[Critical assessment of long-term proton pump inhibitor use in the elderly]. / Approche critique du traitement prolongé par inhibiteurs de la pompe à protons chez les personnes âgées.

Proton pump inhibitors (PPI) are drugs frequently used for gastric acid-induced conditions. Their use is constantly increasing and due to the apparent absence of side-effects, the treatment is not reassessed, even for the elderly. However, there are many cases of misprescribing while concerns about some side-effects are rising. Old people are weakened by their particular homeostasis and their associated medical conditions. Therefore, it seems useful to particularly insist on side-effects of the PPI, their indications and the ways of withdrawal, first of all for the elderly.

Les inhibiteurs de la pompe à protons (IPP) sont des médicaments fréquemment prescrits pour la prise en charge de pathologies secondaires à l'acidité gastrique. Leur utilisation est en constante augmentation et la question d'un éventuel sevrage, notamment chez les personnes âgées, est rarement soulevée en raison de leur bonne tolérance clinique apparente. Pourtant, leur utilisation est régulièrement injustifiée et il existe de plus en plus de preuves d'effets secondaires variés et potentiellement sévères. Les personnes âgées étant fragiles en raison de leur homéostasie particulière et de leurs comorbidités, il semble intéressant d'insister, dans cette population, sur les manifestations indésirables potentiellement médiées par les IPP, les indications reconnues de traitement et les méthodes de sevrage disponibles, le cas échéant.

[How I treat... Delirium in the aged]. / COMMENT JE TRAITE le delirium chez le patient âgé.

Delirium is an acute psycho-organic disorder, most of the time reversible, that happens in various situations (acute disease, drugs ... ). It can also result from an acute or long term stress when the patient is already in an unstable homeostatic balance. Delirium is common in the geriatric population and can have serious consequences in terms of morbidity and mortality. Unfortunately, it is often not well known by hospital doctors. It is the consequence of predisposing factors (age, polypharmacy, multiple illnesses, neurodegenerative diseases, ... ) and precipitating factors (inadequate medications, dehydration, infections, ...). Diagnosis of delirium is simple with the Confusion Assessment Method (CAM). Rapid diagnosis and management are mandatory to limit functional decline. In people at risk, simple non-drug interventions can prevent the occurrence of delirium. Psychotropic drugs should be used with caution. The prevention of delirium is important and a standardized geriatric assessment to identify old patients at risk should be performed before any surgery or heavy treatment.

Le delirium, ou syndrome confusionnel aigu, est un trouble psycho-organique aigu et habituellement réversible qui peut survenir sous l'influence de conditions diverses (affection somatique, médicaments…), mais aussi être la conséquence d'un stress aigu ou de longue durée, lorsque le patient se trouve déjà dans un équilibre homéostatique très instable. Il est fréquent dans la population gériatrique, souvent peu connu des médecins hospitaliers, et influence considérablement la morbi-mortalité. Il est la conséquence de l'association de facteurs prédisposants (grand âge, polymédication, polypathologie, maladies neurodégénératives, …) et de facteurs précipitants (médications inadaptées, déshydratation, infections, contention, …). Son dépistage est rapide à l'aide de la Confusion Assessment Method (CAM). Son diagnostic et sa prise en charge sont importants afin de limiter le déclin fonctionnel du patient âgé qui en est atteint. Chez les personnes à risque, il existe des interventions non médicamenteuses simples pour limiter la survenue du delirium. Les psychotropes doivent être utilisés avec précaution. La prévention du delirium est importante et une évaluation gériatrique standardisée pour repérer les patients âgés à risque devrait être réalisée avant toute intervention chirurgicale ou traitement lourd.

[Swallowing disorders in elderly patients: a multidisciplinary approach]. / Personnes âgées et troubles de la déglutition: une approche pluridisciplinaire.

Presbyphagia represents the physiological aging of swallowing function. It predisposes to difficulty in swallowing, namely dysphagia, which is of high incidence in the elderly population. The consequences of dysphagia are multiple and always a tragedy for the patient; they consist of aspiration pneumonia, malnutrition, dehydration, social isolation, and death. The diagnosis is difficult and is based on the medical history and clinical examination, associated with diagnostic tests. Its management is multidisciplinary, leaving only little room for medications or surgery.

[Nutrition in the elderly]. / La nutrition de la personne âgée.

Ageing of the body predisposes to a high incidence of undernutrition in the elderly person wherever he or she is living, but the prevalence of malnutrition is particularly high in hospitalized or instutionalized patients. Early detection of malnutrition is important because malnutrition may have significant consequences and evaluation of nutritional status has to be a routine screening in the elderly. There is no single parameter which supplies a full assessment of the patient's nutritional status. It is then necessary to use screening tools for the identification of patients at nutritional risk, based on anamnestic, antropometric and biological data. The MNA (Mini Nutritional Assessment) test is a simple, non invasive, well-validated screening tool for malnutrition in the elderly and is recommended for early detection of risks of malnutrition. Numerous conditions in relationship with physiological ageing, comorbidity, polymedication and the way of life of the individual predispose to undernutrition. Healthy nutrition in older patients should respect the guidelines for protein and energy requirements, excepted in severely ill patients and/or in case of malnutrition in which case the protein-energy intake should be increased.

[Screening for frailty: a benefit for both patients and physicians]. / Dépister la fragilité: un bénéfice pour le patient et pour le soignant.

Preventing the increasing number of depending persons is a novel priority in European Union health policy. One of the means to succeed relies on identifying, among elderly persons, those at risk of dependency, also named "the frail elderly". Screening for frailty is also useful to better assess the physiological reserves of the elderly before any therapeutic decision, as early as the first consultation. Researchers currently work on developing a new simple tool allowing a distinction between frail and robust persons. Since frailty is partly reversible, the global geriatric evaluation, in a one-day clinic, will lead to a personalized program to prevent or reverse frailty by a multidisciplinary approach.

Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study.

BACKGROUND: To evaluate the large-scale feasibility and usefulness of geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions. PATIENTS AND METHODS: Eligible patients who had a malignant tumour were ≥70 years old and treatment decision had to be made. Patients were screened using G8; if abnormal (score ≤14/17) followed by Comprehensive Geriatric Assessment (CGA). The assessment results were communicated to the treating physician using a predefined questionnaire to assess the topics mentioned above. RESULTS: One thousand nine hundred and sixty-seven patients were included in 10 hospitals. Of these patients, 70.7% had an abnormal G8 score warranting a CGA. Physicians were aware of the assessment results at the time of treatment decision in two-thirds of the patients (n = 1115; 61.3%). The assessment detected unknown geriatric problems in 51.2% of patients. When the physician was aware of the assessment results at the time of decision making, geriatric interventions were planned in 286 patients (25.7%) and the treatment decision was influenced in 282 patients (25.3%). CONCLUSION: Geriatric screening and assessment in older patients with cancer is feasible at large scale and has a significant impact on the detection of unknown geriatric problems, leading to geriatric interventions and adapted treatment.

[Breast cancer in the elderly patient]. / Le cancer du sein de la femme âgée.

There is no standard of care for breast cancer treatment in the elderly patient. Given the heterogeneity of this population, the treatment of both localized and metastatic disease, requires to take into account not only the characteristics of this cancer but also factors related to the patient such as co-morbidities, life expectancy and the social environment.

Clinical Impact of Nutritional Status and Energy Balance in Elderly Hospitalized Patients.

OBJECTIVES: This study aimed 1) to assess the nutritional status of patients hospitalized in a geriatric ward using the recent Global Leadership Initiative on Malnutrition (GLIM) criteria, 2) to determine the balance between the energy intake (EI) with an enriched diet and the energy requirement (ER) using indirect calorimetry, and 3) to assess whether undernutrition is associated with 1-year outcome. DESIGN: This is a prospective cross-sectional study. SETTING: This study was performed in a geriatric unit. PARTICIPANTS: Patients of this geriatric unit were eligible for the study if they agreed to participate and if they did not meet the exclusion criteria (presence of malignant tumour, uncontrolled heart or renal failure, thyroidal disease, uncontrolled sepsis, oedema of the lower limbs, wearing of a pacemaker, biological thyroid dysfunction and inability to perform walking tests). MEASUREMENTS: Rest energy expenditure (REE) was measured by indirect calorimetry within the week of hospitalization. Total energy expenditure (TEE) was obtained by multiplying REE by a physical activity level coefficient and energy expenditure that was related to thermogenesis (i.e., 10% of the total amount of energy ingested over 24 h) was added. Food intake was measured over a 3-day period. Undernutrition was defined using MNA and the criteria of the GLIM leadership. Clinical outcomes included 1-year institutionalisation and mortality. RESULTS: Seventy-nine patients (84.9 ± 5.3 years) were included. A total of 21 (26.6 %) patients were found undernourished. REE was 1088 ± 181kcal/day (17.8 ± 2.9 kcal/kg/day) and TEE was 1556 ± 258 kcal/day (25.4 ± 4.2 kcal/kg/day). Weight-adjusted REE and TEE were higher in undernourished patients compared to those well-nourished (19.8 ± 3.1 vs. 17.1 ± 2.6 kcal/day and 28.4±4.5 vs. 24.4±3.7 kcal/day) (p<0.05). The lower was the Body Mass Index (BMI), the higher was the energy needs (p<0.01). EI was significantly greater than energy requirements (difference requirements - intake with enriched diet = -354 ± 491 kcal/day; p<0.0001). This difference did not depend on BMI (p=0.82), appendicular skeletal mass index (ASMI) (p=0.63), or the presence of undernutrition (p=0.33). At 1-year follow-up, 15 (19%) patients died and 20 (25.6%) were institutionalized. On multivariable analysis, male gender (OR=5.63; p=0.015) and undernutrition (OR=7.29; p=0.0043) emerged as independently associated with death. On multivariable analysis, only ASMI (OR 0.59 (0.35-0.99), p=0.044) and activities of daily living (ADL) (OR 1.14 (1.00-1.30), p=0.043) were significantly associated with institutionalization. CONCLUSIONS: Undernutrition as assessed by the GLIM criteria remains common in elderly patients hospitalized in a geriatric unit and is associated with increased 1-year mortality but not with institutionalization. Energy requirements are higher in undernourished patients and in patients with a low BMI. Enriched energy intakes could sufficiently cover the energy needs of this population.

[Swallowing disorders in the elderly: an underestimated problem]. / Les troubles de la déglutition du sujet âgé: un problème trop souvent sous-estimé.

Swallowing disorders are frequently observed in the elderly and often accompany an organic pathology. Such disorders may quickly constitute a threat for life: inhalation syndrome, pulmonary infection, undernutrition, dehydration. Diagnosing swallowing disorders is difficult and relies on anamnesis, clinical examination combined with paraclinical investigations. However, there is little place for medicinal or surgical treatment, their management being integral and multidisciplinary.

[Clinical case of the month. An elderly patient with bronchiectasis: a case report]. / Bronchectasies chez une dame de 84 ans.

This case report describes a geriatric patient suffering from infected bronchiectasis and severe denutrition. This pathology is common and its treatment clearly defined, but an adapted and specific therapeutic approach, consisting in a global assessment and geriatric multidisciplinary interventions should be performed because of the frailty of the patient. This approach has result in a favorable issue for the patient.

Energy and Nutrient Content of Food Served and Consumed by Nursing Home Residents.

OBJECTIVE: The aim of this study was to compare energy and protein content of the served food with the actual intake from the food consumed by nursing home residents. This study also aimed to compare food intake and dietary allowances. DESIGN: This is a cross sectional study. SETTING: This study was performed in nursing homes. PARTICIPANTS: Residents of these 2 nursing homes were eligible for the study if they agreed to participate and if they meet the selection criteria (to be older than 65 years and have a regular texture diet). MEASUREMENT: Nutrient content of the served food and real food consumption was calculated for all meals during a 5-day period by precise weighting method. Difference between consumed and served dietary content was evaluated by the Chi² test. RESULTS: Seventy-four Belgian nursing home residents (75% of women, 85.8 ± 7.04 years on average) were included in this study. These subjects had a mean body mass index of 24.9 ± 4.83 kg/m². The mean energy content of the served food was 1783.3 ± 125.7 kcal per day. However, residents did not eat the whole of the meals and the actual energy content of the consumed food was significantly less (1552.4 ± 342.1 kcal per day; p<.001). The average protein content of the food served was equal to 0.96 ± 0.20 g/kg/day and the average consumption of protein by the residents was 0.88 ± 0.25 g/kg/day. The difference between protein served and consumed was also significant (p=.04). Moreover, people considered as well nourished, eating significantly more energy than the others (p=.04). CONCLUSION: Meals served in nursing homes are not entirely consumed by their residents. As expected, the energy consumed are lower in subjects considered as malnourished or at risk of malnutrition.

[Prevention of cardiovascular disease in the elderly]. / Prévention cardiovasculaire chez la personne âgée.

The aging of the cardiovascular system leads to an increased incidence of hypertension, coronary artery disease and ischemic stroke. Since cardiovascular disease is the leading cause of morbidity and mortality in patients > or = 70 years old, prevention seems crucial for improving quality of life and reducing medical costs. In this article we present some aspects of cardiovascular prevention in elderly patients.