Factors Associated with Transfer from an Acute Geriatric Unit to a Post-Acute Care Facility among Community-Dwelling Patients: Results from the DAMAGE Cohort.

Background: Acute geriatric units (AGUs) require efficient discharge planning tools. Risk factors for discharge from an AGU to post-acute care (PAC) have not previously been investigated in detail. Methods: The objective is to identify risk factors for PAC transfer. The DAMAGE (prospective multicenter cohort) consecutively included more than 3500 subjects aged 75 or older and admitted to an AGU. The patients underwent a comprehensive geriatric assessment (CGA) during their stay in the AGU. Only community-dwelling patients admitted to the AGU from the emergency department were included in the analysis. We recorded the characteristics of the care pathway and identified risk factors for discharge to home or to a PAC facility. Results: 1928 patients were included. Loss of functional independence (a decrease in the Katz activities of daily living (ADL) score between 1 month prior to admission and AGU admission), living alone, social isolation, a high Katz ADL score at home, a low Katz ADL on admission, and delirium on admission were risk factors for transfer to PAC. Obesity, an elevated serum albumin level, and community-acquired infection were associated with discharge to home. Neither sex nor age was a risk factor for home discharge or transfer to PAC. Conclusion: The present results might help clinicians and discharge planning teams to identify patients at risk of transfer to PAC more reliably and promptly in AGUs.

Efficacy of benzodiazepines and related drugs in patients over 75 years of age and impact on cognition.

BACKGROUND: In France, despite the known risks, the use of benzodiazepines and related (BZD) is excessive, particularly in older populations. Over the age of 70, 1 person in 2 uses BZD on a long-term basis (more than 3 years), whereas it is recommended not to exceed 12 weeks. To compensate for the numerous undesirable effects and to maintain a positive benefit-risk balance, these treatments must be very effective and improve significantly the quality of life. AIMS: This study aims to determine whether the efficacy of BZD outweighs their adverse effects in older population. METHODS: In a population of 109 patients with cognitive impairment and hospitalized in Saint-Quentin (France), we recorded the use of BZD and medical background. Neuropsychological and geriatric assessments allowed cognitive and thymic evaluation. RESULTS: In our cohort of 109 patients, 50% of the subjects were BZD + and 78% were women. Patients in the BZD + group were no longer anxious but had poorer cognitive and executive performance than controls. DISCUSSION: Long-term treatment of anxiety in patients aged 75 and over with BZD appears to be effective. The deleterious impact of BZD on cognition has been demonstrated. CONCLUSIONS: These results tend to consider non-medicinal therapies as serious alternatives to BZD for treating anxiety in the older population.

Development of a Predictive Score for Mortality at 3 and 12 Months After Discharge From an Acute Geriatric Unit as a Trigger for Advanced Care Planning.

BACKGROUND: There is a need for a mortality score that can be used to trigger advanced care planning among older patients discharged from acute geriatric units (AGUs). OBJECTIVE: We developed a prognostic score for 3- and 12-month mortality after discharge from an AGU, based on a comprehensive geriatric assessment, in-hospital events, and the exclusion of patients already receiving palliative care. METHODS: Devenir Après la Médecine Aigue Gériatrique (DAMAGE) is a French multicenter, prospective, cohort study. The broad inclusion criteria ensured that the cohort is representative of patients treated in an AGU. The DAMAGE participants underwent a comprehensive geriatric assessment, a daily clinical checkup, and follow-up visits 3 and 12 months after discharge. Multivariable logistic regression models were used to develop a prognostic score for the derivation and validation subsets. RESULTS: A total of 3 509 patients were assessed and 3 112 were included. The patient population was very old and frail or dependant, with a high proportion of deaths at 3 months (n = 455, 14.8%) and at 12 months (n = 1 014, 33%). The score predicted an individual risk of mortality ranging from 1% to 80% at 3 months and between 5% and 93% at 12 months, with an area under the receiving operator characteristic curve in the validation cohort of 0.728 at 3 months and 0.733 at 12 months. CONCLUSIONS: Our score predicted a broad range of risks of death after discharge from the AGU. Having this information at the time of hospital discharge might trigger a discussion on advanced care planning and end-of-life care with very old, frail patients. Clinical Trials Registration Number: NCT02949635.

Risk Factors for Hospital Readmission and Death After Discharge of Older Adults from Acute Geriatric Units: Taking the Rank of Admission into Account.

OBJECTIVE: To analyze the impact of the number of hospital readmissions on the risks of further hospital readmission and death after adjustment for a range of risk factors. METHODS: We performed a multicentre prospective study of the DAMAGE cohort in the Hauts-de-France region of France. Patients aged 75 and over hospitalized initially in an acute geriatric unit (AGU) were included and followed up for 12 months. The risk of hospital readmission was analyzed using a Cox model, and its extension for recurrent events and the risk of death were analyzed using a Cox model for time-dependent variables. RESULTS: A total of 3081 patients were included (mean (SD) age: 86.4 (5.5)). In the multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital readmission rose progressively to 2.66 (1.44; 5.14), and the risk of death rose to 2.01 (1.23; 3.32) after five hospital admissions, relative to a patient with no hospital readmissions. The number of hospital readmissions during the follow-up period was the primary risk factor and the best predictor of the risk of hospital readmission and the risk of death. CONCLUSION: Hospital readmission is the primary risk factor for further hospital readmissions and for death in older subjects discharged from an AGU.

Communication during the COVID-19 pandemic: evaluation study on self-perceived competences and views of health care professionals.

PURPOSE: The aims of this study were to describe communication experiences while wearing a mask during COVID-19 pandemic in 2020, to identify possible mask-related barriers to COVID-19-adapted communications and to investigate whether the ABC mnemonic (A: attend mindfully; B: behave calmly; C: communicate clearly) might address these. METHODS: This study was a cross-sectional, voluntary, web-based survey between January and February 2021. A 22-item survey was developed using the Surveymonkey platform and question styles were varied to include single choice and Likert scales. The respondents were also asked to view a short video presentation, which outlined the ABC mnemonic. CHERRIES (Checklist for Reporting Results of Internet E-Surveys) was used to ensure completeness of reporting. Diverging stacked bar charts were created to illustrate Likert scale responses. RESULTS: We received 226 responses. The respondents were mostly women (60.2%) and the majority worked in a teaching hospital (64.6%). The majority of the respondents indicated issues related to lack of time during clinical encounters, uncertainty about how to adapt communication, lack of personal protective equipment, lack of communication skills and lack of information about how to adapt their own communication skills. In addition, the participants indicated acknowledging emotions and providing information using clear, specific, unambiguous, and consistent lay language while wearing a mask were among the main communication challenges created during the COVID-19 pandemic. Finally, the study showed significantly improved self-perceived competency regarding key communication after watching the short video presentation. CONCLUSION: Effective communication in medical encounters requires both verbal and nonverbal skills.

A Particularly Tragic Case of Possible Alzheimer's Disease, that of Marshal Pétain.

After World War I and more particularly in June 1940, the prestige of French Marshal Philippe Pétain, considered as the winning general the battle of Verdun, was very high. He became President of Council while the French army was unable to stop the German offensives. But five years later he was sentenced to death for high treason. By rereading his bibliography from a medical perspective, it is possible to find multiple suggestive events and to affirm a posteriori Pétain suffered from a neurodegenerative disorder, whose first signs appeared in the 1930s, suggestive of Alzheimer's disease, which had an impact on French politics. The modern medical knowledge of this disease casts a new light on the behavior of Petain during the last war.

Decreased Cerebrospinal Fluid Flow Is Associated With Cognitive Deficit in Elderly Patients.

Background: Disruptions in cerebrospinal fluid (CSF) flow during aging could compromise protein clearance from the brain and contribute to the etiology of Alzheimer's Disease (AD). Objective: To determine whether CSF flow is associated with cognitive deficit in elderly patients (>70 years). Methods: We studied 92 patients admitted to our geriatric unit for non-acute reasons using phase-contrast magnetic resonance imaging (PC-MRI) to calculate their ventricular and spinal CSF flow, and assessed their global cognitive status, memory, executive functions, and praxis. Multivariable regressions with backward selection (criterion p < 0.15) were performed to determine associations between cognitive tests and ventricular and spinal CSF flow, adjusting for depression, anxiety, and cardiovascular risk factors. Results: The cohort comprised 71 women (77%) and 21 (33%) men, aged 84.1 ± 5.2 years (range, 73-96). Net ventricular CSF flow was 52 ± 40 µL/cc (range, 0-210), and net spinal CSF flow was 500 ± 295 µL/cc (range, 0-1420). Ventricular CSF flow was associated with the number of BEC96 figures recognized (ß = 0.18, CI, 0.02-0.33; p = 0.025). Spinal CSF flow was associated with the WAIS Digit Span Backward test (ß = 0.06, CI, 0.01-0.12; p = 0.034), and categoric verbal fluency (ß = 0.53, CI, 0.07-0.98; p = 0.024) and semantic verbal fluency (ß = 0.55, CI, 0.07-1.02; p = 0.024). Conclusion: Patients with lower CSF flow had significantly worse memory, visuo-constructive capacities, and verbal fluency. Alterations in CSF flow could contribute to some of the cognitive deficit observed in patients with AD. Diagnosis and treatment of CSF flow alterations in geriatric patients with neurocognitive disorders could contribute to the prevention of their cognitive decline.

Sleep Apnea Syndrome in an Elderly Population Admitted to a Geriatric Unit: Prevalence and Effect on Cognitive Function.

BACKGROUND: Sleep apnea leads to cognitive impairment in older patients, but its association with neurodegeneration remains controversial, and most studies do not distinguish between the more common obstructive form (OSAS) and the rarer central form (CSAS). OBJECTIVE: The purpose of this study was to assess the prevalence of the different forms of sleep apnea in a cohort of cognitively impaired elderly patients (>70 years) and to investigate their associations with cognitive deficit, weighted against known risk factors for neurodegeneration. METHODS: Overnight polygraphy was performed for 76 consecutive patients admitted to our geriatric unit. Their cognitive function was assessed using the Mini Mental-State Exam (MMSE), Mattis Dementia Rating Scale (MDRS) and Stroop test. Multivariable analyses were performed to determine associations between cognitive function and independent variables describing demographics, sleep apnea measures, and cardiovascular risk factors. RESULTS: The cohort comprised 58 women and 18 men aged a mean of 84 years (range, 73-96). Sleep apnea syndrome (SAS) was diagnosed in 48 patients (63%), of which 31 (41%) with OSAS and 17 (22%) with CSAS. Multivariable regression analysis revealed that MDRS was lower in patients with OSAS (ß = -10.03, p = 0.018), that Stroop Colors and Words delays increased with AHI (ß = 0.17, p = 0.030 and ß = 0.31, p = 0.047) and that that Stroop Interference delay was higher in patients with CSAS (ß = 24.45, p = 0.002). CONCLUSION: Sleep apnea is thus highly prevalent in elderly patients with cognitive impairment. OSAS was associated with lower general cognitive function, while CSAS was only associated with increased Stroop Interference delays. Elderly patients with cognitive deficit could benefit from sleep apnea screening and treatment.

Arterial hypertension impact on cerebral blood flow in patients with Alzheimer's disease / Impacto da hipertensão arterial sobre fluxo de sangue cerebral em pacientes com a doença de Alzheimer

Background: Studies show the potential deterioration of brain vascularization and probable involvement of hypertension in Alzheimer disease (AD). Objective: The objective was to evaluate the potential impact of hypertension on cerebral vascular flows in a sample of Alzheimer's patients. Methods: 19 patients with AD, including 10 with hypertension (aHT+) and 9 without hypertension (aHT-) were recruited. They underwent clinical evaluation and phase-contrast MRI protocol for flow assessment. Cerebral arterial flow distributions were evaluated using kurtosis and skewness indices at the intracranial and extracranial levels. Results: No significant differences were found in the mean arterial flow, pulse flow and kurtosis between the levels in the AD aHT+ population. There was a significant difference in skewness between extra- and intracranial levels (p = 0.01). No significant differences were found in the mean arterial flow between the levels in the AD aHT- population. A significant difference was observed in the pulse flow (p = 0.03), kurtosis (p = 0.02) and skewness (p = 0.008) between the levels. At the extracranial level we did not find any significant differences in the mean arterial flow, pulse flow or skewness between aHT+ and aHT-. There was a significant difference in kurtosis at the extracranial level between the aHT+ and aHT- (p = 0.03). At the intracranial level, there were no significant differences in all parameters. Conclusion: Results showed a difference between cerebral vasculature in AD for aHT+ and aHT- groups. This is probably related to the loss of arterial compliance induced by the degradation of the vascular system.

Introdução: Estudos demonstram a potencial deterioração da vascularização cerebral e a provável relação da hipertensão na doença de Alzheimer (DA). Objetivo: O objetivo foi avaliar o potencial impacto da hipertensão no fluxo vascular cerebral numa amostra de pacientes de Alzheimer. Métodos: foram selecionados 19 pacientes com DA, incluindo 10 com hipertensão (aHT+) e 9 sem hipertensão (aHT+). Foram submetidos a avaliação clínica e a um protocolo de ressonância magnética de contraste de fase para avaliação de fluxo. A distribuição de fluxo arterial cerebral foi avaliada através dos índices de curtose e assimetria nos níveis intra e extracraniano. Resultados: Não foram encontradas diferenças significativas no fluxo arterial médio, no fluxo de pulso e curtose entre os níveis da população DA aHT+. Houve uma diference significativa na assimetria entre os níveis extra e intracranianos (p = 0,01). Não foram encontradas diferenças significativas no fluxo arterial médio entre os níveis da população DA aHT-. Uma diferença significativa foi observada no fluxo de pulso (p = 0,03), na curtose (p = 0,02) e na assimetria (p = 0,008) entre os níveis. Não foram observadas diferenças significativas no fluxo arterial médio, no fluxo de pulso ou na assimetria entre aHT+ e aHT- para o nível extracraniano. Foi observada diferença significativa na curtose extracraniana entre aHT+ e AHT- (p = 0,03). Não houve diferença significativa em todos os parâmetros do nível intracraniano. Conclusão: Os resultados mostraram uma diferença entre a vasculatura cerebral nos grupos de DA aHT+ e aHT-. Isso está provavelmente relacionado à perda de complacência arterial induzida pela degradação do sistema vascular.

The role of PC-MRI in neurodegenerative diseases / O papel da RM com contraste nas doenças neurodegenerativas

Introduction: Neurodegenerative diseases, a major public health problem, could have a vascular origin. Phase-contrast magnetic resonance imaging (PC-MRI) enables reliable, non-invasive, and rapid measurements of cerebrospinal fluid (CSF) and blood flows, and evaluation of the mechanical coupling between cerebral blood and CSF flows throughout the cardiac cycle (CC). Objectives: Our purpose was to evaluate the potential of PC-MRI to the study of cerebral blood and CSF flows in patients with neurodegenerative diseases such as Alzheimer's disease (AD), Mild cognitive impairment with amnesic disorders (MCIa) and Vascular Dementia (VD). Methods: The elderly population consisted of 20 AD (age: 80 ± 5 years); 12 AD patients with vascular cerebral lesions (ADvasc) (age: 81 ± 5 years), 10 MCIa patients (age: 80 ± 7 years), and 8 VD patients (age: 78 ± 7 years) were identified. They underwent the same PC-MRI protocol and were compared to 13 age-matched Healthy Elderly (HE) (age: 71± 9 years). Arterial blood pressure was analyzed to detect patients with hypertension. Results: Significantly higher cerebral blood and CSF flows were observed in HE when compared to VD, AD and ADvasc, (p<0.05), but not MCIa patients who yielded the highest cerebral arterial and venous blood flows and stroke volumes compared to the other patients, (p<0.05). The highest oscillations of CSF were also detected in MCIa patients (p<0.05). Conclusion: Our preliminary data suggests an increase in cerebral arterial blood and CSF flows in MCIa. PC-MRI provides a new hydrodynamic view, which may help evaluate a potential role of cardiovascular alterations in neurodegenerative diseases.

Introdução: As doenças neurodegenerativas, um grande problema de saúde pública, podem ser de origem vascular. A ressonância magnética (RM) com contraste de fase permite medições confiáveis, não invasivas e rápidas do líquido cefalorraquidiano (LCR) e dos fluxos sanguíneos para avaliação do acoplamento mecânico de circulação cerebral e fluxo de LCR ao longo do ciclo cardíaco (CC). Objetivos: Nosso objetivo foi avaliar o potencial da RM com contraste de fase para o estudo do fluxo sanguíneo no cérebro e LCR em pacientes com doenças neurodegenerativas, como doença de Alzheimer (DA), comprometimento cognitivo leve (CCL) com distúrbios amnésicos e demência vascular (DV). Métodos: A população foi composta por 20 sujeitos idosos com DA (idade: 80 ± 5 anos); foram identificados 12 pacientes com lesões cerebrais vasculares (idade: 81 ± 5 anos), 10 pacientes com CCL e distúrbios amnésicos (idade: 80 ± 7 anos) e 8 com DV (idade: 78 ± 7 anos). Eles foram submetidos ao mesmo protocolo de RM com contraste de fase e comparados a 13 idosos saudáveis (idade: 71 ± 9 anos). A pressão arterial foi aferida para detectar pacientes com hipertensão arterial. Resultados: Observaram-se fluxos sanguíneos cerebrais e CSF significativamente maiores em pacientes com DV, DA e com lesões cerebrais (p<0,05), mas não nos pacientes com CCL, que tiveram os maiores fluxos arteriais e venosos cerebrais em relação aos demais pacientes (p<0,05). Maiores oscilações de LCR também foram detectadas em pacientes com CCL (p<0,05). Conclusão: Nossos dados preliminares sugerem um aumento no fluxo arterial cerebral e nos fluxos de LCR na CCL. A RM com contraste e fase fornece uma nova visão hidrodinâmica, o que pode ajudar a avaliar o possível papel das alterações cardiovasculares em doenças neurodegenerativas.