Effect of a multimodal training on the ability of medical students to administer the MMSE: a comparative study.

BACKGROUNDS: The Mini-Mental State Examination (MMSE) is the main screening and follow-up test for neurocognitive disorders. In France, it is often administered by medical students. Conditions allowing to administer the MMSE are strict but not well known by students, leading to mistakes in scoring. Our objectives were to assess the effect of a multimodal training on medical students' ability to administer the MMSE and to describe their previous training. METHODS: 75 medical students between the 4th and 6th year of study were included. Previous MMSE training was assessed by a standardized questionnaire. The teaching material used for our training was the article validating MMSE in French, a video explaining the steps on how to administer the MMSE test, and MMSE's scoring exercises. The ability to administer the MMSE was assessed by a Standardized practical exam (SPE). Students were self-selected and then assigned in two groups, one benefiting from all the training before SPE, and the other receiving only the article before SPE. RESULTS: 41 students were included in the training group and 34 in the control group. There was no difference between groups regarding previous training. 71% of the students had already administered a MMSE test and only 17% had received specific training. Students considered their previous training as insufficient in most cases. The overall score and scores of each subpart of the SPE were significantly higher in the training group than in the control group (overall score: median [IQR]: 71 [62-78] vs. 52 [41-57], p < 0.001). The rate of students able to complete the MMSE was higher in the training group compared to the control (85% vs. 44%, p < 0.001). Quality of the training and its usefulness were judged to be good or very good by all participants. CONCLUSIONS: A multimodal training improves the ability of medical students to administer the MMSE.

[Deliberate intoxication with Datura Stramonium, a rare cause of confusion]. / L'intoxication volontaire à Datura Stramonium, une cause rare de confusion.

Many drugs can be responsible for this syndrome. Although it remains rare, poisoning by Datura Stramonium should be considered in the event of anticholinergic syndrome in the elderly, particularly in the event of anticholinergic manifestations.

Clinical Pharmacist Intervention Reduces Potentially Inappropriate Prescriptions in a Geriatric Perioperative Care Unit Dedicated to Hip Fracture.

INTRODUCTION: Clinical pharmacist (CP) intervention improves drug prescription by identifying potentially inappropriate prescriptions (PIPs). Geriatric perioperative care units (UPOGs) provide enhanced care for patients with hip fracture, including drug prescription. However, it is not known whether adding a CP intervention in a UPOG decreases the number of PIPs. This study aimed to evaluate the effect of a CP intervention, combining an implicit and an explicit method, on the number of PIPs in a UPOG. METHODS: This single centre before-after-control-impact study recruited patients aged over 75 years admitted to a UPOG for a hip fracture. The "control group" ("before period") received usual care including two medication reconciliations, one at admission and one at discharge. The "intervention group" ("after period") received usual care and a CP intervention including two medication reconciliations, a medication review with two tools, STOPP/START and Medication Appropriateness Index, and a meeting between a CP and geriatricians. PIPs were assessed in both groups by STOPP/START and Medication Appropriateness Index and compared from hospital admission to discharge. RESULTS: A total of 209 patients were included, 150 in the control group and 59 in the intervention group (mean age: 87.2 ± 5.9 years). The number of PIPs decreased in both groups from hospital admission to discharge (p < 0.001). The number of PIPs, potentially inappropriate medications, and potential prescribing omissions decreased more in the intervention group than in the control group (adjusted intervention effect: -2.46 (95% CI: -2.63; -2.24); -1.13 (95% CI: -1.27; -0.98); and -1.35 (95% CI: -1.52; -1.18), respectively, p < 0.001 for all). DISCUSSION/CONCLUSION: A CP intervention with an explicit and implicit method improved prescriptions in a UPOG. Further randomized studies are necessary to evaluate the effect of a CP intervention on adverse drug events, health costs, and mortality.

Association between orthostatic blood pressure dysregulation and geriatric syndromes: a cross-sectional study.

BACKGROUND: Orthostatic blood pressure dysregulation, including orthostatic hypotension (OH) and orthostatic hypertension (OHT), is common in the elderly. The association between OH and, to a lesser extent, OHT with geriatric syndromes is controversial and little investigated. Our objective was to assess the association between orthostatic blood pressure dysregulation and geriatric syndromes in an ambulatory outpatient population. METHODS: This observational study included all outpatients for whom a one-visit comprehensive geriatric assessment was performed during a year. OH was defined as a decrease of at least 20 mmHg in systolic blood pressure (SBP) and/or 10 mmHg in diastolic blood pressure (DBP) after 1 or 3 min of standing. OHT was defined as an increase of more than 20 mmHg in SBP after 1 or 3 min of standing. Comorbidities, drugs regimen, a history of previous falls, nutritional, frailty, functional and cognitive status were compared between patients with OHT or OH and controls (NOR). RESULTS: Five hundred thirty patients (mean age: 82.9 ± 5.1 years) were included. 19.6% had an OH and 22.3% an OHT. OHT patients were more frequently female, had more diabetes and a lower resting SBP than patients with NOR. OH patients had a higher resting SBP than NOR. After adjusting for age, sex, resting SBP and diabetes, OHT was associated with a low walking speed (OR = 1.332[1.009-1.758]; p = 0.043) and severe cognitive impairment at MMSe score (OR = 1.629[1.070-1.956]; p = 0.016) compared to NOR. Conversely, OH was associated with a lower grip strength (p = 0.016) than NOR. CONCLUSION: OHT and OH are common in elderly but associated with different geriatric phenotypes.

Analysis of the impact of a medication reconciliation tool on the hospital-community interface.

OBJECTIVE: To analyse the impact of a medication reconciliation tool (MRT), which contains information on all the treatments a patient is receiving upon admission as well as intra-hospital therapeutic adjustments and the rationale behind them, on the transmission and quality of the follow-up of prescribing recommendations outside the hospital setting. METHODS: The MRT involved the prescriptions of patients who were aged 75 and over, who were admitted to a geriatric short-stay unit, and who were referred to a general practitioner (GP) upon discharge. Drug discrepancies (DD) and polypharmacy after an intra-hospital medication reconciliation and at the time of renewing the out-patient prescription (one month after discharge) were measured. Satisfaction among GPs was investigated. RESULTS: The medication lists of 173 patients (1242 drugs; median eight drugs/day) were reconciled, optimised, and communicated using the MRT to the 89 GPs of the 103 patients who returned home. Intra-hospital reconciliation identified 779 DDs (4.6 ± 2.3), of which 39.0% were additions to treatment that had been overlooked. After the discharge prescription was renewed, only 1.6 ± 1.6 DDs were measured. Between admission, discharge, and repeat prescription, polypharmacy was reduced from 83.2% to 74.6% and 67.7% (p < 0.05). Despite a 31.5% response rate to the postal questionnaire, 79.3% of physicians thought the MRT facilitated continuity of care and 75.5% wanted it to be rolled-out more widely. CONCLUSION: This study shows that the MRT is a useful tool and of interest for documenting the process of intra-hospital therapeutic optimisation and with regard to the rapid transmission and follow-up of recommendations by partners in the community.

[A rare but increasing aetiology of febrile dyspnea in the elderly]. / Une dyspnée fébrile chez un patient âgé.

Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infectious disease well described in patients living with HIV (PLHIV) but that can occur in other immunosuppressed patients. Currently, its incidence decreases in PLHIV but increases in non-HIV immunosuppressed patients, particularly in case of hematological diseases. Thus, in elderly, the diagnosis of PJP should be evoked in case of subacute pneumonia rapidly evolving to an acute respiratory distress, with or without interstitial pneumonia at chest radiography, and a context of immunosuppression.

Consensus of experts from the French Society of Geriatrics and Gerontology on the management of heart failure in very old subjects.

The prevalence of heart failure increases with age. In France, the 1-year mortality rate is 35% in subjects aged 80-89 years with heart failure, and 50% after the age of 90 years. In octogenarians, heart failure is associated with high rates of cardiovascular and non-cardiovascular events, and is one of the main causes of hospitalization and disability. The prevalence of frailty increases in elderly subjects with heart failure, and the co-occurrence of heart failure and frailty increases the risk of mortality in patients with heart failure. In the elderly, the presence of frailty must be evaluated using a comprehensive geriatric assessment to manage geriatric syndromes, such as cognitive disorders, malnutrition, falls, depression, polypharmacy, disability and social isolation. The objective of heart failure therapy in octogenarians is to reduce symptoms, mortality and hospitalizations, but also to improve quality of life. In the absence of specific studies involving very old subjects, most recommendations are extrapolated from evidence-based data from younger populations. Overall, the epidemiological studies in patients with heart failure aged>80 years highlight the underprescription of recommended drugs. This underprescription may be related to comorbidity, a fear of side-effects and the lack of specific recommendations for drug prescription in heart failure with preserved ejection fraction, which is common in this very old population. The benefit/risk ratio related to heart failure treatment and comorbidity should be carefully weighed and reassessed on a regular basis. Consideration of disease prognosis according to factors that predict mortality can help to better define the care plan and promote palliative and supportive care when needed.

Buccofacial Apraxia, Oropharyngeal Dysphagia, and Dementia Severity in Community-Dwelling Elderly Patients.

Apraxia occurs frequently in patients with dementia. Buccofacial apraxia (BFA) characteristics have been less investigated than limb or speech apraxia. An association between BFA and oropharyngeal dysphagia (OD) in old patients with dementia has not yet been explored. We aimed to assess the prevalence of BFA in patients with dementia and evaluate the relationship between BFA, OD, and dementia. We have prospectively included 117 outpatients with dementia referred to a geriatric consultation. Oropharyngeal dysphagia was diagnosed using the volume viscosity swallowing test (V-VST). Buccofacial apraxia was evaluated by miming 7 meaningless gestures. A complementary geriatric assessment of 6-domains completed the evaluation. Buccofacial apraxia was present in 54 (48.6%) patients. Proxies reported OD more frequently in the group of patients with BFA compared to the group without (P = .04). Prevalence of OD assessed with the V-VST was similar between patients with and without apraxia (P = .9). Patients with BFA had a significant lower Mini-Mental State Examination suggesting a more severe cognitive decline (18.1 ± 4.5 vs 15.8 ± 5, P = .01), a lower activities of daily living relative to disabilities (5 ± 0.8 vs 4.3 ± 1.3, P = .001), and had a lower gait speed that indicated frailty (P = .03).In conclusion, our results indicate a relationship between BFA and severity of dementia, disability, and frailty with no significant association between BFA and OD.

[Analysis of the impact of a medication reconciliation toolkit in the hospital-community interface]. / Analyse de l'impact d'un outil de conciliation médicamenteuse dans l'interface hôpital-ville.

OBJECTIVE: To analyse the impact of a medication reconciliation toolkit (OCM) which details all the treatment at the admission, intra-hospital therapeutic adjustment and their justifications, on the transmission and quality of extra-hospital follow-up of prescribing recommendations. METHODS: The OCM was fulfilled with the prescriptions of patient aged ≥75 years admitted to a geriatric short-stay unit and sent to general practitioners (GPs) upon discharge. Drug discrepancies (DD) and exposure to polypharmacy after intra-hospital medication conciliation and the ambulatory repeat prescribing (1 month after discharge) were measured. GPs' satisfaction was investigated. RESULTS: The medication list of 173 patients (1242 molecules; median 8 molecules/day) were reconciled, optimized, and transmitted using the OCM to the 89 GPs of the 103 patients who were returned home. Intra-hospital conciliation identified 779 DD (4.6 ± 2.3) of which 39.0% were missed treatment additions. After renewal of the discharge order, only 1.6 ± 1.6 DD were measured. Between admission, discharge, and repeat prescribing, exposure to polypharmacy was reduced from 83.2 to 74.6 and 67.7% (p<0.05). Despite a 31.5% response rate to the mail questionnaire, 79.3% of physicians thought the OCM facilitated continuity of care and 75.5% wanted it generalized. CONCLUSION: This study shows that the OCM is a useful tool and of interest for documenting the process of intra-hospital therapeutic optimization and in the rapid transmission and the follow-up of recommendations by partners in the community.

[Frailty syndrome: evaluation of its knowledge and screening tools by general medicine interns]. / Syndrome de fragilité : évaluation des connaissances et de ses outils de dépistage concernant les internes de médecine générale.

Screening and management of frail elderly patients is essential in general practice. OBJECTIVE: This study aims to describe and evaluate the knowledge about frailty, its screening tests and management in a population of general practice interns. METHOD: A prospective, descriptive and mono-centric study using an online survey was conducted. The 2018's promotion of general practice interns in Rouen's University participated. Evaluation of the general knowledge (e.g diagnostic criteria) and specific knowledge (e.g ranking different conditions such as: undernourishment leading to asthenia) and management algorithm (e.g to address the patient for geriatric evaluation) Results: 90 questionnaires were analyzed. Ten interns (11%) stated to know at least one screening test or to know a set of 4 major frailty criteria. Thirty four interns knew at least 4 frailty criteria (major or minor) and 46 interns had partial knowledge. Fried's phenotype was the most known. Seventy-five interns (83%) stated to know the frailty syndrome. However, 88% of the interns had little knowledge about its pathophysiology. Concerning frailty management, 78% (70 interns) stated to know how to screen frailty and prescribe first line treatments. Thirty-one among them knew how to reassess initial treatment if failure. In 59 interns (65%), identifying frailty would have led to a geriatric consultation. Seventy-nine interns (87%) were favorable to go through further training on frailty. CONCLUSION: These general practice interns were able to identify frailty criterion but, in contrast, global understanding of the syndrome was missing. Further training about this topic seems to be necessary.

[Intraoperative hypotension and delirium in patients with hip fracture]. / Hypotension per-opératoire et syndrome confusionnel chez les patients présentant une fracture de l'extrémité supérieure du fémur.

Postoperative delirium is common after hip fracture surgery in elderly patients and is associated with poor outcome (higher risk of mortality, institutionalization and length of stay). The relationship between modifiable intra-operative risk factors, such as intra-operative hypotension, and postoperative delirium is unclear. The main objective of this study was to evaluate the association between intra-operative hypotension and the development of a postoperative delirium in older patients with hip fracture. A secondary aim was to assess the impact of other pre- and intra-operative predisposing factors (anaesthetic approaches or specific anaesthetic drugs, surgery duration, timing of surgery, type of implants used as primary treatment, intra-operative blood loss) on developing postoperative delirium in this elderly population. This retrospective monocentric study included 100 consecutive hip fracture patients, aged 75 years and older, admitted to a dedicated ortho-geriatric unit. All patients were screened for post-operative delirium using the confusion assessment method performed by a geriatrician. Intra-operative hypotension was defined as a decrease of more than 30% below the preoperative baseline for systolic blood pressure or a decrease in mean arterial pressure (MAP) below 60 mmHg. Post-operative delirium (n = 37; 37.8%) and intra-operative hypotension (n = 80; 81.6%) are both common in old patients but we did not demonstrate a significant association regardless of the chosen definition. The following risk factors were significantly associated with postoperative delirium: surgical delay (OR 1.47[1.01-2.02]; p = 0.02), institutionalisation (OR 2.25[1.33-3.8]; p = 0.02) and postoperative acute kidney injury (OR 2.34[1.32-4.15]; p = 0.02). Postoperative delirium is common in old patients with hip fracture and is associated with postoperative complications, institutionalisation and surgical delay but not with intra-operative risk factors.

Chronic neurological disorders and related comorbidities: Role of age-associated physiological changes.

Current knowledge indicates that the physiological aging process starts with subclinical changes at the molecular and cellular level, which affect nearly all physiological systems. For example, the age-associated remodeling of the immune system (i.e., immunosenescence) and vascular aging per se can contribute to frailty and vulnerability among older adults. They are also described as being implicated in the pathophysiology of some major chronic comorbid conditions such as age-associated diseases of the central (e.g., stroke, Parkinson's disease, Alzheimer's disease, and related disorders) and peripheral (e.g., polyneuropathy) nervous systems. These neurologic disorders are also among the greatest contributors to geriatric syndromes, which refer to highly prevalent and chronic conditions among aged people of multifactorial origin, such as delirium, falls, incontinence, and frailty. Neurologic disorders can also occur in patients with one or more geriatric syndromes and thus further interfere with the quality of life, physical function, morbidity, and mortality. This chapter presents and discusses in three sections the complex interrelationships between the main determinants of aging with a specific focus on vascular aging, chronic neurologic disorders, and the specific clinical presentation of geriatric syndromes in older people.

Using a structured reconciliation medication form improves medication transition from hospital to community care and primary care physicians' adherence with medication adaptations and recommendations.

BACKGROUND: Hospital admission and discharge are weakness points in the transition of care. OBJECTIVE: To lower the risk of errors and improve medication information transfer to primary care physician (PCP), we conducted an experimental study using a structured medication reconciliation form (SMRF) in an Acute Care for Elders unit. RESULTS: 1242 drugs of 173 patients were reconciliated at admission, optimized during the stay, and transmitted via the SMRF to the 143 corresponding PCPs. While the optimization led to 779 adaptations from admission to discharge, of which 39.0% were omissions, exposure to polypharmacy was reduced from 83.2 to 74.6% (P < 0.05). One-month post-discharge, with an answer rate of 62.2% among PCPs, the adherence to recommendations was high (85.0%) and the exposure to polypharmacy was further decreased (67.7%; P < 0.05). CONCLUSION: These results provide elements to consider SMRF as an example of good practice for which the impact should be analyzed at larger scale.

Oropharyngeal Dysphagia in Community-Dwelling Older Patients with Dementia: Prevalence and Relationship with Geriatric Parameters.

OBJECTIVES: To define the prevalence of oropharyngeal dysphagia (OD) in community-dwelling older persons with dementia, using V-VST (Volume-Viscosity Swallow Test), the reference clinical screening test for swallowing disorders, to assess the feasibility of the V-VST in an ambulatory care setting, to search for associations between geriatric parameters and OD, and to identify a relationship between severities of cognitive impairment and OD. DESIGN: Prospective, monocentric study. SETTING: Population from a geriatric outpatients clinic. PARTICIPANTS: Patients older than 70 with a diagnosis of dementia (NINCDS-ADRDA criteria), effective cough, and ability of voluntary swallowing for testing. MEASUREMENTS: OD screening was realized using V-VST during consultation. Severity of cognitive impairment was estimated by the MMSE and severity of OD by the Dysphagia Outcome Severity Scale (DOSS). Six geriatric domains were evaluated (comorbidities, functional abilities, cognition, nutrition, mood disorders, frailty). RESULTS: 117 patients participated in the study (77 women, mean age = 84.5 ± 5.1 years). Prevalence of OD was 86.6%. Among the 97 patients with OD, 3 (3.1%) had only safety impairment, 52 (53.6%) had only efficacy impairment and 42 (43.3%) had both. The mean time necessary to realize V-VST was 8.7 ± 2.7 minutes with a rate of success of 96%. Dependency was independently associated with OD [odds ratio (OR) 4.8; 95% confidence interval (CI) 1.5-15.9; P < .05], and age and grip strength were associated with safety impairment (OR 1.1; 95% CI 1.0-1.2 and OR 1.9; 95% CI 1.2-3.2 respectively; both P < .05). No significant relationship was found between severity of OD and severity of cognitive impairment. CONCLUSION: OD is very frequent in community-dwelling older persons with dementia and is associated with dependency and frailty. The V-VST is an easy-to-perform and well tolerated screening test in this population and therefore should be systematically included in the geriatric assessment of older persons with dementia. The role of V-VST in therapeutic strategies of OD remains to be evaluated.

[Geriatric medicine]. / Gériatrie.

2017 highlights benefits of prevention. Better control of cardiovascular risk reduces the incidence of dementia and monthly high-dose vitamin D the incidence of respiratory infections in nursing home. Pre-operative geriatric assessment lowers by 20% the rate of delirium after hip-fracture surgery and complications in vascular surgery. Deleterious effects are also reported. High-dose vitamin D triples the rate of falls in supplemented residents and doesn't improve gait speed in sedentary men. Widely used in cardiovascular prevention, antithrombotic therapy is associated with an astonishing risk of subdural bleeding that further increases with the number of drugs combined together. Finally, the non-pharmacological management of behavioral and psychotic symptoms in advanced dementia, although effective, doesn't reduce the associated burden for proxies.

2017, année de la prévention. Un meilleur contrôle des facteurs de risque cardiovasculaires réduit l'incidence de la démence et des fortes doses mensuelles de vitamine D diminuent l'incidence des infections respiratoires en EMS. L'évaluation gériatrique préopératoire diminue de 20% le taux de confusion postopératoire après chirurgie d'une fracture du col fémoral et de complications précoces en chirurgie vasculaire. De hautes doses de vitamine D multiplient par 3 le risque de chutes chez des résidents vivant en institution et n'améliorent pas la vitesse de marche chez des hommes sédentaires. Très utilisés en prévention cardiovasculaire les médicaments antithrombotiques sont associés à un risque élevé d'hématomes sous-duraux. Ce risque augmente avec le nombre de médicaments prescrits. Enfin, le traitement non pharmacologique des troubles psycho-comportementaux dans les démences avancées réduit l'intensité des troubles et aussi le fardeau des aidants.

Tracking tool for frailty: ABCDEF.

The aging population leads to psychological, medical and social reflection for optimal care of the elderly, especially characterized by a frailty state. The frailty is the cause of morbi-mortality require screening to anticipate these complications. The objective was to evaluate the statistical performance and feasibility of the tool "ABCDEF" to screen frailty defined by Fried's criteria. A prospective multicenter study including 300 ambulatory elderly consultants was conducted. ABCDEF appears feasible without major prior training or special equipment by any doctor or caregiver during an assessment in 98% of consultants. His sensitivity to detect frailty, is of 75% and specificity of 64%. The frailty tracking threshold is 3 criteria (6). Its negative predictive value is interesting because it eliminates the hypothesis of frailty in 91% of cases. This tracking tool requires, when abnormal, further geriatric assessment. It provides a standardized and normative approach to describe frailty whose frequency is high in people older than 80 and whose consequences are major.

Acute cardiac failure secondary to senile systemic amyloidosis.

Hereditary or senile transthyretin (TTR) cardiac amyloidosis is a rare and underestimated cause of heart failure in old patients. New diagnostic methods, particularly cardiac MRI and proteomic analysis, have been recently developed that enable both earlier identification and development of specific treatments.We report a case of cardiac amyloidosis revealed through late-onset heart failure.

[Anticoagulation in old fallers : a common challenge]. / Les chuteurs âgés traités par anticoagulants : un challenge quotidien.

Long term anticoagulation is required to reduce the risk of stroke or other thromboembolic events resulting from atrial fibrillation. Thus, anticoagulation is frequently considered in older persons who are at increased risk for hemorrhagic adverse events. This is even more so as about a third of older persons aged 65 years and over will fall over a year. Nevertheless, benefits from risk reduction in stroke incidence and its consequences (functional depen-dency, cognitive decline, altered quality of life, death) resulting from anticoagulant prescription remains superior to its related risk.

Les anticoagulants peuvent être prescrits au long cours, par exemple en prévention primaire pour diminuer le risque thromboembolique artériel, associé à une fibrillation atriale (FA). Ces médicaments sont souvent utilisés chez des personnes âgées chez qui le potentiel iatrogène hémorragique est redouté. Ce risque est d'autant plus marqué que les chutes affectent au moins un tiers de ces personnes au cours d'une année. Néanmoins, le bénéfice, pour réduire l'incidence et les conséquences d'un AVC (dépendance, surmortalité, qualité de vie altérée, atteinte cognitive) de ces médicaments, est supérieur à leur risque intrinsèque.