Frédérique Retornaz

Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Société Française de Gériatrie et de Gérontologie) Workshop--Athens January 20-21, 2012.

AbstractFrailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate.ObjectivesThe purpose of this paper is to present expert’s positions on the main aspects of the frailty syndrome in the older persons.ParticipantsWorkshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG).ResultsFrailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from “very fit” to “severely frail,” but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice.ConclusionFrailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

Aging of sensorimotor processes: a systematic study in Fitts’ task

Though age-related decrease in information-processing capacities is hypothesized to be a prominent cause of behavioral slowing, it has been scarcely systematically studied in goal-directed motor tasks. The present study investigated how the decrease in information processing affects the sensorimotor processes underlying the control of a discrete Fitts’ task. The index of difficulty (ID) of the task was manipulated using changes in either target distance (D) or target width (W). In each manipulation, movement (MTs), acceleration (ATs) and deceleration times (DTs) of young and older participants were compared across eight ID levels. They were analyzed with efficiency functions, state traces and Brinley plots. Our results showed that older participants were always slower. However, in both age groups, MTs were longer in D manipulation, which resulted from a slowing of both ATs and DTs, while W manipulation affected mainly DTs. In D manipulation, equivalent age-related slowing ratios were observed for AT and DT (1.3). In W manipulation, ATs of older participants were additively slower than those of young participants. Conversely, DTs presented a multiplicative slowing ratio of 1.3. These findings showed that ID manipulations differentially loaded information processing in the nervous system and that age-related slowing of multisensory control processes was independent of the manipulated dimension. Nevertheless, ID manipulations revealed different age-related adaptations to task constraints, suggesting that D and W manipulations are complementary means to assess age-related slowing of the processes involved in target-directed rapid-aiming tasks, with D scaling being more specific to capture the slowing of force-impulse control.

Difficulties in decision making regarding chemotherapy for older cancer patients: A census of cancer physicians

INTRODUCTION The management of older cancer patients is often suboptimal. This study aims to understand the management of older cancer patients who may receive chemotherapy. METHODS A questionnaire was mailed in 2006-2007 to 181 medical oncologists and hematologists practicing in the Province of Quebec, Canada. Physicians, involved in treatment decisions regarding chemotherapy in cancer patients aged 70 years and older, were eligible. RESULTS The response rate was 45.7%. Treatment toxicity (24.4%), comorbidities (20.5%), and lack of social support (10.9%) were reported as challenges when caring for older cancer patients. Comorbidities and functional status were reported as principal factors when making treatment decisions regarding chemotherapy; 77.5% of respondents expressed interest in collaborating with geriatricians. CONCLUSIONS The concerns of respondents about comorbidities, functional status, and social support, along with their interest to collaborate with geriatricians, support the need for a partnership between these two disciplines.

Geriatric assessment and care for older cancer inpatients admitted in acute care for elders unit

PURPOSE The goal of this study was to characterize an elderly population admitted to an Acute Care for Elders Unit (ACE) and to determine their trajectory as well as the prevalence of functional dependencies. DESIGN AND METHODS We conducted a retrospective chart review of 186 older cancer inpatients, admitted over a period of 30 months. Demographic and oncologic data, reasons for admission, and geriatric assessment (comorbidity, dependency, medication, nutritional status, neurosensory deficits, cognition, mood, and mobility) were recorded. RESULTS Older cancer inpatients presented a high prevalence of disability, impaired mobility, malnutrition, and depression. Reasons for admission were mostly due to non-specific symptoms. For one-third of the patients, hospitalization led to the diagnosis of cancer. Patients already diagnosed with cancer presented advanced stage disease and progressive disease; only a few received specific care. CONCLUSION Older cancer inpatients seen in ACE present numerous geriatric problems, non-specific symptoms, and advanced disease.

Complementary or Alternative Medicine as Possible Determinant of Decreased Persistence to Aromatase Inhibitor Therapy among Older Women with Non-Metastatic Breast Cancer

Purpose Aromatase inhibitor therapy (AI) significantly improves survival in breast cancer patients. Little is known about adherence and persistence to aromatase inhibitors and about the causes of treatment discontinuation among older women. Methods We constituted a cohort of women over 65 receiving a first AI therapy for breast cancer between 2006 and 2008, and followed them until June 2011. Women were selected in the population-based French National Health Insurance databases, and data was collected on the basis of pharmacy refills, medical records and face-to-face interviews. Non-persistence to treatment was defined as the first treatment discontinuation lasting more than 3 consecutive months. Time to treatment discontinuation was studied using survival analysis techniques. Results Overall among the 382 selected women, non-persistence to treatment went from 8.7% (95%CI: 6.2–12.1) at 1 year, to 15.6% (95%CI: 12.2–19.8) at 2 years, 20.8% (95%CI: 16.7–25.6) at 3 years, and 24.7% (95%CI: 19.5–31.0) at 4 years. In the multivariate analysis on a sub-sample of 233 women with available data, women using complementary or alternative medicine (CAM) (HR = 3.2; 95%CI: 1.5–6.9) or suffering from comorbidities (HR = 2.2; 95%CI: 1.0–4.8) were more likely to discontinue their treatment, whereas women with polypharmacy (HR = 0.4; 95%CI: 0.2–0.91) were less likely to discontinue. In addition, 13% of the women with positive hormonal receptor status did not fill any prescription for anti-hormonal therapy. Conclusion AI therapy is discontinued prematurely in a substantial portion of older patients. Some patients may use CAM not as a complementary treatment, but as an alternative to conventional medicine. Improving patient-physician communication on the use of CAM may improve hormonal therapy adherence.

Frailty Markers and Treatment Decisions in Patients Seen in Oncogeriatric Clinics: Results from the ASRO Pilot Study

Background Comprehensive Geriatric Assessment (CGA) is the gold standard to help oncologists select the best cancer treatment for their older patients. Some authors have suggested that the concept of frailty could be a more useful approach in this population. We investigated whether frailty markers are associated with treatment recommendations in an oncogeriatric clinic. Methods This prospective study included 70 years and older patients with solid tumors and referred for an oncogeriatric assessment. The CGA included nine domains: autonomy, comorbidities, medication, cognition, nutrition, mood, neurosensory deficits, falls, and social status. Five frailty markers were assessed (nutrition, physical activity, energy, mobility, and strength). Patients were categorized as Frail (three or more frailty markers), pre-frail (one or two frailty markers), or not-frail (no frailty marker). Treatment recommendations were classified into two categories: standard treatment with and without any changes and supportive/palliative care. Multiple logistic regression models were used to analyze factors associated with treatment recommendations. Results 217 patients, mean age 83 years (± Standard deviation (SD) 5.3), were included. In the univariate analysis, number of frailty markers, grip strength, physical activity, mobility, nutrition, energy, autonomy, depression, Eastern Cooperative Oncology Group Scale of Performance Status (ECOG-PS), and falls were significantly associated with final treatment recommendations. In the multivariate analysis, the number of frailty markers and basic Activities of Daily Living (ADL) were significantly associated with final treatment recommendations (p<0.001 and p = 0.010, respectively). Conclusion Frailty markers are associated with final treatment recommendations in older cancer patients. Longitudinal studies are warranted to better determine their use in a geriatric oncology setting.

Chemotherapy in Old Women with Breast Cancer: Is Age Still a Predictor for Under Treatment?

Breast cancer affects mostly older women but there are no guidelines especially devoted to adjuvant chemotherapy for this population. In this context, this study was carried out in a population‐based cohort of French elderly women with breast cancer, to check adherence to the existing national guidelines according to the womens age, taking into account the evolution of the situation over time for women requiring chemotherapy. Between October 2006 and December 2008, all consecutive women included in the French Health registry for a biopsy‐proven primary nonmetastatic breast cancer, aged 65–80 years at diagnosis, and living in South Eastern France, were asked to participate in a cohort study. Medical information was collected from physicians. The study population was restricted to the 223 women who were recommended adjuvant chemotherapy according to national guidelines. Those who received chemotherapy were compared to those who did not receive this treatment. Among these 223 women 55% had received chemotherapy. Only three women refused the treatment. Less than 8% have had a geriatric assessment before treatment decision and only two were proposed to participate in a clinical trial. After adjustment for comorbidity score, tumor characteristics, socio‐demographic characteristics, and year of diagnosis, increasing patient age was independently associated with decreased guideline concordance for adjuvant chemotherapy. Women aged 75–80 years received chemotherapy more than four times less often than women aged 65–74 years. However, the percentage of women who received chemotherapy increased from 33% to 58% between 2006 and 2008, in parallel with the setting up of Onco‐Geriatric Coordination Units in the area. In France, chronological age remains a barrier to receive chemotherapy for older breast cancer women but the establishment of a formal collaboration between oncologists and geriatricians seems to be an effective way to improve care delivery in this population.

High-grade glioma in elderly patients: can the oncogeriatrician help?

Gliomas are the most frequent primary brain tumors in adults. As the population ages in Western countries, the number of people being diagnosed with glioblastoma is expected to increase. Clinical management of elderly patients with primary brain tumors is difficult, owing to multiple comorbidities, polypharmacy, decreased tolerance to chemotherapy, and an increased risk of radiation-induced neurotoxicity. A few specific randomized studies have shown a benefit for radiotherapy in elderly patients with good performance status. For patients with poor performance status, chemotherapy (temozolomide) has been shown to be associated with prolonged duration of response. Patients with methylated O6-alkylguanine deoxyribonucleic acid alkyltransferase promoter seem to have better outcomes. Oncogeriatrics proposes the geriatric evaluation of elderly patients to improve therapeutic choices and optimize the management of treatment toxicities and comorbidities.

Assessment of glycemic control in nursing home residents with diabetes

ObjectiveTo describe glycemic control in nursing home residents with diabetes and to evaluate the relevance of HbA1c in the detection of hypoglycemia risk.Design and methodsDiabetes treatment, geriatric assessment, blood capillary glucose (n= 24,682), and HbA1c were collected from medical charts of 236 southern France nursing home residents during a 4-month period. Glycemic control was divided into four categories: tight, fair, and moderate or severe chronic hyperglycemia using the High Blood Glucose Index or the analysis of blood glucose frequency distribution. Hypoglycemia episodes were identified by medical or biological records.ResultsGlucose control was tight in 59.3 % and fair in 19.1 % of the residents. Chronic exposure to hyperglycemia was observed in 21.6 % of the residents (severe in 9.7 % and moderate in 11.9 %). Hypoglycemia was noticed in 42/236 (17.8%), in all categories of glycemic control. Relative hypoglycemia risk was significantly (P = 0.0095) higher in residents with moderate chronic hyperglycemia compared with those with tight control. The majority of residents with hypoglycemia (39/42) or chronic hyperglycemia (45/51) were insulin-treated. The relative risk of hypoglycemia was not significantly associated with HbA1c values.ConclusionHypoglycemia risk in nursing home residents is observed in all categories of glycemic control. In tight control, the potency of antidiabetic treatment should be reduced. In chronic hyperglycemia, diet and treatment should be reevaluated in order to reduce glucose variability. HbA1c is not sufficient for hypoglycemia risk detection; capillary blood glucose monitoring is warranted for nursing homes residents with diabetes.

Management and new current French recommendations for tetanus care

Tetanus is an acute severe disease induced by an exotoxin, often lethal. All cases occur in untreated or inadequately vaccinated patients and mainly in elderly patients who accumulate many risk factors. The current management of wounds faced difficulties in the assessment of immunization status and wound risks status. Indeed, all injuries can potentially lead to tetanus. Minor risks and chronic wounds are mainly found as tetanus cause. Vaccination remains the key element in reducing the morbidity and mortality associated with tetanus. It is estimated that the vaccines coverage is fairly good, but decreases with age. To improve tetanus prevention, new vaccine recommendations have been established which recommend vaccines injections at fixed age, but their impact seems to be limited especially in the elderly. The immunochromatographic tests have demonstrated cost-effectiveness in the Emergency department settings. They are currently not available outside hospital while general practionners also face a significant risk. Effectiveness of these tests should be studied in outpatients population including cost-effectiveness.