R. Gonthier

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.

Etiologic and Outcome Profiles in Hypoactive and Hyperactive Subtypes of Delirium

The existence of hyperactive, hypoactive, or mixed clinical subtypes of delirium is widely accepted. But relationships between these motor profiles and etiology or outcome remain unclear. The aim of this study was to compare etiologic and outcome profiles in a case series of 183 elderly patients (mean age = 84.1 years, SD = 5.9) consecutively admitted into the geriatric wards of two French university hospitals or referred to a geriatric psychiatry consultation-liaison unit within a Swiss university hospital. All patients met DSM-III-R criteria for delirium and were classified into clinical subtypes according to the results of a previous factor analysis of scores on a 19-item checklist rating a wide range of delirium symptoms. The hyperactive subtype was more frequent (n = 85, 46.5%) than the unspecified (n = 50, 27.3%) and hypoactive subtypes (n = 48, 26.2%). There was no significant difference in terms of etiologic or outcome profile between clinical subtype groups. The presence of acute metabolic disorders, cardiovascular disease, and hyperthermia as etiologic factors was significantly associated with full recovery of the episode at 3 weeks follow-up, whereas probable preexisting dementia was significantly associated with partial recovery or failure to recover. (J Geriatr Psychiatry Neurol 2000; 13:38-42).

Derivation and validation of a mortality-risk index from a cohort of frail elderly patients hospitalised in medical wards via emergencies: the SAFES study

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.

Factor analysis supports the evidence of existing hyperactive and hypoactive subtypes of delirium.

The aim of this study was to examine whether delirium has specific clinical subtypes.

L'âge très élevé constitue-t-il un facteur pronostique du devenir après un premier accident vasculaire cérébral?

AIM To determine whether very old age, older than 80 years, after a stroke is a significant predictor of mortality, orientation to a specific care pathway after the acute phase and functional status at 6 months after the stroke. PATIENTS A sample of 112 consecutive patients admitted to the emergency department because of a first stroke, with hemiplegia and/or aphasia over 6 months, who satisfied strict inclusion/exclusion criteria. Forty-seven patients were older than 80. METHOD After initial diagnosis and enrolment in the study, follow-up assessments were conducted at 48 hours, 15 days and 6 months. Demographic, medical, and radiographic data were collected, and patients were evaluated on the NIHSS, MMSE, Barthel Index, FIM(TM) and FAM scales. Descriptive statistics were generated, as were uni- and multivariate between group comparisons. RESULTS Our study shows that after a first stroke, old age is significantly associated with a high rate of death, a low rate of orientation to a physical medicine and rehabilitation unit and return to home but not poorer functional outcome. CONCLUSION Old age is therefore a determinant of post stroke management. Further studies are needed to evaluate whether in patient rehabilitation would result in significant functional benefit, considering the high cost of care, high risk of recurrent stroke, and high rate of death.

Consensus sur la démence de type Alzheimer au stade sévère

Resume Sous l’egide de la Societe Francaise de Geriatrie et Gerontologie, un groupe pluridisciplinaire de specialistes en geriatrie, neurologie, epidemiologie, psychiatrie, neuroradiologie, pharmacologie, sante publique a entrepris une demarche de consensus sur les modalites d’evaluation, de suivi et de prise en charge globale de la demence de type Alzheimer au stade severe. Cette reflexion, fondee sur l’etat des connaissances en 2005, a permis de formuler 21 recommandations a destination des praticiens hospitaliers, medecins traitants, medecins coordonnateurs et specialistes. Quel que soit le stade evolutif de la maladie, l’objectif de la prise en charge est d’ameliorer la qualite de vie de la personne malade et de sa famille, en associant projet de soins et projet de vie et ce jusqu’en fin de vie. La prise en charge, pour etre globale, doit etre necessairement pluridisciplinaire et coordonnee, en mobilisant les ressources sanitaires et medico-sociales de proximite pour optimiser leur utilisation. Le groupe a souligne egalement l’importance d’une recherche dynamique : recherche clinique visant a mieux connaitre l’evolution des troubles, evaluation des strategies de prise en soins.

Consensus statement on severe dementia

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary team including geriatritians, neurologists, epidemiologists, psychiatrists, pharmacologists and public health specialists developed a consensus on care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians and specialists based on knowledge available in 2005. At all stages of the disease, the objective of care is to improve as much as possible quality-of-life for the patient and his/her family, including a life project until the end of life. It is always possible to do something for these patients and their family: nutritional status, behavior disorders, and incapacities to deal with basic activities of daily life have to be taken in consideration. Resource allocation and proximity care have to be targeted. Research areas necessary to improve the care of patients with severe dementia has been selected.

Existe-t-il un sur-risque d’accidents médicamenteux chez les sujets âgés atteints de troubles cognitifs ?

Resume Les effets indesirables medicamenteux evitables sont actuellement une priorite de sante publique. Nous avons cherche a savoir si les personnes âgees presentant des troubles cognitifs avaient un risque medicamenteux augmente. Nous avons mene une enquete prospective chez des patients dements de 80 ans et plus (âge moyen 87 ± 4,9 ans) pendant 6 mois. Quatre-vingt deux dements (MMS moyen 15,8 ± 5,7) ont ete recenses. Nous avons comptabilise les effets indesirables medicamenteux evitables ayant pu conduire a leur hospitalisation et nous avons defini leur degre d’evitabilite. Quatre-vingt cinq pour cent des dements qui etaient hospitalises ne prenaient pas correctement leur traitement a domicile et 21 % des hospitalisations etaient directement dues a un effet indesirable medicamenteux evitable. On a constate qu’il y avait une sous-estimation de la demence, ceci conduisant a une aide insuffisante. Les types d’erreurs les plus frequents etaient l’oubli et le refus (38 % et 19 %). Les classes medicamenteuses les plus souvent incriminees etaient les psychotropes et les anticoagulants (31 % et 24 %). Les manifestations des accidents medicamenteux les plus frequentes etaient les troubles neuropsychiatriques (26 %) suivis des chutes (20 %). Il existe donc chez les personnes dementes un risque particulier d’accidents medicamenteux. Pour parer a ce phenomene le medecin doit insister sur la recherche de troubles cognitifs, prevoir un systeme d’aide suppleant ces derniers et reevaluer regulierement le traitement de ces personnes âgees.

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.

Traitement prophylactique de la maladie thromboembolique veineuse en soins palliatifs: Hétérogénéité des pratiques des médecins en réponse à 4 situations cliniques différentes

UNLABELLED There are no specific studies evaluating the benefit/risk of antithrombotic prophylactic treatment in patients hospitalised in a palliative care unit. So, the aim of this study was to evaluate the clinicians attitudes about antithrombotic prophylaxis for patients in palliative care units and the elements which determined their decisions. METHODS The clinical data of 4 terminally ill patients were extracted from database of a Palliative Care Unit in France. These 4 patients were selected as they represented several different situations according to the presence or not of major thrombotic risk factors, bleeding risk factors, and request of compassionate care. Through an open questionnaire, fourteen clinicians usually in charge of palliative care patients were individually interviewed about antithrombotic prophylactic therapy for each case of patients. RESULTS except in the case of a patient with major thrombotic risk factors, no bleeding risk factor and wishing to receive active care, both the attitudes of clinicians to initiate or continue a prophylactic therapy and the elements which lead to their decisions were heterogeneous at least. CONCLUSION the absence of recommendations based on validated clinical trials evaluating the efficacy and safety of thromboembolism prophylactic treatment in palliative care patients lead to uncertain decisions for clinicians. Added to an objective evaluation of thrombotic and hemorrhagic risks factors, the wish of patient to receive or not active care is probably the most important element to consider.