Risk factors and management of diabetes in elderly French patients.

AIMS: The aim of this study was to assess the characteristics of elderly diabetic patients, evaluate the relationship between glycaemic control and diabetes complications, and compare the day-to-day management of such patients with the published recommendations. METHODS: The study included 238 elderly diabetic patients, for whom data for the past six months' medical history, clinical examination (including ocular fundus) and standard biological tests were collected. RESULTS: The patients' mean age was 82.2+/-7.2, HbA(1c) value was > or =8.5% in 24% of patients and the mean number of cardiovascular risk factors (CVRF) was 4.1+/-0.7 per patient. Dementia or cognitive impairment was present in 68% of patients. Estimated glomerular filtration rate was 30 mL/min or lesser than 16%. Retinopathy was present in 37% of patients, and 64% had a history of infection in the past six months; more than 50% of patients took insulin. The prevalence of retinopathy, cognitive dysfunction and infections were significantly less frequent in patients with HbA(1c) < or =6.5%. There was a positive correlation between the number of CVRF and the number of cardiovascular anomalies (r=0.19, P<0.001). With the exception of HbA(1c), standard paraclinical tests were performed in less than 50% of patients. There was positive agreement between day-to-day HbA(1c) and HbA(1c) target values in 36% of patients. CONCLUSION: Complications and/or associated diseases were more frequent in this cohort of elderly diabetic patients compared with those in studies not based on clinical examinations. Our results highlight the inadequate management, given the frequent discrepancy between day-to-day HbA(1c) and HbA(1c) targets, of such patients.

Nosocomial febrile illness in the elderly: frequency, causes, and risk factors.

BACKGROUND: Although nosocomial febrile illness (NFI) is common in hospitalized patients, it has been less extensively studied in the elderly. OBJECTIVE: To determine the frequency, causes, and risk factors of NFI in elderly inpatients. METHODS: This prospective study involved 608 patients (> or = 65 years of age) admitted in an acute geriatric unit. Investigators followed this cohort until 1 of the following events occurred: development of NFI, discharge from the geriatric unit, or death. The cause of NFI was classified into 3 groups: infectious, noninfectious, and no apparent diagnosis. We systematically studied 17 comorbid conditions, 6 drugs, and 7 invasive procedures. For comparison, the patients were stratified into 2 groups: patients with NFI and patients without NFI. RESULTS: Sixty-six patients (10.9%) with NFI were identified. They were compared with the remaining 542 patients without NFI. In 49 patients (74%) with NFI, the cause was infectious; in 9 (13.5%), it was noninfectious; and in 8 (12.5%), there was no apparent cause. After multivariate analysis, only fecal incontinence (odds ratio [OR], 5.54; 95% confidence interval [CI], 2.13-14.5), congestive heart failure (OR, 2.97; 95% CI, 1.53-5.76), and pressure ulcers (OR, 2.93; 95% CI, 1.19-7.17) were independent risk factors for NFI. The number of invasive procedures preceding the febrile episode was a significant predictor of infection (OR, 3.68; 95% CI, 1.14-9.21). CONCLUSIONS: Nosocomial febrile illness is a common event in elderly hospitalized patients. In 74% of the patients with NFI, an infection is found. Measures to decrease infectious NFI in the elderly require a reduction in the number of invasive procedures.

Fecal incontinence in the institutionalized elderly: incidence, risk factors, and prognosis.

PURPOSE: This study was conducted to evaluate the incidence, identify the risk factors, and assess the prognosis of elderly institutionalized patients who develop fecal incontinence. PATIENTS AND METHODS: We enrolled 1,186 patients 60 years of age and older living in long-term care facilities who did not have fecal incontinence. We assessed their medical history, treatment, mobility, and cognitive function. Patients were followed up for 10 months to determine the incidence of fecal incontinence, defined as at least one involuntary loss of feces. Independent risk factors associated with fecal incontinence were identified using Cox proportional hazards models. The prognosis of incontinent patients was assessed by comparing their survival rate with that in the continent patients. RESULTS: Fecal incontinence occurred in 234 patients (20%), and was usually associated with acute diarrhea or fecal impaction. We identified five risk factors for the development of fecal incontinence: a history of urinary incontinence (rate ratio [RR]: 2.0, 95% confidence interval [CI] 1.5 to 2.6); neurological disease (RR: 1.9, 95% CI 1.0 to 3.4); poor mobility (RR: 1.7, 95% CI 1.2 to 2.4); severe cognitive decline (RR: 1.4, 95% CI 1.1 to 1.9); and age older than 70 years (RR: 1.7, 95% CI 1.0 to 2.8). Ten-month mortality in the 89 patients with long-term (> or = 8 days) incontinence was 26%, significantly greater than that observed in the continent group (6.7%) or in the 145 patients with transient incontinence (10%). CONCLUSIONS: Long-lasting or permanent fecal incontinence was associated with increased mortality, suggesting that this symptom is a marker of poor health in older patients. Actions that improve mobility might help prevent fecal incontinence in elderly patients.

Differences in the signs and symptoms of hyperthyroidism in older and younger patients.

OBJECTIVES: To determine if aging modifies the clinical presentation of hyperthyroidism and the signs of thyrotoxicosis in older people. DESIGN: Prospective cohort study. SETTING: A French university hospital. SUBJECTS: Eighty-four new patients with overt hyperthyroidism confirmed chemically between January 1992 and January 1993. Controls were 68 older euthyroid patients matched to the older hyperthyroid patients. MEASUREMENTS: Comparison of 19 classical signs of hyperthyroidism between 34 older patients (> or = 70 years; mean age 80.2) and 50 younger patients (< or = 50 years; mean age 37.4). Older patients were also compared with controls (mean age 81.3). RESULTS: Three signs were found in more than 50% of older patients: tachycardia, fatigue, and weight loss. Seven signs were found significantly less frequently in older patients (P < .001): hyperactive reflexes, increased sweating, heat intolerance, tremor, nervousness, polydipsia, and increased appetite. Only anorexia (32% vs 4%) and atrial fibrillation (35% vs 2%) were more found frequently in older people (P < .001). A goiter was present in 94% of the younger and in 50% of the older patients (P < .001). The mean number of clinical signs found in the older subjects was significantly smaller than the number found in younger patients (6 vs 10.8; P < .001). Comparison with older controls showed three signs that were highly associated with thyrotoxicosis in older people: apathy (Odd ratio (OR): 14.8), tachycardia (OR: 11.2), and weight loss (OR: 8.7). CONCLUSION: This study confirms the paucity of clinical signs of hyperthyroidism in older adults. These results suggest the necessity of routine screening for thyroid disease in this age group.

Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients.

OBJECTIVE: To investigate the frequency, nature, and side effects of drug-drug interactions (DDI) in a group of geriatric inpatients. DESIGN: Study of drugs administered at home in the 2 weeks preceding hospitalization. SETTING: Evaluation of patients admitted to a geriatric unit from the emergency unit. PATIENTS: One thousand inpatients more than 70 years of age (83.0 +/- 7.1 years), admitted consecutively to a hospital for acute illness. MEASUREMENTS: All possible two by two combinations of drugs administered at home were considered to determine whether these associations could lead to a DDI and whether side effects resulted from these interactions. RESULTS: Five hundred thirty-eight patients were exposed to 1087 DDI. The most frequently involved drugs were cardiovascular and psychotropic medications. There were 189 side effects observed in 130 patients. The most frequent side effects were neuropsychological impairment, arterial hypotension, and acute renal failure. The number of side effects did not differ between the 66 contraindicated drug associations and the 1021 associations that only required precautionary use. CONCLUSIONS: DDI frequently lead to side effects in older adults. Classifications of DDI must be adapted to increased DDI sensitivity in this population. Nevertheless the frequency of side effects might be reduced by limiting the prescription of the most frequent and dangerous DDI.

[Increase of aminotransferases]. / Elévation des aminotransférases.

Elevated aminotransferases activities are frequent in medical practice. In acute elevations, the mains causes are generally easily found (viral, drug-induced, toxic, ischemic). In moderate or prolonged elevations, the most frequent causes are steatosis (alcoholic, diabetes, obesity) and chronic hepatitis (viral B, D, C, drug-induced and auto-immune diseases.

[Crushing drugs in geriatric units: an "handicraft" practice with frequent errors which imposed recommendations]. / L'écrasement des médicaments en gériatrie: une pratique « artisanale ¼ avec de fréquentes erreurs qui nécessitait des recommandations.

PURPOSE: Swallowing disorders or psycho-behavioural distress frequently interfere on drug administration in elderly inpatients. Crushing drugs is a common although non validated practice. The objective of this first prospective study, performed in all geriatric units of the Rouen university hospital by a multidisciplinary group, was to assess the crushing practice, from the prescription to the administration of the drugs in order to elaborate corrective measures. METHODS: A survey was performed in June 2009 and included 683 inpatients, 65 years and above, in 23 geriatric units. If a patient received drugs after crushing, we recorded the reason for crushing, what drugs were crushed, the galenic presentations and the technique used for preparation and administration. RESULTS: Two hundred and twenty-one patients (32.3%) (85.5 ± 6.5 years, females 74.2%) received 1528 drugs (6.9 ± 4 per patient) including 966 drugs (63.2%) after crushing (crushed pills or crushed content of opened capsules), mainly in the morning (50.4%). The main reasons for crushing drugs were swallowing disorders and psycho-behavioural distress. Forty-two percent of crushed drugs had a galenic presentation which did not allow crushing. The patient's drugs were crushed together three out of four times and mixed with different vehicules for administration. The material used for crushing (a mortar, 92.6%) was often the same for several patients (59.4%); 83.5% of crushed drugs were immediately administered to the patients, though there were important variations about schedules of administration. CONCLUSION: Crushing drugs expose both to iatrogenic hazards and professional risks. Regional and national recommendations were developed in order to correct the errors linked to this practice.

Pulmonary artery thrombosis in giant cell arteritis. A new case and review of literature.

Pulmonary artery thrombosis caused by giant cell arteritis is an extremely rare condition. We report the case of an 86-year-old woman, who was hospitalized for dyspnea. Pulmonary artery thrombosis was confirmed by pulmonary angiogram and was linked to giant cell arteritis. This observation is accompanied by a discussion of the literature.