What are the preferences of patients attending a memory clinic for disclosure of Alzheimer's disease?

BACKGROUND/AIMS: This report shares and discusses the collected personal preferences of patients attending a memory clinic for disclosure of a potential Alzheimer's disease (AD) diagnosis. METHODS: In this prospective study of outpatients attending a single memory clinic over a 6-year period (March 2004-October 2010), doctors collected their patients' wishes (willingness to be informed, motivation, presence of the family) through a standardized procedure. RESULTS: Of the 1005 patients questioned throughout the study period-with a final diagnosis of dementia for 480 of them-858 (85.3%) wished to be informed of an AD diagnosis, whereas 72 (7.2%) did not and 75 (7.5%) were not sure. Older age and reduced cognitive functioning were independently associated with a preference to not be informed of a potential AD diagnosis. CONCLUSION: Our study provides evidence of the willingness of most patients to know the truth vis-à-vis AD and also offers some insight into their motivations.

Effect size for the main cognitive function determinants in a large cross-sectional study.

BACKGROUND AND PURPOSE: The aim of our study was to examine the effect sizes of different cognitive function determinants in middle and early old age. METHODS: Cognitive functions were assessed in 11 711 volunteers (45 to 75 years old), included in the French CONSTANCES cohort between January 2012 and May 2014, using the free and cued selective reminding test (FCSRT), verbal fluency tasks, digit-symbol substitution test (DSST) and trail making test (TMT), parts A and B. The effect sizes of socio-demographic (age, sex, education), lifestyle (alcohol, tobacco, physical activity), cardiovascular (diabetes, blood pressure) and psychological (depressive symptomatology) variables were computed as omega-squared coefficients (ω2 ; part of the variation of a neuropsychological score that is independently explained by a given variable). RESULTS: These sets of variables explained from R2 = 10% (semantic fluency) to R2 = 26% (DSST) of the total variance. In all tests, socio-demographic variables accounted for the greatest part of the explained variance. Age explained from ω2 = 0.5% (semantic fluency) to ω2 = 7.5% (DSST) of the total score variance, gender from ω2 = 5.2% (FCSRT) to a negligible part (semantic fluency or TMT) and education from ω2 = 7.2% (DSST) to ω2 = 1.4% (TMT-A). Behavioral, cardiovascular and psychological variables only slightly influenced the cognitive test results (all ω2 < 0.8%, most ω2 < 0.1%). CONCLUSION: Socio-demographic variables (age, gender and education) are the main variables associated with cognitive performance variations between 45 and 75 years of age in the general population.

[Use of social and health primary care services for older people with complex needs: Comparison of three types of gerontological coordination]. / Utilisation des services d'aide et de soins à domicile pour les personnes âgées en situations complexes : comparaison entre trois types de coordination gérontologique.

BACKGROUND: Older people with complex needs live mainly at home. Several types of gerontological coordinations have been established on the French territory to meet their needs and to implement social and primary health care services. But we do not have any information on the use of these services at home as a function of the coordination method used. METHODS: We compared the use of home care services for older people with complex needs in three types of coordination with 12 months' follow-up. The three coordinations regrouped a gerontological network with case management (n=105 persons), a nursing home service (SSIAD) with a nurse coordination (n=206 persons) and an informal coordination with a non-professional caregiver (n=117 persons). RESULTS: At t0, the older people addressed to the gerontological network had less access to the services offered at home; those followed by the SSIAD had the highest number of services and of weekly interventions. Hours of weekly services were two-fold higher in those with the informal coordination. At t12, there was an improvement in access to services for the network group with case management and an overall increase in the use of professional services at home with no significant difference between the three groups. CONCLUSION: The use of social and primary health care services showed differences between the three gerontological coordinations. The one-year evolution in the use of home services was comparable between the groups without an explosion in the number of services in the network group with case management.

[Factors facilitating and impairing implementation of integrated care]. / Intégration des services: obstacles et facteurs facilitant leur implantation.

BACKGROUND: Better integration of healthcare is the focus of many current reforms in Western countries. The goal is to reduce fragmentation of health and social care delivery for patients with chronic diseases. In France, Alzheimer autonomy integration experimentations (Maison Autonomie Intégration Alzheimer [MAIA]) were introduced as part of the 2008-2012 National Alzheimer Plan. To date, implementation of such organizations remains challenging. It is thus paramount to identify factors obstructing, and on the contrary facilitating, implementation of integrated care. METHODS: After an in-depth literature review of qualitative studies published from January 1995 to December 2010. We selected 10 qualitative studies on health care professionals' perceptions of barriers and facilitators to the implementation of integrated care. RESULTS: Barriers and facilitating factors linked to the implementation of integrated care were identified at several levels: leadership; collaboration between services and clinicians; and funding and policy making. The operative strategy applied to change care delivery and the role of the leading pilot are key elements during the implementation phase. CONCLUSION: Strong leadership and active involvement of a broad spectrum of professionals from clinical practitioners to healthcare managers is crucial for a successful implementation of integrated care services.

Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort.

BACKGROUND: The objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization. METHODS: A prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period. RESULTS: Crude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR=1.83; 95% CI=1.27-2.62) or a higher number of children (HR=0.86; 95% CI=0.78-0.96), balance problems (HR=1.72; 95% CI=1.19-2.47), malnutrition or risk thereof (HR=1.93; 95% CI=1.24-3.01), and dementia syndrome (HR=1.88; 95% CI=1.32-2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR=1.92; 95% CI=1.17-3.16), delirium (HR=1.80; 95% CI=1.24-2.62), and a high level of comorbidity (HR=1.62; 95% CI=1.09-2.40). Institutionalization (HR=1.92; 95% CI=1.37-2.71) and unplanned readmission (HR=4.47; 95% CI=3.16-2.71) within the follow-up period were also found as independent predictors. CONCLUSION: The main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects' prognosis favorably.

Association between Hospitalization and Change of Frailty Status in the GAZEL Cohort.

OBJECTIVES: To assess the relationship between changes of frailty status and intervening hospitalizations, using information of the GAZEL cohort, matched with the data of the French National Health Data System. DESIGN: Observational cohort study. PARTICIPANTS: Community-dwelling adults of the GAZEL cohort (n = 12145; aged between 58 and 73 years in 2012). MEASUREMENTS: Frailty was determined with the Strawbridge questionnaire in 2012, 2013 and 2014. Data regarding hospitalizations (notably their number, length of stay, emergency department use, and main diagnosis) were collected from the French National Health Data System. The relationship between intervening hospitalizations and changes of frailty status over time was assessed with multivariate Markov models. RESULTS: The prevalence of frailty was 14% in 2012 and 2013 and 17% in 2014. A total of 2715 changes in frailty status were observed from 2012 to 2014. At least one hospitalization was recorded for 1453 people (12%) between the 2012 and 2013 questionnaires, and 1472 (13%) between the 2013 and 2014 questionnaires. No association was found between intervening hospitalizations and changes of frailty status (aHR 1.14 [0.97-1.35] for robust to frail transition and aHR 0.89 [0.73-1.08] for frail to robust transition). However, repeated hospitalizations, hospitalizations after emergency department use, surgery and several diagnosis groups were significantly associated with transitions towards frailty or its recovery. CONCLUSION: Hospitalizations encompass a wide range of clinical situations, some of them being associated with incident frailty. An early recognition of these situations could help to better prevent and manage frailty in the early old age.

Derivation and validation of a mortality-risk index from a cohort of frail elderly patients hospitalised in medical wards via emergencies: the SAFES study.

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.

Association Between Potentially Inappropriate Medications and Frailty in the Early Old Age: A Longitudinal Study in the GAZEL Cohort.

OBJECTIVES: High-risk prescribing can have deleterious effects on the health of older people. This study aimed to assess the role of inappropriate prescribing on changes in frailty status over 3 years of follow-up. DESIGN, SETTING: This is a prospective observational study nested in the GAZEL cohort. PARTICIPANTS: The study sample included 12,405 community-dwelling people aged 58 to 73 in 2012, and followed for 3 years. MEASUREMENT: Polypharmacy and potentially inappropriate medications (PIMs) were assessed from reimbursement data by the French National Health Insurance. Frailty was evaluated each year with the Strawbridge questionnaire. PIMs were defined according to the Laroche list plus additional criteria dealing with inappropriate prolonged use of medications. The relationship between PIMs and changes in frailty status (incident frailty and recovery) was analyzed with Markov multistate modeling. RESULTS: The prevalence of frailty increased from 14% in 2012 to 17% in 2014, whereas the frequency of PIMs was 29% in 2012 and 23% in 2014. Polypharmacy (5-9 drugs: aHR 1.31, 95% CI 1.14-1.50; and 10 drugs or more: aHR 1.57, 95% CI 1.28-1.92) and potentially inappropriate use of nonsteroidal anti-inflammatory drugs (aHR 1.33, 95% CI 1.04-1.71) were significantly associated with incident frailty, when the presence of at least 1 PIM presented a small association with the risk of becoming frail (aHR 1.15, 95% CI 1.01-1.32). CONCLUSIONS/IMPLICATIONS: This study brings new elements to our knowledge regarding the association between inappropriate prescribing and frailty in older adults, which support research development to alert on inappropriate prescribing and to improve drug prescribing among old people, especially with polypharmacy.

[Evaluation of a multifaceted intervention for implementing national guidelines: the case of physical restraint in geriatric care]. / Evaluation d'une intervention multiple pour implanter des recommandations nationales: le cas de la contention physique passive en gériatrie.

BACKGROUND: There is a growing interest in developing guidelines. The French Agency for accreditation and Evaluation (Anaes) published in October 2000 guidelines on the use of restraint in geriatric care settings because in spite of the risks this practice remains widespread in that type of care setting. A multifaceted intervention was conducted in a Parisian geriatric hospital in order to improve the implementation of the published guidelines. An epidemiological study was conducted to assess the outcomes of this intervention. METHODS: The intervention consisted in distributing educational materials and a specific prescription sheet, and in staff training sessions. A time series study was used to assess outcomes. The three time points were: before the intervention, just after the end of the intervention and one year later. Two dimensions were studied: implementation of the guidelines using markers collected from patients' charts and restraining practices noted in an observational study of hospitalized patients. RESULTS: The results of the study suggest that five recommendations were followed better: restraint prescription (8.7 to 57.4%), writing in the patient chart the reasons for restraining (3.5 to 35.3%), follow-up prescription, assessment of potential benefits and risks for the patient and patient information (0% to 19-34%). Nevertheless, the prevalence of restraint and of devices employed (around 70%) remained unchanged after the intervention. The various outcomes of the intervention might be explained by the guidelines themselves, which were variably practical or precise. Moreover, the effect of certain factors directly related with the use of restraint, a routine practice strongly supported by myths about its efficacy, as well as factors related to intervention design may merely have prevented any decrease in the use of restraint practices. CONCLUSION: Multifaceted intervention can favour implementation of certain national guidelines such as prescribing restraint, but can also fail in stimulating the implementation of others such as decreasing the prevalence of restraint in geriatric practice. Therefore the next intervention should emphasize alternatives to physical restraint practices.

Erratum to: Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5).

[This corrects the article DOI: 10.1186/s13601-016-0116-9.].

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA.

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

Health, frailty and disability after ninety: Results of an observational study in France.

BACKGROUND: In spite of their increasing demographic weight, health characteristics of the oldest old remain poorly described in epidemiological studies. OBJECTIVE: To describe the health of people aged 70 years and over included in the SIPAF study, and to compare the prevalence of health indicators including successful aging, frailty, and disability between three age groups including the oldest old. METHODS: The study population is composed of 2350 retired people recruited between 2008 and 2010, of whom 512 are aged 90 and over (21.8%). A comprehensive geriatric assessment was performed at home by trained nurses. The prevalence of health and functional indicators, as well as the distribution of people among successful ageing, frailty, and disability, were described by age group (70-79, 80-89, 90+) and sex. RESULTS: Compared to their younger counterparts, people aged 90 years and over were more likely to experience functional limitations, sensory impairment, cognitive impairment, poor mood, and frailty. One third of the nonagenarians needed help in at least one basic activity of daily living and 25% met the frailty criteria. In contrast, the prevalence of most chronic diseases did not increase after ninety. Successful ageing concerned 9% of the oldest old. Women were less likely to experience successful ageing and more likely to be frail or dependent. CONCLUSION: This study shows the diversity of health states in very old age and points out that one quarter of the people aged 90 and over said frail are likely to take advantage of preventive actions of disability.

Should Sensory Impairment Be Considered in Frailty Assessment? A Study in the GAZEL Cohort.

OBJECTIVES: The assessment of sensory difficulties is sometimes included in the screening of frailty in ageing population. This study aimed to compare the prevalence of frailty and associated risk of adverse outcomes depending on whether sensory difficulties participated in the definition of frailty. DESIGN: Prospective cohort study - GAZEL cohort. SETTING: France. PARTICIPANTS: The 13,128 subjects who completed a questionnaire in 2012. MEASUREMENTS: According to the Strawbridge questionnaire, subjects were considered frail if they reported difficulties in two domains or more among physical, nutritive, cognitive and sensory domains. The risk of adverse health outcomes was assessed by using logistic regression models (hospitalisations, onset of difficulty in performing movements of everyday life) and multivariate Cox proportional hazards models (mortality). RESULTS: Mean age was 66.8 +/- 3.4 years and 73.8% were males. The prevalence of frailty varied from 4.4 to 14.2% depending on whether the sensory domain was excluded or included. During follow-up, 182 deaths (1.4%), 479 hospitalisations (3.6%) and 703 cases of new disability (8.0%) were observed. Both definitions of frailty predicted the onset of difficulties to perform everyday movements, with 2 to 3-fold increase in the risk. The inclusion of the sensory domain in the definition made frailty predictive of hospitalisations (Odds Ratio 1.31 [1.01-1.70]) but the association with mortality was only observed when sensory difficulties were ignored (Hazard Ratio 2.28 [1.32-3.92]). CONCLUSION: The inclusion of a sensory domain into a frailty screening instrument has a major impact in terms of prevalence and modifies the risk profile associated with frailty. In order to develop the use of frailty screening instruments in clinical practice, further researches will need to carefully evaluate the impact on risk prediction of the different domains involved.

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5).

Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.

Operational Definition of Active and Healthy Ageing (AHA): A Conceptual Framework.

Health is a multi-dimensional concept, capturing how people feel and function. The broad concept of Active and Healthy Ageing was proposed by the World Health Organisation (WHO) as the process of optimizing opportunities for health to enhance quality of life as people age. It applies to both individuals and population groups. A universal Active and Healthy Ageing definition is not available and it may differ depending on the purpose of the definition and/or the questions raised. While the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) has had a major impact, a definition of Active and Healthy Ageing is urgently needed. A meeting was organised in Montpellier, France, October 20-21, 2014 as the annual conference of the EIP on AHA Reference Site MACVIA-LR (Contre les Maladies Chroniques pour un Vieillissement Actif en Languedoc Roussillon) to propose an operational definition of Active and Healthy Ageing including tools that may be used for this. The current paper describes the rationale and the process by which the aims of the meeting will be reached.

Use of the EQ-5D among patients suffering from dementia.

BACKGROUND AND OBJECTIVE: This study was designed to determine the acceptability, feasibility, reliability, and validity of the French version of EQ-5D measuring HRQol in subjects with dementia. METHODS: EQ-5D was administered to 142 subjects. The feasibility and acceptability were determined by the refusal rate, the type of administration, and the percentage and distribution of missing data. Test-retest reliability was studied by kappa coefficients and validity by agreement between subjects' and proxies' assessments. RESULTS: The response rate was satisfactory. The instrument discriminated well among the subjects. Test-retest reliability was average. The validity was poor if we consider the agreement between patients' and caregivers' reports, but other criteria of validity produced better results. Subjects' responses on each dimension were related with their global judgment of health in the expected direction. Significant relations were found between the Katz index of ADL and self-rated difficulties only for expected dimensions. Relations with age and with gender were in line with expectations. CONCLUSION: Results led to consider that patients' responses are not entirely devoid of judgment. It seems that dementia patients are capable of expressing their health-related quality of life through a brief instrument as the EQ-5D.

Diflunisal versus placebo for treatment of pain in general practice.

The efficacy and safety of diflunisal versus placebo in the treatment of pain were compared in a multicenter, double-blind study of 1,037 patients treated for seven days by general practitioners. A statistically significant (P less than 0.001) difference in favor of diflunisal was seen using four evaLuation criteria. The incidence of side effects was generally low with both treatments; nevertheless, the number of patients suffering at least one side effect was greater after diflunisal than after placebo (P less than 0.05). A comparison of the profile of responders to diflunisal and to placebo showed no particular pattern.

[Behavior regarding therapeutic drugs and self concept of elderly persons with chronic diseases]. / Comportements vis à vis des medicaments et representations de soi chez des personnes agées souffrant de maladies chroniques.

This research on a sample of 133 persons older than 60 years and suffering from chronic diseases, concerns their practices towards medicines. Various practices displayed can be grouped in three different ways according to the regularity and the order of medicine taking, forgetting, self-medication, etc.; they seem to be linked neither to sex or age of subjects nor to variables directly or indirectly affected by the disease (number and type of medicines, gravity of the disease, subjective health). The understanding of these differential practices is improved if we consider the self-concept of subjects, that is to say their different positions in an organized whole of personality traits; this position reflects traits that they recognize as being more or less constitutive of their identity, that which motivates and gives sense to the totality of their life conduct.

[Prevalence and incidence of dementia among the very old. Review of the literature]. / Prévalence et incidence des démences au grand âge. Analyse de la littérature.

BACKGROUND: The increasing number of elderly and very old people observed in France for more than 20 years raises the problem of an expected increase in the prevalence and incidence of dementia in this population. Prevalence and incidence estimates for persons older than 85 years are incomplete and discordant. This information is crucial for organizing future health and social care. OBJECTIVE: Review of literature of prevalence and incidence of dementia for people older than 85 and their link to aging. METHODS: A Medline search has led to a selection of 50 articles. RESULTS: Some studies conclude that there is an exponential relationship of incidence with age; some, a decrease of dementia in the oldest old population. Prevalence estimates in these studies fluctuate between 15 and 40% and incidence between 60 and 100 person-years. CONCLUSION: The variation of prevalence and incidence estimates for 85 and over are partly due to methodological differences and limitations between studies. Further research is needed to include larger samples of persons aged 85 and over and to confirm results where clinical and public health consequences are major issues.