[Frequency of incidentalomas on computed tomography scans in the hospitalised elderly]. / Fréquence des incidentalomes sur les imageries en coupe par tomodensitométrie du sujet âgé hospitalisé.

INTRODUCTION: Incidentaloma is the result of the medical problem created by the development of imaging. Without a universal definition, incidentaloma describes any incidental finding revealed by a medical examination performed for another indication, and which will be the origin of a questioning intended to give it a clinical meaning. The frequency of incidentalomas is very variable depending on the imaging technique, the organ affected and the definition used. The aim of this study was to investigate the frequency of incidentalomas on computed tomography (CT) scans in a geriatric hospitalised population. METHODS: In an observational, retrospective, monocentric study, we analysed, for a full year, all the planned CT scans performed, during a hospitalisation in acute and subacute care service of a Parisian geriatric hospital in search of incidentalomas. RESULTS: 113 patients were included in the study, with a mean age of 87,4 years. The frequency of incidentalomas on CT scans in this population was 53 %, with an average of two incidentalomas per patient. Eight percent of the incidentalomas required further examination, specialist advice or treatment. We found incidentalomas in half of the brain and abdomino-pelvic CT scans and in a quarter of the chest CT scans. Age was not associated with the presence of incidentalomas. DISCUSSION: Incidentaloma has become an important part of current medical practice. The geriatrician must know how to anticipate it and propose to his patient an adapted management.

[Heart failure treatments]. / Les traitements de l'insuffisance cardiaque.

Heart failure is a frequent pathology in the elderly. In particular, it is responsible for many hospitalizations. A distinction is made between chronic and acute forms of heart failure. The management of these forms of heart failure is well established, with treatment recommendations that are regularly updated on the basis of new studies.

[Emergency room transfers for residents of the 16th arrondissement of Paris]. / Transferts aux urgences des résidents d'Ehpad du 16e arrondissement de Paris.

Access to care for the population residing in residential facilities for dependent elderly people (Ehpad), i.e. 600,000 people in France in 2019, is a major public health issue. Description of the characteristics and pathways of the residents of Ehpad transferred to the emergency department (SAU) in the Paris 16th district.

Real-life impact of respiratory panel PCR assay on antibiotic prescription in geriatric acute care in the pre-COVID-19 era.

OBJECTIVES: In this era of bacterial resistance, avoiding inappropriate use of antibiotic treatments is of major importance. Respiratory tract infections are frequent among older patients, and differentiating viral from bacterial infections is a challenge. The aim of our study was to evaluate the impact of recently available respiratory PCR testing on antimicrobial prescription in geriatric acute care. METHODS: We performed a retrospective study, including all hospitalized geriatric patients who had had multiplex respiratory PCR testing prescribed from 1st October 2018 to 30th September 2019. The PCR test comprised a respiratory viral panel (RVP) and a respiratory bacterial panel (RBP). PCR testing could be prescribed at any time during hospitalization by geriatricians. Our primary endpoint was antibiotic prescription after viral multiplex PCR testing results. RESULTS: All in all, 193 patients were included, 88 (45.6%) of whom had positive RVP, while none had positive RBP. Patients with positive RVP had significantly fewer antibiotic prescriptions following test results than patients with negative RVP (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.22-0.77; p = 0.004). Among positive-RVP patients, factors associated with antibiotic continuation were presence of radiological infiltrate (OR 12.02, 95%CI 3.07-30.29), and detected Respiratory Syncytial Virus (OR 7.54, 95%CI 1.74-32.65). That said, discontinuation of antibiotic treatment seems safe. CONCLUSION: In this population, the impact of viral detection by respiratory multiplex PCR on antibiotic therapy was low. It could be optimized by means of clearly formulated local guidelines, qualified staff and specific training by infectious disease specialists. Cost-effectiveness studies are necessary.

Persistent eosinopenia is associated with in-hospital mortality among older patients: unexpected prognostic value of a revisited biomarker.

INTRODUCTION: Infection is one of the major causes of mortality and morbidity in older adults. Available biomarkers are not associated with prognosis in older patients. This study aimed to analyze the value of eosinopenia (eosinophil count< 100/mm3) as a prognosis marker among older patients with suspected or confirmed bacterial infection. METHODS: A retrospective study was performed from 1 January to 31 December 2018 among patients in a geriatrics ward suffering from a bacterial infection treated with antibiotics. Biomarker data including the eosinophil count, neutrophil count and C-reactive protein (CRP) were collected within 4 days after patient diagnosis. Persistent eosinopenia was defined as a consistent eosinophil count< 100/mm3 between Day 2 and Day 4. The association of biomarkers with 30-day hospital mortality in a multivariate analysis was assessed and their predictive ability using the area under the ROC curve (AUC) was compared. RESULTS: Our study included 197 patients with a mean age of 90 ± 6 years. A total of 36 patients (18%) died during their stay in hospital. The patients who died were more likely to have persistent eosinopenia in comparison to survivors (78% versus 34%, p < 0.001). In the multivariate analysis, persistent eosinopenia was associated with in-hospital mortality with an adjusted HR of 8.90 (95%CI 3.46-22.9). The AUC for eosinophil count, CRP and neutrophil count between Day 2 and Day 4 were 0.7650, 0.7130, and 0.698, respectively. CONCLUSION: Persistent eosinopenia within 4 days of diagnosis of bacterial infection appeared to be a predictor of in-hospital mortality in older patients.

Acceptability of oral liquid pharmaceutical products in older adults: palatability and swallowability issues.

BACKGROUND: In institutional care, oral liquid pharmaceutical products are widely prescribed for older patients, especially for those with swallowing disorders. As medicines acceptability is a key factor for compliance in the older population, this study investigated the acceptability of oral liquid pharmaceutical products in this targeted population. METHODS: An observational, multicenter, prospective study was conducted in eight geriatric hospitals and eight nursing homes in France. Observers reported several behaviours/events describing the many aspects of acceptability for various pharmaceutical products' uses in patients aged 65 and older. Acceptability scores of oral liquid pharmaceutical products were obtained using an acceptability reference framework (CAST - ClinSearch Acceptability Score Test®): a 3D-map summarizing the different users' behaviors, with two clusters defining the positively and negatively accepted profiles materialized by the green and red zones, respectively. RESULTS: Among 1288 patients included in the core study and supporting the acceptability reference framework, 340 assessments were related to the administration of an oral liquid pharmaceutical product. The mean age of these patients was 87 (Range [66-104y]; SD = 6.7), 68% were women and 16% had swallowing disorders. Globally, the oral liquid pharmaceutical products were classified as "positively accepted," the barycenter of the 340 assessments, along with the entire confidence ellipses surrounding it, were positioned on the green zone of the map. Sub-populations presenting a different acceptability profile have also been identified. For patients with swallowing disorders, the oral liquid pharmaceutical products were classified as "negatively accepted," the barycenter of the 53 assessments along with 87% of its confidence ellipses were associated with this profile. A gender difference was observed for unflavored oral liquids. In women, they were classified "negatively accepted," the barycenter of the 68 assessments with 75% of its confidence ellipses were located in the red zone, while they were classified "positively accepted" in men. CONCLUSION: This study showed that oral liquid pharmaceutical products are a suboptimal alternative to solid oral dosage forms in patients with swallowing disorders. To ensure an optimal acceptability, prescribers should also consider the presence of a taste-masker in these oral liquids. As highlighted herein, palatability remains crucial in older populations, especially for women.

Rehospitalization following a stay in geriatric rehabilitation wards: rates and predictive factors.

Hospitalization in the elderly patients is highly associated with morbi-mortality. Geriatric post-acute and rehabilitation care wards are designed to provide care and to implement life project of elderly patients. Objective of this study was to characterize rehospitalizations after a stay in geriatric post-acute and rehabilitation care wards. METHODS: The study was retrospective, case-control, including all the patients hospitalized in the 4 geriatric post-acute and rehabilitation care wards of a hospital in Paris (France) and returned at home. Data collection was carried out on the basis of the hospitalization report and the information system of the hospital. Rehospitalizations were documented by the information system as well as by telephone interview. We compared patients according to whether they had been rehospitalized or not within 60 days after discharge. RESULTS: Out of a total of 1,063 stays during a 12 months period, 435 (41%) were discharged at home. Re-admission rate was 10.1% at 30 days and 18.4% at 90 days. Mean age of rehospitaliszed patients was 87.2 years ± 5.3 vs 87.9 years ± 5.8 for non-rehospitalized patients. Patients rehospitalized had more often a delirium during the prior hospitalization. CONCLUSION: Unplanned rehospitalisation is a major public health issue and should be prevented particularly after a stay in a geriatric post-acute and rehabilitation care wards.

A Decision Support Tool Facilitating Medicine Design for Optimal Acceptability in The Older Population.

PURPOSE: Medicine acceptability, which is of the utmost importance for vulnerable patients' adherence, is driven by both user and product characteristics. Herein, a novel multivariate approach integrating the many aspects of acceptability is used to discriminate positively and negatively accepted medicines in the older population. METHODS: An observational study was carried out in eight hospitals and eight nursing homes to collect a large set of real-life data on medicines uses in older patients (≥65 years). Mapping and clustering explored these multiple observational measures and summarised the main information into an intelligible reference framework. Resampling statistics were used to validate the model's reliability. RESULTS: A three-dimensional map and two clusters defining acceptability profiles, as positive or negative, emerged from the 1079 evaluations. Factors of interest (medicines, user features…) were positioned on the map at the barycentre of their evaluations and assigned to an acceptability profile. Focusing on patients' ability to swallow, we have highlighted the tool's efficacy in demonstrating the impact of user features on medicine acceptability. CONCLUSIONS: This multivariate approach provides a relevant judgement criterion for this multi-dimensional concept. Facilitating the choice of the most appropriate dosage form to achieve optimal acceptability in a targeted population, this tool is of real potential to improve clinical decisions.

Potentially inappropriate prescription of antidepressants in old people: characteristics, associated factors, and impact on mortality.

ABSTRACTBackground:The increasing use of antidepressants (ADs) has raised concerns about their inappropriate use in old people. OBJECTIVE: To examine the prevalence of potentially inappropriate prescribing (PIP) of ADs, their associated factors, and their impact on mortality in a sample of old people in France. METHODS: The analysis used data from the SIPAF study, a cross-sectional study consisting of 2,350 people aged ≥ 70 years. Trained nurses interviewed participants at home between 2008 and 2010. Information was collected concerning socio-demographic and health characteristics, including medication use. The study population consisted of the 318 AD users from the SIPAF study (13.5%). PIP of ADs was defined according to national and international criteria. Factors associated with PIP of ADs were assessed using a multivariate logistic regression model. The influence of PIP of ADs on mortality was assessed using a Cox model (median follow-up 2.8 years). RESULTS: Among the SIPAF study, 71% of AD users were female and the mean age was 84 ± 7 years. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed ADs (19.8%). We found PIP of ADs in 36.8% of the study population, mainly the co-prescription of diuretics with SSRIs (17.6%) and the prescription of tricyclics (12.9%). PIP of ADs was associated with polypharmacy (aOR5-9 drugs 2. 61, 95% CI 1.11-6.16 and aOR≥10 drugs 2.69, 95% CI 1.06-6.87) and comorbidity (aOR3-4 chronic diseases 2.59, 95%CI 1.04-6.44 and aOR≥5 chronic diseases 2.33, 95%CI 0.94-5.79), and increased the risk of mortality during follow-up (aHR 2.30, 95%CI 1.28-4.12). CONCLUSIONS: This study shows that more than one third of AD prescriptions may be inappropriate in old people. PIP of ADs was related to polypharmacy and comorbidity and increased mortality among AD users.

[First year prognosis of patients hospitalized in an acute geriatric ward with a known dementia or newly diagnosed]. / Devenir à un an des patients hospitalisés en court séjour gériatrique, avec un syndrome démentiel connu, ou nouvellement diagnostiqué.

In France, only a third of demented patients have an established diagnostic of dementia. Hospitalization is often an opportunity to perform a diagnostic of dementia. Real benefits for patients of such a diagnostic process are unknown. The objective of the study was to observe prognosis of elderly patients hospitalized in geriatric courses in terms of mortality, hospitalization rate and entry into an institution. This was a monocentric prospective study with a one-year follow-up of 90 patients hospitalized in an acute geriatric ward with either dementia known by general practitioner, either diagnosed during the hospitalization according to DSM IV criteria. A one year follow-up by phone has been conducted. From a consecutive set of 159 inpatients for 18 weeks, we included in this study 49 patients with a known dementia (group 1, mean age 85.7±4.6 years, mean Mini-mental state examination (MMSE) score 12.4±6.2) and 41 patients with dementia diagnosed during hospitalization (group 2, mean age 88.4±6.4 years, mean MMSE score 16.1±6.5). Differences between the two groups were significant for age (p<0.03) and MMSE score (p<0.02). One-year mortality rate was near 30% in the 2 groups. Rate of institutionalization was 33% in group 1 and 49% in group 2 (not statistically significant). There was a significant difference in number of days spent at home between group 1 and group 2, respectively 190.9±159.9 days vs 111.1±148.1 days (p<0.03). Demented patients previously diagnosed lived longer at home at one year than patients newly diagnosed. These results tend to support the diagnosis of dementia in very elderly patients with multiple comorbidities. Conditions of living at home, in particular the quality of life, should be the object of further studies.

Opening the black box of clinical collaboration in integrated care models for frail, elderly patients.

PURPOSE: The purpose of the study was to understand better the clinical collaboration process among primary care physicians (PCPs), case managers (CMs), and geriatricians in integrated models of care. METHODS: We conducted a qualitative study with semistructured interviews. A purposive sample of 35 PCPs, 7 CMs, and 4 geriatricians was selected in 2 integrated models of care for frail elderly patients in Canada and France: System of Integrated Care for Older Patients of Montreal and Coordination of Care for Older Patients of Paris. Data were analyzed using a grounded theory approach. FINDINGS: The dynamics of the collaboration process develop in three phases: (1) initiating relationships, (2) developing real two-way collaboration, and (3) developing interdisciplinary teamwork. The findings suggest that CMs and geriatricians collaborated well from the start and throughout the care management process. Real collaboration between the CMs and the PCPs occurred only later and was mostly fostered by the interventions of the geriatricians. PCPs and geriatricians collaborated only occasionally. IMPLICATIONS: The findings provide information about PCPs' commitment to the integrated models of care, the legitimization of the CM's role among PCPs, and the appropriate positioning of geriatricians in such models.

[Impact of low-molecular-weight heparin practice guidelines in a geriatric hospital]. / Impact d'un guide de bon usage des anticoagulants sur la prescription des héparines de bas poids moléculaire dans un hôpital gériatrique.

The purpose of this study was to assess the impact of good use of anticoagulants guidelines implementation on low molecular weight heparin (LMWH) prescription in a french geriatric hospital. This interventional "before and after" study was conduced by the same geriatrician on a d-day in 2006 and 2009. Guidelines for anticoagulant's prescription based on selected references in the literature was established by an expert's consensus and implemented in 2008. Data were collected in all departments at the Sainte-Perine geriatric hospital for each patient with an LMWH prescription. Assessment was based on quality judgment criteria (indication, dosage, treatment duration, biological monitoring of LMWH). Data were collected for 72 prescriptions prior to the guidelines implementation and for 54 after. Sex-ratio, mean age and percentage of LMWH prescription did not differ significantly between the two periods. There was a better conformity for LMWH dosage prescription (p = 0.002) and biological monitoring prescription (p = 0.036) after the guidelines implementation. Conformity of LMWH indication and treatment duration were improved but the difference remained not significant (respectively p = 0.49 and p = 0.80). Implementing guidelines for LMWH use in geriatrics can improve quality of prescription. The impact was effective but limited. These guidelines are now in general use in the Sainte-Perine hospital.

Patterns of loss of basic activities of daily living in Alzheimer patients: A cross-sectional study of the French REAL cohort.

BACKGROUND/AIMS: To characterize loss of basic activities of daily living (BADL) in 687 Alzheimer's disease (AD) community-dwelling patients included in the French REAL cohort. METHODS: Patients had mild to moderately severe AD, and the mean age was 77.8 years. Patterns of loss of the 6 BADL were described at inclusion using the Lawton scale. RESULTS: With 6 binary BADL scores, each patient presented at inclusion a set of losses. For 53% of women, the sets of losses were included within each other or were identical, adding losses in physical ambulation, grooming, bathing, dressing, toilet and feeding, respectively. For 47% of men, a similar sequence was identified, with loss of dressing occurring secondly. A global cohesion of sets of losses was found for 87% of women and 86% of men. The Lawton scale is very useful for the assessment of AD patients.

Patterns of loss of abilities in instrumental activities of daily living in Alzheimer's disease: the REAL cohort study.

BACKGROUND/AIMS: To determine patterns of loss of abilities in instrumental activities of daily living (IADL) in community-dwelling women with Alzheimer's disease (AD). METHODS: Sixteen French university hospitals included 471 consecutive women with mild to moderately severe AD (Mini-Mental State Examination scores between 10 and 26) from April 2000 to June 2002 in the noninterventional REAL cohort. At inclusion, 6 and 12 months, IADL were assessed with the Lawton scale. Patterns of loss of abilities in the 8 IADL of the Lawton scale were described using Lawton binary grading. RESULTS: At inclusion, 56.7% of the patients shared the same pattern of loss of abilities and 84.3% had this pattern or variants of it. Frequencies of the 8 incapacities were: 80.7% to do the grocery shopping, 76.0% to take medication, 72.2% to prepare meals, 41.4% to travel on public transportation even when assisted, 40.6% to manage purchases, 30.1% to launder small items, 14.2% to participate in some housekeeping tasks and 11.0% to answer the telephone. CONCLUSION: In this study including 471 community-dwelling women with AD of the French REAL cohort, the loss of the 8 IADL, assessed with the Lawton binary grading, was homogeneous for more than four fifths of the patients.