[Analysis of 736 blood transfusions in a geriatric teaching hospital]. / Seuils et objectifs transfusionnels chez des patients de plus de 75ans : analyse de 736 transfusions de culots globulaires et comparaison aux recommandations.

BACKGROUND: Red blood cell transfusion in elderly patients with anemia requires taking into account a hemoglobin threshold, as well as comorbidities that may be decompensated by anemia. In the absence of consensual indications for blood transfusion in the elderly population, it seems important to evaluate the practical approach of blood transfusion in geriatrics. We analyzed prescriptions of red blood cell transfusion in very old patients hospitalized in a geriatric teaching hospital. METHODS: This retrospective study was based on information collected during one year in 736 red blood cell transfusion prescriptions. Hemoglobin levels, numbers of red blood cell units and clinical informations notified by prescribing physicians have been collected and analyzed. RESULTS: The mean hemoglobin level before red blood cell transfusion was 8.45±0.94g/dL. Two variables were significantly associated with an increase of the transfusion threshold above 9g/dL: the poor tolerance of anemia (P<10(-4)) and clinical situations at risk for poor tolerance of anemia (P=0.0076). The most frequent symptoms of poor tolerance of anemia were cardiovascular symptoms and also acute neuropsychiatric symptoms that could be considered as specific criteria for the red cell transfusion in the elderly. The mean number of red blood cell units prescribed for each transfusion was 1.88±0.55 and the only predictive factor was the hemoglobin level (P<0.001). PERSPECTIVES: In our geriatric practice, transfusion thresholds and target hemoglobin levels after transfusion seemed to be comparable with the thresholds recommended in the only available French guidelines edited in 2002 by the Afssaps. However, our study pointed out specific geriatric particularities in red blood cell transfusion prescriptions with the use of some tolerance criteria that seem related to non-cardiovascular comorbidities. Future prospective interventional studies could be conducted in order to evaluate the clinical relevance of these potential specific geriatric criteria in transfusion indications.

[Focus on digitalis intoxication in the elderly. Report of a case treated with digoxin-specific Fab antibody fragments]. / Mise au point sur la prise en charge des intoxications digitaliques chez le sujet age. À propos d'un cas traité par anticorps antidigitaliques.

The indications for digoxin are currently limited to rare cases of heart failure and/or atrial fibrillation. Its use should be even more rare in geriatrics its pharmacological characteristics, associated with age-related changes and comorbidities, particularly increase the risk of digoxin poisoning in the elderly. However, at least a third of aged patients suffering from heart failure and/or atrial fibrillation is treated by digitalis. Digoxin intoxication can provoke gastrointestinal troubles, neurological disturbances and, above all, cardiac conduction impairment and dysrythmias, which explain its severity and high mortality rate. Presently, first-line therapy is the administration of digoxin specific antibodies. Poor prognosis factors, frequently found in digoxin intoxications in the elderly, have been established for guiding the prescription of antibodies and their dosage. It is important for geriatricians to be able to recognize poisoning signs and the conditions in which an antidote treatment is necessary. This will permit a more effective management of the case, with the support of a poison control center and possible referral of the patient to an intensive care unit.

Anemia in the elderly: usefulness of an easy and comprehensive laboratory screen.

Anemia, the most common hematological disorder in the elderly, increases the risk of mortality and morbidity and adversely affects quality of life. However, few studies focused specifically on anemia in the elderly, especially regarding the underlying causes. The main objective of this prospective study was to evaluate the causes of anemia in non-institutionalized elderly patients. We included 190 consecutive patients ≥70 years, admitted to a geriatric short-stay unit over a 1-year period. When the hemoglobin level was <120 g/L, the following serum assays were performed routinely: iron, ferritin, transferrin saturation, folate, vitamin B12, C-reactive protein, TSH, albumin, and haptoglobin. When these tests were normal, bone marrow aspiration was performed to look for myelodysplastic syndrome. Hemoglobin was <120 g/L in 83 (43.7%) of 190 included patients. Patients with anemia had a mean hemoglobin level of 105 ± 11 g/L. The most common potential causes of anemia were inflammation, severe renal impairment, severe malnutrition, and iron deficiency; each of these causes was found in at least one-third of patients with anemia. Myelodysplastic syndrome was found in all anemic patients with a normal serum screen (12/83, 14.5%). Anemia was multifactorial in most patients: the mean number of potential causes per patient was 1.85 ± 1, and 65.4% of the patients had two to four concomitant causes. The serum screen used in our study is easy to perform in ambulatory patients and identifies potential causes of anemia for which safe and effective treatments are available. Second-line bone marrow aspiration adds to the diagnostic yield.

[Sleep apnea syndrome and cognitive impairment]. / Syndrome d'apnées du sommeil et troubles cognitifs.

The sleep apnoea syndrome is a common disorder, unrecognised in the elderly. Several studies have shown that it can cause or exacerbate cognitive impairment, mainly related to attention, memory and learning and adaptation abilities. However, continuous positive airway pressure treatment appears to be effective on these cognitive disorders, including in elderly patients.Accordingly, the sleep apnoea syndrome can be a conceivable diagnostic as part of the cognitive deterioration check-up in elderly patients.

[Divisibility of warfarin and fluindione tablets tested in elderly patients and their family circle]. / Sécabilité comparée des comprimés de warfarine et de fluindione pour les patients âgés et leur entourage.

BACKGROUND: Vitamin K antagonist tablets are often split to fractionate the dose by elderly patients. We performed a study in order to assess the divisibility of one dosage strength of score-lined warfarin and of score-lined fluindione. METHODS: Due to a recent change in the pharmaceutical form of fluindione in order to improve the divisibility, the study was performed over 2 different periods (with the « old ¼ and with the « new ¼ pharmaceutical form). In each period, 10 patients mean aged 82 years, 10 relatives, 10 nurses, 10 medical doctors) were asked to split in half warfarin tablets (W2 1(st) period et W2 2(d) period) and fluindione tablets (F2 et F'2), and to split fluindione tablets into 4 fragments (F4 et F'4). The first end-point was the accuracy of splitting estimated by the difference between the real and the expected weight of fragmented tablets. The statistical analysis was performed using an ANOVA test with 2 variables, subject and drug. The difference between the 2 periods were analyzed using an ANOVA test with 2 variables, subject and period. RESULTS: Over the 2 periods, the differences between real and expected weight were of 4.65% for W2 1(st) phase, 9.48% for F2, 15.35% for F4, 5.56% for W2 2(d )period, 4.30% for F'2, and 6.98% for F'4. The quality of splitting was statistically poorer in the elderly patient group compared to other subjects. CONCLUSION: This study was not design to assess the clinical relevance (bleeding or thromboembolism) or the anticoagulation control of the variations in drug mass due to inappropriate splitting of tablets. However, split form of drugs should be prescribe with caution to elderly patients.

[Hodgkin lymphoma in the elderly]. / Le lymphome de Hodgkin chez le sujet âgé

We report a case of Hodgkin's lymphoma in a patient aged 75, presenting with acute cardiopulmonary insufficiency, hospitalized in a geriatrics ward. The deterioration of his general condition and the discovery of several lymph nodes led us to perform an aspiration of a lymph node and a bone marrow biopsy. Reed-Sternberg cells, pathognomonic of Hodgkin's disease were identified on the smears and biopsy sections. Due to the poor condition of the patient, it was decided not to treat with chemotherapy. The diagnostic approach and treatment strategy of Hodgkin's disease are summarized in this paper, especially the particular features of the disease in the elderly.

[Management of complications with antivitamin K in elderly people]. / Gestion des accidents des antivitamines K chez la personne âgée.

latrogenic complications with antivitamin K (AVK) largely entail haemorrhages, apparently more frequent in the elderly. Recent French and North American recommendations are available and must be widely circulated, in community practices as well as hospitals, in order to improve the treatment of overdoses and/or haemorrhagic accidents under AVK.

Reversal of overanticoagulation in very elderly hospitalized patients with an INR above 5.0: 24-hour INR response after vitamin K administration.

BACKGROUND: Reversal of overanticoagulation to minimize the bleeding risk is important in elderly inpatients receiving vitamin K antagonist therapy. However, no study has specifically focused on this population. The objective of this study is to evaluate whether guidelines based on American College of Chest Physicians recommendations for the management of overanticoagulation (international normalized ratio [INR] ≥5.0) can apply to elderly inpatients, and notably allow 24-hour INRs to return to the 1.8-3.2 range in this population. The influence of different factors on the vitamin K response also was evaluated. METHODS: Inpatients aged ≥75 years with INR ≥5.0 were included in this observational study. INRs were assessed on the day of the overdosage (Day 0) and on the following day (Day 1). RESULTS: Of 385 Day 0 INRs ≥5.0 (239 patients; 86±6 years), 217 were managed according to recommendations, with a mean INR decreasing from 6.8±2.4 (range: 5.0-20.0) on Day 0 to 2.7±1.3 (range: 1.1-10.1) on Day 1 (P<.0001); 55% of INRs were within the 1.8-3.2 range, 20% <1.8, and 25% >3.2. In the subset of Day 0 INRs between 5.0 and 6.0, mean INR decreased from 5.5±0.3 to 2.7±1.0 (P<.0001) on Day 1 after oral administration of 1 mg vitamin K1 (n=121) and from 5.3±0.3 to 5.0±1.6 (P=.149) without vitamin K1 administration (n=48). Among covariates entered in the multivariate analysis, including co-medications, only the vitamin K1 dose influenced Day 1 INRs, with higher doses of vitamin K1 associated with Day 1 INRs <1.8 (P<.0001). CONCLUSION: In elderly inpatients with INR ≥5.0, both vitamin K antagonist dose omission and vitamin K1 administration according to recommendations were effective in reversing overanticoagulation, allowing most INRs to return to the 1.8-3.2 range without excessive overcorrection. Therefore, American College of Chest Physicians recommendations may be applied to elderly inpatients.

[Screening for thrombophilic abnormalities in very elderly patients]. / Bilan biologique de thrombophilie chez le sujet très âgé.

Few data are available regarding biological risk factors for venous thromboembolism in the elderly who are at high risk of thrombosis. In the present study, we assessed the prevalence of antithrombin, protein C, protein S deficiency, G1691A factor V Leiden and G20210A prothrombin (FII) gene variant, and antiphospholipid antibodies in patients over 75 years who were referred to us for thrombophilia testing and who presented with unprovoked recurrent venous thromboembolic disease or venous thrombosis at unusual site. Seventy-eight patients, mean aged 86 years, were included in the cohort. No deficiency in natural coagulation inhibitors was found. Ten patients (12.8%) and 6 patients (7.7%) were found heterozygous carriers of the factor V Leiden and of the G20210A FII mutation, respectively. One patient was a double heterozygote. Two patients were diagnosed with antiphospholipid syndrome. These results are discussed along with those obtained in cohorts of elderly patients or in cohorts of younger patients presenting with idiopathic venous thromboembolic disease, either recurrent or not. Our results trend to confirm the recently published French recommendations regarding inherited thrombophilia screening in the elderly: in patients aged 60 years or older, testing should be limited given the weak impact of this finding on the anticoagulation management.