[Frailty in nursing home : contribution of the SENIOR study]

Over the past 20 years, clinicians and researchers have shown increasing interest in frailty. However, there is still no consensus regarding its operational definition. An interesting definition in this context could be the one that best predicts functional decline and the occurrence of negative health outcomes. Moreover, frailty could be avoided, delayed and sometimes cured by the implementation of targeted interventions. The SENIOR cohort, a longitudinal study of nursing home residents, initiated in 2013, aims to contribute to the understanding of risk factors, consequences and dynamic of frailty. It also contributes to its management. This cohort is of great interest among scientists. Because of the large number of demographic, clinical and anamnestic data collected each year, the SENIOR study could fill the gap in the literature related to the frailty.

Prevalence of Frailty in Nursing Home Residents According to Various Diagnostic Tools

BACKGROUND

Although the theoretical foundations of frailty are well established in the literature, it remains an evolving concept lacking any unique definition or diagnostic criteria for use in clinical practice and epidemiological research. No consensus exists about the accurate prevalence rates of frailty. The various operational definitions of frailty can at least partly explain such discrepancies.

OBJECTIVE

To compare the prevalence of frailty, measured with different diagnostic tools, among elderly nursing home residents.

DESIGN

This is an analysis of baseline data collected among the SENIOR (Sample of Nursing home Elderly Individuals: an Observational Research) cohort.

SETTING

Nursing homes.

POPULATION

A total of 662 volunteer subjects from 28 nursing homes were included in this analysis. Among them, the mean age was 83.2 ± 8.99 years and 484 (72.5%) of them were women.

MEASUREMENT

The percentages of frail and non-frail subjects were calculated according to 10 different definitions.

RESULTS

Prevalence of frailty varies from 1.70% (Frailty Index) to 76.3% (Groningen Frailty Indicator) depending on the tool used.

CONCLUSIONS

The prevalence of frailty is highly dependent on the diagnostic tool used. It would be necessary to reach a consensus on which diagnostic tools to use if one wishes to have comparable data obtained in epidemiological studies.

Prevalence of Concomitant Bone and Muscle Wasting in Elderly Women from the SarcoPhAge Cohort: Preliminary Results

BACKGROUND

Recent studies suggest that bone and muscle wasting are closely interconnected.

OBJECTIVE

The aim was of this study is to assess the prevalence of osteoporosis in a population of women diagnosed with sarcopenia. Participants, setting and design: We analyzed cross-sectional data of women, aged 65 years and above, for whom bone mineral density was available at the time of inclusion in the SarcoPhAge (Sarcopenia and Physical impairment with advancing Age) cohort, an ongoing prospective study with the aim to assess consequences of sarcopenia.

MEASUREMENTS

Muscle strength was evaluated with a hydraulic hand-dynamometer, appendicular lean mass and bone mineral density by Dual-Energy X-Ray Absorptiometry and physical performance by the Short Physical Performance Battery test (SPPB). Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People definition, i.e. a low muscle mass plus either low muscle strength or low physical performance. A bone mineral density T-score equal to or below -2.5SD at the lumbar spine, at the total hip or at the femoral neck was used to define osteoporosis (World Health Organization definition).

RESULTS

A total of 126 women aged 74.38±6.32 years were included. Among them, 26 were assessed with sarcopenia (20.6%) and 34 (27.0%) with osteoporosis. There were more osteoporotic women among sarcopenic subjects (46.1%) than among non-sarcopenic subjects (22.0%) (p-value=0.011). A significant lower appendicular lean mass index was observed in osteoporotic women (p-value=0.025). We also observed, in osteoporotic subjects, a lower muscle strength (p-value=0.023). Numerical values of bone mineral density were lower in the sarcopenic population but the differences did not reach the level of statistical significance.

CONCLUSION

Our study demonstrated that muscle mass and strength are lower in patients with osteoporosis. Prospective changes in bone and muscle mass will be investigated during the follow-up of our cohort.

Data set of healthy old people assessed for three walking conditions using accelerometric and opto-electronic methods

BACKGROUND

Gait patterns of healthy aging are needed to allow a comparison with pathological situations. However, little data is available.

OBJECTIVE

To present gait pattern of healthy older specially selected to be "healthy walkers".

METHOD

Fifty-seven older people benefited from a geriatric assessment including clinical and functional evaluations to include only those without gait disorders. Gait data were simultaneously recorded using a tri-axial accelerometer placed on the waist and four 3D position markers placed on the feet at the level of the heel and the toe. Volunteers walked at comfortable self-selected speed (CW), fast self-selected speed (FW), and finally in dual task walking condition (DTW). The extracted gait parameters were: gait speed, stride length, stride frequency, regularity and symmetry, swing, stance and double support time and ratio and minimum toe clearance. Gait speed and stride length were normalized to the right leg length.

RESULTS

Fifty-seven older people with a mean age of 69.7 ± 4.2 years old (range from 65 to 82 years) were included. Data were analyzed according to the gender and according to the age (<70 or ≥70 years old). After normalization to leg length, the main significant differences were shown for stride length and minimum toe clearance in CW, FW and in DTW that were shorter in women. The regularity in FW was significantly lower among older volunteers.

CONCLUSIONS

This work provides a data set considering 14 gait parameters obtained from 57 healthy old people strictly selected and assessed for three walking conditions and shows that GS, SL and MTC have to be related to the gender. The age-related impact on gait performances appears reduced in this cohort.

Prevalence of sarcopenia in a population of nursing home residents according to their frailty status: results of the SENIOR cohort

OBJECTIVE

To investigate the relationship between frailty and sarcopenia, by evaluating the prevalence of sarcopenia among frail, pre-frail and robust elderly nursing home residents in Belgium.

METHODS

This is an analysis of baseline data collected from the SENIOR (Sample of Elderly Nursing home Individuals: an Observational Research) cohort. All subjects received a sarcopenia evaluation, based on the definition proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). The frailty evaluation was primarily based on FRIED's definition but also on 9 other operational definitions.

RESULTS

A total of 662 subjects (73.1% of women) were included in this analysis (mean age: 83.2±8.99 years). The prevalence of sarcopenia was 38.1% whereas the prevalence of frail and pre-frail persons was respectively 24.7% and 61.4%. Among frail, pre-frail and robust subjects, respectively 47%, 38.9% and 16.3% were diagnosed sarcopenic. The prevalence of sarcopenia according to ten different operational definitions of frailty ranged between 32.8 % (i.e. Frail scale Status and Frailty Index) and 47% (i.e. Fried definition).

CONCLUSION

This research highlights that over a third of nursing home residents are sarcopenic and the percentage is almost 50% among frail subjects; those latter constitute about 1 in 4 of the population of nursing home residents studied here.

Energy and Nutrient Content of Food Served and Consumed by Nursing Home Residents

OBJECTIVE

The aim of this study was to compare energy and protein content of the served food with the actual intake from the food consumed by nursing home residents. This study also aimed to compare food intake and dietary allowances.

DESIGN

This is a cross sectional study.

SETTING

This study was performed in nursing homes.

PARTICIPANTS

Residents of these 2 nursing homes were eligible for the study if they agreed to participate and if they meet the selection criteria (to be older than 65 years and have a regular texture diet).

MEASUREMENT

Nutrient content of the served food and real food consumption was calculated for all meals during a 5-day period by precise weighting method. Difference between consumed and served dietary content was evaluated by the Chi² test.

RESULTS

Seventy-four Belgian nursing home residents (75% of women, 85.8 ± 7.04 years on average) were included in this study. These subjects had a mean body mass index of 24.9 ± 4.83 kg/m². The mean energy content of the served food was 1783.3 ± 125.7 kcal per day. However, residents did not eat the whole of the meals and the actual energy content of the consumed food was significantly less (1552.4 ± 342.1 kcal per day; p<.001). The average protein content of the food served was equal to 0.96 ± 0.20 g/kg/day and the average consumption of protein by the residents was 0.88 ± 0.25 g/kg/day. The difference between protein served and consumed was also significant (p=.04). Moreover, people considered as well nourished, eating significantly more energy than the others (p=.04).

CONCLUSION

Meals served in nursing homes are not entirely consumed by their residents. As expected, the energy consumed are lower in subjects considered as malnourished or at risk of malnutrition.

Relationship between frailty, physical performance and quality of life among nursing home residents: the SENIOR cohort

BACKGROUND

The aim of this study was to assess the relationship between frailty and a large number of indicators related to physical and muscular performance as well as quality of life.

METHODS

This is an analysis of data collected at baseline in the Sample of Elderly Nursing home Individuals: an Observational Research (SENIOR) cohort including nursing home residents. Subjects are volunteer, oriented and able to walk (walking assistance allowed) nursing home residents in Belgium. A large number of demographic and clinical characteristics, including physical and muscular performance, were collected from each patient. The prevalence of frailty in this population was assessed using Fried's definition.

RESULTS

In total, 662 subjects are included in this analysis. The mean age of the sample is 83.2 ± 8.99 years, and 484 (73.1 %) are women. In this population of nursing home residents, the prevalence of frailty is 25.1 %, pre-frailty, 59.8 % and robustness, 15.1 %. Compared to non-frail subjects, frail subjects have lower physical and muscular performances and a lower quality of life.

CONCLUSION

Frailty, according to Fried's definition, seems to be associated with several clinical indicators suggesting a higher level of disability and an increased propensity to develop major clinical consequences. Follow-up data of the SENIOR cohort will be helpful in confirming these findings, establishing cause-effect relationships and identifying the most predictive components of physical frailty for adverse outcomes in nursing homes.

[How I treat... Delirium in the aged]

Delirium is an acute psycho-organic disorder, most of the time reversible, that happens in various situations (acute disease, drugs ... ). It can also result from an acute or long term stress when the patient is already in an unstable homeostatic balance. Delirium is common in the geriatric population and can have serious consequences in terms of morbidity and mortality. Unfortunately, it is often not well known by hospital doctors. It is the consequence of predisposing factors (age, polypharmacy, multiple illnesses, neurodegenerative diseases, ... ) and precipitating factors (inadequate medications, dehydration, infections, ...). Diagnosis of delirium is simple with the Confusion Assessment Method (CAM). Rapid diagnosis and management are mandatory to limit functional decline. In people at risk, simple non-drug interventions can prevent the occurrence of delirium. Psychotropic drugs should be used with caution. The prevention of delirium is important and a standardized geriatric assessment to identify old patients at risk should be performed before any surgery or heavy treatment.

Added value of a triaxial accelerometer assessing gait parameters to predict falls and mortality among nursing home residents: A two-year prospective study

BACKGROUND

Gait impairment seems to be a risk factor for falls and mortality. Because gait change cannot be determined easily with classical clinical tests, some authors have suggested that it might be useful to use a gait-analysis system among elderly community-dwelling people.

OBJECTIVE

The main objective of the present study was to determine the predictive value of a quantitative evaluation of the gait characteristics in nursing home residents for the occurrence of falls and death performed using a tri-axial accelerometer (Locométrix®).

MATERIAL AND METHODS

One hundred elderly nursing home residents (80 women and 20 men, mean age 86.4 ± 6.04 years) were included in this study with the aim to follow them for 2 years. Deaths and falls were systematically recorded. A quantitative evaluation of a 10-second walk was performed with a tri-axial accelerometer (Locometrix®). Demographic data (i.e age, sex, body mass index) and clinical data (i.e. fall risk evaluated by the Tinetti test) were also recorded.

RESULTS

During the two years of follow-up, 27 patients died. After adjustment on all potential confounding variables, only body mass index was significantly associated with the risk of mortality with an odds ratio of 0.86 (95% CI: 0.77-0.96, p=0.04). At the end of the study period, 440 falls had occurred (mean: 4.44 ± 6.79 falls per patient) but no single factors were independently associated with fall incidence.

CONCLUSION

Our results show that a quantitative gait analysis performed using a tri-axial accelerometer is not predictive of long-term falls and mortality among nursing home residents.

Relationship between Isometric Strength of Six Lower Limb Muscle Groups and Motor Skills among Nursing Home Residents

This research aimed to assess the correlation between isometric muscle strength of the lower limb and motor skills. This is a cross sectional study performed among volunteer nursing home residents included in the SENIOR (Sample of Elderly Nursing home Individuals: an Observational Research) cohort. The present analysis focused on isometric muscle strength of 6 lower limb muscle groups (i.e. knee extensors, knee flexors, hip abductors, hip extensors, ankle flexors and ankle extensors), assessed using a validated hand-held dynamometer (i.e. the MicroFET2 device), and motor skills evaluated using the Tinetti test, the Timed Up and Go test, the Short Physical Performance Battery test (SPPB) and the walking speed. The relationship between all these parameters was tested by means of a multiple correlation, adjusted on age, sex and body mass index. 450 nursing home residents (69.8% of women) with a mean age of 83.1±9.4 years were included in this study. Our results showed a significant inverse correlation between lower limb muscle strength and the time required to perform the TUG test or gait speed, except for ankle flexors and ankle extensors. The relationship between the Tinetti test or the SPPB score, and lower limb muscle strength was significant, except for ankle flexors and ankle extensors. In conclusion, a positive association between lower limb muscle strength of the four main muscle groups and motor skills of the elderly nursing residents was found in this research. Therefore, special attention should be given to these muscle groups during rehabilitation programs.

Gait speed or gait variability, which one to use as a marker of risk to develop Alzheimer disease? A pilot study

BACKGROUND

Previous literature demonstrates the interest of gait analysis to predict cognitive decline in old people.

AIMS

This pilot study aims to determine if gait speed or gait variability is a marker able to early identify, among mild cognitive impairment (MCI) subjects, those at risk to develop Alzheimer's disease (AD) in the future.

METHODS

13 MCI subjects were included in 2007. Their gait parameters (walking speed, stride length and gait frequency, regularity and symmetry) were measured in 2007 and 2008 in simple task (ST) and in dual task (DT) using a triaxial accelerometer (Locometrix(®)). Among the 13 MCI subjects included in 2007, 10 were assessed in 2008. So, 23 (13 in 2007 + 10 in 2008) gait tests were collected. In 2011, MCI people were considered as "MCI+" when they developed AD (between baseline and 2011) and as "MCI-" if they did not. Among the 23 gait tests, 15 were from MCI+ (9 gait tests in 2007 and 6 in 2008) and 8 from MCI- (4 gait tests in 2007 and 4 gait tests in 2008). Mann-Whitney non-parametric U test was used to compare gait parameters of MCI+ and MCI-.

RESULTS

Gait speed, symmetry and regularity were lower in MCI+ than in MCI-.

DISCUSSION

Despite the small sample size, the results presented in this original pilot study are in line as the infrequent previous literature related to this topic. The authors discuss lacks and strengths of this work.

CONCLUSIONS

These results suggest that both gait speed and gait variability could be markers to early identify MCI at risk to develop AD.

Determinants of vitamin D supplementation prescription in nursing homes: a survey among general practitioners

SUMMARY

A total of 119 GPs participated to a survey aimed to assess the profile and determinants of vitamin D supplementation prescription in nursing homes. Among the respondent GPs, 65 (54.6%) systematically prescribe vitamin D to their institutionalized patients and the 54 (45.4%) others prescribe only sometimes.

INTRODUCTION

The aim of this study is to assess the profile and determinants of vitamin D supplementation prescription in nursing homes.

METHODS

General practitioners (GPs) having at least one patient in a nursing home in Liège, Belgium, were asked to complete the survey.

RESULTS

A total of 119 GPs participated in the survey. Among the respondent GPs, 65 (54.6 %) systematically prescribe vitamin D to their institutionalized patients and the 54 (45.4%) others prescribe only sometimes. The main reasons for prescribing vitamin D cited by GPs who do so systematically are as follows: because they believe nursing home residents are mostly deficient in vitamin D status (92.1%), because they believe that vitamin D supplementation prevents osteoporotic fractures (77.8%), and because vitamin D supplementation is recommended by various scientific societies (38.1%). GPs who only prescribe vitamin D supplementation in some patients mainly do so following a diagnosis of osteoporosis (82.4%), on the basis the 25(OH)D level (78.4%), in the case of history of fracture (54.9%) or after a recent fracture (43.4%). Surprisingly, 16 physicians (31.4%) only prescribe vitamin D when they think of it. Interestingly, while 40.7% of GPs always prescribe the same dose of vitamin D, the remaining 59.3% prescribe a dose that will mainly depend on the results of the 25(OH)D level (94.0%), the patient's bone health (49.3%), or history of fracture (43.3%).

CONCLUSIONS

More than half of GPs systematically prescribe vitamin D to their patients living in nursing homes. The other GPs usually prescribe vitamin D following the result of the vitamin D status or after a diagnosis of osteoporosis.

Estimation of sarcopenia prevalence using various assessment tools

BACKGROUND

Sarcopenia is defined as a progressive and generalized loss of muscle mass with either a loss of muscle strength or a loss of physical performance but there is no recommendation regarding the diagnostic tools that have to be used. In this study, we compared the prevalence of sarcopenia assessed using different diagnostic tools.

METHODS

To measure muscle mass, muscle strength and physical performance, we used for each outcome two different diagnostic tools. For muscle mass, we used Dual Energy X-Ray Absorptiometry (DXA) and bio-electrical impedance analysis (BIA); for muscle strength, we used a hydraulic dynamometer and a pneumatic dynamometer; for physical performance we used the Short Physical Performance Battery test (SPPB test) and the walk speed. Eight diagnostic groups were hereby established.

RESULTS

A total of 250 consecutive subjects were recruited in an outpatient clinic in Liège, Belgium. Estimated prevalence of sarcopenia varied from 8.4% to 27.6% depending on the method of diagnosis used. Regarding muscle mass, BIA systematically overestimated muscle mass compared to DXA (mean estimated prevalence with BIA=12.8%; mean prevalence with DXA=21%). For muscle strength, the pneumatic dynamometer diagnosed twice more sarcopenic subjects than the hydraulic dynamometer (mean estimated prevalence with PD=22.4%; mean estimated prevalence with HD=11.4%). Finally, no difference in prevalence was observed when the walking speed or the SPPB test was used. A weak overall kappa coefficient was observed (0.53), suggesting that the 8 methods of diagnosis are moderately concordant.

CONCLUSION

Within the same definition of sarcopenia, prevalence of sarcopenia is highly dependent on the diagnostic tools used.

Management of osteoporosis of the oldest old

This consensus article reviews the diagnosis and treatment of osteoporosis in geriatric populations. Specifically, it reviews the risk assessment and intervention thresholds, the impact of nutritional deficiencies, fall prevention strategies, pharmacological treatments and their safety considerations, the risks of sub-optimal treatment adherence and strategies for its improvement.

INTRODUCTION

This consensus article reviews the therapeutic strategies and management options for the treatment of osteoporosis of the oldest old. This vulnerable segment (persons over 80 years of age) stands to gain substantially from effective anti-osteoporosis treatment, but the under-prescription of these treatments is frequent.

METHODS

This report is the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores some of the reasons for this and presents the arguments to counter these beliefs. The risk assessment of older individuals is briefly reviewed along with the differences between some intervention guidelines. The current evidence on the impact of nutritional deficiencies (i.e. calcium, protein and vitamin D) is presented, as are strategies to prevent falls. One possible reason for the under-prescription of pharmacological treatments for osteoporosis in the oldest old is the perception that anti-fracture efficacy requires long-term treatment. However, a review of the data shows convincing anti-fracture efficacy already by 12 months.

RESULTS

The safety profiles of these pharmacological agents are generally satisfactory in this patient segment provided a few precautions are followed.

CONCLUSION

These patients should be considered for particular consultation/follow-up procedures in the effort to convince on the benefits of treatment and to allay fears of adverse drug reactions, since poor adherence is a major problem for the success of a strategy for osteoporosis and limits cost-effectiveness.

[Aging and cancer: coincidence or etiologic relationship?]

In Belgium and in other countries, the Cancer Registry data show an increased incidence of cancers related to age, the majority of tumors being diagnosed beyond 60 years. However, the mechanisms responsible for this increase are not clear. Cancer could be chronologically associated with aging because of the long latency period between the exposition to carcinogenic agents and the appearance of clinical signs. Aging could also predispose directly to cancer by different mechanisms (impaired immune response, increased oxidative stress, shortening of telomeres, accumulation of senescent cells). In this review, we propose to describe different hypotheses which could explain the increased incidence of cancers in the elderly.

[Falls in the elderly]

Falls are frequent in the elderly; they can have severe consequences, and sometimes reveal some underlying pathology. They represent a real public health problem which prompts numerous teams to search for adequate preventative measures, adapted therapeutic options, and means to reduce the various resulting costs. This paper describes the multidisciplinary hospital day service organized, by the CHU of Liege, for older patients who fall, or are at risk of falling.

[Oxidative stress, antioxydants and the ageing process]

Antioxidant supplementation in the form of pills is thought to slow down the aging process through the "free radical" scavenger activity of these compounds. The idea arose from the "Free Radical Theory of Ageing" (FRTA), initially developed by Harman in 1956. In the present paper, we present some arguments against this theory. One of the most pertinent is that "free radicals", more properly renamed as reactive oxygen species (ROS), play important biological roles in defense mechanisms of the organism as illustrated, in particular, by the hormesis phenomenon. Surprisingly, a moderate production of ROS has been shown to extend the life span in animals.

[End of life care in the elderly]

The increase in life expectancy is associated with a good quality of life until a very old age. However, the unavoidable aging process eventually affects the autonomy of the patient and may force the individual to live in a nursing home. The alteration of sensorial functions and the increased number of degenerative diseases may finally induce a physical and psychological burden that might lead to resort to palliative care, end of life sedation, and in some cases, euthanasia.

[Screening for frailty: a benefit for both patients and physicians]

Preventing the increasing number of depending persons is a novel priority in European Union health policy. One of the means to succeed relies on identifying, among elderly persons, those at risk of dependency, also named "the frail elderly". Screening for frailty is also useful to better assess the physiological reserves of the elderly before any therapeutic decision, as early as the first consultation. Researchers currently work on developing a new simple tool allowing a distinction between frail and robust persons. Since frailty is partly reversible, the global geriatric evaluation, in a one-day clinic, will lead to a personalized program to prevent or reverse frailty by a multidisciplinary approach.

[The role of the geriatrician in the organization of the health care system]

The purpose of this paper is to define the role of the geriatrician in the organization of the health care for the elderly. In Belgium, the healthcare program for the geriatric patient defines the various functions; at present, the classical geriatric hospitalization, the hospital day care, and the internal links within the hospital are well developed around the geriatrician. The standardized, comprehensive geriatric assessment of hospitalized patients has demonstrated its value for the prevention of functional decline. The efficiency of the day care services and of the link teams remains to be further appraised. Outside the hospital, the general practionner plays the major role in the treatment of the elderly living at home, or in nursing homes. The demographic evolution and the frailty of the elderly require a good coordination of all those involved in the care of the aged. A model of healthcare organization is proposed to better coordinate the in- and out of hospital activities.

[Swallowing disorders in elderly patients: a multidisciplinary approach]

Presbyphagia represents the physiological aging of swallowing function. It predisposes to difficulty in swallowing, namely dysphagia, which is of high incidence in the elderly population. The consequences of dysphagia are multiple and always a tragedy for the patient; they consist of aspiration pneumonia, malnutrition, dehydration, social isolation, and death. The diagnosis is difficult and is based on the medical history and clinical examination, associated with diagnostic tests. Its management is multidisciplinary, leaving only little room for medications or surgery.

[Sarcopenia: what's new in 2014]

The term "sarcopenia" was first introduced in 1989 by Irwin Rosenberg to define a progressive and generalized loss of muscle mass and muscle strength with advancing age. Above certain thresholds, that loss of muscle mass and muscle strength is considered abnormal. Despite the progress of scientific knowledge, a universally accepted definition of sarcopenia is still lacking to date. Therefore, it is a real challenge to establish the prevalence of sarcopenia because the results highly depend on the definition used for its diagnosis. This geriatric syndrome represents a public health issue with multiple clinical consequences. Loss of autonomy and quality of life, altered functional status, increase of fatigue, falls and a higher mortality rate are well-known consequences of sarcopenia. Although many pharmacological and non-pharmacological therapeutical strategies seem to have a positive impact on muscle strength and muscle mass, very few studies have yet assessed the effects of those treatments on sarcopenia itself. Therefore, developing high-quality interventional studies, in this field, seem necessary.

[Pathological ageing: a myth or reality?]

Senescence is a continuous and complex process which takes place over the whole lifetime. Its genetic and biological causes are now better known, particularly thanks to the study of telomers outcome and the oxydative stress. The replicative senescence theory seems to explain an adaptative process that accompanies oldness. Some markers such as the length of telomers, the loss of antioxydant activity and the accumulation of materials resulting from the cellular metabolism seem to be involved in this phenomenon and will probably be measurable soon. These parameters should be part of the biological assessment of the old person's clinical status. Such alterations have physiological and clinical impacts from which result the vulnerability or often frailty that must be carefrully assessed because they greatly influence the old person's stress response and could explain the phenotypical and heterogenous differences observed in the old population. Frailty is not irreversible, but can be treated by classical therapies or be delayed or prevented by various interventions. Physical exercise and well adapted nutrition seem promising. All these markers of oldness influence the functional decline and must be integrated as much as possible in the therapeutic decisions, which sometimes lead to heavy and complex treatments.

[Psychomotor disadaptation syndrome: a poorly known clinical entity]

Psychomotor disadaptation syndrome is a typical geriatric clinical syndrome. It includes postural disorders such as body retropulsion, specific gait disorders, with axial akinesia and hypertonia, and psychobehavioral disorders akin to those found in depression. The diagnosis is essentially based on clinical observation rather than on iconographic data. This syndrome causes falls which induce a fear of falling. The old patient has a tendency to put himself down, to withdraw from society and to lose autonomy. This article briefly describes the physiopathology of the syndrome, recalls the diagnostic tools, and makes some suggestions regarding the care of patients suffering from this clinical entity.

The Belgian geriatric day hospitals as part of a care program for the geriatric patient: first results of the implementation at the national level

PURPOSE

In order to deliver individual, specialized and multidisciplinary care for older people, the Belgian national health authorities developed the care program for the geriatric patient. In that context, 48 geriatric day hospitals (GDHs) have been financed by the government since January 1st 2006. The main objective of this study is to describe the patient characteristics, facility features and activities related to the Belgian GDHs.

METHODS

A prospective, multicenter study was performed from October 1st till December 31st 2006 in all 48 GDHs. For each GDH a transversal data collection was carried out. In the same period all patients scheduled for the GDHs were registered and followed for 3 months. Therefore two questionnaires were developed using Filemaker software: one for each GDH and one for each patient. There were no exclusion criteria.

RESULTS

Six GDHs did not complete one or both questionnaires. Consequently, the results of 42 GDHs were included. GDHs with more years of activity had significantly more new patient contacts per day. Activities in the Belgian GDHs were mainly diagnostic with emphasis on geriatric syndromes and specific medical problems. The reason for admission to the GDH was often multifactorial. The syndromes that motivated patients 75 or older to visit the GDH were clearly geriatric (mainly cognitive disorders) and represent the principle public health problems in this age category. Despite the legal provision preserving GDHs for patients 75 years or older a quarter of all patients was younger than 75, presenting with a geriatric syndrome. The contribution of the general practitioners was limited.

CONCLUSIONS

Activities in the Belgian GDHs are mainly diagnostic with emphasis on geriatric syndromes (particularly cognitive disorders) and specific medical problems. More information is needed on the knowledge and expectations of general practitioners in order to establish a closer collaboration.

First-generation versus third-generation comprehensive geriatric assessment instruments in the acute hospital setting: a comparison of the Minimum Geriatric Screening Tools (MGST) and the interRAI Acute Care (interRAI AC)

OBJECTIVE

Comparison of the first-generation Minimum Geriatric Screening Tools (MGST) and the third-generation interRAI Acute Care (interRAI AC).

DESIGN

Based on a qualitative multiphase exchange of expert opinion, published evidence was critically analyzed and translated into a consensus.

RESULTS

Both methods are intended for a multi-domain geriatric assessment in acute hospital settings, but each with a different scope and goal. MGST contains a collection of single-domain, internationally validated instruments. Assessment is usually triggered by care givers' clinical impression based on geriatric expertise. A limited selection of domains is usually assessed only once, by disciplines with domain-specific expertise. Clinical use results in improvement to screen geriatric problems. InterRAI AC, tailored for acute settings, intends to screen a large number of geriatric domains. Based on systematic observational data, risk domains are triggered and clinical guidelines are suggested. Multiple observation periods outline the evolution of patients' functioning over stay in comparison to the premorbid situation. The method is appropriate for application on geriatric and non-geriatric wards, filling geriatric knowledge gaps. The interRAI Suite contains a common set of standardized items across settings, facilitating data transfer in transitional care.

CONCLUSION

The third-generation interRAI AC has advantages compared to the first-generation MGST. A cascade system is proposed to integrate both, complementary methods in practice. The systematic interRAI AC assessment detects risk domains. Subsequently, clinical protocols suggest components of the MGST as additional assessment. This cascade approach unites the strength of exhaustive assessment of the interRAI AC with domain-specific tools of the MGST.

[Presbyastasis and application of vestibular rehabilitation in geriatrics]

Balance disorders can have a major functional impact among the elderly. The main risk is falling. Three elements are implicated in the loss of balance: vision, proprioception and the vestibular system. This article will discuss mainly vestibular damage and its implications. The assessment of balance disorders, particularly in geriatric patients, is based on validated scales composed of several items. These provide scores and are based on the results of chronometric measurements. They can be useful for the application of Vestibular Rehabilitation (VR), a technique improving the adaptation and autonomy of these patients. Vestibular rehabilitation is therefore part of an overall support, the goal of therapy being to improve daily life and to reduce the risk of falls.

[Sarcopenia: a physical marker of frailty]

Sarcopenia is defined by loss of muscular mass, strength and quality that occur in elderly. Multiple factors underlie this process: low physical activity, low steroids hormones, increase of cytokines, loss of motoneurons, decrease of protein synthesis...However, the role of these factors is not yet well understood and consensual clinical definition and assessment are still needed. It has become an important area of research because of its frequency and the influence in the disability of old people. It is a major component of frailty. So far, no pharmacological treatment has proven definitive evidence to treat or prevent sarcopenia. Nevertheless, it needs a multidimensional approach based on physical activity and prevention of malnutrition.

[Therapeutic adherence in elderly]

Therapeutic adherence can be defined as the degree of concordance between the behaviour of a person in relation with drugs prescription and medical recommendations. It represents the ability of people to follow a treatment. Bad adherence is frequent in geriatric patients. The behaviour of the patient is important but the role of the prescriptor and distributor of the drugs should also be emphasized. A bad adherence is responsible for iatrogenic consequences, which has a great impact on the functionality of the old person, but also on the cost and organization of care. Therapeutic education, a standardised method to help the patient take care of his own treatment, must be developed. The aims and means should be clearly efined. The patient himself must be involved and human or material sources of help must be sought.

[Clinical inertia in geriatrics]

Therapeutic inertia is a phenomenon with multiple etiologies, characterized by a "lack of initiation or modification of therapy when appropriate" and mainly affecting common chronic diseases (hypertension, diabetes, dyslipidemia). Caused by various processes including the lack of clinical evidence for the elderly, it can lead, in the elderly fragile by nature, to inappropriate prescribing. In a multidisciplinary approach, integrating the expertise of a pharmacist in the health care team improves the pharmacotherapeutic management of the geriatric patient.

The primary care physician and Alzheimer's disease: an international position paper

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.