Exercise Interventions With Trained Home Helpers for Preventing Loss of Autonomy and Falls in Community-Dwelling Older Adults Receiving Home Heath Physical Therapy T4H: A Randomized Controlled Pilot Study.

BACKGROUND AND PURPOSE: Older adults at risk for falls live independently in the community in their own home and have rehabilitation needs. However, little is known about whether home coaching of older adults can decrease falls at home. We sought to determine whether a novel program for preventing falls and a loss of exercise capacity, the T4H program, in which home helpers act as exercise coaches by using an information technology (IT) device, was acceptable and feasible. METHODS: Between February 2015 and October 2015, we performed a cluster randomized controlled trial in which home helpers either assisted older adults 75 years and over, to participate in the T4H program, or provided standard home help over 3 months. We assessed levels of acceptability and satisfaction among the older adults and home helpers with regard to the exercise program and the technologies used. To measure efficacy, the main outcome measures for the older adults were the absence of falls requiring medical or paramedical care, unplanned hospitalizations, walking ability in a Timed Up and Go test (TUG), and self-care ability by the Barthel Index at the 3-month follow-up visit. RESULTS AND DISCUSSION: Overall, 35 older adults were included, aged 89 years and with 68.6% women. Eighty-five percent of the respondents were pleased or very pleased to have participated in the T4H exercise program, 70% were satisfied with the IT devices, and 92% were satisfied with their home helper's level of involvement. Two of the 4 home helper respondents were satisfied or very satisfied with the exercise program, and 2 were moderately satisfied. The proportions of older adult participants with no falls or no unplanned hospitalizations were higher in the T4H group (92.3% and 85.7%, respectively) than in the control group (81.8% and 71.4%, respectively), although these intergroup differences were not statistically significant. The T4H and control groups did not differ significantly with regard to the TUG time (median [IQR]: 27.6 seconds [17.9-58.6] vs 30.7 seconds [19.7-57.2], respectively) or the Barthel Index (median [IQR]: 90 [75-95] and 90 [75-95], respectively). CONCLUSIONS: The novel T4H home help model was feasible and was associated with a high level of participant satisfaction. We observed a trend toward fewer falls and hospitalizations and better quality of life in the older adults.

Leukocyte Telomere Length in Alzheimer's Disease Patients with a Different Rate of Progression.

BACKGROUND: Age and short leukocyte telomeres have been associated with a higher risk of Alzheimer's disease (AD). Inflammation is involved in AD and it is suggested that anti-inflammatory interleukin-10 (IL-10) may partly antagonize these processes. OBJECTIVE: The aim is to correlate telomere length (TL) in peripheral blood mononuclear cells (PBMC) from patients with AD to disease progression rate. Moreover, we evaluated whether TL was associated with IL-10 production by unstimulated or amyloid-ß (Aß)-stimulated PBMC. METHODS: We enrolled 31 late-onset AD and 20 age-matched healthy elderly (HE). After a two-year follow-up period, patients were retrospectively evaluated as slow-progressing (ADS) (Mini Mental State Examination (MMSE) decline over the two years of follow-up ≤3 points) or fast progressing AD (ADF) (MMSE decline ≥5 points). TL was measured by flow cytometry and in vitro IL-10 production by enzyme-linked immunosorbent assay. RESULTS: TL (mean±SD) for HE, ADS, and ADF was 2.3±0.1, 2.0±0.1, and 2.5±0.1 Kb, respectively. ADS showed a shorter TL compared to HE (p = 0.034) and to ADF (p = 0.005). MMSE decline correlated with TL in AD (R2 = 0.284; p = 0.008). We found a significant difference in IL-10 production between unstimulated and Aß-stimulated PBMC from ADS (40.7±13.7 versus 59.0±27.0; p = 0.004) but not from ADF (39.7±14.4 versus 42.2±22.4). HE showed a trend toward significance (47.1±25.4 versus 55.3±27.9; p = 0.10). CONCLUSION: PBMC from ADF may be characterized by an impaired response induced by Aß and by a reduced proliferative response responsible for the longer telomeres. TL might be a contributing factor in predicting the rate of AD progression.

Interleukin-10 Production in Response to Amyloid-ß Differs between Slow and Fast Decliners in Patients with Alzheimer's Disease.

We investigated IL-10 and IL-6 production in amyloid-ß (Aß) stimulated peripheral blood mononuclear cells (PBMCs) in twenty Alzheimer's disease (AD) patients with slow progression, eleven with fast progression, and twenty age-matched controls. Promoter polymorphisms in IL-10 (position -592, -819, -1082), IL-6 (-174), transforming growth factor-ß1 (TGF-ß1) (-10, -25), interferon-γ (IFN-γ) (-874), and tumor necrosis factor-α (TNF-α) (-308) genes were analyzed. IL-10 production after Aß stimulation was high in PBMCs from slow decliners and almost completely abrogated in fast decliners. Association between AA IFN-γ low-producing genotype and fast progression was demonstrated. Investigations in a larger sample will clarify these findings.

Fall related to epileptic seizures in the elderly.

It is well known that both falls and epileptic seizures are very frequent and harmful in the elderly. Moreover, although seizures may cause falls, their relationship is poorly documented in this population. We report four women (mean age: 84.5 years) who presented falls with: late-onset focal seizures of possible parietal (Case 1) or frontal localisation (Case 2), early onset with late aggravation of juvenile myoclonic epilepsy (Case 3), and generalised situation-related myoclonic seizures (Case 4). Falls were presumably associated with tonic posturing of left (Case 1) or right (Case 2) hemibody, to bilateral and massive myoclonic jerks (Cases 3 and 4) with a loss of consciousness (Case 3). The diagnosis of seizures was difficult and routine EEG was unremarkable in Cases 1 and 2, requiring video-EEG monitoring to capture the clinical events. Adequate treatment offered recovery from seizures and falls in all patients. Other mechanisms of seizure-induced falls in older patients and their management are discussed. In conclusion, falls may be caused by different seizure types and appear to be underestimated due to difficulties in seizure diagnosis in the elderly. Recognizing falls related to seizures is important in geriatric practice, as it facilitates adequate management.

[Needs, uses, cons-pros, good practices and opportunities about walker in elderly with loss of autonomy]. / Besoins, usages, bénéfices-inconvénients, bonnes pratiques et perspectives en matière de déambulateurs chez les sujets âgés dépendants.

Non-use of the walker may be secondary to an initial inappropriate prescribing, a lack of adequate training, a lack of monitoring and side effects of using. Improving both stability and mobility in users is due to several biomechanical mechanisms. The benefits of walker are: general physiological effects, more confidence, better social life and decrease in the burden of care. The disadvantages of walker are: technical or practical aspects criticized by users, musculoskeletal disorders, delayed reaction time, fall risk and stigma. Few scientific data evaluating the interest of the walker concerning mobility exist, thus recommendations are low grade and are often taken from professional clinical experiences. The choice of technical walking assistance depends on the pathology and biomechanical mechanism. The walker robots are few distributed.

[Clinical pharmacology and aging]. / Pharmacologie clinique et vieillissement.

Clinicians must be aware that aging can lead to changes in the pharmacokinetics and pharmacodynamics of many drugs. Drug distribution may be modified with aging secondarily to the decrease of serum albumin and to modifications of body composition (increase in the proportion of fat mass and decrease of lean mass). Hepatic metabolism of several drugs is reduced with age, especially drugs which depend of hepatic blood flow or P450 cytochroms. The incidence of renal failure increase largely with age. Glomerular filtration rate should be systematically estimated in older patients and, when needed, the doses of those drugs having significant renal elimination should be adjusted. In older patients, changes in the response to drugs can also develop, concerning specially the central nervous system (increased sensibility to any neurological effect of drugs), the cardiovascular system and the renal management of water and electrolytes. In many cases, the pharmacological changes associated to age are mild and requires no dose adjustment. However, many drugs should be adapted depending on the individual situation of each patient, particularly his renal function and nutritional state. Finally, some drugs should be avoided in older patients because of a bad effectiveness/tolerance ratio compared to alternatives.

Long-term use of standardised Ginkgo biloba extract for the prevention of Alzheimer's disease (GuidAge): a randomised placebo-controlled trial.

BACKGROUND: Prevention strategies are urgently needed to tackle the growing burden of Alzheimer's disease. We aimed to assess efficacy of long-term use of standardised ginkgo biloba extract for the reduction of incidence of Alzheimer's disease in elderly adults with memory complaints. METHODS: In the randomised, parallel-group, double-blind, placebo-controlled GuidAge clinical trial, we enrolled adults aged 70 years or older who spontaneously reported memory complaints to their primary-care physician in France. We randomly allocated participants in a 1:1 ratio according to a computer-generated sequence to a twice per day dose of 120 mg standardised ginkgo biloba extract (EGb761) or matched placebo. Participants and study investigators and personnel were masked to study group assignment. Participants were followed-up for 5 years by primary-care physicians and in expert memory centres. The primary outcome was conversion to probable Alzheimer's disease in participants who received at least one dose of study drug or placebo, compared by use of the log-rank test. This study is registered with ClinicalTrials.gov, number NCT00276510. FINDINGS: Between March, 2002, and November, 2004, we enrolled and randomly allocated 2854 participants, of whom 1406 received at least one dose of ginkgo biloba extract and 1414 received at least one dose of placebo. By 5 years, 61 participants in the ginkgo group had been diagnosed with probable Alzheimer's disease (1·2 cases per 100 person-years) compared with 73 participants in the placebo group (1·4 cases per 100 person-years; hazard ratio [HR] 0·84, 95% CI 0·60-1·18; p=0·306), but the risk was not proportional over time. Incidence of adverse events was much the same between groups. 76 participants in the ginkgo group died compared with 82 participants in the placebo group (0·94, 0·69-1·28; p=0·68). 65 participants in the ginkgo group had a stroke compared with 60 participants in the placebo group (risk ratio 1·12, 95% CI 0·77-1·63; p=0·57). Incidence of other haemorrhagic or cardiovascular events also did not differ between groups. INTERPRETATION: Long-term use of standardised ginkgo biloba extract in this trial did not reduce the risk of progression to Alzheimer's disease compared with placebo. FUNDING: Ipsen.

A short-term, multicomponent infection control program in nursing homes: a cluster randomized controlled trial.

OBJECTIVES: To assess the impact of a hygiene-encouragement program on reducing infection rates (primary end point) by 5%. DESIGN: A cluster randomized study was carried out over a 5-month period. SETTINGS AND PARTICIPANTS: Fifty nursing homes (NHs) with 4345 beds in France were randomly assigned by stratified-block randomization to either a multicomponent intervention (25 NHs) or an assessment only (25 NHs). INTERVENTION: The multicomponent intervention was targeted to caregivers and consisted of implementing a bundle of infection prevention consensual measures. Interactive educational meetings using a slideshow were organized at the intervention NHs. The NHs were also provided with color posters emphasizing hand hygiene and a kit that included hygienic products such as alcoholic-based hand sanitizers. Knowledge surveys were performed periodically and served as reminders. MEASUREMENTS: The primary end point was the total infection rate (urinary, respiratory, and gastrointestinal infections) in those infection cases classified either as definite or probable. Analyses corresponded to the underlying design and were performed according to the intention-to-treat principle. This study was registered (#NCT01069497). RESULTS: Forty-seven NHs (4515 residents) were included and followed. The incidence rate of the first episode of infection was 2.11 per 1000 resident-days in the interventional group and 2.15 per 1000 resident-days in the control group; however, the difference between the groups did not reach statistical significance in either the unadjusted (Hazard Ratio [HR] = 1.00 [95% confidence interval (CI) 0.89-1.13]; P = .93]) or the adjusted (HR = 0.99 [95% CI 0.87-1.12]; P = .86]) analysis. CONCLUSION: Disentangling the impact of this type of intervention involving behavioral change in routine practice in caregivers from the prevailing environmental and contextual determinants is often complicated and confusing to interpret the results.

Excess winter mortality in France: influence of temperature, influenza like illness, and residential care status.

BACKGROUND: Despite a surge of 15,000 deaths caused by the 2003 heat wave in France, the annual winter excess mortality rate remains a recurring phenomenon that is quantitatively greater than the isolated summer event. METHODS: Coefficients of Seasonal Variations in Mortality (CSVMs) were calculated using monthly mortality data from 1998 to 2007 in France. CSVM was a percentage representing the excess death rate from December to March inclusively, against average, monthly mortality from the other 8 non-winter months. Sociodemographic parameters and environmental factors were also obtained. Univariate and multivariate analyses were performed to identify risk factors of increased winter mortality. RESULTS: The data revealed an annual winter excess death of 23,836 (± 7951) (mean ± 1 standard deviation) cases. On average, CSVM in France was +14.94% (13.54 [12.03; 19.70]) (mean, median, and interquartile intervals). Multivariate analysis results revealed that several factors contributed to the CSVM: sociodemographics, such as age (CSVM higher for the population older than 75) and death location (CSVM higher in nursing homes), environmental factors, such as the severity of the winter season (per monthly minimal temperature), and estimated number of influenza-like illnesses (ILI). Correlation between observed and predicted CSVMs was extremely consistent (R(2) = 0.91). CONCLUSION: There was a fundamental belief that residents in nursing homes were well protected from cold spells and their consequences. Our results revealed this to be a mere misperception.

[Management of pneumonia in the elderly]. / Prise en charge d'une pneumonie du sujet agé.

Pneumonias in elderly are frequent and severe. They require an accurate assessment following clinical, biological and radiological steps. Each of them can contribute to give answers to the following questions: does this patient need emergency hospitalisation? Is the infection really bacterial and pulmonary? Should antibiotics be started? Which others treatments should be associated for the infection itself and for comorbid conditions? Concerning prevention, every effort must be done to decrease the incidence of these infections, especially vaccination. Pulmonary infections in nursing home need specific attention: cumulation of bad prognosis factors, risk of epidemic propagation, and vaccination of all people caring patients when required.

Leptin is better than any other biological parameter for monitoring the efficacy of renutrition in hospitalized malnourished elderly patients.

OBJECTIVE: Despite malnutrition being a major problem in hospitalized elderly patients, there is a lack of studies focusing on the comparative value of biological parameters for monitoring renutrition. The aim of this study was to determine which biological parameter(s) could best monitor successful renutrition in hospitalized malnourished elderly patients. DESIGN: The objective of the study was to explore the impact of a 6-week renutrition process on anthropometric and biological parameters in elderly patients and to define the biological parameters associated with weight regain. PATIENTS: A total of 72 hospitalized malnourished elderly patients admitted to a hospital-based geriatric rehabilitation unit. MEASUREMENTS: Patients were evaluated at admission and at 6 weeks for anthropometric measurements of weight, sum of the four subcutaneous skinfold thicknesses, calf circumference and biological serum parameters including albumin, transthyretin, leptin, IGF-1, IGFBP-1 and IGFBP-3. Renutrition was considered successful if a patient gained at least 5% of body weight over 6 weeks. RESULTS: Leptin was the only biological parameter that increased at 6 weeks in successful renutrition. Leptin variations were not influenced by C-reactive protein variations, in contrast to transthyretin which can be modified by the inflammatory states frequently encountered in geriatric patients. CONCLUSIONS: Serum leptin is a more appropriate parameter than transthyretin for monitoring renutrition.

Masitinib as an adjunct therapy for mild-to-moderate Alzheimer's disease: a randomised, placebo-controlled phase 2 trial.

INTRODUCTION: Neuroinflammation is thought to be important in Alzheimer's disease pathogenesis. Mast cells are a key component of the inflammatory network and participate in the regulation of the blood-brain barrier's permeability. Masitinib, a selective oral tyrosine kinase inhibitor, effectively inhibits the survival, migration and activity of mast cells. As the brain is rich in mast cells, the therapeutic potential of masitinib as an adjunct therapy to standard care was investigated. METHODS: A randomised, placebo-controlled, phase 2 study was performed in patients with mild-to-moderate Alzheimer's disease, receiving masitinib as an adjunct to cholinesterase inhibitor and/or memantine. Patients were randomly assigned to receive masitinib (n = 26) (starting dose of 3 or 6 mg/kg/day) or placebo (n = 8), administered twice daily for 24 weeks. The primary endpoint was change from baseline in the Alzheimer's Disease Assessment Scale - cognitive subscale (ADAS-Cog) to assess cognitive function and the related patient response rate. RESULTS: The rate of clinically relevant cognitive decline according to the ADAS-Cog response (increase >4 points) after 12 and 24 weeks was significantly lower with masitinib adjunctive treatment compared with placebo (6% vs. 50% for both time points; P = 0.040 and P = 0.046, respectively). Moreover, whilst the placebo treatment arm showed worsening mean ADAS-Cog, Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory, and Mini-Mental State Examination scores, the masitinib treatment arm reported improvements, with statistical significance between treatment arms at week 12 and/or week 24 (respectively, P = 0.016 and 0.030; P = 0.035 and 0.128; and P = 0.047 and 0.031). The mean treatment effect according to change in ADAS-Cog score relative to baseline at weeks 12 and 24 was 6.8 and 7.6, respectively. Adverse events occurred more frequently with masitinib treatment (65% vs. 38% of patients); however, the majority of events were of mild or moderate intensity and transitory. Severe adverse events occurred at a similar frequency in the masitinib and placebo arms (15% vs. 13% of patients, respectively). Masitinib-associated events included gastrointestinal disorders, oedema, and rash. CONCLUSIONS: Masitinib administered as add-on therapy to standard care during 24 weeks was associated with slower cognitive decline in Alzheimer's disease, with an acceptable tolerance profile. Masitinib may therefore represent an innovative avenue of treatment in Alzheimer's disease. This trial provides evidence that may support a larger placebo-controlled investigation. TRIAL REGISTRATION: Clinicaltrials.gov NCT00976118.

Electroclinical features of idiopathic generalized epilepsies in the elderly: a geriatric hospital-based study.

PURPOSE: Idiopathic generalized epilepsies (IGE) are age-related epileptic syndromes mainly described in children and adolescence. Our aim is to describe their electroclinical features in the elderly. METHODS: Patients aged 70 years or more were prospectively selected in a geriatric EEG laboratory on the basis of rhythmic generalized spikes and waves discharges. Their clinical data were then examined to ascertain the syndromic diagnosis. RESULTS: Among 1181 geriatric patients referred for EEG over a 30-month period, IGE were identified in 10 cases. Eight patients began seizures in childhood or adulthood (3 childhood absence epilepsies, 2 juvenile/adult myoclonic epilepsies and 3 epilepsies with-generalized-tonic-clonic-seizures alone (EGTCS)) and 2 very late in life with EGTCS. The early-onset IGE cases had usually experienced a quiescent long period in adulthood before relapsing late in life. This relapse, mostly severe, consisted of absence status, myoclonic status or repeated generalized tonic clonic seizures and was often not-situation related. Absence status and myoclonic status were stopped by Clonazepam. The two late-onset IGE cases had familial history of epilepsy. Inappropriate antiepileptic drugs (AED) previously given in four patients with two worsenings were corrected. CONCLUSIONS: In this study, the non-negligible number of elderly cases observed over a short period of time suggests that IGE are frequent in the elderly but underestimated until recently. IGE may be lifelong with late severe exacerbations. A few very late-onset IGE cases exist. EEG remains useful in contributing to diagnose IGE and AED adjustment continues to be beneficial at extreme age.

French healthcare workers in geriatric healthcare settings staunchly opposed to influenza vaccination: the VESTA study.

The observational diagnosis phase of the VESTA study was aimed to determine the composite profiles of vaccinated/non-vaccinated HCWs by analyzing reasons to accept/decline influenza vaccination. Between June and September 2005, 2485 HCWs (female: 82.9%; nursing auxiliaries: 42.1%; vaccination coverage: 23.4%) from 53 French geriatric HCSs were included in the study. Cluster analysis determined 3 composite profiles: HCWs for whom information programs on vaccination can be useful (59%), HCWs staunchly opposed to vaccination (36%), and skeptical HCWs (5%). Qualitative analysis provided some aspects of influenza vaccine reluctance. Effective programs would be multidimensional and target the most susceptible group.

Influence of geriatric consultation with comprehensive geriatric assessment on final therapeutic decision in elderly cancer patients.

Elderly patients represent a heterogeneous population in which decisions on cancer treatment are often difficult. The present study aims to report a 2-year period of the activity of geriatric assessment consultations and the impact on treatment decisions. Since January 2007, we have systematically carried out geriatric consultations, using well-known international scales, for elderly patients in whom treatment decisions appear complex to oncologists. From January 2007 to November 2008, 161 patients (57 men, 104 women; median age 82.4 years, range 73-97) were seen at geriatric consultations. Most of the patients (134/161) were undergoing first-line treatment and cancer was metastatic in 86 patients (53%). Geriatric assessment found severe comorbidities (grade 3 or 4 in CIRS-G scale) in 75 patients, dependence for at least one activity of daily living (ADL) in 52 patients, cognitive impairment in 42 patients, malnutrition in 104 patients (65%) and depression in 39 patients. According to the oncologists' prior decisions, there were no changes in treatment decisions in only 29 patients. Cancer treatment was changed in 79 patients (49%), including delayed therapy in 5 patients, less intensive therapy in 29 patients and more intensive therapy in 45 patients. Patients for whom the final decision was delayed or who underwent less intensive therapy had significantly more frequent severe comorbidities (23/34, p<0.01) and dependence for at least one ADL (19/34, p<0.01). In this study, we have found that comprehensive geriatric evaluation did significantly influence treatment decisions in 82% of our older cancer patients.

[Geriatric oncology: epidemiological evidence]. / Oncogériatrie : une évidence épidémiologique.

In Europe, 60% of all cancers and 75% of all deaths from cancer occur in patients older than 65 years. The incidence of many cancers (prostate, colorectal, and hematological) either increases with age or remains high (breast and lungs). The two principal characteristics of cancer in the elderly are late diagnosis and comorbidity that requires specific geriatric assessment and cooperation between the oncologist and the geriatrician. Academic and pharmaceutical industry research must focus on the specificities of cancers in the elderly and of response to treatment according to functional abilities and comorbidity. Equal access to high quality medical care and procedures must be ensured, regardless of age; this is not currently the case everywhere.

Assessment of healthcare worker influenza vaccination program in French geriatric wards: a cluster-randomized controlled trial.

BACKGROUND AND AIMS: The French institute for study of geriatric infection risk (ORIG) has run a multiphase multicenter study (VESTA) to develop and implement active programs promoting healthcare worker (HCW) influenza vaccination. The present article reports results after implementation of the first active program. METHOD: A cluster-randomized controlled trial was conducted from December 1 to December 15, 2005, and a total of 43 geriatric wards (3646 HCWs) were randomly assigned to two clusters. The program cluster (24 wards; 1918 HCWs) received the active program whereas no action was taken in the control cluster (19 wards; 1728 HCWs). The program was educational; its objective was to convince HCWs to be vaccinated by giving them topdown scientific information and developing a sense of altruism. Data from 1201 HCWs (63%) from the program cluster and 1144 HCWs (66%) from the control cluster were collected. RESULTS: The program failed to increase the HCW influenza vaccination rate (program: 34%; control: 32%; p>0.05), but won the faithfulness of vaccinated HCWs (5% vs 8% HCWs quitted vaccination; p<0.05). CONCLUSIONS: Resistance to active influenza vaccination programs was found. Future active programs will have to restore a climate of confidence between sources of knowledge and HCWs and promote "self-protection" in contrast with the protection of elderly people.