R. Mahmoudi

Potentially inappropriate use of psychotropic medications in hospitalized elderly patients in France: cross-sectional analysis of the prospective, multicentre SAFEs cohort.

AbstractBackground: In France, there is evidence to suggest that 50% of elderly individuals are prescribed psychotropic medications. However, it is known that use of these agents increases the risk of falls, fractures and delirium in older people. Objective: To study the consumption of ‘potentially inappropriate medication’ (PIM) among patients aged ≥75 years, paying particular attention to psychotropic drugs and the factors influencing the use of ‘potentially inappropriate psychotropics’ (PIPs). Method: This was a cross-sectional analysis of a prospective multicentre cohort of 1306 hospitalized French patients aged ≥75 years (the SAFEs [Sujet Âgé Fragile: Évaluation et suivi (Frail Elderly Subjects: Evaluation and follow-up)] cohort). The present analysis involved the 1176 patients for whom there was information on the usual treatments being taken in the 2 weeks before hospitalization. The drugs were coded according to the Anatomical Therapeutic Chemical classification; the Beers list as updated in 2003 defined which medications were considered PIPs. Standardized geriatric assessment variables were recorded on inclusion in the study. Logistic regression analysis was performed to identify factors linked to use of psychotropics and PIPs. Results: The mean number of drugs taken was 5.7 ± 2.9 per patient. Twenty-eight percent of patients took at least one PIM. The number of patients who had taken at least one psychotropic drug in the 2 weeks before hospitalization (mean 1.6 ± 0.9 psychotropics per patient) was 589 (50.1%). More than half of both the 510 patients with a depressive syndrome and the 543 patients affected by dementia were treated with psychotropics. Multivariate analysis showed that prescription of psychotropics was linked to the presence of a dementia syndrome (odds ratio [OR] = 1.4; 95% CI 1.1, 1.9; p = 0.03), the presence of a depressive syndrome (OR = 1.7; 95% CI 1.3, 2.1; p < 0.001), living in an institution (OR = 2.2; 95% CI 1.5, 3.4; p < 0.001), use of more than five drugs (OR = 3.2; 95% CI 2.5, 4.2; p < 0.001) and Charlson’s co-morbidity score >1 (OR = 0.6; 95% CI 0.5, 0.8; p = 0.001). Nineteen percent of all psychotropics prescribed were PIPs. Of these PIPs, 66.5% were anxiolytics, 28.4% were antidepressants and 5.1% were antipsychotics. Use of PIPs in the multivariate analysis was associated only with consumption of more than five drugs (OR = 1.7; 95% CI 1.1, 2.5; p = 0.01). Conclusion: PIM use is common among hospitalized older adults in France. The most important determinant of risk of receiving a psychotropic medication or a PIP was the number of drugs being taken. The elderly, who have multiple comorbidities, complex chronic conditions and are usually receiving polypharmacy, are at increased risk for adverse drug events. These adverse events are often linked to problems that could be preventable such as delirium, depression and falls. Regular review of prescriptions would help optimize prescription of psychotropics in the elderly. The Beers list is a good tool for evaluating PIMs but is too restrictive with respect to psychotropics; in the latter respect, the list could usefully be widened.

Factors Associated with Caregivers’ Underestimation of Quality of Life in Patients with Alzheimer’s Disease

Objective: The aim of this study was to identify the factors associated with differences between how Alzheimer’s disease (AD) patients and their caregivers rate the patient’s health-related quality of life (QoL). Methods: Cross-sectional, multicentre study. Patients were 65 years or more, suffering from mild to moderate AD, native French speakers, with a main caregiver. Interrater agreement of the QoL-AD was assessed using the intraclass coefficient. A generalised linear model was used to identify factors related to the difference in health-related QoL scores between patients and their caregivers. Results: The 122 patients of the study were 82 ± 6 years old and mainly women (69%). Independent factors related to the difference between patients and caregivers were: Mini Mental State Exam score (β = 0.32; 95% CI = 0.05–0.59); instrumental activities of daily living score (β = –0.61; 95% CI = –1.14 to –0.07); total Neuropsychiatric Inventory score (β = 0.10; 95% CI = 0.05–0.59), and Zarit’s burden score (β = 0.09; 95% CI = 0.01–0.17). Conclusion: Practitioners must take into account the trend towards underestimation when health-related QoL is rated by caregivers or proxies.

Adverse drug reactions in elderly patients with cognitive disorders: A systematic review.

Elderly subjects with cognitive disorders are at particularly high risk of adverse drug reactions (ADRs). The objectives of our systematic review were to describe the prevalence of ADRs in elderly patients with cognitive disorders, the different types of ADRs and the medications suspected of involvement; to describe whether the ADRs were preventable or not, and to identify risk factors for occurrence of ADRs in this population. A bibliographic search was performed in the following databases: PubMed, Embase, Google Scholar, Opengrey and Scopus. The search included all publications up to and including 4th February 2015, with no specific start date specified. Studies concerning ADRs in elderly patients with cognitive disorders or dementia were included. Two senior authors identified eligible studies and extracted data independently. In total, 113 studies were identified by the bibliographic search, of which six full-text articles were retained and analyzed. Prevalence of ADRs ranged from 4.8 to 37%. The main ADRs reported were neurological and psychological disorders, gastro-intestinal disorders, dermatological and allergic disorders, falls, renal and urinary disorders, cardiovascular disorders, metabolic disorders and electrolyte imbalance, and hemorrhagic events. The medications most commonly suspected of involvement in the ADRs were drugs affecting the nervous system, cardiovascular drugs, anticoagulants, and painkillers. Medical prescriptions should take into account the presence of Alzheimers disease and related syndromes. Compliance should systematically be evaluated, and cognitive disorders need to be better recognized. Therapeutic education of patients and/or their caregiver is key to management of elderly patients with cognitive disorders.

Alzheimer's disease is associated with low density of the long CR1 isoform

The long complement receptor type 1 (CR1) isoform, CR1*2 (S), has been identified as being associated with Alzheimers disease (AD) risk. We aimed to analyze the phenotypic structural and expression aspects (length and density) of CR1 in erythrocytes of 135 Caucasian subjects (100 AD and 35 controls). CR1 length polymorphism was assessed at protein and gene levels using Western blot and high-resolution melting, respectively. CR1 sites on erythrocytes were enumerated by flow cytometry. CR1 gene analysis, spotting the rs6656401 and rs3818361 polymorphisms, was performed by pyrosequencing. The CR1 density was significantly lower in AD patients expressing the CR1*2 isoform compared with the controls (p = 0.001), demonstrating lower expression of CR1 in CR1*2 carriers. Our data suggested the existence of silent CR1 alleles. Finally, rs6656401 and rs3818361 were strongly associated with CR1 length polymorphism (p < 0.0001). These observations indicate that AD susceptibility is associated with the long CR1 isoform (CR1*2), albeit at a lower density, suggesting that AD results from insufficient clearance of plaque deposits rather than increased inflammation.

Is obesity a marker of robustness in vulnerable hospitalized aged populations? Prospective, multicenter cohort study of 1 306 acutely ill patients

BackgroundThe “obesity paradox” is poorly understood in vulnerable older hospitalized populations.ObjectivesTo prospectively analyze the impact of body mass index (BMI) and comorbidities on early (6-week), one- and two-year mortality.DesignProspective multicenter study with a two-year follow-up of old patients participating in the SAFES cohort study.SettingsNine university hospitals in France.ParticipantsPatients aged 75 or older hospitalized in medical divisions through the emergency department.MeasurementInpatients’ characteristics were obtained through a comprehensive geriatric assessment of inpatients, conducted in the first week of hospitalization. All-cause mortalities at 6-week, one- and two-year were determined using bivariable and multivariable Cox proportional hazard model.ResultsThe SAFES cohort included 1,306 patients, aged 85±6 years, with a majority of women (65%). One- and two-year mortality were inversely associated with BMI ≥30 kg/m2 while early mortality was not, and positively associated with age, burden of comorbidities, walking disorders, level of dependency and presence of a dementia syndrome. Survival rates between patients in low (< 18.0 kg/m2) and intermediate (18–24.9 and 25–29.9 kg/m2) BMI categories were not significant.ConclusionWhile our findings seem to confirm the reality of the “obesity paradox” in vulnerable older hospitalized population, the exact understanding of underlying mechanisms and even the truthfulness of this paradoxical relationship are still fraught with considerable methodological, epidemiological and metabolic challenges.

Facteurs prédictifs de mortalité à long terme chez des patients âgés de 75 ans ou plus hospitalisés en urgence : la cohorte SAFES

OBJECTIVES To identify the factors predictive of long-term mortality among a cohort of subjects aged 75 years or older hospitalized from the emergency department. METHODS Variables from the standardized geriatric assessment of members of the multicenter SAFES cohort were applied to a Cox model to predict mortality over a 3-year follow-up. RESULTS This cohort comprised 1306 patients with a mean age of 85+/-6 years. Half the patients died during the 3 years of follow-up. After adjustment for center, social and demographic variables (age, sex, educational level, and community or institutional residence) and level of comorbidity, the variables that significantly influenced mortality over the next 36 months were: severe malnutrition (p<0.03), dementia (p<0.001) and/or confusion (p<0.001), walking problems (p=0.001) and recent hospitalization (p<0.001). No significant association was found between depression and mortality (p=0.40). CONCLUSION A predictive approach to mortality at 3 years is possible with simple scales widely used in geriatrics. Correction of malnutrition, recognition and management of cognitive disorders, and functional rehabilitation must be included in the priorities of care.

Screening for frailty in elderly subjects living at home: Validation of the modified Short Emergency Geriatric Assessment (SEGAm) instrument

OBJECTIVES To validate the modified version of the Short Emergency Geriatric Assessment (SEGAm) frailty instrument in elderly people living at home. DESIGN Longitudinal, prospective, multicentre study. SETTING Four departments (Ardennes, Marne, Meurthe-et-Moselle, Meuse) in two French Regions (Champagne-Ardenne and Lorraine). PARTICIPANTS Subjects aged 65 years or more, living at home, who could read and understand French, with a degree of autonomy corresponding to groups 5, or 6 in the AGGIR autonomy evaluation scale. MEASUREMENTS Assessment included demographic characteristics, comprehensive geriatric assessment, and the SEGAm instrument. Psychometric validation was used to study feasibility and acceptability, internal structure validity, reliability, and discriminant validity of the SEGAm instrument. RESULTS Between July 1st 2012 and March 31st 2013, 167 patients were included in the study. Averaged age was 77±7 years, the majority were women (70.7%). Feasibility and acceptability of the SEGAm instrument were excellent: we observed no refusal to participate, no drop-out during administration, no missing items, no ceiling or floor effects, and the administration time was short (5.0±3.5 min). By factor analysis, the instrument proved to be unidimensional. It showed good internal consistency (Cronbachs alpha coefficient: 0.68) and good test-retest (intra-class correlation: 0.88) at 7 days interval. Discriminant validity showed a significant difference, mainly for nutritional status, fall risk, dependency, mood and depression risk, and comorbidities. CONCLUSION Based on these psychometric properties, the SEGAm appears to be an easy-to-use instrument that is particularly suitable for use in the community to identify frail elderly people who could benefit from early targeted interventions.

Is health-related quality of life an independent prognostic factor for 12-month mortality and nursing home placement among elderly patients hospitalized via the emergency department?

OBJECTIVES To assess whether health-related quality of life is an independent prognostic factor for mortality or nursing home placement in frail elderly patients. DESIGN A prospective, multicenter study with a 12-month follow-up. SETTING Nine French hospitals. PARTICIPANTS A total of 1306 patients aged 75 and older hospitalized through an emergency department. MEASUREMENTS Data obtained from sociodemographic characteristics, Comprehensive Geriatric Assessment and the Duke Health Profile (DHP) were used into a Cox model to identify prognostic variables for 12-month mortality and institutionalization. RESULTS Crude mortality and nursing home placement rates were 34.1% (n = 445) and 16.1% (n = 210), respectively. Independent prognostic factors identified for mortality were: Comorbidity level (moderate: hazard ratio [HR] [95% confidence interval (CI)] = 1.40 [1.09-1.78]; severe: 2.70 [1.63-4.46]), dependence for activities of daily living (1.68 [1.06-2.67]), pressure sore risk (1.49 [1.16-1.90]), risk of malnutrition (2.09 [1.46-3.00]), delirium (2.25 [1.75-2.90]), and 10-point increase in the DHP perceived health score (0.96 [0.93-0.99]). Independent prognostic factors identified for nursing home placement were the following: living alone at home (1.82 [1.30-2.55]), having 2 children or more (0.71 [0.51-0.99]), dependence for activities of daily living (2.48 [1.39-4.44]), dementia (1.93 [1.39-2.69]), unplanned hospital readmission during follow-up (2.05 [1.45-2.91]), and 10-point increase in the DHP social health score (0.90 [0.83-0.99]). Balance troubles and risk of malnutrition were no more significant when adjusted for the DHP scores and other clinical variables. CONCLUSION The perceived health and social health scores of the DHP were independent prognostic factors of survival and nursing home placement among hospitalized elderly patients, respectively. When associated with Comprehensive Geriatric Assessment, they could help screen frail patients to set up as early as possible targeted interventions to restore/maintain modifiable prognostic factors, such as nutritional status, functional ability, and social support.

Comparison of QoL-AD and DQoL in elderly with Alzheimer's disease

Objective: The Dementia Quality of Life (DQoL) and the Quality of Life in Alzheimers Disease (QoL-AD) are the two most widely used dementia-specific QoL instruments in the world. We aimed to compare the psychometric properties of these two instruments and identify which is most adapted to use in geriatric consultations. Methods: To evaluate the psychometric properties of the French language validation of DQoL and QoL-AD, 123 patients aged 65 years and over suffering from AD (Mini Mental State Examination score ≥10) were recruited in seven French hospitals and one Switzerland hospital. The DQoL comprises 29 items, ranked on a five-point Likert scale and measuring five QoL domains: self-esteem, positive affect, negative affect, feeling of belonging and sense of aesthetics. The QoL-AD contains 13 items giving an overall score ranging from 13 to 52 and evaluating the domains of interpersonal relationships, financial difficulties, physical condition, memory, mood and overall health. Results: Both questionnaires showed adequate reproducibility at 2 weeks interval (intra-class correlation coefficient >0.80), good internal consistency (Cronbachs alpha coefficient >0.70) and good convergent validity with the general health dimension of the Duke Health Profile. The time required to complete the QoL-AD was significantly shorter (p < 0.0001). DQoL had better discriminant capacity (with at least one dimension significant for each subgroup of severity of cognitive decline, dependency, presence of depression or behavioural disorders). Conclusions: For quick evaluation of QoL during consultations in geriatric care, the QoL-AD is preferable, whereas for the purposes of research and more in-depth evaluation, the DQoL is more suitable.

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.