Preserving bone in cancers of the elderly: A necessity.

The occurrence of bone fractures is frequent in the elderly population, and in cancer patients, especially with bone metastases. The growing incidence of cancer associated with an aging population implies important health challenges, including bone health. Decisions on cancer care in older adults have to take into account older adults' specificities. Screening tools as G8 or VES 13 and evaluating tools as comprehensive geriatric assessment (CGA) do not include bone-related items. Bone risk assessment is indicated according to identification of geriatric syndromes such as falls, history, and the oncology treatment plan. Some cancer treatments disrupt bone turnover and decrease bone mineral density. This is mainly caused by hypogonadism, induced by hormonal treatments and some chemotherapies. Treatments can also cause direct (i.e., chemotherapy, radiotherapy or glucocorticoids) or indirect toxicity through electrolyte disorders (i.e., some chemotherapies or tyrosine kinase inhibitors) on bone turnover. Bone risk prevention is multidisciplinary. Certain interventions proposed in the CGA aim to improve bone health and reduce the risk of falling. It is also based on the drug management of osteoporosis, and the prevention of complications from bone metastases. Management of fractures, related or not to bone metastases relates to the concept of orthogeriatrics. It is also based on the benefit-risk ratio of the operation, access to minimally invasive techniques, prehabilitation or rehabilitation, but also the prognosis related to cancer and geriatric syndromes. Bone health is essential in older cancer patient's care. Bone risk assessment should be part of CGA in routine use and specific decision-making tools should be developed. Bone event management must be integrated throughout the patient's care pathway and oncogeriatrics multidisciplinarity should include rheumatological expertise.

Factors Associated with Transfer from an Acute Geriatric Unit to a Post-Acute Care Facility among Community-Dwelling Patients: Results from the DAMAGE Cohort.

Background: Acute geriatric units (AGUs) require efficient discharge planning tools. Risk factors for discharge from an AGU to post-acute care (PAC) have not previously been investigated in detail. Methods: The objective is to identify risk factors for PAC transfer. The DAMAGE (prospective multicenter cohort) consecutively included more than 3500 subjects aged 75 or older and admitted to an AGU. The patients underwent a comprehensive geriatric assessment (CGA) during their stay in the AGU. Only community-dwelling patients admitted to the AGU from the emergency department were included in the analysis. We recorded the characteristics of the care pathway and identified risk factors for discharge to home or to a PAC facility. Results: 1928 patients were included. Loss of functional independence (a decrease in the Katz activities of daily living (ADL) score between 1 month prior to admission and AGU admission), living alone, social isolation, a high Katz ADL score at home, a low Katz ADL on admission, and delirium on admission were risk factors for transfer to PAC. Obesity, an elevated serum albumin level, and community-acquired infection were associated with discharge to home. Neither sex nor age was a risk factor for home discharge or transfer to PAC. Conclusion: The present results might help clinicians and discharge planning teams to identify patients at risk of transfer to PAC more reliably and promptly in AGUs.

Effectiveness of Geriatric Assessment-Driven Interventions on Survival and Functional and Nutritional Status in Older Patients with Head and Neck Cancer: A Randomized Controlled Trial (EGeSOR).

This study assesses the efficacy of Geriatric Assessment (GA)-driven interventions and follow-up on six-month mortality, functional, and nutritional status in older patients with head and neck cancer (HNC). HNC patients aged 65 years or over were included between November 2013 and September 2018 by 15 Ear, Nose, and Throat (ENT) and maxillofacial surgery departments at 13 centers in France. The study was of an open-label, multicenter, randomized, controlled, and parallel-group design, with independent outcome assessments. The patients were randomized 1:1 to benefit from GA-driven interventions and follow-up versus standard of care. The interventions consisted in a pre-therapeutic GA, a standardized geriatric intervention, and follow-up, tailored to the cancer-treatment plan for 24 months. The primary outcome was a composite criterion including six-month mortality, functional impairment (fall in the Activities of Daily Living (ADL) score ≥2), and weight loss ≥10%. Among the patients included (n = 499), 475 were randomized to the experimental (n = 238) or control arm (n = 237). The median age was 75.3 years [70.4-81.9]; 69.5% were men, and the principal tumor site was oral cavity (43.9%). There were no statistically significant differences regarding the primary endpoint (n = 98 events; 41.0% in the experimental arm versus 90 (38.0%); p = 0.53), or for each criterion (i.e., death (31 (13%) versus 27 (11.4%); p = 0.48), weight loss of ≥10% (69 (29%) versus 65 (27.4%); p = 0.73) and fall in ADL score ≥2 (9 (3.8%) versus 13 (5.5%); p = 0.35)). In older patients with HNC, GA-driven interventions and follow-up failed to improve six-month overall survival, functional, and nutritional status.

Transition to Comfort Care Only and End-of-Life Trajectories in an Acute Geriatric Unit: A Secondary Analysis of the DAMAGE Cohort.

OBJECTIVES: Comfort care for a dying patient increases the quality of the end of life. End-of-life situations are frequently managed in acute geriatric units (AGUs), and transition to comfort care only is often necessary. However, the frequency of transition to comfort care and the latter's putative link with the end-of-life trajectory (sudden death, cancer, organ failure, and frailty with or without dementia) have not previously been studied in acute geriatric units. We sought to (1) describe end-of-life trajectories and the transition to comfort care only, and (2) analyse the relationship between the two, prior to death in an AGU. DESIGN: A secondary analysis of a subgroup of the DAMAGE cohort (a prospective multicentre cohort of 3509 patients aged 75 years and over and admitted consecutively to an AGU). SETTING/PARTICIPANTS: DAMAGE patients who died in an AGU after a stay of at least 48 hours. METHODS: Data on the end-of-life trajectory and the transition to comfort care only were extracted from medical records. RESULTS: Of the 177 included patients, 123 (69.5%) transitioned to comfort care only in the AGU. A frailty trajectory (in patients living with dementia or not) accounted for nearly 70% of deaths. Paradoxically, only frailty among people living without dementia was not significantly associated with a more frequent transition to comfort care [odds ratio (95% confidence interval): 1.44 (0.44-4.76), relative to a patient dying suddenly]. CONCLUSIONS AND IMPLICATIONS: Transition to comfort care only is frequent in AGUs and is linked to the end-of-life trajectory (except for frail patients living without dementia). The frailty trajectory is one of the most frequent, and, therefore, physicians must be aware of the need to improve practice in this context.

Development of a Predictive Score for Mortality at 3 and 12 Months After Discharge From an Acute Geriatric Unit as a Trigger for Advanced Care Planning.

BACKGROUND: There is a need for a mortality score that can be used to trigger advanced care planning among older patients discharged from acute geriatric units (AGUs). OBJECTIVE: We developed a prognostic score for 3- and 12-month mortality after discharge from an AGU, based on a comprehensive geriatric assessment, in-hospital events, and the exclusion of patients already receiving palliative care. METHODS: Devenir Après la Médecine Aigue Gériatrique (DAMAGE) is a French multicenter, prospective, cohort study. The broad inclusion criteria ensured that the cohort is representative of patients treated in an AGU. The DAMAGE participants underwent a comprehensive geriatric assessment, a daily clinical checkup, and follow-up visits 3 and 12 months after discharge. Multivariable logistic regression models were used to develop a prognostic score for the derivation and validation subsets. RESULTS: A total of 3 509 patients were assessed and 3 112 were included. The patient population was very old and frail or dependant, with a high proportion of deaths at 3 months (n = 455, 14.8%) and at 12 months (n = 1 014, 33%). The score predicted an individual risk of mortality ranging from 1% to 80% at 3 months and between 5% and 93% at 12 months, with an area under the receiving operator characteristic curve in the validation cohort of 0.728 at 3 months and 0.733 at 12 months. CONCLUSIONS: Our score predicted a broad range of risks of death after discharge from the AGU. Having this information at the time of hospital discharge might trigger a discussion on advanced care planning and end-of-life care with very old, frail patients. Clinical Trials Registration Number: NCT02949635.

Risk Factors for Hospital Readmission and Death After Discharge of Older Adults from Acute Geriatric Units: Taking the Rank of Admission into Account.

OBJECTIVE: To analyze the impact of the number of hospital readmissions on the risks of further hospital readmission and death after adjustment for a range of risk factors. METHODS: We performed a multicentre prospective study of the DAMAGE cohort in the Hauts-de-France region of France. Patients aged 75 and over hospitalized initially in an acute geriatric unit (AGU) were included and followed up for 12 months. The risk of hospital readmission was analyzed using a Cox model, and its extension for recurrent events and the risk of death were analyzed using a Cox model for time-dependent variables. RESULTS: A total of 3081 patients were included (mean (SD) age: 86.4 (5.5)). In the multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital readmission rose progressively to 2.66 (1.44; 5.14), and the risk of death rose to 2.01 (1.23; 3.32) after five hospital admissions, relative to a patient with no hospital readmissions. The number of hospital readmissions during the follow-up period was the primary risk factor and the best predictor of the risk of hospital readmission and the risk of death. CONCLUSION: Hospital readmission is the primary risk factor for further hospital readmissions and for death in older subjects discharged from an AGU.

Prevalence and prognostic impact of cachexia among older patients with cancer: a nationwide cross-sectional survey (NutriAgeCancer).

BACKGROUND: Nutritional impairment is common in cancer patients and is associated with poor outcomes. Only few studies focused on cachexia. We assessed the prevalence of cachexia in older cancer patients, identified associated risk factors, and evaluated its impact on 6 month overall mortality. METHODS: A French nationwide cross-sectional survey (performed in 55 geriatric oncology clinics) of older cancer patients aged ≥70 referred for geriatric assessment prior to treatment choice and initiation. Demographic, clinical, and nutritional data were collected. The first outcome was cachexia, defined as loss of more than 5% of bodyweight over the previous 6 months, or a body mass index below 20 kg/m2 with weight loss of more than 2%, or sarcopenia (an impaired Strength, Assistance with walking, Rise from chair, Climb stairs and Falls score) with weight loss of more than 2%. The second outcome was 6 month overall mortality. RESULTS: Of the 1030 patients included in the analysis [median age (interquartile range): 83 (79-87); males: 48%; metastatic cancer: 42%; main cancer sites: digestive tract (29%) and breast (16%)], 534 [52% (95% confidence interval: 49-55%)] had cachexia. In the multivariate analysis, patients with breast (P < 0.001), gynaecologic (P < 0.001), urinary (P < 0.001), skin (P < 0.001), and haematological cancers (P = 0.006) were less likely to have cachexia than patients with colorectal cancer. Patients with upper gastrointestinal tract cancers (including liver and pancreatic cancers; P = 0.052), with previous surgery for cancer (P = 0.001), with metastases (P = 0.047), poor performance status (≥2; P < 0.001), low food intake (P < 0.001), unfeasible timed up-and-go test (P = 0.002), cognitive disorders (P = 0.03) or risk of depression (P = 0.005), were more likely to have cachexia. At 6 months, 194 (20.5%) deaths were observed. Cachexia was associated with 6 month mortality risk (adjusted hazard ratio = 1.49; 95% confidence interval: 1.05-2.11) independently of age, in/outpatient status, cancer site, metastatic status, cancer treatment, dependency, cognition, and number of daily medications. CONCLUSIONS: More than half of older patients with cancer managed in geriatric oncology clinics had cachexia. The factors associated with cachexia were upper gastrointestinal tract cancer, metastases, poor performance status, poor mobility, previous surgery for cancer, cognitive disorders, a risk of depression, and low food intake. Cachexia was independently associated with 6 month mortality.

[Discharge from hospital into nursing home: conditions and quality of transmissions]. / Retour en EHPAD après une hospitalisation : modalités et qualité des transmissions.

CONTEXT: Nursing home residents are very old, with multiple comorbidities and disabled for activities of daily living (ADLs). Therefore, they have a higher risk of accidents as falls or fractures or acute diseases as infections, which require hospitalization. Care's coordination and sharing of informations between hospitals and nursing homes are often insufficient even with agreements. Thus, discharge to nursing homes after hospitalization may be difficult for old patients because of incomplete oral or written transmissions. OBJECTIVE: To examine both protocols and the quality of the return to the nursing homes after an hospitalization for old residents. METHOD: A prospective multicenter study done by collecting data about consecutive returns into their nursing home after an hospitalization of more than 24 hours of nursing home residents aged 65 years and more. RESULTS: Twenty-eight nursing homes of the North of France were enrolled in the study. During the 3 months period of the study, 246 discharges after an hospitalization of 24 hours or more were registered. 225 residents (165 women and 60 men), mean age 85.0 ± 7.2, were concerned. Most of them were ADLs disabled, with a dementia for 47.1% of them. The average length of hospitalization was 11.6 days. At the end of hospitalization, the notification of return, which was made only in 82% of cases, was announced in average 1.3 days before the discharge. Unfortunately, in 32% of cases, the notification was made the day of the discharge. Residents went back home indifferently any day of the week but more often the Friday and less often the weekend. The day and the hour of the planned discharge were respected in 79.1% of cases. In most cases, nursing home caregivers have considered that the clinical status was stable or improved compared to the previous one. However in 28% of cases, a loss of autonomy was found. Medical doctors wrote a letter of discharge in 85.8% of cases. Nurses gave written transmissions only in 41.9% of cases. CONCLUSION: Many points concerning discharge from hospital, about old people living in nursing home, have to be improved: oral transmissions about patient's status, notification of the return, discharge's letter, nurse's transmissions and assessment of the loss of autonomy.

Attitudes toward Alzheimer's disease: a qualitative study of the role played by social representation on a convenient sample of French general practitioners.

BACKGROUND AND AIMS: It is commonly thought that Alzheimer's disease (AD) is under-diagnosed and that insufficient numbers of patients are receiving pharmacological treatment. These observations are often attributed to poor management of the disease by general practitioners (GPs) related to their lack of training in identifying cognitive decline. Our hypothesis is that there may be a relation between GPs' perceptions and their attitudes toward AD. METHODS: We conducted a qualitative study, through semi-directive interviews focusing on their representations, of 25 GPs, masters in training courses, in Paris. RESULTS: Analysis of interviews revealed five general trends. AD is seen by GPs as a "disease of autonomy", without specific medical treatment. Cognitive symptoms are less meaningful in GPs' view than the loss of autonomy. The main thing is to keep the patient at home. For GPs, the family is described as an essential partner in coping with the insufficiencies of available social programs. The use of specialists is less to confirm the diagnosis than to announce the "bad news". GPs declare scepticism as to the efficacy of AD medications, only granting them a certain "care" effect or a social role. The image of AD remains highly negative. The stigma of AD is seen as a barrier to its diagnosis. CONCLUSIONS: This study is somewhat preliminary because of sample size. Nevertheless, the social representations of the disease influence GPs' attitudes toward making diagnoses in France. Priority seems to focus more on assisting GPs and families at the social level, rather than diagnosis or access to treatment.

[Cognitive impairment and chronic kidney disease: which links?]. / Troubles cognitifs et insuffisance rénale: quels liens?

Ageing of the population leads to an increase of cognitive disorders and chronic renal failure incidence. Compared to the general population, prevalence of cognitive impairment is more important in renal failure patients, especially in dialyzed patients. No direct link has been established between renal failure and cognitive impairment. The care of older and older patients and the high frequency of vascular risk factors, in particular hypertension and diabetes, partially explain the prevalence of vascular dementia and Alzheimer disease in this population. Other factors as the anemia, phosphocalcic metabolism disorders facilitate the cognitive impairment. The present work reviews the links existing between chronic renal failure and cognitive impairment.

Soluble receptor for advanced glycation end products: a new biomarker in diagnosis and prognosis of chronic inflammatory diseases.

The formation of advanced glycation end products (AGEs) is a result of the non-enzymatic reaction between sugars and free amino groups of proteins. AGEs, through interacting with their specific receptor for AGEs (RAGE), result in activation of pro-inflammatory states and are involved in numerous pathologic situations. The soluble form of RAGE (sRAGE) is able to act as a decoy to avoid interaction of RAGE with its pro-inflammatory ligands (AGEs, HMGB1, S100 proteins). sRAGE levels have been found to be decreased in chronic inflammatory diseases including atherosclerosis, diabetes, renal failure and the aging process. The use of measuring circulating sRAGEs may prove to be a valuable vascular biomarker and in this review, we describe the implications of sRAGE in inflammation and propose that this molecule may represent a future therapeutic target in chronic inflammatory diseases.

[Renal aging: risk factors and nephroprotection]. / Vieillissement rénal: facteurs de risque et néphroprotection.

Renal failure in the elderly is currently underestimated and presents a real challenge for the public health system. Kidney function must be routinely assessed by creatinine clearance, estimated with either the Cockcroft and Gault formula or the simplified MDRD formula, which appears especially appropriate for the elderly. Normal kidney aging is related to tissue and functional changes that make older patients very vulnerable to environmental modifications. Numerous factors can accelerate the impairment of rental function during aging. Some of them cannot be modified: sex, genome, and initial kidney disease. Most of them can be managed or treated: hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, proteinuria, and the presence of oxidation and glycation products. Chronic renal failure in the elderly must be managed early with strict treatment targets to avoid the development of end-stage renal disease. Inhibitors of the renin-angiotensin-aldosterone system play an essential role in optimizing nephroprotection: control of hypertension, diabetes complications, and proteinuria. They should be prescribed very carefully in older patients. Age is not a prerequisite for consultations with nephrologists, which should take place early so that nephroprotection can still be useful.

Low-dose aspirin prevents age-related endothelial dysfunction in a mouse model of physiological aging.

The age-related impairment of endothelium-dependent vasodilatation contributes to increased cardiovascular risk in the elderly. For primary and secondary prevention, aspirin can reduce the incidence of cardiovascular events in this patient population. The present work evaluated the effect of low-dose aspirin on age-related endothelial dysfunction in C57B/J6 aging mice and investigated its protective antioxidative effect. Age-related endothelial dysfunction was assessed by the response to acetylcholine of phenylephrine-induced precontracted aortic segments isolated from 12-, 36-, 60-, and 84-wk-old mice. The effect of low-dose aspirin was examined in mice presenting a decrease in endothelial-dependent relaxation (EDR). The effects of age and aspirin treatment on structural changes were determined in mouse aortic sections. The effect of aspirin on the oxidative stress markers malondialdehyde and 8-hydroxy-2'-deoxyguanosine (8-OhdG) was also quantified. Compared with that of 12-wk-old mice, the EDR was significantly reduced in 60- and 84-wk-old mice (P < 0.05); 68-wk-old mice treated with aspirin displayed a higher EDR compared with control mice of the same age (83.9 +/- 4 vs. 66.3 +/- 5%; P < 0.05). Aspirin treatment decreased 8-OHdG levels (P < 0.05), but no significant effect on intima/media thickness ratio was observed. The protective effect of aspirin was not observed when treatment was initiated in older mice (96 wk of age). It was found that low-dose aspirin is able to prevent age-related endothelial dysfunction in aging mice. However, the absence of this effect in the older age groups demonstrates that treatment should be initiated early on. The underlying mechanism may involve the protective effect of aspirin against oxidative stress.

Multiple myeloma presenting with widespread osteosclerotic lesions.

Sclerotic lesions are rare in malignant monoclonal gammopathies, although they are occasionally associated with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes). In most cases, osseous lesions in POEMS syndrome present as an isolated sclerotic deposit or a combination of both lytic and sclerotic lesions. Diffuse osteosclerosis is extremely rare and may lead to the diagnosis of multiple myeloma, classically known to present as lytic lesions in the skeleton, with or without diffuse osteoporosis. We report a 74-year-old woman with widespread and substantial osteosclerotic lesions, associated with IgA-lambda myeloma, and with no other criteria for POEMS syndrome, and who was rapidly diagnosed with compression of the spinal cord. Detailed knowledge of imaging features in myeloma emphasises the need to consider plasma cell neoplasm in the differential diagnosis of any pattern of bone sclerosis. Although exceptional, multiple myeloma must be borne in mind in the presence of diffuse bone sclerosis.