Effect of the Great Recession on regional mortality trends in Europe.

Previous studies have consistently shown the recurrent relationship between macroeconomic cycles and changes in mortality trends, so that recessions are generally associated with periods of faster life expectancy rise, and periods of economic growth with slower reductions or even increases in mortality trends. Here we analyze the link between annual per capita estimates of gross domestic product and daily atmospheric temperatures and standardized death rates for a large ensemble of European regions to describe the effect of the Great Recession on annual and seasonal changes in all-cause human mortality trends. Results show that the countries and regions with the largest (smallest) economic slowdown were also those with the largest (smallest) strengthening of the declining mortality trend. This procyclical evolution of mortality rates is found to be stronger during the cold part of the year, showing that it also depends on the seasonal timing of the underlying causes of death.

Validation of the French Version of the Edmonton Symptom Assessment System.

CONTEXT: The Edmonton Symptom Assessment System (ESAS) is a brief, widely adopted, multidimensional questionnaire to evaluate patient-reported symptoms. OBJECTIVES: The objective of this study was to define a standard French version of the ESAS (F-ESAS) to determine the psychometric properties in French-speaking patients. METHODS: In a first pilot study, health professionals (n = 20) and patients (n = 33) defined the most adapted terms in French (F-ESAS). In a prospective multicentric study, palliative care patients completed the three forms of F-ESAS (F-ESAS-VI, F-ESAS-VE, and F-ESAS-NU, where VI is visual, VE, verbal, and NU, numerical), the Hospital Anxiety and Depression Scale. All patients had a test-retest evaluation during the same half-day. Standardized distraction material was used between each scale. RESULTS: One hundred twenty-four patients were included (mean age [±SD]: 68.3 ± 12; 70 women; 54 men). Test-retest reliability was high for all three F-ESAS, and the correlation between these scales was nearly perfect (Spearman rs = 0.66-0.91; P < 0.05). F-ESAS-VI, F-ESAS-VE, and F-ESAS-NU performed similarly and were equally reliable, although there was a trend toward lower reliability for F-ESAS-VI. Correlation between F-ESAS depression and anxiety and HADS depression and anxiety, respectively, were positive (Spearman rs = 0.38-0.41 for depression; Spearman rs = 0.48-0.57 for anxiety, P < 0.05). Among patients, 59 (48%), 45 (36%), and 20 (16%) preferred to assess their symptoms with F-ESAS-VE, F-ESAS-NU, and F-ESAS-VI, respectively. CONCLUSION: The F-ESAS is a valid and reliable tool for measuring multidimensional symptoms in French-speaking patients with an advanced cancer. All forms of F-ESAS performed well with a trend for better psychometric performance for F-ESAS-NU, but patients preferred the F-ESAS-VE.

Is patient satisfaction with organizational aspects of their general practitioner's practice associated with patient and doctor gender? An observational study.

BACKGROUND: No study has assessed the association between patients' and doctors' gender and patient satisfaction with organizational aspects of health care in primary care. However, just like satisfaction regarding communication styles or technical skills, satisfaction towards organization of the general practitioner (GP) practice could also depend on doctors' and/or patients' gender. Different expectations between female and male patients regarding the organization of the practice or different ways of organizing care delivery between female and male GPs could act on this satisfaction. We aimed to compare female and male patients' satisfaction towards their GP overall, and according to GPs' gender. METHODS: In a cross-sectional study in Geneva, 23 randomly selected GPs (participation rate: 31 %) were asked to recruit up to 100 consecutive patients coming to the practice for a scheduled medical consultation. The patients completed an anonymous questionnaire about their satisfaction with their GP. Patient satisfaction was assessed using the six questions from the Europep questionnaire regarding organizational aspects of health care in terms of accessibility and availability, and presented in two different ways: % of patients very satisfied and mean score (SD). Multivariate analyses adjusting for patient and GP characteristics were conducted to compare outcomes between genders. RESULTS: One thousand six hundred thirty-seven patients agreed to participate (participation rate: 97 %, women: 63 %, mean age: 54 years). The majority of patients were very satisfied (women 96.2 %, men 95.3 %, p = 0.38). Mean satisfaction scores were slightly higher in women (for overall satisfaction: women 4.7/5 (SD 0.6), men 4.6/5 (SD 0.6), p = 0.02) and in women visiting male GPs (women 4.6 (SD 0.6), men 4.5 (SD 0.6), p = 0.01), and the gender differences showed consistency across satisfaction items. These differences were small and no longer statistically significant in multivariate analyses. CONCLUSIONS: These findings suggest that patients are highly satisfied with the organization of their GP's practice, regardless of patients' and GPs' gender. As patients' and GPs' gender are known to influence patient satisfaction towards primary care delivery and as the current study is the first to explore this aspect in relation to organizational aspects of GP practice, further studies are needed in various primary care settings to confirm our results.

Assessment of mental workload: A new electrophysiological method based on intra-block averaging of ERP amplitudes.

The present study contributes to the current debate about electrophysiological measurements of mental workload. Specifically, the allocation of attentional resources during different complexity levels of tasks and its changes over time are of great interest. Therefore, we investigated mental workload using tasks varying in difficulty during an auditory oddball target paradigm. For data analysis, we applied a novel method to compute event-related potentials (ERPs) by intra-block epoch averaging of P2, P3a and P3b amplitude components for the infrequent target stimuli. We obtained eight consecutive blocks of 5 epochs each, which allowed us to develop an electrophysiological parameter to measure mental workload. In both the easy and the more constraining tasks, the amplitude of P2 decreased beginning with the second block of the sequence. In contrast, the amplitudes of P3a and P3b components linearly decreased following the repetition of the target in the more constraining task, but not in the easy task. Statistical analysis revealed intra-block differences on amplitudes of ERPs of interest between the easy and the more constraining tasks, confirming this method as a measure to assess mental workload. Since a subject is his own control, the present method represents an electrophysiological parameter for individual measurement of mental workload and may therefore be applicable in clinical routine.

Accuracy of the centenarian numbers in Okinawa and the role of the Okinawan diet on longevity: responses to Le Bourg about the article "Exploring the impact of climate on human longevity".

This response letter addresses two points raised by le Bourg when discussing our previous paper entitled "Exploring the impact of climate on human longevity". First, the arguments explaining the accuracy of the numbers of centenarian in Okinawa are developed, and second the composition and healthfulness of the traditional Okinawan diet are described as well as the changes in dietary pattern and their impact on longevity.

[Is it possible to reduce health inequalities in old age?]. / Est-il possible de réduire les inégalités de santé au grand âge?

Analysis of prospective data collected between 1984 and 2008 by the CERN medical team (European Centre of Nuclear Research, Geneva) concerning 2040 former employees who were retired or had died stimulated our interest on the impact of inequalities in socioeconomic conditions, employment, lifestyle and classical risk factors on health and life expectancy. Such inequalities explain differences in life expectancy, potentially reaching several decades, between rich and poor countries (France vs Swaziland), but also within a given country (USA), a given city (Glasgow) or even a given enterprise (CERN) where all employees have the same level of healthcare insurance and access to treatment. Classical cardiovascular and neurovascular risk factors (smoking, arterial hypertension and lipid disorders) interact with socioeconomic status, intelligence, education, emotions and job responsibility/complexity, precipitating or preventing cardiovascular events. The same is true of dementia, for which midlife risk factors (obesity, arterial hypertension and hypercholesterolemia) should be considered in the psychosocioeconomic context, which influences cognitive reserves and thus affects the risk and severity of dementia in old age. Thus, in addition to lifestyle and classical risk factors, socioeconomic status appears as a major health determinant, by imposing behaviors and habits and by determining access to healthcare.

[Intermediate geriatric care in Geneva: experience of ten years]. / Soins intermédiaires gériatriques a l'hôpital des Trois-Chêne: une expérience genevoise de dix ans.

Population aging has generated an increased demand for acute healthcare services in persons aged over 65, who may represent up to half of all patients treated in intensive care units (ICU). However, the number of available ICU beds is limited. Intermediate care units (IntCU) require less human and technical resources, and may represent an interesting alternative to intensive care in the geriatric population. This article describes a 10-year, single centre experience at a geriatrics IntCU in Geneva. We observed a significant reduction in in-hospital mortality after the creation of the IntCU (2000-2001) compared to the 2 years immediately preceding its inception (1998-1999).

Exploring the impact of climate on human longevity.

The purpose of this study was to examine the impact of physical geographic factors and climate conditions on human longevity. The centenarian rate (CR) in 2005 was computed for Japan's 47 prefectures, whose geography and climate vary greatly. Several pathways, such as excess winter mortality, land use and agricultural production, possibly linking physical and climate factors with extreme longevity, were explored. The probability of becoming a centenarian varies significantly among the Japanese prefectures. In particular, the computation of CR(70) demonstrated that the actual probability for individuals 70 years old in 1975 of becoming centenarians in 2005 was 3 times higher, on average, in Okinawa, both for males and females, than in Japan as a whole. About three quarters of the variance in CR(70) for females and half for males is explained by the physical environment and land use, even when variations in the level of socio-economic status between prefectures are controlled. Our analysis highlighted two features which might have played an important role in the longevity observed in Okinawa. First, there is virtually no winter in Okinawa. For instance, the mean winter temperature observed in 2005 was 17.2°C. Second, today, there is almost no rice production in Okinawa compared to other parts of Japan. In the past, however, production was higher in Okinawa. If we consider that long term effects of harsh winters can contribute to the mortality differential in old age and if we consider that food availability in the first part of the 20th century was mainly dependent on local production, early 20th century birth cohorts in Okinawa clearly had different experiences in terms of winter conditions and in terms of food availability compared to their counterparts in other parts of Japan. This work confirms the impact of climate conditions on human longevity, but it fails to demonstrate a strong association between longevity and mountainous regions and/or air quality.

The prognostic significance of malnutrition as assessed by the Mini Nutritional Assessment (MNA) in older hospitalized patients with a heavy disease burden.

BACKGROUND & AIMS: Malnutrition is common in older persons. However, it is unclear whether malnutrition diagnosed with the Mini Nutritional Assessment (MNA) predicts mortality in older hospitalized patients. METHODS: We prospectively studied the impact of the MNA-short form (MNA-SF) and co-morbidities on long-term mortality in 444 patients (mean age 85.3 ± 6.7; 74.0% women) receiving geriatric inpatient care. In a cross-sectional study we studied the interplay between the MNA, nutritional markers and co-morbidities (using the Cumulative Illness Rating Scale, CIRS). RESULTS: The prevalence of malnutrition and "at risk of malnutrition", defined by MNA-SF, was 25.5 and 50.5% respectively in our prospective study. CIRS scores (HR = 1.09, p < 0.001) and a low BMI (HR = 0.96, p < 0.05), but not the MNA-SF (HR = 0.79 and 0.89 for "at risk" and malnutrition respectively, P = NS), were associated with 4-year mortality. CIRS scores, albumin and other nutritional markers were similar between MNA categories. High CIRS scores and hypoalbuminemia were observed even in patients with normal MNA scores. There was good agreement (>80%) between the MNA-SF and the complete MNA. CONCLUSIONS: Malnutrition as diagnosed with the MNA at admission failed to predict long-term mortality in older inpatients, likely due to the overriding impact of co-morbidities and acute disease.

Comparison of the interobserver variability of 2 different methods of dietary assessment in a geriatric ward: a pilot study.

BACKGROUND: Protein-energy malnutrition is highly prevalent in aged populations. Associated clinical, economic, and social burden is important. A valid screening method that would be robust and precise, but also easy, simple, and rapid to apply, is essential for adequate therapeutic management. OBJECTIVES: To compare the interobserver variability of 2 methods measuring food intake: semiquantitative visual estimations made by nurses versus calorie measurements performed by dieticians on the basis of standardized color digital photographs of servings before and after consumption. DESIGN: Observational monocentric pilot study. SETTING/PARTICIPANTS: A geriatric ward. The meals were randomly chosen from the meal tray. The choice was anonymous with respect to the patients who consumed them. MEASUREMENTS: The test method consisted of the estimation of calorie consumption by dieticians on the basis of standardized color digital photographs of servings before and after consumption. The reference method was based on direct visual estimations of the meals by nurses. Food intake was expressed in the form of a percentage of the serving consumed and calorie intake was then calculated by a dietician based on these percentages. The methods were applied with no previous training of the observers. Analysis of variance was performed to compare their interobserver variability. RESULTS: Of 15 meals consumed and initially examined, 6 were assessed with each method. Servings not consumed at all (0% consumption) or entirely consumed by the patient (100% consumption) were not included in the analysis so as to avoid systematic error. The digital photography method showed higher interobserver variability in calorie intake estimations. The difference between the compared methods was statistically significant (P < .03). CONCLUSIONS: Calorie intake measures for geriatric patients are more concordant when estimated in a semiquantitative way. Digital photography for food intake estimation without previous specific training of dieticians should not be considered as a reference method in geriatric settings, as it shows no advantages in terms of interobserver variability.

Knowledge and attitude of elderly persons towards dental implants.

BACKGROUND: Despite their unrivalled place in restorative treatment, dental implants are still scarcely used in elderly patients. INTRODUCTION: The aim of this survey was therefore to identify potential barriers for accepting an implant treatment. MATERIALS AND METHODS: Participants were recruited from a geriatric hospital, two long-term-care facilities and a private clinic. The final study sample comprised 92 persons, 61 women and 31 men with an average age of 81.2 ± 8.0 years. In a semi-structured interview, the participants' knowledge of implants and attitude towards a hypothetical treatment with dental implants were evaluated. RESULTS: Twenty-seven participants had never heard of dental implants, and another 13 participants could not describe them. The strongest apprehensions against implants were cost, lack of perceived necessity and old age. Univariate and multiple linear regression analysis identified being women, type and quality of denture, having little knowledge on implants and being hospitalised as the risk factors for refusing implants. However, old age as such was not associated with a negative attitude. CONCLUSION: The acceptance of dental implants in the elderly population might be increased by providing further information and promoting oral health in general. Regardless of the age, dental implants should be placed when patients are still in good health and live independently.

[General trend of hip fractures]. / Tendances séculaires des fractures de hanche.

Osteoporosis constitutes a major public health problem and hip fractures are a major cause of burden associated with osteoporosis in terms of mortality, disability, and costs. Since around 1990, a trend for a decrease of the age-adjusted incidence of hip fractures has been observed in western countries, particularly in women. In Geneva, with a confirmation at the Swiss level, a similar secular trend was observed. Nevertheless, due to the ageing of the population, this decrease of the incidence of hip fracture will probably not be sufficient to reduce the absolute number of these fractures over the next decades. Furthermore, age-adjusted hospitalizations in Switzerland for major non-hip osteoporotic fractures have continued to increase these last years.

[Fee schedules and cost containment]. / Tarifs, forfaits et economicité.

Medical fee schedules are controversial. In this paper we examine the reasons that justify the imposition of fee schedules in the presence of a socially financed health insurance system, and examine the ways of constructing a medical fee schedule. The weakness of fee-for-service tariffs is that they do not allow a control of health care costs if the volume of services is unchecked. Current solutions to this problem--audit of doctors' average cost per case, freeze on new medical practices, or the insurers' discretion in choosing the doctors they reimburse--have multiple drawbacks. Alternatives to fee-for-service payment--such as flat fees, or payment based on the quality of medical services--are discussed.

Submission of the entire lymph node dissection for histologic examination in gynecologic-oncologic specimens. Clinical and pathologic relevance.

BACKGROUND AND AIMS: Lymph node (LN) status in gynecologic malignancies plays an important role in patient staging, management, and prognosis. Therefore, an adequacy of LN harvest is crucial. The aim of this study is to determine whether the submission of the entire LN dissection for histologic examination will affect patients' outcome or clinical stage. We also evaluated the time required and cost-effectiveness for the laboratory. MATERIALS AND METHODS: A prospective study of 134 surgical cases from various gynecologic malignancies was conducted. The LN dissection specimen was performed using a conventional manual node dissection method with all the remaining fat being submitted in additional cassettes. One pathologist evaluated (1) the number and status of palpable LNs identified by the conventional method as well as the number of tissue cassettes and (2) the number, size, and status of the non-palpable LNs as well as the number of tissue cassettes. RESULTS: The palpable LNs ranged from 0 to 36 with average 14.8 LNs per case (Poisson 95% CI: 14.1-15.4). The additional non-palpable LNs ranged from 0 to 16 with an average of 3.1 (Poisson 95% CI: 2.8-3.4). In only one case, a 3-mm non-palpable LN with metastasis was identified; however, it did not affect tumor staging or patient management. CONCLUSION: The impact on patient outcome is minimal and it does not prove to be cost and time effective when submitting the entire LN dissection specimen in gynecologic malignancies. However, this method could be justified in selective cases in which the manual node dissection does not reveal an adequate number of LNs.

Longitudinal assessment of psychotherapeutic day hospital treatment for neuropsychiatric symptoms in dementia.

OBJECTIVE: Behavioral and psychological symptoms (BPSD) of dementia are associated with more rapid cognitive deterioration as well as increased caregiver stress. The effectiveness of psychiatric day hospital care for this condition remains disputed. We report here the assessment of a psychotherapeutic day hospital program in a series of elderly people with dementia and concomitant BPSD. METHODS: Treatment setting: The day hospital program combined music, movement, psychodynamic group therapies, sociotherapy as well as individual interviews and family interventions. PARTICIPANTS: 76 individuals with mild to moderate dementia. OUTCOME MEASURES: The Neuropsychiatric Inventory (NPI), Therapeutic Community Assessment scale including staff (SAS) and client assessments (CAS) and a Group Evaluation Scale (GES) were administrated at admission, 3, 6 and 12 months and discharge. RESULTS: Linear regression analysis showed that SAS (but not CAS) and GES scores significantly increased while the NPI total scores decreased across the different time points. NPI item score modifications were significant for anxiety and apathy. These changes remained significant when demographic variables, drug treatment changes and occurrence of life events were also considered. CONCLUSION: A psychotherapeutic day hospital program designed for older people with dementia and neuropsychiatric symptoms allows for a significant reduction of anxiety and apathy, better adhesion to therapeutic community treatment and clinical progress in group therapy. Controlled interventional studies are needed to further confirm these data.

Longitudinal assessment of psychotherapeutic day hospital treatment for elderly patients with depression.

OBJECTIVE: Although previous studies suggested that psychiatric day hospital care is a valuable alternative to inpatient treatment, its effectiveness for elderly patients is disputed. Small number of cases, poor definition of the psychotherapeutic setting, and absence of systematic assessment at different time points may explain the observed discrepancies. We performed an assessment of a psychiatric day hospital treatment combining individual and group psychotherapy in a series of 122 elderly depressed outpatients. METHODS: The Geriatric Depression Scale, Short Form Survey, as well as a Therapeutic Community Assessment Scale and Group Evaluation Scale were repeated at admission, 3, 6, 12 months and discharge. The day hospital program was based on psychotherapeutic treatment combining individual and group settings. All patients presented with major depression or a depressive episode of bipolar disease. Variables included severity of depressive symptoms, quality of life, adhesion to therapeutic community treatment and progress in groups of psychotherapy, art-therapy, and psychomotricity. RESULTS: There was a significant reduction of depressive symptoms, and improvement in mental quality of life across all time points studied. Adhesion to therapeutic community increased from admission to discharge. This was also the case for the progress in group therapy for all three groups used, yet the evolution of this parameter at intermediate time points was highly variable. Neither demographic characteristics, nor pharmacological treatment or presence of stressful life events predicted the clinical improvement. CONCLUSIONS: Psychotherapeutic care program in day hospitals may improve clinical status and quality of life in elderly depressed patients.

Psychometric properties of the Doloplus-2 observational pain assessment scale and comparison to self-assessment in hospitalized elderly.

OBJECTIVES: Self-report is the "gold standard" for pain assessment, however, observational pain scales, such as Doloplus-2 must be used for patients who cannot communicate. In this follow-up study, we report the psychometric properties of the observational Doloplus-2 scale using the visual analog scale (VAS) pain score as a gold standard and evaluate its performance. METHOD: Prospective clinical study of 180 hospitalized older patients who demonstrated good comprehension and reliable use of the VAS: 131 participants with dementia and 49 without. All participants assessed their chronic pain using the VAS. Doloplus-2 was independently completed by the nursing team. RESULTS: Mean age of patients (133 women, 47 men) was 83.7+/-6.5. Median mini-mental state examination of patients with diagnosis of dementia was 18.0+/-7.7. Nearly half of the patients (49%) reported that they experienced pain in response to a direct question. The administration of Doloplus-2 was possible in all 180 patients. Doloplus-2 correlated moderately with self-assessment (Spearman coefficient: 0.46). In a multiple regression model, Doloplus-2 predicted 41% of the variability in pain intensity measured by VAS. The somatic dimension alone explained 36% of the variance, the psychosocial bloc 5% with no better contribution of the psychomotor bloc. To shorten Doloplus-2, we constructed a version with only the 5 items that were significantly associated with the VAS score in the multiple regression models. DISCUSSION: The observational Doloplus-2 scale correlates moderately with self-assessment pain score and has adequate internal consistency. Our data also suggest that Doloplus-2 could be substantially shortened as the brief version performed similarly to the complete Doloplus-2.

Structured assessment of mental health status in psychogeriatrics: validity of the French HoNOS65+.

OBJECTIVE: To assess the reliability, validity, and feasibility of a French version of the Health of the Nation Outcome Scales for Elderly People (HoNOS65+). METHOD: Twenty mental health professionals completed the scale for 126 elderly patients. We assessed interrater reliability in inpatient and outpatient settings, together with construct and discriminant validity, as well as concurrent validity compared with several widely used clinical instruments. RESULTS: Excellent agreement among raters was observed in the outpatient subgroup (kappa range 0.77 to 1.00), whereas interrater reliability was modest in the inpatient subgroup (kappa values < 0.55). In cases where the patient-caregiver relationship lasted more than 1 month, the reliability of the scale improved. Construct validity analysis revealed no subscale structure. All items except "self-injury" displayed high concurrent validity (significant Spearman correlations with 8 other questionnaires). In terms of discriminant validity, the "cognitive impairment" (area under the curve [AUC] 0.91) and "depressive symptoms" (AUC 0.79) items showed high sensitivity and specificity values. CONCLUSION: Our results indicate that the French version of HoNOS65+ is a promising clinical assessment tool to evaluate mental disorders in the elderly in outpatient settings. We support its use in routine clinical practice, with the condition that a relatively long and individualized patient-caregiver relationship has been established.

Pain in severe dementia: self-assessment or observational scales?

OBJECTIVES: To assess the performance of self-assessment scales in severely demented hospitalized patients and to compare it with observational data. DESIGN: Prospective clinical study. SETTING: Geriatrics hospital and a geriatric psychiatry service. PARTICIPANTS: All patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for dementia, with a Mini-Mental State Examination score less than 11 and a Clinical Dementia Rating score of 3. MEASUREMENTS: Three self-assessment tools--the verbal, horizontal visual, and faces pain scales--were administered in randomized order. A nursing team independently completed an observational pain rating scale. Main outcomes were comprehension (ability to explain scale use and correctly indicate positions for no pain and extreme pain, on two separate occasions), inter- and intrarater reliability, and comparison of pain intensities measured by the different scales. RESULTS: Sixty-one percent of 129 severely demented patients (mean age 83.7, 69% women) demonstrated comprehension of at least one scale. Comprehension rates were significantly better for the verbal and the faces pain scales. For patients who demonstrated good comprehension, the inter- and intrarater reliability of the three self-assessment scales was high (intraclass correlation coefficient=0.88-0.98). Correlation between the three self-assessment scales was moderate to strong (Spearman correlation coefficient (r)=0.45-0.94; P<.001). Observational rating correlated at least moderately with self-assessment (r=0.25-0.63), although for patients reporting pain, the observational rating scale underestimated severity compared with all three self-assessment scales. CONCLUSION: Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.