Importance of lack of interest in patients with mild cognitive impairment.

OBJECTIVE: Apathy is one of the most common behavioral symptoms in mild cognitive impairment (MCI). The aim of the authors' study was to examine the influence of the apathy dimensions, i.e., emotional blunting, lack of initiative, and lack of interest, on the risk of developing of Alzheimer disease (AD) in patients with MCI. DESIGN: Longitudinal study. SETTING: Fourteen French memory clinics. PARTICIPANTS: Apathy was assessed in 214 MCI patients. The main endpoint considered was the development of AD during the 3-year follow-up. MEASUREMENTS: The neuropsychiatric evaluation included the Goldberg anxiety scale and the Montgomery and Asberg Depression Rating Scale; apathy was assessed with the Apathy Inventory. RESULTS: After 3 years, 59 patients (27.2%) had developed AD. The risk of conversion to AD was significantly higher for patients with lack of interest. Using Cox analyses, controlling for age, gender and education, the difference between survival curves was significant for lack of interest. CONCLUSIONS: Lack of interest, a mild behavioral sign, could be an indicator of potential decline in MCI patients and underlines the importance of checking the cognitive status of these patients.

[Prescription to elderly patients: reducing underuse and adverse drug reactions and improving adherence]. / Mieux prescrire chez le sujet âgé en diminuant I' "underuse", la iatrogénie et en améliorant l'observance.

Many elderly people take multiple medications, usually for multiple health disorders. This "polymedication" increases the risk of iatrogenic disorders, may affect adherence to treatment, and represents an economic burden for society. It is therefore essential to optimize drug prescription to the elderly. The general practitioner is most involved in treating the elderly, who tend not to consult specialists as frequently as younger adults do. Most elderly subjects with comorbidities and polymedication are excluded from clinical trials, and geriatrics is not considered a priority during medical training. Three suboptimal prescription modalities have been described in the elderly population : "overuse", "misuse", and "underuse". Adverse drug reactions are frequent in the elderly and have a major economic cost. They are behind about 10 % of hospital admissions over the age of 65, and 20 % over 80. Yet most advers drug reactions are preventable. The public health consequences of non adherence to drug therapy are poorly documented. Elderly people may have several risk factors for non adherence, and a combination of measures may be necessary to improve the situation.

Apathy in patients with mild cognitive impairment and the risk of developing dementia of Alzheimer's disease: a one-year follow-up study.

OBJECTIVE: To evaluate the relation between apathy and development of dementia in patients with amnestic mild cognitive impairment (MCI). METHODS: Two hundred and fifty-one French-speaking outpatients fulfilling the criteria of amnestic MCI were enrolled. Apathy was assessed with the Apathy Inventory (IA). Neuropsychiatric evaluation also included the Goldberg anxiety scale and the Montgomery and Asberg Depressive Rating Scale (MADRS). The main end point considered after a 1-year follow-up was the development of dementia of Alzheimer type (DAT). RESULTS: At baseline there were 86 (39.8%) subjects presenting at least one symptom of apathy among the 216 included in analysis. After a 1-year follow-up, 22 patients developed DAT. Of the patients with apathy at baseline 13 (15.1%) developed DAT in comparison with 9 (6.9%) of the non-apathetic patients. At the 1-year follow-up, patients developing DAT had a significantly higher frequency of apathetic symptoms (91.7%) than patients without DAT (26.9%). CONCLUSION: Taking into account that apathy is one of the most frequently observed neuropsychiatric symptoms in MCI and in DAT the present study suggests that patients with MCI and apathy should be more closely observed.

Leukoaraiosis and mobility decline: a high resolution magnetic resonance imaging study in older people with mild cognitive impairment.

Patterns of leukoaraiosis were analyzed on both T2-weighted fast fluid-attenuated inversion-recovery and 3D T1-weighted sequences in 23 community-dwelling older subjects with mild cognitive impairment. Mobility assessment had allowed their classification into higher and lower mobility groups (P<0.0001). Lower mobility appeared correlated with frontal subependymal lesions (P=0.0005). The absence of marked ventriculomegaly, any thick caps, deep white matter lesions curved along the ventricles bodies, large deep white matter lesions, deep grey matter leukoaraiosis was an hallmark of the higher mobility group (P<0.0001). High resolution MRI demonstrated regular patterns of the subependymal lesions and detected perivascular distribution in other forms of leukoaraiosis. It suggests that the underlying mechanism of mobility decline in the elderly may be impairment of cerebrospinal fluid dynamics with cerebral small vessel disease.

Pharmacology and therapeutic effects of dehydroepiandrosterone in older subjects.

Man and higher primates have adrenals that secrete large amounts of dehydroepiandrosterone (DHEA) [prasterone] and its sulphate (DHEAS) [PB 008]. A remarkable feature of plasma DHEAS levels in humans is their great decrease with aging. Researchers have postulated that this age-related decline of DHEAS levels may explain some of the degenerative changes associated with aging. Moreover, administration of DHEA to laboratory animals has demonstrable beneficial effects such as prevention of diabetes mellitus, obesity, cancer, heart disease and positive immunomodulator effects. However, in rodents DHEA(S) circulating levels are so low that it is impossible to detect any significant age-related decrease. Therefore results from rodent experiments are not relevant to human beings. Three mechanisms of action of DHEA(S) have been identified. DHEA and DHEAS are precursors of testosterone and estradiol, DHEAS is a neurosteroid which modulates neuronal excitability via specific interactions with neurotransmitter receptors and DHEA is an activator of calcium-gated potassium channels. Randomised, placebo-controlled clinical trials which included healthy individuals aged 60 years and over treated with (near) physiological doses of DHEA (50-100 mg/day) have yielded very few positive results. Impact of DHEA replacement treatment was assessed on mood, well being, cognitive and sexual functions, bone mass, body composition, vascular risk factors, immune functions and skin. The major limitations of these trials were their short duration (maximum 1 year) and the low number of study participants involved (maximum 280). Many elderly people in western countries take DHEA without medical supervision. In the US, DHEA is even classified as food supplement. At present there is no scientific evidence to recommend DHEA replacement in the elderly. Further studies are needed to form conclusions about the efficacy and the safety of DHEA replacement in elderly, and to better understand the mechanisms of action of DHEA at the molecular and cellular levels.

Drug-related readmissions to medical units of older adults discharged from acute geriatric units: results of the Optimization of Medication in AGEd multicenter randomized controlled trial.

OBJECTIVES: To assess the effect of an intervention on drug-related problem (DRP; adverse drug reactions, adherence problems, underuse)-related readmission rates in older adults. DESIGN: Ancillary study from a 6-month, prospective, randomized, parallel-group, open-label trial. SETTING: Six acute geriatric units in Paris and suburbs. PARTICIPANTS: Six hundred sixty-five consecutively admitted individuals were included: 317 in the intervention group (IG) and 348 in the control group (CG) (aged 86.1 ± 6.2, 66% female). INTERVENTION: Discharge-planning intervention combining chronic drug review, education, and enhanced transition-of-care communication. MEASUREMENTS: Chronic drugs at discharge of the two groups were compared. An expert committee blinded to group assignment adjudicated whether 6-month readmission to the study hospitals was related to drugs. RESULTS: Six hundred thirty-nine individuals were discharged and followed up (300 IG, 339 CG). The intervention had no significant effect on drug regimen at discharge, characterized by prescriptions that are mostly appropriate but increase iatrogenic risk. Three hundred eleven readmissions occurred during follow-up (180 CG, 131 IG), of which 185 (59.5%) were adjudicated (102 CG, 83 IG). For 16, DRP imputability was doubtful. Of the remaining 169, DRPs were the most frequent cause for readmission, with 38 (40.4%) readmissions in the CG and 26 (34.7%) in the IG (relative risk reduction = 14.3%, 95% confidence interval = 14.0-14.5%, P = .54). The intervention was associated with 39.7% fewer readmissions related to adverse drug reactions (P = .12) despite the study's lack of power. CONCLUSION: Drug-related problem prevention in older people discharged from the hospital should be a priority, with a focus on improving the monitoring of drugs with high iatrogenic risk.

[Definition and issue of medications underuse in frail elderly patients]. / Omission de traitement chez la personne âgée : quelle définition pour quels enjeux ?

Underuse is defined as the absence of initiation of an effective treatment in subjects with a condition for which one or several drug classes have demonstrated their efficacy. Indeed, "effective treatment" actually means favourable benefit/risk ratio. To propose a detailed and functional definition of underuse for frail elderly we should discuss, beforehand, the better way to assess benefit/risk ratio of drugs in this population. Our work is based on a literature review in the field of inappropriate prescription and therapeutic optimization. We can foresee the hard way to accurately define underuse for frail geriatric patients because of the difficulties encountered to demonstrate drug efficacy, drug effectiveness, or even more drug risk in this specific population. Potential benefit of underused medications in this population are poorly evaluated before and even after market authorization. Premarketing clinical trials and pharmacovigilance also yield only relatively restricted information on safety of use. Underuse is a non optimal prescription modality and presumes a judgment on prescription act. This can lead to recommendations or quality indicators. It should therefore be scientifically valid and closely fit with a loss of health or loss of quality of life with a satisfying proof level. But the literature generally adopts an unsophisticated point of view. Medication introduction on the basis of a debatable definition of underuse could lead to an accumulation of useless drugs with potential adverse effects which is overuse.

[Hospitalization of elderly in an acute-care geriatric department]. / Mode d'hospitalisation des patients âgés dans une unité de gériatrie aiguë

Hospital admissions following emergency visits of elderly people are frequent. This admission modality is often problematic both for the patients and the emergency healthcare professionals. Direct admission from home (or nursing home) in acute geriatric units (AGU) has been developed but has never been prospectively assessed. We conducted a 6-month prospective observational study to compare the 97 patients admitted through the emergency room (ER) in the AGU of Bichat's hospital to the 76 patients admitted directly. Collected data included socio-demographic and medical baseline data, clinical severity score at admission, cause of hospitalization, final diagnosis, in-hospital occurrence of urinary retention and of pressure ulcer, length of stay, discharge disposition and mortality. No significant differences between the groups were found for most baseline characteristics, clinical severity score, occurrence of pressure ulcers, length of stay and mortality. However ER patients were significantly older (88±6 vs 86±7 years, p=0.04) and had more often history of arrhythmia (29% vs 15%, p=0.02) and protein-energy malnutrition preceding admission (63% vs 46%, p=0.03). Falls as admission cause was more common in ER patients while unexplained health status or functional decline were most common in those admitted directly. Clinical outcomes were less favourable in ER patients with significantly more urinary retentions (25% vs 4%, p=0.0002) and transfers to rehabilitation units (48% vs 31%, p=0.04). The patients admitted directly returned more often at home without additional social support (53% vs 30%, p=0.001). Direct admission in AGU is feasible, medically effective and provides an alternative to attending an emergency room. This admission modality could be specially suitable for elder people suffering from an unexplained functional or health status declines. Further studies are necessary to support the hypothesis that quality gains and cost-effective measures may be achieved by dissemination of such an admission modality at the hospital.

A mini geriatric assessment helps treatment decision in elderly patients with digestive cancer. A pilot study.

UNLABELLED: Comprehensive geriatric assessment (CGA) is advocate to improved care of elderly with cancer but is not available in every hospital within a short delay. Therefore, a tool allowing gastroenterologist to detect rapidly specific abnormalities in elderly is needed. PATIENTS AND METHODS: the aim of our pilot study was to evaluate feasibility of a mini geriatric assessment (MGA) to adapt the anticancer treatments. MGA was done by a gastroenterologist and was taken into account during the cancer multidisciplinary team meeting for making decision. Then, CGA was realised and suggested adaptation of care. RESULTS: 21 patients over 75 years treated for different digestive cancers were enrolled. The treatments recommended by the cancer multidisciplinary team meeting after the GMA were: standard treatments in 9 (41%); modified in 10 (47%) and best supportive care in 2 (12%) patients. CGA led to an adaptation of the non-oncological treatment in 15 (72%) and of the social care in 8 (38%) patients, but never modified the oncological strategy. CONCLUSIONS: MGA could help gastroenterologists for adaptation of anticancer treatment. The characteristics of the patients that should subsequently have a geriatric follow-up remain to be defined.

A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalizations of older adults: the optimization of medication in AGEd multicenter randomized controlled trial.

OBJECTIVES: To determine whether a new multimodal comprehensive discharge-planning intervention would reduce emergency rehospitalizations or emergency department (ED) visits for very old inpatients. DESIGN: Six-month prospective, randomized (Zelen design), parallel-group, open-label trial. SETTING: Six acute geriatric units (AGUs) in Paris and its surroundings. PARTICIPANTS: Six hundred sixty-five consecutive inpatients aged 70 and older (intervention group (IG) n = 317; control group (CG) n = 348). INTERVENTION: Intervention-dedicated geriatricians different from those in the study centers implemented the intervention, which targeted three risk factors for preventable readmissions and consisted of three components: comprehensive chronic medication review, education on self-management of disease, and detailed transition-of-care communication with outpatient health professionals. MEASUREMENTS: Emergency hospitalization or ED visit 3 and 6 months after discharge, as assessed by telephone calls to the participant, the caregiver, and the general practitioner and confirmed with the hospital administrative database. RESULTS: Twenty-three percent of IG participants were readmitted to hospital or had an ED visit 3 months after discharge, compared with 30.5% of CG participants (P = .03); at 6 months, the proportions were 35.3% and 40.8%, respectively (P = .15). Event-free survival was significantly higher in the IG at 3 months (hazard ratio (HR) = 0.72, 95% confidence interval (CI) = 0.53-0.97, P = .03) but not at 6 months (HR = 0.81, 95% CI = 0.64-1.04, P = .10). CONCLUSION: This intervention was effective in reducing rehospitalizations and ED visits for very elderly participants 3 but not 6 months after their discharge from the AGU. Future research should investigate the effect of this intervention of transitional care in a larger population and in usual acute and subacute geriatric care.

[Diagnosing the cause of acute dyspnea in elderly patients: role of biomarkers in emergencies]. / Diagnostic étiologique de la dyspnée aiguë du sujet âgé: place des biomarqueurs en urgence.

Acute dyspnea is one of the leading causes of emergency hospitalization of elderly patients. Clinical diagnostic procedures are difficult in this geriatric population. Acute heart failure is the most frequent cause of acute dyspnea in geriatric patients. The use of plasma B natriuretic peptide (BNP) assays in the general population has profoundly improved its medical management. There has also been progress recently for other frequent causes of dyspnea in the elderly, including infection and venous thromboembolic disease. Procalcitonin assays may be useful as a prognostic factor for infectious disease. Nevertheless, the real value of BNP assays in geriatric populations must be clarified by interventional studies.

Neuropsychological performance in mild cognitive impairment with and without apathy.

OBJECTIVE: To investigate the neuropsychological characteristics of patients diagnosed with mild cognitive impairment (MCI) with and without apathy. METHODS: A cohort of 245 MCI patients (mean age = 72 +/- 5.5 years; mean MMSE = 27.5 +/- 1.3) was divided into two subgroups according to their Apathy Inventory score and underwent an extensive neuropsychological battery. RESULTS: There were 94 (38.4%) patients with and 151 (61.6%) patients without apathy. At baseline the apathetic subgroup had a significantly lower total score on the free and cued selective reminding test (FCSR). Furthermore, the apathetic subgroup showed a significant deterioration in FCSR total recall score between baseline and the 1-year assessment. In conclusion, the presence of apathy in MCI patients is not associated with frontal task performance but with a higher degree of memory impairment.

Frequency and risk factors of potentially inappropriate medication use in a community-dwelling elderly population: results from the 3C Study.

OBJECTIVE: To estimate the frequency of potentially inappropriate medication use among community-dwelling elderly subjects and to identify socio-demographic factors associated with this use. METHODS: Data were collected in the Three-City Study, a French longitudinal study on vascular factors and cognitive decline. The study population was composed of 9,294 subjects aged 65 years and older, living in the community. Inappropriate medication use was assessed using a list derived from the Beers criteria by a panel of French experts. RESULTS: Nearly 40% of the participants used at least one potentially inappropriate medication: 23.4% used cerebral vasodilators, 9.2% long-acting benzodiazepines and 6.4% drugs with anticholinergic properties. Excluding cerebral vasodilators from the list, the frequency of potentially inappropriate medication use was 21.7%. This use was significantly more frequent among women, older subjects and poorly educated subjects. Adjusted analyses showed that these associations could not be explained by a confounding effect of medical factors. Compared with 13.0% of men with a high educational level, 27.9% of women with a low educational level used at least one potentially inappropriate medication (odds ratio=2.0; 95% confidence interval: 1.7-2.3). CONCLUSION: This study is the first attempt to evaluate the frequency of potentially inappropriate medication use in the elderly French population. Female gender and low socio-economic characteristics reduced the chances of receiving optimal pharmacotherapy. The proportion of elderly subjects receiving potentially inappropriate medication was higher than shown in previous studies. This is mainly explained by differences in the use of cerebral vasodilators.