Sandra De Breucker

Could Geriatric Characteristics Explain the Under-Prescription of Anticoagulation Therapy for Older Patients Admitted with Atrial Fibrillation?: A Retrospective Observational Study

AbstractBackground Anticoagulation therapy with anti-vitamin K (AVK; vitamin K antagonist) for the prevention of thromboembolism in patients with atrial fibrillation (AF) is based on information derived from numerous well constructed, randomized controlled trials. Despite this conclusive evidence of efficacy, several studies have shown that ‘real world’ use of AVK in patients with AF is suboptimal. Our hypothesis was that geriatric characteristics (functional impairment, cognitive disorders, malnutrition, risk for falls, depression) could be an explanation for the underprescription of AVK in older patients with AF. Objective To analyse the barriers to the prescription of AVK therapy, with special attention on geriatric characteristics. Methods This was a retrospective study of 768 consecutive geriatric patients admitted to an acute geriatric unit of an academic hospital between April 2006 and November 2008. Data from comprehensive geriatric assessments were collected from computerized medical charts. Results Analysis of data from the 768 medical charts showed that 111 patients (14%) presented with AF. Among the 111 patients (72% women), 45% were living in an institution before admission. These patients presented a high prevalence of geriatric syndromes: cognitive disorders 59%, malnutrition risk 59%, incontinence 35%, depression 37%, and falls 61%. Ninety percent of the patients had an Identification of Seniors At Risk (ISAR) questionnaire score ≥2, which indicates an increased risk of frailty and functional decline during hospitalization. The prevalence of conditions measured by the CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus and previous stroke or transient ischaemic attack [TIA]) clinical prediction scale was as follows: heart failure 19%, hypertension 79%, age >75 years 95%, diabetes 15% and stroke 24%. The mean ± SD number of daily classes of drugs received at admission was 7.1±3.3 (median 7, range 0–20). Forty-nine percent of patients had not received any AVK treatment before admission. The level of functional dependence for basic and instrumental activities of daily living did not differ between patients receiving AVK before admission and those not receiving AVK. Similarly, the proportion of geriatric problems (cognitive, malnutrition, depression and falls) did not differ between these two groups. To determine whether the decision to administer AVK therapy before admission was influenced by the risk of an embolic stroke, determined by the presence of CHADS2 conditions, we compared the proportions of patients who fulfilled those conditions in each group: again, no difference was found. Conclusions Almost half of the patients presenting with AF did not receive any AVK therapy before admission. In this population, in which most patients had multiple impairments, no single impairment or geriatric characteristic was identified as a barrier to AVK use. It is possible that combinations of impairments and geriatric characteristics were barriers to the prescription of AVK therapy across the whole of this population. More research is needed to identify and clarify the relative importance of patient-, physician- and healthcare system-related barriers to the prescription of AVK therapy in older patients with AF.

Frailty in old age is associated with decreased interleukin-12/23 production in response to toll-like receptor ligation.

Aging is associated with progressive alterations of immune functions, leading to higher susceptibility to bacterial and viral infections and reduced vaccine responses. Data concerning cytokine production in response to Toll-like receptor (TLR) ligands are highly variable in old people, reflecting the heterogeneity of the geriatric population. The aim of our study was to define the relative contribution of age and clinical status on TLR-induced interleukin (IL)-12p70 and IL-23 production as these cytokines play an important role in the protection against intracellular and extracellular pathogens, respectively. For this purpose, we recruited 100 subjects (aged 23–96 years) in the general population or hospitalized for chronic diseases. We collected information on clinical status (medical history, ongoing comorbidities, treatments and geriatric scales), biological parameters (biochemical and hematological tests, telomere length determination, cytomegalovirus serology). Whole blood samples were stimulated with a combination of TLR4 and TLR7/8 ligands. We performed univariate and stepwise backward multivariate analyses regression to define which set of clinical variables could be predictive for IL-12p70 and IL-23 production in these conditions. Our results indicated that age was not correlated with TLR-mediated IL-12p70 and IL-23 production. In contrast, poor nutritional status and frailty in subjects >75 years were associated with decreased IL-12p70 and IL-23 production. By intracytoplasmic staining, we confirmed that production of IL-12/23p40 by conventional dendritic cells (DCs) upon TLR ligation was decreased in frail patients. However, proportion of DCs and monocytes subsets, phenotypic maturation and proximal signaling events were found to be comparable in frail and healthy old subjects. These results suggest the importance of age-associated clinical parameters and not age by itself in the alteration of innate immune responses in old individuals and emphasis the importance of innate immune responses in the susceptibility of frail geriatric patients to infections.

Correlates of Unrecognized Depression Among Hospitalized Geriatric Patients

Objectives. The goal of this study was to assess the level and analyze the determinants of under-recognition of symptomatic depression by geriatricians in hospitalized geriatric patients. Methods. This was a prospective study of 155 patients who were consecutively hospitalized in the geriatric unit of an academic hospital. The diagnosis of symptomatic depression was established, in a parallel blinded manner either by one psychogeriatrician using a geriatric depression scale and the DSM-IV criteria for depression or by one geriatrician using a global assessment score included in a comorbidity index or by both. Results. The psychogeriatrician diagnosed symptomatic depression in 67 of the 155 patients (43%). In contrast, the geriatrician identified symptomatic depression in 29 (19%) of the 155 patients, one of whom was not diagnosed with depression by the psychogeriatrician. Thus the geriatrician failed to identify 39 patients who were diagnosed with depression by the psychogeriatrician. Conclusions. In this study of hospitalized geriatric patients, a geriatrician failed to recognize more than half of those who were diagnosed with symptomatic depression by a psychogeriatrician. Uncontrolled comorbidity and therapeutics may be misleading factors in diagnosing depression. The presence of a psychogeriatrician in a geriatric unit could prevent underestimation of depressive symptoms among geriatric patients.

Study of the association of total and differential white blood cell counts with geriatric conditions, cardio-vascular diseases, seric IL-6 levels and telomere length

BACKGROUND/OBJECTIVES Geriatric patients are highly susceptible to infections. While reduced lymphocyte count has been associated with age, other studies found no change in WBC counts with age. Increased circulating white blood cell (WBC) count has been associated with cardiovascular (CV) diseases and frailty but there are discrepancies. Frailty, geriatric conditions, cardiovascular diseases and WBC count have also been associated with low grade inflammation. Association between geriatric conditions and WBC has been scarcely studied. The aim of the study is to assess the association between WBC and geriatric conditions, CV diseases, and seric IL-6 levels. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS We recruited 100 subjects in the general population and hospitalized for chronic medical conditions (age, 23-96years). We collected information on clinical status (medical history, comorbidities, treatments and geriatric syndromes), biological parameters (hematological tests, cytomegalovirus serology) and cytokine production (basal IL-6). Using stepwise backward multivariate analyses, we defined which set of clinical and biological variables could be predictive of increased total and differential WBC counts. RESULTS We found that low-grade inflammation is independently associated with total WBC, monocyte and neutrophil counts, but not geriatric conditions. CV diseases were the only significant associated factor for high monocyte count. CONCLUSION In this study, we observed that differential and total WBC counts do not seem to be associated with geriatric conditions but with CV diseases, low-grade inflammation and telomere length.

Comprehensive geriatric assessment and comorbidities predict survival in geriatric oncology

Objectives: The comprehensive geriatric assessment (CGA) can detect geriatric problems and potentially improve survival, physical, and cognitive state of patients, as well as increase an older person’s chances of staying at home longer. In older people, the number and severity of comorbidity increase with age and are an important determinant of survival. The aim of the study was to assess to which extent CGA and comorbidities could be seen as determinants of survival. Materials and methods: This study analyzed data from two hospitals that included geriatric assessments of patients aged 70 years and more with cancer linked to mortality. Logistic regression was used to model survival predictors. Results: Two hundred and five various cancer patients (47% females) with a median age of 79 were included. They presented with a lot of undiagnosed geriatric problems. Screening scales (G8, SEGA), cognitive, and psychological disorders, and low albumin levels appeared to be independent survival factors. A frailty profile classification was associated with higher mortality. The average comorbidity was graded 2 according to the Charlson scale. By the geriatric cumulative illness rating scale (CIRS-G), the arithmetic average number of affected organ systems was 5 (range 0–10) in all patients. Cardiovascular disorders were the most common comorbidity. Renal insufficiency and anaemia were negatively associated with survival. Conclusion: Old cancer patients present a lot of comorbidities and newly diagnosed geriatric problems. Several tools provide determinants of survival in old cancer patients. Prospective trials evaluating the utility of a CGA to guide interventions to improve quality of cancer care in older adults are justified.

Increased Basal and Alum-Induced Interleukin-6 Levels in Geriatric Patients Are Associated with Cardiovascular Morbidity

Background/Aim of the study Low-grade systemic inflammation was suggested to participate to the decline of physiological functions and increased vulnerability encountered in older patients. Geriatric syndromes encompass various features such as functional dependence, polymorbidity, depression and malnutrition. There is a strong prevalence of cardiovascular diseases and related risk factors and chronic cytomegalovirus infections in the geriatric population. As these underlying conditions were proposed to influence the inflammatory state, the aim of this study was to assess their potential contribution to the association of geriatric syndromes with inflammatory parameters. Methodology We recruited 100 subjects in the general population or hospitalized for chronic medical conditions (age, 23-96 years). We collected information on clinical status (medical history, ongoing comorbidities, treatments and geriatric scales), biological parameters (hematological tests, cytomegalovirus serology) and cytokines production (basal and alum-induced interleukin (IL)-1β and IL-6 levels). Using stepwise backward multivariate analyses, we defined which set of clinical and biological variables could be predictive for increased inflammatory markers. Principal Findings We confirmed the age-associated increase of circulating IL-6 levels. In contrast to geriatric scales, we found history of cardiovascular diseases to be strongly associated for this parameter as for high IL-6 production upon ex vivo stimulation with alum. Conclusions Association between low-grade inflammation and geriatric conditions could be linked to underlying cardiovascular diseases.

The Use of Mobile Games to Assess Cognitive Function of Elderly with and without Cognitive Impairment.

BACKGROUND In the past few years numerous mobile games have been developed to train the brain. There is a lack of information about the relation between the scores obtained in these games and the cognitive abilities of the patients. OBJECTIVE The aim of this study was to determine whether or not mobile games can be used to assess cognitive abilities of elderly. METHODS Twenty healthy young adults, 29 old patients with cognitive impairments (Mini-Mental State Exam (MMSE) [20- 24]) and 27-aged controls participated in this study. Scores obtained in 7 mobile games were correlated with MMSE and the Addenbrookes Cognitive Evaluation revised (ACE-R). RESULTS Statistically significant differences were found for all games between patients with cognitive impairments and the aged controls. Correlations between the average scores of the games and the MMSE and ACE-R are significant (R = 0.72 [p < 0.001] and R = 0.81 [p < 0.001], respectively). CONCLUSION Scores of cognitive mobile games could be used as an alternative to MMSE and ACE-R to evaluate cognitive function of aged people with and without cognitive impairment at least when MMSE is higher than 20/30.

Baseline hepcidin measurement in the differential diagnosis of anaemia for elderly patients and its correlation with the increment of transferrin saturation following an oral iron absorption test

Abstract Background Anaemia is often multifactorial in the elderly, with a frequent association between iron deficiency anaemia (IDA) and anaemia of chronic disease (ACD). The primary objective of our study was to investigate whether baseline hepcidin measurement could be useful for identifying iron deficiency (ID) in anaemic elderly patients. The secondary objective was to assess whether baseline hepcidin concentrations correlated with the relative increase of transferrin saturation (TS) after an oral iron absorption test (OIAT). Methods Blood samples were collected between 7:30 am and 10:00 am in 328 geriatric outpatients, 102 underwent the OIAT. Types of anaemia were classified according biochemical and clinical criteria. TS and hepcidin were measured at baseline and 4 h after the iron dose. The ability of baseline hepcidin measurement to highlight ID in elderly anaemic patients was assessed using a receiver operator curve (ROC) analysis. Correlations between baseline hepcidin levels and the increment of TS following the OIAT were investigated using the Spearman coefficient. Results Among 328 included patients, 78 (23.8%) suffered from anaemia; 13 (4.0%), 19 (5.8%), 27 (8.2%) and 19 (5.8%) patients fulfilled criteria for IDA, IDA/ACD, ACD and unexplained anaemia, respectively. By multivariable analysis, creatinine, C-reactive protein, ferritin, Delta TS and Delta hepcidin were independently associated with baseline hepcidin concentrations. The area under the ROC curve (95% confidence interval) was 0.900 (0.830–0.970) for baseline hepcidin measurement. Baseline hepcidin levels correlated negatively with the relative increase in TS with a Spearman coefficient of −0.742. Conclusions Baseline hepcidin levels could be a useful tool to identify ID in anaemic elderly patients and may predict acute iron response following OIAT.

An exceptional cause of hemoptysis in the elderly patient : IgA vasculitis

ABSTRACT We describe here the case of a 73-year-old woman who presented a recurrent macular rash, acute respiratory distress, and hemoptysis. Chest CT scan showed diffuse ground-glass opacities that were suggestive of alveolar hemorrhage. With the development of severe acute kidney injury and nephrotic-range proteinuria (creatininemia 2.6 from 1.9 mg/dL with overt proteinuria 34 from 2.1 g/g creat), a kidney-lung syndrome was evoked. Skin biopsy revealed leukocytoclastic vasculitis with IgA deposits. Blood tests showed an increased IgA level. Those findings were consistent with a rare form of IgA vasculitis (formerly Henoch-Schönlein syndrome), the originality of the case lying in the occurrence of a kidney-lung syndrome in an elderly patient.

Massive subdural haematoma and dementia: a "yin and yang" paradigm.

Massive subdural haematoma and dementia: a “yin and yang” paradigm An 85-year-old man with a 2-year history of cognitive decline and falls, and signs of brain atrophy on previous computed tomography imaging, presented with severe drowsiness. Axial and coronal non-contrasted cerebral computed tomography images (Figure, A and B respectively) showed massive bi-hemispheric acute (hyperdense) and chronic (hypodense) subdural haematoma, with extensive parenchymal compression. Dementia is strongly associated with brain atrophy and frequent falling, both of which are risk factors for subdural bleeding1 caused by stretching and tearing of subdural veins2. The formation of a subdural haematoma can have further adverse effects in terms of cognitive decline. Surgical decompression of the subdural haematoma led to progressive improvement of the patient’s neurological status in the following weeks. The axial image resembles the black and white “yin and yang” symbol, which is conceptually relevant to the patient’s clinical history of subdural haematoma and dementia — two interdependent entities giving rise to each other. 