Survival of very preterm infants: Epipage, a population based cohort study

OBJECTIVE

To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital.

DESIGN

A prospective observational population based study.

SETTING

Nine regions of France in 1997.

PATIENTS

All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation.

MAIN OUTCOME MEASURE

Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge.

RESULTS

A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age.

CONCLUSION

Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care.

Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly

BACKGROUND

Anaesthesia could provoke persistent alterations in specific cognitive domains in the elderly where ageing-related neuronal changes may exacerbate pharmacotoxic effects.

AIMS

To evaluate anaesthesia effects on the incidence of cognitive dysfunction after orthopaedic surgery in elderly patients.

METHOD

A total of 140 patients over the age of 64 years completed a full range of computerised cognitive tests. The study takes into account effects of pre-operative cognitive dysfunction, depressive symptomatology and ability to perform activities of daily living.

RESULTS

Postoperative cognitive decline persisted for up to 3 months in 56% of subjects. Dysfunction was limited to verbal, visuo-spatial and semantic abilities and secondary and implicit memory. Age, low educational level, pre-operative cognitive impairment or depression are risk factors.

CONCLUSIONS

Cognitive functions are not equally affected, type of impairment being determined by the risk factors described above and anaesthesia type.

Subclinical cognitive impairment: epidemiology and clinical characteristics

Subclinical cognitive impairment is commonly reported in elderly populations, but its clinical significance is largely undetermined. It is commonly perceived as a normal feature of the aging process or a separate nosological entity. The clinical status of this disorder is explored herein by reference to longitudinal observations. It is concluded that persons with subclinical cognitive impairment constitute a highly heterogeneous group. There is an elevated risk in this group for senile dementia, with an estimated 18% incidence rate over 3 years, but in the majority of cases, this problem is more commonly associated with depressive symptomatology and physical illness. Only 13% of persons with recent observable change in cognitive functioning appear to have a totally benign and transient syndrome. Caution should be exercised in applying single unifying nosological entities such as age-associated memory impairment to this group of the elderly.

Depressive illness, depressive symptomatology and regional cerebral blood flow in elderly people with sub-clinical cognitive impairment

BACKGROUND

Depressive illness in dementia is often assumed to be a unitary clinical phenomenon.

AIM

To describe changes in patterns of depressive symptomatology with time, and associated changes in cerebral blood flow to the frontal and temporal regions.

METHOD AND RESULTS

397 elderly people with sub-clinical cognitive dysfunction were observed over 3 years. Sixteen percent of them developed dementia during the study The prevalence of depressive symptomatology was higher in this group than in the general population, especially in women, who also had higher recovery rates. A changing profile of depressive symptoms was found in depressed elderly people progressing to dementia, with fewer affective symptoms and increases in agitation and motor slowing. These changes were paralleled by greater reductions in left temporal regional cerebral blood flow than in non-depressed subjects with Alzheimer's disease.

CONCLUSION

In dementia, there may be two separate and interacting depressive syndromes whose differentiation may be clinically important.

The effects of wine and tobacco consumption on cognitive performance in the elderly: a longitudinal study of relative risk

BACKGROUND

Evidence relating to the potentially protective effect of smoking and alcohol consumption in relation to senescent cognitive decline and Alzheimer's disease is inconclusive.

METHODS

The relationship between wine and tobacco consumption and cognitive change was assessed within a longitudinal study of normal elderly people showing recent instability in cognitive functioning using an extensive battery of cognitive tests.

RESULTS

While moderate wine consumption was found to be associated with a fourfold diminishing of the risk of Alzheimer's disease (OR = 0.26), as found in other studies, this effect was found to disappear when institutionalization was taken into account. Wine consumption was associated with an increased risk of decline over time in attention and in secondary memory. No protective effect for Alzheimer's disease was found for smoking, although smoking was associated with a decreased risk for decline over time in attentional and visuospatial functioning. No clear combined effect of smoking and drinking was found, even though smoking was found to increase the risk of decline in language performance when adjusted on wine consumption.

CONCLUSIONS

There is no evidence to suggest that wine and tobacco consumption may protect against Alzheimer's disease.

Progressive disability in senile dementia is accelerated in the presence of depression

OBJECTIVES

To assess the extent to which loss of ability to perform everyday activities in early stage senile dementia is worsened by the presence of depressive illness.

METHODS

To evolution of disabilities is measured by an activity scale permitting observation of small changes in everyday performance in a cohort of 397 elderly persons with subclinical cognitive deficit. Over the 3 years of the study, 11% of the cohort developed dementia without depression and 5% dementia with depression.

RESULTS

Progressive disablement was found to be greater in persons with senile dementia as compared to normal subjects. Depression alone had no significant effect over the time period. Persons with both senile dementia and depression had significantly higher rates of disability at 3 years than persons with senile dementia alone. Significantly greater decrements across the observation period were observed in dressing, washing, use of telephone and continence in the senile dementia-depression group only.

CONCLUSION

Depression does not in itself engender significant disability, but interacts with senile dementia to accelerate loss of functioning. Effective treatment of depressive illness in senile dementia may have significant impact on the prevalence and severity of disability.

[Renal replacement therapy for chronic renal failure patients in the Languedoc-Roussillon region in 1994]

BACKGROUND

Unbiased and reliable data are presently required for health planning concerning end stage renal diseases (ESRD) in Languedoc-Roussillon region of France.

METHODS

A comprehensive retrospective study has been carried out on patients with ESRD in 1994 in this area. Information was collected from medical and social documents by physicians. The present report describes the management of patients and their demographic and epidemiologic characteristics. Multiple correspondence analysis was carried out to estimate to what extent mode of renal replacement therapy is determined by patient characteristics.

RESULTS

An incidence of 11.4 for new cases of renal replacement therapy was found per 100,000 inhabitants. This represents an increase of 4.8% in the total number of patients. The patients were found to be elderly (25% being over 72 years) and to present with multiple pathologies (32.5% severe cardiac pathology; 20.7% arteritis of the lower limbs; 15.1% diabetes; 11.2% manifesting malignant tumors). Only 57.5% received dialysis within a hospital setting; 30.1% received dialysis at home; 13% perform autodialysis; 1.2% were being trained for home dialysis in December. The renal transplantation rate was 5.5%. No significant relationship was found between choice of therapy and age, renal disease, comorbidities and place of dwelling.

CONCLUSIONS

This study demonstrates the great variety in the modes of treatment used, the facilities provided and the evolutive trend, which together make programming planning difficult.

Establishing the limits and characteristics of normal age-related cognitive decline

BACKGROUND

Research into ageing-related pathology relies not only on exploration of disease aetiology, but also a clear understanding of the normal ageing process. The present study aims to examine the characteristics of elderly subjects who lie on the borderline between normal and pathological ageing.

METHOD

Cognitive functioning is examined using computerized neuropsychometric assessment in a population of 833 normal elderly from which a cohort of 397 subjects with sub-clinical cognitive impairment are followed over three years. Subjects receive a standardized neurological examination and ApoE genotypes are established.

RESULTS

Analysis of covariance revealed no cross-sectional age differences for syntax comprehension (p = 0.19), articulation (p = 0.46), semantic matching (p = 0.12), reading (p = 0.79), and implicit memory (p = 0.21) while explicit memory, language skills and visuospatial skills were found to deteriorate both in the cross-sectional age comparisons and across time. An overall intellectual ability factor, derived from Principal Components Analysis, was found by regression to decline principally in persons with low education, and a high initial IQ level was observed to provide a protective effect over age 75. Persons with higher levels of education show relative stability over time on language and secondary memory tasks but deteriorate as rapidly as persons with low education on visuospatial tasks. Five separate patterns of sub-clinical cognitive deficit were isolated by cluster analysis. Two groups, with differing clinical profiles (of which only one manifested the ApoE4 allele), were found to have an increased risk of developing senile dementia (OR = 4.4 and 3.9). A third group had a high prevalence of depressive illness, and the remaining two showed very little change.

CONCLUSION

Ageing does not affect all cognitive functions uniformly: a high initial education level slowing rate of decline for certain tasks. Separate patterns of cognitive change are observed in early senile dementia, benign change and changes related to depressive illness. Results suggest the need for more stringent selection of normal control groups.

Does education level determine the course of cognitive decline?

Many studies have implicated low education as a risk factor for cognitive impairment in elderly people. Findings are, however, inconsistent and the mechanism by which education level may intervene in senescent cognitive change is uncertain. The present study examines cognitive change over a 1-year period in 283 elderly persons manifesting recent subclinical deterioration in at least one area of cognitive functioning. The results suggest that the impact of both education level and young adult IQ on the degree of cognitive change over the year is greater in the older age groups. Secondary memory and language functions were found to be more resistant to decline in the high-education group, while attention, implicit memory and visuospatial skills are found to decline irrespective of education level.

A typology of sub-clinical senescent cognitive disorder

BACKGROUND

Cognitive impairment without dementia is commonly observed in ageing populations. The present study aims to describe types of impairment and evolution over a one-year period.

METHOD

Three hundred and ninety-seven normal French elderly persons demonstrating recent, observable change in cognitive performance were examined annually using a computerised cognitive examination.

RESULTS

Five subtypes were differentiated by cluster analysis. Two of the groups were predicted by logistic regression to be at high risk of senile dementia. Of 16 incident cases of senile dementia diagnosed in the following year, 13 were found to have derived from these two groups. The typology was also found to be useful in the description of age-associated memory impairment.

CONCLUSIONS

Subclinical cognitive impairment was found to not constitute a unitary phenomenon and heterogeneous subgroups could be differentiated. The concept of 'normality' in elderly cohorts is reconsidered in the light of these findings.

Menopause and perceived health status among the women of the French GAZEL cohort

The aim of this study was to evaluate the effect of menopause on women's quality of life. Women (1171) aged from 45-52 years who work for the French national gas and electricity company volunteered for this study (response rate 75%). They completed a self-administered questionnaire pertaining to general health. Quality of life was measured by the Nottingham Health Profile (NHP). Within this group 289 women were postmenopausal. After controlling for age, those women were more likely to show a lower quality of life than women still menstruating for 4 of the 6 sections of the NHP: social isolation (odds ratio 1.4; 95% confidence interval 1.1-1.9), pain, sleep and energy (odds ratios 1.5; 95% confidence intervals 1.1-2.0). Those alterations of quality of life are explained by the climacteric complaints the women report. Those findings suggest that the treatment of menopausal symptoms with medication of proven efficacy may prevent lowering of quality of life due to menopause.

Risk factors for high blood pressure among workers in French poultry slaughterhouses and canneries

The aim of the present study is to examine the relationship between the working conditions of employees in the food industry and blood pressure. An epidemiological survey was conducted between 1987 and 1988 in 17 poultry slaughterhouses and 6 canneries in the French regions of 'Bretagne' and 'Pays de Loire'. One thousand, four hundred and seventy-four workers were included in the study. Data was collected in the course of the medical visit organized annually for employees. Mean diastolic (DBP) and systolic blood pressure (SBP) were analyzed separately for male and female workers. The results indicate a significant relationship between blood pressure, and age and obesity. Amongst the various features of working condition studies, loud noise and the number of work breaks were found to be associated with heightened mean values of DBP or SBP in men only. Type and size of the factory was found to be associated with blood pressure readings for both sexes. A number of working conditions giving rise to heightened mental strain were found to be related to a lowering in mean blood pressure: for example, irregular work finishing times for men and production-line work for women. A discussion of these results reveals the complexity of the relationships which exist between physical and environmental factors in this type of setting and blood pressure of employees.

Determinants of hormone replacement therapy among postmenopausal women enrolled in the French GAZEL cohort

Although the efficacy of hormonal replacement therapy (HRT) regarding numerous consequences of menopause is proven, its prevalence of use is low, as is compliance with the prescribed treatment. The aim of this work was to study the factors influencing a woman's decision to take HRT by analyzing the determinants of HRT use of at least 6 months' duration among post-menopausal women working for a French company and enrolled in a cohort study. Special attention was paid to the women's expectations of HRT. We compared two groups of women: 113 current HRT users who had been users for at least 6 months and 101 never users. Among the 113 current users, the most frequent treatment was a combination of oestrogen and progestin (86%). The determinants of HRT use for at least 6 months included a prior spinal radiograph, which showed a significant relationship with the use of hormone treatment (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.2-4.7), a current marriage (OR 2.5; 95% CI 1.3-5.1) and previous hot flushes (OR 2.4; 95% CI 1.2-4.9). The strongest determinant was an expectation that HRT would prevent osteoporosis (OR 5.0; 95% CI 2.2-11.6). In this population concern about osteoporosis appears to be an important determinant of HRT use. Our results underline the importance of the diffusion of information among physicians and women about HRT's benefits, especially its efficacy in preventing osteoporosis.

Determinants of hormonal replacement therapy in recently postmenopausal women

Although the efficacy of hormonal replacement therapy (HRT) on the consequences of the menopause is not questioned, it appears that in Europe and in the USA only a small proportion of women are users of HRT. In this study, we examined the prevalence and the determinants of HRT among 1986 French menopausal women, aged 45 to 55 years, presenting to a preventive medicine centre. Overall, 8.1% of women reported current use of HRT. The estrogen preparation most commonly reported was transcutaneous 17 beta-oestradiol. The first determinant of current HRT was birth-place. Women born in France were nearly four times more likely to be on treatment than foreign-born women. A surgical menopause multiplied the probability of current HRT by 2, as did a high level of education. An age at first pregnancy of more than 20 and less than 4 children were also positively linked with HRT use. Even in this population of recently menopausal women, volunteering to undergo health evaluation, the prevalence of HRT was low. The reservations towards HRT may be partly due to the women themselves, and partly due to the physicians. It seems very important to inform the medical profession about the risks and benefits of HRT, and to understand more precisely the reasons why so few women use HRT.