[Geriatric profile according to the Identification of Seniors At Risk (ISAR) tool in the emergency department in a teaching hospital]. / PROFIL GÉRIATRIQUE selon l'INSTRUMENT IDENTIFICATION SYSTÉMATIQUE des AÎNÉS à RISQUE (ISAR) au SERVICE des URGENCES d'un CENTRE HOSPITALIER UNIVERSITAIRE.

BACKGROUND: With the anticipated increase in the number of elderly people in Lebanon, it is important to develop services tailored to their specific needs. The Identification of Seniors At Risk (ISAR) tool identifies, in emergency setting, frail elderly people at risk of adverse outcomes, who are more likely to benefit from a geriatric approach. OBJECTIVES: i) Assess the geriatric profile according to ISAR score ii) correlate the score to outcomes two months after Emergency Department (ED) visit. METHODS: A two-month prospective study: at the ED of Hôtel-Dieu de France Hospital, we interviewed 273 people aged 70 years and older (or their caregiver) using the ISAR tool. Telephone follow-up was done two months later. RESULTS: The prevalence of subjects with ISAR score ≥ 2 and thus likely to benefit from the establishment of a geriatric service is 70.7% (95% CI: 64.9-76.0). Elderly patients admitted to ED with ISAR score ≥ 2 are more likely to be hospitalized (51.6%) than subjects of the same age and sex with ISAR score < 2 (36.9%) (p = 0.034). After two months of follow-up, the risk of hospital readmission and the risk of death was significantly associated with the ISAR score (p = 0.0005) CONCLUSION: The percentage of elderly people likely to benefit from specialized geriatric care network upon admission to the ED of a university hospital is significantly high [70.7% (95% Cl: 64.9-76 .0)].

[Effectiveness of "contact" precautions to prevent the spread of vancomycin resistant enterococci in a long-term care facility]. / Suivi prospectif de patients excréteurs d'entérocoques résistants aux glycopeptides en unité de soins de longue durée et efficacité des mesures de précaution « contact ¼

INTRODUCTION: Vancomycin-resistant enterococci (VRE) are major nosocomial pathogens in many countries. VRE can spread rapidly, mostly by cross-transmission through hands of healthcare workers, leading to outbreaks. Moreover, VRE have the possibility to transfer vancomycin resistance genes to other Gram-positive organisms. OBJECTIVES: We conducted a 9-month prospective study to demonstrate the effectiveness of "contact" precautions to prevent the spread of VRE in a long-term care facility. METHODS: Six patients with VRE colonisation were admitted in an 80-bed long-term care facility. The following interventions were implemented to prevent the spread of VRE: gathering patients with VRE colonisation in the same unit, reinforcement of hand hygiene practices, "contact" precautions, reduction of some antibiotics and extensive screening of VRE carriers and contact patients by rectal swabs. RESULTS: There was no secondary case of VRE colonisation. Screening tests converted from positive to negative in four of the six patients. CONCLUSION: Compliance with hand hygiene recommendations and "contact" precautions can prevent the spread of VRE in a long-term care facility.

[Elderly people, precariousness, social handicap and length of stay: pilot study at the Lariboisière-Fernand Widal Hospital Group in Paris]. / Personnes âgées, précarité, handicap social et durée de séjour: étude pilote au groupe hospitalier Lariboisière-Fernand Widal de Paris.

OBJECTIVES: To administer a social handicap questionnaire associated with French DRGs (PMSI) to determine the social handicaps of a population hospitalized in a public health establishment and to measure the cost implications for the establishment due to increased length of stay (DMS). METHOD: A prospective pilot study has been carried out in the Lariboisière-Fernand Widal Hospital Group in Paris targeting users 50 or more years old hospitalized for short stays in medicine, surgery and obstetrics. Data of the PMSI and answers to the questionnaire for hospitalisations longer than 24 hours have been exploited. RESULTS: Two hundred twenty-two stays from 8 to 23 November 2005 have been analyzed: 140 pertained to patients aged 50-69 years (27.8%) and 82 to patients aged 70 or more years (16.3%). Three-fourths of the persons aged 50-69 and 70 or over presented a social handicap: 45% showed a strong handicap and a third an average handicap. The three indicators "renter/owner", "interior comfort" and "family relations" were the major determinants of social handicap for those aged 70 or more, 50-69 and 50 or more years. For the patients 70 years and over and those 50-69 years, with an average handicap, the indicator was "income" with the domain "patrimony." For strong handicaps, it was the indicator "scolarisation" for the 70 or more years and the indicator "income" for the 50-69 years old. When all classes and populations were pooled, the DMS was significantly lower than that of the ENC (p<0.001 for the 70 years and over; p<0.05 for the 50-69 years). With again all classes and populations pooled, patients 70 and over stayed in hospital 6.50 days less on average compared to data published by the ENC; those 50-69 years stayed 3.57 days less. Persons aged 50 and over with a social handicap remained hospitalized on average more than 2.5 days: 2.2 days for the 70 and over and 3.1 days for the 50-69 years group. In terms of hospital days that produces an increase of 18%, corresponding to a supplementary expenditure attributable to social handicap of approximately 5.9 million euros. CONCLUSION: This pilot study with a questionnaire disability social PMSI proposing specific aid, but also reducing the DMS, provides several promising information but also indicates the limits of our approach. Among these, we note in particular: (a) its regular feasibility requires constant supervision, wider and well-trained, (b) that the measurement of our tool can only be affirmed after its use in many patients, and (c) the classification of disability in social class could even be discussed again. We still wanted to explore whether through this initiative without much logistical, markers of interest had emerged, which seems to be the case.

[Analysis of fourteen French national programmes on physical activity and sports as determinants of health from 2001 to 2006]. / Analyse de quatorze actions nationales pour le déterminant de santé activités physiques et sportives en France de 2001 à 2006.

Physical activity and sports are considered as one of the determinants of health. The aim of this study is to review the rationale for the formulation of this public health issue and its integration in national action plans. The study shows that fourteen national programmes were drafted and implemented between 2001 and 2006 by seven institutions. The research methodology was based on crossing data obtained from semi-directed interviews and documents regarding the design, implementation and follow-up of these programmes. For the conditions of the success, the fourteen actions scored an average of 175.0 +/- 66.9 out of 300%. Public health actors and professionals must be given more opportunities to involve themselves and engage in developing stronger relationships and linkages, in particular with the institutional and community settings. In general, the most invested parts of a programme are the structural and operational aspects of activities. Six significant points surfaced from the study: consideration of drug use as an addictive behaviour; recognition of the psychological stress of professional athletes; acknowledgment of youth as being at high risk for doping behaviour; integration of the concept that physical activity and sports must take the benefit/risk perspective into account; and the necessity to promote health. Through the exchange of numerous local and regional experiences, an optimisation of their synergistic connections was made possible on a continuum extending from "health promotion through physical activity and sports" to "prevention of drug-use and doping behaviours". Professionals have been able to develop actions in the above-mentioned domains across this continuum that have, to date, remained isolated. Proposals are made to strengthen these dynamics. Other health determinants and public health priorities could be investigated with the same methodology.

[What prevention programmes and which organizations are needed to support healthy ageing?]. / Quelles actions de prévention et quelles organisations pour un vieillissement réussi?

Physical activity and exercise are recognized as one of the determinants of health. This study aims to produce a review of the logical foundations at work that support the identification of a public health problem for this determinant and how to address it through national action. The research is based on cross-analysis of data from semi-directed interviews and data extracted from documents on the development, implementation and follow-up of such actions and programmes. The study shows that fourteen national programmes were created and implemented by seven different agencies. These fourteen activities scored an average of 175 +/- 66.9 out of 300%. Actors and professionals in the field must be given more capacity to be implicated and involved while simultaneously encouraging the strengthening of relationships with their environment, in particular the institutional and organizational settings as well as the community components. In general, the structural and operational aspects of action are those which receive the most investment in such activities. Six main points arose as important: doping considered as a addictive mechanism, acknowledgement of the psychological suffering of professional athletes, youth at high risk of doping, and that the concepts of physical activity and sports should take into account a risk/ benefit analysis and the necessity to first and foremost promote health. The act of sharing and exchanging a number of experiences, at the local and regional level, resulted in the identification of synergies between these experiences on a continuum from "health promotion through physical activity and sports" to "prevention of doping". Within this framework, professionals were able to develop activities in the aforementioned domains, which until now had remained isolated and marginal. Recommendations were made to reinforce and strengthen this dynamic. Other determinants of health and public health priorities could be explored using the same methodology.

[Prospective study of oral anticoagulation control in 110 very elderly hospitalized patients and of risk factors for poor control]. / Difficultés pour équilibrer les antivitamines K chez des personnes très âgées hospitalisées: étude prospective chez 110 patients avec recherche de facteurs de risque de déséquilibre.

OBJECTIVES: The primary aim of this study was to analyze the quality of oral anticoagulation management in the real-life practice of hospital geriatric departments, in the absence of a formal dose-adjustment protocol. The secondary objective was to identify factors associated with international normalized ratios (INR) outside the target range. METHODS: This prospective study was conducted between November 2004 and August 2005 in our hospital's acute geriatric care and geriatric rehabilitation units. It included 110 subjects older than 65 years, all taking fluindione (target INR range of 2 to 3). Indications for oral anticoagulation were atrial fibrillation, venous thromboembolism, and pulmonary embolism. Patients were eligible for inclusion if they had at least 4 INR measurements, and we assessed a maximum of 20 such measures per patient. RESULTS: The study included 74 patients in the acute geriatric unit and 36 subjects in rehabilitation units (mean age: 85 years [65-97 years]), who had 1079 INR tests during the study period (mean per patient: 9.8 (+/-5.5)). Overall, 333 patients (31%) were in the target range of 2-3, 48% below 2, 21% above 3, and 3.6% above 5. The time interval between INR tests did not vary when INR was below 2, but we noted a nonsignificant trend towards a reduction in the average testing interval when INR was above 3 (p=0.079). No bleeding or thrombotic complications were reported during the study. Of the 11 predefined variables, only cancer (history or current) was significantly associated with elevated INR. CONCLUSION: This study confirms the difficulty of controlling INR in anticoagulation therapy of elderly subjects. Only 31% of tests showed INR in the target range of 2 to 3, a rate lower than in other cohorts. These results may be explained by the high rate of comorbidities in this very old study population.

[Risk factors for Alzheimer: towards prevention?]. / Facteurs de risque de la maladie d'Alzheimer: vers une prévention?

Recent longitudinal studies have highlighted associations between Alzheimer's disease (AD) and several factors, especially some cardiovascular risk factors, including hypertension, diabetes, diet, obesity, and elevated levels of homocysteine and lipids in the blood. The strongest associations are with hypertension and diabetes. Moderate alcohol consumption also appears to be associated with a decreased risk of incident AD. Studies of the effect of interventions to control these risk factors on the onset and course of dementia report encouraging results about antihypertensive agents and statins. Benefits from other drug therapies such as nonsteroidal antiinflammatory drugs and antioxidants remain uncertain, and initial hopes for hormonal replacement therapy for postmenopausal women have not been confirmed. Physical, cognitive and leisure activities seem to provide protection against incident AD. Cautious interpretation is necessary in view of the possible biases in these studies (confounding factors as well as survival, regression dilution, and indication biases). These epidemiologic data raise questions about the diagnostic boundaries between AD and vascular dementia. Additional studies are needed to validate these concepts and to confirm the possible benefits of preventive measures.

[Hypertension and Alzheimer's disease]. / L'hypertension artérielle est-elle associée a la maladie d'Alzheimer?

Case-control transversal studies have suggested the existence of an association between low blood pressure and Alzheimer's disease, although there is some doubt on the cause to effect relationship. A drop in blood pressure preceding the onset of dementia has been evoked but never confirmed. Longitudinal studies, with long term follow-up on the existence of hypertension during middle-age, have demonstrated a significant increase in the risk of developing Alzheimer's disease in cohorts of hypertensive patients compared to normotensive subjects. The potential benefit of preventive treatment with antihypertensive drugs in decreasing the risk of Alzheimer's disease has not been confirmed in clinical trials. The hypothesis of the formation of a cerebrovascular disease that would combine with the neuropathological lesions has been evoked, raising doubts on the diagnostic criteria used to define Alzheimer's disease. The novel concept that vascular risk factors could directly induce the formation of neuropathological lesions is interesting but warrants confirmation.

Intracerebral aneurysms: a review with special attention to geriatric aspects.

Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.

[Early response to oral cobalamin therapy in older patients with vitamin B12 deficiency]. / Réponse précoce au traitement oral par vitamine B12 chez des sujets âgés hypovitaminiques.

PURPOSE: Standard treatment of vitamin B12 deficiency involves regular intramuscular cobalamin administration. The aim of this study was to determine whether oral cobalamin treatment may be an effective therapy for treating older patients with cobalamin deficiency related to nutritional deficiency and food-cobalamin malabsorption. PATIENTS AND METHODS: We prospectively studied 20 patients older than 80 years with established cobalamin deficiency related to food-cobalamin malabsorption (n=14) and nutritional deficiency (n=6) who received 1000 micro g of oral cyanocobalamin per day. Levels of serum cobalamin and blood counts were determined at baseline and after the first week of treatment. RESULTS: After an average of 8 days of treatment, 17 out of 20 patients normalized their serum cobalamin levels; the patients had increased their serum cobalamin level (mean increase of 0.23 micro g/L; p<0.01 compared with baseline), reticulocyte count (mean increase of 27400/mm(3); p<0.05), hemoglobin levels (mean increase of 0.7 g/dL; NS), and decreased the mean erythrocyte volume (mean decrease of 0.7 fL; NS). CONCLUSION: Our findings suggest that cyanocobalamin given orally during one week may be an effective treatment for cobalamin deficiency related to food-cobalamin malabsorption and nutritional deficiency and may avoid painful intra-muscular injections in older patients.