4 toxicity, 41 (33%) had a dose-intensity reduction of more than 33%, and 54 (44%) had at least one unexpected hospitalization during the first 4 months after starting treatment. In multivariate analysis, significant predictive factors for grade 3-4 toxicity were IRI arm (odds ratio [OR], 5.03), MMSE ≤ 27/30 (OR, 3.84), and impaired IADL (OR, 4.67); for dose-intensity reduction of > 33%, the significant predictive factors were alkaline phosphates > 2 × upper limit of normal (OR, 4.16) and IRI arm (OR, 6.85); and for unexpected hospitalization, significant predictive factors were MMSE ≤ 27/30 (OR, 4.56) and Geriatric Depression Scale ≤ 2 (OR, 5.52). Conclusion Geriatric factors (MMSE and IADL) are predictive of severe toxicity or unexpected hospitalization (MMSE) in a randomized prospective phase III study in mCRC. These results suggest that cognitive function and autonomy impairment should be taken into account when choosing a regimen for chemotherapy.

For people born in France, age is a major risk factor for developing tuberculosis.This curable pathology still has a high mortality rate which increases with age. Diagnosis difficulties, tolerance and compliance with treatment are issues specific to old age. An active policy of prevention, monitoring and training should enable the incidence of this pathology to continue to fall.

Due to the potential seriousness of its consequences, particular attention must be paid to malaise occurring in elderly people. It represents between 5 and 10% of hospital admissions of patients over the age of seventy. A full clinical examination as well as some additional examinations usually enable the cause(s) to be identified. Cardio-vascular and iatrogenic pathologies are the most frequent aetiologies.

A geriatric syndrome in its own right, malnutrition must be systematically looked for whenever an elderly patient is being treated. A marker of vulnerability, once identified it requires repeated assessment and adapted treatment. Undernutrition is often the consequence of various aetiologies justifying a full assessment and an assertive, multi-professional treatment.

The aim of this prospective study was to determine incidence, duration, and risk factors for postoperative delirium (PD) in elderly patients undergoing major abdominal surgery.The incidence and risk factors of PD after major abdominal surgery in elderly patients are not well documented.From May 2006 to May 2008, 118 patients aged 75 years or more without severe preoperative cognitive dysfunction (mini mental state examination score10/30) and undergoing major elective abdominal surgery were included. The preoperative geriatric assessment battery consisted of 4 tests evaluating physical (instrumental activities of daily living and timed get up and go test score) and cognitive function (mini mental state examination score), and detecting the presence of an underlying depression (Short-GDS). After the operation, geriatric patients were assessed for PD by the Confusion Assessment Method. Univariate and multivariate analyses were used to determine risk factors for PD.Overall, PD occurred in 28 patients (24%). Multivariate analysis showed that an American Society of Anesthesiologists status of 3-4 (P = 0.02), impaired mobility (timed get up and go test score20 seconds) (P = 0.009) and postoperative tramadol administration (P = 0.0009) were risk factors for PD. The mortality rate was 14% in 28 patients with PD and 3.3% in 90 patients without PD (P = 0.051). The morbidity rate was 35.5% in 28 patients with PD and 32% in 90 patients without PD (NS). The mean hospital stay was 19 +/- 11 days for patients with PD and 14 +/- 8 for patients without PD (P = 0.01). Fifteen of 24 (62.5%) surviving patients with PD and 28 of 87 (32%) surviving patients without PD were discharged to geriatric rehabilitation unit (P = 0.007).PD is a frequent and severe postoperative event in elderly patients after major abdominal surgery. A perioperative geriatric assessment should be recommended to patients with an American Society of Anesthesiologists status of 3-4 and preoperative impaired mobility to facilitate the management of PD. In these patients, the postoperative administration of tramadol should be avoided.

Gene expression in aging kidney and pituitary was determined by subtractive hybridization, DNA micro arrays and RT-PCR. Kidneys and pituitary were removed from 10- and 30-month-old female WAG/Rij rats, which were free from chronic progressive nephrosis and had a low incidence of pituitary tumors with age. From 350 cDNA fragments isolated by subtractive hybridization, just one showed a more than twofold change in expression between 10 and 30 months. The use of a specific micro array with 4050 rodent genes also failed to detect downregulation lower than 0.5 or upregulation larger than 2.0 in aging rat kidney. Similarly,mRNA content for vasopressin V2 and V1 receptors, aquaporin 2 and 3, and adenylyl cyclase type VI was not significantly modified with age as determined by RT-PCR. In contrast,microarray analysis of pituitary mRNA expression showed upregulation of 11 genes with ratios equal to or greater than 2.0 and downregulation of 6 genes with ratios equal to or less than 0.5. Two cDNA sequences of unknown genes from the kidney subtractive library were part of the age-related up- and downregulated genes of the pituitary. Other genes were mainly related to cell differentiation, control of homeostasis, cellular signaling, endoplasmic reticulum trafficking and metabolism. These data indicated that mRNA expression is barely modified in aging kidney free from chronic progressive nephrosis, at least in the 0.5–2.0 range, in contrast to pituitary. They also suggest that the downregulation of proteins reported in aging kidneys free from gross disease is related to post-transcriptional changes.

The mechanisms underlying age-related polyuria were investigated in 10- and 30-mo-old female WAG/Rij rats. Urinary volume and osmolality were 3.9 ± 0.3 ml/24 h and 2,511 ± 54 mosmol/kgH2O in adult rats and 12.8 ± 0.8 ml/24 h and 1,042 ± 44 mosmol/kgH2O in senescent animals. Vasopressin V2receptor mRNA did not significantly differ between 10 and 30 mo, and [3H]vasopressin binding sites in membrane papilla were reduced by 30%. The cAMP content of the papilla was unchanged with age, whereas papillary osmolality was significantly lowered in senescent animals. The expression of aquaporin-1 (AQP1) and -4 was mostly unaltered from 10 to 30 mo. In contrast, aquaporin-2 (AQP2) and -3 (AQP3) expression was downregulated by 80 and 50%, respectively, and AQP2 was markedly redistributed into the intracellular compartment, in inner medulla of senescent animals, but not in renal cortex. These results indicate that age-related polyuria is associated with a downregulation of AQP2 and AQP3 expression in the medullary collecting duct, which is independent of vasopressin-mediated cAMP accumulation.

Aging is frequently associated with impaired ability to retain water. This is accounted for by changes in thirst and altered kidney concentrating ability. The mechanisms involved in this process hasve been studied in many different models. In humans, the thirst threshold appears to increase with age which results in impaired water homeostasis (see Vellas et al., 1998 for a review). In addition, a defect in renal water reabsorption has been described. In rodents, in particular, aging is characterized by polyuria and decreased urinary osmolality (Corman & Michel, 1987). Because water reabsorption in kidney is regulated by vasopressin (AVP), these changes can be due to impaired AVP secretion or to inappropriate kidney response to AVP.

International audience; The ability of the kidney to regulate water balance is impaired with age, although the secretion of vasopressin is maintained in senescent animals. This suggests that the cellular response to antidiuretic hormone is reduced in aging kidney. To test this hypothesis, the relationship between the expression of the vasopressin. V2 receptor mRNA and adenosine 3',5'-cyclic monophosphate (cAMP) accumulation was investigated in the medullary thick ascending limb of Henle's loop (MTAL) of adult and aging rats. Tubular suspensions of MTAL were prepared from 10- and 30-mo-old female WAG/Rij rats. The accumulation of cAMP for maximal concentration of vasopressin was 34% larger in adult than in old animals (9.5 +/- 0.5 pmol/4 min, n = 16, and 7.1 +/- 0.6 pmol/4 min, n = 12, respectively). The concentration of vasopressin corresponding to half-maximal stimulation was similar in the two groups (0.66 +/- 0.20 and 0.52 +/- 0.09 nmol, n = 5, in adult and old animals), indicating comparable sensitivity of the renal cells with age. The age-related impaired response to vasopressin of the V2 receptor was specific for females and was not observed in males. Direct stimulation of adenylyl cyclase by forskolin induced a comparable accumulation of cAMP in adult and senescent rats. The V2 receptor mRNA level in the MTAL was constant between 10 and 30 mo whether the animals were normally hydrated or dehydrated for 2 days. These data indicate that, in MTAL, the age-related impaired cAMP accumulation by vasopressin would be linked to a change either in the translation of V2 mRNA or in posttranslational processing mechanisms or in the coupling between the V2 receptor and adenylyl cyclase.

Background Major and minor tranquillisers can be used to chemically restrain a patient. Use of chemical restraint (CR) has been described mainly in long care settings but there is very limited information when considering acute care hospitals. Purpose To study the prescriptions for major and minor tranquillisers in 3 clinical wards of a French teaching hospital and to determine if they can be considered CR. Materials and Methods This prospective study took place over 2 weeks in 3 different wards: geriatrics, pneumology and vascular surgery. Tranquilizers were defined as anxiolytics (minor) and neuroleptics (major). Prescriptions were checked daily and for each patient with a tranquilliser, medical records were screened to determine whether it was newly prescribed. For every newly-prescribed tranquilliser the practitioner was asked the indication, if he considered his prescription was a CR and if the patient was being physically restrained. Results 45.2% of the 137 patients included had been prescribed at least 1 tranquilliser. 54.5% of the 77 tranquillisers prescribed were introduced during the hospitalisation. Among those 42 newly-introduced tranquillisers, 9 (21.4%) were considered as CR by the prescribers. 6.6% of the patients included were chemically restrained, which is comparable with previous retrospective studies of restraint in acute care wards. The most frequently prescribed CR was alprazolam (55.6%) and the most frequent indication for CR was anxiety. In addition 88.9% of the CR drugs were prescribed ‘when required’ leaving responsibility for administration to nurses alone. None of the patients with tranquillisers had physical restraint. Conclusions This is the first prospective study on restraint in an acute care hospital. CR is used for a minority of patients; however it is mostly prescribed ‘when required’. Hence it should be used with the utmost care and prescribed with the most precise instructions in order to avoid misuse and risk of abuse. No conflict of interest.

First published August 8, 2001; 10.1152/ajprenal.00139.2001.—The mechanisms underlying the prevention of age-related polyuria by chronic food restriction were investigated in female WAG/Rij rats. The decreased osmolality of renal papilla observed in senescent rats was not corrected by food restriction. A reduced urea content in the inner medulla of senescent rats, fed ad libitum or food-restricted, was suggested by the marked decrease in expression of UT-A1 and UT-B1 urea transporters. Aquaporin-2 (AQP2) downregulation in the inner medulla of senescent rats was partially prevented by food restriction. Both AQP2 and the phosphorylated form of AQP2 (p-AQP2), the presence of which was diffuse within the cytoplasm of collecting duct principal cells in normally fed senescent rats, were preferentially targeted at the apical region of the cells in food-restricted senescent animals. Plasma vasopressin (AVP) was similar in 10- and 30-mo-old rats fed ad libitum, but was doubled in food-restricted 30-mo-old rats. This study indicates that 1) kidney aging is associated with a marked decrease in AQP2, UT-A1, and UT-B1 expression in the inner medulla and a reduced papillary osmolality; and 2) the prevention of age-related polyuria by chronic food restriction occurs through an improved recruitment of AQP2 and p-AQP2 to the apical membrane in inner medulla principal cells, permitted by increased plasma AVP concentration.