[Evaluation of the perspectives and experiences regarding lumbar puncture in cognitively impaired older adults over 70, their relatives and the care teams]. / Évaluation des représentations et du vécu liés à la ponction lombaire chez des patients âgés de plus de 70 ans atteints de troubles cognitifs, leurs accompagnants et les équipes soignantes.

INTRODUCTION: Lumbar puncture (LP) is an essential diagnostic procedure, which raises major concerns in older adults. Some patients may be denied LP because of the fear of complications in healthcare teams which are not familiar with the procedure. The objectives of our work were to analyze the perspectives and the experiences regarding scheduled LP in cognitively impaired older adults, as well as in their relatives, and the healthcare teams from geriatric day hospitals. METHODS: We conducted a qualitative, observational and multicentric study, based on semi-directive interviews of patients aged over 70 years with cognitive complaints undergoing a scheduled LP in a day hospital. Patients were interviewed before and after LP. Their relatives and the involved healthcare teams were also interviewed to analyze their expectations and perspectives regarding the procedure. The full interviews were transcribed and analyzed using interpretative phenomenological analysis. RESULTS: Ten patients (mean age 80.2 ± 7.2), five relatives and four healthcare teams were included. The goals and operating procedure of LP were poorly understood by several patients. Some individuals feared irreversible neurological consequences or LP-related pain, which was often overestimated with regards to the post-LP interviews. The patients' major expectation was to establish an accurate and early diagnosis of their cognitive disorder to provide optimal care plan. Relatives reported similar fears of major adverse events. They also expected an accurate diagnosis with biomarkers. The perspectives and experiences of the healthcare teams were heterogeneous, according to their level of practice of LP, but seemed in line with current scientific guidelines. CONCLUSION: This study highlighted the existence of false beliefs and poor knowledge regarding the LP procedure and its associated risks. The post-LP patients' feedbacks were better than their expectations, especially in day hospitals with solid experience in LP. Better patient information may be a key to improve our practice.

Clinical Characteristics and Outcomes of 821 Older Patients With SARS-Cov-2 Infection Admitted to Acute Care Geriatric Wards.

BACKGROUND: There is limited information describing the characteristics and outcomes of hospitalized older patients with confirmed coronavirus disease 2019 (COVID-19). METHOD: We conducted a multicentric retrospective cohort study in 13 acute COVID-19 geriatric wards, from March 13 to April 15, 2020, in Paris area. All consecutive patients aged 70 years and older, with confirmed COVID-19, were enrolled. RESULTS: Of the 821 patients included in the study, the mean (SD) age was 86 (7) years; 58% were female; 85% had ≥2 comorbidities; 29% lived in an institution; and the median [interquartile range] Activities of Daily Living scale (ADL) score was 4 [2-6]. The most common symptoms at COVID-19 onset were asthenia (63%), fever (55%), dyspnea (45%), dry cough (45%), and delirium (25%). The in-hospital mortality was 31% (95% confidence interval [CI] 27-33). On multivariate analysis, at COVID-19 onset, the probability of in-hospital mortality was increased with male gender (odds ratio [OR] 1.85; 95% CI 1.30-2.63), ADL score <4 (OR 1.84; 95% CI 1.25-2.70), asthenia (OR 1.59; 95% CI 1.08-2.32), quick Sequential Organ Failure Assessment score ≥2 (OR 2.63; 95% CI 1.64-4.22), and specific COVID-19 anomalies on chest computerized tomography (OR 2.60; 95% CI 1.07-6.46). CONCLUSIONS: This study provides new information about older patients with COVID-19 who are hospitalized. A quick bedside evaluation at admission of sex, functional status, systolic arterial pressure, consciousness, respiratory rate, and asthenia can identify older patients at risk of unfavorable outcomes.

COVID-19 In-Hospital Mortality and Use of Renin-Angiotensin System Blockers in Geriatrics Patients.

OBJECTIVE: The role of treatment with renin-angiotensin-aldosterone system blockers at the onset of COVID-19 infection is not known in the geriatric population. The aim of this study was to assess the relationship between angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitor (ACEI) use and in-hospital mortality in geriatric patients hospitalized for COVID-19. DESIGN: This observational retrospective study was conducted in a French geriatric department. Patients were included between March 17 and April 18, 2020. SETTING AND PARTICIPANTS: All consecutive 201 patients hospitalized for COVID-19 (confirmed by reverse-transcriptase polymerase chain reaction methods) were included. All nondeceased patients had 30 days of follow-up and no patient was lost to follow-up. METHODS: Demographic, clinical, and biological data and medications were collected. In-hospital mortality of patients treated or not by ACEI/ARB was analyzed using multivariate Cox models. RESULTS: Mean age of the population was 86.3 (8.0) years, 62.7% of patients were institutionalized, 88.6% had dementia, and 53.5% had severe disability (activities of daily living [ADL] score <2). Sixty-three patients were treated with ACEI/ARB and 138 were not. Mean follow-up was 23.4 (10.0) days, 66 (33.8%) patients died after an average of 10.0 days (6.0). Lower mortality rate was observed in patients treated with ACEI/ARB compared with patients not treated with ARB or ACEI (22.2% [14] vs 37.7% [52], hazard ratio [HR] 0.54; 95% confidence interval 0.30-0.97; P = .03). In a multivariate Cox regression model including age, sex, ADL score, Charlson index, renal function, dyspnea, C-reactive protein, and white blood cell count, use of ACEI/ARB was significantly associated with lower in-hospital mortality (HR 0.52 (0.27-0.99), P = .048). CONCLUSION AND IMPLICATIONS: In very old subjects hospitalized in geriatric settings for COVID-19, mortality was significantly lower in subjects treated with ARB or ACEI before the onset of infection. The continuation of ACEI/ARB therapy should be encouraged during periods of coronavirus outbreak in older subjects.

National survey on the management of heart failure in individuals over 80 years of age in French geriatric care units.

BACKGROUND: To evaluate the prevalence and management of heart failure (HF) in very old patients in geriatric settings. METHODS: Members of the French Society of Geriatrics and Gerontology throughout France were invited to participate in a point prevalence survey and to include all patients ≥80 years old, hospitalized in geriatric settings, with HF (stable or decompensated) on June 18, 2012. General characteristics, presence of comorbidities, blood tests and medications were recorded. RESULTS: Among 7,197 patients in geriatric institution, prevalence of HF was 20.5% (n = 1,478): (27% in acute care, 24.2% in rehabilitation care and 18% in nursing home). Mean age was 88.2 (SD = 5.2) and Charlson co morbidity score was high (8.49 (SD = 2.21)). Left ventricular ejection fraction (LVEF) was available in 770 (52%) patients: 536 (69.6%) had a preserved LVEF (≥ 50%), 120 (15.6%) a reduced LVEF (< 40%), and 114 (14.8%) a midrange LVEF (40-49%). Prescription of recommended HF drugs was low: 42.6% (629) used Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARBs), 48.0% (709) ß-blockers, and 21.9% (324) ACEI or ARB with ß-blockers, even in reduced LVEF. In multivariate analysis ACEI or ARBs were more often used in patients with myocardial infarction (1.36 (1.04-1.78)), stroke (1.42 (1.06-1.91)), and diabetes (1.54 (1.14-2.06)). ß blockers were more likely used in patients with myocardial infarction (2.06 (1.54-2.76)) and atrial fibrillation (1.70 (1.28-2.28)). CONCLUSION: In this large very old population, prevalence of HF was high. Recommended HF drugs were underused even in reduced LVEF. These results indicate that management of HF in geriatric settings can still be improved.

Blood pressure-lowering efficacy of indapamide SR/amlodipine combination in older patients with hypertension: A post hoc analysis of the NESTOR trial (Natrilix SR vs Enalapril in Hypertensive Type 2 Diabetics With Microalbuminuria).

To examine the antihypertensive efficacy and safety of indapamide sustained-release (SR)/amlodipine compared with enalapril/amlodipine in patients 65 years and older with uncontrolled blood pressure (BP) on monotherapy, a post hoc analysis of the NESTOR trial (Natrilix SR vs Enalapril in Hypertensive Type 2 Diabetics With Microalbuminuria) was conducted. NESTOR randomized 570 patients (n=197, aged ≥65 years) with hypertension (systolic BP 140-180/diastolic BP <110 mm Hg) to indapamide SR 1.5 mg or enalapril 10 mg. If target BP (<140/85 mm Hg) was not achieved at 6 weeks, amlodipine 5 mg was added with uptitration to 10 mg if required. A total of 107 patients aged 65 years and older received dual therapy (53 indapamide SR/amlodipine and 54 enalapril/amlodipine). Amlodipine uptitration occurred in 22 and 24 patients, respectively. At 52 weeks, mean systolic BP (±SE) reduction was significantly greater with indapamide SR/amlodipine vs enalapril/amlodipine 6.2±2.7 mm Hg (P=.02). Indapamide SR/amlodipine was also associated with a greater BP response rate (88% vs 75%, respectively). Both regimens were well tolerated. Indapamide SR/amlodipine may be more effective than enalapril/amlodipine for lowering systolic BP in patients with hypertension aged 65 years and older.

Brain natriuretic peptide usefulness in very elderly dyspnoeic patients: the BED study.

AIMS: To evaluate the interest of brain natriuretic peptide (BNP) for heart failure (HF) diagnosis in very old patients. METHODS AND RESULTS: A total of 383 patients aged 80 years or older, hospitalized in geriatrics care for dyspnoea, had a BNP measurement at the acute phase. Independent cardiologists blinded to BNP values classified the patients into cardiac vs. respiratory aetiology according to the European Society of Cardiology guidelines. Mean (SD) age was 88.5 (5.4) years, 66% (n = 254) of patients were women, 62% (n = 238) had cardiac dyspnoea and 38% (n = 145) had respiratory dyspnoea. The BNP levels were significantly higher in the cardiac group (median = 385.5 ng/L, interquartile range = 174.0-842.0) than in the respiratory group (median = 172.0 ng/L, interquartile range = 70.8-428.0; P < 0.001). On its own, BNP showed poor discriminative ability [area under the curve (AUC) = 0.68; 95% confidence interval (CI) 0.62-0.73] for the diagnostic. In multivariate analysis, BNP remained independently associated with the cardiac aetiology after full-adjustment (odds ratio 1 log increase = 1.87; 95% CI 1.28-2.74), but did not improve the discrimination between the cardiac and the respiratory aetiologies (ΔAUC = 0.013, P = 0.16). In addition, although adding BNP to the other predictive covariates yielded a significant continuous NRI of 57.8% (95% CI 31.2-83.5%), the mean changes in individual predicted probabilities were too low (<3%) to be clinically relevant. CONCLUSION: In this population of very old patients with acute dyspnoea, despite being independently associated with the cardiac aetiology, BNP was not useful for better discriminating cardiac vs. respiratory origin.

Rehabilitation of the psychomotor consequences of falling in an elderly population: A pilot study to evaluate feasibility and tolerability of virtual reality training.

BACKGROUND: A fall in elderly subjects can lead to serious psychological consequences. These symptoms can develop into Fear of Falling with behavioural disorders comparable to PTSD that may severely limit autonomy. Virtual reality training (VRT) could be seen as a worthwhile therapeutic approach for this syndrome since it has been shown to be a useful tool for motor rehabilitation or combat-related PTSD. We thus developed a training scenario for VRT with psychomotor therapists. OBJECTIVE: To test the feasibility and acceptability of VRT when used by elderly adults for fall rehabilitation. METHODS: Our population of 8 patients older than 75 years, with a Mini Mental Score Examination greater than 18/30 performed sessions of VRT and answered a questionnaire on the feasibility and acceptability of it. RESULTS: This sample showed a highly favourable response to the prototype of VRT. They found it easy to use, enjoyed the experience, and thought it realistic and helpful. CONCLUSION: The conclusions of our study are limited by sample size. However, applications with VRT can offer the potential of an acceptable technique for elderly subjects. The next step will be to show the efficacy of this method in the management of post-fall PTSD.

[Heart failure and comorbidities]. / Insuffisance cardiaque et pathologies associées.

Heart failure is a frequent disease in the elderly. Its clinical presentation is less typical and the prognosis more severe than in younger subjects because heart failure occurs in patients with multiple comorbidities. A comprehensive geriatric assessment should therefore be performed to detect the vulnerabilities and manage the comorbidities. The main diseases associated with heart failure are dementia, depression, malnutrition, atrial fibrillation, coronary artery disease, orthostatic hypotension, renal failure, anemia and iron deficiency. Comorbidities worsen heart failure and makes its treatment more difficult. The identification and treatment of comorbidities improve the prognosis in terms of mortality but especially in terms of quality of life. Caution with drugs is necessary because of pharmacokinetic or pharmacodynamic changes related to aging and the comorbidities. In this context, clinical and laboratory monitoring should be increased, mostly during an acute event (acute heart failure, infection, dehydration, fall, new therapy…). Therefore, the follow-up of elderly patients with heart failure requires a multidisciplinary approach that involves close cooperation between cardiologists, geriatricians, general practitioners, nurses, and pharmacists.

[Falls in the elderly, from the risk factors to prevention]. / La chute de la personne âgée, des facteurs de risque à la prévention.

There are a number of causes of falls in the elderly. The psychological trauma following a fall can be significant and require early care management. There are multidisciplinary prevention strategies which must be adapted to each case.

Treatment of Hypertensive Patients With Diabetes and Microalbuminuria With Combination Indapamide SR/Amlodipine: Retrospective Analysis of NESTOR.

BACKGROUND: Combination treatments for hypertension most often include a renin-angiotensin-aldosterone system (RAAS) inhibitor. However, systolic blood pressure (SBP) remains difficult to control. Non-RAAS-inhibiting strategies such as calcium channel blocker/thiazide-like diuretic combinations may offer effective alternatives. METHODS: Hypertensive diabetic patients with microalbuminuria were included in this retrospective, post-hoc analysis of the Natrilix SR Versus Enalapril Study in Hypertensive Type 2 Diabetics With MicrOalbuminuRia (NESTOR) trial if they were uncontrolled on monotherapy (indapamide slow release (SR) 1.5 mg or enalapril 10mg) and had been given add-on amlodipine 5 mg. Patients uncontrolled with monotherapy/amlodipine 5mg were uptitrated to 10 mg. RESULTS: After 52 weeks, supine SBP/diastolic BP (DBP) decreased from baseline by 26±13/14±9 mm Hg in the indapamide SR/amlodipine group (n = 135) and by 21±14/11±9 mm Hg in the enalapril/amlodipine group (n = 156) (P = 0.006 for ΔSBP). In the amlodipine 10mg subgroup, SBP/DBP decreased from baseline by 26±13/13±9 mm Hg in the indapamide SR/amlodipine group (n = 62) and by 20±13/12±8 mm Hg in the enalapril/amlodipine group (n = 77) (P = 0.02 for ΔSBP). Treatment with indapamide SR/amlodipine was well tolerated. Few patients experienced edema, with no between-group differences. As expected with diuretics, slight changes in kalemia and in uricemia were observed in the indapamide SR/amlodipine group. Changes in fasting glucose, lipids, natremia, and creatinine clearance were similar between groups. CONCLUSIONS: Indapamide SR/amlodipine results in superior SBP reduction with a safety profile in line with that of its components and tolerability equivalent to that of an angiotensin-converting enzyme inhibitor/amlodipine strategy.

Home blood pressure measurement in elderly patients with cognitive impairment: comparison of agreement between relative-measured blood pressure and automated blood pressure measurement.

OBJECTIVES: Home blood pressure measurement (HBPM) is recommended by guidelines for hypertension management. However, this method might be difficult to use in elderly individuals with cognitive disorders. Our aim was to assess the agreement and the feasibility of HBPM by a relative as compared with 24-h ambulatory blood pressure monitoring (ABPM) in elderly patients with dementia. METHODS: Sixty outpatients with dementia aged 75 years and older with office hypertension (≥140/90 mmHg) were subjected successively to HBPM by a trained relative and 24-h ABPM. The order of the two methods was randomized. Current guidelines' thresholds for the diagnosis of hypertension were used. RESULTS: The mean (SD) age of the patients was 80.8 (6.1) years (55% women) and the mean (SD) mini-mental state examination score was 20.1 (6.9). The feasibility of relative-HBPM was very high, with a 97% success rate (defined by ≥12/18 measurements reported). The blood pressure measurements were highly correlated between the two methods (r=0.75 and 0.64 for systolic blood pressure and diastolic blood pressure, respectively; P<0.001 for both). The agreement between the methods for the diagnosis of sustained hypertension and white-coat hypertension was excellent (overall agreement, 92%; κ coefficient, 0.81; 95% CI, 0.61-0.93). Similar results were found for daytime-ABPM. CONCLUSION: In cognitively impaired elderly patients, HBPM by a relative using an automated device was a good alternative to 24-h ABPM.