Bruno Chicoulaa

Description of 1,108 older patients referred by their physician to the "Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability" at the gerontopole.

IntroductionFrailty is considered as an early stage of disability which, differently from disability, is still amenable for preventive interventions and is reversible. In 2011, the “Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability” was created in Toulouse, France, in association with the University Department of General Medicine and the Midi-Pyrenees Regional Health Authority. This structure aims to support the comprehensive and multidisciplinary assessment of frail older persons, to identify the specific causes of frailty and to design a personalized preventive plan of intervention against disability. In the present paper, we describe the G.F.C structure, organization, details of the global evaluation and preventive interventions against disability, and provide the main characteristics of the first 1,108 patients evaluated during the first two years of operation.MethodsPersons aged 65 years and older, considered as frail by their physician (general practitioner, geriatrician or specialist) in the Toulouse area, are invited to undergo a multidisciplinary evaluation at the G.F.C. Here, the individual is assessed in order to detect the potential causes for frailty and/or disability. At the end of the comprehensive evaluation, the team members propose to the patient (in agreement with the general practitioner) a Personalized Prevention Plan (PPP) specifically tailored to his/her needs and resources. The G.F.C also provides the patient’s follow-up in close connection with family physicians.ResultsMean age of our population was 82.9 6.1 years. Most patients were women (n=686, 61.9%). According to the Fried criteria, 423 patients (39.1%) were pre-frail, and 590 (54.5%) frail. Mean ADL (Activities of Daily Living) score was 5.5±1.0. Consistently, IADL (Instrumental ADL) showed a mean score of 5.6 2.4. The mean gait speed was 0.78±0.27 and 25.6% (272) of patients had a SPPB (Short Physical Performance Battery) score equal to or higher than 10. Dementia was observed in 14.9% (111) of the G.F.C population according to the CDR scale (CDR ≥2). Eight percent (84) presented an objective state of protein-energy malnutrition with MNA (Mini Nutritional Assessment) score < 17 and 39.5% (414) were at risk of malnutrition (MNA=17–23.5). Concerning PPP, for 54.6% (603) of patients, we found at least one medical condition which needed a new intervention and for 32.8% (362) substantial therapeutic changes were recommended. A nutritional intervention was proposed for 61.8% (683) of patients, a physical activity intervention for 56.7% (624) and a social intervention for 25.7% (284). At the time of analysis, a one-year reassessment had been carried out for 139 (26.7%) of patients.ConclusionsThe G.F.C was developed to move geriatric medicine to frailty, an earlier stage of disability still reversible. Its particularity is that it is intended for a single target population that really needs preventive measures: the frail elderly screened by physicians. The screening undergone by physicians was really effective because 93.6% of the subjects who referred to this structure were frail or pre-frail according to Fried’s classification and needed different medical interventions. The creation of units like the G.F.C, specialized in evaluation, management and prevention of disability in frail population, could be an interesting option to support general practitioners, promote the quality of life of older people and increase life expectancy without disability.

French general practitioners’ sense of isolation in the management of elderly cancer patients

BACKGROUND Cancer care in people over 75 years of age is particularly complex and requires collaboration between oncologists, geriatricians, GPs and other professional and family carers. To improve the care pathways for elderly people living with cancer, the French health authorities have created a network of oncologists and geriatricians; however, GPs experience difficulties in establishing their place in this network. OBJECTIVE This study aimed to analyse the impressions of French GPs involved in the care of elderly patients with cancer, including their feelings regarding their relationships with their oncologist and geriatrician colleagues. METHODS A qualitative approach using focus groups was employed. The proceedings of these focus groups were recorded, retranscribed and subjected to thematic analysis. RESULTS Although heavily involved in the care of their elderly patients living with cancer, the GPs who participated reported feeling isolated in their role at each step during the course of the disease. The principal themes addressed were screening and diagnosis, therapeutic decisions, multidisciplinary consultation meetings, the announcement of the diagnosis and monitoring at home. Their relationships with their oncologist colleagues showed much room for improvement, and they were unaware of the oncogeriatric network. CONCLUSIONS Improving the communication between GPs, oncologists and geriatric medicine seems to be one response to the isolation that GPs feel when caring for older people with cancer. At the primary care level, integration of GPs into the oncogeriatric network and the creation of a cancer care communication system in collaboration with the relevant hospital teams may be effective solutions.

“Frailty” in Geriatry and Oncology: One Term for Two Widely Differing Concepts

To the Editor: Obtaining operational and consensual criteria to define frailty is a major challenge for oncogeriatry. Although the concept of frailty is currently used by both oncologist and geriatricians, the definitions and instruments they use for its evaluation are very different. This creates confusion, hampering the development of joint research in this area. For geriatricians, there is a continuum between normal aging and dependence.1 Frailty should be considered as a dynamic and potentially reversible process.2e4 Frailty has been shown to significantly predict major negative health-related events, including functional decline, disability, falls,5 hospitalizations, and mortality. The concept of frailty is applied here to the prevention of dependence. For Clegg et al6 frailty has been associated with loss of physiological reserves in the respiratory, cardiovascular, renal, hematopoietic and clotting systems, and nutritional status.6 The concept of frailty is intended to identify older persons at risk of adverse outcomes, with the goal of preventing or delaying the occurrence of the adverse outcomes or reverse frailty.7 Many tools have been developed to evaluate or quantify frailty.8e10 Each tool seems to have advantages and disadvantages, but they each seem to designate sensitive subpopulation topics.11,12 To provide a new instrument to diagnose frailty, the frailty trait scale, has been created.13 Its characteristics offer some advantages with potential utility in research and clinical practice. A consensus group created 4 major consensus points on frailty: (1) physical frailty as a medical syndrome; (2) the potentiality to be prevented or treated; (3) the recognition by simple, rapid screening tests to allow physicians to objectively recognize frail persons; and (4) all persons older than 70 years and all individuals with significant weight loss (>5%) because of chronic disease should be screened for frailty.14 For oncologists, the evaluation of the potential frailty of an individual should help determine the appropriate cancer treatment plan. Frailty and cancer are linked. In terms of pathophysiology, physical symptoms of the disease,15,16 hypercatabolism (increased circulating levels of C-reactiveprotein,fibrinogen, andwhite bloodcells), and the elevated prevalence of malnutrition17e19 mean that the cancer acts as a “catalyst” in the “frailty” process. Moreover, cancer treatments, especially chemotherapy, are considered strong stressors that will reveal which patients have sufficient functional reserves to regain stable homeostasis20,21 or can be enough to accelerate the patient’s

A complex consultation

It was interesting to read Clare Gerada’s editorial ‘Doctors and suicide’.1 The majority of doctors manage their health alone for several reasons: neglectfulness or denial, self-prescribing, the desire to present a picture of good health to others,2 fear of causing their colleagues difficulty,3 or fear that medical confidentiality will not be respected. Questions …

Reliability and validity of the script concordance test for postgraduate students of general practice

Abstract Background: The script concordance test (SCT) is a validated method of examining students’ clinical reasoning. Medical students’ professional skills are assessed during their postgraduate years as they study for a specialist qualification in general practice. However, no specific provision is made for assessing their clinical reasoning during their postgraduate study. Objective: The aim was to demonstrate the reliability and validity of the SCT in general practice and to determine if this tool could be used to assess medical students’ progress in acquiring clinical reasoning. Methods: A 135-question SCT was administered to postgraduate medical students at the beginning of their first year of specialized training in general practice, and then every six months throughout their three-year training, as well as to a reference panel of 20 expert general practitioners. For score calculation, we used the combined scoring method as the calculator made available by the University of Montreal’s School of Medicine in Canada. For the validity, student’ scores were compared with experts, p <.05 was considered statistically significant. Results: Ninety students completed all six assessments. The experts’ mean score (76.7/100) was significantly higher than the students’ score across all assessments (p <.001), with a Cronbach’s alpha value of over 0.65 for all assessments. Conclusion: The SCT was found to be reliable and capable of discriminating between students and experts, demonstrating that this test is a valid tool for assessing clinical reasoning skills in general practice.