François Blanchard

Early Markers of Prolonged Hospital Stays in Older People: A Prospective, Multicenter Study of 908 Inpatients in French Acute Hospitals

OBJECTIVES: To identify early markers of prolonged hospital stays in older people in acute hospitals.

Measuring general health status in dementia: Practical and methodological issues in using the SF-36

The objective of this study was to examine the measurement properties of the Medical Outcomes Study (MOS) 36-Item Short-Form health survey (SF-36) in a representative sample of dementia patients. A total of 138 subjects with dementia were evaluated with the SF-36. They were recruited from 16 centers, including 7 university hospital centers. Dementia severity, demographic variables, comorbidity and functional limitations were also measured. The measurements obtained were compared by source of information (patient, family proxy, and care provider proxy). Thirteen patients refused to complete this questionnaire. Help from the interviewer was necessary in 72.8% of the cases. The average completion time was 18.8 minutes. Missing data exist in only 5.6% of the cases on average, except among patients with severe dementia (Mini Mental State Examination <10). With regard to reliability, internal consistency was acceptable to good; Cronbach’s ranged from a low of 0.59 to a high of 0.92 across subscales (median 0.75). Test-retest intraclass correlation coefficients were moderate to good (range 0.51–0.81) except for Role emotional (0.17), Bodily pain (0.49) and Mental health (0.45). For patients with MMSE ≥15, test- retest coefficients were better (range 0.53–0.90). Intraclass correlation coefficient suggests that proxies are a poor substitute for obtaining a patient’s perspective of his/her health status. In conclusion, the SF-36 is unsuitable for severe dementia, because severity of disease mainly affected the feasibility, acceptability, and reproducibility of the instrument. This study, however, confirms that it is possible to question subjects with mild to moderate dementia on their health status.

A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly

Despite strong evidence for the efficacy of integrated systems, securing the participation of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel approaches are needed to resolve these problems. We developed a model — COPA — that is based on scientific evidence and an original design process in which health professionals, including PCPs, and managers participated actively. COPA targets very frail community-dwelling elders recruited through their PCP. It was designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits and hospitalizations, and prevent inappropriate long-term nursing home placements. The model’s originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment and care plan development; 2) having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the PCP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community to see patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions. Since COPA is currently the subject of both a quasi-experimental study and a qualitative study, we are also providing preliminary findings. These findings suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results indicate that the level of service utilization in COPA was less than what is reported at the national level, without any compromises in quality of care.

Healthcare professionals and managers' participation in developing an intervention: A pre-intervention study in the elderly care context

BackgroundIn order to increase the chances of success in new interventions in healthcare, it is generally recommended to tailor the intervention to the target setting and the target professionals. Nonetheless, pre-intervention studies are rarely conducted or are very limited in scope. Moreover, little is known about how to integrate the results of a pre-intervention study into an intervention. As part of a project to develop an intervention aimed at improving care for the elderly in France, a pre-intervention study was conducted to systematically gather data on the current practices, issues, and expectations of healthcare professionals and managers in order to determine the defining features of a successful intervention.MethodsA qualitative study was carried out from 2004 to 2006 using a grounded theory approach and involving a purposeful sample of 56 healthcare professionals and managers in Paris, France. Four sources of evidence were used: interviews, focus groups, observation, and documentation.ResultsThe stepwise approach comprised three phases, and each provided specific results. In the first step of the pre-intervention study, we gathered data on practices, perceived issues, and expectations of healthcare professionals and managers. The second step involved holding focus groups in order to define the characteristics of a tailor-made intervention. The third step allowed validation of the findings. Using this approach, we were able to design and develop an intervention in elderly care that met the professionals and managers expectations.ConclusionThis article reports on an in-depth pre-intervention study that led to the design and development of an intervention in partnership with local healthcare professionals and managers. The stepwise approach represents an innovative strategy for developing tailored interventions, particularly in complex domains such as chronic care. It highlights the usefulness of seeking out the insight of healthcare professionalnd managers and emphasizes the need to intervene at different levels. Further research will be needed in order to develop a more thorough understanding of the impacts of such strategies on the final outcomes of intervention implementations.

Normal and Pathological Aging of Attention in Presymptomatic Huntington’s, Huntington’s and Alzheimer’s Disease, and Nondemented Elderly Subjects

Background: Attention models view attention as having at least two components: endogenous attention defined as executive and directed by voluntary acts, and exogenous attention defined as automatic and directed by external stimulation. Methods: Three studies (2 of our own) were designed to evaluate the decline of these two components of attention in normal aging and two neurodegenerative diseases. Standardized tests derived from Posner’s model of visuospatial attention were administered to normal healthy elderly participants (n = 13), patients suffering from Huntington’s disease (HD; n = 17) and Alzheimer’s disease (n = 15), and matched control subjects (n = 57). Outcome measures were reaction time (RT) and RT difference score (defined as invalid RT minus valid RT). Results: In healthy elderly participants, the decline was more pronounced for endogenous attention in situations of perceptual conflict. In Alzheimer’s disease, there was a significant decline in both attention components, while in HD, voluntary attention was markedly impaired and automatic attention preserved. Conclusions: Normal aging and HD are characterized by decreased endogenous attention in situations of perceptual conflict. Our data support previous findings that older people display impairment of attention in complex perceptual situations. We propose a model which allows for the separation of attention pathologies, thus improving therapeutic strategies for patients and elderly.

Development of an Individualized Service Plan Tool and Rules for Case Management in Québec

From past experience with integrated service delivery, there appears to be a need for a clinical tool to help case managers plan, monitor, and coordinate services. In this context the Québec Ministry of Health and Social Services created a task force to suggest improvements to the Individualized Service Plan tool included in the Multiclientele Assessment Tool. This article reports the findings of this multidisciplinary task force working with various clienteles (older, with physical or mental disabilities, mental diseases). Based on a literature review and recent results from the Program of Research on the Integration of Services for the Maintenance of Autonomy, the task force proposed a dynamic, concise, user-friendly tool and a clear definition of how it should be used. The Individualized Service Plan must list the patient’s needs, with an orientation regarding the action plan for each, and a list of services allocated in response to these needs that work in the defined direction. The tool must also contain a section for analyzing variations between the services needed and allocated. This tool was presented to case managers for validation and received an enthusiastic response. It should be implemented in the coming years in the provincial Multiclientele Assessment Tool.

Qualité de vie et démence : état des connaissances

BACKGROUNDnDementia is a chronic and evolutive disease, for which no curative treatment exists. Evaluating the quality of life of patients suffering from dementia is therefore an important component of management.nnnAIMSnTo summarise existing literature regarding quality of life instruments specific to dementia, and to identify factors associated with quality of life.nnnMETHODSnWe analysed studies published between November 1996 and December 2010 and referenced in PubMed, and focusing on the development and/or validation of quality of life instruments specific to dementia, or studies having used any such instrument to evaluate a therapeutic intervention.nnnRESULTSnNine quality of life instruments were identified. Place of residence and level of education do not appear to play any significant role. Results were conflicting for age and sex. There appears to be a relation, albeit a weak one, with cognitive function. The factors most frequently associated with lower quality of life were behavioural disorders, dependence, and caregiver burden. Quality of life of patients under pharmacological treatment is poorly documented, while occupational therapy and cognitive stimulation appear to have moderate positive effects.

Frailty: learnings from the SAFEs cohort study and future perspectives for the research

Even though the efforts in research have detailed further the physiopathology and the dynamics of the frailty process an operational definition of frailty is still far from being unequivocal. Studies carried out from the SAFEs cohort study allowed a pragmatic approach in the identification of the at-risk groups for the lost of independency during the hospital stay and factors influencing their future at short-, mid- and long-term. Based upon these results, we propose to discuss the relevance of the current operational indicators of frailty in order to show that clinical markers or indicators are insufficient to differentiate the frailty process from normal ageing. Finally we give rise to the imperative necessity to detect frailty at a preclinical stage with the help of biological and more particularly inflammatory markers.

Validation externe de la grille de fragilité SEGA sur la cohorte SAFES

The aim of the study was to achieve the external validation of the SAGA instrument on the SAFES cohort. This was a prospective longitudinal multicentre cohort study, including patients aged 75 years or over, hospitalized in a short stay medical ward via emergency department. A comprehensive geriatric assessment was implemented. The psychometric validation enabled the study of feasibility, internal consistency, convergent, discriminant, and predictive validity of the instrument. The 1xa0306 patients of the cohort was 85±6 years, with a majority of women (65%). The completion rate of the SEGA instrument was 94%. Internal consistency was good (Cronbach alpha coefficient=0.7). Convergent validity was poor: Donini instrument (kappa=0.18; IC 95%=0.13-0.23), Rockwood instrument (kappa=0.04; IC 95%=0.02-0.06), and Winograd instrument (kappa=0.04; IC 95%=0.01-0.07). The ability of the instrument to discriminate clinically different groups was good. The SEGA instrument predicted well one-year mortality as well as one-year institution admission. Despite poor convergent validity (which is classic with frailty tools, SEGA instrument has satisfactory metrological properties, allowing its use in emergency departments and immediate post-emergency circumstances.

Quelques réflexions sur les « vieux » et les territoires gérontologiques

Les « vieux » ne parlent jamais de gerontologie et encore moins de territoire gerontologique. Par contre, chacun s’enracine dans un territoire. Mais, s’il y a un ancrage initial, la vie nous transporte et l’endroit ou l’on meurt est rarement l’endroit ou l’on est ne. C’est un truisme de dire qu’il n’y a pas une vieillesse mais des vieillesses. Mais cela influe sur le rapport a l’espace et au territoire. A la distinction liee a l’âge s’ajoute une distinction, tout aussi nefaste, entre le sanitaire et le social que l’on habille de « medicosocial » car toute decision a ce niveau-la implique un minimum de relation avec la sphere medicale. On a ainsi des niveaux de prise de decision difficile a coordonner entre entites geographiques superposees : un territoire de proximite au niveau des communes, (et des organisations fort differentes d’une commune a l’autre), au-dessus le departement territoire essentiel pour le « medico-social », le financement de la prise en charge de la dite « dependance ». Au final, cette question des territoires gerontologiques fait apparaitre bien des incoherences. On ne peut que souhaiter que disparaisse enfin cette distinction entre le sanitaire et le medico-social d’une part, et entre le handicap et la dependance d’autre part. Cela pose la question de la place des personnes âgees dans notre societe en tant que citoyen a part entiere.