De la dépendance à la fin de vie du sujet âgé : évènements iatrogènes et prévention

Le vieillissement est associé à de nombreux évènements indésirables graves tels que les hospitalisations, l'évolution vers la dépendance, l'entrée en institution et le décès. Actuellement plus de 1,2 millions de sujets âgés sont dépendants en France. Cette dépendance peut s'expliquer par deux facteurs majeurs : les pathologies chroniques, et les hospitalisations. Lors d'une hospitalisation, le sujet âgé est à risque de dépendance du fait de la pathologie aigue qui le mène à l'hôpital, mais également du fait des soins hospitaliers qui peuvent être inappropriés et à l'origine d'évènements iatrogènes. Nous avons montré qu'une part significative de la dépendance acquise à l'hôpital était iatrogène et quels évènements iatrogènes pouvaient y contribuer. Parmi les pathologies chroniques, la survenue d'un cancer est également un facteur de risque significatif de dépendance, du fait de la pathologie elle-même, mais également des traitements spécifiques proposés. La réalisation d'une évaluation gériatrique standardisée (EGS) est actuellement recommandée en oncogériatrie, notamment pour évaluer si l'état général du sujet est compatible avec le traitement oncologique proposé. Notre objectif était de déterminer quels facteurs de l'EGS étaient associés à une modification du traitement oncologique initial dans cette population. Enfin, lorsque la dépendance évolue chez le sujet âgé, l'entrée en institution est fréquente. Près de 600 000 personnes vivent en EHPAD en France, et 90 000 y décèdent chaque année. Lors de la fin de vie de ces sujets, la gestion des symptômes inconfortables est prioritaire. Sur le plan médicamenteux, cela implique le recours à des thérapeutiques ciblant ces symptômes inconfortables, mais également d'éviter les effets indésirables médicamenteux. Nous avons évalué les prescriptions médicamenteuses en fin de vie chez les résidents d'EHPAD, notamment les prescriptions inappropriées.Hospitalization, functional decline, institutionalization and ultimately death, are common and serious risks in the elderly population. More than 1.2 million older adults in France experience disability. Disability can be explained by two leading causes: chronic diseases and hospitalizations. In older patients, hospitalization associated disability can be triggered by the acute illness that requires hospitalization, but also by inappropriate health care management, and iatrogenic events. We demonstrated that hospitalization associated disability was high in older hospitalized patients, and often explained by iatrogenic events that could be preventable. Previous studies have reported a high risk of functional decline in older patients with cancer. In this population, functional decline can be explained by the impact of the cancer itself, but also adverse effects of the oncologic treatment. To prevent treatment-related complications and assess the appropriateness of the oncologic treatment, a comprehensive geriatric assessment (CGA) is recommended in oncology practice. We aimed to identify domains of CGA that could influence treatment decision in older patients with cancer. Institutionalization is a common outcome in disabled older adults. Nearly 600 000 older adults live in nursing home in France, and 90 000 residents die in nursing home each year. The management of pain and uncomfortable symptoms is a priority in end of life residents. An optimal palliative care management involves optimization of drug prescriptions, including the prescription of symptom-oriented drug therapy but also the limitation of adverse drug events. We assessed drug prescriptions in end of life residents in nursing home, including inappropriate drug prescriptions

Can We Distinguish Age-Related Frailty from Frailty Related to Diseases? Data from the MAPT Study

Abstract Background No study has tried to distinguish subjects that become frail due to diseases (frailty related to diseases) or in the absence of specific medical events; in this latter case, it is possible that aging process would act as the main frailty driver (age-related frailty). Objectives To classify subjects according to the origin of physical frailty: age-related frailty, frailty related to diseases, frailty of uncertain origin, and to compare their clinical characteristics. Materials and methods We performed a secondary analysis of the Multidomain Alzheimer Preventive Trial (MAPT), including 195 subjects ≥70 years non-frail at baseline who became frail during a 5-year follow-up (mean age 77.8 years ± 4.7; 70% female). Physical frailty was defined as presenting ≥3 of the 5 Fried criteria: weight loss, exhaustion, weakness, slowness, low physical activity. Clinical files were independently reviewed by two different clinicians using a standardized assessment method in order to classify subjects as: "age-related frailty", "frailty related to diseases" or "frailty of uncertain origin". Inconsistencies among the two raters and cases of uncertain frailty were further assessed by two other experienced clinicians. Results From the 195 included subjects, 82 (42%) were classified as age-related frailty, 53 (27%) as frailty related to diseases, and 60 (31%) as frailty of uncertain origin. Patients who became frail due to diseases did not differ from the others groups in terms of functional, cognitive, psychological status and age at baseline, however they presented a higher burden of comorbidity as measured by the Cumulative Illness Rating Scale (CIRS) (8.20 ± 2.69; vs 6.22 ± 2.02 frailty of uncertain origin; vs. 3.25 ± 1.65 age-related frailty). Time to incident frailty (23.4 months ± 12.1 vs. 39.2 ± 19.3 months) and time spent in a pre-frailty condition (17.1 ± 11.4 vs 26.6 ± 16.6 months) were shorter in the group of frailty related to diseases compared to age-related frailty. Orthopedic diseases (n=14, 26%) were the most common pathologies leading to frailty related to diseases, followed by cardiovascular diseases (n=9, 17%) and neurological diseases (n = 8, 15%). Conclusion People classified as age-related frailty and frailty related to diseases presented different frailty-associated indicators. Future research should target the underlying biological cascades leading to these two frailty classifications, since they could ask for distinct strategies of prevention and management

Caring for a Person With Dementia on the Margins of Long-Term Care: A Perspective on Burden From 8 European Countries

© 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine Objectives To explore associations between carer burden and characteristics of (1) the informal carer, (2) the person with dementia, and (3) the care support network in 8 European countries. Design Cross-sectional study. Setting People with dementia judged at risk of admission to long-term care (LTC) facilities in 8 European countries (Estonia, Finland, France, Germany, Netherlands, Spain, Sweden, United Kingdom). Participants A total of 1223 people with dementia supported by community services at home or receiving day care or respite care and their informal carers. Measurements Variables regarding the informal carer included familial relationship and living situation. Variables relating to the person with dementia included cognitive functioning (S-MMSE), neuropsychiatric symptoms (NPI-Q), depressive symptoms (Cornell depression scale), comorbidity (Charlson Comorbidity Index), and physical functioning (Katz Activity of Daily Living [ADL] Index). The care support network was measured using hours of caregiving (ADLs, instrumental ADLs [IADLs], supervision), additional informal care support, and service receipt (home care, day care). Experience of carer burden was recorded using the Zarit Burden Interview. Logistic regression analysis was used to determine factors associated with high carer burden. Results Carer burden was highest in Estonia (mean 39.7/88) and lowest in the Netherlands (mean 26.5/88). High burden was significantly associated with characteristics of the informal carer (family relationship, specifically wives or daughters), of the person with dementia (physical dependency in ADLs; neuropsychiatric symptoms, in particular nighttime behaviors and irritability), the care support network (hours of caregiving supervision; receipt of other informal care support) and country of residence. Conclusion A range of factors are associated with burden in informal carers of people with dementia judged to be on the margins of LTC. Support for informal carers needs to take account of gender differences. The dual challenges of distressed behaviors and difficulties in ADLs by the person with dementia may be addressed by specific nonpharmacological interventions focusing on both elements. The potential protective effect of additional informal support to carers highlights the importance of peer support or better targeted home support services. The implementation of appropriate and tailored interventions to reduce burden by supporting informal carers may enable people with dementia to remain at home for longer

Facteurs prédictifs d'entrée en institution des sujets atteints de maladie d'Alzheimer

TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF

« From disability to end of life in older adults : iatrogenic events and prevention »

Le vieillissement est associé à de nombreux évènements indésirables graves tels que les hospitalisations, l'évolution vers la dépendance, l'entrée en institution et le décès. Actuellement plus de 1,2 millions de sujets âgés sont dépendants en France. Cette dépendance peut s'expliquer par deux facteurs majeurs : les pathologies chroniques, et les hospitalisations. Lors d'une hospitalisation, le sujet âgé est à risque de dépendance du fait de la pathologie aigue qui le mène à l'hôpital, mais également du fait des soins hospitaliers qui peuvent être inappropriés et à l'origine d'évènements iatrogènes. Nous avons montré qu'une part significative de la dépendance acquise à l'hôpital était iatrogène et quels évènements iatrogènes pouvaient y contribuer. Parmi les pathologies chroniques, la survenue d'un cancer est également un facteur de risque significatif de dépendance, du fait de la pathologie elle-même, mais également des traitements spécifiques proposés. La réalisation d'une évaluation gériatrique standardisée (EGS) est actuellement recommandée en oncogériatrie, notamment pour évaluer si l'état général du sujet est compatible avec le traitement oncologique proposé. Notre objectif était de déterminer quels facteurs de l'EGS étaient associés à une modification du traitement oncologique initial dans cette population. Enfin, lorsque la dépendance évolue chez le sujet âgé, l'entrée en institution est fréquente. Près de 600 000 personnes vivent en EHPAD en France, et 90 000 y décèdent chaque année. Lors de la fin de vie de ces sujets, la gestion des symptômes inconfortables est prioritaire. Sur le plan médicamenteux, cela implique le recours à des thérapeutiques ciblant ces symptômes inconfortables, mais également d'éviter les effets indésirables médicamenteux. Nous avons évalué les prescriptions médicamenteuses en fin de vie chez les résidents d'EHPAD, notamment les prescriptions inappropriées.Hospitalization, functional decline, institutionalization and ultimately death, are common and serious risks in the elderly population. More than 1.2 million older adults in France experience disability. Disability can be explained by two leading causes: chronic diseases and hospitalizations. In older patients, hospitalization associated disability can be triggered by the acute illness that requires hospitalization, but also by inappropriate health care management, and iatrogenic events. We demonstrated that hospitalization associated disability was high in older hospitalized patients, and often explained by iatrogenic events that could be preventable. Previous studies have reported a high risk of functional decline in older patients with cancer. In this population, functional decline can be explained by the impact of the cancer itself, but also adverse effects of the oncologic treatment. To prevent treatment-related complications and assess the appropriateness of the oncologic treatment, a comprehensive geriatric assessment (CGA) is recommended in oncology practice. We aimed to identify domains of CGA that could influence treatment decision in older patients with cancer. Institutionalization is a common outcome in disabled older adults. Nearly 600 000 older adults live in nursing home in France, and 90 000 residents die in nursing home each year. The management of pain and uncomfortable symptoms is a priority in end of life residents. An optimal palliative care management involves optimization of drug prescriptions, including the prescription of symptom-oriented drug therapy but also the limitation of adverse drug events. We assessed drug prescriptions in end of life residents in nursing home, including inappropriate drug prescriptions

Prise en charge thérapeutique des sujets âgés en EHPAD durant les six derniers mois de leur vie (données de l'étude IQUARE)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF

Carence en vitamine C chez les sujets âgés hospitalisés (une étude transversale sur 119 patients au CHU de Toulouse)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF

Impact of the comprehensive geriatric assessment on treatment decision in geriatric oncology

International audienceBackground: The comprehensive geriatric assessment (CGA) is the gold standard in geriatric oncology to identify patients at high risk of adverse outcomes and optimize cancer and overall management. Many studies have demonstrated that CGA could modify oncologic treatment decision. However, there is little knowledge on which domains of the CGA are associated with this change. Moreover, the impact of frailty and physical performance on change in cancer treatment plan has been rarely assessed.Methods: This is a cross-sectional study of older patients with solid or hematologic cancer referred by oncologists for a geriatric evaluation before cancer treatment. A comprehensive geriatric assessment was performed by a multidisciplinary team to provide guidance for treatment decision. We performed a multivariate analysis to identify CGA domains associated with change in cancer treatment plan.Results: Four hundred eighteen patients, mean age 82.8 ± 5.5, were included between October 2011 and January 2016, and 384 of them were referred with an initial cancer treatment plan. This initial cancer treatment plan was changed in 64 patients (16.7%). In multivariate analysis, CGA domains associated with change in cancer treatment plan were cognitive impairment according to the MMSE score (p = 0.020), malnutrition according to the MNA score (p = 0.023), and low physical performance according to the Short Physical Performance Battery (p = 0.010).Conclusion: Cognition, malnutrition and low physical performance are significantly associated with change in cancer treatment plan in older adults with cancer. More studies are needed to evaluate their association with survival, treatment toxicity and quality of life. The role of physical performance should be specifically explored

Diabetes and Frail Older Patients: Glycemic Control and Prescription Profile in Real Life

(1) Background: The latest recommendations for diabetes management adapt the objectives of glycemic control to the frailty profile in older patients. The purpose of this study was to evaluate the proportion of older patients with diabetes whose treatment deviates from the recommendations. (2) Methods: This cross-sectional observational study was conducted in older adults with known diabetes who underwent an outpatient frailty assessment in 2016. Glycated hemoglobin (HbA1c) target is between 6% and 7% for nonfrail patients and between 7% and 8% for frail patients. Frailty was evaluated using the Fried criteria. Prescriptions of glucose-lowering drugs were analyzed based on explicit and implicit criteria. (3) Results: Of 110 people with diabetes with an average age of 81.7 years, 67.3% were frail. They had a mean HbA1c of 7.11%. Of these patients, 60.9% had at least one drug therapy problem in their diabetes management and 40.9% were potentially overtreated. The HbA1c distribution in relation to the targets varied depending on frailty status (p < 0.002), with overly strict control in frail patients (p < 0.001). (4) Conclusions: Glycemic control does not seem to be routinely adjusted to the health of frail patients. Several factors can lead to overtreatment of these patients

RETRACTED: Association Between Frailty and Cognitive Impairment: Cross-Sectional Data From Toulouse Frailty Day Hospital

International audienc