Precipitants of Delirium in Older Inpatients Admitted in Surgery for Post-Fall Hip Fracture: An Observational Study.

BACKGROUND: Hip fractures precipitate several acute adverse outcomes in elderly people, thus leading to chronic adverse outcomes. OBJECTIVES: The objective of our study was to examine the clinical characteristics associated with incident delirium in community dwelling elderly individuals who have a hip fracture. DESIGN: Retrospective observational cohort study. SETTING: Data was collected from an academic tertiary hospital affiliated with McGill University. PARTICIPANTS: 114 elderly individuals who were above 65 years of age, who underwent surgery for a fractured hip. MEASUREMENTS: The main outcome variable was incident delirium, which was assessed by chart reviews of notes and observations recorded by nurses and physicians when patients were admitted post operatively to the surgical unit. Covariates included age, sex, length of stay, delay to surgery, number of medical comorbidities, number of medications and hip fracture location, and were extracted from medical records. Baseline mobility and functional status, preoperative cognitive impairment, postoperative complications, regular psychotropic medications, psychotropic medications in hospital, and location of discharge were also assessed through chart review. RESULTS: The results demonstrated that 17.5% of participants with a diagnosis of delirium had a longer length of hospitalization (p = 0.01), a lower baseline functional status (p = 0.03) and pre-operative cognitive impairment (p = 0.01). Patients receiving new psychotropic medications in hospital were more likely to have delirium (OR = 4.6, p = 0.01) which was independent of pre-operative cognitive impairment. CONCLUSION: We have shown that an association exists between psychotropic medication prescription and incident delirium in patients with hip fractures, even when adjusting for cognitive impairment. Hence, the prescription of psychotropic drugs should be judicious in these patients so as minimize the risk of adverse outcomes.

Predicting prolonged length of hospital stay in older emergency department users: use of a novel analysis method, the Artificial Neural Network.

OBJECTIVE: To examine performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], likelihood ratios [LR], area under receiver operating characteristic curve [AUROC]) of a 10-item brief geriatric assessment (BGA) for the prediction of prolonged length hospital stay (LHS) in older patients hospitalized in acute care wards after an emergency department (ED) visit, using artificial neural networks (ANNs); and to describe the contribution of each BGA item to the predictive accuracy using the AUROC value. METHODS: A total of 993 geriatric ED users admitted to acute care wards were included in this prospective cohort study. Age >85years, gender male, polypharmacy, non use of formal and/or informal home-help services, history of falls, temporal disorientation, place of living, reasons and nature for ED admission, and use of psychoactive drugs composed the 10 items of BGA and were recorded at the ED admission. The prolonged LHS was defined as the top third of LHS. The ANNs were conducted using two feeds forward (multilayer perceptron [MLP] and modified MLP). RESULTS: The best performance was reported with the modified MLP involving the 10 items (sensitivity=62.7%; specificity=96.6%; PPV=87.1; NPV=87.5; positive LR=18.2; AUC=90.5). In this model, presence of chronic conditions had the highest contributions (51.3%) in AUROC value. CONCLUSIONS: The 10-item BGA appears to accurately predict prolonged LHS, using the ANN MLP method, showing the best criteria performance ever reported until now. Presence of chronic conditions was the main contributor for the predictive accuracy.

A regression tree for identifying combinations of fall risk factors associated to recurrent falling: a cross-sectional elderly population-based study.

BACKGROUND: Regression tree (RT) analyses are particularly adapted to explore the risk of recurrent falling according to various combinations of fall risk factors compared to logistic regression models. The aims of this study were (1) to determine which combinations of fall risk factors were associated with the occurrence of recurrent falls in older community-dwellers, and (2) to compare the efficacy of RT and multiple logistic regression model for the identification of recurrent falls. METHODS: A total of 1,760 community-dwelling volunteers (mean age ± standard deviation, 71.0 ± 5.1 years; 49.4 % female) were recruited prospectively in this cross-sectional study. Age, gender, polypharmacy, use of psychoactive drugs, fear of falling (FOF), cognitive disorders and sad mood were recorded. In addition, the history of falls within the past year was recorded using a standardized questionnaire. RESULTS: Among 1,760 participants, 19.7 % (n = 346) were recurrent fallers. The RT identified 14 nodes groups and 8 end nodes with FOF as the first major split. Among participants with FOF, those who had sad mood and polypharmacy formed the end node with the greatest OR for recurrent falls (OR = 6.06 with p < 0.001). Among participants without FOF, those who were male and not sad had the lowest OR for recurrent falls (OR = 0.25 with p < 0.001). The RT correctly classified 1,356 from 1,414 non-recurrent fallers (specificity = 95.6 %), and 65 from 346 recurrent fallers (sensitivity = 18.8 %). The overall classification accuracy was 81.0 %. The multiple logistic regression correctly classified 1,372 from 1,414 non-recurrent fallers (specificity = 97.0 %), and 61 from 346 recurrent fallers (sensitivity = 17.6 %). The overall classification accuracy was 81.4 %. CONCLUSIONS: Our results show that RT may identify specific combinations of risk factors for recurrent falls, the combination most associated with recurrent falls involving FOF, sad mood and polypharmacy. The FOF emerged as the risk factor strongly associated with recurrent falls. In addition, RT and multiple logistic regression were not sensitive enough to identify the majority of recurrent fallers but appeared efficient in detecting individuals not at risk of recurrent falls.

Association of calcium concentration with pulse pressure in older women: data from a large population-based multicentric study.

OBJECTIVE: High arterial pulse pressure is a predictor of cardiovascular morbimortality. Mineral metabolism has been associated with blood pressure regulation. Our objective was to determine which variable among serum calcium, parathyroid hormone and 25-hydroxyvitamin D concentrations, was associated with pulse pressure among older adults. DESIGN: Cross-sectional study corresponding to the baseline assessment of the EPIDOS study. SETTING: Five French cities including Amiens, Lyon, Montpellier, Paris and Toulouse. PARTICIPANTS: Randomized sample of 610 community-dwelling older women (mean age 80.2±3.5years) using no antihypertensive drugs. MEASUREMENTS: Serum calcium, parathyroid hormone and 25-hydroxyvitamin D concentrations; supine pulse pressure after 15 minutes of rest (hypertension defined as pulse pressure >50mmHg). Age, body mass index, the number of morbidities and of drugs daily taken, diabetes mellitus, dysthyroidy, the use of estrogenic drugs, smoking, alcohol consumption, practice of a regular physical activity, creatinine clearance, and the effects of season and study centers were used as potential confounders. RESULTS: Hypertensive participants (n=539) had higher calcium concentrations than normotensive ones (94.33±4.12mg/L versus 93.28±3.36mg/L respectively, P=0.040). There were no between-group differences for serum parathyroid hormone and 25-hydroxyvitamin D concentrations. The multiple logistic regressions examining the serum calcium, parathyroid hormone and 25-hydroxyvitamin D concentrations as predictors of hypertension found an association only with calcium (adjusted odds ratio=1.19, P=0.015), but not with parathyroid hormone (adjusted OR=1.01, P=0.349) or 25-hydroxyvitamin D concentration (adjusted OR=0.99, P=0.971). CONCLUSION: Increased serum calcium concentration was independently and positively associated with high pulse pressure in our study, possibly due to increased arterial stiffness. Interventions aimed at normalizing calcaemia may be attractive to prevent hypertension and cardiovascular risk in older adults.

Do not resuscitate orders and aging: impact of multimorbidity on the decision-making process.

BACKGROUND: The "Do Not Resuscitate" orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients. METHODS: A systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: "resuscitation orders" OR "do-not-resuscitate" combined with "aged, 80 and over" combined with "comorbidities" OR "chronic diseases". RESULTS: Of the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19-1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07-1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08-3.20) for cancer, OR=1.07 (95% CI: 0.92-1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61-2.40) for stroke. CONCLUSIONS: This systematic review and meta-analysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.

Vitamin D deficiency is associated with orthostatic hypotension in oldest-old women.

OBJECTIVES: Orthostatic hypotension, a condition that mostly affects 'oldest-old' (i.e. ≥80 years) adults, is primarily explained by age-related dysfunction of blood pressure control. Vitamin D may contribute to blood pressure control. The aim of this study was to determine whether vitamin D deficiency is associated with orthostatic hypotension in oldest-old adults. DESIGN: Cross-sectional analysis at baseline of the EPIDOS study. SETTING: Five French areas. PARTICIPANTS: A total of 329 community-dwelling oldest-old women (mean age 83.3 ± 0.2 years). MAIN OUTCOMES MEASURES: Orthostatic hypotension was defined as a systolic blood pressure drop of ≥20 mmHg and/or a diastolic blood pressure drop of ≥10 mmHg within 3 min of standing. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D (25OHD) concentration ≤10 ng mL(-1) . Covariates included in the models were age, body mass index, diabetes mellitus, supine mean arterial pressure, number of drugs taken per day, use of antihypertensive or psychoactive drugs, cognition, quadriceps strength, current smoking, alcohol consumption, serum concentrations of parathyroid hormone, calcium and creatinine and season of testing. RESULTS: Diastolic orthostatic hypotension was observed more often among women with vitamin D deficiency (19.2%) compared to those without (10.0%; P = 0.03). There was an inverse linear association between 25OHD concentration and change in diastolic blood pressure after 3 min of standing (adjusted ß = -0.07, P = 0.046). Similarly, 25OHD deficiency was associated with orthostatic hypotension [adjusted odds ratio (OR) 3.36, P = 0.004], specifically with diastolic orthostatic hypotension (adjusted OR 3.81, P = 0.003). CONCLUSIONS: 25OHD deficiency was associated with orthostatic hypotension in oldest-old women, due to a greater drop in diastolic blood pressure on standing. This finding may lead to better understanding of the pathophysiology of falls in oldest-old adults with vitamin D deficiency.

Derivation and validation of a Short Form of the Mini-Mental State Examination for the screening of dementia in older adults with a memory complaint.

BACKGROUND AND PURPOSE: To validate a Short Form of the Mini-Mental State Examination (SMMSE) as a screening test for dementia in older ambulatory individuals followed in a memory clinic for a memory complaint. METHODS: A total of 202 cognitively healthy individuals, 100 individuals with a mild cognitive impairment and 304 demented individuals sent for a memory complaint by their primary care physician to a memory clinic were prospectively included in this cross-sectional study. They were randomized into derivation (n = 303) and validation (n = 303) groups. The SMMSE score was built from six memory items of MMSE, with a score ranging from 0 to 6 (i.e. best performance). RESULTS: The receiver operating characteristic curve showed an area under the curve of 0.98 for the derivation group and 0.97 for the validation group without differences between curves (P = 0.254). The cut-off between the sensitivity and the specificity of the SMMSE score for clinically diagnosed dementia was ≤4. The performance of the SMMSE for the diagnosis of dementia was high in the derivation and validation groups: sensitivity at 93.1% and 93.8%, specificity at 93.8% and 90.5%, positive predictive value at 94.3% and 90.1%, negative predictive value at 92.5% and 94.0%, likelihood ratio of positive test at 14.9 and 9.8 and of negative test at 0.07 and 0.07, respectively. CONCLUSIONS: The Short Form of the Mini-Mental State Examination was a good screening test for dementia in older individuals followed in a memory clinic for a memory complaint. The next step should be the confirmation of its discriminative value in older primary care patients.

Slow gait in MCI is associated with ventricular enlargement: results from the Gait and Brain Study.

Slow gait is ubiquitous among older adults and predicts cognitive decline and progression to dementia. Age-related structural brain changes could be responsible for abnormal gait. The purpose of this study was to determine whether brain lateral ventricle volume, a measure of brain atrophy, was associated with gait velocity among older adults with mild cognitive impairment (MCI), while considering the effects of age and brain vascular burden. Twenty community-dwellers with MCI, free of hydrocephalus, aged 76 years (69/80) [median (25th/75th percentile)] (35 % female) from the 'Gait and Brain Study' were included in this analysis. Quantitative gait performance was measured while steady-state walking at self-selected pace with a 6-m electronic portable walkway (GAITRite). Brain ventricle volume was quantified using semi-automated software from three-dimensional T1-weighted magnetic resonance imaging. Age, white matter hyperintensity burden and Mini-Mental State Examination score were used as potential confounders. Median gait velocity was 118.7 cm/s (104.4/131.3). Median brain ventricle volume was 39.9 mL (30.0/46.6) with the left ventricle being slightly larger than the right (P = 0.052). Brain ventricle volume was inversely associated with gait velocity (adjusted ß = -0.63, P = 0.046). Volume of both the ventricular main bodies and the temporal horns correlated inversely with gait velocity (respectively, P = 0.009, P = 0.008). Left ventricle volume correlated with decreased gait velocity (P = 0.002) while right ventricle did not (P = 0.068). Slower gait velocity was associated with larger brain ventricle volume in our sample of people with MCI independent of age, cerebrovascular burden and cognitive worsening. This result may help elucidate the trajectories of cognitive and gait declines in people with MCI.

[First epileptic seizure in the elderly: electroclinical and etiological data in 341 patients]. / Première crise d'épilepsie chez le sujet de plus de 60 ans: données électrocliniques et étiologiques.

This study included 341 subjects aged over 60 years, 174 females and 167 males, (mean age 72-years), who experienced their first epileptic seizure and fulfilled all inclusion criteria over an 8-year period. Data were available from the physical examination, EEG, laboratory tests and CT scan or MRI for all patients. The international classification of epileptic seizures was applied, 41 p.cent of the seizures were generalized and 59 p.cent were partial. Status epilepticus occurred in 8 p.cent of the patients. The EEG recording was contributive to diagnosis or helpful for localizing the epileptic focus in 55 p.cent of the patients. Normal brain imaging was observed in 40 p.cent of the patients. The main etiology was cerebrovascular disease (33 p.cent), acute stroke (27 patients), or more often postvascular epilepsy (87 patients). Other etiologies were degenerative cortical dementia in 7 p.cent of the patients, metabolic and toxic disorders in 11 p.cent, and benign or malignant brain tumors in 6.5 p.cent. Thirty-two percent of the seizures were of unknown origin (cryptogenic seizures). No correlation was found between sex, age, and etiology. An antiepileptic drug treatment was initiated in 77 p.cent of the patients who were given either valproate (43 p.cent), carbamazepine (26 p.cent) or barbiturates (7 p.cent). These findings are in agreement with those reported in the reviewed literature.

[Roles of arterial dysplasia, chronic ergotism and other factors in a case multiple spontaneous arterial dissections]. / Rôles d'une dysplasie artérielle, d'un ergotisme chronique et d'autres facteurs dans un cas de dissections artérielles multiples spontanées.

INTRODUCTION: Spontaneous dissection of cervical and visceral arteries are rare and usually associated with an underlying arterial disease. EXEGESIS: The authors report the unusual case of a 50-year-old woman with high blood pressure who presented spontaneous dissection of cervico-cephalic, renal and hepatic arteries and of the descending aorta. She had been taking ergotamine tartrate for ten years for migraine. She also suffered from Raynaud's syndrome worsened by treatment. CONCLUSION: The respective roles of arterial dysplasia, chronic ergotism, renovascular hypertension and migraine are discussed.