A Simple Questionnaire as a First-Step Tool to Detect Specific Frailty Profiles: The Lorraine Frailty-Profiling Screening Scale.

OBJECTIVES: To propose a simple frailty screening tool able to identify frailty profiles. DESIGN: Cross-sectional observational study. SETTING: Participants were recruited in 3 different clinical settings: a primary care outpatient clinic (RURAL population, N=591), a geriatric day clinic (DAY-CLINIC population, N=76) and healthy volunteers (URBAN population, N=147). PARTICIPANTS: A total of 817 older adults (>70 years old) living at home were included. INTERVENTION: A 9-item questionnaire (Lorraine Frailty Profiling Screening Scale, LoFProSS), constructed by an experts' working group, was administered to participants by health professionals. MEASUREMENTS: A Multiple Correspondence Analysis (MCA) followed by a hierarchical clustering of the results of the MCA performed in each population was conducted to identify participant profiles based on their answers to LoFProSS. A response pattern algorithm was resultantly identified in the RURAL (main) population and subsequently applied to the URBAN and DAY-CLINIC populations and, in these populations, the two classification methods were compared. Finally, clinically-relevant profiles were generated and compared for their ability to similarly classify subjects. RESULTS: The response pattern differed between the 3 sub-populations for all 9 items, revealing significant intergroup differences (1.2±1.4 positive responses for URBAN vs. 2.1±1.3 for RURAL vs. 3.1±2.1 for DAY-CLINIC, all p<0.05). Five clusters were highlighted in the main RURAL population: "non-frail", "hospitalizations", "physical problems", "social isolation" and "behavioral", with similar clusters highlighted in the remaining two populations. Identification of the response pattern algorithm in the RURAL population yielded a second classification approach, with 83% of tested participants classified in the same cluster using the 2 different approaches. Three clinically-relevant profiles ("non-frail" profile, "physical frailty and diseases" profile and "cognitive-psychological frailty" profile) were subsequently generated from the 5 clusters. A similar double classification approach as above was applied to these 3 profiles revealing a very high percentage (95.6%) of similar profile classifications using both methods. CONCLUSION: The present results demonstrate the ability of LoFProSS to highlight 3 frailty-related profiles, in a consistent manner, among different older populations living at home. Such scale could represent an added value as a simple frailty screening tool for accelerated and better-targeted investigations and interventions.

Characteristics of polymedicated (≥ 4) elderly: a survey in a community-dwelling population aged 60 years and over.

BACKGROUND: Polypharmacy is an important concern for patient safety and has been associated with increased adverse drug reactions, hospitalization and mortality in the elderly. OBJECTIVE: In light of the above, the present study aimed to assess the major characteristics associated with polypharmacy (≥ 4 drugs) in a larger population of apparently healthy older subjects over 60 years. STUDY-DESIGN: Cross-sectional study. SETTING: The preventive medical center (CMP) in Nancy. PARTICIPANTS: 2,545 volunteers (1,175 women, 1,370 men) aged 60 years and older (66 ± 4.8 years) were included from the Senior health examination study. MEASUREMENTS: All subjects underwent clinical, biological examinations. Sociodemographic data, practice of regular physical activity and drug intake data were collected. A self-administered questionnaire of health status, psychological status and questions regarding falls were collected. RESULTS: The prevalence of polypharmacy in this study was 29.9%. The number of drugs in polymedicated people was 5.67 ± 1.82 versus 1.32 ± 1.11 in non polymedicated people; p≤0.01. Multivariate analyses identified 6 independent variables associated with polypharmacy: age over 65 years (OR = 1.58 95% CI: [1.05 - 2.38]; p = 0.03), poor self-perceived health status (2.79 [1.80 - 4.31]; p ≤ 0,01), history of falls (1.66 [1.02 - 2.71]; p = 0.04), lack of a physical activity (1.50 [1.001 - 2.26]; p = 0.049), metabolic syndrome (3.17 [1.95 - 5.15]; p ≤ 0,01), low or medium education level (2.20 [1.24 - 4.30]; p = 0.02). CONCLUSION: Among community-dwelling people aged 60 years and over, in addition to the presence of several diseases and advanced age, the psychological and socio-educative factors may influence drug intake and polypharmacy in the elderly. Physicians should be take into account these considerations before issuing any prescriptions and review all medications used at every visit to avoid unnecessary addictions or dangerous drug-drug interactions.

Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Société Française de Gériatrie et de Gérontologie) Workshop--Athens January 20-21, 2012.

UNLABELLED: Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate. OBJECTIVES: The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons. PARTICIPANTS: Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG). RESULTS: Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice. CONCLUSION: Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

[A new instrument to measure quality of life in older people: The French version of the WHOQOL-OLD]. / Un nouvel instrument destiné à mesurer la qualité de vie des personnes âgées : le WHOQOL-OLD version française.

PURPOSE: We present the validation data of the French version of a new quality of life questionnaire, specifically developed for use with older adults (>60 years old): the WHOQOL-OLD module. This questionnaire, which contains 24 items in six domains, is a complementary module of the WHOQOL-BREF quality of life questionnaire. It was internationally developed by a World Health Organization (WHO) group. METHODS: The first development and pilot studies led to a first questionnaire applied in field studies in 20 centers all over the world. They were done in 5566 subjects and allowed the validation of the final form of the WHOQOL-OLD questionnaire. For its French version, 281 subjects, with a mean age of 74 years, were recruited in three centers (Paris, Nancy and Geneva). RESULTS: The results of the psychometric properties of the questionnaire, particularly the multitrait analysis, are compatible with the assumptions underlying the construction of scores. Otherwise, scores present a sufficient accuracy to use this instrument in group comparisons. CONCLUSION: The WHOQOL-OLD questionnaire can be used in older people in health services, clinical research and epidemiologic studies.

Glomerular filtration rate estimated by Cockcroft-Gault formula better predicts anti-Xa levels than modification of the diet in renal disease equation in older patients with prophylactic enoxaparin.

OBJECTIVES: Older people have an increased risk of low molecular weight heparin accumulation leading to an increased bleeding risk. The objective of this study was to assess whether reduced glomerular filtration rate (GFR), estimated by the Cockcroft-Gault or modification of the diet in renal disease (MDRD) equations, indicates drug accumulation by increased anti-Xa levels in older subjects receiving prophylactic enoxaparin treatment. DESIGN: Cohort study. SETTING: Acute geriatric units in Nancy Hospital. PARTICIPANTS: Ninety-two consenting consecutive patients, 65 and older, confined to bed for an acute medical condition requiring enoxaparin for prevention of venous thromboembolism, and hospitalized for at least six days were enrolled. MEASUREMENTS: Serum creatinine and peak plasma anti-Xa levels 3 to 4 hours after the daily injection of enoxaparin were measured at days 3, 6, 9 and 12 (first dose of enoxaparin at day one). Analyses of variance for repeated measures were used to evaluate significant predictors of peak anti-Xa activity in univariate and multivariate analyses. RESULTS: A significant correlation was observed between anti-Xa activity and GFR estimated with the Cockcroft formula r=0.43. Following univariate analysis, the three factors associated with higher anti-Xa levels were a lower Cockcroft-Gault GFR (p=0.0002), female gender (p=0.0003) and a lower bodyweight (p<.0001). No significant association between anti-Xa levels and MDRD GFR (p=0.33) was observed. Following multivariate analysis, female gender (p=0.02), bodyweight (p=0.04) and Cockcroft GFR (p=0.05) remained independent determinants of anti-Xa levels. CONCLUSION: In hospitalized patients older than 65 years old, the Cockcroft-Gault equation, in contrast to the MDRD equation, is able to predict the risk of higher anti-Xa levels.

Increased risk for heart valve disease associated with antiphospholipid antibodies in patients with systemic lupus erythematosus: meta-analysis of echocardiographic studies.

BACKGROUND: Heart valve disease (HVD) is frequent in patients with systemic lupus erythematosus (SLE), and the role of antiphospholipid antibodies (aPL) is controversial. Thus, our objective was to estimate the risk of HVD, including Libman-Sacks endocarditis, associated with aPL in patients with SLE. METHODS AND RESULTS: Studies were selected if they investigated the association between aPL and HVD in SLE patients and if aPL-negative patients were included for comparison. Data sources were MEDLINE, Embase, Cochrane Library, hand search, contact with investigators, and reference lists of studies, without language restrictions. Data on study and patient characteristics, risk estimates, and study quality were independently extracted by 2 investigators. Pooled effect estimates were obtained by using the DerSimonian-Laird method. Of 234 identified abstracts, 23 primary studies (15 cross-sectional, 7 cohort, 1 case-control) met inclusion criteria, including 1656 SLE patients and 508 cases of HVD. Compared with SLE patients without aPL (n=988), the overall pooled odds ratios for HVD and Libman-Sacks endocarditis in aPL-positive patients (n=668) were 3.13 (95% confidence interval, 2.31 to 4.24) and 3.51 (95% confidence interval, 1.93 to 6.38), respectively. The risk of HVD depending on aPL subtypes was the highest for lupus anticoagulant at 5.88 (95% confidence interval, 2.92 to 11.84) and IgG anticardiolipin antibodies at 5.63 (95% confidence interval, 3.53 to 8.97). CONCLUSIONS: Overall, the presence of aPL in SLE patients is significantly associated with an increased risk for HVD including Libman-Sacks endocarditis. The risk conferred by IgG anticardiolipin antibodies is as strong as by lupus anticoagulant. Systematic echocardiographic examinations in SLE patients with aPL should be performed.

Which generic health related Quality of Life questionnaire should be used in older inpatients: comparison of the Duke Health Profile and the MOS Short-Form SF-36?

OBJECTIVES: The objective of our study was to compare advantages and limitations of two generic Quality of Life questionnaires administered in older inpatients. DESIGN: Two validated generic health-related Quality of Life instruments : the MOS Short-Form 36 (9 dimensions, 36 items) and the Duke Health Profile (6 dimensions, 4 dysfunctions, 17 items) were administered to inpatients over 65 years. SETTING AND PARTICIPANTS: The sample was drawn from the CliniQualVie program that assessed systematically Quality of Life among hospitalized inpatients (18-79 years) in 10 medical and surgical wards at Nancy University Hospital. RESULTS: The two self-administered questionnaires were completed by 701 patients over 65 years at admission (mean age 71 +/- 4, 63% men). The proportion of patients who completed all items were 72.5% for the Duke and 66.9% for the SF-36 (p < .001). The Duke's internal consistency was low as compared with the SF-36, but other psychometric properties were comparable. Good correlations (Spearman) were observed between the two questionnaires for physical health (0.59, p < .0001), mental health (0.68, p < .0001) and health perception (0.56, p < .0001) scores. Low correlations were observed for the social score. CONCLUSIONS: This is the first study to our knowledge to assess the interest of using the Duke Health Profile in a general elderly inpatients population as compared with the SF-36 questionnaire. Although these two questionnaires have four comparable dimensions, they differ in their content and psychometric properties. The Duke questionnaire, due to its better completion rate and despite some psychometric limitations may be useful in this population, particularly in the more frail patients.

Quality of Life in elderly inpatients with atrial fibrillation as compared with controlled subjects.

OBJECTIVES: Since few studies have investigated Health related Quality of Life (HRQoL) in older patients with atrial fibrillation, the aim of this cross-sectional study was to compare HRQoL in AF elderly inpatients of 65 and more with that of age-matched controlled subjects. DESIGN: HRQoL was assessed with two generic HRQoL instruments: the MOS-SF 36, a largely recognized instrument, and the Duke Health Profile. SETTING AND PATIENTS: Nancy University Hospital patients presenting with atrial fibrillation and three controls per patient free of cardiac arrhythmias, matched by age, sex and hospital department to atrial fibrillation patients. RESULTS: Forty one atrial fibrillation patients and 123 controls were included. Both groups were comparable for associated disorders, other than coronary artery disease and chronic respiratory failure. After adjustment, scores among atrial fibrillation patients were lower than among controls in 8 of 10 Duke and 6 of 8 SF-36 subscales. In terms of Quality of Life, meaningful differences (>or= 5 points) were recorded in the Duke: Mental, Depression, Anxiety, General Score; and in the SF-36: Physical functioning, Role emotional, Social functioning and Vitality. Nevertheless statistically significant differences were only observed for the Duke Mental (p=0.01), Depression (p=0.003) and Anxiety (p=0.03) scores. CONCLUSIONS: In our study HRQoL measured in elderly inpatients with atrial fibrillation as compared with matched controlled was mainly altered in the "psychological" domains of the Duke Health Profile. From the patient's point of view, atrial fibrillation appears to have more mental than physical consequences. This study pointed out the utility to assess HRQoL in the management and treatment of elderly hospitalised atrial fibrillation patients.

[Should all old hypertensive subjects have Mini-Mental State Examination?]. / Faut-il réaliser un "Mini-Mental State Examination" chez tout sujet âgé hypertendu?

Hypertension constitutes a recognized risk factor of vascular dementia but also of Alzheimer-type dementia. Various longitudinal studies showed that midlife blood pressure level is one of the factors conditioning the onset of dementia syndrome in late life. The high risk of dementia is linked to leukoaraiosis, vascular rigidity, microcirculation disorders, oxidative stress, blood pressure fluctuations including orthostatic hypotension and strokes, all of those being associated with hypertension. Numerous clinical trials showed the positive effect of effective treatment of hypertension on the prevention of cognitive disorders and dementias. Thus, screening and early management of dementia and cognitive decline, in particular in the hypertensive subject, are essential. The Mini-Mental State Examination (MMSE) is a major first-intention screening test because it allows a full assessment of cognitive aptitudes. If cognitive decline is suspected and the MMSE score is considered to be abnormal, the elderly subject must be sent to a specialist or a referent memory centre; the MMSE is only a first stage in the diagnostic reasoning. MMSE should be included in the follow-up of all hypertensive elderly subjects and should be performed once a year by the general practitioner.

Effects of lean and fat mass on bone mineral density and arterial stiffness in elderly men.

SUMMARY: The role of body composition on arterial stiffness and osteoporosis remains unclear, especially in the elderly male population. Our results indicate that elderly men with high lean mass and low fat mass exhibit the best arterial and bone profile with the lowest arterial stiffness and the highest bone mineral density. INTRODUCTION: The aim of this study was to evaluate the influence of fat and lean mass on both arterial stiffness and bone mass density (BMD) in elderly men. METHODS: This study was performed in 169 French males over 60 years old. Aortic stiffness was assessed by carotid/femoral pulse wave velocity (PWV). BMD and body composition were determined with a dual-energy X-ray absorptiometry device in the lumbar spine L1-L4, femoral neck, and total body. RESULTS: Lean mass was positively correlated with the three T scores accounting for 11.6%, 26.6%, and 12.2% of the variability in the lumbar spine L1-L4, femoral neck, and total body BMD T scores, respectively. Fat mass had no effect on BMD. However, fat mass was positively correlated with aortic PWV, accounting for 9.8% of its variability. Lean mass was not a determinant of PWV. Hypertension, diabetes, and dyslipidemia were associated with higher PWV but had no effect on BMD. CONCLUSIONS: In males from a general population over 60 years of age, bone and arterial aging are differently influenced by lean and fat mass. Our results indicate that elderly men with high lean mass and low fat mass exhibit the best arterial and bone profile with the lowest arterial stiffness and the highest BMD.

[The management of thrombosis in the antiphospholipid antibody syndrome: insights from recent clinical trials and remaining unsolved issues]. / Traitement des complications thrombotiques du syndrome des anticorps antiphospholipides: éclairages des essais thérapeutiques récents et zones d'ombre.

The antithrombotic therapy of the antiphospholipid syndrome (APS) has long been based on an empirical strategy. In the absence of appropriate randomised controlled trials, data of retrospective cohort studies were used to establish these strategies. Here we report the results of recent clinical trials, what they add to patient management and the issues that remain unsolved. SECONDARY PROPHYLAXIS OF THROMBOTIC EVENTS: While there is a consensus for prolonged vitamin K antagonist anticoagulation after a first event, two recent randomised clinical trials have compared various intensities of anticoagulation. Both studies have shown that high intensities of warfarin were not superior to conventional intensities. Patients included in these studies had mainly venous thromboembolic events. There has been no study comparing different antithrombotic strategies for arterial thrombosis associated with APS. The WARSS/APASS study, in particular has not been conducted in patients with definite APS and should not be applied to these patients. For now, vitamin K antagonist anticoagulants should remain the treatment of choice in these patients. PRIMARY PROPHYLAXIS OF THROMBOTIC EVENTS: Because of the high incidence of thrombotic events in asymptomatic patients with antiphospholipid antibodies, especially in systemic lupus erythematosus, a clinical trial compared aspirin and placebo in this setting. This study did not demonstrate any benefit of aspirin. We conclude that recent clinical trials indicate the optimal antithrombotic strategy in APS with venous thromboembolism. However, the best options for patients with arterial thrombosis and for primary prophylaxis remain to be established by further studies.

Determinants of arterial stiffness in an apparently healthy population over 60 years.

Arterial stiffness assessed by the pulse wave velocity (PWV), a non-invasive and reproducible method, predicts cardiovascular morbidity and mortality. The main determinants of arterial stiffness are well established in younger and middle-aged populations, but much less in the elderly. The aim of this study was to describe the determinants of arterial stiffness in elderly apparently healthy subjects. The study included 221 voluntary subjects born before 1944 (mean age 67.4+/-5.0 years), who had a standard health check-up at the 'Centre de Médecine Préventive' of Nancy. Arterial stiffness was evaluated by measuring the carotid-femoral PWV with the PulsePen automatic device. Clinical and biological parameters were evaluated at the same day. Measurements were valid and analysed in 207 subjects (94 women). Mean PWV was 9.39+/-2.64 m/s. Men showed higher PWV values than women (9.99+/-2.56 vs 8.66+/-2.56, P<0.001). In univariate analysis, PWV was correlated with age (r=0.26, P<0.001) and mean arterial pressure (MAP) (r=0.40, P<0.001), and these relationships were similar in men and women. Subjects with hypertension (P<0.001), diabetes mellitus (P<0.001) and obesity (P<0.01) had higher values of PWV. In multiple regression analysis, PWV correlated positively and independently with age, male gender, MAP and diabetes mellitus. In conclusion, in an apparently healthy elderly population, the main determinants of arterial stiffness are the age, MAP, diabetes and gender. Our study also shows that the gender-related differences in arterial stiffness observed in middle-aged subjects are maintained in the elderly.

[Blood pressure control by antihypertensive agents in people older than 60]. / Contrôle de la pression artérielle par le traitement antihypertenseur chez le sujet âgé de 60 ans et plus.

PURPOSE: The prevalence or hypertension increases with aging, reaching more than 50% in people aged 60 years and older. The increase of systolic blood pressure is a major risk of cardiovascular event. METHODS: With the aim of assessing risk factors in old people "in apparent good health", we analysed blood pressure and treatments in people aged 60 years and older who had a periodic check-up that was adapted to older people. RESULTS: This check-up concerned, between April and December 2003, 1638 people with a mean age of 68 years (SD 5.7): 815 men and 823 women. Fourty percent had a systolic blood pressure (SBP) >or=140 mmHg (44% of men, 36% of women); 6% (8% of men, 4% of women) had a diastolic blood pressure (DBP) >or=90 mmHg. A treatment for hypertension was followed by 473 people: 31% of men and 26% of women. Fifty percent were controlled for the SBP and the DBP. Fourty-two percent were not controlled for the SBP, but were controlled for the DBP. Seven percent were not controlled for the SBP nor the DBP. Only 3 subjects (<1%) were not controlled for the DBP, whereas they were controlled for SBP. CONCLUSION: These results, combined with data of literature on the predominant role of SBP in cardio-vascular risk, as compared with DBP, underline the need for a better treatment of systolic hypertension in older people.

Antibodies against phospholipids and beta 2-glycoprotein I increase the risk of recurrent venous thromboembolism in patients without systemic lupus erythematosus.

We studied the prognostic significance of antiphospholipid antibodies for recurrence of venous thromboembolism (VTE), in 71 patients admitted for acute VTE (deep-vein thrombosis or pulmonary embolism) in a single internal medicine unit. Lupus anticoagulant (LA), antibodies directed against beta 2-glycoprotein I (beta 2GPI) and antibodies against both beta 2GPI and a mixture of phospholipids (cardiolipin, phosphatidylserine and phosphatidic acid) (APAs) were measured. The patients were followed-up (mean 4.9 years) to determine the time to the next VTE. We found LA in nine patients, anti-beta 2GPI antibodies in seven patients and APAs in six patients. The cumulative risk of recurring VTE was higher in patients with beta 2GPI-binding antibodies (hazard ratio 12.6, 95% CI 1.5-104.9; p = 0.0029). The risk associated with APAs was 11.5 (95% CI 1.3-98.9; p = 0.0049) and that for LA was 3.7 (95% CI 0.9-15.6; p = 0.055). The risk of VTE recurring was higher both in patients with antibodies directed against beta 2GPI, and in patients with antibodies directed against beta 2GPI and a mixture of phospholipids, than in patients without these antibodies.

Meta-analysis of the risk of venous thrombosis in individuals with antiphospholipid antibodies without underlying autoimmune disease or previous thrombosis.

Patients with systemic lupus erythematosus (SLE) and antiphospholipid antibodies (aPL) are at a greater risk for venous thromboembolism (VTE) than SLE patients without these antibodies. For patients without SLE there is a controversy about the risk associated with these antibodies and about their prognostic significance. We reviewed the degree of evidence and describe the odds ratio for VTE associated with aPL, namely the lupus anticoagulant (LA) and anticardiolipin antibodies (aCL), in patients without SLE. The study was a meta-analysis of seven observational studies of risk for antiphospholipid associated venous thromboembolism (VTE), excluding SLE patients. The strategies to identify published research included a computerized literature search and the review of citations in primarily relevant articles for the period 1983 to 1997. A summary of study characteristics and a critical appraisal of study quality were done. Summary odds ratios were obtained conducted using a random and a fixed effects-model. The overall odds ratio for aCL associated VTE obtained by fixed-effects model was 1.56 (95% CI, 1.10-2.24) and 1.64 (95% CI, 0.93-2.89) by random-effects model. The heterogeneity of these results appeared to be due in part to the detection limit of the aCL assay: the odds ratio was 3.21 (95% CI, 1.11-9.28) with both models when high titres only were considered. The overall odds ratio for LA associated VTE was 11.1 (95% CI, 3.81-32.3). In conclusion meta-analysis of the risk for antiphospholipid associated thrombosis demonstrated a higher risk in patients with the LA than in other patients. This risk was also higher than in patients with aCL even when high titres only were considered.