Spousal Caregiving Is Associated with an Increased Risk of Frailty: A Case-Control Study.

BACKGROUND: Evidence suggests that providing care for a disabled elderly person may have implications for the caregiver's own health (decreased immunity, hypertension, and depression). OBJECTIVE: Explore if older spousal caregivers are at greater risks of frailty compared to older people without a load of care. DESIGN: Case-control study. SETTING: Participants were assessed at home in Wallonia, Belgium. PARTICIPANTS: Cases: community-dwelling spousal caregivers of older patients, recruited mainly by the geriatric outpatient clinic. CONTROLS: people living at home with an independent spouse at the functional and cognitive level matched for age, gender and comorbidities. MEASUREMENTS: Mini nutritional assessment-short form (MNA-SF), short physical performance battery (SPPB), frailty phenotype (Fried), geriatric depression scale (GDS-15), clock drawing test, sleep quality, and medications. The multivariable analysis used a conditional logistic regression. RESULTS: Among 79 caregivers, 42 were women; mean age and Charlson comorbidity index were 79.4±5.3 and 4.0±1.2, respectively. Among care-receivers (mean age 81.4±5.2), 82% had cognitive impairment. Caregiving was associated with a risk of frailty (Odd Ratio (OR) 6.66; 95% confidence interval (CI) 2.20-20.16), the consumption of antidepressants (OR 4.74; 95% CI 1.32 -17.01), shorter nights of sleep (OR 3.53; 95% CI 1.37-9.13) and more difficulties maintaining a social network (OR 5.25; 95% CI 1.68-16.40). CONCLUSIONS: Spousal caregivers were at an increased risk of being frail, having shorter nights of sleep, taking antidepressants and having difficulties maintaining their social network, compared to non-caregiver controls. Older spousal caregivers deserve the full attention of professionals to prevent functional decline and anticipate a care breakdown.

Age-related normative values for handgrip strength and grip strength's usefulness as a predictor of mortality and both cognitive and physical decline in older adults in northwest Russia.

OBJECTIVES: This paper sought to provide normative values for grip strength among older adults across different age groups in northwest Russia and to investigate their predictive value for adverse events. METHODS: A population-based prospective cohort study of 611 community-dwelling individuals 65+. Grip strength was measured using the standard protocol applied in the Groningen Elderly Tests. The cut-off thresholds for grip strength were defined separately for men and women of different ages using a weighted polynomial regression. A Cox regression analysis, the c-statistic, a risk reclassification analysis, and bootstrapping techniques were used to analyze the data. The outcomes were the 5-year mortality rate, the loss of autonomy and mental decline. RESULTS: We determined the age-related reference intervals of grip strength for older adults. The 5th and 10th percentiles of grip strength were associated with a higher risk for malnutrition, low autonomy, physical and mental functioning and 5-year mortality. The 5th percentile of grip strength was associated with a decline in autonomy. CONCLUSIONS: This study presents age- and sex-specific reference values for grip strength in the 65+ Russian population derived from a prospective cohort study. The norms can be used in clinical practice to identify patients at increased risk for adverse outcomes.

Reduction of potentially inappropriate medications using the STOPP criteria in frail older inpatients: a randomised controlled study.

BACKGROUND: Hospital admissions may provide an opportunity to discontinue potentially inappropriate medications (PIMs) in older patients. Little is known about the effect of using the Screening Tool of Older People's potentially inappropriate Prescriptions (STOPP) in this context. This study aimed to test the hypothesis that specific STOPP recommendations from an inpatient geriatric consultation team (IGCT) to the hospital physician leads to reductions in PIMs for patients at discharge. METHODS: This was a randomised controlled study in 146 frail inpatients (in 2011). The intervention consisted of STOPP recommendations made by the IGCT to ward physicians to discontinue PIMs, in addition to the standard geriatric advice. RESULTS: Intervention (n = 74) and control (n = 72) groups were similar in terms of patient characteristics (median age 85 years; median number of daily drugs, seven) and PIM distribution (68 and 57 PIMs in 53 and 51 % of patients, respectively). At discharge, the reduction in PIMs was twice as high for the intervention group as for the control group (39.7 and 19.3 %, respectively; p = 0.013). The proportion of patients who still had one or more PIM at discharge did not differ between groups. In the 50 patients followed-up a year later, the majority of PIMs that had been stopped during hospitalisation had not been restarted after discharge (17/28; 61 %). The clinical relevance of PIMs identified at baseline in those patients was considered major (29 %), moderate (37 %), minor (5 %), deleterious (8 %), or not assessed (11 %). Discontinuation rate was not associated with clinical importance. CONCLUSION: Specific STOPP recommendations provided to hospital physicians doubled the reduction of PIMs at discharge in frail older inpatients. To further improve the appropriateness of prescribing in older patients, clinicians should focus on the STOPP criteria that are of major clinical importance, and general practitioners should be actively involved.

The relationship between grip strength and muscle mass (MM), inflammatory biomarkers and physical performance in community-dwelling very old persons.

The main consequence of the loss of MM and muscle strength is limitations of physical performance and disability in older people. It is unclear whether a decline in functional capacity results from the loss of MM and/or the qualitative impairment of the muscle tissue. The aim of our research was to investigate the relationship between physical performance and grip strength, inflammatory markers and MM in a population of community-dwelling very old persons. This study is a cross-sectional analysis within the BELFRAIL-study, a cohort study of subjects aged 80 years and older (n=567). MM was assessed by bioelectrical impedance. Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) concentrations were determined on fasting blood samples. Logistic regression analysis was build using a low physical performance level evaluated according to Short Physical Performance Battery (SPPB) (dependent variable) and grip strength, pro-inflammatory status and MM (independent variables) adjusted for age and for the total number of chronic diseases. Low SPPB scores were associated with grip strength scores for women (OR 0.86 (95% CI 0.77-0.96)), and for men (OR 0.89 (95% CI 0.81-0.96)). The relationships between low SPPB and MM or inflammatory profile were not significant. Our results show that low physical performance remains associated with low grip strength even after considering other risk factors for sarcopenia in the oldest old and support the hypothesis that low muscle strength is a better indicator than low MM. The role of an inflammatory component in the age-related loss of muscle strength and function could not be confirmed.

The influence of renal function on vitamin D metabolism in the very elderly.

OBJECTIVES: Hypovitaminosis D and chronic kidney disease (CKD) are highly prevalent in older adults. The factors correlating with 25-OH-vitamin D and PTH levels were analyzed in older adults with and without CKD. DESIGN: We performed a cross-sectional analysis embedded within the BELFRAIL study. SETTING: A population-based prospective cohort study of the very elderly in Belgium. PARTICIPANTS: 325 participants, all aged 80 or older. MEASURMENTS: Time of year and LAPAQ score were used as proxies for sunshine exposure. Vitamin D3 supplementation, gender, institutionalisation, age, level of education, and serum calcium and phosphorus level were examined as possible confounders in the analyses. RESULTS: There was no correlation between the presence of CKD and low 25-OH-vitamin D levels, but there was a significant (p<0.01) correlation between CKD and high PTH levels. Among the participants with a normal eGFR, the LAPACQ score, vitamin D supplementation, season, log PTH value and eGFR were correlated with log 25-OH-vitamin D levels. Among the participants with CKD, only vitamin D supplementation, log PTH levels and serum calcium levels were correlated with log 25-OH-vitamin D levels. Gender, log 25-OH-vitamin D values, serum calcium and phosphorus levels and eGFR were correlated with log PTH values in the patients with normal eGFR. Log 25-OH-vitamin D values, serum phosphorus levels, vitamin D supplementation (p=0.07), season (p=0.10) and eGFR were correlated with log PTH values in the patients with CKD. CONCLUSION: Exposure to sunshine and an active lifestyle were correlated with higher 25-OH-vitamin D levels in older adults without CKD. The PTH level in patients with CKD may be influenced by the season.

Measuring the glomerular filtration rate in different age groups using iohexol, the protocol from the Belgian iohexol study.

OBJECTIVES: Measuring the exact glomerular filtration rate (GFR) is difficult. Iohexol can be used instead of inulin or labeled EDTA or DTPA. In recent years, different studies have validated GFR-estimating equations in adults. Validation of these estimations in adolescents and elderly is lacking. With this study, we aim to develop a simplified (only 1-3 blood collections) iohexol protocol to measure the true GFR for patients of all ages and try to develop GFR-estimating equations for adolescents and the elderly. DESIGN AND SETTING: Participants of different ages will be recruited: 50 adolescent (14-18 years) and 30 adults (20-65 years), 60 elderly (65-80 years) and 60 very elderly (80+ years old) stratified based on their GFR. Biometric data, serum creatinine and cystatin C will be measured. After injecting 5 mL iohexol, 9 blood samples will be taken between 20 and 360 min. First, the GFR will be calculated by using the double exponential decay method and different GFRs based on 1-3 blood samples, which will be compared with the GFR of the abovementioned 9 samples. Second, the GFR will be calculated by using new and existing equations and compared to the true GFR. DISCUSSION: The availability of a reliable GFR measurement is important in situations such as screening patients for kidney donation or when taking potentially nephrotoxic treatments. This study will allow us to develop a simplified protocol for measuring the true GFR in all ages and will allow us to validate existing equations and develop new eGFR equations for adolescents and the elderly.

COPD awareness survey: do Belgian pulmonary physicians comply with the GOLD guidelines 2010?

Chronic Obstructive Pulmonary Disease (COPD) is underestimated, underdiagnosed and often under-treated in the general population. A survey of 17 structured questions, delivered to all Belgian pulmonary physicians (PPs) (116 responses), evaluated diagnosis and treatment strategies in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines 2010 and assessed opinions about the importance of diurnal variation of COPD symptoms. All COPD diagnoses (37% new cases) were spirometry confirmed. Main diagnostic parameters were symptoms (99%), external risk factors (99%), clinical examination (97%), exacerbations (96%) and patient mobility (96%). FEV1 (forced expiratory volume in 1s) (97%) or FEV1/FVC (ratio of FEV1 to forced vital capacity) (93%) were used most to assess diagnosis and severity. The 3 most important therapeutic objectives were symptom relief, preventing exacerbations, and improving quality of life; if these were not reached, the preferred strategy (60% of PPs) was adding another medication. Treatment strategies varied with COPD stage: short-acting beta2-agonists (90%) and short-acting anti-cholinergics (59%) were used for GOLD I disease, whereas for higher stages long-acting beta2-agonists (36-48%) and long-acting anti-cholinergics (79%) were given with inhaled corticosteroids (21-67%). Symptoms were perceived to vary throughout the day, affecting quality of life (97%) and mobility (89%). In particular, respiratory symptoms were more severe in the morning (51-92%), leading PPs to adapt treatment (69%). This survey demonstrated that management of COPD by PPs in Belgium is generally in line with the GOLD guidelines 2010 and that they perceive morning symptoms as being frequent and having an impact on patient's life.

Accuracy of office spirometry performed by trained primary-care physicians using the MIR Spirobank hand-held spirometer.

BACKGROUND: With the availability of compact, portable, effective microspirometers, pulmonary function tests no longer need to be performed only in specialized laboratories. However, the perception persists that small flow-sensing devices are less accurate than volume-sensing spirometers. OBJECTIVES: To study the accuracy of spirometry performed with the MIR Spirobank® and to investigate how accurately trained primary-care physicians can perform spirometry using a portable electronic spirometer. METHODS: Patients with suspected occupational asthma were submitted to specific bronchial challenge tests in the pulmonary function laboratory according to published recommendations. Serial measurements were performed with the Jaeger MasterScope device (reference standard) or the Spirobank device. Data were generated from 908 parallel measurements on 34 patients. Furthermore, 16 patients with documented moderate to severe COPD were examined in a carousel set-up by four trained physicians who each used his/her own Spirobank device coupled to a laptop computer. RESULTS: The Spirobank spirometer performed very well compared with the Jaeger MasterScope in a laboratory environment, displaying an underestimation of the forced expiratory volume in 1 s (FEV(1)) and FEV(1)/forced vital capacity (FVC) of 2-5%. High correlations were found for the pulmonary function parameters. The highest correlation was for FEV(1) (r(2) = 0.949) and the lowest for the maximum expiratory flow at 25% of FVC (MEF(25)) (r(2) = 0.864). Only 2% of the observed variation in the measurement results could be explained by the type of device. CONCLUSIONS: The Spirobank device seems to be appropriate for research purposes if the standardized protocol is used correctly and the acceptability criteria are respected.

Prevalence of impaired renal function in the elderly in the St. Petersburg District: results of the Crystal study.

Chronic kidney disease (CKD) has a high prevalence in the elderly. It has been recognized as an independent cardiovascular risk factor and detecting CKD is also important to ensure the appropriate dose of medication and to prevent further damage by limiting the use of potential harmful drugs. The aim of the research was to study the prevalence of CKD in elderly (> or = 65 years) in a St. Petersburg district and to study the impact of using different methods to estimate the GFR on the prevalence of different stages of CKD. The cross-sectional analysis of prospective population based study in the district of Kolpino was conducted. All creatinine measurements were performed in the same laboratory. Renal function was assessed calculating the eGFR using different creatinine based formulas. 611 elderly (65-91 years) were examined. Using the MDRD formula a prevalence of CKD stage III-V for males of 11% was found in stratum 1 and of 15% in stratum 2 and for females prevalence was 14 and 29%, respectively. A considerable mismatch in classification of stages of CKD was found when comparing the MDRD based estimations with the CG-based ones. Compared to what has been reported internationally in other studies a considerable lower prevalence of CKD stage IV-V was found in both age groups. Thus, the prevalence of an impaired renal function in elderly in the St. Petersburg district is relatively low, especially in the subgroup of males aged 75 years and over compared to what been reported in other studies. The CG and MDRD formula generate significantly different results when they are used to classify the population of elderly according to the stages of CKD.

[The health status of the elderly patients in a St. Petersburg district: results of Crystal project].

Using the "Crystal" study as an example of an epidemiological study that investigates global health of the elderly, the potential of a comprehensive geriatric assessment in primary care is illustrated. The results of the first cross-sectional data collection are presented in this paper with emphasis on the global health picture of the elderly; the average age was 75.08 +/- 5.96 years. In our study population one out of four participants was a male. Elderly mostly have a normal nutritional status with an average BMI of 28.6 +/- 4.94 kg/m2. On average, each participant has 2 +/- 1.27 pathologies, often cardiovascular. One out of four presents anemia. One third has symptoms of depression. In 44.4% of the patients a mild cognitive impairment was revealed. A more severe cognitive deficit was found in 26.2% of elderly. Every other old person has difficulties to keep balance in supine position for more than 10 seconds. One out of four elderly is partially dependent in their daily activity. Comprehensive geriatric assessment has the potential to identify priority issues in elderly health care and to inspire a management strategy. Further research is needed to create a simple instruments and an effective model to identify real health care needs of the elderly and to improve the quality of care and the successful collaboration between geriatricians and general practitioners.

[Prolonged cough in children in the primary care office]. / La toux prolongée chez l'enfant au cabinet du praticien de première ligne.

Prolonged cough, defined as a cough lasting more than three weeks, is frequent in population studies however we don't know if a lot of them are consulting their general practitioner. The aim of this study was to evaluate the frequency of this complaint in general practice and to explore what diagnoses and treatments general practitioners give for it. Every child between 5 and 17 years consulting their physicians (N=34) were prospectively recruited over a period of two weeks. The data of this consultation and from their field were analyzed. 10.7% of the children had suffered from prolonged cough in the six months preceding the consultation. Diagnoses were by order of frequency: asthma, lower respiratory tract infection, ENT causes, gastro-oesophageal reflux. Inhaled medications were the most frequently prescribed treatment followed by antitussive drugs and antibiotics. In conclusion, prolonged cough was a frequent problem for the general practitioner. They thought about the most importance etiology according to the Belgian guideline expect environmental etiology.

An evaluation of a computer based education program for the diagnosis and management of dementia in primary care. An international study of the transcultural adaptations necessary for European dissemination.

OBJECTIVES: The aim of this study is to make an inventory of the changes that are needed to make an interactive computer based training program (ICBT) with a specific educational content, acceptable to professional communities with different linguistic,cultural and health care backgrounds in different European countries. METHODS: Existing educational software, written in two languages was reviewed by GPs and primary care professionals in three different countries. Reviewers worked through the program using a structured critical reading grid. RESULTS: A 'simple' translation of the program is not sufficient. Minor changes are needed to take account of linguistic differences and medical semantics. Major changes are needed in respect of the existing clinical guidelines in every country related to differences in the existing health care systems. CONCLUSIONS: ICTB programs cannot easily be used in different countries and cultures. The development of a structured educational program needs collaboration between educationalists, domain experts, information technology advisers and software engineers. Simple validation of the content by local expert groups will not guarantee the program's exportability. It is essential to involve different national expert groups at every phase of the development process in order to disseminate it in other countries.