Use of a clustering method to describe the clinical profiles of older fallers: the value of a multidisciplinary consultation.

OBJECTIVES: The population of older adults is particularly heterogeneous with regard to frailty and the risk of falling, the two of which are linked. We conducted an exploratory, analysis (with no preconceived ideas) of data collected during multidisciplinary falls consultations (MFCs), to identify people with similar profiles. MATERIALS AND METHODS: We performed an observational, multicentre study of older patients (aged 75 and over) having been evaluated in an MFC. We excluded adults with a Mini Mental State Examination score < 14/30, an activities of daily living score < 4/6, or an unstable medical condition. Each participant underwent a clinical interview, impedancemetry, and a physical activity assessment (a questionnaire, and use of an activity tracker on 5 consecutive days). The K-means method and ascending hierarchical clustering were used to identify clusters of people with common characteristics. RESULTS: Of the 106 participants, the median [IQR] mean number of falls in the previous 6 months was 1 [2]. Three functional clusters were identified: (i) fallers with poor mobility, difficulty getting up off the ground after a fall, and using a mobility aid for walking; (ii) an intermediate sedentary group with a gait speed of ~ 0.6 m s-1, and (iii) active people with a timed "up and go" test time below 15 s and a gait speed above 0.8 m s-1. CONCLUSIONS: The population of older fallers referred for an MFC is heterogeneous. The presence of certain clinical characteristics enabled the definition of three patient clusters, which might help physicians to determine the most appropriate care objectives and pathways.

Impact of the COVID-19 pandemic on drug-related problems and pharmacist interventions in geriatric acute care units.

OBJECTIVES: To assess and compare the pharmaceutical analysis on drug management in a geriatric acute care unit prior to and during the COVID-19 pandemic. METHODS: This was a single-centre, retrospective, and comparative cohort study. All Pharmacist Interventions (PIs) carried out in the unit between 27 January 2020 and 30 April 2020 were distinguished according to whether they were conducted prior to or during the first wave of COVID-19. The main outcome measure was the rate of PIs per patient and per prescription lines analysed. Other data collected were the drug class managed by the PI, the Drug Related Problems (DRP) identified, the nature of the advice given, and the acceptance rate by geriatricians. RESULTS: A total of 355 patients were analysed, with PIs generated for 21.7% of the patients prior to COVID-19, and for 53.4% of the patients during the first wave (p<0.001). Among the 4402 prescription lines analysed, 54 PIs were carried out for prescriptions prior to COVID-19, and 177 during the first wave (p=0.002). DRPs were mostly related to anti-infectious drugs during the pandemic (20.3%, p=0.038), and laxatives prior to the pandemic (13.0%, p=0.023). The clinical impact of the PIs was mainly moderate (43.7%). The acceptance rate was 59.3%. CONCLUSIONS: A greater amount of DRPs were detected and more therapeutic advice was proposed during the first wave of COVID-19, with a focus on drugs used for the management of COVID-19 rather than geriatric routine treatments. The needs for clinical pharmacists were strengthened during the pandemic.

Hypercalcemia as a Biomarker of Poor Prognosis in Frail Elderly Patients with COVID-19.

The objective of this cohort study was to determine whether hypercalcemia in early COVID-19 was associated with 3-month mortality in frail elderly patients. Circulating calcium and albumin concentrations at hospital admission and 3-month mortality were assessed in geriatric patients hospitalized for COVID-19 with normal-to-high calcium concentrations. Hypercalcemia was defined as corrected calcium >2.5mmol/L. Covariables were age, sex, functional abilities, malignancies, hypertension, cardiomyopathy, number of acute health issues, use antibiotics and respiratory treatments. In total, 94 participants (mean±SD 88.0±5.5years; 47.9% women; 22.3% hypercalcemia; 0% hypocalcemia) were included. Sixty-five participants who survived at 3months exhibited less often hypercalcemia at baseline than the others (13.9% versus 41.4%, P=0.003). Hypercalcemia was associated with 3-month mortality (fully-adjusted HR=3.03, P=0.009) with specificity=0.86 and sensitivity=0.41. Those with hypercalcemia had shorter survival time than those with normocalcemia (log-rank P=0.002). In conclusion, hypercalcemia was associated with poorer survival in hospitalized frail elderly COVID-19 patients.

Implementation of the Integrated Care of Older People (ICOPE) App and ICOPE Monitor in Primary Care: A study protocol.

INTRODUCTION: The World Health Organization (WHO) has recently launched the term "intrinsic capacity", defined as "the composite of all the physical and mental capacities of an individual". Intrinsic capacity has a positive value towards healthy aging, and is constructed by five domains: cognition, vitality/nutrition, sensory, psychology, and mobility. ICOPE App and ICOPE Monitor are applications for the assessment (screening) of intrinsic capacity. HYPOTHESIS: Intrinsic capacity assessed by the ICOPE Apps at baseline could be associated with the incidence of frailty, functional decline, and health outcomes during 1-year follow-up. OBJECTIVES: To assess the association between intrinsic capacity measured by the ICOPE Apps at baseline and the incidence of frailty in community-dwelling older adults during 1-year follow-up. Secondarily, to assess the association of intrinsic capacity and functional decline, mortality, pre-frailty, falls, institutionalization, and quality of life. METHODS: Protocol for a cohort study of community-dwelling adults ≥65-year-old, with no other exclusion criteria than the inability to use the Apps or communicate by telephone/video-call for any reason (cognitive or limited access to telephone/video-call) OR being considered frail at baseline (defined as having a Rockwood's clinical frailty scale, CFS score ≥4). Intrinsic capacity measured by the ICOPE Apps and CFS will be assessed at baseline, 4-, 8- and 12-month follow-up by telephone/video-call. Assuming a prevalence of frailty of 10.7%, and incidence of 13% (alpha-risk=0.05), 400 participants at 12-month end-point (relative precision=0.10) and 600 participants at baseline will be required. RESULTS: Associations among the decrease in intrinsic capacity and higher risk of frailty, functional decline, and health adverse outcomes during 1-year follow-up are expected. CONCLUSIONS: ICOPE Apps might identify individuals at higher risk of frailty, functional decline, and health adverse outcomes. The implementation of the ICOPE Apps into clinical practice might help to deliver efficient person-centered care-plans, and benefit the healthcare systems.

Association between serum 25-hydroxyvitamin D concentration and severity of first-diagnosed bullous pemphigoid in older adults.

BACKGROUND: Higher vitamin D status has been associated with symptom improvement and decreased risk of various autoimmune disorders. Our objective was to determine whether higher serum 25-hydroxyvitamin D (25OHD) concentration correlated with less severe first-diagnosed bullous pemphigoid (BP) in older inpatients. METHODS: This cross-sectional study was performed from November 2012 to February 2014 among 30 consecutive older inpatients (21 women; mean ± SD, 83 ± 7 years; all Caucasian) with a de novo diagnosis of active BP recruited in the Department of Dermatology of Angers University Hospital, France. The severity of BP was graded clinically on the basis of i) the number of bullae during the first three days of hospitalization (grade 0-4, worse), and ii) the extent of the lesions (grade 0-5, worse). RESULTS: Sixteen participants had ≤ 5 bullae at the time of diagnosis, 8 had 6-20 bullae, 3 had 20-50 bullae, and 3 had >50 bullae. The lesions were spread over 5 cutaneous areas in 5 participants (17%). The median 25OHD concentration was 23 [IQR, 16-42] nmol/L. Serum 25OHD concentration was inversely correlated with the bullae grade (ρ = - 0.38, p = 0.04) and the lesion extension grade (ρ = - 0.50, p = 0.005). CONCLUSIONS: Higher serum 25OHD concentration correlated with less severe BP prior to initiation of treatment among our sample of older inpatients. This result suggests that vitamin D may be involved in the pathophysiology of BP and could serve as prognostic biomarker of BP.

Association of hypovitaminosis D with triceps brachii muscle fatigability among older women: Findings from the EPIDOS cohort.

BACKGROUND: Vitamin D affects physical performance in older adults. Its effects on muscles, notably on muscle strength, remain unclear. The objective of this cross-sectional study was to determine whether hypovitaminosis D is associated with triceps brachii muscle fatigability in community-dwelling older women. METHODS: A randomized subset of 744 women aged ≥75years from the EPIDOS cohort was categorized into two groups according to triceps brachii muscle fatigability, defined as loss of strength >5% between two consecutive maximal isometric voluntary contractions. Hypovitaminosis D was defined using consensual threshold values (i.e., serum 25-hydroxyvitamin D concentration [25OHD] ≤10 ng/mL, ≤20 ng/mL, and ≤30 ng/mL). Age, body mass index, comorbidities, use psychoactive drugs, physical activity, first triceps strength measure, hyperparathyroidism, serum concentrations of calcium, albumin and creatinine, season and study centers were used as potential confounders. RESULTS: The prevalence of hypovitaminosis D ≤ 30 ng/mL was greater among women with muscle fatigability compared with the others (P = .009). There was no between-group difference using the other definitions of hypovitaminosis D. The serum 25OHD concentration was inversely associated with the between-test change in triceps strength (adjusted ß = -0.09 N, P = .04). Hypovitaminosis D ≤ 30 ng/mL was positively associated with triceps fatigability (adjusted OR = 3.15, P = .02). CONCLUSIONS: Vitamin D concentration was inversely associated with the ability to maintain strength over time in this cohort of community-dwelling older women. This is a relevant new orientation of research toward understanding the involvement of vitamin D in muscle function.

Association between hypovitaminosis D and cognitive inhibition impairment during major depression episode.

BACKGROUND: Major depressive episode (MDE) has been associated with cognitive functioning alteration and hypovitaminosis D (hypoVD), but the relationship between hypoVD, depression, and cognition is not well understood. We aimed to compare patient with MDE with or without hypoVD in regard of cognitive functioning. METHODS: 91 patients (38.5 years old, 65.9% female) with MDE were included in a cross-sectional study and were evaluated with a complete cognitive battery. None of the participants were medicated at the time of the inclusion. Serum 25-hydroxyvitamin D was measured using LC-MS/MS method, and hypovitaminosis was defined as 25OHD < 50nmol/L. Covariates were gender, season of dosage, first MDE onset, age, body mass index and depression severity RESULTS: Patients with hypoVD demonstrated a higher stroop intereference index time underscoring that means low cognitive inhibition ability. Mutiple logistic regression confirmed that hypoVD was significantly associated with high stroop interference time index after controlling by gender, season of dosage, first MDE onset, age, body mass index and depression severity. CONCLUSION: Our results suggest that patient with MDE having hypoVD may be more prone to cognitive impairment.

Vitamin D and the Mechanisms, Circumstances and Consequences of Falls in Older Adults: A Case-Control Study.

OBJECTIVES: To determine i) whether cases of elderly fallers had lower serum 25-hydroxyvitamin D (25OHD) concentration than controls without history of falls; and ii) whether serum 25OHD concentration was associated with specific mechanisms, circumstances and consequences of falls. DESIGN: Case-control study with a 1:2 ratio. SETTING: Geriatric ward of the University Hospital of Angers, France, between February 2012 and March 2014. PARTICIPANTS: 216 inpatients (72 cases and 144 age- and gender-matched controls). MEASUREMENT: Falls were defined as involuntary events causing the person to the ground or other lower level. The main mechanisms, circumstances and consequences of falls were identified using standardized questionnaires. Vitamin D deficiency was defined as serum 25OHD concentration ≤25nmol/L. Age, gender, body mass index, polypharmacy, use antihypertensive drugs, use psychoactive drugs, disability, cognitive performance, serum concentrations of parathyroid hormone, creatinine and albumin, and season of evaluation were used as potential confounders. RESULTS: 216 participants (72 cases and 144 controls) were included in the study. There was no between-group difference in the prevalence of vitamin D deficiency (P=0.176). After adjusting for confounding factors, vitamin D deficiency was positively associated with falls (OR=4.03, P=0.014). Finally, the fallers with vitamin D deficiency exhibited more often orthostatic hypotension (68.8% against 33.3%, P=0.039) and a history of recurrent falls (85% against 50%, P=0.002) than those without vitamin D deficiency. CONCLUSION: This case-control study reported that vitamin D deficiency was associated with falls in older inpatients. There was a greater prevalence of orthostatic hypotension and of the reccurrence of falls among fallers with vitamin D deficiency, suggesting that vitamin D may influence the conditions predisposing to falls rather than the fall by itself.

Vitamin D insufficiency and cognitive impairment in Asians: a multi-ethnic population-based study and meta-analysis.

BACKGROUND: The relationship between vitamin D insufficiency and cognitive impairment remains equivocal in Asians. We examined the association between circulating 25-hydroxyvitamin D (25OHD) concentration and cognitive performance in a large multi-ethnic Singaporean population-based study. We also conducted a meta-analysis of 25OHD concentrations amongst cognitively impaired older adults in Asia. METHODS: Our population-based cross-sectional study included 2273 persons ≥60 years of age from the Singapore Epidemiology of Eye Diseases (SEED) study (mean ± SD age 70.4 ± 6.2 years; 44.7% female), who were categorized according to 25OHD concentration (i.e. ≤10, 10.1-20 and >20 ng mL(-1) ). The 25OHD concentration was measured and adjusted to reflect a deseasonalized value. Cognition was assessed using the total and domain scores of the Abbreviated Mental Test (AMT). Global cognitive impairment was defined as AMT score of ≤6 if 0-6 years of education and AMT score of ≤8 if >7 years of education. Fully adjusted multivariate models were used. We included seven studies in a meta-analysis of 25OHD and cognition in Asia (6068 participants; 1179 cognitively impaired cases). RESULTS: Participants with 25OHD levels >20 ng mL(-1) (n = 1302) had higher AMT total scores (mean ± SD 8.5 ± 1.9) and were less likely to have cognitive impairment (14.1%) than participants with lower 25OHD levels (overall P < 0.001, P-trend < 0.001). Deseasonalized 25OHD concentration was associated with AMT score (ß = 0.10 per 10 ng mL(-1) , P = 0.035). Vitamin D insufficiency (25OHD ≤20 ng mL(-1) ) was associated with global cognitive impairment (OR 1.56, P = 0.028). Specifically, 25OHD concentration correlated with semantic memory (r = 0.08, P = 0.009) and orientation in time (r = 0.09, P = 0.003). In the meta-analysis, the pooled mean 25OHD difference was -6.83 ng mL(-1) (95% confidence interval -11.36; -2.30), indicating lower 25OHD concentrations amongst cognitively impaired compared to cognitively healthy participants in Asia. CONCLUSION: Vitamin D insufficiency is associated with a greater likelihood of and more severe cognitive impairment in Asian populations.

Hypovitaminosis D in pregnancy in the Mediterranean region: a systematic review.

Despite high levels of sunshine, maternal hypovitaminosis D during pregnancy is prevalent in the Mediterranean region. The aim of this study is to systematically review trials that investigated vitamin D concentrations during pregnancy in this region, in order to determine predictors of hypovitaminosis D and explain this phenomenon. After applying inclusion/exclusion criteria, 15 studies were entered into the systematic review involving 2649 pregnant women and 820 neonates. The main outcome was maternal vitamin D status, assessed by serum 25-hydroxy-vitamin D (25(OH)D) concentrations. Possible predictors of the outcome included maternal age, body mass index (BMI), race, socioeconomic status, skin type, gestational age, sun exposure, calcium and vitamin D intake and supplementation, smoking status, parity and season of delivery. Studies differed widely in vitamin D deficiency criteria, method of measurement and outcomes. The prevalence of vitamin D insufficiency ranges from 9.3 to 41.4%, whereas that of vitamin D deficiency from 22.7 to 90.3%. A positive association with 25(OH)D concentrations exists for light skin color, white race, uncovered dressing pattern, maternal vitamin D supplementation and season of gestation (spring/summer). An inverse association exists for BMI and gestational age, whereas data for smoking and socioeconomic status are controversial. We concluded that vitamin D deficiency in pregnancy seems to be quite common, even in the Mediterranean region. Racial, social and cultural habits, as well as the absence of preventive supplementation/dietary strategies, seem to negate the benefits of sun exposure.

Association between bullous pemphigoid and hypovitaminosis D in older inpatients: Results from a case-control study.

OBJECTIVES: To compare serum vitamin D status in older inpatients with bullous pemphigoid (BP) and matched inpatients without BP, and to examine whether hypovitaminosis D, a high comorbidity burden or their combination were associated with BP. METHODS: This prospective case-control study was performed from November 2012 to February 2014. A total of 90 consecutive older inpatients (31 consecutive inpatients with a de novo diagnosis of active BP, and 59 matched controls without BP) were recruited in the Department of Dermatology of Angers University Hospital, France. Hypovitaminosis D was defined as serum 25-hydroxyvitamin D (25OHD) concentration<50nmol/L. Age, gender, functional level, sun exposure, season, comorbidity burden and cognitive performance were used as covariates. RESULTS: There was no significant difference between older inpatients with and without BP. Fully adjusted logistic regression showed a significant association between BP and hypovitaminosis D (odds ratio [OR]=3.7, P=0.046). The analysis of interaction between hypovitaminosis D and comorbidity burden showed that only the association of both was significantly associated with PB (OR=3.1, P=0.042). CONCLUSIONS: BP was significantly associated with hypovitaminosis D solely in patients with a high comorbidity burden among the older in-patients studied. This result suggests a complex interplay between hypovitaminosis D and BP, explaining the mixed results reported previously in the literature.

Risk of Unplanned Emergency Department Readmission after an Acute-Care Hospital Discharge among Geriatric Inpatients: Results from the Geriatric EDEN Cohort Study.

OBJECTIVES: The study aims 1) to examine whether items of the brief geriatric assessment (BGA) or their combinations predicted the risk of unplanned emergency department readmission after an acute care hospital discharge among geriatric inpatients, and 2) to determine whether BGA could be used as a prognostic tool for unplanned emergency department readmission. METHODS: A total of 312 older patients (mean age, 84.6 ± 5.4 years; 64.1% female) hospitalized in acute care wards after an emergency department visit were recruited in this observational prospective cohort study and separated into 2 groups based on the occurrence or not of an unplanned emergency department readmission during a 12-month follow-up period after their hospital discharge. A 6-item BGA was performed at emergency department admission before the discharge to acute care wards. Information on incident unplanned emergency department readmission was prospectively collected by phone call and by consulting the hospital registry. Several combinations of items of BGA identifying three levels of risk of unplanned emergency department readmission (i.e., low risk, intermediate risk and high risk) were examined. RESULTS: The unplanned emergency department readmission was more frequently associated with a temporal disorientation (P=0.004). Area under receiver operating characteristic curves of unplanned emergency department readmission based on BGA items and their combinations ranged from 0.53 to 0.61. The best predictor of unplanned emergency department readmission was the temporal disorientation (hazard ratio>1.65, P<0.035), which defined the high-risk group. Inpatients classified in high-risk group of unplanned emergency department readmission were more frequently readmitted to emergency department than those in intermediate- and low-risk groups (P log Rank <0.004). Prognostic values for unplanned emergency department readmission of items and their combinations were poor with sensitivity below 67%, specificity ranging from 36.4 to 53.7, and positive likelihood ratio below 1.4. CONCLUSIONS: The items of BGA and their combinations were significant risk factors for unplanned emergency department readmission, but their prognostic value was poor.

Gait phenotype from mild cognitive impairment to moderate dementia: results from the GOOD initiative.

BACKGROUND AND PURPOSE: The differences in gait abnormalities from the earliest to the later stages of dementia and in the different subtypes of dementia have not been fully examined. This study aims to compare spatiotemporal gait parameters in cognitively healthy individuals, patients with amnestic mild cognitive impairment (MCI) and non-amnestic MCI, and patients with mild and moderate stages of Alzheimer's disease (AD) and non-Alzheimer's disease (non-AD). METHODS: Based on a cross-sectional design, 1719 participants (77.4 ± 7.3 years, 53.9% female) were recruited from cohorts from seven countries participating in the Gait, Cognition and Decline (GOOD) initiative. Mean values and coefficients of variation of spatiotemporal gait parameters were measured during normal pace walking with the GAITRite system at all sites. RESULTS: Performance of spatiotemporal gait parameters declined in parallel with the stage of cognitive decline from MCI status to moderate dementia. Gait parameters of patients with non-amnestic MCI were more disturbed compared to patients with amnestic MCI, and MCI subgroups performed better than demented patients. Patients with non-AD dementia had worse gait performance than those with AD dementia. This degradation of gait parameters was similar between mean values and coefficients of variation of spatiotemporal gait parameters in the earliest stages of cognitive decline, but different in the most advanced stages, especially in the non-AD subtypes. CONCLUSIONS: Spatiotemporal gait parameters were more disturbed in the advanced stages of dementia, and more affected in the non-AD dementias than in AD. These findings suggest that quantitative gait parameters could be used as a surrogate marker for improving the diagnosis of dementia.

Anti-dementia drugs-related changes in gait performance while single and dual tasking in patients with Alzheimer disease: a meta-analysis.

BACKGROUND: The effects of anti-dementia drugs on gait performance in Alzheimer disease (AD) are questionable. The objective of this meta-analysis was to examine the effects of anti-dementia drugs on the mean value and the coefficient of variation (CoV) of stride time among patients with AD while taking into account the type of drugs (i.e., acetylcholinesterase inhibitors [AChEIs] versus memantine) and the walking conditions (i.e., single versus dual-task). METHODS: An English and French Medline search was conducted in March 2015, with no limit of date, using the Medical Subject Headings terms "pharmaceutical preparations" combined with terms "Pharmaceutical preparations" OR "Therapeutic uses" OR "Drug substitution" OR "Drugs essential" OR "Drugs, Generic" OR "Psychotropic drugs" combined with "Delirium" OR "Dementia" OR "Amnestic" OR "Cognitive disorders" AND "Gait" OR "Gait Ataxia" OR "Gait disorders, Neurologic" OR "Gait apraxia". Fixed-effects meta-analyses were used to examine anti-dementia drugs-related changes in mean value and CoV of stride time. RESULTS: Of the 66 identified abstracts, 5 (7.6%) were included in the meta-analysis. Inter-group comparison of between-visit change underscored a significant decrease in CoV of stride time (P<0.004) in intervention group compared to control group, whatever the pooled analysis considered, but no significant change in the mean value (P>0.06). Intra-group changes in stride time parameters following the use of anti-dementia drugs showed a significant decrease for memantine (P<0.001) and while pooling AChEIs and memantine (P<0.001) under single task condition. Under dual task condition, only AChEIs improved significantly stride time parameters (P=0.002). CONCLUSION: Anti-dementia drugs demonstrated a significant improvement of gait performance with specific class effect depending on the walking conditions and on the type of stride time parameters considered.

Vitamin D during pregnancy: why observational studies suggest deficiency and interventional studies show no improvement in clinical outcomes? A narrative review.

A considerable number of studies have examined vitamin D status during pregnancy. Although data from observational studies denote vitamin D hypovitaminosis (deficiency or insufficiency) during pregnancy is associated with a plethora of adverse maternal and neonatal outcomes, data from interventional (supplementation) trials fail to reveal a significant impact on maternal and offspring health. The aim of this narrative review was to critically appraise the methodology of the most representative published randomized controlled trials in an attempt to explain the difference between observational and supplementation results. We found that this difference could be attributed to a variety of factors, namely: (i) study design (lack of a specific outcome in conjunction with timing of supplementation, enrolment of participants with heterogeneous vitamin D status); (ii) pitfalls in the interpretation of vitamin D equilibrium (lack of determination of plasma half-life); (iii) supplementation regimen (administration of a wide range of regimens, in terms of dose, bolus and form); (iv) geographical characteristics (vitamin D needs could vary significantly within a country, particularly in areas with a wide range of latitude gradient); (v) adaptations of vitamin D metabolism during pregnancy (vitamin D and calcium equilibrium are changed during pregnancy compared with the non-pregnant state) and (vi) supplementation of populations with low baseline 25(OH)D values would likely manifest beneficial effects. All these parameters should be taken into consideration in the design of future vitamin D supplementation trials.