Do informal caregivers of demented patients refuse clinic comprehensive medico-psycho-social assessment? Prevalence and reasons for refusal.

OBJECTIVE: Caregivers do not usually use services that could alleviate their burden. The objectives were to determine the refusal's prevalence and the reasons why informal caregivers of demented patients refuse clinic medico-psycho-social assessment in the first day care hospital dedicated to caregivers in France. METHODS: Caregivers of patients hospitalized in geriatric ward were prospectively asked to fill in a questionnaire (demographic data, risk for depression and caregiver burden (Zarit scale) about their willingness to benefit from a clinic checkup. If caregivers refused eleven close questions were asked. Characteristics of the caregivers were compared according to the caregivers' agreement or refusal to the clinic checkup. RESULTS: Seventy-seven caregivers (mean age (standard deviation): 68.2 (11.5)) were included: 68.8% of women, 51.9% of children and 35.1% of spouses, mean Zarit scale score was 32.8 (8.8)/88. Clinic checkup was accepted by 28 caregivers. Agreement was associated with exhaustion (p<0.001), depression (p=0.003), memory complaints (p<0.001) and higher burden (p=0.008). Reasons for refusal were mostly the belief that support was sufficient (67.3%) and good self-perceived health (44.9%). Nearly 1/4 of caregivers though that the clinic checkup would be useless. CONCLUSION: Two third of caregivers refused the evaluation because subjective feeling of good physiological and psychological health and that currently provided support was sufficient. Studies to address caregivers 'needs should be conducted.

Do medical French students know how to properly score a mini mental state examination?

The mini mental state examination (MMSE) is a validated tool to assess global cognitive function. Training is required before scoring. Inaccurate scoring can lead to inappropriate medical decisions. In France, MMSE is usually scored by medical students. To assess if medical French students know how to properly score a mini mental state examination. Two « physician-patient ¼ role playings performed by 2 specialized physicians, were performed in front of University Paris V medical students. Role playing A: Scoring of a MMSE according to a script containing five tricks; Role playing B: Find the 5 errors committed in a pre-filled MMSE form, according to the second script. One hundred and five students (64.4% of women, 49.5% in fifth medical school year) anonymously participated. Eighty percent of students had already scored a MMSE and 40% had been previously trained to MMSE scoring. Forty five percent of students previously scored an MMSE, without previously being trained. In test A, 16% of students did not commit any errors, 45.7% one error and 38.1% two errors. In test B, the proportion of students who provided 0, 1, 2, 3, 4 and 5 good answers was 3.3%, 29.7%, 29.7%, 25.3%, 7.7% and 4.4% respectively. No association between medical school year, previous training to MMSE scoring and performances at both tests were found. French students do not properly score MMSE. MMSE scoring is not enough or accurately taught (by specialists). The university will provide on line the tests and a short filmed teaching course performed by neuropsychological specialists.

Comparison between the three most popular formulae to estimate renal function, in subjects 75 years of age or older.

OBJECTIVES: The aim of the study was to compare the accuracy of three formulae that estimate creatinine clearance (CL(CR)), in elderly hospitalized patients: the Cockcroft-Gault (CG) formula and the Modification of Diet in Renal Disease formulae with 4 and 6 variables (MDRD4 and MDRD6). METHODS: A prospective, cross-sectional, observational study was conducted in four hospital geriatric wards. Consecutive patients admitted to the wards who were aged ≥75 years and had an indwelling urinary catheter for the purpose of care were eligible for enrolment. CL(CR) was determined via four methods: measurement of CL(CR) from plasma and urine creatinine plus 24-h urine volume; the CG formula; and the MDRD4 and MDRD6 formulae. Moderate and severe renal impairments were defined as a CL(CR) of 30.0-59.9 and <30.0 mL/min, respectively. RESULTS: A total of 157 patients were included. Their mean age (±SD) was 86.5 ± 6.1 (range 75-105) years and 46.5 % were male. The median values and interquartile ranges (IQRs) (in mL/min) were 44.0 (IQR 32.1-64.5) for measured CL(CR), 42.1 (IQR 31.3-56.3) for CG-estimated CL(CR), 64.3 (IQR 49.8-81.7) for MDRD4-estimated CL(CR) and 49.3 (IQR 37.4-63.4) for MDRD6-estimated CL(CR) (respectively, p < 0.05, p < 0.001 and p = 0.44 compared with measured CL(CR)). Biases (±SD) for CG, MDRD4 and MDRD6 CL(CR) estimates were -3.6 (±22.2), 19.3 (±26.4) and 2.4 (±22.5) mL/min, respectively. When estimated CL(CR) values were assessed against the measured value, it was found that misclassification of renal impairment (absent/moderate/severe) occurred in 41 % of patients when using the CG, in 40 % when using the MDRD6, and in 45 % when using the MDRD4. The 30 % accuracies of the three formulae were 63 % for CG, 37 % for MDRD4 and 59 % for MDRD6. CONCLUSION: In elderly hospitalized patients, CG and MDRD6 gave better predictions for measured CL(CR) than MDRD4, with no significant difference between them.

Renal function in older hospital patients is more accurately estimated using the Cockcroft-Gault formula than the modification diet in renal disease formula.

OBJECTIVES: To compare the accuracy of the two most popular creatinine clearance (CrCl) estimation formulae (Cockcroft-Gault (CG) and Modification Diet in Renal Disease (MDRD)) in older hospitalized patients. DESIGN: Prospective, cross-sectional, observational study. SETTING: Two hospital geriatric wards. PARTICIPANTS: Consecutive patients aged 70 and older with an indwelling urinary catheter for the purpose of care. MEASUREMENTS: CrCl was determined according to three methods: measured CrCl from plasma and urine creatinine and 24-hour urine volume, CG (CG-CrCl), and MDRD (MDRD-CrCl). Results were expressed as median and interquartile range (IQR). Moderate and severe renal impairment were defined as a CrCl between 30.0 and 59.9 mL/min and less than 30.0 mL/min, respectively. RESULTS: One hundred twenty-one patients were included (46% male). Mean age was 86.1+/-6.7 (range 72-100). Median measured CrCl was 43.8 mL/min (IQR 33.6-61.1 mL/min), CG-CrCl was 40.9 mL/min (IQR 31.0-52.6 mL/min), and MDRD-CrCl was 61.3 mL/min (IQR 49.4-77.0 mL/min). The biases of CG-CrCl and MDRD were -3.5+/-22.5 and 20.1+/-28.2, respectively (P<.001). Misclassification of renal impairment (absent/moderate/severe) occurred in 33% of patients according to CG-CrCl, and concordance was mild to moderate (kappa=0.50). Misclassification occurred in 50% of patients according to MDRD-CrCl, and concordance was poor (kappa=0.33). Bias was significantly related to bed confinement for both formulae and to plasma creatinine for MDRD. CONCLUSION: In elderly hospitalized patients, CG slightly underestimates CrCl, and MDRD strongly overestimates it. CG gave a better prediction of measured CrCl than MDRD.

[Prevention of coronary heart disease and heart failure in the elderly]. / Prévention de la coronaropathie et de l'insuffisance cardiaque chez le sujet âgé.

Cardiovascular diseases are responsible for disability, quality of life impairment and mortality in the elderly. Although it is efficient, cardiovascular prevention is underused in old individuals. Coronary heart disease can be prevented by antihypertensive agents in old subjects with hypertension, and by statins and antiplatelet agents in high risk subjects. In addition, betablockers and angiotensin converting enzyme inhibitors prevent cardiovascular events in patients with coronary heart disease. Heart failure can also be prevented in the elderly. The treatment of hypertension results in a two-fold decrease in heart failure incidence, even in subjects >80 years. Influenza vaccine reduces the risk of hospital admission for heart failure in old subjects, even in those with no history of cardiac or respiratory diseases. Lifestyle modifications should be encouraged in old individuals, especially smoking cessation, physical activity and mediteranean type diet, because their effects on cardiovascular health seem as positive in the elderly as in younger adults.