Cédric Annweiler

Higher Vitamin D Dietary Intake Is Associated With Lower Risk of Alzheimer’s Disease: A 7-Year Follow-up

BACKGROUNDnHypovitaminosis D is associated with cognitive decline among older adults. The relationship between vitamin D intakes and cognitive decline is not well understood. Our objective was to determine whether the dietary intake of vitamin D was an independent predictor of the onset of dementia within 7 years among women aged 75 years and older.nnnMETHODSnFour hundred and ninety-eight community-dwelling women (mean, 79.8 ± 3.8 years) free of vitamin D supplements from the EPIDemiology of OSteoporosis Toulouse cohort study were divided into three groups according to the onset of dementia within 7 years (ie, no dementia, Alzheimers disease [AD], or other dementias). Baseline vitamin D dietary intakes were estimated from self-administered food frequency questionnaire. Age, body mass index, initial cognitive performance, education level, physical activity, sun exposure, disability, number of chronic diseases, hypertension, depression, use of psychoactive drugs, and baseline season were considered as potential confounders.nnnRESULTSnWomen who developed AD (n = 70) had lower baseline vitamin D intakes (mean, 50.3 ± 19.3 μg/wk) than nondemented (n = 361; mean intake = 59.0 ± 29.9 μg/wk, p = .027) or those who developed other dementias (n = 67; mean intake = 63.6 ± 38.1 μg/wk, p = .010). There was no difference between other dementias and no dementia (p = .247). Baseline vitamin D dietary intakes were associated with the onset of AD (adjusted odds ratio = 0.99 [95% confidence interval = 0.98-0.99], p = .041) but not with other dementias (p = .071). Being in the highest quintile of vitamin D dietary intakes was associated with a lower risk of AD compared with the lower 4 quintiles combined (adjusted odds ratio = 0.23 [95% confidence interval = 0.08-0.67], p = .007).nnnCONCLUSIONSnHigher vitamin D dietary intake was associated with a lower risk of developing AD among older women.

Vitamin D in the elderly: 5 points to remember

Vitamin D is a secosteroid hormone. Vitamin D receptors are present in the majority of body tissues. The manifestations of hypovitaminosis D - linked to dysfunction of target tissues - are various, including osteoporosis, cancer, tuberculosis, hypertension, multiple sclerosis, depression, dementia, sarcopenia, propensity to fall… The serum 25-hydroxyvitamin D threshold value to avoid these adverse health events is around 30u200ang/mL. Only 15% of the elderly reach this target concentration. For the remaining 85% with no supplements, the severity of hypovitaminosis D appears to be a biomarker of chronic diseases and of frailty. Conversely, the supplementation for correction of hypovitaminosis D positively impacts bone and non-bone morbidities - such as risks of falls and fractures - and reduces the mortality rate. A daily intake of at least 800-1,000u200aIU supplemental vitamin D(3) per day is the key.

[Older adults and emergency department: who is at risk of hospitalization?].

OBJECTIVEnScreening older adults at risk of hospitalisation after an admission in emergency Department (ED) is an objective to be reach. The objective of this study was to examine the association between clinical characteristics (items of brief geriatric assessment (BGA), score of clinical classification of emergency diseases (CCED), diagnosis) and hospital stay in older adults admitted in ED.nnnMETHODSnBased on a prospective cohort study design, 426 elderly patients were assessed in ED using a BGA composed by age, gender, number of drugs daily taken, history of falls during the past 6 months, incorrect orientation for year and month, no caregivers or relatives help, added to CCED gravity score and principal diagnosis. Hospitalization was defined as a hospital stay of more than 24 hours after admission to the SAU.nnnRESULTSn313 people (72.3%) were hospitalized for more than 24 hours. The prevalence of temporal disorientation was higher in hospitalized patients over 24 hours (p=0.016). Logistic regression models showed that an organ failure with a CCED score other class I (p<0.010), cognitive impairment (p<0.030) and an admission for social problem (p<0,001) were associated with a length of stay longer than 24 hours.nnnCONCLUSIONSnOur study showed an association between organ failure, neuropsychiatric disorders, social problems and hospitalization after an admission in ED. These clinical characteristics may be useful for the early identification of older patients at risk for complex hospital pathway.

How to manage gait and balance disorders among older adults aged 65 years and older with mild to moderate dementia in clinical practice

Gait and balance disorders are frequent in demented older adults. Their management (i.e., diagnosis, assessment and treatment) is challenging in daily practice because of numerous evaluation tests available, difficulties to select the most adapted intervention, and the lack of knowledge of physicians and health professionals concerning adapted centers to refer their patients to those patients. Thus, a working group of experts was organized by the Gérontopôle of Pays de Loire, France, in December 2010 with the aim to provide clinical guidelines for the management of older adults aged 65 years and older with mild to moderate dementia with gait and balance disorders. These guidelines provide answers to the following questions: 1) Is there gait and/or balance disorders? 2) Which specific tests used? and 3) How to treat patients?

Comprehensive geriatric assessment in intensive care unit: a pilot study (pre-Seniorea)

BACKGROUNDnlong-term outcomes of elderly patients after an intensive care unit (ICU) stay are not fully elucidated. The objective of the pre-Seniorea study was to examine the feasibility of comprehensive geriatric assessment (CGA) during and after the ICU stay.nnnMETHODSninpatients aged 75 years and over admitted to medical and surgical ICUs of Angers University Hospital, France, from june to september 2012, received a SGA (assessment of morbidities, frailty, cognition, anxiety, mood, nutrition, functional abilities, motor function, pain, caregiver burden and quality of life) at ICU admission (through a proxy interview), at the end of the ICU stay, and 3 month later in the place of life.nnnRESULTSnfifty-two patients were included (81 [78; 83] years (median [25(th); 75(th) percentile]); 35 males; SAPSII 47 [38; 56]; 80% ventilation). ICU survival was 73% (n=38), 58% (n=30) after three months, and 54% (n=28) after 12 months. The CGA at ICU admission was performed in all patients and lasted 10 [5; 10] minutes. The CGA at discharge was performed in all survivors and lasted 10 [5; 15] minutes. In all, 26 survivors received CGA in their place of life after 3 months. Travel time by evaluators was 42 minutes, and time on site 45 [45; 60] minutes. At 3 months, 85% of surviving patients were at home and felt happy, 80% had preserved autonomy. The only variable predictive of survival at three months was the SAPSII score.nnnCONCLUSIONnthe follow-up of elderly inpatient admitted to ICU with repeated CGAs, including long-term evaluations in the place of life, was feasible and well-accepted. These results set the place for larger multicentric trials.

Beyond to pattern of risk factors in elderly subjects

UNLABELLEDnMost falls in the elderly result from an interaction between several risk factors in. Interventions targeting risk factors for a fall have been effective in the prevention of falls. The aim of this prospective study was to identify pattern of risk factors in hospitalized elderly subjects for fall in a geriatric acute care unit.nnnMETHODSnover a 5-year period, 471 patients hospitalized in the geriatric unit of Angers Hospital following a fall were randomly assigned to 471 patients without any fall history. The prevalence of risk factors for a fall, and the existence of predisposing and precipitating factors were compared between the two groups.nnnRESULTSnrisk factors for fall, namely gait unsteadiness, hip disorders, peripheral neuropathy, convulsions and syncope, were significantly more prevalent in the group of fallers compared to the controls. Two faller patterns were proposed: (1) patients with depression and receiving benzodiazepine and neuroleptic, and (2) patients with poor vision and osteoarticular disorders. Two further factors, namely parkinsonism and foot disorders, seemed to be sufficient to explain a fall.nnnCONCLUSIONnthis study for the first time has identified risk factors patterns of fall in elderly patients hospitalized in a geriatric acute care unit, which can be used to implement diagnosis and treatment strategies.

Médicaments et chute de la personne âgée

The use of curative support for the treatment of the pressure sores, simple to handle, compatible with ambulatory care, is a goal important to reach to reduce the durations of hospitalization and to support the maintenance in residence. We led an exploratory study with an alternate pressure air support. 14 patients carrying 22 pressure sores of stage 2 or more (7 had several pressure sores), of average age 68 years, analyzed in 4 hospital sites (2 of physical therapy, 2 of geriatrics), were followed according to 3 methods: healing, improvement, aggravation or appearance. The surface, depth and speed of healing, were systematically measured. In parallel, thanks to a scale of Likert on 4 levels, comfort was described by the patient thanks to 7 items (felt comfort, pain, maceration, facility of reversal, passage in sitting position, noise, impact on the sleep). According to same methodology, the conditions of use of the mattress were analyzed by 7 items (facilitated of operation, installation with the daily newspaper, technical facility of use, maintainability, facilitated for the care, safety, solidity and reliability). 13 pressure sores out of 22 evolved to the healing with an average reduction of similar surface of 4,2 cm 2 according to localizations. The average duration of healing was longer on the level of the heel than on the level of the sacrum (33 versus 18 days) and according to the initial stage (stage 3: 45 days versus 25 days for stage 2). 9 pressure sores out of 12 evolved/moved in the direction of the improvement (they were more severe forms). No pressure sores worsened. The mean velocity of healing was 0,21 cm2/day. On 79 evaluations of comfort made by the patients, the majority brought back very satisfactory appreciations. The most appreciated elements were the effect on the pain, the noise level and felt comfort. In parallel, the personnel considered to be very satisfactory the items quality of the support, facility of cleaning and facility of use at the time of the care. This prospective clinical trial multicentric, even among patients carrying pressure sores of stage 2 or more and high-risk, showed the clinical effectiveness, comfort, the handiness of mattress Barmat 2 Modena ® which is a support with alternated low air pressure likely to be used for continuous ambulatory care.

Vitamine D chez l’adulte : mise au point sur le dosage et la supplémentation

Hypovitaminosis D, a frequent condition in adults, is accompanied by adverse skeletal and non-skeletal events. The objective of the present article was to propose an update on the indications and use of vitamin D testing and supplementation in adults. Among healthy middle-aged adults, the serum 25-hydroxyvitamin D (25(OH)D) target concentration is 50 nmol/L. Natural intakes (sun exposure and diet) are sufficient, and there is no indication for systematic blood test or supplementation. In middle-aged adults who are either sick or dependent or frail, natural intakes are generally insufficient but should be encouraged. In this population, the loading phase of the supplementation targets a 25(OH)D concentration of 75 nmol/L, and the pattern of supplementation (200,000 to 400,000 IU orally over 2 months) depends on the measure of circulating 25(OH)D (which is not reimbursed outside the scope defined by the French national authority for health). In adults over 65 years of age, the loading phase of the supplementation should be systematic and targets a concentration of 75 nmol/L (pattern of 300,000 IU orally over 3 months). Regardless of age, the loading phase should be followed by a long-term maintenance phase of supplementation to maintain the 25(OH)D concentration above the target. A measure of serum 25(OH)D is useful after 9 months of supplementation to adjust the frequency or dosage of supplements if necessary.

‘‘Stops walking when talking’’: 12 years later

Simple and efficient detection of the risk of falling in older adults is an objective yet to be reached. Twelve years ago, a study published by Lundin-Olsson et al., entitled «Stops walking when talking», showed that an interruption of walking while talking was a predictor of fall. Most of the subsequent studies using dual-task paradigm combining walking and attention-demanding tasks, have reported more dual-task related gait changes among fallers than non-fallers. But despite the development of dual-task-based fall risk assessment tests, the relationship between dual-task related gait changes and the risk of falling remain controversial. The divergence may be related to three main reasons. First of all, there was a lack of understanding of the theoretical models of dual-task interferences. Secondly, confusion factors such as a cognitive impairment or depressive symptoms were not taken into account. Thirdly, the analysis of dual-task related gait changes depended on visual observation that does not give sufficient measures of gait and has poor inter-rater reliability related to its subjectivity. A better understanding of the nature of dual-task interferences, the use of user-friendly portable gait analysis systems that provide simple and objective gait measurements most likely allow the development of efficient dual-task-based fall risk assessment tests. Additionally, the analysis of changes in the performance of attention-demanding tasks seems to constitute a relevant new orientation of research in the detection of risk of falling.

« Stops walking when talking » : 12 ans après

Predire simplement et efficacement la chute du sujet âge reste un objectif a atteindre. Il y a douze ans, Lundin-Olsson et al. publiaient une etude intitulee « Stops walking when talking as a predictor of falls in elderly people », montrant que s’arreter de marcher lors d’une conversation predisait la survenue d’une chute. Bien qu’une grande majorite d’etudes montre que les chuteurs ont des performances, en condition de double tâche, plus faibles que les non-chuteurs, il n’existe toujours pas de test clinique fiable, c’est-a-dire suffisamment sensible et specifique, base sur l’analyse des performances de la marche sous condition de double tâche permettant de predire la chute. Les etudes publiees sur les relations entre les modifications de la marche, en condition de double tâche, et la survenue d’une chute sont rares et contradictoires. Les divergences sont probablement dues a un manque de puissance de certaines etudes, une mauvaise comprehension des modeles explicatifs des interferences observees sous double tâche, l’absence de prise en compte des facteurs de confusion tels qu’un declin cognitif ou un etat depressif, et au fait que l’analyse des perturbations de la marche reposait sur l’œil du clinicien. Une meilleure comprehension de la nature des interferences, la standardisation des conditions de passation des tests, ainsi que l’utilisation des nouvelles techniques d’analyse spatio-temporelle de la marche permettront probablement le developpement d’un test efficient. Par ailleurs, l’analyse des modifications des performances de la tâche attentionnelle semble etre une nouvelle voie de recherche pertinente pour predire la chute.