[Improving fall prevention in the elderly]. / Mieux prévenir les chutes chez les personnes âgées.

The prevention of falls in the elderly requires action on several levels. Firstly, it is essential to identify those at risk of a fall. They must then be encouraged to do appropriate physical and sports activities, a factor of prevention. Social workers have a major role to play in supporting elderly people and encouraging them to participate in such programmes.

Trends of the potentially inappropriate medication consumption over 10 years in older adults in the East of France.

PURPOSE: To describe the trends of potentially inappropriate medication (PIM) use in older adults from 1995 to 2004 in the East of France, by using the 1997 Beers criteria and its French update, and to assess risk factors for this PIM use. METHODS: We carried out a repeated cross-sectional study using data collected among people aged >/=65 years, examined in the Center for Preventive Medicine. Studied variables were socio-demographic, clinical data, medication consumption and the self-health status. Joinpoint regression analysis was used to estimate the temporal changes in PIM rate. RESULTS: 30 683 participants were included. 51.2% were women. The mean age was 70.1 +/- 4.3 years [65-99]. The annual overall rate of PIM use decreased significantly during the study period. These rates range from 14.9% in 1995 to 9.0% in 2004 according the Beers criteria (-3.4% per year) and from 33.5% in 1995 to 19.3% in 2004 according to the French update criteria (-3.6% per year). The annual rate of medication users increased during the same period (+0.75% per year). The risk of PIM consumption increased with age, number of drugs and frequency of the visits to the physician (OR = 1.26 [1.18-1.35]). This risk was also higher among women (OR = 1.29 [1.18-1.40]), elderly living alone (OR = 1.09 [1.02-1.17]) and with those with low education level (OR = 1.19 [1.02-1.38]). CONCLUSION: This study shows a decrease in PIM consumption. Despite an increase of drug use in the elderly, an improving of the quality of this consumption remains possible.

Exercise Frequency Determines Heart Rate Variability Gains in Older People: A Meta-Analysis and Meta-Regression.

BACKGROUND: Previous studies have suggested that exercise training improves cardiac autonomic drive in young and middle-aged adults. In this study, we discuss the benefits for the elderly. OBJECTIVES: We aimed to establish whether exercise still increases heart rate variability (HRV) beyond the age of 60 years, and to identify which training factors influence HRV gains in this population. METHODS: Interventional controlled and non-controlled studies were selected from the PubMed, Ovid, Cochrane and Google Scholar databases. Only interventional endurance training protocols involving healthy subjects aged 60 years and over, and measuring at least one heart rate global or parasympathetic index, such as the standard deviation of the normal-to-normal intervals (SDNN), total frequency power (Ptot), root mean square of successive differences between adjacent NN intervals (RMSSD), or high frequency power (HF) before and after the training intervention, were included. HRV parameters were pooled separately from short-term and 24 h recordings for analysis. Risks of bias were assessed using the Methodological Index for Non-Randomized Studies and the Cochrane risk of bias tool. A random-effects model was used to determine effect sizes (Hedges' g) for changes, and heterogeneity was assessed using Q and I statistics. RESULTS: Twelve studies, seven of which included a control group, including 218 and 111 subjects, respectively (mean age 69.0 ± 3.2 and 68.6 ± 2.5), were selected for meta-analysis. Including the 12 studies demonstrated homogeneous significant effect sizes for short-term (ST)-SDNN and 24 h-SDNN, with effect sizes of 0.366 (95% CI 0.185-547) and 0.442 (95% CI 0.144-0.740), respectively. Controlled study analysis demonstrated homogeneous significant effect sizes for 24 h-SDNN with g = 0.721 (95% CI 0.184-1.257), and 24 h-Ptot with g = 0.731 (95% CI 0.195-1.267). Meta-regression analyses revealed positive relationships between ST-SDNN effect sizes and training frequency ([Formula: see text] = 0.000; [Formula: see text] = 0.000; p = 0.0462). CONCLUSION: This meta-analysis demonstrates a positive effect of endurance-type exercise on autonomic regulation in older adults. However, the selected studies expressed some risks of bias. We conclude that chronic endurance exercise leads to HRV improvements in a linear frequency-response relationship, encouraging the promotion of high-frequency training programmes in older adults.

[Early indicators of prolonged hospitalization of the elderly: pilot study at Strasbourg University Hospital]. / Indicateurs précoces de durée de séjour prolongée chez les sujets âgés: étude pilote réalisée au CHRU de Strasbourg.

OBJECTIVES: The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients. METHODS: This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Agé Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG). RESULTS: The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A "risk of malnutrition" (OR=14.07) and "mood disorders" (OR=2,5) were both early markers for prolonged hospitalization. Although not statistically significant, "walking difficulties" (OR=2.72) and "cognitive impairment" (OR=5.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katz's Activities of Daily Living Index or its course during hospitalization. CONCLUSION: Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

[Assessment of cognitive complaints and depressive symptoms in health check-up centers]. / Exploration de la plainte cognitive dans une population de consultants de Centres d'examens de santé

UNLABELLED: Memory clinics, where cognitive impairment is diagnosed, have to deal with an increasing number of requests. In this context, this study was aimed to evaluate the feasibility of cognitive complaint assessment in a health check-up performed in preventive Health check-up centers. METHODS: The study population included 60-year and over subjects who were proposed a health check-up in the Health check-up centers of five French cities (Amiens, Nîmes, Longwy, Rennes and Sélestat). Cognitive complaint and anxio-depressive symptoms were collected for all participants. Subjects presenting a cognitive complaint fulfilled a neuropsychological screening including MMSE, 5-word test, Clock Drawing test, verbal fluencies and exploration of 4 Instrumental Activities of Daily Living. Subjects suspected to have cognitive impairment were then referred to a memory clinic. RESULTS: One thousand and twenty participants were included in the study; 31.5% had a cognitive complaint, and 12.3% of these subjects were referred to a memory clinic. A dementia was diagnosed in one third of them, corresponding to 1% of the study participants. However, all the patients with dementia were referred by the same check-up centre, which staff was well experienced in cognitive disorders. Moreover, 29.3% of the participants had a depressive symptomatology. CONCLUSION: exploration of cognitive functions in a preventive health check-up center for elderly people can be interesting, but requires a staff's former experience in cognitive disorders, especially for the diagnosis of Mild Cognitive Impairment. Moreover, depressive symptoms, which are frequent and can be cared for, should be explored in a health check-up for senior citizens.

Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission.

OBJECTIVE: To describe triage decisions and subsequent outcomes in octogenarians referred to an ICU. DESIGN AND SETTING: Prospective observational study in the medical ICU in a tertiary nonuniversity hospital. PARTICIPANTS: Cohort of 180 patients aged 80 years or over who were triaged for admission. MEASUREMENTS: Age, underlying diseases, admission diagnoses, Mortality Probability Model score, and mortality were recorded. Self-sufficiency (Katz Index of Activities of Daily Living) and quality of life (modified Perceived Quality of Life scale and Nottingham Health Profile) were measured 1year after triage. RESULTS: In 132 patients (73.3%) ICU admission was refused, including 79 (43.8%) considered too sick to benefit. Factors independently associated with refusal were nonsurgical status, age older than 85 years, and full unit. Greater self-sufficiency was associated with ICU admission. Hospital mortality was 30/48 (62.5%), 56/79 (70.8%), 9/51 (17.6%), and 0/2 in the admitted, too sick to benefit, too well to benefit, and family/patient refusal groups, respectively; 1-year mortality was 34/48 (70.8%), 69/79 (87.3%), 24/51 (47%), and 0/2, respectively. Self-sufficiency was unchanged by ICU stay. Quality of life (known in only 28 patients) was significantly poorer for isolation, emotional, and mobility domains compared to the French general population matched on sex and age. CONCLUSIONS: More than two-thirds of patients aged over 80 years referred to our ICU were denied admission. One year later self-sufficiency was not modified and quality of life was poorer than in the general population. These results indicate a need to discuss patient preferences before triage decisions.

Hierarchical components of physical frailty predicted incidence of dependency in a cohort of elderly women.

OBJECTIVE: To identify the most important predictors of early disability incidence and devise a simple score of physical frailty. METHODS: A cohort of 545 high-functioning women aged 75 years and older was followed for 7 years. Every year, the self-reported loss of at least one instrumental activity of daily living was chosen as definition of disability. An extension of the logistic regression for repeated responses, the random-effect model, was used to assess the effects of baseline predictors. The regression coefficients of the final multivariate model were scaled and rounded to create a practical score. RESULTS: The proportion of women reporting disability increased from 22.1% to 52.1% throughout the follow-up. In the multivariate model, increasing age, lower performances in mobility and balance tests, bad perceived health, lower muscle strength, higher body mass index, lower educational level, and lower reported physical activity were strong predictors of disability. Evaluating the predictive value of the simplified predictive score on an independent cohort gave a c-statistic equal to .71. CONCLUSION: The use of a powerful fitting method allows to establish a hierarchy between the components of physical frailty and to provide a predictive score with substantial practical value for clinicians and public health professionals.

Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union.

BACKGROUND: In 1998, a research study was conducted to compare existing programs in the European Union providing both care to people with senile dementia of the Alzheimer type, and support to their informal caregiver. METHOD: Five programs were selected in seven centres. Home social services (Denmark), Day centres (Germany), Expert Centres (Belgium, Spain), Group Living/Cantou (Sweden, France), Respite hospitalization (France). In each centre, 50 patients were randomly selected. The questionnaire addressed informal caregivers (or referents). It included the Nottingham Health Profile (NHP), the Zarit Scale, and it collected data on age, sex and position (spouse or child) of the informal caregiver, as well as age, level of mental deterioration and disabilities of the patient. RESULTS: (n=322 subjects) Comparatively with caregivers of Respite hospitalization patients chosen as the reference, caregivers of patients cared by Group living/Cantou and Home social services experienced a significantly lower burden. The benefit from the Expert centre program concerned emotional reactions (depression) (odds ratio=0.32; P=0.02) and work burden (Zarit) (OR=0.32; P=0.04). The main benefit for caregivers who received Day centre help was the important reduction of feelings of social isolation (OR=0.13; P=0.0003). CONCLUSIONS: The Group Living/Cantou program appeared as the most efficient way to reduce informal caregiver burden, independently from the country considered.

[What is dementia? 8. Alzheimer's disease early diagnosis: a public health point of view]. / Qu'est-ce que la démence? 8. Le diagnotic précoce de la maladie d'Alzheimer: un point de vue de santé publique.

It is justified to develop early diagnosis for Alzheimer disease and related disorders in order to offer professional support to patients and informal caregivers. On the other hand, the usefulness of screening cases, which have no repercussion on daily life, is not proven considering the difficulty to discriminate early stages from age-related intellectual performance decline. Taking into account a general population point of view, we assume that there is a risk to evolve from early diagnosis to screening. This trend is increased by the fear of the general population, which sees Alzheimer disease as a new plague, the movement towards medicalization in the general population, and the pressure of the pharmaceutical industry. The definition of thresholds for screening, diagnosis and therapy is a central issue. Improving the sensitivity of a test by lowering the threshold leads to a reduction of specificity and a rise of the false positive rate. It is necessary to evaluate the negative impact of labelling normal persons as Alzheimer disease's patients. In the present situation, it would not be sensible to leave the responsibility of the diagnosis to primary care professionals and to give up the validation process performed by the expert or reference centres.

Visual acuity thresholds associated with activity limitations in the elderly. The Pathologies Oculaires Liées à l'Age study.

PURPOSE: Activity limitations, which induce loss of autonomy in the elderly, are a major public health problem. We investigated the associations between objectively determined visual impairments and activity limitations and assessed the visual acuity thresholds associated with these restrictions. METHODS: The study sample consisted of 1887 people aged 63 years and over from a population-based cohort. Moderate to severe visual impairment was defined as presenting visual acuity lower than 20/70, according to the World Health Organization (WHO) definition. In addition, we studied mild visual impairment, defined as visual acuity [20/70-20/40]. Multivariate logistic regressions were used to estimate the associations between vision and instrumental activities of daily living (IADL) limitations. Using receiver-operating characteristic (ROC) curves, we identified visual acuity thresholds that maximized the Youden index ([sensitivity + specificity]-1) for predicting IADL limitations. RESULTS: After adjustment for potential confounders, moderate to severe visual impairment and mild visual impairment were strongly associated with IADL limitations (odds ratio [OR] = 3.49; 95% confidence interval [CI] = 1.93, 6.32 and OR = 1.77; 95% CI = 1.07, 2.91, respectively). Visual acuity was a strong predictor of IADL limitations, with an area under the ROC curve of 0.72 (95% CI = 0.68, 0.76). The best discrimination between subjects with or without IADL limitations (global, physical and cognitive) was obtained for visual acuities around 20/40-20/50. CONCLUSION: This study confirms major increased risk for IADL limitations in subjects with moderate to severe visual impairment. In addition, it suggests that milder visual impairments (in particular below 20/40) may also be related to an increased risk for IADL limitations and should be considered for early medical intervention, before the decline of the subject autonomy.

A screening tool with five risk factors was developed for fall-risk prediction in community-dwelling elderly.

OBJECTIVE: To develop a simple clinical screening tool for community-dwelling older adults. STUDY DESIGN AND SETTING: A prospective multicenter cohort study was performed among healthy subjects of 65 years and older, examined in 10 health examination centers for the French health insurance. Falls were ascertained monthly by telephone for 12-month follow-up. Multivariate analyses using Cox regression models were performed. Regression coefficients of the predictors in the final model were added up to obtain the total score. The discriminative power was assessed using the area under the curve (AUC). RESULTS: Thousand seven hundred fifty-nine subjects were included. The mean age was 70.7 years and 51% were women. At least one fall occurred among 563 (32%) participants. Gender, living alone, psychoactive drug use, osteoarthritis, previous falls, and a change in the position of the arms during the one-leg balance (OLB) test were the strongest predictors. These predictors were used to build a risk score. The AUC of the score was 0.70. For a cutoff point of 1.68 in a total of 4.90, the positive predictive value and negative predictive value were 72.0% and 72.7%, respectively. CONCLUSION: A screening tool with five risk factors and the OLB test could predict falls in healthy community-dwelling older adults.

Reliability of a new instrument for measuring maximum rising strength.

OBJECTIVE: To assess the intrarater test-retest reliability of a newly developed instrument for measuring maximum rising strength (MRS) in comparison with that of maximum knee extension strength (KES). DESIGN: Three replications of isometric MRS and KES were measured on three test occasions separated by 1 wk in 97 healthy men and women aged 23-90. MRS was measured in seated subjects using a dynamometer fixed on the ground and connected by an adjustable nonelastic cord to a padded belt. RESULTS: The intraclass coefficients (ICCs) of MRS were 0.92 and 0.93 at 60 and 70 degrees of knee flexion, respectively, and 0.98 when the mean of three highest peak values of MRS at 60 degrees and the three highest peak values at 70 degrees knee flexion on each session were considered vs. 0.95 for KES. A significant increase in MRS and KES strength was found between the first and the third sessions (+7 to 8%)(P < 0.001). No side effects of strength measurements were noticed. CONCLUSION: Despite a significant learning effect, MRS measurement is reliable in men and women of a wide range of ages. Whether this instrument will be useful for targeting individuals with early sit-to-stand difficulties requires further investigation.