Cognitive Function and Amyloid Marker in Frail Older Adults: The COGFRAIL Cohort Study

BACKGROUND

Frailty and cognitive impairment are common manifestations of the ageing process and are closely related. But the mechanisms linking aging, physical frailty, and cognitive disorders, are complex and remain unclear.

OBJECTIVES

We aim to explore the role of cerebral amyloid pathology, but also a range of nutritional, physical, biological or brain-aging marker in the development of cognitive frailty.

METHOD

COGFRAIL study is a monocentric prospective study of frail older patients with an objective cognitive impairment (Clinical Dementia Rating Scale global score at 0.5 or 1). Three-hundred-and-twenty-one patients are followed up every 6 months, for 2 years. Clinical assessment at baseline and during follow-up included frailty, physical, mood, sensory, nutritional, and cognitive assessment (with a set of neuropsychological tests). Cerebral amyloid pathology is measured by amyloid Positron Emission Tomography (PET) or amyloid-β-1-42 level in cerebrospinal fluid. Brain magnetic resonance imaging, measurement of body composition using Dual X Ray Absorptiometry and blood sampling are performed. The main outcome of the study is to assess the prevalence of positive cerebral amyloid status according to amyloid PET or amyloid-β-1-42 level CSF. Secondary outcomes included biological, nutritional, MRI imaging, cognitive, clinical, physical and body composition markers to better understand the mechanisms of cognitive frailty.

PERSPECTIVE

COGFRAIL study will give the opportunity to better understand the link between Gerosciences, frailty, cognitive impairment, and Alzheimer's disease, and to better characterize the physical and cognitive trajectories of frail older adults according to their amyloid status. Understanding the relationship between physical frailty and cognitive impairment is a prerequisite for the development of new interventions that could prevent and treat both conditions.

Guidance for the Prevention of the COVID-19 Epidemic in Long-Term Care Facilities: A Short-Term Prospective Study

BACKGROUND

Guidance aiming at limiting the entry and spread of the COVID-19 have been widely communicated to Long-term Care Facilities (LTCFs). However, no clinical research has investigated their relevance.

OBJECTIVE

Our objective was to compare the guidance applied for the prevention of the COVID-19 epidemic between the LTCFs having been contaminated by COVID-19 and LTCFs having not been contaminated.

METHODS

A questionnaire was sent and systematically accompanied by phone call to the 132 LTCFs of Haute-Garonne (Occitania region, South-West of France). The questionnaire focused on the preventive measures implemented before March 23, 2020 (first LTCFs contaminated in this area). The questionnaire focused on physician support, implementation of usual guidance (eg, masks, hydro-alcoholic solute used), training on hygiene, containment in residents' rooms and other distancing measures, use of temporary workers, compartmentalization within zones of residents and staff and a self-assessment analogic scale on the quality of the application of the preventive measures. We compared implementation of the guidance between the LTCFs with at least one case of COVID-19 among residents and/or health care professionals and LTCFs without COVID-19 case (between March 23rd and May 6th).

RESULTS

124 LTCFs participated (93.9%). 30 LTCFs (24.19%) were contaminated with COVID-19. Large heterogeneity of the application of the guidance was observed. Public LTCFs (OR= 0.39 (0.20-0.73), LTCFs which organized staff compartmentalization within zones (OR= 0.19 (0.07-0.48)), and LTCF with a staff who self-assessed a higher quality implementation of the preventive measures (OR= 0.65 (0.43-0.98)) were significantly more likely to avoid contamination by the COVID-19 outbreak.

CONCLUSION

Our study supports the relevance of guidance to prevent the entry of COVID-19, in particular the staff compartmentalization within zones, as well as the perception of the staff regarding the quality of implementation of those measures in LTCFs.

Rhegmatogenous Retinal Detachment with Posteriorly Located Break Treated with Temporary Buckle. A Case Report

A rhegmatogenous retinal detachment with a break 19 mm from the limbus in the nasal quadrant was treated with a temporary balloon buckle. This technique was applied to avoid the surgical trauma of vitreous surgery. The operation was successful and the procedure appears to be valid for buckling posterior breaks.

Validation of the Mini Nutritional Assessment-Short Form in a Population of Frail Elders without Disability. Analysis of the Toulouse Frailty Platform Population in 2013

OBJECTIVE

To assess the validity of the Mini Nutritional Assessment-Short Form (MNA-SF) in elderly patients from the Toulouse Frailty Platform.

PARTICIPANTS

Overall, 267 patients aged 65 and over, without severe cognitive impairment (i.e. Mini Mental Status Examination > 20 and CDR<1), no physical disability (i.e. Activities of Daily Living ≥ 5) and no active cancer history (over the past 12 months) were included in 2013.

MEASUREMENTS

Receiver operating characteristic (ROC) analyses were used to assess the predictive validity of the French version of the MNA-SF for good nutritional status (defined as a full MNA score≥24/30). Analyses were conducted in the overall sample and then in subgroups of frail and pre-frail subjects according to the frailty phenotype. Optimal cut-off points were determined to obtain the best sensitivity/specificity ratio and the highest number of correctly classified subjects.

RESULTS

Among 267 patients, mean age=81.5±5.8; women=67.0%; 138 (51.7%) were frail, 98 (36.7%) were pre-frail and 31 (11.6%) were robust. Given their MNA-SF scores, 201 (75.3%) had a good nutritional status, 61 (22.8%) were at risk of malnutrition and 5 (1.9%) were malnourished. In the overall sample, but also in subgroups of pre-frail or frail elders, the areas under ROC curves were 0.954, 0.948 and 0.958 respectively. The 11 points cut-off provided the best correct classification ratio (91.4%); sensitivity=94.0%, specificity=83.3%.

CONCLUSION

The MNA-SF appeared to be a validated and effective tool for malnutrition screening in frail elders. Implementing this tool in clinical routine should contribute to improving the screening of malnourished frail individuals.

Nutrition, Frailty and Prevention of Disabilities with Aging

The heterogeneous group of older adults may be differentiated into three subgroups in order to facilitate the development and implementation of personalized healthcare interventions: 1) "disabled individuals" (i.e., those needing assistance in the accomplishment of basic activities of daily living), 2) "frail individuals" (i.e., those presenting some limitations and impairments in the absence of functional disability), and 3) the "robust individuals" (i.e., those who are neither frail or disabled). Despite the growing evidence linking frailty to poor outcomes, this syndrome is yet adequately considered in the clinical practice. There is indeed a lack of recognition of frail individuals, frequently leading to inadequate or inappropriate offer of healthcare services. The assessment of frailty in older adults is recommended to preventively act before the activation of the irreversible cascade of disability. Characteristic features of frailty (e.g., weakness, low energy, slow walking speed, low physical activity, and weight loss) clearly suggest the existence of a close link between nutrition and the status of extreme vulnerability (to intend both from a physical and cognitive viewpoint). Interestingly, recent clinical experiences in the field of frailty and nutrition have demonstrated that this syndrome is often related to relevant prevalence of malnutrition and risk of becoming malnourished. In the present article, it is proposed a review of existing evidence in the field of nutrition and frailty. Potential nutritional interventions for preventing frailty and age-related disabling conditions are also discussed.

Validation of a new tool: the calorie intake tool, to easily estimate the energy intake of diseased aged patient

OBJECTIVE

The aim of the study was to validate the Calorie Intake Tool (CIT), a new tool to estimate energy intake.

DESIGN, SETTING AND PATIENTS

100 patients older than 75 were randomly selected in seven geriatric units at Toulouse University Hospital.

MEASUREMENTS

Energy intake was calculated for each subject with the CIT and by weighing the food consumed.

RESULTS

Total calorie intake did not differ significantly between the two methods, 1318 ± 586 for CIT and 1353 ± 625 for food weighing. The Intraclass Correlation coefficient (ICC) was higher than 0.89 for total calorie intake and the Bland and Altman analysis was consistent with these results and showed a bias for high calorie intake (mean error 35 ± 420 kcal).

CONCLUSION

The study shows that the CIT for the evaluation of calorie intake in elderly diseased patients is valid against the reference method (weighing the food consumed).

Description of 1,108 older patients referred by their physician to the "Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability" at the gerontopole

INTRODUCTION

Frailty is considered as an early stage of disability which, differently from disability, is still amenable for preventive interventions and is reversible. In 2011, the "Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability" was created in Toulouse, France, in association with the University Department of General Medicine and the Midi-Pyrénées Regional Health Authority. This structure aims to support the comprehensive and multidisciplinary assessment of frail older persons, to identify the specific causes of frailty and to design a personalized preventive plan of intervention against disability. In the present paper, we describe the G.F.C structure, organization, details of the global evaluation and preventive interventions against disability, and provide the main characteristics of the first 1,108 patients evaluated during the first two years of operation.

METHODS

Persons aged 65 years and older, considered as frail by their physician (general practitioner, geriatrician or specialist) in the Toulouse area, are invited to undergo a multidisciplinary evaluation at the G.F.C. Here, the individual is assessed in order to detect the potential causes for frailty and/or disability. At the end of the comprehensive evaluation, the team members propose to the patient (in agreement with the general practitioner) a Personalized Prevention Plan (PPP) specifically tailored to his/her needs and resources. The G.F.C also provides the patient's follow-up in close connection with family physicians.

RESULTS

Mean age of our population was 82.9 ± 6.1 years. Most patients were women (n=686, 61.9%). According to the Fried criteria, 423 patients (39.1%) were pre-frail, and 590 (54.5%) frail. Mean ADL (Activities of Daily Living) score was 5.5 ± 1.0. Consistently, IADL (Instrumental ADL) showed a mean score of 5.6 ± 2.4. The mean gait speed was 0.78 ± 0.27 and 25.6% (272) of patients had a SPPB (Short Physical Performance Battery) score equal to or higher than 10. Dementia was observed in 14.9% (111) of the G.F.C population according to the CDR scale (CDR ≥2). Eight percent (84) presented an objective state of protein-energy malnutrition with MNA (Mini Nutritional Assessment) score < 17 and 39.5% (414) were at risk of malnutrition (MNA=17-23.5). Concerning PPP, for 54.6% (603) of patients, we found at least one medical condition which needed a new intervention and for 32.8% (362) substantial therapeutic changes were recommended. A nutritional intervention was proposed for 61.8% (683) of patients, a physical activity intervention for 56.7% (624) and a social intervention for 25.7% (284). At the time of analysis, a one-year reassessment had been carried out for 139 (26.7%) of patients.

CONCLUSIONS

The G.F.C was developed to move geriatric medicine to frailty, an earlier stage of disability still reversible. Its particularity is that it is intended for a single target population that really needs preventive measures: the frail elderly screened by physicians. The screening undergone by physicians was really effective because 93.6% of the subjects who referred to this structure were frail or pre-frail according to Fried's classification and needed different medical interventions. The creation of units like the G.F.C, specialized in evaluation, management and prevention of disability in frail population, could be an interesting option to support general practitioners, promote the quality of life of older people and increase life expectancy without disability.

Alzheimer disease: protective factors

Approximately 6-8% of all persons aged >65 y have Alzheimer disease and the prevalence of the disease is increasing. Any intervention strategy aimed at decreasing risks or delaying the onset of the disease will therefore have a substantial effect on health care costs. Nutrition seems to be one of the factors that may play a protective role in Alzheimer disease. Many studies suggest that oxidative stress and the accumulation of free radicals are involved in the pathophysiology of the disease. Several studies have shown the existence of a correlation between cognitive skills and the serum concentrations of folate, vitamin B-12, vitamin B-6, and, more recently, homocysteine. However, nutritional factors have to be studied not alone but with the other factors related to Alzheimer disease: genetics, estrogen, antiinflammatory drug use, and socioeconomic variables. The objective of this article was to review recent studies in this field.

Nutritional support and aging in preoperative nutrition

In the past 20 years, an increased interest geriatric nutrition has induced researchers to document the distribution and magnitude of nutritional problems in the elderly population. It has been observed that the prevalence of malnutrition is greatly affected by the general health status and autonomy of the elderly. Among free-living healthy elderly persons, the prevalence of protein-caloric undernutrition is low. As health and functional capacities deteriorate with age, however, the prevalence increases dramatically to 30-65% of those in home care, nursing homes or in hospital. Formal nutritional assessment has typically been absent from most published programmes of geriatric evaluation and comprehensive geriatric assessment. This is frequently because of the lack of a specific validated tool to assess nutritional status in older persons and, at least partly, to explain this phenomenon. The Mini Nutritional Assessment was developed and validated on large representative samples of elderly persons to address these specific issues. Recent experimental studies have shown that advanced malnutrition is much more difficult to treat in the elderly than in younger adults. Trials of nutritional support using oral supplements or enteral tube feeding have shown improved outcome in those identified as malnourished on admission to hospital.

[Simplification in locating and dissecting the levator muscle of the upper eyelid in surgery for ptosis]

BACKGROUND

While repairing eyelid ptosis by aponeurotic resection by anterior approach, the risk of damaging the levator complex and the conjunctiva is significant. In order to simplify the dissection between Müller's muscle and the underneath conjunctiva, we use a modification of the usual surgical technique.

METHODS

Before the skin incision, the eversion of the upper eyelid allows to dissect the conjunctiva from the Müller's muscle under direct visual control, starting from the upper tarsal margin. A silicone band is then passed through the so created horizontal subconjunctival tunnel. The upper eyelid can be physiologically replaced, and the levator muscle aponeurosis exposed. The two ends of the band are then pulled on surface through two lateral incision performed close to the upper tarsal edge. Now the band plays the role of a useful landmark: every tissue above the band is levator complex; when stretched downwards, it points the upper edge of the tarsal plate. We operated by this technique 24 eyes, affected of acquired or congenital ptosis. Fourteen eyelids had already undergone ptosis surgery elsewhere.

RESULTS

We achieved good-to-excellent results in all cases, without any important postoperative complications.

CONCLUSIONS

The proposed manoeuvre makes easier the dissection of the inner aspect of the levator complex, because of the material control. Therefore it minimises the tissue trauma and the postoperative complications, particularly in complicated cases characterised by scarring and fibrosis.

[Ambulatory blood pressure in hypertension with dysautonomia]

The purpose of the study was to evaluate the interest of ambulatory blood pressure (BP) recording (ABPR) in the management of arterial hypertension (AH) with dysautonomia. The study concerned 8 hypertensive patients (pts), 5 men, 3 females 52 +/- 10 years old, with orthostatic hypotension (OH): BP was 162 +/- 19/87 +/- 16 mmHg and 129 +/- 15/76 +/- 8 mmHg in lying and standing position respectively. In two cases AH was associated with a central degenerative disorder whereas the six other pts had a diabetic dysautonomia: bad metabolic control (HBA1c 14.4 +/- 2.7%), and incipient or over nephropathy (4 pts). ABPR was performed in all pts during 24 hours (space-labs system). In these hypertensive pts with OH, the mean 24 hour-BP was surprisingly normal at 128 +/- 11/76 +/- 6 mmHg. ABPR demonstrated the loss of nocturnal decline in BP: diurnal and nocturnal BP were respectively 125 +/- 13/74 +/- 6 mmHg and 133 +/- 16/78 +/- 10 mmHg (NS). 6 of 8 pts had an increase in BP at night resulting for the population (n = 8) in a nocturnal increase (%) of + 5.6%, this pattern widely differs from controls--13%. The decrease in heart rate during sleep was blunted but significant from 89 +/- 9 b/min to 81 +/- 9 b/min (p 0.01). Diurnal and nocturnal BP variability (V), assessed by variation coefficient were not significantly different: SBP-V was 10.3 +/- 6.4% day and 12.3 +/- 4.2% night, DBP-V 7.5 +/- 6.3% day and 12.5 +/- 3.1% night.(ABSTRACT TRUNCATED AT 250 WORDS)

Seasonal variations in rhegmatogenous retinal detachment as related to meteorological factors

The seasonality of rhegmatogenous retinal detachment was investigated in 363 consecutive patients over the period 1974-1983 and compared to meteorological parameter variations over the same period. A highly significant correlation between rhegmatogenous retinal detachment incidence and light flux values was found. Light is suggested to act as a precipitating factor for rhegmatogenous retinal detachment in a damaged retina. The possible mechanisms by which the light could be responsible for retinal detachment occurrence are discussed.

Clinicopathologic and immunologic characteristics of non-Hodgkin's lymphomas presenting in the orbit. A report of eight cases

Of 325 consecutive cases of non-Hodgkin's malignant lymphomas, 8 patients (2.4%) showed orbital presentation. The clinicopathologic and immunologic analysis of the eight patients revealed characteristic biologic features. Despite the apparently isolated orbital presentation, all cases had subclinical systemic disease. Seven of the eight cases exhibited lymphoplasmacytic/cytoid features, with concurrent type II cryoglobulinemia in five of them. In addition, during their clinical course, five patients showed single or multiple subcutaneous nodules with the same histologic and immunologic pattern as the orbital tumor. This study demonstrates that most orbital lymphomas share particular clinicopathologic and immunologic features, suggesting an origin from a B-cell subset with preferential homing to orbital tissues and subcutis.

[A case of retinal degeneration in a man exposed to organophosphorus pesticides]

The AA describe a case of retinal degeneration (cones and rods degeneration) which has arisen in a subject exposed to organophosphorous pesticides. The AA. discuss about the evidences of specialistic tests and point out the necessity of a particular attention to the sight apparatus in field of toxic exposures.

Millimetric cover test--a linear strabismometric technique

In ten normal subjects we measured the angular rotations of the globe, both in adduction and in abduction, corresponding to limbus shifts from 1 to 7 mm. Our study demonstrated that to each millimeter of temporal limbus shift corresponds an average adduction of about 4.6 degrees and to each millimeter of nasal limbus shift an average abduction of about 4.8 degrees. These experimental results give a sound foundation to the clinical evaluation of the strabismic angle by measuring, with a millimeter ruler, the limbus shift of the nonfixating eye by assuming fixation. This technique appears particularly useful as a substitute for the simultaneous prism and cover test, in the evaluation of a squint with a variable angle, and in measurements in other positions of gaze.

[Ocular rotation and corneal reflexes (author's transl)]

The location of the corneal reflex (Purkinje's first image) produced by an electronic flash was studied at various degrees of ocular rotation both in adduction and abduction. A statistical analysis of the results showed a good correlation between the decentration of the corneal reflex and the degrees of ocular rotation. The results thus obtained give an experimental basis to the clinical use of the so-called Hirschberg test for measuring the strabismus angle.

[Blood circulation of the optic nerve with respect to the development of glaucomatous papilla excavation]

Recent research findings in microvascular anatomy enable the authors to make as new suggestion regarding the arrangement of the intraorbital vasculature of the optic nerve. In anatomical specimens three separate zones can be identified, sharply delimited and each with its own source of blood supply. After briefly describing the vasculature of the distal segment (neck) of the optic nerve the authors report several new theories concerning the pathogenesis of glaucomatous cupping of the optic disk.