Mortality in COVID-19 older patients hospitalized in a geriatric ward: Is obesity protective?

BACKGROUNDS: To investigate the relationship between obesity and 30-day mortality in a cohort of older hospitalized COVID-19 inpatients. METHODS: Included patients were aged 70 years or more; hospitalized in acute geriatric wards between March and December 2020; with a positive PCR for COVID-19; not candidate to intensive care unit admission. Clinical data were collected from patients electronic medical records. Data on 30-day mortality were retrieved from the hospital administrative database. RESULTS: Patients included (N = 294) were on average 83.4 ± 6.7 years old, 50.7% were women, and 21.7% were obese (BMI > 30 kg/m2). At 30-day, 85 (28.9%) patients were deceased. Compared to survivors in bivariable analysis, deceased patients were older (84.6 ± 7.6 vs 83.0 ± 6.3 years), more frequently with very complex health status (63.5% vs 39.7%, P < .001), but less frequently obese (13.4% vs 24.9%, P = .033) at admission. Over their stay, deceased patients more frequently (all P < .001) developed radiologic signs of COVID-19 (84.7% vs 58.9%), anorexia (84.7% vs 59.8%), hypernatremia (40.0% vs 10.5%), delirium (74.1% vs 30.1%), and need for oxygen (87.1% vs 46.4%) compared to survivors. In multivariable analysis that controlled for all markers of poor prognosis identified in bivariable analysis, obese patients remain with 64% (adjOR 0.36, 95%CI 0.14-0.95, P = .038) lower odds to be deceased at 30-day than non-obese patients. CONCLUSIONS: In this population of older COVID-19 inpatients, an inverse association between obesity and 30-day mortality was observed even after adjusting for all already-known markers of poor prognosis. This result challenges previous observations in younger cohorts and would need to be replicated.

[An assessment of an orhthogeriatrics unit 5 years after its creation]. / Bilan 5 ans après la création d'une unité d'orthogériatrie.

On January 1st, 2018, we established an orthogeriatrics (OG) unit for patients aged ≥ 70 years old with hip fracture, based on a purely geriatric management 24-hours post-operation. In this article we discuss the results of the implemented measures (geriatric follow-up with standardized protocols) on mortality after 6 weeks, operative delay, and complications. Among the 607 treated patients, the mortality rate was 6.75 %, which was unaffected by the average operative delay of 35 hours. Age, male gender, dependency status, cognitive disorder and malnutrition all significantly increased the mortality rate. Presenting at least one complication multiplied the mortality rate by 4.79, a cardiac complication by 3.92, and severe malnutrition by 4.95.

Le 1er janvier 2018, nous avons créé une unité d'orthogériatrie (OG) pour les sujets âgés de ≥ 70 ans avec fracture de hanche, reposant sur une prise en charge purement gériatrique après 24 heures postopératoires. Dans cet article, nous présentons le bilan des mesures appliquées (suivi gériatrique, avec protocoles standardisés) sur la mortalité après 6 semaines, le délai opératoire et les complications. La mortalité des 607 patients pris en charge était de 6,75 %, non influencée par le délai opératoire moyen de 35 heures. L'âge, le sexe masculin, l'état de dépendance, les troubles cognitifs et la malnutrition ont significativement augmenté la mortalité. Présenter au moins une complication a multiplié le risque de mortalité par 4,79, une complication cardiaque par 3,92 et une malnutrition sévère par 4,95.

[Geriatric syndromes and polypharmacy: to prescribe or to proscribe that is the question]. / Syndromes gériatriques et polypharmacie : prescrire ou proscrire, il faut choisir.

How to apply treatment recommendations from various knowledgeable specialist societies concerning the very complex patient? Within a population weakened by the cumulative effect of comorbidities, loss of autonomy aggravated by geriatric syndromes and biological changes linked to aging which interact with the pharmacokinetics and pharmacodynamics of drugs, there is fertile soil for the advent of adverse conditions linked to simultaneously prescribing multiple treatments. Our aim is to analyze various clinical reasoning tools permitting an appropriate drug prescription while considering the state of health, life expectancy and time to benefit with the aim of reducing iatrogenesis.

Comment mettre en pratique les recommandations de prise en charge médicamenteuse suggérées par les différentes sociétés savantes de spécialistes face à un patient âgé non robuste ? Dans une population fragilisée par le cumul des comorbidités, les handicaps liés aux syndromes gériatriques et les modifications biologiques liées au vieillissement, le terrain est fertile pour la survenue d'effets indésirables lors de la prescription simultanée de plusieurs médicaments. Nous analysons dans cet article divers aides au raisonnement clinique menant à la prescription d'une médication adaptée aux objectifs partagés avec le patient, en tenant compte de l'état de santé, de l'espérance de vie et du temps nécessaire au bénéfice escompté de la prescription, afin de pallier toute iatrogénie.

[Treatment of the frail older diabetic : less is so much more]. / Traitement du diabétique âgé fragile : less is so much more.

Improving glycaemia level is helpful to the clinician in diabetes management. Elderly diabetics make up a group that is non-homogeneous and with a very varied health status, whose treatment must be adjusted to take into account comorbidities, degree of frailty and both functional and mental disability, in addition to their life expectancy and personal preferences. Thus, the target of treatment should be defined along three categories of patients: robust, vulnerable and dependent. This article reviews information from the literature high-lighting current recommendations for treatment, the clear inclination towards overtreatment of the elderly diabetic and the resulting noxious effects of occurring hypoglycemia, that are often not recognized by the patient and his doctor.

Améliorer la valeur glycémique guide le clinicien dans la prise en charge du diabète. Les sujets âgés diabétiques forment un groupe à l'état de santé très variable et inhomogène dont le suivi doit être affiné en prenant en compte les comorbidités, le degré de vulnérabilité et de handicap tant fonctionnel que psychique, l'espérance de vie, ainsi que les préférences du patient. Ainsi, les cibles de traitement pourront être définies en répartissant les patients en trois catégories : solides, vulnérables et dépendants. Cet article passe en revue les données de la littérature en illustrant les recommandations actuelles de prise en charge, la tendance marquée au surtraitement du sujet âgé diabétique et les effets délétères de la survenue d'hypoglycémies souvent non identifiées par le patient et son médecin.

[Anticoagulation in vulnerable elderly patients with atrial fibrillation†: risks and benefits]. / Anticoagulation du sujet âgé vulnérable avec fibrillation auriculaire†:risques et bénéfices.

Atrial fibrillation is a common cardiac disease of aging. The risk of stroke and bad prognosis increase with age and atrial fibrillation. Compared with younger people, elderly people have higher risks for both thrombosis and bleeding. Stroke prevention with oral anticoagulants is the cornerstone of the management of atrial fibrillation but is often questioned because of the risk of bleeding, furthermore comorbidities, comedications, fall risks, poor compliance. These factors frequently found in frail elderly patients complicate the management of antithrombotic therapy. This article reviews the evidence for the risks and benefits of anticoagulation in the elderly with atrial fibrillation, by comparing the new oral anticoagulants to vitamin K antagonists.

La fibrillation auriculaire est une pathologie cardiaque fréquente du vieillissement et l'accident vasculaire cérébral en est une complication reconnue et redoutable. L'anticoagulation préventive des événements thromboemboliques est souvent mise en doute chez le sujet âgé vulnérable ou dépendant en raison du risque hémorragique élevé lié aux caractéristiques de cette population : nombreuses comorbidités, risques de chute, faible compliance, polymédication. S'appuyant sur une revue de la littérature, cet article décrit les risques et les bénéfices de l'anticoagulation du sujet âgé souffrant d'une fibrillation auriculaire, en comparant les nouveaux anticoagulants oraux aux antagonistes de la vitamine K.

[Too old or too frail for intensive care?] / Trop âgé ou trop fragile pour bénéficier des soins intensifs ?

What are the criteria for admitting an elderly polymorbid patient to intensive care ? The multidimensional geriatric evaluation is a tool to screen for geriatric syndromes, with the division of elderly patients into 3 categories: robust, vulnerable and dependent. Targeting certain co-morbidities such as cognitive disorders, delirium, frailty, polymedication and malnutrition, allows clinicians to estimate the risks of mortality and functional and cognitive handicaps during a stay in intensive care. Based on a review of the literature, this article offers some guidelines for triage of older patients for admission to intensive care, using an ethical, multidisciplinary approach that takes into account the patient's fears and preferences.

Selon quels critères admettre un sujet âgé polymorbide aux soins intensifs ? L'évaluation gériatrique multidimensionnelle est une aide qui permet le dépistage des syndromes gériatriques, avec la répartition des patients âgés en 3 catégories: les robustes, les vulnérables et les dépendants. Cibler certaines comorbidités telles que les troubles cognitifs, le delirium, la fragilité, la polymédication et la malnutrition s'avère particulièrement judicieux pour estimer les risques de mortalité, de handicaps fonctionnels et cognitifs, lors d'un séjour aux soins intensifs. S'appuyant sur une revue de la littérature, cet article offre quelques pistes qui devraient faciliter le triage des plus âgés pour l'admission aux soins intensifs. Et celà dans une démarche éthique, multidisciplinaire, qui prend en compte les craintes et les préférences du patient.

[Fracture in older diabetic, harm of intensive diabetic therapy†?] / Fracture chez le diabétique âgé†: conséquence d'un surtraitement†.

Does inappropriate treatment contribute to the risk of falls and fractures in older diabetic patients ? Among 2205 diabetics hospitalized in a geriatric ward, this retrospective study analyses the follow-up of the group with a fracture (12 %) according to the glycated hemoglobin (HbA1c) and the recommended targets. In our collective where only 4 % are healthy (50 % are vulnerable, 46 % are frail), the average value of HbA1c is 6.9 %. When we compare HbA1c, we find that more than 79.3 % of patients have HbA1c at least 0.5 % below the recommended target for their category. This suggests overtreatment that may have contributed to falls.

Un traitement inadapté contribue-t-il au risque de chute et de fracture du diabétique âgé ? Rétrospectivement, parmi les 2205 diabétiques hospitalisés dans un service de gériatrie, cette étude analyse le suivi du groupe ayant présenté une fracture (12 %) en fonction du taux d'hémoglobine glyquée (HbA1c) et des cibles recommandées. Dans notre collectif, où seuls 4 % des patients sont robustes (50 % sont vulnérables, 46 % fragiles), la valeur moyenne d'HbA1c est de 6,9 %. En comparant les valeurs d'HbA1c, nous constatons que plus de 79,3 % des patients ont une HbA1c inférieure d'au moins 0,5 % aux cibles recommandées pour leur catégorie de santé, évoquant un surtraitement ayant possiblement contribué aux chutes.

[Geriatrician and orthopedist†: happy wedding†?] / Gériatre et orthopédiste†: un mariage heureux†?

Proximal femur fractures in the elderly are still a major event in the functional trajectory of patients. In order to optimize their care, a pilot orthogeriatric unit was created in 2018 at the Valais Hospital. This innovative unit, managed by the internist-geriatrician within the orthopedic department, allows the early and standardized management of geriatric syndromes and postoperative complications. This article describes the practical operation of the unit, presents the preliminary results, and develops suggestions for improvement.

Les fractures du fémur proximal chez le sujet âgé constituent aujourd'hui encore un événement majeur dans la trajectoire fonctionnelle des patients. Afin d'optimiser leur prise en charge, une unité pilote d'orthogériatrie a vu le jour en 2018 à l'Hôpital du Valais. Cette unité novatrice, gérée par l'interniste-gériatre au sein du service d'orthopédie, permet la prise en charge précoce et standardisée des syndromes gériatriques et des complications postopératoires. Cet article décrit le fonctionnement pratique de l'unité, livre nos résultats préliminaires et élabore des suggestions d'amélioration.

[Prevention in older age : key factors]. / Prévention chez le senior : les facteurs clés.

The extended life expectancy questions the quality of life of these additional years: with or without disability ? A review of the literature gives us some tips on preventive measures to maintain good health at an advanced age. Engaging in regular and moderate physical activity (such as walking) offers a range of health benefits, including reduced risk of all-cause mortality, lower risk for various diseases (ischemic stroke, ischemic heart disease, diabetes, breast and colon cancer), prevention of falls and functional decline in seniors living at home. Maintaining a healthy lifestyle (non-smoking, low alcohol consumption, adequate nutrition) as well as up-to-date immunization status and vitamin D supplementation in the deficient or vulnerable population, are factors that contribute to a better health in the last years of life.

L'allongement de l'espérance de vie interroge sur la qualité de vie de ces années supplémentaires : avec ou sans handicap ? Une revue de la littérature nous apporte quelques réponses sur les mesures de prévention pour préserver un bon état de santé à un âge avancé. La pratique d'une activité physique modérée comme la marche amène des avantages reconnus : diminution de la mortalité, prévention des chutes et du déclin fonctionnel pour le senior vivant à domicile, diminution de la survenue de plusieurs maladies (accident vasculaire cérébral, maladie coronarienne, diabète) et de plusieurs cancers. Le maintien d'un style de vie sain (alimentation équilibrée, absence de tabac, consommation modérée d'alcool) ainsi qu'un statut vaccinal à jour et la substitution de la carence en vitamine D chez le sujet carencé ou fragile, sont autant d'éléments garantissant une meilleure santé dans les dernières années de vie.

[Capgras delusion and Alzheimer disease]. / Syndrome de Capgras et maladie d'Alzheimer.

Capgras delusion is classified with the misidentification syndromes. In dementia it associates cognitive deficiency of memory and facial recognition (prosopoagnosia) with delirious idea of substitution by a double. The first reported case in the paper describes the important affective and comportmental reactions due to the identification of a double perceived as an imposter, affecting both the suffering person and his family. Rarely, as reported in the second case, misrecognition concerns the person itself (autoprosopagnosia) who can have the illusion to be in front of a twin brother (« auto-Capgras ¼). We discuss data from the literature concerning prevalence, results of cerebral imaging and functional prognosis associated with this curious syndrome.

Le syndrome de Capgras fait partie des troubles de l'identification des personnes. Dans la démence, il associe des déficits cognitifs de la mémoire et de la reconnaissance des visages (prosopagnosie) et des idées délirantes de substitution par des sosies. La première situation rapportée dans l'article décrit les importantes réactions affectives et comportementales engendrées par l'identification d'un sosie qui est perçu comme un imposteur, affectant à la fois le malade et son entourage. Rarement, comme rapporté dans la deuxième situation, la fausse reconnaissance concerne la personne elle-même (autoprosopagnosie) qui peut avoir l'illusion d'avoir en face d'elle un frère jumeau (« auto-Capgras ¼). Nous discutons de données issues de la littérature concernant la prévalence, les résultats de l'imagerie cérébrale ainsi que le pronostic fonctionnel liés à ce curieux syndrome.

[Hypertension, diabetes, hyperlipidemia : what are the treatment goals for the elderly ?] / Hypertension, diabète, hyperlipidémie : quelles cibles de traitementpour les seniors ?

Will my patient actually benefit from the medication that I've prescribed? Faced with an elderly, frail patient, the family doctor is often confronted by this dilemma. This article reviews the evidence that can assist clinicians in determining the best approach to treating diabetes, hypertension and hyperlipidemia in elderly patients, by defining treatment goals specific to each patients' functional and cognitive capacities. Avoiding hypoglycemia and hypotension, with all of their consequences, must remain the highest priority driving objectives for optimal management of diabetes and hypertension in the geriatric population.

Mon patient va-t-il réellement bénéficier des traitements que je lui propose ? Face à un patient âgé et fragile, le médecin de famille est très souvent préoccupé par cette interrogation. Cet article passe en revue les différents arguments qui permettent d'affiner le jugement et la prescription du clinicien face aux objectifs de traitement du diabète, de l'hypertension et de l'hyperlipidémie du sujet âgé, en définissant les cibles adaptées à l'état fonctionnel et cognitif du patient. Eviter la survenue d'épisodes d'hypoglycémie et d'hypotension, avec leurs cortèges de complications sévères, devrait être la priorité dans la conduite de tout traitement du diabète et de l'hypertension en médecine gériatrique.

[Doctor, physical activity at my age ?] / Docteur, de l'activité physique à mon âge ?

Engaging in regular and appropriate physical activity confers health benefits at any age. For seniors, swapping the role of « sedentary ¼ for « someone who's on the move ¼ offers much more substantial benefits than any medication, and notably even starting at a dose of 10-15 minutes per day ! Any physician who cares for elderly patients must pursue the objective of encouraging physical activity that is integrated into daily life (e.g. walking, gardening, shopping). This article consists of a literature review concerning the evidence for the benefits of physical activity in seniors in terms of quality of life, longevity, maintenance of functional independence, and prevention of cognitive decline.

La pratique d'une activité physique régulière et adaptée amène des effets bénéfiques sur la santé à tout âge. Pour le senior, troquer son statut de « sédentaire ¼ contre celui « d'individu en mouvement ¼ conduit à des profits bien supérieurs à la prise de n'importe quelle médication, et ceci déjà à partir d'une dose de 10 à 15 minutes par jour ! Encourager l'activité physique en lien avec les loisirs et les activités de la vie quotidienne (promenade, jardinage, courses,…) doit être un objectif de tout médecin prenant en charge une personne âgée. Cet article propose une revue de la littérature des bienfaits avérés de l'activité physique chez les seniors, en termes de qualité et d'espérance de vie, de maintien de l'indépendance fonctionnelle et de prévention du déclin cognitif.

[From thiamine deficiency to Wernicke encephalopathy, unknown pathology]. / Du déficit en thiamine à l'encéphalopathie de Gayet-Wernicke, pathologie méconnue.

The thiamine deficiency and its clinical consequences, especially the Wernicke encephalopathy, are still often not diagnosed. The etiologies are numerous, but the most frequent is the alcohol dependence. The diagnostic is mainly clinical and the treatment must be started as soon as possible by substituting the thiamine with intravenous injection.

Le déficit en thiamine et ses conséquences cliniques, en particulier l'encéphalopathie de Gayet-Wernicke, sont encore très souvent non diagnostiqués. Les étiologies sont multiples, la plus fréquente étant la dépendance à l'alcool. Le diagnostic est avant tout clinique et le traitement doit être débuté le plus rapidement possible en substituant la thiamine par voie intraveineuse.

[Diabetes: glycemic targets and over-treatment in older patients]. / Diabète: cibles glycémiques au grand âge et surtraitement.

Diabetic glycemic targets in older patients must reflect their preferences, clinical status and life expectancy. The presence of multiple comorbidities as well as functional or cognitive impairment are better predictors than age alone of both limited life expectancy and reduced benefit of intensive treatment. For most of these patients, the harms of intensive diabetes therapy outweigh the benefits. Our retrospective study analyzing 257 diabetic patients hospitalized in a geriatric ward shows a very high incidence of over-treatment and suggests the need to review our practices and to adopt individualized treatment goals.

Long-Term Mortality in Very Old Survivors of COVID-19.

OBJECTIVES: This report aimed to describe mortality at 18 months in older survivors of the first wave of COVID-19. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: Patients aged ≥65 years hospitalized for COVID-19 in the acute geriatric wards of 2 centers. METHODS: Characteristics of deceased and survivors were compared by Fisher exact, Mann-Whitney U, or 2-tailed t tests. Survival rates were analysed by Cox proportional hazards regression models. RESULTS: Of a total of 323 patients admitted during the first wave, 196 survived the acute phase, with 34 patients who died in the 18 months after hospital discharge (17.3%). Higher mortality was observed in patients living in nursing homes (P = .033) and in those who were hospitalized after discharge during the follow-up period (97.1% vs 72.8%, P = .001). There was no difference in survival curves according to age, sex, presence of dyspnea, and dementia. Living in a nursing home significantly increased the mortality rates in the multivariate model adjusted for age and sex (hazard ratio 3.07, 95% CI 1.47-6.40; P = .007). CONCLUSIONS AND IMPLICATIONS: No excess mortality was observed during 18 months in older survivors of COVID-19. Living in a nursing home was associated with decreased survival rates.

Impact of biomass fuel smoke on respiratory health of children under 15 years old in Madagascar.

BACKGROUND: Children exposed to biomass used in households are at risk to develop diseases or respiratory symptoms. In Madagascar more than 95% of households use it daily. The main objective is to study the impact of chronic exposure to biomass on respiratory health of children under 15 years old in Madagascar. METHODS: Descriptive cross-sectional study conducted with questionnaires among urban and rural population of Antananarivo and Mahajanga provinces between 2016 and 2017. Variables were collected: number of hours spent in kitchen per day, respiratory symptoms and spirometric data. Categorized symptoms score and exposure index expressing chronic exposure to biomass were analyzed with multinomial logistic regression models. RESULTS: Of the 661 children included in the analysis, 27.7% had 1 respiratory symptom and 29.3% had 2 or more respiratory symptoms. Moderate exposure index (aOR=1.57; CI95%=[1.30-1.89]; p<0.001) and high exposure index (aOR=1.76; CI95%=[1.39-2.24]; p<0.001) were significantly associated with 1 respiratory symptom, adjusted with provinces, household members and visitors smoking, perceived discomfort related to air pollution and birthweight. Exposure index was not significantly associated with an increased risk of having 2 or more respiratory symptoms (p = 0.754). CONCLUSION: Respiratory symptoms were associated with exposure to biomass, living in coastal areas, birthweight, tobacco and perceived discomfort related to air pollution. Recommendations and actions must be implemented in order to improve respiratory health related to biomass among children.

[Orthogeriatric unit: a marriage of convenience between orthopedic surgeon and geriatrician?]. / L'unité d'ortho-gériatrie mariage de raison entre orthopédiste et gériatre?

Hip fracture in the elderly can be associated with dramatic issues like death in the year or severe handicap requiring admission in a nursing home. Implementation of a close cooperation between orthopaedic surgeon and geriatrician materialize in the creation of unit, known as orthogeriatric unit where the roles of each member are precisely defined from admission to discharge, with coordinated care protocols and standardized orders. Benefits of the orthogeriatric ward are clarified in this paper, referring to literature, with description of an improvement of functional score after 3 months, reduction of in-hospital mortality and post-operative complications.

[Amyotrophic lateral sclerosis also threatens the octogenarian]. / La sclérose latérale amyotrophique atteint aussi te quatrième age.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease, incurable, mostly declared near the age of sixty-seventy, but more rarely for the older individuals. Because presenting symptoms are non specific (muscle weakness, functional decline, loss of ambulation, dyspnea, dysphagia), diagnosis in early stages may be difficult and delayed, particularly on polymorbid older patients. Symptomatic management is the mainstay of treatment for ALS; care in multidisciplinary team, with maximal psychologic support, is associated with enhanced quality of life. In this article we remind markings aspects of ALS of the older subject, in the light of the follow-up of five patients in our geriatric service.