[Initial pattern of elderly patients and effect on their orientation after their visit in the emergency departments. Results from a national study]. / Trajectoire initiale des patients âgés et impact sur leur orientation après leur passage dans les services d'urgences. Résultats d'une enquête nationale.

PURPOSE: We have little information on the geriatric characteristics of elderly patients visiting the emergency departments (ED) in France. In order to develop an adapted prevention of the arrival of some elderly patients, the determinants of their arrival to the ED deserves to be better known. METHODS: A one-day cross-sectional study was conducted in French ED. A standardized questionnaire was used for each patient over 80 years (Pts), specifying the sociodemographic characteristics, the circumstances of visit to and care received in the ED, and the orientation of the patients after consulting the ED. RESULTS: On a sample of 1298 Pts, health event leading to ED started at home in 63.8% of cases. When the patients initiated themselves the recourse to health care (RHC), they called less often a general practitioner (61.9% of cases) than when the RHC was triggered by their family (69.6%, p=0.01). When a health care professional initiated the RHC, it was a GP in more than 80% of cases. Return to residence was more frequent when the patient triggered the RHC (34.5% versus 22.9% for the family and 16.0% for the professional health care, p<0,001). CONCLUSION: The actor of the decision of arrival to the ED has an impact in the RHC, in resources utilisation, and on the patient's orientation after coming in ED. The results of this study may help to design strategies aiming at avoiding unnecessary ED consultations of elderly persons.

[Haematological malignancies in older adults: experience in a geriatric acute care department]. / Hémopathies et sujets âgés: expérience d'un service de court séjour gériatrique.

BACKGROUND: Ageing of population due to improvement in life expectancy has increased blood diseases (BD) incidence in the elderly population. In addition, treatments get more and more complex with increasingly late diagnosis as well as concomitant comorbidities. METHODS: We describe a series of 54 patients with BD, followed-up in an acute care geriatric department. Autonomy, way of life, nutritional status, comorbidities, treatment, mortality and evolution were analyzed. RESULTS: Mean age at BD was 86+/-6 years (range 75-99) for 29 women and 25 men. Median follow up was 20 months (0-60). Lymphoma was the most frequent BD (44%). Thirty-one patients (57%) received chemotherapy. Mortality rate was 41% (22 patients). Forty patients (74%) were discharged and 25 patients (46%) required enhanced professional assistance. Survival was significantly decreased in patients with albuminemia less than or equal to 30 g/l. IADL score less than or equal to 3, ADL score less than or equal to 5, performance status more than or equal to 2, MMS less than 25 and weight loss more than or equal to 3 kg. After multivariate analysis, only albuminemia less than or equal to 30 g/l tended to predict death (hazard ratio 3.57, 95% confidence interval 0.96-13.3, p=0.06). CONCLUSION: Our study confirms the importance of nutritional status on survival. A global geriatric evaluation is required for appropriate treatment, as currently available therapeutic protocols are not really adapted for old population. Additional studies should be conducted in this direction.

[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.

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s.

BACKGROUND: Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays. METHODS: The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance. RESULTS: During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions. CONCLUSION: Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

[Two cases of superficial pemphigus induced by pyritinol (author's transl)]. / Deux cas de pemphigus superficiel induit par le pyritinol.

Pyritinol is presently prescribed in rhumatoid polyarthritis because of its structural analogy to D-penicillamin. Only benign cutaneous side effects had been mentioned up to now. We report two cases of pemphigus occurring during pyritinol therapy given in one case for rhumatoid polyarthritis, in the other case for memory deficiency. Clinical aspect was that of a superficial pemphigus. The histologic picture was in some instances that of a superficial acantholysis, and in other instances, that of an eosinophilic spongiosis. Definite proof of pemphigus was shown by presence of anti-intercellular substance antibodies in the serum and in the skin of both patients.

[HL-A system in psoriasis; study of 31 families (author's transl)]. / Le système HL-A dans le psoriasis. Etude de 31 families.

31 families with at least two psoriatic members, including sometimes three generations (4 families) have been studied looking for HL-A markers. They include 80 affected (45 females, 35 males) and 75 healthy persons. BW 17 has been found present in 58 p. 100 of the unrelated patients, versus 7 p. 100 only in the normal population (p less than 10-9). Relative risk (R.R.) for the people bearing BW 17 is 38.34. Increase of B 13 is slight and non significant. BW 16, BW 37, BW 27 are within normal range. B 12 (R.R. :0.36) seems to have a protecting effect. B 8, B 14 are also decreased. Study of way of genetic transmission favours existence of a dominant gene of susceptibility frequently associated with BW 17 and particularly with haplotype A 1, BW 17. But other genetic or environmental factors may also play a role.

The geriatric patient: use of acute geriatrics units in the emergency care of elderly patients in France.

We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR)=1.79 (1.38-2.32) (95% confidence interval=95% CI); "failure to thrive" syndrome OR=1.54 (1.01-2.35), depression: OR=1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR=1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the "geriatrics patient" is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.