Mobility impairment is associated with urge but not stress urinary incontinence in community-dwelling older women: results from the Ossébo study.

OBJECTIVE: To assess the association between functional limitations related to mobility and urinary incontinence (UI) in elderly women. DESIGN: An observational cross-sectional study. SETTING: Nine 'balance' workshops in France. POPULATION: A total of 1942 community-dwelling women aged 75-85 years, who were invited, based on voter registration lists, to a 'balance assessment'. METHODS: Mobility and balance test results for incontinent women were compared with those for continent women according to the severity and type of incontinence. MAIN OUTCOME MEASURES: Data on UI were collected using a self-administered questionnaire (International Consultation on Incontinence Questionnaire-Short Form). Motor-related physical abilities were assessed using standardised balance and functional gait tests. RESULTS: Forty-two per cent of women had involuntary urine leakage, with daily leaks in 57% of them; 24% had stress UI, 31% had urge UI, and 37% had mixed UI. Results for each functional test were poorer for women with UI and the limitation was more pronounced when the incontinence was severe. Multivariate logistic regression analyses showed that balance and gait impairments were significantly and independently associated with urge UI (walking speed, lower versus higher quartile, odds ratio (OR) 2.2; 95% confidence interval (95% CI) 1.4-3.5; walking balance, unable versus able to do four tandem steps (OR 1.6; 95% CI 1.2-2.2) but not with stress UI. CONCLUSIONS: In this large population of older women living at home, there was a strong association between limitation of motor and balance skills and UI, which was proportional to the severity of incontinence and related specifically to urge incontinence. These results offer new perspectives on the prevention and treatment of urge incontinence in elderly women.

[Evaluation of a multifaceted intervention for implementing national guidelines: the case of physical restraint in geriatric care]. / Evaluation d'une intervention multiple pour implanter des recommandations nationales: le cas de la contention physique passive en gériatrie.

BACKGROUND: There is a growing interest in developing guidelines. The French Agency for accreditation and Evaluation (Anaes) published in October 2000 guidelines on the use of restraint in geriatric care settings because in spite of the risks this practice remains widespread in that type of care setting. A multifaceted intervention was conducted in a Parisian geriatric hospital in order to improve the implementation of the published guidelines. An epidemiological study was conducted to assess the outcomes of this intervention. METHODS: The intervention consisted in distributing educational materials and a specific prescription sheet, and in staff training sessions. A time series study was used to assess outcomes. The three time points were: before the intervention, just after the end of the intervention and one year later. Two dimensions were studied: implementation of the guidelines using markers collected from patients' charts and restraining practices noted in an observational study of hospitalized patients. RESULTS: The results of the study suggest that five recommendations were followed better: restraint prescription (8.7 to 57.4%), writing in the patient chart the reasons for restraining (3.5 to 35.3%), follow-up prescription, assessment of potential benefits and risks for the patient and patient information (0% to 19-34%). Nevertheless, the prevalence of restraint and of devices employed (around 70%) remained unchanged after the intervention. The various outcomes of the intervention might be explained by the guidelines themselves, which were variably practical or precise. Moreover, the effect of certain factors directly related with the use of restraint, a routine practice strongly supported by myths about its efficacy, as well as factors related to intervention design may merely have prevented any decrease in the use of restraint practices. CONCLUSION: Multifaceted intervention can favour implementation of certain national guidelines such as prescribing restraint, but can also fail in stimulating the implementation of others such as decreasing the prevalence of restraint in geriatric practice. Therefore the next intervention should emphasize alternatives to physical restraint practices.

Predictors of life satisfaction amongst retired people in Paris.

BACKGROUND: The objective of the present study was to examine predictors of life satisfaction in a survey of retired men and women living in the Paris Metropolitan area. METHODS: In all 627 subjects took part in the first phase of the survey (1982-1983, T1), and 464 in the follow-up phase (1987-1988, T2) during which life satisfaction was evaluated, using the Life Satisfaction Index A (LSIA). Possible predictors were explored among the factors characterizing subjects at T1 and among those related to their occupational history. RESULTS: In the multivariate analyses, significant relationships were found between life satisfaction and the number of physical impairments and leisure activities, marital and mental health status and family relations. Taking into account the changes in these factors between the two phases of the survey increased the predictiveness of the regression models. CONCLUSIONS: These results confirm the links between life satisfaction and the factors generally recognized as its determinants. On the other hand, no effect of past occupational characteristics on life satisfaction long after retirement was shown.

Nosocomial infections in geriatric long-term-care and rehabilitation facilities: exploration in the development of a risk index for epidemiological surveillance.

OBJECTIVE: To compute a risk index for nosocomial infection (NI) surveillance in geriatric long-term-care facilities (LTCFs) and rehabilitation facilities. DESIGN: Analysis of data collected during the French national prevalence survey on NIs conducted in 1996. Risk indices were constructed based on the patient case-mix defined according to risk factors for NIs identified in the elderly. SETTING: 248 geriatric units in 77 hospitals located in northern France. PARTICIPANTS: All hospital inpatients on the day of the survey were included. RESULTS: Data from 11,254 patients were recorded. The overall rate of infected patients was 9.9%. Urinary tract, respiratory tract, and skin were the most common infection sites in both rehabilitation facilities and LTCFs. Eleven risk indices, categorizing patients in 3 to 7 levels of increasing NI risk, ranging from 2.7% to 36.2%, were obtained. Indices offered risk adjustment according to NI rate stratification and clinical relevance of risk factors such as indwelling devices, open bedsores, swallowing disorders, sphincter incontinence, lack of mobility, immunodeficiency, or rehabilitation activity. CONCLUSION: The optimal index should be tailored to the strategy selected for NI surveillance in geriatric facilities in view of available financial and human resources.

Physical diability after retirement and occupational risk factors during working life: a cross sectional epidemiological study in the Paris area.

STUDY OBJECTIVE: The aim was to examine the relationship between exposure to occupational risk factors during working life and physical disability after retirement. DESIGN: The study was a cross sectional epidemiological survey of a representative sample of retired subjects belonging to a supplementary pension fund in the Paris area. SETTING: The study took place in the general community. PATIENTS: 307 men and 320 women (63.1% of those approached) answered a questionnaire during home interviews. Their average age was 69 (SD4) years at the beginning of the survey. Whether or not subjects had been exposed to occupational risks was determined from their statements concerning the presence or absence of eight harmful environmental conditions while at work. Physical disability was defined as difficulty in carrying out seven basic activities of daily life. MAIN RESULTS: The results of univariate analyses showed significant relationships between exposure during working life to occupational risks including noise, heat, dust, carrying heavy loads, and awkward postures on the one hand, and the presence of a physical disability after retirement on the other. Multivariate analysis based on logistic regression models that took account of age, sex, and health impairments revealed a specific link between exposure to carrying heavy loads and physical disability after retirement. CONCLUSIONS: These results suggest that occupational risk factors might be important in determining such disability in retired people.

Social prognostic factors of mortality in a random cohort of Geneva subjects followed up for a period of 12 years.

STUDY OBJECTIVE: To analyse the relative risk (RR) of mortality related to social factors independent of health status and occupational category. SETTING: Subjects were Swiss men and women aged 40-65 years. DESIGN: A random sample of 820 people living in Geneva were followed up prospectively between 1984 and 1996. The social, occupational, and health data were gathered at subjects' homes in 1984 using a standardised questionnaire. Information about deaths and the corresponding dates were obtained from updated files of the Swiss Federal Office of Statistics (OFS). Risk of mortality was examined according to a Cox model. MAIN RESULTS: There were several social prognostic factors of mortality with relative risks greater than 3.0 (RR > 3.0) independent of health and occupational status. These factors were: a period of unemployment during life time, the feeling of not demonstrating initiative in the occupational setting, and not having participated in social activities. CONCLUSION: The results suggest that differential mortality determined by occupational status can be explained in part by factors that are characteristic of "life style", social dynamics, occupational context, and ruptures during the course of occupational life.

Relation between locomotion impairment, functional independence in retirement, and occupational strain resulting from work carried out during working life. Study of a sample population of 350 miners in the Loire valley in France.

STUDY OBJECTIVES: To analyse long term effects of working conditions experienced at an advanced age, and after retirement by quantifying occupational strain, impairment, and disability to establish their interrelation. DESIGN: Retrospective study. PARTICIPANTS: Retired miners from The French Coal Board who had worked in the coal fields of the Loire valley. From a potential population of 507 retired miners, 350 were completely evaluated. MEASUREMENT: The study examines the occupational strain experienced by each subject, measured using both auto-evaluation and evaluation by experts and the locomotion impairment and the functional independence. MAIN RESULTS: A significant relation between the evaluation of occupational strain and functional independence and locomotion impairment of the low back was found and also a significant relation between locomotion impairment of the low back and the length of time spent working at the coal face. CONCLUSIONS: This study confirms other studies as regards the effects of occupation on health status and on the aging process, but it goes further to show the consequences of this relation on functional independence.

Risk factors of early menopause in two generations of gainfully employed French women.

OBJECTIVES: Numerous studies have been focused on the detection of factors which can act on the age of menopause. Little is known about the factors related to the occurrence of an early menopause. Some factors such as occupational work factors and generational effects have not been taken into account as yet. METHODS: We examined the risk factors of early natural menopause (before age 45) in a large random sample of gainfully employed French women born in the years 1938 (n = 1743) and 1943 (n = 1959). The subjects were selected from files of an occupational physician. A woman was considered to be post-menopausal when at least 12 consecutive months had passed without menstruation at the time of the survey. Subjects were questioned and examined during their annual visit by the occupational physician. Occupational history, working conditions, living conditions, smoking habits and reproductive history were explored. RESULTS: The prevalence of early natural menopause, before age 45, was higher in the generation of 1938 (5.3%) than in that of 1943 (3.3%) with P < 0.01. After multivariate regressions, significant relationships existed statistically between the occurrence of early natural menopause and marital status, educational level, age at first childbirth and breast-feeding of children. CONCLUSIONS: Our results show important generation effects. There was no evidence of a significant relationship between early natural menopause at 45 years of age and factors relative to heavy physical work conditions.

Behcet's syndrome and renal involvement: a histological and immunofluorescent study of eleven renal biopsies.

The finding of focal glomerulonephritis in a patient with Behcet's syndrome led us to perform systematic renal biopsies in ten other patients with the disease. None of the patients had symptoms of renal disease. Proteinuria was found in five, two of whom had associated leukocyturia. By light microscopy mesangial and extramembranous glomerular deposits were observed in eight patients. Arterioles in ten patients showed subendothelial and medial hyaline deposits. A granular pattern of fluorescent staining identified the presence of the third component of complement in these deposits. Circulating immune deposits were sought and found in six out of seven patients. The finding of circulating immune complexes and deposition of complement in glomerular and arteriolar tissues supports an immune complex mediated nephropathy and is consistent with the hypothesis of an immunological pathogenesis in Behcet's syndrome.

[Occupational cancers: notification, compensation and prevention]. / Cancers professionnels: connaissance, réparation et prévention.

Less than 140 occupational cancers (OC) are compensated every year in France although the incidence is estimated for at least 6,000 new cases, as estimated by the epidemiologists (4% of the mortality by cancers). This situation can be explained by different factors: few compensation claims by the patients or families, frequent lack of interest from medical doctors for relation between cancer and work, occurrence of the OC after retirement, difficulty to distinguish the role of occupational factors from individual comportmental factors in many OC (for ex. a lung cancer hitting a smoker). The consequences of such a situation are multiple: no compensation for more than 95% of patients or relatives, taking for granted that OC is a minor problem, insufficient prevention of the carcinogenic factors on the work place, prevention of cancers restricted to individual comportmental changes. Physicians working in cancerology units have to incite their patients in notifying the OC and help them in compensation claims. They have also to ask for epidemiologic and toxicologic research when clusters of OC are identified in a plant, in order to get better prevention, compensation and regulations.

[Impairments, disabilities and handicaps in a group of retired people in the Paris metropolitan area in relation to their socio-occupational status]. / Déficience, incapacité et handicap dans un groupe de retraités de la Région Parisienne en relation avec la catégorie socio-professionnelle.

Interviewers using a questionnaire carried out a home survey among 627 retired persons (62.7% of the sample) in the greater Paris area for the purpose of exploring relationships between disablement (impairments, disabilities, and handicaps) and socio-professional status. The subjects were randomly selected from a pension fund roll. Among men, manual laborers had higher rates of disablement than did white-collar employees and executives. Among women, laborers, office workers and those in the services had similar disablement rates, while rates among executive women were lower. Overall, women had higher rates than men. But no relationship between age and disablement was observed. The examination of disablement indicates that socioeconomic differences--earlier shown to exist with regard to mortality and morbidity--also have their effect in retirement.

[Age, work and spinal pain]. / Age, travail et douleurs rachidiennes.

BACKGROUND: To examine whether the relationship between age and musculoskeletal disorders in the spine is specific to one localization (cervical, dorsal, lumbar) or due to the accumulation of lesions with age. METHODS: Data were gathered from the ESTEV study among a randomly selected sample of 21,378 French workers, followed by 390 occupational physicians during the year 1990. The subjects, males or females, were born in 1938, 1943, 1948, 1953. Participation rate (88%) did not depend on age and sex. Data were collected during annual medical examination for medical variables, and using standardized self questionnaires for occupational exposures and work constraints for actual or past jobs. RESULTS: Data on musculo-skeletal disorders, defined as pains during the last 6 months before examination, were recorded by occupational physician. Each painful localization was associated with the main factors described in the literature, particularly heavy physical work factors and psycho-social factors of work. There was no interaction between age and any of these. At the opposite, in male as female subjects, there was a statistically significant interaction between age, multiple exposures to heavy physical work factors and the frequency of multiple localizations of pain in the spine. CONCLUSION: Results suggest that accumulation of pain in the different localizations of the spine might account for accelerated aging process of the musculo-skeletal structure of the spine which can reflect effects of environmental work factors.

[Locomotor and cardiorespiratory impairments after retirement in relation to certain occupational exposures during working life]. / Déficiences locomotrice et cardiorespiratoire après la retraite en relation avec certaines expositions professionnelles durant la vie active.

The relationships between locomotor and cardiorespiratory impairments and occupational exposures during working life were examined, using a sample of 627 retired persons in the greater Paris area. Among men, there was a significant statistical association between carrying heavy weights and locomotor impairment. There were also significant associations between exposure to toxic products, tiring postures and vibrations and cardiorespiratory impairment among men. Concerning women, associations between exposure to dust and tiring postures during working life and cardiorespiratory impairment were observed. These results were obtained after adjusting for age, socio-professional status, tobacco use, living alone and after adjusting also for the other occupational exposures. These results are compatible with the hypothesis of long-term effects of occupational exposures on the principal health characteristics of the aged.

[Development in health status of a group of retired subjects in the Paris region according to their practice of physical activity]. / Evolution de l'état de santé d'un groupe de retraités de la région parisienne selon la pratique d'une activité physique.

The relation between physical activity and health among retired people aged 65 and over was studied in a sample of 993 subjects, men and women, living at home in the Paris area and randomly selected from a pension fund roll. In 1982-1983 (T1), 627 subjects were interviewed. Five years later (T2), 464 subjects participated in the survey. Health was measured by the number and types of impairments and disability. The incidence of cardiorespiratory impairment and the incidence of disability were weaker among subjects with physical activity in T1 than among subjects without physical activity. These findings were unchanged after adjustment for age, sex, socioeconomic status, cigarette smoking, body mass index, uncomfortable housing, living alone and hard physical conditions during working life. This result suggests the beneficial effect of physical activity in promoting health among retired people aged 65 and over.

[Predictive factors of physical disability in a cohort of retired persons in Paris followed during 10 years]. / Facteurs prédictifs d'incapacité physique dans une cohorte de retraités parisiens suivis pendant dix ans.

OBJECTIVE: The objective of the present study was to examine predictors of physical disability in a survey of retired men and women living in the Paris area followed-up longitudinally for 10 years. METHODS: Subjects were randomly selected in a supplementary retirement pension fund. In all 627 subjects took part in the first phase of the survey (1982-83) and 392 in the follow-up phase (1992-93). At the 10-year follow-up, there were 185 confirmed deaths and 50 subjects refused to participate or could not be traced. Physical disability was measured by difficulties reported by the subjects for seven basic activities of daily life. Possible predictors, socio-demographic, impairments, physical activities, working conditions during working life were explored at T1. RESULTS: The incidence of physical disability was 41.4% for men and 57.6% for women. For disability in mobility, the incidence was 37.1% for men and 54.7% for women. In multivariate analysis, predictors of physical disability were social category (clerks), no physical activities, use of medicine, mental impairment. The predictors of disability in mobility were sex (women), social category (clerks), use of medicine, cardio-respiratory and sensory impairments. On the contrary, subjects with mental impairment had a lower incidence of disability in mobility than subjects without mental impairment. CONCLUSION: The results confirm the two poles of disability: biomedical and social. Working conditions during working life do not seem to play a direct part in incidence of disability at ten years follow-up.

[Disabled and handicapped in the Aquitaine region]. / Incapacités et handicaps dans la région Aquitaine.

An extension of the national survey on health and medical consumption conducted in 1981 on a random sample of the population living at home in Aquitaine used questionnaire on presence of disability and handicap (according to WHO definition). Occupations, mobility, personal care, communication restriction are observed in respectively 10.6, 3.3 and 1.5% of the sample. Because people aged 60 and over are concerned in 60 to more than 80% according disability or handicap dimension, analysis of those was follow up for this only population. Personal and domestic care disabilities are then noted for one out of eight persons, communication disabilities are present among one subject out of twenty. One person out of seven is restricted for mobility and physical independence whereas one out of four was restricted for customary occupations and one out of ten for social relationships. Those aged 75 and over are three of four times more often involved than those aged 60 to 74 with the exception of usual occupations. The 5% of those defined as dependent and nevertheless living alone are the ones that are likely to be institutionalized because of a minor intercurrent health problem.

[Survival after 60 years of age among elderly retired miners]. / Survie après 60 ans chez les anciens salariés des mines.

This study analyses long term effects of working conditions at an advanced age and post retirement. A longitudinal study was done among 63,000 retired miners between 60 to 65 years old. The standardised mortality ratio (SMR) in the cohort was above that expected on the basis of concurrent mortality in the reference population (SMR = 111; 95% confidence interval (CI): 108-114). The excess mortality was observed in occupational groups with exposure to underground tasks (10 years of underground tasks: RR = 2; 95% CI: .1.7-2.5), but there was sign of a healthy worker effect after 25 underground years. The effects of modern technologies and of medical progress have changed working conditions and care has reduced mortality for retired manual workers: exposure to underground tasks before 1950: RR = 1.7; CI 95%: 1.4-2.0; after 1950: RR = 1.2; CI 95%: 1.1-1.2.

Workers' participation and occupational health: the French experience.

In France, workers' participation in occupational health was organized for the first time in 1947, when Hygiene and Safety Committees were created. However, these committees remained ineffective in many firms for more than 20 years. Their role and power were greatly extended in 1976; in 1982, the Auroux Laws gave wage-earners new rights, mainly rights of expression. Here too, the way these laws have been put into operation varies a lot. Generally speaking, a great many regulations and laws exist that should give workers very good protection, but control systems are weak, and wage-earners' information on health is insufficient. Workers' participation is generally set up through trade unions, which are more often nationwide than locally organized. Workers' membership in unions is rather weak. The recent creation and development of quality circles in many firms, controlled by the company, give a false impression of workers' freedom of speech and do not really improve participation. But recent social movements have shown that people increasingly wish to express themselves and to deal with their own employers without any go-between. Nevertheless, participation will become effective only if workers' knowledge is taken into account, if they are trained in analysis and expression, and if their suggestions are seriously considered.

The effects of system characteristics on policy implementation and functioning of care for the elderly in France.

In the early 1960s, old age in France was replaced by the notion of "troisième âge," a new definition stressing the possibility of pursuing social and leisure activities and greater independence. Old age itself was postponed to a later age, and acquired a purely negative image and one confused with that of incurable illness. As a result, a living-at-home policy was elaborated, and also a program of adapting institutions to the problems of those now defined as being in the "quatrième âge." This dual-faceted medicosocial policy was originally intended to be comprehensive and coordinated. Analysis of the structural characteristics of the care providers and of the agencies responsible for organization and financing of services shows fragmentation at the levels of service delivery and policy development. This prevents the coordination of service provision, gives rise to a mismatch between people and provision, and leads to a lack of coherent regulation and of adequate financing, in particular with regard to domiciliary care and social services. External factors, such as scarcity of funds related to the economic crisis, reinforce system dysfunctions.

[Nosocomial infections in geriatric facilities]. / L'infection nosocomiale en contexte gériatrique.

EPIDEMIOLOGY: In long term geriatric facilities, the prevalence of nosocomial infections (to the order of 10% in the surveys) is greater than that observed in short-term medical care centers. An endemia of methicillin-resistant Staphylococcus aureus, of between 24 and 57% of hospitalized patients, is noted in many geriatric facilities. In decreasing order, the infections that predominate are: urinary (1/3), lower respiratory tract (1/4) and cutaneous tissue infections (1/5). However, these are often manifested by misleading semiology, and orient towards an organ other that which is infected. TRANSMISSION AND PREVENTION: Nosocomial infections are frequently related to the general health of the patient and/or to transmission during handling. Invasive treatments are rarely the cause in geriatry. Preventive measures are identical to those used in short-term care centers (handwashing, source isolation and appropriate use of antibiotics). PROBLEMS: Encountered However, their application raises many problems. The living conditions (few facilities with single beds), the state of health of these elderly patients, often exhibiting multiple diseases and requiring assistance for their daily gestures, and the reduced number of staff at the bedside, require that these measures be adapted to each particularity.