Virginie Gardette

Screening Older People at Risk of Malnutrition or Malnourished Using the Simplified Nutritional Appetite Questionnaire (SNAQ): A Comparison With the Mini-Nutritional Assessment (MNA) Tool

OBJECTIVESnThe Mini-Nutritional Assessment (MNA) is recommended to assess malnutrition in older people. However, its implementation is challenging in large elderly population, nursing home, or community or large clinical research programs. The Simplified Nutritional Appetite Questionnaire (SNAQ), a self-assessment nutritional screening tool that predicts weight loss, could be used to screen older people at risk of malnutrition or malnourishment. Our objective was to assess whether the SNAQ is related to the MNA and can screen older people at risk of malnutrition or malnourishment.nnnDESIGN/SETTING/PARTICIPANTSnCross-sectional study conducted of 175 persons aged 65 or older who were community dwelling, hospitalized, and nursing home residents.nnnMEASUREMENTSnThe SNAQ and the MNA score were performed. Correlation between the scores was studied. The most discriminating SNAQ value, which separated the participant at risk of malnutrition or malnourishment from the participant with a normal nutrition status (defined by MNA), was calculated.nnnRESULTSnThe SNAQ and the MNA score were significantly correlated (Spearman test r = 0.48, P < .001). The distribution of the population using the SNAQ or the MNA was significantly different (MacNemar P < .01). The area under the receiver operator characteristic curve, which assesses the ability of the SNAQ score to predict an abnormal MNA score, was 0.767 (95% confidence interval, 0.69-0.85). An SNAQ score under 14 was the best clinical indicator of older people at risk of malnutrition or malnourishment (sensitivity = 71%, specificity = 74%). Using this cut-off, 26.8% of the population (n = 47) were misclassified. Most of them (n = 33; 18.8%) had an abnormal SNAQ with a normal MNA.nnnCONCLUSIONnThe SNAQ is a poor screening tool to predict older people with an abnormal MNA score. However, an abnormal SNAQ might identify those who will lose weight earlier than will the MNA.

Potentially inappropriate medication use among patients with Alzheimer disease in the REAL.FR cohort: be aware of atropinic and benzodiazepine drugs!

ObjectiveFew studies have investigated potentially inappropriate medication (PIM) use in patients with Alzheimer’s disease (AD). The aim of our study was to assess the prevalence of PIM in community-dwelling patients diagnosed with mild-to-moderate AD and identify the clinical factors associated with PIM prescriptions.MethodsREAL.FR is a 4-year, prospective, multicenter French cohort of AD patients recruited in centers of expertise. We analyzed patient baseline data at entry into the study. PIMs were assessed using the Laroche list. A multivariate logistic regression was conducted to assess factors associated with PIMs.ResultsA total of 684 AD patients were enrolled in the study [mean age 77.9u2009±u20096.8 years, 486 (71.0xa0%) females]. According to the Laroche list, 46.8xa0% [95xa0% confidence interval (CI) 43.0–50.5xa0%] of the patients had at least one PIM. “Cerebral vasodilators” were the most widely used class of PIM, accounting for 24.0xa0% (95xa0% CI 20.9–27.3xa0%) of all prescriptions, followed by atropinic drugs (17.0xa0%, 95xa0% CI 14.1–19.8xa0%) and long half-life benzodiazepines (8.5xa0%, 95xa0% CI 6.4–10.6xa0%). Atropinic drugs were associated with cholinesterase inhibitors in 16xa0% of patients. In the multivariate analysis, only two factors, namely, female gender [odds ratio (OR)u20091.5, 95xa0% CI 1.1–2.2] and polypharmacy (≥5 drugs; ORu20093.6, 95xa0% CI 2.6–4.5) were associated with prescriptions for PIMs.ConclusionsThese results reveal that approximately one out of two community-dwelling patients with mild-to-moderate AD treated by AD specialists use PIMs. They also indicate that the characteristics of the disease and the pharmacodynamic/pharmacokinetic profile of the drugs prescribed are not sufficiently taken into account by physicians when prescribing for AD patients.

Long-term progression of Alzheimer's disease in patients under antidementia drugs

Patients with Alzheimers disease (AD), even in the presence of symptomatic relief from medical intervention, face a persistent worsening of cognitive decline and performance in activities of daily living. Data regarding the long‐term disease progression outside of therapeutic trials are lacking. We examined the effects of standard of care for AD patients on the prognosis of the disease in a real‐life study over a 4‐year period.

Predictive Factors of Attrition in a Cohort of Alzheimer Disease Patients

Background: Attrition, i.e. patient dropout, can threaten the validity of results in longitudinal studies. The aim of this study was to identify patient and caregiver factors predictive of attrition in a cohort of Alzheimer disease (AD) patients. Methods: 686 patients with mild to moderate AD were included in the multicenter prospective REAL.FR study. Standardized gerontological evaluations were carried out twice yearly. Factors associated with attrition were assessed by survival analysis using a Cox proportional hazard model. Results: After 2 years, 278 (40.5%) patients had dropped out. Causes of attrition included refusal (20.9%), death (20.1%), institutionalization (19.8%), and loss to follow-up (19.8%). Attrition rates between each 6-month wave were constant at 12%. After adjustment, several independent factors remained associated with attrition: patients cared for by an unrelated caregiver [HR 1.7; 95% CI (1.08–2.59)], loss of autonomy [HR = 1.37; (1.03–1.82)], increasing caregiver burden [HR = 1.014; (1.005–1.022)], use of cholinesterase inhibitors [HR = 0.40; (0.27–0.59)], use of 1 to 3 other types of medication [HR = 0.57; (0.36–0.89)]. Conclusions: The identification of both patient and caregiver factors predictive of attrition is of particular interest for the development and targeting of attrition prevention strategies. In patients with chronic diseases, particular attention should be paid to caregiver well-being to limit attrition.

Predictive factors of discontinuation and switch of cholinesterase inhibitors in community-dwelling patients with Alzheimer’s disease

AbstractBackground: The efficacy of cholinesterase inhibitors (ChEIs), especially over the long term, is still under discussion. There is a lack of data concerning the optimal drug treatment duration and the reasons for discontinuation, particularly outside the clinical trial setting.n Objective: To identify predictive factors of discontinuation and switch of ChEIs in a real-world setting.n Methods: A multicentre cohort study of 686 patients with mild-to-moderate ambulatory Alzheimer’s disease who were diagnosed in 16 Alzheimer’s disease expert centres in 2000–2 and who were assessed twice yearly for 2 years. The main outcome measure was ChEI discontinuation and switch (analysed using Cox survival analyses).n Results: After 2 years, of the 611 subjects treated with a ChEI at baseline, 100 subjects had switched or discontinued ChEI therapy (incidence rate 12.7 [95% CI 10.2, 15.2] per 100 person-years). The incidences of switching and discontinuation were 9.2 (95% CI 7.0, 11.3) and 3.6 (95% CI 2.3, 4.8) per 100 person-years, respectively. In the multivariate analysis, predictive factors for switching were an ineffective ChEI dose (adjusted hazard ratio [HRa] = 6.91, 95% CI 3.08, 15.49), rapid cognitive decline (HRa = 4.10, 95% CI 1.85, 9.05), hospitalization unrelated to Alzheimer’s disease (HRa = 2.33,95% CI 1.07, 5.09) and anxiety (HRa= 2.08, 95% CI 1.16, 3.73). Predictive factors of discontinuation were: hospitalization related (HRa = 9.14, 95% CI 2.69, 31.07) or unrelated (HRa = 4.23, 95% CI 1.54, 11.59) to Alzheimer’s disease, use of an anticholinergic drug (HRa = 4.26, 95% CI 1.46, 12.45) and weight loss (HRa = 3.77, 95% CI 1.15, 12.33).n Conclusions: This study highlights four types of predictors of switch or discontinuation, reflecting disease progression, reconsideration of ChEI benefits, adverse drug reactions to ChEIs and inappropriate concurrent use of anticholinergic drugs. Attention should be paid to anticholinergic agents and prescribers should be given better information about these drugs.

Ten-Year All-Cause Mortality in Presumably Healthy Subjects on Lipid-Lowering Drugs (from the Prospective Epidemiological Study of Myocardial Infarction [PRIME] prospective cohort)

Lipid-lowering drugs are one of the most prescribed drugs worldwide. The aim was to compare 10-year all-cause mortality according to initial dyslipidemia status and lipid-lowering drug exposure. The PRIME study was a multicenter population-based prospective cohort study of men recruited in 1991 to 1993, aged 50 to 59 years at baseline, and followed up for 10 years. The 4 groups compared were normolipidemic, untreated dyslipidemic, and dyslipidemic subjects on fibrate or statin therapy. Data were analyzed using multivariate Cox models. The cohort included 7,722 French men (statin group 4.0%, fibrate group 7.9%, untreated dyslipidemic subjects 19.0%, and normolipidemic subjects 69.1%). After 10 years, 4.8% of the sample was lost to follow-up and 416 deaths occurred (cancers 53.1%, cardiovascular diseases 17.1%, and other 29.8%). After adjustment for center, age, educational level, cardiovascular risk factors, lipids, alcohol intake, and history of cardiovascular and severe chronic diseases, hazard ratios (HRs) for all-cause mortality were 0.49 (95% confidence interval [CI] 0.26 to 0.94, p = 0.031) for subjects treated with a statin, 0.65 (95% CI 0.42 to 0.99, p = 0.046) for those on fibrate therapy, and 0.76 (95% CI 0.56 to 1.03, p = 0.080) for normolipidemic men compared with untreated dyslipidemic subjects. In the statin group, HRs for death from cardiovascular disease, cancer, and other causes were 0.55 (p = 0.348), 0.41 (p = 0.067), and 0.68 (p = 0.546) compared with dyslipidemic subjects, respectively. In the fibrate group, HRs were 0.76 (p = 0.499), 0.52 (p = 0.041), and 0.87 (p = 0.746). In conclusion, in this cohort study carried out in a real-life setting, all-cause mortality was significantly lower in dyslipidemic subjects on fibrate or statin therapy than in untreated dyslipidemic patients. No excess risk of noncardiovascular death was observed.

Gynecomastia Associated with Fenofibrate

Objective: To report a case of probable fenofibrate-induced gynecomastia. Case Summary: A 56-year-old white hypercholesterolemic man was treated with fenofibrate 160 mg/day for 1 year. During the course of treatment, he developed gynecomastia on the left side, which resolved after the drug was stopped and replaced with alpha tocopherol acetate. Sixteen months after fenofibrate discontinuation, the patient was rechallenged and subsequently developed gynecomastia symptoms on the right side. The usual etiologies of gynecomastia were excluded by careful assessment of the patients medical history, physical examination, and results of diagnostic tests such as chest X-ray, mammography, scrotal ultrasonography, routine blood chemistry, and extensive hormonal panel. Gynecomastia again resolved after discontinuation of fenofibrate. Discussion: In this case, the resolution of gynecomastia on discontinuation of fenofibrate and recurrence after rechallenge highly suggest the role of fenofibrate. Use of the Naranjo probability scale registered causality as probable. Case reports of gynecomastia caused by different drugs have been previously published, but, to our knowledge, this is the first report linking gynecomastia to the use of fenofibrate. The pathogenesis of this adverse drug reaction remains unclear. Conclusions: Although fenofibrate-induced gynecomastia appears to be uncommon, patients receiving this medication should be monitored for this adverse drug reaction.

A follow-up intervention in severely demented patients after discharge from a special Alzheimer acute care unit: impact on early emergency room re-hospitalization rate

Emergency room (ER) re‐hospitalizations are prevalent in severe Alzheimers disease affected older patients.

Persistent use of Analgesic Medications in Mild-to-Moderate Alzheimer’s Disease

Background and ObjectivesPrevious studies have reported a lower use of analgesics in patients with Alzheimer’s disease (AD) than in non-AD elderly. To date, no study has focused on persistent analgesic use in patients with mild-to-moderate AD.MethodsThe “Réseau sur la maladie d’Alzheimer Français” (REAL.FR) cohort study enrolled community-dwelling patients with mild-to-moderate AD. Persistent analgesic use was defined as the consumption of at least one analgesic drug during two consecutive visits (6xa0months). Associated factors were identified in a nested case–control study.ResultsIn REAL.FR, 595 patients were present during at least two consecutive visits [mean agexa0=xa077.5xa0±xa06.8xa0years, mini-mental state examination (MMSE)xa0=xa020.1xa0±xa04.2]. Prevalence of persistent analgesic use was 13.1xa0% (95xa0% CIxa0=xa010.4–15.9). The incidence of persistent analgesic use was 5.9/100 patient-years (95xa0% CIxa0=xa05.2–6.6). Women (adjusted odds ratio [OR]xa0=xa03.1, 95xa0% CIxa0=xa01.2–8.1), patients with musculoskeletal disorders (ORxa0=xa03.4, 95xa0% CIxa0=xa01.6–7.3) and patients treated with numerous medications (ORxa0=xa03.0, 95xa0% CIxa0=xa01.5–5.8) were more likely to use analgesics persistently. Statistically significant associations were found with disease duration and disease progression but not with AD severity at baseline.ConclusionsOur results suggest a low use of analgesics in AD patients, which could vary with AD progression.

A Longitudinal Study of Transitions Between Informal and Formal Care in Alzheimer Disease Using Multistate Models in the European ICTUS Cohort.

BACKGROUNDnWe aimed to describe longitudinal patterns of care in community-dwelling European patients with Alzheimer disease (AD), and determine patient-, caregiver-, and country-related predictors of transitions across different care levels.nnnMETHODSnTwo-year follow-up data from ICTUS cohort (1375 patients with AD, 12 countries) were analyzed using multistate Markov models to describe transitions across states of care and identify their predictors.nnnRESULTSnOf the patients, 61.3% stayed in the same state during follow-up, and only 9.5% experienced ≥2 changes between states. Six-month transition probabilities were 11% for informal to formal care and 13% for formal to informal care (in the community). Older age, male gender, poorer cognitive and behavioral scores, and country of residence were associated with transitioning from informal to formal care, but only country of residence was associated with the reverse transition.nnnDISCUSSIONnChanges between different types of care were rare during follow-up, and country factors in particular influenced these transitions.