Prospective audits of quality of PEM recognition and nutritional support in critically ill elderly patients.

BACKGROUND AND AIMS: Undereating is a frequent concern in acute care geriatric settings and is supposed to worsen the outcomes of the underlying diseases, while the quality of nutritional support could be improved. METHODS: Two consecutive and prospective audits (A and B) with team training over a 1 year period investigated the quality of malnutrition recognition and nutritional support and outcomes in immobilized, critically ill elderly subjects. RESULTS: Audit A included 170 patients (86.3+/-6.1 years old) and audit B, 232 patients (86.3+/-6.3), respectively 20.6% and 31.4% of the hospitalized population. Misclassifications occurred in A in 54.0% compared to 34.05% in B (P < 0.001). 32.6% in A versus 86.9% in B adequately received oral supplements (P = 0.02). Significant risk factors for the adverse outcomes in the combined two audits were: dementia (RR: 1.8, 95%CI: 1.0 to 3.0, P= 0.04) and dehydration (RR: 2.0, 95%CI:1.0 to 4.1, P= 0.05) for pressure ulcer incidence; stroke (RR: 8.8, 95%CI: 4.8 to 16.0, P < 0.001) for pressure ulcer prevalence at discharge; neoplasms (RR: 1.1, 95%CI: 1.0 to 1.2, P = 0.02) for nosocomial infections; bladder indwelling for urinary tract infections (RR: 4.8, 95%CI: 2.9 to 7.7, P<< 0.001); swallowing problems for pulmonary infections (RR: 5.4, 95%CI: 2.8 to 10.5, P < 0.001); venous indwelling for septicaemia (RR: 5.4, 95%CI: 1.3 to 23. 3, P= 0.02). However, after adjustment on significant risk factors, the outcome rate was similar in audit B: death rate: A (15.6%), B (14.2%); length of stay: A (17.3+/-10.4 days), B (17.4+/-10.0); pressure ulcer incidence: A (26.4%), B (20.2%), (83% were erythema); pressure ulcer prevalence at discharge: A (14.7%), B (10.3%), (40% were erythema); nosocomial infections: A (26.4%), B (19.0%). CONCLUSION: The improvement of malnutrition recognition and nutritional support was not followed by a perceptible decrease in adverse outcome rate, this latter being mainly related to the underlying conditions of these critically ill elderly patients.

[Relation between global cognitive performance and dependency evaluated by the AGGIR scale]. / Relation entre performances cognitives globales et dépendance évaluée par la grille AGGIR.

BACKGROUND: The aim of the present study was to investigate the relation between cognitive performances and dependency state according to the AGGIR model, the national standardized instrument determining the attribution of the "Prestation Spécifique Dépendance" (PSD) in France. METHOD: The sample of the study comprised 1,052 subjects aged 73 and over seen at the 8-year follow-up of the Paquid cohort. The "Autonomie Gérontologie Groupes Iso-Ressources" (AG-GIR) model relies on the assessment of eight measures of disability and two additional measures of intellectual coherence and orientation. The model results in a classification of six Iso-Resources Groups (GIR), only the subjects from GIR 1, 2 or 3 being potential beneficiaries of the PSD. RESULTS: The percentage of completely independent subjects (GIR 6) was 85% and only 6.1% were dependent according to the level of the attribution of the PSD (GIR 1 to 3). Among these subjects, 57.8% had been diagnosed as cases of dementia. Conversely, less than half of the cases of dementia were not potential beneficiaries of the PSD. Cognitive performances assessed by the Mini Mental State Examination (MMSE), were associated to a risk of dependency with an odds ratio of 1.4 for the subjects who lost one point on the MMSE (95% CI: 1.3-1.5, p < 0.001). Even when dementia was not diagnosed, low cognitive performances and dyspnea were the main factors of the dependency classification according to the AGGIR model. CONCLUSIONS: This study confirms the relationship between cognitive performances and dependency assessed by the AGGIR model. However the model seems to lack sensitivity for taking into account functional impairment associated with dementia. Consideration of Instrumental Activities of Daily Living in the classification procedure could improve the satisfaction of the needs of these subjects.

Variability of reported headache symptoms and diagnosis of migraine at 12 months.

Assignment of a diagnosis of migraine has been formalized in diagnostic criteria proposed by the International Headache Society. The objective of the present study is to determine the reproductibility of the formal diagnosis of migraine in a cohort of headache sufferers over a one-year period. The study was performed in a community cohort taking part in a long-term prospective health survey, the GAZEL study. Two thousand five hundred individuals reporting headache in the GAZEL cohort were sent two postal questionnaires concerning headache symptoms and features at 12-monthly intervals. Replies to the questions allowed a migraine diagnosis to be attributed retrospectively using an algorithm based on the IHS classification scheme. The response rate was 82% for the first questionnaire and 69% for both questionnaires. Of the 1733 subjects providing information at both time-points, the agreement rate for the diagnosis of strict migraine (IHS categories 1.1 or 1.2) was 77.7% (kappa = 0.48), with 62.2% of the patients with this diagnosis (IHS categories 1.1 or 1.2) at Month 0 retaining the same diagnosis at Month 12. When diagnostic criteria were widened to include IHS category 1.7 (migrainous disorder), the agreement rate of the diagnosis was similar at 77.6% (kappa = 0.52), but 82% of the patients with this diagnosis (IHS categories 1.1 or 1.2 or 1.7) at Month 0 now retained the same diagnosis at Month 12. In conclusion, the one-year reproducibility of reporting of migraine headache symptoms is only moderate, varies between symptoms, and leads to instability in the formal assignment of a migraine headache diagnosis and to diagnostic drift between headache types. This finding is compatible with the continuum model of headache, where headache attacks can vary along a severity continuum from episodic tension-type headaches to full-blown migraine attacks.

The value of external anal sphincter electromyography for the diagnosis of multiple system atrophy.

OBJECTIVE: To assess the value of external anal sphincter electromyography (ASEMG) for the diagnosis of multiple system atrophy (MSA) among various causes of parkinsonism. ASEMG denervation profiles have previously been proposed as a diagnosis test for MSA, but their specificity is disputed. METHODS: ASEMG variables of 52 parkinsonian patients were analyzed according to the clinical diagnosis: MSA (n = 31) or no MSA (n = 21). Mean motor unit potential duration, percentage of polyphasicity, and the electromyographer's interpretation were analyzed according to clinical diagnosis, disease duration, genitourinary symptoms, gender, parity, and history of pelvic surgery. RESULTS: All patients with MSA showed ASEMG denervation. Mean motor unit potential duration was the most discriminant variable. No patient with MSA had a mean duration less than 12 ms and no patient without MSA had one greater than 16 ms. ASEMG discriminates between patients with MSA and Parkinson's disease. Using a threshold of 13 ms, the sensitivity was 80% and specificity was almost 70% (positive predictive value, 80%) for the diagnosis of MSA. Age, history of pelvic surgery, and to a lesser extent, female gender, parity, disease duration, and presence of urinary symptoms increased the likelihood of abnormal ASEMG. CONCLUSION: ASEMG was highly sensitive and rather specific for the diagnosis of MSA.

Routine MRI for the differential diagnosis of Parkinson's disease, MSA, PSP, and CBD.

We assessed the usefulness of routine MRI for the differential diagnosis of Parkinson's disease (PD) with "atypical" parkinsonian syndromes in everyday clinical practice. We studied routinely performed MRI in PD (n = 32), multiple system atrophy (MSA, n = 28), progressive supranuclear palsy (PSP, n = 30), and corticobasal degeneration (CBD, n = 26). From a preliminary analysis of 26 items, 4 independent investigators rated 11 easily recognizable MRI pointers organized as a simple scoring system. The frequency, severity and inter-rater agreement were determined. The total severity score was subdivided into "cortical", "putaminal", "midbrain", and "pontocerebellar" scores. The frequency of putaminal involvement (100%) and vermian cerebellar atrophy (45%) was significantly higher in MSA, but that of cortical atrophy (50%), midbrain atrophy and 3(rd) ventricle enlargement (75%) was higher in PSP and CBD. The median total score fairly differentiated "atypical" parkinsonian syndromes from PD (positive predictive value-PPV-90%). However, the median total score was unable to differentiate atypical parkinsonian syndromes each other. The "cortical" score distinguished CBD and PSP from MSA with a fair PPV (>90%). The PPV of the "putaminal" score was high (70%) for the differential diagnosis of MSA with PSP and CBD. The "midbrain" score was significantly higher in PSP and CBD compared to MSA. These results are in accordance with the underlying pathology found in these disorders and demonstrate that a simple MRI scoring procedure may help the neurologist to differentiate primary causes of parkinsonism in everyday practice.

Detection of depressive symptomatology in elderly people: a short version of the CES-D scale.

This study aims to test a short form of the Center for Epidemiological Studies--Depression Scale (CES-D) which can be a useful screening tool for depressive symptomatology in epidemiological studies of elderly patients. The study was conducted on 2792 subjects from the PAQUID (Personnes Agées QUID?) cohort, an epidemiological survey of community dwellers living in South-West France. CES-D items with high sensitivity and good specificity were selected for the short form, then the best cut-off scores were determined with Receiver Operating Characteristics (ROC) curves. The external validity of the 5-item scale was then assessed against the full scale at different PAQUID follow-ups. Sensitivity was 99% and specificity 81% for detecting depressive symptomatology when compared to the 20-item scale. The external validity on the different follow-ups was good, yielding a sensitivity varying from 95 to 100%, and a specificity from 83 to 89%. In conclusion, the 5-item CES-D is a simple, rapid and reliable tool which could be useful for screening depressive symptoms in epidemiological studies of the elderly.

Epidemiology of multiple system atrophy: a prevalence and pilot risk factor study in Aquitaine, France.

We investigated the prevalence of multiple system atrophy (MSA) in Gironde, France, through a network of 120 public and private specialists and assessed the relationship between some environmental factors and MSA in a case-control study involving 50 MSA patients, 50 Parkinson's disease (PD) patients and 50 healthy controls. The occupational exposure to pesticides was evaluated through a job-exposure matrix. On prevalence day (November 1, 1998), the crude prevalence of MSA in Gironde was 1.94/100,000 inhabitants. We found no significant relationship between occupational exposure to pesticides and MSA. PD patients were significantly less frequently ever-smokers than controls and the same tendency was observed for MSA patients. We also described the clinical features that heralded the disease among this nonselected population.