Amylose cardiaque dite sénile : diagnostic et nouvelles perspectives thérapeutiques.

Résumé L'amylose cardiaque dite sénile, également dénommée « sauvage ¼, était considérée comme une maladie rare. Actuellement, grâce à des moyens diagnostiques non invasifs et à partir d'études autopsiques, nous estimons la prévalence à environ 10 à 20 % des sujets de plus de 80 ans. De même, l'amylose était un diagnostic sans conséquence thérapeutique, mis à part le traitement de l'insuffisance cardiaque et des troubles de conduction. De nouveaux traitements permettent de stabiliser le tétramère de transthyrétine et de diminuer la production d'oligomères, sources des dépôts d'amylose, en cas de formes héréditaires et sauvage d'amylose à transthyrétine. Deux médicaments bloquant la production de transthyrétine (anti-sens et oligonucléotides) sont également en phase d'essais cliniques dans les amyloses cardiaques. Ainsi, le diagnostic et la prise en charge de l'amylose cardiaque deviennent des démarches diagnostiques de pratique clinique et doivent être connus des cardiologues, mais également des gériatres qui permettront une prise en charge précoce et donc plus efficace. Abstract So-called senile cardiac amyloidosis was considered rare. Nowadays, thanks to non-invasive diagnostic means and autopsy studies, we estimate the prevalence to be about 20% of subjects over 75 years of age. Similarly, amyloidosis was a diagnosis with no therapeutic consequences, apart from the treatment of heart failure and conduction disorders. New treatments make it possible to stabilise the transthyretin tetramer and to reduce the production of oligomers that are the source of amyloid deposits, by acting in a non-genetic way and therefore adapted to the "wild" transthyretin forms of so-called senile cardiac amyloidosis. Thus, the diagnosis and management of cardiac amyloidosis are becoming diagnostic procedures in clinical practice and must be known by cardiologists, but also by geriatricians, who will allow early and therefore more effective management.

[Looking for frailty in elderly using the Gérontopôle Frailty Screening Tool: an observational cross-sectional study]. / Repérage de la fragilité du sujet âgé en médecine générale à l'aide du Gérontopôle Frailty Screening Tool : une étude observationnelle transversale.

Frailty in elderly people is frequent and places a person at increased risk of adverse outcomes, but it is potentially reversible. Easy and quick to complete, the Gérontopôle Frailty Screening Tool (GFST) has been designed for early diagnosis of frail elderly. The answer comes from the GP's impression in front of the patient, guided by six frailty characteristic parameters. The aim of this study was to determine the proportion of frail patients among the 75-and-older population, using the GFST. Quantitative cross-sectional observational study. A Chi2 square test and a multivariate analysis have been performed. Twenty-six GPs have taken part in this study, enabling the collection of 191 tests: 42% [95% CI, 0,35-0.49] of surveyed patients are considered frail. Frailty is significantly associated with each of the GFST parameters, except "living alone". After adjusting on age, gender and other parameters, the factors most strongly associated with frailty are: difficulty with walking, memory complaint (P < 0.001) and age (P < 0.05). The prevalence observed is consistent with the literature data. Our results confirm the relationship between frailty and physical domain, and reaffirm the close interaction between frailty and cognitive domain.

National French Survey of Coronavirus Disease (COVID-19) Symptoms in People Aged 70 and Over.

The objective of this national French survey was to determine the coronavirus disease 2019 (COVID-19) semiology in seniors (n = 353; mean, 84.7 ±â€…7.0 years). A total of 57.8% of patients exhibited ≤3 symptoms, including thermal dysregulation (83.6%), cough (58.9%), asthenia (52.7%), polypnea (39.9%), and gastrointestinal signs (24.4%). Patients ≥80 years exhibited falls (P = .002) and asthenia (P = .002). Patients with neurocognitive disorders exhibited delirium (P < .001) and altered consciousness (P = .001). Clinical peculiarities of COVID-19 were reported in seniors. CLINICAL TRIALS REGISTRATION: NCT04343781.

Association of Preoperative Geriatric Assessment With Length of Stay After Combined Cardiac Surgery.

BACKGROUND: For older patients undergoing cardiac surgery, geriatric factors are known to increase postoperative complications and prolong length of stay (LOS). Comprehensive geriatric assessment (CGA) is an evidence-based method for geriatric evaluation to develop an individualized-care plan to optimize physical, functional, and social issues. This study analyzed the association between preoperative CGA and hospital LOS after combined cardiac surgery. METHODS: This retrospective monocentric study included all patients aged 75 years and greater who underwent combined cardiac surgery between 2014 and 2017. Hospital LOS, intensive care unit LOS, and postoperative complications were compared between patients with or without preoperative CGA before and after propensity-score matching. RESULTS: Mean age of the 407 patients was 79.6 years; 114 underwent a preoperative CGA (28%). For 305 patients (74.9%), coronary artery bypass was associated with aortic valve replacement. After propensity-score matching, a significant difference was found between the 2 groups (preoperative CGA versus none) for in-hospital LOS (12 versus 13 days; P = .04) and intensive care unit LOS (3 versus 4 days; P = .01). In multivariable analysis, a significant association remained between hospital LOS and CGA (P = .02), renal function (P = .02), mitral replacement (P = .001), and complications (P = .001). CONCLUSIONS: Our results favor the use of systematic preoperative CGA. These encouraging results need to be validated by prospective studies that assess the impact of individualized-care plan established after CGA on postoperative outcomes. With an aging population, efforts are required to determine how to implement preoperative individualized-care plans to improve postoperative outcomes for vulnerable patients undergoing cardiac surgery.

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.

Sex Differences in the Occurrence of Major Clinical Events in Elderly People with Type 2 Diabetes Mellitus Followed up in the General Practice.

AIMS: The main aim of the present work was to assess if sex influences the occurrence of major clinical events in elderly people with type 2 diabetes followed up in the primary care. METHODS: 983 subjects aged ≥65years with type 2 diabetes were included by 213 general practitioners and followed up prospectively for three years. Major clinical events were recorded every six month. The first endpoint was a composite of all-cause death and major vascular events (acute coronary syndrome, non-fatal stroke or transient ischemic attack, or revascularization for peripheral artery disease). The second endpoint was all-cause hospitalization. The occurrence of each endpoint was analyzed in order to estimate the role of sex and determine other predictors of major clinical events. RESULTS: At baseline, women were older than men but they had a lower prevalence of coexisting diseases (cardiovascular disease and cancer) and equivalent diabetes control (Glycated hemoglobin A1C: 6.9%±0.9 vs. 7.0%±1.1). Over the follow-up period, women were at lower risk to develop the composite endpoint (HR 0.60, 95% CI 0.40-0.91, p=0.016) and the hospitalization endpoint (OR 0.71, 95% CI 0.52-0.96, p=0.029). Coexisting diseases, functional ability and concomitant medications emerged as significant predictors of both endpoints. CONCLUSIONS: Elderly women with well-controlled type 2 diabetes were less likely to experience major clinical events than their male counterparts. More studies are needed to determine the reasons for the higher hospitalization rate in men.

Multimorbidity and epilepsia in the elderly.

Epilepsia is a frequent disease in the elderly. Most of the time seizures are the consequence of another or other comorbidities and they are generally partial. Causal pathologies are either cerebral or general. The most common is the stroke, especially if it is haemorrhagic. If the seizure is delayed in relation to stroke, it defines vascular epilepsy and is an indication for long-term antiepileptic therapy. Neurodegenerative diseases, primarily Alzheimer's disease, are associated with epilepsy, but the pathophysiological links between the two are poorly understood. The clinical presentation of seizures is often atypical and the existence of memory disorders complicates the diagnosis because they make it difficult to reconstruct the anamnesis. Cranial trauma and tumours are the other classic brain causes of epilepsy. The general causes include metabolic and hydroelectrolytic disorders (especially hypoglycaemia and hyponatremia), drugs (either by their toxicity or by a withdrawal syndrome), and uraemic encephalopathy of renal failure. Finally, alcohol is a common cause not to be neglected, including among institutionalised patients.

[Screening risk and protective factors of nursing home admission]. / Repérage des facteurs influençant le risque d'admission en établissement médico-social.

Many aged adults want to stay as long as possible in their own homes. Hence, it is important to identify factors that can predict nursing home admission, in order to prevent this admission and maintain people at home. Several studies have investigated the risk factors of nursing home admission but syntheses are still rare. The present study aimed to identify risk and protective factors for nursing home admission for aged adults. A literature review was conducted using the PubMed search engine. Of 177 relevant reports, 27 were analyzed. We have included studies, literature reviews and meta-analyses that have highlights 59 potential factors. Falls, especially when fall causes serious injuries, cognitive impairment, activities daily living dependencies and stroke were identified as the highest risk factors. In contrast, living with spouse, having adult children, receiving a home care program based on case management or being homeowner were identified as protectives factors. This knowledge of risk and protective factors can help our prevention strategies to delay or find alternatives to nursing home admission.

[Cancer and microbiota in elderly patients: challenges and management]. / Apport de l'analyse du microbiote intestinal pour améliorer la prise en charge oncologique chez le sujet âgé.

Aging is a major risk factor of cancers. In recent years, several studies highlighted a change in the diversity and the abundance of the intestinal microbiota associated with aging. Moreover, epidemiological studies, experimental and clinical studies have suggested that the microbiota is implicated in cancer physiopathology and could modulate the efficacy and the tolerance of oncological treatments, for example the incidence of gastrointestinal toxicity and infectious disease. In this review, our objective was first to described the main studies that have focused on the composition of the microbiota associated with aging, cancer and during cancer therapies. Second, we discussed challenges and perspectives on cancer management and research, in elderly patients. Finally, we assume that further studies will confirm that the composition of the intestinal microbiota could be considered as a biomarker of frailty that could be used to optimize cancer management in elderly patients.

Geriatric factors associated with 1-year mortality after aortic valve replacement.

BACKGROUND: Surgical aortic valve replacement has been shown to improve survival and quality of life in patients with severe aortic stenosis. However, clinical variables are known to be associated with an increased mortality rate. As geriatric conditions are highly prevalent in this older population, the aim of this study was to identify geriatric factors associated with 1-year mortality after a surgical aortic valve replacement among older patients with severe symptomatic aortic stenosis. METHODS: Between January 2012 and September 2014, all patients ≥ 75 years referred for a surgical aortic valve replacement after a complete pre-operative evaluation in a university-affiliated center were included in this observational study. Association between 1-year mortality surgical aortic valve replacement and baseline characteristics including cardiac and geriatric factors was analysed by Cox models. RESULTS: Mean age of the 197 patients studied was 81.3 ± 3.5 years and 48.2% were men. At 1 year of the intervention, 19 patients (9.6%) were dead. On multivariate analysis, previous cardiac surgery (Hazard ratio [HR] = 10.47, p = 0.03), undergoing concomitant cardiac surgery (HR = 6.22, p = 0.03), pulmonary hypertension (HR = 3.73, 0.04) were still associated with 1-year mortality. Moreover, cognitive impairment was also associated with 1-year mortality (HR = 4.67, p = 0.04). CONCLUSIONS: This study is the first study to show that among geriatric factors, cognitive impairment was a strong predictor of 1-year mortality after a surgical aortic valve replacement in patients aged 75 years old and older, independently of other geriatric and cardiac factors. This study highlights the importance of pre-operative cognitive assessment.

Association between cachexia, chemotherapy and outcomes in older cancer patients: A systematic review.

BACKGROUND & AIMS: The aims of this systematic review were (i) to determine the prevalence of malnutrition and cachexia in older cancer patients in a chemotherapy setting, and (ii) to report the chemotherapy-related causes of malnutrition and (iii) the consequences of malnutrition on the outcomes of these patients. METHODS: We searched MEDLINE for articles published in English or French between 2005 and 2016 and which reported retrospective or prospective, observational or interventional studies of the prevalence of malnutrition and its consequences in patients 65 years or older with solid tumors and chemotherapy-related causes of malnutrition. RESULTS AND CONCLUSION: Malnutrition is prevalent up to 83% in older patients with cancer scheduled to receive chemotherapy. One third or more of patients were malnourished before receiving chemotherapy. A weight loss of 10% or more during the past three or six months was reported in 8%-40% of cancer patients, while a body mass index <21 kg/m2 was found in 10.7%-23%. Malnutrition was more prevalent in digestive (28%-75%) than in non-digestive cancers (8%-46.9%), and also in metastatic cancers (64%-76.5%). During the course of chemotherapy, weight loss was observed in 40%-91.6% of patients, depending on cancer location. The most frequently reported chemotherapy-related digestive symptoms likely to impair nutritional status were dry mouth, nausea, stomach pain, diarrhea and constipation. Low Mini-Nutritional-Assessment score was an independent predictor of early discontinuation of chemotherapy and increased the risk of mortality.

[Comprehensive assessment of comorbidity in the elderly]. / Évaluation des comorbidités chez la personne âgée.

The ageing is accompanied by a progressive decline in physical activity, a social vulnerability and an increase in the prevalence of the chronic diseases. The comorbidity brings a description which modifies the repercussion of the usual processes of the ageing in term of vital and functional prognosis. The comorbidities must be integrated into the comprehensive geriatric assessment as well as the other aspects like cognition or the nutrition. The tools for global evaluation of the comorbidity bring information on their presence and on the load which they will impose on the medical decisions because they are predictive tolerance and benefit. The comorbidities can also be described in the context of a pathology like the oncology for example. The comorbidities could be the cause of delay diagnosis, will influence the evolution and the therapeutic tolerance and will give information about the forecast. It will then be necessary to use scales of comorbidities adapted to the speciality while avoiding having a scale by pathology what would reduce feasibility without increasing its utility. The comorbidities were often forgotten in comprehensive geriatric assessment pratice and should be studied in order to adapt the therapeutic decisions in an approach of personalised medicine.

[Cancer screening practices in elderly with dementia]. / Étude des pratiques de dépistage du cancer chez la personne âgée ayant une démence.

Current demographic trends and medical practices raise the question of cancer screening in the elderly, especially those with dementia. Furthermore, studies have suggested that patient with Alzheimer disease showed a reduced risk of cancer. However, this link may be biased by the absence of cancer screening. That's why we conducted a survey to poll general practitioners' (GP) opinion on screening cancer in the elderly. In this study, 304 general practitioners were asked, from May to March 2014, about their cancer screening practices and on the elements influencing it. Eighty-two physicians responded. The rate of response was 29.4%. Forty-nine (60%) GP said practicing cancer screening in the elderly, 60 (64%) thought that screening does not lead to treatment, 51 (62%) GP were not favorable to cancer screening in patients with dementia, 63 (77%) GP thought that there is a lack of recommendations to guide cancer screening in the elderly. Finally, this study shows that cancer screening is less performed in patients with dementia. Further, promote exchange between general practitioners and specialists, by strengthening Cancer and Geriatrics networks, could probably increase cancer screening in the elderly, with or without dementia.

There is no correlation between peripheral inflammation and cognitive status at diagnosis in Alzheimer's disease.

BACKGROUND: Besides the neurofibrillary tangles and amyloid plaques, an inflammatory process is involved at central and peripheral levels in Alzheimer's disease (AD). We aimed to determine whether peripheral inflammatory parameter levels, in plasma and in peripheral blood mononuclear cells (PBMCs), could be correlated with the cognitive status at the time of AD diagnosis. METHODS: Patients were included at diagnosis with MMSE score between 16 and 25 and were naive of symptomatic treatment for AD. C-reactive protein >10 mg/L and any acute or chronic inflammation were considered as exclusion criteria. Cognitive assessment also included the ADAScog scale. Plasma interleukins (IL)-1ß, IL-6, tumor necrosis factor (TNF)-α and the chemokine ligand 5 (CCL5) were measured using Luminex(®) X-MAP(®) technology. A subgroup of patients also underwent measures of these parameters in extracellular and intracellular compartments of PBMCs (ancillary study). RESULTS: One hundred and nine patients were included; mean age 79.4 ± 6.8 years with 37 patients in the ancillary study. The mean values of IL-1ß, TNF-α, IL-6 and CCL5 values were 1.49, 7.18, 3.09 and 69,615.81 pg/mL, respectively. No correlation between plasma cytokines or chemokine levels and cognitive scores was found. In PBMCs, the levels of cytokines were detectable but did not either show any correlation with cognitive scores. CONCLUSION: Our data indicate that at diagnosis, peripheral levels of cytokines and CCL5 display low values without any correlation with the cognitive status. Further results of our study will show if these circulating markers are related to the progression of AD.

Association between Cardiovascular Drugs and Chronic Kidney Disease in Non-Institutionalized Elderly Patients.

Concern about the renal safety of commonly used cardiovascular drugs with demonstrated clinical benefit appears to be an obstacle to their use in the elderly. The objective was to describe the relationship between cardiovascular drugs and chronic kidney disease (CKD) in elderly individuals in the real-life setting. This is an ancillary study of the prospective non-interventional S.AGE (aged individuals) cohort. General physicians were free to prescribe any drug their patients needed. The participants were non-institutionalized patients aged 65 years and older treated by their primary physician for either chronic pain or atrial fibrillation or type 2 diabetes mellitus. The estimated glomerular filtration rate (eGFR) derived from the CKD-EPI formula was determined at inclusion and every year during 2 years of follow-up. This study comprised 2505 patients aged 77.8 ± 6.2 years. At inclusion, the factors associated with CKD (eGFR < 60 ml/min/1.73 m(2) ) in multivariate analysis were age, female gender, hypertension, heart failure, history of atherothrombotic disease and renin angiotensin system blockers, loop diuretics and calcium channel inhibitors. Introduction of each of these three drug classes during the follow-up period led to only a small decrease in the eGFR: -3.8 ± 12.7 (p < 0.0006), -2.2 ± 12.0 (p < 0.003) and -1.0 ± 13.4 ml/min./1.73 m(2) (NS), respectively. Only the introduction of loop diuretics was associated with CKD (OR 1.91, 95% CI: 1.25-2.90; p = 0.002). Renal safety of cardiovascular drugs in the elderly appears acceptable and should not be a barrier to their use.

[Immunosenescence: a review]. / Immunosénescence : une revue.

Immunosenescence is a progressive deterioration of the immune system with ageing. A multifactorial condition, including multimorbidities and environmental factors in the elderly, increases the frailty risks. Some infection and nutritional factors contribute to the onset of decline of response to infection. The epithelial barrier is the front line against infection. The renewal capacity of hematopoietic stem cells is reduced and provide in turn decrease of immune cells like lymphocytes, antigen-presenting dendritic cells, and phagocytes. The cellular immunity decreases considering the low cytotoxicity of natural killer. The impairment of dendritic cells alters both non-adaptive and humoral immunities. The reduction of antibody producing B-cells alters humoral production and the diversity of immunoglobulins and their affinity. Somme evidence suggests that retained function of both innate and acquired immunity in the elderly is correlated with health status. CMV might play a part in the process of immunosenescence. CMV status is included in the immune risk profile. Some factors like nutritional status and inflammatory biomarkers should be added to define a immune risk profile in the elderly.

[Care of elderly subject with iron deficiency anaemia: evaluation of geriatric practice]. / Prise en charge d'un patient âgé présentant une anémie par carence martiale : évaluation des pratiques en gériatrie.

UNLABELLED: The anemia with iron deficiency is frequent in the elder subjects. Few studies have reported the practice of the geriatric medicine about anemia. METHODS: A national survey asked geriatric medical practitioners of hospital geriatric ward from June till September, 2013. Questionnaires were sent, filled over the phone. On 568 sent questionnaires, 312 (55%) were filled. The frequency of the anemia is considered of 46 ± 21%. The definition of the anemia in an elderly person is on average 10.7 ± 0.8 g/dL, taking into account the situation of the patient. The wanted biological examinations are the haemoglobin and the ferritinaemia, but many people suggest measuring also folates and vitamin B12 given strong prevalence of comorbidity. Prevalence of iron deficiency anemia estimated between 20 and 80% because of high prevalence of mixed cause which modified the answer. The major causes were reported as of digestive, gynecological and post-operative origins. The treatment is proposed from 9 g/dL. The oral iron and the transfusions are the most quoted. The possibility of injectable iron is reported only by 17%, of the geriatricians. CONCLUSION: The answers of the geriatricians show strong coherences in the management of the iron deficiency anemia. Guidelines should be adapted for elderly people for exercice capacity, mainly on high frequency of mixed cases.