Sandrine Sourdet

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.

Preventable Iatrogenic Disability in Elderly Patients During Hospitalization.

BACKGROUNDnIn older patients, hospitalization is often associated with new or worsening disability. This hospitalization-associated disability may be explained in part by the cumulative effect of aging, frailty, comorbidities, and illnesses that led to hospitalization but may also result from health care management issues and the hospital environment. Our objective was to determine the frequency, causes, and the preventability of disability induced by the processes of care or iatrogenic disability.nnnMETHODSnA total of 503 patients, aged 75 years and older, hospitalized in the 105 medical and surgical units of Toulouse University Hospital between October 2011 and March 2012, with a minimal length of stay of 2 days, were included. Hospitalization-associated disability was defined as a loss of 0.5 points or more in the Katz Activity of Daily Living Score between the time of hospital admission and discharge. To determine the iatrogenic component of hospitalization-associated disability, an expert panel in geriatric medicine reviewed each medical chart using a standardized record review and identified precipitating iatrogenic adverse events resulting in functional decline.nnnRESULTSnIncidence of iatrogenic disability was 11.9% (95% confidence interval, 9.2%-15.1%). Of the 60 cases of iatrogenic disability, 49 (81.7%, 95% confidence interval, 69.6%-90.5%) were judged to be potentially preventable. The most common health management issues identified in patients with preventable iatrogenic disability were low mobilization [by excessive bed rest (26.5%) and lack of physical therapist intervention (55.1%)], overuse of diapers (49.0%), and transurethral urinary catheterization (30.6%).nnnCONCLUSIONSnThe present study suggests that a significant proportion of hospitalization-associated disability may be induced by iatrogenic events, and that most of them are potentially preventable. Health care professionals need to be educated on the specific needs of elderly hospitalized patients and should consider hospitalization-associated disability as an outcome of care.

Exposure to Atropinic Drugs and Frailty Status

BACKGROUNDnAtropinic 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.nnnMETHODSnWe 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).nnnRESULTSnWe 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).nnnCONCLUSIONSnIn a geriatric day hospital, population frailty is associated with a high atropinic burden.

Apathy as a feature of prodromal Alzheimer's disease: an FDG-PET ADNI study†

The goal of this study is to evaluate brain metabolism in mild cognitive impairment (MCI) patients with and without apathy (as determined by the Neuropsychiatric Inventory Questionnaire).

Associated Factors With Antipsychotic Use in Long-Term Institutional Care in Eight European Countries: Results From the RightTimePlaceCare Study

OBJECTIVESnTo determine factors associated with the antipsychotic (AP) prescription for people with dementia (PwD) recently admitted to institutional long-term care facilities (LTCFs) and to ascertain differences in the use of this medication in 8 European countries.nnnDESIGNnAn exploratory cross-sectional study.nnnSETTINGnLTCFs from 8 European countries (Estonia, Finland, France, Germany, The Netherlands, Spain, Sweden, and England).nnnPARTICIPANTSnA total of 791 PwD recently admitted to an LTCF and their caregivers.nnnMEASUREMENTSnBaseline data from RightTimePlaceCare survey was used. Patients medical conditions, neuropsychiatric symptoms, physical and cognitive status, and medications were recorded. Multiple logistic regression models were used to assess associations with the AP use.nnnRESULTSnA group of 296 patients (37.4%) of 791 patients recently admitted received AP medication. The prevalence of the use of 1 or more APs varied between study countries, ranging from 12% in Sweden to 54% in Spain. Factors independently associated with the AP use were living in Sweden [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.05-0.30], Finland (OR 0.26, 95% CI 0.14-0.48), Germany (OR 2.75, 95% CI 1.55-4.86) and Estonia (OR 6.79, 95% CI 3.84-12.0). The odds of AP use decreased with the presence of a dementia specific unit in the LTCF (OR 0.60, 95% CI 0.39-0.92), but was higher among residents with a hyperactivity behavior (OR 2.12, 95% CI 1.41-3.18).nnnCONCLUSIONnThe current study shows that more than one-third of the residents recently admitted received APs and that prescription frequency across countries varied significantly. This study raises the possibility that the presence of a dementia-specific unit might play a role in the AP use. Further studies should investigate this association and seek better understanding of what will achieve optimal quality of AP use among newly admitted residents in LTCF.

Descriptive analysis of hospitalizations of patients with Alzheimer’s disease: A two-year prospective study of 686 patients from the REAL.FR study

OBJECTIVESnThere is lack of data on the frequency and the causes of hospitalization in mild to moderate Alzheimers disease (AD) patients. The aims of the present study were to evaluate the frequency and the causes of hospitalization in a large prospective cohort of mild to moderate patients with AD.nnnDESIGNnSix hundred and eighty-six AD patients from the French Network on AD (REAL.FR) were followed up and assessed every 6 months for 2 years. During follow-up, all events occurring between two visits, in particular hospital admissions or nursing home placements were carefully recorded.nnnRESULTSnAnnual incidences for hospitalizations were 26.2% (95% CI, 22.5 to 29.7). After two years, 202 subjects were hospitalized for 296 hospitalizations. 139 subjects were hospitalized once, 40 twice, 13 three times, 4 four times and 2 five times during the two-year follow-up. The duration of hospitalization was 14.3 +/- 23.5 days. For repeated hospitalizations, the time interval between the first and the second hospitalization was 176.4 days (SD 150.2) and the cause of multiple hospitalizations was most different. Fractures and falls not causing fracture were the main reasons for hospital admission (20.9%), followed by cardiovascular disorders (14.5%) and by behavioural disorders (11.0%). Admission due to associated diseases or life events was the main reason for hospitalization (75.7%).nnnCONCLUSIONSnHospitalization is a frequent event for AD patients even at mild to moderate stage of the disease. In this cohort, the major causes for hospital admission were due to associated diseases or life events and not due to the direct consequences of the disease itself.

Frailty and aging

Aging is associated with functional decline and loss of autonomy, and age is a major risk factor for a wide spectrum of clinical conditions, including cardiovascular disease, cognitive impairment, and physical disability. As life expectancy continues to rise, the maintain of physical functioning advanced age has emerged as a major clinical and public health priority. It is estimated that by 2025, 1.2 billion people worldwide will be over 60 years old, with similar prevalence in Europe. In France, men and women aged 50 years old can expect to live free of disability respectively for another 18.0 years and 19.7 years. These data are similar among all 25 EU countries where healthy aging in men and women is expected until age 67 and 68 years, respectively. However, in adults age 50 years and older, approximately 40% of men and 46% of women, will experience some functional limitation. Frailty has been operationally defined by Fried and colleagues based on a phenotypic definition in older adults. From a clinical perspective, frailty is marked by three or more of the following criteria: unintentional weight loss in the past year (>4 kg), self-reported exhaustion, weakness (measured by loss of grip strength), slow walking speed, low physical activity. The term frailty is commonly used to indicate a state of high vulnerability to negative health-related outcomes, such as falls, physical and cognitive decline, hospitalization, physical disability, and mortality. Clinically, frailty is a loss of functional homeostasis resulting in a pathophysiological state characterized by the accumulation of molecular, cellular, and tissue damage in different organ systems. When function has already been lost due to injury or illness, frailty can confound the loss and lead to disability. Frailty and functional decline are frequent consequences of aging, but their etiologies remain unclear. Older adults may experience progressive decline in function and develop disabilities without any clinical explanation. The frailty syndrome is possibly a result of the early stages and non-specific symptoms of both age-related diseases and complex pathophysiological processes not yet identified. Thus, early interventions aimed at preventing the progression of frailty and disability are critical in older adults. An intermediate status, pre-frail, is characterized by the presence of one or two of the criteria defined above. Pre-frail older adults are at an increased risk of adverse outcomes, as well as increased risk of meeting criteria for frailty in three to four years. Together, pre-frail and frail adults represent almost half of the population aged 60 and older. In France and other countries of the EU, previous epidemiological studies have reported rates of frailty and pre-frailty in approximately 15% and 50% in community-dwelling adults aged 65 years and older, respectively. Although these groups are at an increased risk for disease and disability, they are also the most to benefit from interventions. More specifically, interventions designed for older adults with pre-frailty might reduce the risk of progression to a more serious condition. Given the global trend of an aging population, increased efforts are necessary to identify ways to better predict risk of frailty and interventions to prevent the occurrence of frailty in the elderly. Frailty is a medical syndrome characterized by multiple changes and deficits in different biological systems, including sarcopenia (i.e., the loss of both muscle mass and strength), osteoporosis (i.e., low bone mineral density), neuroendocrine and metabolic dysregulation, elevation in inflammatory factors, malnutrition, and cardiovascular abnormalities. Some of these manifestations have been largely studied in older adult populations. For instance, a slow gait speed is a criterion for the diagnosis of sarcopenia. People with slow gait speed have also been found to be more likely to exhibit several other age-related diseases (e.g., Mild Cognitive Impairment and osteoporosis). Thus, gait speed can be used as a reliable measure for frailty. Despite the empirical evidence for certain biological etiologies for frailty, there are many factors that warrant further investigation to better understand their role in aging and frailty in older adults. For example, Kaya and Saurat demonstrated that dermatoporosis, a condition of frail aging skin, frequently occurs in older adults, and more specifically in those who are frail. It is possible to restore the function of the skin after dermatoporosis begins; however, if it is left untreated it can produce ulceration and hypercatabolism. It can also contribute to pain, functional impairment, slow gait speed, and further disability. Frailty and concurrent age-related diseases are key targets for the prevention of disability in older age. Nearly half of adults over 50 are at risk of developing some functional limitations, however, healthy aging is possible well beyond this age and into later life. Although some functional decline is expected during the aging process, older adults are at higher risk of developing diseases and disabilities associated with changes that occur with aging. Established criteria have improved our ability to identify frailty and pre-frailty, yet there are no empirically supported interventions to delay or prevent this syndrome. Continuous efforts and well-designed intervention studies are needed to reduce frailty and consequent disability in our rapidly increasing aging population. Language: en

The association between physical dependency and the presence of neuropsychiatric symptoms, with the admission of people with dementia to a long-term care institution: A prospective observational cohort study.

BACKGROUNDnDementia is a progressive neurological disorder that causes a high degree of dependency. This dependency has been defined as an increased need for assistance due to deterioration in cognition and physical functioning, and changes in behavior. Highly dependent people with dementia are more likely to be institutionalized.nnnOBJECTIVESnTo investigate the association between specific categories of physical dependency and the presence of neuropsychiatric symptoms in people with dementia admitted to a long-term care institution.nnnDESIGNnA prospective observational cohort study.nnnSETTINGSnHome care and long-term care institutions in eight European countries.nnnPARTICIPANTSnPeople with dementia living at home but at risk of institutionalization and recently institutionalized people with dementia.nnnMETHODnBaseline and 3-month follow-up interviews were performed between November, 2010 and April, 2012. The sample consisted of 116 recently institutionalized dementia sufferers and 949 people with dementia still living at home. Physical dependency was measured using the Katz Activity of Daily Living index, and neuropsychiatric symptoms were assessed through The Neuropsychiatric Inventory. Specific categories of dependency were analyzed by performing a logistic regression analysis. This followed examination of baseline characteristics to define the degree of physical dependency, as factors associated with institutionalization, and evaluation of the same characteristics at 3-month follow-up to detect changes in the degree of physical dependency and neuropsychiatric symptoms associated with recent admission to a long-term care institution.nnnRESULTSnToileting, dressing and continence dependency was higher in institutionalized people than in those receiving home-care. Delusion, hallucination, agitation, anxiety, apathy, motor-disturbances, night-time behavior and eating disorders were also worse in the institutionalized. Logistic regression analysis showed that independent factors significantly associated with being recently institutionalized were toileting (odds ratio=2.3; 95% confidence interval=1.43-3.71) and motor disturbances (odds ratio=1.81; 95% confidence interval=1.15-2.87).nnnCONCLUSIONSnThis study supports the association between type and degree of physical dependency in people with dementia and long-term institutionalization. Institutionalization is associated with physical dependency and the presence of neuropsychiatric symptoms.

Potentially inappropriate prescribing in a population of frail elderly people

Background Frailty is a clinical syndrome highly predictive of functional decline after a stress or a medical event, such as adverse drug events. Objective To describe the prevalence of potentially inappropriate prescribing in a population of frail elderly patients. Setting Geriatric day hospital for assessment of frailty and prevention of disability, Toulouse, France. Method A cross-sectional study performed from January to April 2014. Two pharmacists retrospectively analyzed the prescriptions of elderly patients who were sent to the day hospital to assess their frailty and to be given a personalized plan of care and prevention. Potentially inappropriate prescribing was defined by combining explicit criteria: Laroche list, screening tool of older people’s prescriptions, and screening tool to alert to right treatment with an implicit method (drug utilization review for each medication). Prescriptions’ optimizations were then suggested to the geriatricians of the day hospital and classified according to criteria defined by the French Society of Clinical Pharmacy. Main outcome measure Prevalence of potentially inappropriate prescribing. Results Among the 229 patients included, 71.2% had potentially inappropriate prescribing. 76 patients (33.2%) had at least one drug without any valid indication. 51 (22.3%) had at least one drug with an unfavorable benefit-to-risk ratio according to their clinical and biological data, 42 (18.3%) according to the Laroche list and 38 (16.6%) had at least one drug with questionable efficacy. Conclusion Our work shows that the incidence of PIP is high in the frail elderly and that, in most cases, it could be avoided with an adequate and regular reassessment of the prescriptions. In future, prescription optimization will be integrated into the personalized medical care plan to further prevent drug-related disability.

Cognitive Frailty: Mechanisms, Tools to Measure, Prevention and Controversy

Physical frailty is often associated with cognitive impairment, possibly because of common underlying pathophysiologic mechanisms. To stimulate research in this field, the concept cognitive frailty was proposed, emphasizing the important role of brain aging. Cognitive frailty was defined as the presence of cognitive deficits in physically frail older persons without dementia. This subtype of frailty is deemed important, as it may represent a prodromal phase for neurodegenerative diseases and is potentially a suitable target for early intervention. The aim of this report is to refine the framework for the definition and mechanisms of cognitive frailty and relevant screening tools.