Use of a clustering method to describe the clinical profiles of older fallers: the value of a multidisciplinary consultation.

OBJECTIVES: The population of older adults is particularly heterogeneous with regard to frailty and the risk of falling, the two of which are linked. We conducted an exploratory, analysis (with no preconceived ideas) of data collected during multidisciplinary falls consultations (MFCs), to identify people with similar profiles. MATERIALS AND METHODS: We performed an observational, multicentre study of older patients (aged 75 and over) having been evaluated in an MFC. We excluded adults with a Mini Mental State Examination score < 14/30, an activities of daily living score < 4/6, or an unstable medical condition. Each participant underwent a clinical interview, impedancemetry, and a physical activity assessment (a questionnaire, and use of an activity tracker on 5 consecutive days). The K-means method and ascending hierarchical clustering were used to identify clusters of people with common characteristics. RESULTS: Of the 106 participants, the median [IQR] mean number of falls in the previous 6 months was 1 [2]. Three functional clusters were identified: (i) fallers with poor mobility, difficulty getting up off the ground after a fall, and using a mobility aid for walking; (ii) an intermediate sedentary group with a gait speed of ~ 0.6 m s-1, and (iii) active people with a timed "up and go" test time below 15 s and a gait speed above 0.8 m s-1. CONCLUSIONS: The population of older fallers referred for an MFC is heterogeneous. The presence of certain clinical characteristics enabled the definition of three patient clusters, which might help physicians to determine the most appropriate care objectives and pathways.

The Care Coordinator's Tasks During the Implementation of an Integrated Care Pathway for Older Patients: A Qualitative Study Based on the French National "Health Pathway of Seniors for Preserved Autonomy" Pilot Program.

Background: Although integrated care and care coordination are known to be beneficial for older adults' population, the specific tasks of a Care Coordinator (CC) for integrated care pathways for this population have not been studied in detail. Setting & Subjects: The French national pilot program PAERPA provided an integrated care pathway for older adults. In North France, a CC was recruited to support patients and professionals. Objectives: (i) To analyse the CC's tasks in an integrated care pathway for older patients, and (ii) to record perceptions on the CC's tasks among the participating general practitioners (GP) and community pharmacists. Design & Methods: Qualitative, two-phase study: (i) Task analysis of the CC's tasks, to compare the planned and actual tasks; (ii) semi-structured interviews among GPs and community pharmacists involved in the pathway. Results: (i) The task analysis showed that the CC's actual tasks differed from planned tasks. The CC was only meant to be involved in the early stages of the process; actually, the CC undertook more or even unforeseen tasks in coordination, communication, and administrative support throughout the care pathways. (ii) The 28 interviewed healthcare professionals considered the CC's tasks to be essential to the success of pathways. They appreciated the CC's administrative support. However, CC's tasks related to interprofessional communication, and patient and family information, were controversially perceived among GPs and pharmacists. Conclusions: The CC's tasks in an integrated care pathway for older adults showed that the CC's overall workload was greater than expected and appreciated by healthcare professionals.

[Implementation of a multi-interventional approach to improve medication safety in older hospitalized patients: Feasibility and impact on 30-day rehospitalization rate]. / Mise en place d'une procédure multi-interventionnelle de prise en charge médicamenteuse chez la personne âgée hospitalisée : faisabilité et efficacité sur la réhospitalisation à 30jours.

BACKGROUND: The impact of a multi-interventional approach for medication safety (MIMS) on rehospitalization rate have been inconstant in the literature. This would be due to difficulty in implementing the interventions and insufficient information transmission at discharge. The purpose of this study was to determine the effect of a MIMS on the 30-day rehospitalization rate after discharge from an acute geriatric unit (AGU). METHOD: This was a single-center interventional randomized controlled trial that included patients hospitalized in an AGU and were at least 75 years old. The intervention group benefited from a MIMS including medication reconciliation at admission and at discharge, medication review, and standardized transmission of hospital's medication changes sent to community practitioners (general practitioners and pharmacists) at discharge. The control group benefited from the usual approach applied in the AGU. RESULTS: One hundred nine patients (mean age 87,5±6,1 years) were included. At intention-totreat analysis, the rehospitalization rate was 30% in the intervention group and 15,2% in the control group. The difference was non-significant before and after adjustments (P=0,27 and 0,28 respectively). However, the intervention protocol was not effectively completed in 40% of patients in the intervention group and no intervention was performed in 10%. CONCLUSION: The implementation of a MIMS in an AGU showed a non-significant decrease in the number of rehospitalizations. Other indicators should be analysed, such as the reason for rehospitalisation or the maintenance of treatment at 30 days.

Hip fractures and characteristics of living area: a fine-scale spatial analysis in France.

We investigated the association between hip fracture incidence and living area characteristics in France. The spatial distribution of hip fracture incidence was heterogeneous and there was a significant relationship between social deprivation, urbanization, health access, and hip fracture risk. INTRODUCTION: Several studies have shown great disparities in spatial repartition of hip fractures (HF). The aim of the study was to analyze the association between HF incidence and characteristics of the living area. METHODS: All patients aged 50 or older, living in France, who were hospitalized for HF between 2012 and 2014 were included, using the French national hospital discharge database. Standardized incidence ratio (SIR) was calculated for each spatial unit and adjusted on age and sex. An ecological regression was performed to analyze the association between HF standardized incidence and ecological variables. We adjusted the model for neighborhood spatial structure. We used three variables to characterize the living areas: a deprivation index (French-EDI); healthcare access (French standardized index); land use (percentage of artificialized surfaces). RESULTS: A total of 236,328 HF were recorded in the French hospital national database, leading to an annual HF incidence of 333/100,000. The spatial analysis revealed geographical variations of HF incidence with SIR varying from 0.67 (0.52; 0.85) to 1.45 (1.23; 1.70). There was a significant association between HF incidence rates and (1) French-EDI (trend p = 0.0023); (2) general practitioner and nurse accessibility (trend p = 0.0232 and p = 0.0129, respectively); (3) percentage of artificialized surfaces (p < 0.0001). CONCLUSION: The characteristics of the living area are associated with significant differences in the risk of hip fracture of older people.

Correction to: Secondary prevention of osteoporotic fractures: evaluation of the Lille University Hospital's Fracture Liaison Service between January 2016 and January 2018.

The original version of this article, published on 5 June 2019, an author's name was misspelled.

Secondary prevention of osteoporotic fractures: evaluation of the Lille University Hospital's Fracture Liaison Service between January 2016 and January 2018.

The purpose of this study was to assess the performance of our Fracture Liaison Service (FLS) over a period of 2 years. Osteoporosis medication was prescribed for 243 patients, and zoledronic acid was the main drug prescribed (60.2%). INTRODUCTION: A Fracture Liaison Service (FLS) was implemented at Lille University Hospital in 2016. The main purpose of this study was to assess the performance of the FLS using criteria proposed by the International Osteoporosis Foundation (IOF). METHODS: The criteria used were patient identification, patient evaluation, post-fracture assessment timing, vertebral-fracture identification, blood and bone mineral density (BMD) testing, falls prevention, multifaceted health and lifestyle risk-factor assessment, and medication initiation and review. RESULTS: Between January 2016 and January 2018, 736 patients (≥ 50 years old) with a recent history of fragility fracture (≤ 12 months) were identified. The identification rate for hip fractures was 74.2%. However, patient evaluation for all type of fractures was quite low (30.3%) since many patients failed to attend the FLS unit. The reasons for non-attendance were refusal, agreed but subsequently failed to attend, and still waiting to be seen. In all, 256 patients (76.6% female, mean (SD) age 74.3 (11.0) years) were seen at the FLS. Mean (SD) post-fracture assessment timing was 13.3 (9.3) weeks. Of the 139 patients seen for a non-vertebral fracture, 103 were assessed for vertebral fractures, and at least one new vertebral fracture was found in 45 of them (43.7%). Osteoporosis medication was prescribed for 243 (94.9%) patients. The main osteoporosis drug prescribed was zoledronic acid (60.2%). CONCLUSIONS: Secondary prevention of osteoporotic fractures has improved since the implementation of the FLS. However, patient identification, patient evaluation, and post-fracture assessment timing still need to be improved.

Factors Associated with Alzheimer's Disease: An Overview of Reviews.

Alzheimer's disease (AD) is a frequent pathology, with a poor prognosis, for which no curative treatment is available in 2018. AD prevention is an important issue, and is an important research topic. In this manuscript, we have synthesized the literature reviews and meta-analyses relating to modifiable risk factors associated with AD. Smoking, diabetes, high blood pressure, obesity, hypercholesterolemia, physical inactivity, depression, head trauma, heart failure, bleeding and ischemic strokes, sleep apnea syndrome appeared to be associated with an increased risk of AD. In addition to these well-known associations, we highlight here the existence of associated factors less described: hyperhomocysteinemia, hearing loss, essential tremor, occupational exposure to magnetic fields. On the contrary, some oral antidiabetic drugs, education and intellectual activity, a Mediterranean-type diet or using Healthy Diet Indicator, consumption of unsaturated fatty acids seemed to have a protective effect. Better knowledge of risk factors for AD allows for better identification of patients at risk. This may contribute to the emergence of prevention policies to delay or prevent the onset of AD.

[Changes in drug management of Alzheimer's disease in nursing homes: Impact of the media campaign against specific drugs for Alzheimer's disease]. / Évolution de la prise en charge médicamenteuse de la maladie d'Alzheimer en EHPAD : impact de la campagne médiatique contre les médicaments spécifiques de la maladie d'Alzheimer.

CONTEXT: Alzheimer's disease is a common disease in nursing homes. Evolution is constantly negative and specific treatments, which are only symptomatic, are subject to controversy. In a context of media exposure, the Transparency Committee of the Haute Autorité de santé (HAS) downgraded their medical service in October 2011, seeing it as weak. AIM: Assess the evolution of the consumption of specific treatments for Alzheimer's disease; assess changes in the quality of monitoring in specific consultation. METHODS: This is a retrospective and descriptive study, cross-sectional in three times (T0 January 2011, T1 October 2011 and T2 June 2012), in 6 nursing homes of Lille and its surroundings. RESULTS: In total, 262 residents with dementia and present at least once during the three times of the study were included. Their mean age was 85.8 years. Among them, 40 % had Alzheimer's disease clearly identified. At T0, 76.7 % of patients present who were supposed to receive a specific treatment of Alzheimer's disease were actually receiving such treatment, 73.6 % at T1 and 71.6 % at T2. After 17 months of observation, the discontinuation rate of anticholinesterase was 34 %, 24 % for anti-glutamate. The monitoring in specific consultations decreased slightly between the three stages. CONCLUSION: Our work did not show major impact of the media campaign against specific drugs for Alzheimer's disease. There is however a trend towards a decrease of their consumption in people with dementia living in nursing homes with no obvious link between monitoring in specific consultation and specific prescription. This trend would ask to be confirmed by a study on a larger scale.

Alcohol and psychotropic drugs: risk factors for orthostatic hypotension in elderly fallers.

We assess orthostatic hypotension (OH) prevalence in elderly fallers and determine OH-associated risk factors in this patient population. A monocentric prospective study at Lille University Hospital Falls Clinic included 833 consecutive patients who had fallen or were at high risk of falls and who were assessed for the presence of OH. Among 833 patients aged 80.4±7.4 years, OH was found in 199 subjects (23.9% of cases). Multivariate analysis showed that selective serotonin reuptake inhibitors (odds ratio (OR) 2.42, 95% confidence interval (CI): 1.56-3.75), serotonin-norepinephrine reuptake inhibitors (OR 5.37, 95% CI: 1.93-14.97), Parkinsonian syndrome (OR 2.54, 95% CI: 1.54-4.19), excessive alcohol consumption (OR 2.17, 95% CI: 1.32-3.56), meprobamate (OR 2.65, 95% CI: 1.12-6.25) and calcium channel blockers (OR 1.79, 95% CI: 1.16-2.76) were all risk factors for OH. In contrast, angiotensin receptor blockers (OR 0.52, 95% CI: 0.30-0.91) appeared to be protective factors against OH. This study demonstrates that a systematic investigation should be made in all elderly fallers and those at high risk of falls to detect the presence of OH. In OH patients, in addition to the usual predisposing factors, excessive alcohol consumption and psychotropic drug intake-in particular, the intake of serotonergic antidepressants-should be taken into account as potential risk factors.

Connaissances, attitudes et pratiques des jeunes et adultes face aux personnes âgées au Congo-Brazzaville : étude CAPPA

Contexte : L'image traditionnelle de la famille africaine qui a fait pendant longtemps une place de choix aux personnes âgées, ne correspond peut-être plus à la réalité d'aujourd'hui. Le rapport de l'OMS de 2002 sur la violence et la santé et quelques études menées dans d'autres pays africains suggèrent que la maltraitance des personnes âgées existe aussi en Afrique subsaharienne. Objectif : Décrire le regard que portent les jeunes adultes congolais sur les personnes âgées et les actes de maltraitance qui peuvent en résulter. Méthode : L'enquête de nature transversale a été réalisée entre les mois de janvier et avril 2008 auprès de 300 personnes âgées de 15 à 55 ans, dont 203 âgés de 25 ans ou moins, habitant Brazzaville ou Pointe-Noire. L'échantillon de 300 personnes a été constitué selon la méthode d'échantillonnage non probabiliste. La collecte des données a été effectuée sur le terrain par des fonctionnaires du ministère de la santé, des affaires sociales et de la famille au moyen d'un questionnaire préétabli contenant des questions ouvertes et fermées. Résultats : Les jeunes et les adultes ont des représentations contrastées et contradictoires des personnes âgées. Dans 70% des cas les personnes interrogées ont dit entretenir de bons rapports avec les personnes âgées, les qualifiant de sages et de modèles mais, à l'inverse, plus de 50% d'entre eux les ont décrits comme indésirables et dérangeantes. Les accusations de sorcellerie portées sur elles sont fréquentes avec souvent des conséquences graves. Conclusion : Les transformations sociales dépossèdent peu à peu les personnes âgées de leurs statuts et de leurs prérogatives au Congo-Brazzaville. Elles s'accompagnent d'un changement de regard et de comportement des jeunes adultes à leur égard. La maltraitance des personnes âgées au Congo-Brazzaville est un problème méconnu, insuffisamment dénoncé et combattu

[Adequacy of antibiotic therapy for urinary tract infection in a Medical Department from the university hospital of Lille: A retrospective cohort study]. / Évaluation de la qualité de l'antibiothérapie des infections urinaires dans le service de médecine polyvalente post-urgence du CHRU de Lille: une étude de cohorte rétrospective.

INTRODUCTION: The main objective of the study was to assess the adequacy of antibiotic therapy for urinary tract infections (UTI) in a French hospital medical department. The secondary objective was to identify factors associated with inadequacy of the antibiotic therapy. METHODS: A retrospective single centre cohort study was performed in the Post-Emergency Medicine Department (PEMD) of the university hospital of Lille. All patients presenting with an UTI from May 2012 to April 2014 were included. Adequacy of antibiotic therapy was assessed with reference to local guidelines. Factors associated with inadequacy of antibiotic prescription were determined using a multivariate logistic regression model. RESULTS: Two hundred and twenty-eight patients were included. The antibiotic prescription was fully adequate in 173 patients (76%) with appropriate use of a single or a combination antibiotic therapy in 96%, appropriate drug in 80%, appropriate dosage in 89% and appropriate route of administration in 95%. The risk for antibiotic inadequacy was significantly higher in patients with cystitis than in those with pyelonephritis (OR 12.01; 95% CI 4.17-34.65), when antibiotics were prescribed in the Emergency Department (OR 6.84; 95% CI 2.29-20.47) or before hospital admission (OR 382.46; 95% CI 19.61≥999.99) compared to when antibiotics were first administered in the PEMD, and in patients with severe UTI (OR 19.55; 95% CI 2.79-137.01). CONCLUSION: Adequacy of antibiotic therapy for UTI is relatively high in our study, reflecting the effective dissemination of antibiotic guidelines. However, antibiotic therapy is still inappropriate in cystitis, severe UTI and in case of prescription before the admission in the PEMD.

[Appropriate medication prescribing in older people]. / Bon usage des médicaments chez le sujet âgé.

Drug-induced adverse effects are one of the main avoidable causes of hospitalization in older people. Numerous lists of potentially inappropriate medications for older people have been published, as national and international guidelines for appropriate prescribing in numerous diseases and for different age categories. The present review describes the general rules for an appropriate prescribing in older people and summarizes, for the main conditions encountered in older people, medications that are too often under-prescribed, the precautions of use of the main drugs that induce adverse effects, and drugs for which the benefit to risk ratio is unfavourable in older people. All these data are assembled in educational tables designed to be printed in a practical pocket format and used in daily practice by prescribers, whether physicians, surgeons or pharmacists.

Systematic skin examination in an acute geriatric unit: skin cancer prevalence.

BACKGROUND: Ageing is a determining factor in skin cancer, but the incidence and prevalence of skin cancer in elderly patients are not known. AIM: To determine the prevalence of skin cancers in elderly patients and to assess their associated geriatric syndromes. METHODS: Between January and April 2013, all consecutive incident patients hospitalized in the Acute Geriatric Unit of Lille University Hospital underwent a geriatric assessment and a systematic dermatological examination. A biopsy was taken whenever there was any lesion with suspicion of malignancy. RESULTS: In total, 204 patients (mean age 85.4 years) were included, and 16 cutaneous biopsies were taken from 15 patients. Histological examination confirmed skin cancer in 11 biopsies from 10 patients: 9 basal cell carcinomas, 1 squamous cell carcinoma (SCC) and 1 malignant lentigo. The prevalence of skin cancer was 4.9%. The geriatric assessment revealed severe geriatric syndromes in the 10 patients with skin cancer: severe dependence (8/10), possible cognitive impairment (10/10), and moderate or severe malnutrition (5/10). CONCLUSIONS: The prevalence of skin cancer is high in frail elderly patients. The association of severe geriatric syndromes suggests that close collaboration between geriatricians and dermatologists is essential to optimize the treatment of skin carcinoma in elderly patients.

Glycation: the angiogenic paradox in aging and age-related disorders and diseases.

Angiogenesis is generally a quiescent process which, however, may be modified by different physiological and pathological conditions. The "angiogenic paradox" has been described in diabetes because this disease impairs the angiogenic response in a manner that differs depending on the organs involved and disease evolution. Aging is also associated with pro- and antiangiogenic processes. Glycation, the post-translational modification of proteins, increases with aging and the progression of diabetes. The effect of glycation on angiogenesis depends on the type of glycated proteins and cells involved. This complex link could be responsible for the "angiogenic paradox" in aging and age-related disorders and diseases. Using diabetes as a model, the present work has attempted to review the age-related angiogenic paradox, in particular the effects of glycation on angiogenesis during aging.

Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly.

Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).

Fear of falling as seen in the Multidisciplinary falls consultation.

UNLABELLED: Fear of falling may be as debilitating as the fall itself, leading to a restriction in activities and even a loss of autonomy. OBJECTIVES: The main objective was to evaluate the prevalence of the fear of falling among elderly fallers. The secondary objectives were to determine the factors associated with the fear of falling and evaluate the impact of this fear on the activity "getting out of the house". PATIENTS AND METHOD: Prospective study conducted between 1995 and 2006 in which fallers and patients at high risk for falling were seen at baseline by the multidisciplinary falls consultation team (including a geriatrician, a neurologist and a physical medicine and rehabilitation physician) and then, again 6 month later, by the same geriatrician. The fear of falling was evaluated with a yes/no question: "are you afraid of falling?". RESULTS: Out of 635 patients with a mean age of 80.6 years, 502 patients (78%) expressed a fear of falling. Patients with fear of falling were not older than those who did not report this fear, but the former were mostly women (P<0,001), who experienced more falls in the 6 months preceding the consultation (P=0.01), reported more frequently a long period of time spent on the floor after a fall (P<0.001), had more balance disorders (P=0.002) and finally, were using more frequently a walking technical aid (P=0.02). Patients with fear of falling were not going out alone as much as the fearless group (31% vs 53%, P<0.0001). Eighty-two percent of patients in the fearful group admitted to avoiding going out because they were afraid of falling. CONCLUSION: The strong prevalence of the fear of falling observed in this population and its consequences in terms of restricted activities justifies systematically screening for it in fallers or patients at risk for falling.

Structural modifications in the arterial wall during physiological aging and as a result of diabetes mellitus in a mouse model: are the changes comparable?

AIM: Vascular accelerated aging represents the major cause of morbidity and mortality in subjects with diabetes mellitus. In the present study, our aim was to compare premature functional and morphological changes in the arterial wall resulting from streptozotocin (STZ)-induced diabetes mellitus in mice over a short-term period with those that develop during physiological aging. The effect of aminoguanidine (AG) on the prevention of these alterations in the diabetic group was also analyzed. METHODS: The vascular relaxation response to acetylcholine (ACh) in the mouse was tested in isolated segments of phenylephrine (Phe)-precontracted aorta at 2, 4 and 8 weeks (wk) of STZ-induced diabetes and compare to 12- and 84-wk-old mice. Aortic structural changes were investigated, and receptor for AGE (RAGE) aortic expression was quantified by western blot. RESULTS: Compared to the 12-wk control group (76 ± 5%), significant endothelium-dependant relaxation (EDR) impairment was found in the group of 12-wk-old mice, which underwent a 4-wk diabetes-inducing STZ treatment (12wk-4WD) (52 ± 4%; P < 0.01) and was yet more apparent in the group of 16-wk-old mice, which underwent an 8-wk diabetes-inducing STZ treatment (16wk-8WD) (34 ± 4%; P < 0.001). The alteration in EDR was relatively comparable between the diabetic 12wk-4WD group and the 84-wk-old group (52.7 ± 4 vs. 48 ± 4%). Intima/media aortic thickening and aortic structural changes were significantly increased in the diabetic 12wk-4WD group and were even more apparent in the 84-wk group compared to the 12-wk controls. AG treatment in the 12wk-4WD+AG diabetic group significantly improved EDR, decreased RAGE expression and showed an aging preventive effect on the structural changes of the arterial wall. CONCLUSION: Our study compared EDR linked to physiological aging with that observed in the case of STZ-induced diabetes over a short-term period, and demonstrated the beneficial effect of AG.

Impact of different types of walking aids on the physiological energy cost during gait for elderly individuals with several pathologies and dependent on a technical aid for walking.

UNLABELLED: In elderly individuals balance disorders and muscle weakness can lead to prescribing a walker. There are several different models. According to the very poor effort tolerance in this population, the energy cost necessary to operate walking technical aids should be taken into account when making a choice. OBJECTIVE: Compare two types of walker in regards to energy cost produced during gait in weakened elderly individuals. METHOD: Thirty subjects over the age of 65 (six men and 24 women, mean age 81.9 years) were admitted in geriatrics care. They all required a walker and performed the same 10-m course with a fixed walker, then with a model bearing front wheels. The walking speed (S) was computed, heart rate at rest (HRrest) and maximum heart rate (HRmax) were recorded during the test. The physiological cost index (PCI=HRmax-HRrest/S) was calculated. Finally a timed get-up-and-go (TGUG) test was performed with each of these technical aids. RESULTS: With a rollator walker, HRmax was lower (P<0.05) and S higher (P<0.001). It was 2.01 with a fixed walker versus 1.23 with a rollator walker (P<0.01). We found this speed difference during the TGUG test (72.26 sec vs. 82.93 sec, P=0.001). DISCUSSION AND CONCLUSION: There are very little studies on the evaluation of physiological energy cost produced during gait with a walker. The characteristics of our population did not allow us to conduct our test without a technical aid. The use of a fixed walker leads to a major increase in gait PCI, probably due to the required repeated efforts for lifting the walker. This model must be avoided in case of cardiac or respiratory disorders.