Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management.

OBJECTIVES: A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke. DESIGN: A cohort observational study over a 4-year period. SETTING: Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France). PARTICIPANTS: We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017. INTERVENTION: Patients transferred in the PSGU were compared to those admitted in other rehabilitation units. MEASUREMENTS: The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score). RESULTS: Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88). CONCLUSION: The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

[Effects of pony-assisted therapy on the behavior of older people with neurocognitive disorders living in nursing homes]. / Effets de la thérapie assistée par le poney sur le comportement des personnes âgées ayant des troubles neurocognitifs vivant en Ehpad.

CONTEXT: Experienced in psychomotricity in two nursing homes, pony-assisted therapy shows first positive effects on psycho-behavioral symptoms. Recognized in the field of disability and psychiatry, this form of therapy is not developed in gerontology. OBJECTIVES: To measure the effects of this therapy on the behavior of elderly people with neurocognitive disorders living in long-term care and especially on the involvement in this activity. Anxiety and apathy were chosen as the measurement criteria. METHODS: An intervention study with an experimental cross-study design was conducted over two months for 23 subjects. An intervention group was studied during a period with TAP and a period without TAP. Another group without intervention was also studied. All participants were assessed before and after intervention with the NPI-R scale. The engagement during two TAP sessions and one animation time was also evaluated with the ECPAI scale. RESULTS: In the crossover study, positive engagement is more important in participant/pony interaction than in participant/facilitator interaction (p<0.01). The ECPAI score reflecting apathetic behavior was significantly decreased during interaction with the animal than in the interaction with the facilitator in patients undergoing therapy (p<0.01). The ECPAI score reflecting engagement is greater in pony interaction for participants in therapy than in the control group in facilitator interaction (p<0.01). There is no significant change in the scores for the anxiety and apathy items on the NPI-R scale. CONCLUSION: TAP participates in the positive engagement of the elderly people in the interaction with the animal. These results are consistent with the conclusions of the studies on animal mediation and confirm the clinical observations collected. TAP could work by improving self-esteem and valuing all of the person's preserved abilities.

The value of B-type natriuretic peptide plasma concentrations in very old people with chronic peripheral oedema.

BACKGROUND: Chronic peripheral oedema is frequent in old patients, and very often results from multiple causes. AIM: To investigate whether determination of B-type natriuretic peptide plasma concentration helps with the diagnosis of chronic peripheral oedema aetiologies. METHODS: This was a cross-sectional observational study conducted in geriatric hospital wards (intermediate and long-term care) on consecutive in-hospital patients aged>75 years with chronic peripheral oedema and no dyspnoea. From medical history, physical examination, routine biological tests and chest radiography, two investigators determined the aetiologies of oedema, with special attention paid to recognizing chronic heart failure. This reference diagnosis was compared with the clinical diagnosis mentioned in the medical chart. Brain natriuretic peptide plasma concentrations were measured soon after the investigators' visit. RESULTS: Among the 141 patients (113 women and 28 men) aged 86±6 years, a single aetiology was identified in 53 (38%), and multiple aetiologies in 84 (60%). The main aetiologies were venous insufficiency (69%), chronic heart failure (43%), hypoproteinaemia (38%) and drug-induced oedema (26%). Chronic heart failure was frequently misdiagnosed by attending clinicians (missed in 18 cases and wrongly diagnosed in 14 cases). Brain natriuretic peptide concentration was significantly higher in patients with chronic heart failure than in those without: median (interquartile range) 490 (324-954) versus 137 (79-203) pg/mL, respectively (P<0.0001). The receiver operating characteristic curve showed that a concentration of 274pg/mL was appropriate for diagnosing chronic heart failure, with a specificity of 0.89 and a sensitivity of 0.82. Brain natriuretic peptide concentrations above this cut-off were significantly and independently associated with the diagnosis of chronic heart failure. CONCLUSIONS: Chronic heart failure is frequently misdiagnosed in old patients with chronic peripheral oedema, and B-type natriuretic peptide plasma concentration helped to improve the diagnosis of this condition and identify chronic heart failure.

Validation of the French version of the Vulnerable Elders Survey-13 (VES-13).

BACKGROUND: Identifying and assessing degree and type of frailty among older persons is a major challenge when targeting high risk populations to identify preventive interventions. The Vulnerable Elders Survey-(VES-13) is a simple instrument to identify frailty defined as risk for death, functional decline or institutionalization. OBJECTIVE: Translate VES-13 into French and validate it. METHODS: The French version of VES-13 was developed by forward-backward translation of the VES-13 survey instrument. The authors assessed its feasibility, construct validity, and ability to predict the combined outcomes of admission to institution or death at 18 months, in 135 persons over 70 years of age living in the community. Subjects were recruited from three settings: Group 1 - a health prevention center (n = 45); Group 2 - an ambulatory care geriatric clinic (n = 40); and Group 3 - an intermediate care hospital unit (n = 50). The combined outcomes data were recorded by telephone interview with participants or a proxy. RESULTS: Feasibility of the French version, named Echelle de Vulnérabilité des Ainés-13 or EVA-13, was excellent. The scale classified 5 (11%) persons as vulnerable (score of 3 or more) in Group 1, 23 (58%) in Group 2 and 45 (90%) in Group 3 (p < 0.001) with scores of 0.91 +/- 1.16, 4.27 +/- 3.17 and 6.90 +/- 3.17, respectively (p < 0.001). At follow-up, among the 60 non-vulnerable subjects, 58 (96%) were alive and living at home, whereas 46 (65%) of the 70 vulnerable subjects were alive and living at home (p < 0.001). CONCLUSIONS: EVA-13 was determined to be valid and reliable.

Aging-simulation experience: impact on health professionals' social representations.

BACKGROUND: Health professionals working with older persons are not sufficiently aware of the sensory and functional difficulties experienced by older patients. Innovative educational activities, such as the aging-simulation experience, can facilitate this awareness. This study describes the effects of an aging-simulation experience on health professionals' representations towards age-related limitations. METHODS: 306 health professionals, enrolled in university training in geriatrics/gerontology in the 2015-2016 and 2016-2017 academic years, experienced an aging-simulation session wearing a special suit according to a predefined scenario. Before and after the aging-simulation experience, participants completed free association tests, with the inductive words vision, hearing, movement, fine dexterity and balance. Semantic categories were created from participants' free evocations using a correspondence table manually produced in Excel 2013 for Windows (Microsoft Corporation, Redmond, Washington). Moreover, participants' opinions on difficulties experienced by older people in relation to age-related limitations were studied using Likert scale questions. RESULTS: In total, 3060 free evocations were collected, and ten semantic categories were created. These categories were composed of participants' geriatric knowledge, about age-related limitations, and participants' feelings, about the experience of these limitations. These two aspects were impacted by the aging-simulation experience. Moreover, changes observed resulted in a better consideration of difficulties associated with age-related limitations. CONCLUSIONS: The aging-simulation experience is an effective educational tool to raise awareness among health professionals of age-related difficulties. This sensory activity allows health professionals to put themselves in the shoes of older patients and to feel age-related difficulties.

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence. This is an update of a review previously published in 2006, 2012 and 2015. OBJECTIVES: To determine the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects and recurrence of atrial fibrillation in people who had recovered sinus rhythm after having atrial fibrillation. SEARCH METHODS: We updated the searches of CENTRAL, MEDLINE and Embase in January 2019, and ClinicalTrials.gov and WHO ICTRP in February 2019. We checked the reference lists of retrieved articles, recent reviews and meta-analyses. SELECTION CRITERIA: Two authors independently selected randomised controlled trials (RCTs) comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored, spontaneously or by any intervention. We excluded postoperative atrial fibrillation. DATA COLLECTION AND ANALYSIS: Two authors independently assessed quality and extracted data. We pooled studies, if appropriate, using Mantel-Haenszel risk ratios (RR), with 95% confidence intervals (CI). All results were calculated at one year of follow-up or the nearest time point. MAIN RESULTS: This update included one new study (100 participants) and excluded one previously included study because of double publication. Finally, we included 59 RCTs comprising 20,981 participants studying quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol. Overall, mean follow-up was 10.2 months.All-cause mortalityHigh-certainty evidence from five RCTs indicated that treatment with sotalol was associated with a higher all-cause mortality rate compared with placebo or no treatment (RR 2.23, 95% CI 1.03 to 4.81; participants = 1882). The number need to treat for an additional harmful outcome (NNTH) for sotalol was 102 participants treated for one year to have one additional death. Low-certainty evidence from six RCTs suggested that risk of mortality may be higher in people taking quinidine (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646). Moderate-certainty evidence showed increased RR for mortality but with very wide CIs for metoprolol (RR 2.02, 95% CI 0.37 to 11.05, 2 RCTs, participants = 562) and amiodarone (RR 1.66, 95% CI 0.55 to 4.99, 2 RCTs, participants = 444), compared with placebo.We found little or no difference in mortality with dofetilide (RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence) or dronedarone (RR 0.86, 95% CI 0.68 to 1.09; high-certainty evidence) compared to placebo/no treatment. There were few data on mortality for disopyramide, flecainide and propafenone, making impossible a reliable estimation for those drugs.Withdrawals due to adverse eventsAll analysed drugs increased withdrawals due to adverse effects compared to placebo or no treatment (quinidine: RR 1.56, 95% CI 0.87 to 2.78; disopyramide: RR 3.68, 95% CI 0.95 to 14.24; propafenone: RR 1.62, 95% CI 1.07 to 2.46; flecainide: RR 15.41, 95% CI 0.91 to 260.19; metoprolol: RR 3.47, 95% CI 1.48 to 8.15; amiodarone: RR 6.70, 95% CI 1.91 to 23.45; dofetilide: RR 1.77, 95% CI 0.75 to 4.18; dronedarone: RR 1.58, 95% CI 1.34 to 1.85; sotalol: RR 1.95, 95% CI 1.23 to 3.11). Certainty of the evidence for this outcome was low for disopyramide, amiodarone, dofetilide and flecainide; moderate to high for the remaining drugs.ProarrhythmiaVirtually all studied antiarrhythmics showed increased proarrhythmic effects (counting both tachyarrhythmias and bradyarrhythmias attributable to treatment) (quinidine: RR 2.05, 95% CI 0.95 to 4.41; disopyramide: no data; flecainide: RR 4.80, 95% CI 1.30 to 17.77; metoprolol: RR 18.14, 95% CI 2.42 to 135.66; amiodarone: RR 2.22, 95% CI 0.71 to 6.96; dofetilide: RR 5.50, 95% CI 1.33 to 22.76; dronedarone: RR 1.95, 95% CI 0.77 to 4.98; sotalol: RR 3.55, 95% CI 2.16 to 5.83); with the exception of propafenone (RR 1.32, 95% CI 0.39 to 4.47) for which the certainty of evidence was very low and we were uncertain about the effect. Certainty of the evidence for this outcome for the other drugs was moderate to high.StrokeEleven studies reported stroke outcomes with quinidine, disopyramide, flecainide, amiodarone, dronedarone and sotalol. High-certainty evidence from two RCTs suggested that dronedarone may be associated with reduced risk of stroke (RR 0.66, 95% CI 0.47 to 0.95; participants = 5872). This result is attributed to one study dominating the meta-analysis and has yet to be reproduced in other studies. There was no apparent effect on stroke rates with the other antiarrhythmics.Recurrence of atrial fibrillationModerate- to high-certainty evidence, with the exception of disopyramide which was low-certainty evidence, showed that all analysed drugs, including metoprolol, reduced recurrence of atrial fibrillation (quinidine: RR 0.83, 95% CI 0.78 to 0.88; disopyramide: RR 0.77, 95% CI 0.59 to 1.01; propafenone: RR 0.67, 95% CI 0.61 to 0.74; flecainide: RR 0.65, 95% CI 0.55 to 0.77; metoprolol: RR 0.83 95% CI 0.68 to 1.02; amiodarone: RR 0.52, 95% CI 0.46 to 0.58; dofetilide: RR 0.72, 95% CI 0.61 to 0.85; dronedarone: RR 0.85, 95% CI 0.80 to 0.91; sotalol: RR 0.83, 95% CI 0.80 to 0.87). Despite this reduction, atrial fibrillation still recurred in 43% to 67% of people treated with antiarrhythmics. AUTHORS' CONCLUSIONS: There is high-certainty evidence of increased mortality associated with sotalol treatment, and low-certainty evidence suggesting increased mortality with quinidine, when used for maintaining sinus rhythm in people with atrial fibrillation. We found few data on mortality in people taking disopyramide, flecainide and propafenone, so it was not possible to make a reliable estimation of the mortality risk for these drugs. However, we did find moderate-certainty evidence of marked increases in proarrhythmia and adverse effects with flecainide.Overall, there is evidence showing that antiarrhythmic drugs increase adverse events, increase proarrhythmic events and some antiarrhythmics may increase mortality. Conversely, although they reduce recurrences of atrial fibrillation, there is no evidence of any benefit on other clinical outcomes, compared with placebo or no treatment.

[Zoster and postherpetic neuralgia: vaccine prevention is available]. / Zona et douleurs post-zostériennes : la prévention vaccinale est possible.

Herpes zoster (HZ) infection is a common condition in the elderly. Immunosuppression involving cellular immunity favors its occurrence. The pain is the most frequent complications of HZ. It occurs in about 30% of people aged over 70 years. The virological diagnosis of typical HZ is not useful, and the diagnosis is mainly based on clinical data. Skin care is essential to limit cutaneous damage. Antiviral drugs will reduce the risk of post-herpetic neuralgia, if they are early prescribed within 72 hours after the rash onset. Analgesia is essential and should be conducted in relation evolution. Vaccination is the most effective way to prevent the occurrence of HZ complications in the elderly, in particular post-herpetic neuralgia.

Effect of early syphilis infection on plasma viral load and CD4 cell count in human immunodeficiency virus-infected men: results from the FHDH-ANRS CO4 cohort.

BACKGROUND: Concomitant syphilis and human immunodeficiency virus (HIV) infection is increasingly frequent in industrialized countries. METHODS: From a large hospital cohort of HIV-infected patients followed up in the Paris area between 1998 and 2006, we examined the effect of early syphilis on plasma HIV-1 RNA levels and CD4 cell counts. We compared 282 HIV-1-infected men diagnosed as having incident primary or secondary syphilis with 1233 syphilis-free men matched for age (±5 years), sexual orientation, participating center, length of follow-up (±6 months), and immunologic and virologic status before the date of syphilis diagnosis (index date). Increase in viral load (VL) (plasma HIV-1 RNA) of at least 0.5 log or a rise to greater than 500 copies/mL in patients with previously controlled VL during the 6 months after the index date was analyzed, as were CD4 cell count variations and CD4 slope after the index date. RESULTS: During the 6 months after the index date, VL increase was observed in 77 men with syphilis (27.3%) and in 205 syphilis-free men (16.6%) (adjusted odds ratio [aOR], 1.87; 95% CI, 1.40-2.49). Even in men with a VL of less than 500 copies/mL undergoing antiretroviral therapy, syphilis was associated with a higher risk of VL increase (aOR, 1.52; 95% CI, 1.02-2.26). The CD4 cell count decreased significantly (mean, -28/µL) compared with the syphilis-free group during the syphilis episode (P = .001) but returned to previous levels thereafter. CONCLUSIONS: In HIV-infected men, syphilis was associated with a slight and transient decrease in the CD4 cell count and with an increase in VL, which implies that syphilis may increase the risk of HIV transmission, even in patients receiving antiretroviral therapy and with a VL of less than 500 copies/mL.