Association between low eosinophil count and acute bacterial infection, a prospective study in hospitalized older adults.

BACKGROUND: The incidence of sepsis increases significantly with age, including a high incidence of bacterial infection in the old adults. Eosinopenia and the CIBLE score have been proposed in critically ill adults and in internal medicine wards. This study aimed to assess whether a low eosinophil count was associated with acute bacterial infection among hospitalized older adults, and to find the most efficient eosinophil count cut-off to differentiate acute bacterial infection from other inflammatory states. METHODS: This was a prospective study from July 2020 to July 2022 in geriatric wards of the University Paul Brousse Hospital (Villejuif, France) including patients aged of 75 y/o or over suffering from fever or biological inflammation. Acute bacterial infection was assessed using biological identification and/or clinical and radiological data. RESULTS: A total of 156 patients were included. Eighty-two (53%) patients suffered from acute bacterial infection (mean age (SD) 88.7 (5.9)). Low eosinophil count was independently associated with acute bacterial infection: OR [CI95%] 3.03 [1.04-9.37] and 6.08 [2.42-16.5] for eosinophil count 0-0.07 G/L and 0.07-0.172 G/L respectively (vs. eosinophil count > 0.172 G/L). Specificity and sensitivity for eosinophil count < 0.01 G/L and CIBLE score were 84%-49% and 72%-62%, respectively with equivalent AUCs (0.66 and 0.67). CONCLUSION: Eosinophil count < 0.01 G/L is a simple, routinely used and inexpensive tool which can easily participate in antibiotic decisions for older adults. Further studies are needed to assess clinical benefits. TRIAL REGISTRATION: The study was registered at Clinical trial.gov (NCT04363138-23/04/2020).

Persistence of Neutralizing Antibodies and Clinical Protection up to 12†Months After Severe Acute Respiratory Syndrome Coronavirus 2 Infection in the Elderly.

Background: Coronavirus disease 2019 (COVID-19) has severely affected the elderly, who are expected to display decreased immune responses due to immunosenescence. Methods: This study retrospectively assesses neutralizing antibody (NAb) production up to 12 months after infection in long-term care patients. We used Roche Diagnostics immunoassay to quantify anti-spike (S) antibodies and a competitive immunoassay from YHLO as a surrogate test for NAb. Results: We included 91 patients (mean age, 86 years). There was no significant variation in anti-S titers over time. There was a significant decrease of NAb titers between month 3 and month 6 but no further significant change up to month 12. Overall, 75 of 91 (82%) and 52 of 91 (57%) patients had, at least once, anti-S titers >75 U/mL and NAb titers >50 AU/mL, respectively, corresponding to a significant neutralizing activity in vitro. All 68 patients studied at M12 had detectable anti-S antibodies and 60 (88%) had detectable NAb; 60 of 68 (88%) and 29 of 68 (42.6%) still had anti-S titers >75 U/mL and NAb titers >50 AU/mL. Higher NAb titers were correlated with severe infection, higher levels of C-reactive protein, and lower lymphocyte counts. No patient developed reinfection. Conclusions: Elderly people can display robust and persistent humoral response after severe acute respiratory syndrome coronavirus 2 infection, with NAb lasting up to 12 months.

Validation study of a French version of the modified telephone interview for cognitive status (F-TICS-m) in elderly women.

OBJECTIVE: To evaluate the performance of a French version of the modified Telephone Interview for Cognitive Status (F-TICS-m) in identifying cognitive decline among elderly women. METHODS: All women aged 72-86 participating in the 'Etude Epidémiologique auprès de Femmes de l'Education Nationale' (E3N) cohort and living in or near Paris constituted the target population of the validation study. Volunteer women (n = 120) underwent both a 20-min telephone interview and a face-to-face neuropsychological examination at an interval of few days (median interval: 10 days). The telephone interview included F-TICS-m, as well as a recall of key elements of a short story, arithmetic/verbal problems and two verbal fluency tests. Neuropsychological examination consisted of a standardized battery of cognitive tests (including the Mini-Mental State Examination (MMSE), the Free and Cued Selective Reminding Test-FCSRT, Trailmaking tests A and B, the similarities subtest of the Wechsler Adult Intelligence Scale-III, etc.) the Instrumental Activities of Daily Living questionnaire, and the Geriatric Depression Scale. Neuropsychological examination led to classification of each subject as cognitively normal (n = 92) or impaired/demented (n = 28). RESULTS: F-TICS-m showed satisfactory internal consistency (Cronbach's alpha = 0.69). It correlated linearly with MMSE (Pearson's r = 0.72). Concurrent validity against the gold-standard classification was satisfactory, with an area under the ROC curve (AUC) of 0.83. The combination of F-TICS-m and the other telephone tests had no additional effect on discrimination power in our sample (AUC = 0.81). CONCLUSION: F-TICS-m is a valid instrument for assessing the overall cognitive status of French elderly women. Its validity in men and its reproducibility warrant further studies.

Prognostic value of serum interleukin-6 (IL-6) levels in long term care.

The aim of this prospective study was to examine the relationship between IL-6 levels and survival in an elderly population in a long term hospital care ward. All of the 184 women and 65 men hospitalized in the geriatric unit regardless of their health status were included. The plasma levels of interleukin-6 were measured at baseline and deaths were assessed over a 2-year period. IL-6 levels of at least 3pg/ml in men and 5.6pg/ml in women were respectively associated with a relative risk of death of 2.28 (CI(95): 1.04-4.95) and 1.52 (CI(95): 1.06-2.18). After adjustment for age class, the reduced survival observed with these thresholds only remained unchanged in men, the difference in survival in women was not significant. Our conclusion is that even in an elderly hospitalized population, high IL-6 levels were associated with poor survival. The lower survival rate after adjustment for class of age found in men but not in women suggests a gender-related specificity.

The cognitive disorders examination (Codex) is a reliable 3-minute test for detection of dementia in the elderly (validation study on 323 subjects).

BACKGROUND: Dementia often remains undiagnosed until it has reached moderate or severe stages, thereby preventing patients and their families from obtaining optimal care. Tools that are easy to use in primary care might facilitate earlier detection of dementia. AIM: Develop and validate a very brief test for the detection of dementia. METHODS: In the derivation study, we recorded educational level, Mini Mental State Examination (MMSE) scores and subscores and results of a simplified clock-drawing test (sCDT) for consecutive patients attending a single memory clinic over a two-year period,. Dementia was diagnosed according to DSM-IV criteria. The independent variables related to dementia were determined by a multivariable logistic model (MLM) and used to develop a decision tree to predict this diagnosis. In the validation study, the decision tree was applied to consecutive patients of six memory clinics for whom status about dementia was previously determined with DSM-IV criteria. The decision tree, MLM, and MMSE were applied to detect dementia in these patients. The sensitivity and specificity of each diagnostic tool were estimated and compared. RESULT: Of 242 patients in the derivation study, the following independent variables were correlated with dementia: sex, sCDT, and two MMSE subscores - the 3-word recall test and spatial orientation. We used Bayesian statistics to develop a brief 2-step decision analysis tree (2-3 min.), which we named Codex (cognitive disorders examination). The validation study applied Codex to 323 patients. Sensitivity was 93% and specificity 85%. The corresponding values were 88% and 87% for the MLM, 94% and 67% or 91% and 70% for the MMSE, depending on the MMSE cutoff score. The sensitivity of Codex was significantly higher than that of MLM, and its specificity was significantly greater than that of MMSE. CONCLUSION: Codex is a simple, brief, and reliable test for detecting dementia and requires three minutes or less to administer. Its simplicity and brevity make it appropriate for and easy to use in primary care.

Factors that influence influenza vaccination among healthcare workers in a French geriatric hospital.

In a geriatric hospital in France, only 80 (21%) of 390 healthcare workers (HCWs) were vaccinated against influenza. Predictive factors for accepting influenza vaccination were occupation as a physician (odds ratio [OR], 9.79), previous receipt of influenza vaccination (OR, 36), and desire to protect their own health (OR, 2.42) and residents' health (OR, 3.68). Predictive factors for refusing influenza vaccination were occupation as a nurse (OR, 6.41) or nursing assistant (OR, 4.04) and belief that homeopathic medication is more effective than the vaccine (OR, 5.75).

[Patients with severe dementia in geriatric facilities]. / La personne démente en institution.

The institutional management for demented patients has been improved by new specific treatments, behavioural approach, better architectural adaptation, and environmental characteristics. This management must be global, including patients, families and nursing staffs. The nursing staff must be diversified, motivated, and specifically trained to manage demented patients.

Determination of Cutoff Values for DEXA-Based Body Composition Measurements for Determining Metabolic and Cardiovascular Health.

The two components of the body weight (i.e., fat mass and muscle mass) appeared to be of high interest to consider in predicting metabolic health related risks. We aimed to determine cutoff values for fat mass index (FMI) and muscle mass index (MMI), FM/MM, and BMI for metabolic and cardiovascular health. This study was a cross-sectional analysis study conducted in a center of preventive medicine. It included 616 consecutive outpatients: mean age was 56.0±10.0 years (74.6% aged ≥50), and 61.4% were female. Fat and muscle mass were obtained with dual energy X-ray absorptiometry scan analyses. Metabolically unhealthy individuals were defined as people with biological features of dyslipidemia, hyperuricemia, diabetes, and/or hepatitis steatosis. Documented hypertension and/or atherosclerosis of at least one major artery defined individuals with cardiovascular complications. Receiver-operating characteristic curve analysis revealed that the cutoff values for MMI, FMI, and FM/MM were respectively 18.8kg/m(2) (sensitivity [Se]=58%; specificity [Sp]=59%), 5.5kg/m(2) (Se=61%; Sp=62%), and 0.31 (Se=62%; Sp=62%) in men; and 14.1kg/m(2) (Se=52%; Sp=54%), 5.5kg/m(2) (Se=65%; Sp=67%), 0.39 (Se=73%; Sp=73%) in women for predicting metabolic health. Values were 19.3kg/m(2) (Se=58%; Sp=59%), 7.0kg/m(2) (Se=61%; Sp=62%) and 0.49 (Se=62%; Sp=62%) in men; and 15.7kg/m(2) (Se=58%; Sp=59%), 6.4kg/m(2) (Se=61%; Sp=62%) and 0.35 (Se=62%; Sp=62%) in women for cardiovascular complications. Whatever the outcomes considered, the Youden indexes for BMI values were systematically below 25 kg/m(2), except for cardiovascular complications in men, where the threshold for the best Se/Sp was 25.7 kg/m(2). These cutoff values for FMI, MMI, and FM/MM could be of practical value for the clinical evaluation of a deficit in MM with or without excess of FM. They complement the classical concept of BMI in a more qualitative manner and extend the analysis of its impact on health outcomes to all BMI categories.

Markers of metabolic and cardiovascular health in adults: Comparative analysis of DEXA-based body composition components and BMI categories.

OBJECTIVES: To investigate how body composition components fit body mass index (BMI) categories and whether they could be considered as markers of metabolic and cardiovascular health. DESIGN: Prospective study. SETTING: A center for preventive medicine. PARTICIPANTS: Six hundred and sixteen consecutive outpatients: mean age of 56.0±10.0 years; 74.6% aged ≥50 years and 61.4% were females. MEASUREMENTS: Fat mass (FM) and muscle mass (MM) were obtained by dual energy X-ray absorptiometry analyses. Metabolically unhealthy individuals were defined as people with biological features of dyslipidemia, hyperuricemia, diabetes, and/or hepatitis steatosis. Documented hypertension and/or atherosclerosis of one major artery, at least, defined individuals with cardiovascular complications. RESULTS: According to BMI categories, 45.8% of the sample was of normal weight, while 19.2% and 16.5% were classified as overweight and obese. A total of 78.0% and 86.3% of overweight and obese individuals were metabolically unhealthy respectively, 46.8% and 52.6% of subjects classified into normal and underweight BMI categories were also diagnosed. Cardiovascular complications mainly concerned the two highest BMI groups (78.2%). In multifactorial analyses the overweight and obese BMI categories were predictive of health outcomes [respectively, odds ratio (OR)=8.05, 95% confidence interval (CI): 4.23-12.07 and 5.74, 95% CI: 3.41-8.98]. FM and MM indexes were significantly associated with metabolic (OR=1.30, 95% CI: 1.19-1.47; and 0.84, 95% CI: 0.78-0.91) and cardiovascular (OR=1.22, 95% CI: 1.13-1.32; and 0.72, 95% CI: 0.65-0.80) health respectively, and FM/MM (respectively, OR=15.45, 95% CI: 11.77-20.17; and 16.61, 95% CI: 10.49-21.33) as well. CONCLUSION: Our findings suggest that FM and MM readouts are important measurements of nutritional status and they extend the analysis of its impact on health outcomes to all BMI categories. Moreover, they highlight the interest of measuring body composition in medical check-ups to predict metabolic and cardiovascular diseases.

[The risk of contagious epidemics in geriatric facilities]. / Le risque d'épidémie contagieuse en institution gériatrique.

THE RISKS OF EPIDEMICS IN INSTITUTIONAL SETTINGS: An epidemic must be suspected when an increase in the number of cases of a same type of infection is observed. Numerous microorganisms are responsible for epidemics in geriatric facilities: viruses, bacteria and parasites. In the case of an epidemic, a certain number of specific measures must be taken in order to prevent the transmission of infection and eradicate the epidemic. IN THE CASE OF INFLUENZA: Other than the vaccination of elderly institutional residents, that of the nursing staff appears essential. If a severe epidemic occurs, specific antivirals can be used, three of which are already available. IN THE CASE OF PNEUMOCOCCI: Examples of epidemics of pneumococcal infections in elderly institutional residents in the United States underlines the interest of pneumococcal vaccines, particularly since the strain responsible corresponded to a serotype contained in the 23 valence vaccine. WITH REGARD TO SCABIES: All the patients and all the staff must be treated on the same day and at the same time their clothing and bed linen. All persons in contact with the patient, the families and friends of the staff, their clothes and the environement must be treated.

Mortality and bloodstream infections in geriatrics units.

The purpose of this retrospective study was to evaluate risk factors of mortality in bloodstream infections in old and very old people in a French geriatric unit (Paul Brousse Hospital, APHP). 167 older patients with bloodstream infections were included and two groups were compared according to age (60-85 years and ≥85 years). Information was collected for each patient: age, sex, diseases, urinary catheter, temperature, signs of severe sepsis, biological examinations, bacteria and antibiotic treatments. All bacteremias were nosocomial. There was no difference between groups for pathogen, source or prognosis. Mortality rate at 60 days was 32.3%. The risk factors for mortality were: low albumin rate (p<0.001), high C-reactive protein (CRP) (p=0.02) and moderate fever (p=0.006). Multivariate logistic regression showed that these three parameters were significantly associated with a risk of mortality. The parameter with the highest risk was a low albumin rate <30 g/l. Malnutrition may be a more long-term risk factor. A moderate fever probably results in a more frequent delay in diagnosis in this population. Our work supports that age is not a risk factor of mortality for bloodstream infections. However management of bacteremia has to be adapted to elderly.

Vaccination in older adults: development of an educational tool, Vaxisenior, in France.

The benefits of vaccination in older adults are well documented yet there is poor uptake of such preventive measures, and one of the main reasons in France is a lack of recommendation and support from healthcare professionals. To address this issue a multidisciplinary group of experts has developed an educational tool, Vaxisenior, to assist in the training of physicians/healthcare workers who can act as advocates for immunization programs. The tool comprises of eight sections (general introduction; immunosenescence; diphtheria-tetanus-poliomyelitis; influenza; pneumococcus; pertussis; herpes zoster; and vaccines for travelers). In addition, it includes national immunization schedules and recommendations, practical information regarding opportunities to expand vaccine coverage that is convenient to the patient and a questions and answers section covering topics relating to particular usage and responsibilities. Implementation of vaccination policies for older adults is a major issue and will require extensive promotional campaigns, as well as active support from healthcare and public health professionals to improve overall vaccine coverage.

Educational vaccine tools: the French initiative.

Prevention is an important but neglected issue in geriatric medicine. Vaccination plays a major role in prevention of infectious diseases, but its implementation in clinical practice is far from perfect. To improve practice, a group of French experts composed of geriatricians and infectious disease specialists prepared a set of educational material about vaccination for older subjects. The tool has been designed to be used by medical teachers to help them teach this topic to other physicians, nursing staff and students. The group first defined teaching objectives and reviewed the scientific literature on the efficacy and use of various vaccines in the elderly. Results were recorded in 217 slides. These slides were grouped to allow their use for short presentations: the immune system in the elderly and general information about vaccination; universal vaccines, influenza vaccines, pneumococcal vaccines, Herpes zoster vaccine, pertussis vaccine, vaccines for old travellers. Written comments were added to most slides to help presenters teach the topics. The content and design of the slides were analyzed and discussed by the whole group. The set was collected in a CD with ready-to-use files for oral presentations. This educational tool was presented and given to French teachers in geriatrics. It has been used for educational sessions in geriatric hospital wards, for continuous medical education for general practitioners and for courses for physicians learning geriatrics. It has also been proposed to physicians in charge of medical coordination of nursing homes and is available on a web site.