RESUMEN
In France, the goal of the pertussis vaccination program is to protect newborns. All infants are vaccinated under the program and then given booster shots up to the age of 25 years. Pregnant women are likewise vaccinated, with the cocooning strategy reserved for infants born to unvaccinated mothers. Real-world data shows (i) inadequate coverage among adolescents and adults under 25; (ii) improper use of the tetanus, diphtheria, and polio (Td/IPV) vaccine in children under six years, adolescents, and young adults; and (iii) underdiagnosis of pertussis in adults. Older patients or those with specific chronic medical conditions are at risk of developing severe disease. Improving the diagnosis and surveillance of pertussis in adults and seniors would be one of the first steps in the right direction. Aligning pertussis vaccination in adults with the Td/IPV program (boosters at 45, 65 years of age, and then every 10 years) would make the vaccination schedule simpler, easier to understand, and easier to implement. Large-scale awareness campaigns targeting this population would increase coverage, thereby boosting the effectiveness of the other measures.
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Vacuna contra la Tos Ferina , Vacunación , Tos Ferina , Humanos , Tos Ferina/prevención & control , Tos Ferina/epidemiología , Francia , Adulto , Vacuna contra la Tos Ferina/administración & dosificación , Vacunación/métodos , Femenino , Programas de Inmunización/métodos , Embarazo , Adolescente , Adulto Joven , Inmunización Secundaria , Esquemas de Inmunización , Anciano , Vacuna contra Difteria, Tétanos y Tos Ferina/administración & dosificación , Persona de Mediana Edad , Cobertura de Vacunación/estadística & datos numéricosRESUMEN
Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners' habits. METHOD: ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017. RESULTS: 220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP. CONCLUSION: Even if practice and number of patients follow up differ from each place of care, doctors' intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.
Asunto(s)
Médicos Generales , Cuidados Paliativos , Anciano , Antibacterianos/uso terapéutico , Estudios Transversales , Humanos , Prescripciones , Encuestas y Cuestionarios , Enfermo TerminalRESUMEN
INTRODUCTION: Notwithstanding high prevalence of presumably bacterial infections in elderly persons (EP) in palliative care (PC), there exists no recommendation on the role of antibiotic therapy (ABP) in this type of situation. OBJECTIVE: To describe the determinants of antibiotic prescription by general practitioners (GP) and by doctors practicing in institutions (DPI) for patients>75 years, in end-of-life situations in PC. METHOD: Descriptive investigation by anonymous self-administered questionnaire disseminated in France by e-mail. RESULTS: A total of 301 questionnaires analyzed: 113 GP, 188 DPIs. The latter were mainly geriatricians (69, 36.6%) and infectologists/internists (41, 21.8%). Sixty-three (55,75%) GPs and 144 (78.7%) DPIs stated that they had prescribed antibiotics. Practice in "EHPAD" retirement homes or intensive care was often associated with non-prescription of antibiotics. Age, PC training and number of patients monitored bore no influence. Family involvement in decision-making was more frequent for GPs than for DPIs. The main purpose of antibiotic therapy was to relieve different symptoms (fever, respiratory congestion, functional urinary signs). Most of the doctors (81%) had previously encountered complications (allergy, adverse effect), which represented the main causes of treatment discontinuation. CONCLUSION: Antibiotic use in end-of-life EPs in PC seems frequent. In accordance with the principle of beneficence, its goal of often symptom-related; that said, in the absence of scientific data, antibiotic prescription in end-of-life situations should be individualized in view of observing the other ethical caregiving principles (beneficence, non-maleficence, justice, patient autonomy) and re-evaluated daily.
Asunto(s)
Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Prescripciones de Medicamentos/estadística & datos numéricos , Cuidados Paliativos/métodos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cuidado Terminal/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fiebre/tratamiento farmacológico , Francia/epidemiología , Médicos Generales , Humanos , Masculino , Persona de Mediana Edad , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Encuestas y CuestionariosRESUMEN
Cancer prevalence increases with aging. Prevalent or incident neurocognitive disorders are frequent in geriatric oncology. Cognitive decline associated with cancer increases the risk of under or over-cancer treatment and makes therapeutic decisions complex. In this context, we present tools to optimize cognitive impairment screening, identification of underlying mechanisms and specific treatments. Geriatric specialists intervention can help global care, social services utilization and patient's orientation when ambulatory cares become difficult.
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Disfunción Cognitiva/diagnóstico , Disfunción Cognitiva/terapia , Oncología Médica , Neoplasias/complicaciones , Anciano , Encéfalo/efectos de los fármacos , Disfunción Cognitiva/etiología , Confusión/diagnóstico , Toma de Decisiones , Diagnóstico Diferencial , Evaluación Geriátrica , Humanos , Neoplasias/terapiaRESUMEN
INTRODUCTION: The Confusion Assessment Method (CAM) is a validated key tool in clinical practice and research programs to diagnose delirium and assess its severity. There is no validated French version of the CAM training manual and coding guide (Inouye SK). The aim of this study was to establish a consensual French version of the CAM and its manual. METHODS: Cross-cultural adaptation to achieve equivalence between the original version and a French adapted version of the CAM manual. RESULTS: A rigorous process was conducted including control of cultural adequacy of the tool's components, double forward and back translations, reconciliation, expert committee review (including bilingual translators with different nationalities, a linguist, highly qualified clinicians, methodologists) and pretesting. A consensual French version of the CAM was achieved. CONCLUSION: Implementation of the CAM French version in daily clinical practice will enable optimal diagnosis of delirium diagnosis and enhance communication between health professionals in French speaking countries. Validity and psychometric properties are being tested in a French multicenter cohort, opening up new perspectives for improved quality of care and research programs in French speaking countries.
Asunto(s)
Confusión/diagnóstico , Características Culturales , Delirio/diagnóstico , Lenguaje , Psicometría/métodos , Traducciones , Enfermedad Aguda , Anciano , Confusión/psicología , Comparación Transcultural , Delirio/psicología , Evaluación Geriátrica/métodos , Humanos , Reproducibilidad de los Resultados , Encuestas y CuestionariosAsunto(s)
Antiparasitarios/uso terapéutico , Ropa de Cama y Ropa Blanca/normas , Desinfección , Ivermectina/uso terapéutico , Escabiosis/terapia , Administración Cutánea , Antiparasitarios/administración & dosificación , Ropa de Cama y Ropa Blanca/parasitología , Benzoatos/administración & dosificación , Desinfección/métodos , Francia , Calor , Humanos , Insecticidas/administración & dosificación , Ivermectina/administración & dosificación , Permetrina/administración & dosificación , Escabiosis/diagnóstico , Escabiosis/tratamiento farmacológico , Escabiosis/epidemiología , Escabiosis/transmisiónRESUMEN
INTRODUCTION: Urinary tract infection (UTI) is one of the most frequent infections in geriatric patients. Nevertheless, the diagnosis remains difficult because of the high prevalence of asymptomatic bacteriuria (AB). We studied the diagnosis criteria used by physicians in geriatric patients 75 years of age or more. METHOD: A multicenter study was carried out in October 2009 in acute care wards (geriatrics, infectious diseases, internal medicine). During 1 week, the local investigator collected all positive urine microscopy and culture in geriatric patients 75 years of age or more and filled out a questionnaire on the final diagnosis (AB, cystitis, pyelonephritis, prostatitis), symptoms, clinical signs, and other infectious diagnosis. RESULTS: Two hundred and forty-one questionnaires were filled out in 48 wards. Physicians diagnosed AB in 91 patients (37.8%), cystitis in 72 (29.9%), pyelonephritis in 48 (19.9%), prostatitis in 20 (8.3%). 28.2% of patients were asymptomatic; 35% presented with clinical signs. General signs were significantly associated with invasive infection and the absence of functional signs with AB. Among the patients presenting with an invasive UTI, 27.9% also presented with another infection. This other infection was not statistically associated with AB, cystitis, or invasive UTI. CONCLUSION: Too many urine microscopy and culture procedures are not justified, and too many patients are diagnosed with several infections. Usual functional and clinical signs are important for the diagnosis but are infrequent. It seems necessary to review the range of clinical presentations and diagnostic criteria for UTI in geriatric patients.
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Pacientes Internos/estadística & datos numéricos , Infecciones Urinarias/diagnóstico , Anciano , Anciano de 80 o más Años , Enfermedades Asintomáticas , Bacteriuria/diagnóstico , Coinfección/epidemiología , Recuento de Colonia Microbiana , Estudios Transversales , Femenino , Francia/epidemiología , Departamentos de Hospitales/estadística & datos numéricos , Humanos , Leucocitos , Masculino , Prevalencia , Estudios Prospectivos , Prostatitis/diagnóstico , Prostatitis/epidemiología , Prostatitis/orina , Evaluación de Síntomas , Procedimientos Innecesarios , Urinálisis/métodos , Urinálisis/estadística & datos numéricos , Infecciones Urinarias/epidemiología , Infecciones Urinarias/orina , Orina/citología , Orina/microbiologíaRESUMEN
BACKGROUND: The objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization. METHODS: A prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period. RESULTS: Crude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR=1.83; 95% CI=1.27-2.62) or a higher number of children (HR=0.86; 95% CI=0.78-0.96), balance problems (HR=1.72; 95% CI=1.19-2.47), malnutrition or risk thereof (HR=1.93; 95% CI=1.24-3.01), and dementia syndrome (HR=1.88; 95% CI=1.32-2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR=1.92; 95% CI=1.17-3.16), delirium (HR=1.80; 95% CI=1.24-2.62), and a high level of comorbidity (HR=1.62; 95% CI=1.09-2.40). Institutionalization (HR=1.92; 95% CI=1.37-2.71) and unplanned readmission (HR=4.47; 95% CI=3.16-2.71) within the follow-up period were also found as independent predictors. CONCLUSION: The main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects' prognosis favorably.
Asunto(s)
Anciano , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Anciano de 80 o más Años , Algoritmos , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Francia/epidemiología , Evaluación Geriátrica/estadística & datos numéricos , Humanos , Masculino , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Pronóstico , Factores de TiempoRESUMEN
Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).
Asunto(s)
Anciano , Trastornos de Deglución/complicaciones , Neumonía/etiología , Enfermedades Respiratorias/etiología , Algoritmos , Trastornos de Deglución/diagnóstico , Trastornos de Deglución/epidemiología , Trastornos de Deglución/terapia , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Humanos , Modelos Biológicos , Neumonía/diagnóstico , Neumonía/epidemiología , Prevalencia , Enfermedades Respiratorias/diagnóstico , Enfermedades Respiratorias/epidemiologíaRESUMEN
OBJECTIVES: To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD - defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes. DESIGN: One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study. SETTING: Nine university hospitals in France. PARTICIPANTS: 1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department. MEASUREMENTS: Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: G1 - not frail; G2 - moderately frail; and G3 - severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient. RESULTS: All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died. With the Rockwood index, all subjects who experienced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used. No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from -0.02 to 0.15. CONCLUSION: These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology.
Asunto(s)
Trastornos del Conocimiento/diagnóstico , Anciano Frágil/psicología , Evaluación Geriátrica , Hospitalización , Mortalidad , Pruebas Psicológicas , Anciano , Anciano de 80 o más Años , Envejecimiento , Estudios de Cohortes , Progresión de la Enfermedad , Anciano Frágil/estadística & datos numéricos , Francia , Humanos , MasculinoRESUMEN
In France, although there are 445,000 beds in nursing homes (NHs) for elderly people, no studies on the burden of infections in NHs have been published. We sought to estimate the prevalence of infection among the residents and to assess the extent to which infections were associated with the residents' risk factors. We performed a nationwide, multicentre, cross-sectional, clustered period prevalence survey over five one-month periods. Cases of infection were classified as definite or, in the absence of laboratory confirmation, as probable. A total of 44,869 residents in 578 volunteer facilities were enrolled in the survey. The overall prevalence rate of infections was 11.23% [95% confidence interval (CI): 10.50-11.97] and differed significantly (P<0.001) across survey periods (the time of the year the survey was carried out). The rate of definite cases was 4.60% (95% CI: 4.04-5.54) and the rate of probable cases was 6.63% (95% CI: 5.77-7.98). Respiratory tract infections were the most frequent and accounted for 41% of all infections. Infections were significantly associated with age, length of stay, full disability, urinary device, bedsores and the survey period. Only prevention programmes may reduce the impact of infections on this frail population.
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Hogares para Ancianos/estadística & datos numéricos , Infecciones/epidemiología , Casas de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Francia/epidemiología , Humanos , Masculino , Prevalencia , Infecciones del Sistema Respiratorio/epidemiología , Factores de RiesgoRESUMEN
A nationwide survey was performed using a two-round web-based Delphi procedure to develop a set of consensus guidelines for preventing infections among residents in nursing homes (NHs). The research group was led by an investigative group of six specialists. Research analysts conducted a literature search and review of practice guidelines, systematic reviews and articles or abstracts published in English and French on the topic of infection prevention. The literature search was examined by 23 specialists (who compiled a preliminary list of 301 recommendations). Using a Delphi survey online instrument, 81 experts from all relevant medical specialties in the fields of infection prevention and control and geriatrics rated their agreement with each of the recommendations using a nine-point scale (1 = strongly disagree, 9 = strongly agree). During the second round, 79 participants received anonymous feedback from the first round and assessed a narrowed list of 130 recommendations. Recommendations were retained and classified according to the overall median score and ratings percentages by stakeholders. A total of 79 raters rated ≥ 10% of items, and 264 recommendations were retained and rated as follows: 240 items reached consensus, 24 items reached near consensus, 37 items were discarded and one recommendation was deleted. Many infections, though not all, can be prevented in the frail elderly. Thus, these guidelines should be adopted by each healthcare professional and facility to implement routine infection control procedures.
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Infección Hospitalaria/prevención & control , Control de Infecciones/métodos , Casas de Salud , Anciano , Anciano de 80 o más Años , Recolección de Datos , Técnica Delphi , Humanos , InternetRESUMEN
OBJECTIVES: The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED). DESIGN: Prospective multicentre cohort. SETTING: Nine French university teaching hospitals. PARTICIPANTS: One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub-group analysis was performed on the 894 subjects with a caregiver. MEASUREMENTS: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year. RESULTS: Within one year after hospital admission, 210 (20.1%) subjects were institutionalised. For the overall study population, age >85 years (HR 1.6; 95%CI 1.1-2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1-2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1-2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4-2.6; p<0.001) proved to be independent predictors of institutionalisation; while a greater number of children was inversely linked to institutionalisation (HR 0.8; 95%CI 0.7-0.9; p<0.001). Bathing was of borderline significance (p=.09). For subjects with a caregiver, initial caregiver burden was significantly linked to institutionalisation within one year, in addition to the predictors observed in the overall study population. CONCLUSIONS: CGA performed at the beginning of hospitalisation in acute medical wards is useful to predict institutionalisation. Most of the predictors identified can lead to targeted therapeutic options with a view to preventing or delaying institution admission.
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Actividades Cotidianas , Demencia/complicaciones , Evaluación Geriátrica/métodos , Hospitalización/estadística & datos numéricos , Institucionalización/estadística & datos numéricos , Equilibrio Postural , Hijos Adultos , Factores de Edad , Anciano , Anciano de 80 o más Años , Cuidadores , Femenino , Estudios de Seguimiento , Humanos , Masculino , Modelos de Riesgos Proporcionales , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
BACKGROUND: Because of a lack of efficacy of influenza vaccination in elderly population, there are still numerous outbreaks in geriatric health care settings. The health care workers (HCW) flu vaccination is known to get herd immunity and decrease the impact of influenza in elderly population living in geriatric health care settings. However, the rates of vaccinated HCWs are still low in France. The French Geriatric Infection Risk Institute (ORIG) performed the VESTA study, a three-phase multicentre to identify factors limiting vaccination in HCWs, and to develop and implement active programs promoting HCWs influenza vaccination. OBJECTIVES: To implement multicenter programs to enhance HCW influenza vaccination. DESIGN: It was a cluster randomised interventional studies. SETTING: 43 geriatric health care settings (GHCSs), long term care and rehabilitation care settings in France. PARTICIPANTS: 1814 Health care workers from 20 GHCSs in the interventional group and 2,435 health care workers in 23 GHCSs in the control group. INTERVENTION: After the failure of a first educational program giving scientific information and. tested during the 2005-06 flu season in 43 HCSs, a second program was designed with the help of marketing experts, one year after Program 1. The objectives were to involve HCWs in the creation of "safety zones", and to give personal satisfaction. Program 2 was tested during the 2006-07 season. 20 of the 24 HCSs from the Program 1 cluster were included in the Program 2 cluster (1,814 HCWs), and 16 of the 19 HCSs from the Control 1 cluster, plus 7 new HCSs with interest in participating, were included in the Control 2 cluster (23 HCSs; 2,435 HCWs). MEASUREMENTS: The efficacy of each program was assessed by calculating and comparing the percentage of vaccinated HCWs, from all HCSs taken together, in the program and control clusters. RESULTS: Program 1 failed to increase the HCW vaccination coverage rate (VCR) (Program 1: 34%; Control 1: 32%; p > 0.05),). Program 2 increased the VCR in HCWs (Program 2: 44%; Control 2: 27%; Chi2 test, p < 0.001) regardless their occupational group but only in the non previous vaccinated subgroup. CONCLUSIONS: In geriatric health care centres in France, an active multicenter program giving personal satisfaction and taking into account the profile of non-vaccinated HCWs was more effective in promoting flu vaccination than a scientifically factual information program. HCW involvement is required in program implementation in order to avoid rejection of top-down information.
Asunto(s)
Transmisión de Enfermedad Infecciosa/prevención & control , Personal de Salud/psicología , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Evaluación de Programas y Proyectos de Salud , Anciano de 80 o más Años , Actitud del Personal de Salud , Análisis por Conglomerados , Femenino , Francia , Geriatría , Servicios de Salud para Ancianos/estadística & datos numéricos , Humanos , Gripe Humana/transmisión , Masculino , Enfermedades Profesionales/prevención & control , Vacunación/psicologíaRESUMEN
We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR)=1.79 (1.38-2.32) (95% confidence interval=95% CI); "failure to thrive" syndrome OR=1.54 (1.01-2.35), depression: OR=1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR=1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the "geriatrics patient" is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.
Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Geriatría/estadística & datos numéricos , Departamentos de Hospitales/estadística & datos numéricos , Actividades Cotidianas , Factores de Edad , Anciano de 80 o más Años , Trastornos del Conocimiento/terapia , Intervalos de Confianza , Trastorno Depresivo/terapia , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Francia , Evaluación Geriátrica/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Análisis Multivariante , Oportunidad Relativa , Factores SexualesRESUMEN
Chronic obstructive pulmonary disease (COPD) is a chronic disease characterized by incompletely reversible airflow limitation, measured by a decrease of FEV(1)/FVC ratio. International consensus does not agree on a single threshold for this ratio, which can define airflow obstruction. Although the prevalence of COPD in the elderly population varies according to the definition used, it definitely increases with age and could reach 15% in those over 65 years of age. Therefore, ageing of the population should result in increased prevalence and socioeconomical costs of COPD during coming years. In France, diagnosis of COPD in the elderly is difficult, late and insufficient. Management, which has the same goals as in younger populations, has to be global and coordinated. Some points should be considered with particular attention considering the cumulative risks related on the one hand to COPD and on the other to ageing: pharmacological side-effects, decreased physical and social autonomy, nutritional impairment, comorbidities. Given the lack of specific data in elderly populations, pharmacological indications are generally considered to be the same as in younger populations, but some additional precautionary measures are necessary. Pulmonary rehabilitation seems to be beneficial at any age. Palliative care comes up against important difficulties: an indefinite beginning of the palliative stage in COPD; insufficient palliative care resources; insufficient communication; insufficient utilization of palliative care resources. Global COPD management in elderly requires coordination, best reached in health care network organizations involving medical and/or social professionals.
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Enfermedad Pulmonar Obstructiva Crónica , Factores de Edad , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/epidemiología , Manejo de Caso , Comorbilidad , Depresión/epidemiología , Depresión/etiología , Interacciones Farmacológicas , Francia/epidemiología , Humanos , Desnutrición/epidemiología , Desnutrición/prevención & control , Cuidados Paliativos , Grupo de Atención al Paciente , Educación del Paciente como Asunto , Prevalencia , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/psicología , Enfermedad Pulmonar Obstructiva Crónica/rehabilitación , Fármacos del Sistema Respiratorio/efectos adversos , Fármacos del Sistema Respiratorio/uso terapéutico , RiesgoRESUMEN
Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).
Asunto(s)
Trastornos de Deglución/complicaciones , Neumonía por Aspiración/etiología , Infecciones del Sistema Respiratorio/prevención & control , Anciano , Antibacterianos/uso terapéutico , Trastornos de Deglución/diagnóstico , Trastornos de Deglución/etiología , Trastornos de Deglución/terapia , Fluoroscopía , Humanos , Neumonía por Aspiración/epidemiología , Neumonía por Aspiración/terapia , Infecciones del Sistema Respiratorio/etiologíaRESUMEN
To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.
Asunto(s)
Anciano Frágil , Evaluación Geriátrica/métodos , Mortalidad , Medición de Riesgo/métodos , Índice de Severidad de la Enfermedad , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Servicio de Urgencia en Hospital , Femenino , Anciano Frágil/estadística & datos numéricos , Francia/epidemiología , Hospitales de Enseñanza , Humanos , Entrevistas como Asunto , Masculino , Pronóstico , Modelos de Riesgos Proporcionales , Curva ROCRESUMEN
INTRODUCTION: The diagnosis of relapsing polychondritis is difficult as various manifestations may be encountered aside the characteristic episodes of recurrent chondritis. CASE REPORTS: From the retrospective analysis of the medical charts of patients presenting with relapsing polychondritis seen at Nîmes hospital between 1995 to 2006, four were selected for their original extra-cartilaginous manifestations. Case 1: relapsing polychondritis was diagnosed at the time of a thromboembolic event associated with a right uveitis, left temporomandibular arthritis and bilateral sensorineural deafness. Case 2: relapsing polychondritis occurred in a patient with history of bilateral sensorineural deafness with punctuated keratitis followed by a relapsing cutaneous leucocytoclastic vasculitis. Case 3: relapsing polychondritis associated with recurrent thromboembolic disease and a Sweet's syndrome and case 4: relapsing polychondritis presenting with a febrile erythema. CONCLUSION: The reported observations highlight the difficulty of the initial diagnosis of relapsing chondritis and the variety of the extra-chondritis manifestations that could be observed in this disease.