[Age related dehydroepiandrosterone decrease: clinical significance and therapeutic interest]. / Baisse de la déhydroépiandrostérone avec l'âge: pertinence clinique et intérêt thérapeutique.

Dehydroepiandrosterone (DHEA) and its sulfate ester (DHEAS) are the most abundant steroids in humans, but their levels fall with age. This decrease has been associated with several age related diseases such as falls, osteoporosis, depression, atherosclerosis and sexual disorders. Moreover, studies have shown positive effects of DHEA administration on several of these disorders, with a satisfying safety profile. Unfortunately, DHEA has been too frequently mediatized as a "fountain of youths, which was responsible for either inadequate prescription, or prescription refusal. Longer studies in large populations should help to better define indications, treatment modalities and long-term treatment safety.

The Hospital Anxiety and Depression Scale: low sensitivity for depression screening in demented and non-demented hospitalized elderly.

BACKGROUND: We currently use the depression subscale (HADD) of the Hospital Anxiety and Depression Scale (HADS) for depression screening in elderly inpatients. Given recent concerns about the performance of the HADD in this age group, we performed a quality-control study retrospectively comparing HADD with the diagnosis of depression by a psychiatrist. We also studied the effect of dementia on the scale's performance. METHODS: HADS produces two 7-item subscales assessing depression or anxiety. The HADD was administered by a neuropsychologist. As "gold standard" we considered the psychiatrist's diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Patients older than 65 years, assessed by both the HADD and the psychiatrist, with a clinical dementia rating (CDR) score lower than 3, were included. The effect of dementia was assessed by forming three groups according to the CDR score (CDR0-0.5, CDR1, and CDR2). Simple and multiple logistic regression models were applied to predict the psychiatrist's depression diagnosis from HADD scores. Areas under the receiver operating characteristics curve (AUC) were plotted and compared by χ(2) tests. RESULTS: On both univariate and multiple analyses, HADD predicted depression diagnosis but performed poorly (univariate: p = 0.009, AUC = 0.60 (95% confidence interval (CI) = 0.53-0.66); multiple: p = 0.007, AUC = 0.65 (95% CI = 0.58-0.71)), regardless of cognitive status. Because mood could have changed between the two assessments (they occurred at different points of the hospital stay), the multiple analyses were repeated after limiting time interval at 28, 21, and 14 days. No major improvements were noted. CONCLUSION: The HADD performed poorly in elderly inpatients regardless of cognitive status. It cannot be recommended in this population for depression screening without further study.

[Dementia prevention: potential treatments and how to target high risk patients]. / Prévention de la démence: comment cibler les patients a risque et traitements potentiels.

The burden related to the ever-increasing dementia prevalence in older individuals, imposes the implementation of prevention strategies. It is now known that brain lesions related to Alzheimer's disease precede the onset of the first symptoms. Consequently, prevention strategies should be implemented early, before clinically overt dementia. Blood and spine fluid tests, electroencephalogram, brain magnetic resonance and brain nuclear imaging should help physicians to better target "high-risk" patients prone to benefit from such strategies, already in a preclinical disease stage. Since no efficient pharmacological treatments exist for the time being, lifestyle factors such as nutritionand physical exercise are the cornerstones for dementia prevention.

Mediating role of atherogenic lipoproteins in the relationship between liver fat and coronary artery calcification.

Non-alcoholic fatty liver disease (NAFLD) is associated with increased secretion of apoB-containing lipoproteins and increased risk of coronary heart disease (CHD). ApoB-containing lipoproteins include low-density lipoproteins (LDLs) and triglyceride-rich lipoproteins (TRLs); and since both LDLs and TRLs are causally related to CHD, they may mediate a portion of the increased risk of atherosclerosis seen in people with NAFLD. In a cohort of 4161 middle aged men and women, we performed mediation analysis in order to quantify the mediating effect of apoB-containing lipoproteins in the relationship between liver fat and atherosclerosis-as measured by coronary artery calcium score (CACS). We found plasma apoB to mediate 17.6% (95% CI 11-24) of the association between liver fat and CACS. Plasma triglycerides and TRL-cholesterol (both proximate measures of TRL particles) mediated 22.3% (95% CI 11-34) and 21.6% (95% CI 10-33) of the association respectively; whereas LDL-cholesterol mediated 5.4% (95% CI 2.0-9.4). In multivariable models, the mediating effect of TRL-cholesterol and plasma triglycerides showed, again, a higher degree of mediation than LDL-cholesterol, corroborating the results seen in the univariable models. In summary, we find around 20% of the association between liver fat and CACS to be mediated by apoB-containing lipoproteins. In addition, we find that TRLs mediate the majority of this effect whereas LDLs mediate a smaller effect. These results explain part of the observed CAD-risk burden for people with NAFLD and further suggest that TRL-lowering may be particularly beneficial to mitigate NAFLD-associated coronary artery disease risk.

[The impact of medication on vitamins and trace elements]. / Statut en vitamines et en oligoéléments: impact des médicaments.

Epidemiological studies have shown that vitamin or trace-element deficiencies are frequent in the general population. Food intake can be incriminated, but various drugs may also precipitate micronutrient deficits. Indeed, the consequences of pharmacotherapy on micronutrients are yet modestly explored in clinical practice settings. We aim at sensitizing physicians on the impact of frequently used drugs on vitamins and trace-elements. High risk populations for micronutrient deficiencies and indications for substitution are discussed.

Femur Osteomyelitis and Associated Fracture as an Initial Presentation of Aortoenteric Fistula.

Aortoenteric fistula is a rare condition. Atypical presentations may cause significant management delays. We present the case of a 64-year-old male who experienced a pathological femoral fracture as an initial presentation of an underlying aortoenteric fistula. The aortoenteric fistula, possibly related to a poor graft tunneling technique, induced femur osteomyelitis and the associated pathological fracture.

Predicting Goal-directed Attention Control Using Inverse-Reinforcement Learning.

Understanding how goals control behavior is a question ripe for interrogation by new methods from machine learning. These methods require large and labeled datasets to train models. To annotate a large-scale image dataset with observed search fixations, we collected 16,184 fixations from people searching for either microwaves or clocks in a dataset of 4,366 images (MS-COCO). We then used this behaviorally-annotated dataset and the machine learning method of inverse-reinforcement learning (IRL) to learn target-specific reward functions and policies for these two target goals. Finally, we used these learned policies to predict the fixations of 60 new behavioral searchers (clock = 30, microwave = 30) in a disjoint test dataset of kitchen scenes depicting both a microwave and a clock (thus controlling for differences in low-level image contrast). We found that the IRL model predicted behavioral search efficiency and fixation-density maps using multiple metrics. Moreover, reward maps from the IRL model revealed target-specific patterns that suggest, not just attention guidance by target features, but also guidance by scene context (e.g., fixations along walls in the search of clocks). Using machine learning and the psychologically meaningful principle of reward, it is possible to learn the visual features used in goal-directed attention control.

Older patients in the emergency department: a review.

Older patients account for up to a quarter of all emergency department (ED) visits. Atypical clinical presentation of illness, a high prevalence of cognitive disorders, and the presence of multiple comorbidities complicate their evaluation and management. Increased frailty, delayed diagnosis, and greater illness severity contribute to a higher risk of adverse outcomes. This article will review the most common conditions encountered in older patients, including delirium, dementia, falls, and polypharmacy, and suggest simple and efficient strategies for their evaluation and management. It will discuss age-related changes in the signs and symptoms of acute coronary events, abdominal pain, and infection, examine the yield of different diagnostic approaches in this population, and list the underlying medical problems present in half of all "social" admission cases. Complete geriatric assessments are time consuming and beyond the scope of most EDs. We propose a strategy based on the targeting of high-risk patients and provide examples of simple and efficient tools that are appropriate for ED use.

Midterm experience of Scarf osteotomy as a new technique in a General Orthopaedic Department.

Scarf osteotomy has become popular as a versatile procedure that could correct most cases of hallux valgus. The purpose of this study is to report the experience with scarf osteotomy performed as a new technique by different surgeons of a general orthopaedic department. This study reviewed the outcome of 67 patients with 78 feet with hallux valgus deformity treated by scarf osteotomy at our institution, with an average follow-up of 24 months (12-84). Results were analyzed by clinical examination, a questionnaire including the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score and plain radiographs. The mean AOFAS score increased from 35 points (range, 15-50) preoperatively to 87 points (range, 73-100) at the final follow-up. The radiological angles Hallux Valgus Angle (HVA), 1-2 Intermetatarsal Angle (IMA) and Tibial Sesamoid Position (TSP) improved significantly. Among the 7 recurrences and 15 complications recorded, seven required an additional procedure. Multiple potential pitfalls can occur with scarf osteotomy. Although soft tissue dissection is relative extensive, adherence to careful technique and endurance to the learning curve can produce effective radiological correction of hallux valgus and good clinical results. LEVEL OF CLINICAL EVIDENCE: III.

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.

Off-label use of hormones as an antiaging strategy: a review.

Given demographic evolution of the population in modern societies, one of the most important health care needs is successful aging with less frailty and dependency. During the last 20 years, a multitude of anti-aging practices have appeared worldwide, aiming at retarding or even stopping and reversing the effects of aging on the human body. One of the cornerstones of anti-aging is hormone replacement. At present, women live one third of their lives in a state of sex-hormone deficiency. Men are also subject to age-related testosterone decline, but andropause remains frequently under-diagnosed and under-treated. Due to the decline of hormone production from gonads in both sexes, the importance of dehydroepiandrosterone (DHEA) in steroid hormone production increases with age. However, DHEA levels also decrease with age. Also, growth hormone age-associated decrease may be so important that insulin growth factor-1 levels found in elderly individuals are sometimes as low as those encountered in adult patients with established deficiency. Skin aging as well as decreases in lean body mass, bone mineral density, sexual desire and erectile function, intellectual activity and mood have all been related to this decrease of hormone production with age. Great disparities exist between recommendations from scientific societies and actual use of hormone supplements in aging and elderly patients. In this article, we review actual data on the effects of age related hormone decline on the aging process and age-related diseases such as sarcopenia and falls, osteoporosis, cognitive decline, mood disorders, cardiovascular health and sexual activity. We also provide information on the efficiency and safety of hormone replacement protocols in aging patients. Finally, we argue on future perspectives of such protocols as part of everyday practice.

Pulmonary rehabilitation: the reference therapy for undernourished patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) combines the deleterious effects of chronic hypoxia, chronic inflammation, insulin-resistance, increased energy expenditure, muscle wasting, and exercise deconditioning. As for other chronic disorders, loss of fat-free mass decreased survival. The preservation of muscle mass and function, through the protection of the mitochondrial oxidative metabolism, is an important challenge in the management of COPD patients. As the prevalence of the disease is increasing and the medical advances make COPD patients live longer, the prevalence of COPD-associated nutritional disorders is expected to increase in future decades. Androgenopenia is observed in 40% of COPD patients. Due to the stimulating effects of androgens on muscle anabolism, androgenopenia favors loss of muscle mass. Studies have shown that androgen substitution could improve muscle mass in COPD patients, but alone, was insufficient to improve lung function. Two multicentric randomized clinical trials have shown that the association of androgen therapy with physical exercise and oral nutritional supplements containing omega-3 polyinsaturated fatty acids, during at least three months, is associated with an improved clinical outcome and survival. These approaches are optimized in the field of pulmonary rehabilitation which is the reference therapy of COPD-associated undernutrition.

A review of age-related dehydroepiandrosterone decline and its association with well-known geriatric syndromes: is treatment beneficial?

Dehydroepiandrosterone (DHEA) and its sulfate ester are the most abundant steroids in humans. DHEA levels fall with age in men and women, reaching values sometimes as low as 10%-20% of those encountered in young individuals. This age-related decrease suggests an "adrenopause" phenomenon. Studies point toward several potential roles of DHEA, mainly through its hormonal end products, making this decline clinically relevant. Unfortunately, even if positive effects of DHEA on muscle, bone, cardiovascular disease, and sexual function seem rather robust, extremely few studies are large enough and/or long enough for conclusions regarding its effects on aging. Moreover, because it has been publically presented as a "fountain of youth" equivalent, over-the-counter preparations lacking pharmacokinetic and pharmacodynamic data are widely used worldwide. Conceptually, supplementing a pre-hormone is extremely interesting, because it would permit the human organism to adequately use it throughout long periods, increasing or decreasing end products according to his needs. Nevertheless, data on the safety profile of long-term DHEA supplementation are still lacking. In this article, we examine the potential relation between low DHEA levels and well-known age-related diseases, such as sarcopenia, osteoporosis, dementia, sexual disorders, and cardiovascular disease. We also review risks and benefits of existing protocols of DHEA supplementation.

Effects of widely used drugs on micronutrients: a story rarely told.

Vitamins and trace elements are essential to the body, however, deficiencies are frequently observed in the general population. Diet is mostly responsible for these deficiencies but drugs also may play a significant role by influencing their metabolism. These effects are rarely assessed in clinical practice, in part because of limited data available in the literature. Drug-induced micronutrient depletions, however, may be the origin of otherwise unexplained symptoms that might sometimes influence medication compliance. We present various examples of widely prescribed drugs that can precipitate micronutrient deficiencies. This review aims at sensitizing physicians on drug-micronutrient interactions. High-risk population groups also are presented and supplementation protocols are suggested.

A view of geriatrics through hormones. What is the relation between andropause and well-known geriatric syndromes?

Age related male hypogonadism, or "andropause", is increasingly recognized as of frequent occurrence in older patients. Diagnosis requires both the presence of clinical symptoms and low testosterone levels. However, diagnosing andropause in this age group may be challenging since symptoms are frequently non specific and testosterone levels are influenced by a multitude of parameters such as lifestyle factors and chronic diseases. In this article we discuss the pathophysiology, definition and diagnostic difficulties of andropause in geriatric patients. Moreover, we review the relation between testosterone levels and frequent geriatric syndromes such as falls, osteoporosis, cognitive and mood disorders, anemia and cardiovascular disease. Finally, we examine the potential benefits and risks of testosterone replacement therapy in this age group.

Aging adults and seasonal influenza: does the vitamin d status (h)arm the body?

Vitamin D (VitD), although originally described as an essential hormone for bone and mineral homeostasis, appears to have an active role in regulating specific facets of human immunity. Indeed, VitD has been shown to have significant effects on cytokine production and lymphocyte proliferation. Evidence that VitD affects clearance of selected pathogens is supported by epidemiological and clinical data, while its coadministration with influenza vaccine in mice enhanced both mucosal and systemic antibody responses. This paper aims to examine how VitD may contribute to limiting the burden of influenza infection in the aging and aged adults, a population in which this burden remains considerable. Furthermore, we discuss how VitD status may play a role in host resistance to influenza virus and influence the immunogenicity of the influenza vaccines currently licensed for adults aged 65 years or over by its effects on innate and adaptive immunities.

Testosterone replacement therapy in reversing "andropause": what is the proof-of-principle?

Abstract Testosterone replacement therapy is often equated with the macho male physique and virility and is viewed by some as an antiaging tonic. The growth in testosterone's reputation and its increased use by men of all ages has seemed to outpace the scientific evidences. This review will aim to examine the uncertainty regarding the nature and the clinical importance of the age-related reduction in the testosterone levels. Considerations will be given both to clinical symptoms, biochemical and clinical diagnostic criteria, and to the risk-to-benefit ratio of reversing late-onset hypogonadism in aging and older men.

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.

Delayed fracture of a zirconium head after total hip arthroplasty.

We present a case of fracture of a zirconium head after a cemented total hip arthroplasty. The fracture occurred 81 months after the index operation without any history of trauma. The patient was thin, not participating in sports, and the zirconium head had 0-mm neck length. Preoperative radiographs demonstrated aseptic loosening of both components and significant polyethylene wear. Fracture pattern was unusual as the major fragment was half of the head. A revision was performed to a cementless arthroplasty. The authors have obtained the patient's informed written consent for print and electronic publication of the case report.

Influenza vaccination in the face of immune exhaustion: is herd immunity effective for protecting the elderly?

At the start of the 21st century, seasonal influenza virus infection is still a major public health concern across the world. The recent body of evidence confirms that trivalent inactivated influenza vaccines (TIVs) are not optimal within the population who account for approximately 90% of all influenza-related death: elderly and chronically ill individuals regardless of age. With the ever increasing aging of the world population and the recent fears of any pandemic influenza rife, great efforts and resources have been dedicated to developing more immunogenic vaccines and strategies for enhancing protection in these higher-risk groups. This paper describes the mechanisms that shape immune response at the extreme ages of life and how they have been taken into account to design more effective immunization strategies for these vulnerable populations. Furthermore, consideration will be given to how herd immunity may provide an effective strategy in preventing the burden of seasonal influenza infection within the aged population.