Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents.

OBJECTIVES: To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately. DESIGN: Multicenter, observational, case-control study. SETTING AND PARTICIPANTS: 17 hospitals in France, 1037 NH residents. MEASURES: All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer. RESULTS: A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs. CONCLUSIONS AND IMPLICATIONS: Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions. TRIAL REGISTRATION: clinicaltrials.gov, NCT02677272.

Cognitive, functional, physical, and nutritional status of the oldest old encountered in primary care: a systematic review.

BACKGROUND: The oldest old (individuals over 90 years) are a fast-growing population. Characterizing their specificity would be helpful to adapt health care. This study aimed to characterize the cognitive, functional, nutritional, and physical status of individuals over 90. METHODS: We conducted a systematic review of cross-sectional or cohort studies of individuals aged 90 years old or more, living at home or in a nursing home, in April 2018. Two reviewers selected eligible articles, extracted data, and evaluated the risk of bias (assessed by the Newcastle-Ottawa Scale). RESULTS: The search strategy identified 3086 references; 35 articles were included referring to 8 cross-sectional and 27 longitudinal studies. Dementia was diagnosed in 30-42.9% of study participants, cognitive impairment in 12-50%, and 31-65% had no cognitive impairment. In terms of activities of daily living, 14-72.6% of individuals had no difficulty, 35.6-38% had difficulty, and 14.4-55.5% were dependent. For instrumental activities of daily living, 20-67.9% needed help. Regarding nutritional status, the Mini Nutritional Assessment Short Form mean score ranged from 10.3 (SD: 1.8) to 11.1 (SD: 2.4). Eight to 32% of individuals could not stand up from a chair, 19-47% could stand without the use of their arms; and 12.9-15% were not able to walk 4 m. CONCLUSIONS: These results suggest a heterogeneous population with a certain proportion of oldest old with a low level of disability. These findings suggest that a specific approach in the care of the oldest old could help prevent disability.

[General practitioners' satisfaction after a geriatric assessment into primary care: data from FAP study]. / Ressentis des médecins généralistes ayant participé à un projet d'évaluation gériatrique en soins premiers : données issues de l'étude FAP.

In response to demographic challenges, primary care need to get familiar with the concept of frailty and the early detection of cognitive impairment. The « Frailty and Alzheimer's disease prevention into primary care ¼ (FAP) project introduced a geriatric evaluation with a nurse in primary care in order to assess older patients. Our work aimed to evaluate the general practitioner's (GPs) opinion involved in FAP project. METHODS: This is an observational descriptive study performed in Occitanie region. 26 GPs have involved in this project. The gathering of information was performed through an online survey. RESULTS: GPs estimated that most of the patients benefiting from a primary care geriatric evaluation would have declined hospital evaluation. 92% of the surveyed GPs gave a strongly positive or positive opinion regarding the detection of previously unidentified health issues and the improvement of patient care following this evaluation. 42% of the GPs found that the personalized plan of cares is difficult or very difficult to do. 73% of the GPs considered that they have a better knowledge of frailty syndrome and cognitive impairment after the evaluation. CONCLUSION: GPs feedback was very positive and promising for the future. It could be interesting to develop this geriatric evaluation in primary care into new regions.

Becoming frail: a major turning point in patients' life course.

BACKGROUND: The frailty concept requires that practices should be adapted to meet the challenge of dependence. The GP is in the front line of management of frail elderly patients. OBJECTIVES: To explore the perception of elderly persons of the term and concept of frailty and to understand their perception of the risk of loss of independence. METHODS: Two qualitative studies by individual interviews in the homes of elderly persons identified as potentially frail by their GP, or diagnosed as frail and at risk of loss of independence. The sampling was theoretical. The analysis was carried out using an inductive approach following the phases of thematic analysis. The researchers used triangulation and collection was concluded when theoretical saturation had been reached. RESULTS: The concept of frailty was seen as forming an integral part of physiological ageing and appeared to be irreversible. The term of frailty had a negative connotation. The physical, cognitive and psychological components of frailty were present in the participants' discourse. Nutritional and sensory components were less present. Frailty due to inappropriate medication was not cited. Seven risk factors for loss of independence were identified: social isolation, poor physical health, poor mental health, loss of mobility, unsuitable living conditions, unsuitable environment, and low resources. CONCLUSIONS: Becoming frail is a major turning point in patients' life course. Coordinated multiprofessional management that takes account of patients' perceptions could help in negotiating a feasible care plan adapted to the patient's needs.

Benzodiazepines and frail elderly people: how prescribing can be optimized?

In France, benzodiazepine (BZD) is frequently prescribed in elderly people (EP). Long-term efficacy is often questioned, and treatment has to be regularly re-examined, especially in EP. In our Geriatric day-hospital for assessment of frailty, a multidisciplinary team evaluates the patients and gives them preventative measures against the loss of autonomy. Medication evaluation is part of these measures. The aim of our study was to evaluate the impact of a standardized intervention on the optimization of BZD treatment. Setting and method: After a short interview and the delivery of an information booklet about BZD, patients were proposed an optimization of their BZD treatment (dosage reduction, occasional medication, switch to a short half-life BZD, or total discontinuation). Patients were followed up monthly by a phone-interview over a 6-months period. The main outcome measure was the prevalence of BZD optimized treatments after a 6 months follow-up. Results: 18 patients were included. Among them, 50% have been taking a BZD for more than 10 years, and 39% were prescribed a long half-life BZD, which can be qualified as inappropriate in EP. 50% of the subjects were frail and 44% pre-frail, according to the Fried criteria. At the end of the study, 33% of the patients had their BZD treatments optimized, including 17% of total discontinuation. Conclusion: In the frail elderly population, a standardized intervention can be useful to improve BZD treatment. An extension to this intervention would be the creation of an organization tasked with routinely monitoring the patients' withdrawal over a six month period.

Patients' satisfaction after a geriatric assessment into primary care: data from FAP study.

Given the current demographic situation, the primary care must consider the frailty concept. The « Frailty and Alzheimer's disease prevention into Primary care ¼ project (FAP) enabled geriatric assessment by a nurse in general practitioner's office to assess older persons. The aim of our study was to evaluate patients' satisfaction after geriatric assessment into primary care. METHODS: This is an observational descriptive study performed in the Occitanie area on a population of 268 older patients. Gathering of information was performed through a phone survey. RESULTS: A total of 133 questionnaires were filled in. Average age was 80 (±6) years old and 60% were women. 75.2% (n=100) were frail or pre-frail; 72% (n=89) of participants have been completely satisfied by this assessment; 71% (n=24) have been completely satisfied about their personalized plan of care; 79% (n=89) of them thought the general practitioners' office as the best place for geriatric assessment; 42% (n=52) would have refused the evaluation in the hospital. DISCUSSION: Patient's feedback is very encouraging. They were favorable to the development of the geriatric assessment into primary care and the generalization of the FAP project in other areas. Further studies must be carried out in order to evaluate the medico-economic effect of this care model.

Reliability and validity of the script concordance test for postgraduate students of general practice.

BACKGROUND: The script concordance test (SCT) is a validated method of examining students' clinical reasoning. Medical students' professional skills are assessed during their postgraduate years as they study for a specialist qualification in general practice. However, no specific provision is made for assessing their clinical reasoning during their postgraduate study. OBJECTIVE: The aim was to demonstrate the reliability and validity of the SCT in general practice and to determine if this tool could be used to assess medical students' progress in acquiring clinical reasoning. METHODS: A 135-question SCT was administered to postgraduate medical students at the beginning of their first year of specialized training in general practice, and then every six months throughout their three-year training, as well as to a reference panel of 20 expert general practitioners. For score calculation, we used the combined scoring method as the calculator made available by the University of Montreal's School of Medicine in Canada. For the validity, student' scores were compared with experts, p <.05 was considered statistically significant. RESULTS: Ninety students completed all six assessments. The experts' mean score (76.7/100) was significantly higher than the students' score across all assessments (p <.001), with a Cronbach's alpha value of over 0.65 for all assessments. CONCLUSION: The SCT was found to be reliable and capable of discriminating between students and experts, demonstrating that this test is a valid tool for assessing clinical reasoning skills in general practice.

How French general practitioners manage and prevent recurrent respiratory tract infections in children: the SOURIRRE survey.

BACKGROUND: Recurrent respiratory tract infections (RRTIs) are the most common reason for children's visits to primary care physicians in France; however, little is known about general practitioners' (GPs) opinions and expectations concerning the management and prevention of these common and recurrent pathologies. PURPOSE: To describe French GPs' daily practice in the management of respiratory infections and the prevention of their recurrence in children. METHODS: A sample group of French GPs answered a structured questionnaire on risk factors, RRTI management, antibiotic use and prevention measures. RESULTS: A total of 358 GPs participated in the survey. Rhinopharyngitis, the most frequent respiratory infection, was considered to be recurrent if six or more episodes occurred in a year. Four risk factors were acknowledged as substantial: living in communities, passive smoking, pollution and allergies. Around 63% of GPs said that RRTIs are too often treated with antibiotics. More than 85% thought that prevention of RRTIs is possible. Smoking cessation, vaccination, allergen avoidance and hygiene were identified as the main preventive measures. A large majority of GPs (84%) prescribed products for prevention and ~90% would prescribe a product stimulating immunity if the efficacy and tolerability of these agents was proven and confirmed in their daily practice. CONCLUSIONS: French GPs are well aware of the health and socioeconomic burdens resulting from RRTIs, as well as the risk of antibiotic overuse. They have a prevention-oriented approach, implement preventive measures when possible and prescribe products for prevention.

General Practitioners' Clinical Impression in the Screening for Frailty: Data From the FAP Study Pilot.

BACKGROUND: The progression of frailty is marked by an increased risk of adverse health outcomes in the elderly including falls, physical and/or cognitive disability, hospitalizations, and mortality. In primary care, the general practitioner's (GP's) clinical impression about their elderly patients' frailty state seems to be a key point in identifying frail individuals in their clinical practice. The aim of this article is to examine if GPs' clinical impressions regarding frailty concurs with objective measures of the gold standard frailty phenotype as described by Fried in community-dwelling older persons. DESIGN: Cross-sectional study in 14 primary care GP offices in the Toulouse area from May 1st to October 31st, 2015. PARTICIPANTS: Fourteen GPs screened their patients ≥70 years old. MEASUREMENTS: GPs' "frailty impression" was based on the Gérontopôle Frailty Screening Tool. "Objective measures of the five Fried frailty criteria" were obtained by a geriatric nurse through standardized testing. The capacity of the GPs' clinical impression to detect participants objectively measured as frail was examined with diagnostic values of observed sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). RESULTS: A total of 268 participants were screened by GPs and assessed by a nurse. Mean age was 81 years and 62.3% were female. According to the objective measures of Fried's criteria, frailty (three to five criteria) and pre-frailty (one to two criteria) states were identified in 31% and 45.2% of participants, respectively. The Se of the GPs' impression was good (80.39%; 95% confidence interval [CI], 74.27%-85.61%), and the Sp was moderate (64.06%; 95% CI, 5.10%-75.68%). The overall PPV of the GPs' impression was 87.70% (95% CI, 82.12%-92.04%), and the NPV was 50.51% (95% CI, 39.27%-61.91%). Although the PPV increased with age reaching 93.33% (95% CI, 85.12%-97.80%) among patients ≥ 85 years old, the NPV decreased accordingly to a minimal 21.43% (95% CI, 4.66%-50.80%) in that subgroup. CONCLUSION: The present study highlights the importance of the GPs' clinical impression on frailty as a fair means to identify this syndrome in community-dwelling older patients in primary care. This clinical impression may not be sufficient, however, and some objective tests could be added to improve the accuracy of frailty detection in older patients in primary care.

Factors predisposing nursing home resident to inappropriate transfer to emergency department. The FINE study protocol.

BACKGROUND: Each year, around one out of two nursing home (NH) residents are hospitalized in France, and about half to the emergency department (ED). These transfers are frequently inappropriate. This paper describes the protocol of the FINE study. The first aim of this study is to identify the factors associated with inappropriate transfers to ED. METHODS/DESIGN: FINE is a case-control observational study. Sixteen hospitals participate. Inclusion period lasts 7 days per season in each center for a total period of inclusion of one year. All the NH residents admitted in ED during these periods are included. Data are collected in 4 times: before transfer in the NH, at the ED, in hospital wards in case of patient's hospitalization and at the patient's return to NH. The appropriateness of ED transfers (i.e. case versus control NH residents) is determined by a multidisciplinary team of experts. RESULTS: Our primary objective is to determine the factors predisposing NH residents to inappropriate transfer to ED. Our secondary objectives are to assess the cost of the transfers to ED; study the evolution of NH residents' functional status and the psychotropic and inappropriate drugs prescription between before and after the transfer; calculate the prevalence of potentially avoidable transfers to ED; and identify the factors predisposing NH residents to potentially avoidable transfer to ED. DISCUSSION: A better understanding of the determinant factors of inappropriate transfers to ED of NH residents may lead to proposals of recommendations of better practice in NH and would allow implementing quality improvement programs in the health organization.

Implementing Assessment of Cognitive Function and Frailty Into Primary Care: Data From Frailty and Alzheimer disease prevention into Primary care (FAP) Study Pilot.

BACKGROUND: Aging can be affected by frailty and chronic diseases causing physical, cognitive, sensory, and functional decline evolving gradually to disability. The assessment of older patients is carried out in some geriatric day hospitals (GDHFs). However, it seems difficult to assess all patients in these GDHFs. In this context, a care model, which uses a specialist nurse trained in primary care and geriatric assessment, has been developed. In this article, we describe the organization, details of the evaluation, and provide the main characteristics of the first 200 patients assessed over a 6-month period. METHODS: Persons aged 70 years and older were invited to undergo an evaluation at the general practitioner's (GP) office by a nurse if the GP thought that the patient was frail or if the patient had cognitive complaint or for both reasons. RESULTS: A total of 200 patients from 14 GP offices were assessed. Overall, the mean age was 81.3 (±5.92) years. More than one-half were female (66%), and 32% of participants lived alone. The average Mini-Mental State Examination score was 25.2 (±4.23); 16.7% had dementia; 12% of mild cognitive impairment were identified; 78% of patients were followed by their GP; and 2.5% were referred to a GDHF, 12% to specialized memory center, and 7.5% to geriatric consultation. CONCLUSIONS: This work foreshadows any other ambulatory options for older persons in his/her living area representing an alternative to the GDHF. It seems to meet the needs for this population and demonstrates the feasibility to implement in primary care a nurse trained to assess older patients in a GP office.

Pregabalin use disorder and secondary nicotine dependence in a woman with no substance abuse history.

This is an addictovigilance report of a pregabalin use disorder case in a young female patient who secondarily presented a tobacco use disorder after smoking initiation combined with pregabalin intake. Pregabalin was first prescribed for anxiety. Concomitant use of pregabalin with tobacco led to a synergic effect of both substances. She presented a craving behavior for pregabalin, with a tolerance phenomenon and a withdrawal syndrome between pregabaline intakes. The patient had a history of depressive disorder, personality disorder and anorexia, but never had any history of substance use disorder. This case report is noteworthy for 3 reasons: 1: this is one of the first report of pregabalin use disorder in a patient without any substance abuse disorder (licit or illicit), with the exception of a personal vulnerability factors to substance abuse; 2: the patient presented characteristics of pregabalin use disorder at usual dose (below 300mg per day), with drug-seeking behavior, tolerance phenomenon and intense craving with these moderate doses; 3: concomitant use of pregabalin with tobacco led to a synergic effect of both substances.

French general practitioners' sense of isolation in the management of elderly cancer patients.

BACKGROUND: Cancer care in people over 75 years of age is particularly complex and requires collaboration between oncologists, geriatricians, GPs and other professional and family carers. To improve the care pathways for elderly people living with cancer, the French health authorities have created a network of oncologists and geriatricians; however, GPs experience difficulties in establishing their place in this network. OBJECTIVE: This study aimed to analyse the impressions of French GPs involved in the care of elderly patients with cancer, including their feelings regarding their relationships with their oncologist and geriatrician colleagues. METHODS: A qualitative approach using focus groups was employed. The proceedings of these focus groups were recorded, retranscribed and subjected to thematic analysis. RESULTS: Although heavily involved in the care of their elderly patients living with cancer, the GPs who participated reported feeling isolated in their role at each step during the course of the disease. The principal themes addressed were screening and diagnosis, therapeutic decisions, multidisciplinary consultation meetings, the announcement of the diagnosis and monitoring at home. Their relationships with their oncologist colleagues showed much room for improvement, and they were unaware of the oncogeriatric network. CONCLUSIONS: Improving the communication between GPs, oncologists and geriatric medicine seems to be one response to the isolation that GPs feel when caring for older people with cancer. At the primary care level, integration of GPs into the oncogeriatric network and the creation of a cancer care communication system in collaboration with the relevant hospital teams may be effective solutions.

RETRACTED: Development and Implementation of the Advanced Practice Nurse Worldwide With an Interest in Geriatric Care.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editors-in-Chief. The authors have plagiarized part of a report that had already appeared in Delamaire M-L, Lafortune G. Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries. OECD Health Working Papers No. 54. Paris: Organisation for Economic Co-operation and Development, 2010. One of the conditions of submission of a paper for publication is that authors declare explicitly that their work is original and has not appeared in a publication elsewhere. Re-use of any data should be appropriately cited. As such this article represents a severe abuse of the scientific publishing system. The scientific community takes a very strong view on this matter and apologies are offered to readers of the journal that this was not detected during the submission process.