Profile and needs of primary informal caregivers of older patients in Belgian geriatric day hospitals: a multicentric cross-sectional study.

BACKGROUND: With the improvement of life expectancy, the world faces increasing demands for care of older persons. In this manuscript, we define the characteristics of primary informal caregivers (PIC) of patients aged 75 years and older admitted to geriatric day hospitals (GDH) in Belgium. A PIC is defined as the person who most often provides care and assistance to persons who need to be cared for. We describe PIC socio-demographic characteristics, satisfaction, burden and wishes about caring; the type of assistance provided and received, their self-rated health, socio-demographic and medical characteristics of proxies, in particular the presence of behavioural disorders. METHODS: We conducted a cross-sectional study in 25 GDH. PARTICIPANTS: Four hundred seventy-five PIC of patients ≥75 years and their proxies. PIC completed a questionnaire at the GDH assessing burden by Zarit Burden Index-12 (ZBI-12), self-rated health, social restriction due to caregiving and financial participation. We compared the characteristics of PIC with high and low burden, and the characteristics of spouses and adult children PIC. We also analyzed factors associated with a high burden in a multivariable logistic regression model. RESULTS: PIC were mainly women (72%), adult children (53.8%) and spouses (30.6%). The mean age was 64 ± 14 years for PIC and 84 ± 5 years for care recipients. PIC helped for most of Activities in Daily Living (ADL) and Instrumental ADL (iADL). The median ZBI-12 score was 10 [IQR 5-18]. In multivariable regression analysis, a high burden was positively associated in the total group with living with the relative (p = 0.045), the difficulty to take leisure time or vacation (p < 0.001), behavioral and mood disorders (p < 0.001;p = 0.005), and was negatively associated with bathing the relative (p = 0.017) and a better subjective health status estimation (p < 0.001). CONCLUSION: Primary informal caregivers, who were predominantly women, were involved in care for ADL and iADL. A high burden was associated with living with the relative, the difficulty to take leisure time or vacation and the relative's behavioral and mood disorders. Bathing the relative and a subjective health status estimated as good as or better than people the same age, were protective factors against a high burden.

Predictive Factors of In-Hospital Mortality in Older Adults with Community-Acquired Bloodstream Infection.

OBJECTIVES: To assess the prevalence of intra-hospital mortality and associated risk factors in older people aged 75+, admitted with blood stream infections (BSI). DESIGN: Single center retrospective study performed in an 850-bed of the academic hospital of the Université Libre de Bruxelles. SETTING AND PARTICIPANTS: From January 2015 to December 2017, all inpatients over 75 years old admitted with BSI were included. MEASURES: Demographical, clinical and microbiological data were collected. RESULTS: 212 patients were included: median age was 82 [79-85] years and 60 % were female. The in-hospital mortality rate was 19%. The majority of microorganisms were Gram-negative strains, of which Escherichia coli was the most common, and urinary tract infection was the most common origin of BSI. Compared to patients who survived, the non-survivor group had a higher SOFA score (6 versus 3, p<0.0001), a higher comorbidity score (5 versus 4, p<0.0001), more respiratory tract infections (28 vs 6 %, p < 0.0001) and fungal infections (5 vs 1 %, p = 0.033), bedridden status (60 vs 25 %, p < 0.0001), and healthcare related infections (60 vs 40 %, p = 0.019). Using Cox multivariable regression analysis, only SOFA score was independently associated with mortality (HR 1.75 [95%IC 1.52-2.03], p<0.0001). CONCLUSIONS AND IMPLICATIONS: BSI in older people are severe infections associated with a significant in-hospital mortality. Severity of clinical presentation at onset remains the most important predictor of mortality for BSI in older people. BSI originating from respiratory source and bedridden patients are at greater risk of intra-hospital mortality. Further prospective studies are needed to confirm these results.

Relating the MNA Mobility Single Item to Usual Walking Speed in Hospitalized and Community-Dwelling Geriatric Patients.

Usual walking speed (WS) is a relatively easy and reproducible tool for detecting mobility impairment. For some reasons, however, geriatric patients might not be able to perform walking tests. Therefore, a subjective assessment could be an alternative method to screen for mobility impairment. In the present paper, we explore the use of the mobility item from the Mini Nutritional Assessment-short form (MNA-sf) to assess mobility and its congruence with walking speed in hospitalized and ambulatory patients. We analyzed retrospective data from 357 patients and found a highly significant correlation between WS and the MNA-sf mobility item. After dichotomization of the MNA-sf mobility score (mobility impairment ≤1 and no impairment >1), AUC for ROC curves showed that the mobility item derived from the MNA-sf reflects fairly well the mobility of geriatric hospitalized patients (AUC = 0.773), while it performs better in ambulatory patients (AUC = 0.838).

[Oncogeriatrics: An update on recent advances and knowledge]. / L'oncogériatrie : Une mise à jour des connaissances actuelles.

Oncogeriatrics has made huge progress due to the numerous studies published in the fields of geriatric assessment, recommendations by experts of the International Society of Geriatric Oncology (SIOG) concerning the evaluation and treatment of a large number of solid and haematological forms of cancer, and of the intervention on geriatric syndromes. This article is a review of the most important publishings in the field of oncogeriatrics, among them the Belgian publishings, brought out in the last five years.

L'oncogériatrie a fait d'importantes avancées grâce aux nombreuses études publiées dans le domaine de l'évaluation gériatrique, des recommandations d'experts de la Société Internationale d'Oncogériatrie pour l'évaluation et le traitement de nombreux cancers solides et hématologiques et de l'intervention sur les syndromes gériatriques. Cet article est une revue des publications les plus importantes dans le domaine de l'oncogériatrie des cinq dernières années et dont les publications belges font partie.

The Addenbrooke's Cognitive Examination Revised is as effective as the original to detect dementia in a French-speaking population.

INTRODUCTION: This paper presents the validation of the French version of the Addenbrooke's Cognitive Examination Revised (ACE-R). METHODS: The variability of the 3 versions of the ACE-R (A, B and C), performed by the same observer, hence mainly 2 or 3 times on 119 patients showing no progression, was first calculated by Cronbach's alpha coefficient, t test and linear regression. The alpha coefficients of the 3 versions were obtained showing that the ACE-R versions can be considered as one, and an analysis of the interobserver variability was performed by Cohen's kappa coefficient, t test and linear regression on 12 patients. Eventually, we performed a receiver operating characteristic (ROC) analysis to compare the sensitivities and specificities to detect dementia of the ACE, the ACE-R and Mini Mental State Examination on 319 consecutive patients. RESULTS: The ROC areas of sensitivities and specificities of the ACE and ACE-R were very similar. Two cutoffs were identified at 83/100 and 89/100 with a specificity to normality of 98.6% if the ACE-R score was ≥83 and a sensitivity to dementia of 98.4% if the ACE-R score was ≤89. CONCLUSION: ACE-R in French is as reliable and valid as the original version to detect dementia.

Chronic urticaria in a middle-aged woman.

We report the case of a 56-year-old female who suffers from chronic urticaria and digestive symptoms, suggesting parasitic infection. Neither repetitive ova and parasite examinations in stools, nor duodenal aspiration examination reveals any parasite. The patient is treated by tinidazole, but the symptoms reappear ten days later. An additive ELISA test on stool remains positive for Giardia Lamblia; the patient receives once more tinidazole and symptoms totally disappear. This case report illustrates that the association between urticaria and digestive symptoms should guide the clinician to the diagnosis of Giardia Lamblia infection, and it shows the importance of a rapid and highly sensitive diagnostic test for giardiasis, like the ELISA test.

[Oncogeriatrics: an attempt to operational definition]. / Oncogériatrie: essai de définition opérationnelle.

Comprehensive geriatric assessment (CGA) represents a multidisciplinary comprehensive evaluation of an older individual's functional status, comorbid medical conditions, cognition, psychological state, social support, nutritional status, and a review of the patient's medications. Initially, the use of a CGA in the care of older patients with cancer was based on an extrapolation of its ability to predict morbidity and mortality in the general geriatric population. More recently, however, accumulating data show the benefits of using a CGA particularly in patients with cancer to predict morbidity and mortality. Prospective trials evaluating the utility of a CGA to guide interventions to improve the quality of cancer care in older adults are justified.

[Parkinson syndromes in geriatrics]. / Les syndromes parkinsoniens en gériatrie.

Geriatric teams are more and more in front of patients presenting Parkinson syndromes. The frailty of the geriatric patient could be responsible of the non recognition of the diagnosis of the Parkinson and related diseases. A diagnostic approach is proposed in order to better define a care plan and to target the priorities. In collaboration with the general practitioner, the neurologist and the caregivers, an appropriate diagnosis allows to optimize and/or to adapt the treatment, to prevent the functional decline, to decrease the caregiver's burden, and eventually to improve the end of life.

Inefficacy of intravenous immunoglobulins and infliximab in Degos' disease.

We report the case of a 60-year-old man who presented with sudden visual loss, a history of postprandial abdominal pain, malabsorption, and skin lesions typical of systemic Degos' disease. Despite anti-aggregants and prednisone the patient's status did not improve. On the basis of the hypothetical dysimmune origin of this disease, we attempted treatment with intravenous immunoglobulins, without success. We then administered infliximab (Remicade), but 2 months after the third injection the patient developed mesenteric infarction and died. We therefore believe that both intravenous immunoglobulins and antiTNFalpha are ineffective for the treatment of Degos' disease.

[Falls of older individuals: medical assessment]. / Les chutes du patient âgé: aspects médicaux.

Falls are one of the most common problems that threaten the independence of older individuals. They usually occur when impairments in multiple domains compromise the compensatory ability of the individual, as is the case for many geriatric syndromes. A number of the physical conditions and environmental situations predispose to falls. The medical risk factors of falls are reviewed. Falls in older individuals are rarely due to a single cause. Mechanisms that maintain postural stability are altered with aging (balance, gait speed, cardiovascular function). Female gender, past history of a fall, cognitive impairment, lower extremity weakness, balance problems, psychotropic drug use, arthritis, history of stroke, orthostatic hypotension, dizziness, and anemia represent the most frequent causes of risk of falls. Physical examination should focus upon the above mentioned risk factors and also on the presence of orthostatic hypotension, visual acuity, hearing assessment, examination of the extremities for deformities or neuropathies, and carotid sinus hypersensitivity which contributes to falls in people with unexplained falls. In conclusion, assessment of older individual at risk of falls or who fall present medical specificities. However, these latter specificities should be included in a comprehensive assessment which focus on intrinsic and extrinsic factors. Interventional strategies including comprehensive and interdisciplinary assessment lead to effective prevention.

[Fear of falling in older people]. / La peur de chuter et le "syndrome post-chute " de la personne âgée.

Fear of falling and poor physical performance are prominent symptoms in many older people. The prevalence of fear of falling in community-living elderly ranges between 12 % and 65 %, and is higher in women than men. It commonly occurs after falls, but it also occurs without a previous fall history. One of the major consequences of fear of falling is the restriction and avoidance of activities. However, not all elderly with fear of falling avoid activities in daily life. Some elderly only become cautious, which may be functional in preventing falls. Only a small percentage of elderly show a pattern of excessive fear and restriction of activities. The consequences of this pattern may, however, be debilitating and devastating. Excessive fear and avoidance may compromise the quality of life, and may result in a decline of physical capabilities and, ultimately, in an increased risk of falls, which may further fuel fear and avoidance. Future research should investigate whether individualised intervention strategies are efficient in preventing falls and activity-related fear of falling within this population in order to improve her quality of life.

[When a multiple trauma complains about abdominal pains six weeks after the fall. . ]. / Quand un polytrauma se plaint de douleurs abdominales six semaines après la chute. . .

A 18-year old patient presents abdominal pains associated with nausea and vomiting six weeks after a multiple trauma leading to paraplegia. Esophagitis, urolithiasis, and acalculous cholecystitis were diagnosed. This report illustrates two rare abdominal complications of a multiple trauma with immobilisation: acalculous cholecystitis, hypercalcaemia, coralliform urolithiasis following urinary infection and bacteriurie with Enterobacter Cloacae. The interpretation of the abdominal semiology of a multiple trauma's patient presenting long-term immobilization may be misleading.

[Control of hypertension in nursing homes]. / Contrôle de i'hypertension en maison de repos et maison de repos et de soins.

In a cross sectional study we determined prevalence of hypertension among institutionalized old subjects. Prevalence of hypertension was 69%. Among detected hypertensive patients, 76% received an antihypertensive drug treatment. 61% of the declared hypertensive patients and 80% of the treated hypertensive patients had their blood pressure controlled. The general practitioners should better detect and treat this common geriatric problem associated with a high comorbidity.

[Management of arterial hypertension in octogenarian]. / Prise en charge de l'hypertension artérielle chez l'octogénaire.

Hypertension is the most common chronic condition for which elderly people see a health provider and is increasing in prevalence as people age. The most powerful risk factor for death, cardiovascular death, and hypertension in large populations is age. In the very elderly patient the most common abnormality is elevated systolic blood pressure, which is much more predictive of stroke and heart disease death. With the exception of the Antihypertensive and Lipid Lowering to prevent Heart Attack Trial (ALLHAT), recent trials have emphasized the overriding importance of lowering blood pressure rather than the specific agent chosen to begin therapy. A metaanalysis of 7 clinical trials that enrolled 1.670 subjects > 80 years od age indicated that active antihypertensive drug therapy significantly reduce stroke by 34% and heart failure by 39% was associated with a non significant 6 increase in mortality. The Hypertension in the Very Elderly Trial (HYVET) will enrol 2.100 patients > 80 years of age and will compare 2 groups randomized to indapamide +/- perindopril versus placebo +/- placebo for incident stroke during 5 years follow-up. This study should answer lingering question about whether active antihypertensive therapy is associated with a major and significant reduction in cardiovascular morbidity and mortality in this age group as it clearly does in younger hypertensives. For frail patients, further studies are needed to assess the potential risks associated to antihypertensive therapy according to the characteristics of the geriatric patient.

Translocation of Shiga toxin across polarized intestinal cells in tissue culture.

Escherichia coli strains producing Shiga toxins (Stx) 1 and 2 colonize the lower gastrointestinal tract in humans and are associated with gastrointestinal and systemic diseases. Stx are detectable in the feces of infected patients, and it is likely that toxin passes from the intestinal tract lumen to underlying tissues. The objective of this study was to develop an in vitro model to study the passage of Stx across intact, polarized cell monolayers. Translocation of biologically active Stx was examined in four cell lines grown on polycarbonate filters. Stx1 translocated across intestinal cell monolayers (CaCo2A and T84 cells) in an energy-requiring and saturable manner, while the monolayers maintained a high level of electrical resistance. Stx1 had no effect on electrical resistance or inulin movement across these cell lines for at least 24 h. Induction of specific Stx receptors with sodium butyrate reduced the proportion of toxin translocated across CaCo2A monolayers but had no major effect on the movement of horseradish peroxidase or [3H]inulin. We have shown that biologically active Stx1 is capable of moving across intact polarized intestinal epithelial cells without apparent cellular disruption, probably via a transcellular pathway. The data also suggest that the presence of Stx receptors on the apical surface of intestinal epithelial cells may offer some protection against the absorption of luminal Stx1.

Expression and purification of Shiga-like toxin II B subunits.

Shiga-like toxins (SLTs), which are produced by certain strains of Escherichia coli, are composed of enzymatically active A and B subunit multimers responsible for the toxin's binding. We have previously purified large amounts of the SLT-I B subunit by using a hyperexpression vector in Vibrio cholerae under the control of the trc promoter. In this study we examined various expression vectors to maximize yields of the SLT-II B subunit. The SLT-II B subunit has been expressed by using both the T7 promoter and the tac promoter in E. coli. When expressed from a plasmid containing the structural gene for SLT-II B deleted of the leader sequence, SLT-II B was able to form multimers when cross-linked, although SLT-II B production from this plasmid was unreproducible. SLT-II B expressed in all three systems appeared to form unstable multimers, which did not readily bind to a monoclonal antibody which preferentially recognizes B subunit multimers. SLT-II B expression was not increased by moving any of the plasmids into V. cholerae. Polyclonal antibodies raised to SLT-II B in rabbits recognized B subunit in SLT-II holotoxin yet were poorly neutralizing. SLT-II B was also expressed as a fusion protein with maltose-binding protein and could be cleaved from maltose-binding protein with factor Xa. Although the expression vectors were able to make large amounts of SLT-II B, as determined by Western blotting (immunoblotting), the levels of purified SLT-II B subunit were low compared with those obtained previously for SLT-I B subunit, probably because of instability of the multimeric SLT-II B subunit.

Antigenic diversity in Haemophilus ducreyi as shown by western blot (immunoblot) analysis.

The antigenic diversity within a panel of 63 Haemophilus ducreyi isolates was examined by Western blot (immunoblot) analysis with a pool of 238 well-characterized human antisera. When a serum pool adsorbed on a mixture of Haemophilus influenzae, H. parainfluenzae, and H. parahaemolyticus was used, the immunoprofiles suggested that prominent antigenic proteins involved in the human immune response have apparent molecular masses of 63, 42, 34 to 30, and 28.5 to 28 kDa. Preliminary subcellular localization revealed that these antigens are associated with the cellular membrane. Two subsets of antigens were discriminated by detergent extraction. There was no evidence that the antigen composition is altered by changing the growth conditions. With a serum pool adsorbed on the Haemophilus spp. mixture supplemented with Actinobacillus actinomycetemcomitans, Pasteurella ureae, Neisseria gonorrhoeae, and Escherichia coli, antigenic determinants more specific for H. ducreyi were identified. An immunodominant 28.5- to 28-kDa protein was expressed by all H. ducreyi isolates. In the range from 34 to 30 kDa, 56 isolates revealed a dominant protein with variable molecular mass. By using both proteins (28.5 to 28 kDa and 34 to 30 kDa) as immunotypic markers, seven different immunopatterns were identified. Antigenic diversity among isolates from different geographical origins as well as from a single area was observed.