Assessment of Health Inequalities Among Older People Using the EPICES Score: A Composite Index of Social Deprivation.

BACKGROUND: Most of the indicators commonly used to assess social deprivation are poorly suited to study health inequalities in older people. The EPICES (Evaluation of Deprivation and Inequalities in Health Examination Centres) score is a new composite index commonly used to measure individual deprivation. OBJECTIVE: To assess the relationships between health indicators and the EPICES score in older people. Design, Setting, and participants: We performed a cross-sectional study using the data from the 2008 ESPS Survey (Health, HealthCare and Insurance Survey). Of the 4235 survey respondents aged 60 and over in 2008, 2754 completed the 11 items of the EPICES score and were included in the study. MAIN OUTCOMES AND MEASURES: Deprivation was measured using the EPICES score. Health indicators were: Disability, physical performance, cognitive decline, self-perceived health status, and health-care use and participation in prevention programs (missing teeth not replaced, healthcare renunciation, no hemoccult test [60-75 years] and no mammography [60-75 years]). RESULTS: Of the 4235 survey respondents aged 60 and over in 2008, 2754 completed the 11 items of the EPICES score and were included in the study. The mean age was 70.5± 8.2 years. 52.8% were women. 25.8% were living in poor households. According to the EPICES score, 35.1% were deprived. The EPICES score is linked to all the health indicators assessed in this study: Physical disability, cognitive decline; lifestyle and health care accessibility. These relationships increase steadily with the level of social deprivation. For example, the risk of having difficulties in walking 500m without help or an assistive device is multiplied by 13 (RR=13.5 [7.9-20.8]) in the elderly of quintile 5 (maximum precariousness). Limitations: The observational nature limits inferences about causality.CONCLUSION: The EPICES score is linked to health indicators. It could be a useful instrument to assess health inequalities in older people living in the community.

Potentially inappropriate drug prescription in the elderly in France: a population-based study from the French National Insurance Healthcare system.

BACKGROUND: Inappropriate prescribing is a known risk factor for adverse drug event occurrence in the elderly. In various countries, several studies have used insurance healthcare databases to estimate the national prevalence of potentially inappropriate medications (PIM) in the elderly, as defined by explicit PIM lists. Recently, a representative sample of the French National Insurance Healthcare database, known as the "Echantillon Généraliste des Bénéficiaires" (EGB), was created, making it possible to assess the quality of drug prescription in France. Our objective was to evaluate the prevalence and the regional distribution of PIM prescription in the elderly aged 75 years and over in France, using the French PIM list and the EGB database. METHODS: The list of drugs reimbursed to patients aged 75 years and over from 1 March 2007 to 29 February 2008 was extracted from the EGB. Drugs were classified as inappropriate using the French PIM list. A PIM user was defined as a person receiving at least one PIM reimbursement during the study period. Interregion variability was estimated from logistic regression. RESULTS: In 53.6% (95% CI: 53.0-54.1) of the elderly aged 75 years and over, at least one PIM was given during the study period. The three main drug groups identified were cerebral vasodilators (19.4%), drugs with antimuscarinic properties (19.3%), and long half-life benzodiazepines (17.8%). There was an important disparity in PIM prescription among the French regions. In 14 out of 22 regions, the risk of PIM prescription was significantly elevated. This geographical variation differed for the different drug groups. CONCLUSION: PIM prescription in the elderly is a major and worrying problem in France. As in other countries, recent accessibility of the National Insurance Healthcare database makes it possible to create local indicators that the regional health agencies could use to manage public health policy in closer alignment to the needs of the patients within each French region.

Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study.

BACKGROUND: While the association between benzodiazepines (BZD) and single fall is long-known, the association between BZD and recurrent falls has been few studied. OBJECTIVE: The aims of this study were 1) to examine whether BZD were associated with recurrent falls while taking into account the effect of potential confounders, and 2) to determine whether there was an interaction in terms of risk of falls between BZD and balance impairment in a community-dwelling population-based adults aged 65 and older. STUDY DESIGN: Cross-sectional. SETTING: Three health centers in North-East of France. POPULATION: 7643 community-dwelling volunteers aged 65 and older. OUTCOME MEASURES: The use of BZD, the Mini Mental State Examination (MMSE) score, the Clock Drawing Test (CDT), the One Leg Balance (OLB) test, the Five Times Sit-To-Stand test (FTSS), and a history of falls were recorded. Subjects were separated into 4 groups based on the number of falls: 0, 1, 2 and ≥ 3 falls. RESULTS: Among the 1456 (19.2%) fallers, 994 (13.0%) were single fallers and 462 (6.1%) were recurrent fallers (i.e., > 2 falls). The number of falls increased significantly with age (Incident Rate Ratio (IRR)=1.04, P < 0.001), female gender (IRR=2.24, P < 0.001), the use of benzodiazepine (IRR=1.65 P < 0.001) and especially while subjects used bromazepam (IRR=1.44, P=0.006), clobazam (IRR=3.01, P=0.014) and prazepam (IRR=2.29, P < 0.001). A low MMSE score (IRR=0.96, P < 0.001), an impaired CDT (IRR=0.91, P < 0.001), and a bad performance at OLB and FTSS (respectively IRR=1.85, P < 0.001 and IRR=1.26, P < 0.001) were related to the recurrence of falls. After adjustment only the advance in age (IRR=1.02, P < 0.001), female gender (IRR=2.15, P < 0.001), clobazam (IRR=2.54, P=0.04), prazepam (IRR=1.63, P=0.03) and OLB (IRR=1.55, P < 0.001) were still significantly related to the number of falls. CONCLUSION: The current study shows that the age, the female gender, the use of clobazam or prazepam and a low score at OLB are related to the recurrence of falls.

Balance and walking speed predict subsequent 8-year mortality independently of current and intermediate events in well-functioning women aged 75 years and older.

BACKGROUND: Physical performance may predict survival independently of other current predictors in non selected elderly subjects. We determined if poor balance and decreased gait speed may predict mortality after adjustment for both baseline and follow-up confounders in well-functioning elderly women. METHODS: A subgroup of participants in the Epidemiology of osteoporosis (EPIDOS) study (N = 1,300) was followed for 8 years. Participants were community-dwelling women aged 75 or older able to go outside home without assistance. The baseline examination included a questionnaire and a clinical and functional examination. Participants were contacted every year thereafter by mail. RESULTS: Poor balance, defined by the inability to stand in a tandem position or to complete ten foot taps in less than 4.6 seconds, and poor mobility, defined by a gait speed of less than 0.80 m/s or a stride length of less than 0.5 m were significant predictors of low 8-year survival, independently of other predictors of death at baseline (educational level, social network, number of drugs, fear of falling, visual acuity, perceived health, IADL score, physical activity, and comorbidities) and during follow-up (falls, IADL score, the need to be accompanied to go outside, weight loss, hospitalization, and the report of new comorbidities). CONCLUSION: The current study shows that poor balance and mobility are significant predictors of 8-year mortality independently of baseline and intermediate events in pre-disabled women aged 75 years and older, suggesting that they may reflect a certain failure to respond adequately in the face of present and future medical and non-medical events.

Functional autonomy measurement system: development of a social subscale.

The purpose of this study was to develop a subscale assessing social functioning for the functional autonomy measurement system (SMAF). The development of this new dimension was based on consultations (focus groups and nominal groups) of experts from different health care disciplines in Quebec, Canada, and France. Two interrater reliability studies were carried out with older people presenting a loss of functional autonomy and living either in an institution or at home. With the focus groups, the experts clarified the definition of social functioning and identified the factors involved. The nominal groups were used to construct a subscale composed of six items. The results of the first interrater reliability study showed a mean agreement percentage of 60% for the subscale and an intraclass correlation coefficient (ICC) of 0.70 (CI: 0.57-0.80). The results of the second interrater reliability study showed higher coefficients with an agreement percentage of 74% for the subscale and an ICC of 0.83 (CI: 0.61-0.93). These preliminary results demonstrate that the new social functioning subscale has good reliability, but more studies are needed to show its validity. The new SMAF, including the social functioning subscale, should help clinicians and researchers to obtain a comprehensive profile of functional autonomy. It could also contribute to the improvement of health care for older people.

[Recovery from disability in an older population. Results of long-term follow-up in Upper-Normandy (France)]. / Réversibilité de l'incapacité chez les personnes âgées. Une étude du devenir à long terme en Haute-Normandie.

BACKGROUND: The recovery of people initially disabled was addressed using the National Institute of Health and Medical Research Upper-Normandy survey, conducted on a representative sample of the older population from 1978 to 1999. METHODS: The survey was based on 1082 older people aged 65 and over. A follow-up was organized to register mortality and disability at point 3, 6, 10 and 20 years. Among the persons initially disabled were taken into account those who were able to go outside their home without help during the 20-year follow-up. Each case of recovery was validated. RESULTS: Among the 1046 subjects for whom data could be analyzed, 218 presented mobility disability necessitating help to go outside their home. Recovery from disability was observed in 23 subjects (10.5%; CI: 6.5-14.5). Among the 195 subjects (89.5%) without any recovery, 107 (49%) had died before 4 years, 44 (20%) had died between 4 and 6 years, and 44 (20%) survived with disability more than 6 years. The rate of recovery was 18.6% before age 80, and 4.1% for people aged 80 and over. It was 1.3% for home-confined or bed- or chair-confined people and 15.4% for the others. Before age 80 the recovery rate was significantly higher in women. No recovery was observed for people with mental deterioration. Cerebrovascular diseases were significantly associated with a low rate of recovery (5%). CONCLUSIONS: Recovery from disability should be taken into account for the health prospects of the elderly population. It concerns about one person out of five before the age of 80. Increased rate of recovery after the age of 80 should be one of the objectives for the health system in the future.

[In search of a typology of drugs used by the aged living in the community]. / Recherche d'une typologie des consommations médicamenteuses des personnes âgées vivant à domicile.

BACKGROUND: The objective was to identify the determining factors of drug utilization in the elderly by using several classes of drugs. METHODS: We studied drug utilization in 1373 women, aged 75 and over, selected in the EPIDOS study concerning hip fractures in the Languedoc-Roussillon region (France) and in 2525 men and women, aged 60 and over selected for the POLA study (age-related eye diseases) in the town of Sete. We defined a priori three types of drugs considering the perceived risk by the physician, and the potential demand from the patient (I - Etio-pathogenic drugs with iatrogenic risk; II - Symptomatic drugs without perceived risk; III - Psychotropic drugs). To validate this classification, we studied drug consumption by age and sex, its relationship with mortality and education level, the fact of living alone, subjective health and level of physical activity. RESULTS: The total drug consumption level, measured by the number of drugs taken daily, was higher in women but, at any age, men more often used type I drugs. Survival was also related to the number of type I drugs, that may be considered as an indicator of serious pathology. Inversely, no relationship was observed between survival and the number of type II drugs that grouped symptomatic or comfort drugs. CONCLUSION: Such typology can help to understand drug over-utilization in the elderly.

Associations of cardiovascular disease and its risk factors with age-related macular degeneration: the POLA study.

The POLA study (June 1995 through July 1997) is a population-based study on cataract and age-related macular degeneration (AMD) and their risk factors in 2584 residents of Séte (South of France), aged 60--95 years. Classification of AMD was performed on 50 degrees fundus photographs, according to an international classification. The presence of cardiovascular disease and its risk factors was determined by interviewer-based questionnaire, clinical examination (anthropometry, blood pressure) and fasting plasma measurements. Using a logistic model adjusted for age and gender, late AMD was not significantly associated with a history of cardiovascular disease, diabetes, use of hypocholesterolemic drugs, hypertension, blood pressure or plasma lipids. Obese subjects (body mass index greater than 30 kg/m( 2)) had a 2.29-fold (95% confidence interval (CI): 1.00--5.23) and 1.54-fold (CI: 1.05--2.26) increased risk of late AMD and pigmentary abnormalities in comparison with lean subjects. Finally, the risk of soft drusen was decreased in those subjects with a history of cardiovascular disease (odds-ratio (OR) = 0.72, CI: 0.54--0.97), and increased with increasing levels of HDL-cholesterol (OR = 1.52, CI: 1.14--2.02). None of these results were modified by further adjustments for smoking, educational level and plasma alpha-tocopherol. These results need to be confirmed by other studies, which ideally should be longitudinal and prospective.

Quality of life in spinal cord injury patients with urinary difficulties. Development and validation of qualiveen.

BACKGROUND: Quality of life (QoL) may be severely affected in patients with spinal cord injury (SCI) and resulting urinary difficulties (UD). There is, however, a need for instruments capable of measuring QoL in these patients. The aim of this study was to develop and validate a questionnaire suitable for use in SCI patients with urinary disorders. METHODS: Following patient interviews, a questionnaire was developed in French that was subjected to item reduction and cross-sectional validation. The resulting Qualiveen (Qualiveen is a pending registration trade mark of Coloplast A/S, DK-3050 Humlebaek, Denmark) questionnaire underwent multi-trait and principal component analysis and the test-retest reliability of the questionnaire was examined in stable patients. RESULTS: Patient interviews identified 257 concepts relevant to SCI patients with urinary disorders. Item reduction led to a 30-item questionnaire, which was psychometrically validated in 281 SCI patients with UD. The median age of patients was 41 years, 78% were male and the majority were paraplegic (55%). The construct and clinical validity of the Qualiveen was confirmed, as well as its reliability in patients whose condition was stable over a 15-day period. Patients confirmed that it was easy to understand, complete and comprehensive. CONCLUSIONS: The Qualiveen is a reliable and psychometrically validated instrument that may be used to measure the QoL of SCI patients with UD.

Social disadvantage in the international classification of impairments, disabilities, and handicap.

The revision process of the international classification of impairments, disabilities and handicaps (ICIDH) is now in progress. Major changes are being considered which question one of the main fields, that of handicap, or social disadvantage. The scope of these changes goes beyond simple technical adjustments. It reaches the level where fundamental positions are adopted regarding the mainspring of public health policies. The purpose of this article is to review and discuss the main criticisms that have appeared in the literature about the dimension of handicap, including a study of the consequences that may result from keeping this dimension or from leaving it out. We suggest that the definition of handicap as a disadvantage has been overlooked, so that discussion has mainly taken place about the environment. Our opinion is that each criticism is based upon the emphasis given to a choice of strategy for preventing or reducing disablement. For some experts, the emphasis is on health care. For others, it is on social change. We share this interest in strategy. This is why we suggest that the conceptual framework is meant only for description, that it does not and should not include choices of strategy. We argue that it is the best way to promote appropriate description and therefore appropriate choice of strategies. Finally, we state that social disadvantage is a major dimension of the consequences of disorders and related problems, and should therefore remain in the framework, in order to provide appropriate information for better choices in strategy.

Risk of syncope in the elderly and consumption of drugs: a case-control study.

A multicenter case-control study (588 cases and 1807 controls) was performed to assess the risk of syncope in the elderly according to drug consumption within the three days before syncope, controlling the underlying cardiovascular diseases. Pair-matched and non-pair-matched analyses using logistic regression were performed, providing consistent results. After adjustment for age, sex, and cardiovascular disease, cases were shown to consume more often than non-cases drugs in classes of non-tricyclic antidepressants, neuroleptic drugs, and antiparkinsonians. A detailed analysis has shown that only four drugs were significantly associated with an excess risk of syncope: fluoxetine (OR = 2.6; 95% CI: [1.8-3.5]), aceprometazine (OR = 2.0; [1.5-2.5]), haloperidol (OR = 2.8; [2.0-3.6]), and L-dopa (OR = 2.8; [2.2-3.7]). This analysis shows that these drugs should be prescribed with special caution in the elderly.

[Objective and subjective determinants in the benefits of home help services for the elderly]. / Déterminants objectifs et subjectifs du bénéfice de l'aide ménagère pour le maintien à domicile des personnes âgées.

In this paper, we analyze the factors related to the allocation of home help services, a main component for maintaining elderly at home. The study is based on a random sample of 889 people aged 65 and over, living at home in the areas of Lunel and Pézenas (Hérault, France). The factors taken into account were disabilities, income, social support, and subjective health assessed through the Nottingham Health Profile (NHP). A logistic model allowed to bring out the factors related to the delivery of home help services. Positive statistical correlations were found for age (OR = 1.6 per 10-year age groups), disabilities for instrumental activities of daily living (OR = 3.8) and for the notion of mobility assessed through the NHP (OR = 3.3); negative statistical correlations were found for the level of income (OR = 0.3), as well as for disabilities for activities of daily living (physical dependency) (OR = 0.5). These results show that the main criterion for allocating home help services is not severe disability and that subjective aspects play an important part. Accordingly, current practices should be modified to obtain a better targeting of home help services for disabled elderly at home.

[Drugs and brief losses of consciousness in the elderly. Results of a case-control multicenter study]. / Médicaments et pertes brèves de connaissance chez les personnes âgées. Résultats d'une étude multicentrique cas contrôle. Le groupe Médicaments et PCB.

To study the possible role of drugs intake in syncope in elderly patients, we conducted a multicentric case-control study in 588 cases and 1818 controls, controlling as an essential confounding variable the underlying cardiovascular diseases. The following class were in excess among the case: non tricyclic antidepressants (p < 0.0001, RR: 4.5), neuroleptic drugs (p < 0.05, RR: 1.8), and antiparkinsonian drugs (p < 0.02, RR: 2.7).

[Survival rate of elderly patients with senile dementia according to type of institutional care. Comparison between "long stay hospitals" and structures of the type "cantou"]. / Survie des personnes âgées atteintes de démence sénile selon le type d'établisement d'accueil. Comparaison entre les "longs séjours hospitaliers" et les structures de type "cantou".

The proliferation of new forms of so-called "non-medical" care for the elderly suffering from dementia raises the problem of the subsequent impact of this development on the quality of the care given. One way of approaching this question is to examine survival of the persons admitted to this form of care. A comparison was made of the survival of elderly persons admitted to an innovative "non-medical" form of care (units known as "cantou") with that of elderly patients in long-stay hospital care. A retrospective analysis was carried out of the survival of 707 elderly persons with dementia admitted into both types of care between the 1st of May 1978 and the 15th of September 1988. After controlling for age, sex and date of admission no significant difference in survival was found between the two forms of care. This supports the notion that the quality of medical care in the "cantou" is not fundamentally different from that provided by long-stay hospitals.

[Development of a conversion table of dependence of the aged on home aide needs]. / Etablissement d'une table de passage de la dépendance des personnes âgées au besoin d'aide à domicile.

Planning home help for geographical areas requires information on disabilities and required needs. This paper proposes a methodology to estimate the amount of help required. The analysis is based on survey data from three French regions: Ile-de-France, Languedoc-Roussillon and Basse-Normandie and from a team of experts. The total need, whether covered by professionals or by the patient's social network is considered for three aspects: Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and additional help resulting from home conditions. The required average number of hours per week varies from 49.9 for people confined to bed or chair, to 3.8 for people able to get out of their house without help (group 4). The need for IADL represents 44% of the total need for group 1 and 60% for group 4. Housing conditions generated an additional time representing 3 to 5% of total need, according to the group considered. The methodology allows to identified discrepancies between requirements and help provided by region and by disability group within each region. It appears to be a useful tool in planning home-help.

[Drugs and short losses of consciousness in the elderly. A case/control study]. / Médicaments et pertes brèves de connaissance chez les personnes âgées. Etude cas/témoin.

To study the possible role of multiple medications and different types of drugs prescribed to the elderly as a risk factor for short-term loss of consciousness, we compared the drug consumption by 188 patients (65 and over) hospitalized for short-term loss of consciousness to that by 188 controls (65 and over) taken from the general population. The two groups were age- and sex-matched. We took into consideration the evolution of drug consumption due to the time-lag between the two studies. There was no significant difference between the mean number of drugs taken per group. Beta-blocker and anti-angina drug usage was significantly increased in the patient group. For diuretics, tranquilizers and anti-depressants, a large difference was noted but it was not significant. Use of vasodilators, hypnotic drugs and antihypertensive agents was similar in both groups. We discuss the possible lack of statistical potency for several drugs and the fact that it is sometimes difficult to distinguish between the respective roles of certain medications and the underlying disease in the etiology of the loss of consciousness.

[Longitudinal study of the functional capacity of aged persons in Upper Normandy, 1978-1985]. / L'enquête longitudinale de Haute-Normandie sur les capacités fonctionnelles des personnes âgées, 1978-1985.

A longitudinal study of 1,082 elderly persons was conducted by INSERM over a six-year period in order to identify risk factor in pathological ageing. Several functional capacities were selected for study on the basis of their relevance to independent daily living. This article describes the methodology and the extent to which research objectives were able to be fulfilled. The initial survey took place in 1978-79. A follow-up study targeted two distinct areas of interest: the monitoring of mortality rates and the re-evaluation of the performance of survivors at three and six year intervals. Re-evaluation of performance involved the exploration of the individual's mobility, capacity to carry out activities of daily living etc. The consistency of the entire data set assembled over the six-year period was assessed in various ways. At six year follow-up survival rate could be determined for 98.8% of the initial cohort, and 87.1% of the survivors were able to be reinterviewed. The different probabilities of healthy survival, by sex and age, are tabulated in the appendices.

[1-year prognosis of syncope and brief loss of consciousness in patients over 65. A multicenter study of 188 cases]. / Pronostic à un an des lipothymies et pertes de connaissance brèves après 65 ans. Etude multicentrique de 188 cas.

The one-year outcome of syncope and transient loss of consciousness was studied prospectively in 188 patients aged over 65 admitted to internal medicine departments. Thirty-seven patients (19.6 p. 100) died. This mortality rate at one year was 2.34 times higher than that of a non-hospitalized french population of the same age group (standardized mortality ratio, SMR = 2.34, P less than 0.001). The frequency of sudden death (7 cases) was much higher than that observed in the reference population (0.05 expected deaths, P less than 0.0001). Overmortality was clearly apparent in groups with an initial diagnosis of heart disease (SMR = 2.36, P less than 0.01) or neurological disease (SMR = 4.25, P less than 0.001). The relapse rate was 28 p. 100 globally and up to 43 p. 100 in cardiac patients. In the group with iatrogenic symptoms treatment was appropriately corrected in 86 p. 100 of the patients, and none of these relapsed. One year after the initial episode 11 p. 100 of the surviving patients had been institutionalized.