Prevalence of iron deficiency in patients admitted to a geriatric unit: a multicenter cross-sectional study.

BACKGROUND: Iron deficiency (ID) is often associated with other comorbidities in older patients and is a factor of morbimortality. However, the prevalence of ID remains poorly documented in this population. METHODS: The CARENFER PA study was a French multicenter cross-sectional study whose objective was to evaluate ID in patients (> 75 years) admitted to a geriatric unit. The primary endpoint was the ID prevalence defined as: serum ferritin < 100 µg/L and/or transferrin saturation coefficient (TSAT) < 20%. The Short Physical Performance Battery (SPPB) test was used to identify older patients at high risk of adverse events (e.g., disability, falls, hospitalization, death). RESULTS: A total of 888 patients (mean age, 85.2 years; women, 63.5%) from 16 French centers were included from October 2022 to December 2022. The prevalence of ID was 57.6% (95% CI, 54.3-60.9) in the cohort of older patients (62.6% in anemic and 53.3% in non-anemic patients; p = 0.0062). ID prevalence increased significantly with the presence of more than three comorbidities (65.6% vs. 55.9%; p = 0.0274), CRP ≥ 12 mg/L (73.0% vs. 49.3%; p < 0.001) and treatment that may influence ID/anemia (60.5% vs. 49.6%; p = 0.0042). In multivariate analysis, only CRP ≥ 12 mg/L was an independent predictive factor of ID (odds ratio, 2.78; 95% CI, 1.92-4.08; p < 0.001). SPPB scores were low (0-6) in 60.5% of patients with ID versus 48.6% of patients without ID (p = 0.0076). CONCLUSION: More than half of older patients had ID, including non-anemic patients. ID was associated with the presence of inflammation and a low SPPB score. TRIAL REGISTRATION: NCT05514951.

Tele-ophthalmology for screening for eye diseases in older patients with cognitive complaints.

INTRODUCTION: Population-based studies show a significant increase in the prevalence of visual impairment in older patients. However, older patients and patients with lower Mini-Mental State Examination (MMSE) scores have few ophthalmological assessments. The main objective of our study was to evaluate the feasibility of tele-ophthalmological screening for ophthalmological diseases in older patients referred for cognitive assessment. METHODS: This monocentric prospective study included patients referred to a memory clinic for cognitive assessment. All patients underwent a geriatric assessment comprising a cognitive assessment associated with tele-ophthalmological screening undertaken by an orthoptist, including undilated retinal photography. The retinal photographs were subsequently sent to an ophthalmologist. We identified patients who were not eligible for ophthalmological assessment, for patients that had to come back due to poor-quality retinal photographs and finally for detected eye diseases. The association between the geriatric variable and newly detected eye diseases was analysed in univariable and multivariable analyses. RESULTS: The mean age of the 298 patients included was 83.5 years ± 5.65; 29.5% were male. The mean MMSE score was 20.8 ± 5.2; 66.3% of patients had a diagnosis of dementia. Eighteen patients (6.0%) were not eligible for ophthalmological examination and 13 patients (4.6%) were asked to come back owing to poor-quality retinal photographs. Forty-one patients (13.7%) had a newly detected eye disease. In multivariable analysis, patients with a lower MMSE had significantly more newly identified eye diseases. DISCUSSION: The tele-ophthalmological screening method identified unknown ophthalmological diseases requiring specialised management in this older population with cognitive complaints.

Direct oral anticoagulants in non-valvular atrial fibrillation in elderly: for a treatment adapted to patient profile.

Atrial fibrillation is the most frequent rhythm disorder in elderly patients. Moreover, the risk of stroke and the bleeding risk under anticoagulant treatment are the highest in this population. Vitamin K antagonists were until now the reference treatment of the anticoagulant treatment and they demonstrated a net benefit, including in elderly patients. The availability of the new oral anticoagulants, which do not require biological monitoring, simplified the anticoagulant treatment. However, data for the use of these molecules in elderly population remain limited. The benefit-risk ratio must not be assessed for this therapeutic class taken as a whole but for each molecule and according to the patient profile.

[Appropriateness of direct admissions to acute care geriatric unit for nursing home patients: an adaptation of the AEPf GRID]. / Pertinence des admissions en court séjour gériatrique de patients résidant en Ehpad : adaptation de la grille AEPf.

The patient population staying in nursing homes is increasingly vulnerable and dependent and should benefit from a direct access to an acute care geriatric unit. Nevertheless, the easy access by a simple phone call from the general practitioner to the geriatrician, as well as the lack of orientation of these patients by emergency units, might lead to inappropriate admissions. This work studied the appropriateness of direct admissions of 40 patients living in nursing home in an acute care geriatric unit. Based on the AEPf assessment grid, 82.5% of these admissions were considered as appropriate (52.5%) or justified (30% based on an expert panel decision), and 17.5% were inappropriate. In conclusion, the process of direct admission does not seem to increase the rate of inappropriate admissions. Some actions could decrease this rate: implementation of geriatric mobile teams or psychogeriatric mobile teams intervening in nursing home, a better and more adapted use of ambulatory structures, a better information to the general practitioners. In order to reduce the intervention of the panel of experts, an adaptation of the AEPf assessment grid to these geriatric patients has been proposed. The "AEPg" assessment grid should benefit from a validation study.

Sarcoidosis diagnosed in elderly subjects: retrospective study of 30 cases.

STUDY OBJECTIVE: This study investigated the clinical features and disease course of sarcoidosis diagnosed in patients > 70 years of age. METHODS: A retrospective analysis was made of cases treated at the University Hospital in Nantes, France, between 1986 and 2000. The diagnosis of sarcoidosis was confirmed histopathologically. Cases involving progressive cancer and active tuberculosis were excluded. RESULTS: Thirty white patients with sarcoidosis diagnosed after age 70 years (mean, 74 years) were included. An alteration of general health (asthenia and/or anorexia and/or weight loss) was frequent (53%) and characteristic of the systemic form of the disease. Dyspnea was a fairly common sign (23%). The intrathoracic form of sarcoidosis was most frequent (43.3%). Diagnosis was difficult and lengthy, and symptomatology was atypical. Accessory salivary gland biopsy was an important contributing factor to diagnosis (70.6% were positive). Oral corticosteroid therapy was often required (60.7%). The disease course was satisfactory overall (81.8% of cases), but only for 50% of patients in intrathoracic stage IV. CONCLUSIONS: The clinical presentation of sarcoidosis in elderly subjects is mainly characterized by an alteration of general health. Diagnosis is difficult and should include accessory salivary gland biopsy. Therapy frequently involves corticosteroids. Overall prognosis is similar to that for young subjects.

[Atrial fibrillation, comorbidities and new anticoagulants]. / Fibrillation atriale, comorbidités et utilisation des nouveaux anticoagulants.

UNLABELLED: The atrial fibrillation (AF) is one of the most important cause of arythmia and cerebrovascular disease in clinical practice. Comorbidity is defined as the association of active chronical diseases and a target disease. METHOD: comparison between burden illness of the patients in interventional (n=4) and observational studies, form Medline database (n=4), was performed. RESULTS: the level of comorbidity tend to be higher in patients from interventional than large observational studies. DISCUSSION: in interventional studies, the level cerebro-vascular risk was calculated to compare interventional and control groups. So contrary to what was expected the patients of the general population who can receive anticoagulants have a lesser burden of illness. A recent paper studying new anticoagulants in general population finds this difference again, and would indicate that the risk related to the use of new anticoagulants would not be upper to that observed in the princeps pivotal studies.

[General characteristics of the new oral anticoagulants]. / Caractéristiques générales des nouveaux anticoagulants oraux.

Treatment with vitamin K antagonists are subject to a common iatrogenic mainly characterized by hemorrhagic stroke. Their narrow therapeutic range associated with variability largely explains this phenomenon. New oral anticoagulants (NOAC) are now available. dabigatran (Pradaxa®) is a direct and specific thrombin inhibitor. It is excreted mainly by the kidney and is the only which can be dialyzed. Rivaroxaban (Xarelto®) and apixaban (Eliquis®) are factor X activated direct inhibitors. They are highly bound to plasma proteins and are metabolized mainly by the liver, via CYP3A4. All NOAC are substrates of P-glycoprotein (P-gp). Due to pharmacological changes, some populations at risk were identified: patients with hepatic impairment, renal impairment, elderly patients or low weight. Some pharmacokinetic or pharmacodynamic drug interactions alter the concentration and the expected impact of NOAC. The NOAC does not require biological monitoring. They interfere with the routine coagulation tests which should be interpreted with caution. Specific tests exist and can be used in case of emergencies. Currently, no antidote is available. The new oral anticoagulant look promising in the elderly. However, certain rules must be followed to reduce the risk of iatrogenic.

[Arterial stiffness a new risk factor to measure]. / La rigidité artérielle, un nouveau facteur de risque à mesurer.

We revue the epidemiology of cardiovascular disease in the elderly, their relationship to arterial stiffness. The measurement of arterial stiffness is of considerable increasing interest in this early 21 century. This paper is focusing on modeling, in different measurement methods. Several measurement techniques are presented. A review of the bibliography that explain the link between cardiovascular risk factors and arterial stiffness is summarized, as are the relationships between the various risk factors and arterial stiffness. The current role of these measurement methods seems to be time consuming although the European consensus recommends the measure once a year in the management of vascular patients. New techniques for the assessment of the arterial stiffness, more reproducible and easy to use, could ultimately trivialize this measurement, contributing in medical practice to the assessment and the management of the vascular risk.

[Six-months outcomes after admission in acute geriatric care unit secondary to a fall]. / Devenir à 6 mois après une hospitalisation en court séjour gériatrique à la suite d'une chute.

UNLABELLED: Fall in elderly subject is a main event by its medical and social consequences, but few studies were dedicated to the prognosis from hospitalization in geriatric acute care unit. AIM: Describe the outcome of elderly subjects hospitalized after a fall in geriatric acute care unit. METHODS: Longitudinal study of 6 months follow-up, 100 patients of 75 and more years old hospitalized after a fall in acute care geriatric unit. RESULTS: On a total of 128 patients hospitalized for fall, 100 agreed to participate in the study, 3 died during the hospitalization, so 97 subjects were able to be followed. During 6 months after the hospitalization, 14 patients died (14.9%), 51 (58%) have fallen again (58%) and 11 (22%) of them suffer from severe injuries. Thirty seven (39.7%) were rehospitalized and 10 of them related to fall. Among the patients coming from their home, 25 had been institutionalized. The main risk factor which have been identified to be associated with a new fall during the follow-up was a known dementia at the entry. CONCLUSION: The medical and social prognosis of an elderly subject hospitalized in an acute care unit is severe. The main comorbidity which influences the medical and social outcome is a known dementia, in addition to a history of previous fall.

[Nutrition and osteoporosis in elderly]. / Nutrition et ostéoporose chez le sujet âgé

Osteoporosis concerns 50% of women over 80 years. Prevalence of energizing and protein malnutrition is high as for institutional elderly people as for community dwelling elderly people. Malnutrition, physical inactivity and many etiological factors lead to tissular losses especially on protein compartment, named sarcopenia. Among the common etiological factors, some cytokines have an effect on proteolysis and bone restructuring, interfering with osteoclast metabolism. Inflammation or stress, mechanisms which product cytokines, are responsible for unfavourable bone restructuring and for a loss of protein mass, deteriorating the muscular functional prognostic. We researched articles on Medline® between 1980 and 2010 about relations between protein compartment, malnutrition and bone density. Several studies in literature suggest that increase in protein intake in daily caloric needs could have a positive effect on bone mineral density and functional performances (in primary prevention as in secondary prevention). So, primary and secondary preventive measures must comprise an increase in protein intake and a sufficient physical activity.

[Modalities of hospitalization in emergency of institutionalized patients]. / Modalités d'hospitalisations en urgence des sujets âgés hébergés en établissements pour personnes âgées dépendantes.

BACKGROUND AND AIM: Institutionalized people represent 9 to 37% of the patients hospitalized in emergency. The aim of this study is to clarify practical conditions of decision and realization of an hospitalization in emergency from an institution. PATIENTS AND METHOD: This is a prospective and descriptive longitudinal study of the hospitalizations in emergency of institutionalized elderly during six months, from 11 nursing homes. RESULTS: The patients hospitalized in emergency are old (86.7 ± 7.3 years), more than 80% are women, widows and dependent (GIR 3). Main reasons for hospitalization in emergency are falls in a third of cases and cardio-pulmonary failure (27%). The alert is given by nurses and auxiliary nurses in 60% of cases. The decision of hospitalization is medical in more than 80% of cases. The medical opinion is only on phone in 24.4% of cases. After hospitalizations, 85% of patients came back straight to their institution and 10% died during their stay at the hospital. CONCLUSION: The terms of hospitalization in emergency of institutionalized patients must be improved. Nursing homes are an integral part of the geriatric network.

Aortic involvement in recent-onset giant cell (temporal) arteritis: a case-control prospective study using helical aortic computed tomodensitometric scan.

OBJECTIVE: The prevalence of the involvement of large vessels in giant cell arteritis (GCA) is 3-13%. Aortitis is the most serious complication of GCA. Computed tomodensitometric (CT) scan allows analysis of both the aortic wall and endoluminal part of the aorta. Therefore, we conducted a study using CT scan to analyze aortic abnormalities in patients with recent-onset GCA. METHODS: This prospective controlled study compared patients with biopsy-proven GCA with a matched control group based on sex, age, and cardiovascular risk factors. During the 4-week period following diagnosis of GCA, patients underwent an aortic CT scan. The aortic imaging results were blindly compared between both groups. RESULTS: From January 5, 1998 to January 11, 1999, 22 patients and 22 controls were screened by CT scan for aortic involvement. Thickening of the aortic wall was more frequent among patients than controls (45.4% versus 13.6%; P = 0.02). Aortic thickening (mean 3.3 mm) was located on the ascending part of the thoracic aorta in 22.7% of the patients, with no evidence of thickening in the controls (P = 0.05). Thickening of the abdominal aortic wall was noted in 27.3% of the patients and none of the controls (P = 0.02). CONCLUSION: This study suggests that inflammatory aortic thickening, detected by CT scan, occurs frequently at the time of diagnosis of GCA, and that this condition predominantly occurs on the ascending part of the aorta.

Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France.

BACKGROUND: In the US and Canada, dialysis discontinuation is one of the more frequent causes of death in elderly patients on haemodialysis, particularly after the age of 75. The aim of this study was to analyse the practices of some French nephrologists, 17 of whom (in six nephrology units) were interviewed for this study. METHODS: A questionnaire was formulated on the basis of a bibliographical search of the topic. A series of questions, initially open and then more targeted, regarding scientific and non-scientific factors influencing the decision to discontinue or refuse haemodialysis in elderly patients, were put to nephrologists. RESULTS: Psychological and physical deterioration emerged as the principal factors governing decisions to refuse or discontinue treatment. The interviewees felt that severe dementia (15 out of 17 nephrologists), irreversible neurological sequelae of a CVA (11 out of 17) and, paradoxically, patient refusal (10 out of 17) were factors to be taken into account in the decision to discontinue haemodialysis. Although the main reasons for refusing dialysis were cognitive disorders, severe dementia and irreversible neurological conditions, none of these factors where actually found to be in and of themselves decisive. CONCLUSIONS: This study has shown that refusing or discontinuing dialysis are practices accepted by the vast majority of nephrologists in one region of France. Patient refusal is not a basis for denial or discontinuation of dialysis in elderly patients. Our investigation has demonstrated a consensus regarding decisions to refuse or discontinue dialysis.

[Giant cell arteritis after the age of 75]. / Maladie de Horton chez le sujet âgé de plus de 75 ans.

Despite its increasing incidence giant cell arteritis is not well detected in the elderly. Response to corticosteroid treatment is the same before and after the age of 75, but there are many steroid-induced side effects, particularly bone fractures, in the elderly. Therefore, it is important to reduce the corticosteroid load in elderly and frail people. In this cases, 0.3 to 0.5mg/kg, or 15 to 25mg daily prednisone-equivalent dose at start seems to be enough to prevent blindness in simple forms. This dose has to be rapidly reduced whenever the C-reactive protein remains moderately elevated. Moreover, an anti-agregant or anticoagulant treatment must be associated at the beginning of steroid treatment to prevent ischemic complications, as well as biphosphonates, which could prevent corticosteroid-induced osteoporosis.