Alzheimer's disease and related syndromes and hospitalization: a nationwide 5-year longitudinal study.

BACKGROUND AND PURPOSE: To study the association between Alzheimer's disease and related syndromes (ADRS) and the incidence of short-stay hospitalizations from the year before (Y-1 ) to 4 years after (Y1 -Y4 ) ADRS identification in the healthcare system. METHODS: Among all beneficiaries of the French health insurance general scheme aged 40 years or more, those with an incident ADRS in 2011, identified through long-term disease registry, hospitalization diagnoses or ADRS-specific drug delivery, were matched with beneficiaries without ADRS of the same age, gender and residence area. The annual incidence rates of all-cause hospitalizations (excluding those with a diagnosis code of ADRS) were compared between individuals with or without ADRS using incidence ratios (IRs) globally and by age, gender, deprivation index and modified Charlson score. We also studied cause-specific hospitalizations using patients' diagnoses and procedure codes. RESULTS: A total of 90 871 subjects with and 90 871 subjects without ADRS were included (mean age 79.6 years, 66% females). From Y-1 to Y4 , incidence rates were significantly higher in subjects with ADRS than in those without for all-cause hospitalization [IR(Y-1 ) = 1.73; 95% confidence intervals, 1.71-1.75; IR(Y4 ) = 1.37; 95% confidence intervals, 1.35-1.39], hospitalizations for social reasons [IR(Y-1 ) = 4.28; IR(Y4 ) = 2.70], fall [IR(Y-1 ) = 5.36; IR(Y4 ) = 2.59], injury [IR(Y-1 ) = 2.71; IR(Y4 ) = 2.09] and infection [IR(Y-1 ) = 2.04; IR(Y4 ) = 2.07]. The inverse was observed for hospitalizations for cataract surgery [IR(Y-1 )=0.73; IR(Y4 ) = 0.51] or total hip prosthesis after 2 years [IR(Y4 ) = 0.72]. CONCLUSIONS: Incident ADRS cases were associated with a higher incidence of hospitalization, but these subjects underwent some common non-emergency surgeries less frequently. Future studies need to assess the clinical impact of these differences.

A web-based multidomain lifestyle intervention with connected devices for older adults: research protocol of the eMIND pilot randomized controlled trial.

BACKGROUND: Multidomain interventions composed of nutritional counseling, exercise and cognitive trainings have shown encouraging results as effective preventive strategies delaying age-related declines. However, these interventions are time- and resource-consuming. The use of Information and Communication Technologies (ICT) might facilitate the translation from research into real-world practice and reach a massive number of people. AIM: This article describes the protocol of the eMIND study, a randomized controlled trial (RCT) using a web-based multidomain intervention for older adults. METHODS: One hundred and twenty older adults (≥ 65 years), with a spontaneous memory complaint, will be randomly assigned to a six-month web-based multidomain (nutritional counseling, physical and cognitive trainings) intervention group with a connected accelerometer (number of steps, energy expenditure), or to a control group with access to general information on healthy aging plus the accelerometer, but no access to the multidomain intervention. The main outcome is the feasibility/acceptability of the web-based intervention. Secondary clinical outcomes include: cognitive functions, physical performance, nutritional status and cost-effectiveness. RESULTS: We expect a high amount of adherers (ie, > 75% compliance to the protocol) to reflect the feasibility. Acceptability, assessed through interviews, should allow us to understand motivators and barriers to this ICT intervention. We also expect to provide data on its effects on various clinical outcomes and efficiency. CONCLUSION AND DISCUSSION: The eMIND study will provide crucial information to help developing a future and larger web-based multidomain lifestyle RCT, which should facilitate the translation of this ICT intervention from the research world into real-life clinical practice for the healthcare of older adults.

Intrinsic Capacitiy Monitoring by Digital Biomarkers in Integrated Care for Older People (ICOPE).

The WHO action plan on aging expects to change current clinical practices by promoting a more personalized model of medicine. To widely promote this initiative and achieve this goal, healthcare professionals need innovative monitoring tools. Use of conventional biomarkers (clinical, biological or imaging) provides a health status assessment at a given time once a capacity has declined. As a complement, continuous monitoring thanks to digital biomarkers makes it possible to remotely collect and analyze real life, ecologically valid, and continuous health related data. A seamless assessment of the patient's health status potentially enables early diagnosis of IC decline (e.g. sub-clinical or transient events not detectable by episodic evaluations) and investigation of its probable causes. This narrative review aims to develop the concept of digital biomarkers and its implementation in IC monitoring.

Framework Implementation of the INSPIRE ICOPE-CARE Program in Collaboration with the World Health Organization (WHO) in the Occitania Region.

INTRODUCTION: Limiting the number of dependent older people in coming years will be a major economic and human challenge. In response, the World Health Organization (WHO) has developed the «Integrated Care for Older People (ICOPE)¼ approach. The aim of the ICOPE program is to enable as many people as possible to age in good health. To reach this objective, the WHO proposes to follow the trajectory of an individual's intrinsic capacity, which is the composite of all their physical and mental capacities and comprised of multiple domains including mobility, cognition, vitality / nutrition, psychological state, vision, hearing. OBJECTIVE: The main objective of the INSPIRE ICOPE-CARE program is to implement, in clinical practice at a large scale, the WHO ICOPE program in the Occitania region, in France, to promote healthy aging and maintain the autonomy of seniors using digital medicine. METHOD: The target population is independent seniors aged 60 years and over. To follow this population, the 6 domains of intrinsic capacity are systematically monitored with pre-established tools proposed by WHO especially STEP 1 which has been adapted in digital form to make remote and large-scale monitoring possible. Two tools were developed: the ICOPE MONITOR, an application, and the BOTFRAIL, a conversational robot. Both are connected to the Gerontopole frailty database. STEP 1 is performed every 4-6 months by professionals or seniors themselves. If a deterioration in one or more domains of intrinsic capacity is identified, an alert is generated by an algorithm which allows health professionals to quickly intervene. The operational implementation of the INSPIRE ICOPE-CARE program in Occitania is done by the network of Territorial Teams of Aging and Prevention of Dependency (ETVPD) which have more than 2,200 members composed of professionals in the medical, medico-social and social sectors. Targeted actions have started to deploy the use of STEP 1 by healthcare professionals (physicians, nurses, pharmacists,…) or different institutions like French National old age insurance fund (CNAV), complementary pension funds (CEDIP), Departmental Council of Haute Garonne, etc. Perspective: The INSPIRE ICOPE-CARE program draws significantly on numeric tools, e-health and digital medicine to facilitate communication and coordination between professionals and seniors. It seeks to screen and monitor 200,000 older people in Occitania region within 3 to 5 years and promote preventive actions. The French Presidential Plan Grand Age aims to largely implement the WHO ICOPE program in France following the experience of the INSPIRE ICOPE-CARE program in Occitania.

Effectiveness of Therapeutic Patient Education Interventions for Older Adults with Cancer: A Systematic Review.

The incidence of cancer increases with age and demographics shows that the population of western countries is dramatically ageing. The new discipline of Geriatric Oncology is emerging aiming at providing tailored and patient-centred support to older adults with cancer. With the development of oral cancer therapy and outpatient treatments, Therapeutic Patient Education (TPE), aiming at enabling the patient and their relatives to cope with the disease in partnership with health professionals, appears to be an interesting and useful tool. The purpose of this paper is to search for evidence of the effectiveness of educational interventions for patients in older adults with cancer. The first screening found 2,617 articles, of which 150 were eligible for review. Among them, fourteen finally met the inclusion criteria: experimental and quasi-experimental studies enrolling older adults (over 65 years old), suffering from cancer and receiving an educational intervention. The types of educational intervention were diverse in these studies (support by phone and web base material). The results appear to be positive on anxiety, depression and psychological distress, patient knowledge and pain. However, data currently available on the effectiveness of a TPE program in Geriatric Oncology is lacking. Further studies are needed to assess the effectiveness of TPE programs adapted to the specific circumstances of the older adult.

Depression, diabetes and metabolic-nutritional factors in elderly Hispanics.

OBJECTIVE: To examine the relationship of depression to metabolic and nutritional risk factors in older Hispanics. DESIGN: Crossectional study. SETTING: Subjects were part of a community-based, cognitive evaluation project that examined 301 subjects in the Eastern San Fernando Valley of Southern California. PARTICIPANTS: Two elderly Hispanic groups: 53 clinically depressed, with memory complaints but not demented subjects, and 33 generally healthy, cognitively asymptomatic subjects. MEASUREMENTS: The results of functional and nutritional questionnaires, a medical and neurological examination, 12-hour fasting clinical laboratory tests, MRI or CT scans, and neuropsychological testing. RESULTS: Both groups were nearly identical along socio-demographic variables. However, the depressed group differed significantly from the general healthy group not only in percent of diabetics (38% vs.18%), but in the amount of poorly controlled diabetes, and the depressed group consumed about half the amount of fish that the generally healthy group did. CONCLUSIONS: This study suggests that factors such as poorly controlled diabetes combined with low consumption of foods high in omega-3 fatty acid content such as sea fish may be associated with an increased risk of developing depression in late life. These factors may be socio-economically and culturally influenced and are therefore amenable to modification.

A randomized trial of the impact of a specific care plan in 1120 Alzheimer's patients (PLASA Study) over a two-year period: design and baseline data.

OBJECTIVE: To describe the design anf baseline patient characteristics of a multicomponent specific care and assistance plan (PLASA) study in Alzheimer's Disease (AD). The study is designed to evaluate the effect of PLASA in AD primarily looking at change in functional capacity. DESIGN: Two-years prospective cluster randomized controlled trial comparing PLASA and usual care. SETTING: Forty-nine hospitals in France. PARTICIPANTS: 1120 community-dwelling AD. INTERVENTION: Patients in the intervention group are evaluated biannually using a standardized comprehensive global assessment. In the case of decline in any one domain a standardized study protocol recommends specific physician directed intervention in addition to information and training for the caregiver. MEASUREMENTS: Alzheimer Disease Cooperative Study-Activities of Daily Living scale, Resource Utilization in Dementia scale, Clinical Global Impression of Change. RESULTS: At baseline, the two groups were similar regarding patient and caregiver characteristics. The mean patient age was 79.61+5.72 years and the mean MMSE 19.73+4.01 for the whole cohort. Time since dementia diagnosis was about 1.37+1.65 years in the whole cohort. Almost a third of the patients lived alone at baseline. Mean monthly time spent in caregiving in the whole cohort was 52.70+71.83 hours for instrumental activities and 17.73+51.38 hours for basic activities. CONCLUSION: Persons with dementia suffer different losses at different stages of the disease and therefore accurate assessment of abilities and losses is critical to assist the person in planning for their future and for care needs. The PLASA intervention study is ongoing with 2 year follow-up to be completed in 2007.

Frailty, osteoporosis and hip fracture: causes, consequences and therapeutic perspectives.

OBJECTIVE: The aim of this review of the literature is to report the factors which both contribute to the frailty syndrome and increase hip fracture risk in the elderly. This work is the fruit of common reflection by geriatricians, endocrinologists, gynecologists and rheumatologists, and seeks to stress the importance of detection and management of the various components of frailty in elderly subjects who are followed and treated for osteoporosis. It also sets out to heighten awareness of the need for management of osteoporosis in the frail elderly. DESIGN: The current literature on frailty and its links with hip fracture was reviewed and discussed by the group. RESULTS: The factors and mechanisms which are common to both osteoporosis and frailty (falls, weight loss, sarcopenia, low physical activity, cognitive decline, depression, hormones such as testosterone, estrogens, insulin-like growth factor-I (IGF-I), growth hormone (GH), vitamin D and pro-inflammatory cytokines) were identified. The obstacles to access to diagnosis and treatment of osteoporosis in the frail elderly population and common therapeutic pathways for osteoporosis and frailty were discussed. CONCLUSION: Future research including frail subjects would improve our understanding of how management of frailty can can contribute to lower the incidence of fractures. In parallel, more systematic management of osteoporosis should reduce the risk of becoming frail in the elderly population.

Prevention of progression to dementia in the elderly: rationale and proposal for a health-promoting memory consultation (an IANA Task Force).

Alzheimer's disease (AD) is the most frequent form of dementia and according to the most recent estimation it affects nearly 27 million people in the world. The onset of the disease is generally insidious. It is becoming increasingly evident that the underlying pathophysiological mechanisms are active long before the appearance of the clinical symptoms of the disease. In the current context, it is important to develop strategies to delay the onset of cognitive decline. Delaying the onset by 5 years would reduce the prevalence by half at term, and a delay of 10 years would reduce it by three-quarters. The effectiveness of currently suggested preventive approaches remains to be confirmed, but certain strategies could be applied straight away to at-risk subjects. We propose that a health-promoting memory consultation should be set up for elderly persons who have attended a specialized memory consultation and in whom the diagnosis of dementia and of AD in particular, has not been established by standardized tools. Through this consultation, they would be offered full multidimensional investigation of all aspects of their health status, follow-up could be organized, general practitioners in private practice could be made more conscious of this population and the elderly could be made more aware of the risk factors to which they are exposed. The development of an information policy for the elderly would meet a present need. In our reflection, we must take into account the question of how to give this preventive consultation its due place in the healthcare pathway of the elderly person in order to ensure coordinated follow-up with all the other health professionals involved. The principle of the health-promoting memory consultation is undergoing validation in a large French multicentre preventive trial in 1200 frail elderly persons aged 70 years followed for three years, the Multidomain Alzheimer Preventive Trial (MAPT).

Drug Prescriptions in Nursing Home Residents during their Last 6 Months of Life: Data from the IQUARE Study.

OBJECTIVE: To assess the drug prescriptions of nursing home (NH) residents during the 6 months prior to their death, and the impact of the recognition of « life expectancy lower than 6 months ¼ by the NH staff on the prescriptions. DESIGN: Prospective study. SETTING: 175 nursing homes in France. PARTICIPANTS: 6275 residents were included from May to June 2011. MEASUREMENTS: The initial drug prescriptions of the residents who deceased within 6 months were compared with those who did not decease. Among the residents deceased within 6 months, the drug prescriptions were compared between the residents who were «considered at the end of their life¼ and those who were not. Potentially inappropriate prescriptions (PIP) were analyzed using Laroche criteria and a list of therapies considered as inappropriate at the end of life. RESULTS: 498 residents (7.9%) died within 6 months after their inclusion: they had significantly more therapies (8.3 ± 3.8 vs. 7.9 ± 3.5, p=0.048) than non-deceased people. Sixty-one of the residents deceased within 6 months were considered by the NH staff as «end of life residents ¼ (12.2%). They received significantly less drugs (6.4 ± 4.2 vs 8.5 ± 3.6, p<0.001) than NH's residents not identified at the end of their life. They had a more frequent prescription of opioids (p<0.001), and less antipsychotics (p<0.001), lipid-lowering drugs (p=0.006), or antihypertensive therapies (p<0.01). They also received significantly less PIP (59.0% received at least one inappropriate prescription, vs. 87.2%, p<0.001). CONCLUSION: An important proportion of nursing home residents received PIP. The quality of prescriptions in patients identified at the end of their life seems to improve, but more than half still receive inappropriate drugs. Special attention in prescribing should be given to these patients presenting a high risk of adverse events.

How to Manage Frail Older Adults in the Community? Proposal of a Health Promotion Program Experienced in a City of 16,638 Inhabitants in France.

BACKGROUND: Health promotion programs could prevent and delay frailty and functional decline. However, in practice, the planning and establishment of such a program is a challenge for health care providers. We report an experimental model of screening and management for frail elderly conducted in Cugnaux, city of 16,638 inhabitants in France, by the Toulouse Gerontopole and the social care service of the Cugnaux City Hall. METHODS: A frailty screening self-administered questionnaire (FiND questionnaire) was sent to community-dwelling residents of 70 years old and over of Cugnaux. The completed questionnaires were analyzed and the subjects were classed into three groups: robust, frail, mobility disability, based on their score. Frail subjects and those with mobility disability invited to undergo a frailty assessment in the premises of the town hall realized by a nurse in order to identify the causes of their frailty and propose them a personalized intervention plan (PIP). RESULTS: The FiND questionnaire was sent to the residents of Cugnaux of 70 years old and over (n=2,003). After two mailings, 860 (42.9%) completed questionnaires were received. Mean age of the responders was 79.0 ± 6.2 years and 59.6% women (n= 511). According to the questionnaires analysis, 393 (45.7%) were robust, 212 (24.6%) frail, 240 (27.9%) had a mobility disability and 15 (1.7%) could not be classified due to missing data. 589 (68.5%) subjects accepted to be contacted by the Gerontopole nurse. The assessment by the nurse was proposed to frail subjects and those with mobility disability (n=313). Until 31 December 2016, 136 patients have been evaluated. The mean age was 80.1±5.4 and most patients were women (69.9%). The mean ADL score was 5.8±0.5 and the IADL showed a mean score of 6.9±1.7. According to Fried definition of frailty, 76 patients (55.9%) were pre-frail, and 35 (25.7%) frail. Concerning the frailty domains identified, 75 patients (55.1%) showed the alteration of physical performance, 70 (51.5%) thymic disorders and 46 (33.8%) sensory disorders. Preventive interventions proposed in the PIP were mostly physical interventions (86.8%, n=118) followed by cognitive (61.8%, n=84) and nutritional (39.7%, n=54) interventions. DISCUSSION: This project shows the feasibility to implement a care model in the community. It permitted a large identification of frail elderly people in the city population, insuring their assessment and clinical follow up to maintain their capacities and referring them to social services.

IANA task force on nutrition and cognitive decline with aging.

Cognitive impairment can be influenced by a number of factors. The potential effect of nutrition has become a topic of increasing scientific and public interest. In particular, there are arguments that nutrients (food and/or supplements) such as vitamins, trace minerals, lipids, can affect the risk of cognitive decline and dementia, especially in frail elderly people at risk of deficiencies. Our objective in this paper is to review data relating diet to risk of cognitive decline and dementia, especially Alzheimer's disease (AD). We chose to focus our statements on homocysteine-related vitamins (B-vitamins), antioxidant nutrients (vitamins E and C, carotenoids, flavonoids, enzymatic cofactors) and dietary lipids. Results of epidemiological studies may sometimes appeared conflicting; however, certain associations are frequently found. High intake of saturated and trans-unsaturated (hydrogenated) fats were positively associated with increased risk of AD, whereas intake of polyunsaturated and monounsaturated fats were protective against cognitive decline in the elderly in prospective studies. Fish consumption has been associated with lower risk of AD in longitudinal cohort studies. Moreover, epidemiologic data suggest a protective role of the B-vitamins, especially vitamins B9 and B12, on cognitive decline and dementia. Finally, the results on antioxidant nutrients may suggest the importance of having a balanced combination of several antioxidant nutrients to exert a significant effect on the prevention of cognitive decline and dementia, while taking into account the potential adverse effects of these nutrients. There is no lack of attractive hypotheses to support research on the relationships between nutrition and cognitive decline. It is important to stress the need to develop further prospective studies of sufficiently long duration, including subjects whose diet is monitored at a sufficiently early stage or at least before disease or cognitive decline exist. Meta analyses should be developed, and on the basis of their results the most appropriate interventional studies can be planned. These studies must control for the greatest number of known confounding factors and take into account the impact of the standard social determinants of food habits, such as the regional cultures, social status, and educational level.

IANA (International Academy on Nutrition and Aging) Expert Group: weight loss and Alzheimer's disease.

Weight loss, together with psychological and behavioural symptoms and problems of mobility, is one of the principal manifestations of Alzheimer's disease (AD). Weight loss may be associated with protein and energy malnutrition leading to severe complications (alteration of the immune system, muscular atrophy, loss of independence). Various explanations have been proposed such as atrophy of the mesial temporal cortex, biological disturbances, or feeding behaviours; however, none has been proven. Prevention of weight loss in AD is a major issue. It requires regular follow-up and must be an integral part of the care plan. The aim of this article is to review the present state of scientific knowledge on weight loss associated with AD. We will consider four points: the natural history of weight loss, its known etiological factors, its consequences and the various management options.

Visual Impairment Screening at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability at the Gérontopôle.

OBJECTIVES: To evaluate visual performance and factors associated with abnormal vision in patients screened for frailty at the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability at Toulouse University Hospital. DESIGN: Retrospective, observational cross-sectional, single-centre study. SETTING: Institutional practice. PARTICIPANTS: Patients were screened for frailty during a single-day hospital stay between October 2011 and October 2014 (n = 1648). MEASUREMENTS: Collected medical records included sociodemographic data (including living environment and educational level), anthropometric data, and clinical data. The general evaluation included the patient's functional status using the Activities of Daily Living (ADL) scale and the Instrumental Activity of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE) for cognition testing, and the Short Physical Performance Battery (SPPB) for physical performance. We also examined Body Mass Index (BMI), the Mini-Nutritional Assessment (MNA), and the Hearing Handicap Inventory for the Elderly Screening (HHIE-S) tool. The ophthalmologic evaluation included assessing visual acuity using the Snellen decimal chart for distant vision, and the Parinaud chart for near vision. Patients were divided into groups based on normal distant/near vision (NDV and NNV groups) and abnormal distant/near vision (ADV and ANV groups). Abnormal distant or near vision was defined as visual acuity inferior to 20/40 or superior to a Parinaud score of 2, in at least one eye. Associations with frailty-associated factors were evaluated in both groups. RESULTS: The mean age of the population was 82.6 ± 6.2 years. The gender distribution was 1,061 females (64.4%) and 587 males (35.6%). According to the Fried criteria, 619 patients (41.1%) were pre-frail and 771 (51.1%) were frail. Distant and near vision data were available for 1425 and 1426 patients, respectively. Distant vision was abnormal for 437 patients (30.7%). Near vision was abnormal for 199 patients (14%). Multiple regression analysis showed that abnormal distant vision as well as abnormal near vision were independently associated with greater age (P < 0.01), lower educational level (P < 0.05), lower performance on the MMSE (P < 0.001), and lower autonomy (P < 0.02), after controlling for age, gender, educational level, Fried criteria, and MMSE score. CONCLUSION: The high prevalence of visual disorders observed in the study population and their association with lower autonomy and cognitive impairment emphasises the need for systematic screening of visual impairments in the elderly. Frailty was not found to be independently associated with abnormal vision.

Predictive factors for rapid loss on the mini-mental state examination in Alzheimer's disease.

OBJECTIVES: To seek predictors of rapid loss of cognition and to evaluate their frequency in a prospective study of patients suffering from Alzheimer's disease (AD). DESIGN: A one-year prospective study. METHODS: 312 AD patients from the memory clinic at Toulouse University Hospital, participants in the ELSA study, were enrolled. Rapid cognitive decline was defined as a 4-point or greater loss on the Mini-Mental State Examination (MMSE) in 6 months. Comprehensive geriatric and neuropsychological assessment was conducted at baseline, 6 months and one year. RESULTS: Seventy-nine (24.8%) patients presented rapid cognitive loss over 6 months. The majority were stable at one year whereas 15 experienced continued rapid cognitive loss. Multivariate analysis showed that only the Mini Nutritional Assessment score (MNA) was correlated with rate of decline. Patients with rapid cognitive decline were also significantly more dependent at 6 months. CONCLUSIONS: Our findings demonstrate that rapid cognitive loss is frequent in AD patients, probably indicating underlying frailty. Future studies should lead to a practical approach to detecting these frail patients and to increasing preventive interventions.

Recent data on the natural history of Alzheimer's disease: results from the REAL.FR Study.

OBJECTIVES: This paper aims to present the changes observed in the evolution of Alzheimer's disease (AD) in the cohort REAL.FR after one year by taking account new treatments and improved management. METHODS: Four hundred and ninety-eight patients recruited for the REAL.FR study were followed for one year with a standardized case report filled for each patient every 6 months. Changes in the status of these patients were evaluated on various levels: cognitive, functional, behavioural, global, nutritional, social, medical and caregiver burden. Specific treatments were also recorded. RESULTS: A high proportion of patients received specific treatment for AD throughout the year (86%), mainly acetylcholinesterase inhibitors (AChEI) . As expected we observed statistically significant changes in cognitive function (MMS: -1.93 +/- 3.74, p < 0.0001 and ADAS-cog: +2.40 +/- 3.74, p < 0.0001), an overall loss of autonomy (ADL: -0.56 +/- 1.05, p < 0.0001 and IADL: -1.00 +/- 1.46, p < 0.0001), worsening of behavioral disturbances (NPI: +1.85 +/- 14.83, p=0.0047) and a deterioration of general status (CDRSB: +1.63 +/- 2.55, p< 0.0001). Even if the MNA score decreased not significantly, the loss was close to the threshold of significativity (MNA: -0.31 +/- 3.07, p=0.0531). CONCLUSION: We observed a statistically significant change for the worse in most parameters. However, it appears that this deterioration had been relatively slowed by non-pharmacological management and the specific AD treatments. This resulted in stability or improvement of the condition in 63.4% of patient at 1 year. The management proposed (including prescription of AChEI) seemed to have a real impact on the course of the disease during this first year of follow-up.

Living alone with Alzheimer's disease: cross-sectional and longitudinal analysis in the REAL.FR Study.

OBJECTIVES: The purpose of this study was to examine the characteristics of Alzheimer's disease (AD) patients living alone and to describe the rate of cognitive and functional impairment after a one-year follow-up. DESIGN AND SETTING: In a prospective longitudinal study conducted by the French network on Alzheimer's disease (the REAL.FR study), 677 older community-dwelling AD patients were interviewed and completed questionnaires and evaluation scales every 6 months during a one-year follow-up. MEASUREMENTS: All patients were assessed by trained staff who collected data on neuropsychological status using the Mini Mental State Examination (MMSE), behavioural disturbances with the Neuropsychiatric Inventory (NPI) and nutritional status with the Mini Nutritional Assessment (MNA). Patients were assessed for current mobility and function in activities of daily living (ADL) and instrumental activities of daily living (IADL). RESULTS: At inclusion, 28% of the 677 non-institutionalised individuals with AD lived alone. Those who lived alone were significantly older than those who did not, and among them the percentage of women was significantly higher. Patients living alone were at increased risk of malnutrition and were more likely to have a low income than those living with others. Persons with AD living alone made greater use of health services. Dementia stage evaluated by cognitive impairment (MMSE) and ADL disabilities was similar in both groups. At one-year follow-up, the mortality rate was significantly higher in AD patients living with others. Institutionalisation and hospitalisation rates were similar. CONCLUSION: These results draw attention to the fact that elderly persons with AD living alone are a subpopulation with specific needs which require the development of targeted interventions. Further investigation of the factors associated with the lower mortality rate in AD patients living alone is necessary, and the results of long-term follow-up in this prospective study should shed light on this question.

Changes in informal care over one year for elderly persons with Alzheimer's disease.

BACKGROUND: Informal caregivers play a major role in all types of assistance for elderly persons with Alzheimer's disease but few longitudinal studies reports change in this role over time. OBJECTIVE: The aim of our research was to describe the objective and subjective burden of informal caregivers of elderly persons with dementia of Alzheimer type, and to follow its evolution during one year. METHODS: A multicentre prospective study of 333 principal caregivers of patients with Alzheimer's disease, followed for one year. RESULTS: At inclusion, the majority of caregivers were involved in most tasks of assistance (activities of daily living, handling money, supervision, organisation of support services) but only 13.4% were involved in basic activities of daily living. As expected, during follow-up, the involvement of caregivers increased and extended to all tasks: whereas at inclusion 11.0% regularly assisted in all tasks, after only 12 months follow-up this figure rose to 28.9% (P < 0.001). Whereas 45.9% of caregivers became involved in carrying out new tasks (mainly organisation of support services and help with basic activities of daily living), 8.9% no longer carried out certain tasks (essentially supervision and organisation of support services), 7.3% replaced one task by another, and for 37.8% there was no change. During the same time, the mean burden experienced by the caregiver showed a very slight change (increasing from a mean score of 21.08 +/- 14.65 to 22.68 +/- 16.45, P = 0.044) with great variation between caregivers. Those who increased their involvement also had a significant increase in caregiver burden. CONCLUSION: While home caregiving appeared to follow an even course, the needs of the care recipient changed rapidly over time and caregivers differed in their response to these changes, indicating that regular follow-up is required.

Impact of nutritional status on the evolution of Alzheimer's disease and on response to acetylcholinesterase inhibitor treatment.

BACKGROUND: Weight loss is frequently observed in patients with Alzheimer's disease (AD), as observed in clinical practice and reported in the literature. However, information on the evolution of nutritional status and its impact on the prognosis of AD is still scarce. OBJECTIVE: Our aim was to determine the impact of nutritional status on the evolution of AD and on the response to treatment with acetylcholinesterase inhibitors (AChEI) by prospective one-year follow-up of AD patients living at home. METHODS: We studied a cohort of 523 patients with Alzheimer's disease referred from 1994 to 2002 to an Alzheimer centre. After diagnosis, they were followed for one year in a prospective observational study in clinical practice. At entry and every 6 months, patients underwent standardised neurocognitive and geriatric evaluation (MMSE, ADAS-cog, IADL, MNA, caregiver burden). These evaluations were accompanied by complete clinical examination, standard paraclinical investigations and recording of treatment received. RESULTS: Of our patients, 25.8% presented at inclusion a risk of undernutrition with an MNA score of 23.5 or less. During follow-up, the number of patients with rapid loss on the MMSE (3 points or more in one year) was higher in subjects who presented a risk of undernutrition at inclusion (53.6%) than in well-nourished subjects (43.2%) (P = 0.07). Similarly, increased dependence at one year was more frequent in subjects at risk of undernutrition at inclusion (57.7% versus 44.4%, P = 0.0219). The beneficial effect of AChEI treatment on cognitive function was not influenced by initial nutritional status; on the contrary, among the subjects at risk of undernutrition at inclusion, the risk of rapid loss on the MMSE in one year was decreased in subjects treated during follow-up compared with untreated subjects (43.9% versus 73.1% ; OR = 0.29; 95% CI = 0.10-0.83; P = 0.0219). This relationship was not found in subjects whose initial MNA score was greater than 23.5. CONCLUSION: Our work indicates that AD patients living at home with a caregiver are frequently at risk of undernutrition. Undernourished patients seem to present more rapid aggravation of the disease, but paradoxically, these patients appear to be those who best respond to AChEI treatment.

[Consensus statement on severe dementia]. / Consensus sur la démence de type Alzheimer au stade sévère.

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary team including geriatritians, neurologists, epidemiologists, psychiatrists, pharmacologists and public health specialists developed a consensus on care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians and specialists based on knowledge available in 2005. At all stages of the disease, the objective of care is to improve as much as possible quality-of-life for the patient and his/her family, including a life project until the end of life. It is always possible to do something for these patients and their family: nutritional status, behavior disorders, and incapacities to deal with basic activities of daily life have to be taken in consideration. Resource allocation and proximity care have to be targeted. Research areas necessary to improve the care of patients with severe dementia has been selected.