Increased ischemic stroke, acute coronary artery disease and mortality in patients with granulomatosis with polyangiitis and microscopic polyangiitis.

OBJECTIVE: The aim of our study was to assess major cardiovascular event incidence, predictors, and mortality in ANCA-associated vasculitis (AAV). METHODS: We conducted a retrospective cohort study of all GPA or MPA, according to Chapel Hill Consensus Conference classification criteria, diagnosed between 1981 and 2015. Major cardiovascular event was defined as acute coronary artery disease, or ischemic stroke, or peripheral vascular disease requiring a revascularization procedure. We calculated the comparative morbidity/mortality figure (CMF) and we used Cox proportional hazards regression models to assess the risk of coronary artery disease, ischemic stroke associated with AAV, after adjusting for covariates. RESULTS: 125 patients, 99 GPA (79,2%) and 26 MPA (20,8%), were followed 88.4 ±â€¯78.3 months. Ischemic stroke incidence was four times higher than in the general population (CMF 4,65; 95% CI 4,06-5,31). Coronary artery disease incidence was four times higher than in the general population (CMF 4,22; 95% CI 1,52-11,68). Smoking habits and history of coronary artery disease were strongly associated with coronary artery disease occurrence (adjusted HR 8.8; 95% CI 2.12-36.56, and adjusted HR 10.3; 95% CI 1.02-104.5, respectively). ENT flare-up was an independent protective factor for coronary artery disease occurrence. We did not identify factors significantly associated with stroke occurrence. The age-adjusted mortality rate was 22.5 per 1000 person-years. Mortality in AAV was 1.5 times higher than in the general population (CMF 1.56; 95% CI 1.34-1.83). CONCLUSION: AAV have a significantly increased risk of mortality, ischemic stroke, and coronary artery disease.

ICP Monitoring and Phase-Contrast MRI to Investigate Intracranial Compliance.

OBJECTIVE: The amplitude of intracranial pressure (ICP) can be measured by ICP monitoring. Phase-contrast magnetic resonance imaging (PCMRI) can quantify blood and cerebrospinal fluid (CSF) flows. The aim of this work was to investigate intracranial compliance at rest by combining baseline ICP monitoring and PCMRI in hydrocephalus patients. MATERIALS AND METHODS: ICP monitoring was performed before infusion testing to quantify ΔICP_rest at the basal condition in 33 suspected hydrocephalus patients (74 years). The day before, patients had had a PCMRI to assess total cerebral blood flow (tCBF), intracranial blood volume change (stroke volume SVblood), and cervical CSF volume change (the stroke volume CSV). Global (blood and CSF) intracranial volume change (ΔIVC) during each cardiac cycle (CC) was calculated. Finally, Compliance: C_rest = ΔIVC/ΔICP_rest was calculated. The data set was postprocessed by two operators according to blind analysis. RESULTS: Bland-Altman plots showed that measurements presented no significant difference between the two operators. ΔICP_rest = 2.41 ± 1.21 mmHg, tCBF = 469.89 ± 127.54 mL/min, SVblood = 0.82 ± 0.32 mL/cc, CSV = 0.50 ± 0.22 mL/cc, ΔIVC = 0.44 ± 0.22 mL, and C_rest = 0.23 ± 0.15 mL/mmHg. There are significant relations between SVblood and CSV and also SVblood and tCBF. CONCLUSIONS: During "basal" condition, the compliance amplitude of the intracranial compartment is heterogeneous in suspected hydrocephalus patients, and its value is lower than expected! This new parameter could represent new information, complementary to conventional infusion tests. We hope that this information can be applied to improve the selection of patients for shunt surgery.

Methodology of phase II clinical trials in metastatic elderly breast cancer: a literature review.

PURPOSE: As the incidence of invasive breast cancer will increase with age, the number of elderly patients with a diagnosis metastatic breast cancer will also rise. But the use of cytotoxic drugs in elderly metastatic breast cancer patients is not systematic and is dreaded by medical oncologists. The need for prospective oncologic data from this population seems increasingly obvious. The main objective of this review is to investigate design and characteristics of phase II trials that assess activity and feasibility of chemotherapies in elderly advanced/metastatic breast cancer patients. METHODS: An electronic search in PUBMED allowed us to retrieve articles published in English language on phase II trials in elderly metastatic breast cancer between January 2002 and May 2016. Sixteen publications were finally included in this review. RESULTS: The primary endpoint was a simple, a composite, and a co-primary endpoints in 11, three, and two studies, respectively. Efficacy was the primary objective in 15 studies: simple (n = 10), composite (n = 3), co-primary endpoints (n = 2). Composite or co-primary endpoints combined efficacy and toxicity. Thirteen studies used multistage designs. CONCLUSIONS: Only five studies evaluated the feasibility, i.e., to jointly assess efficacy and tolerance to treatment (toxicity, quality of life, etc) as primary endpoint. Development of elderly specific phase III clinical trials might be challenging, it therefore seems essential to conduct phase II clinical trials evaluating jointly efficacy and toxicity in a well-defined geriatric population. Use of multistage designs that take into account heterogeneity would allow to identify a subpopulation at interim analysis and to reduce the number of patients exposed to an inefficient or a toxic treatment regimen. It is crucial to evaluate new therapies (targeted therapies, immunotherapies) using adequate methodologies (Study design, endpoint).

[Mood and cognitive disorders, and androgen deprivation]. / Troubles de l'humeur et cognitifs et suppression androgénique.

Prostate cancer has become a chronic disease. In this context, it is important to take into account the quality of life of patients and their family in the therapeutic approach. Recent studies have demonstrated the importance of depression and the risk of suicide in patients with prostate cancer as well as the repercussions of the disease on the spouse and their relationship. The implication of hormonal treatment in the increase in risk of depression is difficult to affirm. Few studies have investigated this subject and they present methodological biases. Some authors report an increased risk of cognitive decline in patients on androgen deprivation. However, even if certain physiopathological hypotheses have been put forward, the imputability of the treatment on the alteration of cognitive functions has not been clearly established. Urologists are at the forefront of diagnosis and treatment of prostate cancer occurring most often in elderly subjects. Therefore, given the prevalence of depression syndromes and/or the alteration of cognitive functions in this population, the urologist must be aware of these different factors, which are potentially aggravated by the introduction of androgen deprivation. Based on a review of the recent literature, the authors suggest using a simple depression screening tool: confirmation of the diagnosis and management is within the competence of the general practitioner. As for the risk of cognitive decline, it seems difficult to imagine, and not necessarily relevant, to systematically propose a battery of neuropsychometric screening tests. On the other hand, giving the patient the G8 screening test can allow the urologist to assess whether the patient needs a geriatric consultation or not.

Framework Implementation of the INSPIRE ICOPE-CARE Program in Collaboration with the World Health Organization (WHO) in the Occitania Region.

INTRODUCTION: Limiting the number of dependent older people in coming years will be a major economic and human challenge. In response, the World Health Organization (WHO) has developed the «Integrated Care for Older People (ICOPE)¼ approach. The aim of the ICOPE program is to enable as many people as possible to age in good health. To reach this objective, the WHO proposes to follow the trajectory of an individual's intrinsic capacity, which is the composite of all their physical and mental capacities and comprised of multiple domains including mobility, cognition, vitality / nutrition, psychological state, vision, hearing. OBJECTIVE: The main objective of the INSPIRE ICOPE-CARE program is to implement, in clinical practice at a large scale, the WHO ICOPE program in the Occitania region, in France, to promote healthy aging and maintain the autonomy of seniors using digital medicine. METHOD: The target population is independent seniors aged 60 years and over. To follow this population, the 6 domains of intrinsic capacity are systematically monitored with pre-established tools proposed by WHO especially STEP 1 which has been adapted in digital form to make remote and large-scale monitoring possible. Two tools were developed: the ICOPE MONITOR, an application, and the BOTFRAIL, a conversational robot. Both are connected to the Gerontopole frailty database. STEP 1 is performed every 4-6 months by professionals or seniors themselves. If a deterioration in one or more domains of intrinsic capacity is identified, an alert is generated by an algorithm which allows health professionals to quickly intervene. The operational implementation of the INSPIRE ICOPE-CARE program in Occitania is done by the network of Territorial Teams of Aging and Prevention of Dependency (ETVPD) which have more than 2,200 members composed of professionals in the medical, medico-social and social sectors. Targeted actions have started to deploy the use of STEP 1 by healthcare professionals (physicians, nurses, pharmacists,…) or different institutions like French National old age insurance fund (CNAV), complementary pension funds (CEDIP), Departmental Council of Haute Garonne, etc. Perspective: The INSPIRE ICOPE-CARE program draws significantly on numeric tools, e-health and digital medicine to facilitate communication and coordination between professionals and seniors. It seeks to screen and monitor 200,000 older people in Occitania region within 3 to 5 years and promote preventive actions. The French Presidential Plan Grand Age aims to largely implement the WHO ICOPE program in France following the experience of the INSPIRE ICOPE-CARE program in Occitania.

Effectiveness of Therapeutic Patient Education Interventions for Older Adults with Cancer: A Systematic Review.

The incidence of cancer increases with age and demographics shows that the population of western countries is dramatically ageing. The new discipline of Geriatric Oncology is emerging aiming at providing tailored and patient-centred support to older adults with cancer. With the development of oral cancer therapy and outpatient treatments, Therapeutic Patient Education (TPE), aiming at enabling the patient and their relatives to cope with the disease in partnership with health professionals, appears to be an interesting and useful tool. The purpose of this paper is to search for evidence of the effectiveness of educational interventions for patients in older adults with cancer. The first screening found 2,617 articles, of which 150 were eligible for review. Among them, fourteen finally met the inclusion criteria: experimental and quasi-experimental studies enrolling older adults (over 65 years old), suffering from cancer and receiving an educational intervention. The types of educational intervention were diverse in these studies (support by phone and web base material). The results appear to be positive on anxiety, depression and psychological distress, patient knowledge and pain. However, data currently available on the effectiveness of a TPE program in Geriatric Oncology is lacking. Further studies are needed to assess the effectiveness of TPE programs adapted to the specific circumstances of the older adult.

Biomechanical response of the CNS is associated with frailty in NPH-suspected patients.

Frailty is known to predict dementia. However, its link with neurodegenerative alterations of the central nervous system (CNS) is not well understood at present. We investigated the association between the biomechanical response of the CNS and frailty in older adults suspected of normal pressure hydrocephalus (NPH) presenting with markers of multiple co-existing pathologies. The biomechanical response of the CNS was characterized by the CNS elastance coefficient inferred from phase contrast magnetic resonance imaging and intracranial pressure monitoring during a lumbar infusion test. Frailty was assessed with an index of health deficit accumulation. We found a significant association between the CNS elastance coefficient and frailty, with an effect size comparable to that between frailty and age, the latter being the strongest known risk factor for frailty. Results were independent of CSF dynamics, showing that they are not specific to the NPH neuropathological condition. The CNS biomechanical characterization may help to understand how frailty is related to neurodegeneration and detect the shift from normal to pathological brain ageing.

No Difference in the Phenotypic Expression of Frailty among Elderly Patients Recently Diagnosed with Cancer Vs Cancer Free Patients.

OBJECTIVES: To examine frailty determinants differences in patients with a recent diagnosis of cancer compared to non-cancer patients among older adult. Revealing those differences will allow us to individualize the exact frailty management in those patients diagnosed with cancer. DESIGN: This is an observational cross-sectional, monocentric study. SETTING: Patients were evaluated at the Geriatric Frailty Clinic (GFC), in the Toulouse University Hospital, France, between October 2011 and February 2016. PARTICIPANTS: 1996 patients aged 65 and older were included (1578 patients without cancer and 418 patients with solid and hematological cancer recently diagnosed). MEASUREMENTS: Frailty was established according to the frailty phenotype. The frailty phenotype measures five components of frailty: weight loss, exhaustion, low physical activity, weakness and slow gait. Frailty phenotype was categorized as robust, pre-frail and frail. RESULTS: In a multinomial logistic regression, cancer, compared to the non-cancer group, is not associated with an increased likelihood of being classified as pre frail (RRR 0.9, 95% CI [0.5 ; 1.6 ], p 0.9) or frail (RRR 1.2, 95% CI [0.7 ; 2.0], p 0.4) rather than robust. When considering each Fried criterion, a significant higher odd of weight loss was observed in older patients with cancer compared to the non-cancer patients (OR 2.3, 95% CI [1.8; 3.0], p <0.001) but no statistically significant differences was found among the four other Fried criteria. Sensitivity analysis on the frailty index showed that cancer was not associated with a higher FI score compared to non-cancer (ß 0.002, 95%CI [-0.009; 0.01], p 0.6). CONCLUSION: In this real-life study evaluating elderly patients with and without cancer, we didn't confirm our hypothesis, in fact we found that cancer was not associated with frailty severity using both a phenotypic model and a deficit accumulation approach. Cancer may contribute, at least additively, to the development of frailty, like any other comorbidity, rather than a global underlying condition of vulnerability.

Drug Prescription Including Interactions with Anticancer Treatments in the Elderly: A Global Approach.

BACKGROUND: Consequences of inappropriate prescriptions and polymedication in patients suffering from cancer are beginning to be well documented. However, the methods used to evaluate these consequences are often discussed. Few studies evaluate the risk of interaction with anticancer drugs in elderly patients suffering from cancer. OBJECTIVES: To describe the prevalence (i) of polypharmacy, (ii) of potentially inappropriate drug prescriptions and (iii) of drug interactions involving anticancer treatments, using a multiple reference tools. DESIGN: A retrospective, cross-sectional, multicenter study performed from January to December 2012. PARTICIPANTS: Patients aged 65 years or older suffering from cancer presented at the oncogeriatric multidisciplinary meeting. MEASUREMENTS: Polymedication (>6 drugs), potentially inappropriate prescriptions and drug interactions involving anticancer treatment were analyzed in combination with explicit and implicit criteria within a global approach. RESULTS: Among the 106 patients included in this study, polypharmacy was present in 60.4% of cases, potentially inappropriate drug prescription in 63.1% and drug interactions in 16% of case, of which 47% involved anti-cancer treatments. Twenty-seven major drug interactions were identified and eight interactions involved chemotherapy. CONCLUSION: Polymedication, inappropriate prescribing and drug interactions involving anti-cancer drugs are common and largely underestimated in elderly cancer patients.

Influence of Age on Decision-Making Process to Limit or Withdraw Life-Sustaining Treatment in the Intensive Care Unit - A Single Center Prospective Observational Study.

BACKGROUND: The increasing age in the industrialized countries places significant demands on intensive care unit (ICU) resources and this triggers debates about end-of-life care for the elderly. OBJECTIVES: We sought to determine the impact of age on the decision-making process to limit or withdraw life-sustaining treatment (DWLST) in an ICU in France. We hypothesized that there are differences in the decision-making process for young and old patients. DESIGN, SETTING, PARTICIPANTS: We prospectively studied end-of-life decision-making for all consecutive admissions (n=390) to a tertiary care university ICU in Toulouse, France over a period of 11 months between January and October 2011. RESULTS: Among the 390 patients included in the study (age ≥70yo, n=95; age <70yo, n=295) DWLST were more common for patients 70 years or older (43% for age ≥70yo vs. 16% for age <70yo, p <0.0001). Reasons for DWLST were different in the 2 groups, with the 'no alternative treatment options' and 'severity of illness' as the most frequent reasons cited for the younger group whereas it was 'severity of illness' for the older group. 'Advanced age' led to DWLSTs in 43% of the decisions in the group ≥70yo (vs. 0% in the group <70yo, p <0.0001). Multivariate logistic regression showed a high SAPS II score and age ≥70yo as independent risk factors for DWLSTs in the ICU. We did not find age ≥70yo as an independent risk factor for mortality in ICU. CONCLUSION: We found that age ≥70yo was an independent risk factor for DWLSTs for patients in the ICU, but not for their mortality. Reasons leading to DWLSTs are different according to the age of patients.

Visual Impairment Screening at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability at the Gérontopôle.

OBJECTIVES: To evaluate visual performance and factors associated with abnormal vision in patients screened for frailty at the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability at Toulouse University Hospital. DESIGN: Retrospective, observational cross-sectional, single-centre study. SETTING: Institutional practice. PARTICIPANTS: Patients were screened for frailty during a single-day hospital stay between October 2011 and October 2014 (n = 1648). MEASUREMENTS: Collected medical records included sociodemographic data (including living environment and educational level), anthropometric data, and clinical data. The general evaluation included the patient's functional status using the Activities of Daily Living (ADL) scale and the Instrumental Activity of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE) for cognition testing, and the Short Physical Performance Battery (SPPB) for physical performance. We also examined Body Mass Index (BMI), the Mini-Nutritional Assessment (MNA), and the Hearing Handicap Inventory for the Elderly Screening (HHIE-S) tool. The ophthalmologic evaluation included assessing visual acuity using the Snellen decimal chart for distant vision, and the Parinaud chart for near vision. Patients were divided into groups based on normal distant/near vision (NDV and NNV groups) and abnormal distant/near vision (ADV and ANV groups). Abnormal distant or near vision was defined as visual acuity inferior to 20/40 or superior to a Parinaud score of 2, in at least one eye. Associations with frailty-associated factors were evaluated in both groups. RESULTS: The mean age of the population was 82.6 ± 6.2 years. The gender distribution was 1,061 females (64.4%) and 587 males (35.6%). According to the Fried criteria, 619 patients (41.1%) were pre-frail and 771 (51.1%) were frail. Distant and near vision data were available for 1425 and 1426 patients, respectively. Distant vision was abnormal for 437 patients (30.7%). Near vision was abnormal for 199 patients (14%). Multiple regression analysis showed that abnormal distant vision as well as abnormal near vision were independently associated with greater age (P < 0.01), lower educational level (P < 0.05), lower performance on the MMSE (P < 0.001), and lower autonomy (P < 0.02), after controlling for age, gender, educational level, Fried criteria, and MMSE score. CONCLUSION: The high prevalence of visual disorders observed in the study population and their association with lower autonomy and cognitive impairment emphasises the need for systematic screening of visual impairments in the elderly. Frailty was not found to be independently associated with abnormal vision.

Body Composition and Anti-Neoplastic Treatment in Adult and Older Subjects - A Systematic Review.

BACKGROUND: The estimation of the risk of poor tolerance and overdose of antineoplastic agents protocols represents a major challenge in oncology, particularly in older patients. We hypothesize that age-related modifications of body composition (i.e. increased fat mass and decreased lean mass) may significantly affect tolerance to chemotherapy. METHOD: We conducted a systematic review for the last 25 years (between 1990 and 2015), using US National library of Medicine Medline electronic bibliographic database and Embase database of cohorts or clinical trials exploring (i) the interactions of body composition (assessed by Dual X-ray Absorptiometry, Bioelectrical Impedance Analyses, or Computerized Tomography) with pharmacokinetics parameters, (ii) the tolerance to chemotherapy, and (iii) the consequences of chemotherapies or targeted therapies on body composition. RESULTS: Our search identified 1504 articles. After a selection (using pre-established criteria) on titles and abstract, 24 original articles were selected with 3 domains of interest: impact of body composition on pharmacokinetics (7 articles), relationship between body composition and chemotoxicity (14 articles), and effect of anti-cancer chemotherapy on body composition (11 articles). The selected studies suggested that pharmacokinetic was influenced by lean mass, that lower lean mass could be correlated with toxicity, and that sarcopenic patients experienced more toxicities that non-sarcopenic patients. Regarding fat mass, results were less conclusive. No studies specifically explored the topic of body composition in older cancer patients. CONCLUSIONS: Plausible pathophysiological pathways linking body composition, toxicity, and pharmacokinetics are sustained by the actual review. However, despite the growing number of older cancer patients, our review highlighted the lack of specific studies in the field of anti-neoplastic agents toxicity regarding body composition conducted in elderly.

Predictive factors of emergency hospitalisation in Alzheimer's patients: results of one-year follow-up in the REAL.FR Cohort.

OBJECTIVE: To determine the predictive factors of hospitalisation in patients with Alzheimer's disease followed in the REAL.FR cohort. METHODS: A French multicentre prospective study (REAL.FR) following 516 patients who had mild to moderate AD at inclusion. Analysis of the data after one year of follow-up. RESULTS: 139 (26,9%) of the 516 initial AD patients were hospitalized during the 1 year of follow-up. After bivariate analysis, the principal predictive factors of hospitalisation were high scores on the Reisberg scale (> or = 5: P = 0.0149) and the CDR (1: P = 0.0289; 2 or 3: P = 0.0078); > or = 2 intercurrent diseases (P = 0.00104); > or = 3 other treatments (not including specific treatments for AD) (P = 0.0026); BMI (kg/m2) between 25 and 30 (P = 0.0147); impossibility of single-leg stance (P = 0.02); > or = 1 disabilities on the ADL (P = 0.0009) and > or = 2 disabilities on the IADL (P = 0.0017); use of medical services (P = 0.0236) and of non-medical services (P = 0.0403); delirium or hallucinations (P = 0.0135), depression (P = 0.0014), or disinhibited behaviour (P = 0.0030); the gravity and frequency of behavioural symptoms (NPI freq x grav > or = 11 (median), P = 0.0012); and lastly, a score of > or = 20 for subjective caregiver burden on the Zarit scale (P < 0.0001). Multivariate analysis revealed an association between the risk of hospitalisation and the following variables : the type of centre to which the patient was admitted (neurological, psychiatric or geriatric), impaired orientation on the MMS, BMI, the number of disabilities on the ADL, and caregiver burden as evaluated by the Zarit scale. CONCLUSION: At inclusion, patients with more severe cognitive disorders, poor nutritional status and those who were the most dependent for basic activities of daily living were already at greater risk of hospitalisation. Exhaustion of the informal caregiver was an independent and supplementary predictive factor of hospitalisation.

[Cryofibrinogenemia: a single-center study at the University Hospital of Toulouse, France]. / Cryofibrinogénémie : étude monocentrique au CHU de Toulouse.

PURPOSE: Cryofibrinogenemia is an unknown disorder and studies dedicated to it are limited. The aim of our study was to report on the incidence, clinical manifestations and associated diseases in patients with isolated cryofibrinogenemia. METHODS: This is a retrospective single-center study. Patients included in this study had a positive and isolated detection of cryofibrinogen between January 1st, 2011 and December 31st, 2012. Identification was possible through the database of the laboratory of immunology. RESULTS: Two hundred and eighty-one consecutive orders of cryofibrinogenemia were identified. Seventy-three patients had a positive detection of cryofibrinogenemia. Among them, 12 had an isolated cryofibrinogenemia and sixty-one patients (84%) had concomitant cryofibrinogenemia and cryoglobulinemia. The mean age was 59±19years. Seven patients were female (58%). Cutaneous manifestations were present in half case. Peripheral nerve involvement was present in 5 cases (42%) and rheumatic manifestations in 4 patients (33%). A thrombotic event was reported in 7 patients (58%). Renal impairment was present in 7 patients. The median cryofibrinogen concentration was 254±304mg/L. Five patients had a secondary cryofibrinogenemia. The most often prescribed treatment was corticosteroids. CONCLUSION: Cryofibrinogenemia is an unknown disorder. Testing for cryoglobulinemia is more frequent than for cryofibrinogenemia whereas clinical manifestations are similar. Detection of cryofibrinogen is positive in most of the cases, with an important prevalence of thrombotic events in this population. This study confirms the importance of conducting prospective studies on cryofibrinogenemia.

[Vascular risk factors and Alzheimer's disease]. / Facteurs de risque vasculaire et maladie d'Alzheimer.

BACKGROUND AND OBJECTIVE: Recent epidemiological study and clinico-pathologic data suggest overlaps between Alzheimer disease and cerebrovascular lesions that may magnify the effect of mild Alzheimer disease pathology and promote progression of cognitive decline. There is now strong epidemiologic evidence supporting an association between Alzheimer disease and two major vascular risk factors--blood pressure and diabetes. The major objective of this study is to analyse the impact of vascular risk factors on natural history of Alzheimer's disease. METHODS: Descriptive analyse of the vascular risk factors on 520 Alzheimer's disease patients issue from the population of the "Programme Hospitalier de Recherche Clinique: "Réseau sur la maladie d'Alzheimer français". RESULTS: The description of the vascular risk factors in the Alzheimer's disease patients from the "Programme Hospitalier de Recherche Clinique. "Réseau sur la maladie d'Alzheimer Français" was made and the projects and perspectives of analyses based on the longitudinal data were discussed. 45% of subjects have high blood pressure, they were significantly older (p < 0.05), have more frequent impairment of ADLs (p < 0.05), and one-leg balance impairment (p < 0.05). 10% of patients have diabetes and 23.95% hypercholesterolemia. CONCLUSIONS: The first data on vascular risk factors of the "Programme Hospitalier de Recherche Clinique: "Réseau sur la maladie d'Alzheimer français"" are the first step on comprehension of the impact of vascular risk factors and their traitments on Alzheimer's disease.

[The French network multicenter study. Predictive factors of hospitalization and management of Alzheimer's disease patients (REAL.FR)]. / Présentation de l'étude multicentrique en réseau. Facteurs prédictifs d'hospitalisation et filières de soins chez des patients atteints de la maladie d'Alzheimer (REAL.FR).

We present in this article the REAL.FR research program on Alzheimer disease (AD) and its management. This is a French multicenter prospective study whose objectives are to study the natural history of AD and the modalities of its management. In order to pursue these aims, we set up a cohort of 700 AD patients in France. They entered the study in year 2000 and will be followed for at least four years. The study population consists of AD patients, living in the community at the time of enrollment and looked after by an informal caregiver. On inclusion, each patient underwent a full investigation which included gerontological and social evaluation. Patients will be seen every six months for at least four years. During follow-up, events which have occurred during the previous six months are noted (i.e. admissions to hospital or to an institution, use of new in-home help services...). To date, 577 patients have been reviewed at 6 month, 489 at 12 month, 358 at 18 month, 266 at 24 month, 178 at 30 month and 31 at 36 month. 48 death have been registered, 42 patients have been institutionalised and 124 have been dropped out. Mean age of patients on inclusion was 77.4 +/- 7 years. Nearly one-third of patients were living at home when they were enrolled in the study. Our preliminary results are encouraging regarding the feasibility of patients follow-up. The satisfactory participation of patients and their families in the later evaluations which have already been carried out also seem promising for the continuation of follow-up.

[Factors associated with the moderately severe stage of Alzheimer's disease: first results of the REAL.FR study]. / Facteurs associés au stade modérément sévére de la maladie d'Alzheimer: premiers résultats de l'étude REAL.FR.

OBJECTIVE: Most studies of Alzheimer's disease deal with the mild to moderate stages of the disease. However the great majority of cases evolve toward a stage of marked severity which can last many years. The few studies of severe dementia that have been carried out have included institutionalized patients. The aim of this study is to describe associated factors with a moderately severe Alzheimer's disease in a French community dwelling patients. METHODS: Initial data from a French cohort Study of Alzheimer's patients (REAL.FR: Réseau sur la maladie d'Alzheimer français) were analysed. These included sociodemographic and medical factors and measures of cognitive and non cognitive performance. We compared two groups according the stage of the disease: moderately severe patients (Mini Mental Status score < 15) and mild to moderate patients (Mini Mental Status score > or = 15). RESULTS: Moderately severe stage of disease was independently related to age (OR: 0.35; 95% CI: 0.16-0.78 for patient aged between 75-80 years compared to patient < or = 75 years), low educational level (non-obtention of french certificate of primary education, OR: 2.43; IC à 95%: 1.28-4.59) and disability to perform activities of daily living (OR: 3.35; 95% CI: 1.62-6.93). After multivariate analysis, there was no difference between the 2 groups for the other factors like behavioral symptoms. CONCLUSIONS: Severe dementia represents major medical and socio-economical problem. Better knowledge of the natural history of the severe stage of the disease is necessary for better clinical practice.

[Burden experienced by informal caregivers assisting Alzheimer's patients in the REAL.FR study]. / Charge ressentie par les aidants informels de patients atteints de la maladie d'Alzheimer au sein de l'étude REAL.FR: méthode de mesure et facteurs associés.

BACKGROUND: Most AD patients are cared for at home by informal caregivers. The effect of different kind of stressors on caregivers has been referred to as caregiver burden. OBJECTIVE: To determine (1) the level of burden of informal caregivers of Alzheimer's patients in a French national sample; (2) the factors associated with a high level of burden. METHODS: Cross-sectional study of informal caregivers of the demented elderly referred to a psychogeriatric, geriatric or neurological service. The principal caregivers of 531 patients with mild to moderate dementia attending an outpatient cognitive assessment clinic were interviewed via a structured questionnaire that focused upon caregiver-related characteristics such as whether they were living with the patients, their feelings of burden assessed by the Zarit Burden Interview and patients were examined at baseline to evaluate their cognitive, behavioral and functional limitation. RESULTS: Logistic regression analysis showed that patients' characteristics (MMSE, behavioral problems, nutritional problems), caregiver's characteristics (female gender, number of tasks involved in caregiving, cohabitation) and the provision of medical services were independently associated with a high level of burden. In this study increased caregiver burden was related independently to increased levels of patient behaviour disturbance and cognitive impairment. However, neither the illness duration nor the functional disabilities in activities of daily living affected the level of burden. This may have relevance to appropriate interventions for informal caregivers.

Description of 1,108 older patients referred by their physician to the "Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability" at the gerontopole.

INTRODUCTION: Frailty is considered as an early stage of disability which, differently from disability, is still amenable for preventive interventions and is reversible. In 2011, the "Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability" was created in Toulouse, France, in association with the University Department of General Medicine and the Midi-Pyrénées Regional Health Authority. This structure aims to support the comprehensive and multidisciplinary assessment of frail older persons, to identify the specific causes of frailty and to design a personalized preventive plan of intervention against disability. In the present paper, we describe the G.F.C structure, organization, details of the global evaluation and preventive interventions against disability, and provide the main characteristics of the first 1,108 patients evaluated during the first two years of operation. METHODS: Persons aged 65 years and older, considered as frail by their physician (general practitioner, geriatrician or specialist) in the Toulouse area, are invited to undergo a multidisciplinary evaluation at the G.F.C. Here, the individual is assessed in order to detect the potential causes for frailty and/or disability. At the end of the comprehensive evaluation, the team members propose to the patient (in agreement with the general practitioner) a Personalized Prevention Plan (PPP) specifically tailored to his/her needs and resources. The G.F.C also provides the patient's follow-up in close connection with family physicians. RESULTS: Mean age of our population was 82.9 ± 6.1 years. Most patients were women (n=686, 61.9%). According to the Fried criteria, 423 patients (39.1%) were pre-frail, and 590 (54.5%) frail. Mean ADL (Activities of Daily Living) score was 5.5 ± 1.0. Consistently, IADL (Instrumental ADL) showed a mean score of 5.6 ± 2.4. The mean gait speed was 0.78 ± 0.27 and 25.6% (272) of patients had a SPPB (Short Physical Performance Battery) score equal to or higher than 10. Dementia was observed in 14.9% (111) of the G.F.C population according to the CDR scale (CDR ≥2). Eight percent (84) presented an objective state of protein-energy malnutrition with MNA (Mini Nutritional Assessment) score < 17 and 39.5% (414) were at risk of malnutrition (MNA=17-23.5). Concerning PPP, for 54.6% (603) of patients, we found at least one medical condition which needed a new intervention and for 32.8% (362) substantial therapeutic changes were recommended. A nutritional intervention was proposed for 61.8% (683) of patients, a physical activity intervention for 56.7% (624) and a social intervention for 25.7% (284). At the time of analysis, a one-year reassessment had been carried out for 139 (26.7%) of patients. CONCLUSIONS: The G.F.C was developed to move geriatric medicine to frailty, an earlier stage of disability still reversible. Its particularity is that it is intended for a single target population that really needs preventive measures: the frail elderly screened by physicians. The screening undergone by physicians was really effective because 93.6% of the subjects who referred to this structure were frail or pre-frail according to Fried's classification and needed different medical interventions. The creation of units like the G.F.C, specialized in evaluation, management and prevention of disability in frail population, could be an interesting option to support general practitioners, promote the quality of life of older people and increase life expectancy without disability.