[A rare case of hepatotoxicity in geriatrics]. / Un cas rare d'hépatotoxicité en gériatrie.

We report a case of hepatotoxicity following the introduction of two drugs to treat a 81 years old man. The presence of liver alterations following the introduction of a new drug must suggest an adverse drug reaction. Manifestations of adverse drug reactions are often non-specific. Thus, the most important problem in assessing adverse drug reactions is establishing whether there is a causal association between the suspected drug and the untoward clinical event. The use of the Naranjo score could help the clinician to assess the probability of a causal relationship between a drug and the suspected adverse drug reaction.

Nous présentons le cas d'un patient de 81 ans qui développe une hépatotoxité après l'introduction de deux médicaments dans son traitement. La présence d'une perturbation du bilan hépatique à l'introduction d'un nouveau médicament doit faire évoquer une hépatotoxicité médicamenteuse. Les manifestations des effets secondaires médicamenteux ne sont généralement pas spécifiques. Dans ce contexte, le problème le plus important pour le clinicien est d'établir la probabilité d'une relation causale entre l'effet et le médicament suspecté. Le calcul du score de Naranjo permet d'aider le clinicien dans l'évaluation de la probabilité d'une relation causale entre un médicament et la suspicion de l'apparition d'un effet secondaire.

[Recognize the frailty: A challenge in general medicine]. / Reconnaître la fragilité : Un défi en Médecine Générale.

Frailty is the most problematic expression of population ageing. It is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime leading to functional dependence. It is before the onset of functional dependence that detection of the frailty by the general practitioner is essential in order to tend to compress morbidity. After an attempt for operational definition of frailty this paper reviews methodological, semantic and logistical pitfalls of screening for frailty in general medicine. The use of frailty would allow general practitioners to introduce early interventions in the care for the older person, thus shifting the care towards a preventive course and thereby reducing the adverse outcomes as well as the public costs.

L'apparition de la fragilité devient l'expression la plus problématique du vieillissement de la population. La fragilité se développe comme une conséquence du déclin lié à l'âge de nombreux systèmes physiologiques qui, ensemble, peuvent provoquer une vulnérabilité responsable de changements soudains dans l'état de santé face à des événements stressants pouvant être mineurs, conduisant le patient dans un état de dépendance fonctionnelle. C'est en amont de ces situations de dépendance fonctionnelle que la détection de la fragilité par le médecin généraliste est primordiale dans le but de tenter de comprimer la morbidité. Après une tentative de définition opérationnelle de la fragilité, cet article revoit les écueils méthodologiques, sémantiques et logistiques du dépistage de la fragilité en médecine générale. L'utilisation du concept de fragilité en médecine générale devrait permettre d' introduire des interventions préventives précoces pour éviter les effets indésirables et les coûts en santé publique.

[Appropriate use of psychotropic drugs in institutionalized elderly presenting acute confusional state (delirium)]. / Usage adéquat des psychotropes chez les personnes âgées institutionnalisées en cas d'état confusionnel aigu (delirium).

Delirium (acute confusion) is a common, morbid, and costly geriatric syndrome that affects onethird of hospitalized older adults. As evidence mounts that delirium may persist for weeks to months, concern about delirium can no longer be restricted to acute hospitals. We present a review about non-pharmacologic and pharmacologic management of delirium in institution.

Le " Delirium " (état confusionnel) est un syndrome gériatrique fréquent et coûteux qui affecte un tiers des personnes âgées hospitalisées ; sa prévalence en institution est mal connue. Il apparaît que ce syndrome peut persister pendant des semaines à des mois, et n'est donc pas limité aux hospitalisations aiguës. Nous présentons une revue de la littérature sur la prise en charge du delirium en institution suivie d'une proposition d'algorithme définissant l'approche pharmacologique et non pharmacologique de ce syndrome gériatrique.

[Non valvular atrial fibrillation: the place of the new anticoagulants]. / La fibrillation atriale non valvulaire : place des nouveaux anticoagulants.

Atrial fibrillation (AF) increases the risk of mortality and stroke. The prevention of these complications is based on oral anticoagulants that are more efficient than salycilates. As compared with antivitamins K agents, new oral anticoagulants are promising for patients presenting non valvular atrial fibrillation because of lower cerebral hemorragic risk (with respect of assessment of renal function and therapeutic compliance). Available studies and recommendations are presented.

[Specificities of pneumonia in geriatrics]. / Spécificités de la pneumonie en gériatrie.

Pneumonia is a major cause of morbidity and mortality leading to a high rate of hospitalization especially in theelderly. It is often a sign of frailty and is associated with a poor prognosis. However, taking into account the geriatric specificities (risk factors, atypical clinical presentations with "geriatric syndromes", ethical debate) using an interdisciplinary and a comprehensive geriatric approach remains an important responsibility of the general practitionner. This article summarizes these specificities and offers interventions targeted on the characteristics of elderly patients.

[Anemia in the elderly]. / L'anémie de la personne âgée.

Anaemia is a problem that affects almost 10% over 65 years and 20% over 85 years. There is no physiological anaemia in the elderly. Any anaemia expresses the existence of a pathological process, regardless of its severity. Anaemia in the elderly is always associated with a poor prognosis that is in terms of mortality, morbidity and risk of fragility. The diagnostic approach to anemia in the elderly is the same as in younger individual. There are many causes of anaemia; anaemia balance is a complex diagnostic process. Most anaemias are due to a deficiency, chronic inflammation or comorbidity. However, in the elderly, the etiology of anaemia is often multifactorial. In a number of cases remain unexplained anaemia. In a number of cases, anemia remain unexplained. Treatment of anaemia is the treatment of the cause, but specific therapeutic aspects to the elderly should be considered, as among other martial substitution or use of erythropoietin (EPO).

Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study.

BACKGROUND: To evaluate the large-scale feasibility and usefulness of geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions. PATIENTS AND METHODS: Eligible patients who had a malignant tumour were ≥70 years old and treatment decision had to be made. Patients were screened using G8; if abnormal (score ≤14/17) followed by Comprehensive Geriatric Assessment (CGA). The assessment results were communicated to the treating physician using a predefined questionnaire to assess the topics mentioned above. RESULTS: One thousand nine hundred and sixty-seven patients were included in 10 hospitals. Of these patients, 70.7% had an abnormal G8 score warranting a CGA. Physicians were aware of the assessment results at the time of treatment decision in two-thirds of the patients (n = 1115; 61.3%). The assessment detected unknown geriatric problems in 51.2% of patients. When the physician was aware of the assessment results at the time of decision making, geriatric interventions were planned in 286 patients (25.7%) and the treatment decision was influenced in 282 patients (25.3%). CONCLUSION: Geriatric screening and assessment in older patients with cancer is feasible at large scale and has a significant impact on the detection of unknown geriatric problems, leading to geriatric interventions and adapted treatment.

[Orthogeriatrics: supportive evidence for the process]. / Ortho-geriatrie: les preuves du concept.

Incidence of hip fractures increases dramatically in the aging population leading to increased admissions of frail old patients. The proof of concept of the efficacy of comprehensive geriatric assessment exists for non orthopaedic old subjects. This review identifies innovative models of care for the management of older adults with hip fracture, distinguished mainly on the basis of the role of the healthcare professionals involved in the care and their responsabilities. The managements are heterogeneous and the models are often combined. The choice to implement a model should depend of his level of evidence, the existing resources, and the willingness of both orthopaedic, and geriatric teams. The heterogeneity of the models, of the nature of interventions, of the populations and of the outcomes is challenging to undertake meta-analysis in order to choice one "universal" model. However there is a tendency to better overall outcomes in patient receiving co managed care: subjects admitted for hip fracture are often frail adults requiring a comprehensive management in order to identify and treat geriatric syndromes.

[Inappropriate prescribing in the elderly]. / La prescription inappropriée en gériatrie.

Potentially inappropriate medications are a preventable cause of negative clinical and economic consequences in older people. A range of educational interventions and the implemention of clinical tools to sensitize physicians to inappropriate prescriptions appear to have positively impacted physicians' awareness and prescribing behaviour, which led to significant reductions in inappropriate drugs exposures and likely translated to significant population health benefits among their older patients. Although the level of evidence is not high, the general practitioner has a central position and its sensitization to inappropriate prescription allow to improve health of the olders.

The Addenbrooke's Cognitive Examination Revised is as effective as the original to detect dementia in a French-speaking population.

INTRODUCTION: This paper presents the validation of the French version of the Addenbrooke's Cognitive Examination Revised (ACE-R). METHODS: The variability of the 3 versions of the ACE-R (A, B and C), performed by the same observer, hence mainly 2 or 3 times on 119 patients showing no progression, was first calculated by Cronbach's alpha coefficient, t test and linear regression. The alpha coefficients of the 3 versions were obtained showing that the ACE-R versions can be considered as one, and an analysis of the interobserver variability was performed by Cohen's kappa coefficient, t test and linear regression on 12 patients. Eventually, we performed a receiver operating characteristic (ROC) analysis to compare the sensitivities and specificities to detect dementia of the ACE, the ACE-R and Mini Mental State Examination on 319 consecutive patients. RESULTS: The ROC areas of sensitivities and specificities of the ACE and ACE-R were very similar. Two cutoffs were identified at 83/100 and 89/100 with a specificity to normality of 98.6% if the ACE-R score was ≥83 and a sensitivity to dementia of 98.4% if the ACE-R score was ≤89. CONCLUSION: ACE-R in French is as reliable and valid as the original version to detect dementia.

[End of life of demented patients: ethical aspects]. / Fin de vie des patients déments: aspects éthiques.

Most people in contemporary western society die of the chronic diseases of old age. Whilst palliative care is appropriate for elderly patients with chronic, non-malignant disease, few of these patients access such care compared with cancer patients. That patients dying with dementia have significant health care needs, comparable with cancer patients, is now well established. Yet, their families typically describe poor advance-care planning and an inadequate level of symptom control, with distress associated with pain, pressure sores, constipation, restlessness and shortness of breath. A comparison of people dying with advanced dementia or terminal cancer found that those with dementia were more likely to experience burdensome interventions and restraints and to have had poor advance-care planning. Prognostic models that attempt to estimate survival of >6 months in demented patients have generally poor discrimination, reflecting the unpredictable nature of most nonmalignant disease. However, a number of generic and disease-specific predictor variables were identified that may help clinicians identify older, non-cancer patients with poor prognoses and palliative care needs. Simple, well-validated prognostic models that provide clinicians with objective measures of palliative status in demented patients are needed. Additionally, research that analyses the effect of comprehensive geriatric assessment and geriatric palliative care on psychosocial outcomes in demented patients and their caregivers is needed. Advances care planning and directives making before death allow meeting patient's preferences.

[How to avoid the inappropriate prescriptions in nursing homes?]. / Comment éviter les prescriptions inappropriées en maison de repos?

The inappropriate prescription is frequent in the Belgian nursing homes. Which are the better tools to control and improve our prescription? Is it relevant to start or continue medications for prevention in the context of moderate or severe dementia? STOPP-START seems to be a good screening tool for detecting the inappropriate prescriptions by the general practitioner.

Orthostatic blood pressure drop and cardiovascular and psychotropic medication dosages in acutely ill geriatric inpatients.

OBJECTIVES: . To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients. METHODS: . This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used. RESULTS: . The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r2 = 0.04; dBP: p = 0.59; r2 = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r2 = 0.02; dBP: p = 0.82; r2 = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes. CONCLUSION: . No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

[Oncogeriatrics: an attempt to operational definition]. / Oncogériatrie: essai de définition opérationnelle.

Comprehensive geriatric assessment (CGA) represents a multidisciplinary comprehensive evaluation of an older individual's functional status, comorbid medical conditions, cognition, psychological state, social support, nutritional status, and a review of the patient's medications. Initially, the use of a CGA in the care of older patients with cancer was based on an extrapolation of its ability to predict morbidity and mortality in the general geriatric population. More recently, however, accumulating data show the benefits of using a CGA particularly in patients with cancer to predict morbidity and mortality. Prospective trials evaluating the utility of a CGA to guide interventions to improve the quality of cancer care in older adults are justified.

[Parkinson syndromes in geriatrics]. / Les syndromes parkinsoniens en gériatrie.

Geriatric teams are more and more in front of patients presenting Parkinson syndromes. The frailty of the geriatric patient could be responsible of the non recognition of the diagnosis of the Parkinson and related diseases. A diagnostic approach is proposed in order to better define a care plan and to target the priorities. In collaboration with the general practitioner, the neurologist and the caregivers, an appropriate diagnosis allows to optimize and/or to adapt the treatment, to prevent the functional decline, to decrease the caregiver's burden, and eventually to improve the end of life.

Relating the MNA Mobility Single Item to Usual Walking Speed in Hospitalized and Community-Dwelling Geriatric Patients.

Usual walking speed (WS) is a relatively easy and reproducible tool for detecting mobility impairment. For some reasons, however, geriatric patients might not be able to perform walking tests. Therefore, a subjective assessment could be an alternative method to screen for mobility impairment. In the present paper, we explore the use of the mobility item from the Mini Nutritional Assessment-short form (MNA-sf) to assess mobility and its congruence with walking speed in hospitalized and ambulatory patients. We analyzed retrospective data from 357 patients and found a highly significant correlation between WS and the MNA-sf mobility item. After dichotomization of the MNA-sf mobility score (mobility impairment ≤1 and no impairment >1), AUC for ROC curves showed that the mobility item derived from the MNA-sf reflects fairly well the mobility of geriatric hospitalized patients (AUC = 0.773), while it performs better in ambulatory patients (AUC = 0.838).

Minimum geriatric screening tools to detect common geriatric problems.

BACKGROUND: Health services for the elderly are becoming increasingly important in industrialized nations, and comprehensive geriatric assessment (CGA) is one of the procedures designed to improve the health of this sector of the population. In 2003 a survey among Belgian geriatricians showed that despite the interest of the geriatric teams for comprehensive geriatric assessment, it was not used enough. Considering these results, as a first step, screening tools were proposed for the main geriatric domains (Minimum Geriatric Screening Tools, MGST). OBJECTIVES: To assess the feasibility of a MGST within the teams of geriatric units and to evaluate the efficacy of a MGST on the detection rate of the geriatric problems of admitted subjects. DESIGN: Prospective observational survey. METHODS: The teams were first asked to encode active geriatric problems suspected according to their conventional assessment. Then, in a second phase, a complete MGST was completed by the same team within the first week after admission. RESULTS: Three hundred and twenty six registrations from 33 centres were available. Mean (+/- SD) number of screened geriatric problems was 1.5 +/- 1.2 without MGST and 4.7 +/- 1.7 (p < 0.0001) using the MGST. Except for the assessment for the risk of falls, the MGST leads to a better screening for the seven other main geriatric domains (functional, continence, cognition, depression, nutrition, pain, social). CONCLUSIONS: An improvement associated with the use of simple minimal geriatric tools to screen geriatric problems was evident. This approach has additional value for education and quality assurance.

[Disclosing a diagnosis of Alzheimer's disease]. / L'annonce du diagnostic de la maladie d'Alzheimer.

How many practitioners do inform their patients about the diagnosis of Alzheimer's disease? Does this announcement increase the risk of depression and/or suicide or in the contrary the compliance to the care? Do the caregivers want that the information will be gave to their parents? In the case where the caregivers could present Alzheimer's disease, do they want to know their diagnosis? The arguments pro- or contra- the announcement of the diagnosis to the patients are discussed then a strategy of announcement is proposed in order to give a clear message to the patient, his family and caregivers. A pluridisciplinary approach is essential. Empathy is the optimal professional attitude in front of the emotional reactions secondary to the announcement. The announcement of the diagnosis produces rather a positive impact but the risks have to be appreciated and controlled. The announcement of the diagnosis represents a comprehensive medical act which demands a technical approach.

[Treatment of osteoporosis in octogenarians]. / Traitement de li'ostéoporose des octogénaires.

Osteoporosis is a major public health problem of older people. Most types of osteoporotic fractures increase in incidence with age, and the number of elderly individuals affected with osteoporosis is expected to increase dramatically in the coming years. Beside non pharmacological intervention and calcium and vitamin D administration, available pharmacological therapies for the treatment of osteoporosis include antiresorptive drugs (such as bisphosphonates, calcitonin, and raloxifene) and the bone forming drug teriparatide and drug which can have both anti resorptive effect and bone forming effect (strontium ranelate). Age does not affect the efficacy and the safety of most anti osteoporotic agents. Despite the debilitating effects of osteoporosis fractures and the availability of therapies to reduce fracture incidence, many elderly patients do not receive treatment and the proportion of treated subjects decreases with increasing age. One explanation for this decrease is the perception that it is too late to alter the course of the disease in its late stage. Given the known antifracture efficacy of available drugs, lack of appropriate and needed therapy in patients with osteoporosis may result in costly and debilitating fractures. Comprehensive geriatric assessment can help the practitioner to prioritize the problems and to adapt the treatment to the profile of frailty of the patient.

[Risk factors for not benefiting from palliative care in end-of-life geriatric patients]. / Risques d'exclusion des soins palliatifs des patients en fin de vie dans un service gériatrique.

Palliative care should represent good medical practice for all clinicians. Their still exist many barriers to good palliative care in general and in geriatrics in particular. The present observational study aimed to identify these barriers. During the six months study period, patients hospitalized in a Belgian geriatric hospital and benefiting from palliative care were prospectively compared to those who died without palliative care. Nearly half of our patients died without access to palliative care. Compared to the patients who had received palliative care, these patients showed less often pain and more often dyspnea. Invasive medical interventions and use of antibiotics were more frequent in patients who died without access to palliative care. Benzodiazepines were used less frequently compared to palliative care patients. In patients who died without access to palliative care, communication with the patient was inferior as compared to palliative care patients. The former group showed more often cognitive impairment, social isolation, and a more rapid, unanticipated death. We identified the following risk factors for not benefiting from palliative care in geriatrics: absence of identified pain syndrome; presence of dyspnea; absence of oncologic diagnosis; social isolation and poor communication with the patient and her/his family; cognitive dysfunction and unexpected death.