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CONTEXT The External Mobile Geriatric Team (EMGT) of the University Hospital of Grenoble-Alps (UHGA) intervenes with elderly subjects in a complex medicosocial situation at home at the request of the general practitioner (GPs). OBJECTIVE To evaluate the satisfaction of GPs after EMGT intervention. The secondary outcomes were the follow-up of recommendations and the training request of community partners. METHOD Retrospective monocentric satisfaction survey of the 124 GPs who used EMGT from January 2015 to December 2018. RESULTS Participation rate of 44 %, representative of GPs liberal urban or semi-rural. Participants were "satisfied" or "very satisfied" with the responsiveness of EMGT to 84,2 % and 85,5 % respond favorably to the content of the evaluation. EMGT was described as having an expert and supportive role for GPs. The recommendations were followed more than 89 %. The participants wanted to 83,6 % that the EMGT conducts training sessions, mainly for "behavioral disorders management". Following this survey, five improvement proposals were formulated: decrease the response time by recruiting trained staff, systematically send an e-mail post-analysis of the report to the doctor-applicant, use a platform of exchange, develop the partnership with the psychiatry team, and create a dematerialized resource space. CONCLUSION This study contributed to the improvement of the city-hospital relationship by strengthening the links between the GPs of the CHUGA sanitary territory and the EMGT.

A reliable interpretation of albumin levels is essential when assessing nutrition in elderly people, but this is complex as it is affected by a number of parameters. The main objective of this study was to evaluate whether a correction formula proposed for prolonged inflammation could be extrapolated to acute biological inflammation situations: corrected albuminemia = measured albuminemia + CRP/25. This prospective, single-centre observation study included patients over 65 years of age who were the subject of an unscheduled hospitalisation in the geriatrics and internal medicine departments of Grenoble University Hospital, excluding carriers of active neoplasia, hepatic insufficiency, nephrotic syndrome and those who continued to present with an acute biological inflammation on the eighth day. Clinical and biological samples were taken on the first and eighth days. The primary objective was the comparison of albumin levels, corrected using the formula on day (d) 1, with albumin levels measured on d8. One hundred and seventy-five patients were analysed. Average CRP was 64 (3; 324) mg/L on d1 and 24 (3; 99) mg/L on d8. Between the corrected albumin levels on d1 and albumin levels measured on d8, the correlation was ρ = 0.58, 95% CI [0.47; 0.67], P 0.001, with a mean difference of 2.9 (-13.5; 18) mg/L, 95% CI [-3.68-2.20], P 0.001. Between the albumin levels measured on d1 and d8, the correlation was ρ = 0.74, 95%CI [0.66; 0.80], P 0.001, with a mean difference of 0.4 (-14; 11) mg/L, 95%CI [-0.24; 1.02], P = 0.23. The proposed formula cannot be extrapolated to acute inflammatory situations. Albumin levels appear to be stable during acute biological inflammation. Albumin levels could be used as a reference for biological nutritional assessments and be integrated into the patient's clinical history.

The external mobile geriatric team (équipe mobile de gériatrie extrahospitalière [EMGEH]) at the University Hospital of Grenoble-Alps intervenes with elderly subjects in complex medical and social situations at home at the request of general practitioners (GPs). To evaluate the satisfaction of GPs after EMGEH intervention. The secondary outcomes were the follow-up of recommendations and training requests from community care partners. Retrospective monocentric satisfaction survey of the 124 GPs who used the EMGEH between January 2015 and December 2018. Participation rate of 44%, representative of independent GPs in urban or semi-rural practices. Participants were "satisfied" or "very satisfied" (84.2%) with the responsiveness of the EMGEH, and 85.5% responded favourably to the content of the evaluation. The EMGEH was described as playing an expert and supportive role for GPs. The recommendations were followed by more than 89% of respondents. As many as 83.6% of participants wanted the EMGEH to conduct training sessions, mainly for the management of "behavioural disorders". Following this survey, five recommendations were formulated: decrease the response time by recruiting trained staff, systematically send an e-mail following the report to the requesting doctor, use a platform to exchange information, develop partnerships with the psychiatry team, and create an online resource space. This study contributed towards improving the relationship between the community and the hospital by strengthening links between the GPs within the CHUGA health region and the EMGEH.

Background The discharge summary is the main vector of communication at the time of hospital discharge, but it is known to be insufficient. Direct phone contact between hospitalist and primary care physician (PCP) at discharge could ensure rapid transmission of information, improve patient safety and promote interprofessional collaboration. The objective of this study was to evaluate the feasibility and benefit of a phone call from hospitalist to PCP to plan discharge. Methods This study was a prospective, single-center, cross-sectional observational study. It took place in an acute medicine unit of a French university hospital. The hospitalist had to contact the PCP by telephone within 72 h prior discharge, making a maximum of 3 call attempts. The primary endpoint was the proportion of patients whose primary care physician could be reached by telephone at the time of discharge. The other criteria were the physicians’ opinions on the benefits of this contact and its effect on readmission rates. Results 275 patients were eligible. 8 hospitalists and 130 PCPs gave their opinion. Calls attempts were made for 71% of eligible patients. Call attempts resulted in successful contact with the PCP 157 times, representing 80% of call attempts and 57% of eligible patients. The average call completion rate was 47%. The telephone contact was perceived by hospitalist as useful and providing security. The PCPs were satisfied and wanted this intervention to become systematic. Telephone contact did not reduce the readmission rate. Conclusions Despite the implementation of a standardized process, the feasibility of the intervention was modest. The main obstacle was hospitalists lacking time and facing difficulties in reaching the PCPs. However, physicians showed desire to communicate directly by telephone at the time of discharge. Trial registration French C.N.I.L. registration number 2108852. Registration date October 12, 2017.

The team of the geriatric department of the Grenoble-Alpes (38) University Hospital Center has created the Accompagner therapeutic education program to meet the needs of patients suffering from neurocognitive disorders in the context of a neurodegenerative disease and their families. Presentation and current organization of the workshops.

The team of the geriatric department of the Grenoble-Alpes (38) University Hospital Center has created the Accompagner therapeutic education program to meet the needs of patients suffering from neurocognitive disorders in the context of a neurodegenerative disease and their families. Presentation and current organization of the workshops.

BACKGROUND Despite growing interest for home care, little evidence exists on the perception of domestic risk among carers for dependent older persons. This study aims to characterize the risks to which carers of aging dependent individuals are exposed, and to determine whether these risk dimensions are predictive for effective support, for burden, and for psychological distress. METHODS Seventy care partners were questioned about the risk situations identified at the homes of the old people they care for, about the burden they felt in their role, and about their feelings of psychological distress. Securing was evaluated by means of sensibility measures, and overprotection was evaluated by means of specificity measures. RESULTS Risk rates were high for loneliness of the old people, wandering, burns, and unsatisfactory health monitoring. There was very little overlap between identification of the risks and implementation of solutions by the caregiver, except for the risks that involved heat. The distinction between accurate securing and overprotection is especially important, because the burden of care partners was linked to uncontrolled domestic risks. CONCLUSION Typologies of reactions to risk, characterized by a signal detection approach, could contribute to a better understanding of the situations experienced by care partners, especially situations of neglect and of overprotection.

Objectives To describe a human metapneumovirus (hMPV) outbreak occurring in a nursing home for older adults and to identify the risk factors associated with the clinical infection. Design A retrospective, case-controlled study. Setting and participants A French nursing home for older adults between December 27, 2014 and January 20, 2015. Probable cases were residents presenting at least 1 respiratory symptom or 1 constitutional symptom. Confirmed cases identified in the same way as probable cases but with a positive RT-PCR test for hMPV. Controls were residents with no symptoms of respiratory infection. Measures Identification of hMPV was realized on nasal swab samples by RT-PCR. Results Seventy-eight older people were resident at the time of the outbreak. Three of the 4 tested were positive for hMPV by RT-PCR and negative for 13 other viruses or bacteria. All probable infected residents presented cough; other symptoms were scarcer. An inflammatory response was present, with median C-reactive protein at 50 mg/L. The median duration of the illness was 7 days. The rate of infection among residents was high (51%), with 5 hospitalizations (12.5%) and 1 death (2.5%). In multivariate analysis, vaccination against influenza virus appeared to emerge as associated with a probable hMPV infection, but this might be an artifact, as the proportion of unvaccinated residents was low (15%). A clear infected population profile was hard to define, although limited autonomy and low ADL score may play a role. Basic hygiene precautions were reinforced, but droplet precautions seemed difficult to apply rigorously to this population. Conclusions/implications Clinical and biological presentations were nonspecific. The rate of infection was high, highlighting the need for the rapid introduction of strict precautions to contain the infection.

Hip fracture (HF) is a serious complication of the elderly who have suffered a fall. Studies focused on patients over 75 years old without excluding the most vulnerable are not frequent. Before we can think about the creation of an orthogeriatric unit, we evaluated the mortality rate one year after a HF only of patients over 75 years old and we identified associated factors with mortality, functional status and living. METHODS Prospective observational study of 75 years and older hospitalized for a HF in a conventional orthopaedic unit. Surgical and geriatric data collected was: instrumental activities of daily life ADL (IADL), comorbidity (cumulative illness rating scale-geriatric (CIRS-G)), mini nutritional assessment (MNA), severity, preoperative delay. A phone assessment one year after HF was about: vital and functional status, living place. RESULTS The mean age of 113 patients included was 87 years (76-100). The mortality rate was 35%. It was associated with low IADL day -15 (p< 0.01), elevated CIRS-G (p< 0.01), severity (p=0.05) and malnutrition (p=0.05). Preoperative delay average was 70.7 h (+/- 59) and 48.6% had surgery within 48 hours. Among survivors and from the data available, 45% had a functional decline one year after the HF and 11% were admitted in a nursing home. CONCLUSION Without any exclusion of frailty patients, the one-year mortality rate of HF of people aged 75 years and older was 35%. HF is a public health challenge due to its high prevalence, poor prognosis with considerable expense. The associated factors help to explain why geriatricians are required and support the project of creating an orthogeriatric unit. Nevertheless, geriatric care will not likely change prognosis of the most vulnerable patients but could improve the level of care.

The pertinence of a therapeutic program of education has been studied with regard to carers of patients suffering from major neurocognitive disorders. The program, adapted to the needs expressed by the carers, consisted of three workshops with a view to supplying general information about the pathologies, specific information on behavioral disorders, and specific aids to identify and manage their emotional reactions. The results of this preliminary study show a moderate significant benefit to the level of anxiety in the participants, taking into account the specific expectations of the carers and bringing to light further needs.

Assessed the difficulties encountered by general practitioners in the care of the elderly with complex medical and psycho-social conditions, their knowledge of the geriatric network, the interest engendered by setting-up mobile community based geriatric units.The survey was both qualitative and quantitative and took the form of a telephone interview and a multimodal questionnaire (telephone interview, postal or email questionnaire) of general practitioners in the areas of Annecy, Grenoble and Roanne (France).Sixty five per cent of the 129 GPs contacted by telephone said the survey interested them. One hundred and eleven physicians replied to the questionnaire. The first priority for intervention of the mobile geriatric unit should be the management of the elderly with cognitive disorders and behavioural symptoms (43 replies) that pose the most problems for physicians. The mobile team should be available, and easy to contact rapidly. The request for intervention should be made by the GP (69 replies, 72.6%), by telephone (95 replies, 86%) and the visit made within the following 48 - 72 hours (60 replies, 67.4%).Our results confirm the existence of difficulties in the care the elderly people with complex conditions that justify experimentation of community mobile geriatric teams.

Despite growing interest for home care, little evidence exists on the perception of domestic risk among carers for dependent older persons. This study aims to characterize the risks to which carers of aging dependent individuals are exposed, and to determine whether these risk dimensions are predictive for effective support, for burden, and for psychological distress.Seventy care partners were questioned about the risk situations identified at the homes of the old people they care for, about the burden they felt in their role, and about their feelings of psychological distress. Securing was evaluated by means of sensibility measures, and overprotection was evaluated by means of specificity measures.Risk rates were high for loneliness of the old people, wandering, burns, and unsatisfactory health monitoring. There was very little overlap between identification of the risks and implementation of solutions by the caregiver, except for the risks that involved heat. The distinction between accurate securing and overprotection is especially important, because the burden of care partners was linked to uncontrolled domestic risks.Typologies of reactions to risk, characterized by a signal detection approach, could contribute to a better understanding of the situations experienced by care partners, especially situations of neglect and of overprotection.

Introduction : La malnutrition proteino-energetique (MPE) jouerait un role dans la survenue de chutes et de fractures, et serait un facteur de fragilite determinant pour le devenir fonctionnel du patient âge. Le Mini nutritional assessment (MNA) est un outil recemment recommande pour le diagnostic de MPE de la personne âgee. Materiel et methode : Notre etude epidemiologique observationnelle prospective concernait 50 patients de plus de 75 ans admis en Orthopedie pour une fracture de l'extremite superieure du femur (FESF). Notre objectif principal etait de determiner la prevalence de la MPE. Le critere de jugement principal etait un MNA

La Presse Medicale - In Press.Proof corrected by the author Available online since mardi 23 decembre 2014

To assess whether the decline of decision-making processes in people diagnosed with Alzheimer’s disease (AD) is explained by the use of an inappropriate analytic strategy induced by their high level of uncertainty about their ability, we used happiness induction to activate an appropriate heuristic processing of information. Healthy older adults and AD patients performed the Iowa Gambling Task either in a standard condition or after viewing a funny film clip. Although AD patients had impaired performances in the standard condition, the happiness condition significantly increased AD patient performance level compared with that of the control subgroups. Additional analyses showed that uncertainty levels were reduced in happy AD patients and that performances in the Iowa Gambling Task were not due to impairment in executive or memory functions. We suggest that higher uncertainty levels in patients with mild AD, which induce an inappropriate analytic strategy, can be reduced through emotional remediation techniques.

Cognitive disorders with memory loss are common among the patients of general practitioners. In collaboration with an outpatient diagnosis service and referral memory consultations, they are involved in the diagnosis, the implementation and the follow-up of suitable care for the patient and their family.

International audience; Evidence before this study We searched PubMed on June 30, 2016, for English-language cohort studies published since Jan 1, 1980, of patients with invasive listeriosis worldwide with the keywords " listeria " , " listeriosis " , " maternal " , and " neurolisteriosis ". Studies had to include epidemiological or clinical data on listeriosis. All clinical forms of infection were included (bacteraemia, neurolisteriosis, and maternal–neonatal infection). Host risk factors for listeriosis have been well identified, but the clinical features and prognostic factors of the disease are based on retrospective studies compiling heterogeneous data or random collected cases. Furthermore, no clinical trial has ever been done and medical management is not evidence based. Added value of the study Our study is the first prospective clinical study focusing on all forms of invasive listeriosis. The study is based on a national mandatory system that allowed the nearly complete capture of microbiologically proven cases. The study shows a higher burden of listeriosis than reported before: more than 80% of infected mothers experienced major fetal or neonatal complications (fetal loss, very high prematurity, early or late onset disease); only 39% of patients with neurolisteriosis survived and fully recovered. The study provides important new data to improve management and predict outcome in listeriosis, such as determination of the time window for fetal losses (

We try, from our clinical practice in a geriatric medicine department, to identify the processes involved in family crisis, especially in the relationship carer/cared. Psychodynamic and systemic determinants are highlighted to understand how family caregivers may suffer burn out, and suggest preventive measures.

Fall-related visits to emergency departments (EDs) are common among older individuals. We aimed to assess effectiveness of a healthcare intervention program for the management of elderly patients admitted to EDs after a fall.Using a before-after observation method, we investigated ED healthcare staff practices related to fall-related injuries in 2010 (period 1) and 2012 (period 2) in 13 centers participating in the Northern French Alps Emergency Network. Following the identification of initial weaknesses, several information and training tools were introduced between the two periods to improve patient management. All individuals aged 75 years or over who presented to an ED after a fall were included in the study. We reviewed the completeness and quality of medical records during both periods and compared the rate of clinical-paraclinical check-ups performed, geriatric evaluation/assessment in the ED, and the 1-month recurrence of visits to the ED for the same reason.During period 1, a total of 2,425 falls were recorded, while 2,684 were reported in period 2. The 2012 medical charts contained significantly more information about risk factors than those of 2010. An electrocardiogram (64% vs. 53%; p0.001), biologic check-up (65% vs. 57%; p0.001), balance, orthostatic hypotension, and cognitive impairment tests were more often performed in 2012. There was no change in the hospitalization rate, although short-duration hospitalization in the ED was more frequent in 2012. Geriatrists were more often consulted by patients in 2012 (18% vs. 13%; p0.001) and more involved in ED evaluation and hospitalization. The intervention program had a beneficial impact on the fall recurrence rate (n = 29 [3.6%] in period 1 and n = 17 [2.0%] in period 2; odds ratio = 0.52; p = 0.037), which significantly decreased between 2010 and 2012.The intervention program was associated with a decrease of fall recurrence. Further efforts should be made in EDs to ensure a sustained level of satisfactory and long-lasting management of the elderly.

Objectives: To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD — defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes. Design: One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study. Setting: Nine university hospitals in France. Participants: 1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department. Measurements: Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: Gl — not frail; G2 — moderately frail; and G3 — severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient. Results: All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died With the Rockwood index, all subjects who expenenced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from −0.02 to 0.15. Conclusion: These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology

Cardiovascular disease is a major cause of mortality in end-stage renal disease patients (ESRD). The rate of elderly and polypathologic patients in ESRD is increasing. Elevated levels of C-reactive protein (CRP) have been shown to be associated with increased mortality in ESRD patients. The aim of this study was to examine whether, in elderly ESRD patients, the conventional relationship between elevated CRP and cardiovascular mortality is maintained.This prospective European cohort study included 150 ESRD patients. Data obtained at baseline included demographics, comorbidity, late referral to a nephrologist, high-sensitivity CRP, and serum albumin and hemoglobin levels. Cardiovascular events were analysed as a combined end-point.The mean age of the cohort was 61 years (22-90), with 33.3% of patients over 70 years (75 yrs, 70-83 yrs). Forty-two patients (28.2%) experienced at least one cardiovascular event. Interaction between age over 70 years and CRP exceeding 3 mg/L was a protective factor. Patients over 70 years beginning dialysis with a CRP value3 mg/L had a higher cardiovascular risk than those with a CRP value3 mg/L. Multivariate analysis showed that the independent risk factors for cardiovascular events were, in the whole cohort, age over 70 years, previous cardiovascular comorbidity, and interaction between age and CRP.This trial shows a reverse relation between cardiovascular risk in dialysis patients over 70 and CRP level. This may be a useful element in evaluating older patients before long-term dialysis.

We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR)=1.79 (1.38-2.32) (95% confidence interval=95% CI); "failure to thrive" syndrome OR=1.54 (1.01-2.35), depression: OR=1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR=1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the "geriatrics patient" is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.

We conducted a feasibility study of a system for non-invasive monitoring of subjects at home. Electrical activity was recorded from room lights and from electrical domestic appliances; this was translated into the probability of physical activity or a particular Activity of Daily Living (ADL). Thirteen volunteer subjects were monitored for a period of 6.4 months (range 3–8). The mean age of the subjects was 80 years and they all lived alone at home; one had moderate Alzheimer's disease. A one-week validation was carried out to ascertain whether the recorded activity actually occurred. The results showed that daily and nocturnal activity could be well differentiated. The probability of having eaten, taken a bath and going to the toilet could be calculated each day. Eating was the most accurately measured ADL; toileting and bathing results were less accurate. The system appears to be a promising component of home telecare.

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.

OBJECTIVES: To identify risk factors for deep vein thrombosis (DVT) in older patients with restricted mobility or functional disability. DESIGN: Cross-sectional. SETTING: Forty-two postacute care departments in France. PARTICIPANTS: Eight hundred twelve patients aged 65 and older. MEASUREMENTS: Twenty-two predefined characteristics were investigated, including medical and surgical risk factors, dependence in six basic activities of daily living (ADLs) rated using the Katz index, mobility, the reported value of the Timed Up and Go Test, and pressure ulcers. All patients underwent lower limb ultrasonography on the day of the cross-sectional study. RESULTS: DVT was found in 113 patients (14%, 33 proximal DVTs (4%) and 80 isolated distal DVTs (10%)). A positive trend was found in the odds of DVT for higher values on the Timed Up and Go Test for patients who were not bedridden or confined to a chair (P=.007). In two-level multivariable analysis adjusting for prophylaxis against venous thromboembolism, independent risk factors for DVT were aged 80 and older (adjusted odds ratio (aOR)=1.71, 95% confidence interval (CI)=1.05-2.79), previous history of venous thromboembolism (aOR=2.03, 95% CI=1.06-3.87), regional or metastatic-stage cancer (aOR=2.71, 95% CI=1.27-5.78), dependence in more than three ADLs (aOR=2.18, 95% CI=1.38-3.45), and pressure ulcers (aOR=1.85, 95% CI=1.05-3.24). CONCLUSION: Severe dependence in basic ADLs and higher Timed Up and Go Test score are associated with greater odds of DVT in older patients in postacute care facilities in France.

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.

Bleeding is the main complication on vitamin K antagonist treatment (VKA), particularly in elderly patients. However, the bleeding risk prediction in geriatric patients remains difficult. We evaluated the predictive value of the HAS-BLED and ATRIA bleeding scores in VKA-treated patients aged 75 and over. Various clinical bleeding risk factors in elderly were also studied. 208 patients were included in a case-control study: 52 hemorrhages cases were compared to 156 hemorrhage-free cases (controls), mean age 83.1 years in cases and 82.6 in controls. This elderly subgroup was provided from the prospective SCORE cohort study (study designed to validate the use of bleeding scores in an ambulatory population). The patients were included during a VKA-therapeutic education between May 2009 and May 2010 in 4 French hospitals, and followed for 1 year. The primary endpoint, collected prospectively, was the occurrence of severe and clinically relevant bleeding events. According to the Receiver operating characteristics (ROC), the ATRIA score was as effective as HAS- BLED to predict all bleeding (c-statistic: 0.59 [95% CI 0.50-0.68] vs 0.56 [0.48-0.65]) including severe bleeding (c-statistic: 0.64 [95% CI 0.49-0.79] vs 0.62 [0.49-0.75]). Multivariate Cox regression analysis showed increasing bleeding risk with anemia (OR = 2.6 [95% CI 1.34-5.23], p = 0.005), serotonin reuptake inhibitors (2.8 [1.08-7.47], 0.034), and family-management of VKA-treatment (2.8 [1.28-6.15], 0.01). ATRIA hemorrhage predictive value can be improved by adding such parameters as family-management of VKA-treatment and serotonin reuptake inhibitors treatment. ATRIA appears as relevant as HAS-BLED in predicting all bleeding including major hemorrhages in elderly patients educated VKA-management. The ATRIA bleeding score is improved by including items of serotonin reuptake inhibitors treatment and family-management of VKA-treatment.

Improving care and health course for hospitalized elderly patients is one of the tasks set out in the "Rapport du parcours de santé des PAERPA" (elderly people with or at risk of functional decline). Identification of the needs of a mobile geriatric team (MGT) intervention for the patients remain difficult in emergency department and in medical surgical units. A screening tool is needed and should be simple and fast to use. Its implementation implies that it is efficient and previously validated. The aim of our study was to evaluate the validity and predictive performances of the Triage risk stratification tool (TRST) for identify patients aged over 75 years, requiring the intervention of the MGT. This is a prospective, national, multicenter study including consecutive patients aged 75 years and older, hospitalized in emergency services and medical-surgical units in September and October 2013. The TRST was considered positive when the score was greater than 2 of 5 points. A supplementary question with binary answer (yes/no) was asked to MGT, in order to define if MGT intervention was useful. This issue has served as a "gold standard" for assessing the validity and predictive test performance. In emergency departments, the TRST was performed in 427 patients, 347 were positive. Results showed high sensitivity (79%), and poor specificity (19%) of the test in emergency units, showing that TRST did not permit to identify patients requiring MGT intervention. In contrast, the TRST seems more performant in medical-surgical (n=63 patients) units with good predictive performances (positive predictive value 90% and negative predictive value 87%). The specificity of TRST in emergency services is insufficient to generalize its use. However, performances of the TRST in other units are encouraging to propose a validation as part of a national research project.

Resume Objectif Evaluer la faisabilite clinique de la communication visiophonique, entre un malade a son domicile et les equipes soignantes d’un reseau d’Hospitalisation a domicile (HAD). Methodes Etude cas-temoins, concernant les secteurs adulte, maternite et pediatrie du reseau HAD. Apres accord de participation, les patients qui remplissaient les criteres d’inclusion ont ete tires au sort pour leur appartenance au groupe telemedecine (appareil de visiophonie au domicile) ou au groupe temoin (prise en charge habituelle en HAD). Le groupe telemedecine comportait 16 patients apparies a 16 autres qui constituaient le groupe temoin. Les criteres d’appariement etaient l’âge, l’indice de Karnofsky et l’objectif d’admission en HAD. Resultats La duree de communication visiophonique a ete en moyenne de 6 minutes. Le nombre moyen d’appels a ete de 23 par patient, soit 0,7 appels par jour ouvrable. La visiophonie a permis une coordination en temps reel et un meilleur suivi des plaies avec prise de photos. C’etait un apport pour le suivi de patients douloureux, les soins techniques infirmiers, l’education du patient ou de son entourage. Le score d’anxiete a l’echelle HAD ( Hospital Anxiety Depression scale ) a diminue significativement au cours de la prise en charge des patients du groupe telemedecine contrairement a ceux du groupe temoin (p = 0,048). Dans le groupe telemedecine, tous les patients et leur entourage ont ete tres satisfaits ou satisfaits de la prise en charge et de la communication (15 cas sur 15), alors que 88 % des soignants le sont (14 cas sur 16), sans difference significative avec le groupe temoin. Conclusion Le programme ViSaDom a confirme la faisabilite et l’acceptabilite de la communication visiophonique. C’est un outil prometteur pour la qualite et l’efficacite des soins en HAD.

La prise en charge des personnes âgees fragiles represente un axe important de la prevention secondaire en geriatrie notamment en termes de risques medicaux: chutes, troubles psychiques, isolement et accidentologie. Les familles et les professionnels ne peuvent garantir une presence constante aupres de ces personnes. Le depistage des situations a risque repose sur l’identification precoce des facteurs dits de «fragilite» dont, notamment, le niveau d’activite motrice. Le concept d’actimetrie permet d’offrir une mesure objective de l’activite motrice en utilisant des capteurs inseres dans l’environnement ou portes par le sujet. Plusieurs situations cliniques de fragilite pourraient justifier l’utilisation de ces dispositifs a domicile ou en institution afin de depister des variations anormales de l’activite. Le service apporte par ces technologies est de favoriser l’autonomie des personnes fragiles tout en leur assurant securite et assistance.

Cognitive disorders with memory loss are common among the patients of general practitioners. In collaboration with an outpatient diagnosis service and referral memory consultations, they are involved in the diagnosis, the implementation and the follow-up of suitable care for the patient and their family.

La notion de fragilite est entree progressivement dans le vocabulaire geriatrique du fait de l’identification d’une sous-population de personnes âgees a plus grand risque de mortalite et d’incapacite. En deux decennies environ, sa definition a progressivement evolue, mais aujourd’hui encore, elle a du mal a faire consensus. Cependant, cliniciens, chercheurs et responsables politiques restent unanimes sur la necessite de developper des outils de depistage precoce afin de mettre en place une strategie de prise en charge adaptee et une demarche preventive coherente.

OBJECTIVES: To compare the epidemiological and microbiological characteristics of bloodstream infection (BSI) between the young old (65–75), old (76–85), and old old (>85). DESIGN: Retrospective study. SETTING: Forty-six hospitals in southeast France. PARTICIPANTS: One thousand seven hundred forty patients aged 65 and older with BSI, seen between January 1 and December 31, 1998. MEASUREMENTS: Epidemiological and microbiological data and outcome. RESULTS: Community-acquired BSIs (CABSIs) were significantly more frequent in the old old, but microbiological data were similar to those in the young-old group. Conversely, microbiological data were significantly different for nosocomial BSIs (NSBIs). Escherichia coli was the main pathogen in the old old and Staphylococcus aureus in the young old. Mortality was independently associated with the presence of methicillin-resistant S. aureus in NSBI and CABSI. CONCLUSIONS: The differences in NBSI are important in serious infectious diseases and often require empirical antibiotic therapy. Age is also a risk factor but only for CABSI and suggests that the old-old patients represent a frail population in the community. Further prospective studies are needed to confirm these findings and analyze predisposing factors.

La mesure de la satisfaction des patients par les hopitaux est obligatoire en France depuis les ordonnances de 1996. L’utilisation de questionnaires de sortie est la principale methode de mesure utilisee. Nous avons mene une enquete aupres de sept etablissements publics volontaires, qui porte sur les modalites d’elaboration et d’utilisation de ces questionnaires de sortie, leurs resultats et la facon dont ces resultats sont pris en compte pour ameliorer la qualite des soins. Les resultats montrent une politique d’elaboration variee, sans controle de la qualite metrologique des questionnaires. Le plus souvent, les questionnaires sont distribues passivement, lors de la sortie du patient. Le taux de retour est faible (entre 4 et 18 %) et l’analyse du contenu des questionnaires, quand elle est faite, n’entraine pas de modification de la prise en charge des patients. Une mesure fonctionnelle de la satisfaction, capable d’impulser une meilleure prise en charge des patients, reste a etablir dans les etablissements de l’enquete.

Age-related immune impairment may be one of the factors influencing successful and pathological aging, being strongly tied to nutritional status. Several long term cohort studies suggest that a lower total lymphocyte count is associated with higher mortality. Nevertheless, prevalence, incidence and impact of lymphopenia on frailty and prediction of pathological events have not been described extensively. The principal aim of this study was to examine the relation of lymphopenia and intra-hospital mortality in the elderly.This cohort study has been carried out in a geriatric acute care unit of the Grenoble University hospital in France. Clinical and biological data have been retrospectively retrieved from the electronic medical record of each patient. All patients aged 75 or older admitted in the unit from May to October 2011 were eligible for inclusion. A lymphocyte count was obtained within 48h hours before or after admission.239 patients were included. Mean age (SD) was 87.04(5.50) years, 82(34.3%) patients were men, median ADL (activities of daily living) score prior to hospitalization was 4 (Q1:2; Q3:6). 31(13%) patients died during their admission. A lympocyte's threshold of 1,100cells/μL establishes a sensitivity of 79.3%, a specificity of 57.2%, a positive predictive value (PV+) of 21.7%, as well as a negative predictive value (PV-) of 94.9%. The OR was 3.44(IC95%, [(1.54-8.10]). The AL's threshold was found to be 3g/dL, establishing a sensitivity of 79.3%, a specificity of 62.0%, a PV+ of 22.8%, PV- of 95.5%. The OR was 4.90(IC 95%, [(2.17-11.87]). In multivariate analysis, LC and AL were significantly predicting in hospital death (OR=2.80 IC95% [(1.18-7.02] p=0.02, OR=3.34 (IC95%, [(1.41 -8.36]) p=0.007 respectively).This observational study carried out with malnourished, functionally impaired older inpatients with multiple comorbidities shows that lymphopenia independentely predicts intra-hospital mortality. In multivariate analysis lymphocyte count and albumin level independently predict intra-hospital mortality in with a similar predictive performance. Low albumin levels have previously been shown to be an independent risk factor for all-cause mortality in community-dwelling older persons as well as to predict intra-hospital mortality. However in our study we included patients with an acute condition and multiple comorbidities, potentially confounding the relation between lymphopenia and mortality. Lymphopenia may be an interesting marker of frailty and prognosis in very elderly people presenting an acute condition.

Resume Les auteurs decrivent l’utilisation d’un outil d’evaluation de la qualite des soins palliatifs donnes a domicile. Ce questionnaire intitule Support Team Assessment Schedule (STAS) a ete traduit de l’anglais pour cette etude. Il a ensuite ete utilise comparativement avec differents instruments d’evaluation de la qualite de vie. Seuls les resultats du STAS sont decrits ici. La demarche permet de mettre en evidence semaine apres semaine les problemes non resolus dans les soins. Le STAS comprend 9 items interessant le patient et sa famille. Sept items concernent les services fournis L’etude expose le resultat des 107 evaluations realisees aupres de 50 malades atteints de cancer ou de sida en phase avancee. La mise a disposition de cet outil d’auto audit clinique, utilisable a domicile et a l’hopital, constitue une etape initiale indispensable dans le champ de l’evaluation clinique francophone des soins palliatifs.

Although elderly people are one of the major target groups for telemedicine applications, they remain under-represented in studies of teleconsultation. Videolinks appear to be easily used by many elderly people as a means of communicating with health-care staff, including psychologists and doctors. To date, studies of psychometric teleconsultation have been confined to screening tests, or have used very small numbers of patients. There is a need to examine the reliability of more complex psychometric batteries and to use larger samples of older people. Some recommendations for conducting clinical interviews and psychometric tests are presented, based on clinical experience and a review of the literature. The importance of ergonomic considerations, patient comfort and professional preparation are explained.

recurrent falls are a major public health problem associated with high morbidity and mortality as well as increased dependence. Multifactorial intervention has been shown to reduce recurrence by 20% (Profet study). The French Health Authority (Haute autorité de santé or HAS) recommends since 2009 a systematic screening for and assessment of risk factors as well as the implementation of preventive measures.to examine whether the management of falls in older patients discharged home from the emergency department is consistent with the HAS guidelines.descriptive retrospective analysis of 1238 medical records of patients over 75 years, who consulted for falls from April to October 2010 in the emergency department of in 13 centers in the North-Alps region. The study is part of a program to improve the quality of care led by the French Network of North-Alps Emergency Departments (Réseau nord alpin des urgences, RENAU).Screening of risk factors for falls was documented in varying rates: electrocardiogram 29%, cognitive impairment 25%, functional assessment 16%, walking difficulties 11%, postural hypotension 5%. A comprehensive geriatric assessment was undertaken for 3.8% of the patients.risk factors for falls are insufficiently documented in elderly patients discharged home from the emergency room after a fall-related visit. Completeness rates are similar to those found in previous studies. A standardized protocol for older fallers, specifically adapted to the work routine in the emergency department could be useful. The RENAU has proposed an algorithm to streamline the orientation of older fallers and promote the use of geriatric network.

The objective was to determine the factors affecting French GPs' implementation of annual screening for falls among patients of 75 years old and over. We conduct a cross-sectional study in two areas in the South-east of France (Savoie and Isere). An anonymized survey was sent by e-mail and/or post in May 2008 to all GPs with a large practice. Reminder letters were sent to GPs who hadn't answered between June and July 2008. Potentials barriers were measured by dichotomous scale. On GPs characteristics (socio-demographic, knowledge, attitude and practice), a multiple logistic regression was performed to identify others factors affecting falls screening. 493 questionnaires were analyzed (26.8%). 65.3% of respondents considered annual screening for falls to be useful, though only 28.8% of them implemented it each year and 9.3% every two to five years. Barriers to achieving annual screening included patient selecting (56.3%), forgetting to screen (26.6%), unsuitable working conditions (18.5%), lack of time (13.3%), of knowledge (13.3%), or of financial compensation (11.1%). Perception of the usefulness of annual screening for falls (OR=5.38 (2.07-14.08); p=0.001), satisfaction with medical care for falls (OR=1.34 (1.09-1.65); p=0.006) and increased consultation time (OR=2.65 (1.37-5.13); p=0.004), were found to have a significant impact on the implementation of annual screening for falls. Asking your patient each year if s/he has had any falls, inquiring about gait and balance disturbance is not time consuming. Finally, to improve a health-related quality of life, GPs should consider fall assessment as a fundamental feature of medical care.

In patients aged 75 years and above, dementia is associated with increased expenditure and high morbimortality. Although the incidence of dementia is well known, it is often underrecognized in primary care. We conducted a cross-sectional study in 2 areas in the southeast of France to identify the factors affecting dementia-screening implementation by the French general practitioners (GPs). In May 2008, an anonymized survey was sent by e-mail and/or post to all GPs with a large clinic practice. Two months later, reminder letters were sent. Overall, 493 GPs answered (26.8%) to self-reported behavior. Of these, 73.2% felt that annual screening was useful, although only 24.5% implemented it each year and 17.5% implemented it every 2 to 5 years. Factors that favorably influenced screening practices were: the older age of the GPs; belief in the usefulness of annual dementia screening; increased frequency of follow-up visits by elderly patients; and the proportion of dementia in the GP's practice. The main barrier to annual screening was the social problems encountered in the medical care of 75-year-old patients. Regardless of the differences in European national health policies or health care systems, all GPs encounter the same difficulties when dealing with elderly dementia patients.

Les gerontologues ont apporte une contribution importante a l'elaboration d'indicateurs de sante et de qualite de vie sous la forme de grilles de dependance. Cet article a pour objet de rendre compte d'une partie des travaux menes par le Laboratoire interuniversitaire de Gerontologie de Grenoble dans le cadre d'un de ses programmes de recherche, QALIDOVIE. Une approche economique d'aide a la decision en matiere de sante est presentee. Puis les indicateurs sont classes en cinq categories : les indicateurs d'efficacite specifique ; les indicateurs d'etat de sante generiques ; les indicateurs de valeur attribuee aux etats de sante ; les indicateurs de qualite des soins ou des prises en charge ; les indicateurs de qualite de vie. Quelques exemples d'outils de mesure sont ensuite fournis : le score de Karnofsky se rapporte a l'aptitude physique ; l'EORTC QLQ-30 est specifique aux patients cancereux ; EUROQOL attribue une « valeur sociale » aux etats de sante ; enfin le STAS a pour but d'evaluer la qualite des soins. La plupart des outils sont des echelles analogiques, parfois incluses dans un questionnaire d'etat de sante, ce qui respecte la singularite a laquelle renvoie la notion de qualite de vie

Cytomegalovirus (CMV) colitis is uncommon in immunocompetent patients, despite a high seroprevalence rate of CMV in the general population. CMV infection has been described in individuals with compromised immune systems: in AIDS, under corticosteroid and immune modulating treatment, with cancer or haematological malignancies. Its most frequent clinical presentation is a necrotising ulcerative form; pseudotumoural CMV colitis has been described as highly exceptional. We report a case of CMV colitis mimicking rectal carcinoma in an immunocompetent elderly woman. The immunosenescence and protein-energy malnutrition increase incidence and severity of infectious diseases in elderly individuals. Immunosenescence may affect all aspects of immunity; severe protein malnutrition modifies mostly cellular immunity, growing susceptibility to infections.

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

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