Laurent Balardy

Searching for a Polypharmacy Threshold Associated With Frailty

Second, psychosocial resources may serve as mediators of the relationship between frailty and adverse outcomes. Mediation analyses tell us why or how psychosocial resources affect clinical outcomes in frail older people, because mediator variables are usually in the causal pathway between predictors and outcomes.10 It is possible that frailty alters the psychosocial resources of individuals and makes them even more vulnerable to adverse outcomes. Mediation analyses test the extent to which a mediator accounts for the effects of the predictor (frailty) on the outcomes.10 A recent article investigating the mediation effects of several factors on frailty found that although social participation increased the likelihood of frailty worsening, the worsening of frailty was not able to be explained by social participation, or lack thereof.13 However, no studies have yet looked at psychosocial resources as mediators of the association of frailty with adverse outcomes. All in all, it is likely that psychosocial resources are both moderators and mediators of frailty. However, with so little research in existence, no conclusive results can be drawn. Moreover, the 2 studies known to date have used only relatively short follow-up periods ( 3 years). Given the long life-course progression of psychosocial resources14 and frailty,15 it is likely that both moderation and mediation effects will become more evident with longer-term follow-up. Subsequently, a need exists to investigate the long-term protective effect of psychosocial resources on frailty, particularly using mediation effect studies. Gaining a more comprehensive understanding of how an older person handles frailty, whether by the use of copingmechanisms, having a strong sense of self-control, or an involvement in social support networks, can be used to tailor patient-centered care and potentially reduce the burden associated with frailty.

Exposure to Atropinic Drugs and Frailty Status

BACKGROUND Atropinic drugs can increase the risk of falls, cognitive impairment, and mortality in older patients; however, whether exposure to atropinic drugs is associated with frailty status remains unknown. Our aim was to assess the association between frailty status and exposure to atropinic drugs in a geriatric day hospital population. METHODS We carried out a cross-sectional study that included all the patients consulting for the first time at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability in Toulouse, France, from January 2013 to October 2013. Frailty was defined by 3 or more of Fried et als criteria. Atropinic drugs were those with clinical antimuscarinic effect from the Anticholinergic Drug Scale (excluding drugs weighted 1 point and not listed by Durán et al) and from Laroche et al list (to include drugs marketed in France not present in the Anticholinergic Drug Scale). To explore a dose-effect relationship, we calculated the atropinic burden using the Anticholinergic Drug Scale weights. We performed logistic regression models adjusted for age, gender, comorbidities, being community dwelling or not, cognitive status, educational level, and polypharmacy (≥6 drugs). RESULTS We included 437 patients (227 frail and 210 robust or prefrail). Exposure to at least one atropinic drug was associated with frailty (odds ratio 1.97, 95% confidence interval 1.10-3.53, P = .02). Due to a statistically significant interaction between age and atropinic burden, a dose-effect relationship for atropinic burden was explored in patients younger than 85 years, showing a significant association between atropinic burden score and frailty (P = .01). The Odds ratio for an atropinic burden greater than or equal to 3 versus 0 was 3.84, 95% confidence interval 1.43-10.34 (P < .01). CONCLUSIONS In a geriatric day hospital, population frailty is associated with a high atropinic burden.

Polypharmacy and Potentially Inappropriate Medication Use Among Senior Adults With Cancer: What Is the Best Approach?

TO THE EDITOR: In the original report by Nightingale et al, a pharmacist-led comprehensive medication assessment demonstrated a high prevalence of polypharmacy (PP) and potentially inappropriate medication (PIM) use among ambulatory senior adults with cancer. For at least 234 patients, the mean number of medications used was 9.23. The prevalence rates of PP and PIM use were 41% and 51%, respectively. PP and increased comorbidities were associated with PIM use. The elderly patient with cancer is exposed to a high medication risk: treatment for comorbidities, cancer treatment, supportive treatments, and self-medication. Evaluation of medicine-related illness and of medication risk seems essential to the development of a personalized care project in geriatric oncology. However, this factor currently may seem neglected. The study by Nightingale et al leads to a certain number of remarks. As stressed by Lichtman et al, gerontologic evaluation is an indispensable tool in any geriatric oncologic approach. All patients enrolled onto the study reported by Nightingale et al received gerontologic evaluation at inclusion. However, the principal tools used and the results of the evaluation are not given by the authors. This raises several problems. Notably, because there is no information on the patients’ cognitive statuses, we cannot be certain that data collection on medication was exhaustive and relevant. (The authors do not specify how the aid of the caregiver was enlisted.) Without knowledge of the cognitive profile of the patient, it is also difficult to determine the ability of the patient to take treatment. Several elements need to be taken into account to adapt and prioritize treatments: polymedication, the risk of drug interaction, the risk of inappropriateprescriptions(treatmentnot indicatedorcontraindicated), the risk of overtreatment, and the risk of undertreatment. Treatment adaptation requires full knowledge of the disease context and comorbidities of the patient. In this study, although the prevalence and type of comorbidities are well described by the authors, there is no evaluation of their potential seriousness. Use of a comorbidity evaluation scale, such as the Cumulative Illness Rating Scale for Geriatrics, would seem to be an indispensable tool for prioritizing treatments. Conversely, the risk of inappropriateprescribingandofovertreatmentiswell takenintoaccount, in particular through the 2012 combined Beers, Screening Tool of Older Persons’ Prescriptions, and Healthcare Effectiveness Data and Information Set criteria. Thanks to these criteria, in the study by Nightingale et al, pharmacists identified173occurrencesofPIMspresentin40%,38%,and 21% of patients, respectively. However, the risk of underuse is probably underestimated by the authors, because the Screening Tool to Alert Doctors to the Right Treatment criteria were not used. Also, the risk of interactions with cancer treatments, and with chemotherapies in particular, did not seem to be considered. To identify PIM use in nursing home residents, Cool et al used a specific indicator, which was based on the Summary of Product Characteristics, on the Laroche list and on residents’ clinical data. PIM use was defined as the presence of at least one of the following criteria: drug with an unfavorable benefit-to-risk ratio; drug with questionable efficacy according to the Laroche list; absolute contraindication; or significant drug-drug interaction. The advantage of this method lies in the use of multiple reference tools, which yields a more overall view of these drug prescriptions and drug-drug interactions. By using this method, a higher proportion of PIMs would probably be identified. Cool et al identified PIMS among 71% of the 974 patients included. Nevertheless, thestudybyNightingaleetal is still an interestingone. Inparticular, itunderlines thekeyroleof thepharmacist in theadaptation of treatment in the elderly patient with cancer. Adaptation should be a collegialprocess that involvesall thosewhocareforthepatient, suchasthe oncologist, the geriatrician, and the patient’s general practitioner. This study does not show whether the findings of the pharmacists’ assessments are put into practice, nor whether they are effective: Do the assessments result in fewer adverse events or fewer and shorter hospital admissions? Prospective studies could usefully analyze adverse outcomes or adverse events and could examine whether a strategy of cleaning up patients’ prescriptions is effective and how it can affect patient welfare.

Impact of an oncogeriatric consulting team on therapeutic decision-making

Increased life expectancy and cancer incidence imply the need to develop a specialized care policy for elderly patients with cancer. We created an oncogeriatric consulting team (OGCT) in Toulouse University Hospital to carry out comprehensive gerontological assessment at the bedside of hospitalized patients. We analyze the impact on the final cancer treatment decision of this mobile geriatric assessment. We carried out a descriptive, retrospective real-life analysis of a patient cohort over a two-year period. The OGCT assessed 124 patients, of whom the majority were women (54.8%), median age 81 years, living at home (95.2%) and with family caregivers (86.5%). Nearly all were frail (96.7% according to the classification of Balducci and colleagues) and 3.2% were vulnerable. The team’s decisions were analyzed for patients who had not yet been treated (n=107). After analysis, the team’s proposal was in line with the initial cancer treatment plan in 68.2% of cases (n=73). In cases where there was a disagreement, the final decision was in line with the mobile team’s proposal in 17.75% of 107 patients (n=19). The decision of the team was followed more often when their assessment proposed strictly palliative treatment. The decision to give elderly patients specific cancer treatment seems in our experience rather to be a matter for the oncologists, and is not very susceptible to modification by geriatric opinion. On the other hand, the geriatrician appears to be more credible and his/her opinion more likely to be followed when the patient is considered too frail and less aggressive, or even exclusively palliative, treatment is proposed.

Exceptional bone metastasis of basal cell carcinoma in Gorlin-Goltz syndrome.

Background: Basal cell carcinoma (BCC), the most prevalent form of cancer worldwide, is a malignant skin neoplasm. It is locally invasive, with an exceptional incidence of reported metastasis. It can also be part of the Gorlin-Goltz syndrome, an autosomal dominant genetic disorder with high penetrance and variable expressivity, which is principally characterized by cutaneous BCC, odontogenic keratocysts, palmar and/or plantar pits, and falx cerebri calcification. Observation: We report the exceptional clinical observation of a 54-year-old man presenting bone metastasis from BCC in Gorlin-Goltz syndrome. Conclusion: Less than 300 cases of metastatic BCC have been reported in the literature. The present case is the second associated with Gorlin-Goltz syndrome.

Visual impairment screening at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability at the Gérontopôle

ObjectivesTo evaluate visual performance and factors associated with abnormal vision in patients screened for frailty at the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability at Toulouse University Hospital.DesignRetrospective, observational cross-sectional, single-centre study.SettingInstitutional practice.ParticipantsPatients were screened for frailty during a single-day hospital stay between October 2011 and October 2014 (n = 1648).MeasurementsCollected medical records included sociodemographic data (including living environment and educational level), anthropometric data, and clinical data. The general evaluation included the patient’s functional status using the Activities of Daily Living (ADL) scale and the Instrumental Activity of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE) for cognition testing, and the Short Physical Performance Battery (SPPB) for physical performance. We also examined Body Mass Index (BMI), the Mini-Nutritional Assessment (MNA), and the Hearing Handicap Inventory for the Elderly Screening (HHIE-S) tool. The ophthalmologic evaluation included assessing visual acuity using the Snellen decimal chart for distant vision, and the Parinaud chart for near vision. Patients were divided into groups based on normal distant/near vision (NDV and NNV groups) and abnormal distant/near vision (ADV and ANV groups). Abnormal distant or near vision was defined as visual acuity inferior to 20/40 or superior to a Parinaud score of 2, in at least one eye. Associations with frailty-associated factors were evaluated in both groups.ResultsThe mean age of the population was 82.6 ± 6.2 years. The gender distribution was 1,061 females (64.4%) and 587 males (35.6%). According to the Fried criteria, 619 patients (41.1%) were pre-frail and 771 (51.1%) were frail. Distant and near vision data were available for 1425 and 1426 patients, respectively. Distant vision was abnormal for 437 patients (30.7%). Near vision was abnormal for 199 patients (14%). Multiple regression analysis showed that abnormal distant vision as well as abnormal near vision were independently associated with greater age (P < 0.01), lower educational level (P < 0.05), lower performance on the MMSE (P < 0.001), and lower autonomy (P < 0.02), after controlling for age, gender, educational level, Fried criteria, and MMSE score.ConclusionThe high prevalence of visual disorders observed in the study population and their association with lower autonomy and cognitive impairment emphasises the need for systematic screening of visual impairments in the elderly. Frailty was not found to be independently associated with abnormal vision.

Body composition and anti-neoplastic treatment in adult and older subjects - A systematic review

BackgroundThe estimation of the risk of poor tolerance and overdose of antineoplastic agents protocols represents a major challenge in oncology, particularly in older patients. We hypothesize that age-related modifications of body composition (i.e. increased fat mass and decreased lean mass) may significantly affect tolerance to chemotherapy.MethodWe conducted a systematic review for the last 25 years (between 1990 and 2015), using US National library of Medicine Medline electronic bibliographic database and Embase database of cohorts or clinical trials exploring (i) the interactions of body composition (assessed by Dual X-ray Absorptiometry, Bioelectrical Impedance Analyses, or Computerized Tomography) with pharmacokinetics parameters, (ii) the tolerance to chemotherapy, and (iii) the consequences of chemotherapies or targeted therapies on body composition.ResultsOur search identified 1504 articles. After a selection (using pre-established criteria) on titles and abstract, 24 original articles were selected with 3 domains of interest: impact of body composition on pharmacokinetics (7 articles), relationship between body composition and chemotoxicity (14 articles), and effect of anti-cancer chemotherapy on body composition (11 articles). The selected studies suggested that pharmacokinetic was influenced by lean mass, that lower lean mass could be correlated with toxicity, and that sarcopenic patients experienced more toxicities that non-sarcopenic patients. Regarding fat mass, results were less conclusive. No studies specifically explored the topic of body composition in older cancer patients.ConclusionsPlausible pathophysiological pathways linking body composition, toxicity, and pharmacokinetics are sustained by the actual review. However, despite the growing number of older cancer patients, our review highlighted the lack of specific studies in the field of anti-neoplastic agents toxicity regarding body composition conducted in elderly.

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.

Cryofibrinogénémie : étude monocentrique au CHU de Toulouse

PURPOSE Cryofibrinogenemia is an unknown disorder and studies dedicated to it are limited. The aim of our study was to report on the incidence, clinical manifestations and associated diseases in patients with isolated cryofibrinogenemia. METHODS This is a retrospective single-center study. Patients included in this study had a positive and isolated detection of cryofibrinogen between January 1st, 2011 and December 31st, 2012. Identification was possible through the database of the laboratory of immunology. RESULTS Two hundred and eighty-one consecutive orders of cryofibrinogenemia were identified. Seventy-three patients had a positive detection of cryofibrinogenemia. Among them, 12 had an isolated cryofibrinogenemia and sixty-one patients (84%) had concomitant cryofibrinogenemia and cryoglobulinemia. The mean age was 59±19years. Seven patients were female (58%). Cutaneous manifestations were present in half case. Peripheral nerve involvement was present in 5 cases (42%) and rheumatic manifestations in 4 patients (33%). A thrombotic event was reported in 7 patients (58%). Renal impairment was present in 7 patients. The median cryofibrinogen concentration was 254±304mg/L. Five patients had a secondary cryofibrinogenemia. The most often prescribed treatment was corticosteroids. CONCLUSION Cryofibrinogenemia is an unknown disorder. Testing for cryoglobulinemia is more frequent than for cryofibrinogenemia whereas clinical manifestations are similar. Detection of cryofibrinogen is positive in most of the cases, with an important prevalence of thrombotic events in this population. This study confirms the importance of conducting prospective studies on cryofibrinogenemia.

Giant cell arteritis: a reversible cause of oculomotor nerve palsy.

La Presse Medicale - In Press.Proof corrected by the author Available online since jeudi 4 juin 2015