Exergame-Assisted Rehabilitation for Preventing Falls in Older Adults at Risk: A Systematic Review and Meta-Analysis.

INTRODUCTION: Exergaming is increasingly employed in rehabilitation for older adults. However, their effects on fall rate and fall risk remain unclear. METHODS: We conducted a systematic review and meta-analysis that included randomized controlled trials (RCTs) comparing exergame-assisted rehabilitation with control groups, published in French or English, from Web of Science, CINHAL, Embase, Medline, and CENTRAL (last search in June 2021). Two reviewers independently assessed the studies. Risk of bias was assessed using RoB2, PEDRO scale, and the GRADE system. The outcomes of interest were (a) fall rate, (b) risk of falling, measured by the Short Physical Performance Battery (SPPB), Timed Up and Go (TUG), One-Leg Stance, or Berg Balance Scale (BBS), (c) fear of falling, measured with the Fall Efficacy Scale (FES-I) or the Activities-specific Balance Confidence (ABC) score. Data were pooled and mean differences (MDs) between exergame and control groups were calculated using a random-effects model. RESULTS: Twenty-seven RCTs were included (1,415 participants, including 63.9% of women, with mean age ranging from 65 to 85.2 years old). Exergame-assisted interventions were associated with a reduction in the incidence of falls (4 studies, 316 participants, MD = -0.91 falls per person per year; 95% CI: -1.65 to -0.17, p = 0.02, moderate quality). Regarding fall risk (20 studies included, low-quality evidence), SPPB did not change (MD = 0.74; 95% CI: -0.12 to 1.60, p = 0.09), but all other scores were improved: BBS (MD = 2.85; 95% CI: 1.27 to -4.43, p = 0.0004), TUG (MD = -1.46; 95% CI: -2.21 to -0.71, p = 0.0001) and One-Leg Stance (MD = 7.09; 95% CI: 4.21 to 9.98, p < 0.00001). Fear of falling scores (FES-I and ABC) showed no difference. CONCLUSION: There is moderate-quality evidence of a reduction in the fall rate with exergame-assisted rehabilitation and low-quality evidence suggesting a mild reduction in the risk of falling. Statistically significant benefits from exergame-assisted rehabilitation did not achieve clinically meaningful changes in risk of falling assessments.

Assessment of Frailty by the French Version of the Vulnerable Elders Survey-13 on Digital Tablet: Validation Study.

BACKGROUND: Frailty assessment is a major issue in geriatric medicine. The Vulnerable Elders Survey-13 (VES-13) is a simple and practical tool that identifies frailty through a 13-item questionnaire completed by older adults or their family caregivers by self-administration (pencil and paper) or by telephone interview. The VES-13 provides a 10-point score that is also a recognized mortality predictor. OBJECTIVE: This study aims to design an electronic version of the Echelle de Vulnérabilité des Ainés-13, the French version of the VES-13 (eEVA-13) for use on a digital tablet and validate it. METHODS: The scale was implemented as a web App in 3 different screens and used on an Android tablet (14.0× 25.6 cm). Participants were patients attending the outpatient clinic of a French geriatric hospital or hospitalized in a rehabilitation ward and family caregivers of geriatric patients. They completed the scale twice, once by a reference method (self-administered questionnaire or telephone interview) and once by eEVA-13 using the digital tablet. Agreement for diagnosis of frailty was assessed with the κ coefficient, and scores were compared by Bland and Altman plots and interclass correlation coefficients. User experience was assessed by a self-administered questionnaire. RESULTS: In total, 86 participants, including 40 patients and 46 family caregivers, participated in the study. All family caregivers had previously used digital devices, while 13 (32.5%) and 10 (25%) patients had no or infrequent use of them previously. We observed no failure to complete the eEVA-13, and 70% of patients (28/40) and no family caregivers needed support to complete the eEVA-13. The agreement between the eEVA-13 and the reference method for the diagnosis of frailty was excellent (κ=0.92) with agreement in 83 cases and disagreement in 3 cases. The mean difference between the scores provided by the 2 scales was 0.081 (95% CI-1.263 to 1.426). Bland and Altman plots showed a high level of agreement between the eEVA-13 and the reference methods and interclass correlation coefficient value was 0.997 (95% CI 0.994-0.998) for the paper and tablet group and 0.977 (95% CI 0.957-0.988) for the phone and tablet groups. The tablet assessment was found to be easy to use by 77.5% (31/40) of patients and by 96% (44/46) of caregivers. Finally, 85% (39/46) of family caregivers and 50% (20/40) of patients preferred the eEVA-13 to the original version. CONCLUSIONS: The eEVA-13 is an appropriate digital tool for diagnosing frailty and can be used by older adults and their family caregivers. The scores obtained with eEVA-13 are highly correlated with those obtained with the original version. The use of health questionnaires on digital tablets is feasible in frail and very old patients, although some patients may need help to use them.

First-Dose Coronavirus 2019 Vaccination Coverage among the Residents of Long-Term Care Facilities in France.

BACKGROUND: Long-term care facilities (LTCFs) experienced severe burden from the Coronavirus 2019 (COVID-19), and vaccination against SARS-CoV-2 is a major issue for their residents. OBJECTIVE: The objective of this study was to estimate the vaccination coverage rate among the residents of French LTCFs. METHOD: Participants and settings: 53 medical coordinators surveyed 73 LTCFs during the first-dose vaccination campaign using the BNT162b2 vaccine, conducted by health authorities in January and early February 2021. MEASUREMENTS: in all the residents being in the LTCF at the beginning of the campaign, investigators recorded age, sex, history of clinical or asymptomatic COVID-19, serology for SARS-CoV-2 or severe allergy, current end-of-life situation, infectious or acute disease, refusal of vaccination by the resident or by the representative person of vaccine, and the final status, vaccinated or not. RESULTS: Among the 4,808 residents, the average coverage rate for COVID-19 vaccination was 69%, and 46% of the LTCFs had a coverage rate <70%. Among unvaccinated residents, we observed more frequently a history of COVID-19 or a positive serology for SARS-CoV-2 (44.6 vs. 11.2% among vaccinated residents, p < 0.001), a history of severe allergy (3.7 vs. 0.1%, p < 0.001), end-of-life situation (4.9 vs. 0.3%, p < 0.001), current infectious or acute illness (19.6 vs. 0.3%, p < 0.001), and refusal of vaccination by residents or representative persons (38.9 vs. 0.4%, p < 0.001). CONCLUSIONS: About 3 out of 10 residents remained unvaccinated, and half of the LTCFs had a coverage rate <70%. This suggests that COVID-19 will remain a threat to many LTCFs after the vaccination campaigns.

COVID-19 Outbreaks in Nursing Homes Despite Full Vaccination with BNT162b2 of a Majority of Residents.

BACKGROUND: It is not known if widespread vaccination can prevent the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in subpopulations at high risk, like older adults in nursing homes (NH). OBJECTIVE: The objective of the study was to know if coronavirus disease 2019 (COVID-19) outbreaks can occur in NH with high vaccination coverage among its residents. METHODS: We identified, using national professional networks, NH that suffered COVID-19 outbreaks despite having completed a vaccination campaign, and asked them to send data, using predefined collecting forms, on the number of residents exposed, their vaccination status and the number, characteristics, and evolution of patients infected. The main outcome was to identify outbreaks occurring in NH with high vaccine coverage. Secondary outcomes were residents' risk of being infected, developing severe disease, or dying from COVID-19 during the outbreak. SARS-CoV-2 infection was defined by a positive reverse transcriptase-polymerase chain reaction. All residents were serially tested whenever cases appeared in a facility. Unadjusted secondary attack rates, relative risks, and vaccine effectiveness during the outbreak were estimated. RESULTS: We identified 31 NH suffering an outbreak during March-April 2021, of which 27 sent data, cumulating 1,768 residents (mean age 88.4, 73.4% women, 78.2% fully vaccinated). BNT162b2 was the vaccine employed in all NH. There were 365 cases of SARS-CoV-2 infection. Median secondary attack rates were 20.0% (IQR 4.4%-50.0%) among unvaccinated residents and 16.7% (IQR 9.5%-29.2%) among fully vaccinated ones. Severe cases developed in 42 of 80 (52.5%) unvaccinated patients, compared with 56 of 248 (22.6%) fully vaccinated ones (relative risks [RR] 4.17, 95% CI: 2.43-7.17). Twenty of the unvaccinated patients (25.0%) and 16 of fully vaccinated ones (6.5%) died from COVID-19 (RR 5.11, 95% CI: 2.49-10.5). Estimated vaccine effectiveness during the outbreak was 34.5% (95% CI: 18.5-47.3) for preventing SARS-CoV-2 infection, 71.8% (58.8-80.7) for preventing severe disease, and 83.1% (67.8-91.1) for preventing death. CONCLUSIONS: Outbreaks of COVID-19, including severe cases and deaths, can still occur in NH despite full vaccination of a majority of residents. Vaccine remains highly effective, however, for preventing severe disease and death. Prevention and control measures for SARS-CoV-2 should be maintained in NH at periods of high incidence in the community.

Validation of the French version of the Vulnerable Elders Survey-13 (VES-13).

BACKGROUND: Identifying and assessing degree and type of frailty among older persons is a major challenge when targeting high risk populations to identify preventive interventions. The Vulnerable Elders Survey-(VES-13) is a simple instrument to identify frailty defined as risk for death, functional decline or institutionalization. OBJECTIVE: Translate VES-13 into French and validate it. METHODS: The French version of VES-13 was developed by forward-backward translation of the VES-13 survey instrument. The authors assessed its feasibility, construct validity, and ability to predict the combined outcomes of admission to institution or death at 18 months, in 135 persons over 70 years of age living in the community. Subjects were recruited from three settings: Group 1 - a health prevention center (n = 45); Group 2 - an ambulatory care geriatric clinic (n = 40); and Group 3 - an intermediate care hospital unit (n = 50). The combined outcomes data were recorded by telephone interview with participants or a proxy. RESULTS: Feasibility of the French version, named Echelle de Vulnérabilité des Ainés-13 or EVA-13, was excellent. The scale classified 5 (11%) persons as vulnerable (score of 3 or more) in Group 1, 23 (58%) in Group 2 and 45 (90%) in Group 3 (p < 0.001) with scores of 0.91 +/- 1.16, 4.27 +/- 3.17 and 6.90 +/- 3.17, respectively (p < 0.001). At follow-up, among the 60 non-vulnerable subjects, 58 (96%) were alive and living at home, whereas 46 (65%) of the 70 vulnerable subjects were alive and living at home (p < 0.001). CONCLUSIONS: EVA-13 was determined to be valid and reliable.

Aging-simulation experience: impact on health professionals' social representations.

BACKGROUND: Health professionals working with older persons are not sufficiently aware of the sensory and functional difficulties experienced by older patients. Innovative educational activities, such as the aging-simulation experience, can facilitate this awareness. This study describes the effects of an aging-simulation experience on health professionals' representations towards age-related limitations. METHODS: 306 health professionals, enrolled in university training in geriatrics/gerontology in the 2015-2016 and 2016-2017 academic years, experienced an aging-simulation session wearing a special suit according to a predefined scenario. Before and after the aging-simulation experience, participants completed free association tests, with the inductive words vision, hearing, movement, fine dexterity and balance. Semantic categories were created from participants' free evocations using a correspondence table manually produced in Excel 2013 for Windows (Microsoft Corporation, Redmond, Washington). Moreover, participants' opinions on difficulties experienced by older people in relation to age-related limitations were studied using Likert scale questions. RESULTS: In total, 3060 free evocations were collected, and ten semantic categories were created. These categories were composed of participants' geriatric knowledge, about age-related limitations, and participants' feelings, about the experience of these limitations. These two aspects were impacted by the aging-simulation experience. Moreover, changes observed resulted in a better consideration of difficulties associated with age-related limitations. CONCLUSIONS: The aging-simulation experience is an effective educational tool to raise awareness among health professionals of age-related difficulties. This sensory activity allows health professionals to put themselves in the shoes of older patients and to feel age-related difficulties.

Use of Evidence-Based Practice Among Healthcare Professionals After the Implementation of a New Competency-Based Curriculum.

BACKGROUND: Although evidence-based practice (EBP) has been spreading since the 1990s, it has not yet been sufficiently implemented. AIM: Following the reform of initial training for healthcare professions in France 2012, we sought to determine whether the new curriculum was associated with more frequent use of EBP. METHODS: We performed an online, cross-sectional survey of nurses, occupational therapists, and podiatrists (divided into pre- and post-reform groups) in June 2018. The questionnaire covered demographic data, use of EBP, and the perception of EBP. As holding a master's degree may enhance knowledge and use of EBP, we adjusted for this variable. Categories to analyze qualitative data were created regarding the five steps in EBP and its definition. RESULTS: The total sample was N = 595 (pre-reform group n = 301; post-reform group n = 294). The proportion of respondents who frequently read the professional literature was lower in the post-reform group than in the pre-reform group (33% vs. 54%, respectively; OR [95% CI] = .52 [.37-.73]; p < .001). The main stated reasons for reading the professional literature were "keeping up to date with practice" and "making clinical decisions." Respondents in both groups mentioned a lack of time as the most frequent barrier to reading the literature (82%), a lack of access to bibliographical resources, and that EBP was not encouraged. Most professionals limited their definition of EBP to reading the literature and implementing research results. LINKING EVIDENCE TO ACTION: There is a need to teach the five steps of EBP more explicitly and to embed its position into daily practice, for example, through reflective analysis practice. Professional trainings about EBP should be offered on a regular basis. Guidance coming from the healthcare directorate should include expected daily practice time for reading and journal club and giving more access to international healthcare literature.

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence. This is an update of a review previously published in 2006, 2012 and 2015. OBJECTIVES: To determine the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects and recurrence of atrial fibrillation in people who had recovered sinus rhythm after having atrial fibrillation. SEARCH METHODS: We updated the searches of CENTRAL, MEDLINE and Embase in January 2019, and ClinicalTrials.gov and WHO ICTRP in February 2019. We checked the reference lists of retrieved articles, recent reviews and meta-analyses. SELECTION CRITERIA: Two authors independently selected randomised controlled trials (RCTs) comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored, spontaneously or by any intervention. We excluded postoperative atrial fibrillation. DATA COLLECTION AND ANALYSIS: Two authors independently assessed quality and extracted data. We pooled studies, if appropriate, using Mantel-Haenszel risk ratios (RR), with 95% confidence intervals (CI). All results were calculated at one year of follow-up or the nearest time point. MAIN RESULTS: This update included one new study (100 participants) and excluded one previously included study because of double publication. Finally, we included 59 RCTs comprising 20,981 participants studying quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol. Overall, mean follow-up was 10.2 months.All-cause mortalityHigh-certainty evidence from five RCTs indicated that treatment with sotalol was associated with a higher all-cause mortality rate compared with placebo or no treatment (RR 2.23, 95% CI 1.03 to 4.81; participants = 1882). The number need to treat for an additional harmful outcome (NNTH) for sotalol was 102 participants treated for one year to have one additional death. Low-certainty evidence from six RCTs suggested that risk of mortality may be higher in people taking quinidine (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646). Moderate-certainty evidence showed increased RR for mortality but with very wide CIs for metoprolol (RR 2.02, 95% CI 0.37 to 11.05, 2 RCTs, participants = 562) and amiodarone (RR 1.66, 95% CI 0.55 to 4.99, 2 RCTs, participants = 444), compared with placebo.We found little or no difference in mortality with dofetilide (RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence) or dronedarone (RR 0.86, 95% CI 0.68 to 1.09; high-certainty evidence) compared to placebo/no treatment. There were few data on mortality for disopyramide, flecainide and propafenone, making impossible a reliable estimation for those drugs.Withdrawals due to adverse eventsAll analysed drugs increased withdrawals due to adverse effects compared to placebo or no treatment (quinidine: RR 1.56, 95% CI 0.87 to 2.78; disopyramide: RR 3.68, 95% CI 0.95 to 14.24; propafenone: RR 1.62, 95% CI 1.07 to 2.46; flecainide: RR 15.41, 95% CI 0.91 to 260.19; metoprolol: RR 3.47, 95% CI 1.48 to 8.15; amiodarone: RR 6.70, 95% CI 1.91 to 23.45; dofetilide: RR 1.77, 95% CI 0.75 to 4.18; dronedarone: RR 1.58, 95% CI 1.34 to 1.85; sotalol: RR 1.95, 95% CI 1.23 to 3.11). Certainty of the evidence for this outcome was low for disopyramide, amiodarone, dofetilide and flecainide; moderate to high for the remaining drugs.ProarrhythmiaVirtually all studied antiarrhythmics showed increased proarrhythmic effects (counting both tachyarrhythmias and bradyarrhythmias attributable to treatment) (quinidine: RR 2.05, 95% CI 0.95 to 4.41; disopyramide: no data; flecainide: RR 4.80, 95% CI 1.30 to 17.77; metoprolol: RR 18.14, 95% CI 2.42 to 135.66; amiodarone: RR 2.22, 95% CI 0.71 to 6.96; dofetilide: RR 5.50, 95% CI 1.33 to 22.76; dronedarone: RR 1.95, 95% CI 0.77 to 4.98; sotalol: RR 3.55, 95% CI 2.16 to 5.83); with the exception of propafenone (RR 1.32, 95% CI 0.39 to 4.47) for which the certainty of evidence was very low and we were uncertain about the effect. Certainty of the evidence for this outcome for the other drugs was moderate to high.StrokeEleven studies reported stroke outcomes with quinidine, disopyramide, flecainide, amiodarone, dronedarone and sotalol. High-certainty evidence from two RCTs suggested that dronedarone may be associated with reduced risk of stroke (RR 0.66, 95% CI 0.47 to 0.95; participants = 5872). This result is attributed to one study dominating the meta-analysis and has yet to be reproduced in other studies. There was no apparent effect on stroke rates with the other antiarrhythmics.Recurrence of atrial fibrillationModerate- to high-certainty evidence, with the exception of disopyramide which was low-certainty evidence, showed that all analysed drugs, including metoprolol, reduced recurrence of atrial fibrillation (quinidine: RR 0.83, 95% CI 0.78 to 0.88; disopyramide: RR 0.77, 95% CI 0.59 to 1.01; propafenone: RR 0.67, 95% CI 0.61 to 0.74; flecainide: RR 0.65, 95% CI 0.55 to 0.77; metoprolol: RR 0.83 95% CI 0.68 to 1.02; amiodarone: RR 0.52, 95% CI 0.46 to 0.58; dofetilide: RR 0.72, 95% CI 0.61 to 0.85; dronedarone: RR 0.85, 95% CI 0.80 to 0.91; sotalol: RR 0.83, 95% CI 0.80 to 0.87). Despite this reduction, atrial fibrillation still recurred in 43% to 67% of people treated with antiarrhythmics. AUTHORS' CONCLUSIONS: There is high-certainty evidence of increased mortality associated with sotalol treatment, and low-certainty evidence suggesting increased mortality with quinidine, when used for maintaining sinus rhythm in people with atrial fibrillation. We found few data on mortality in people taking disopyramide, flecainide and propafenone, so it was not possible to make a reliable estimation of the mortality risk for these drugs. However, we did find moderate-certainty evidence of marked increases in proarrhythmia and adverse effects with flecainide.Overall, there is evidence showing that antiarrhythmic drugs increase adverse events, increase proarrhythmic events and some antiarrhythmics may increase mortality. Conversely, although they reduce recurrences of atrial fibrillation, there is no evidence of any benefit on other clinical outcomes, compared with placebo or no treatment.

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation frequently recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. This is an update of a review previously published in 2008 and 2012. OBJECTIVES: To determine in patients who have recovered sinus rhythm after having atrial fibrillation, the effects of long-term treatment with antiarrhythmic drugs on death, stroke, embolism, drug adverse effects and recurrence of atrial fibrillation. SEARCH METHODS: We updated the searches of CENTRAL in The Cochrane Library (2013, Issue 12 of 12), MEDLINE (to January 2014) and EMBASE (to January 2014). The reference lists of retrieved articles, recent reviews and meta-analyses were checked. SELECTION CRITERIA: Two independent authors selected randomised controlled trials comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored. Post-operative atrial fibrillation was excluded. DATA COLLECTION AND ANALYSIS: Two authors independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up. MAIN RESULTS: In this update three new studies, with 534 patients, were included making a total of 59 included studies comprising 21,305 patients. All included studies were randomised controlled trials. Allocation concealment was adequate in 17 trials, it was unclear in the remaining 42 trials. Risk of bias was assessed in all domains only in the trials included in this update.Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95% CI) 1.03 to 5.59, number needed to treat to harm (NNTH) 109, 95% CI 34 to 4985) and sotalol (OR 2.23, 95% CI 1.1 to 4.50, NNTH 169, 95% CI 60 to 2068) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality, but our data could be underpowered to detect mild increases in mortality for several of the drugs studied.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of atrial fibrillation (OR 0.19 to 0.70, number needed to treat to beneft (NNTB) 3 to 16). Beta-blockers (metoprolol) also significantly reduced atrial fibrillation recurrences (OR 0.62, 95% CI 0.44 to 0.88, NNTB 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. Only 11 trials reported data on stroke. None of them found any significant difference with the exception of a single trial than found less strokes in the group treated with dronedarone compared to placebo. This finding was not confirmed in others studies on dronedarone.We could not analyse heart failure and use of anticoagulation because few original studies reported on these measures. AUTHORS' CONCLUSIONS: Several class IA, IC and III drugs, as well as class II drugs (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolism, heart failure) remain to be established.

Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management.

OBJECTIVES: A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke. DESIGN: A cohort observational study over a 4-year period. SETTING: Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France). PARTICIPANTS: We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017. INTERVENTION: Patients transferred in the PSGU were compared to those admitted in other rehabilitation units. MEASUREMENTS: The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score). RESULTS: Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88). CONCLUSION: The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

Cholinesterase inhibitors and memantine are associated with a reduced mortality in nursing home residents with dementia: a longitudinal observational study.

BACKGROUND: A large proportion of nursing home (NH) residents suffer from dementia and effects of conventional anti-dementia drugs on their health is poorly known. We aimed to investigate the associations between exposure to anti-dementia drugs and mortality among NH residents. METHODS: This retrospective longitudinal observational study involved 329 French NH and the residents admitted in these facilities since 2014 and having major neurocognitive disorder. From their electronic health records, we obtained their age, sex, level of dependency, Charlson comorbidity index, and Mini mental examination score at admission. Exposure to anti-dementia drugs was determined using their prescription into 4 categories: none, exposure to acetylcholinesterase inhibitors (AChEI) alone, exposure to memantine alone, exposure to AChEI and memantine. Survival until the end of 2019 was studied in the entire cohort by Cox proportional hazards. To alleviate bias related to prescription of anti-dementia drugs, we formed propensity-score matched cohorts for each type of anti-dementia drug exposure, and studied survival by the same method. RESULTS: We studied 25,358 NH residents with major neurocognitive disorder. Their age at admission was 87.1 + 7.1 years and 69.8% of them were women. Exposure to anti-dementia drugs occurred in 2,550 (10.1%) for AChEI alone, in 2,055 (8.1%) for memantine alone, in 460 (0.2%) for AChEI plus memantine, whereas 20,293 (80.0%) had no exposure to anti-dementia drugs. Adjusted hazard ratios for mortality were significantly reduced for these three groups exposed to anti-dementia drugs, as compared to reference group: HR: 0.826, 95%CI 0.769 to 0.888 for AChEI; 0.857, 95%CI 0.795 to 0.923 for memantine; 0.742, 95%CI 0.640 to 0.861 for AChEI plus memantine. Results were consistent in propensity-score matched cohorts. CONCLUSION: The use of conventional anti-dementia drugs is associated with a lower mortality in nursing home residents with dementia and should be widely used in this population.

Active chest compression-decompression for cardiopulmonary resuscitation.

BACKGROUND: Active compression-decompression cardiopulmonary resuscitation (ACDR CPR) uses a hand-held suction device, applied mid-sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials testing this device have shown discordant results. OBJECTIVES: To determine the effect of active chest compression-decompression CPR compared to standard chest compression CPR on mortality and neurological function in adults with cardiac arrest treated either in-hospital or out-of-hospital. SEARCH METHODS: We updated the searches of CENTRAL in The Cochrane Library (Issue 12 of 12, 2012), MEDLINE (OVID, 1946 to January week 1 2013), and EMBASE (OVID, 1980 to week 1 2013) on 14 January 2013. We checked the reference list of retrieved articles, contacted experts in the field, and searched ClinicalTrials.gov. SELECTION CRITERIA: All randomised or quasi-randomised studies comparing active compression-decompression with standard manual chest compression in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team. DATA COLLECTION AND ANALYSIS: We independently extracted data on an intention-to-treat basis. When needed, we contacted the authors of the primary studies. If appropriate, we cumulated studies and pooled relative risk (RR) estimates. We predefined subgroup analyses according to setting (out-of-hospital or in-hospital) and attending team composition (with physician or paramedic only). MAIN RESULTS: In this update, 27 new related publications were found, but they did not all fulfil inclusion criteria or concerned participants already reported in previous publications. In the end, we included 10 trials in this review: Eight were in out-of-hospital settings; one was set in-hospital only; and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in four studies. The two in-hospital studies were different in quality and size (773 and 53 participants). Both found no differences between ACDR CPR and STR in any outcome.Out-of-hospital trials cumulated 4162 participants. There were no differences between ACDR CPR and STR for mortality either immediately (RR 0.98, 95% confidence interval (CI) 0.94 to 1.03) or at hospital discharge (RR 0.99, 95% CI 0.98 to 1.01). The pooled RR of neurological impairment of any severity was 1.71 (95% CI 0.90 to 3.25), with a non-significant trend to more frequent severe neurological damage in survivors of ACDR CPR (RR 3.11, 95% CI 0.98 to 9.83). However, assessment of neurological outcome was limited, and few participants had neurological damage.There was no difference between ACDR CPR and STR with regard to complications such as rib or sternal fractures, pneumothorax, or haemothorax (RR 1.09, 95% CI 0.86 to 1.38). Skin trauma and ecchymosis were more frequent with ACDR CPR. AUTHORS' CONCLUSIONS: Active chest compression-decompression in people with cardiac arrest is not associated with any clear benefit.

Assessment of DOAC in GEriatrics (Adage Study): Rivaroxaban/Apixaban Concentrations and Thrombin Generation Profiles in NVAF Very Elderly Patients.

BACKGROUND: Although a growing number of very elderly patients with atrial fibrillation (AF), multiple conditions, and polypharmacy receive direct oral anticoagulants (DOACs), few studies specifically investigated both apixaban/rivaroxaban pharmacokinetics and pharmacodynamics in such patients. AIMS: To investigate: (1) DOAC concentration-time profiles; (2) thrombin generation (TG); and (3) clinical outcomes 6 months after inclusion in very elderly AF in-patients receiving rivaroxaban or apixaban. METHODS: Adage-NCT02464488 was an academic prospective exploratory multicenter study, enrolling AF in-patients aged ≥80 years, receiving DOAC for at least 4 days. Each patient had one to five blood samples at different time points over 20 days. DOAC concentrations were determined using chromogenic assays. TG was investigated using ST-Genesia (STG-ThromboScreen, STG-DrugScreen). RESULTS: We included 215 patients (women 71.1%, mean age: 87 ± 4 years), 104 rivaroxaban and 111 apixaban, and 79.5% receiving reduced-dose regimen. We observed important inter-individual variabilities (coefficient of variation) whatever the regimen, at C max [49-46%] and C min [75-61%] in 15 mg rivaroxaban and 2.5 mg apixaban patients, respectively. The dose regimen was associated with C max and C min plasma concentrations in apixaban (p = 0.0058 and p = 0.0222, respectively), but not in rivaroxaban samples (multivariate analysis). Moreover, substantial variability of thrombin peak height (STG-ThromboScreen) was noticed at a given plasma concentration for both xabans, suggesting an impact of the underlying coagulation status on TG in elderly in-patients. After 6-month follow-up, major bleeding/thromboembolic event/death rates were 6.7%/1.0%/17.3% in rivaroxaban and 5.4%/3.6%/18.9% in apixaban patients, respectively. CONCLUSION: Our study provides original data in very elderly patients receiving DOAC in a real-life setting, showing great inter-individual variability in plasma concentrations and TG parameters. Further research is needed to understand the potential clinical impact of these findings.

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most frequent sustained arrhythmia. AF recurs frequently after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. OBJECTIVES: To determine, in patients who recovered sinus rhythm after AF, the effect of long-term treatment with antiarrhythmic drugs on death, stroke and embolism, adverse effects, pro-arrhythmia, and recurrence of AF. SEARCH METHODS: We updated the searches of CENTRAL on The Cochrane Libary (Issue 1 of 4, 2010), MEDLINE (1950 to February 2010) and EMBASE (1966 to February 2010). The reference lists of retrieved articles, recent reviews and meta-analyses were checked. SELECTION CRITERIA: Two independent reviewers selected randomised controlled trials comparing any antiarrhythmic with a control (no treatment, placebo or drugs for rate control) or with another antiarrhythmic, in adults who had AF and in whom sinus rhythm was restored. Post-operative AF was excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up. MAIN RESULTS: In this update, 11 new studies met inclusion criteria, making a total of 56 included studies, comprising 20,771 patients. Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95%CI) 1.03 to 5.59, number needed to harm (NNH) 109, 95%CI 34 to 4985) and sotalol (OR 2.47, 95%CI 1.2 to 5.05, NNH 166, 95%CI 61 to 1159) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of AF (OR 0.19 to 0.70, number needed to treat (NNT) 3 to 16). Beta-blockers (metoprolol) also reduced significantly AF recurrence (OR 0.62, 95% CI 0.44 to 0.88, NNT 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. We could not analyse other outcomes because few original studies reported them. AUTHORS' CONCLUSIONS: Several class IA, IC and III drugs, as well as class II (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolisms, heart failure) remain to be established.

Effect of Cholinesterase Inhibitors on Mortality in Patients With Dementia: A Systematic Review of Randomized and Nonrandomized Trials.

BACKGROUND AND OBJECTIVES: Cholinesterase inhibitors (ChEIs) have cardiovascular effects in addition to their neurological activity and might alter mortality. We wanted to know if treatment with ChEIs modifies mortality in patients with dementia. METHODS: We searched PubMed, EMBASE, Cochrane CENTRAL, ClinicalTrials.gov and ICRTP, from their inception to November 2021, and screened bibliographies of reviews, guidelines and included studies. We included randomized controlled trials (RCTs) and non-randomized controlled studies at lower risk of bias comparing ChEI treatment with placebo or usual treatment, for 6 months or longer, in patients with dementia of any type. Two investigators independently assessed studies for inclusion, assessed their risk of bias and extracted data, using predefined forms. Any discordance between investigators was solved by discussion and consensus. Data on all-cause and cardiovascular mortality, measured as either crude death rates or multivariate adjusted hazard ratios (HR), was pooled using a random-effect model. Information size achieved was assessed using trial sequential analysis (TSA). We followed PRISMA guidelines. RESULTS: 24 studies (12 RCTs, 12 cohorts, mean follow-up 6 to 120 months), cumulating 79 153 patients with Alzheimer's (13 studies), Parkinson's (1), vascular (1) or any type (9) dementia, fulfilled inclusion criteria. Pooled all-cause mortality in control patients was 15.1 per 100 person-years. Treatment with ChEIs was associated with lower all-cause mortality (unadjusted RR 0.74, 95%CI 0.66 - 0.84; adjusted HR 0.77, 95%CI 0.70 - 0.84, moderate to high quality evidence). This result was consistent between randomized and non-randomized studies and in several sensitivity analyses. No difference appeared between subgroups by type of dementia, age, individual drug or dementia severity. Less data was available for cardiovascular mortality (3 RCTs, 2 cohorts, 9 182 patients, low to moderate quality evidence), which was also lower in patients treated with ChEIs (unadjusted RR 0.61, 95%CI 0.40 - 0.93, adjusted HR 0.47, 95%CI 0.32 - 0.68). In TSA analysis, results for all-cause mortality were conclusive, but not those for cardiovascular mortality. DISCUSSION: There is moderate to high quality evidence of a consistent association between long-term treatment with ChEIs and a reduction in all-cause mortality in patients with dementia. These findings may influence decisions to prescribe ChEIs in those patients. TRIAL REGISTRATION INFORMATION: This systematic review was registered in the PROSPERO international prospective register of systematic reviews with the number CRD42021254458 (11/06/2021).

Corticosteroid Therapy in COVID-19 Associated With In-hospital Mortality in Geriatric Patients: A Propensity Matched Cohort Study.

BACKGROUND: Few data are available on the prognosis of older patients who received corticosteroids for COVID-19. We aimed to compare the in-hospital mortality of geriatric patients hospitalized for COVID-19 who received corticosteroids or not. METHODS: We conducted a multicentric retrospective cohort study in 15 acute COVID-19 geriatric wards in the Paris area from March to April 2020 and November 2020 to May 2021. We included all consecutive patients aged 70 years and older who were hospitalized with confirmed COVID-19 in these wards. Propensity score and multivariate analyses were used. RESULTS: Of the 1 579 patients included (535 received corticosteroids), the median age was 86 (interquartile range 81-91) years, 56% of patients were female, the median Charlson Comorbidity Index (CCI) was 2.6 (interquartile range 1-4), and 64% of patients were frail (Clinical Frailty Score 5-9). The propensity score analysis paired 984 patients (492 with and without corticosteroids). The in-hospital mortality was 32.3% in the matched cohort. On multivariate analysis, the probability of in-hospital mortality was increased with corticosteroid use (odds ratio [OR] = 2.61 [95% confidence interval (CI) 1.63-4.20]). Other factors associated with in-hospital mortality were age (OR = 1.04 [1.01-1.07], CCI (OR = 1.18 [1.07-1.29], activities of daily living (OR = 0.85 [0.75-0.95], oxygen saturation < 90% on room air (OR = 2.15 [1.45-3.17], C-reactive protein level (OR = 2.06 [1.69-2.51], and lowest lymphocyte count (OR = 0.49 [0.38-0.63]). Among the 535 patients who received corticosteroids, 68.3% had at least one corticosteroid side effect, including delirium (32.9%), secondary infections (32.7%), and decompensated diabetes (14.4%). CONCLUSIONS: In this multicentric matched-cohort study of geriatric patients hospitalized for COVID-19, the use of corticosteroids was significantly associated with in-hospital mortality.

Older patients with COVID-19 and neuropsychiatric conditions: A study of risk factors for mortality.

BACKGROUND: Little is known about risk factors for mortality in older patients with COVID-19 and neuropsychiatric conditions. METHODS: We conducted a multicentric retrospective observational study at Assistance Publique-Hôpitaux de Paris. We selected inpatients aged 70 years or older, with COVID-19 and preexisting neuropsychiatric comorbidities and/or new neuropsychiatric manifestations. We examined demographics, comorbidities, functional status, and presentation including neuropsychiatric symptoms and disorders, as well as paraclinical data. Cox survival analysis was conducted to determine risk factors for mortality at 40 days after the first symptoms of COVID-19. RESULTS: Out of 191 patients included (median age 80 [interquartile range 74-87]), 135 (71%) had neuropsychiatric comorbidities including cognitive impairment (39%), cerebrovascular disease (22%), Parkinsonism (6%), and brain tumors (6%). A total of 152 (79%) patients presented new-onset neuropsychiatric manifestations including sensory symptoms (6%), motor deficit (11%), behavioral (18%) and cognitive (23%) disturbances, gait impairment (11%), and impaired consciousness (18%). The mortality rate at 40 days was 19.4%. A history of brain tumor or Parkinsonism or the occurrence of impaired consciousness were neurological factors associated with a higher risk of mortality. A lower Activities of Daily Living score (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.58-0.82), a neutrophil-to-lymphocyte ratio ≥ 9.9 (HR 5.69, 95% CI 2.69-12.0), and thrombocytopenia (HR 5.70, 95% CI 2.75-11.8) independently increased the risk of mortality (all p < .001). CONCLUSION: Understanding mortality risk factors in older inpatients with COVID-19 and neuropsychiatric conditions may be helpful to neurologists and geriatricians who manage these patients in clinical practice.

Mixed treatment comparison of dronedarone, amiodarone, sotalol, flecainide, and propafenone, for the management of atrial fibrillation.

AIMS: Mixed treatment comparisons (MTC) were performed to assess the relative efficacy and tolerability of the main anti-arrhythmic drugs used for the treatment of atrial fibrillation (AF)/flutter. METHODS AND RESULTS: Electronic databases were systematically searched to identify randomized controlled trials (RCTs) examining amiodarone, dronedarone, flecainide, propafenone, sotalol, or placebo for the treatment of AF. Thirty-nine RCTs met inclusion criteria and were combined using MTC models to provide direct and indirect comparisons in a single analysis. Results are presented vs. placebo. Amiodarone had the largest effect in reducing AF recurrence (OR 0.22, 95% CI 0.16-0.29). Amiodarone was associated with the highest rate of patients experiencing at least one serious adverse event (OR 2.41, 95% CI 0.96-6.06) and treatment withdrawals due to adverse events (OR 2.91, 95% CI 1.66-5.11). Dronedarone was associated with the lowest rate of proarrhythmic events including bradycardia (OR 1.45, 95% CI 1.02-2.08). Dronedarone significantly reduced the risk of stroke (OR 0.69, 95% CI 0.57-0.84). Trends towards increased mortality for sotalol (OR 3.44, 95% CI 1.02-11.59) and amiodarone (OR 2.17, 95% CI 0.63-7.51) were found, which were stronger when small studies randomizing <100 subjects per group were excluded. CONCLUSIONS: Amiodarone has been demonstrated to be the most effective drug in maintaining sinus rhythm. Differences in outcomes between the anti-antiarrhythmic drugs were reported, with sotalol and possibly amiodarone increasing mortality and dronedarone possibly decreasing the incidence of serious adverse events and proarrhythmia.

Computerized Decision Support Systems for Nursing Homes: A Scoping Review.

OBJECTIVES: To summarize the research literature describing the outcomes of computerized decision support systems (CDSSs) implemented in nursing homes (NHs). DESIGN: Scoping review. METHODS: Search of relevant articles published in the English language between January 1, 2000, and February 29, 2020, in the Medline database. The quality of the selected studies was assessed according to PRISMA guidelines and the Mixed Method Appraisal Tool. RESULTS: From 1828 articles retrieved, 24 studies were selected for review, among which only 6 were randomized controlled trials. Although clinical outcomes are seldom studied, some studies show that CDSSs have the potential to decrease pressure ulcer incidence and malnutrition prevalence. Improvement of process outcomes such as increased compliance with practice guidelines, better documentation of nursing assessment, improved teamwork and communication, and cost saving, also are reported. CONCLUSIONS AND IMPLICATIONS: Overall, the use of CDSSs in NHs may be effective to improve patient clinical outcomes and health care delivery; however, most of the retrieved studies were observational studies, which significantly weakens the evidence. High-quality studies are needed to investigate CDSS effects and limitations in NHs.

Chronology of COVID-19 Symptoms in Very Old Patients: Study of a Hospital Outbreak.

BACKGROUND: We wanted to better understand the frequency and temporal distribution of symptoms of COVID-19 in very old patients, which are currently not well defined. METHODS: In an observational, descriptive study, we followed all patients being at three geriatric convalescence and rehabilitation units when a COVID-19 outbreak emerged in those units in March 2020. For those who developed the disease, we recorded any new symptom occurring at diagnosis, in the previous 14 and the following 21 days. A group of SARS-Cov-2-negative patients served as controls. RESULTS: Sixty-nine of the 176 inpatients (mean age: 86 years) were infected by SARS-Cov-2 during the outbreak. At the moment of diagnosis, a majority of patients had fever (71.0%), malaise-asthenia (24.6%), or respiratory symptoms (66.7%). However, 48 patients (69.6% of all SARS-Cov-2 positive patients) also presented, usually several days before, other symptoms: (a) gastrointestinal symptoms (39.1% of all patients, median onset eight days before diagnosis, IQR -9 to +3 days); (b) neurological symptoms (30.4% of all patients, median onset five days before diagnosis, IQR -11 to -3 days), notably delirium (24.6%); and (c) other symptoms, like falls and unexplained decompensation of chronic conditions (29.0% of all patients, median onset four days before diagnosis, IQR -10 to 0). None of those symptoms were observed in similar proportion in 25 control SARS-CoV-2-negative patients, hospitalized during the same period. CONCLUSIONS: Diarrhea, nausea-vomiting, delirium, falls, and unexplained decompensation of chronic conditions were the first symptoms of COVID-19 in a majority of older patients in this cohort, preceding typical symptoms by several days. Recognizing those early symptoms could hasten the diagnosis of COVID-19 in this population.