PRISMA-7 and Risk for Short-Term Adverse Events in Older Patients Visiting the Emergency Department: Results of a Large Observational and Prospective Cohort Study.

BACKGROUND: The "Program of Research on the Integration of Services for the Maintenance of Autonomy" (PRISMA-7) is the reference tool for the assessment of older patients visiting the emergency departments (EDs) in the province of Quebec (Canada). This study aimed to examine 1) whether the PRISMA-7 high-risk level for disabilities was associated with the length of stay in ED and in hospital, and hospital admission; and 2) performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], likelihood ratios [LR]) of the PRISMA-7 high-risk level for the length of stay in ED and hospital, and hospital admission in older ED users. METHODS: A total of 12,983 older ED users of the Jewish General Hospital (Montreal, Quebec, Canada) were recruited in this observational and prospective cohort study. All enrolled participants had a PRISMA-7 assessment upon their arrival at ED. The length of stay in ED and hospital, and hospital admission were used as outcomes. RESULTS: A PRISMA-7 high-risk level was associated with an increased length of stay in ED and hospital (ß ≥2.1 with P≤0.001 and Hazard ratio (HR)= ≥1.2 with P≤0.001) as well as in hospital (HR=1.27 with P≤0.001) in patients on a stretcher. All performance criteria were low (i.e., <0.78). Patients with a PRISMA-7 high-risk level were discharged significantly later from ED and hospital compared to those with low-risk level (P=0.001). INTERPRETATION: A PRISMA-7 high-risk level was associated with a long length of stay in ED and hospital, and hospital admission in patients on a stretcher but had poor performance criteria for these adverse events, suggesting that it cannot be used as a prognostic tool in older ED users.

Motoric cognitive risk syndrome and incident dementia: results from a population-based prospective and observational cohort study.

BACKGROUND AND PURPOSE: Motoric cognitive risk syndrome (MCR), which is the juncture of subjective cognitive complaint and slow gait speed, is a pre-dementia stage. The aims of the study are (i) to compare characteristics between individuals who have MCR defined using slow walking speed and/or increased five-times-sit-to-stand (FTSS) time as its motor component(s); and (ii) to characterize the association of MCR and its various motor components with incident dementia including Alzheimer disease and non-Alzheimer dementia in the participants of the Epidémiologie de l'Ostéoporose (EPIDOS) study. METHODS: This prospective and observational cohort study selected 651 participants recruited from the EPIDOS study in Toulouse (France). MCR was defined as the association of subjective cognitive complaint and slow gait speed and/or increased FTSS time in participants without either dementia and mobility disabilities at baseline. Individuals with dementia were prospectively diagnosed during the physical and neuropsychological assessments included in the 7-year follow-up. RESULTS: The prevalence of MCR was around 7% when using an exclusive motor criterion, either slow gait speed or increased FTSS time, and was 20.9% when MCR subgroups were pooled. MCR was positively associated with incident dementia regardless of its type, and with Alzheimer disease in the slow gait speed MCR subgroup [odds ratio (OR) > 2.18 with P ≤ 0.037] but not with non-Alzheimer dementia. No significant association between incident dementia and MCR defined using increased FTSS time was shown. CONCLUSIONS: Our findings confirm that MCR is associated with incident dementia and that slow gait speed is the appropriate motor criterion for detecting dementia risk.

Motoric cognitive risk syndrome and mortality: results from the EPIDOS cohort.

BACKGROUND AND PURPOSE: Cognitive impairment, slow walking speed and motoric cognitive risk syndrome (MCR) have separately been associated with an increased risk for mortality in the short term. The aim of the study was to examine the association of MCR and its components [i.e. subjective cognitive complaint (SCC) and slow walking speed] with short-, medium- and long-term mortality in older community-dwellers. METHODS: In all, 3778 participants from the Epidémiologie de l'Ostéoporose (EPIDOS) study were selected. MCR was defined as the combination of slow walking speed and SCC in participants without major neurocognitive disorders. Deaths were prospectively recorded using mail, phone calls, questionnaires and/or the French national death registry at 5, 10, 15 and 19 (end of follow-up period) years. RESULTS: Over the follow-up of 19 years, 80.5% (n = 3043) participants died. Slow walking speed and MCR were associated with mortality [hazard ratio (HR) 1.20 with P = 0.004 for slow walking speed and HR = 1.26 with P = 0.002 for MCR at 10 years; HR = 1.27 with P ≤ 0.001 for slow walking speed and HR = 1.22 with P = 0.001 for MCR at 15 years; HR = 1.41 with P ≤ 0.001 at 19 years for slow walking speed and MCR]. There was no association between SCC and mortality. Kaplan-Meier distributions of mortality showed that participants with MCR and slow walking speed died earlier compared to healthy participants and those with SCC (P < 0.001). CONCLUSIONS: Slow walking speed and MCR were associated with an increased risk for mortality at the medium and long term, whereas no association was found with SCC.

Age effect on the prediction of risk of prolonged length hospital stay in older patients visiting the emergency department: results from a large prospective geriatric cohort study.

BACKGROUND: With the rapid growth of elderly patients visiting the Emergency Department (ED), it is expected that there will be even more hospitalisations following ED visits in the future. The aim of this study was to examine the age effect on the performance criteria of the 10-item brief geriatric assessment (BGA) for the prolonged length of hospital stay (LHS) using artificial neural networks (ANNs) analysis. METHODS: Based on an observational prospective cohort study, 1117 older patients (i.e., aged ≥ 65 years) ED users were admitted to acute care wards in a University Hospital (France) were recruited. The 10-items of BGA were recorded during the ED visit and prior to discharge to acute care wards. The top third of LHS (i.e., ≥ 13 days) defined the prolonged LHS. Analysis was successively performed on participants categorized in 4 age groups: aged ≥ 70, ≥ 75, ≥ 80 and ≥ 85 years. Performance criteria of 10-item BGA for the prolonged LHS were sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], likelihood ratios [LR], area under receiver operating characteristic curve [AUROC]). The ANNs analysis method was conducted using the modified multilayer perceptron (MLP). RESULTS: Values of criteria performance were high (sensitivity> 89%, specificity≥ 96%, PPV > 87%, NPV > 96%, LR+ > 22; LR- ≤ 0.1 and AUROC> 93), regardless of the age group. CONCLUSIONS: Age effect on the performance criteria of the 10-item BGA for the prediction of prolonged LHS using MLP was minimal with a good balance between criteria, suggesting that this tool may be used as a screening as well as a predictive tool for prolonged LHS.

Falls Risk Prediction for Older Inpatients in Acute Care Medical Wards: Is There an Interest to Combine an Early Nurse Assessment and the Artificial Neural Network Analysis?

BACKGROUND: Identification of the risk of falls is important among older inpatients. This study aims to examine performance criteria (i.e.; sensitivity, specificity, positive predictive value, negative predictive value and accuracy) for fall prediction resulting from a nurse assessment and an artificial neural networks (ANNs) analysis in older inpatients hospitalized in acute care medical wards. METHODS: A total of 848 older inpatients (mean age, 83.0±7.2 years; 41.8% female) admitted to acute care medical wards in Angers University hospital (France) were included in this study using an observational prospective cohort design. Within 24 hours after admission of older inpatients, nurses performed a bedside clinical assessment. Participants were separated into non-fallers and fallers (i.e.; ≥1 fall during hospitalization stay). The analysis was conducted using three feed forward ANNs (multilayer perceptron [MLP], averaged neural network, and neuroevolution of augmenting topologies [NEAT]). RESULTS: Seventy-three (8.6%) participants fell at least once during their hospital stay. ANNs showed a high specificity, regardless of which ANN was used, and the highest value reported was with MLP (99.8%). In contrast, sensitivity was lower, with values ranging between 98.4 to 14.8%. MLP had the highest accuracy (99.7). CONCLUSIONS: Performance criteria for fall prediction resulting from a bedside nursing assessment and an ANNs analysis was associated with a high specificity but a low sensitivity, suggesting that this combined approach should be used more as a diagnostic test than a screening test when considering older inpatients in acute care medical ward.

The spectrum of pre-dementia stages: cognitive profile of motoric cognitive risk syndrome and relationship with mild cognitive impairment.

BACKGROUND AND PURPOSE: Motoric cognitive risk (MCR) syndrome is a pre-dementia syndrome. There is little information on the cognitive profile of individuals with MCR syndrome and its overlap with mild cognitive impairment (MCI) syndrome. This study aimed to examine and compare the cognitive performance of non-demented older community dwellers with and without MCR and MCI syndromes. METHODS: A total of 291 non-demented individuals were selected from the Gait and Alzheimer Interactions Tracking study, which is a cross-sectional study. All participants were referred to a memory clinic. Individuals with and without MCR were separated into those with and without MCI. Cognitive performance was measured using the scores of the Mini Mental Status Examination, Frontal Assessment Battery, Free and Cued Selective Reminding Test, Trail Making Test part A and B, and Stroop test. RESULTS: The prevalence of MCI was 40.1% and that of MCR was 18.2%, with a higher prevalence of MCI in MCR group compared with the non-MCR group (47.2% vs. 39.5%). Individuals with MCR and MCI syndromes had poorer cognitive performance in all domains compared with those without MCR (P < 0.005), except for the ratio part III: part I of the Stroop test (P = 0.345). The association between cognitive performance and MCR syndrome was worse on the Mini Mental Status Examination score [effect size, -0.57 (95% confidence interval, -1.02 to -0.12)] and Trail Making Test part B [effect size, 0.59 (95% confidence interval, 0.14-1.04)] in individuals with MCR and MCI syndromes. CONCLUSIONS: Motoric cognitive risk syndrome is associated with low global cognitive performance. Association of MCR and MCI syndromes is characterized by a worse cognitive performance.

Risk of Unplanned Emergency Department Readmission after an Acute-Care Hospital Discharge among Geriatric Inpatients: Results from the Geriatric EDEN Cohort Study.

OBJECTIVES: The study aims 1) to examine whether items of the brief geriatric assessment (BGA) or their combinations predicted the risk of unplanned emergency department readmission after an acute care hospital discharge among geriatric inpatients, and 2) to determine whether BGA could be used as a prognostic tool for unplanned emergency department readmission. METHODS: A total of 312 older patients (mean age, 84.6 ± 5.4 years; 64.1% female) hospitalized in acute care wards after an emergency department visit were recruited in this observational prospective cohort study and separated into 2 groups based on the occurrence or not of an unplanned emergency department readmission during a 12-month follow-up period after their hospital discharge. A 6-item BGA was performed at emergency department admission before the discharge to acute care wards. Information on incident unplanned emergency department readmission was prospectively collected by phone call and by consulting the hospital registry. Several combinations of items of BGA identifying three levels of risk of unplanned emergency department readmission (i.e., low risk, intermediate risk and high risk) were examined. RESULTS: The unplanned emergency department readmission was more frequently associated with a temporal disorientation (P=0.004). Area under receiver operating characteristic curves of unplanned emergency department readmission based on BGA items and their combinations ranged from 0.53 to 0.61. The best predictor of unplanned emergency department readmission was the temporal disorientation (hazard ratio>1.65, P<0.035), which defined the high-risk group. Inpatients classified in high-risk group of unplanned emergency department readmission were more frequently readmitted to emergency department than those in intermediate- and low-risk groups (P log Rank <0.004). Prognostic values for unplanned emergency department readmission of items and their combinations were poor with sensitivity below 67%, specificity ranging from 36.4 to 53.7, and positive likelihood ratio below 1.4. CONCLUSIONS: The items of BGA and their combinations were significant risk factors for unplanned emergency department readmission, but their prognostic value was poor.

Predicting prolonged length of hospital stay in older emergency department users: use of a novel analysis method, the Artificial Neural Network.

OBJECTIVE: To examine performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], likelihood ratios [LR], area under receiver operating characteristic curve [AUROC]) of a 10-item brief geriatric assessment (BGA) for the prediction of prolonged length hospital stay (LHS) in older patients hospitalized in acute care wards after an emergency department (ED) visit, using artificial neural networks (ANNs); and to describe the contribution of each BGA item to the predictive accuracy using the AUROC value. METHODS: A total of 993 geriatric ED users admitted to acute care wards were included in this prospective cohort study. Age >85years, gender male, polypharmacy, non use of formal and/or informal home-help services, history of falls, temporal disorientation, place of living, reasons and nature for ED admission, and use of psychoactive drugs composed the 10 items of BGA and were recorded at the ED admission. The prolonged LHS was defined as the top third of LHS. The ANNs were conducted using two feeds forward (multilayer perceptron [MLP] and modified MLP). RESULTS: The best performance was reported with the modified MLP involving the 10 items (sensitivity=62.7%; specificity=96.6%; PPV=87.1; NPV=87.5; positive LR=18.2; AUC=90.5). In this model, presence of chronic conditions had the highest contributions (51.3%) in AUROC value. CONCLUSIONS: The 10-item BGA appears to accurately predict prolonged LHS, using the ANN MLP method, showing the best criteria performance ever reported until now. Presence of chronic conditions was the main contributor for the predictive accuracy.

Anti-dementia drugs-related changes in gait performance while single and dual tasking in patients with Alzheimer disease: a meta-analysis.

BACKGROUND: The effects of anti-dementia drugs on gait performance in Alzheimer disease (AD) are questionable. The objective of this meta-analysis was to examine the effects of anti-dementia drugs on the mean value and the coefficient of variation (CoV) of stride time among patients with AD while taking into account the type of drugs (i.e., acetylcholinesterase inhibitors [AChEIs] versus memantine) and the walking conditions (i.e., single versus dual-task). METHODS: An English and French Medline search was conducted in March 2015, with no limit of date, using the Medical Subject Headings terms "pharmaceutical preparations" combined with terms "Pharmaceutical preparations" OR "Therapeutic uses" OR "Drug substitution" OR "Drugs essential" OR "Drugs, Generic" OR "Psychotropic drugs" combined with "Delirium" OR "Dementia" OR "Amnestic" OR "Cognitive disorders" AND "Gait" OR "Gait Ataxia" OR "Gait disorders, Neurologic" OR "Gait apraxia". Fixed-effects meta-analyses were used to examine anti-dementia drugs-related changes in mean value and CoV of stride time. RESULTS: Of the 66 identified abstracts, 5 (7.6%) were included in the meta-analysis. Inter-group comparison of between-visit change underscored a significant decrease in CoV of stride time (P<0.004) in intervention group compared to control group, whatever the pooled analysis considered, but no significant change in the mean value (P>0.06). Intra-group changes in stride time parameters following the use of anti-dementia drugs showed a significant decrease for memantine (P<0.001) and while pooling AChEIs and memantine (P<0.001) under single task condition. Under dual task condition, only AChEIs improved significantly stride time parameters (P=0.002). CONCLUSION: Anti-dementia drugs demonstrated a significant improvement of gait performance with specific class effect depending on the walking conditions and on the type of stride time parameters considered.

[Cognitive remediation therapy for children: literature data and clinical application in a child and adolescent psychiatry department]. / Thérapie par remédiation cognitive chez les enfants : données de la littérature et application clinique dans un service de psychiatrie de l'enfant et de l'adolescent.

The hypothesis of cerebral plasticity in psychiatric disorders has encouraged clinicians to develop cognitive remediation therapy (CRT), a new therapeutic approach based on attention, memory, planning, and mental flexibility tasks. The first cognitive remediation programs were developed and validated for adults with schizophrenia and were shown to have a positive impact on executive functions as well as on quality of life. In children and adolescents, researchers emphasized the existence of executive dysfunction in neurodevelopmental disorders such as autistic spectrum disorder, attention deficit disorder, and eating disorders. For these disorders, neuropsychological studies suggest that memory, planning, attention and mental flexibility are impaired. Despite the paucity of studies on cognitive remediation (CR) in children, preliminary results have suggested, as in adults with schizophrenia, good compliance and optimization of executive functioning. Consequently, programs dedicated to young subjects were developed in English-speaking countries, and the Department of Child and Adolescent Psychiatry of Sainte Anne Hospital (Paris) developed a new CR program for children with attention deficit disorder, academic problems, or eating disorders. These programs complete the field of CRT proposed by Sainte Anne Hospital's Remediation and Psychosocial Rehabilitation Reference Center, initially designed for adults with schizophrenia. Our team used and adapted validated tools such as Delahunty and Wykes's CRT program (translated and validated in French by Amado and Franck) and Lindvall and Lask's CRT Resource Pack. One program was developed for an adolescent with anorexia nervosa and applied to the subject and her family, but the purpose of this paper is to present a CR approach for children with attention deficit disorder or academic disorder, a 6-month program based on paper-pencil tasks and board and card games. The team was trained in different kinds of cognitive remediation, and the program was applied by a clinical nurse with the supervision of a child and adolescent psychiatrist and the department's neuropsychologists. Paper-pencil tasks were adapted from the CRT program for adults; the card and board games used were geometric figures, illusions, Rush Hour(®), Set(®), Jungle Speed(®), Color Addict(®), etc. These games are available in stores and the program can be applied at home, which helps families set aside their preoccupations with their child's academic performance. Diagnostic and neuropsychological evaluations were done before the beginning of the therapy and repeated at the end of the 6-month program. This program does not ignore the metapsychological impact of the therapy, and work on self-esteem is also done. The presence of the therapist is necessary, which seems better than a computer program, which cannot encourage the young subject in the same personalized and empathetic way. We therefore conducted the first clinical feasibility trial of cognitive remediation in young subjects and present a clinical case of a 6-year-old boy with attention deficit disorder and academic disorder. The results of neuropsychological evaluations before and after therapy suggest improvement in executive functions and better self-esteem. Satisfaction for the boy and his family was high. Even if these results need to be replicated, cognitive remediation appears to be a new therapeutic tool, complementary to classical approaches used in childhood psychiatric disorders. The Department of Child and Adolescent Psychiatry will submit this program to a research program conducted by the National Health Department to study the impact of this approach in a controlled study.

Modulation of energy and protein supplies in sequential feeding in laying hens.

Sequential feeding (SF) consists of splitting energy (E) and protein/calcium (P) fractions temporally, improving the feed conversion ratio (FCR) of hens compared with a continuous distribution during the day. In a previous study, the E fraction (with a low level of protein) was provided in the morning, whereas the P fraction (with low level of energy) was given in the afternoon. However, there is no clear evidence that a requirement in energy or proteins is connected to these distribution sequences, whereas the requirement for calcium is known to be required in the afternoon. To evaluate the effects on performances of the modulation of energy and protein supplies in SF, five different sequential treatments were offered: E0P0/E0P0; E+P+/E-P-; E+P-/E-P+; E0P+/E0P- and E+P0/E-P0 where E+ represents a high energy level, E0 a moderate one and E- a low one (with the same meaning for P regarding protein supply). Afternoon fractions were provided with particulate calcium. A total of 168 Hendrix hens were housed in individual cages from 20 to 39 weeks of age in two environmentally contrasted rooms. Feed intake in the morning and afternoon fractions, egg production, egg weight, BW and weight of digestive organs were recorded. No diet effect was observed concerning feed intake, egg production and BW. These results suggested that hens are not able to fit their feed intake on energy or protein level of fractions within half-day duration, whereas at the day scale same protein and energy intakes were observed. Moreover, the time of nutrient distribution in feeding did not seem to have an impact on birds' performances. These studies have also demonstrated that, despite strong environmental pressure, the hens with SF had attenuated performance but continue to produce eggs.

Changes in gait variability with anti-dementia drugs: a systematic review and meta-analysis.

BACKGROUND: Studies have examined the effects of anti-dementia drugs on gait performance. No structured critical evaluation of these studies has been done so far. The objectives of this study were (1) to perform a qualitative analysis of all published studies on changes in stride time variability (STV) with anti-dementia drugs among patients with Alzheimer disease through a systematic review, and (2) to quantitatively synthesize anti-dementia drug-related changes in STV. METHODS: An English and French MEDLINE search was conducted on November 2013, with no limit of date, using the Medical Subject Headings term "pharmaceutical preparations" combined with "delirium", "dementia", "amnestic", "cognitive disorders" AND "gait" OR "gait disorders, neurologic" OR "gait apraxia". Fixed-effects meta-analyses were performed to compare STV before and after the use of anti-dementia drugs, and to compare the final STV among participants in intervention and control groups. RESULTS: Of the 110 originally identified abstracts, four studies (i.e., one assessing galantamine, one donepezil, one memantine, and one memantine and acetylcholinesterase inhibitors) were included in the qualitative review, and three studies in the quantitative synthesis. Results were mixed, as two studies showed significant between-visit improvements (i.e., decrease in mean value) in STV, while one study did not, and the last one reported mixed results. In the meta-analysis, there was no difference between intervention and control groups (summary mean difference of final STV = -0.38 % [95 % confidence interval -1.14 to 0.37]) and no before-after difference in the intervention group (summary mean difference of STV = 0.66 [95 % confidence interval -0.17 to 1.49]). CONCLUSIONS: Our findings showed inconclusive effects of anti-dementia drugs on STV.

A regression tree for identifying combinations of fall risk factors associated to recurrent falling: a cross-sectional elderly population-based study.

BACKGROUND: Regression tree (RT) analyses are particularly adapted to explore the risk of recurrent falling according to various combinations of fall risk factors compared to logistic regression models. The aims of this study were (1) to determine which combinations of fall risk factors were associated with the occurrence of recurrent falls in older community-dwellers, and (2) to compare the efficacy of RT and multiple logistic regression model for the identification of recurrent falls. METHODS: A total of 1,760 community-dwelling volunteers (mean age ± standard deviation, 71.0 ± 5.1 years; 49.4 % female) were recruited prospectively in this cross-sectional study. Age, gender, polypharmacy, use of psychoactive drugs, fear of falling (FOF), cognitive disorders and sad mood were recorded. In addition, the history of falls within the past year was recorded using a standardized questionnaire. RESULTS: Among 1,760 participants, 19.7 % (n = 346) were recurrent fallers. The RT identified 14 nodes groups and 8 end nodes with FOF as the first major split. Among participants with FOF, those who had sad mood and polypharmacy formed the end node with the greatest OR for recurrent falls (OR = 6.06 with p < 0.001). Among participants without FOF, those who were male and not sad had the lowest OR for recurrent falls (OR = 0.25 with p < 0.001). The RT correctly classified 1,356 from 1,414 non-recurrent fallers (specificity = 95.6 %), and 65 from 346 recurrent fallers (sensitivity = 18.8 %). The overall classification accuracy was 81.0 %. The multiple logistic regression correctly classified 1,372 from 1,414 non-recurrent fallers (specificity = 97.0 %), and 61 from 346 recurrent fallers (sensitivity = 17.6 %). The overall classification accuracy was 81.4 %. CONCLUSIONS: Our results show that RT may identify specific combinations of risk factors for recurrent falls, the combination most associated with recurrent falls involving FOF, sad mood and polypharmacy. The FOF emerged as the risk factor strongly associated with recurrent falls. In addition, RT and multiple logistic regression were not sensitive enough to identify the majority of recurrent fallers but appeared efficient in detecting individuals not at risk of recurrent falls.

Do not resuscitate orders and aging: impact of multimorbidity on the decision-making process.

BACKGROUND: The "Do Not Resuscitate" orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients. METHODS: A systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: "resuscitation orders" OR "do-not-resuscitate" combined with "aged, 80 and over" combined with "comorbidities" OR "chronic diseases". RESULTS: Of the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19-1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07-1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08-3.20) for cancer, OR=1.07 (95% CI: 0.92-1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61-2.40) for stroke. CONCLUSIONS: This systematic review and meta-analysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.

Risk of in-hospital mortality following emergency department admission: results from the geriatric EDEN cohort study.

OBJECTIVE: To determine whether being admitted to emergency department (ED) for social disorders may predict a higher risk of in-hospital mortality among older inpatients. DESIGN: Prospective cohort study (mean follow-up: 9.1±10.0 days). SETTING: Angers University Hospital, France. PARTICIPANTS: Four hundred twenty-two inpatients (mean age 84.9±5.6years, 64.2% women). METHODS: At their admission to ED, inpatients aged 75 years and over received an assessment composed of 6 items: age, gender, number of drugs daily taken, history of falls during the past 6 months, usual place of life, and use of formal and/or informal home and social services. The reasons for admission to ED as well the diagnosis at the time of hospital discharge were separated into social and health disorders. The length of hospital stay was calculated in number of days using the hospital registry. Inpatients were separated into 2 groups based on the occurrence or not of death during the hospital stay. RESULTS: Older inpatients who died at hospital were more frequently institutionalized (P=0.034) and admitted to ED for social disorders (P=0.002) than those who did not. Multiple Cox regression model revealed that living in institution and social disorders as a reason for admission to ED were significantly associated with the occurrence of death at hospital (P=0.008 and P=0.036). Kaplan-Meier distributions of in-hospital mortality showed that home-living inpatients admitted to ED for social disorders died more and faster during hospitalization than those admitted for health disorders (P=0.016). CONCLUSION: Being admitted to ED for social disorders and living in institution predicted a higher risk of in-hospital mortality.

Physical training-related changes in gait variability while single and dual tasking in older adults: magnitude of gait variability at baseline matters.

OBJECTIVES: Few studies have examined the effects of physical training programs on gait variability while single and dual tasking, and they reported mixed results. The aim of this study was to compare the stride time variability while single and dual tasking before and after a physical training program developed to improve gait stability in French community-dwelling older adults. DESIGN: A prospective pre-post interventional cohort study. SETTING: The community-dwelling area of "Pays de la Loire", France. POPULATION: Forty-eight older adults (mean age ± standard deviation 72.2±8 years; 75% female). METHODS: Physical training program consisted in 12 sessions scheduled to attend physical exercises 1 time a week with total time duration of 3 months. Coefficient of variation (CoV) of stride time under three walking conditions (i.e., walking alone, walking while backward counting, and while performing a verbal fluency task) was determined while steady-state walking using the SMTEC® footswitches system before and after the physical training program. Participants were separated into two groups based on being or not in the highest tertile (i.e., worst performance with cutpoint >4.4%) of the CoV of stride time while walking alone. RESULTS: After physical training compared to before period, a significant decrease in CoV of stride time (i.e., better gait performance) while walking alone (2.8±2.8% versus 7±7.1%, P=0.001) but not while dual tasking (P=0.600 for counting backward and P=0.105 for verbal fluency task) was shown in participants who had highest (i.e., worst) gait variability at baseline. In addition, physical training modified the strategy of dual tasking in participants with highest gait variability at baseline compared to the other participants. Before training, a significant decrease in CoV of stride time (7±7.1% versus 4.9±4.6%, P=0.017) while counting backward was shown, but there was a significant increase after training (2.8±2.8% versus 5.4±5.8%, P=0.007). CONCLUSIONS: Physical training reduced gait variability while walking alone in participants with gait instability, and influenced their strategy for dual tasking. CLINICAL REHABILITATION IMPACT: Physical program training developed in the community to improve gait stability should included participants with high gait variability.

Who is at risk of long hospital stay among patients admitted to geriatric acute care unit? Results from a prospective cohort study.

OBJECTIVE: (1) To confirm that vitamin D deficiency, defined as serum 25-hydroxyvitamin D (25OHD) concentration < 25 nmol/L, was associated with long length-of-stay (LOS) among older inpatients admitted to geriatric acute care unit; and (2) to examine which combination of risk factors of longer LOS including vitamin D deficiency best predicted longer LOS. STUDY DESIGN AND SETTING: Based on a prospective cohort study with a 25-day follow-up on average, 531 consecutive older inpatients (mean age 85.0±7.2 years, 59.1% women) admitted to the geriatric acute care unit of Angers University Hospital, France, were included. RESULTS: Linear regression models showed that male gender (P<0.025), delirium (P<0.015) and vitamin D deficiency (P<0.001) were independently associated with a longer LOS. The highest risk of a longer LOS was shown while combining vitamin D deficiency with male gender (Odds ratio (OR)=3.70 with P< 0.001). The risk increased significantly while delirium was associated with these two baseline characteristics (OR=4.76 with P=0.001). Kaplan-Meier distributions of discharge differed significantly between participants who had or not the combination of the 3 criteria (P<0.007). CONCLUSIONS: Vitamin D deficiency, delirium and male gender were significant risk factors for a longer LOS in the studied sample of older inpatients.